Stereotactic Body Radiation Therapy as a Bridge to Transplantation and for Recurrent Disease in the Transplanted Liver of a Patient with Hepatocellular Carcinoma
A 52-year-old male, undergoing surveillance because of long-standing hepatitis C, was found to have a rising α fetoprotein (AFP) level and a new 1.7-cm liver lesion consistent with HCC on a CT scan in October 2007. He was placed on the transplant list and underwent transarterial chemoembolization as bridging therapy in February 2008. The AFP level declined to normal, but within several months began to rise again. In August 2008, the patient was referred for SBRT.\nThe Novalis ExacTrac patient positioning platform (BrainLab AG, Heimstetten, Germany) was used for immobilization. Treatment planning was performed using the BrainScan system (BrainLab AG) and BrainLab treatment software. Treatment was prescribed to the 100% isodose line, with the 80% isodose line covering the planning target volume. Conformal arcs were used to deliver 50 Gy in ten 5 Gy daily fractions using 6-MV photons.\nOn May 10, 2009, the patient underwent an OLT. Pathologic examination of the native liver showed a 2.2-cm necrotic mass with no viable tumor identified. He did well following transplant until March 2011, when a rise in AFP up to 328 IU/ml was found.\nA CT scan revealed an enlarged pericaval lymph node, which was biopsied and showed metastatic carcinoma. The lymph node was treated in May 2011 with SBRT to a dose of 50 Gy in 10 fractions. There was a good response to treatment based on repeat imaging studies as well as a significant decline in the AFP level.\nHowever, in August 2012 there was a rapid rise in the patient's AFP level, reaching 1,590 IU/ml by October. In an October 2012 CT scan, a new 2.2-cm mass was seen in the left lobe of the liver and was treated with SBRT, 62.5 Gy in 5 fractions (fig. ). At an initial follow-up after treatment, the lesion was stable on CT, and the AFP level had declined to 76 IU/ml. The most recent CT scan, almost 1 year after treatment, shows complete resolution of the treated lesion with no new suspicious disease. Follow-up examination also did not reveal any signs of liver disease or radiation-related toxicity (fig. ).