Stereotactic body radiotherapy and other locoregional therapies for hepatocellular carcinoma in patients with cirrhosis: real-world treatment allocation, BCLC-stratified outcomes, and prognostic determinants.

BACKGROUND AND

aimsStereotactic body radiotherapy (SBRT) has emerged as a treatment option for hepatocellular carcinoma (HCC) in patients ineligible for thermal ablation or surgery. However, real-world evidence on how physicians select between locoregional therapies, the stage-specific outcomes of these treatment decisions, and the prognostic determinants that transcend treatment modality remains limited. We aimed to (1) characterize real-world treatment allocation patterns between SBRT and other locoregional therapies (OLT) in patients with cirrhosis and HCC, (2) describe disease control, recurrence, and survival outcomes stratified by Barcelona Clinic Liver Cancer (BCLC) stage, and (3) identify adverse prognostic factors for mortality across the overall cohort. PATIENTS AND

methodsThis retrospective, single-centre, descriptive observational study included patients with HCC treated between April 2021 and October 2024. Patients received either SBRT or OLT (n = 42, including radiofrequency or microwave ablation, trans-arterial chemoembolization, or combinations thereof). Disease control was assessed at 90 days using modified RECIST criteria. Outcomes were analysed within BCLC strata, and competing risks analysis was performed for recurrence. Prognostic factors for mortality were assessed using Cox regression and Kaplan-Meier analyses across the entire cohort.

resultsReal-world physician choices revealed significant confounding by indication: SBRT was preferentially selected for patients with more advanced disease (BCLC B/C/D: 69.5% vs. 47.6%; p = 0.017) and worse baseline liver function (CTP score: 7.2 ± 1.9 vs. 6.4 ± 1.5; p = 0.015). Within the BCLC B stratum, the only stage with adequate patients in both arms, baseline characteristics were comparable across key parameters. Ninety-day disease control rates were comparable overall (92.9% vs. 83.3%; p = 0.074) and within BCLC B (86.3% vs. 76.5%; p = 0.448). All 19 deaths occurred exclusively in BCLC B/C/D patients (p = 0.001), regardless of treatment modality, with no deaths among 61 early-stage (BCLC 0/A) patients. Across the entire cohort, serum albumin (dead 3.17 ± 0.58 vs. alive 3.51 ± 0.55; p = 0.016), ALBI score (p = 0.030), and BCLC stage were dominant mortality predictors. Mortality was driven by sepsis rather than tumor progression.

conclusionsIn this real-world descriptive study, SBRT was reserved for higher-risk patients yet achieved comparable disease control across BCLC stages. Survival was ultimately determined by BCLC stage and hepatic reserve, particularly serum albumin, rather than treatment modality. These findings support risk stratification using albumin and diabetes status to guide treatment selection. Prospective, BCLC-stage matched studies are needed to confirm treatment-specific effects.