Yan Michael, Li Zhihao, Claasen Marco P A W, Santiago Anna T, Rajendran Luckshi, Munoz-Schuffenegger Pablo, Lee Cameron, Magyar Christian T J, McGilvray Ian, Shwaartz Chaya, Reichman Trevor, Moulton Carol-Anne, Cleary Sean, O'Kane Grainne, Vogel Arndt, Grant Robert, Kim Tae Kyoung, Naidoo Catherine Soo-Yee, Hosni Ali, Mesci Aruz, Dawson Laura A, Sapisochin Gonzalo
Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
HBP and Multi-Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.
Ann Surg Oncol. 2025 Mar;32(3):1771-1783. doi: 10.1245/s10434-024-16456-6. Epub 2024 Dec 18.
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.
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.
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.
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.
根据指南，晚期肝细胞癌（HCC）合并大血管侵犯（MVI）的患者建议接受全身治疗。立体定向体部放疗（SBRT）和手术在这一患者群体中的应用越来越多。本研究比较了这些局部治疗的疗效。
纳入1999年至2022年间诊断为HCC合并MVI并接受手术或SBRT治疗的患者。倾向评分匹配法最大限度地减少了混杂因素的偏差。采用Kaplan-Meier法分析总生存期（OS），并通过竞争风险法评估局部、区域和远处复发情况。采用Lasso法进行单变量和多变量分析，评估OS的预测因素。
175例患者中，38例行手术治疗，137例接受SBRT治疗。中位年龄为61岁，肿瘤体积为158.6立方厘米，甲胎蛋白水平为197国际单位/毫升。大多数手术患者通过开放手术（97%）进行了大切除（74%）。SBRT的中位生物等效剂量（BED）为53.7戈瑞。匹配后，每组35例患者的中位OS为16个月。SBRT组1年时的局部失败率（20%）高于手术组（12%）（p = 0.028）。与SBRT组（17%）相比，手术组的远处失败更常见（54%）[p = 0.003]。排除接受辅助全身治疗的SBRT患者后，结果未改变。术后住院死亡率为9%，SBRT后14%出现肝功能损害。
手术和SBRT均能提供良好的长期OS和控制效果。手术提供更好的局部控制，而SBRT的远处复发率较低。虽然SBRT的毒性可接受，但手术具有显著的死亡风险。
