At the 2020 Great Debates & Updates in Gastrointestinal Cancer, Constantinos T. Sofocleous, MD, PhD, Professor of Radiology, Weill Cornell Medical College, New York, participated in a lively virtual debate regarding the optimal treatment of early hepatocellular carcinoma (HCC).

While his opponent, Michael A. Choti, MD, Chief of Surgery, Banner MD Anderson Cancer Center, Gilbert, Arizona, argued in favor of surgery, Dr Sofocleous advocated strongly for the use of ablative therapy.

“Resection, transplantation, and ablation are the curative intent therapies available for patients with Barcelona Clinic Liver Cancer (BCLC) stage A HCC, and a third of patients with HCC are eligible for curative intent therapy at diagnosis,” Dr Sofocleous said.

However, although surgical hepatic resection (HR) has been shown to improve survival and disease-free survival over ablation, surgery has led to more complications and a higher rate of mortality than ablation.

Specifically, in a study of 180 patients with HCC by Chen et al, radiofrequency ablation (RFA) led to higher rates of 1- and 4-year survival than surgery, and also yielded 0 instances of mortality versus 3.3% with HR.

According to interventional guidelines for the treatment of very early or early HCC, thermal ablation (TA) is recommended for patients with BCLC 0, and surgery or TA is recommended for patients with BCLC A.

Furthermore, EASL–EORTC Clinical Practice Guidelines recommend TA as a first-line treatment option for patients with very early HCC (BCLC 0) and for those with 3 HCC nodules up to 3 cm in size for whom surgery is not suitable.

Other points brought to the table by Dr Sofocleous included that TA offers oncologic outcomes similar to surgery while eliminating mortality, significantly lowering morbidity, reducing lengths of hospital stays, and allowing for faster recovery.

However, he made it clear that TA as a first-line option does not entirely rule out the option for surgery down the line.

“TA may be offered as primary treatment in surgical patients with HCC that can be completely ablated with margins,” he said, adding that TA will not impede future opportunities for surgery for disease recurrence in eligible patients.

“The ‘Test of Time concept’ has excellent applications when ablation is used as a bridge to transplantation,” Dr Sofocleous said.—Hina Porcelli

Sofocleous CT. Debate: SURFs Up: Ablative Therapy for Early HCC? Presented at: the Great Debates & Updates in Gastrointestinal Cancer; August 14-15, 2020; virtual.