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Bieu et al. Hepatoma Res 2020;6:49 I http://dx.doi.org/10.20517/2394-5079.2020.39 Page 5 of 10

time for each fraction was about 30 min: patient set up and verification 20 min, beam on 10 min. The total
SBRT course lasted for two weeks.

Follow-up
The patient was treated with tenofovir (Savi Tenofovir) 300 mg one tablet per day and scheduled for
checkup one month post-SBRT and then every 3 months. Clinical examination, lab tests, and imaging were
done during checkup including cell blood count, LFT, serum AFP, PIVKA II, abdominal ultrasound, chest
Xray and abdominal CT.

The patient was well tolerated with SBRT and showed only minimum adverse effects such as mild fever and
increased AST, ALT. Three months post SBRT, his LFT was still Child Pugh A5, serum PIVKA II and AFP
levels were decreased, the tumor size was also decreased with central necrosis [Table 1, Figure 2]. In July
2019, we found a suitable donor for him, and his LT was successfully performed in August 2019. His post
LT histopathology report showed that the tumor was mostly necrotized. He went on with tenofovir (Savi
Tenofovir) 300 mg one tablet per day, tacrolimus (Prograf) 1 mg six capsules per day to treat HBV, and
prevent rejection and routine follow-up. Until now, seven months post LT, he has no evidence of HCC, his
LFT is normal with a mild increase of AST, ALT.

DISCUSSION
Several locoregional therapies have been used as bridging treatments for HCC patients awaiting LT. The
most common treatments include TACE, RFA, and recently SBRT. Nowadays, TACE is still the most widely
used as bridging therapy. In the procedure, a chemotherapeutic drug (commonly doxorubicin, cisplatin or
mitomycin C), emulsified in lipiodol with embolizing material, is injected into the hepatic artery branch
that feeding the tumor, to induce hypoxemia and tumor necrosis. The technique has been enhanced by
drug-eluting beads (DEB-TACE), which allows a higher dose and uptake of chemotherapeutic drugs
into the tumor and less systemic toxicity. In the histological examination, TACE achieves a complete
pathological response in less than 30% of cases. Some studies focused on the efficacy of TACE as bridging
treatment to LT on dropout rates in WL, survival, and recurrence after LT. The reported results of bridge
therapy with TACE are controversial and no prospective randomized control trials have confirmed its
[2]
efficacy in reducing dropout rates . Several authors demonstrated that a good response to TACE (necrosis
[18]
> 60%) is significantly related to improved long-term survival after LT and a lower recurrence rate .
Others did not find any significant advantage of bridge therapy with TACE in overall and recurrence-free
survival after LT in HCC patients [19,20] .

SBRT uses stereotactic conformal RT with 1-5 fractions of large fraction sizes (8-20 Gy/fraction) to the
tumor while reducing the dose to adjacent normal tissues. The precise treatment and steep dose gradient
within the target volume lead to excellent conformity with steep dose fall-off and high dose delivery to the
[21]
target volume . These advantages of SBRT over conventional radiotherapy allows a high chance of tumor
[22]
control and minimizing treatment toxicities. SBRT for liver tumors was first introduced in the 1990s ;
however, it has not frequently been performed because of the concern of radiation-induced liver disease
(RILD). Recently, with the development of medical linear accelerators and motion management solutions
as well as supported data, SBRT has been recommended as a local treatment for HCC by NCCN guidelines.
[23]
Now it is considered as an option for HCC patients who are not candidates to other bridging therapies .
[24]
Data regarding the use of SBRT as a bridging treatment are emerging. In a paper by Sandroussi et al. , ten
HCC patients awaiting LT with tumor diameters ranging from 2.5 to 10.8 cm received conformal radiation
therapy in 5-6 fractions. The treatment was done in nine patients with acceptable toxicities. Five patients
underwent LT, and their explant pathology report showed that tumor necrosis ranging from 40%-90%.
At a median follow-up of 6 months, no patients had tumor recurrence after LT. The author suggested that