2128 - Stereotactic Body Radiation for Hepatocellular Carcinoma in Patients with Child Pugh C Cirrhosis

Purpose/Objective(s): Patients with Child-Pugh (CP) class C cirrhosis and hepatocellular carcinoma (HCC) are typically considered contraindicated for radiation therapy due to hepatic decompensation risk. Limited data exist on stereotactic body radiation therapy (SBRT) in this population. We report safety and efficacy outcomes of SBRT in CP C HCC patients.

Materials/Methods: We conducted a single-institution retrospective review of CP C cirrhosis patients (score 10-15) with HCC treated with SBRT between January 2010 and July 2025. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier methodology from SBRT completion. Toxicity was evaluated using CP score and CTCAE v6.0. Log-rank tests were used to compare OS across subgroups, and Fisher's exact tests were used to evaluate associations with grade =3 toxicity. Analyses were performed in R (version 4.5.1).

Results: Twenty-eight CP C patients treated with SBRT were identified. Median age was 64 years (54-82); 75% were male. Predominant etiologies included non-alcoholic steatohepatitis (32%), alcohol-related disease (21%), and viral hepatitis (22%). Among 28 patients, 30 lesions were treated, with median GTV volume of 30.8 cc. Median pre-treatment CP score was 11 (10-14). Median radiation dose was 40 Gy in 5 fractions. Grade =3 toxicity occurred in 60.7% of patients (n=17), most commonly encephalopathy and hepatic failure, including 3 (10.7%) grade 5 hepatic failure events. Four patients (14.3%) were successfully bridged to liver transplant; one (3.6%) died intraoperatively. Median OS was 13.4 months (95% CI: 3.8 months-not reached (NR)) and median PFS was 3.3 months (95% CI: 3.1-12.1 months). Transplanted patients had longer OS (median NR) compared with non-transplanted patients (median 4.3 months; 95% CI: 3.2-NR; p=0.004). On exploratory analyses, CP score 10 versus >10 (p=0.03) and male sex (p=0.02) were significantly associated with improved OS, while etiology, age, mean liver dose, and tumor volume were not. No factors were associated with grade =3 toxicity.

Conclusion: In this largest reported series of true CP C patients treated with SBRT, outcomes suggest that SBRT is a feasible treatment option in highly selected patients, particularly those who can be successfully bridged to transplant. From this series, it is not possible to determine how much SBRT added to the morbidity in this high-risk population.