DR BENDELL: When I see an HCC patient for the first time, my first question is, is this disease confined to the liver or is it not confined to the liver? So is this metastatic disease? Is there significant portacaval adenopathy? And there’s still some controversy as to how aggressive you are when you see portacaval adenopathy.

And then, if it’s liver disease only, is the patient, A, a resection candidate? Is the patient going to be a transplant candidate? The answer is no, which at least in my practice it’s usually no, because of proximity to the porta hepatis or proximity to blood vessels or the size of the tumor.

Then the next question goes, can I locally control it? And I think that’s where the question of TACE versus RFA versus even radioembolization comes in. Radiofrequency ablation, I think you’re limited in terms of size, to how big the tumor can be. And I think that outskirts of the upper limit of what they can do is 4 or 5 centimeters. And if it’s next to a blood vessel, a major blood vessel, then you can’t do it.

Chemoembolization, one of the issues is, one, how’s the hepatic function? Because oftentimes these cases are diagnosed in cirrhotic patients. Two, is there any portal vein thrombosis? There’s a lot of cases that present, at least mine, initial, present with portal vein thrombosis. And if that’s the case, then chemoembolization is not usually a potential.

Radioembolization I personally like because you can still give radioembolization when patients have portal vein thrombosis. And I find, at least in my personal experience, that there’s less adverse events after radioembolization than chemoembolization. I find that after chemoembolization, patients tend to be more tired, and there’s more of an LFT bump than for patients that I’ve used radioembolization in.

In terms of sorafenib, if I can get some local control over the tumor, in my own practice I’ll prefer to do that prior to thinking about something like sorafenib. I try to put off sorafenib as long as I can, just because it has benefit, but it also has toxicity that goes along with it.

DR LOVE: So Eileen, what are some of the spectrum of toxicities and complications you see from therapy to the liver, RFA, TACE, et cetera?

DR O'REILLY: So for embolization — and there’s a couple of types of embolization, chemotherapy, as you mentioned, or bland embolization, which is primarily what we do, which results its effect by ischemia, predominantly. And the toxicities there are pain and discomfort right after the treatments. And often people will require a PCA for a day or so to manage that. There can be bleeding complications and, rarely, infection complications from embolization. But the biggest thing is that it’s pretty uncomfortable for a few days, and most people, if they’re working and well are off work for a couple of weeks after that.

But I think the plus of a regional-based approach, which is what you’re getting at, is it’s an intervention, and then you’re done and life moves on, as opposed to continuously taking a treatment on a daily basis. So there’s no consensus on this between oncologists, surgeons, gastroenterologists as to what’s the best strategy, but I personally like the approach of maximizing local-regional treatments first for these patients.

DR LOVE: And Johanna was referring to, also, the issue of local therapy, surgery and transplant. How do you sort out those 2 options?

DR O'REILLY: So in consultation, this is multidisciplinary consensus discussion, depending on the distribution of the disease in the liver, depending on the underlying cause of — presumably cirrhosis. So, for example, if people have cirrhosis from hepatitis B or hepatitis C and a small tumor, they may be better served by not just addressing the tumor by surgery but by a transplant, where you address both the tumor and the underlying etiology of their cirrhosis or chronic liver disease.

So I think one of our deficits as an institution is we don’t have an on-site transplant program, which, for looking after people with HCC, is somewhat of a limitation, but we collaborate closely with colleagues across the city.

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