HCC, SBRT vs RFA

[Ray D. Ayshun]

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Happen to be seeing a patient who's going to ask about this tomorrow and I just noticed this trial just got published

https://ascopubs.org/doi/10.1200/JCO-24-01532

How are other institutions generally approaching HCC?

 

[Bequerel]

Think like a surgeon. Dominate tumor board and don’t let IR have HCC until it’s Y-90 time. I always have a few HCC or liver met SBRT patients under treatment because of this mentality. We know it’s a better treatment and easier for the patient and if you teach the surgeons then no one will think of IR until Y-90 time.

 

[BobbyHeenan]

In my tumor board/mult d team we are slowly turning the bus away from IR to SBRT....but it's a struggle.

IR very pushy about "selective TARE" or Microwave. They don't care much about data (though there's nothing randomized selective TARE vs. SBRT that I'm aware of). A lot of the referral patterns are just inertia from old days when EBRT didn't play as much of a role and frankly the Barcelona guidelines have a MAJOR blind spot for EBRT too, so that plays a role as well.

Regional transplant centers in my area have also been heavily IR-driven for their hepatobiliary tumor boards, so that has played a role as well.

 

[cmw021]

Two large RCTs (SARAH andSIRveNIB) ofTARE vs Sorafenib were negative w/ a lack of OS or PFS benefit. We now have an RCT of SBRT vs sorafenib that with PFS benefit and borderline OS benefit. Generally try not to compare across trials, but if this were the other way around I would imagine that SBRT would no longer be considered let alone preferred...

edit w/ link: The SIRveNIB and SARAH trials, radioembolization vs. sorafenib in advanced HCC patients: reasons for a failure, and perspectives for the future - PMC

 

[BobbyHeenan]

Two large RCTs (SARAH andSIRveNIB) ofTARE vs Sorafenib were negative w/ a lack of OS or PFS benefit. We now have an RCT of SBRT vs sorafenib that with PFS benefit and borderline OS benefit. Generally try not to compare across trials, but if this were the other way around I would imagine that SBRT would no longer be considered let alone preferred...

edit w/ link: The SIRveNIB and SARAH trials, radioembolization vs. sorafenib in advanced HCC patients: reasons for a failure, and perspectives for the future - PMC

Yes.

Here are the IR party lines though...

- we now use more selective, higher dose "selective" TARE that was not used on this trial
- we now use microwave ablation not RFA

I hope someone is running a selective TARE vs. SBRT trial with local control and liver function endpoints.

 

[Doctorer]

In my tumor board/mult d team we are slowly turning the bus away from IR to SBRT....but it's a struggle.

IR very pushy about "selective TARE" or Microwave. They don't care much about data (though there's nothing randomized selective TARE vs. SBRT that I'm aware of). A lot of the referral patterns are just inertia from old days when EBRT didn't play as much of a role and frankly the Barcelona guidelines have a MAJOR blind spot for EBRT too, so that plays a role as well.

Regional transplant centers in my area have also been heavily IR-driven for their hepatobiliary tumor boards, so that has played a role as well.

Similar story here. Our liver tumor board has a lot of inertia with its practice patterns, and that appears to be the case in many places. Heck, at one place I've worked, the GI/IR clinics ran out of the same location at the same time.

 

[Palex80]

Yes.

Here are the IR party lines though...

- we now use more selective, higher dose "selective" TARE that was not used on this trial
- we now use microwave ablation not RFA

I hope someone is running a selective TARE vs. SBRT trial with local control and liver function endpoints.

Exactly. The new phrase I am hearing is "SIRT-segmentectomy".
And they likely do have a point there. If (and only if) the tumor is well confined in a segment and there's a good vessel feeder, they can use spheres to more or less ablate that segment with TARE.

 

[medgator]

In my tumor board/mult d team we are slowly turning the bus away from IR to SBRT....but it's a struggle.

IR very pushy about "selective TARE" or Microwave. They don't care much about data (though there's nothing randomized selective TARE vs. SBRT that I'm aware of). A lot of the referral patterns are just inertia from old days when EBRT didn't play as much of a role and frankly the Barcelona guidelines have a MAJOR blind spot for EBRT too, so that plays a role as well.

Regional transplant centers in my area have also been heavily IR-driven for their hepatobiliary tumor boards, so that has played a role as well.

This is where I think it's actually easier out in the community, esp with med onc buy-in in combination with seeing unscrupulous IRs that have already burned bridges by pushing inappropriate RFA in early stage lung leading to complications and poor oncologic outcomes

 

[BobbyHeenan]

Exactly. The new phrase I am hearing is "SIRT-segmentectomy".
And they likely do have a point there. If (and only if) the tumor is well confined in a segment and there's a good vessel feeder, they can use spheres to more or less ablate that segment with TARE.

Yes. they often recommend a "radiation segmentectomy" at our tumor board.

 

[gmsquid]

Rad seg is.a great idea theoeretically but it’s still a circulation problem. The number of failures I’ve seen for even smaller size tumors is surprising. Sbrt delivery far more reliable

 

[BobbyHeenan]

Rad seg is.a great idea theoeretically but it’s still a circulation problem. The number of failures I’ve seen for even smaller size tumors is surprising. Sbrt delivery far more reliable

agree completely.

there are very often cold spots and small but significant peripheral feeder vessels.

 

[ramsesthenice]

agree completely.

there are very often cold spots and small but significant peripheral feeder vessels.

Agree completely. I consider all embolization therapies as inferior to ablation or SBRT for most unifocal lesions where local control is the goal and the data support this. We can quip about SBRT vs RFA/MWA but there is no one sizes fits all approach and balanced TB discussion isn’t too hard too hard. Size? Vascular proximity? Abutting bowel? On the capsule? The bottom line is many people will do fine either way and you can always use the other as a salvage if they fail locally.

This is a sphere where I strongly encourage people to show careful thoughtfulness at TB and with referring providers. Saying “we could think about SBRT, but in this case I may actually prefer MWA because…” builds trust with the rest of the team when you want to guide them towards radiation.

Also, if you are at a transplant center, the only opinion that matters is the surgeon. Having a good relationship with them is critical.

 

[OTN]

My liver surgeons moved away from RFA long ago and are now super interested in histiotripsy.

How we allowed that to be the domain of the surgeons rather than us will always upset me. After all, histiotripsy is putting dose to volume via imaging - exactly what we do. Maybe if we hadn't been pursuing non-inferiority study after non-inferiority study we would have been more involved. Who knows, but the cat is now well out of the bag.

 

[evilbooyaa]

My liver surgeons moved away from RFA long ago and are now super interested in histiotripsy.

How we allowed that to be the domain of the surgeons rather than us will always upset me. After all, histiotripsy is putting dose to volume via imaging - exactly what we do. Maybe if we hadn't been pursuing non-inferiority study after non-inferiority study we would have been more involved. Who knows, but the cat is now well out of the bag.

?? Data for this? Seems like everybody wants all sorts of data for SBRT but literally do **** that they just found in their back pocket, simply because they can bill for it