Multidisciplinary Systemic Therapy in HCC

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Despite all the treatments available for patients with localized hepatocellular carcinoma (HCC) many will ultimately develop systemic disease, says Ghassan K. Abou-Alfa, MD. At this point, there is a need for the administration of systemic therapy.

If a patient is not cured with transplant or resection, they will eventually require systemic treatment, notes Richard Finn, MD. Patients who develop extra hepatic disease, traditional stage IV disease, or Barcelona C with extra hepatic disease will need systemic therapy. However, for a patient who still has liver-confined disease, but has had ongoing embolization or ablation, the next step in treatment should be made through a multidisciplinary, consensual process.

In the field of interventional oncology, Jeff Geschwind, MD, explains that there are lines of therapy, just as there are with medical oncology. Guidelines describe chemoembolization as the first line, the standard of care. If chemoembolization fails, radioembolization or another form of therapy would be the next step. This is when there must be a multidisciplinary discussion.

One important point, notes Robert G. Gish, MD, FAASLD, is that there are different subtypes of HCC. A recent development, he states, is the recognition of a mixed hepatocellular tumor with cholangiocarcinoma, which may occur in up to 20% of the tumors seen with the background of hepatitis C or fatty liver disease. Thus, patients with anything atypical or indeterminate are the ones that need biopsy.

With all the new medications being investigated, Gish adds that having tissue for genetic profiling may assist in assigning patients to clinical trials. Within a few years, Gish expects that biopsy will be performed in most patients with HCC, because there will be more targeted options.