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