Table 1.
Current indications for use of EBRT for HCC and representative reference studies
| Author | Treatment | Candidates | Study type | Number of patients/study | Treatment outcomes | Toxicity ≥ G3 | Category of indication | Clinical experience | Evidence of literature | ||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Tumor response | Median OS | OS rates | |||||||||
| Rim et al28 | 3DCRT | HCC with PVT | MA | 1,903 22 studies | RR 51.3% (95% CI: 45.7–57.0) | mOS 11.6 mo. | 1-year OS 43.5% (95% CI: 37.6–50.2) | Less than <10% in most of studies | EBRT to HCC with PVT | Abundant | Low to moderate |
| Rim et al31 | EBRT | HCC with IVCT and/or RA | MA | 164 8 studies | RR 59.2% (95% CI: 39.0–76.7) | mOS 13.2 mo. | 1-year OS 53.6% (95% CI: 45.7–61.3) | 2 cases among 164 (1.2%, 1 ER and 1 PE) | EBRT to HCC with IVCT and/or RA | Scarce, but currently no better option than EBRT | Low |
| Huo and Eslick35 | Combined RT with TACE (TACE & RT vs TACE alone) | Unresectable HCC | MA | 2,577 25 studies (11 RCTs) | Favors TACE and RT (complete response: OR 2.73, 95% CI: 1.95–3.81) | 22.7 mo. (TACE & RT) 13.5 mo. (TACE alone) | Favors TACE plus RT (1-year OS, OR 1.36, 95% CI: 1.19–1.54; 2-year OS, OR 1.55, 95% CI: 1.31–1.85) | GU/DU higher in combined group (OR 12.80, 95% CI: 1.6–104.3) | Combined RT with TACE for unresectable HCC | Abundant | High |
| Yoon48 | Combined RT with TACE (TACE & RT vs sorafenib) | HCC with major vascular invasion | RCT | 90 | Favors TACE and RT RR, 28.9% vs 4.7% (p<0.001) | Favors TACE plus RT 6-month PFS 65.8% vs 13.7% (p<0.001) | |||||
| Lee et al37 | Combined RT with HAIC | Unresectable HCC | RS | 243 | 16.7% underwent curative resection after RT 5-year OS 49.6% | Combined RT with HAIC for unresectable HAIC | Scarce | Scarce | |||
| Byun et al38 | Combined RT with HAIC | BCLC-C HCC | RS | 637 (VI 73%, multiple tumors 35.3%) | Overall mOS: 15 mo. (>60 Gy vs <60 Gy, mOS 39 vs 14 mo. (p=0.001) | No GI toxicity ≥ G3 | |||||
| Bujold et al42 | SBRT | Unsuitable for OP, TACE, RFA, PEI | PS | 102 (PVT 55%, median TD 7.2 cm) | RR 54%, 1-year LC 87% (95% CI: 78–93) | mOS 17 mo. | 23.5% of liver related toxicity | SBRT for HCC unsuitable for conventional local Tx | Moderate to abundant | Low to moderate | |
| Lasley et al43 | SBRT | HCC | PS | CPC-A: 33 CPC-B: 46 | 2-year LC: 91% (CPC-A) 82% (CPC-B) | mOS: 48 mo. (CPC-A) 17 mo. (CPC-B) | 2-year OS: 72% (CPC-A) 33% (CPC-B) | Liver toxicity: 11% (CPC-A) 38% (CPC-B) | |||
| Scorsetti et al44 | SBRT | Unresectable HCC | PS | 43 (CPC-B 47%) | 1-year LC: 85.8% | mOS: 18 mo. | Liver toxicity in 7 patients (16%); 5 of 7 was CPC-B | ||||
| Qi et al46 | SBRT | HCC | MA | 1,473 30 cohorts | 1-year LC: 87% (95% CI: 71–87) | 1-year OS: 80% (95% CI: 71–87) | Acute: hepatic 4.9% (95% CI: 3.0–8.1), BM 4.9% (3.4–7.2), overall 9.6% (6.0–15.1) late: 6.4% (4.0–10.1) | ||||
| Rim et al28 | SBRT | HCC with PVT | MA | 208 (7 cohorts) | RR 70.7% (95% CI: 63.7–76.8) LC 86.9% (95% CI: 81.0–91.2) | mOS: 14 mo. (range: 11–19) | 1-year OS: 48.5% (95% CI: 39.4–57.8) | Less than <10% in most of studies | |||
Abbreviations: 3DCRT, 3-dimensional conformal radiotherapy; BCLC, Barcelona Clinic of Liver Cancer; BM, bone marrow; CI, confidence interval; CPC, Child-Pugh Class; DU, duodenal ulcer; EBRT, external beam radiation therapy; ER, esophageal rupture; G3, grade 3; GI, gastrointestinal; GU, gastric ulcer; HAIC, hepatic arterial infusion chemotherapy; HCC, hepatocellular carcinoma; IVCT, inferior vena cava thrombosis; LC, local control; MA, meta-analysis; mOS, median overall survival; OP, operation; OR, odds ratio; OS, overall survival; PE, pulmonary embolism; PEI, percutaneous ethanol injection; PFS, progression-free survival; PS, prospective study; PVT, portal vein thrombosis; RA, right atrium; RCTs, randomized controlled trials; RFA, radiofrequency ablation; RR, response rate; RS, retrospective study; RT, radiotherapy; SBRT, stereotactic body radiotherapy; TACE, transarterial chemoembolization; TD, tumor diameter; Tx, treatment; VI, vascular invasion.