2019 in Liver Therapy: The Year in Review

Friday, October 11, 2019 (Miami, FL) — As liver therapy continues to rapidly evolve, the Symposium on Clinical Interventional Oncology featured a morning session updating attendees on changes that have occurred in recent months.

Sarah B. White, MD, MS, FSIR, Medical College of Wisconsin, reviewed new organ allocation criteria for liver transplant, explained how stereotactic ablative radiotherapy (SBRT) may be an alternative treatment for hepatocellular carcinoma (HCC), and described several combination therapies in which interventional oncology pairs with immuno-oncology. Continuing her review, Dr. White covered the re-introduction of cisplatin to the U.S. market, including the protocol for mixing. She concluded her presentation by discussing optimization of emulsions.

Following Dr. White, a panel of experts discussed other notable areas within HCC treatment.

• Daniel Sze, MD, PhD Stanford University Medical Center, delved into the OPTIMIS registry and which groups of patients may benefit from transarterial chemoembolization (TACE). He also reviewed research this year on Y-90 dosimetry and noted that voxel-based dosimetry would be optimal, though better software is needed before it is widely adopted.
• Isabel Gala Newton, MD, PhD, University of California San Diego, described the role of SBRT in treating HCC and urged caution in interpreting randomized controlled trials championed by radiation oncologists.
• William S. Rilling, MD, FSIR, Medical College of Wisconsin/Froedtert Hospital, reviewed the results of immunotherapy trials that recently reported results on HCC. At this time, he said, immunotherapy is not playing a major role in treatment of HCC.
• Antonio Ucar, MD, Miami Cancer Institute, reviewed the REFLECT trial, which compared frontline lenvatinib vs sorafenib in unresectable HCC, and the CELESTIAL trial, which evaluated cabozantinib for previously treated HCC.

David Liu, MD, FSIR, FRCPC, University of British Columbia, discussed turning gaps in the literature into goals for interventional oncology, with a focus on metastatic colorectal cancer (mCRC).  He reviewed immunomodulatory drugs used to treat metastatic colorectal cancer (mCRC), including PD-1/PD-L1 inhibitors and chimeric antigen receptor-T cell (CAR-T) therapy. “Immuno-oncology, at least within the domain of mCRC, is still in its nascent phase,” he said. He emphasized that interventionalists have the opportunity to introduce locoregional therapies into treatment models. He also discussed evidence for ablation and emphasized the importance of margins. “We do have opportunities to turn gaps into goals and improve our patients’ lives,” he concluded.

A multidisciplinary panel continued the discussion of liver metastatic disease.

• Nadine Abi-Jaoudeh, MD, University of California Irvine, reviewed mCRC Y-90 and surgery, as well as an article by Winter and colleagues on hepatic resection following selective internal radiation therapy for colorectal cancer metastases in the FOXFIRE clinical trial.
• Horacio Asbun, MD, FACS, a surgeon from Miami Cancer Institute, spoke about the importance of staining in evaluating resection and margins. He also questioned whether segmental liver anatomy is best represented by squares.
• Fernando I. De Zarraga, MD, Miami Cancer Institute, said that the paradigm has changed and is no longer about only treating patients with metastatic liver disease with systemic therapy. With a variety of treatment options available, multidisciplinary tumor boards are important, as is patient selection.
• Dr. Rilling talked about the differences in in embryology between the right and left side of the colon and potential implications for clinical practice.

Santiago Aparo, MD, MS, Miami Cancer Institute, spoke from the perspective of a medical oncologist. There were six new drugs approved by the FDA for systemic therapy for HCC between 2017 and 2019. Systemic therapy options for HCC are expanding and include first- and second-line treatments, as well as biologic and immunologic agents. Dr. Aparo reviewed the clinical trial evidence for several therapeutic options and mentioned trials that are still underway.

The state of liver surgery was outlined by Dr. Asbun. His take-home message was that there is hope for treatment for liver cancer and that the only chance to cure primary liver cancer or colorectal cancer liver metastases is through surgical resection. He explained that laparoscopic liver resection (LLR) has been performed in over 10,000 patients worldwide, and he showed data on oncologic outcomes for LLR.

Michael Chuong, MD, a radiation oncologist from Miami Cancer Institute, spoke on radiation therapy in the liver and reviewed data showing that SBRT can improve outcomes for oligometastatic disease and can be curative for lung cancer. He also covered proton therapy, which delivers less dose to the normal liver, allowing for safe dose escalation and outstanding long-term tumor control, especially in large tumors. He urged colleagues to continue exploring combination therapies for advanced disease, and he discussed the advantages of magnetic resonance imaging (MRI) guided radiation therapy. “With MRI-guided radiation therapy, we’re able to more selectively treat smaller margins and really see what we’re doing,” he said. 

Raul N. Uppot, MD, Massachusetts General Hospital, updated the audience on hepatic ablation with a review of all major journals from October 2018 to present, as well as recent meeting abstracts. He covered new tools and techniques such as hydrodissection of the gallbladder, and he also shared data on immune response and radiomics.

Riad Salem, MD, MBA, Northwestern University Feinberg School of Medicine, spoke on contemporary imaging endpoints with locoregional therapies, focusing on response to therapy. He began by differentiating between RECIST 1.1 and modified RECIST (mRECIST) criteria, with mRECIST focusing on intrahepatic assessment.  He also explained guaranteed-time bias and how specific statistical analyses, particularly Landmark analyses, can determine whether radiographic response actually evaluates survival benefit. “Stable disease, in many cases, is actually insufficient,” he said.

Wrapping up the session, an expert panel discussed clinical cases brought to tumor boards.

• Dr. Liu shared focused on ablation strategies in multicentric disease presentations. The panel evaluated Dr. Liu’s case and shared a range of strategies that could treat the patient. Dr. Liu revealed that he chose to perform a lipiodol-based chemoembolization, which was different than the advice offered by the panel. He emphasized that “there is no right or wrong here. Multidisciplinary discussion and collaboration is important in navigating these decisions.”
• Dr. Brown shared a case in which the tumor was “big,” necessitating starting with microspheres of 100μ or larger. Findings on post-embolization computed tomography correlate with response, she noted, and it is important to look at all four phases of the scan.

Moderator Constantino S. Peña, MD, FSIR, Miami Cancer Institute, concluded the session by thanking everyone for their engagement and for the valuable multidisciplinary discussion.

About the Symposium on Clinical Interventional Oncology (CIO)

Renowned for its originality, practicality, and focus on improving patient care, CIO, an HMP event, highlights the most viable and sought-after treatments in the rapidly expanding field of interventional oncology. CIO is led by course directors Ripal Gandhi, MD; Ziv Haskal, MD; Constantino Peña, MD; Daniel Sze, MD; and Alda Tam, MD. The program contains a mix of didactic lectures, case presentations and debates between experts, hands-on workshops, and pre-recorded cases woven together with audience interactivity through polling and question and answer sessions. For more information, visit theiomeeting.com. 

About HMP 

HMP is the force behind Healthcare Made Practical – and is a multichannel leader in health care events and education, with a mission to improve patient care. The company produces accredited medical education events and clinically relevant, evidence-based content for the global health care community across a range of therapeutic areas. Its brands include Consultant360, the year-round, award-winning platform relied upon by primary care providers and other specialists; Psych Congress, the largest independent mental health meeting in the U.S.; EMS World Expo, North America’s largest EMT and paramedic event; and the Symposium on Advanced Wound Care (SAWC), the largest wound care meeting in the world. For more information, visit hmpglobal.com.