Although cerebral angiography could potentially demonstrate thrombosis causing large vessel obstruction, it is unlikely to have the resolution to detect stasis at a microvascular level. Microcirculatory stasis with reversible ischemia is the likely pathogenic mechanism in this case.

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Despite the widespread use of locoregional therapies [radiofrequency ablation and transarterial chemoembolization (TACE)], there is currently a lack of high-quality evidence supporting their use for hepatocellular carcinoma (HCC) in patients on the liver transplantation (LT) waiting list or requiring down-staging. Radiotherapy has rarely been used in this setting and has usually been in the form of more complex and less accessible techniques such as proton-beam and stereotactic body radiation therapy. Only 1 report describes the use of conventional 3-dimensional conformal external-beam radiotherapy (cEBRT) techniques as neoadjuvant or down-staging therapy for patients who are LT candidates. This report describes the use of cEBRT in a 52-year-old hepatitis C-positive man with cirrhosis. A 40-mm right lobe HCC was treated initially with TACE while he was on the waiting list. The lesion progressed beyond transplant criteria (76 mm). Conventional external-beam radiotherapy (EBRT) was used (54 Gy in 27 fractions) to down-stage the lesion. EBRT was well tolerated and resulted in a complete radiological response with no arterial enhancement of the lesion for a total of 16 months. Subsequent LT and a review of the explant demonstrated complete histological necrosis of the lesion. This report provides the first description of complete histological necrosis of HCC through the use of cEBRT techniques as down-staging/neoadjuvant therapy before LT. Because of its potential efficacy, accessibility, tolerability, noninvasive and outpatient nature, and ability to treat lesions adjacent to vessels and biliary structures, further trials examining the efficacy of cEBRT versus other neoadjuvant techniques are urgently required. Liver Transpl 19:1119-1124, 2013. V C 2013 AASLD.Received April 2, 2013; accepted July 8, 2013.Locoregional therapies (LRTs) for hepatocellular carcinoma (HCC) are commonly used in patients on the liver transplantation (LT) waiting list to prevent tumor progression and to down-stage tumors to meet transplant criteria. The most common modalities are transarterial chemoembolization (TACE) and percutaneous radiofrequency ablation (RFA). Despite the widespread use of these LRTs, their pretransplant efficacy and improved survival for treated patients versus untreated patients have not been established in either retrospective cohort studies 1 or randomized controlled trials. In addition, these treatments can be associated with significant morbidity and mortality.Because of this lack of high-quality evidence, an exploration of alternative therapies in this setting with potentially greater efficacy, fewer side effects, and lower costs is appropriate. Conventional 3-dimensional (3D) conformal external-beam radiotherapy (cEBRT)

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