Of many locoregional options, clinicians commonly use transarterial chemoembolization (TACE) to decrease the risk of tumor progression in patients with hepatocellular carcinoma (HCC) until a liver transplant can be carried out. This modality offers excellent disease control and a potentially reduced risk of recurrence post transplant, yet the need for hospitalization and the small but pertinent risk of major morbidity that could knock patients off the transplant list leaves something to be desired.
Dr. Francis W. Nugent
To begin to discern the best bridging modality in HCC prior to transplant, Francis W. Nugent, MD, and his colleagues at the Lahey Hospital and Medical Center conducted a small randomized phase II feasibility study in 31 patients with HCC slated for a new liver (Abstract 223). Patients in the trial received either individualized SBRT or TACE with doxorubicin drug-eluting beads.
TACE consisted of two applications of up to 100 mg doxorubicin-loaded beads performed 1 month apart. All patients had to stay in the hospital overnight after each application to monitor recovery.
Patients assigned to SBRT received a total dose of 40 to 50 Gy delivered in 5 fractions using fiducial markers as a point of reference. Treatment was administered every other day in the outpatient setting, with each of the 5 treatments lasting 30 to 50 minutes.
All patients fell within the Milan criteria, had no more than two tumors, and had Child-Turcotte-Pugh (CTP) Class A-B cirrhosis. Of the 30 patients evaluable for review, the majority had stage 1 HCC (87%), a single lesion (79%), and a baseline CTP score of approximately 5.8.
In the SBRT arm, five of 13 patients (38%) underwent liver transplant a median of 148 days following the completion of treatment. In the TACE arm, six of 17 patients (35%) received a transplant a median of 336 days after treatment. Dr. Nugent commented that the time to transplant was much shorter in the SBRT arm because two of the five patients received a graft from a live donor, which hastens the wait time.
SRBT appeared better than TACE with regard to the need for retreatment. Four patients (24%) who received TACE had residual disease and required additional therapy a median of 83 days after their initial rounds of bridging therapy. In contrast, no patients with SBRT required retreatment.
In terms of tolerability, there was a lesser degree of acute toxicity reported with SBRT as compared with TACE. Whereas a sizeable proportion of patients treated with TACE experienced fatigue (35%), anorexia (29%), nausea (29%), and/or pain (29%) of grade 2 or higher, the most common and sole adverse event of grade 2 or higher among the SBRT group was nausea (23%). Of note, one patient in the TACE arm also experienced two major events—a thrombus within the main portal vein and liver infarction—although this did not lead to hepatic decompensation, and the patient was still able to undergo transplant.
SBRT also produced a much smaller impact on patients’ physical and mental quality of life as compared with TACE (e.g., change from baseline in physical functioning on the Short Form Health Survey (SF-36): -0.7 vs. -2.7), although the clinical relevance of these differences is not clear.
Dr. Nugent summarized his talk by saying, “These are small numbers. Having said that, SBRT appears equivalent to TACE at controlling the treated lesion when utilized as a bridge to transplant in patients with Child-Pugh Class A-B disease,” while also possibly engendering less acute toxicity and avoiding hospitalization.
–Kara Nyberg, PhD