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Radiotherapy Use in HCC

Panelists: Ghassan K. Abou-Alfa, MD, Weill Cornell Medical College; Peter Galle, MD, PhD Johannes Gutenberg University, Mainz; Riad Salem, MD, Northwestern University; Amit Singal, MD UT Southwestern Medical Center
Published: Tuesday, Dec 11, 2018



Transcript: 

Ghassan K. Abou-Alfa, MD: Let me carry on with another important discussion, in regard to local therapy, that is relatively new in HCC [hepatocellular carcinoma]—radiation, radiotherapy. Riad, what are your thoughts on radiotherapy use in HCC?

Riad Salem, MD: There’s no doubt that over the last 5, 10 years, there’s been an increased interest in the investigation and in the implementation of radiotherapy for HCC. In a manner akin to radioembolization, however, there is a center-specific expertise that is applicable here. In some of those centers, the results are quite comparable to ablation, to resection in the right patient, and to Y-90 [Yttrium-90], etc. So there certainly is that level of expertise. I do think that, as you mentioned before, you’re going to have to figure out which patients qualify for what. I think SBRT [stereotactic body radiation therapy] plays a great complementary role for a lot of lesions that are difficult to identify, treat, see, etc. We can use that. We can improve that with fiducials.

The major limitation that I see with SBRT and radiotherapy is the language that we use compared to the language that they use. For SBRT, they say things like local tumor control, 90%, 2-year, etc, etc. For locoregional therapies and systemic therapies, we don’t use those terms. We say response rate, progression-free survival, and time to progression. It’s very easy to have a very high local tumor control rate but a TTP [time to progression] of 3 months, for example. So I think that radiotherapy has to normalize their language and nomenclature to match everything else, or we need to switch to theirs. We’re speaking a different language. That’s very important because the survival is ultimately the same with all of the therapies, but, yet, there are very high LTR rates. These are some of the things that I think about. But again, center expertise is very, very important. That’s what the literature shows.

Ghassan K. Abou-Alfa, MD: Peter, to talk a bit more about radiation, there is currently an effort by Laura Dawson, part of the multicooperative group study from Princess Margaret in Canada, that’s looking into radiation plus sorafenib [Nexavar]. Start on that.

Peter Galle, MD, PhD: I think SBRT is promising and it’s underinvestigated. That’s what we felt when we put together the EASL [European Association for the Study of the Liver] guidelines over the last year. We discussed that heavily, and everybody had that feeling. There are very promising early data on small numbers of patients that need to be continued. My recommendation is to first study that before you go to combinations, just to make that clear. But then, of course, it will be very interesting to combine things. We are coming back to the same situation we were discussing when we were talking about Y-90 and immuno-oncologic drugs. Again, it’s very tempting to add something that has a local destruction to immunotherapy. Immune-directed therapy is probably better tolerated and more effective in combination with radiotherapy than sorafenib. Nevertheless, this is an interesting question, and everything which results in large numbers of patients is pushing the field forward.

Transcript Edited for Clarity 

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Transcript: 

Ghassan K. Abou-Alfa, MD: Let me carry on with another important discussion, in regard to local therapy, that is relatively new in HCC [hepatocellular carcinoma]—radiation, radiotherapy. Riad, what are your thoughts on radiotherapy use in HCC?

Riad Salem, MD: There’s no doubt that over the last 5, 10 years, there’s been an increased interest in the investigation and in the implementation of radiotherapy for HCC. In a manner akin to radioembolization, however, there is a center-specific expertise that is applicable here. In some of those centers, the results are quite comparable to ablation, to resection in the right patient, and to Y-90 [Yttrium-90], etc. So there certainly is that level of expertise. I do think that, as you mentioned before, you’re going to have to figure out which patients qualify for what. I think SBRT [stereotactic body radiation therapy] plays a great complementary role for a lot of lesions that are difficult to identify, treat, see, etc. We can use that. We can improve that with fiducials.

The major limitation that I see with SBRT and radiotherapy is the language that we use compared to the language that they use. For SBRT, they say things like local tumor control, 90%, 2-year, etc, etc. For locoregional therapies and systemic therapies, we don’t use those terms. We say response rate, progression-free survival, and time to progression. It’s very easy to have a very high local tumor control rate but a TTP [time to progression] of 3 months, for example. So I think that radiotherapy has to normalize their language and nomenclature to match everything else, or we need to switch to theirs. We’re speaking a different language. That’s very important because the survival is ultimately the same with all of the therapies, but, yet, there are very high LTR rates. These are some of the things that I think about. But again, center expertise is very, very important. That’s what the literature shows.

Ghassan K. Abou-Alfa, MD: Peter, to talk a bit more about radiation, there is currently an effort by Laura Dawson, part of the multicooperative group study from Princess Margaret in Canada, that’s looking into radiation plus sorafenib [Nexavar]. Start on that.

Peter Galle, MD, PhD: I think SBRT is promising and it’s underinvestigated. That’s what we felt when we put together the EASL [European Association for the Study of the Liver] guidelines over the last year. We discussed that heavily, and everybody had that feeling. There are very promising early data on small numbers of patients that need to be continued. My recommendation is to first study that before you go to combinations, just to make that clear. But then, of course, it will be very interesting to combine things. We are coming back to the same situation we were discussing when we were talking about Y-90 and immuno-oncologic drugs. Again, it’s very tempting to add something that has a local destruction to immunotherapy. Immune-directed therapy is probably better tolerated and more effective in combination with radiotherapy than sorafenib. Nevertheless, this is an interesting question, and everything which results in large numbers of patients is pushing the field forward.

Transcript Edited for Clarity 
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