Long-term outcomes of stereotactic body radiation therapy in the treatment of hepatocellular cancer as a bridge to transplantation.

Hepatocellular carcinoma (HCC) is potentially curable with hepatic resection or transplantation. Few patients are eligible for resection, and many face a long wait for donor organ availability for liver transplantation. Here we report the safety and efficacy of stereotactic body radiation therapy (SBRT), the explant pathology findings and survival of patients treated with SBRT as a bridge to transplantation for HCC. From April 2005 to August 2010, 10 patients with 11 HCCs were treated with SBRT as a bridge to transplantation. All patients were evaluated by a liver transplant surgeon before radiosurgery. SBRT was delivered with the CyberKnife robotic radiosurgery system. After SBRT, all patients underwent orthotopic liver transplantation. The tumor response was determined by explant pathology. The median follow-up was 62 months from the time of SBRT. The mean time on the liver transplant wait list was 163 days. The median tumor size was 3.4 cm (range = 2.5-5.5 cm). The median SBRT dose was 51 Gy (range = 33-54 Gy) in 3 fractions. The median time from SBRT to liver transplantation was 113 days (range = 8-794 days). At 5 years, the overall survival rate and the disease-free survival rate were both 100%. Overall, 4 of the 10 patients (40%) experienced acute toxicity. Most toxicities were grade 1, and they included nausea, fatigue, and abdominal discomfort. One patient had grade 2 nausea/vomiting. Explant pathology revealed no viable tumor in 3 of the 11 tumors for a complete response rate of 27%. The remaining 8 tumors decreased or remained stable in size. In conclusion, with a median follow-up over 5 years, we have found that SBRT as a bridge to liver transplantation for HCC is feasible and well tolerated. SBRT for HCC may enable patients to remain on the list for frequently curative transplantation during the wait for organ availability.

Hepatocellular carcinoma: management of an increasingly common problem.

Hepatocellular carcinoma (HCC) is a common cancer that typically occurs in the setting of cirrhosis and chronic hepatitis virus infections. Hepatitis B and C account for approximately 80% of cases worldwide. HCC is currently the fifth most common malignancy in men and the eighth in women worldwide; its incidence is increasing dramatically in many parts of the world. Recognition of those at risk and early diagnosis by surveillance with imaging, with or without serologic testing, are extremely important. Many highly effective and even curative therapies are now available and include resection, liver transplantation, and local ablation. Appropriate application of these interventions offers hope of prolonged survival to many patients with this otherwise lethal complication of liver disease.

Radiofrequency thermal ablation of hepatocellular carcinoma before liver transplantation--a clinical and histological examination.

BACKGROUND: Radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) is an optional treatment for patients awaiting liver transplantation (LTX). The study evaluates the efficacy of RFA in the explanted liver and its effect on patient outcome. MATERIAL AND METHOD: Forty-seven patients underwent RFA and were listed for transplant between January 1998 and May 2003. The patients were divided into two groups: transplanted and non-transplanted. Both groups were evaluated in terms of tumor characteristics, recurrence, mortality rate, and time on the waiting list. The ablation sites in the explanted livers were examined for percentage of necrosis by Hematoxylin & Eosin (H&E) stain and by TUNEL stain. RESULTS: Transplantation was carried out in 35 patients (74.5%). Ten patients (21.3%) died before transplant or were removed from the wait list, while two patients (4.2%) are still listed. Mortality and tumor-related mortality were significantly higher in the non-transplanted group. The time spent on the waiting list was longer in the non-transplanted patients (350 vs. 186 d average, p = 0.0345). Thirty-eight ablation sites were examined in the explanted livers. The percentage of tumor necrosis by TUNEL staining was 19.6% higher than that reported by H&E staining. After TUNEL staining, 28 sites (73.7%) had more than 90% necrosis, eight sites (21.0%) had 50-90%, and two sites (5.3%) had less than 50% necrosis. CONCLUSIONS: RFA and LTX can be used successfully in HCC patients, and in most cases, tumor necrosis can be achieved with ultrasound-guided RFA. H&E stain tends to under-represent the amount of tumor necrosis on the ablation sites. Survival of RFA patients after LTX is excellent.