Taking a Multidisciplinary Approach to Hepatocellular Carcinoma - Episode 3
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The two primary curative approaches for patients with hepatocellular carcinoma (HCC) are transplantation and resection. Deciding between these two options will depend on several factors. First, a Model for End-stage Liver Disease (MELD) score, which is a combination of bilirubin, INR, and creatinine, is typically the measure used to determine transplantation eligibility in patients who don’t have HCC. Depending on the region of the country, a transplant can occur fairly quickly, states Adam C. Yopp, MD, even within the first couple of months of a patient being placed on the transplant list. In New York and Texas, he comments, transplants are being conducted in patients with MELD scores around 30.
In patients with HCC, if a tumor is above 2 cm, a patient starts with 22 MELD “exception points,” and every couple of months “3 points” are added. At the University of Texas Southwestern Medical Center, Yopp shares, most patients with solitary lesions are resected. With the addition of MELD “exception points” for HCC in 2005, he explains, there is a preponderance of patients with HCC on the waiting list, many of whom cannot afford to wait for a transplant.
Because of the paucity of organs, most centers are now considering resection for some of these patients. In fall 2015, Robert G Gish, MD, explains, the rules for liver cancer organ distribution will undergo two dramatic changes. First, he states, there will be a MELD cap of 34. Second, patients will not get any points until they are on the list with a cancer for at least 6 months.
Getting a patient to transplant is always the goal, says Jeff Geschwind, MD. However, long-term survival, even after a successful transplant, cannot be assumed. The Milan and UCSF criteria are used to predict survival after transplant. The Milan criteria suggest that the chances of a cure—free of any recurrence for 5 years—are higher in patients who had only 1 lesion <5 cm or 3 lesions, each <1 cm, and no vascular invasion or metastases. Most transplantation centers are using the UCSF criteria, according to Yopp, which expands the size of tumors to include 1 lesion <6.5 cm, or 2 to 3 lesions, none exceeding 4 to 5 cm, with total tumor diameter not >8 cm.
In terms of what type of resection to perform, the decision of whether to use a wedge (non-anatomical) or anatomical resection remains a source of debate, explains Yopp. Unlike with colorectal liver metastasis, there is a belief that vascular invasion exists with HCC tumors. Surgery aims to achieve a negative margin by about 1 cm, but this can be a difficult with lesions located in the center of the right lobe, Yopp adds. In these difficult cases, depending on a patient’s comorbidities, radiofrequency ablation (RFA) may be an appropriate option. RFA is also considered a curative therapy, and the guidelines support that concept, notes Geschwind. Data comparing RFA and surgical resection find comparable survival, and ability to kill the tumor; however, rate of recurrence with RFA is higher.