Stereotactic Body Proton Radiotherapy for the Treatment of Liver Cancer

Inclusion Criteria

• •Age \>= 18 years
• •Radiologically presumed or histologically proven, newly diagnosed or recurrent, hepatocellular carcinoma
• •Clinical stage T0-T4N0M0 (American Joint Committee on Cancer \[AJCC\] 8th edition).
• •* One to three discrete Liver Reporting and Data System-5 (LIRADS-5) lesions that can be encompassed within a single radiation treatment plan
• •* Patients treated with external beam radiation as a bridge to transplant are allowed
• •* Minimum single lesion size \>= 1 cm, maximum cumulative diameter =\< 15 cm
• •* Vascular involvement (including portal vein, inferior vena cava \[IVC\] and/or hepatic vein) is allowed
• •Target lesion must be amenable to a SBRT regimen utilizing proton beam therapy (i.e. SBPT)
• •Prior local liver treatment including surgery, percutaneous ablation, transarterial bland or chemoembolization (TACE), or Y-90 radioembolization is allowed if completed at least 6 weeks prior to treatment start date
• •Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 to 2
• •Life expectance \>= 3 months based on medical comorbidities, tumor extent and other clinical factors as determined by treating physician
• •Child Pugh score of A or B7
• •Absolute neutrophil count (ANC) \>= 1000 cells/mm\^3 (within 45 days of study entry)
• •Platelets (Plt) \>= 30,000 cells/mm\^3 (the use of transfusion or other intervention to achieve the minimum platelet level is allowed) (within 45 days of study entry)
• •Hemoglobin (Hgb) \>= 8.0 g/dL (the use of transfusion or other intervention to achieve the minimum hemoglobin level is allowed) (within 45 days of study entry)
• •Total bilirubin \< 2 mg/dL (within 45 days of study entry)
• •Able to and provides Institutional Review Board (IRB) approved study specific written informed consent
• •Willing to return to enrolling institution for follow-up (during the active monitoring phase of the study)
• •Enrollment on a second independent protocol is allowed if the second protocol intervention will not significantly affect results of the current protocol as determined by the study investigators