Reimagining Hepatocellular Carcinoma Treatment: Insights from Professor Vitale

In a recent “Ask the Author” session, we had the pleasure of hosting Professor Vitale from the University of Padova, Italy.

Renowned for his contributions to the field of hepatocellular carcinoma (HCC), Professor Vitale discussed his latest publication, “Merits and Boundaries of the BCLC Staging and Treatment Algorithm: Learning From the Past to Improve the Future with a Novel Proposal,” available on the Journal of Hepatology website. Here, we explore the insights shared by Professor Vitale on this transformative approach to HCC treatment.

Understanding the BCLC System’s Limitations

The Barcelona Clinic Liver Cancer (BCLC) system serves dual roles as a staging system and a treatment algorithm for HCC. While its efficacy as a staging system is undisputed, Professor Vitale highlighted significant issues within its treatment algorithm. The primary concern lies in its rigid stage hierarchy philosophy, which prescribes a single treatment option per stage. This often results in a lack of adherence to the algorithm, with real-life adherence rates falling below 50%. More critically, it risks undertreating patients by not always offering the best treatment tailored to individual needs.

Introducing New Concepts: Multiparametric and Converse Therapeutic Hierarchies

To address these shortcomings, Professor Vitale and his co-author propose two novel concepts: the multiparametric therapeutic hierarchy and the converse therapeutic hierarchy.

1. Multiparametric Therapeutic Hierarchy:

  • Vertical Axis – Ordinal Therapeutic Hierarchy: This approach removes the dependency of treatment choice on tumor stage, establishing a clear hierarchical order of treatments. From liver transplantation at the top, followed by liver resection, ablation, intra-arterial therapies, to systemic therapies.
  • Horizontal Axis – Multiparametric Expert Decision Parameter: This dimension introduces a comprehensive checklist of critical variables for treatment decisions, including patient fitness, tumor characteristics, biomarkers, liver function (using Child-Pugh and ALBI scores), liver volume remnant, treatment feasibility, resources, and costs. This holistic view aims to prevent both over and undertreatment, ensuring the best possible outcomes for each patient.

2. Converse Therapeutic Hierarchy:

This innovative concept, though still emerging with limited evidence, proposes a revolutionary approach where systemic therapies, especially novel immunotherapies, can be used to enhance the effectiveness of radical therapies. It encompasses conventional conversion, enabling patients initially unsuitable for radical treatments to become candidates for such therapies, and improves outcomes for those already eligible.

Impact on the Field of HCC Treatment

Professor Vitale’s proposal has sparked significant debate within the medical community. The recent discussion in the Journal of Hepatology, where the BCLC authors critiqued his paper for lacking an evidence-based foundation, led to a robust response from Professor Vitale. With the support of an expert methodologist, they argued that their proposal, when evaluated using the GRADE method, is indeed more inclusive of the available literature and evidence than the current BCLC scheme.

The most profound impact of this new proposal lies in its patient-centered approach, moving away from the stage-centered model of the BCLC. By focusing on individualized care, Professor Vitale’s model aims to optimize treatment outcomes for each patient, potentially setting a new standard in HCC management.

In conclusion, Professor Vitale’s innovative perspectives on HCC treatment present a compelling case for rethinking established algorithms. As further evidence emerges, these concepts may well pave the way for more personalized and effective therapeutic strategies in hepatocellular carcinoma.

For further details, you can read the full text of the paper here.

Stay tuned for more insights and updates on advancements in medical research and treatments. If you have any questions or topics you’d like us to cover, feel free to reach out!

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