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Finally, sorafenib is the only molecular agent approved for the treatment of patients with advanced hepatocellular carcinoma. Sorafenib is a multikinase inhibitor that targets vascular endothelial growth factor receptor, platelet-derived growth factor receptor and RFA. The use also of CTLA-4 showed good safety profile and antitumor activity, supporting further investigation[23]. Studies have shown an overall survival benefit selleck chemical with diarrhea, fatigue, hand-foot skin reaction and rash being the most common drug-related adverse events[24,25]. Traditionally, the role of external beam radiation therapy (EBRT) has been limited to the palliation of HCC metastases associated with distressing symptoms. There are numerous reports of bone[26,27], lymph node[28,29] and soft tissue[30] metastases that were successfully treated with external beam radiation therapy, as shown in Table ?Table1.1. HCC has been considered a radioresistant tumor for a long time. The dose delivered by conventional external beam radiotherapy could not exceed 30 Gy on the whole liver as this is the threshold for radiation-induced liver disease. However, this dose level is far less than standard tumoradical doses for most solid tumors. Technological advances in the field of radiotherapy precision delivery and sparing of normal tissues have given the opportunity of dose escalation. Nowadays, radiotherapy is gaining ground in the treatment of advanced-stage HCC patients, irrespectively of tumor location, with promising results. Table 1 Palliative radiotherapy for ATP7A hepatocellular carcinoma metastatic CP-690550 in vitro sites OPTIONS OF RADIOTHERAPY Internal radiotherapy Internal radiotherapy is the delivery of radioisotopes either percutaneously or through transarterial approach. Yttrium-90 (Y90) is a pure beta emitter isotope that decays to stable 90 Zr with a physical half-life of 64.2 h. It has been applied to unresectable HCC by intratumoral injection of glass microspheres by percutaneous assess to the hepatic artery[31,32]. This approach, called radioembolization, is based on the different arteriolar density between the hypervascular HCC and the normal liver parenchyma. Arterial administrated Y90 microspheres depose selectively in tumor nodules and limit tumor dose to surrounding normal liver[33]. This technique can be used in downstaging large tumors to bring within transplantable criteria, in patients with portal vein thrombosis and in the palliative setting[34]. Overall, radioembolization of unresectable HCC with Y90 is associated with acceptable toxicity and favorable median survival time[35-38]. Radioembolization-induced liver disease, defined as jaundice and ascites appearing 4-8 wk after treatment, has been described in the literature[39]. It is more common in cirrhotic patients with an incidence of
