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Zeng et al. Hepatoma Res2020;6:43 I http://dx.doi.org/10.20517/2394-5079.2020.29 Page 11 of 12

[22]
fatalities from liver failure occurred in patients with Child-Pugh Class B liver function . However, we have
observed no fatal radiation-induced liver disease in our clinical practice.

The safety of SBRT for HCC in patients with Child-Pugh Class C liver function has not been established.
Class C function is generally considered a contraindication to all HCC treatment except liver transplantation.
No deterioration in liver function occurred after SBRT in Cases 5 and 11, who had Child-Pugh Class C liver
function. Furthermore, some patients undergo > 1 course of SBRT, as exemplified by Case 10, who received
a total of three courses because of the development of de novo HCCs. Together, these observations suggest
that SBRT produces little liver parenchymal damage.

Other toxicities
Gastrointestinal toxicity is another potential concern with SBRT, especially when luminal structures, such as
the esophagus, stomach, duodenum, or intestines, are close to the tumors being treated. Grade 3 or higher
gastrointestinal toxicities were reported in 1.4% of patients from previously published studies, but fatal
[22]
gastrointestinal bleeding did not occur . Other complications, such as rib fractures, chest or abdominal wall
pain, biliary stricture, and musculoskeletal discomfort, have been noted occasionally. Overall, most toxicities
from SBRT are generally infrequent and mild.

THE LIMITATION OF SBRT
Firstly, there is a lack of randomized clinical trials to compare the treatment outcome among SBRT, resection,
and RFA. Thus, SBRT can only be used as an alternative treatment when operation and RFA are impossible.
Secondly, vaguely defined SBRT has led to inconsistent radiation doses and fractions globally, with ≤ 5
fractions in the United States and ≤ 10 fractions in the rest of the world. A dose of 55.5 Gy in 15 fractions was
delivered to Case 8, and complete response was achieved. This is not strictly part of SBRT; at this point, we
are not interested in the definition of SBRT, as we care more about the local control and long-term survival.

CONCLUSION
SBRT is an effective therapeutic option based on proven studies for patients with small HCCs; is
complementary to the existing treatment options, as illustrated by the typical cases; and is safe with minimal
toxicities.

DECLARATIONS
Authors’ contributions
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it
for publication.

Availability of data and materials
Not applicable.

Financial support and sponsorship
The research was supported by a grant from the National Key R & D Program of China (2017YFC0112100).

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.