Treatment Plan for Stage II Liver Cancer – Proton Therapy Approach

Comprehensive assessment by a multidisciplinary team, including a radiation oncologist, hepatobiliary surgeon, and medical oncologist.
Review of medical history, liver function, and previous treatments.
Discussion of treatment goals, expected outcomes, and potential side effects of proton beam therapy (PBT).

Analysis of prior imaging, pathology reports, and treatment history.
Evaluation of liver function (Child-Pugh score, ALBI score) and performance status (ECOG/KPS).

Multiphasic contrast-enhanced CT or MRI to assess tumor size, location, and vascular involvement.
PET-CT (if indicated) to rule out metastasis.
Simulation CT scan for proton therapy planning, including 4D-CT to account for liver motion due to breathing.

Case discussion among radiation oncologists, medical oncologists, hepatobiliary surgeons, and interventional radiologists.
Decision on proton therapy fractionation:
Definitive proton therapy for non-surgical candidates.
Neoadjuvant proton therapy to downsize tumors before surgery or transplantation.
Adjuvant proton therapy if there is residual disease post-resection.

Patient positioning and immobilization with a customized immobilization device to reduce movement during treatment.
Respiratory motion management (e.g., breath-hold technique or respiratory gating).
Proton therapy dose planning:
Standard fractionation (e.g., 67.5 Gy in 15 fractions).
Hypofractionated regimens may be considered based on tumor location and liver function.
Dosimetric assessment to ensure optimal tumor coverage while sparing healthy liver tissue.

Outpatient treatment schedule: Sessions administered 5 days per week for approximately 3–5 weeks.
Each session lasts 20–30 minutes, with actual proton delivery taking only a few minutes.
Real-time imaging (CBCT or X-ray) before each session to verify positioning.

First imaging follow-up (MRI or CT) at 1–2 months post-treatment to assess tumor response.
Serial AFP monitoring to evaluate treatment efficacy.
Liver function tests every 4–6 weeks for early detection of radiation-induced toxicity.
Long-term surveillance every 3–6 months with imaging and lab tests.

Surgical reassessment if tumor downsizing is successful.
Consideration for systemic therapy (e.g., immunotherapy or targeted therapy) if tumor progression occurs.
Liver transplantation evaluation in eligible patients.