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When to Use Locoregional Therapies in HCC

Insights From: Catherine T. Frenette, MD, Scripps Green Hospital; Darren S. Sigal, MD, Scripps Green Hospital
Published: Monday, May 07, 2018



Transcript: 

Darren S. Sigal, MD: Dr. Frenette, can you tell me your thoughts about when a patient should get resection or an ablative therapy, such as radiofrequency ablation [RFA]?

Catherine T. Frenette, MD: Sure. This is often a little bit of a difficult choice. So, there are several types of ablation. There’s radiofrequency ablation, which has been around for 15 to 20 years. There’s ethanol injection, which is a type of ablation that was around even before RFA. That has largely been abandoned, just because it has been shown to not quite be as effective as RFA. And then there’s microwave ablation, which is sort of a newer thing where the ablation zone is burned hotter and faster. And then there are some newer types of ablations that we really haven’t seen be taken on globally, such as irreversible electroporation.

There are actually randomized controlled trials having patients be randomized to RFA versus resection for small lesions or patients within the Milan criteria. And what we found is actually overall survival for RFA versus resection is really pretty equivalent. So, either one of those could potentially be an option. However, we do know that recurrence rates are higher after ablation as compared to resection. So, if we can go to resection, we do. Ablation would be a great option for somebody who can’t get a resection because of other medical problems, such as they’re older, their performance status is maybe an ECOG [Eastern Cooperative Oncology Group] 1, they’re not going to be able to tolerate a liver surgery, or they have cardiovascular problems. Something like that would have somebody go to an ablation as compared to a resection.

Darren S. Sigal, MD: So, just continuing down this path about ablation and radiofrequency ablation or even microwave ablation that you brought up, how does that compare to TACE, or transarterial chemoembolization, and how do you make a decision whether what modality to use?

Catherine T. Frenette, MD: That’s a really good question, and it’s one that we discuss a lot in our multidisciplinary tumor board. So, we know that ablation is very good for small lesions, less than 3 cm. And, in fact, ablation of small lesions is considered curative therapy, especially on the BCLC [Barcelona Clinic Liver Cancer] staging system. Chemoembolization is not a curative therapy, and I always make sure to tell this to my patients. This is not curative. It buys us time. So, ablation for small lesions is an excellent option, but it is somewhat limited by adjacent structures. For instance, if the tumor is right next to the gallbladder, it’s very difficult to ablate because you also injure the gallbladder. Ablation is also somewhat limited by the location. For instance, if it’s high in the dome of the liver, it’s very difficult for the radiologist to get a probe up in their tumor to actually ablate it. Sometimes ablation isn’t an option or if the lesions are larger, such as 5, 6, or 7 cm, ablation is not going to get you a complete response.

So, TACE, or transarterial chemoembolization, we use more frequently than ablation. I would say we look at all of our locoregional therapies. Probably two-thirds to three-quarters of them are chemoembolization-based or TACE-based. TACE has a very good response rate. About 60% to 65% of patients will have a radiographic complete response on the first treatment. You can re-treat patients, and we’ve had patients that have had as many as 4 or 5 TACE procedures. With TACE, we do know, again, this isn’t curative, and the tumor will come back. After the TACE or after the ablation, we do have to continue to monitor, and we scan every 3 months. And if tumors are coming back, we can re-treat.

As far as how many times can you treat, what you don’t want to do is treat someone so many times that now their liver is starting to fail from the number of locoregional therapies that they’ve had. And now they’re no longer a candidate for systemic treatments because they’ve been TACEd so many times. So, we do have to be a little bit careful with balancing what we can do with what we should do. In general, if someone has no response to 2 TACE procedures, you should move to the next treatment. It has been shown that no response to 2 treatments, they’re not going to respond to that treatment. We also know that after 4 TACE procedures, you really aren’t seeing a survival benefit anymore. Number of TACEs that you perform, your incremental survival benefit decreases with each further procedure. And really after 4, you’re not giving the patient any survival benefit. We’re just treating a scan.

Transcript Edited for Clarity 
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Transcript: 

Darren S. Sigal, MD: Dr. Frenette, can you tell me your thoughts about when a patient should get resection or an ablative therapy, such as radiofrequency ablation [RFA]?

Catherine T. Frenette, MD: Sure. This is often a little bit of a difficult choice. So, there are several types of ablation. There’s radiofrequency ablation, which has been around for 15 to 20 years. There’s ethanol injection, which is a type of ablation that was around even before RFA. That has largely been abandoned, just because it has been shown to not quite be as effective as RFA. And then there’s microwave ablation, which is sort of a newer thing where the ablation zone is burned hotter and faster. And then there are some newer types of ablations that we really haven’t seen be taken on globally, such as irreversible electroporation.

There are actually randomized controlled trials having patients be randomized to RFA versus resection for small lesions or patients within the Milan criteria. And what we found is actually overall survival for RFA versus resection is really pretty equivalent. So, either one of those could potentially be an option. However, we do know that recurrence rates are higher after ablation as compared to resection. So, if we can go to resection, we do. Ablation would be a great option for somebody who can’t get a resection because of other medical problems, such as they’re older, their performance status is maybe an ECOG [Eastern Cooperative Oncology Group] 1, they’re not going to be able to tolerate a liver surgery, or they have cardiovascular problems. Something like that would have somebody go to an ablation as compared to a resection.

Darren S. Sigal, MD: So, just continuing down this path about ablation and radiofrequency ablation or even microwave ablation that you brought up, how does that compare to TACE, or transarterial chemoembolization, and how do you make a decision whether what modality to use?

Catherine T. Frenette, MD: That’s a really good question, and it’s one that we discuss a lot in our multidisciplinary tumor board. So, we know that ablation is very good for small lesions, less than 3 cm. And, in fact, ablation of small lesions is considered curative therapy, especially on the BCLC [Barcelona Clinic Liver Cancer] staging system. Chemoembolization is not a curative therapy, and I always make sure to tell this to my patients. This is not curative. It buys us time. So, ablation for small lesions is an excellent option, but it is somewhat limited by adjacent structures. For instance, if the tumor is right next to the gallbladder, it’s very difficult to ablate because you also injure the gallbladder. Ablation is also somewhat limited by the location. For instance, if it’s high in the dome of the liver, it’s very difficult for the radiologist to get a probe up in their tumor to actually ablate it. Sometimes ablation isn’t an option or if the lesions are larger, such as 5, 6, or 7 cm, ablation is not going to get you a complete response.

So, TACE, or transarterial chemoembolization, we use more frequently than ablation. I would say we look at all of our locoregional therapies. Probably two-thirds to three-quarters of them are chemoembolization-based or TACE-based. TACE has a very good response rate. About 60% to 65% of patients will have a radiographic complete response on the first treatment. You can re-treat patients, and we’ve had patients that have had as many as 4 or 5 TACE procedures. With TACE, we do know, again, this isn’t curative, and the tumor will come back. After the TACE or after the ablation, we do have to continue to monitor, and we scan every 3 months. And if tumors are coming back, we can re-treat.

As far as how many times can you treat, what you don’t want to do is treat someone so many times that now their liver is starting to fail from the number of locoregional therapies that they’ve had. And now they’re no longer a candidate for systemic treatments because they’ve been TACEd so many times. So, we do have to be a little bit careful with balancing what we can do with what we should do. In general, if someone has no response to 2 TACE procedures, you should move to the next treatment. It has been shown that no response to 2 treatments, they’re not going to respond to that treatment. We also know that after 4 TACE procedures, you really aren’t seeing a survival benefit anymore. Number of TACEs that you perform, your incremental survival benefit decreases with each further procedure. And really after 4, you’re not giving the patient any survival benefit. We’re just treating a scan.

Transcript Edited for Clarity 
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