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Background: To assess the significance of alpha-fetoprotein (AFP) normalization as a prognostic surrogate after stereotactic body radiotherapy (SBRT) for patients with small hepatocellular carcinoma (HCC).Methods: Patients who underwent SBRT for primary or recurrent HCC were registered and a database thereof was retrospectively reviewed. Among 165 total registered patients, 77 patients were selected who satisfied the following criteria: (1) their AFP levels were > 20 ng/mL before SBRT, and (2) their AFP levels were checked within three months after SBRT. Propensity score based matching analysis was performed to minimize potential confounding bias. AFP normalization was defined as a reduction of AFP level to ≤ 20 ng/mL. Overall survival (OS) and progression-free survival (PFS) curves were estimated by the Kaplan-Meier method.Results: Thirty-seven (48.1 %) patients displayed AFP normalization (normalized group), while 40 (51.9 %) patients comprised the non-normalized group. The OS rates at 3-year were 62.0 % and 44.0 % (p = 0.023), and the PFS rates at 3-year were 27.9 % and 12.0 % (p = 0.019), in the normalized and non-normalized groups, respectively. Local control rates were 97.2 % in the normalized group and 94.7 % in the non-normalized group at three years (p = 0.579). In the propensity score matching cohort (25 pairs), OS and PFS were significantly longer in the normalized group than in the non-normalized group (p = 0.017 and 0.049, respectively). The local control rates were 100 % in both matched groups.Conclusions: AFP normalization within three months after SBRT is a prognostic surrogate for OS and PFS in patients with small HCC. AFP monitoring should be considered a useful tool for HCC patients with an elevated AFP level before SBRT. [ABSTRACT FROM AUTHOR]