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Considerations for Biopsy in Diagnosing HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; A. Ruth He, MD, PhD, Georgetown University Medical Center; Mark W. Karwal, MD, University of Iowa Health Care; Mark H. OHara, MD, Hospital of the University of Pennsylvania; Manish R. Sharma, MD, University of Chicago; Amit Singal, MD, UT Southwestern Medical Center
Published: Monday, Jul 30, 2018



Transcript: 

Ghassan K. Abou-Alfa, MD: Hello. Welcome to this OncLive® Peer Exchange® panel discussion titled “An Evolving Treatment Paradigm for Hepatocellular Carcinoma.” It is a very exciting time to treat patients with hepatocellular carcinoma, with 3 new FDA approvals beyond sorafenib and a phase III trial showing unprecedented survival in the frontline setting. In this OncLive® Peer Exchange® panel discussion, we are going to discuss multidisciplinary management of advanced hepatocellular carcinoma, or liver cancer. We’ll take a detailed look at the new agents and provide you with practical perspective on the best ways to use them while treating patients with metastatic disease. In addition, we’ll look at the abstracts from the 2018 ASCO Annual Meeting and talk about how the new research will impact clinical practice.

I am Dr. Ghassan Abou-Alfa. I’m a medical oncologist at Memorial Sloan Kettering Cancer Center and an associate professor at Weill Cornell Medical College in New York City.

Participating today on this distinguished panel are Dr. Ruth He, associate professor of medicine and a hematology/oncology specialist at Georgetown University Medical Center in Washington, DC; Dr. Mark Karwal, clinical associate professor of internal medicine in the Division of Hematology, Oncology and Blood and Marrow Transplantation at University of Iowa Health Care in Iowa City, Iowa; Dr. Mark O’Hara, assistant professor of medicine and attending physician for the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia; Dr. Manish Sharma, assistant professor of medicine in the Section of Hematology/Oncology and associate director of the Committee of Clinical Pharmacology and Pharmacogenomics at the University of Chicago in Illinois; and Dr. Amit Singal, associate professor of medicine, medical director of the Liver Tumor Program, and clinical chief of hepatology at UT Southwestern Medical Center in Dallas, Texas. Thank you so much for joining us. Let’s begin.

It has really been an exciting year for HCC. Not long ago, probably even within 2 years ago, I would be at a social event talking to a colleague. I would ask, “What do you do?” And, for example, they would say, “I work in melanoma.” We would talk a little about this, and then they would look at me and say, “So, what do you do?” I would say that I work in HCC, and their next words would be, “Oh. Great weather today.” And this year, no kidding, a Fellow in training came into my office and said, “I would like to consider doing my research with you.” My response to him was, “I think you are looking for colorectal cancer next door.” And he said, “No, no, no. I’m here for HCC.” I’m said, “Wow. I’ve never had this happen before.”

It’s incredible how much is going on. If anything, this is really great news for patients. All of us are involved, one way or another, in taking care of patients with HCC. In the community, there is more and more attention to the disease as well. And this is, of course, because of the multiple advances that we’re seeing.

That said, let’s start to help each other and, at the same time, help our colleagues who are listening to and are watching us today. HCC is really rather foreign in oncology. Many times, we get questions as simple as “Do we need to biopsy or not?” Understandably and historically, we have heard about the screening component, which would not necessarily require biopsy. Amit, maybe you can help us here because this is more common in your field, as a hepatologist. What’s the story of screening and no biopsies in regard to HCC?

Amit Singal, MD: HCC is a cancer where we have a very defined high-risk population. Over 90% of HCC in the United States actually happens in the setting of cirrhosis—the end-stage component for any chronic liver disease. We have a population in whom we can implement screening programs using ultrasound with a biomarker—alpha-fetoprotein. When you find this, you should then perform a 4-phase CT or a contrast-enhanced MRI. Because of the high risk of developing HCC in this setting of cirrhosis, which can extend anywhere from 2% to 6% per year, if you find a lesion, at least in a hepatologist’s eye, it’s HCC until proved otherwise.

And so, when you have these contrast-enhanced imaging studies, if you see arterial enhancement and delayed washout, based on the classic criteria that we’ve been using for years, the chance of its being HCC is somewhere on the order of 95% to 97% certainty. When I talk to my patients, I say, “We can say with near certainty that this is HCC.” The question is, do you really need to put that patient through the risk of a biopsy to confirm and to lower that risk of having a false positive?

Ghassan K. Abou-Alfa, MD: I hear your point, and I definitely hear the kind of historical background to the whole story. But Mark, we biopsy patients even before we apply any therapy. Why would HCC be different? What would be your argument to biopsy for HCC?

Mark H. O’Hara, MD: I think there are a couple of different points. Sometimes, while you might have some convincing evidence, if you have a LI-RADS (Liver Imaging Reporting and Data System) 5 case, or something on the imaging that sort of suggests that you definitely have HCC, there’s a chance there actually might be a mixed picture of HCC and a cholangiocarcinoma that may or may not respond to an HCC-directed therapy.

Ghassan K. Abou-Alfa, MD: I see. So, in other words, the biopsy is needed simply because you might not even be dealing with HCC alone. It could be HCC plus cholangiocarcinoma, for example.

Transcript Edited for Clarity 

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Transcript: 

Ghassan K. Abou-Alfa, MD: Hello. Welcome to this OncLive® Peer Exchange® panel discussion titled “An Evolving Treatment Paradigm for Hepatocellular Carcinoma.” It is a very exciting time to treat patients with hepatocellular carcinoma, with 3 new FDA approvals beyond sorafenib and a phase III trial showing unprecedented survival in the frontline setting. In this OncLive® Peer Exchange® panel discussion, we are going to discuss multidisciplinary management of advanced hepatocellular carcinoma, or liver cancer. We’ll take a detailed look at the new agents and provide you with practical perspective on the best ways to use them while treating patients with metastatic disease. In addition, we’ll look at the abstracts from the 2018 ASCO Annual Meeting and talk about how the new research will impact clinical practice.

I am Dr. Ghassan Abou-Alfa. I’m a medical oncologist at Memorial Sloan Kettering Cancer Center and an associate professor at Weill Cornell Medical College in New York City.

Participating today on this distinguished panel are Dr. Ruth He, associate professor of medicine and a hematology/oncology specialist at Georgetown University Medical Center in Washington, DC; Dr. Mark Karwal, clinical associate professor of internal medicine in the Division of Hematology, Oncology and Blood and Marrow Transplantation at University of Iowa Health Care in Iowa City, Iowa; Dr. Mark O’Hara, assistant professor of medicine and attending physician for the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia; Dr. Manish Sharma, assistant professor of medicine in the Section of Hematology/Oncology and associate director of the Committee of Clinical Pharmacology and Pharmacogenomics at the University of Chicago in Illinois; and Dr. Amit Singal, associate professor of medicine, medical director of the Liver Tumor Program, and clinical chief of hepatology at UT Southwestern Medical Center in Dallas, Texas. Thank you so much for joining us. Let’s begin.

It has really been an exciting year for HCC. Not long ago, probably even within 2 years ago, I would be at a social event talking to a colleague. I would ask, “What do you do?” And, for example, they would say, “I work in melanoma.” We would talk a little about this, and then they would look at me and say, “So, what do you do?” I would say that I work in HCC, and their next words would be, “Oh. Great weather today.” And this year, no kidding, a Fellow in training came into my office and said, “I would like to consider doing my research with you.” My response to him was, “I think you are looking for colorectal cancer next door.” And he said, “No, no, no. I’m here for HCC.” I’m said, “Wow. I’ve never had this happen before.”

It’s incredible how much is going on. If anything, this is really great news for patients. All of us are involved, one way or another, in taking care of patients with HCC. In the community, there is more and more attention to the disease as well. And this is, of course, because of the multiple advances that we’re seeing.

That said, let’s start to help each other and, at the same time, help our colleagues who are listening to and are watching us today. HCC is really rather foreign in oncology. Many times, we get questions as simple as “Do we need to biopsy or not?” Understandably and historically, we have heard about the screening component, which would not necessarily require biopsy. Amit, maybe you can help us here because this is more common in your field, as a hepatologist. What’s the story of screening and no biopsies in regard to HCC?

Amit Singal, MD: HCC is a cancer where we have a very defined high-risk population. Over 90% of HCC in the United States actually happens in the setting of cirrhosis—the end-stage component for any chronic liver disease. We have a population in whom we can implement screening programs using ultrasound with a biomarker—alpha-fetoprotein. When you find this, you should then perform a 4-phase CT or a contrast-enhanced MRI. Because of the high risk of developing HCC in this setting of cirrhosis, which can extend anywhere from 2% to 6% per year, if you find a lesion, at least in a hepatologist’s eye, it’s HCC until proved otherwise.

And so, when you have these contrast-enhanced imaging studies, if you see arterial enhancement and delayed washout, based on the classic criteria that we’ve been using for years, the chance of its being HCC is somewhere on the order of 95% to 97% certainty. When I talk to my patients, I say, “We can say with near certainty that this is HCC.” The question is, do you really need to put that patient through the risk of a biopsy to confirm and to lower that risk of having a false positive?

Ghassan K. Abou-Alfa, MD: I hear your point, and I definitely hear the kind of historical background to the whole story. But Mark, we biopsy patients even before we apply any therapy. Why would HCC be different? What would be your argument to biopsy for HCC?

Mark H. O’Hara, MD: I think there are a couple of different points. Sometimes, while you might have some convincing evidence, if you have a LI-RADS (Liver Imaging Reporting and Data System) 5 case, or something on the imaging that sort of suggests that you definitely have HCC, there’s a chance there actually might be a mixed picture of HCC and a cholangiocarcinoma that may or may not respond to an HCC-directed therapy.

Ghassan K. Abou-Alfa, MD: I see. So, in other words, the biopsy is needed simply because you might not even be dealing with HCC alone. It could be HCC plus cholangiocarcinoma, for example.

Transcript Edited for Clarity 
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