Two-stage treatment with hepatectomy and carbon-ion radiotherapy for multiple hepatic epithelioid hemangioendotheliomas

Figure 4 Treatment course. A: Post-operative abdominal computed tomography (CT) showed the greater omental flap (arrows) around the tumor, maintaining a sufficient space between the tumor and the gastrointestinal tract; B: Treatment plan for carbon-ion radiotherapy with a total dose of 76 GyE in 20 fractions. Isodose lines demonstrate 100% of the prescribed dose at the center and decreasing by 10% of the dose from the inside to the outside. Owing to the greater omental flap, the tumor was entirely irradiated with full dose, and the gastrointestinal tract was successfully spared; C: Comparison of abdominal CT and magnetic resonance imaging scans taken over a period of 24 mo after carbon-ion radiotherapy indicated shrinkage of the tumor with decreasing tumor vascularity. The maximum tumor diameter was 35 mm before treatment, and tumor size decreased thereafter to 27 mm after 6 mo; D: Tumor size of 26 mm after 12 mo; E: Tumor size of 24 mm after 24 mo.