Radiation Segmentectomy for Small, Solitary Hepatocellular Carcinoma.

Abstract

T Barcelona Clinic Liver Cancer staging and treatment guidelines suggest surgery or ablation for very early stage and early stage HCC, with transarterial chemoembolization recommended for the intermediate stage. These guidelines do not include radioembolization. While the main prospective trial (1) that assessed radioembolization in HCC resulted in no overall survival benefit, focus on selective internal radiation therapy has shifted toward optimizing dosimetry with higher absorbed tumor doses conferring improved disease control and survival. RS aims to deliver an ablative dose of internal radiation to downstage the patient’s disease or potentially achieve complete remission. Arndt and colleagues recently published their experience using RS to treat solitary, unresectable HCC measuring less than 4 cm. They compared RS with MWA in a propensity-matched study with 24 patients in each cohort. While overall survival did not differ between groups (mean of 59.0 and 44.3 months for RS and MWA, respectively), RS improved progression-free survival (57.8 vs 38.6 months). Interestingly, six of the patients in the RS group went on to transplantation, and none of these patients showed any viable disease on explant. Transplants in two patients who underwent MWA both had viable residual tumor. Despite the limitations of a small cohort and a retrospective design, the data from this study show great promise for expanded applications of RS. While considered equivalent to surgery for early stage HCC, thermal ablation shows a higher rate of local progression. In treating a similar stage of disease, RS may result in oncologic and survival benefits more comparable to surgery in patients who are otherwise not candidates for surgery. The exact role of radioembolization, specifically RS, in the treatment of HCC remains to be defined, but this study adds further evidence to support its investigation within a prospective trial. —Matthew J. Seager