New considerations for an overall approach to treat hepatocellular carcinoma in cirrhotic patients

Multidisciplinary approach for HCC patients: hepatology for the oncologists

Hepatocellular carcinoma (HCC) is a complex and heterogeneous disease, often associated with underlying conditions, like cirrhosis or other relevant co-morbidities that worsen the prognosis and make the clinical management more challenging. Current recommendations emphasize the importance of a multidisciplinary approach for the management of HCC patients and stress the crucial role of careful prevention and the management of cirrhosis-associated complications. This article discusses the importance of a multidisciplinary approach in the treatment of HCC patients. Current recommendations for the treatment of cirrhotic patients with HCC are also reviewed.

Role of the multidisciplinary team in the diagnosis and treatment of hepatocellular carcinoma

It has long been appreciated that hepatocellular carcinoma (HCC) is a complex disease. HCC is typically preceded by liver cirrhosis, which is itself caused by various types of hepatitis of both viral and nonviral etiologies. Thus, the treatment of patients with HCC requires multiple healthcare professionals, including hepatologists, medical oncologists, surgical oncologists, transplantation surgeons, diagnostic radiologists, pathologists, nurses, nurse practitioners and interventional radiologists. These specialists should meet regularly to review patients' progress, ensure that treatments are individualized for each patient and agree on next steps. We review case presentations provided by the authors to illustrate the benefits and advantages of the multidisciplinary team matrix in the management of patients with HCC, including the effects of this treatment technique on patient outcome, survival and quality of life.

Trends in the utilization and impact of radiofrequency ablation for hepatocellular carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is rising and radiofrequency ablation (RFA) appears to be increasingly used. The nationwide use and impact of RFA have not been well characterized.

STUDY DESIGN

We performed an historical cohort study of US patients 18 years old and older, with a diagnosis of HCC (n = 22,103) using the national Surveillance, Epidemiology, and End Results (SEER) limited-use database (1998 to 2005). Main outcomes measures were receipt of different therapeutic interventions (ablation, RFA, resection, or transplantation) and adjusted 1- and 2-year survivals.

RESULTS

A total of 4,924 (22%) patients underwent any intervention, with a 93% increase over the 8-year study period (trend test, p < 0.001). RFA accounted for 43% of this increase. Despite increased use of therapeutic interventions, 1- and 2-year survival rates did not improve over time for patients in the study cohort (48% and 34%, 52% and 37%, 50% and 36%; in 1998, 2002, and 2004, respectively; p = 0.31). Among patients with solitary lesions, adjusted 1- and 2-year survivals remained stable over time after transplantation (97% and 94%, 95% and 89%, 94% and 86% in 1998, 2002, and 2004, respectively; p = 0.99) and RFA (86% and 64%, 76% and 54%, in 2002 and 2004, respectively; p = 0.97), but improved after resection (83% and 71%, 91% and 84%, 97% and 94% in 1998, 2002, and 2004, respectively; p = 0.03).

CONCLUSIONS

Use of interventions for the treatment of HCC, and specifically RFA, have markedly increased over time. Because increased use of RFA among patients with potentially resectable disease is likely to occur, and because of a lack of high-level evidence supporting expanded indications, continued evaluation of the indications for RFA and subsequent outcomes among US patients is warranted.

Comparative study of resection and radiofrequency ablation in the treatment of solitary colorectal liver metastases

BACKGROUND

We compared outcomes in patients with solitary colorectal liver metastases treated by either hepatic resection (HR) or radiofrequency ablation (RFA).

METHODS

A retrospective analysis from a prospective database was performed on 67 consecutive patients with solitary colorectal liver metastases treated by either HR or RFA.

RESULTS

Forty-two patients underwent HR and 25 patients underwent RFA. The 5-year overall and local recurrence-free survival rates after HR (50.1% and 89.7%, respectively) were higher than after RFA (25.5% and 69.7%, respectively) (P = .0263 and .028, respectively). In small tumors less than 3 cm (n = 38), the 5-year survival rates between HR and RFA were similar, including overall (56.1% vs 55.4%, P = .451) and local recurrence-free (95.7% vs 85.6%, P = .304) survival rates. On multivariate analysis, tumor size, metastases treatment, and primary node status were significant prognostic factors.

CONCLUSIONS

HR had better outcomes than RFA for recurrence and survival after treatment of solitary colorectal liver metastases. However, in tumors smaller than 3 cm, RFA can be recommended as an alternative treatment to patients who are not candidates for surgery because the liver metastases is poorly located anatomically, the functional hepatic reserve after a resection would be insufficient, the patient's comorbidity inhibits a major surgery, or extrahepatic metastases are present.

Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis

OBJECTIVES

Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.

METHODS

A Markov decision model was developed that compared three management strategies - immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression - for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model's strength was assessed with sensitivity analyses.

RESULTS

In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.

CONCLUSIONS

The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.

Transplantation and palliative care: the convergence of two seemingly opposite realities

One of the authors once asked a great transplant surgeon what came to his mind when asked about palliative care. He had two answers: the first,was somewhat simplistic; the second was profound. He said that this type of service was helpful in the ICU when there was not much more to be done surgically for a patient who was dying; the second, was a story about an individual whom he had transplanted three times (who survived!) because he and his team did not want the patient and family to give up hope. The second answer is fundamentally more in keeping with the philosophy of palliative care, despite the extraordinary specific circumstances. The surgeon demonstrated ongoing presence and non abandonment. This patient was palliated, although few surgeons could have accomplished this by doing two retransplantations! Fortunately, for the less gifted and lucky, there are many ways in which to continue a meaningful presence to an ailing or dying patient on a transplant service that do not require a transplantation procedure. One wonders why palliative care and transplantation have not been more formally acquainted in the past given the extensive overlap of the populations served, the nature of the day-to-day problems, and the intensity of the commitment to the patient. The time is ripe for a formal mutual acquaintance between palliative care specialists and transplant teams,perhaps in the format of a work group that is similar to the work groups that promoted excellence in palliative care, such as the End Stage Renal Disease Workgroup, that were grant funded by the Robert Wood Johnson Foundation. The fields of transplantation and palliative care have a treasure trove of experience that is lacking in the other that could be exchanged profitably with a great sense of satisfaction for all.

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

Orthotopic liver transplantation (OLT) can be a definitive treatment for patients with hepatocellular carcinoma (HCC). Prolonged waiting times for cadaveric livers, however, may lead to dropout from the waiting list or worsened post-OLT prognosis as a result of interval tumor progression. Percutaneous radiofrequency ablation (RFA) is widely used for local control of small unresectable HCC, but its pretransplant role remains unclear. We studied the outcome of 52 consecutive patients accepted for OLT bearing 87 HCC nodules and treated with percutaneous RFA. On initial staging, the tumor burden exceeded the Milan criteria in 10 patients. Complete tumor coagulation was observed in 74 of 87 (85.1%) nodules based on postablation imaging. After a mean of 12.7 months (range: 0.3-43.5) on the waiting list, 3 of 52 patients (5.8%) had dropped out due to tumor progression. Forty-one patients had undergone transplantation, with 1- and 3-year post-OLT survival rates of 85% and 76%, respectively. No patient developed HCC recurrence. There were three major complications in 76 RFA procedures (hepatic arterial hemorrhage, small bowel perforation, and liver decompensation salvaged by OLT), without resultant death or dropout. In conclusion, percutaneous RFA is an effective bridge to OLT for patients with compensated liver function and safely accessible tumors. Tumor-related dropout rate and post-OLT outcome compared favorably with published controls of patients with early-stage disease. This can be attributed to the efficacy of RFA in producing local cure or curbing tumor progression during the waiting period.

Comparing the outcomes of radiofrequency ablation and surgery in patients with a single small hepatocellular carcinoma and well-preserved hepatic function

GOALS

To compare the efficacy of radiofrequency ablation (RFA) and surgical resection in a group of patients with a Child-Pugh score of 5 and a single HCC less than 4 cm in diameter.

BACKGROUND

Radiofrequency ablation (RFA) has become a popular method for treatment of hepatocellular carcinoma (HCC) and has been applied as an alternative primary therapy to surgical resection.

STUDY

We compared outcomes for 148 patients treated with RFA (n = 55) and those treated surgically (n = 93).

RESULTS

The rate of local recurrence among patients in the RFA group was significantly higher than in the surgery group (P = 0.005), while the incidence of remote recurrence was similar between the two groups (P = 0.30). The cumulative 1- and 3-year overall survival rates (P = 0.24) and the cumulative 1- and 3-year recurrence-free survival rates (P = 0.54) were not significantly different between the two groups.

CONCLUSIONS

Despite a higher rate of local recurrence, RFA was found to be as effective as surgical resection for the treatment of single small HCC in patients with well-preserved liver function, in terms of the incidence of remote recurrence and the patients' likelihood of achieving overall and/or recurrence-free survival.

Current treatment for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. In the United States, the incidence of HCC has increased by nearly 75% since the 1980s. The rise in HCC diagnoses in the United States has been attributed to an increased number of patients infected with viral hepatitis and better diagnostic techniques. The management of HCC begins with diagnostic confirmation, followed by accurate staging. Historically, the prognosis for patients with HCC has been poor; however, improved surveillance and radiologic imaging techniques have led to earlier detection of HCC and an increased opportunity to treat patients. Treatment options for HCC include surgical and nonsurgical modalities. Surgical therapy, by way of partial hepatectomy or orthotopic liver transplantation, is the only potentially curative treatment for HCC, but most patients are not eligible for these procedures by the time of diagnosis. Palliative options include ablative techniques, radiation, and systemic therapies. As the incidence of this malignancy continues to rise, oncology nurses, who are an integral part of the multidisciplinary team caring for these patients, must be aware of current management for HCC. This article will provide an overview of the complex management of patients with HCC in the United States.

Living donor liver transplantation for adult patients with hepatocellular carcinoma: experience in Japan

OBJECTIVE

We sought to determine the outcome of living donor liver transplantation (LDLTx) in 316 adult patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

LDLTx has increasingly been performed worldwide, but the impact of the procedure on HCC has not been evaluated in a large series.

METHODS

Between October 1989 and December 2003, 1389 adults underwent LDLTx at 49 centers in Japan. In 316 (22.8%) who received LDLTx for HCC (70 females, 22%, median age 57 years; and 246 males, 88%, median age, 54 years), we analyzed pretransplant clinical status, imaging diagnosis, transplant procedure, pathologic study of explanted liver, and outcome. In 232 patients (73.4%), various surgical and nonsurgical therapies had been employed prior to LDLTx. The median follow-up period was 16 months (range, 2.5-72.0)

RESULTS

Currently, 236 (74.7%) of the patients are living. One- and 3-year patient survivals were 78.1% and 69.0%, respectively. Model end-stage liver disease score and preoperative serum alpha-fetoprotein level were independent risk factors for patient survival. Forty patients (12.7%) developed HCC recurrence. Alpha-fetoprotein level, tumor size, vascular invasion, and bilobar distribution were independent risk factors for HCC recurrence. Grade of histologic differentiation of HCC showed close correlation with tumor characteristics and recurrence. One- and 3-year recurrence-free survivals were 72.7% and 64.7%, respectively. When the Milan criteria were applied, patient survival and disease-free survival at 3 years were 78.7% and 79.1%, respectively, in patients who met the criteria, and 60.4% and 52.6%, respectively, in those who did not.

CONCLUSION

LDLTx can achieve acceptable survival in HCC patients, even when liver function is markedly impaired, or HCC is uncontrollable by conventional antitumor treatments.

Living donor liver transplantation for adult patients with hepatocellular carcinoma: experience in Japan

OBJECTIVE

We sought to determine the outcome of living donor liver transplantation (LDLTx) in 316 adult patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

LDLTx has increasingly been performed worldwide, but the impact of the procedure on HCC has not been evaluated in a large series.

METHODS

Between October 1989 and December 2003, 1389 adults underwent LDLTx at 49 centers in Japan. In 316 (22.8%) who received LDLTx for HCC (70 females, 22%, median age 57 years; and 246 males, 88%, median age, 54 years), we analyzed pretransplant clinical status, imaging diagnosis, transplant procedure, pathologic study of explanted liver, and outcome. In 232 patients (73.4%), various surgical and nonsurgical therapies had been employed prior to LDLTx. The median follow-up period was 16 months (range, 2.5-72.0)

RESULTS

Currently, 236 (74.7%) of the patients are living. One- and 3-year patient survivals were 78.1% and 69.0%, respectively. Model end-stage liver disease score and preoperative serum alpha-fetoprotein level were independent risk factors for patient survival. Forty patients (12.7%) developed HCC recurrence. Alpha-fetoprotein level, tumor size, vascular invasion, and bilobar distribution were independent risk factors for HCC recurrence. Grade of histologic differentiation of HCC showed close correlation with tumor characteristics and recurrence. One- and 3-year recurrence-free survivals were 72.7% and 64.7%, respectively. When the Milan criteria were applied, patient survival and disease-free survival at 3 years were 78.7% and 79.1%, respectively, in patients who met the criteria, and 60.4% and 52.6%, respectively, in those who did not.

CONCLUSION

LDLTx can achieve acceptable survival in HCC patients, even when liver function is markedly impaired, or HCC is uncontrollable by conventional antitumor treatments.