CIO 2018: Spotlight Shines on Liver Metastatic Disease Therapies

By Brenda Silva

As the 10th Annual Symposium on Clinical Interventional Oncology gets underway, the first session addressed the latest developments in hepatocellular carcinoma (HCC) treatments and therapy options. Course Director Shaun Samuels, MD, began with an observation about the mature status of the interventional oncology (IO) specialty, as well as an assertion that these services are still needed and provide valuable benefits to patients and physicians alike.

Co-Course Director Constantino Peña, MD, moderated the first session and introduced Riccardo Lencioni, MD, who gave a year-in-review update on recent HCC developments. The update pointed out that while IO techniques have been refined, the industry players remain the same. Dr. Lencioni predicted, “There’s no question that the future of HCC will be targeting systemic responses and focusing on systemic therapies.”

On the question of whether stereotactic body radiotherapy (SBRT) offers the potential for replacing ablation, Dr. Lencioni said, “Based on hundreds of patients, radiofrequency ablation (RFA) is unequivocally superior to SBRT in non-surgical management of early-stage HCC. The best today is RFA; SBRT is not improving nor will it replace ablation as the best therapy option.”

Peter Littrup, MD, commented on local treatments and their systemic effects. “In addition to better local control, we’re now entering a new age of treatments with immunotherapies.”

Continuing the topic, Daniel Sze, MD, presented a year-in-review report on liver metastatic disease. He noted, “In comparison to last year, the advance of the year is immunotherapy again.” He provided statistics on lower cancer rates and increased approvals of cancer-related drugs, along with estimates of increased cancer-related deaths by 2030 despite the approval of new drugs.

Dr. Sze continued, “The biggest news in IO is that the FDA did approve 2 CAR T-cell therapies. The FDA also approved pembrolizumab for any MSI-H/dMMR-positive solid tumor, regardless of organ or origin. This is the first-ever tissue-agnostic designation.”

As part of a panel discussion that elaborated on Dr. Sze’s comments, Robert Lewandowski, MD, agreed on the need to focus on immuno-oncology options and systemic therapies as the best way to treat HCC patients.

Taking the podium next was Santiago Aparo, MD, who addressed colorectal cancer (CRC) with liver metastases only, as well as trials and drugs for HCC.

He pointed out, “When you look at the NCCN guidelines, you have eight treatment options to consider but the guidelines don’t tell you which ones will work best for patients with CRC with liver metastases only. We need to consider all the statistics for each regimen when we’re looking to downstage these patients.”

Expanding industry concerns on the same topic, Susanne Gray Warner, MD, compared HCC transplants versus resection as treatment options and asserted it may be better to resect some early-stage patients.

Looking to the role of proton beams (and SBRT) in relation to radiation oncology in the liver, Michael Chuong, MD, noted, “Both SBRT and RFA are viable modalities, and while there are pros and cons for both options, there’s no clear winner in my mind. They both offer important options and should be considered equally.”

In questioning the use of proton beams, Dr. Chuong said, “protons can help spare the liver and can allow dose escalation to the tumor. The use of proton therapy is definitely growing, and is expected to continue growing.”

Detailing the current state of the art in liver detection and treatment planning, Bradford Wood, MD, summed up, “With immunotherapy and local therapy, the more treatment options you use, the more standard we’re all going to be in the future.”

Ending the first morning session, Dr. Samuels moderated a panel discussion of liver case reviews. Dr. Chuong presented the case of a 67-year-old woman with comorbidities. The panelists reviewed the case with applicable treatment options such as resection, chemoembolization, Y-90 inclusion, and SBRT.

Santiago Aparo, MD, also presented the case of a 63-year-old woman with a mass in the transverse colon and liver metastases. Panelists discussed the potential of SBRT as a treatment option and whether the patient is a candidate for catheter-based therapy or surgical resection. All panelists agreed on the importance of reassessing the patient after treatment to review the efficacy of their chosen treatment.