Liver-Directed Combined Radiation Therapy for Downstaging Beyond-Milan Hepatocellular Carcinoma to Liver Transplantation

Abstract

Background & AimsCurative surgery involving either resection or liver transplantation (LT) is indicated only for early stage hepatocellular carcinoma (HCC). Over the years, numerous efforts have been made to downstage advanced HCC to curative surgery using various locoregional therapies. In this study, we investigated the role of liver-directed combined radiotherapy (LD-CRT) as a downstaging strategy for converting beyond-Milan advanced HCC to LT. ApproachFrom January 2009 to February 2022, 53 HCC patients who were initially beyond-Milan criteria were treated with LD-CRT and subsequent LT. These patients were compared to those who underwent upfront LT for within-Milan HCCs. The primary endpoint was overall survival (OS), and the secondary endpoint was recurrence-free survival (RFS). ResultsAfter LD-CRT, substantial downstaging was achieved in 35 (66 %) patients who were initially beyond-Milan to within-Milan. At a median follow-up period of 47.6 months (range, 6.9-151.7 months), 5-year OS and 2-year RFS of the patients who received downstaging LD-CRT followed by LT was 66.9% and 63.2%, respectively. Patients who were successfully downstaged to within-Milan following LD-CRT had improved 5-year OS compared with their counterparts (81.9% vs. 74.3%, p = 0.219). Recurrence after transplantation was observed in 18 patients (4 intrahepatic recurrences and 14 extrahepatic metastases). ConclusionsLiver-directed combined radiotherapy achieved favorable oncological outcomes as a downstaging strategy for liver transplantation in patients with beyond-Milan HCC. This study suggests that the active adoption of liver-directed combined radiotherapy needs full consideration for patients with beyond-Milan HCC, opening a chance of curing patients with advanced HCC.