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Treatment Strategies for Early-Stage 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, Nov 27, 2018


Transcript: 

Ghassan K. Abou-Alfa, MD: Hello. Welcome to this OncLive® Peer Exchange panel discussion. We’re here to discuss the advance in therapies for HCC [hepatocellular carcinoma]. As we all know, almost a decade ago, our job was easy. We had 1 drug. We always worried about sorafenib. Of course, sorafenib caused side effects. Nowadays we have so many advances with regard to systemic therapy, let alone the advance with regard to local therapies and the combination of them.

So today, in this OncLive® Peer Exchange panel discussion, we are going to delve into these new therapies and further dissect details about what they mean with regard to biology as well as tolerance for patients.
I am Ghassan Abou-Alfa, and I’m a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, New York.

Joining me on this panel are global experts: Dr Peter Galle, a professor and director at the Johannes Gutenberg University in Mainz, Germany; Dr Riad Salem, a professor of radiology, medicine, and surgery and the chief of interventional radiology at Northwestern University in Chicago, Illinois; and Dr Amit Singal, an associate professor of medicine and the medical director of the liver tumor program at UT Southwestern Medical Center in Dallas, Texas.

Thank you so much for joining us. Let’s get started with our discussion.

Amit, I’ll start with you. The whole HCC story is evolving way too fast for us. To be fair, at the end of the day, there are some patients who we can really take care of and put this disease behind them. We can cure them. Tell us a bit about this perspective of surgery. Who goes for surgery and why?

Amit Singal, MD: I think you’re right. As the field changes and we have more and more therapies—with liver-directed therapies and systemic therapies—we have to remember that the best prognosis happens when we find this disease early and can treat the patient with curative therapies. And the curative therapies remain to be surgical resection, liver transplantation, and local ablation. So we tend to be very aggressive with curative therapies, when possible, because it provides the best long-term survival. So for example, for anyone who has a lack of cirrhosis or has compensated cirrhosis, we tend to be very aggressive with surgical resection. For anyone who has more advanced liver cirrhosis and has tumors within transplant criteria, we tend to be very aggressive, in terms of offering them a transplant.

Ghassan K. Abou-Alfa, MD: Peter, with this introduction, do you have any thoughts on any differences with regard to etiology and resection or the use of transplant versus resection? Hepatitis B versus hepatitis C, for example?

Peter Galle, MD, PhD: Well, the situation is certainly changing. For hepatitis C patients, we now have the option to curatively treat. We can now do that, both before transplant and after transplant. Moving forward, it’s to be expected that there will be a dramatic drop in the numbers of patients with hepatitis C virus–driven liver disease. For the last 10, 15 years, hepatitis B has been easy to control. Its impact is seen on very different levels. For example, our assessment based on AFP [alpha-fetoprotein] will probably be redefined in a situation in which infection can be quite well controlled. In the past, the signals had been obscured by hepatitis. Now there are stronger signals that are tumor driven. So there have been lots of changes.

Is there a difference in etiology with respect to treatment option? No. We do the same thing. We know that there are some differences in outcome. For example, NASH [nonalcoholic steatohepatitis]-driven tumors are more benign. They grow more slowly. But that will not influence a treatment decision on resection, for example.

Ghassan K. Abou-Alfa, MD: Riad, as an interventional radiologist, patients should get a resection or get a transplant and move on. Is there a demarcation line between when a patient is in a curative intent setting versus when they need your help with some form of embolization?

Riad Salem, MD: The reality is, when you have early disease, you try to provide curative therapy. The issue arises that many patients aren’t candidates for that, for whatever reason: location of tumor, comorbidities, etc. Based on guidelines, you stage migrate to the next-best treatment. As an interventional radiologist, while I perform the ablations, many patients end up needing some form of embolization. They migrate to the next stage. That means there are many patients getting embolization who actually have early-stage disease. Any sort of modern center practicing and managing HCC has to involve that. There are several embolic therapies. You have the bland embolizations, chemoembolizations, and yttrium radioembolizations. So I think you really have to understand where the stage migration concept comes from. And when you implement that, you need to provide a comprehensive treatment plan for the patient.

Ghassan K. Abou-Alfa, MD: Amit, I get a scenario, and I’m sure you get the same scenario. The patient gets surgery. They get congratulated. The tumor is out. Then they look at you and say, “Now what?” Any adjuvant therapy?

Amit Singal, MD: There are a couple of things to keep in mind. As you’re pointing out, even though resection is curative upfront, there’s a very high recurrence rate. And so, you take a look over the next 5 years. Those patients have a 50% to 70% chance of recurrence. This has really highlighted the fact that we really would love to have an adjuvant therapy. And unfortunately, so far, as we’ll talk about later in this discussion, right now we’ve been really limited with TKI [tyrosine kinase inhibitor] therapy. In the trials, the use of TKI therapy in the adjuvant setting have been negative. There are now ongoing trials looking at immunotherapy in the adjuvant setting. I’m hopeful that the results will be positive. So I think we will see advances in this field.

Transcript Edited for Clarity 

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Transcript: 

Ghassan K. Abou-Alfa, MD: Hello. Welcome to this OncLive® Peer Exchange panel discussion. We’re here to discuss the advance in therapies for HCC [hepatocellular carcinoma]. As we all know, almost a decade ago, our job was easy. We had 1 drug. We always worried about sorafenib. Of course, sorafenib caused side effects. Nowadays we have so many advances with regard to systemic therapy, let alone the advance with regard to local therapies and the combination of them.

So today, in this OncLive® Peer Exchange panel discussion, we are going to delve into these new therapies and further dissect details about what they mean with regard to biology as well as tolerance for patients.
I am Ghassan Abou-Alfa, and I’m a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, New York.

Joining me on this panel are global experts: Dr Peter Galle, a professor and director at the Johannes Gutenberg University in Mainz, Germany; Dr Riad Salem, a professor of radiology, medicine, and surgery and the chief of interventional radiology at Northwestern University in Chicago, Illinois; and Dr Amit Singal, an associate professor of medicine and the medical director of the liver tumor program at UT Southwestern Medical Center in Dallas, Texas.

Thank you so much for joining us. Let’s get started with our discussion.

Amit, I’ll start with you. The whole HCC story is evolving way too fast for us. To be fair, at the end of the day, there are some patients who we can really take care of and put this disease behind them. We can cure them. Tell us a bit about this perspective of surgery. Who goes for surgery and why?

Amit Singal, MD: I think you’re right. As the field changes and we have more and more therapies—with liver-directed therapies and systemic therapies—we have to remember that the best prognosis happens when we find this disease early and can treat the patient with curative therapies. And the curative therapies remain to be surgical resection, liver transplantation, and local ablation. So we tend to be very aggressive with curative therapies, when possible, because it provides the best long-term survival. So for example, for anyone who has a lack of cirrhosis or has compensated cirrhosis, we tend to be very aggressive with surgical resection. For anyone who has more advanced liver cirrhosis and has tumors within transplant criteria, we tend to be very aggressive, in terms of offering them a transplant.

Ghassan K. Abou-Alfa, MD: Peter, with this introduction, do you have any thoughts on any differences with regard to etiology and resection or the use of transplant versus resection? Hepatitis B versus hepatitis C, for example?

Peter Galle, MD, PhD: Well, the situation is certainly changing. For hepatitis C patients, we now have the option to curatively treat. We can now do that, both before transplant and after transplant. Moving forward, it’s to be expected that there will be a dramatic drop in the numbers of patients with hepatitis C virus–driven liver disease. For the last 10, 15 years, hepatitis B has been easy to control. Its impact is seen on very different levels. For example, our assessment based on AFP [alpha-fetoprotein] will probably be redefined in a situation in which infection can be quite well controlled. In the past, the signals had been obscured by hepatitis. Now there are stronger signals that are tumor driven. So there have been lots of changes.

Is there a difference in etiology with respect to treatment option? No. We do the same thing. We know that there are some differences in outcome. For example, NASH [nonalcoholic steatohepatitis]-driven tumors are more benign. They grow more slowly. But that will not influence a treatment decision on resection, for example.

Ghassan K. Abou-Alfa, MD: Riad, as an interventional radiologist, patients should get a resection or get a transplant and move on. Is there a demarcation line between when a patient is in a curative intent setting versus when they need your help with some form of embolization?

Riad Salem, MD: The reality is, when you have early disease, you try to provide curative therapy. The issue arises that many patients aren’t candidates for that, for whatever reason: location of tumor, comorbidities, etc. Based on guidelines, you stage migrate to the next-best treatment. As an interventional radiologist, while I perform the ablations, many patients end up needing some form of embolization. They migrate to the next stage. That means there are many patients getting embolization who actually have early-stage disease. Any sort of modern center practicing and managing HCC has to involve that. There are several embolic therapies. You have the bland embolizations, chemoembolizations, and yttrium radioembolizations. So I think you really have to understand where the stage migration concept comes from. And when you implement that, you need to provide a comprehensive treatment plan for the patient.

Ghassan K. Abou-Alfa, MD: Amit, I get a scenario, and I’m sure you get the same scenario. The patient gets surgery. They get congratulated. The tumor is out. Then they look at you and say, “Now what?” Any adjuvant therapy?

Amit Singal, MD: There are a couple of things to keep in mind. As you’re pointing out, even though resection is curative upfront, there’s a very high recurrence rate. And so, you take a look over the next 5 years. Those patients have a 50% to 70% chance of recurrence. This has really highlighted the fact that we really would love to have an adjuvant therapy. And unfortunately, so far, as we’ll talk about later in this discussion, right now we’ve been really limited with TKI [tyrosine kinase inhibitor] therapy. In the trials, the use of TKI therapy in the adjuvant setting have been negative. There are now ongoing trials looking at immunotherapy in the adjuvant setting. I’m hopeful that the results will be positive. So I think we will see advances in this field.

Transcript Edited for Clarity 
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