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Options in Unresectable HCC

Insights From: Richard S. Finn, MD, Geffen School of Medicine;Arndt Vogel, MD, Hannover Medical School
Published: Monday, Nov 14, 2016


Transcript:

Arndt Vogel, MD:
Patients who are not good candidates for liver transplantation or liver resection are, in general, patients who have intermediate-stage disease. And here, we have two studies that have shown that transarterial chemoembolization, TACE, is a good treatment option that can improve survival. With this study, TACE has made it to be the most commonly used treatment modality all over the world for patients with HCC. The question is, who is a good candidate for TACE? I think the clinical trials were done in a very selected patient population, so these were patients who really had good liver function, who had smaller tumors, and did not have major vascular invasion or extrahepatic disease. And, if you have such a selected patient population, you can really achieve impressive results with TACE. On the other hand, if the patients have larger tumors or advanced liver disease, you might lose a lot of the advantage you see in patients with smaller tumors and better liver function.

Richard Finn, MD: We know that surgery is the only way to cure this disease. A minority of patients are candidates for a straightforward liver resection, at least in the United States where we see most of the liver cancers still associated with hepatitis C. So, they do have significant cirrhosis. But liver transplant does play a big role. Candidates for liver transplant have to have certain tumor characteristics. Ideally, they’re within Milan criteria, which is one tumor less than 5 cm or three tumors less than 3 cm. In certain regions, they use the UCSF criteria, which allows for tumor burdens up to a total of 8 cm with multifocal disease. But, regardless, the question is, if a patient is beyond Milan criteria or a patient has a tumor that’s too big just to be resected, is there a way to make them smaller? And while the data are not clear, chemoembolization procedures are often done to try to shrink the tumor or even a radiofrequency ablation to try to decrease the tumor burden to make them resectable or to put them back within Milan criteria.

Of all the treatments we use in liver cancer for patients that present to the clinic, probably liver-directed therapies play the biggest role because most patients do present with relatively preserved liver function, Child-Pugh A or early B, and liver confined disease. Chemoembolization, which involves going into the femoral artery, into the hepatic artery, and injecting drugs and embolizing the vessels that are feeding the tumor, plays a major role in the management of these patients. It’s been shown to improve survival. Other approaches that are liver-directed, such as radiofrequency ablation, play a significant role. The choice between those two approaches really depends on tumor size and tumor location, but both of them have been shown to improve survival.

The challenge becomes that they’re not curative. So, if a patient has a liver-directed therapy, the tumor, generally, will recur or continue to grow. Whether or not they will be a candidate for another liver-directed therapy really depends on the location, their disease-free interval, and their underlying physiology of the liver. I think the real challenge in practice is recognizing that chemoembolization’s outcomes are really optimized by patient selection. And for patients who have symptomatic liver cancer or have invasion of their tumor into the liver vasculature, those are areas where outcomes with chemoembolization are not as good as when those characteristics are not present. That is where many of the guidelines suggest going to systemic treatment.

Transcript Edited for Clarity
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Transcript:

Arndt Vogel, MD:
Patients who are not good candidates for liver transplantation or liver resection are, in general, patients who have intermediate-stage disease. And here, we have two studies that have shown that transarterial chemoembolization, TACE, is a good treatment option that can improve survival. With this study, TACE has made it to be the most commonly used treatment modality all over the world for patients with HCC. The question is, who is a good candidate for TACE? I think the clinical trials were done in a very selected patient population, so these were patients who really had good liver function, who had smaller tumors, and did not have major vascular invasion or extrahepatic disease. And, if you have such a selected patient population, you can really achieve impressive results with TACE. On the other hand, if the patients have larger tumors or advanced liver disease, you might lose a lot of the advantage you see in patients with smaller tumors and better liver function.

Richard Finn, MD: We know that surgery is the only way to cure this disease. A minority of patients are candidates for a straightforward liver resection, at least in the United States where we see most of the liver cancers still associated with hepatitis C. So, they do have significant cirrhosis. But liver transplant does play a big role. Candidates for liver transplant have to have certain tumor characteristics. Ideally, they’re within Milan criteria, which is one tumor less than 5 cm or three tumors less than 3 cm. In certain regions, they use the UCSF criteria, which allows for tumor burdens up to a total of 8 cm with multifocal disease. But, regardless, the question is, if a patient is beyond Milan criteria or a patient has a tumor that’s too big just to be resected, is there a way to make them smaller? And while the data are not clear, chemoembolization procedures are often done to try to shrink the tumor or even a radiofrequency ablation to try to decrease the tumor burden to make them resectable or to put them back within Milan criteria.

Of all the treatments we use in liver cancer for patients that present to the clinic, probably liver-directed therapies play the biggest role because most patients do present with relatively preserved liver function, Child-Pugh A or early B, and liver confined disease. Chemoembolization, which involves going into the femoral artery, into the hepatic artery, and injecting drugs and embolizing the vessels that are feeding the tumor, plays a major role in the management of these patients. It’s been shown to improve survival. Other approaches that are liver-directed, such as radiofrequency ablation, play a significant role. The choice between those two approaches really depends on tumor size and tumor location, but both of them have been shown to improve survival.

The challenge becomes that they’re not curative. So, if a patient has a liver-directed therapy, the tumor, generally, will recur or continue to grow. Whether or not they will be a candidate for another liver-directed therapy really depends on the location, their disease-free interval, and their underlying physiology of the liver. I think the real challenge in practice is recognizing that chemoembolization’s outcomes are really optimized by patient selection. And for patients who have symptomatic liver cancer or have invasion of their tumor into the liver vasculature, those are areas where outcomes with chemoembolization are not as good as when those characteristics are not present. That is where many of the guidelines suggest going to systemic treatment.

Transcript Edited for Clarity
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