J Korean Med Assoc.  2013 Nov;56(11):983-992. 10.5124/jkma.2013.56.11.983.

Recent developments in radiotherapy for hepatocellular carcinoma

  • 1Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. rophc@skku.edu


The role of radiotherapy in practice is mainly palliative. According to the Practice Guidelines for Management of Hepatocellular Carcinoma (2009) developed by the Korean Liver Cancer Study Group and the National Cancer Center, Korea, radiotherapy can be applied for 1) refractoriness to trans-catheter hepatic arterial chemo-embolization, 2) portal vein tumor thrombosis, and 3) palliative therapy to reduce the symptoms caused by hepatocellular carcinoma. Radiotherapy is one of the most rapidly developing fields of medical research. Recent advances in intensity-modulated radiotherapy, image-guided radiotherapy, and respiratory-gated radiotherapy technologies have enabled more accurate and precise radiation delivery for the treatment of hepatocellular carcinoma. Proton therapy is also emerging as a candidate therapy for ablative measures for patients ineligible for other curative local therapies. Due to recent advances in radiotherapy technologies, radiotherapy for hepatocellular carcinoma has been evolving into stereotactic ablative radiotherapy, which delivers an ablative dose of radiation in 1 to 4 sessions. Clinical series have confirmed that it is safe in Child-Pugh A patients and local control is sustained. The possibility for performing phase 3 randomized clinical trials involving the radiotherapy modality has increased with those advances. Not merely palliative, the role of radiotherapy in the treatment of hepatocellular carcinoma will be expanded to potentially curative therapy in patients who are ineligible for other curative local therapies.


Intensity-modulated radiotherapy; Image-guided radiotherapy; Respiration-gated radiotherapy; Proton therapy; Stereotactic ablative radiotherapy

MeSH Terms

Carcinoma, Hepatocellular*
Liver Neoplasms
Palliative Care
Portal Vein
Proton Therapy
Radiotherapy, Image-Guided
Radiotherapy, Intensity-Modulated


  • Figure 1 Isodose curves with different external radiotherapy techniques. (A) Two-dimensional radiotherapy. (B) Three-dimensional radiotherapy. (C) Intensity-modulated radiotherapy. CTV, clinical target volume.

  • Figure 2 Concepts of image-guided radiotherapy (IGRT). (A) Linear accelerator equipped with in-room imaging devices (On-Board Image, Varian, Palo Alto, CA, USA; ExacTrac, Brain-Lab, Feldkirchen, Germany) for IGRT. (B) Daily setup using 2-dimensional imaging modality. (B-1) Reference images using digitally reconstructed radiographs, and (B-2) kV images using on-board imager. (C) Daily setup using 3-dimensional volumetric imaging modality. (C-1) Reference images using 3-dimentional reconstruction of planning computed tomography images, and (C-2) in-room cone-beam computed tomography images.

  • Figure 3 Concepts of respiration-gated radiotherapy. (A) Red-line indicates the level of liver dome at end-exhale phase (50%) and yellow-line indicates the level of liver dome at end-inhale phase (0%). In the respiratory-gated radiotherapy setting, treatment delivery is done in only gating window periods when the target position is pre-determined end-exhale phases. (B) Treatment Fields with and without Gating Technique (B-1 and B-2, respectively). (C) Dose volume histogram with gating (solid line) and without gating (dotted line); with same target coverage, treatment with gating delivers less radiation to normal tissues.

  • Figure 4 Comparison between proton therapy and radiotherapy using X-ray. (A) Characteristics of percentage depth dose from radiation delivery. (B) Comparison of isodose curves between intensity-modulated proton therapy (B-1) and three-dimensional conformal radiotherapy using 10 MV photon (B-2). SOBP, Spread out bragg peak.


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