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Radiofrequency Ablation and Curative Intent in HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, UCLA; Laura M. Kulik, MD, Northwestern University Feinberg School of Medicine; R. Kate Kelley, MD, University of California-San Francisco; Riad Salem, MD, Northwestern University Feinberg School of Medicine
Published: Friday, Feb 24, 2017



Transcript:

Ghassan K. Abou-Alfa, MD:
Riad, no doubt that transplant and surgery are considered THE curative intents. But, RFA (radiofrequency ablation) is also a curative approach. Please tell us a little bit more about that.

Riad Salem, MD: There’s no doubt that in the last few years, ablation has gained recognition in the level of evidence and people have started to recognize it as a potentially curative option in that you can ablate a small area of the liver without undergoing resection. So, it’s bypassing the complications of possible surgery and potentially offering it to patients that wouldn’t be candidates as the ones that Richard and Laura were alluding to. Recently now, ablation has been moved way ahead of resection for small lesions in the guidelines, recognizing that there certainly is a role here. You can achieve complete pathologic necrosis, good quality of life done safely, and, again, eliminate or mitigate the use of general anesthesia and major surgery. This is clearly something that is being adopted now in practice worldwide.

Ghassan K. Abou-Alfa, MD: Any comment on alcohol injection, which is a rather old practice?

Riad Salem, MD: Alcohol injection is one of the old practices certainly developed in the East, and the idea is the simplicity of it—the needle injection. There are now needles that are developed where you can inject alcohol in a more uniform matter. There is no real survival benefit demonstrated from comparing alcohol to RFA. And pretty much the worldwide now, RFA and microwave, I would add, have really been the primary ablative modalities that are used for the liver for small early stage HCC.

Ghassan K. Abou-Alfa, MD: Katie, in all 3 of those situations—transplant, surgery, RFA—the patient is going to, of course, come to you and ask, “What’s next? What can happen?” So, is there any role for adjuvant therapy?

R. Kate Kelley, MD: Right. This is a really tricky question because, particularly depending on some of the prognostic markers—including the number of tumors, whether there was vascular invasion at explant after a transplant or after surgery—there is still high risk for recurrence with this cancer, in some more so than others. Unfortunately, we have yet to find a definitive therapy to really help prevent that or reduce that risk. There’s certainly a role for close surveillance and hopes that we can potentially do another intervention if there is a recurrence. But the one proven systemic therapy at this time for advanced unresectable liver cancer, which is the multikinase inhibitor, sorafenib, unfortunately has been studied in the adjuvant setting in a large randomized phase III trial called the STORM trial—which was recently reported in 2015—and it showed really no benefit in reducing recurrence or improving survival after curative surgery or curative ablation in high-risk patients. And so, right now, we don’t have a systemic therapy or a medical oncology intervention to help change the fate of these treatments afterwards. We rely on close surveillance, hoping that we’ll have a chance to do a second intervention if we catch a recurrence early.

Ghassan K. Abou-Alfa, MD: To summarize that first part, we heard, other than academic debates, there are really 3 interventions that can be used for curative intent in HCC: surgery, liver transplant, and RFA. Also, we heard that there is no role for an adjuvant therapy at this point in time, but, of course, there’s a continued interest in that regard. I wouldn’t be surprised if we notice that there will be more clinical trials looking into different venues from that regard. Then, we’ll probably cover some of those a little bit later.

Transcript Edited for Clarity

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Transcript:

Ghassan K. Abou-Alfa, MD:
Riad, no doubt that transplant and surgery are considered THE curative intents. But, RFA (radiofrequency ablation) is also a curative approach. Please tell us a little bit more about that.

Riad Salem, MD: There’s no doubt that in the last few years, ablation has gained recognition in the level of evidence and people have started to recognize it as a potentially curative option in that you can ablate a small area of the liver without undergoing resection. So, it’s bypassing the complications of possible surgery and potentially offering it to patients that wouldn’t be candidates as the ones that Richard and Laura were alluding to. Recently now, ablation has been moved way ahead of resection for small lesions in the guidelines, recognizing that there certainly is a role here. You can achieve complete pathologic necrosis, good quality of life done safely, and, again, eliminate or mitigate the use of general anesthesia and major surgery. This is clearly something that is being adopted now in practice worldwide.

Ghassan K. Abou-Alfa, MD: Any comment on alcohol injection, which is a rather old practice?

Riad Salem, MD: Alcohol injection is one of the old practices certainly developed in the East, and the idea is the simplicity of it—the needle injection. There are now needles that are developed where you can inject alcohol in a more uniform matter. There is no real survival benefit demonstrated from comparing alcohol to RFA. And pretty much the worldwide now, RFA and microwave, I would add, have really been the primary ablative modalities that are used for the liver for small early stage HCC.

Ghassan K. Abou-Alfa, MD: Katie, in all 3 of those situations—transplant, surgery, RFA—the patient is going to, of course, come to you and ask, “What’s next? What can happen?” So, is there any role for adjuvant therapy?

R. Kate Kelley, MD: Right. This is a really tricky question because, particularly depending on some of the prognostic markers—including the number of tumors, whether there was vascular invasion at explant after a transplant or after surgery—there is still high risk for recurrence with this cancer, in some more so than others. Unfortunately, we have yet to find a definitive therapy to really help prevent that or reduce that risk. There’s certainly a role for close surveillance and hopes that we can potentially do another intervention if there is a recurrence. But the one proven systemic therapy at this time for advanced unresectable liver cancer, which is the multikinase inhibitor, sorafenib, unfortunately has been studied in the adjuvant setting in a large randomized phase III trial called the STORM trial—which was recently reported in 2015—and it showed really no benefit in reducing recurrence or improving survival after curative surgery or curative ablation in high-risk patients. And so, right now, we don’t have a systemic therapy or a medical oncology intervention to help change the fate of these treatments afterwards. We rely on close surveillance, hoping that we’ll have a chance to do a second intervention if we catch a recurrence early.

Ghassan K. Abou-Alfa, MD: To summarize that first part, we heard, other than academic debates, there are really 3 interventions that can be used for curative intent in HCC: surgery, liver transplant, and RFA. Also, we heard that there is no role for an adjuvant therapy at this point in time, but, of course, there’s a continued interest in that regard. I wouldn’t be surprised if we notice that there will be more clinical trials looking into different venues from that regard. Then, we’ll probably cover some of those a little bit later.

Transcript Edited for Clarity
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