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Treating Small Hepatocellular Carcinoma: Stereotactic Body Radiation Therapy Versus Radiofrequency Ablation

We read with interest the paper “Clinical outcomes of stereotactic body radiation therapy for small hepatocellular carcinoma” published in an upcoming issue of Journal of Gastroenterology and Hepatology. It is an elegant study that investigated the long-term outcomes of patients with hepatocellular carcinoma (HCC) undergoing stereotactic body radiation therapy (SBRT). Although the findings highlight the potential role of SRBT in treating small HCC, the conclusions remain to be carefully interpreted. Radiofrequency ablation (RFA) has been widely available and is currently the recommended treatment modality for small (< =3 cm) HCC. A classical single-center study which enrolled a large cohort of 1170 HCC patients undergoing RFA in Japan showed that the 5-year overall survival rate was 60.2%. Notably, when the outcome was stratified by tumor size, the survival for patients with HCC < =3 cm and >3 cm was 65.1% and 46.5%, respectively. However, in Park et al.’s cohort, the 5-year survival was only 44.9% for patients (n = 290) with median tumor diameter of 1.7 cm. Although SBRT is still quite effective, this new form of therapy should not be considered “an excellent ablative treatment option for patients with small HCC” as the authors have concluded. In addition, for SBRT, complete treatment typically takes 3–4 days (fractions), compared with only one to two treatment sessions of RFA which is associated with a shorter hospital stay. Although randomized trials are required for a direct comparison between SBRT and RFA, the latter should still be regarded as a more effective and feasible therapy for small HCC in current clinical practice.