A Phase I Dose Escalation Trial of Conformal Hypofractionated Radiation Therapy for Patients With Hepatitis B Virus-Related Child A Cirrhosis and Hepatocellular Carcinoma
All enrolled patients will receive 3.5 Gy per fraction (five fractions per week) at the
Dose escalation by 7 Gy in 2 fractions to maximum of 63 Gy, as follows:
Dose Level I: 3.5 Gy for 12 fractions (42 Gy total) Dose Level II*: 3.5 Gy for 14 fractions
(49 Gy total) Dose Level III: 3.5 Gy for 16 fractions (56 Gy total) Dose Level VI: 3.5 Gy
for 18 fractions (63 Gy total) *Protocol treatment begins at level 2 for patients with the
sum of the diameters of irradiated tumor(s) less than 10 cm.
Hepatocellular carcinoma based on the diagnostic criteria of European Association for the
Study of the Liver (EASL), either confirmed cyto-histologically or confirmed non-invasively
(restricted to cirrhotic patients) by radiological criteria (two coincident imaging
techniques and focal lesion >2 cm with arterial hypervascularization) or combined criteria
(one imaging technique associated with alpha-fetoprotein (AFP), focal lesion >2 cm with
arterial hypervascularization, and AFP levels >400 ng/ml); Hepatitis B virus carrier
serologically; Child-Pugh grade A for cirrhosis; The patients should be considered not
suitable for surgery, ablation therapy, or trans-arterial chemoembolization judged by the
caring physician. In addition, no systemic anti-cancer therapy with high priority is
available judged by the caring physician.
Required sample size: Minimum of 15 (if starting from level II)
Primary To identify the maximally tolerated dose (from 42 Gy up to 63 Gy in 3.5 Gy per
fraction), conformal radiation therapy in patients with HBV-related Child-Pugh grade A
cirrhosis and hepatocellular carcinoma (HCC) who are not eligible for other conventional
Secondary To evaluate the local tumor control rate within the irradiated fields. To assess
patterns of failure and survival of patients treated with conformal liver radiation therapy.
To analyze the dose volume characteristics that influence whether radiation-induced liver
disease (RILD), HBV reactivation, or other toxicities occur.
To collect blood samples for translational research.
Radiation therapy must start within 4 weeks of patient registration. Intensity modulated
radiation therapy or volumetric modulated arc therapy is acceptable. Helical tomotherapy or
cyberknife is not allowed in this study. H2 blockers or proton pump inhibitors will be
required in an attempt to reduce the risk of late gastrointestinal bleeding. Oral anti-viral
agents are allowed at the discretion of the treating physician to prevent the reactivation
The target dose is determined based on the study dose level and the volume of normal liver
excluded from radiation, using the liver dose-volume histogram (DVH). Treatment at the
allocated dose level is only permitted if the normal tissue criteria are maintained. If the
normal tissue criteria are not met at that dose, treatment at a lower dose level is
permitted, as long as the normal tissue constraints are met at the lower dose level.
The dose per fraction to the planning target volume (PTV) is 3.5 Gy. Dose will start at dose
level 2 (49 Gy), but may vary from 42 Gy to 63 Gy, in 12 to 18 fractions, Monday through
Friday, in 2-fraction increments. The starting level will be Level 2, 49 Gy in 14 fraction
for patients with the sum of the diameters of irradiated tumor(s) less than 10 cm and
Child-Pugh grade A of liver cirrhosis, and level 1, 42 Gy in 12 fraction for patients
Doses will be prescribed to a peripheral covering isodose covering the PTV. Assuming dose is
normalized to this isodose at 100%, the maximal dose can be 120% and the minimum PTV dose
90%. Any dose > 110% must be within the PTV (except for adjacent tumors, in which the
maximum dose outside the PTV must be < 115%). Minor variation is defined as minimum PTV dose
falling between 85 and 90% (of the required 100% isodose prescription). Major variation
(unacceptable) is defined as minimum PTV dose < 85 % (for the required 100% isodose
prescription). The acceptable exception is the underdose of PTV adjacent to small bowels to
keep less than any 3cc of small bowels or stomach with the dose more than 42 Gy. This part
of PTV should be specified and recorded.
Maximum doses are defined at 1 cc of volume. Minimum dose to the PTV is defined as minimum
dose to 99.0% of the PTV.
*Protocol treatment begins at level 2 for patients with the sum of the diameters of
irradiated tumor(s) less than 10 cm and Child-Pugh grade A of liver cirrhosis.
The minimum, maximum, and mean dose to the PTV is to be recorded for each gross tumor volume
External beam equipment: Treatment will be delivered with 6 - 25 MV photons, with selection
of appropriate energies to optimize the radiotherapy dose distribution within the target
volume and minimize the dose to non-target tissues.
Localization, simulation and immobilization Patient positioning will be based on clinical
judgment to best achieve the ideal dose distribution.
The target volume will be identified on an IV contrast CT scan and/or MRI that is registered
to the planning CT dataset. The planning CT and all subsequent CT studies will be obtained
using the identical immobilization technique used for treatment.
An immobilization frame may be used, but is not required. A variety of immobilization
methods may be utilized for planning and treatment, including active breathing control
(ABC), voluntary breath hold, gating, shallow breathing, or abdominal compression. For free
breathing, 4D-CT can be used to aid in PTV definition.
Treatment planning/volume definitions
CT-based 3D treatment planning shall be used for all patients. Intensity modulated radiation
therapy (IMRT) can be used for selected patients with breathing control device during IMRT.
The GTV will be defined by IV contrast CT or MRI. The clinical target volume (CTV) will be
the GTV + 5 mm, within the liver. The PTV will be determined by the immobilization device
used and/or the individual patient breathing motion. The minimal and maximal PTV margins
permitted are 4 mm and 30 mm, respectively, dependent on the immobilization method used and
DVH shall be calculated for the liver (liver minus the GTVs), both kidneys, the spinal cord,
small bowels and stomach as well as the target lesions (GTVs. CTVs, and PTVs). The maximum,
minimum, and mean dose and dose per fraction must be documented.
Normal liver: The normal liver is defined as the normal liver volume minus GTV. In all
patients, it is required that there is at least 700 cc of normal liver. No more than 30% of
the normal liver may receive more than 27 Gy, and no more than 50% of normal liver may
receive over 24 Gy.
Kidney: No more than 50% of the combined renal volume may receive 20 Gy or more.
Spinal cord: Maximal permitted dose to spinal cord is 37 Gy. Small bowel: Maximal permitted
dose to small bowel is 42 Gy for any 3 cc volume. The underdose of PTV adjacent to small
bowels or stomach is acceptable.
Stomach: Maximal permitted dose to stomach is 42 Gy for any 3 cc of volume. All doses are
physical doses (not biologically corrected). Note that 42 Gy is biologically equivalent to
56.8 Gy in 2 Gy/fraction using an α/β of 3.
Radiation adverse events
Liver: Radiation therapy should be held at any point in the protocol for CTCAE v3.0 hepatic
adverse event Grade 4. It is expected that a proportion of patients will have transient
elevation of liver enzymes following treatment (possibly up to Grade 3 CTCAE levels). If
elevation of liver enzymes is observed up to Grade 3 levels, more frequent measurements (at
least once a week) of the liver enzymes are recommended until the enzymes stabilize or
return to baseline levels. Repeat of all Grade 4 blood work is required at least 5 days
following the first abnormal lab value to determine if the Grade 4 levels are transient
(defined here as < 5 days) or persistent. Patients will be evaluated at 1-month and 3-month
follow-up visits for symptoms and signs of radiation induced liver disease (RILD). In
patients who have elevation of liver enzymes near Grade 4 levels and/or in patients with
early non-specific signs or symptoms of liver injury, close follow-up is recommended with
repeat blood work. If no tumor progression is documented in these patients, liver injury
will be presumed to be treatment related.
HBV-related hepatitis: HBV-related hepatitis flare is defined as a greater than 3-fold
increase of pre-treatment baseline serum ALT level and more than 100 IU/L. The HBV-related
hepatitis flare (HBV reactivation) should be accompanied with the preceding or simultaneous
greater than 10-fold increase, compared with previous nadir levels, of HBV DNA or by the
reappearance of hepatitis B e antigen (HBeAg) in the serum of patients whose baseline HBeAg
is negative. Oral anti-viral agent should be initiated in patients without prophylactic use
of oral antiviral agents after HBV reactivation is confirmed.
Gastrointestinal: The dose constraints required for the normal stomach and small intestine
should limit the GI toxicity observed and it is not expected that GI toxicity will be dose
limiting. However, if a portion of the stomach or small intestine is treated (> 30 Gy), H2
blockers or proton pump inhibitors will be required to attempt to decrease the chance of
late GI bleeding. Patients will be followed for GI toxicity at each follow up visit.
Other: The occurrence of Grade 4 adverse events, related to protocol treatment, in any organ
system will prompt discontinuance of protocol therapy while appropriate physical
examination, laboratory, and imaging assessments are undertaken. Protocol treatment will not
be resumed in the absence of recovery from adverse events of this magnitude. Once recovery
to grade 1 has occurred, treatment may continue at the discretion of the treating physician.
Evaluation of partial and complete response will be based on the 3-month follow-up CT scan.
Only very gross increase in tumor size seen in less than that time will be scored as
progressive disease. Response to radiation may continue up to 12 months follow-up and time
of maximal response will be recorded.
Measurement of Response
Response will be evaluated in this study using the international criteria proposed by the
Response Evaluation Criteria in Solid Tumors (RECIST) Committee. The sum of the longest
diameter (LD) for all target lesions will be calculated and reported as the baseline sum LD.
The baseline sum LD will be used as reference by which to characterize the objective tumor.
Response Criteria: Evaluation of target lesions Complete Response (CR): Disappearance of all
target lesions. Any pathological lymph nodes (whether target or non-target) must have
reduction in short axis to <10 mm.
Partial Response (PR): At least a 30% decrease in the sum of diameters of target lesions,
taking as reference the baseline sum diameters.
Progressive Disease (PD): At least a 20% increase in the sum of diameters of target lesions,
taking as reference the smallest sum on study (this includes the baseline sum if that is the
smallest on study). In addition to the relative increase of 20%, the sum must also
demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new
lesions is also considered progression). Stable Disease (SD): Neither sufficient shrinkage
to qualify for PR nor sufficient increase to qualify for PD, taking as reference the
smallest sum diameters while on study
In-field local control: For this study, local control is defined as the lack of progressive
disease in the treated fields.
Cause of death: The treating physician will evaluate whether the cause of death was hepatic
or non-hepatic, and/or due to tumor or due to toxicity
SPECIMEN COLLECTION FOR TRANSLATIONAL RESEARCH
Peripheral Blood Collection
Sample collection time points:
Blood samples will be collected in 5 occasions along the protocol treatment:
1. baseline (within 1 week before the first radiotherapy fraction);
2. 5-10 days after the last radiotherapy fraction;
3. 4 weeks after the last radiotherapy fraction.
Preparation of Plasma and Buffy coat:
1. Collect 5-10 mL of anticoagulated blood (EDTA). Invert tube several times to assure
blood is mixed thoroughly with anticoagulant.
2. Using three (3) 1mL cryovials, label them patient's case number, procedure date, and
clearly mark cryovials "plasma". Similarly, label three (3) 1mL cryovials and mark as
1. Centrifuge specimens within one hour of collection. EDTA (purple top) tubes should be
centrifuged in a standard clinical centrifuge at ~2500 RPM at 4° Celsius for 10
2. If the interval between specimen collection and processing is anticipated to be greater
than one hour, keep specimen on ice until centrifuging is done.
3. Remove plasma close to the buffy coat taking cared not to disturb the white cell layer.
Aliquot plasma into three 1mL cryovials labeled with the RTOG study and case numbers,
procedure date, and clearly mark as "plasma".
4. Remove the buffy coat cells carefully and place into the 1 mL cryovials labeled "buffy
coat" (it is okay if a few packed red cells below the buffy coat layer are
inadvertently collected in the process)
5. Place cryovials into biohazard bag.
6. Store plasma and buffy coat specimens frozen. Buffy coat samples must be shipped to the
tissue bank within one (1) week of collection.
Preparation of Serum:
1. Collect one 5-10 mL red-topped tube. Allow 30 minutes for clotting at room temperature
2. Using four (4) 1ml cryovials, label them with the study number, and patient's case
number, procedure date, and clearly mark cryovials as "serum".
1. Allow one 5ml red top tube to clot for 30 minutes at room temperature.
2. Spin red-topped tube in a standard clinical centrifuge at ~2500 RPM at 4°Celsius for 10
3. Aliquot serum into the four 1mL cryovials labeled with the RTOG study and case numbers,
procedure date, and marked "serum".
4. Store serum frozen (at -80° Celsius) until ready to ship
Analysis of Blood Samples
Serum or plasma samples:
Soluble cytokines and growth factors related to inflammation and angiogenesis will be
analyzed by enzyme-linked immunosorbent assay (ELISA) for serum samples and plasma samples.
Inflammatory factors, such as IL-6, TNF-alpha, CRP, MMP-2, MMP-9, VEGF, IL-8, pro-angiogenic
factors, such as VEGF, basic-FGF, PDGF, PIGF, and TNF, and anti-angiogenic factors, such as
thrombospontin-1 (TSP-1), will be included. Serum HBV DNA level will also be analyzed.
RNA samples from blood mononuclear cells:
1. Tumor-associated gene expression in peripheral blood reflects the presence of
circulating hepatocellular carcinoma (HCC) cells and might be associated with
aggressive features of HCC. We will assess the prognostic significance of AFP and human
telomerase reverse transcriptase protein (hTERT) mRNA expression in the peripheral
blood of HCC patients.
2. Circulating endothelial cells and their progenitors have been shown as surrogate
markers of angiogenic activity. Several cellular markers, including VEGFR2, Tie-2, and
CD133, have been shown to be specifically expressed in activated endothelial cells or
endothelial progenitor cells. The expression of these markers will be detected by
real-time quantitative PCR.
DNA samples from blood mononuclear cells:
The polymorphic inheritance of human drug-metabolizing enzymes, such as those encoded by the
glutathione-S-transferase (GST), microsomal epoxide hydrolase (mEPHX), and CYP systems, have
been implicated in both cancer risk and prognosis. DNA samples from blood mononuclear cells
will be used for the analysis of GST, mEPHX, CYP, and p53 polymorphism by PCR and sequencing
Data Management and Analysis
1. Evaluation of soluble factors related to inflammation or angiogenesis and the surrogate
quantification of circulating endothelial cells or progenitors (the B-2 section) will
be conducted according to standard procedures by personnel who have no access to the
clinical outcomes of the patients.
2. The clinical outcomes of the patients will be included for further correlation study
include clinical responses (responders vs. non-responders), other patterns of failure
(intrahepatic recurrence outside radiation field vs. no intrahepatic recurrence;
extrahepatic metastasis vs. no metastasis), radiation induced liver disease (RILD vs.
no RILD), and survival.
3. The correlation of clinical outcomes with the surrogate markers evaluated from the
after-mentioned markers will be made.
Study Endpoints The primary endpoint of this study is to determine the maximally tolerated
dose of highly conformal radiation therapy in patients with HCC. The secondary endpoints are
to evaluate local control rate within the irradiated fields,to assess patterns of failure
and survival, and to analyze the dose volume characteristics that influence whether RILD,
HBV reactivation, or other toxicities occur.
Evaluation of Adverse Events
Adverse events will be graded according to the CTCAE v. 3.0 criteria. Dose limiting toxicity
(DLT) is defined as any of the following occurring within 90 days from the start of
a) grade 4 or 5 hepatic b) grade 4 or 5 gastrointestinal c) grade 4 or 5 thrombocytopenia d)
Radiation Induced Liver Disease (RILD) requiring treatment (including diuretics). RILD will
be defined using the following adverse events: i) grade 3 or higher alkaline phosphatase
(ALP) in the presence of ascites occurring in the absence of disease progression ii) grade 4
hepatic liver enzyme elevations persisting for ≥ 5 days e) any adverse event requiring
interruption of therapy by ≥ 2 weeks (14 calendar days). This does not include patient
desire to discontinue therapy. It does include failure for thrombocytopenia to improve to a
level of 80 requiring interruption of therapy.
f) Any grade 5 adverse event The goal of this study is to determine the maximally tolerated
dose (MTD) for patients with HCC, such that the rate of DLT is less than 35%.
The following are the four possible dose levels for this study:
Dose Level I: 3.5 Gy for 12 fractions (42 Gy total) Dose Level II: 3.5 Gy for 14 fractions
(49 Gy total) Dose Level III: 3.5 Gy for 16 fractions (56 Gy total) Dose Level VI: 3.5 Gy
for 18 fractions (63 Gy total)
Patients will receive highly conformal radiotherapy starting at Dose Level II. Dose levels
will be escalated by 7 Gy in 2 fractions per level up to 21 Gy in 6 fractions and a total
dose of 63 Gy. Evaluable patients will be defined as any eligible patient that begins
treatment. After 5 evaluable patients have been followed for a minimum of 90 days from the
start of treatment, if there are 0 or 1 DLT, the dose level will be judged to be acceptable.
If this occurs, then patients will begin to be accrued at the next higher dose level. If ≥ 3
of 5 patients have DLT, the preceding dose level will be declared to be the MTD. If 2 of 5
patients have DLT, the addition of 5 more patients to the same level will be done. If ≥ 4 of
10 patients have DLT, the preceding dose level will be declared to be the MTD. If 2 or 3 of
the 10 patients have DLT, patients will begin to be accrued at the next higher dose level.
If there are 3 or more DLT at the starting dose level (Dose Level II), then the dose will be
de-escalated to Dose Level I. If this occurs, then after 5 evaluable patients have been
followed for a minimum of 90 days from the start of treatment at Dose Level I, if there are
0 or 1 DLT, the 3.5 Gy per fraction for a total of 42 Gy will be declared to be the MTD. If
at any time a grade 5 treatment-related adverse event is observed, the study chairs will
review the event.
The number of evaluable patients that will be needed depends on the number of times the dose
is escalated or possibly de-escalated. If the escalation continues up through Dose Level IV,
15 evaluable patients will be required. If the dose is de-escalated after Dose Level II,
then 10 evaluable patients will be required.
Allocation: Non-Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
Maximally tolerated dose of RT
weekly during radiotherapy
Jason Chia-Hsien Cheng, Ph.D.
National Taiwan University Hospital
Taiwan: Department of Health