What is the role of stereotactic body radiotherapy to treat inoperable hepatocellular carcinoma?

Wahl et al., in a recent retrospective analysis, compared patients with inoperable, non-metastatic hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) or stereotactic body radiotherapy (SBRT) (1). Over an 8 years’ time period, there were 161 in the RFA group and 63 patients in the SBRT group. Treatment plans were made based on multidisciplinary tumor board review. The two groups were similar in tumor size and number of lesions treated per patient. However, the SBRT group had lower Child-Pugh scores and had more prior liver directed treatments. Overall one-year survival was 70% in the RFA group and 74% in the SBRT group. There was no statistically significant difference in complication rates between the two groups. For tumors >2 cm, the freedom from local progression (FFLP) was worse in the RFA group than the SBRT group (P=0.025). From this finding, the authors concluded that SBRT should be first line treatment for inoperable, larger HCC. This is an important study that examines the role for SBRT in the treatment of HCC. However, the overall conclusion that SBRT is a reasonable first-line treatment of inoperable, larger HCC is premature and is not justified by the data.