Opening their discussion on the management of hepatocellular carcinoma, expert panelists take a broad look at the treatment landscape.
Josep Llovet, MD: Hello, and welcome to this OncLive® Peer Exchange® titled “The Evolving Treatment Paradigm of HCC: An Expert Case-Based Discussion.” I’m Josep Maria Llovet. I’m the director of the liver cancer program and a professor of medicine at the Mount Sinai School of Medicine in New York [New York], and a professor of medicine in the liver unit at the Hospital Clinic of Barcelona. I’m joined by a panel of experts in the field in liver cancer. I welcome my esteemed fellow panelists to introduce themselves.
Andrea Casadei-Gardini, MD: I’m Andrea Casadei-Gardini. I’m an oncologist at San Raffaele Hospital in Milan [Italy].
Katie Kelley, MD: Hello, I’m Katie Kelly. I’m a GI [gastrointestinal] medical oncologist at the University of California San Francisco [UCSF].
Amit Singal, MD: My name is Amit Singal. I’m a transplant hepatologist the medical director of the liver cancer program at UT [The University of Texas] Southwestern Medical Center in Dallas, Texas.
Arndt Vogel, MD: My name is Arndt Vogel. I’m a hepatologist from Hanover, Germany, and I’m responsible for the GI cancer program [at Hannover Medical School].
Josep Llovet, MD: Let’s talk first [about] the potential role of systemic therapy in early and intermediate HCC [hepatocellular carcinoma]. You can see the flowchart of the treatment of HCC in 2022. We divide the patients into 5 stages: very early, early, intermediate, advanced, and terminal stage. Very early stages are the finest—patients with a single tumor less than 2 cm, well-preserved liver function, and an ECOG performance status of 0. According to guidelines, these patients are first amenable for either ablation or resection. Patients at early stage are defined as single tumors, patients with a single tumor of 3 or less, well preserved liver function, and ECOG performance status 0. These patients are first considered for surgery. In the West, we define optimal candidates for surgery generally with single tumors and well-preserved liver function, defined as Child-Pugh A but also without portal hypertension and normal bilirubin. If the patients don’t fulfill these criteria, they’re considered for liver transplantation. Here we expand the candidates to not only single less than 5, but also 3 novels, less than 3. If the patients have any contraindication for surgical therapies, they’re considered first for ablation. These can be radiofrequency ablation or microwave.
Patients at the intermediate stage, BCLC [Barcelona Clinic Liver Cancer] stage B, are generally considered those with multinodular tumors, liver-only disease, no…vascular invasion, and an ECOG performance status of 0. These patients are considered for TACE [transarterial chemoembolization] as a frontline therapy. If they have any contraindication for TACE, they can be considered for other locoregional therapies or directly to systemic therapies. Patients who downstage to the UCSF criteria or UNOS [United Network for Organ Sharing] criteria for transplant are considered for transplantation, particularly in the United States.
Several randomized control trials are trying to prevent recurrence after resection or ablation. This is 1 of the … needs: 50% of the patients recur after resection at 3 years, 70% at 5 years. At this point, we have at least 5 trials in the adjuvant setting. We’ll talk about these trials. TACE has been the standard of care for intermediate HCC for the last 20 years. We have around 6 trials, either combining TACE with systemic therapies, or 2 trials that are challenging systemic therapies head-to-head with TACE.
Transcript edited for clarity.