Maria Andreea Catana, MD, on Hepatocellular Carcinoma

In this video Dr Catana provides highlights of presentations and panel discussions at the American Association for the Study of Liver Diseases meeting on hepatocellular carcinoma.

Maria Andreea Catana, MD, is codirector of the liver tumor program at Beth Israel Deaconess Medical Center in Boston, Massachusetts. 

 

My name is Maria Andreea Catana.  I am a transplant hepatologist and the medical codirector of the liver tumor program at BIDMC. I want to share with you some of the updates on liver cancer that I learnt from this year’s digital AASLD meeting

Given the large number of excellent presentation and posters on liver cancer, it is impossible to highlight all the important topics within next 10 mins but I will do my best to summarize what I found useful for every day clinical practice.

My first topic that I will cover is hepatocellular carcinoma (HCC) surveillance that we all know is associated with improved survival in patients with cirrhosis.

The current AASLD guideline is to screen cirrhotic patients with abdominal ultrasound with or without AFP.  [alpha feroprotein]. However, the ultrasound has a poor sensitivity for early HCC detection with nearly 20% of ultrasounds being suboptimal, especially in patients with NASH, obesity, or drinking. MRI is more sensitive (86% versus 28%) but its broad use is not cost effective. As stated by Dr. Amit Singal, the use of LIRADs [liver Imaging Reporting and Data System] visualization scores will help triaging patients, to select those who would benefit from upfront cross-sectional screening imaging and improve early detection of liver cancer. 

AFP appears to be of benefit for early HCC detection based on a cost effectiveness analysis published by Drs. Parikh and Tapper in the American Journal of Gastroenterology. So we should all use AFP along with imaging every 6 months for HCC screening in cirrhotic population.

 We all know here is a huge need for sensitive and specific biomarkers, markers of tumor biology for HCC early detection, prognostication and response to treatment. GALAD is a promising novel biomarker (gender, age, AFP-L3, AFP, and DCP) for early HCC detection with more data expected in 2021.

We have updated AGA guidelines on cholangiocarcinoma (CCA) surveillance by Dr. Chris Bowlus and colleagues published in Clinical Gastroenterology and Hepatology: CCA surveillance is associated with curative treatment and increased survival in PSC [primary sclerosing cholangitis]. Surveillance for CCA and gallbladder cancer should include imaging by ultrasound, CT or MRI with or without serum CA 19-9 every 6-12 months.  The addition of CA 19-9 may increase sensitivity, but decrease specificity. ERCP [endoscopic retrograde cholangiopancreatography] with brush cytology should NOT be routinely used for surveillance of cholangiocarcinoma in PSC.

The next topic I will cover is screening in F3 fibrosis.

Do we need to screen all patients with stage 3 fibrosis for HCC? Probably not just high-risk patients might benefit according to Dr. Sanchez-Azofra who presented the results of the first multicenter observational study performed in 12 hospitals in Spain to assess the risk of HCC in stage 3 fibrosis patients, they included 506 patients who achieved SVR after DAA treatment. Over 33 months of observation, 5 patients developed HCC and 1iCCA (Incidence rate IR 0.49/100pt-yrs).  The risk factors include male gender, age over 33, and low platelets. 

Dr. Laura Kulik gave an update, an excellent talk on loco-regional treatment (LRT) for HCC. 

Should Y-90 be utilized whenever possible over TACE [transarterial chemoembolization] or Deb TACE [Drug-eluting bead transarterial chemoembolization]? Her answer is yes, whenever feasible based on the longer time to tumor progression (TTP) observed in the PREMIERE trial by Salem and collogues and the significantly improved TTP and overall survival with transarterial radioembolization Y90 (glass) observed in the recent TRACE trail. 

Y-90 can be used successfully as a bridge to transplant as published in a single center 15 years experience by Dr. Ahmed Gabr et al in Hepatology 2020. Remarkably, in their study 8% of patients 17 patients BCLC D (Child PC) who were treated with segmental Y90 and transplanted and had a 5 years overall survival of 91.5%. 

Personalized dosimetry is associated with increased overall survival from 10.7 months to 26.6 month (Dosisphere-01 Trial). 

We have several studies available using SBRT [stereotactic body radiation therapy] as a bridge to LT in patients with HCC as an alternative to TACE or RFA, suggesting this approach may offer advantages in patients with borderline liver function who otherwise may not tolerate TACE or RFA [radio frequency ablation]. 

In 2021 we expect the results of ongoing studies of Y90 prior to resection and Y90 radiation segmentectomy versus SBRT for treatment of HCC.

Dr. Julie Heimbach presented data in liver transplantation (LT) for “very early” iCCA. Recent studies have shown that LT might be a treatment option for patients with unresectable very-early iCCA (i.e., ≤2 cm without nodal disease), with survival outcomes similar to those of HCC data published by Mazzaferro and collogues in the Journal of Hepatology this year.

The next topic I will cover is the management of advanced HCC BCLC-C patients.

Advanced HCC management has drastically changed since the 2018 AASLD guidelines as highlighted by Drs. Jorge Marrero and Richard Finn who gave a comprehensive summary of all systemic treatment strategies available for BCLC stage C patients. Atezolizumab and bevacizumab is the first-line treatment for patients with HCC not candidates for LRT (based on IMbrave 150 study published in NEJM 2020). Nivolumab and  ipilinumab appear to be the best second-line after sorafenib failure.

Multiple ongoing studies will likely change the systemic treatment strategies in the near future.   There are multiple unanswered questions and areas of need: Earlier transition to systemic therapy? Sequence after progression of first-line therapy, biomarkers that predict who responds to both immuno and targeted therapies.

I want to finish with a study presented by Cristiana Gainey on striking rural-urban disparities in HCC trend in USA that vary by race and ethnicity. The reality is the rural residents are facing distinct health inequities and more research is needed to determine the underlying cases. We need to ensure availability of novel HCC diagnostic tools and treatments to these populations in need to minimize disparities in outcomes.

I hope you will find this video useful for your everyday clinical practice.  I’m looking forward for Liver Meeting 2021, hopefully in person next year. Thank you for watching!