Insights From: Arndt Vogel, MD, Hannover Medical School; Oliver Waidmann, MD, Goethe-Universitat Frankfurt am Main
Oliver Waidmann, MD: Radiofrequency ablation and resection are 2 good options for patients with early-stage HCC or even a bit larger stages. But I think the problem is we know that they are really comparable concerning the oncological outcome. However, we have to consider some special parameters of the patients. Radiofrequency ablation is probably very good in patients who have advanced cirrhosis, if they have severe portal hypertension but we cannot do resection, and in patients who have comorbidities, namely lung disease or chronic heart disease. With these patients, we cannot do surgery. So, in these patients, I recommend radiofrequency ablation. In patients where they don’t have fibrosis, who are fit, younger, and who do not have portal hypertension, I would recommend to do the resection.
I think there’s no good consensus, and it’s always depending on the center where the patient is treated. But in the end, every patient whom you consider treatment, such as radiofrequency ablation, laser ablation, microwave ablation, or surgery, you should have an interdisciplinary tumor board. In this tumor board, there should be an interventional radiologist and also a hepatobiliary surgeon who’s quite familiar with doing liver resections. I think this is the most important conclusion for me, if you would consider ablation or resection.
Arndt Vogel, MD: Patients with small tumors are good candidates for local therapies. That could be either surgery or radiofrequency ablation, and sometimes other techniques such as microwave ablation are used nowadays. The decision on what is the best treatment really depends on the tumor, and, again, we have to acknowledge both the underlying liver disease, the remaining liver function, and also the tumor. And for the tumor, we specifically have to see where the tumor nodules are, if they are more central or more at the periphery at the liver. Based on that, we can make the decision on what would be the best approach: surgery or radiofrequency ablation. In general, radiofrequency ablation is recommended for patients with tumors smaller than 3 cm because we know if they have larger tumors, they have microsatellite metastases around the tumor. And the chance that we really get a complete extraction of the tumor is significantly lower than compared to patients with smaller tumors.
When we have really small tumors, 1 cm to 3 cm, the decision between radiofrequency ablation and surgery can also depend on the availability in the specific hospital. If you look at the outcome in long-term retrospective studies with a lot of patients, it seems to be very equal. In general, surgery is always a little bit better, but not that good or so much better that we could recommend that everybody needs to receive surgery. So, I think both treatments are very good options for patients with small tumors.
Oliver Waidmann, MD: I think adjuvant treatment is really a problem for patients with HCC, because we learned from the STORM trial that patients have a high rate or recurrence. Even in patients who get complete resection and complete ablation, we had—in the treatment arm, but also in the placebo arm, the patients who got treated with sorafenib—high rates of recurrence. The median recurrence-free survival was less than 3 years. It means more than 50% got recurrence within 3 years, so it is a severely unmet need. And I think as we have really potent treatments with immunotherapy, immunotherapy will be the way to go. I think that immunotherapy such as PD-L1 antibodies—in the monotherapy trials but also according to the melanoma trials—there will be also combination of checkpoint inhibitors, such as pembrolizumab or nivolumab, and other combinations with ipilimumab, the CTLA-4 antibody. So, I think immunotherapy will be the way it goes.