Radiotherapy for Metastatic Fibrolamellar Hepatocellular Carcinoma
A 28-year-old Caucasian female presented to her local urgent care center with flu-like symptoms and fatigue. On physical exam, an abdominal mass was palpated, prompting a computed tomography (CT) scan of her abdomen. A large, heterogenous enhancing mass with central low attenuation change was discovered in the left liver lobe. She later indicated that she had felt abdominal fullness and pain in the left upper quadrant, but denied constitutional symptoms, jaundice, or pruritis. The patient had a significant family history for ovarian, lung, prostate, and breast cancer. She had a 10 year history of smoking one pack per week. Testing for Hepatitis B and C were both negative. The patient’s presenting lab values included AFP 7.8 ng/mL, alkaline phosphatase 115, AST 72, ALT 124, total/direct bilirubin 0.9/0.2, Na 139, K 4.2, Platelets 400, and INR 1.0. Biopsy of the mass confirmed a grade 1-2 FLHCC and chest imaging did not reveal any metastases.\nThe patient underwent a left lateral liver resection to remove the 11.7×9.8×6.1 cm FLHCC mass. The surgical margins were negative with no evidence of vascular invasion; however, three out of six hepatic artery and periportal lymph nodes were positive for FLHCC. Following resection, the patient did not receive chemotherapy. Three months after the operation, her AFP levels had declined to <0.8 ng/mL and imaging was negative for metastatic disease. During the seventeen months following the liver resection, the patient had two separate surgical interventions to remove growing abdominal and thoracic lymph nodes and masses. At twenty-two months following the liver resection, the patient noted a cough and was found to have a new, large (2.6×2.3 cm), right hilar lymph node as well as old and new pulmonary nodules. At this time, radiation oncology was consulted to treat the right hilar lymph node. She was not deemed a suitable candidate for definitive radiation treatment at that time, due to the numerous enlarging areas of metastatic disease and the lack of symptoms from the hilar metastasis. After three months of watching, the right hilar node decreased in size, but multiple subpleural and subcarinal nodules arose, and a perigastric lymph node continued to grow slightly. The patient decided to not pursue treatment at that time and decided to watch and wait. Three months later CT imaging showed significant growth of the sub-pleural nodules and right hilar nodules with maintenance of the subcarinal lymph nodes. The patient continued to decline standard treatments.\nFour months later, the pulmonary nodules had grown significantly large (one measured 6×10 cm) as well as a lymph node on the gastrohepatic ligament (). The patient began to have symptoms of a dry cough and shortness of breath due to mass effect and invasion of the chest wall. At this time, we began palliative radiation treatment of the pulmonary metastasis with 40 Gy in ten fractions over a thirteen day time period (). The patient tolerated the radiation therapy well and began capecitabine and interferon alfa-2b therapy eight days after the radiation treatment. She developed symptoms consistent with radiation pneumonitis approximately 85 days after treatment, which resolved with prednisone.\nThe FLHCC pulmonary metastases showed a remarkable response to the radiation treatment. We utilized Eclipse software to contour and record dimensions and volumes for the treated metastatic tumor. According to the RECIST criteria, the patient was classified as a partial response. Measurements of the treated metastatic right lung mass pre-treatment resulted in a maximal left-right (LR) diameter of 9.1 cm, a maximal anterior-posterior (AP) diameter of 10.6 cm, a maximal superior-inferior (SI) diameter of 14.0 cm, and a volume of 538 cm3 (). At four months post-treatment, the mass measured LR diameter 7.6 cm, AP diameter 5.6 cm, SI diameter 9.1 cm, and volume 100 cm3 (), and at six months post-treatment, the mass measured LR diameter 7.6 cm, AP diameter 5.8 cm, SI diameter 8.5 cm, and volume 75.8 cm3 (). These changes constitute a 81.4% and 85.9% decrease in tumor volume and a 35.0% and 39.3% decrease in the longest diameter (SI diameter) at four and six months respectively. The effect was exclusive to the treated pulmonary metastases treated with radiation. Other known metastatic lesions progressed during the chemotherapy suggesting the response was due primarily to the radiotherapy. Unfortunately the patient continued to develop pulmonary metastases ( and ). Due to the prior pneumonitis, radiotherapy had been held and chemotherapy was used to treat the progressive disease. The response in the treated metastases had been durable during the 6 months of follow-up ( and ).