title: Treatment of primary liver cancer using highly-conformal radiotherapy with kV-image guidance and respiratory control.
abstract: OBJECTIVE
  To implement a reliable, practical and reproducible treatment procedure, based on in-room kV-image guidance and respiratory control, for liver cancer patients treated with high dose conformal radiotherapy using a commercially available treatment system.
  
  
  METHODS
  CT stimulation was conducted under voluntary breath hold or gating using the Varian Real-time Position Management™ (RPM) System. Treatments were delivered daily under kV image guidance to verify the diaphragmatic or lipiodol-defined tumor position.
  
  
  RESULTS
  Thirty-three patients with liver confined hepatocellular carcinoma were treated between May 2006 and Dec 2009. After a median follow-up period of 16.5 months (range: 3.5-40.7), all but 2 patients demonstrated radiological tumor regression. Eight patients (24%) achieved complete remission. The median tumor shrinkage was 42% (27-100%). Subsequent in-field tumor progression was observed in only three patients (10%). For the 23 patients with abnormal alpha fetoprotein level, 22 of them showed biochemical response with a median AFP level drop of 78%. The treatment was well tolerated: Grade 3 toxicities occurred in 5 patients (1 leucopenia, 1 elevated liver enzyme and 3 elevated bilirubin level) but there was no grade 4 toxicity or treatment related death. The 1 year overall survival rate is 71.7% and median survival time is 17.2 months (3.5-40.7 months).
  
  
  CONCLUSIONS
  Excellent treatment results with minimal toxicities could be achieved in a clinical environment with a commercially available highly sophisticated radiotherapy system.
authors.affiliation: Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, People's Republic of China. lawly@ha.org.hk
authors.forename: Ada L Y
authors.initials: AL
authors.lastname: Law
authors.forename: Wai-Tong
authors.initials: WT
authors.lastname: Ng
authors.forename: Michael C H
authors.initials: MC
authors.lastname: Lee
authors.forename: Augustine T S
authors.initials: AT
authors.lastname: Chan
authors.forename: Kai-Hung
authors.initials: KH
authors.lastname: Fung
authors.forename: Francis
authors.initials: F
authors.lastname: Li
authors.forename: Wai-Cheung
authors.initials: WC
authors.lastname: Lao
authors.forename: Anne W M
authors.initials: AW
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000032:analysis; D006528:Carcinoma, Hepatocellular / Q000532:radiotherapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008113:Liver Neoplasms / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D011788:Quality of Life; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D020266:Radiotherapy, Conformal / Q000379:methods*; D012074:Remission Induction; D012119:Respiration; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D014408:Biomarkers, Tumor