title: Stereotactic ablative radiation therapy prior to liver transplantation in hepatocellular carcinoma.
abstract: OBJECTIVE
  Stereotactic ablative radiotherapy (SABR) is a safe treatment approach for hepatocellular carcinoma (HCC) with comparable effectiveness to other local therapies. Only scant information is available concerning the role of SABR prior to liver transplantation (LT) for HCC. We present a consecutive case series investigating the role of SABR as a bridge or downstaging option in HCC patients subsequently submitted to LT.
  
  
  METHODS
  Between September 2012 and May 2014, 8 patients for a total of 13 lesions underwent SABR prior to LT. Inclusion criteria were a pathological or radiological diagnosis of HCC, lesion size ≤6 cm or lesion number ≤3 with a total diameter ≤6 cm, no extrahepatic metastases, Child-Pugh class A-B, ECOG performance status ≤1. Patients were prescribed 36-48 Gy in 3-5 fractions (8 Gy × 5 fractions or 16 Gy × 3 fractions), in 3-5 consecutive days according to clinical and dosimetric decision making. Radiological response was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Pathological response was assessed through the rate of tumor necrosis relative to the total tumor volume. Acute and late toxicities were scored using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4 (CTCAE v 4.0).
  
  
  RESULTS
  Among the 13 pathologically evaluated lesions, 8 (61.5 %) lesions had a complete response 2 (15.3 %) had a minimal pathological response and other 2 (15.3 %) showed stable disease. The remaining lesion had a significant pathological response. Maximum detected toxicity included a G2 GGT increase in two patients (at 1 and 3 months respectively). One patient developed a non-classic RILD with a fivefold increase in transaminase enzymes level and a shift in Child-Pugh category from B7 to C10 due to bilirubin increase. Only one modification in the surgical strategy was needed during LT.
  
  
  CONCLUSIONS
  SABR proved to be a safe and effective local therapy prior to LT in HCC patients. Prospective controlled clinical trials are needed to evaluate its efficacy compared to other local therapies in this setting.
authors.affiliation: Department of Oncology, Radiation Oncology, University of Turin School of Medicine, Via Genova 3, 10126, Turin, Italy.
authors.forename: Alessia
authors.initials: A
authors.lastname: Guarneri
authors.affiliation: Department of Oncology, Radiation Oncology, University of Turin School of Medicine, Via Genova 3, 10126, Turin, Italy. pierfrancesco.franco@unito.it.
authors.forename: Pierfrancesco
authors.initials: P
authors.lastname: Franco
authors.affiliation: Department of Surgical Sciences, Liver Transplantation Center, University of Turin, Turin, Italy.
authors.forename: Renato
authors.initials: R
authors.lastname: Romagnoli
authors.affiliation: Department of Oncology, Radiation Oncology, University of Turin School of Medicine, Via Genova 3, 10126, Turin, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Trino
authors.affiliation: Department of Surgical Sciences, Liver Transplantation Center, University of Turin, Turin, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Mirabella
authors.affiliation: Pathology Unit, Department of Medical Sciences, University of Torino, Turin, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Molinaro
authors.affiliation: Department of Surgical Sciences, Liver Transplantation Center, University of Turin, Turin, Italy.
authors.forename: Giorgia
authors.initials: G
authors.lastname: Rizza
authors.affiliation: Department of Oncology, Radiation Oncology, University of Turin School of Medicine, Via Genova 3, 10126, Turin, Italy.
authors.forename: Andrea Riccardo
authors.initials: AR
authors.lastname: Filippi
authors.affiliation: Department of Gastro-Hepatology, AOU Città della Salute e della Scienza, Turin, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Carucci
authors.affiliation: Department of Surgical Sciences, Liver Transplantation Center, University of Turin, Turin, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Salizzoni
authors.affiliation: Department of Oncology, Radiation Oncology, University of Turin School of Medicine, Via Genova 3, 10126, Turin, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Ricardi
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011879:Radiotherapy Dosage; D013238:Stereotaxic Techniques; D016896:Treatment Outcome; D047368:Tumor Burden
keywords: Bridge; Hepatocellular carcinoma; Liver transplantation; Local control; Stereotactic ablative radiotherapy; Surgery