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Page 2 of 10 Bieu et al. Hepatoma Res 2020;6:49 I http://dx.doi.org/10.20517/2394-5079.2020.39

INTRODUCTION
Hepatocellular carcinoma (HCC) is one of the 5 most common cancers worldwide, and its incidence is
[1]
increasing in Vietnam and Southeast Asian countries . According to Milan criteria, the liver transplant
(LT) is the treatment of choice for HCC patients with tumor less than 5 cm and up to 3 tumors ≤ 3 cm. The
[2]
5 years survival rate in these patients are 70% with less than 20% recurrence rate . However, not all HCC
patients can undergo transplantation due to a lack of liver donors, resulting in an extended time on the
[3]
waiting list (WL) and a high dropout rate .

Bridging treatments are locoregional therapies given to HCC patients on the WL to reduce the disease
progression as well as the dropout rate. These treatments act as a temporary “bridge” until a suitable donor
is identified. Liver resection, radiofrequency ablation (RFA), transarterial chemoembolization (TACE),
[2]
and stereotactic body radiation therapy (SBRT) are main bridge modalities to LT in patients with HCC .
The rates of drop out at 6 months and 1 year were estimated as high as 12% and 15%-30%, respectively, if
[4,5]
HCC is left untreated . The strongest risk factors for dropout from WL are tumor size ≥ 3 cm or multiple
tumors, waiting time ≥ 6 months, alpha fetoprotein (AFP) ≥ 200 ng/mL, and poor response to bridging
[6]
therapies . In patients with HCC within Milan criteria, bridging therapy is estimated to decrease the
dropout rate to 0-10%. To reduce the dropout rate from the WL, a consensus statement recommends that
bridging therapies should be considered for HCC patients with one nodule size 2 cm-5 cm or up to 3
[2]
nodules each ≤ 3 cm, expected to wait longer than 6 months .
Another aim of bridge therapy is to treat patients initially outside criteria for LT to fulfill Milan criteria
which allows entry to the WL for LT after an adequate period of follow-up. In this case, bridge therapy is
[3]
used as a downstaging procedure .

There are several studies of bridge therapy to LT for HCC with TACE or SBRT [10-12] alone. Some trials
[7-9]
have shown that adjuvant SBRT post-TACE was safe and effective for patients with HCC [13-15] . In this paper,
we report an HCC patient in the BCLC intermediate stage who we successfully treated with a combination
of TACE and SBRT as a bridge therapy to LT in our center.

CASE REPORT
A 39-year-old male with a history chronic hepatitis B virus infection was diagnosed with intermediate
BCLC HCC in October 2018. His liver function test (LFT) showed that he had Child-Pugh A5 cirrhosis.
The tumor was in VI-VII segments and the patient characteristics were shown in Table 1. He had one
tumor with a size bigger than 5 cm and very high serum AFP levels.

Because the patient was young with a good performance status of ECOG 0, the LT team decided that he
was an optimal candidate for LT and bridge therapy was needed to downstage the tumor while he was
on the WL. Two DC beads TACE treatments were carried out in October and November 2018. The DC
beads TACE technique was done in the same manner as conventional TACE. We used doxorubicin (Ebewe,
Austria) loaded with DC-beads (Bicompatibles, UK) at least 90-120 min before the intervention. The dose of
doxorubicin was 100 mg per each treatment. Two sizes of DC-beads were used (100-300 µm and 300-500 µm).
These treatments resulted in partial response according to the modified Response Evaluation Criteria in
[16]
Solid Tumors and Response Evaluation Criteria in Cancer of the Liver .

Due to serum AFP level still too high post-TACE, as well as there was no suitable donor, we decided that
he needs further bridge therapy with SBRT. The patient underwent SBRT with a total dose of 45 Gy in 3
fractions, one fraction delivered in every other day in January 2019.