Comparative Study

. 2025 Mar;32(3):1771-1783.

doi: 10.1245/s10434-024-16456-6. Epub 2024 Dec 18.

Outcomes of Stereotactic Body Radiotherapy Compared with Surgical Resection in Patients with Hepatocellular Carcinoma and Macrovascular Invasion: A Propensity Score-Matched Analysis

Michael Yan^#¹, Zhihao Li^#², Marco P A W Claasen^{2

3}, Anna T Santiago⁴, Luckshi Rajendran², Pablo Munoz-Schuffenegger^{1

5}, Cameron Lee¹, Christian T J Magyar^{2

6}, Ian McGilvray², Chaya Shwaartz², Trevor Reichman², Carol-Anne Moulton², Sean Cleary², Grainne O'Kane^{7

8}, Arndt Vogel^{7

9}, Robert Grant⁷, Tae Kyoung Kim¹⁰, Catherine Soo-Yee Naidoo¹⁰, Ali Hosni¹, Aruz Mesci¹, Laura A Dawson¹, Gonzalo Sapisochin¹¹

Affiliations

¹ Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
² HBP and Multi-Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.
³ Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁴ Department of Biostatistics, University Health Network, Toronto, ON, Canada.
⁵ Radiation Oncology Unit, Department of Hematology - Oncology, Pontificia Universidad Catolica de Chile, Santiago, Chile.
⁶ Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁷ Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
⁸ Department of Medical Oncology, Trinity St James's Cancer Institute, Dublin, Republic of Ireland.
⁹ Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany.
¹⁰ Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.
¹¹ HBP and Multi-Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada. Gonzalo.sapisochin@uhn.ca.

^# Contributed equally.

PMID: 39692983
DOI: 10.1245/s10434-024-16456-6

Comparative Study

Outcomes of Stereotactic Body Radiotherapy Compared with Surgical Resection in Patients with Hepatocellular Carcinoma and Macrovascular Invasion: A Propensity Score-Matched Analysis

Michael Yan et al. Ann Surg Oncol. 2025 Mar.

. 2025 Mar;32(3):1771-1783.

doi: 10.1245/s10434-024-16456-6. Epub 2024 Dec 18.

Authors

Affiliations

¹ Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
² HBP and Multi-Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.
³ Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁴ Department of Biostatistics, University Health Network, Toronto, ON, Canada.
⁵ Radiation Oncology Unit, Department of Hematology - Oncology, Pontificia Universidad Catolica de Chile, Santiago, Chile.
⁶ Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁷ Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
⁸ Department of Medical Oncology, Trinity St James's Cancer Institute, Dublin, Republic of Ireland.
⁹ Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany.
¹⁰ Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.
¹¹ HBP and Multi-Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada. Gonzalo.sapisochin@uhn.ca.

^# Contributed equally.

PMID: 39692983
DOI: 10.1245/s10434-024-16456-6

Abstract

Introduction: Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) are recommended to receive systemic therapy according to guidelines. Stereotactic body radiotherapy (SBRT) and surgery are increasingly used in this patient population. This study compares outcomes from these local treatments.

Methods: Patients diagnosed with HCC with MVI and treated with surgery or SBRT between 1999 and 2022 were included. Propensity score matching minimized bias from confounders. Overall survival (OS) was analyzed using the Kaplan-Meier method,. and local, regional, and distant recurrences were assessed via competing risk methods. Univariable and multivariable analyses adjusted by the Lasso method evaluated OS predictors.

Results: Among 175 patients, 38 underwent surgery and 137 received SBRT. The median age was 61 years, tumor volume was 158.6 cc, and α-fetoprotein level was 197 IU/mL. Most surgical patients had major resection (74%) via an open approach (97%). The median biologically effective dose (BED) for SBRT was 53.7 Gy. After matching, 35 patients per group had a median OS of 16 months. Local failure was higher in the SBRT group (20%) than in the surgery group (12%) at 1 year (p = 0.028). Distant failure was more frequent in surgery (54%) compared with SBRT (17%) [p = 0.003]. Excluding SBRT patients receiving adjuvant systemic therapy did not change the results. In-hospital mortality was 9% post-surgery and 14% experienced post-SBRT liver impairment.

Conclusion: Both surgery and SBRT offer good long-term OS and control. Surgery provides better local control, while SBRT had lower distant relapse. While SBRT has acceptable toxicity, surgery carries a significant mortality risk.

Keywords: Hepatectomy; Hepatocellular carcinoma; Macrovascular invasion; Propensity score; Stereotactic body radiotherapy.

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Conflict of interest statement

Disclosures: Gonzalo Sapisochin has undertaken consultancy work for Astra-Zeneca, Roche, Evidera, Novartis, HepaRegenix, and Integra; has received financial compensation for talks for Roche, Astra-Zeneca, Chiesi, and Integra; and has received research funding from Roche and Astra-Zeneca. Laura A. Dawson received funding from Merck for a grant (monies paid to the institution) and has received honorarium from Astra-Zeneca. Michael Yan has undertaken consultancy work for Need Inc. Arndt Vogel has undertaken consultancy and advisory roles for Roche, AstraZenca, Böhringer-Ingelheim, Ipsen, Incyte, Cogent, EISAI, Zymeworks, Biologix, BMS, Terumo, Elevar, Servier, MSD, Tahio, Jazzpharma, Medivir, Abbvie, Tyra, Falk, Janssen, and Lilly. Grainne O'Kane has received an institutional grant and honoraria from Roche and AstraZeneca; honoraria from Incyte and Servier; and travel grants from MSD. Robert Grant has received a graduate scholarship from Pfizer, and undertaken consulting or advisory roles for Astrazeneca, Tempus, Eisai, Incyte, Knight Therapeutics, Guardant Health, and Ipsen. Ali Hosni declares non-financial leadership of the liver TSG at ELEKTA MRL consortium. Zhihao Li, Marco P.A.W. Claasen, Anna T. Santiago, Luckshi Rajendran, Pablo Munoz-Schuffenegger, Cameron Lee, Christian T.J. Magyar, Ian McGilvray, Chaya Shwaartz, Trevor Reichman, Carol-Anne Moulton, Sean Cleary, Tae Kyoung Kim, Catherine Soo-Yee Naidoo, and Aruz Mesci have no conflicts of interest to declare that may be relevant to the contents of this study.

References

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Outcomes of Stereotactic Body Radiotherapy Compared with Surgical Resection in Patients with Hepatocellular Carcinoma and Macrovascular Invasion: A Propensity Score-Matched Analysis

Affiliations

Outcomes of Stereotactic Body Radiotherapy Compared with Surgical Resection in Patients with Hepatocellular Carcinoma and Macrovascular Invasion: A Propensity Score-Matched Analysis

Authors

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