Prognostic factors and survival in advanced large hepatocellular carcinomas treated with combined transarterial chemoembolisation and hypofractionated image-guided radiotherapy

Abstract

Objectives: Large (≥10 cm) hepatocellular carcinomas (HCCs) carry a dismal prognosis and respond poorly to transarterial chemoembolisation (TACE). Combined TACE and hypofractionated image-guided radiotherapy (HIGRT) has emerged as a new treatment strategy. We evaluated its efficacy among these tumours and report the predictors of overall survival (OS). Methods: Data from 55 consecutive cases treated with preplanned combined TACE and HIGRT from 2007 to 2017 were evaluated from a prospectively collected database. Patients with advanced HCCs ≥10 cm, ineligible for curative intervention and with Child-Pugh scores ≤B7, received one dose of preplanned TACE 4 weeks prior to HIGRT. HIGRT doses were individualised according to the dose constraints of uninvolved liver and neighbouring organs at risk. OS was the primary endpoint. Results: In all, 55 patients with median tumour sizes of 15.3 cm were included. Tumour vascular thromboses and extrahepatic diseases were present in 25.5% and 32.7%, respectively. The median total equivalent dose in 2 Gy/fr (EQD2, α/β ratio = 10) was 32.7 Gy. The 2-year OS reached 24.9%. Clinical benefit rate was 83.6% with a 1-year local control rate of 57.4%. Multivariate analyses revealed alpha-fetoprotein (AFP) level (hazard ratio = 2.2, p = 0.025) and subsequent local treatment (hazard ratio = 0.2, p = 0.001) to be independent OS predictors. Responders undergoing subsequent curative resection achieved significantly better median OS than those without. Conclusion: Combined TACE and HIGRT achieved favourable survival outcomes among large HCCs. AFP level and subsequent local surgery were independent negative and positive OS predictors, respectively. Future studies are warranted.