This retrospective study from Taiwan compared local control and overall survival (OS) between stereotactic body radiation therapy (SBRT) and transarterial chemoembolization (TACE) in medium-sized (3-8 cm) hepatocellular carcinoma (HCC).

They found superior in-field control (IFC) rates at 3 years with SBRT vs TACE (73.3% vs 63%) and improved 3-year OS with SBRT (47.4% vs 22.9%). The results were similar when a propensity score analysis was performed. In subgroup analysis, SBRT showed improved 3-year IFC (75% vs 57.5%) and 3-year OS (58.3% vs 5.9%) compared with TACE for recurrent tumors. No difference in IFC or OS between TACE and SBRT for patients with newly diagnosed HCC.

This is the first study comparing the efficacies of SBRT and TACE in treating medium-sized (3-8 cm) HCC.  They demonstrated that SBRT had significant benefit over TACE in both IFC and OS. Toxicity was similar in both group with 19.6% rate of radiation-induced liver disease and 18.3% rate of hepatic failure after TACE. On subgroup analysis, they found that the superiority of SBRT held in the recurrent setting, but not in the newly diagnosed case. This could be due to anatomic changes and neovascularization from repeated TACE that results in superior results from SBRT as radiation should overcome vascular-related problems of prior treated lesions. These results suggest that both SBRT and TACE are viable options for newly diagnosed HCC but that SBRT may be preferential for treatment of recurrent HCC.

The major limitation of this study was that it was a retrospective study conducted on patients from a single center. Another limitation was that not all adverse effects are likely to be captured in a retrospective setting. However, prior publications have shown that both TACE and SBRT are safe treatments. 

Overall, these findings showed that SBRT exhibited IFC and OS rates superior to those for TACE for patients with medium-sized HCCs, especially in recurrent cases. Additional prospective randomized trials are needed to compare the efficacy of SBRT and TACE. In the absence of such data, SBRT may be the preferred treatment for recurrent HCC.

Reference (PubMed Link): Shen PC, Chang WC, Lo CH, et al. Comparison of stereotactic body radiation therapy and transarterial chemoembolization for unresectable medium-sized hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2019;105:307-318.

Key Institution: Tri-Service General Hospital, Taiwan
Keywords: Hepatocellular carcinoma, SBRT, TACE

Hepatocellular carcinoma (HCC) is the third leading cause of death worldwide and has a propensity to invade the portal venous system and for a portal vein tumor thrombus (PVTT). PVTT is a predictor of poor survival. This was a randomized multicenter trial in patients with resectable HCC and PVTT. Patient were randomly allocated to receive neoadjuvant (presurgery) radiation therapy followed by hepatectomy or hepatectomy alone. The radiation dose was 18Gy in 6 fractions using respiratory gating. 82 patients received RT+ hepatectomy and 83 patients received hepatectomy alone. The overall survival rates at 6, 12, 18, and 24 months were 89.0%, 75.2%, 43.9%, and 27.4%, compared to 81.7%, 43.1%, 16.7%, and 9.4% in the surgery only group, which was significantly different. On multivariable analysis, neoadjuvant RT significantly reduced the risk of dying from HCC compared to surgery alone. Interestingly, increased expression of IL-6 in serum and tumor tissues prior to treatment with radiation were associated with resistance to radiation therapy. This study provides evidence that pre-surgery RT for resectable HCC may improve survival compared to surgery alone.  

(Open Access)

Reference (PubMed Link): Wei X, Jiang Y, Zhang X, et al. Neoadjuvant three-dimensional conformal radiotherapy for resectable hepatocellular carcinoma with portal vein tumor thrombus: A randomized, open-label, multicenter controlled study. J Clin Oncol 2019;37:2141-2151.

Key Institution: Eastern Hepatobiliary Surgery Hospital, Navy Military Medical University, Shanghai, China
Keywords: HCC, 3D conformal radiation, neoadjuvant RT 

The purpose of this single arm phase 2 trial was to determine R0 resection rate after a specified course of total neoadjuvant therapy. Investigators enrolled 48 patients with newly diagnosed and untreated borderline resectable pancreatic cancer. Patients received 8 cycles of FOLFIRINOX, after which restaging was performed. If they experienced resolution of vascular involvement, patients underwent hypofractionated radiotherapy (25Gy in 5fx with protons or 30Gy in 10 fx with photons) with concurrent chemotherapy. If persistent vascular involvement, patients underwent a long course radiotherapy 50.4Gy in 28 fractions. Intraoperative radiotherapy was allowed at the surgeon’s discretion. 81% completed all planned chemotherapy, 92% proceeded to chemoradiation, of which 89% underwent resection, showing the tolerability of the treatment regimen. R0 resection was achieved in 65% of patients undergoing surgery, an impressive rate compared to historical standards. The most common grade 3+ toxicity was diarrhea (10%), indicating a favorable toxicity profile of this treatment course. Median PFS and OS were 14.7 and 37.7 months, respectively. In conclusion, this trial demonstrated the tolerability and efficacy of a regimen of total neoadjuvant therapy for pancreatic cancer, and supports the design of the phase 3 Alliance trial for borderline resectable pancreatic cancer.

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