Locoregional Treatment Strategies in Early-/Intermediate-Stage HCC Locoregional Treatment Strategies in Early-/Intermediate-Stage HCC
Tanios Bekaii-Saab, MD: Pierre, are there any patients with earlier stages of the disease that may not be technically resectable or candidates for transplant? What are potential local regional options, or are we thinking about integrating some systemic options into these earlier-stage patients?
Pierre Gholam, MD: For patients with very small early disease, typically a tumor that is solitary and less than 2 centimeters in greatest diameter, the evidence has shown for over a decade and a half now that ablative therapy previously performed—primarily with radiofrequency ablation, and now increasingly with microwave ablation—is equivalent to surgery in terms of long-term outcomes. That's a generally accepted alternative, especially if a patient has significant portal hypertension or contraindications to anesthesia or surgery. In someone with a solitary tumor, even very large, in the absence of macrovascular invasion or extrahepatic spread—local regional therapy has been shown to be effective with very good disease control rates. That would be the dominant strategy for this prototypical BCLC [Barcelona Clinic Liver Cancer] stage B patient. What you would use to treat those patients is a matter of speculation and center preference. To be fair and objective, I would say that despite efforts to prove that radioembolization is superior to chemoembolization, I might add bland embolization or the evidence does not unequivocally point to 1 modality versus the other.
Tanios Bekaii-Saab, MD: Do you have a preferred modality in your clinic?
Pierre Gholam, MD: For very small lesions, ablative therapy in the right patient does very well. For patients who have larger solitary tumors or a relatively low number of lesions in the same segment, the so-called radiation segmentectomy, which has now been popularized by several groups, is an effective treatment, and for someone who has a larger solitary tumor, chemoembolization and radioembolization are largely equivalent. I would submit that the AE [adverse event] profile for chemoembolization may be superior to radioembolization, but every patient is different.
Tanios Bekaii-Saab, MD: Mark?
Mark Yarchoan, MD: I was going to make the comment that 1 thing we haven't mentioned yet is SBRT [stereotactic body radiation therapy] or proton beam [therapy]. Interestingly, this has been left out of the Barcelona staging system despite level 1 evidence now that this is another option for early-stage HCC [hepatocellular carcinoma] and intermediate-stage. One of the frustrations for me is that I continue to see very large HCCs that are technically still Barcelona stage A be treated with noncurative intent like TACE, and I think those patients should be offered surgery when possible. If not, radiation is a great option for very large HCCs. I don't know what everyone else thinks.
Arndt Vogel, MD: Maybe not only for large HCCs, but also for small HCCs. We have seen comparison to radiofrequency ablation with SBRT. This was not only equivalent, it was even better in terms of local control, so I completely agree that this is something that is left out---not by the ESMO [European Society for Medical Oncology] algorithm. We have included the SBRT because we truly believe that the data they have published are important. In our center, we use it quite often in patients with not so well-preserved liver function before transplantation as a bridging therapy. This seems to be very effective, so we have a good local control. The problem is, there's so much competition in this intermediate stage, we do not have these head-to-head trials.
Tanios Bekaii-Saab, MD: How do you decide what patient goes 1 route versus the other when you're picking your local regional therapies? What are your biases in some ways? And I know a lot of our biases are based on data and experience.
Arndt Vogel, MD: We have probably discussed the patients in the multidisciplinary tumor board. I personally think resection always wins. If our surgeons says they go for resection and are cautious. I generally agree, and I'm sometimes even trying to push them to do surgery actually. If that is not feasible, it depends. With the more effective systemic therapies, the local regional therapies, specifically those in BCRCB have declined in the number of treatments we are doing. We are more reluctant to go straight away to systemic therapies. For smaller lesions it's radiofrequency ablation or SBRT, which we use more and more.
Tanios Bekaii-Saab, MD: I'm hearing that your preference is gearing more towards radiation, and away from RFA [radiofrequency ablation].
Arndt Vogel, MD: RFA is still what we do preferentially. But our radiooncologist is part of the multidisciplinary tumor board, and we discuss it. Sometimes it's the tumor location—close to vessels and difficult to reach. We don't try to push the limits of radiofrequency ablation, and we say, “OK, this is somebody who can go for SBRT.”
Tanios Bekaii-Saab, MD: It's an additional option for patients where the RFA may be a little bit on the risky side.
Transcript edited for clarity.