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Simple Summary  The number of very elderly patients with hepatocellular carcinoma (HCC) aged 80 years and older has been steadily increasing with extensions in life expectancy due to improvements in medication and healthcare, and many recent studies focused on this specific population. Since these patients often have a higher incidence of associated co-morbidities, and improving or maintaining their quality of life is important, minimally invasive treatment is warranted. We retrospectively investigated the efficacy and safety of image-guided proton therapy (IGPT) for elderly HCC patients. IGPT was safe and considered effective for HCC in elderly patients. Since there was no worsening of quality of life during and after treatment, IGPT may cure HCC with a high probability without changing the daily living of elderly patients.    Abstract  This study retrospectively investigated the efficacy and safety of image-guided proton therapy (IGPT) for elderly (≥80 years old) hepatocellular carcinoma (HCC) patients. Proton therapy was performed using respiratory-gated and image-guided techniques. Seventy-one elderly HCC patients were treated using IGPT. The Child–Pugh score was A5 in 49 patients, A6 in 15, and B7-9 in 7. Forty-seven patients with a peripherally located tumor were administered 66 gray relative biological effectiveness (GyRBE) in 10 fractions, whereas 24 with a centrally located tumor received 72.6 GyRBE in 22 fractions. The median follow-up period of surviving patients was 33 months (range: 9–68). Two-year overall survival (OS) and local control (LC) rates estimated by the Kaplan–Meier method were 76% (95% confidence interval: 66–87%) and 88% (80–97%), respectively. According to the Common Terminology Criteria for Adverse Events version 4.0, no grade 2 or higher radiation-induced liver disease was observed, and only 1 patient developed grade 3 dermatitis. The quality of life score (European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 version 3.0, QLQ-HCC18, and SF-36) did not change after 1 year, except for the three-mental component summary (SF-36, improvement). IGPT is a safe and effective treatment for HCC in elderly patients.

Image-Guided Proton Therapy for Elderly Patients with Hepatocellular Carcinoma: High Local Control and Quality of Life Preservation