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Zhao et al. Hepatoma Res 2019;5:17 I http://dx.doi.org/10.20517/2394-5079.2018.116 Page 7 of 10

Figure 6. Meta-analysis of the negative conversion rate of AFP in 6 studies comparing transarterial chemoembolization (TACE) plus
stereotactic body radiation therapy (SBRT) with TACE or SBRT monotherapy for intermediate-to advanced-stage hepatocellular
carcinoma patients

HCC is a malignant tumor which seriously endangers human health. Due to the difficulty in early diagnosis
and its hidden character, most patients are diagnosed at the intermediate- to advanced-stage. Sorafenib
or lenvatinib is currently used as a first-line standard therapeutic agent for advanced HCC according to
the BCLC criteria [13,14] . Besides, apatinib may be a substitute for HCC patients with sorafenib resistance in
the future, especially for those with high expression of VEGF . With the rapid development of clinical
[15]
medicine, the appearance of more and more treatment methods which lead to no uniform suggestion for the
treatment of intermediate to advanced HCC patients.

TACE is recognized as an alternative treatment option for intermediate-to advanced- HCC patients . It is
[16]
to inject chemotherapy drugs directly into tumor blood supply artery through a catheter which can improve
local drug concentration of tumor to increase the ability to kill cancer cells, achieve embolization of tumor
blood vessels and block the blood supply of a tumor, tumor tissue necrosis, shrinkage, and disappearance.
However, tumor tissues could not be eliminated through TACE . There are mainly three reasons. Firstly,
[17]
after TACE, some infiltrating cells and metastatic liver cells are still alive, and repeated treatment by TACE
may produce a specific resistance to chemotherapy drugs. Secondly, the liver tissue is damaged due to
hypoxia and ischemia, embolization agents and chemotherapy drugs, which influences the clinical efficacy
of transcatheter arterial chemoembolization. Thirdly, after TACE, part of the tumor tissue will recover blood
supply. Therefore, although the short-term effectiveness of TACE is justifiable, it still has limitations, and the
long-term effectivness remains unsatisfactory.

The liver is a radiosensitive organ which ranks only behind bone marrow, lymphoid tissue, and kidney .
[18]
As a result, in spite of the rapid development of radiotherapy for HCC, the efficacy was not significantly
improved. In recent years, with the growth of stereotactic radiotherapy, SBRT is gradually appropriate
for intermediate-to advanced-HCC [19-22] . SBRT delivers a high dose of radiation to HCC within a short
period time and is effective and less invasive for the delivery of high radiation doses to the tumor with
hypofractionation. Employing the high-dose irradiation to the tumor area which can reduce irradiation
dose of the healthy liver tissue at the same time, SBRT can make the tumor vascular degrade and mortify,
lower the blood supply of the cancer to achieve the goal of killing tumor cells. Besides, it is efficient that
multiple lesions can be operated at the same time by the use of SBRT. The features of SBRT above, to a large
extent, make up the defect of TACE.

Recently, the therapeutic role of SBRT combined with TACE for intermediate-to advanced-stage HCC has
been emphasized more than before [23,24] . Jun and Kim showed that SBRT combined with TACE is a feasible
[25]