Clinical outcome and pathologic correlation of stereotactic body radiation therapy as a bridge to transplantation for advanced hepatocellular carcinoma: a case series

Abstract

Background Stereotactic body radiotherapy (SBRT) is an emerging modality for hepatocellular carcinoma (HCC). However, there is scant information about its safety and effectiveness in the neoadjuvant setting prior to liver transplantation (LT). We present the clinical outcome and pathologic assessment of SBRT followed by LT for patients with advanced HCC. Methods This retrospective study included HCC patients treated with neoadjuvant SBRT prior to LT between 2009 and 2018. Radiographic response and adverse effects, including radiation-induced liver disease (RILD), were evaluated. Pathologic response was assessed by the percentage of tumor necrosis relative to the total tumor volume. Overall survival (OS) and recurrence-free survival (RFS) were calculated using the Kaplan–Meier method. Results Fourteen patients underwent SBRT for a total of 25 HCC lesions, followed by LT. The median tumor size was 4.45 cm in diameter, and the median prescribed dose was 45 Gy in 5 fractions. SBRT provided significant AFP reduction, 100% infield control, and a 62.5% response rate. The maximum detected toxicity included grade 3 thrombocytopenia and two grade 3–4 hyperbilirubinemia. One patient developed non-classic RILD. Patients were bridged to LT with a median time of 8.4 months after SBRT, and 23.1% of them achieved a complete pathologic response. The median OS and RFS were 37.8 and 18.3 months from the time of LT, respectively. Conclusions SBRT provides favorable tumor control and acceptable adverse effects for patients awaiting LT. Further prospective studies to test SBRT as a bridging therapy for LT are feasible.

High rate of complete histopathological response in hepatocellular carcinoma patients after combined transarterial chemoembolization and stereotactic body radiation therapy

“…However, from a sample size this small and above all a very short time interval between SBRT and LT in three out of four patients in the SBRT only group ( ) it cannot be ruled out that SBRT alone might be equally efficient to TACE and SBRT combination therapy. However, recently published data from a cohort of 14 patients showing complete response by histopathology in 23.1% of tumor nodules in liver explants is in line with our data[ 36 ] – indicating that complete tumor necrosis is not commonly achieved after SBRT alone.…”

Stereotactic Body Radiation Therapy for the Management of Hepatocellular Carcinoma: Efficacy and Safety

“…Out-field HCC was found in eight patients, which is consistent with the above-mentioned fact that HCC is a multicentric disease. Previous studies have found similar results with good local control rates and favorable toxicity profiles [ 14 , 51 ]. In a series of 38 patients treated with SBRT, the histologic response rate (complete plus partial response) was 68% [ 52 ].…”

Role of Pretransplant Treatments for Patients with Hepatocellular Carcinoma Waiting for Liver Transplantation

“…Gabr et al [ 116 ], examining 207 cases of Yttrium-90 therapy as bridging or downstaging prior to LT, reported tumor response with complete necrosis (100%) in 94% of patients, extensive necrosis (51–99%) in 29%, and partial necrosis (<50%) in 26%, with a recurrence rate of 12% after LT. SBRT is an external beam radiation therapy method that precisely delivers a high dose of radiation to an extracranial target using either a single dose or a small number of high-dose fractions. The frequency of complete pathological necrosis of the tumor after SBRT varies from 13.3% to 61.5% [ 101 , 117 , 118 ]. Wong et al [ 119 ] reported that pre-transplant SBRT had a higher frequency of complete pathological necrosis and a lower frequency of drop-outs from the waiting list compared to conventional bridging therapy.…”