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Resection vs Transplant in HCC: Factors to Consider

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, UCLA; Laura M. Kulik, MD, Northwestern University Feinberg School of Medicine; R. Kate Kelley, MD, University of California-San Francisco; Riad Salem, MD, Northwestern University Feinberg School of Medicine
Published: Tuesday, Feb 21, 2017



Transcript:

Ghassan K. Abou-Alfa, MD:
With this said, I go back to Richard. Whom don’t you transplant? Whom do you resect rather than transplant?

Richard S. Finn, MD: Well, in general, resection is always the preferred treatment if someone can be resected, meaning they don’t have contraindications to resection. The value of a transplanted organ should obviously be saved, I think, as a last resort, and I think that’s the general acceptance in the field. Given that these patients have underlying liver disease and a malignancy, who are the ideal patients? I think what limits most patients is probably their liver physiology. Obviously, patients need to be considered well-compensated or Child Pugh A. At our center, we use a platelet cutoff to measure portal hypertension. That is to say, someone with a platelet count less than 100,000 will not be a good candidate for resection. And I think, as it turns out, practicing in the United States, a lot of the patients that we see have hepatitis C. Unfortunately, by the time they develop liver cancer, many of them do have less compensated cirrhosis in which case transplant is a better option as compared to hepatitis B patients where they have better liver function at the time they come to presentation.

Ghassan K. Abou-Alfa, MD: Sure. Laura, I would say if we had a transplant surgeon, they would not necessarily totally agree with Richard. So, I think the debate is still on because some people will argue that transplant will be a first indication as well.

Laura M. Kulik, MD: I think you can debate it both ways. So, to be listed for a transplant for liver cancer, it’s supposed to be an unresectable disease, and that may be different based on what surgeon you see. Degree of portal hypertension is very important, and if you have a corrected sinusoidal pressure above a certain level, the magic number has been 10; that’s what Barcelona has preached. I think most people in Europe and the United States use that as a cutoff or surrogate—such as a spleen greater than 12 cm, presence of varices in a large portal vein, or platelets less than 100,000—for increased portal pressures. But we’re seeing with the Hong Kong criteria—and there have been some recent articles that challenge that, even with increased portal pressures—as long as it is a minimal resection and you have a MELD score less than 10, some of these people could be resected. And when you look at a Child Pugh A patient, resection versus transplant, we’re never going to have a randomized controlled trial. But when you try to look at Markov modeling, the difference in overall survival is not very much. It has been quoted to be about 7 months with transplant in terms of life gained. What you do gain is decrease in recurrence rates. So, recurrence rates are much higher with resection as opposed to transplant, but most patients care about, “Well, how long am I going to live?”

Ghassan K. Abou-Alfa, MD: Very, very important. And as such, really this debate will go on, as we heard. So, the transplant is really aimed at the sick liver, kind of just translating what Dr. Kulik said. In other words, a sick liver means that you can’t resect it. In addition to that, the debate will continue to go on with the Child Pugh A patients who really have a healthy liver, but at the same time are resectable. And the question is a transplant or not. This is a continued debate. And, as we heard, probably a certain randomized trial of that nature would never happen. This is going to continue to evolve in the academic setting and really will depend on whom you’re talking to and what kind of opinion is being built around it.

Transcript Edited for Clarity

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Transcript:

Ghassan K. Abou-Alfa, MD:
With this said, I go back to Richard. Whom don’t you transplant? Whom do you resect rather than transplant?

Richard S. Finn, MD: Well, in general, resection is always the preferred treatment if someone can be resected, meaning they don’t have contraindications to resection. The value of a transplanted organ should obviously be saved, I think, as a last resort, and I think that’s the general acceptance in the field. Given that these patients have underlying liver disease and a malignancy, who are the ideal patients? I think what limits most patients is probably their liver physiology. Obviously, patients need to be considered well-compensated or Child Pugh A. At our center, we use a platelet cutoff to measure portal hypertension. That is to say, someone with a platelet count less than 100,000 will not be a good candidate for resection. And I think, as it turns out, practicing in the United States, a lot of the patients that we see have hepatitis C. Unfortunately, by the time they develop liver cancer, many of them do have less compensated cirrhosis in which case transplant is a better option as compared to hepatitis B patients where they have better liver function at the time they come to presentation.

Ghassan K. Abou-Alfa, MD: Sure. Laura, I would say if we had a transplant surgeon, they would not necessarily totally agree with Richard. So, I think the debate is still on because some people will argue that transplant will be a first indication as well.

Laura M. Kulik, MD: I think you can debate it both ways. So, to be listed for a transplant for liver cancer, it’s supposed to be an unresectable disease, and that may be different based on what surgeon you see. Degree of portal hypertension is very important, and if you have a corrected sinusoidal pressure above a certain level, the magic number has been 10; that’s what Barcelona has preached. I think most people in Europe and the United States use that as a cutoff or surrogate—such as a spleen greater than 12 cm, presence of varices in a large portal vein, or platelets less than 100,000—for increased portal pressures. But we’re seeing with the Hong Kong criteria—and there have been some recent articles that challenge that, even with increased portal pressures—as long as it is a minimal resection and you have a MELD score less than 10, some of these people could be resected. And when you look at a Child Pugh A patient, resection versus transplant, we’re never going to have a randomized controlled trial. But when you try to look at Markov modeling, the difference in overall survival is not very much. It has been quoted to be about 7 months with transplant in terms of life gained. What you do gain is decrease in recurrence rates. So, recurrence rates are much higher with resection as opposed to transplant, but most patients care about, “Well, how long am I going to live?”

Ghassan K. Abou-Alfa, MD: Very, very important. And as such, really this debate will go on, as we heard. So, the transplant is really aimed at the sick liver, kind of just translating what Dr. Kulik said. In other words, a sick liver means that you can’t resect it. In addition to that, the debate will continue to go on with the Child Pugh A patients who really have a healthy liver, but at the same time are resectable. And the question is a transplant or not. This is a continued debate. And, as we heard, probably a certain randomized trial of that nature would never happen. This is going to continue to evolve in the academic setting and really will depend on whom you’re talking to and what kind of opinion is being built around it.

Transcript Edited for Clarity
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