Correspondence
Case 23-2005: A Man with a Mass in the Liver
N Engl J Med 2005; 353:2195-2197November 17, 2005
- Article
To the Editor:
Tanabe et al. (July 28 issue)1provide an excellent example of the multidisciplinary decision making required in the case of a typical patient with hepatocellular carcinoma. Although radioactive yttrium-90 microspheres delivered through the hepatic artery were discussed as a treatment option, external-beam radiation was not. Historically, radiation therapy has played a minor role in the treatment of hepatocellular carcinoma, primarily because of the low tolerance of the whole liver to radiation. However, technological advances in tumor imaging, conformal-radiation planning, and radiation delivery have facilitated the safe use of high-dose radiotherapy for focal hepatocellular carcinomas, including tumors unsuitable for other ablative approaches. Evidence is emerging, mainly from Asia, that conformal radiotherapy is well tolerated in patients with hepatocellular carcinoma,2 with response rates from 66 percent3 to 91 percent4 and one-year survival rates of 47 percent3 to 94 percent4 after radiation treatment, with or without transhepatic arterial chemoembolization. Conformal radiotherapy should be considered as a treatment option for this challenging cancer, which is the third most common cause of cancer-associated death globally.5
5 ReferencesMaria A. Hawkins, M.D.
Laura A. Dawson, M.D.
Princess Margaret Hospital, Toronto, ON M5G 2M9, Canada
laura.dawson@rmp. uhn. on. ca 1
Case Records of the Massachusetts General Hospital (Case 23-2005). N Engl J Med 2005;353:401-410
Full Text | Web of Science | Medline2
Dawson LA ,Normolle D ,Balter JM ,McGinn CJ ,Lawrence TS ,Ten Haken RK . Analysis of radiation-induced liver disease using the Lyman NTCP model. Int J Radiat Oncol Biol Phys 2002;53:810-821[Erratum, Int J Radiat Oncol Biol Phys 2002;53:1422.]
CrossRef | Web of Science | Medline3
Park W ,Lim do H ,Paik SW , et al. Local radiotherapy for patients with unresectable hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2005;61:1143-1150
CrossRef | Web of Science | Medline4
Wu DH ,Liu L ,Chen LH . Therapeutic effects and prognostic factors in three-dimensional conformal radiotherapy combined with transcatheter arterial chemoembolization for hepatocellular carcinoma. World J Gastroenterol 2004;10:2184-2189
Medline5
Parkin DM ,Bray F ,Ferlay J ,Pisani P . Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74-108
CrossRef | Web of Science | Medline
To the Editor:
It is unclear why no application was made to the United Network for Organ Sharing regional review board on this patient's behalf for additional Model for End-Stage Liver Disease (MELD) listing points for orthotopic liver transplantation. On the basis of the data supplied, the patient's calculated MELD score was probably no greater than 10, denoting no realistic priority for orthotopic liver transplantation, as the authors observed. Recent evidence suggests that unless a patient's MELD score is at least 15, the risks associated with transplantation surgery, lifelong immunosuppressive therapy thereafter, and the possibility of recurrent liver disease outweigh the projected benefits of orthotopic liver transplantation.1
The presence of a single biopsy-proven hepatocellular cancer with a diameter larger than 1.9 cm but no larger than 5 cm without computed tomographic evidence of metastatic disease or obvious macrovascular invasion of portal veins, hepatic veins, or both would have rendered the patient eligible for additional MELD listing points, for a total score of 22.2 This score reflects a 15 percent probability of the patient's dying within three months. Such data are central to any discussion about orthotopic liver transplantation in the management of hepatocellular cancer.
2 ReferencesAlastair D. Smith, M.B., Ch.B.
Michael A. Morse, M.D.
Paul C. Kuo, M.D., M.B.A.
Duke University Medical Center, Durham, NC 27710
smith267@mc.duke. edu 1
Merion RM . When is a patient too well and when is a patient too sick for a liver transplant? Liver Transpl 2004;10:S69-S73
CrossRef | Web of Science | Medline2
Organ Procurement and Transplantation Network/United Network for Organ Sharing Liver and Intestinal Organ Transplantation Committee. Members: committees. (Accessed October 27, 2005, at http://www.optn.org/members/committees.asp.)
To the Editor:
On reading the well-documented case history of the 57-year-old man with a mass in the center of the liver, I felt impelled to comment that 50 years ago the term “middle hepatic lobectomy” was introduced for the treatment of an invasive cancer of the gallbladder. At the time, an injection-corrosion specimen of a liver affected by this disease clearly indicated that this was the appropriate treatment for this condition.1
Also, the beautiful anatomical drawings of the lobes and segments of the liver, clarifying the type of liver resection employed in the present case, are very similar to those we published 50 years ago.2
2 ReferencesHenry Gans, M.D., Ph.D.
522 Colorado Ave., Stuart, FL 34994Author/Editor Response
We appreciate Dr. Gans's reminder that the modern-day central hepatectomy bears some similarities to his description of what was called a “middle hepatic lobectomy” in 1955. We did not coin the phrase “central hepatectomy,” but used this term to remain consistent with the definition of “lobe,” which is defined by Stedman's medical dictionary as “subdivisions of an organ or other part, bounded by fissures, sulci, connective tissue septa, or other structural demarcations.” The morphologically defined lobes of the liver (right, left, quadrate, and caudate) are bounded by these surface demarcations. In contrast, the “middle lobe” as described by Dr. Gans relies on functional anatomy rather than surface landmarks, thereby calling into question the appropriateness of the term “middle lobe.”
Dr. Smith and colleagues correctly point out that an exception could have been granted for additional MELD listing points. However, even with assignment of that disease exception, we anticipated a waiting period of 9 to 15 months for a cadaveric liver. Given the described growth rate of the tumor, which had reached 4.7 cm by the time the patient was seen at our hospital, it is likely that he would have exceeded eligibility limits for transplantation during this waiting period, as was discussed in the case history. As also discussed, consideration was given to using a living donor or a bridging strategy such as radiofrequency ablation. However, ultimately a decision was reached with multidisciplinary input to use a central hepatectomy.
Drs. Hawkins and Dawson remind us that a few centers have reported promising results using external-beam radiation treatment for hepatocellular carcinoma. And as pointed out by these authors, several technological advances including conformal-radiation techniques allow for the safer delivery of higher doses. A wide range of fractionation schedules have been used both with and without radiosensitizers, and it is difficult to identify a standard radiation regimen. We are currently conducting a clinical trial to evaluate the safety and efficacy of proton-beam therapy for unresectable hepatocellular carcinoma. We believe that external-beam radiation is deserving of careful evaluation in clinical trials.
Kenneth K. Tanabe, M.D.
Raymond T. Chung, M.D.
Lawrence S. Blaszkowsky, M.D.
Harvard Medical School, Boston, MA 02115
