The actual high morbidity and mortality rates related to the ALPPS procedure should lead us to a more cautious selection of the candidates for this operation and restriction of the indications through an accurate work-up based on interdisciplinary cooperation among hepatologists, oncologists, radiologists and surgeons.

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This retrospective study evaluates high versus low dose SBRT of liver metastases. Methods: Between 2009 and 2017, 90 patients with 97 liver metastases (77% colorectal origin) received SBRT. Patients were divided in a low dose group of 45Gy (group 1; n=33) and a high dose group of 50Gy (group 2; n=57). The median dose in group 1 and 2 was 37.5Gy (range: 36-45Gy) and 60Gy (range: 51-60Gy) in 3-5 fractions. Primary outcome was local control and toxicity. Secondary outcomes were overall survival and progression-free survival.Results: The median follow-up through CT/MRI/PET-CT was 15 months. One year local control rate in group 1 was 64% (CI: 45-82%) and in group 2 95% (CI: 90-100%) (p = 0.004). Two year local control rate was 64% (CI: 45-82%) and 85% (CI: 70-99%), respectively. Grade 3 toxicity (requiring hospitalization) occurred in 3% in both groups. Grade 4-5 toxicity was not observed. The 2-year survival in group 1 and 2 was 53% (CI: 35-71%) and 75% (CI: 61-90%) (P=0.06). The median progression-free survival was 5 and 8 months (P=0.04), respectively. Conclusion: High dose SBRT provides significantly better local control than low dose SBRT for liver metastases without increased toxicity. When surgical resection is not feasible, high dose SBRT provides an effective and safe treatment for liver metastases.