Clinical Edge Journal Scan Commentary: HCC July 2021

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.