Hepatocellular carcinoma with child Pugh-A Cirrhosis treated with stereotactic body radiotherapy

Shaakir Hasan, Ngoc Thai, Tadahiro Uemura, Vijay Kudithipudi, Paul Renz, Stephen Abel, Alexander V Kirichenko, Shaakir Hasan, Ngoc Thai, Tadahiro Uemura, Vijay Kudithipudi, Paul Renz, Stephen Abel, Alexander V Kirichenko

Abstract

Aim: To evaluate the control, survival, and hepatic function for Child Pugh (CP)-A patients after Stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC).

Methods: From 2009 to 2016, 40 patients with Barcelona Liver Clinic (BCLC) stages 0-B HCC and CP-A cirrhosis completed liver SBRT. The mean prescription dose was 45 Gy (40 to 50 Gy in 4-5 fractions). Local relapse, defined as recurrence within the planning target volume was assessed with intravenous multiphase contrast computed tomography or magnetic resonance imaging every 4-6 mo after completion of SBRT. Progression of cirrhosis was evaluated by CP and Model for End Stage Liver Disease scores every 3-4 mo. Toxicities were graded per the Common Terminology Criteria for Adverse Events (v4.03). Median follow-up was 24 mo.

Results: Forty-nine HCC lesions among 40 patients were analyzed in this IRB approved retrospective study. Median tumor diameter was 3.5 cm (1.5-8.9 cm). Six patients with tumors ≥ 5 cm completed planned selected transarterial chemoembolization (TACE) in combination with SBRT. Eight patients underwent orthotropic live transplant (OLT) with SBRT as a bridging treatment (median time to transplant was 12 mo, range 5 to 23 mo). The Pathologic complete response (PCR) rate in this group was 62.5%. The 2-year in-field local control was 98% (1 failure). Intrahepatic control was 82% and 62% at 1 and 2 years, respectively. Overall survival (OS) was 92% and 60% at 1 and 2 years, with a median survival of 41 mo per Kaplan Meier analysis. At 1 and 2 years, 71% and 61% of patients retained CPA status. Of the patients with intrahepatic failures, 58% developed progressive cirrhosis, compared to 27% with controlled disease (P = 0.06). Survival specific to hepatic failure was 92%, 81%, and 69% at 12, 18, and 24 mo. There was no grade 3 or higher toxicity. On univariate analysis, gross tumor volume (GTV) < 23 cc was associated with freedom from CP progression (P = 0.05), hepatic failure-specific survival (P = 0.02), and trended with OS (P = 0.10).

Conclusion: SBRT is safe and effective in HCC with early cirrhosis and may extend waiting time for transplant in patients who may not otherwise be immediate candidates.

Keywords: Child-Pugh A; Cirrhosis; Hepatocellular carcinoma; Hepatoma; Local control; Radiation; Radiotherapy; Stereotactic body radiotherapy.

Conflict of interest statement

Conflict-of-interest statement: We have no financial relationships to disclose.

Figures

Figure 1
Figure 1
Overall Survival of all patients.
Figure 2
Figure 2
Freedom from child Pugh Progression of all patients. CP progression: Percentage of patients retaining child Pugh A status.
Figure 3
Figure 3
Freedom from child Pugh progression by gross tumor volume. CP progression: Percentage of patients retaining child Pugh A status; GTV: Gross tumor volume in cubic centimeters; Group ≤ 23: Number of patients with a GTV less than or equal to 23 cc; Group > 23: Number of patients with a GTV greater than 23 cc.

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