Hepatocellular Carcinoma: A Rapidly Evolving Treatment Landscape - Episode 1

The Complexity of HCC Multidisciplinary Management

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Richard S. Finn, MD: Hello, and welcome to this OncLive® Peer Exchange® titled “Hepatocellular Carcinoma: A Rapidly Evolving Treatment Landscape.” I’m Dr Richard Finn from UCLA [University of California, Los Angeles] Health. Joining me in this discussion are my colleagues Dr Tony Bekaii-Saab from the Mayo Clinic in Phoenix, Arizona; Dr Peter Galle from the University Medical Center in Mainz, Germany; Dr Pierre Gholam from Case Western Reserve University in Cleveland, Ohio; and Dr Katie Kelley from UCSF [University of California, San Francisco] in San Francisco, California. Today we’re going to be discussing a number of topics pertaining to the use of systemic therapy in advanced liver cancer. We’ll discuss the latest research in the field and the impact of recent clinical trials on making decisions around treatment selection.

Let’s get started with our first topic, which is some background on managing patients with liver cancer in general and our approach to them. As we’ve talked about in other settings, the ideal management for a patient with liver cancer involves a multidisciplinary setting. This is really 2 diseases in 1. There is chronic liver disease and some degree of cirrhosis, which occurs in about 90% of our patients, and there is the tumor and the complications from having a tumor burden. We know that the only way to cure these patients is with surgery: either resection, which is difficult to do at times because of the underlying cirrhosis, or liver transplant, which has its own challenges.

To optimize outcomes for patients, patients need to be assessed at a center that offers all the latest cutting-edge approaches. This includes interventional radiology, which plays a key role; hepatology; and oncology, as well as supportive care. Today we’re fortunate to have a multidisciplinary group. We have Dr Pierre Gholam and Dr Galle, both hepatologists, who are very involved in the liver cancer space.

Pierre, can you give us an overview and discuss some of the complexities and challenges in managing a patient with liver cancer? How do you approach it from the hepatology standpoint and work with your multidisciplinary team, from diagnosis to staging to triaging patients?

Pierre Gholam, MD: Thank you, Richard. It’s a pleasure to join this distinguished group of experts and talk about the interface between chronic liver disease and HCC [hepatocellular carcinoma]. HCC is clearly a major complication of advanced liver disease, which appears in an increasing number of patients because we’re able to take better care of patients; as they live longer, they have more time to develop hepatocellular carcinoma in the background of liver fibrosis. There are multiple challenges that face us when managing someone with cirrhosis who may be at high risk for HCC. We’ve made significant strides in the past decade or more in terms of refining our ability to diagnose these patients effectively.

Perhaps the biggest advancement in the field on a diagnostic level comes from the robustly established criteria for definitive diagnosis of HCC. Our societies, including the American Liver Foundation, the European Association for the Study of the Liver, and even the Asian Pacific Association for the Study of the Liver, all agree that noninvasive diagnosis with imaging in the context of cirrhosis is sufficient and enables us to not only make the diagnosis confidently but also establish a plan of care that includes treatment. I’ll remind this audience that this includes the findings of arterial phase hyperenhanced, followed by delayed venous or later phases washout.

These findings by themselves in the appropriate person who has cirrhosis are sufficient to make the diagnosis without the need for a biopsy. We have wide consensus, including in the medical oncology community, that this is indeed the case. Another relatively recent refinement in our ability to gauge the probability of HCC and less definitive imaging comes from the LI-RADS [Liver Imaging Reporting and Data System]. This system establishes degrees of probability of liver cancer and lesser definitive lesions, which is similar to what the medical oncologist might be familiar with in terms of PI-RADS [Prostate Imaging Reporting and Data System] and in the breast imaging field. The LI-RADS criteria, which have been incorporated in all these professional society guidelines, range from LI-RADS 1, which as you know is definitely benign, to LI-RADS 5, which means definitely HCC, and everything in between.

Our societies have incorporated this into our multidisciplinary discussions, and the government has taken notice. OPTN [Organ Procurement and Transplantation Network] and UNOS [United Network for Organ Sharing], which are the agencies that govern and regulate transplant operations in the United States, now rely on these criteria to allocate priority and the end points in patients who are candidates for liver transplantation. All of these are advancements in our ability to diagnose effectively, without significant liability, on the biopsy side.

There are certainly complexities related to management that have to do with juggling the relative burden of liver disease, from a coagulation deficit standpoint, management of fluid overload, cognitive dysfunction, renal dysfunction, you name it. This is the kind of person who gets HCC, and you have to offer them effective treatment for their cancer but also must also make sure this does not in any deleterious way affect all these other very precarious situations.

Transcript Edited for Clarity