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Impact of Liver Cirrhosis in HCC

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 17, 2017



Transcript:

Jordi Bruix, MD:
We have had the request to make the Barcelona Clinic Liver Cancer staging system complicated, and I said, “No way.” If you make things complicated, it will be a mess. Keep it simple. We have a first picture, and that’s it.

Richard S. Finn, MD: There are a lot of complexities with this disease, and our interventions can affect liver function. I think an important point that was made before is, you could have someone with a small tumor, but if their liver is very sick, the cancer isn’t their biggest problem. Dr. Vogel, as a GI-hepatologist, can you give me a sense of how liver disease and cancer intersect in this diagnosis?

Arndt Vogel, MD, PhD: Yes. There’s a strong and complex interaction between liver disease and cancer. There are different levels on how liver function really affects our treatment options. So, first of all, I think we have to acknowledge that most treatments, which have been analyzed in prospective trials, have been done in highly selected groups of patients with very preserved liver function.

Now, we have to apply these data to our patients in clinical life, who, very often, do not have preserved liver function, which makes the delivery more difficult. Then, we have very good and curative treatments, as was mentioned before. Patients with more tumors can receive resection, and we can get, then, complete destruction or resection of the tumors. But if they have too advanced liver disease, we cannot apply the treatments because the liver function is not good enough.

The other point is, when we decide on a treatment, we always have to keep in mind that the treatment itself might harm the liver. So, indicating that when we decide on a treatment, we need to carefully monitor liver function and see and detect, as early on as possible, at which time point our treatment affects liver function, which would then have a very negative effect on the prognosis of our patients.

And then—this is the third point, and Jordi Bruix mentioned it before—the Child-Pugh scoring system, which we use in our daily clinical life, has never been developed for the treatment of patients with cancer. It’s a scoring system from the field of hepatology. We need better screening tools to identify and to measure liver function.

One of these approaches might be the ALBI score, which only relies on 2 markers—the bilirubin and the albumin. The calculation is quite difficult, but we end up with 3 groups—1, 2, and 3. Group 1 is patients with very good liver function, 2 is medium liver function, and 3 is poor liver function. And within this group of Child-Pugh A patients, there are patients with ALBI grade 1 and 2, indicating that Child-Pugh A is a very heterogeneous group. This also suggests that the ALBI score might be more sensitive than the Child-Pugh scoring system to define liver function.

I think we have to apply these scoring systems to monitor, or to measure, liver function when we start with our treatment, but also to monitor during our treatments to see how it affects liver function.

Richard S. Finn, MD: Hepatocellular carcinoma is a very interesting disease. From all the diseases we treat in cancer medicine, for the clinician in the community who is seeing 20 different diagnoses, HCC is a very unique disease where there are a lot of competing risks at play. It’s not just managing a tumor, but managing an underlying disease.

Transcript Edited for Clarity

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Transcript:

Jordi Bruix, MD:
We have had the request to make the Barcelona Clinic Liver Cancer staging system complicated, and I said, “No way.” If you make things complicated, it will be a mess. Keep it simple. We have a first picture, and that’s it.

Richard S. Finn, MD: There are a lot of complexities with this disease, and our interventions can affect liver function. I think an important point that was made before is, you could have someone with a small tumor, but if their liver is very sick, the cancer isn’t their biggest problem. Dr. Vogel, as a GI-hepatologist, can you give me a sense of how liver disease and cancer intersect in this diagnosis?

Arndt Vogel, MD, PhD: Yes. There’s a strong and complex interaction between liver disease and cancer. There are different levels on how liver function really affects our treatment options. So, first of all, I think we have to acknowledge that most treatments, which have been analyzed in prospective trials, have been done in highly selected groups of patients with very preserved liver function.

Now, we have to apply these data to our patients in clinical life, who, very often, do not have preserved liver function, which makes the delivery more difficult. Then, we have very good and curative treatments, as was mentioned before. Patients with more tumors can receive resection, and we can get, then, complete destruction or resection of the tumors. But if they have too advanced liver disease, we cannot apply the treatments because the liver function is not good enough.

The other point is, when we decide on a treatment, we always have to keep in mind that the treatment itself might harm the liver. So, indicating that when we decide on a treatment, we need to carefully monitor liver function and see and detect, as early on as possible, at which time point our treatment affects liver function, which would then have a very negative effect on the prognosis of our patients.

And then—this is the third point, and Jordi Bruix mentioned it before—the Child-Pugh scoring system, which we use in our daily clinical life, has never been developed for the treatment of patients with cancer. It’s a scoring system from the field of hepatology. We need better screening tools to identify and to measure liver function.

One of these approaches might be the ALBI score, which only relies on 2 markers—the bilirubin and the albumin. The calculation is quite difficult, but we end up with 3 groups—1, 2, and 3. Group 1 is patients with very good liver function, 2 is medium liver function, and 3 is poor liver function. And within this group of Child-Pugh A patients, there are patients with ALBI grade 1 and 2, indicating that Child-Pugh A is a very heterogeneous group. This also suggests that the ALBI score might be more sensitive than the Child-Pugh scoring system to define liver function.

I think we have to apply these scoring systems to monitor, or to measure, liver function when we start with our treatment, but also to monitor during our treatments to see how it affects liver function.

Richard S. Finn, MD: Hepatocellular carcinoma is a very interesting disease. From all the diseases we treat in cancer medicine, for the clinician in the community who is seeing 20 different diagnoses, HCC is a very unique disease where there are a lot of competing risks at play. It’s not just managing a tumor, but managing an underlying disease.

Transcript Edited for Clarity
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