Building the multidisciplinary team for management of patients with hepatocellular carcinoma

The rise of multidisciplinary clinics in hepatology: A practical, how-to-guide, and review of the literature

Multidisciplinary clinics (MDCs) are gaining momentum throughout the medical field, having initially been pioneered in oncology clinics due to their inherent ability to streamline complex care and improve both patient outcomes and the patient care experience. Liver transplant and hepatobiliary tumor clinics are examples of established MDCs in hepatology. With the changing landscape of liver disease in regard to etiology and patient complexity and acuity, there is a clear need for efficient, highly coordinated care. These changes highlight opportunities for hepatology MDCs in alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease, and palliative care. This review provides practical advice in navigating the complex logistics of establishing and maintaining a hepatology MDC while also reviewing the emerging evidence on clinical outcomes for patients seen in these MDCs. As hepatology looks to the future, establishment of MDCs in key clinical areas will be the cornerstone of patient care.

Advanced hepatocellular carcinoma and palliative care: a scoping review

BACKGROUND

Patients with advanced hepatocellular carcinoma (HCC) have specific palliative care needs owing to the influence of the disease on abdominal pain, jaundice, bleeding, appetite, ascites, liver function and hepatic encephalopathy. This research would help develop care models and identify knowledge gaps in the field.

AIMS

To identify the palliative care needs and experiences of patients with advanced HCC.

METHODS

CINAHL, EMBASE and MEDLINE were used to search English literature from January 1998 to March 2022 for 'Palliative care' and 'Hepatocellular cancer' using precise inclusion and exclusion criteria.

RESULTS

The retrieves identified 2710 records, including 33 studies used in our research. Two additional studies were grey items. Among 35 studies, 13 studies were performed in Asia, 11 studies in North America, 8 studies in Europe and 3 studies in Australia. Quantitative investigations were mostly descriptive or observational. Eight studies were conducted on a national scale, while two were in specific regions. 20 studies were conducted by a single institution. 22 studies focused only on patients, 2 on family caregivers and 2 on healthcare professionals. 2 more studies concentrated on patients and family caregivers, while 6 concentrated on patients and healthcare professionals.

CONCLUSIONS

This scoping study illustrates the complexity of advanced HCC treatment and challenges in modern healthcare systems. Formulating appropriate referral criteria, integrating and coordinating care, and assessing care contents are crucial. To enhance the treatment of patients with advanced HCC, it is important to understand the relationships between research and service design across teams, disciplines and care settings.

Effect of multidisciplinary team care on patient survival in chronic hepatitis B or C hepatocellular carcinoma

Introduction

Multidisciplinary team care coordinates with medical teams to improve the quality of cancer care. This study explored multidisciplinary team care in hepatitis B or hepatitis C virus-related hepatocellular carcinoma patients from the time of diagnosis to the first-time treatment interval and investigated treatment outcomes and prognosis.

Methods

This retrospective cohort study included data from a nationwide population from 2007 to 2016. Data were collected from the Taiwan Cancer Registry Database, linked to the Taiwan National Health Insurance Research Database. Propensity score matching was applied at a ratio of 1:2 to reduce the selection bias. A multiple regression model with generalized estimating equations was used to analyze whether multidisciplinary team care affected the diagnosis-to-treatment interval. The stratified Cox proportional hazards model examined whether involvement in multidisciplinary team care influenced survival status.

Results

A total of 10,928 and 21,856 patients with hepatocellular carcinoma received multidisciplinary and non-multidisciplinary care, respectively. Participants with multidisciplinary care had a longer diagnosis-to-treatment interval but a lower risk of cumulative cancer death (HR=0.88, 95% CI:0.84-0.92). In patients with intermediate- to advanced-stage hepatocellular carcinoma, multidisciplinary team care has obvious benefits for improving survival.

Conclusion

Patients with hepatocellular carcinoma who participated in multidisciplinary team care had a longer diagnosis-to-treatment interval but a lower risk of cancer death. Patients with intermediate- to advanced-stage hepatocellular carcinoma who received multidisciplinary team care significantly benefited from this outcome. Hospitals should provide HCC patients with multidisciplinary team care to improve cancer care.

Team-Based Approach to Reduce Malignancies in People with Diabetes and Obesity

PURPOSE OF REVIEW

Numerous observations have indicated an increased risk of developing various types of cancers, as well as cancer-related mortality, among patients with diabetes and obesity. The purpose of this review is to outline multiple-cancer screening among these patients through a team-based approach and to present the findings of a pioneering integrated care program designed for patients with obesity with a specific emphasis on cancer prevention.

RECENT FINDINGS

A community-based multi-cancer prevention program, which provides all services in one location and utilizes team-based approaches, is reported to be feasible and has the potential to enhance the uptake rate of multiple cancers screening among patients with diabetes and obesity. The team-based approach is a commonly utilized method for managing patients with diabetes, obesity, and cancer, and has been shown to be efficacious. Nevertheless, research on team-based cancer screening programs for patients with diabetes and obesity remains limited. Providing a comprehensive screening for colorectal, prostate, and breast cancer, as well as metabolic syndrome, during a single clinic visit has been proven effective and well-received by participants.

Perioperative and long-term survival outcomes of laparoscopic versus open hepatectomy for BCLC stage A large hepatocellular carcinoma patients in difficult segments: A two-centre, propensity score matching analysis

Background

The differences in short- and long-term outcome between laparoscopic liver resection (LLR) and open liver resection (OLR) for BCLC stage A large hepatocellular carcinoma (HCC) in difficult segments (I, IVa, VII, VIII) remain unclear. This PSM two-centre study aimed to compare perioperative and long-term survival outcomes of LLR with OLR for this HCC.

Methods

HCC patients with BCLC stage A who underwent OLR or LLR in two medical centres were enrolled in the study. PSM analysis was performed to match patients between the LLR cohort and OLR cohort. Survival was analysed based on the Kaplan–Meier method. Independent risk factors were identified by Cox regression.

Results

After PSM, 35 patients remained in the LLR cohort, and 84 remained in the OLR cohort. Patients in the LLR cohort had more intraoperative blood loss (p=0.036) and shorter hospital stays after surgery (p<0.001). The LLR cohort and OLR cohort had no difference in intraoperative blood transfusion, surgical margin or postoperative short-term outcomes. The OS and RFS were not significantly different between the two cohorts. The OS and RFS of these two cohorts were not different in the subgroup analysis. Surgical margin was identified as an independent risk factor for tumour recurrence.

Conclusion

For BCLC stage A large HCC patients with lesions in difficult segments, LLR was feasible and had shorter hospital stay than OLR. In addition, a surgical margin ≥1 cm could significantly decrease the recurrence probability for large HCC located in different segments without compromising short-term outcomes.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada

BACKGROUND

Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.

METHODS

A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.

RESULTS & CONCLUSION

The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions

Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.

Gadoxetate-Enhanced MRI as a Diagnostic Tool in the Management of Hepatocellular Carcinoma: Report from a 2020 Asia-Pacific Multidisciplinary Expert Meeting

Gadoxetate magnetic resonance imaging (MRI) is widely used in clinical practice for liver imaging. For optimal use, we must understand both its advantages and limitations. This article is the outcome of an online advisory board meeting and subsequent discussions by a multidisciplinary group of experts on liver diseases across the Asia-Pacific region, first held on September 28, 2020. Here, we review the technical considerations for the use of gadoxetate, its current role in the management of patients with hepatocellular carcinoma (HCC), and its relevance in consensus guidelines for HCC imaging diagnosis. In the latter part of this review, we examine recent evidence evaluating the impact of gadoxetate on clinical outcomes on a continuum from diagnosis to treatment decision-making and follow-up. In conclusion, we outline the potential future roles of gadoxetate MRI based on an evolving understanding of the clinical utility of this contrast agent in the management of patients at risk of, or with, HCC.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of hepatocellular carcinoma

Patients with advanced hepatocellular carcinoma (HCC) have historically had few options and faced extremely poor prognoses if their disease progressed after standard-of-care tyrosine kinase inhibitors (TKIs). Recently, the standard of care for HCC has been transformed as a combination of the immune checkpoint inhibitor (ICI) atezolizumab plus the anti-vascular endothelial growth factor (VEGF) antibody bevacizumab was shown to offer improved overall survival in the first-line setting. Immunotherapy has demonstrated safety and efficacy in later lines of therapy as well, and ongoing trials are investigating novel combinations of ICIs and TKIs, in addition to interventions earlier in the course of disease or in combination with liver-directed therapies. Because HCC usually develops against a background of cirrhosis, immunotherapy for liver tumors is complex and oncologists need to account for both immunological and hepatological considerations when developing a treatment plan for their patients. To provide guidance to the oncology community on important concerns for the immunotherapeutic care of HCC, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). The expert panel drew on the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for HCC, including diagnosis and staging, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with HCC.

Argentinian clinical practice guideline for surveillance, diagnosis, staging and treatment of hepatocellular carcinoma

The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline.

Early Versus Late Hepatocellular Carcinoma Recurrence After Transplantation: Predictive Factors, Patterns, and Long-term Outcome

BACKGROUND

Hepatocellular carcinoma (HCC) is currently the first indication of liver transplantation (LT) in Europe and Asia-Pacific region and the third in the United States. HCC recurrence is the main complication affecting short- and medium-term outcomes after LT.

METHODS

A total of 433 consecutive adult recipients transplanted for HCC between 2000 and 2017 (mean age: 57.8 ± 8.5 y; 83.8% were males) with a mean follow-up of 74.6 ± 58.6 months were included. Patients had to meet Milan criteria and, since 2014, alpha-fetoprotein score to be listed. Patients with HCC recurrence were classified into early (≤2 y) and late recurrence (>2 y) and were retrospectively reviewed.

RESULTS

Patients who developed recurrence (75 patients, 17%) had more tumors outside Milan and University of California San Francisco criteria, high alpha-fetoprotein score, and microvascular invasion at pathology. Early recurrence developed in 46 patients (61.3%); the overall 5- and 10-year survival rates of these patients from time of LT were 6.7% and 0%, which were significantly lower than those with late recurrence 64.0% and 27.1%, respectively (P < 0.001). The median survival times from the diagnosis of HCC recurrence were 15 and 17 months, respectively, in the 2 groups (P < 0.001). Multivariable Cox regression analysis identified alcoholic cirrhosis as etiology of the underlying liver disease (hazard ratio [HR] = 3.074; P = 0.007), bilobar tumor at time of LT (HR = 2.001; P = 0.037), and a tumor size (>50 mm) in the explant (HR = 1.277; P = 0.045) as independent predictors of early recurrence.

CONCLUSIONS

Improving the prediction of early HCC recurrence could optimize patient selection for LT, potential adjuvant therapy with new targeted drugs and hence, improve long-term survival.

High trough levels of everolimus combined to sorafenib improve patients survival after hepatocellular carcinoma recurrence in liver transplant recipients

Recurrence of hepatocellular carcinoma (HCC) following liver transplantation (LT) occurs in 10%-20% of patients transplanted for HCC. The treatment of HCC recurrence after LT remains a challenge. Consecutive patients who underwent LT for HCC between 2005 and 2015 at our center were recruited. Characteristics of patients with recurrence, modalities of treatment and outcome were collected retrospectively. Patient survival was analyzed according to HCC recurrence therapeutic strategy. Among 306 transplanted patients, 43 patients (14.1%) developed recurrence with a median survival time after recurrence of 10.9 months (95%CI: 6.6-18.6). Survival of patients treated with Sorafenib (SOR) and everolimus (EVL) (n = 19) was significantly better than that of the group treated with other strategies (n = 24) (P = 0.001). Multivariable analysis demonstrated that SOR plus EVL therapy and absence of dissemination at diagnosis of recurrence were independent predictive factors of prolonged survival after recurrence. Among the patients who treated with EVL, survival of patients with controlled EVL blood trough levels ≥5 ng/ml was significantly better compared to those with EVL trough levels <5 ng/ml (P = 0.021). Combination therapy of sorafenib and everolimus was an independent predictor for better survival after HCC recurrence. Patients with controlled everolimus trough level ≥5 ng/ml might get the best survival benefit.

Value of multidisciplinary team (MDT) in minimally invasive treatment of complex intrahepatic bile duct stones

This study aimed to investigate the value of multidisciplinary team (MDT) management in minimally invasive treatment of complex intrahepatic bile duct stones (IHDs) by laparoscopy, choledochoscopy and percutaneous choledochoscopy. The characteristics, perioperative index, complication rate and minimally invasive rate of patients in MDT group (n = 75) and non-MDT group (n = 70) were compared. The members of MDT include doctors in ultrasound, imaging, hepatobiliary and pancreatic surgery, anaesthesia and intensive care medicine. The results showed that minimally invasive surgery reduced the incidence of postoperative residual stones, OR (95% CI) = 0.365 (0.141-0.940) (p = 0.037). MDT reduced the operation time, OR (95% CI) = 0.406 (0.207-0.796) (p = 0.009). Minimally invasive surgery significantly reduced intraoperative bleeding, OR (95% CI) = 0.267 (0.133-0.534) (p < 0.001). Minimally invasive surgery also reduced hospitalization time, OR (95% CI) = 0.295 (0.142-0.611) (p = 0.001). The stone clearance rates of MDT group and non-MDT group were 81.33% and 81.43% respectively. In the MDT group, the operative time was less than that in the non-MDT group (p = 0.010); the intraoperative bleeding volume was significantly less than that in the non-MDT group (p < 0.001); the hospitalization time was less than that in the non-MDT group (p = 0.001). Minimally invasive operation rate:48 cases (64.00%) in MDT group were significantly higher than 17 cases (24.29%) in non-MDT group (p < 0.001). In conclusion, minimally invasive procedures can be selected more through MDT. MDT can shorten the operation time, and minimally invasive surgery can reduce the incidence of residual stones, reduce intraoperative bleeding, and may shorten hospital stay. Therefore, MDT management model can provide personalized and minimally invasive surgical protocol for patients with complex IHD, which has high application value.

Palliative medicine referrals for hepatocellular carcinoma: a national survey of gastroenterologists

OBJECTIVES

Palliative care (PC) service involvement for hepatocellular carcinoma (HCC) patients is suboptimal and little is known about the underlying reasons for this. We aimed to study clinicians' experience and attitudes towards PC in HCC.

METHODS

A nationwide survey was conducted of consultants/trainees recruited from the Gastroenterological Society of Australia membership directory. Clinician demographics, experience and attitudes towards PC use for HCC patients were collected.

RESULTS

There were 160 participants. Most attended weekly multidisciplinary team meetings (MDTM, 60%) and had no formal PC training (71%). MDTM with PC attendance was reported by 12%. Rates of PC referral increased incrementally from BCLC 0/A to D patients but were not universal even in advanced (46%) or terminal (87%) stages. Most acknowledged PC patient discussions occurred too late (61%). Those with prior PC training were more likely to refer BCLC 0/A and B patients for early PC. Referral rates for outpatient PC were higher in respondents who attended MDTM with PC present across all BCLC stages. PC service was rated good/very good by 70%/81% for outpatients/inpatients. Barriers to PC referral included clinician-perceived negative patient associations with PC (83%), clinician-perceived patient/caregiver lack of acceptance (81%/77%) and insufficient time (70%).

CONCLUSIONS

PC referral for HCC patients is not universal and occurs late even in late-stage disease. Prior PC training and/or PC presence at MDTM positively influences referral practices. Barriers to PC referral are not related to quality of PC services but rather to clinician-perceived patients' negative reactions to or lack of acceptance of PC.

Huge hepatocellular carcinoma with extrahepatic collateral arteries successfully treated by multidisciplinary treatment including laparoscopic devascularization: a case report

Multidisciplinary treatment is recommended for the management of patients with advanced hepatocellular carcinoma (HCC). Some operative decollateralization of extrahepatic feeding arteries with laparotomy have been introduced for HCC. We herein newly develop laparoscopic devascularization (LDEV) to continue transarterial chemoembolization (TACE) for HCC with extrahepatic collateral arteries. A 74-year-old man with multiple huge HCC (4 tumors, 18 cm in diameter) and poor liver function (non-alcoholic steatohepatitis, Child-Pugh score 7) was treated with 6 times of chemoembolization in combination with LDEV, 3 times of ablation therapies, and lenvatinib therapy. His tumor markers were triple positive (AFP, 12,906.5 ng/ml; PIVKA-II, 491,743 mAU/ml; AFP-L3, 91.8%) before treatments; however, they all returned to normal limits. Complete response was achieved according to the modified RECIST criteria. Unfortunately, he died 6 months after the final treatment with no recurrence of HCC due to the postoperative complication of primary lung cancer. LDEV is a useful tool to continue effective TACE, and multidisciplinary treatment including chemoembolization and LDEV can cure advanced HCC patients with extrahepatic collaterals and impaired liver function.

Multidisciplinary Team Management of Hepatocellular Carcinoma Is Standard of Care

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality, but unlike other leading causes of cancer death, HCC is increasing in mortality and burden of management. Management of HCC is unique because it usually arises in a diseased liver, which itself may be a driver of mortality. Multidisciplinary teams (MDTs) for the management of complex diseases are becoming more common, but are especially needed in the management of patients with HCC. Liver cancer MDTs are used in most centers providing comprehensive care for patients with HCC, and should be considered the standard of care for these patients.

Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.

Establishing a Multidisciplinary Liver Tumour Clinic in a Limited Resource Scenario: Core Concepts and Our Experience

Multidisciplinary tumour clinics represent the modern state-of-the-art cancer care. However, liver tumour clinics are resource exhaustive and establishing them in resource restricted scenarios is a challenge. We present core concepts in establishing a multidisciplinary tumour clinic, followed by our 5-year experience of multidisciplinary liver tumour clinic from Tata Memorial Hospital Mumbai, India, which represents one of the largest hepatobiliary oncology units in the country. This study provides a roadmap for setting up a multidisciplinary liver tumour clinic and explains the stepwise real-time working of the clinic. The account will act as a blueprint for the establishment of such clinics in the country and abroad.

Multidisciplinary Approach to HCC Management: How Can This Be Done?

Multidisciplinary tumor boards have evolved to address the increasing complexity of cancer care management. Given that hepatocellular carcinoma (HCC) often arises in the setting of underlying cirrhosis, expert input from hepatologists alongside hepatobiliary and transplant surgeons, radiation oncologists, interventional and body radiologists, and medical oncologists has become increasingly important in order to offer patients appropriate cancer treatments. The MDLTB structure has evolved since the early 2000s to bring these specialists together at regularly scheduled meetings to develop a therapeutic treatment plan for HCC management. MDLTBs have reduced the time to treatment and improved patient satisfaction. Standardized documentation with common data elements has been recommended to ensure adequate communication from MDLTB to referring healthcare providers. Retrospective studies consistently highlight the frequency of changes in treatment plans after MDLTB review to better adhere to guideline recommended care. Despite several decades of MDLTBs implementation, few studies describe clinical outcomes associated with MDLTBs such as patient survival and cost benefits. More research is needed in this area to further justify the heavy use of resources that are needed to maintain MDLTBs. Development and use of a centralized database to store such information may assist with future studies of clinical outcomes and inform quality improvement projects.

Impact of the Treating Hospital on Care Outcomes for Hepatocellular Carcinoma

Multidisciplinary hepatocellular carcinoma (HCC) treatment is associated with optimal outcomes. There are few data analyzing the impact of treating hospitals' therapeutic offerings on survival. We performed a retrospective cohort study of patients aged 18-70 years with HCC in the National Cancer Database (2004-2012). Hospitals were categorized based on the level of treatment offered (Type I-nonsurgical; Type II-ablation; Type III-resection; Type IV-transplant). Associations between overall risk of death and hospital type were evaluated with multivariable Cox shared frailty modeling. Among 50,381 patients, 65% received care in Type IV hospitals, 26% in Type III, 3% in Type II, and 6% in Type I. Overall 5-year survival across modalities was highest at Type IV hospitals (untreated: Type IV-13.1% versus Type I-5.7%, Type II-7.0%, Type III-7.4% [log-rank, P < 0.001]; chemotherapy and/or radiation: Type IV-18.1% versus Type I-3.6%, Type II-4.6%, Type III-7.7% [log-rank, P < 0.001]; ablation: Type IV-33.3% versus Type II-13.6%, Type III-23.6% [log-rank, P < 0.001]; resection: Type IV-48.4% versus Type III-39.1% [log-rank, P < 0.001]). Risk of death demonstrated a dose-response relationship with the hospital type-Type I (ref); Type II (hazard ratio [HR] 0.81, 95% confidence interval [0.73-0.90]); Type III (HR 0.67 [0.62-0.72]); Type IV hospitals (HR 0.43 [0.39-0.47]). Conclusion: Although care at hospitals offering the full complement of HCC treatments is associated with decreased risk of death, one third of patients are not treated at these hospitals. These data can inform the value of health policy initiatives regarding regionalization of HCC care.

DEB-TACE: a standard review

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a relative new endovascular treatment based on the use of microspheres to release chemotherapeutic agents within a target lesion with controlled pharmacokinetics. This aspect justifies the immediate success of DEB-TACE, that nowadays represents one of the most used treatments for unresectable hepatocellular carcinoma. However, there is no consensus about the choice of the best embolotherapy technique. In this review, we describe the available microspheres and report the results of the main comparative studies, to clarify the role of DEB-TACE in the hepatocellular carcinoma management. We underline that there is no evidence about the superiority of DEB-TACE over conventional TACE in terms of efficacy, but there may be some benefits with respect to safety especially with the improvement of new technologies.

Palliative Care for People With Hepatocellular Carcinoma, and Specific Benefits for Older Adults

PURPOSE

Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, has a rapidly rising prevalence in the United States and a very poor overall rate of survival. This epidemic is driven by the cohort of aging Baby Boomers with hepatitis C viral infection and the increasing prevalence of cirrhosis as a result of nonalcoholic steatohepatitis. Because curative options are limited, the disease course creates, in patients and their families, distressing uncertainty around prognosis and treatment decisions. Older adults are disproportionately affected by HCC and have more comorbidities, adding to the complexity of the disease. This population would benefit from increased access to palliative care services, which can potentially complement the treatments throughout the disease trajectory. The purpose of this review was to use existing evidence to propose a new model of palliative care integration in patients with HCC. Thus, we focus on the HCC stage and the treatment algorithm, the ways that palliative care can offer support in this population at each stage, as well as elements that can enhance patient and family support throughout the entire disease trajectory, with an emphasis on the care of older adults with HCC.

METHODS

This is a narrative review in which we identify evidence-based ways that palliative care can help younger and older adults with HCC and their families, at each stage of HCC and throughout the disease trajectory.

FINDINGS

We propose ways to integrate HCC and palliative care based on the existing evidence in both fields. Palliative care offers support in symptom management, advanced care planning, and decision making in ways that are specific to each stage of HCC. We also discuss the evidence that illustrates the palliative care needs of patients with HCC that span the entire course of illness, including coping with the stigmatization of liver disease, addressing informational needs at different stages, and discussing quality of life longitudinally.

IMPLICATIONS

Integrating palliative care into the treatment of patients with HCC has the potential to improve outcomes, although more research is needed to build this evidence base.

The ART-SCORE is not an effective tool for optimizing patient selection for DEB-TACE retreatment. A multicentre Spanish study

INTRODUCTION

The appropriate selection of hepatocellular carcinoma (HCC) patients who are eligible for transarterial chemoembolization (TACE) remains a challenge. The ART score has recently been proposed as a method of identifying patients who are eligible or not for a second TACE procedure.

OBJECTIVE

To assess the validity of the Assessment for Retreatment with TACE (ART) score in a cohort of patients treated with drug-eluting bead TACE (DEB-TACE).

SECONDARY OBJECTIVE

to identify clinical determinants associated with overall survival (OS).

METHOD

A retrospective, multicentre study conducted in Spain in patients with HCC having undergone two or more DEB-TACE procedures between January 2009 and December 2014. The clinical characteristics and OS from the day before the second DEB-TACE of patients with a high ART score (ART≥2.5) and a low ART score (ART 0-1) were compared. Risk factors for mortality were identified using Cox's proportional hazards model.

RESULTS

Of the 102 patients included, 51 scored 0-1.5 and 51 scored ≥2.5. Hepatitis C was more frequent in patients scoring ≥2.5. Median OS from the day before the second DEB-TACE was 21 months (95% CI, 15-28) in the group scoring 0-1.5, and 17 months (95% CI, 10-25) in the group scoring ≥2.5 (P=0.3562). Platelet count and tumour size, but not the ART score, were independent baseline predictors of OS.

CONCLUSIONS

The ART score is not suitable for guiding DEB-TACE retreatment according to Spanish clinical practice standards.

New concepts in embolotherapy of HCC

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related deaths worldwide with rapidly growing incidence rates in the USA and Europe. Despite improving surveillance programs, most patients are diagnosed at intermediate to advanced stages and are no longer amenable to curative therapies, such as ablation, surgical resection and liver transplantation. For such patients, catheter-based image-guided embolotherapies such as transarterial chemoembolization (TACE) represent the standard of care and mainstay therapy, as recommended and endorsed by a variety of national guidelines and staging systems. The main benefit of these therapies is explained by the preferentially arterial blood supply of liver tumors, which allows to deliver the anticancer therapy directly to the tumor-feeding artery while sparing the healthy hepatic tissue mainly supplied by the portal vein. The tool box of an interventional oncologist contains several different variants of transarterial treatment modalities. Ever since the first TACE more than 30 years ago, these techniques have been progressively refined, both with respect to drug delivery materials and with respect to angiographic micro-catheter and image-guidance technology, thus substantially improving therapeutic outcomes of HCC. This review will summarize the fundamental principles, technical and clinical data on the application of different embolotherapies, such as bland transarterial embolization, Lipiodol-based conventional transarterial chemoembolization as well as TACE with drug-eluting beads (DEB-TACE). Clinical data on ⁹⁰Yttrium radioembolization as an emerging alternative, mostly applied for niche indications such as HCC with portal vein invasion, will be discussed. Furthermore, we will summarize the principle of HCC staging, patient allocation and response assessment in the setting of HCC embolotherapy. In addition, we will evaluate the role of cone-beam computed tomography as a novel intra-procedural image-guidance technology. Finally, this review will touch on new technical developments such as radiopaque, imageable DEBs and the rationale and role of combined systemic and locoregional therapies, mostly in combination with Sorafenib.

Locally advanced head and neck cancer in either the older or the vulnerable adult: Making the case for a team-based, "gero-centric" approach

Multidisciplinary, team-based care goes hand in hand with geriatric oncology paradigms for caring for older adults with cancer. Team-based care was the central theme for the 2015 SIOG Annual Meeting. Team-based approaches to the evaluation and management of older adults with different cancer types, including head and neck cancer, were presented. This review aims to summarize the salient points of that presentation, including a synthesis of recent multidisciplinary, "gero-centric" research efforts to improve the care for older adults with more advanced stages of head and neck cancer.

Quality of Cancer Care in Patients with Cirrhosis and Hepatocellular Carcinoma

Hepatocellular carcinoma is the most common primary liver cancer in patients with cirrhosis and is the leading cause of mortality in these patients. Despite existence of robust clinical practice guidelines for surveillance, diagnosis, and management for hepatocellular carcinoma (HCC), the quality of care received by patients with HCC has been inconsistent. Several studies have reported disappointingly low surveillance rates in high-risk groups which likely contribute to most HCC cases being diagnosed at advanced stages. There is also data from large studies showing that significant under-referral to specialists and delay in initiation of treatment are linked to poor clinical outcomes. Given above circumstances, it is very important to perform studies which can identify areas in need of improvement in the care processes of HCC and design interventions to enhance quality of care. Unfortunately, data on validated quality indicators and quality metrics for HCC are non-existent. In this article, we review the existing literature pertaining to this issue and identify areas that need further research.

Management of Hepatocellular Carcinoma: Current Status and Future Directions

Hepatocellular carcinoma (HCC) is the second most common cause of cancer death worldwide. This cancer commonly arises against a background of chronic liver disease. As a result, a patient with HCC requires multidisciplinary care. Treatment options vary widely based on tumor burden and metastases. The most widely utilized staging system is the Barcelona Clinic Liver Cancer staging system, which recommends treatments based on tumor size and the underlying liver disease and functional status of the patient. Treatment options range from surgical resection or transplantation to locoregional therapies with modalities such as radiofrequency ablation and transarterial chemoembolization to systemic chemotherapies. Future care involves the development of combination therapies that afford the best tumor response, further clarification of the patients best suited for therapies and the development of new oral chemotherapeutic agents.

Hepatic resection provided long-term survival for patients with intermediate and advanced-stage resectable hepatocellular carcinoma

Background

Hepatic resection has the highest local controllability that results in long-term survival for hepatocellular carcinoma (HCC). This study aimed to investigate the role of hepatic resection in selected patients of intermediate and advanced stage.

Methods

Clinical, pathological, and outcome data of 542 consecutive patients were retrospectively analyzed from a single center. The Kaplan-Meier method was used to estimate survival. Postoperative prognostic factors were evaluated using univariate and multivariate analyses.

Results

The 1-, 3-, and 5-year overall survival rates were 89.0, 64.3, and 53.0 %, respectively. The 1-, 3-, and 5-year disease-free survival rates were 72.2, 44.5, and 34.2 %, respectively. Preoperative α-fetoprotein level >400 ng/mL, macroscopic vascular invasion, microscopic portal vein thrombosis, multiple tumor nodules, and the largest tumor size >5 cm were significantly correlated with overall survival. When these clinical risk factors were used in a postoperative staging system, assigning one point for each factor, the total score was precisely predictive of long-term survival. For patients with surgery plus adjuvant TACE (transarterial chemoembolization), the median overall survival was 56 months (range 1–110 months) and the 5-year OS rate was 48.5 %.

Conclusions

Hepatic resection is efficient and safe for HCC patients of intermediate and advanced stage. The adjuvant TACE should be recommended for HCC patients with poor risk factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0811-y) contains supplementary material, which is available to authorized users.

Overexpression of osteopontin promotes resistance to cisplatin treatment in HCC

Osteopontin (OPN) is a multi-functional cytokine involved in cell survival, migration and adhesion. Increasing evidence has elucidated its role in tumorigenesis, progression and metastasis. However, the role of OPN in chemoresistance of human hepatocellular carcinoma (HCC) has not yet been clarified. In the present study, we examined the expression of OPN in human HCC samples before and after cisplatin-treatment, the results showed that OPN was significantly increased in cisplatin-resistant specimens. We then studied the effect of cisplatin on OPN expression in HCC cells, after exposure to cisplatin, the expression of OPN in HCC cells was elevated compared to control cells. We also found that PI3K/AKT signaling pathway was also activated by cisplatin and this effect was induced by the OPN pathway. To study the effect of OPN on chemoresistance, HCC cells were treated with cisplatin along with OPN. Incubation with OPN enchanced the chemoresistance of HCC cells to cisplatin. In contrast, blockage of OPN pathway promoted the chemosensitivity of HCC cells to cisplatin. Our results suggest that OPN enhanced chemoresistance of cisplatin in HCC cells by activating PI3K/AKT signaling pathway, blocking the OPN pathway might be a novel way to overcome the disease.

Hepatic Resection Improved the Long-Term Survival of Patients with BCLC Stage B Hepatocellular Carcinoma in Asia: a Systematic Review and Meta-Analysis

OBJECTIVE

Hepatic resection has been increasingly performed in patients with Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC), but the current evidence supporting its efficacy remains controversial. The aim of this systematic review was to investigate the long-term survival and safety of hepatic resection compared to transarterial chemoembolization (TACE) alone for BCLC stage B HCC.

METHODS

Eligible trials that compared hepatic resection with TACE alone for intermediate HCC were identified from the Embase, PubMed, Web of Science, and Cochrane databases. The study outcomes included overall survival (OS) rate and treatment-related complication rate. Hazard ratios (HRs) with a 95% confidence interval were used to measure the pooled effect according to a random-effects or fixed-effects model, depending on the heterogeneity among the included studies. The heterogeneity among these trials statistically was evaluated using the χ(2) and I (2) tests. Sensitivity analyses were also performed.

RESULTS

A total of 9 studies containing 4958 patients were included. The comparison between hepatic resection and TACE revealed a pooled HR for 3-year OS of 0.403 (95% CI 0.364-0.446, p = 0.000; I (2) = 0 %, p = 0.643) and a pooled HR for 5-year OS of 0.433 (95% CI 0.394-0.475, p = 0.000; I (2) = 0%, p = 0.468). An AFP level >400 ng/ml and being HBV-positive were factors significantly correlated with overall survival. For treatment-related complications, the overall odds ratio (OR) for hepatic resection versus TACE was 0.990 (95% CI 0.934-1.049; p = 0.728; I (2) = 64.5%, p = 0.060).

CONCLUSION

Hepatic resection likely improved overall survival compared with TACE alone in BCLC stage B HCC patients, but did not increase the incidence of treatment-related complications. An AFP level >400 ng/ml and HBV positivity were significantly correlated with poor OS.