A Pilot Trial of Stereotactic Body Radiation Therapy (SBRT) to Induce Tumor Hyperemia in Combination With Transarterial Chemoembolization (TACE) for Unresectable Hepatocellular Carcinoma
A Pilot Trial of Stereotactic Body Radiation Therapy (SBRT) to Induce Tumor Hyperemia in Combination With Transarterial Chemoembolization (TACE) for Unresectable Hepatocellular Carcinoma
This pilot clinical trial studies stereotactic body radiation therapy (SBRT) and transarterial chemoembolization (TACE) in treating patients with liver cancer that cannot be removed by surgery. SBRT is a specialized radiation therapy that delivers a high dose of radiation directly to the tumor and may kill more tumor cells and cause less damage to normal tissue. Chemoembolization kills tumor cells by carrying drugs directly into blood vessels near the tumors and then blocking the blood flow to allow a higher concentration of the drug to reach the tumor for a longer period of time. SBRT may make TACE more beneficial by increasing blood flow to the tumor, which may allow more of the TACE chemotherapy to enter the tumor. Giving SBRT with TACE may work better in treating patients with liver cancer that cannot be removed by surgery.
PRIMARY OBJECTIVES:
I. To establish the feasibility of completing SBRT followed by TACE in a 2 day time period.
SECONDARY OBJECTIVES:
I. To determine acute tumor perfusion changes after SBRT using functional magnetic resonance imaging (MRI) (magnetic resonance [MR]-dynamic contrast enhanced [DCE]/perfusion weighted imaging [PWI], MR-diffusion, blood oxygen level dependent [BOLD] sequences).
II. To establish safety and tolerability of this regimen. III. To determine overall response rates (using modified Response Evaluation Criteria in Solid Tumors [RECIST] criteria), including objective response rate (partial response [PR] + complete response [CR]) and clinical benefit rate (stable disease [SD] + PR + CR) at 1, 3, and 6 months after TACE.
IV. To evaluate local control, progression-free survival, and overall survival at 1, 3, 6, 9, and 12 months after a single-dose of SBRT followed by TACE.
V. To correlate micro ribonucleic acid (miRNA) biomarkers with response and toxicity.
OUTLINE: This is a dose-escalation study of SBRT.
Patients undergo SBRT on day 1 and TACE on day 2.
After completion of study treatment, patients are followed up at 1-2 weeks and at 1, 3, 6, 9, 12, 18, and 24 months.
Inclusion Criteria:
Patients must have a diagnosis of hepatocellular carcinoma by at least one criterion listed below:
Patients must be non-transplantable, unresectable, or medically inoperable and eligible for TACE as determined by a multi-disciplinary team
Absolute neutrophil count >= 1.5 × 10^9/L
Hemoglobin >= 9 g/dl
Platelets >= 50,000/mm^3
Prothrombin time (PT)/international normalized ratio (INR) and activated partial thromboplastin time (PTTa) =< 1.5
Albumin >= 2.5 g/dL
Alkaline phosphatase < 5 x upper limit of normal (ULN)
Total bilirubin =< 2.0 mg/dL
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 5 x ULN
Creatinine =< 1.5 mg/dL and calculated creatinine clearance >= 60 mL/min or 24-hour urine creatinine clearance >= 60 mL/min
Must have Childs-Pugh A or B liver disease
Patients must have no clinical signs of heart failure and meet New York Heart Association functional classification I or II defined as:
Must have 1-3 liver lesions amenable to SBRT with tumor size < 15 cm (single lesion or sum)
Must be able to undergo two MRI scans, one before study treatment begins and another shortly after SBRT
Patients with extrahepatic disease, portal hypertension, or bilobar disease are allowed
Normal renal function (creatinine < 1.5 mg/dL)
Within 2 weeks of registration: patients must have vital signs, history/physical examination, laboratory studies (complete blood count [CBC] with differential, chemistries including liver function tests, AFP, creatinine clearance [CrCl] assessment, pregnancy test if needed)
Life expectancy of at least 12 weeks in the opinion of investigator
Patient has an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
Ability to provide written informed consent obtained prior to participation in the study and any related procedures being performed
Women of child-bearing potential (WOCBP) must have a negative pregnancy test within 14 days of the first administration of study treatment; urine human chorionic gonadotropin (HCG) is an acceptable pregnancy assessment
Women/men of reproductive potential must be counseled on contraception/abstinence while receiving the study treatment
Exclusion Criteria:
Childs-Pugh C liver function
Major liver vascular invasion
Prior radiation to the liver or other upper abdominal regions
Must not have any evidence of bleeding diathesis or active gastrointestinal bleeding
Any concurrent malignancy other than non-melanoma skin cancer, non-invasive bladder cancer, or carcinoma in situ of the cervix; patients with a previous malignancy without evidence of disease for >= 3 years will be allowed to enter the trial
History of active connective tissue disease (scleroderma)
Subjects who are breast-feeding, or have a positive pregnancy test will be excluded from the study; should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately
Medical contraindication to MR imaging (e.g. pacemakers, metallic implants, aneurysm clips, known contrast allergy to gadolinium contrast, pregnancy, nursing mothers, weight greater than 350 pounds)
Any serious and/or unstable pre-existing medical disorder (aside from malignancy exception above), psychiatric disorder, or other conditions that could interfere with subject's safety, obtaining informed consent or compliance to the study procedures, in the opinion of the investigator; this could include severe, active co-morbidities such as: