Photo Credit: Mohammed Haneefa Nizamudeen
Staying current with the surgical management and patient selection guidelines for primary liver cancer and biliary tract cancer is challenging but critical.
Primary liver cancer and biliary tract cancer treatments are complex and continue to evolve. Keeping current with the latest surgical management and patient selection guidelines can be challenging for surgical oncologists, according to Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA.
In an article published in Annals of Surgical Oncology, Dr. Pawlik and coauthors presented diagnosis, staging, surgical management, and perioperative therapy guidelines for intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, and gallbladder cancer. The article also addressed screening for hepatocellular carcinoma.
“This paper presents the latest updates on managing primary liver and biliary tract cancers. We succinctly highlight how to screen and diagnose these tumors and present some of the systemic and surgical treatment options for patients,” says Dr. Pawlik.
Hepatobiliary Cancers Often Require Multimodality Therapy
Primary liver and biliary tract cancers are rare, aggressive, and can present with locally advanced or metastatic disease. Surgery is often the best option for patients with localized, resectable tumors, but recurrence is common.
Patients often require multimodality therapy involving resection, systemic therapy (targeted therapy, cytotoxic chemotherapy, immunotherapy), or loco-regional therapies. Multidisciplinary discussion of treatment plans should consider the tumor, the patient, and practice guidelines.
Some patients with initially unresectable cancers may be downstaged with other therapies. Before surgery, patients need to be evaluated for comorbidities and future liver remnant.
Appropriate patient selection, resection with a negative surgical margin, and careful and appropriate systemic chemotherapy are linked with long-term survival.
New Treatments Offer More Personalized Approaches
“As we better understand the factors driving hepatobiliary tumor growth and development, we’re entering an era of more personalized approaches to treating them,” Dr. Pawlik says. “A lot of exciting things are happening, and practicing surgeons need to work closely with partners in medical oncology and keep up to speed with developments.”
Surgeons need to understand the importance of screening, especially for hepatocellular carcinoma, Dr. Pawlik notes, adding that guidelines call for regularly screening patients with hepatitis or fatty liver with ultrasound for earlier identification and more effective treatment.
There are many more treatment options now for hepatocellular and intrahepatic cholangiocarcinoma than 5 or 10 years ago, according to Dr. Pawlik.
“We went decades without much effective hepatocellular carcinoma therapy,” he says. “In recent years, some interesting published prospective data have changed the way we treat these patients, including a randomized trial showing that a combination of atezolizumab and bevacizumab can increase recurrence-free survival.
He also stresses the importance of genetics. “Several genes that can contribute to intrahepatic cholangiocarcinoma have been identified and are potentially targetable with personalized medicine or therapy,” says Dr. Pawlik. “It’s important to screen patients for genetic alterations, treat them appropriately, and potentially enter them into clinical trials.”
Clinical Trial Opportunities Are Abundant
Dr. Pawlik advises surgeons to become familiar with the latest clinical trial data and enroll their patients in open multiple clinical trials investigating these diseases.
“Some trials are looking at new agents, some are looking at different agents in combination, and some are looking at the timing of chemotherapy relative to surgery,” he explains. Among them is the oncoOPT-IN randomized phase II/III clinical trial currently recruiting adults having surgery for stage II-III gallbladder cancer to compare the effect of adding chemotherapy (gemcitabine/cisplatin) before and after surgery versus after surgery alone (usual treatment).
“With many more therapeutic options available than we had 5 years ago, we’re in a renaissance of understanding primary liver and biliary tract cancers,” Dr. Pawlik adds.
Key Takeaways:
- Primary liver and biliary tract cancers are rare and aggressive
- Patients often require multimodality therapy with resection, systemic therapy, or loco-regional therapies
- Treatment options have improved considerably in the last 5-10 years
- Clinical trials represent important opportunities for these patients
