Why BCLC algorithm is not the perfect algorithm for HCC treatment at the present time?
One of the challenges for a liver surgeon is to work against the challenges deployed by inadequate understanding of the BCLC algorithm for HCC treatment. Liver surgeons and transplant surgeons work to increase the number of patients that would qualify for curative treatments in HCC. Curative treatments in HCC are liver resection and transplantation. Use of radiofrequency ablation and transarterial chemotherapy are considered bridge therapies and would require additional follow up treatments for good results.
In India, especially in Chennai, the challenges are compounded by the belief that less invasive treatments are patient friendly and there are many patients who receive inadequate treatments for their disease and lose precious years of life due to inappropriately selected under treatments.
With most of the patients in India, early detection has become a distant dream. HCC is rarely picked up by screening. These patients are evaluated on symptoms, which can indicate advanced disease. Most of the tumours that I see in clinic are more than 5 cm, a number above which we consider increasing possibility of vascular invasion.
In this blog post, I put before my readers the key reasons why the BCLC algorithm is inadequate in the current scenario for addressing patients with liver cancer.
#1 The size criteria proposed seems to be wrong.
In 2007, SG Lee published an article in the British Journal of Surgery about large HCC (> 10cm) treated with liver resections. This article from one of the world's reputed liver centers reveals a surprising data. Survival in large HCCs were 66 % at 1 year, 44 % in 3 years and 31 % at 1 year. They found that small margins and macrovascular invasion predicted recurrence and they also treated recurrences in 85 % of the patients. The BCLC algorithm has left these patients with no treatment choice. At present, these patients are given sorafenib whose overall surival remains poor (20% at 1 year). It is important not to exclude resection as a possible treatment for large HCC, especially in patients who do not have cirrhosis.
The same discussion about treatment for large tumours was highlighted in another study by the QMH, Hong Kong group in 2003, where resections were offered to patients with Stage 4 HCC. Resections for tumours that had involvement of portal vein and hepatic veins had more recurrences and poor results but they were still better than TACE or just Chemotherapy.
# 2 The presence of portal vein invasion delegates the patient to receive only chemotherapy.
In 2001, Konishi and colleagues, from Chiba, Japan reported the treatment of patients with HCC and cancer in the main portal vein. The key requirements for success in this procedure is adequate residual functional capacity of the liver and complete removal of the tumour thrombus in the main portal vein. This prevents early recurrence and deaths within the first 90 days. 75% of these patients lived for 2 years after the surgery. Under the BCLC algorithm, these patients will get Sorafenib, which at best gives the patient roughly 14 months to live.
# 3 Liver transplant indications for HCC has expanded to include larger tumour sizes.
UCSF criteria for liver transplants in HCC is an established criteria for several years now and is not clearly mentioned in the BCLC algorithm. Obviously, the presence of a large lesion indicates that the tumour would have already had access to the microcirculation and the possibility of distant disease exists. But slow growing tumours whose biology can be observed during the wait time after bridge therapies, benefit from transplantation.
A survival of 75% at 5 years was noted in the original series of patients meeting UCSF critria on pathology, are wonderful results and brings good news for patients with large tumours. For reasons that are beyond understanding for this author, these criteria are not used in the BCLC criteria. The Pittsburgh group looked at their own data of patients who met pathological criteria of USCF criteria and saw a 94% 5 year survival, which is remarkable. Both these data sets indicate that the BCLC algorithm has got it wrong with regard to transplant indications.
After I started my practice in India, I have met several surgeons and physicians who use the BCLC algorithm in their practice and treat most of our patients with chemotherapy and give them dismal prognosis. Slowly after showing them good results with resection, we are winning the doctor's confidence to give more curative options for patients. I am also encouraging patients to look for curative options and short term discomforts can lead to long term benefits, both in survival and quality of life.
The final word will be that it is better not to use the BCLC algorithm for making decisions regarding HCC in the light of many scientific progress made in the last decade.
In India, especially in Chennai, the challenges are compounded by the belief that less invasive treatments are patient friendly and there are many patients who receive inadequate treatments for their disease and lose precious years of life due to inappropriately selected under treatments.
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| Break down of the well known BCLC algorithm for HCC. The box shows the six key therapeutic plans that a patient has in the treatment of HCC. The two curative treatment options are highlighted in a different color. |
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| 7 cm HCC in segment 8 in a 67 year old gentleman with fatty liver. This is the post resection picture. The patient had an uneventful recovery and was discharged on POD 5. |
In this blog post, I put before my readers the key reasons why the BCLC algorithm is inadequate in the current scenario for addressing patients with liver cancer.
#1 The size criteria proposed seems to be wrong.
In 2007, SG Lee published an article in the British Journal of Surgery about large HCC (> 10cm) treated with liver resections. This article from one of the world's reputed liver centers reveals a surprising data. Survival in large HCCs were 66 % at 1 year, 44 % in 3 years and 31 % at 1 year. They found that small margins and macrovascular invasion predicted recurrence and they also treated recurrences in 85 % of the patients. The BCLC algorithm has left these patients with no treatment choice. At present, these patients are given sorafenib whose overall surival remains poor (20% at 1 year). It is important not to exclude resection as a possible treatment for large HCC, especially in patients who do not have cirrhosis.
The same discussion about treatment for large tumours was highlighted in another study by the QMH, Hong Kong group in 2003, where resections were offered to patients with Stage 4 HCC. Resections for tumours that had involvement of portal vein and hepatic veins had more recurrences and poor results but they were still better than TACE or just Chemotherapy.
# 2 The presence of portal vein invasion delegates the patient to receive only chemotherapy.
In 2001, Konishi and colleagues, from Chiba, Japan reported the treatment of patients with HCC and cancer in the main portal vein. The key requirements for success in this procedure is adequate residual functional capacity of the liver and complete removal of the tumour thrombus in the main portal vein. This prevents early recurrence and deaths within the first 90 days. 75% of these patients lived for 2 years after the surgery. Under the BCLC algorithm, these patients will get Sorafenib, which at best gives the patient roughly 14 months to live.
# 3 Liver transplant indications for HCC has expanded to include larger tumour sizes.
UCSF criteria for liver transplants in HCC is an established criteria for several years now and is not clearly mentioned in the BCLC algorithm. Obviously, the presence of a large lesion indicates that the tumour would have already had access to the microcirculation and the possibility of distant disease exists. But slow growing tumours whose biology can be observed during the wait time after bridge therapies, benefit from transplantation.
A survival of 75% at 5 years was noted in the original series of patients meeting UCSF critria on pathology, are wonderful results and brings good news for patients with large tumours. For reasons that are beyond understanding for this author, these criteria are not used in the BCLC criteria. The Pittsburgh group looked at their own data of patients who met pathological criteria of USCF criteria and saw a 94% 5 year survival, which is remarkable. Both these data sets indicate that the BCLC algorithm has got it wrong with regard to transplant indications.
After I started my practice in India, I have met several surgeons and physicians who use the BCLC algorithm in their practice and treat most of our patients with chemotherapy and give them dismal prognosis. Slowly after showing them good results with resection, we are winning the doctor's confidence to give more curative options for patients. I am also encouraging patients to look for curative options and short term discomforts can lead to long term benefits, both in survival and quality of life.
The final word will be that it is better not to use the BCLC algorithm for making decisions regarding HCC in the light of many scientific progress made in the last decade.
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