HKUMed discovers new trimodality therapy for locally advanced liver cancer

A phase II clinical study on a trimodality therapy (START-FIT), conducted by the Departments of Surgery and Clinical Oncology, School of Clinical Medicine, University of Hong Kong (HKUMed; Hong Kong), has found that nearly 50% of patients with inoperable, locally advanced liver cancer, can be cured through this approach, which includes stereotactic body radiation therapy (SBRT) and transarterial chemoembolization (TACE). The results have been published in The Lancet Gastroenterology and Hepatology.

A TOTAL OF 33 PATIENTS WERE screened and enrolled in this treatment method from March 2019 to January 2021, for tumour diameter ranging from 5 to 17.5cm. Just under two thirds (64%) of patients had tumours with major vascular invasion that precluded them from a curative surgical procedure. The research team developed a new approach termed ‘reduce and remove’—a trimodality therapy (START-FIT)—for these 33 patients. Patients received TACE on day one for local tumour control, followed by SBRT on day 28, and then immunotherapy administered 14 days following SBRT and every two weeks thereafter. This trimodality approach is to downstage the tumour status so that it is amenable to curative surgical intervention.

After this trimodality therapy, 55% (18 patients) became suitable to receive curative surgery, of whom four patients (12%) underwent this surgery, and 14 patients (42%) had complete tumour necrosis and are receiving ongoing monitoring with regular scans. After up to 2.5 years of follow-up, two-year survival among these patients exceeded 90%, with mild side-effects experienced throughout the treatment process. The advantages of this approach are that it is minimally invasive with a short hospital stay and a relatively high safety profile.

This treatment strategy provides the opportunity for curative surgery with promising long-term outcomes to patients who would otherwise be

This session also yielded additional tips for those wishing to establish outpatient practices—Jason Greis (Benesch, Friedlander, Coplan & Aronoff, Cleveland, USA), advised prioritising “quality of care, not volume of cases”; maximising the number of interventionalist owners and the percentage of equity they hold; and taking patient, payer and investor complaints seriously.

Against ambulatory practices

This talk was immediately followed by Dipankar Mukherjee’s (INOVA Fairfax Hospital, Falls Church, USA) presentation entitled: “Why I chose not to work in an outpatient lab”. Mukherjee noted that, since the 2011 approval of atherectomy codes for peripheral vascular interventions, migration of talent has become a problem, as “some of our best interventionalists” have moved from hospitals to OBLs. In addition to leaving some of the sickest hospitalised patients in the hands of less experienced operators, and contributing to a “serious manpower crisis” across much of the USA, the speaker stated that these interventionalists have “abandoned their responsibility” in educating future generations as well.

On top of this “immense loss” facing trainees, surgeons working exclusively in OBLs are also likely to “lose all open repair skills”, according to Mukherjee, who asked the ISET audience, ‘where would you and I be now’ if pioneering interventionalists of the past had gone to work in these ambulatory settings? He further called for the “rules of the game” in OBLs to change and for the restoration of “the values that attracted us to the profession and specialty”.

unsuitable. “This treatment strategy provides a definite treatment schedule. Most patients could have an idea on the treatment effect within six months after the start of treatment and be able to have better planning for themselves and their family. Now the team is looking forward to expanding the treatment coverage to more patients, especially those with poor liver function, to help downstage the tumour status and hence, increase the chance of fitting into the criteria for liver transplantation in the future.” This statement was shared by Albert Chan Chi-Yan, clinical professor at HKUMed’s Department of Surgery at the School of Clinical Medicine, who initiated this world-first trimodality therapy.

Speaking to Interventional News, Chan elaborated on the unique advantages of combining these three treatment modalities when treating unresectable liver cancer. “The lipiodol infusion offered by TACE provides a definite tumour staining that facilitates SBRT planning and improves the targeting and accuracy of the delivery

After up to 2.5 years of follow-up, two-year survival among these patients exceeded 90%

2.5 years up to

90% two-year survival exceeded of SBRT. Once tumour necrosis induced by the radiation starts to occur, the host immune system [starts] to recognise their presence and the use of immunotherapy [enhances] the host immune response to recognise and to eradicate the residual tumour cells.” Chan added that the main obstacle his team encountered during this project was when seeking funding due to the novelty of the trimodal treatment, but he is now optimistic about the treatment becoming the standard of care—this will be facilitated, he conveyed, as “apart from the need to stay two to three days [in hospital] after TACE for monitoring, all the other treatments [can] be conducted in an outpatient setting.” Moreover, Chan believes that there is scope for this trimodal approach in treating other cancers—“yes, we do see the potential in lung and kidney cancer.”