AFP as a Prognostic and Predictive Marker in HCC - Episode 4

Optimal Approaches to Liver-Directed Therapy in HCC


Masatoshi Kudo, MD, PhD: According to BCLC criteria, or Japan’s Society of Hepatology treatment guideline, the tumor smaller than 3 cm is indicated for ablation. But, of course resection is a first choice of treatment for early stage HCC [hepatocellular carcinoma]. However, if liver function is Child-Pugh B, which is poor liver function, the ablation is selected. And also, even if it’s resectable and the size is less than 2 cm, the ablation can achieve the same tumor control as a resection. So, we perform ablation.

Arndt Vogel, MD, PhD: This is a very interesting question, whether we should do ablation or surgery for our patient. And we can’t really say that if a patient has a tumor of 3 or 4 cm that he should receive either treatment. Because it really depends on the localization of the tumor and of the liver function of the patient. So if the patient has a very good liver function and the tumor very much in the periphery of the liver, surgery is clearly an easy method to perform. And if you look at the outcome data, it’s very similar between surgery and radiofrequency of patient.

Only if you take really large retrospective analysis, there’s some indication that surgery might be a little bit better in terms of local tumor control. But because the patients usually have 2 diseases, the liver disease and the tumor, it really depends very much on the liver function whether the surgeons can do bigger resections or not. And also the localization. If the tumor is very much in the central part of the liver, it might require a large resection that might not be possible because liver function is impaired.

The question whether a patient receives surgery or radiofrequency ablation needs to be discussed in the multidisciplinary tumor board. It depends on the physicians that are involved, whether they have the experience to do the surgery, and it very much depends on the liver function of the patient.

Masatoshi Kudo, MD, PhD: According to guidelines, the international guideline or Japan’s guideline, all guidelines recommend TACE [transarterial chemoembolization] for mild focal disease or a large-sized tumor, which is very difficult to perform ablation on; it’s not indicated. Ablation and PEIT [percutaneous ethanol injection therapy] is performed for smaller size, and fewer sites. So, it’s a different indication.

Arndt Vogel, MD, PhD: There are different ways on how chemoembolization can be performed. We have the conventional TACE, which includes chemotherapy and also an embolization agent. And more recently the field has evolved and we have the so-called B-TACE, which is more precise than the more standardized way on how we can do TACE. When we look at the efficacy data for blunt embolization conventional TACE or B-TACE, there’s no study which ever has proven that one method would be better than the other way.

There were a few trials that basically compared chemoembolization to blunt embolization. And there was…, none of these trials proved that the addition of chemotherapy would actually lead to more efficacy. So actually, we do not really have good evidence to use chemotherapy, but in general, and from most radiologists, they still use chemotherapy with a TACE, usually doxorubicin, but also sometimes other drugs like mitomycin or cisplatin in the past. But in terms of evidence we have, there’s no evidence that one way would be the perfect way to do the TACE.

Transcript Edited for Clarity