Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2018; 10(10): 772-779
Published online Oct 27, 2018. doi: 10.4254/wjh.v10.i10.772
Proton beam therapy in apneic oxygenation treatment of an unresectable hepatocellular carcinoma: A case report and review of literature
Yi-Lan Lin
Yi-Lan Lin, Department of Radiation Oncology, Rinecker Proton Therapy Center, Munich 81371, Germany
Author contributions: Lin YL performed all research and interpretive functions for this case report.
Supported by Rinecker Proton Therapy Center (RPTC), Munich, Germany.
Informed consent statement: After contacting the patient about the planned publication of his case, he provided written authorization.
Conflict-of-interest statement: The author states there are no potential conflicts of interest relevant to this publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Yi-Lan Lin, MD, Chief Doctor, Department of Radiation Oncology, Rinecker Proton Therapy Center, Schaeftlarnstr 133, Munich 81371, Germany. yi-lan.lin@rptc-1.de
Telephone: +49-89-724670 Fax: +49-89-72467352
Received: April 5, 2018
Peer-review started: April 6, 2018
First decision: May 16, 2018
Revised: June 14, 2018
Accepted: June 27, 2018
Article in press: June 28, 2018
Published online: October 27, 2018
Processing time: 205 Days and 15.8 Hours
ARTICLE HIGHLIGHTS
Case characteristics

In a routine abdominal sonography of a 63-year-old asymptomatic male, a large central tumor in the liver was detected.

Clinical diagnosis

According to the abdominal sonography, the magnetic resonance imaging and the pathologically increased tumor marker alpha-fetoprotein and liver function panel, a hepatic malignancy was urgently suspected.

Differential diagnosis

Liver cirrhosis, cholangiocellular carcinoma, liver angiosarcoma, liver metastases of non-hepatic origin.

Laboratory diagnosis

The laboratory tests showed significant increase of the tumor marker alpha-fetoprotein and the cholestatic parameters gamma-glutamyltransferase and alkaline phosphatase.

Imaging diagnosis

Magnetic resonance imaging and computed tomography of the abdomen revealed the main tumor mass to be of about 13.4 cm × 7.1 cm in size, encompassing segments I, IV, V and VIII, as well as satellite metastases in segments II and III. The tumor involved all three hepatic veins and the portal vein, compressing the inferior vena cava.

Pathological diagnosis

A liver biopsy confirmed a diagnosis of hepatocellular carcinoma (HCC), Edmondson-Steiner-grade II, with partially cirrhotic parenchymal modification.

Treatment

The patient was treated with proton beam therapy (PBT) in apneic oxygenation at the Rinecker Proton Therapy Center, at a total dose of 60 Gy (relative biological effectiveness) in 20 fractions.

Term explanation

We use the apneic oxygenation to manage respiratory motion of the tumor and to reduce the safety margin, which enables the sparing of uninvolved liver parenchyma and other surrounding organs at risk as well as a dose escalation.

Experiences and lessons

The patient is free of tumor recurrence in a period of 4 years after the treatment. PBT is a safe and effective therapy for large unresectable HCC with vascular invasion and intrahepatic metastases.