Radiofrequency Ablation Versus Stereotactic Body Radiotherapy for Localized Hepatocellular Carcinoma in Nonsurgically Managed Patients: Analysis of the National Cancer Database

Predictive And Prognostic Value Of Hepatic Steatosis In Conversion Therapy For Colorectal Liver-limited Metastases: A Propensity Score Matching Analysis

Purpose

To evaluate the role of hepatic steatosis (HS) in patients with synchronous colorectal liver-limited metastases (CLLMs) undergoing conversion therapy.

Patients and methods

From March 2013 to March 2017, a total of 406 patients with initially unresectable CLLMs accepted conversion therapy in multidisciplinary team (MDT). Before the implementation of conversion therapy, all patients underwent CT scan to assess the presence of hepatic steatosis and divided into the HS group (n = 124) and the non-HS group (n = 282). After using propensity score matching (PSM) to eliminate the potential confounding bias of the two groups, the conversion hepatectomy rate and long-term oncological survival in two groups were compared.

Results

After 1:1 PSM, no significant difference was observed at baseline between patients in the HS group (n = 119) and the non-HS group (n = 119). Patients in the HS group had higher conversion hepatectomy rate from MDT evaluation (31.1% vs 18.5%, P = 0.029) and actual hepatectomy rate (30.2% vs 18.5%, P = 0.030), when compared with patients in the non-HS group, respectively. In addition, the HS group achieved better progression-free survival (PFS, P = 0.047) and overall survival (OS, P = 0.035) than that of the non-HS group. Multivariate logistic analysis confirmed that pretreatment HS was an independent predictor for conversion hepatectomy rate (OR, 2.393; 95% CI, 1.463–4.315, P = 0.001), and multivariate Cox analysis revealed that HS was an independent prognostic factor for PFS (HR, 0.493, 95% CI 0.281–0.866, P = 0.014) and OS (HR, 0.559, 95% CI 0.398–0.785, P = 0.001).

Conclusion

For CLLM patients who underwent conversion therapy, hepatic steatosis could be an effective predictor for conversion hepatectomy rate and an independent prognostic factor for PFS and OS.

Microwave ablation versus resection for hepatocellular carcinoma within the Milan criteria: a propensity-score analysis

Background:

Whether the efficient heat-generating mechanism of microwave ablation (MWA) is comparable with resection (RES) in treating hepatocellular carcinoma (HCC) remains unclear.

Methods:

This retrospective cohort study comprised 126 and 1183 patients with HCC meeting the Milan criteria who received MWA or RES between 2002 and 2017. We compared 5-year overall survival (OS) and recurrence-free survival (RFS) using both propensity-score matching (PSM) and inverse-probability-of-treatment-weighting (IPW) analysis and investigated the prognostic factors with multivariate Cox analysis.

Results:

After PSM (1:2), although MWA (n = 116) offered decreased 5-year RFS (30.6% versus 57.5%, p < 0.001) compared with RES (n = 212), both treatments provided similar 5-year OS (82.2% versus 80.5%, p = 0.360) because most patients with intrahepatic recurrence remained eligible for repeat treatments; similar results were found in the IPW analysis. Additionally, the comparable efficacy of MWA and RES was consistent across all subgroups: those with solitary HCC ⩽ 3.0 cm or >3.0 cm, or multifocal HCCs within the Milan criteria, patients with liver function of albumin–bilirubin grade 1 or 2, and older (⩾60 years) or younger (<60 years) patients. Multivariate Cox analysis confirmed that no difference was seen between MWA and RES in OS (hazard ratio = 0.85; p = 0.581) in the overall population; similar results were obtained in the propensity-score-matched and IPW cohorts.

Conclusions:

Compared with RES, MWA offered worse RFS for HCC within the Milan criteria; however, both treatments provided equivalent long-term OS because most patients with intrahepatic recurrence remained eligible for repeat treatments.

Recent clinical applications of external beam radiotherapy for hepatocellular carcinoma according to guidelines, major trials and meta-analyses

External beam radiotherapy (EBRT) for hepatocellular carcinoma (HCC) has not been widely used due to lack of high-level evidence, despite its potent local therapeutic effect. While clinical evidence has accumulated and meta-analyses of observational studies have provided integrated information to help in clinical decision-making, a recent randomized trial demonstrated the benefit of EBRT in cases of HCC with major vessel invasion. Based on these trends, the efficacy of EBRT has been better recognized, and EBRT has been more frequently recommended in several international treatment guidelines newly updated in 2018. This review examined the key issues of EBRT in the guidelines updated in 2018 as well as recently published noteworthy randomized trials and meta-analyses. Ongoing trials to identify the trends and direction of future research on EBRT for HCC were also reviewed.

Effects of adjuvant traditional Chinese medicine therapy on long-term survival in patients with hepatocellular carcinoma

BACKGROUND

Many patients with hepatocellular carcinoma (HCC) in Asian countries seek adjuvant therapy with traditional Chinese medicine (TCM). This study aims to explore the benefits of TCM therapy in the long-term survival of patients with hepatocellular carcinoma in China.

PATIENTS AND METHODS

In total, 3483 patients with HCC admitted to the Beijing Ditan Hospital of Capital Medical University were enrolled in this study. We used 1:1 frequency matching by sex, age, diagnosis time, Barcelona Clinic Liver Cancer staging, and type of treatments to compare the TCM users (n = 526) and non-TCM users (n = 526). A Cox multivariate regression model was employed to evaluate the effects of TCM therapy on the HR value and Kaplan-Meier survival curve for mortality risk in HCC patients. A log-rank test was performed to analyze the effect of TCM therapy on the survival time of HCC patients.

RESULTS

The Cox multivariate analysis indicated that TCM therapy was an independent protective factor for 5-year survival in patients with HCC (adjusted HR = 0.46, 95% CI 0.40-0.52, p < 0.0001). The Kaplan-Meier curve also showed that after PS matching, TCM users had a higher overall survival rate and a higher progression-free survival rate than non-TCM users. TCM users, regardless of the classification of etiology, tumor stage, liver function level, or type of treatment, all benefited significantly from TCM therapy. In addition, it was found that the most commonly used Chinese patent medications are Fufang Banmao Capsule, Huaier Granule, and Jinlong Capsule.

CONCLUSION

Using traditional Chinese medications as adjuvant therapy can probably prolong median survival time and improve the overall survival among patients with HCC. Further scientific studies and clinical trials are needed to examine the efficiency and safety.

Stereotactic Body Radiotherapy as a Salvage Therapy after Incomplete Radiofrequency Ablation for Hepatocellular Carcinoma: A Retrospective Propensity Score Matching Study

(1) Background: To investigate the clinical outcomes between radiofrequency ablation (RFA) and stereotactic body radiotherapy (SBRT) for residual hepatocellular carcinoma (RHCC). (2) Methods: 139 patients were diagnosed with the RHCC after post-operative checkup, among whom 39 and 33 patients underwent RFA or SBRT as salvage treatments, respectively. We applied the propensity score matching (PSM) to adjust for imbalances in treatment assignment. Local disease progression, progression-free survival (PFS), overall survival (OS), and treatment-related side effects were the study endpoints. (3) Results: Before PSM, the SBRT group demonstrated significantly lower local disease progression rate (6/33 vs. 23/39; p = 0.002), better PFS (the 1- and 3-year PFS were 63.3% and 49.3% vs. 41.5% and 22.3%, respectively, p = 0.036), and comparable OS (the 1- and 3-year OS were 85.4% and 71.1% vs. 97.3% and 57.6%, respectively, p = 0.680). After PSM of 23 matched cases, the SBRT group demonstrated significantly lower local disease progression rate, better PFS and comparable OS. Centrally located tumor predicted the worse OS. No acute grade 3+ toxicity was observed in both groups. (4) Conclusion: SBRT might be the preferred treatment for RHCC, especially for patients with larger tumors or tumors abutting major vessels, rather than repeated RFA.

Clinical assessment of magnetic resonance imaging-guided radiofrequency ablation for breast cancer

The aim of the present study was to investigate the efficacy of magnetic resonance imaging (MRI)-guided radiofrequency ablation (RFA) for breast cancer patients who cannot undergo traditional surgery. A total of 10 patients were treated by MRI-guided RFA, of whom 6 had stage IV disease (lung metastasis n=3, bone metastasis n=1, liver metastasis n=1 and mediastinal metastasis n=1) and the remaining 4 patients, who refused surgery, had stage III disease accompanied by severe underlying conditions. The changes in feasibility, tumor volume, bleeding, local recurrence, metastasis and complications were evaluated after RFA. The patients were followed up at 1, 3, 6 and 12 months, and annually thereafter. A total of 14 RFA sessions were successfully performed (100%) in the 10 patients, among whom 7 patients underwent a single RFA session, 2 patients underwent two sessions, and 1 patient underwent three sessions. Compared with pre-RFA, the volume of the tumors at 6 months after RFA was markedly decreased. There was no local tumor recurrence or metastasis detected during a mean follow-up period of 19.5±3.46 months, and no major complications were reported. Therefore, RFA was found to be a minimally invasive and feasible treatment method in the present study, and MRI-guided RFA may be a promising alternative option for breast cancer patients who are unable to tolerate surgery. However, more prospective studies on the applicability of RFA in breast cancer are required.

Patterns of Care and Outcomes of Definitive External Beam Radiotherapy and Radioembolization for Localized Hepatocellular Carcinoma: A Propensity Score-adjusted Analysis

OBJECTIVES

Most localized hepatocellular carcinoma (HCC) patients are not surgically operable or transplantation candidates, increasing the role for nonsurgical therapies. Ablative external beam radiotherapy (XRT) and transarterial radioembolization (TARE) are emerging radiotherapeutic treatments for localized HCC. We sought to evaluate their utilization and efficacy in a large nationwide cohort.

MATERIALS AND METHODS

We conducted an observational study of 2685 patients from the National Cancer Database (NCDB) diagnosed with American Joint Committee on Cancer 7th edition clinical stage I to III HCC between 2004 and 2015, treated with definitive-intent XRT delivered in 1 to 15 fractions or TARE. The association between treatment modality (XRT vs. TARE) and overall survival (OS) was defined using propensity score-weighted Kaplan-Meier estimators and propensity score-weighted multivariable Cox regressions.

RESULTS

Among 2685 patients, 2007 (74.7%) received TARE and 678 (25.3%) received XRT, with increasing usage for both from 2004 to 2015 (Ptrend<0.001), but with overall greater uptake and absolute usage of TARE. Patients who received TARE were more likely to have elevated alpha fetoprotein and more advanced stage (P<0.05 for all). Median OS was 14.5 months for the entire cohort. XRT was associated with an OS advantage compared with TARE on propensity score-unadjusted analysis (adjusted hazard ratio [AHR], 0.89; 95% confidence interval, 0.79-1.00; P=0.049), but not on propensity score-adjusted analysis (AHR, 0.99; 95% confidence interval, 0.86-1.13; P=0.829).

CONCLUSIONS

Our study demonstrates that while both XRT and TARE usage have increased with time, there was greater uptake and absolute use of TARE. We found no difference in survival between XRT and TARE after propensity score adjustment.

Radiotherapy for Hepatocellular Carcinoma Results in Comparable Survival to Radiofrequency Ablation: A Propensity Score Analysis

Potentially curative treatments for early-stage hepatocellular carcinoma (HCC) have drawbacks and contraindications. Recently, radiotherapy has achieved good outcomes. We compared the outcomes of radiotherapy and radiofrequency ablation (RFA) for early-stage HCC. Consecutive patients with ≤3 early-stage HCC lesions and tumor diameters ≤3 cm treated with RFA or radiotherapy were reviewed. RFA was the first choice for HCC unsuitable for surgery. Otherwise, stereotactic body radiotherapy in five fractions was mainly performed. For HCC adjacent to the gastrointestinal tract, radiotherapy with mild hypofractionation was performed. Propensity score matching was performed to reduce the selection bias between the RFA and radiotherapy groups. Between 2012 and 2016, a total of 231 patients with 474 tumors and 143 patients with 221 tumors were eligible and were treated with RFA and radiotherapy, respectively. In an unmatched comparison, the 3-year local recurrence rate was significantly lower for radiotherapy than for RFA (5.3%; 95% confidence interval [CI], 2.7-9.2; versus 12.9%, 95% CI, 9.9-16.2) (P < 0.01). A propensity score matching analysis of 106 patients in each group successfully matched the two treatment groups with regard to Barcelona Clinic Liver Cancer staging, T stage, and tumor size but not the adjacency of the tumor to risk organs or first or salvage treatment. The 3-year overall survival rates for RFA and radiotherapy patients were comparable (69.1%; 95% CI, 58.2-77.7; and 70.4%; 95% CI, 58.5-79.4, respectively; P = 0.86). Conclusion: Radiotherapy has excellent local control and comparable overall survival in patients with well-compensated liver function, exhibiting advantageous characteristics and compensating for the deficiencies of other treatment modalities; radiotherapy appears to be an acceptable alternative treatment option for patients who are not candidates for RFA.

Optimizing radiotherapy with immune checkpoint blockade in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer, and its incidence is rapidly increasing in North America and Western Europe as well as South-East Asia. Patients with advanced stage HCC have very poor outcomes; therefore, the discovery of new innovative approaches is urgently needed. Cancer immunotherapy has become a game-changer and revolutionized cancer treatment. A comprehensive understanding of tumor-immune interactions led to the development of immune checkpoint inhibitors (ICIs) as new therapeutic tools, which have been used with great success. Targeting immune checkpoint molecules such as programmed cell death-1 (PD-1) and cytotoxic T lymphocyte-associated protein-4 (CTLA-4) reinvigorates anti-tumor immunity by restoring exhausted T cells. Despite their effectiveness in several types of cancer, of the many immune suppressive mechanisms limit the efficacy of ICI monotherapy. Radiation therapy (RT) is an essential local treatment modality for a broad range of malignancies, and it is currently gaining extensive attention as a promising combination partner with ICIs because of its ability to trigger immunogenic cell death. The efficacy of combination approaches using RT and ICIs has been well documented in numerous preclinical and clinical studies on various types of cancers but not HCC. The application of ICIs has now expanded to HCC, and RT is recognized as a promising modality in HCC. This review will highlight the current roles of PD-1 and CTLA-4 therapies and their combination with RT in the treatment of cancers, including HCC. In addition, this review will discuss the future perspectives of the combination of ICIs and RT in HCC treatment.

Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Current Trends and Controversies

Hepatocellular carcinoma is the fourth leading cause of cancer-related death worldwide. Depending on the extent of disease and competing comorbidities for mortality, multiple liver-directed therapy options exist for the treatment of hepatocellular carcinoma. Advancements in radiation oncology have led to the emergence of stereotactic body radiation therapy as a promising liver-directed therapy, which delivers high doses of radiation with a steep dose gradient to maximize local tumor control and minimize radiation-induced treatment toxicity. In this study, we review the current clinical data as well as the unresolved issues and controversies regarding stereotactic body radiation therapy for hepatocellular carcinoma: (1) Is there a radiation dose–response relationship with hepatocellular carcinoma? (2) What are the optimal dosimetric predictors of radiation-induced liver disease, and do they differ for patients with varying liver function? (3) How do we assess treatment response on imaging? (4) How does stereotactic body radiation therapy compare to other liver-directed therapy modalities, including proton beam therapy? Based on the current literature discussed, this review highlights future possible research and clinical directions.

Regional therapies for the treatment of primary and metastatic hepatic tumors: A disease-based review of techniques and critical appraisal of current evidence

The practice of hepatic surgery has become increasingly complex as additional therapeutic options emerge to treat both primary and metastatic tumors of the liver. Liver-directed therapy options include selective internal radiation therapy (SIRT), stereotactic body radiation therapy, chemoembolization, bland embolization, hepatic artery infusion chemotherapy (HAIC), and ablative techniques such as microwave or radiofrequency ablation. Hepatocellular carcinoma has been treated with many of these therapies for palliation of symptoms, definitive treatment, and as a bridge to transplantation. Intrahepatic cholangiocarcinoma, particularly patients with unresectable disease, have demonstrated clinical responses to both SIRT as well as HAIC. Colorectal liver metastases have been treated with all of these techniques with varying degrees of success depending on the clinical scenario. A detailed understanding of these technologies and the evidence supporting their use is essential for the modern hepatic surgeon to properly sequence therapies and provide salvage options when first-line treatment has failed. This review describes these techniques and their appropriate usage based on the disease of interest and the respective evidence currently available.

LINE-1 ORF-1p enhances the transcription factor activity of pregnenolone X receptor and promotes sorafenib resistance in hepatocellular carcinoma cells

Background

LINE-1 ORF-1p is encoded by the human pro-oncogene LINE-1. Our previous work showed that LINE-1 ORF-1p could enhance the resistance of hepatocellular carcinoma (HCC) cells to antitumor agents. However, the mechanisms involved in LINE-1 ORF-1p-mediated drug resistance remain largely unknown.

Materials and methods

The endogenous mRNA level of LINE-1 ORF-1p in clinical HCC specimens was examined using quantitative PCR (qPCR). The prognosis of HCC patients was assessed using time to progression and overall survival. The transcription factor activity of pregnenolone X receptor (PXR) was examined using luciferase gene reporter assays, qPCR, chromatin immunoprecipitation assays and cellular subfraction assays. Protein interaction between LINE-1 ORF-1p and PXR was detected by co-immunoprecipitation. The effect of LINE-1 ORF-1p on sorafenib resistance in HCC cells was studied using in vitro and in vivo models.

Results

A high level of LINE-1 ORF-1p in clinical specimens was related to poor prognosis in patients who received sorafenib treatment. LINE-1 ORF-1p increased the transcription factor activity of PXR by interacting with PXR and enhancing its cytoplasmic/nuclear translocation, and recruiting PXR to its downstream gene promoter, in turn enhancing the expression of the sorafenib resistance-related genes, CYP3A4 and mdr-1. LINE-1 ORF-1p enhanced the resistance to and clearance of sorafenib in HCC cells.

Conclusion

LINE-1 ORF-1p enhances the transcription factor activation of PXR and promotes the clearance of and resistance to sorafenib in HCC cells.

Stereotactic body radiation therapy in primary hepatocellular carcinoma: current status and future directions

Stereotactic body radiation therapy (SBRT) is a form of radiation therapy that has been used in the treatment of primary hepatocellular carcinoma (HCC) over the past decade. To evaluate the clinical efficacy of SBRT in primary HCC, a literature search was conducted to identify original research articles published from January 2000 through January 2018 in PubMed on SBRT in HCC. All relevant studies published from 2004 to 2018 were included. Prospective studies demonstrated 2-year local control (LC) rates ranging from 64-95% and overall survival (OS) rates ranging from 34% (2-year) to 65% (3-year). Retrospective studies demonstrated 2-year LC rates of 44-90% and 2-year OS rates of 24-67%. Reported toxicities in primary HCC patients vary but SBRT appears to be relatively well tolerated. Studies comparing SBRT to radiofrequency ablation (RFA) are few, but they suggest SBRT may be more effective than RFA in specific primary HCC populations. Additionally, SBRT appears to increase the efficacy of both transarterial chemoembolization (TACE) and sorafenib in selected primary HCC populations.

Stereotactic Body Radiotherapy: Does It Have a Role in Management of Hepatocellular Carcinoma?

Stereotactic body radiotherapy (SBRT) is a form of radiotherapy that delivers high doses of irradiation with high precision in a small number of fractions. However, it has not frequently been performed for the liver due to the risk of radiation-induced liver toxicity. Furthermore, liver SBRT is cumbersome because it requires accurate patient repositioning, target localization, control of breathing-related motion, and confers a toxicity risk to the small bowel. Recently, with the advancement of modern technologies including intensity-modulated RT and image-guided RT, SBRT has been shown to significantly improve local control and survival outcomes for hepatocellular carcinoma (HCC), specifically those unfit for other local therapies. While it can be used as a stand-alone treatment for those patients, it can also be applied either as an alternative or as an adjunct to other HCC therapies (e.g., transarterial chemoembolization, and radiofrequency ablation). SBRT might be an effective and safe bridging therapy for patients awaiting liver transplantation. Furthermore, in recent studies, SBRT has been shown to have a potential role as an immunostimulator, supporting the novel combination strategy of immunoradiotherapy for HCC. In this review, the role of SBRT with some technical issues is discussed. In addition, future implications of SBRT as an immunostimulator are considered.

MicroRNA-140-3p enhances the sensitivity of hepatocellular carcinoma cells to sorafenib by targeting pregnenolone X receptor

Background

Pregnane X receptor (PXR), which is a member of the nuclear receptor protein family (nuclear receptor subfamily 1 group I member 2 [NR 1I2]), mediates the drug-resistance in the hepatocellular carcinoma (HCC) via enhancing the expression of drug-resistance-related genes which accelerate the clearance of antitumor drugs, eg, sorafenib. However, there are few reports on miRNA targeting PXR participating in the epigenetic regulation of PXR in HCC cells.

Materials and methods

TargetScan 7.2, an online method, was used to predict the miRNAs potentially targeting PXR. The expression of PXR and PXR downstream genes was detected by quantitative real-time PCR (qPCR) and Western blot. The clearance of sorafenib in HCC cells was monitored by liquid chromatograph-mass spectrometer/mass spectrometer (LC-MS/MS). The effects of miRNA on sorafenib’s efficacy were examined by in vitro methods, eg, MTT, and in vivo methods, eg, subcutaneous or intrahepatic tumor model.

Results

By virtual screening, we identified that miR-140-3p possibly targets PXR and then confirmed that the overexpression of miR-140-3p via lentiviral particles inhibited the expression of PXR in HCC cells. The downregulation of PXR’s expression by miR-140-3p led to the reduction of PXR downstream genes’ expression, which finally resulted in the decelerating clearance of sorafenib in HCC cells and enhanced the sensitivity of HCC cells to sorafenib. The effect of miR-140-3p could not modulate the expression of mutated PXR and the effect of miR-140-3p could also be inhibited by miR-140-3p’s inhibitor. Moreover, miR-140-3p enhanced the anti-tumor effect of sorafenib in both the subcutaneous and intrahepatic HCC tumor models.

Conclusion

Our study suggests that targeting PXR by miR-140-3p is a promising strategy for enhancing sorafenib’s efficacy during HCC treatment.

Novel ADAM-17 inhibitor ZLDI-8 enhances the in vitro and in vivo chemotherapeutic effects of Sorafenib on hepatocellular carcinoma cells

Hepatocellular carcinoma (HCC) is one of the greatest life threats for Chinese people, and the prognosis of this malignancy is poor due to the strong chemotherapy resistance in patients. Notch pathway components mediate cell survival and epithelial-mesenchymal transition (EMT), and also participate in the induction of multi-drug resistance (MDR). In the present study, we demonstrated the discovery of a novel inhibitor for Notch activating/cleaving enzyme ADAM-17, named ZLDI-8; it inhibited the cleavage of NOTCH protein, consequently decreased the expression of pro-survival/anti-apoptosis and EMT related proteins. ZLDI-8 treatment enhanced the susceptibility of HCC cells to a small molecular kinase inhibitor Sorafenib, and chemotherapy agents Etoposide and Paclitaxel. ZLDI-8 treatment enhanced the effect of Sorafenib on inhibiting tumor growth in nude HCC-bearing mice model. These results suggest that ZLDI-8 can be a promising therapeutic agent to enhance Sorafenib's anti-tumor effect and to overcome the MDR of HCC patients.

Effectiveness and cost of radiofrequency ablation and stereotactic body radiotherapy for treatment of early-stage hepatocellular carcinoma: An analysis of SEER-medicare

INTRODUCTION

For early-stage hepatocellular carcinoma (HCC) patients, ablative strategies are potentially curative treatment options. Stereotactic body radiotherapy (SBRT) has emerged as a promising ablative therapy, although its comparison with radiofrequency ablation (RFA) remains confined to a single institution retrospective review. We sought to characterize the comparative outcomes and cost between the two treatment strategies.

METHODS

We conducted a secondary analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (2004-2011) and identified adult patients with stage I or II HCC and treated with RFA or SBRT as the initial treatment within 6 months of diagnosis. Survival analysis was conducted using Kaplan-Meier curves and multivariate Cox proportional hazard analysis. Factors associated with overall survival and 90-day hospital admission post-treatment were identified using propensity score (PS) adjusted multivariate analysis. We performed costs analysis and calculated incremental cost-effectiveness ratios (ICER).

RESULTS

Four hundred and forty patients were identified, 408 treated with RFA and 32 SBRT. In the overall cohort, 90-day hospitalization and 1-year mortality were similar between groups but RFA patients had better overall survival (P < 0.001). Multivariate analysis showed advanced age, higher stage, decompensated cirrhosis, and treatment with SBRT (HR 1.80; 95%CI: 1.15-2.82) was associated with worse survival, but in the PS adjusted analysis, survival and costs were similar between the two groups.

CONCLUSION

In a national cohort of early stage HCC patients, treatment with RFA vs SBRT resulted in no significant difference in survival, 90-day hospitalization, or costs. These data highlight the need for a randomized clinical trial comparing these two modalities.