ONCAlert | Upfront Therapy for mRCC

Case 1: Criteria for Surgery vs RFA vs Transplant in HCC

Targeted Oncology
Published Online:1:00 PM, Mon December 2, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ghassan Abou-Alfa, MD, MBA: Now go back to our case. As Amit suggested, surgery in the beginning, and there was RFA [radiofrequency ablation]. We’ll talk about surgery versus RFA, but Riad, what’s your perspective? What do the data show with regard to surgery and RFA?

Riad Salem, MD: That is obviously a controversial topic. There are several lines of thought when we think about resection versus RFA. Obviously, RFA has the advantage of being much less invasive. It’s done faster, and the recovery is simpler. And when you look at resection, it’s a much more involved procedure. There’s a surgical complication rate. Of course, most of these patients are going to develop some sort of recurrence at some point. I think it depends on the audience you’re looking for.

In terms of this case, I like the ablation option when he recurred. This is textbook, a 2-cm lesion. He probably had washout and baseline imaging criteria. And ablation now has become very well tolerated and very well done with reproducible outcomes. I think this person had the right treatment at the right time.

Ghassan Abou-Alfa, MD, MBA: Fair enough. But I will challenge you here, Amit, on 1 thing. The patient had an initial diagnosis of resectable disease and then recurred. There are data in the literature, among which the data that came out of Memorial Sloan Kettering Cancer Center when Yuman Fong was with us, showing that by definition, a recurrence is stage IV disease. Your thoughts?

Amit Singal, MD: Yes, I think the recurrence after resection clearly implies that he has a “worse tumor biology.” I think you have to be aggressive in terms of management at that time. I actually think that when he had recurrence, he had small disease and he underwent ablation. I think the bigger thing is that there are also data for salvage transplant at that time. Honestly, if this patient was seen at our center, we would have listed him for transplant when he had that recurrence with his 2-cm lesion. We would have treated him with locoregional therapy, but we would have listed him for transplant at that time.

He clearly has what’s really shown to be bad tumor biology because even within a year, he had metastatic disease. You can argue that transplant in this patient would have been the wrong thing to do. This patient’s course, once again, suggested what you’re suggesting, that he was heading down that route toward systemic disease.

Ghassan Abou-Alfa, MD: Fair enough. And along that line, if anything for our colleagues, the key elements over here are to really realize what are the criteria that make a patient amenable for a resection, RFA, or transplant? And these are the 3 curative therapies we can offer. With regard to resection, it really becomes decision making done by the surgeons. Definitely surgeons will be mostly concerned about vascular invasion and metastatic disease.

With regard to RFA, there’s limited regard to size. Usually things that are really very small, around 2 cm, are probably amenable to a RFA. We have seen the data showing that 2 entities, being surgery versus RFA, are equivalent in regard to survival outcome, even though sometimes the recurrence-free survival might be a little better on the surgical point. Again, as Riad said, this is a little debatable.

With regard to transplant, we didn’t talk much about that, but if anything, the Mezzaferro criteria, the Milan criteria, remain the basic ones that we go by, which is 1 lesion less than 5 cm; 3 lesions, each of them less than 1 cm; no vascular invasion; and no metastatic disease. From there there’s a lot of discussion with regard to who can be transplanted and if it’s really amenable. This will bring me back to Riad for 1 thing.

I would be curious. Sometimes we hear about patients with great liver functionality, like our patient over here who Amid just mentioned. Despite that, usually the potential for a transplant will be based on liver function with limited disease, but even with the great liver functionality here—and let’s assume the criteria are within the Milan criteria—why people might argue that this is a great patient to be transplanted as well?

Riad Salem, MD: This is the kind of patient where, if they have chronic liver disease, ultimately that’s going to be the chance for the best long-term survival. Those are patients who are selected by the hepatology team and, of course, validated by the transplant surgical team. I think the best long-term outcome is one where you’re dealing with not only the tumor but also the background liver abnormality is probably the best thing.

I did want to add something, Ghassan, to the RFA discussion, but I think it’s 1 of the things sometimes we forget. Yes, small lesions like you mentioned are abatable, but the location of the lesion is also an important narrative, and that’s why sometimes lesions are very difficult to ablate because they have the bile duct or the veins, for example, or they’re difficult to access or difficult to see on their ultrasound. That’s where the stage migration concept comes in. If you can’t ablate small tumors, then you migrate to another locoregional therapy like an embolization of some sort. But that needs to be discussed, because that’s how we’re embolizing a lot of small tumors as well. Because they could be ablated, but it’s very difficult based on their location. It’s just something I wanted to add to that for the audience.

Ghassan Abou-Alfa, MD, MBA: No, that’s an excellent point.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ghassan Abou-Alfa, MD, MBA: Now go back to our case. As Amit suggested, surgery in the beginning, and there was RFA [radiofrequency ablation]. We’ll talk about surgery versus RFA, but Riad, what’s your perspective? What do the data show with regard to surgery and RFA?

Riad Salem, MD: That is obviously a controversial topic. There are several lines of thought when we think about resection versus RFA. Obviously, RFA has the advantage of being much less invasive. It’s done faster, and the recovery is simpler. And when you look at resection, it’s a much more involved procedure. There’s a surgical complication rate. Of course, most of these patients are going to develop some sort of recurrence at some point. I think it depends on the audience you’re looking for.

In terms of this case, I like the ablation option when he recurred. This is textbook, a 2-cm lesion. He probably had washout and baseline imaging criteria. And ablation now has become very well tolerated and very well done with reproducible outcomes. I think this person had the right treatment at the right time.

Ghassan Abou-Alfa, MD, MBA: Fair enough. But I will challenge you here, Amit, on 1 thing. The patient had an initial diagnosis of resectable disease and then recurred. There are data in the literature, among which the data that came out of Memorial Sloan Kettering Cancer Center when Yuman Fong was with us, showing that by definition, a recurrence is stage IV disease. Your thoughts?

Amit Singal, MD: Yes, I think the recurrence after resection clearly implies that he has a “worse tumor biology.” I think you have to be aggressive in terms of management at that time. I actually think that when he had recurrence, he had small disease and he underwent ablation. I think the bigger thing is that there are also data for salvage transplant at that time. Honestly, if this patient was seen at our center, we would have listed him for transplant when he had that recurrence with his 2-cm lesion. We would have treated him with locoregional therapy, but we would have listed him for transplant at that time.

He clearly has what’s really shown to be bad tumor biology because even within a year, he had metastatic disease. You can argue that transplant in this patient would have been the wrong thing to do. This patient’s course, once again, suggested what you’re suggesting, that he was heading down that route toward systemic disease.

Ghassan Abou-Alfa, MD: Fair enough. And along that line, if anything for our colleagues, the key elements over here are to really realize what are the criteria that make a patient amenable for a resection, RFA, or transplant? And these are the 3 curative therapies we can offer. With regard to resection, it really becomes decision making done by the surgeons. Definitely surgeons will be mostly concerned about vascular invasion and metastatic disease.

With regard to RFA, there’s limited regard to size. Usually things that are really very small, around 2 cm, are probably amenable to a RFA. We have seen the data showing that 2 entities, being surgery versus RFA, are equivalent in regard to survival outcome, even though sometimes the recurrence-free survival might be a little better on the surgical point. Again, as Riad said, this is a little debatable.

With regard to transplant, we didn’t talk much about that, but if anything, the Mezzaferro criteria, the Milan criteria, remain the basic ones that we go by, which is 1 lesion less than 5 cm; 3 lesions, each of them less than 1 cm; no vascular invasion; and no metastatic disease. From there there’s a lot of discussion with regard to who can be transplanted and if it’s really amenable. This will bring me back to Riad for 1 thing.

I would be curious. Sometimes we hear about patients with great liver functionality, like our patient over here who Amid just mentioned. Despite that, usually the potential for a transplant will be based on liver function with limited disease, but even with the great liver functionality here—and let’s assume the criteria are within the Milan criteria—why people might argue that this is a great patient to be transplanted as well?

Riad Salem, MD: This is the kind of patient where, if they have chronic liver disease, ultimately that’s going to be the chance for the best long-term survival. Those are patients who are selected by the hepatology team and, of course, validated by the transplant surgical team. I think the best long-term outcome is one where you’re dealing with not only the tumor but also the background liver abnormality is probably the best thing.

I did want to add something, Ghassan, to the RFA discussion, but I think it’s 1 of the things sometimes we forget. Yes, small lesions like you mentioned are abatable, but the location of the lesion is also an important narrative, and that’s why sometimes lesions are very difficult to ablate because they have the bile duct or the veins, for example, or they’re difficult to access or difficult to see on their ultrasound. That’s where the stage migration concept comes in. If you can’t ablate small tumors, then you migrate to another locoregional therapy like an embolization of some sort. But that needs to be discussed, because that’s how we’re embolizing a lot of small tumors as well. Because they could be ablated, but it’s very difficult based on their location. It’s just something I wanted to add to that for the audience.

Ghassan Abou-Alfa, MD, MBA: No, that’s an excellent point.

Transcript edited for clarity.
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