Editor’s Note:
In recent years, there has been rapid progress in the systemic treatment of liver cancer, with new immunotherapies and targeted therapies continually emerging. This has also driven ongoing innovation in the concepts and approaches for treating HCC. From July 6th to 8th, 2023, the 13th Asia-Pacific Primary Liver Cancer Experts Conference (APPLE 2023) was held in Seoul, South Korea. During the conference, one of the founders of APPLE, Dr. Masatoshi Kudo from Kindai University in Japan, shared the latest research developments in systemic treatment for intermediate HCC and its potential applications. Hepatology Digest had the privilege of conducting an in-depth interview with Dr. Kudo at the APPLE conference. Here, we present the contents of that interview for our readers.
The Current Treatment Status of Intermediate HCC Patients in Japan
Dr. Kudo: Intermediate HCC is a highly heterogeneous disease, depending on the tumor burden and liver function of the patient. In Japan, there have been significant advancements in the treatment of intermediate HCC. For instance, drugs such as lenvatinib, atezolizumab, in combination with bevacizumab, have shown high objective response rates. These drugs can be used to treat patients with intermediate HCC who are not eligible for surgical resection. For those intermediate HCC patients who are not suitable for transarterial chemoembolization (TACE), we can start with lenvatinib to shrink the tumor and then proceed with sequential TACE, which is also a very good treatment option. Furthermore, through aggressive systemic therapy, many initially unresectable HCC can be downstaged, offering a chance for curative treatment. Based on this, we can choose surgical resection, ablation, or TACE to achieve complete tumor resolution, ultimately leading to sustained remission without medication.
Improving Clinical Efficacy and Prognosis with New Treatment Strategies for Intermediate HCC
Dr. Kudo: In oncology, achieving sustained complete remission of tumors is essential. However, systemic therapy currently cannot achieve pathological complete remission, which leads clinicians to favor long-term drug maintenance. Nevertheless, this does not entirely prevent immunological escape of tumors, leading to recurrence. Therefore, in the process of achieving complete remission, we must increase local therapies such as ablation or highly selective TACE. This is a crucial strategy to further improve patient prognosis and prevent tumor recurrence.
The Future Shift in the Treatment Paradigm for HCC
Dr. Kudo: With the vibrant development of multidisciplinary treatment for HCC, I believe that the treatment for intermediate HCC patients will continue to be guided by the principle of “surgery as the mainstay, with other treatments as adjuncts.” For example, in intermediate HCC, many patients can still undergo surgical resection, even with multifocal disease or large tumors; liver resection remains the best choice. For patients with a substantial tumor burden and inoperable intermediate HCC, we strive to shrink the tumor volume through early systemic therapy, ultimately transforming it into a resectable state. As mentioned earlier, tumor resection is crucial, as it is the key to preventing recurrence, improving prognosis, and achieving a cure. Of course, for a favorable resection rate, early systemic therapy, especially in combination with immunotherapy, is also vital.
Unmet Needs in Clinical HCC Treatment
Dr. Kudo: As mentioned before, HCC exhibits significant heterogeneity. It can manifest as a large mass, a single small nodule, or multifocal nodules within both lobes of the liver. Therefore, we need to tailor treatment strategies to individual patients based on their unique conditions. For instance, patients with large HCC may have vastly different conditions, potentially complicating treatment with various comorbidities such as intrahepatic metastases, portal vein tumor thrombosis, obstructive jaundice, ascites, gastrointestinal bleeding, and more. These factors pose significant challenges and complexities in treatment. Thus, the clinical treatment of HCC in the future will require personalized treatment plans tailored to each patient’s specific condition, truly achieving “individualized treatment.”
