Arndt Vogel, MD: When we make a diagnosis of metastatic disease at the moment, we do not really have so many treatment options. In general, and if you look at most guidelines, we would recommend systemic therapies. However, this might not always be required. And I think it really depends on the extent of metastatic disease. Sometimes we have patients who just have small lymph nodes, like 1 or 2 metastases in the lung, and the main tumor burden in the liver. I think these patients are also candidates for local therapies—with all the caution I have mentioned before, that we should not overuse local therapies. But I think we should also not underuse local therapies. There could be a mixture. So, if the main tumor burden is within the liver and we have only small and few extrahepatic metastases, I think we can start with local therapies. If we have more extrahepatic disease, of course, these are patients who require systemic therapy.
Oliver Waidmann, MD: In every patient who has a big tumor mass in the liver and there’s only a small metastasis, you can, for example, imagine a patient who has a big bulky liver disease—10-cm large tumor and only some small lung metastasis. Just such patients, they will die from liver failure and from their local problem. Probably they won’t die from their small metastasis in the lung or some small bone metastasis. Patients who have just a few small tumors, have a really big metastasis, and also a metastasis in the bones—which is quite common—or infiltration with other organs, in such patients, I would recommend to start systemic treatment.
We don’t have really good stopping algorithms for patients receiving TACE. What we know—just not as a predictor—from a predictive but prognostic way, the patients who show hepatic decomposition after TACE have really short overall survival. But we don’t know really how many cycles of TACE we can apply to the patients. In my daily business, and I think also many others do it like this, if you don’t see any effects of 2 or 3 cycles of TACE, we stop the TACE and we try to do a systemic treatment because the patient can get liver failure and then we won’t have any options for him anymore. If you have a deterioration of liver function after TACE, please always consider systemic treatment. We have 2 trials in such patients. How many cycles we can do before we have to switch to systemic treatment?
Transcript Edited for Clarity Brought to you in part by Eisai