Would you consider SBRT for a patient with a solitary HCC lesion, with SLE/lupus previously on immunosuppression?
This one is a little bit tough, because there are other treatments for a solitary HCC lesion (surgery, TACE, RFA...), it may be better to use those options and avoid the risk of potentially enhanced toxicity. However, I suspect the risk is not very large as the risk from SBRT to the liver is so small. This depends on the size and location of the lesion. Many patients with non-active collagen-vascular diseases tolerate radiation without worsened toxicities, but the risk appears increased. It is difficult to know as all of the data is limited series and case reports. Not sure this helps.
I personally cannot recall ever treating a patient with HCC and SLE. I would use the same general clinical gestalt to counsel patients that we do with other patients with SLE than need radiation.
What I can comment on is SBRT to the liver in the context of immunosuppression which we have done a lot of in the post-transplant recurrence population where we deliver SBRT to the liver/abdominal lymph nodes/or adrenal glands in the setting of immunosuppression. We have treated a fair number of these patients without any added signal of additional toxicity. We have presented our data on 18 lesions (15 patients) at ASTRO this past year (Stephens et al., IJROBP 2022) and have a manuscript under review right now. Looking at the classic measures like CTP, ALBI, CTCAE, and rejection, we did not see any added signal of excess toxicity. In fact, this could be an important population to advocate for local regional therapies such as SBRT because post-OLT patients cannot get immunotherapy.
Yes. Would not alter the treatment plan specifically based on autoimmunity or immunosuppression (which can be radiosensitizing) but would focus on high quality plan minimizing normal tissue irradiated. Toxicity is volume dependent. Have treated liver transplant patients with colorectal metastasis in the transplanted liver on immunosuppression as well as patients with HCC on immunosuppression for MS, and both have done fine. Similarly treated patients with dermatomyositis/autoimmune hepatitis on immunosuppression with unresectable intrahepatic cholangiocarcinoma, also has done well.
The immunosuppression increases the risk of cancer recurrence (and contributed to its development) so take that into consideration when weighing long term probabilities/outcomes/clinical goals.