The role of radiotherapy and chemoradiation in the management of primary liver tumours

Due to advances in technical radiotherapy delivery over the past two decades there has been a rapid increase in the use of radiotherapy for intrahepatic malignancies. This overview provides a succinct summary of the current evidence for external beam radiotherapy in the management of primary liver tumours, highlighting areas for future research. Internationally, hepatocellular carcinoma is a leading cause of cancer death and UK incidence rates are rising rapidly. The main risk factor is chronic liver disease and, as a result, most patients will be unsuitable for curative surgical modalities of treatment. Conformal radiotherapy may be used in patients with localised disease who are unsuitable for alternative local therapies. It may also be used in patients with portal venous thrombosis or for palliation in advanced disease. Caution should be used in patients with pre-existent liver dysfunction (Childs Pugh B or C) due to increased rates of toxicity. Stereotactic body radiotherapy has been used for early stage disease, with promising long-term local control rates and a favourable toxicity profile. Stereotactic body radiotherapy has also been investigated as a 'bridge to transplant'. Charged particle therapy may be used for patients with more advanced liver dysfunction, or as a means of dose escalation, and warrants further investigation in early stage disease. Cholangiocarcinoma is a rare but aggressive primary liver malignancy in which only a minority of patients will be suitable for resection. Conformal radiotherapy and stereotactic body radiotherapy have been used in both the adjuvant and locally advanced settings, although small patient numbers and a lack of prospective trial data limit interpretation of their role. To fully define the role of radiotherapy in the management pathway for primary liver tumours, prospective randomised studies are required.