Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Prognostic Factors of Local Control, Overall Survival, and Toxicity

Abstract

PurposeStereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) has been evaluated in several recent studies. The CyberKnife® is an SBRT system that allows for real-time tracking of the tumor. The purpose of this study was to evaluate the prognostic factors for local control and overall survival following this treatment.Patients and Methods75 patients with 96 liver-confined HCC were treated with SBRT at the Oscar Lambret Comprehensive Cancer Center. Fiducials were implanted in the liver before treatment and were used as markers to track the lesion’s movement. Treatment response was scored according to RECIST v1.1. Local control and overall survival were calculated using the Kaplan and Meier method. A stepwise multivariate analysis (Cox regression) of prognostic factors was performed for local control and overall survival.ResultsThere were 67 patients with Child-Turcotte-Pugh (CTP) Class A and eight patients with CTP Class B. Treatment was administered in three sessions. A total dose of 40–45 Gy to the 80% isodose line was delivered. The median follow-up was 10 months (range, 3–49 months). The local control rate was 89.8% at 1 and 2 years. Overall survival was 78.5% and 50.4% at 1 and 2 years, respectively. Toxicity mainly consisted of grade 1 and grade 2 events. Higher alpha-fetoprotein (aFP) levels were associated with less favorable local control (HR=1.001; 95% CI [1.000, 1.002]; p=0.0063). A higher dose was associated with better local control (HR=0.866; 95% CI [0.753, 0.996]; p=0.0441). A Child-Pugh score higher than 5 was associated with worse overall survival (HR= 3.413; 95% CI [1.235, 9.435]; p=0.018).ConclusionSBRT affords good local tumor control and higher overall survival rates than other historical controls (best supportive care or sorafenib). High aFP levels were associated with lesser local control, but a higher treatment dose improved local control.

Advances in Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma

“…Abdominal compression with 4D-CT have also been used to reduce respiratory motion 19,21,50,52 as has respiratory gating 29,32,41 and intra-fraction tracking of peri-tumoral implanted fiducials 22,30,34,42,48 or external surface markers 20,22,30,43,48 (which requires daily imaging to ensure the adopted breathing model remains satisfactory). Free breathing with 4D-CT, with individualised margins to account for respiration, have also been employed 23 .…”

Bridging therapy effectiveness in the treatment of hepatocellular carcinoma prior to orthotopic liver transplantation.

“…Patient treated with newer therapies such as SBRT and SIRT may have less rapid tumor progression as compared to individuals treated with TACE (22)(23)(24). In our study, a total of 15 nodules were treated with BTs that included the newer modalities of SIRT and SBRT.…”

Loco-regional therapies for patients with hepatocellular carcinoma awaiting liver transplantation: Selecting an optimal therapy

“…In two sequential studies using SBRT in 102 patients with Child's class A liver disease and locally advanced HCC, Bujold et al [51] reported a median survival of 17 mo [51] , which is substantially higher than the median survival of the cohort receiving placebo in the SHARP study of sorafenib, which also was restricted to patients with mostly preserved liver function [52] . Toxicity from SBRT has been limited, and mostly grade 1 or 2 GI toxicity (nausea, vomiting, pain) [24,53] , though Bujold's study reported grade 3 toxicity in up to 30% [51] . Rare GI ulcers have occurred following SBRT [53] .…”

“…Toxicity from SBRT has been limited, and mostly grade 1 or 2 GI toxicity (nausea, vomiting, pain) [24,53] , though Bujold's study reported grade 3 toxicity in up to 30% [51] . Rare GI ulcers have occurred following SBRT [53] . The role of SBRT is still evolving, and studies comparing SBRT directly to other forms of LRT for bridging therapy to LT are in progress.…”