Hepatic Resection versus Stereotactic Body Radiation Therapy as Initial Local Treatment for BCLC Stage 0 Hepatocellular Carcinoma: A Propensity Score-Weighted Analysis.

INTRODUCTION

This study aimed to compare the real-world effectiveness and safety of hepatic resection versus stereotactic body radiation therapy (SBRT) as initial local treatments for Barcelona Clinic Liver Cancer (BCLC) stage 0 hepatocellular carcinoma (HCC).

METHODS

We retrospectively analyzed 537 treatment-naïve patients with single HCC measuring ≤2 cm who underwent hepatic resection (n = 450) or SBRT (n = 87) between January 2015 and December 2023. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics between treatment groups. Overall survival (OS) and disease-free survival (DFS) were evaluated using weighted Cox proportional hazards models, while competing-risk models estimated the cumulative incidence of overall and intrahepatic recurrence. Treatment-related adverse events (TRAEs) and longitudinal changes in liver function were also assessed.

RESULTS

At baseline, patients in the SBRT group were significantly older, had a higher comorbidity burden, and exhibited poorer liver function compared to those in the resection group. Over a median follow-up of 56.8 months (range, 8.3-117.0), the unadjusted 3-year OS rates were 98.8% for resection versus 92.3% for SBRT (hazard ratio [HR] 3.15; p = 0.002), and 3-year DFS rates were 80.9% versus 64.9%, respectively (HR 1.58; p = 0.026). However, the IPTW-adjusted analysis demonstrated comparable outcomes between treatment groups, with 3-year rates of OS at 98.9% versus 96.2% (HR 1.15; p = 0.775), DFS at 79.1% versus 74.1% (HR 1.06; p = 0.851), and overall recurrence at 20.9% versus 20.2% (HR 0.96; p = 0.906) for resection and SBRT, respectively. Grade ≥3 TRAEs occurred in 31 patients (6.9%) in the resection group and none in the SBRT group. Liver function remained well preserved in both treatment groups.

CONCLUSION

After adjusting for baseline imbalances, SBRT achieved survival outcomes comparable to hepatic resection as initial local therapy, while maintaining an excellent safety profile. These findings suggest that SBRT may serve as a viable alternative for patients with BCLC stage 0 HCC who are suboptimal surgical candidates.