An Evolving Treatment Paradigm for Hepatocellular Carcinoma - Episode 6
Ghassan K. Abou-Alfa, MD: Let’s move on and talk about therapy. Understandably, the easy one to treat is small disease. You take it out, of course, with surgery. In small disease with a bad liver, we might go ahead and consider transplant. From the standpoint of medical oncology, the question becomes, Is there anything else that we can do there? Mark, is there any role for adjuvant therapy after surgery or resection?
Mark W. Karwal, MD: I’ve never seen a trial that showed that it worked. It’s all toxicity, no benefit. There was a study from the late 1990s in China where they gave intraarterial radioactive iodine after resection. That had benefit. That’s the only one I ever saw that was positive.
Manish R. Sharma, MD: Recently, there were negative data from the STORM trial with adjuvant sorafenib. Results showed no survival benefit. I know that there is a trial under way with nivolumab that’s trying to look at this question.
Ghassan K. Abou-Alfa, MD: Let’s make sure that our colleagues are following us. Historically, adjuvant therapy was always attempted in patients with resected hepatocellular carcinoma. There has been quite a bit of activity with retinoic acid, which came out of Japan. We heard about the effort that came out of Hong Kong embedding iodine-131 directly into the liver. But interestingly, short of a prolonged tail regarding the benefits from retinoic acid, we don’t really have any evidence for standard of care. And then, exactly as we just heard, we have the advent of sorafenib, which we’re going to talk about as systemic therapy. It was tried in the adjuvant setting but really did not show any benefit.
There are more things that we’re going to be talking about, and we’ll comment a bit further on adjuvant therapy once we touch on the use of different therapies in advanced disease. Understandably, when you have disease that looks very promising or is already delivering what it promised in metastatic disease, could adjuvant therapy be used? That’s not really particular in HCC. This is what we use across the board. But at least for now, there’s no standard-of-care adjuvant therapy in HCC short, of course, of any clinical trials. By all means, as we just heard, there is a trial that is going on, or maybe you’re already aware of, regarding the use of nivolumab versus best supportive care in HCC. You are encouraged to look into this trial or any other trial that you may have access to.
After multidisciplinary teams address local disease that can be resected, it can be transplanted if the disease functionality is not at its greatest. However, it is debatable whom to transplant and whom to resect. There are different opinions between the surgeons and the transplant surgeons.
Nonetheless, then we come to a very important category of patients with locally advanced disease. They are not resectable, per se, but they don’t have metastatic disease. A lot of work has been done, even before any systemic therapy has been established, with embolization. Amit, what’s embolization? What do they do?
Amit Singal, MD: There’s chemoembolization and radioembolization. Simplistically, these are arterial-based, or catheter-based, therapies where you inject beads of chemotherapy or radiation therapy.
Ghassan K. Abou-Alfa, MD: How do you do that?
Amit Singal, MD: Basically, you go in through the femoral artery. You go up and follow the catheter into the hepatic artery, and it goes into branches of the liver tumor. This is essentially taking advantage of the dual blood supply of the liver. The background liver is getting its blood supply from the portal vein, whereas the HCC is getting its blood supply from the hepatic artery.
Ghassan K. Abou-Alfa, MD: So always remember that cancer is finicky. It loves clean blood on the arterial…You’re absolutely right.
Amit Singal, MD: If you can find the branches of the hepatic artery, these beads that are embedded with chemotherapy or radiation therapy go into the HCC and target that selectively. You can spare the background liver.
Transcript Edited for Clarity.