Outcomes following Stereotactic Body Radiation Therapy for Patients with Child-Pugh B or C Hepatocellular Carcinoma

Abstract

SBRT is a treatment option for patients (pts) with hepatocellular carcinoma (HCC). Due to concern for causing worsening liver function, caution has been recommended when using SBRT in pts with Child-Pugh (CP) B or C disease. Here we report our institutional outcomes. An institutional review board-approved registry was used to identify CP B and C patients with non-metastatic HCC treated with SBRT between 2011 and 2017. Baseline patient and disease factors, laboratory values, and treatment information were recorded. Patients were followed with radiographic imaging as well as clinical and laboratory follow-up. CP score after treatment was calculated at 2 or 3 months as available. Overall survival (OS) was evaluated using the Kaplan-Meier method and logistic regression analysis was used to identify factors predictive for CP change ≥2 and grade III hepatotoxicity. Thirty-seven pts treated with SBRT to 44 lesions met study criteria. About half of pts (54%) had received prior therapies including embolization, radiofrequency ablation, or y90 radioembolization. Twenty pts were treated with definitive intent, 8 as a bridge to transplant, and 9 were treated for downstaging for transplant. At the time of treatment, 27 pts had CP score of B (7-9) and 10 pts had CP score of C (10-12). The median overall survival (OS) was 14.8 months. Thirteen pts proceeded on to liver transplant after SBRT (7 of 8 bridging, 6 of 9 downstaging), and transplantation was associated with a significant improvement in median OS (32.2 months vs 7.3 months, p=0.018). Among non-transplant patients, CP score of B7 predicted for improved OS relative to CP B8-C scores (1 yr OS 56% vs 18.8% p=0.04). The most commonly used regimen was 40 Gy in 5 fractions, median PTV was 103.7 cc, and median liver mean dose was 10.3 Gy. The median radiographic follow up was 8.3 months, during which only one patient experienced local progression. Among the 30 pts undergoing follow-up with laboratory studies, 8 pts (26.7%) had a rise in CP score exceeding 2 points at 2 or 3 month follow-up and only a single patient died of liver toxicity. Among pts treated with definitive intent, only 10% experienced a change in CP score of ≥2. Neither liver mean dose nor PTV size predicted for CP score change ≥2. Following SBRT, 2 pts developed new grade III hypoalbuminemia, 11 pts developed new grade III hyperbilirubinemia, and 6 pts developed new grade III transaminitis. Liver mean dose, PTV size, and prescription dose did not predict for development of new grade III hepatotoxicity. However, in patients who did not have disease progression in the liver, RT dose ≥40 Gy predicted for grade III hepatotoxicity (p=0.003). SBRT can be successfully employed as local therapy for well-selected patients with CP B and C HCC with low rates of clinically significant hepatotoxicity. SBRT is also feasible in such patients as a part of bridging or downstaging prior to liver transplant.