Therapeutic Dilemmas in Advanced Hepatocellular

Prof Jeroen Dekervel, a GI oncologist from Leuven, Belgium, and Dr Julien Edeline, medical oncologist in Rennes, France discuss hepatocellular carcinoma (HCC) treatment strategies. They begin by presenting a case of a patient with compensated liver cirrhosis, portal hypertension, and multifocal HCC. The discussion among oncologists, radiation oncologists, and interventional radiologists focuses on the optimal treatment choices.

Local-regional treatment options for HCC include ablation, which is best for lesions smaller than 3 cm, and transarterial treatments such as transarterial chemoembolisation (TACE) and radioembolisation, suitable for specific cases like those with portal vein thrombosis. Stereotactic body radiotherapy (SBRT) is preferred for a small number of lesions. The choice of treatment depends on disease characteristics and the expertise of the treatment center, highlighting the importance of multidisciplinary team discussions for optimal treatment decisions.

TACE has been the primary treatment for over 20 years but is being supplemented by newer techniques, particularly in academic centers. The EMERALD- 1 study is an important trial that compareD TACE with immunotherapy (durvalumab plus bevacizumab) versus TACE alone. The study found improved PFS with TACE plus durvalumab and bevacizumab, although OS data is still pending.

For advanced-stage HCC, immunotherapy combinations such as atezolizumab plus bevacizumab and durvalumab plus tremelimumab are now standard treatments. There are currently no predictive factors to choose one regimen over another, so decisions are often based on contraindications for specific drugs. The session emphasised the importance of a multidisciplinary approach and expertise in making treatment decisions. It also noted the lack of definitive sequencing guidelines for different treatment modalities. Continuous care and individualized patient management are crucial for HCC treatment.

In conclusion, Prof Dekervel thanked Dr Edeline for sharing his expertise and summarising the key points of this session. The discussion highlighted the complexity of HCC treatment and the need for ongoing research and collaboration among different medical disciplines.