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Page 4 of 7 Li et al. Hepatoma Res 2020;6:39 I http://dx.doi.org/10.20517/2394-5079.2020.13

alcohol injection and other treatments were given during the follow-up periods. The results showed that
the median survival time was 19.6 months for the patients who received surgery combined with external
radiotherapy, and 9.1 months for the patients who did not undergo surgery. There was a significant difference
between the two groups (P = 0.036). The pathology of the surgical specimens showed that 83% of the
tumor thrombi were completely necrotic (completely relieved of disease). Therefore, the main purpose of
surgery is to improve the control rate of primary HCC and dredge the portal vein. For patients with tumor
thrombus, preoperative radiotherapy combined with surgical removal of thrombus is an effective method
of comprehensive treatment. A randomized, prospective, multicenter clinical study was conducted in
Shanghai Oriental Hepatobiliary Surgery Hospital to compare the survival of patients with HCC and PVTT
[24]
before operation with or without neoadjuvant radiotherapy . A total of 82 patients in the radiotherapy
group received 18 Gy/6 times of neoadjuvant external radiotherapy; 82 patients in the control group did not
receive neoadjuvant radiotherapy. The results showed that the OS rates of radiotherapy group and operation
group were 89.0% vs. 81.7%, 75.2% vs. 43.1%, 43.9% vs. 16.7% and 27.4% vs. 9.4% at 6, 12, 18 and 24 months,
respectively (P < 0.001). The DFS rates of the two groups were 56.9% vs. 42.1%, 33.0% vs. 14.9%, 20.3% vs.
[24]
5.0% and 13.3% vs. 3.3% (P < 0.001) . Neoadjuvant radiotherapy can significantly improve the postoperative
survival of patients with HCC.

TRANSFORMATION SBRT FOR HCC
[25]
Kim et al. of Yonsei University in South Korea reviewed the effect of concurrent radiotherapy and
chemotherapy on patients with HCC. A total of 264 patients were selected, most of whom received three-
dimensional conformal radiotherapy because of PVTT or residual liver volume insufficiency. Most of them
received radiotherapy with a single dose of 1.8 Gy and a total dose of 45 Gy, and 5-fluorouracil (5-FU) was
infused in the first and fifth week simultaneous with radiotherapy. One month after radiotherapy, 5-FU
and cisplatin were infused once every 4 weeks for 3-12 cycles. Among them, 18 cases were converted into
resectable cases. Postoperative pathology showed that 4 cases (22.2%) were completely necrotic and 7 cases
(38.9%) were 70%-99% necrotic. Among the 18 patients who underwent surgery, the median survival time
and median progression time were 40 and 24 months, respectively, and the median DFS time of the 4 patients
with complete tumor necrosis was 54.6 months. Therefore, after conformal radiotherapy, some patients with
unresectable HCC could be converted to resectable HCC.

BRIDGING SBRT BEFORE LIVER TRANSPLANTATION
Orthotopic liver transplantation is the most effective treatment for HCC patients with liver transplantation
indications. However, due to the limited number of liver donors, many patients may have tumor progression
while on the long waiting list, thus losing the best opportunity for liver transplantation. Therefore, bridging
therapy to delay tumor progression is very important. SBRT can be used as a bridge treatment for liver cancer
patients waiting for liver transplantation. It is neither a new adjuvant radiotherapy nor a transformation
radiotherapy. Because SBRT belongs to radical treatment, the majority of HCC patients with T1 or T2 can be
reduced to T0. The purpose of liver transplantation is to replace the decompensated liver with normal liver
function. The purpose of radiotherapy is to control tumor progression while lacking a liver donor.

Eighteen patients with liver cancer who received SBRT before transplantation were reported by Rochester
University Medical Center and William Beaumont Hospital in Michigan [26,27] . The median dose of
radiotherapy was 50 Gy/10 times. There was no serious gastrointestinal adverse reactions or radiation
hepatitis. The median waiting period after radiotherapy was 6.3 months. Twelve patients received liver
transplantation successfully, and 10 patients showed complete pathological necrosis. The median follow-
up period was 19.6 months, and all patients survived. Therefore, SBRT is a safe and effective treatment for
liver cancer patients waiting for liver transplantation. It can control the tumor and relieve the pressure of a
[28]
liver donor before liver transplantation. A study reported on 379 patients treated with pre-transplantation