Insights From: Catherine T. Frenette, MD, Scripps Green Hospital; Darren S. Sigal, MD, Scripps Green Hospital
Catherine T. Frenette, MD: Welcome to this OncLive® Insights® series of “New Treatments in Hepatocellular Carcinoma.” My name is Dr. Catherine Frenette, and I am a hepatologist and the medical director of liver transplant at Scripps Health in La Jolla, California. I’m here with my colleague, Dr. Darren Sigal, who is a medical oncologist and the director of the GI cancer section of the Scripps MD Anderson Cancer Center, also in La Jolla, California. Together we’re going to navigate through several topics pertaining to the treatment of advanced liver cancer.
Darren S. Sigal, MD: Let’s start with the topic of HCC diagnosis and how it’s presently done. What is the role of biopsy in HCC diagnosis?
Catherine T. Frenette, MD: Well, that’s a really great question, Darren, and, as you know, we talk about this a lot in our care of patients and our treatment in our tumor boards. And HCC is really unlike other cancers where we don’t often do a biopsy to make the diagnosis. It’s really an imaging diagnosis. We use multiphase CT or MRI to make the diagnosis in patients who were suspected of disease. There is something called the LI-RADS imaging system, which is the Liver Imaging Reporting and Data System. And that has been implemented in the last 5 years—actually, right out of here in San Diego at UCSD (University of California, San Diego). And what that does is, it gives specific criteria to make the diagnosis of liver cancer with very good accuracy, simply based on imaging criteria and not proceeding with a biopsy of the liver lesion.
So, the LI-RADS system goes from a scale of 1 to 5. A LI-RADS 1 lesion would be a lesion that we know is definitely benign and that could be something like a simple cyst, for instance. LI-RADS 5 is a lesion that we know is definitely malignant or meets the criteria for liver cancer, and that’s generally lesions that have the characteristics of arterial enhancement, portal venous washout, potentially a pseudocapsule, or evidence of at least 50% growth in the past 6 months. And then it goes from 2 to 3 to 4 as far as the level of suspicion that you have. If you have a lesion that’s a LI-RADS 5 lesion on imaging, then what that tells you is that that’s a liver cancer with over 95% accuracy, and that has been based on multiple different studies and meta-analyses looking at this LI-RADS system.
This system really has been adopted by most liver radiologists in the recent years, and it’s actually now the system that we use to determine whether someone is going to get extra points on a liver transplant list, for instance. That’s how accurate it is. So, when I’m seeing a patient who I’m worried has liver cancer and has a lesion, I really look at the imaging characteristics; I talk to my radiologist. If it’s a LI-RADS 5, I go ahead and treat it as liver cancer. If it’s something like a LI-RADS 3 or a LI-RADS 4, I’ll often bring that to our multidisciplinary tumor board to really get some further elucidation of the lesion itself. So, we really try to avoid biopsy.
We know that these are very vascular lesions, and they’re often in people who have cirrhosis, so they often have coagulopathy, they have low platelets, and the risk of biopsy is not insignificant. There’s a risk, 1% to 2%, of bleeding. Of the people who bleed—there have actually been studies that said “the people who bleed”—50% of those people actually could have evidence of tumor seeding into the peritoneum from the bleeding. And then there’s about a 0.5% to 1% risk, actually, of needle tract seeding, so tumor seeding along the biopsy track itself. So, that’s why we really try to make this diagnosis on imaging criteria.