Treatment stage migration and treatment sequences in patients with hepatocellular carcinoma: drawbacks and opportunities

Abstract

Purpose This retrospective analysis focuses on treatment stage migration in patients with hepatocellular carcinoma (HCC) to identify successful treatment sequences in a large cohort of real-world patients. Methods 1369 HCC patients referred from January 1993 to January 2020 to the tertiary center of the Heidelberg University Hospital, Germany were analyzed for initial and subsequent treatment patterns, and overall survival. Results The most common initial treatment was transarterial chemoembolization (TACE, n = 455, 39.3%) followed by hepatic resection (n = 303, 26.1%) and systemic therapy (n = 200, 17.3%), whereas the most common 2nd treatment modality was liver transplantation (n = 215, 33.2%) followed by systemic therapy (n = 177, 27.3%) and TACE (n = 85, 13.1%). Kaplan–Meier analysis revealed by far the best prognosis for liver transplantation recipients (median overall survival not reached), followed by patients with hepatic resection (11.1 years). Patients receiving systemic therapy as their first treatment had the shortest median overall survival (1.7 years; P < 0.0001). When three or more treatment sequences preceded liver transplantation, patients had a significant shorter median overall survival (1st seq.: not reached; 2nd seq.: 12.4 years; 3rd seq.: 11.1 years; beyond 3 sequences: 5.5 years; P = 0.01). Conclusion TACE was the most common initial intervention, whereas liver transplantation was the most frequent 2nd treatment. While liver transplantation and hepatic resection were associated with the best median overall survival, the timing of liver transplantation within the treatment sequence strongly affected median survival.

Effects of surgery, chemotherapy, and radiation on hepatocellular carcinoma patients: A SEER-based study

“…However, Wehling et al recently stated that patients undergoing liver resection as an initial treatment had a median overall survival of 11.1 years, then those who underwent locoregional ablative intervention had 8.4 years. Initial transarterial chemoembolization treatment modality had 6.3 years median survival, whereas those treated with radiation had 2.9 or 5.5 years only [ 30 ].…”

Association between Time to Local Tumor Control and Treatment Outcomes Following Repeated Loco-Regional Treatment Session in Patients with Hepatocellular Carcinoma: A Retrospective, Single-Center Study

“…However, only patients diagnosed at an early HCC stage would benefit from treatments with curative intent. The present study assessed the outcomes of patients with HCC ineligible for therapies other than TACE or ablation using a treatment stage migration strategy [21].…”

“…It has become increasingly clear that post-treatment data may provide important prognostic information that can significantly refine risk stratification in patients with HCC treated with TACE [20,21]. This potentially entails an assessment of the dynamic response of HCC to TACE or other locoregional treatments, which may not be fully captured by baseline analysis [6,19].…”

Role of temporary portosystemic surgical shunt during liver resection to prevent a post-resection small for size-like syndrome

“…The barcelona clinic liver cancer (BCLC) staging system [66] initially developed and validated for HCC management, has become somewhat static over time, particularly inadequate for intermediate and advanced stages and decompensated cirrhotic patients due to evolving medical management and tumor biology understanding [67,68] . Increasing evidence demonstrates differences between BCLC recommendations and real-life approaches in HCC treatment [69,70] . In response to the limitations of the BCLC system, alternative staging concepts and treatment stage migration strategies have emerged, but these still focus on stage-oriented HCC treatment strategies [71] .…”