Stereotactic Body Radiotherapy is a Safe and Effective Option for Patients with Hepatocellular Carcinoma with Advanced Cirrhosis

Abstract

Hepatocellular carcinoma (HCC) is a common malignancy worldwide with poor outcomes. While stereotactic body radiotherapy (SBRT) is increasingly being utilized, SBRT has traditionally been contraindicated in patients with Childs Pugh B8 or higher (CPB8+) liver dysfunction due to potential toxicities. However, emerging evidence suggests safety and efficacy in this population. Here we report our institution’s outcomes with SBRT for patients with HCC and CPB8+ liver dysfunction. Patients with HCC treated with SBRT were retrospectively reviewed. Local control (LC) was defined at the treated site and determined by imaging as read by institutional radiologists, multi-disciplinary discussion, or pathologic evaluation on transplantation, and censored at progression, transplant, or last follow-up. Overall survival (OS) was defined at the time of patient death or at last follow-up. Toxicities were defined as a decline in liver function evidence by an increase in Childs Pugh score by 2 (CP+2), radiation induced liver dysfunction (RILD), or grade 4 or 5 toxicity. Possible toxicity was defined as events that occurred within 3 months of SBRT but association with treatment could not be determined. From January 2013 to June 2019, 45 patients with 50 lesions treated with SBRT were identified with 43 patients having information for toxicity analysis. Median follow-up was 12 months (range 1.3 – 46.4 months). Seven, 2, and 2 patients had Childs Pugh B8, B9, and C10, respectively. One- and two-year LC for the entire cohort was 97.3% (95% CI: 82.3-99.6%) and 90.4% (95% CI: 62.7-97.8%), respectively. Among CPB8+ patients, LC was 100% at both 1 and 2 years. One- and 2-year OS for the entire cohort was 72.4% (95% CI: 56.4-83.3%) and 52.4% (95% CI: 33.2-68.4%), respectively. Among CPB8+ patients, OS at 1 and 2 years was 63.6% (95% CI: 29.7-84.5%) and 42.4% (95% CI: 8.2-74.5%), respectively. A total of 4/11 CPB8+ patients were bridged to liver transplant, with all 4 patients alive at last follow-up. Three of 11 CPB8+ patients had definite treatment related toxicity (1 with RILD, 1 with CP+2, and 1 with both). There were no definite grade 4 or 5 toxicities but 3 possible grade 5 toxicities in CPB8+ patients. SBRT for patients with HCC and CPB8+ liver dysfunction results in excellent LC and OS. SBRT can be used safely in patients with advanced cirrhosis, and treatment related worsening of liver function may potentially serve to expedite their transplant.