Riccardo Lencioni, MD: Typically, when patients are assessed on a multidisciplinary tumor board, we look at different factors. The first one is the tumor burden, the second one is the liver function, and the third one is the general condition of the patient. According to the different combinations, there will be different stages of the disease ranging from early stage to an intermediate stage to an advanced stage. And that will then frame the initial part of the discussion concerning the status of the disease. Then, of course, there are multiple options available for each of these stages. And this is where we need to go into the details and truly understand what is the most potentially beneficial strategy for each individual and unique patient.

The liver function is an extremely important factor. We need to clearly understand that if the liver function is compromised—for instance, a patient in Child-Pugh C—there is truly no benefit from receiving any therapy, because these patients, unfortunately, would not have any survival benefit from treating the cancer. The only option for these patients would be if they are transplant candidates and trying to bring them down to the transplant. This is the only option that, by curing both the underlying chronic liver disease, the cirrhosis, and the tumor, will offer a chance for cure to these patients.

For patients with Child-Pugh A class, these are patients with well-compensated cirrhosis. So, typically, these patients may be offered the whole range of therapies. I think where you need to really exercise a lot of fine-tuning is in the Child-Pugh B patient population. Not all of the Child-Pugh B patients are the same. Sometimes you have a patient with a score of B7 without ascites. This patient is likely to do well, especially if he’s stable, on that child score for a while and is a potential candidate for a variety of therapies. A different story is an advanced Child-Pugh B with a high bilirubin above 3 ascites. Then you start entering into an area where it’s very important to understand whether the different plan is likely to truly benefit the patient and not, on the other end, further damage the liver function that is clearly already very compromised.

Locoregional therapies are key in patients in the transplantation setting. There are 2 major roles. One is for patients who are within the criteria for transplant, and here we use locoregional therapy to prevent the tumor progression that eventually will result in a dropout from the waiting list. This is called bridging the patient to the transplant. And this is very important, especially in the United States, because now to grant the exception points, you need to be on the waiting list for at least 6 months. So, there is a waiting time during which the use of locoregional therapy is truly critical to prevent progression and drop out.

Another scenario is for patients who are beyond the transplantation criteria. And in this setting, we are specifically talking about downstaging and trying to downstage them to eventually become transplant candidates.

There are multiple series that have shown that if this downstaging strategy is successful and the original response is in place and patients are brought back to within the criteria, then after the transplant, they will do well with, potentially, a survival expectancy that is similar to patients who were within the criteria since the very beginning. So, the use of locoregional therapies in the downstaging setting is truly critical.

Transcript Edited for Clarity