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Thonglert et al. Hepatoma Res 2023;9:40 https://dx.doi.org/10.20517/2394-5079.2023.47 Page 13 of 23

institutional tumor or liver Treatment volume 90 yr) at 21.2 mo 69% G3: 2 (8%)
retrospective metastasis 26 - GTV = gross tumor Sex: male 65% 2-yr OS G4+ 0 (0%)
study (CCA 2) - CTV = GTV Primary: HCC 6; lung 3; CCA 2; 60% CP score drop in 2 (8%)
- PTV = CTV + (2-5) mm pancreas 1; sarcoma 1; head
Dose: 50 Gy (range 30-60 and neck 1; others 4
3
Gy) in 5 F Median PTV: 98.2 cm (range
Motion management 13-2034)
- Inspiratory breath hold: 16 CP: A 76.9%; B-C 0%; N/A
- Modified shallow internal 23.1%
target volume or exhale-
based setup: 10
ART was not common
Time in treatment room:
40-60 min (20-30 min of
beam-on time)
[70]
Chin et al. 2023 Retrospective USA Primary liver 0.35 T tri-60Co MRgRT Age: median 69 (IQR 63-77)* 10.1 1-yr LC 1-y OS Acute G3+: hepatic 5 (5%;); biliary
study cancer 99 (CCA 52%; 0.35 T MR Linac Sex: male 64% months* 91%* 67% * 6 (6%); GI 6 (6%); AST/ALT 2
or cHCC/CCA system 47% Solitary lesion: 81%* 2-yr LC 2-y OS (2%); ALP 5 (5%); TB 6 (6%)
47) Treatment volume Tumor size: median 2.8 cm 91%* 31%* Late G3+: hepatic 6 (6%); biliary 6
- GTV = gross tumor (IQR 1.7-4.1)* (6%); GI 4 (4%); AST/ALT 5; ALP
- CTV = GTV Metastasis: 6%* 8%; TB 11 (11%)
- PTV = CTV + 5 mm Systemic treatment: 62%*
Dose: 50 Gy in 5 F
Motion management
Daily adaptive treatment
was considered in patients
with tumors located within
2 cm of a luminal GI
structure
Time in treatment room:
N/A
Online ART 53%

*results only iCCA or cHCC/CCA patients; ALP: alkaline phosphatase; ALT: alkaline transaminase; AST: aspartate transaminase; ART: adaptive radiotherapy: cHCC/CCA: combined hepatocellular
carcinoma/cholangiocarcinoma; CP: Child-Pugh; CTV: clinical target volume; F: fractions; GI: gastrointestinal; GTV: gross tumor volume; Gy: gray; iCCA: intrahepatic cholangiocarcinoma; yr: year; LC: local control;
min: minute; mm: millimeter; MRgRT: magnetic resonance-guided radiation therapy; No.: number; N/A: not applicable; OS: overall survival; PTV: planning target volume.

with breath-hold respiratory gating with real-time tumor tracking. Daily adaptive treatment was done for all patients. The median tumor size was 25 mm
(range 14-37 mm), and the median PTV volume was 39.1 cm (range 8.3-411.3 cm ). At a median follow-up of 5 months, there were no occurrences of local
3
3
failure or toxicity at grade 2 or higher. Interestingly, when comparing the nonadaptive and adaptive plans, the results showed that there was less PTV coverage
(90.3% vs. 100.2%; P < 0.0001) and more missed PTV coverage > 10% (46.8% vs. 0%) in the nonadaptive plan. Bowel constraint violations were found in 14.9%,
and duodenum and stomach constraint violations were found in 6.4% without an adaptive plan. These studies show the potential benefit of promising LC with

decreased toxicity of MRgRT in patients with iCCA. However, further large-scale prospective studies are needed to confirm these findings.