Stereotactic Body Radiation Therapy (SBRT) Combined With Transarterial Chemoembolization (TACE) in BCLC Stage B and C Hepatocellular Carcinoma (HCC)

Abstract

Purpose/Objective(s): To evaluate the efficacy and safety of stereotactic body radiation therapy (SBRT) combined with transarterial chemoembolization (TACE) in BCLC stage B and C hepatocellular carcinoma. Materials/Methods: During the period of 2008 to 2015, prospective data of73 consecutive BCLC stage B and C HCC patients, who received single dose of TACE followed by SBRT 4-6 weeks later were analyzed. All patients had tumor size >= 5cm and at least 700 mL of non-HCC liver. Individuals with Child-Pugh (CP) score >B7, main portal vein thrombosis (PVT), infiltrative tumors or extensive extra-hepatic diseases were excluded. SBRT dose, range from 5-8 Gy x 6 fractions, or 4 Gy x 5-10 fractions, was individualized according to normal tissue constraints. No subsequent scheduled treatment was delivered unless disease progression. Primary end point was local control. Secondary end points were overall survival, response rate, and toxicity.

Results: Median follow-up time was 17 months (range: 3-96 months). Patients’ characteristics were as follows: Median age was 60 years (range: 28-87); CP class A/B (n = 68/5); BCLC stage B/C (n = 52/21); TNM stage I-II/III/IV (n = 19/45/9); Solitary/Multifocal (n = 37/36); Portal vein thrombosis (n = 21). Median size of tumor was 11.5cm (range: 5-23.6cm) and median GTV size was 751cc (range: 55-4009cc). Median total equivalent dose in 2 Gy per fraction (EQD2, a/b = 3) given was 57.3 Gy (range: 28-105.6 Gy). The 1-year and 2-year local control was 93.6% (95% Cl, 83.3-97.6%) and 84% (95% Cl, 66-92.4%) respectively. The median overall survival (OS) was 20 months (95% Cl, 11.6-30.6 months), for which size of lesion (HR = 3.1, 95% Cl, 1.7-5.6) was significant on multivariate analysis. Objective tumor response by RECIST criteria was seen in 67% of patients. All except one patient (98.6%) completed the planned treatment. Treatment related death occurred in one patient (1.4%). The commonest >= grade 3 toxicities were transient elevation of liver enzymes (n = 10, 14%) and bilirubin (n = 8, 11%). Around 8% of patients without disease progression had decline of CP class in 3 months. No patient developed classical radiation-induced liver injury (RILD).

Conclusion: Combined SBRT with TACE is safe and achieves favorable local control in BCLC stage B-C HCC. Further prospective studies on this approach are warranted.