Is liver radiotherapy contraindicated in patients with Child-Pugh C liver function?

I think one should be very cautious with regards to radiation for this group, whether palliative or definitive. The CPC patient has a very poor prognosis with a 2 year expected survival of only 30%. We have learned that patients with CPB liver disease, especially those with scores of 8 and above, are a very high risk group when it comes to radiation toxicity. By definition, the goals of palliation are to relieve symptoms and therefore for this indication radiation is even more contraindicated as the risks of toxicity outweigh any potential benefit.

I agree with Tracey totally. A recent study from Indiana University (published in PRO by Lasley and Cardenes) showed that with CPB patients, low dose spillage as low as 2.5 Gy in 5 fxs impacted on the risk of hepatic toxicity. CPC patients are expected to be worse off. That begs the question whether it would be better to use fewer static beams to avoid toxicities in CPB patients. VMAT may be detrimental to patients with high CP scores. Another thought is stereotactic body proton therapy which may work with peripheral but not so much central liver tumours in patients with high CP scores. Tracey, it's delightful to see you here.

We have an IRB approved retrospective review of patients we treated with SBRT to 50 Gy using 5 fraction SBRT with CTP C disease at OHSU. Our manuscript is currently undergoing revision and we hope to have it published sometime soon! We are hopeful these findings will advance this discussion.

We have a very active liver SBRT program at our VA hospital, and working closely with our HCC and liver txp teams have learned to be mindful of frail patients. Child's Pugh C pts are typically dying. We need to remember that tolerance to radiotherapy, including high doses, requires a level of physiological reserve to bounce back. While we can get away with SBRT in pts who are more fit, there is a reason why those with decades of experience with liver SBRT warn us about physiological boundaries. It will be interesting to read Joseph Waller's paper, though...couldn't he have at least given us a teaser?