By: NEIL OSTERWEIL, Family Practice News Digital NetworkORLANDO – Intensive follow-up of patients who have undergone surgery for hepatocellular carcinoma reduces deaths from tumor recurrence and metastases, Dr. Timothy M. Pawlik said at a symposium sponsored by the Society of Surgical Oncology.
Data from surveillance programs for hepatocellular carcinoma (HCC) and empiric data from centers treating colorectal liver metastases (CRLM) suggest that HCC tends to recur locally, and that recurrent HCC and CRLM, if caught early, can be successfully controlled with a variety of therapeutic options, said Dr. Pawlik, associate professor of surgery and oncology, and hepatobiliary surgery program director at Johns Hopkins Medical Center, Baltimore.
"I would favor high-intensity surveillance for patients with hepatocellular carcinoma. This argument is based on level 1 data showing that high-intensity primary surveillance decreases mortality for patients who have cirrhosis," he said.
Although there is a high HCC recurrence rate following surgery, most recurrences will be contained within the liver, and may be successfully treated with salvage transplantation, ablation, or intra-arterial therapy.
"But if we miss that opportunity and patients recur with advanced disease, all those options are off the table, and their prognosis is abysmal," Dr. Pawlik said.
According to National Cancer Institute data, liver cancer holds the dubious distinction of being the fastest growing cancer in terms of death rate in the United States, outpacing lung cancer in women, esophageal cancer, and thyroid cancer.
Risk factors for HCC include cirrhosis from any cause (hepatitis B and C viruses, alcoholism, nonalcoholic fatty liver disease), hepatitis B primary infection (with or without cirrhosis), and inherited metabolic diseases such as hemochromatosis, alpha-1 antitrypsin deficiency, glycogen storage disease, or tyrosinemia.
"Most patients who have HCC don’t simply have a cancer; they also have significant underlying cirrhosis, so when thinking about the approach to HCC, we have to be thinking about all of the tumor-specific factors such as tumor size, location, and number, and we also have to be thinking about all of the liver-specific factors," Dr. Pawlik said.
Surgical treatment options include resection for HCCs of all sizes; transplantation, for single lesions 5 cm or smaller, or up to three lesions of 3 cm or less or advanced cirrhosis; and ablation for small lesions or inoperable or unresectable tumors as a bridge to transplant.
In various series, overall 5-year survival following resection ranges from 42% to 62%, and following transplantation from 57% to 75%.
But as Dr. Pawlik and colleagues noted in a 2008 study, disease-free survival following resection for HCC is only half of the percentage after transplantation (40% vs. 82%, P less than .01). (J. Gastrointest. Surg. 2008;12:1699-1708).
Intrahepatic recurrence is most frequent among patients with hepatitis C infection, but also occurs with hepatitis B and C coinfection, and hepatitis B alone. A subset of patients who have undergone transplantation (about 20%) will also have recurrence, Dr. Pawlik said.
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Data from surveillance programs for hepatocellular carcinoma (HCC) and empiric data from centers treating colorectal liver metastases (CRLM) suggest that HCC tends to recur locally, and that recurrent HCC and CRLM, if caught early, can be successfully controlled with a variety of therapeutic options, said Dr. Pawlik, associate professor of surgery and oncology, and hepatobiliary surgery program director at Johns Hopkins Medical Center, Baltimore.
"I would favor high-intensity surveillance for patients with hepatocellular carcinoma. This argument is based on level 1 data showing that high-intensity primary surveillance decreases mortality for patients who have cirrhosis," he said.
Although there is a high HCC recurrence rate following surgery, most recurrences will be contained within the liver, and may be successfully treated with salvage transplantation, ablation, or intra-arterial therapy.
"But if we miss that opportunity and patients recur with advanced disease, all those options are off the table, and their prognosis is abysmal," Dr. Pawlik said.
According to National Cancer Institute data, liver cancer holds the dubious distinction of being the fastest growing cancer in terms of death rate in the United States, outpacing lung cancer in women, esophageal cancer, and thyroid cancer.
Risk factors for HCC include cirrhosis from any cause (hepatitis B and C viruses, alcoholism, nonalcoholic fatty liver disease), hepatitis B primary infection (with or without cirrhosis), and inherited metabolic diseases such as hemochromatosis, alpha-1 antitrypsin deficiency, glycogen storage disease, or tyrosinemia.
"Most patients who have HCC don’t simply have a cancer; they also have significant underlying cirrhosis, so when thinking about the approach to HCC, we have to be thinking about all of the tumor-specific factors such as tumor size, location, and number, and we also have to be thinking about all of the liver-specific factors," Dr. Pawlik said.
Surgical treatment options include resection for HCCs of all sizes; transplantation, for single lesions 5 cm or smaller, or up to three lesions of 3 cm or less or advanced cirrhosis; and ablation for small lesions or inoperable or unresectable tumors as a bridge to transplant.
In various series, overall 5-year survival following resection ranges from 42% to 62%, and following transplantation from 57% to 75%.
But as Dr. Pawlik and colleagues noted in a 2008 study, disease-free survival following resection for HCC is only half of the percentage after transplantation (40% vs. 82%, P less than .01). (J. Gastrointest. Surg. 2008;12:1699-1708).
Intrahepatic recurrence is most frequent among patients with hepatitis C infection, but also occurs with hepatitis B and C coinfection, and hepatitis B alone. A subset of patients who have undergone transplantation (about 20%) will also have recurrence, Dr. Pawlik said.
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