Systemic Therapy for HCC: A Rapidly Evolving Landscape - Episode 4

Current Role of Locoregional Therapy for Early Stage HCC

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Edward Kim, MD, of Mount Sinai Health System describes where advances in locoregional therapy for early-stage hepatocellular carcinoma fit into the therapeutic landscape.

Tanios S. Bekaii-Saab, MD, FACP: We’re going move on. We have a diagnosis or suspicion of diagnosis. Ed, I want to move on to you to discuss what you see and how you’re part of this multidisciplinary management of HCC [hepatocellular carcinoma]. It’s been evolving. We’re seeing the locoregional therapies, not necessarily surgical or transplant but the more interventional radiology-related locoregional therapies. Where do we see them fit in the landscape in the evolving landscape of HCC?

Edward Kim, MD: I agree with everything that everyone has said, but we do have to take into account—this goes to your question as well, in terms of what staging we’re dealing with—when we’re in the context of early stage, I would caution the role of biopsy in that situation, especially in the role of transplant. For instance, with mixed histologies, let’s say it’s a solitary 2 cm with presumed HCC. You could get a mixed histology back, and that could hurt the patient in terms of transplant listing. Not to mention the potential for seeding, etc, which could lead to a drop metastasis in the future. I’m absolutely on board. We need a repository with biopsies, especially in academic centers. But in advanced-stage HCC, that’s probably more appropriate, especially because we’re getting more targeted therapies; for the early stage, I would caution with that.

In terms of locoregional therapies and multidisciplinary care of patients with HCC, we always manage in that setting. I have joint office hours with our transplant team and oncologists. It depends on the staging system. We use the BCLC [Barcelona Clinic Liver Cancer] staging system. With the early stage, I see our role with locoregional therapies in 2 fashions: to assist our transplant team as a bridge to get patients to transplantation, which is what we call a curative therapy; or as a curative-intent treatment, which can consist of ablation. The recent SURF trial that was presented at ASCO [American Society of Clinical Oncology Annual Meeting] compared ablation vs surgical resection. The median size was about 1.8 cm. It included up to 3 lesions, but 90% of the patients enrolled had solitary HCC.

We all know that Japan has a very good national surveillance system. They catch these lesions quite early, and they follow these patients for up to 6.5 years on average in each arm. They showed no difference in survival. Ablation has always been on par with resection in this early-stage population for lesions about up to 3 cm in size. We’re finding out more, especially with the recent LEGACY trial that was published, that radioembolization has a potential role as a curative therapy for these solitary HCCs. The LEGACY trial had lesions up to 8 cm and had an 80% response rate with modified RECIST. They also had a long duration of response, greater than 6 months, with 76% of the patients treated. We see that as a role, definitely in the early stage. We know that in the intermediate stage, chemoembolization still has been the go-to locoregional therapy for that stage, but we also know that the intermediate stage is a heterogeneous group. Is it multifocal unilobar, or is it multifocal bilobar? Is it 4 lesions or 12 lesions? There have been variations with the Luigi Bolondi and Kinki University School of Medicine criteria as well, which has a limit of 7 cm. Anything beyond that, patients get systemic therapies. If people are following that, we use those as a guide in our practice and adjust accordingly. I’m sure this will open up a host of discussions.

Transcript Edited for Clarity