Changing Outcomes of Liver Cancer by Focused Ablation of Tumour and Its Thrombus

A 61-year-old male patient visited Max Super Speciality Hospital, Patparganj, as a diagnosed case of Chronic Liver Disease (CLD) with hepatocellular carcinoma. His Child-Pugh score was B. His triple phase CT of the abdomen revealed a shrunken liver with a decreased liver span as a result of cirrhosis. It also revealed an ill-defined area of primary hepatocellular carcinoma of about 4.5 cm. This tumour also had a sinister spread via an enhancing tumour thrombus extending into the adjacent middle hepatic vein, hepatic region of IVC, and suprahepatic part of IVC and was going right up to the right atrium. In the right atrium, it measured slightly higher than its size in the liver to approx 5 x 3.2 cm sized filling defect in the right atrium.

It is interesting to note that none of the existing guidelines specifically address this clinical situation. It was discussed in the tumour board and decided that only SBRT (Stereotactic Body Radiotherapy)-based radiation can address something that spans so many different organs, environments, and blood supplies. While chemotherapy is an option, it remains ineffective in situations where there is a need for a quick response. Other options like TACE depend upon embolisation, and localisation of limited blood supply is not feasible in this situation, and SBRT was the most robust option.

SBRT is a focused form of external radiation therapy that can be given confidently by localising small targets like a portal venous thrombus surrounded by a very sensitive organ like the liver. It is delivered by the latest TRUEBEAM Stx at Max hospital, Patparganj. At the centre, the delivery is enhanced by the added precision of ExacTrac, which tracks the tumour throughout the course of radiation therapy. For an added layer of precision, doctors deliver the planned precise SBRT in only a certain phase of respiration to catch the liver in exactly that phase. The patient completed his planned five fractions of SBRT and, on follow-up assessment after two months, had a complete resolution of the tumour from all the blood vessels.

The clinical benefit goes far beyond simply getting a disappearance because this tumour thrombus would have led to a congestive cardiac failure in the patient and reduced the life expectancy far beyond what a 4.5 cm liver tumour can do.

The medical literature is full of case reports and series where similar results can be seen in up to 70 per cent of cases, especially if the liver functions have not deteriorated. While delivering the radiation, respiratory synchronisation with image guidance and tracking via ExacTrac gives truly outstanding results.