Hong Kong Liver Cancer (HKLC) versus Barcelona Clinic Liver Cancer (BCLC)

[MSResident]

Yau T, Tang VYF, Yao TJ, et al. Development of Hong Kong cancer staging system with treatment statification for patients with hepatocellular carcinoma. Gastroenterology 2014 (available online).

Brief Summary: Authors looked at 3856 patients with HCC (mostly 2/2 to Hep B) treated from 1/955 to 12/2008. Included performance status, Child-Pugh grade, tumor status and presence of extrahepatic vascular invasion or mets. Authors found HKLC had a better ability than BCLC to determine specific overall survival times and allowed for subsets of what would constitute BCLC intermediate- and advanced-stage patients to get more aggressive treatments and improved survival outcomes (e.g., HKLC-II v BCLC-B/C).

Several medical centers are discussing replacing BCLC with HKLC. Any thoughts about advantages/disadvantages? What does your hospital typically use now?

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[JoshSt]

Our guys still use the BCLC. It frustrates the rad department because patients with long-standing hepatitis and alcoholism, AFP of 1 million, with all the CT characteristics of HCC still gets a liver bx. MR's barely ever get ordered to dx or stage HCC, some surgeons order them for preop planning.

 

[shark2000]

Our guys still use the BCLC. It frustrates the rad department because patients with long-standing hepatitis and alcoholism, AFP of 1 million, with all the CT characteristics of HCC still gets a liver bx. MR's barely ever get ordered to dx or stage HCC, some surgeons order them for preop planning.

If a lesion has typical imaging appearance of HCC on CT in a patient with cirrhosis or Hep B, no biopsy is need. It is HCC or high grade dysplastic nodule. MRI does not add that much of value. MRI is only good that you can do dynamic post-contrast images esp in delayed phase. But it is usually not helpful in the case of HCC.

I really like Body MRI. But honestly, most of things can be very well characterized on CT.

 

[JoshSt]

If a lesion has typical imaging appearance of HCC on CT in a patient with cirrhosis or Hep B, no biopsy is need.

Much agreed, the Hong Kong guidelines are much more flexible for dx of HCC, they allow for either AFP >400 OR typical imaging characteristics OR tissue pathology. Barcelona, on the other hand, mandates both imaging characteristics AND tissue pathology; AFP levels have no role in those recs (at least for dx).

In the end, they are just recs -- physicians should just use their common sense and the clinical picture even if they prefer Barcelona (e.g., chronic Hep B, characteristic imaging on CT, AFP 1 million - do you really need a biopsy?)

 

[MSResident]

We have a robust MRI screening program. Many patients get screened with CT as well, depending on the clinic, the primary oncologist and certain characteristics of the patient. Interestingly, ultrasound appears to be extremely limited and miss many lesions, despite the AASLD guidelines still calling for its use.

We use hepatobiliary contrast agents (e.g., Eovist) for our MRI screening program with multiple dynamic contrast phases, as well as restricted diffusion. We're also experimenting with new non-invasive MRI techniques to assess for portal hypertension. We've found many, many HCC's that would not have been picked up CT. For some of these, the question of treatment is complicated. For instance, we presented at SIR 2013 our experience with hypovascular HCC. Our preliminary data suggested TACE was less effective for these lesions, as would be expected for lesions that have yet to undergo significant angiogenesis.

 

[JoshSt]

We've found many, many HCC's that would not have been picked up CT. For some of these, the question of treatment is complicated. For instance, we presented at SIR 2013 our experience with hypovascular HCC. Our preliminary data suggested TACE was less effective for these lesions, as would be expected for lesions that have yet to undergo significant angiogenesis.

With finding such virgin tumors, what have y'all tried or rec from prelim work? Ablation?