ASTRO发布原发性肝癌外照射放射治疗临床指南

StephenW

ASTRO发布原发性肝癌外照射放射治疗临床指南

建议涉及何时以及如何使用放射治疗，并概述了以患者为中心的护理的最佳实践
同行评审出版物

美国放射肿瘤学会

美国放射肿瘤学会 (ASTRO) 的一项新临床指南提供了关于使用放射治疗使用外束放射治疗 (EBRT) 治疗成人原发性肝癌患者的指南。循证建议概述了肝细胞癌 (HCC) 和肝内胆管癌 (IHC) 患者的适应症和最佳 EBRT 剂量、技术和治疗计划，重点强调多学科护理。该指南是 ASTRO 第一个针对原发性肝癌的指南，发表在 Practical Radiation Oncology 上。

原发性肝癌是最常见的癌症类型之一，也是全球癌症死亡的第四大原因。自 1980 年以来，美国的发病率增加了两倍多，在过去的二十年中每年增长约 2%；去年估计有42,230个新病例被诊断出来。尽管 HCC 筛查的可得性和导致肝癌的疾病（即乙型肝炎、丙型肝炎、非酒精性脂肪肝病）的预防和治疗得到改善，但 HCC 和 IHC 的死亡率也继续上升。

多学科参与对于原发性肝癌治疗尤为重要，因为诊断和分期的复杂性、广泛的治疗选择的可用性以及需要考虑医学合并症，例如潜在的肝硬化，大约 90% 的肝癌患者存在肝硬化。肝癌。

原发性 HCC 的常见治疗选择包括肝移植、手术切除肿瘤、热消融和基于导管的治疗，适用于疾病局限于肝脏的患者，以及全身治疗（靶向治疗和/或免疫治疗），适用于疾病更多的患者先进的。对于 IHC，标准治疗包括手术和化学疗法的组合，有或没有放射。 EBRT 采用非侵入性技术从体外对肿瘤部位进行高剂量靶向辐射，历来使用频率低于其他方法；例如，最近的一项研究发现，只有 4% 的合格患者在肝移植前接受了 EBRT 作为桥接疗法。

“从历史上看，外部束辐射的低利用率是由于技术限制，这使得避免健康的肝脏组织变得具有挑战性。然而，在过去 15 年中，随着成像和放射治疗提供的显着进步以及对肝脏如何反应的理解的提高辐射，我们现在拥有越来越多的关于 EBRT 对这些疾病患者的作用的临床数据，”指南工作组主席兼威尔康奈尔医学临床放射肿瘤学教授 Higinia Cardenes 医学博士说在纽约。

“被诊断患有肝癌的患者通常有多种治疗选择，在决定治疗方案之前应该向他们介绍每种治疗选择。不同的学科——肝病学、外科肿瘤学、介入放射学和放射肿瘤学——都应该参与多学科治疗讨论，以确定对每位患者最好的治疗方案，”指南工作组副主席、西雅图癌症护理联盟医学主任、华盛顿大学放射肿瘤学教授 Smith Apisarnthanarax 医学博士说。西雅图。 “我们认为该指南是原发性肝癌管理的一个重要里程碑，因为我们希望为从业者和公众提供一个系统和循证的基础，了解 EBRT 可能适合治疗这些具有挑战性的病例的整体复杂情况。”

指南中的建议涉及患者选择以及 EBRT 在一系列临床情况下的计划和实施技术，包括确定/非移植、巩固、抢救、术前（包括移植桥接）、术后和姑息治疗设置。强调多学科讨论和规划，主要建议如下：

    强烈建议 (a) 将 EBRT 作为潜在的一线治疗，用于不适合治愈性治疗的局限于肝脏的 HCC 患者； (b) 作为对其他肝脏导向治疗反应不完全的患者的巩固治疗； (c) 作为其他治疗后局部复发患者的抢救治疗选择。
有条件地推荐 EBRT 用于 (a) 局限于肝脏的多灶性或不可切除的 HCC 患者，或 (b) 大血管侵犯的患者，当采用全身或基于导管的治疗进行测序时。该指南包括治疗局限于肝脏的 HCC（图 1）和伴有大血管侵犯的 HCC（图 2）的治疗流程。

    有条件地推荐 EBRT 用于有症状的原发性 HCC 和/或侵入血管的 HCC 的姑息治疗。在精心挑选的患者中，也有条件地推荐在肝移植前或手术前作为桥接疗法。

    对于无法切除的 IHC 患者，应考虑 EBRT 联合或不联合化疗，通常在全身治疗后进行。对于已切除 IHC 且具有高风险特征的患者，有条件地推荐辅助 EBRT。该指南包括不可切除（图 3）和可切除（图 4）IHC 的治疗流程。

    该指南还涉及 EBRT 的最佳剂量、分割、治疗计划和实施技术，强调治疗应基于个体因素，包括癌症的范围和位置、潜在的肝功能和可用的治疗技术。

关于指南

该指南基于对 2000 年 1 月至 2020 年 2 月发表的文章的系统文献回顾。多学科工作组包括放射、内科和外科肿瘤学家、医学物理学家、肝病学家、移植外科医生和放射肿瘤学住院医师。该指南是与美国临床肿瘤学会、美国移植外科医生学会和肿瘤外科学会合作制定的。 Cardenes 博士和 Apisarnthanarax 博士还录制了关于实用放射肿瘤学建议的播客。

ASTRO 的临床指南旨在作为促进医生和患者之间适当个性化、共享决策的工具。任何内容都不应被解释为严格或取代个别医生和患者的适当知情和深思熟虑的判断。

关于阿斯特罗

美国放射肿瘤学会 (ASTRO) 是世界上最大的放射肿瘤学会，拥有近 10,000 名成员，他们是医生、护士、生物学家、物理学家、放射治疗师、剂量师和其他专门从事放射治疗患者的医疗保健专业人员.有关放射治疗的信息，请访问 RTAnswers.org。要了解有关 ASTRO 的更多信息，请访问我们的网站并在社交媒体上关注我们。

StephenW

ASTRO issues clinical guideline on external beam radiation therapy for primary liver cancers

Recommendations address when and how radiation therapy should be used and outline best practices for patient-centered care
Peer-Reviewed Publication

American Society for Radiation Oncology

A new clinical guideline from the American Society for Radiation Oncology (ASTRO) provides guidance on the use of radiation therapy to treat adult patients with primary liver cancers using external beam radiation therapy (EBRT). Evidence-based recommendations outline indications and optimal EBRT dosing, techniques and treatment planning for patients with hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC), with a strong emphasis on multidisciplinary care. The guideline, ASTRO’s first for primary liver cancers, is published in Practical Radiation Oncology.

Primary liver cancers are among the most commonly diagnosed types of cancer and the fourth leading cause of cancer death worldwide. Incidence rates in the United States have more than tripled since 1980, rising approximately 2% each year in the last two decades; an estimated 42,230 new cases were diagnosed last year. Mortality rates from HCC and IHC also continue to rise despite the growing availability of screening for HCC and improved prevention and treatment of diseases that lead to liver cancer (i.e., hepatitis B, hepatitis C, nonalcoholic fatty liver disease).

Multidisciplinary involvement is particularly important for primary liver cancer treatment, due to complexities in diagnosis and staging, the availability of a wide range of treatment options and a need to consider medical comorbidities such as underlying cirrhosis, which is present in roughly 90% of patients with HCC.

Common treatment options for primary HCC include liver transplantation, surgical removal of the tumor, thermal ablation and catheter-based therapies for patients whose disease is confined to the liver, and systemic therapy (targeted therapy and/or immunotherapy) for those whose disease is more advanced. For IHC, standard treatment includes a combination of surgery and chemotherapy, with or without radiation. EBRT, which aims high doses of targeted radiation at tumor sites from outside the body with non-invasive techniques, has historically been used less frequently than other approaches; for example, a recent study found that just 4% of eligible patients received EBRT as a bridging therapy before liver transplant.

"Historically, low utilization rates for external beam radiation were due to technological limitations that made it challenging to avoid healthy liver tissue. However, with significant advances in imaging and radiation treatment delivery over the past 15 years and improved understanding of how the liver responds to radiation, we now have an increasing amount of clinical data on the role that EBRT can play for patients with these diseases," said Higinia Cardenes, MD, PhD, chair of the guideline task force and a professor of clinical radiation oncology at Weill Cornell Medicine in New York.

"Patients diagnosed with liver cancer often have a number of treatment options available to them, and they should be presented with each of them before a treatment course is decided. The different disciplines — hepatology, surgical oncology, interventional radiology and radiation oncology — should all be involved in multidisciplinary treatment discussions to determine what might be best for each patient," said Smith Apisarnthanarax, MD, vice chair of the guideline task force, medical director of the Seattle Cancer Care Alliance and professor of radiation oncology at the University of Washington in Seattle. "We feel that this guideline is an important milestone in the management of primary liver cancers, as we hope to provide practitioners and the public with a systematic and evidence-based foundation of where EBRT might fit into the overall complex picture of treating these challenging cases."

Recommendations in the guideline address patient selection, as well as planning and delivery techniques for EBRT in a range of clinical situations, including definitive/non-transplant, consolidative, salvage, pre-operative (including bridge-to-transplant), post-operative and palliative treatment settings. With an emphasis on multidisciplinary discussion and planning, key recommendations are as follows:

    EBRT is strongly recommended (a) as a potential first-line treatment for patients with HCC confined to the liver who are not candidates for curative therapy; (b) as a consolidative therapy for patients with incomplete responses to other liver-directed treatments; and (c) as a salvage therapy option for patients with local recurrences after other treatment.
EBRT is conditionally recommended for (a) patients with multifocal or unresectable HCC confined to the liver, or (b) patients with macrovascular invasion, when sequenced with systemic or catheter-based therapies. The guideline includes treatment algorithms for the management of HCC that is confined to the liver (Figure 1) and HCC with macrovascular invasion (Figure 2).

    EBRT is conditionally recommended in the palliative setting for symptomatic primary HCC and/or HCC that has invaded a blood vessel. It also is conditionally recommended as a bridging therapy prior to liver transplant or before surgery in carefully selected patients.

    For patients with unresectable IHC, EBRT with or without chemotherapy should be considered, typically after systemic therapy. For patients with resected IHC and high-risk features, adjuvant EBRT is conditionally recommended. The guideline includes treatment algorithms for unresectable (Figure 3) and resectable (Figure 4) IHC.

    The guideline also addresses optimal dosing, fractionation, treatment planning and delivery techniques for EBRT, emphasizing that therapy should be based on individual factors including the extent and location of the cancer, underlying liver function and available treatment technologies.

About the Guideline

The guideline was based on a systematic literature review of articles published from January 2000 through February 2020. The multidisciplinary task force included radiation, medical and surgical oncologists, medical physicists, a hepatologist, a transplant surgeon and a radiation oncology resident. The guideline was developed in collaboration with the American Society of Clinical Oncology, American Society of Transplant Surgeons and the Society of Surgical Oncology. Dr. Cardenes and Dr. Apisarnthanarax also recorded a podcast about the recommendations for Practical Radiation Oncology.

ASTRO's clinical guidelines are intended as tools to promote appropriately individualized, shared decision-making between physicians and patients. None should be construed as strict or superseding the appropriately informed and considered judgments of individual physicians and patients.

ABOUT ASTRO

The American Society for Radiation Oncology (ASTRO) is the largest radiation oncology society in the world, with nearly 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating patients with radiation therapies. For information on radiation therapy, visit RTAnswers.org. To learn more about ASTRO, visit our website and follow us on social media.