Selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC): informing clinical practice for multidisciplinary teams in England.

Hepatocellular carcinoma (HCC) deaths are rising alarmingly. Many patients are unsuitable for available therapies. Poor response rates further hamper outcomes for those that are. Selective internal radiation therapy (SIRT) offers hope, although which patients benefit over standard approaches remains unclear. As a quality/service improvement, we audited consecutive patients treated with SIRT (2015-2020) by the Newcastle upon Tyne Hospitals National Health Service Foundation Trust HCC multidisciplinary team. Indications, Barcelona clinic liver cancer (BCLC) stage, treatment response, subsequent therapies and survival at 30 September 2021 were assessed. Fifty-one patients received SIRT. Thirty-day mortality was zero. Three months partial response, stable disease and progressive disease on imaging were 50%, 22% and 28%, respectively. Overall median survival was 21 months. There were four subgroups: (1) BCLC-B: HCC>7 cm too large for transarterial chemoembolisation (TACE) alone (n=21); (2) BCLC-B: HCC progressed post TACE (n=7); (3) BCLC-C: HCC with any combination of large tumour burden, branch portal vein thrombosis, non-hepatitis C virus aetiology (n=16); (4) BCLC-C: sorafenib inappropriate (n=7). In group 1, 5/21 (23.8%) of patients were downstaged to resection, 33% received subsequent medical therapies and median survival was >40 months. In BCLC-B patients treated second line (group 2), median survival was 14.2 months. In BCLC-C, median survival was 20.2 months for group 3 and 4.2 months for group 4. SIRT outcomes for advanced HCC, often bridging patients with adverse predictive factors to subsequent surgery or medical therapies, were encouraging. A role after TACE or for BCLC-C patients requires further assessment.

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Competing interests: HLR is a member of the European Association for Study of Liver Disease (EASL) education committee, the HCC-UK Committee, the NCRI hepatobiliary subgroup and the Patient Advocacy group for the International Association for Liver cancer (ILCA). She is an expert advisor to the LiverNorth patient Charity and the British Liver Trust and has acted as an expert advisor to NICE Committee Multiple Technology Appraisal (MTA) assessing selective internal radiation therapies (SIRT) for treating hepatocellular carcinoma (ID1276). On behalf of Newcastle University, she has acted as an advisor to Boston Scientific UK and SIRTEX. JR is a member of the British Society of Interventional Radiology Education Committee. GP is a member of the British Society of Interventional Radiology Scientific Program Committee. DMM is the medical director for NHS British Transplant, council member for British Transplant Society, secretary for Cholangiocarcinoma-UK, member of the Transplant Oncology Group and trustee for British Association for Cancer Surgery (BASO). He has been on advisory boards for Boston Scientific UK and SIRTEX. PL is the secretary for Interventional Oncology UK (IOUK) and the Chair for the British Society of Interventional Radiology Scientific Programme Committee. He has received honoraria for lectures from Boston Scientific UK, Sirtex and Johnson and Johnson. He has participated in advisory boards for Boston Scientific UK, Guerbet and Johnson and Johnson.