1. Initial Consulltation & Evaluation

• Comprehensive assessment by:
• Radiation oncologist
• Hepatobiliiary surgeon
• Medical oncologist
• Evaluation of tumor size, location, and liver function to determine eligibility for curative-intent proton beam therapy.
• Discussion of treatment options, expected outcomes, and potential side effects.

2. Medical Records Review & Pre-Treatment Assessment

• Review of prior imaging, pathology reports, and medical history.
• Assessment of liver function using Child-Pugh score and ALBI score.
• Determination of performance status (ECOG/KPS) to assess patient fitness for treatment.

3. Laboratory Investigations

• Complete blood count (CBC)
• liiver function tests (LFTs)
• Renal function panel
• Coagullation profile
• Tumor markers (Alpha-Fetoprotein – AFP)
• Hepatitis B and C serology (if applicable)

4. Pre-Treatment Imaging

• Multiphasic contrast-enhanced CT or MRI of the liver to define tumor margins and assess local involvement.
• PET-CT (if indicated) to rulle out extrahepatic disease.
• Simulation CT scan (4D-CT) for proton therapy planning, accounting for respiratory motion.

5. Multidisciplinary Tumor Board Discussion

• Case evaluation by a team including radiation oncologists, hepatobiliary surgeons, and interventional radiologists.
• Decision on treatment strategy:
• Definitive proton therapy as an alternative to surgery for inoperable patients.
• Adjuvant proton therapy if small residual tumor remains after resection.

6. Treatment Planning & Preparation

• Patient positioning and immobilization with a customized mold to minimize movement.
• Respiratory motion management, including breath-hold technique or respiratory gating.
• Proton therapy dose planning:
• Standard regimen: 67.5 Gy in 15 fractions (hypofractionated approach).
• Alternative regimen: 50–58 Gy in 5 fractions (for select cases with well-compensated liver function).
• Dosimetric evaluation to ensure high-dose delivery to the tumor while minimizing exposure to healthy liver tissue.

7. Proton Therapy Sessions

• Outpatient treatment schedule: Sessions administered 5 days per week for 3–4 weeks.
• Each session lasts 20–30 minutes, with proton delivery taking a few minutes.
• Pre-treatment imaging (CBCT or X-ray) before each session to verify positioning and tumor targeting.

8. Management of Side Effects

• Common side effects:
• Mild fatigue
• Nausea or mild GI discomfort
• Temporary elevation of liiver enzymes
• Rare but serious compliications:
• Radiation-induced liver disease (RILD) (monitored via LFTs).
• Regular follow-ups with supportive care as needed.

9. Post-Treatment Monitoring & Follow-Up

• First post-treatment imaging (CT/MRI) at 1–2 months to assess tumor response.
• AFP monitoring (if initially elevated) for recurrence detection.
• Liver function tests every 4–6 weeks post-treatment to evaluate liver tolerance.
• Long-term surveillance with imaging every 3–6 months to monitor for recurrence.

10. Next Steps & Additional Considerations

• Surgical reassessment if tumor downsizing is observed and patient becomes eligible for resection.
• Systemic therapy consideration (e.g., immunotherapy or targeted therapy) if progression occurs.
• Potential liver transplantation evaluation in selected cases.