Outcomes After Stereotactic Body Radiation Therapy as a Bridging Modality to Liver Transplantation for Hepatocellular Carcinoma

Abstract

Purpose For patients with hepatocellular carcinoma awaiting liver transplantation (LT), stereotactic body radiation therapy (SBRT) has emerged as a bridging treatment to ensure patients maintain priority status and eligibility per Milan criteria. In this study, we aimed to determine the efficacy and safety of SBRT in such situations. Methods and Materials A retrospective analysis was conducted of the outcomes of 27 patients treated with SBRT who were listed for LT at 1 institution. Among these, 20 patients with 26 tumors went on to LT and were the focus of this study. Operative reports and postoperative charts were evaluated for potential radiation-related complications. The explant pathology findings were correlated with equivalent dose in 2 Gy fractions and tumor size. Results Median pretreatment tumor size was 3.05 cm. Median total dose of radiation was 50 Gy delivered in 5 fractions. Pathologic complete response (pCR) was achieved in 16 tumors (62%). Median interval from end of SBRT to transplant was 287 days. Of the 21 tumors imaged before transplant, 16 or 76% demonstrated a clinical complete response based on modified Response Evaluation Criteria in Solid Tumors criteria. There was no significant correlation between pCR rate and increasing tumor size (odds ratio [OR], 0.95; 95% confidence interval, 0.595-1.53) or pCR rate and equivalent dose in 2 Gy fractions (OR, 1.03; 95% confidence interval, 0.984-1.07.) No patients experienced radiation-related operative or postoperative complications. Of the 27 patients who were listed for transplant, the dropout rate was 22%. Two of the 5 patients with Child-Pugh score 10 died of liver failure. Conclusions These data demonstrate that SBRT as a bridging modality is a feasible option, with a pCR rate comparable to that of other bridging modalities and no additional radiation-related operative or postoperative complications. There was no dose dependence nor size dependence for pCR rate, which may indicate that for the tumor sizes in this study, the radiation doses delivered were sufficiently high.

Stereotactic body radiation therapy for primary liver tumors: An effective liver‐directed therapy in the toolbox

“…SBRT has been used to bridge patients to transplantation if patients are ineligible for TACE or RFA because of anatomy, tumor size, or underlying liver dysfunction. Results have been reported for small series with favorable outcomes 50‐54 . A recent study by Garg et al 52 described 27 patients listed for orthotopic liver transplantation and treated with a median dose of 50 Gy in 5 fractions; 20 of these patients went on to transplantation.…”

“…Results have been reported for small series with favorable outcomes 50‐54 . A recent study by Garg et al 52 described 27 patients listed for orthotopic liver transplantation and treated with a median dose of 50 Gy in 5 fractions; 20 of these patients went on to transplantation. A clinical complete response based on the Response Evaluation Criteria in Solid Tumors was achieved in 76%, whereas a pathologic complete response (pCR) was observed in 62%.…”

SBRT for Liver Tumors: What the Interventional Radiologist Needs to Know

“…17 Due to its efficacy, both retrospective and prospective data also support the utilization of SBRT as a bridge to transplantation and it may reduce waitlist dropout. [18][19][20] In summary, SBRT remains an effective treatment for large or extensive HCC, even when utilizing doses that prioritize safety and decreasing mean dose to uninvolved liver (►Fig. 1).…”

Cell-Free DNA as a Surveillance Tool for Hepatocellular Carcinoma Patients after Liver Transplant

“…Due to the often long waiting times until the LT is performed, it is recommended that most patients undergo some sort of locoregional bridging therapy, especially if the anticipated wait time is longer than six months, to avoid disease progression or even exclusion from the list [ 25 ]. Many of these treatments, including TACE and radioembolization, can also be used as downstaging therapies to make patients eligible for LT according to the selected criteria [ 27 , 28 , 29 ].…”