Incorporating GSA-SPECT into CT-based dose-volume histograms for advanced hepatocellular carcinoma radiotherapy

In single photon emission computed tomography-based three-dimensional radiotherapy (SPECT-B-3DCRT), images of Tc-99m galactosyl human serum albumin (GSA), which bind to receptors on functional liver cells, are merged with the computed tomography simulation images. Functional liver is defined as the area of normal liver where GSA accumulation exceeds that of hepatocellular carcinoma (HCC). In cirrhotic patients with a gigantic, proton-beam-untreatable HCC of ≥ 14 cm in diameter, the use of SPECT-B-3DCRT in combination with transcatheter arterial chemoembolization achieved a 2-year local tumor control rate of 78.6% and a 2-year survival rate of 33.3%. SPECT-B-3DCRT was applied to HCC to preserve as much functional liver as possible. Sixty-four patients with HCC, including 30 with Child B liver cirrhosis, received SPECT-B-3DCRT and none experienced fatal radiation-induced liver disease (RILD). The Child-Pugh score deteriorated by 1 or 2 in > 20% of functional liver volume that was irradiated with ≥ 20 Gy. The deterioration in the Child-Pugh score decreased when the radiation plan was designed to irradiate ≤ 20% of the functional liver volume in patients given doses of ≥ 20 Gy (FLV20Gy). Therefore, FLV20Gy ≤ 20% may represent a safety index to prevent RILD during 3DCRT for HCC. To supplement FLV20Gy as a qualitative index, we propose a quantitative indicator, F 20Gy, which was calculated as F 20Gy = 100% × (the GSA count in the area irradiated with ≥ 20 Gy)/(the GSA count in the whole liver).