Top Line: When 5-fraction liver SBRT can't meet organ-at-risk constraints, is 50 Gy in 10 fractions a reasonable middle ground?
The Study: National guidelines for HCC SBRT favor 3- or 5-fraction regimens, but those schedules don't always fit clinical reality for larger tumors, marginal liver function, or proximity to luminal GI organs that can make 5-fraction constraints unachievable. This VA group adopted 50 Gy in 10 fractions (BED 75 Gy) as an alternative when 50 Gy/5 (BED 100 Gy) couldn't meet constraints. In this report, 147 patients with HCC were treated with either 5 fractions (65%) or 10 fractions (35%). Most had cirrhosis (94%), were Child-Pugh A (82%), and 67% were BCLC stage C. Not unexpectedly, the 10-fraction cohort had worse baseline performance status, more Child-Pugh B disease, larger tumors (median 35 vs 14 cc), smaller spared liver, and a higher mean liver dose (979 vs 801 cGy). Two-year freedom from treated lesion recurrence was higher after 50/5 (91% v 82%), but this difference lost statistical significance after adjusting for tumor volume. OS was worse with 10 fractions (HR 2.08), and although this persisted on multivariable analysis, the authors plausibly attribute it to baseline comorbidity rather than radiation dose. Adverse effects were minimal in both arms (one grade 3 nausea, no grade 4–5). Child-Pugh worsened more often with 10 fractions (HR 2.15), but on MVA only mean liver dose retained significance.
TBL: In this study, 50 Gy in 10 fractions was a reasonable, well-tolerated fallback when 5-fraction OAR constraints weren’t achievable. However, the lower BED and clear selection bias toward sicker patients mean 50 Gy/5 remains the preferred regimen when it can be delivered safely. | Qazi, Int J Radiat Oncol Biol Phys 2026
The Study: National guidelines for HCC SBRT favor 3- or 5-fraction regimens, but those schedules don't always fit clinical reality for larger tumors, marginal liver function, or proximity to luminal GI organs that can make 5-fraction constraints unachievable. This VA group adopted 50 Gy in 10 fractions (BED 75 Gy) as an alternative when 50 Gy/5 (BED 100 Gy) couldn't meet constraints. In this report, 147 patients with HCC were treated with either 5 fractions (65%) or 10 fractions (35%). Most had cirrhosis (94%), were Child-Pugh A (82%), and 67% were BCLC stage C. Not unexpectedly, the 10-fraction cohort had worse baseline performance status, more Child-Pugh B disease, larger tumors (median 35 vs 14 cc), smaller spared liver, and a higher mean liver dose (979 vs 801 cGy). Two-year freedom from treated lesion recurrence was higher after 50/5 (91% v 82%), but this difference lost statistical significance after adjusting for tumor volume. OS was worse with 10 fractions (HR 2.08), and although this persisted on multivariable analysis, the authors plausibly attribute it to baseline comorbidity rather than radiation dose. Adverse effects were minimal in both arms (one grade 3 nausea, no grade 4–5). Child-Pugh worsened more often with 10 fractions (HR 2.15), but on MVA only mean liver dose retained significance.
TBL: In this study, 50 Gy in 10 fractions was a reasonable, well-tolerated fallback when 5-fraction OAR constraints weren’t achievable. However, the lower BED and clear selection bias toward sicker patients mean 50 Gy/5 remains the preferred regimen when it can be delivered safely. | Qazi, Int J Radiat Oncol Biol Phys 2026