China is a major liver cancer country. Half of the liver cancer patients in the world are in China, and a considerable proportion of patients are already in the middle and late stages when they are discovered, and the operation is difficult or there is no chance of surgery at all.
Although with the continuous advancement of targeted therapy and immunotherapy in recent years, combined treatment has made the median survival period of inoperable advanced liver cancer patients with advanced liver cancer exceed 2 years, but it is still very far from the clinical cure of .
Up to now, local treatment methods such as surgical surgery and liver transplantation are still the best way to enable patients with liver cancer to achieve reliable clinical cure. However, in real life, there are some liver cancer patients with central type, huge size, and combined with portal vein cancer thrombosis. The direct surgery of is difficult and has a high recurrence rate. How to ensure that these patients undergo surgery safely and minimize the risk of postoperative recurrence has always been a problem that plagues academic circles and patients circles.
Recently, several studies have suggested: Do a little radiotherapy before surgery to make the tumor retreat, and then the surgery can achieve twice the result with half the effort.
The earliest attempt to neoadjuvant radiotherapy for liver cancer can be traced back to a randomized clinical trial published in the journal JCO in 2019, and was hosted by professors from Shanghai Oriental Hepatobiliary Hospital.
164 patients with liver cancer combined with portal venous carcinoma were randomized 1:1, one group had radiotherapy first and then surgery, one group had direct surgery, and there were 82 patients in each group. The results showed that:
before surgery can significantly improve the overall survival rate of the patients, among which the survival rate of 2 years can double from 9.4% to 27.4% ; the survival rate of 2 years can be increased from 3.3% to 13.3% . In addition, there was no statistical difference in the incidence of complications between the two groups, which means that the radiotherapy performed before the surgery did not increase the difficulty of the surgery or resulted in additional adverse reactions.
After the above research results were published, many scholars in the industry began to explore the use of neoadjuvant radiotherapy to convert some patients with liver cancer who are more difficult to operate into surgical patients, while improving the efficacy of patients with local advanced liver cancer.
In recent years, with the advancement of immunotherapy, more and more models of immune combined radiotherapy have begun to enter the field of neoadjuvant therapy. During the National Day holiday, a professor at the National Cancer Center reported on a successful experience of neoadjuvant radiotherapy for patients with central liver cancer.
This single-arm phase 2 clinical trial started and recruited volunteers in December 2014, and ended the recruitment of subjects in January 2019. The follow-up period was until January 2021. 38 patients with central liver cancer were enrolled, with an average age of 55.6 years and 35 were male. Imaging evaluation prompts after patients undergoing neoadjuvant radiotherapy:
42.1% of patients had significantly reduced tumors, and 57.9% of patients had remained stable. Then all patients received surgical treatment . The cut tumor tissue was carefully tested and examined under a microscope and found that: 13.2% of the patients had no live cancer cells, achieving complete remission of pathology , and 21% of the patients had more than 90% of the cancer cells were no longer active, achieving the main pathological remission. The median follow-up of
was 45.8 months, and the 5-year survival rate of the entire group was 69.1% ; the median disease-free progression-free progression-free progression-generating period was 45.8 months, and the 5-year disease-free progression-generating rate was 41.0% . The implication is that about 40% of patients can achieve clinical cure.
The overall incidence of adverse reactions caused by intensity-modulated radiotherapy before surgery is very low, and the incidence of grade 3 adverse reactions is only 7.9%. The incidence of complications after surgery was 34.2%, mainly mild complications, accounting for 31.6%. Such a combination treatment plan with radiotherapy first and surgery after surgery is safe and effective.
In fact, with the continuous advancement of radiotherapy technology, (from three-dimensional adaptive radiotherapy, to intensity-modulated radiotherapy, to stereotactic radiotherapy, and even to proton heavy ion radiotherapy) , the adverse reactions caused by radiotherapy itself are getting smaller and smaller. In the future, the neoadjuvant radiotherapy model will definitely occupy an increasingly important position in the treatment of liver cancer.
References:
[1]. Neoadjuvant Three-Dimensional Conformal Radiotherapy for Resectable Hepatocellular Carcinoma With Portal Vein Tumor Thrombus: A Randomized, Open-Label, Multicenter Controlled Study. J Clin Oncol. 2019 Aug 20;37(24):2141-2151
[2]. Phase 2 Evaluation of Neoadjuvant Intensity-Modulated Radiotherapy in Centrally located Hepatocellular Carcinoma: A Nonrandomized Controlled Trial. JAMA Surg. 2022 Oct 5. doi: 10.1001/jamasurg.2022.4702
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