Pre-treatment Trends in Child-Pugh Score as an Indicator of Post-treatment Survival in Patients Receiving Liver Stereotactic body radiation therapy for Hepatocellular carcinoma

Purpose: We sought to understand the value of Child-Pugh (CP) score trends prior to undergoing stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) in patients with advanced cirrhosis. We hypothesize that an uptrend in CP score prior to RT increases risk of post-treatment cirrhosis progression, or death.

Methodology: We retrospectively reviewed all patients who underwent definitive SBRT to the liver for HCC between 2014-2022 in our health system. Most patients were referred for salvage treatment, allowing us to determine CP score at multiple points. Response to treatment was evaluated with mRECIST criteria. Acute treatment toxicities were assessed by CTCAE v5 criteria. OS was assessed using the Kaplan-Meier method, and differences between groups were evaluated using a log-rank test.

Results: 61 patients were identified with CP scores ranging from A5-C11. Median dose was 40Gy in 5fx. Median OS of all patients was 24 months. When stratified by CP category, median OS for CP-A was not reached (NR) at time of analysis, CP-B had a median OS of 14.8 months, and CP-C with 1.9 months ( p < 0.01). Local control rate at 6mo was 87.5%. 5 patients (8.3%) had grade 2 acute toxicity. There were 10 patients who had CP score progression of >2pts within 6mo after treatment, and 7 patients who died from end stage liver disease. Median time interval between HCC diagnosis and start of RT was 338 days. In this interval, patients who experienced a CP score increase of >2 pts prior to starting RT had a median OS of 362 days, compared to NR at time of analysis for patients without increase (p=0.02). When excluding the CP-A group, patients with 2 pt increase had median OS of 362 days vs 445 days (p=0.34). Again excluding the CP-A group, patients with a 1 pt increase had median OS of 362 days vs NR (p=0.23). Of 9 patients who had a pre-RT CP score increase of 2 or more, 7 experienced continued CP progression after treatment.

Conclusions: In this multi-institutional retrospective analysis, we found 24 patients with advanced CP B/C cirrhosis who underwent SBRT. While CP-C patients did relatively poorly, we find that some patients with CP-B cirrhosis may tolerate SBRT well. When taking pre-treatment CP score increase into consideration, we saw a trend but no statistical significance indicating that a pre-SBRT increase in CP score may be associated with worse median OS after treatment among CP B/C patients. We conclude that among patients with advanced cirrhosis there may be a subset of patients who, if well selected, remain appropriate candidates for SBRT.

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