Ghassan K. Abou-Alfa, MD: If anything, I recall that there have been well-known studies that were positive regarding the use of chemoembolization. Contrary to that, there have been several studies that were not necessarily positive, per se. Regardless, it really ended up putting embolization on the board as local therapy for advanced disease that’s not really amenable to resection. My question to you is, Whom would you treat with embolization? Is this based on how big their tumor is? What’s the limitation?

Amit Singal, MD: We’re starting to get more data and more insight for whom we should be treating with local therapies and whom we should be thinking about systemic therapy for. As we start to see more and more advances in the systemic therapy space, I think this line is going to start shifting. I think you laid out the first divide: Are they resectable? Are they transplantable? Can you apply curative therapies? That’s first. That line is very clear. If you can do curative therapy, you should do so.

Now, in terms of how big or how much liver is involved, should you switch among locoregional therapies or embolization type of therapies or systemic therapy? That’s where that line is blurred. In some centers, you’ll see people who have branch portal vein thrombosis. You’ll see some centers that will do main portal vein thrombosis. In our center, we typically say that you should have liver involvement. We don’t do local therapies if you have metastatic disease. We don’t do locoregional therapy if you have right portal vein, left portal vein, or main portal vein involvement. Now we have data from the SARAH trial and the SORAMIC trial where you combine radioembolization with sorafenib. We believe that radioembolization doesn’t work very well if you have right, left, or main portal vein involvement. Basically, it’s limited to the liver.

Ghassan K. Abou-Alfa, MD: Mark, a patient comes to your clinic. He or she heard about you, and you end up being the first entry point for them. They have a 22-cm liver lesion, with no metastatic disease. They are clearly not amenable to resection because of some closeness to vessels, and they are questioning whether they should get some form of local therapy (embolization of some form) or systemic therapy. What are your thoughts?

Mark H. O’Hara, MD: It’s a tough case. You know, 22 cm is a pretty big tumor. Whether or not it is amenable to embolization, I would definitely bring it up to our interventional radiologist to see whether they could access it. Unfortunately, we don’t have a lot of systemic therapies that would necessarily yield a response—that could shrink it down to make things a little bit easier.

Ghassan K. Abou-Alfa, MD: Fair. I chose 22 cm because, of course, U Penn will do great things. But more important, the data that we’re referring to, that we spoke about regarding the studies, were positive. Interestingly, at that time, the median size of the tumors that were embolized was 3.5 cm. The median survival, even though they were calculating by 3-year survival, could really go all the way up to 3 years. The data that were reported on 3 years ago in the Journal of Clinical Oncology looked at bland embolization versus chemoembolization. There was no difference there. This really brings up the question regarding chemoembolization, but I will bring this up a little bit later when we talk about checkpoint inhibitors and the possible value of chemotherapy.

But nonetheless, the median survival, even though it was different for the chemoembolization and bland embolization, was only 19 months. And remember, we’re now practicing embolization on larger tumors. In other words, what we are perceiving as being a benefit for patients to be embolized regardless of tumor size is based on data in the 3- to 5-cm range. Now we are attempting to embolize things that are much larger. This really remains to be a big debate.

Transcript Edited for Clarity