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Li et al. Hepatoma Res 2020;6:39 I http://dx.doi.org/10.20517/2394-5079.2020.13 Page 5 of 7

bridging therapy, including 36 patients with SBRT, 99 patients with TACE and 244 patients with
radiofrequency ablation (RFA). Finally, 312 patients received liver transplantation, 30 in the SBRT group, 79
in the TACE group, and 203 in the RFA group. The 1-, 3- and 5-year survival rates were 83%, 61% and 61% in
the SBRT group, 86, 61 and 56% in the TACE group, and 86%, 72% and 61% in the RFA group, respectively
(P = 0.4). SBRT is as safe and effective as TACE and RFA in the treatment of HCC before transplantation.
Compared with TACE and RFA, SBRT has more advantages in the treatment of HCC patients with ascites
and prolonged prothrombin time.

POSTOPERATIVE ADJUVANT SBRT FOR HCC
Liver cancer with the distance of less than 1 cm from the bifurcation of the portal vein, the confluence of
three main hepatic veins and inferior vena cava, is at high risk of recurrence after liver resection. The 5-year
recurrence rate is reported to be more than 90%. At present, there is no effective adjuvant therapy to reduce
[29]
such a high recurrence rate of this kind of liver cancer. Wang et al. reported the results of radiotherapy for
the first time in patients with narrow margin surgery of central type liver cancer, who had retained a silver
positioning mark in the operation area guided by postoperative adjuvant radiotherapy.

From 2007 to 2010, 181 patients were analyzed retrospectively. They were divided into three groups: group
A: narrow margin surgery combined with postoperative radiotherapy (33 patients), group B: narrow margin
surgery (83 patients) and group C: wide margin surgery with cutting edge more than 1 cm (65 patients), and
postoperative radiotherapy dose was 46-60 Gy/23-30 times, with a median dose of 56 Gy; the 3-year OS of
groups A, B and C was 89.1, 67.7 and 86.0%, respectively, while DFS was 64.2, 52.2 and 60.1%, respectively.
Group A had similar OS (P = 0.957) and DFS (P = 0.972) as group C. Compared with group B, the OS
(P = 0.009) and DFS (P = 0.038) of group A showed significant advantages The incidence of grade-3 adverse
reactions in group A was 12.1% and no more than grade-4 adverse reactions occurred. The study showed
that postoperative radiotherapy can make up for the deficiency of narrow margin surgery, and that the effect
of narrow margin surgery combined with postoperative radiotherapy can achieve asimilar effect as wide
margin radical surgery without serious adverse reactions.

Microvascular invasion (MVI) is the most important risk factor for early postoperative recurrence of HCC,
[30]
which has been proved to be an independent predictor of OS and DFS . Even for patients with small liver
cancer, MVI can increase tumor recurrence rate and significantly reduce OS, and MVI can only be detected
by postoperative histological examination.

[31]
Wang et al. reviewed and compared the results of conservative therapy (CT), TACE and radiotherapy in
136 HCC patients with MVI. Narrow margin rate in the radiotherapy group was significantly higher than
in the other two groups (P = 0.010). Postoperative radiotherapy dose was 54-60 Gy/23-30 times, where the
results showed that there were significant differences between the radiotherapy group and TACE group and
the radiotherapy group and CT group in DFS (P < 0.05), and the radiotherapy group and TACE group and
the RT group and CT group in OS (P < 0.05). Subgroup analysis based on MVI degree and surgical margin
showed that RFS and OS of patients in the radiotherapy group with narrow surgical margin were significantly
longer than those of the TACE and CT groups, but not related to MVI degree. There was no significant
difference in survival outcome between the three groups with wide surgical margin.

SUMMARY
To sum up, surgery is an effective way to cure HCC in the early and middle stages. The high recurrence
rate and the lack of effective rescue treatment make the curative effect not very ideal. Although the related
research results of surgery combined with SBRT are limited, they all show that it is a safe and effective
treatment. As a new way of radiotherapy, preoperative SBRT has shown its unique advantages in the adjuvant