Transarterial Chemoembolization vs CyberKnife for Recurrent Hepatocellular Carcinoma

Inclusion Criteria:

   - Confirmed hepatocellular carcinoma by one of the following:

      - Histopathology

      - One radiographic technique that confirms a lesion >=2 cm with arterial
      enhancement with washout on delayed phase

   - Hepatic lesion in patients for whom surgical resection is not possible or would not
   result in an opportunity for cure

   - Radiographic evidence of persistent, progressive or recurrent disease in an area
   previously treated with TACE. This evaluation should be determined after 6 weeks of
   initial TACE

   - Multi-specialty evaluation whereby the recurrent liver lesion was deemed by both the
   attending radiation oncologist and interventional radiologist amenable to treatment by
   the respective modality

      - Eligible patients must undergo an IV contrast CT scan of the liver within 6 weeks
      of enrollment onto the study; a contrast enhanced liver MRI may be substituted
      for the IV contrast CT of the liver.

      - A recent serum AFP must also be obtained within 4 weeks of enrollment.

   - Unifocal liver tumors not to exceed 7.5 cm in greatest axial dimension. Multifocal
   lesions will be restricted to lesions that can be treated within a single target
   volume within the same liver segment and to an aggregate of 7.5cm as long as the dose
   constraints to normal tissue can be met

   - Eastern Clinical Oncology Group performance status 0, 1 or 2

   - Patients with liver disease classified as Child Pugh class A/B; if Child's class B,
   score must be 8 or less

   - Albumin >= 2.5 g/dL

   - Total bilirubin <= 3 mg/dL

   - INR <= 1.5

   - Creatinine <= 2.0 mg/dL

   - Age >= 18 years old

   - Life expectancy>= 6 months

   - Ability of the research subject or authorized legal representative to understand and
   the willingness to sign a written informed consent document.

Exclusion Criteria:

   - Prior radiation for the recurrent liver tumors

   - Prior radiotherapy to the upper abdomen

   - Prior RFA to index lesion

   - Liver transplant

   - Tumors >= 7.5 cm in greatest axial dimension

   - Portal vein thrombus

   - Large varices within 2 cm of index lesion (seen on cross section imaging)

   - Contraindication to receiving radiotherapy

   - Active gastrointestinal bleed within 2 weeks of study enrollment

   - Ascites refractory to medical therapy

   - Women who are pregnant

   - Administration of any systemic chemotherapy within the last 1 month

   - Presence of multifocal lesions located in different lobes of the liver or extrahepatic
   metastases

   - Participation in another concurrent SYSTEMIC treatment protocol

   - Prior history of malignancy other than HCC