The primary treatment for liver and bile duct/gallbladder cancers has been surgical removal, which represents potentially curative therapy for patients with localized disease, including those with limited liver metastases if their primary tumor is controlled (1-8). Unfortunately, many patients are not surgical candidates for a variety of reasons, including inoperability due to the extent of disease itself, patient inability to withstand the surgical procedure due to poor health, or additional malignant activity elsewhere in the body that renders aggressive surgical therapy inappropriate.

Many nonsurgical approaches have also been applied to unresectable liver and bile duct/gallbladder cancers, including radiofrequency ablation (inserting a probe that heats the tumor), cryoablation (inserting a probe that freezes the tumor), chemoembolization (inserting a tube into the blood vessel that feeds the tumor and infusing small foreign bodies coated with chemotherapy drugs), direct liver chemotherapy infusion (inserting a tube into the blood vessel that feeds the tumor and infusing a concentrated dose of chemotherapy drugs), and systemic chemotherapy (delivering chemotherapy to the whole body, including the liver) (9-14).

Radiotherapy has also been used to treat liver and bile duct/gallbladder cancers (15-20). Traditional forms of radiotherapy have had a limited role in the management of liver and bile duct/gallbladder cancers, largely due to the fact that the liver itself is very sensitive to radiation injury (20).

Contemporary high dose conformal radiotherapy (including 3DCRT; IMRT; Proton beam) has yielded more meaningful and durable clinical responses in patients with liver and bile duct/gallbladder cancers, due to its ability to better concentrate the radiation dose in the targeted area and spare uninvolved liver tissue, though cure remains uncommon (15-19).