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HCC TUMOR BOARD: MAKING SENSE OF THE TECHNOLOGIES
Hepatocellular Carcinoma Tumor Board: Making Sense of
the Technologies
Ghassan K. Abou-Alfa, MD, Jorge Marrero, MD, John Renz, MD, PhD, and Riccardo Lencioni, MD, PhD
OVERVIEW
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, with a rising global incidence. The vast majority of HCC cases
occur in the setting of liver cirrhosis, mainly due to chronic hepatitis C (HCV) or hepatitis B (HBV) viral infections, alcohol consumption,
and nonalcoholic fatty liver disease. The new approval of curative therapy with two NS5A inhibitors, ledipasvir and sofosbuvir, for the
treatment of HCV will no doubt affect HCC incidence and outcome. No studies have evaluated the use of the new antivirals in patients
with HCC. Staging and scoring remain an integral part of the management of patients with advanced HCC. Curative therapies for the
treatment of HCC are evolving. Improvements in surgical techniques and risk stratification for orthotopic liver transplantation (OLT)
have expanded access and improved the outlook for patients suffering from HCC. Interventional locoregional treatments continue to
play a key role in the management of HCC. Transarterial chemoembolization is considered the standard of care for patients with
noninvasive multinodular tumors at the intermediate stage. Bland embolization appears to have similar virtues in some studies. Y90
radioembolization represents a promising treatment option for patients unfit or refractory to transarterial chemoembolization. The
advent of sorafenib as a standard of care with an improvement in survival sadly remain the only major breakthrough in the treatment
of advanced HCC, with mounting negative data from multiple clinical trials. Advances in immunotherapy and customized therapy may
hopefully help reverse this tide.
Hepatocellular carcinoma is a leading cause of cancerrelated
death, with a rising global incidence. 1 The vast
majority of HCC cases occur in the setting of liver cirrhosis,
usually because of chronic HCV or HBV, alcohol consumption,
nonalcoholic fatty liver disease, among others. Because
the majority of patients with HCC have cirrhosis, it is important
to understand it and its complications, while we focus on
the recent advancements in prevention of cirrhosis-causing
etiologies, specifıcally HCV. This manuscript also addresses
the recent developments in the curative and palliative whole
treatment armamentarium for HCC from surgery and transplant
through local therapies, up to systemic treatment including
targeted and immunotherapies.
CIRRHOSIS AND LIVER DYSFUNCTION
Cirrhosis is the outcome of a relentless inflammatory event
that ultimately leads to hepatic fıbrosis in response to a
chronic liver disease (e.g., HCV), to the point where most of
the liver parenchyma is replaced by scar. This starts a steady
hepatic decompensation phenomenon, along with a risk of
developing HCC. Hepatic decompensation includes the development
of jaundice, ascites, variceal hemorrhage, hepatic
encephalopathy, hepatopulmonary syndrome, or portopulmonary
hypertension. Cirrhosis can be compensated or decompensated,
with a 2-year survival of 90% compared with
54%, respectively. 2 HCC is the other important complication
of cirrhosis and occurs at an annual incidence rate of 2% to
3%. 3 The presence of cirrhosis and its complications will affect
the prognosis and management of patients with HCC.
Multidisciplinary management including hepatology is critical
in the care for patients with advanced HCC.
The Child-Turcotte classifıcation system was developed in
1964 to risk-stratify patients undergoing shunt surgery for
portal decompression at the University of Michigan. In 1972,
Pugh modifıed the Child-Turcotte system, and it became
known as the Child-Turcotte-Pugh score, also known for
short as the Child-Pugh score. The Child-Pugh score is composed
of levels of albumin, prothrombin time, and total bilirubin
and also with the presence or absence of clinical hepatic
encephalopathy and ascites. Based on these variables, points
are assigned and patients are classifıed as A, B, or C. Although
empirically derived, the Child-Pugh has been shown to accurately
predict outcomes in patients with cirrhosis and portal
hypertension, and it continues to be used today. Because it is
simple and does not require complicated calculation, this
tool is widely used by clinicians to assess the risk of mortality
in patients with cirrhosis. Another important system to as-
From the Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY; The University of Texas Southwestern, Dallas, TX; The University of Chicago,
Chicago, IL; and Pisa University Hospital and School of Medicine, Pisa, Italy.
Disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center, 300 East 66th St., New York, NY: 10065; email: abou-alg@mskcc.org.
© 2015 by American Society of Clinical Oncology.
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
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