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Review Article
Differences in radiotherapy application according to regional disease characteristics of hepatocellular carcinoma
Chai Hong Rim
J Liver Cancer. 2021;21(2):113-123.   Published online August 11, 2021
DOI: https://doi.org/10.17998/jlc.2021.05.26
  • 6,970 Views
  • 114 Downloads
  • 2 Citations
AbstractAbstract PDF
There are differences in opinion regarding the application of external beam radiotherapy in the treatment of hepatocellular carcinoma. Some major guidelines state that external beam radiotherapy is yet to attain a sufficient level of evidence. However, caution should be exercised when attempting to understand the clinical need for external beam radiotherapy solely based on the level of evidence. Previously, external beam radiotherapy had low applicability in the treatment of hepatocellular carcinoma before computed tomography-based planning was popularized. Modern external beam radiotherapy can selectively target tumor cells while sparing normal liver tissues. Recent technologies such as stereotactic body radiotherapy have enabled more precise treatment. The characteristics of hepatocellular carcinoma differ significantly according to the regional etiology. The main cause of hepatocellular carcinoma is the hepatitis B virus. It is commonly diagnosed as a locally advanced tumor but with relatively preserved hepatic function. The majority of these hepatocellular carcinoma cases are found in the East Asian population. Hepatocellular carcinoma caused by hepatitis C virus or other benign hepatitis tends to be diagnosed as a less locally aggressive tumor but with deteriorated liver function. The Western world and Japan tend to have patients with such causes. External beam radiotherapy has been more commonly performed for the former, although the use of external beam radiotherapy in the latter might have more concerns with regard to hepatic toxicity. This review discusses the above subjects along with perspectives regarding external beam radiotherapy in recent guidelines.

Citations

Citations to this article as recorded by  
  • Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines
    Sun Hyun Bae, Seok-Joo Chun, Joo-Hyun Chung, Eunji Kim, Jin-Kyu Kang, Won Il Jang, Ji Eun Moon, Isaure Roquette, Xavier Mirabel, Tomoki Kimura, Masayuki Ueno, Ting-Shi Su, Alison C. Tree, Matthias Guckenberger, Simon S. Lo, Marta Scorsetti, Ben J. Slotman
    International Journal of Radiation Oncology*Biology*Physics.2024; 118(2): 337.     CrossRef
  • Will the collaboration of surgery and external radiotherapy open new avenues for hepatocellular carcinoma with portal vein thrombosis?
    Jung Wan Choe, Hye Yoon Lee, Chai Hong Rim
    World Journal of Gastroenterology.2022; 28(7): 704.     CrossRef
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Case Reports
A Case of Advanced Hepatocellular Carcinoma with Portal Vein Tumor Invasion that Showed Favorable Prognosis after Combined External Radiation Therapy and Sorafenib Therapy
Namyoung Paik, Dong Hyun Sinn, Hee Chul Park, Woo Kyung Jeong, Min Sun Kim, Ji Hye Kim, Bumhee Yang
J Liver Cancer. 2016;16(2):134-138.   Published online September 30, 2016
DOI: https://doi.org/10.17998/jlc.16.2.134
  • 1,260 Views
  • 8 Downloads
AbstractAbstract PDF
A prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal that the median survival is 2 to 4 months without treatment. Sorafenib, the standard regimen of advanced HCC, can prolong median survival only 1.5 months. A 50-year-old man with a history of chronic hepatitis B was diagnosed advanced HCC with PVTT. By a multidisciplinary medical team approach, the combination of 3-demensional conformal radiation therapy with sequential sorafenib was challenged. 4 months after initiation of treatment, he achieved partial response as modified response evaluation criteria in solid tumors criteria. Sorafenib was continued so far, and stable disease has been maintained up to now, without significant adverse effect.
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A Case of Achieving Complete Remission with Stereotactic Body Radiation Therapy in Patients with Hepatocellular Carcinoma with Macrovascular Invasion after Repeated Transarerial Chemoembolization
Sang Youn Hwang, Seon-Mi Lee, Jong Woo Im, Ki Jeong Jeon, Sang Bu Ahn, Eun Kyeong Ji, Jin-Young Park, Cheol-Won Choi Choi, Gwang-Mo Yang
J Liver Cancer. 2016;16(2):123-128.   Published online September 30, 2016
DOI: https://doi.org/10.17998/jlc.16.2.123
  • 1,388 Views
  • 8 Downloads
AbstractAbstract PDF
Transarterial chemoembolization (TACE) is the worldwide procedure performed for patients with various stage hepatoceullar carcinoma (HCC), but is not yet considered as curative treatment because of relatively high local recurrence rate. Moreover, many clinicians frequently experience treatment failure (incomplete necrosis or stage progression etc.) after repeated TACE, but no clear guidelines have been recommended about salvage treatment modalities for this situation. Recently, studies for combination of radiation therapy and TACE for HCC with TACE refractoriness have been tried and reported better therapeutic efficacy. Based on above suggestions, we herein offer our experience of a patient with macrovascular invasion developed after repeated TACE that achieve complete remission by stereotactic body radiation therapy. Further study, maybe regarding a combination of locoregional and systemic therapy, is necessary on how to manage HCC patients with TACE refractoriness.
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Original Article
Bakri and Coda Balloon Placement between the Liver and Bowel in a Swine Model: A Feasibility Study
Man Deuk Kim
J Liver Cancer. 2015;15(2):106-111.   Published online September 30, 2015
DOI: https://doi.org/10.17998/jlc.15.2.106
  • 1,318 Views
  • 5 Downloads
AbstractAbstract PDF
Background/Aims
To investigate the feasibility of Bakri balloon and Coda balloon placement as a spacer between the liver and bowels using a swine model.
Methods
Six adult female swine weighing from 24.0 to 41.5 kg (mean, 31.5 kg) were included for the study. After peritoneal puncture using a 21-G micro-puncture needle under ultrasound and fluoroscopic guidance, a 0.035-inch guidewire (Terumo, Tokyo, Japan) was advanced through the micro-introducer sheath. With sequential dilation of the tract with dilators up to 18-Fr or 10 mm balloon, the Coda and Bakri balloon was advanced between the liver and bowels. 50 mL and 200 mL of contrast were inflated for Coda and Bakri balloon, respectively. Gross examinations focused on whether placement of the Coda or Bakri balloon was at the correct location.
Results
Technical success was achieved for Coda balloon placement in six of the six (100%) swine, and for Bakri balloon placement in five of the six (83.3 %) swine. The median placement time for the Coda balloon was 10 minutes (range, 7-15 minutes), while the median placement time for the Bakri balloon was 25 minutes (range, 17-35 minutes), which was significantly longer (p<0.05). Gross observations at necropsy revealed that the Coda and Bakri balloon was well placed between the liver and bowel.
Conclusions
Placement of Coda and Bakri balloons between the liver and bowels was feasible. These balloons have a potential role as spacers between the liver and bowel during radiation therapy for hepatocellular carcinoma patients. (J Liver Cancer 2015;15:106-111)
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Case Reports
A Case of Achieving Complete Remission with Combination of Stereotactic Body Radiation Therapy and Transarterial Chemoemoblization in Patients with 4.8 cm Sized Infiltrative Hepatocellular Carcinoma with Arteriovenous Shunt
Sang Youn Hwang, Seon-Mi Lee, Jung Woo Im, Joon Suk Kim, Ki Jeong Jeon, Sang Bu Ahn, Eun Kyeong Ji, Hyun-Cheol Kang, Cheol-Won Chol, Gwang-Mo Yang
J Liver Cancer. 2015;15(1):64-69.   Published online March 31, 2015
DOI: https://doi.org/10.17998/jlc.15.1.64
  • 1,402 Views
  • 10 Downloads
AbstractAbstract PDF
Infiltrative hepatocellular carcinoma (HCC) patients have a poor prognosis because most patients present with advanced disease. Although tumor size is small, ablation therapy is difficult because it is difficult to delineate tumor boundary and tumor often combined vascular invasion. Therefore many clinicians still try locoregional therapy (LRT) such as transarterial chemoembolization (TACE), radiation therapy (RT), or combination with LRT and sorafenib in this situation. Stereotactic body radiation therapy (SBRT) is new technology providing very highly conformal ablative radiation dose and is expected to salvage modality for HCC showed incomplete response of TACE due to combined arteriovenous (AV) shunts. Based on above suggestions, we herein offer our experience of a complete remission of tumor by combination of SBRT and TACE in a patient with infiltrative HCC. Further study, maybe regarding a combination of locoregional and systemic therapy is necessary on how to manage infiltrative HCC with AV shunts.
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A Case of Achieving Partial Remission with Combination of Radiation Therapy and Sorafenib inChild-Pugh Class B Patients with Hepatocellular Carcinoma with Main Portal Vein Invasion and Lymph Node Metastasis
Sang Youn Hwang, Seon-Mi Lee, Jung Woo Im, Joon Suk Kim, Sang Bu Ahn, Eun Kyeong Ji, Hyun-Cheol Kang, Cheol-Won Choi, Gwang-Mo Yang
J Liver Cancer. 2014;14(2):120-126.   Published online September 30, 2014
DOI: https://doi.org/10.17998/jlc.14.2.120
  • 1,216 Views
  • 3 Downloads
AbstractAbstract PDF
Reserved liver function is one of the most important determinants of survivial in advanced hepatocellular carcinoma (HCC). Especially in cirrhotic patient with decompensated liver function, sorafenib for HCC with main portal vein invasion have limited efficacy and survival benefit. Therefore many clinicians or centers still try locoregional therapy (LRT) such as transarterial chemoembolization (TACE), radiation therapy (RT), or combination with LRT and sorafenib in this situation. However this multidisciplinary approach may increase treatment related toxicity such as liver failure, etc. Recently, studies for combination of RT and sorafenib for HCC with portal vein invasion have been tried and reported not only better therapeutic efficacy, but also more hepatic toxicity.Based on above suggestions, we herein offer our experience of a patient that although achieved survival gain via partial remission of intrahepatic tumor and main portal vein thrombosis and metastatic lymph node by combination therapy of RT and sorafenib, finally expired due to hepatictoxicity. Further study, maybe regarding a combination of locoregional and systemic therapy, is necessary on how to manage decompenstated cirrhotic patients with HCC with main portal vein invasion. (J Liver Cancer 2014;14:120-126)
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A Case of Hypovascular Hepatocellular Carcinoma Invading Bile Duct with Partial Remission with Combination Therapy of Transarterial Chemoembolization and Stereotactic Body Radiation Therapy and Sorafenib
Sang Youn Hwang, Seon-Mi Lee, Jung Woo Im, Joon Suk Kim, Sang Bu Ahn, Eun Kyeong Ji, Chul Won Choi, Gwang-Mo Yang
Journal of the Korean Liver Cancer Study Group. 2013;13(2):178-184.   Published online September 30, 2013
DOI: https://doi.org/10.17998/jlc.13.2.178
  • 1,072 Views
  • 3 Downloads
AbstractAbstract PDF
Hepatocellular carcinoma (HCC) patients with bile duct invasion have a poor prognosis because many do not receive effective treatment. Surgical resection is thought to be only option of curative treatment, increasing chance of survival, but it is possible to minor group of patients because of poor reserved liver function associated with underlying liver disease and obstructive jaundice. Therefore many clinicians or centers still select locoregional therapy such as transarterial chemoembolization (TACE), radiation therapy (RT) etc. Stereotactic body radiation therapy (SBRT) is new technology providing very highly conformal ablative radiation dose for a small numbers (1-5 fractions) of large fraction size and is expected to salvage modality for HCC showed incomplete response of TACE due to vascularity or accessibility of feeding artery. Based on above suggestions, we herein offer our experience of a patient with partial remission of tumor by combination therapy of TACE, SBRT and sorafenib. Further study, maybe regarding a combination of locoregional and systemic therapy (so called multidisciplinary approach), is necessary on how to manage HCC patients with bile duct invasion or sparse vascularity.
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Review Article
Role of Radiation Therapy as an Ablative Modality for Hepatocellular Carcinoma
Hee Chul Park
Journal of the Korean Liver Cancer Study Group. 2013;13(2):114-122.   Published online September 30, 2013
DOI: https://doi.org/10.17998/jlc.13.2.114
  • 1,221 Views
  • 7 Downloads
AbstractAbstract PDF
Before the introduction of radiation therapy (RT) in the clinical management guidelines for hepatocellular carcinoma (HCC), radiation was used not very frequently in the course of HCC management. According to the “Practice guidelines for management of HCC 2009” published by the Korean Liver Cancer Study Group and the National Cancer Center, Korea, RT can be used for HCC with portal vein tumor thrombosis and can be effective to relieve the symptoms caused by HCC and its metastases once the RT is believed safe in terms of radiobiological considerations. The introduction of RT in the Korean HCC management guideline did the pivotal role in accentuating research efforts to enlighten the role of RT in HCC management. Recently, the application of stereotactic ablative body radiotherapy (SABR), an extra-cranial version of radiosurgery such as Gamma-knife, is tested as an ablative modality for HCC. There are already some published prospective series to test SABR for HCC. In Korea, there is a prospective trial published by Korea Cancer Center Hospital. A multicenter prospective trial (KROG 12-02) is on-going as a Korean Radiation Oncology Group (KROG) study and already 26 patients were accrued to the target number of 54 patients. In this review, the background, rationale and the discussion points in the application of SABR as an ablative modality for HCC will be covered. And the experience of hypofractionated ablative RT for small size HCC less than 3 cm by the author will be introduced.
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Case Report
A Case of Huge Hepatocellular Carcinoma with Complete Remission of Intrahepatic Tumor and Adrenal Gland Metastasis Treated with Combination Therapy of Transarterial Chemoembolization and Radiation Therapy and Sorafenib
Sang Youn Hwang, Seon-Mi Lee, Jung Woo Im, Joon Suk Kim, Sang Bu Ahn, Eun Kyeong Ji, Chul Won Choi, Gwang-Mo Yang
Journal of the Korean Liver Cancer Study Group. 2013;13(1):57-61.   Published online February 28, 2013
DOI: https://doi.org/10.17998/jlc.13.1.57
  • 1,282 Views
  • 6 Downloads
AbstractAbstract PDF
Extrahepatic metastasis (EHM) associated with hepatocellular carcinoma (HCC) has been increasing due to prolonged survival with recent advances in therapeutic approaches including locoregional therapy such as transarterial chemoemoblization (TACE), radiofrequency ablation and radiation therapy (RT). Though many guidelines recommended systemic therapy such as sorafenib in this situation, some clinicians or centers still select locoregional therapy because the survival improvement of 2 or 3 months by sorafenib is far from optimal. Moreover, some studies showed that complete and partial response of intrahepatic tumors can result in significant improvement of patient survival even in situation of EHM. Based on above suggestions, we herein offer our experience of a patient with complete remission of intrahepatic tumor and adrenal gland metastasis treated with combination therapy of TACE and RT and sorafenib. Further study, maybe regarding a combination of locoregional and systemic therapy (so called multidisciplinary approach), is necessary on how to manage HCC patients with EHM.
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Review Article
Debate and Explanation of the “Practice Guidelines for Management of Hepatocellular Carcinoma 2009”: Radiation Therapy
Hee Chul Park
Journal of the Korean Liver Cancer Study Group. 2010;10(1):11-16.   Published online June 30, 2010
  • 560 Views
  • 1 Download
AbstractAbstract PDF
According to the 2003 clinical practice guideline reported by Korean Liver Cancer Study Group (KLCSG) and National Cancer Center (NCC), Radiation therapy (RT) has been considered as alternative or complementary modality in cases where surgical resection is not possible, local treatment or trans-hepatic arterial chemo-embolization (TACE) does not provide a cure. At that time, the guideline suggested that further studies are needed to confirm the beneficial role of RT in the management of HCC because RT lacked the high quality scientific evidences at that time. However, the 2003 guideline did the pivotal role in accentuating research efforts to enlighten the role of RT in HCC management. Recently, many scientific evidences are piled up strengthening the level of evidence. Also there was the quantitative expansion of reported studies dealing with RT role in HCC management. In the 2009 Practice guidelines for the management of HCC, radiation oncologists participated as member of revision committee put every efforts to make good of RT related guideline. And to place RT related guidelines as a special feature of Korean version of HCC management guidelines. Discussions were made among radiation oncologists in the revision committee. The participating radiation oncologists realized that still there are no randomized controlled trials exploring the role of RT in HCC management. The role of RT in the management of HCC is underestimated still. To prepare the next version of practice guideline, the every effort must go on to invigorate the role of RT in the management of HCC.
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Case Reports
A Case of Curative Resection of Advanced Hepatocellular Carcinoma After Localized Concurrent Chemo-Radiation Therapy
Jee Suk Kwon, Jeong Eun Lee, Woo Young Park, Kyung In Lee, Eun Soo Kim, Byoung Kuk Jang, Woo Jin Chung, Kyung Sik Park, Kwang Bum Cho, Jaeseok Hwang
Journal of the Korean Liver Cancer Study Group. 2009;9(1):67-70.   Published online June 30, 2009
  • 586 Views
  • 1 Download
AbstractAbstract PDF
Advanced hepatocellular carcinoma (HCC) with portal vein thrombosis is not suitable candidates for surgical treatment at the most of diagnosis because of poor liver function, extensive tumor involvement of the liver, vascular involvement, and/or intra/extrahepatic metastasis. We attempted localized concurrent chemo-radiation therapy (CCRT) in patients having locally advanced HCC with left and main portal vein thrombosis. We report a case of locally advanced HCC patient who became surgically resectable by downstaging after localized CCRT. Localized CCRT was performed with a total radiation dose of 5,040 cGy (180 cGy×28 times) and hepatic arterial infusion of 5-fluorouracil (5-FU, 250 mg/day) and cisplatin (10 mg/day) for 5 days via implantable port system during the second and the fifth weeks of the radiotherapy. Marked contraction of HCC was noted on follow up computerized tomography (CT) after localized CCRT, and subsequently surgical resection with curative aim was performed. He was gave a additional transcatheter arterial chemoembolization (TACE) because follow up CT revealed intrahepatic metastasis at subcapsular portion of right hepatic lobe after 3 months of operation. The patient is in complete remission status without recurrence to date.
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A Case of Advanced Hepatocellular Carcinoma in Twenties Treated by Multimodality Therapy
Jang Eun Lee, Na Ri Yoon, Si Hyun Bae, Jong Young Choi, Seung Kew Yoon, Dong Goo Kim, Ho Jong Chun, Byung Gil Choi, Hae Giu Lee, Hong Seok Jang, Chan Kwon Jung, Eun Sun Jang
Journal of the Korean Liver Cancer Study Group. 2009;9(1):82-85.   Published online June 30, 2009
  • 657 Views
  • 1 Download
AbstractAbstract PDF
The prognosis of young patients with hepatocellular carcinoma is remains controversial. Here we report a case of advanced hepatocellular carcinoma in twenty, successfully treated with transarterial chemolipidolization (TACL), systemic chemotherapy, radiation therapy and surgical resection. Previously healthy 28 years old woman was admitted for treatment of hepatocellular carcinoma. Abdominal CT showed a diffuse infiltrative HCC involving both lobes with intrahepatic bile duct invasion and pericardial lymphadenopathy. She was treated TAC with systemic chemotherapy and external beam radiotherapy. 6 months after these treatments, main tumor and the pericardial lymph node were decreased in size. And then extended left lobectomy and systemic chemotherapy were done. The pericardial lymph node was markedly decreased. The patient has been followed for 10 months without evidence of regional tumor recurrence.
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Review Article
Hepatic Resection Following Adjuvant Treatments in Hepatocellular Carcinoma
Sae-Byeol Choi, Kyung Sik Kim
Journal of the Korean Liver Cancer Study Group. 2008;8(1):32-38.   Published online June 30, 2008
  • 669 Views
  • 0 Download
AbstractAbstract PDF
The optimal treatment of hepatocellular carcinoma has become increasingly complex with myriad of available treatment options. Although recently the liver transplantation has been accepted the best treatment for survival, the shortage of donor limits the extension of this procedures. As the neoadjuvant chemotherapy is being increasingly employed to downsize colorectal metastasis, the clinical trials have been extended to the hepatocellular carcinoma. Therefore we reviewed the use of liver resection following tumor downstaging with chemotherapeutic agents and Radiation therapy to treat unresectable HCC. Key Words: Hepatic resection․Downstaging․Transarterial chemoembolization․Radiation
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Case Reports
A Case of Curative Resection of Advanced Hepatocellular Carcinoma After Localized Concurrent Chemo-Radiation Therapy
Wonseok Kang, Ki Tae Yoon, Jun Yong Park, Do Young Kim, Sang Hoon Ahn, Chae Yoon Chon, Kyung Sik Kim, Young Nyun Park, Jin Sil Seong, Kwang Hyub Han
Journal of the Korean Liver Cancer Study Group. 2008;8(1):98-101.   Published online June 30, 2008
  • 693 Views
  • 4 Downloads
AbstractAbstract PDF
Most patients with advanced hepatocellular carcinoma (HCC) are not suitable candidates for surgical treatment at the time of diagnosis because of poor liver function, extensive tumor involvement of the liver, vascular involvement, and/or intra/extrahepatic metastasis. We attempted localized concurrent chemo-radiation therapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC) in patients having locally advanced HCC with vascular involvement and preserved hepatic function. We report a case of locally advanced HCC patient who became surgically resectable by downstaging after localized CCRT followed by HAIC. Localized CCRT was performed with a total radiation dose of 4,500 cGy (180 cGy × 25 times) and hepatic arterial infusion of 5-fluorouracil (5-FU, 500 mg/day) via implantable port system during the first and the last weeks of the radiotherapy. Following localized CCRT, the patient was scheduled to receive HAIC with 5-FU (500 mg/m2 for 5 hours, days 1~3) and cisplatin (60 mg/m2 for 2 hours, day 2) every 4 weeks. Marked contraction of HCC was noted on follow up computerized tomography (CT) and positron emission tomography (PET) after localized CCRT and HAIC, and subsequently surgical resection with curative aim was performed. The patient is in complete remission status without recurrence to date.
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A Case of Localized Concurrent Chemo-radiation Therapy Using with Tomotherapy for Hilar Hepatocellular Carcinoma with Invasion of Bilateral Bile Duct
Ki Tae Yoon, Do Young Kim, Jin Sil Seong, Jun Yong Park, Jong Won Choi, Sang Hoon Ahn, Kwang-Hyub Han, Chae Yoon Chon
Journal of the Korean Liver Cancer Study Group. 2008;8(1):102-105.   Published online June 30, 2008
  • 600 Views
  • 2 Downloads
AbstractAbstract PDF
Hepatocellular carcinoma (HCC) usually takes an intrahepatic spread via portal vein branches, and the incidence of portal vein invasion is reported to be 34~40% in surgical resected series. On the other hand, the rate of intrabiliary growth of HCC is rare, ranging from 2.3~13% in surgical and autopsy cases. Here, we report a case of the patient treated with localized concurrent chemo-radiation therapy (CCRT) for hilar HCC with invasion of bilateral bile duct. The tomotherapy was performed with a total radiation dose of 4,240 cGy (20 times, 212 cGy/time) on tumor bed and hepatic arterial infusion of 5-fluorouracil (1,000 mg/day, day 1~5 and day 16~20) and cisplatin (60 mg/m2, day 3 and day 18) was done via implantable port system during the radiotherapy. After that, tumor size and tumor marker was decreased and treatment response was achieved as partial response. CCRT is expected as one of the appropriated treatment options for inoperable HCC with bile duct invasion.
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