Curative Options in Liver Cancer and Cirrhosis

Richard Finn, MD: The question becomes, can this patient be cured? He has a solitary lesion in the liver, but the only way to cure this disease is really with surgery, and that means either a resection or a liver transplant. In regards to surgical resection, the challenge is that this patient has some decompensation in his liver disease. If we calculate his Child-Pugh score, we can see that he has a Child-Pugh score of 7 points, which is just at the entryway into B-class cirrhosis. That by itself probably precludes surgical resection. In addition, we would look at his platelet count as a marker of portal hypertension. In this case, his platelet count is 98,000, and, for many surgeons, a platelet count under 100,000 would indicate a degree of portal hypertension that would preclude a surgical resection.

So, now we’re thinking of a liver transplant. He is within Milan criteria. He has 1 tumor less than 5 cm, the other part of Milan criteria being up to 3 tumors that are all less than 3 cm. With that in mind, the patient can be considered for a liver transplant, but in the United States, that’s not a procedure that’s going to happen very quickly. There’s going to be a fair amount of wait time on the waiting list. So, how do we manage this patient? Well, treatments that are aimed at the liver are very effective at treating cancer. We know that chemoembolization, which is a local regional therapy that goes through the femoral artery up into the liver, can be very effective at managing liver cancer. It can be a definitive treatment for liver cancer. It has been shown to help people live longer.

Also, for some patients, radiofrequency ablation (RFA) is another appropriate liver-directed therapy. Unlike chemoembolization, which goes through the vasculature, radiofrequency ablation goes percutaneously through the liver. But we know the best results with RFA typically occur with a tumor that’s less than 3 cm.

So, we have a patient who has a 4-cm tumor, some liver dysfunction, but otherwise a good ECOG performance status of about 1. We’re trying to figure out what the best management for this patient is, and certainly chemoembolization would be very appropriate. It would be appropriate whether he’s going for a transplant or not. Now, since patients have a long wait time for transplant, we have the sense that we don’t want their tumor to get bigger. Should it get bigger, they may fall out of the wait list or drop out. And so, in practice, it is very common for patients like this to receive a chemoembolization procedure while they wait for transplant. The data that this improves outcomes for transplant do not exist; however, the sense is that we get some time to observe the biologic behavior of this tumor.

Patients who have newly diagnosed liver cancer—even though it’s within Milan criteria—some of them may have aggressive tumors, and to take them to transplant, even if it was feasible right away, might not be in their best interest. And so, local regional therapy plays an important role in managing these patients who are on the liver transplant list—or even if they’re not, just as a definitive treatment. If this patient has a bad heart and could not get a transplant for that reason, chemoembolization would be an important part of their management.

Transcript edited for clarity.

December 2014

• A 64-year old male positive with HCV presents to his PCP with nausea, vomiting, syncope
• ECOG=1
• Child-Pugh B
• T bilirubin 2.1; albumin 3.2; INR 1.1; no ascites, no encephalopathy; platelets 78
• CT scan revealed one 4-cm lesion in the liver
• No extrahepatic disease; no portal vein invasion
• Laboratory results: AFP=400 ng/ml
• Patient is within Milan criteria
• Bridge using TACE until liver transplantation