Liver Cancer Radiation Therapy

The liver was once the organ radiation could not treat. A high dose to a small part of it, in five sessions, now controls most tumors it is aimed at. The rest of the liver is left alone.

Radiation therapy for liver cancer means, in nearly every case, stereotactic body radiation therapy, or SBRT, which delivers a high dose to the tumor in three to six sessions while sparing the liver around it. In the first prospective trials of the technique, 102 patients with hepatocellular carcinoma unsuitable for other local treatments, more than half of them with tumor in the portal vein, had local control of 87 percent at one year (Bujold and colleagues, Journal of Clinical Oncology, 2013). A randomized phase 3 trial then added SBRT to sorafenib for advanced disease and improved median survival from 12.3 to 15.8 months (Dawson and colleagues, JAMA Oncology, 2025). This page explains what radiation can and cannot do for primary liver cancer and for cancers that have spread to the liver, how it compares with ablation, embolization and surgery, what the trials show, what the course involves, the side effects, and how patients from abroad arrange it at Biruni Hospital in Istanbul.

What radiation does for the liver

Four jobs, and the dose and the schedule differ for each.

Local control at one year was 87 percent. Median gross tumor volume was 117 milliliters, tumor vascular thrombosis was present in 55 percent, and median overall survival was 17.0 months in patients who had no other option (Bujold and colleagues, 2013).

How it is delivered here

The Versa HD accelerator at Biruni Hospital delivers liver SBRT with its high dose rate beam, a cone beam CT before every session, and management of breathing, because the liver moves several centimeters with each breath and the beam must know where the tumor is. Patients hold their breath for the seconds the beam runs, or the beam switches on only in one phase of breathing, and a small gold marker placed in the liver beforehand under ultrasound shows the tumor's position on the imaging.

Which patients and cancers

The tumor decides less than the liver does.

What the liver must be able to take

Radiation, ablation, embolization or surgery

Liver cancer has more local treatments than any other cancer, and the right one depends on the size and position of the tumor, the state of the liver and what has already been tried.

Surgery removes the tumor and provides a specimen. Ablation burns it through a needle and works best under three centimeters. Embolization starves it through its artery and suits multiple tumors. Radiation destroys it without touching it, reaches tumors near large vessels and under the dome of the diaphragm that a needle cannot, and needs no anesthetic.

The usual order

Surgery or transplant first, when the patient can have it. Then ablation, for small tumors away from vessels and the liver surface, and embolization for several tumors in a liver that still works. Radiation for the tumor that none of these can reach safely, for the tumor that has come back after ablation or embolization, for the tumor in the portal vein, and, increasingly, as an equal to ablation for tumors between two and five centimeters. The multidisciplinary liver tumor board, with the hepatologist, the liver surgeon, the interventional radiologist and the radiation oncologist, makes the decision for each patient, and a patient referred from abroad with a plan made at home should expect it to be reviewed rather than repeated.

What the trials show

Three studies define what a patient can expect. One prospective series, one comparison, one randomized trial.

1. The Toronto trials, 2004 to 2010. 102 patients with hepatocellular carcinoma unsuitable for other treatment, two thirds at stage III, received 24 to 54 Gy in six sessions. Local control at one year was 87 percent. Serious toxicity occurred in 30 percent, and seven deaths were possibly related to treatment, most in patients with tumor in the portal vein, which taught the field to select patients with care (Bujold and colleagues, 2013).
2. Michigan, SBRT against ablation. Freedom from local progression at one year was 97.4 percent after SBRT and 83.6 percent after ablation. Serious acute complications occurred after 5 percent of SBRT treatments and 11 percent of ablations (Wahl and colleagues, 2016).
3. NRG/RTOG 1112, the randomized trial. 193 patients with advanced hepatocellular carcinoma, three quarters with macrovascular invasion, were randomized to sorafenib alone or SBRT followed by sorafenib. Median survival rose from 12.3 to 15.8 months and progression-free survival from 5.5 to 9.2 months, with no increase in serious side effects and better quality of life at six months (Dawson and colleagues, 2025).

What the randomized trial means

• Local control after SBRT is high, above 85 percent at one year across the studies, and survival depends on what the cancer does elsewhere in the liver and beyond.
• Patient selection, above all liver function and the volume of healthy liver, determines safety more than any detail of the technique.
• Radiation and drugs work together, and the sequence is planned at the outset rather than improvised.

The course

Two weeks, as a rule. Three visits before the first session and three to six sessions after.

1. Marker placement. A gold marker the size of a grain of rice is placed in the liver near the tumor, under ultrasound and local anesthetic, three to seven days before planning so that it settles. Some centers use the tumor's own contrast appearance instead.
2. Planning CT with contrast and breathing control. The patient lies in a mold, practices the breath-hold, and is scanned in that position. An MRI is fused to the scan. The oncologist outlines the tumor and the physicist designs beams that meet the dose to the tumor and the limits for the healthy liver, the bowel, the stomach, the kidney and the spinal cord.
3. Treatment. Three to six sessions, every other day, each lasting thirty to forty-five minutes on the couch, most of it imaging and positioning. The beam itself runs for a few minutes.
4. Follow-up. Blood tests at one month, imaging at three months, then every three months in the first year.

What the patient feels

The tumor does not disappear at once. On the three-month scan it is frequently the same size and no longer enhances with contrast, which means it is dead. Shrinkage follows over the next year.

Side effects

Modest when the patient is well chosen. Serious when the liver was not able to take it.

Radiation-induced liver disease

Coming from abroad

Patients travel for liver SBRT because it needs a team that plans the liver every week, with a physicist who knows its dose limits and a radiologist who reads its scans, and such teams exist in a few centers in each region rather than in every hospital. The length of stay is two to three weeks. That covers the tumor board, the marker, the planning and the sessions, with a rest day between each session, and patients are fit to fly two days after the last one. A patient who has had a recent triple-phase CT and a full liver panel at home saves the first two days, and one who has already had a marker placed for another reason saves the week between placement and planning, which is the reason the coordinator asks for every previous report before proposing dates, since the difference between a two-week and a three-week stay is decided by what has already been done at home rather than by anything the hospital can speed up.

Cost

An estimate follows the file review and depends on the number of tumors, the number of sessions, the marker procedure and whether an MRI is repeated here. Hospitals in this market quote liver SBRT as a package for the course, with the marker, planning and imaging included and drug therapy priced separately.

Confirm what the figure includes and whether the three-month scan review is part of it.