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HCC Staging Systems Explored

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: Thursday, Sep 20, 2018



Transcript: 

Ghassan K. Abou-Alfa, MD: What we have heard so far is quite interesting. Undoubtedly, there are different views in regard to how to diagnose hepatocellular carcinoma. Historically, as we heard, the use of the radiologic assessments to diagnose HCC has been the norm based on the screening directives that were there in time.

There’s one key component that was brought up—the issue of cirrhosis or not. We have not had a clue as to how to diagnose cirrhosis on the BCLC criteria, let alone the LI-RADS. Nonetheless, there is this kind of preponderance to try to do this. We do acknowledge, and have heard from experts, that the extremes are great. We can confirm that this is HCC. We can confirm that this is benign disease. But the in-between is really where we might be lost, and we might need something further, information-wise, to be dissected.

More important, we heard that the combination of diseases, together, can occur. I totally agree that up to 10% to 20% of patients might have combined cholangiocarcinoma and HCC. We cannot ignore that fact because treating the cholangiocarcinoma component is going to be as important. And, of course, there is the genetic makeup. The direct applicability in regard to HCC on a day-to-day basis is not there yet, but it’s coming.

At the end of the day, having the genetic analysis of the disease will be necessary for research purposes, opportunities for clinical trials, or sometimes, of course, the completion of the work-up that we’re doing for our patients. This is still debatable, but no doubt, as oncologists, we definitely are doing some biopsies despite the LI-RADS and its use in certain applications.

I don’t think we have any final answer in that regard. But that said, I would like to move on and discuss staging. If anything, we’ve been using BCLC. We hear about BCLC, which not only splits patients into stage but also gives guidance in regard to therapy, per se. Mark, do you use BCLC in your practice?

Mark W. Karwal, MD: I always put it in the note when I see the patient. I like the CLIP score better—the Cancer of the Liver Italian Program score. It doesn’t have performance score in it. The bad thing about BCLC is that I could take any hepatology or any hepatocellular carcinoma patient and ask them if they’re tired. They’ll say yes. They have a performance score of 1 and are automatically C stage.

Ghassan K. Abou-Alfa, MD: I really picked you to answer that question by chance, and I’m so happy that I did. You definitely excited me. I totally agree with you. In a paper that we published in the Journal of Clinical Oncology, we discovered that BCLC does not necessarily pertain much to the patients with metastatic disease. And, if anything, the one that scored the highest is exactly what you use—the CLIP (the Cancer of the Liver Italian Program). If anything, this probably came from the idea that patients in Italy get HCC for almost the same reasons that they get HCC in the United States. That’s probably where the correlation has been.

Transcript Edited for Clarity 

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Transcript: 

Ghassan K. Abou-Alfa, MD: What we have heard so far is quite interesting. Undoubtedly, there are different views in regard to how to diagnose hepatocellular carcinoma. Historically, as we heard, the use of the radiologic assessments to diagnose HCC has been the norm based on the screening directives that were there in time.

There’s one key component that was brought up—the issue of cirrhosis or not. We have not had a clue as to how to diagnose cirrhosis on the BCLC criteria, let alone the LI-RADS. Nonetheless, there is this kind of preponderance to try to do this. We do acknowledge, and have heard from experts, that the extremes are great. We can confirm that this is HCC. We can confirm that this is benign disease. But the in-between is really where we might be lost, and we might need something further, information-wise, to be dissected.

More important, we heard that the combination of diseases, together, can occur. I totally agree that up to 10% to 20% of patients might have combined cholangiocarcinoma and HCC. We cannot ignore that fact because treating the cholangiocarcinoma component is going to be as important. And, of course, there is the genetic makeup. The direct applicability in regard to HCC on a day-to-day basis is not there yet, but it’s coming.

At the end of the day, having the genetic analysis of the disease will be necessary for research purposes, opportunities for clinical trials, or sometimes, of course, the completion of the work-up that we’re doing for our patients. This is still debatable, but no doubt, as oncologists, we definitely are doing some biopsies despite the LI-RADS and its use in certain applications.

I don’t think we have any final answer in that regard. But that said, I would like to move on and discuss staging. If anything, we’ve been using BCLC. We hear about BCLC, which not only splits patients into stage but also gives guidance in regard to therapy, per se. Mark, do you use BCLC in your practice?

Mark W. Karwal, MD: I always put it in the note when I see the patient. I like the CLIP score better—the Cancer of the Liver Italian Program score. It doesn’t have performance score in it. The bad thing about BCLC is that I could take any hepatology or any hepatocellular carcinoma patient and ask them if they’re tired. They’ll say yes. They have a performance score of 1 and are automatically C stage.

Ghassan K. Abou-Alfa, MD: I really picked you to answer that question by chance, and I’m so happy that I did. You definitely excited me. I totally agree with you. In a paper that we published in the Journal of Clinical Oncology, we discovered that BCLC does not necessarily pertain much to the patients with metastatic disease. And, if anything, the one that scored the highest is exactly what you use—the CLIP (the Cancer of the Liver Italian Program). If anything, this probably came from the idea that patients in Italy get HCC for almost the same reasons that they get HCC in the United States. That’s probably where the correlation has been.

Transcript Edited for Clarity 
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