Updates in Frontline Treatment of Metastatic Liver Cancer - Episode 1

Overview and Diagnosis of HCC

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Richard S. Finn, MD: Hello, and welcome to this OncLive® NewsNetwork®presentation. We’re going to spend the next 45 minutes on recent advances in frontline therapy for advanced liver cancer. I’m your host, Dr Richard Finn, from the Geffen School of Medicine at UCLA in Los Angeles, California. Today I’m joined by 3 of my colleagues who are renowned experts in the treatment of liver cancer: Dr Richard Kim from the Moffitt Cancer Center in Tampa, Florida; Dr Riad Salem from Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr Amit Singal from UC Southwestern Medical Center in Dallas, Texas. Let’s get started.

There have been a lot of interesting data in the liver cancer space over the past few years, even in the past few weeks. Amit, liver cancer is a very complicated disease; before we get into all the recent data, as a hepatologist, will you give us some background about liver cancer?

Amit Singal, MD: Rich, as you know, HCC (hepatocellular carcinoma) is very common, particularly when you consider this as a global problem. It’s the fourth leading cause of cancer-related death worldwide. One of the interesting things about HCC is that it typically happens in the setting of chronic liver disease. Over 90% of these occur in the setting of psoriasis, and this sets up a couple of singularities when you’re treating this disease. The first is that, given the differential blood supply to the tumor in the setting of a cirrhotic liver, we’re able to diagnose this oftentimes by imaging alone.

In that clinical context of having someone with psoriasis, or chronic hepatitis B, in the setting of having a lesion that has arterial enhancement and delayed washout, you can actually call that HCC with 95% to 97% certainty, thereby precluding the need to do a biopsy for diagnosis. The second thing is that when we consider treatment options, we can’t just consider how big the tumor is or how much tumor burden there is; you also have to consider the background of liver dysfunction. It’s important that we work as a multidisciplinary team—including hepatologists, interventional radiologists, and medical oncologists—and really consider the broader clinical context of all these factors when we’re thinking about treatment options.

Richard S. Finn, MD: Those are some very interesting points. One, we don’t need a biopsy to make a diagnosis. That’s unusual for most cancers we treat. When we talk about imaging, we’re talking about a triple-phase, dynamic CT (computed tomography) scan, or MRI (magnetic resonance imaging). Is there a role for PET (positron emission tomography) in liver cancer?

Amit Singal, MD: PET scans, as you’re implying, are used for many cancers in terms of staging. For HCC, we find that it is not very FDG (fludeoxyglucose F 18) avid, so the sensitivity of PET for HCC is actually low. It’s not built into the routine staging protocol for HCC lesions.

Richard S. Finn, MD: You mentioned the word staging. Riad, I’m going to bring you into the conversation because, as an interventional and diagnostic radiologist, you play a pivotal role in staging. Amit, we don’t always consider the radiographic staging, or what I call anatomic staging, but also physiological state. That’s where the Barcelona criteria comes in, BCLC. Can you give us a brief overview of that?

Riad Salem, MD: The Barcelona Clinic Liver Cancer staging system, or the BCLC, incorporates 3 different factors. It incorporates the tumor burden, the degree of liver dysfunction, and the patient performance status, or ECOG performance status. Based on these 3 factors, we’re able to stage people into different stages, ranging from: zero (0), which is very early stage; to ‘A’, early stage; ‘B’, intermediate stage; ‘C’, advanced stage; and then ‘D’, which is terminal stage.

One of the unique things about the BCLC is that it actually gives you treatment recommendations: It’s associated with a treatment allocation system as a starting point, with curative therapies traditionally reserved for those patients at their earliest stages; locoregional therapies, such as chemoembolization or radioembolization, largely delivered to patients in the intermediate stage; and systemic therapies, historically largely given to patients in the advanced stage.

Richard S. Finn, MD: This is actually a curable disease when found early in patients, triaged to resection, or even liver transplant, but most patients aren’t going to be candidates for that.

Transcript Edited for Clarity