Treating Hepatobiliary Cancer With Transplant, Resection, or Radiation

When a full multidisciplinary cancer team is under one roof, like at Vanderbilt University Medical Center (VUMC), patients benefit from faster treatment without delays that occur by having to go to different locations for diagnosis, chemotherapy, surgery, and radiation, explained Kamran Idrees, MD, MSCI, MMHC, FACS, chief of the Division of Surgical Oncology and Endocrine Surgery and director of Pancreatic and Gastrointestinal Surgical Oncology, VUMC.

Idrees and colleagues presented on multidisciplinary care of hepatobiliary cancer at VUMC during an Institute for Value-Based Medicine® event, co-hosted by The American Journal of Managed Care and Vanderbilt-Ingram Cancer Center at VUMC.

Martin Montenovo, MD | Image Credit: VUMC

In the 1990s, removing the liver was typically the answer for curing cancer in the organ, but that’s not the reality based on tumor biology, said Martin Montenovo, MD, FACS, chief of the Division Hepatobiliary Surgery and Liver Transplantation and surgical director of the Adult Liver Transplant Program, VUMC. Liver transplantation isn’t for every patient based on the strict transplant criteria for patients with hilar cholangiocarcinoma.

The protocol for transplants is very selective:

• The tumor has to be above the cystic duct
• The tumor has to be less than 3 cm in diameter locally
• There cannot be evidence of extrahepatic disease
• No prior attempts of resection or previous radiation therapy

The criteria for transplant eligibility are in place to identify the patients who will achieve the best long-term outcomes. According to Montenovo, patients who are eligible need to be transferred to an oncology center with transplant capabilities before attempting other treatments.

“Otherwise, you are burning a bridge…[and] liver transplant is not an option anymore,” he explained. When patients are eligible for transplant, they first have to receive adjuvant chemotherapy radiation with capecitabine for 2 to 3 weeks and then maintenance gemcitabine plus capecitabine.

Transplant has superior outcomes compared with resection. One study concluded that patients who are eligible to undergo transplantation but receive a resection instead have a decreased survival compared with those who do undergo transplantation.¹

However, for patients who are ineligible, surgical resection may be the best option for patients with a noncirrhotic liver or limited cirrhosis with preserved liver function, said Idrees. Up to 80% of a normal, healthy liver can be removed and the remaining 20% will compensate for the loss by increasing, he explained. However, for patients with fatty liver disease or cirrhosis, they should have at least 30% of the remaining liver without evidence of cirrhosis.

Natalie Lockney, MD | Image Credit: VUMC

There are patients who are deemed unresectable, though, and they need to be treated with a therapy they can tolerate, according to Natalie Lockney, MD, assistant professor of medicine in the Department of Radiation Oncology and residency program director, VUMC.

For patients who are not candidates for surgery, transplant, or thermal ablation and whose disease is confined to their liver, they may be treated with radiation.

Anthony Borgmann, MD | Image Credit: VUMC

Anthony Borgmann, MD, assistant professor of clinical, clinical radiology, and radiological sciences, VUMC, reviewed interventional radiology treatment options for hepatocellular carcinoma, reviewing studies^2,3 that found patients on Yttrium-90 (Y90) had a longer time to progression than those on transarterial chemoembolization.

While another 3 trials^4-6 failed to show a survival benefit of transarterial radioembolization with Y90 over sorafenib, Y90 may offer a better safety profile.

“So, fewer complications and better quality of life,” Borgmann said. “So, it is something that we can consider in these patients that have limited portal vein tumor thrombosis.”

References

1. Ethun CG, Lopez-Aguiar AG, Anderson DJ, et al. Transplantation versus resection for hilar cholangiocarcinoma: an argument for shifting treatment paradigms for resectable disease. Ann Surg. 2018;267(5):797-805. doi:10.1097/SLA.0000000000002574

2. Salem R, Gordon AC, Mouli S, et al. Y90 radioembolization significantly prolongs time to progression compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2016;151(6):1155-1163.e2. doi:10.1053/j.gastro.2016.08.029

3. Dhondt E, Lambert B, Hermie L, et al. 90Y radioembolization versus drug-eluting bead chemoembolization for unresectable hepatocellular carcinoma: results from the TRACE phase II randomized controlled trial. Radiology. 2022;303(3):699-710. doi:10.1148/radiol.211806

4. Ricke J, Bulla K, Kolligs F, et al; SORAMIC study group. Safety and toxicity of radioembolization plus sorafenib in advanced hepatocellular carcinoma: analysis of the European multicentre trial SORAMIC. Liver Int. 2015;35(2):620-626. doi:10.1111/liv.12622

5. Vilgrain V, Pereira H, Assenat E, et al; SARAH Trial Group. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial. Lancet Oncol. 2017;18(12):1624-1636. doi:10.1016/S1470-2045(17)30683-6

6. Chow PKH, Gandhi M, Tan SB, et al; Asia-Pacific Hepatocellular Carcinoma Trials Group. SIRveNIB: selective internal radiation therapy versus sorafenib in Asia-Pacific patients with hepatocellular carcinoma. J Clin Oncol. 2018;36(19):1913-1921. doi:10.1200/JCO.2017.76.0892