Commentary on: Efficacy and safety of stereotactic body radiation therapy in elderly patients with cirrhosis and large advanced hepatocellular carcinoma
Year: 2025
Type: editorial
Abstract: Dear Editor, We have perused with keen interest the paper entitled “Efficacy and safety of stereotactic body radiation therapy in elderly patients with cirrhosis and large advanced hepatocellular carcinoma” by Sharma et al.,[1] which speaks to an understudied yet clinically relevant niche in oncologic management. The paper presents useful information regarding the feasibility and tolerability of stereotactic body radiation therapy (SBRT) in a very vulnerable patient subgroup, cirrhotic, elderly patients with large, advanced hepatocellular carcinoma, describing promising local control, as well as tolerability, outcomes. We appreciate the authors for taking their initiative to research this complicated clinical context often under-represented in prospective trials. Their contribution to making geriatric oncologic literature as well as radiation oncologic literature more robust, which was timely as well as impactful, should be appreciated. On closer review, however, we should like to point out respectfully the below additional limitations. First, the literature classifies liver function solely by Child-Pugh scores, which can prove to be insensitive to predict hepatic decompensation after SBRT in elderly cirrhotic patients. This inhibits proper risk stratification, which might overestimate SBRT safety. For instance Yoshino et al.[2] illustrated that ALBI (Albumin-Bilirubin) score provides better prognostic information for hepatic deterioration after SBRT in elderly HCC patients. Chiang et al.[3] Shows that ALBI score is better than CP in predicting survival in HCC patients, who receive SBRT. Thus, Future research should incorporate ALBI or ALBI-T scores in addition to Child-Pugh to better categorize liver reserve as well as stratify risks in SBRT-eligible elderly cirrhotic patients. Second, disregarding liver dosimetry compromises assessment of hepatic toxicity risk, particularly in radiosensitive cirrhotic and elderly livers. Second, Excessive radiation to non-tumor liver tissue can increase liver failure after treatment. For instance, Wang et al.[4] illustrated that uninvolved liver dose constraints are very crucial, particularly in cases of portal vein tumor thrombosis. Wei et al.[5] provided evidence of a correlation among regional delivery of doses with loss of functional liver after SBRT. Thus, Future research should report liver dosimetry (e.g. mean liver dose, V20) and relate these to hepatic adverse effects to better optimize SBRT in this high-risk group. Third, without standard toxicity grading, adverse event reporting is subjective, precluding comparison with other trials, as well as likely underestimation of toxicity in elderly cirrhotic patients. For instance, Pennock et al.[6] in a review of hepatic radiotherapy highlight Common Terminology Criteria for Adverse Events (CTCAE)-based toxicity grading for comparability as well as clinical significance. Thus, adopt standardized reporting of toxicity (e.g., CTCAE version 5.0) to have objective as well as replicable safety profiles in trials in radiation oncology. In summary, though the current research rightfully targets a vital, understudied clinical group, we think that including more sophisticated liver function evaluations such as ALBI, explicit dosimetry reporting of the liver, and uniform grading of toxicity would make future studies in this field more valid, replicable, and clinically relevant. These fine points must be included to ensure proper selection of the patient, safer delivery of SBRT, and better outcome assessment in elderly cirrhotic individuals with advanced HCC. Authors contribution AFA, SA conceived the idea, reviewed the original article, performed the literature search, and drafted the manuscript. All authors reviewed and approved the final version of the letter. Ethics approval and consent to participate Not applicable. This is a commentary on a previously published article and does not involve any original human or animal research. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Availability of data and material Not applicable. No datasets were generated or analyzed during the writing of this commentary.
Authors: Sheraz Ali, Ahmad Furqan Anjum
Institution: Shaikh Zayed Postgraduate Medical Institute
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7117684514