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Ablation vs Resection in Liver Cancer

Panelists: Richard S. Finn, MD, Geffen School of Medicine; Jordi Bruix, MD, Hospital Clinic University of Barcelona; Amit Singal, MD, MSCS, UT Southwestern Medical Center; Richard H. Marshall, MD, University Medical Center New Orleans; Arndt Vogel, MD, PhD, Hanover Medical School
Published: Monday, Jul 24, 2017



Transcript:

Richard S. Finn, MD:
One of the major options for patients who have early disease is surgical resection. The challenge, I think, is that a lot of patients have liver cirrhosis or portal hypertension. At our center, a platelet count under 100,000 would deem someone as not a good surgical candidate. But a lot of patients are good surgical candidates. For small tumors, radiofrequency ablation can be very effective. Dr. Marshall, can you talk to us about this debate on patients who are resectable? Should they be resected or should they undergo percutaneous ablation?

Richard H. Marshall, MD: Well, resection has long been the gold standard for tumors that are small, and it can be used, even, for larger tumors. We’ve seen, in the last few years, data come out that show that RFA can have similar outcomes and similar overall survivals as compared to surgical resection in tumors that are 2 cm, 3 cm, and smaller—especially those tumors that are centrally located, in which a large resection is necessary. So, there is an expanding role for RFA.

There have been other tools that have been introduced, especially microwave ablation. Microwave antennas have been refined, and they can now produce a much more predictable and reliable ablation area. And, indeed, we’ve seen some comparisons of microwave to RFA that show lower recurrence rates—some are in the order of 20% for RFA versus 10% for microwave ablation. We will see, I think, an expanded role of microwave ablation in the future.

Now, it’s important to talk about these, and this is a great topic to discuss along with liver transplantation, because now that we have these tools that can provide patients who are too sick to have their tumors resected with a treatment option, we may have the ability to treat hepatitis and improve liver function over time. So, we may be able to take some of these patients off the transplant list. That remains to be seen, but it’s important to focus on that in the future.

We would be remiss if we didn’t talk about combination therapies, especially combining TACE with an ablation therapy. We’ve seen that when we combine these therapies, we can actually achieve a much bigger ablation. We can treat a tumor and satellite nodules in the area more effectively than we could in the past. And so, we are looking at these treatments right now. There have been some studies that have published some very good retrospective data. There are some prospective studies that have published on larger ablation zones. I think this will become a much better option in the future and will be much more heavily utilized.

Richard S. Finn, MD: Yes. In your center, is everybody getting TACE followed by RFA? Is that the standard approach?

Richard H. Marshall, MD: At my center, we’re trying to combine therapies whenever possible. There’s a lot of debate right now about how to sequence these therapies—whether to do them both at the same time or to do one prior to the other. It remains to be seen what the best treatment is for this. But whenever we can, in patients with small tumors and tumors up to 5 cm, we’re trying to combine the therapies because the data have shown that this is better than any 1 therapy alone.

Richard S. Finn, MD: I think, probably, the jury is still out on that. Like you said, most of this is retrospective data. The randomized data, I don’t think, have been super robust.

Transcript Edited for Clarity

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Transcript:

Richard S. Finn, MD:
One of the major options for patients who have early disease is surgical resection. The challenge, I think, is that a lot of patients have liver cirrhosis or portal hypertension. At our center, a platelet count under 100,000 would deem someone as not a good surgical candidate. But a lot of patients are good surgical candidates. For small tumors, radiofrequency ablation can be very effective. Dr. Marshall, can you talk to us about this debate on patients who are resectable? Should they be resected or should they undergo percutaneous ablation?

Richard H. Marshall, MD: Well, resection has long been the gold standard for tumors that are small, and it can be used, even, for larger tumors. We’ve seen, in the last few years, data come out that show that RFA can have similar outcomes and similar overall survivals as compared to surgical resection in tumors that are 2 cm, 3 cm, and smaller—especially those tumors that are centrally located, in which a large resection is necessary. So, there is an expanding role for RFA.

There have been other tools that have been introduced, especially microwave ablation. Microwave antennas have been refined, and they can now produce a much more predictable and reliable ablation area. And, indeed, we’ve seen some comparisons of microwave to RFA that show lower recurrence rates—some are in the order of 20% for RFA versus 10% for microwave ablation. We will see, I think, an expanded role of microwave ablation in the future.

Now, it’s important to talk about these, and this is a great topic to discuss along with liver transplantation, because now that we have these tools that can provide patients who are too sick to have their tumors resected with a treatment option, we may have the ability to treat hepatitis and improve liver function over time. So, we may be able to take some of these patients off the transplant list. That remains to be seen, but it’s important to focus on that in the future.

We would be remiss if we didn’t talk about combination therapies, especially combining TACE with an ablation therapy. We’ve seen that when we combine these therapies, we can actually achieve a much bigger ablation. We can treat a tumor and satellite nodules in the area more effectively than we could in the past. And so, we are looking at these treatments right now. There have been some studies that have published some very good retrospective data. There are some prospective studies that have published on larger ablation zones. I think this will become a much better option in the future and will be much more heavily utilized.

Richard S. Finn, MD: Yes. In your center, is everybody getting TACE followed by RFA? Is that the standard approach?

Richard H. Marshall, MD: At my center, we’re trying to combine therapies whenever possible. There’s a lot of debate right now about how to sequence these therapies—whether to do them both at the same time or to do one prior to the other. It remains to be seen what the best treatment is for this. But whenever we can, in patients with small tumors and tumors up to 5 cm, we’re trying to combine the therapies because the data have shown that this is better than any 1 therapy alone.

Richard S. Finn, MD: I think, probably, the jury is still out on that. Like you said, most of this is retrospective data. The randomized data, I don’t think, have been super robust.

Transcript Edited for Clarity
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