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BackTable / Tumor Board / Podcast / Transcript #7
Podcast Transcript: Surgery for HCC: What’s Its Role Today?
with Dr. John Seal, Dr. Gabe Schnickel and Dr. Sid Padia
Is surgery truly the "cure" for hepatocellular carcinoma (HCC), and when is it a viable option? In this episode, Dr. Sabeen Dhand leads a roundtable discussion with interventional radiologist Dr. Siddharth Padia and transplant/hepatobiliary surgeons Dr. John Seal and Dr. Gabriel Schnickel, delving into the complexities of surgical treatments for HCC and the evolving landscape of liver resection and transplantation.
Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion: https://www.cmeuniversity.com/course/take/125741 You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Curative vs Palliative Intent for Treating HCC
(2) Surgical Resection Approaches to Treating HCC
(3) Clinical Factors to Determine Surgical Candidacy for Patients with HCC
(4) Liver Transplant Eligibility Criteria
(5) Bridging Patients with HCC to Surgical Therapies
(6) Maintaining Continuity of Care between the Patients’ Providers
(7) Role of Checkpoint Inhibitors in Bridging Patients to Liver Transplant
This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.
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[Dr. Sabeen Dhand]
We're going to be talking about surgical approaches to HCC, and I have got an awesome panel of surgeons and IR here. Can we get everyone to introduce themselves? We'll start with Sid Padia.
[Dr. Sid Padia]
So I'm Sid Padia. I'm not a surgeon, so I have no idea how to do a surgical approach to HCC. I'm an interventional radiologist at UCLA.
[Dr. Gabe Schnickel]
Gabe Schnickel. I'm a transplant and hepatobiliary surgeon at UC San Diego.
[Dr. John Seal]
I'm John Seal. I'm a transplant and hepatobiliary surgeon at Ochsner Clinic in New Orleans.
(1) Curative vs Palliative Intent for Treating HCC
[Dr. Sabeen Dhand]
Great, and I'm Sabeen Dhand, your moderator today. Let's just start off with what is the definition of curative and palliative? It can be a gray zone. What exactly does it mean to you, Gabe?
[Dr. Gabe Schnickel]
Sure. I think curative, in medicine and certainly in surgery, we always talk about measure everything in years. Once you get out to the five-year mark, I think everyone looks at that as being curative. When we approach surgery, we think about it as a curative approach versus palliative, where your intent is to clear and leave the patient with no evidence of disease.
[Dr. Sabeen Dhand]
Y-90 is considered palliative to most, Sid. Why is that?
[Dr. Sid Padia]
I agree with you, but that's not the approach. I don't disagree with those definitions because that's, I think, probably the more widely accepted definitions. I don't end up using those in my practice, particularly in the HCC population, because anytime we say cure, these patients assume they're never getting another cancer again. Unlike every other cancer, a woman has breast cancer, who doesn't have a family history of breast cancer, she gets a lumpectomy, radiation, her risk of getting breast cancer again is 1 in 11, just like the baseline population.
The risk of someone with alcohol-induced cirrhosis, we know that there's a good likelihood they'll get a new cancer. So when I started saying, "You're cured," and then they're like, "Why do I need Q3 month imaging?" Then they don't follow up with me. They're like, "I got another tumor." It's in the other side of the liver. It has nothing to do with what we did or a surgeon did. I got burned in the beginning. So I've just rephrased the way I've interacted with patients. I basically say, that tumor is dead or forever, right? There's always risk of new ones.
So I've used that because I've unfortunately miscommunicated the word "cure" to patients.
[Dr. John Seal]
Yeah, I never use it. That terminology, I don't know, do you all even use those terms? I never do. I think it's like, it's all a process to optimize the treatment options.
[Dr. Sid Padia]
Do you use it for transplant, though? That's the one time I say, okay, look, the real ultimate cure is getting a transplant, even though it's not zero.
[Dr. John Seal]
But it's not.
[Dr. Sid Padia]
It's not zero, but it's so low, right?
[Dr. John Seal]
Whatever, Sid. It's just that I would hate-- because what are you going to tell them they're cured, and then you're going to tell them, "You have to get a scan every six months."
[Dr. Sabeen Dhand]
It's like, "Why?"
[Dr. Sid Padia]
"Why am I getting a scan?" Right.
[Dr. John Seal]
Yeah it's good news when you get the transplant. Is it cured? I'm delicate about that word term. I'm also very delicate about palliative care. You come in with a 18-cm tumor. We probably all have a case or two where there have been a great response. I'm not going to say all the stuff we're doing up front is palliative out of the gate. It's an interesting question, but I avoid both.
[Dr. Sid Padia]
Same.
[Dr. Sabeen Dhand]
It's come up sometimes where someone's like, "Oh, do an ablation or something that's curative," versus–
[Dr. Sid Padia]
There's conversation within the medical community, let's say the four of us. Then there's a different understanding with patients, right, of what cure means or palliation means. When the lay public or a patient hears the word "palliation", they think you are not treating them and you're just going to give them a bunch of oxycodone to treat their pain, right? That's what palliation means. So I think we need to be careful about what we discuss with each other. It's very different than what we discuss with patients because their understanding is very different than what I might come to understand.
[Dr. Sabeen Dhand]
Yeah. We kind of just said it earlier where transplant is the goal, right? We want to get to transplant. Now, the surgical approaches include resection and transplant. When do you decide just a resection only and the patient's not going to go to transplant? What are different things in your treatment strategy that select resection over transplant?
[Dr. John Seal]
I think there's some variability between practitioners. I'll show you how Gabe approaches this. There's really a lot of factors. The first is really the extent of the underlying liver disease. You've got someone with no cirrhosis, de novo tumor that's clearly resectable. Those are the ones where I think resection is a really good option. Any time a tumor occurs in the context of cirrhosis, you have to physiologically think in your brain, there's a lot of damaged liver cells there and there's going to be an increased risk that they're going to form new tumors in the future.
You have to balance how you're going to approach that with what that risk will be. Transplant is not a free ride, right? Even if you want to get to transplant, you would hate to put them through a massive operation when you could have cured it with a little wedge resection or something like that. Then you have to look at the overall health of the patient. There are patients who you know transplant is not an option. Those, we push the envelope on resection a little bit more. You look at a number of factors that sort of dictate how big that operation is going to be and how you expect the patient will recover.
That metric has shifted a lot as the less invasive tools become a lot better. The things that you're achieving with Y-90 are really comparable to the outcomes of resection in a lot of cases. I think we have to think long and hard before we start operating on cirrhotic livers and doing big cases when there's a safer option and similar outcome.
(2) Surgical Resection Approaches to Treating HCC
[Dr. Sabeen Dhand]
Gabe, what would be, different types of surgical approaches as far as what are different resections for our listeners? What's a [trisegmentectomy]? What's anatomical, non-anatomical?
[Dr. Gabe Schnickel]
I think that's a great question. When I think about who should get a resection and who should get a transplant, as John was saying, you have to think about the status of the underlying liver and then how much liver remnant, what's the future remnant going to be? We think about the extent of resection. Just for definition, you have your anatomic resection. When you're taking out an actual segment of liver that is based on the vascular anatomy, if you're taking out a whole, what we might call a lobe or a hemihepatectomy.
Which would be the right hemiliver or the left hemiliver, or you're doing a triseg, as you said, which means you're doing an extended hepatectomy. You're taking out all of the right and some of the left liver. Those operations for HCC are tricky because, again, most of these patients will have some underlying liver disease. I think it's around 80%, right, of patients with HCC will have cirrhosis. Those that don't might have some baseline underlying, whether it's fatty liver disease or they have hepatitis B or whatnot.
Those are all considerations that we have to keep in mind. As John said, it's really evolved over the past couple of decades when we think about transplant and when we think about resection.
[Dr. Sabeen Dhand]
You talked about FLR a little bit, the future liver remnant. Sid, are you doing many things to increase FLR in the setting of surgical resection?
[Dr. Sid Padia]
By FLR, you're meaning like a radiation lobectomy, right, to hypertrophy the other side. What we have seen over the last, let's say, five years when we started doing radiation lobectomy at UCLA, we did them for, I would say, predominantly two indications. Number one is HCC. Number two is metastatic colorectal cancer. For HCC, I would say that our results have not been as great as we and our hepatobiliary surgeons had hoped for. I think there is still this issue of, as you said, 80% of them have underlying cirrhosis.
The ones where we have done a successful radiation lobectomy for them to get to a curative intent surgical resection, it hasn't been as promising as we had hoped. Same thing with portal vein embolization. You do that portal vein embolization to get FLR hypertrophy in the HCC patient. They go to the operating room. There's too much cirrhosis. The tumor grew, et cetera. That's also a problem. In the CRC population, it's been a little bit different. What we've done is much more of a, I would say, staged and much more patient approach in terms of doing, let's say, a radiation lobectomy with the intent of future liver hypertrophy.
But we don't necessarily always go to surgery anymore. We go to surgery if there's certain risk factors, high AFP, there's a risk of them progressing, but there's a good proportion of patients where our surgeons have chosen to leave alone and just do a watchful wait.
[Dr. Sabeen Dhand]
Is that after, the plan is for surgery and then after the local therapy?
[Dr. Sid Padia]
Yes, after the local therapy, let's say we restage, and let's say you get a complete response and everything looks good, patient feels great. The question from our surgeons is, does this patient need a right hepatectomy? I don't know if we know the right answer to that. I think in the non-aggressive tumors, if it looks good, and let's say, as you mentioned, that the risk factors are a little high for a surgical recession, let's say they're 80. Let's say maybe they're not ECOG 0, they're ECOG 1, where your complication rate may be slightly higher than baseline.
Should we just hold off on those patients and see what their biology does? Is it possible that they may never need one?
[Dr. John Seal]
I feel like we're getting the answer to that question. It's really hard to do prospective trials, right, in surgery.
[Dr. Sid Padia]
It's almost impossible.
[Dr. John Seal]
We're not even going to touch that.
[Dr. Sid Padia]
Obviously.
[Dr. John Seal]
I think probably several of us here have a cohort of patients we have in mind that we know they can't be transplanted and they're not great surgical candidates. We're like, we're just going to do radiation therapy and we watch them. Then three years later, you're seeing them in clinic. You're like, "Huh," that worked well for this patient in this context. Now when I have it in a patient where maybe there are some other options that aren't totally straightforward, it might give me a little hesitation to dive in and do the triseg on that patient.
Maybe I'm not really helping them if I do that. Plus, after you all get to these livers, it's not super fun.
[Dr. Sid Padia]
It's not easy.
[Dr. John Seal]
Taking out a middle vein, right? When you get all those radiation changes, and it increases the risk of biliary complications. The surgery post, depending on the timeframe, right? Longer out, the bigger the issue is, but that can make cutting into the liver pretty tricky.
[Dr. Sid Padia]
Would you argue also the exact opposite? Let's say you did a radiation lobectomy and you got great hypertrophy. Let's say I got great hypertrophy, but not a home run on the tumor. I got partial response. Would that push you then go, "You know what? Maybe this person, I'll push the limits." I'll push the limits in terms of resection. I might actually,-- maybe they're a higher risk because they're 78 years old, but it's worth it.
[Dr. John Seal]
Yeah, you have to take it case by case, but for sure.
[Dr. Gabe Schnickel]
I think, yeah. Just the fact that hypertrophy, the data shows that the liver is actually going to respond and regenerate afterwards. That patient's probably more likely to tolerate a major resection. It's really helpful to see that response. That would give me a little bit more courage to step up in that marginal case and be willing to do the bigger resection for that patient.
[Dr. John Seal]
With the inverse being true and equally important, like, "Oh, you did all that and it didn't grow."
[Dr. Sid Padia]
We should have definitely done that.
[Dr. John Seal]
"Do you want me to cut it out?" Yeah. That's a booby trap. I'm not going for that.
[Dr. Sid Padia]
I had one six months ago, radiation lobectomy. He was 79 years old. Procedure went great. No technical issues. I got a complete response. He got moderate ascites. Our hepatobiliary says there's no way I'm doing a right hepatectomy if you got ascites. Now his ascites went away after six months, but I said, "There's no way I'm doing a right hepatectomy on this guy if you got ascites after a radioembolization."
[Dr. Gabe Schnickel]
You're the canary in the coal mine in that situation, right? You're the one testing the waters to see if that liver is going to get tolerated. Thank you.
[Dr. Sid Padia]
Yeah. The patient was upset at me not to have had a major resection for the ascites. Yeah, exactly.
[Dr. John Seal]
Took one for the team.
(3) Clinical Factors to Determine Surgical Candidacy for Patients with HCC
[Dr. Sabeen Dhand]
Sid, thank you. Thanks, Sid. What are some more characteristics when you look from a surgical perspective, say someone's presenting a case at Tumor Board, what are a lot of the patient characteristics that you look for that will make it a surgical candidate?
[Dr. John Seal]
There are a number of things. Obviously, we have to always reference that the background is the extent of the cirrhosis, right? I think that as access and outcomes and transplant get better and better, then more of these people with advanced liver disease are just going to go straight to transplant. At least that's what I've seen in my practice over 10 years. I'm leaning more into transplant for a lot of these cases. The size of the lesion and location of lesion in a relatively healthy liver, I think, dictate that a lot.
A lot of progression with minimally invasive approaches really changes the recovery and the type of patients you can do these on. For lesions that are relatively small and on the periphery of the liver, those are the ones that I don't hesitate to do robotically, and those patients go home in one to three days. You can do that in the context of a much sicker patient and in bigger patients. We see a lot of obesity in the part of the country where we practice, and that becomes a really important tool if you can do it robotically or laparoscopically.
If it's really central and you have to take out a lot of healthy liver to get one little tumor, then that gives me a little bit of pause of, like, maybe I'm not going to take out 70% of your liver for a three-centimeter lesion, knowing what you all can do with the regional approaches. That's my take, Gabe.
[Dr. Gabe Schnickel]
I agree with your sentiments exactly. I think for me, it's evolved over time. I'm much more leaning into transplant in saving resection for either patients that are not cirrhotic or just very minimal, [Childs Pugh Score] A cirrhotic with a lesion that's really more on the periphery, where I'm not having to take the full right lobe. I'm really reluctant to do that, and I'll push them more towards transplant. The reality is, as we have evolved over the past five years, there are more livers available now, and I think the hesitation to save those donor livers for more patients, I think that's shifting.
Honestly, we don't have a lot of HCC patients on our list. They don't stay very long because we transplant them so quickly. I think definitely as the outcomes are getting better with transplant, leaning more towards transplant in general.
[Dr. John Seal]
I think it's only fair to do a little bit of disclosure here that you invited a couple Swiss Army Knights here, right, so we can put both heads on. That's how we think about in our practice. I think there are a lot of other contexts where a patient seeing a surgeon who is a resectionist and doesn't do transplants, and they're going to maybe think about that a little bit differently, and they may lean into surgery a little bit more.
I think the most important thing to think about in those contexts is to always engage with the decision-making in a multidisciplinary setting so that you really get the perspectives from a lot of different people, and that all options are being considered at each step of the patient's treatment.
[Dr. Sabeen Dhand]
It's interesting that you mentioned that these HCC patients are getting transplants quickly. I feel in my experience, and I don't know if this in LA, Sid, is my patients, it takes a long time for my patients to get a transplant.
[Dr. Sid Padia]
Yeah, I'm assuming that all the UNOS regions are different, right? Ours, at least in LA County, is terrible. I would say once someone gets MELD exception points, we're looking at three years. I know that varies across the country.
[Dr. Gabe Schnickel]
I'm going to get in trouble, Sid, by-
[Dr. Sid Padia]
That's fine.
[Dr. Gabe Schnickel]
-asking you to send your patients down south to San Diego. Forgive me, Vatche Agopian.
[Dr. Sabeen Dhand]
Now I know where to send my patients.
[Dr. Gabe Schnickel]
We're not seeing that, and we're being very deliberate and intentional about approaching those patients. As John said, when you're a transplant surgeon and a hepatobiliary surgeon, you keep both options on the table. I think it's really useful to have both options available because different situations, and there's a lot of cases that are on the margin. I would be interested to hear what John thinks. Cases that are on the margin, that could go either way. If you have a three-year waiting time, there's no question that those marginal cases should go to resection, right?
If you have a waiting time of six months or seven months, then, it's the intention to treat, when the clock starts, that makes all the difference.
(4) Liver Transplant Eligibility Criteria
[Dr. Sabeen Dhand]
How much variability is there as far as transplant criteria? Is it very strict? Milan and UNOS, what are we talking about? Because sometimes I don't know whether I could send this patient for a transplant or not. Is it variable?
[Dr. John Seal]
It's not variable in the sense that all of deceased donor organ transplantation is governed by UNOS, which is a national organization. They regulate how donors are approached, how organs are shared between centers, and it's based on how high the MELD score is. It was discovered pretty early on in this process that there's lots of people who have cancer who have a real risk of death with cancer, and it's not reflected in how sick their liver is, so with the MELD score. That's where the exception point process came into play.
People who get listed for transplant have an HCC that's within the Milan criteria. Then they can, after a six-month waiting period, get exception points, and they fall into that median MELD score for a region. It gets really complicated, but basically, that's what it means, minus three. A little bit below the average of where that is. As we're suggesting, depending on where that is in the country, that turnover at the top can be so fast that if you're sitting below the average, then you're not ever going to get there. So that's one factor.
The other is you can take slightly larger tumors and you can shrink them and then get the exception points. All that process is going to be dependent upon waiting for those exception points to kick in. That largely dictates how long you wait, with the exception of all that I said there is about deceased donors. The caveat is really living donors, and we can touch on that how that changes your decision.
[Dr. Sabeen Dhand]
Let's touch on that because in the Los Angeles area, there's not many options for living donors, but that seems to be different in your area.
[Dr. John Seal]
That's the strategy that our center is leaning into now. With a living donor, we take if the patient has a potential donor that's healthy and there's a pretty strict criteria, you have to be pretty healthy to put someone through this operation. Donor safety is always number one priority and we're very careful about doing this. If you have a donor, then we remove the right lobe of that liver and then we take that piece and we transplant that.
It's an operation that you have complete control of if you have a living donor because when that's going to happen, you know all the medical care can be optimized, all the treatment can be optimized. We're not doing this today, but really important for cholangiocarcinoma because they get blasted with radiation and if they sit on this for three years, then that's game over. You can't do that. You basically don't have to play by the rules if you have a living donor and you can get people transplanted really quickly.
That way, not everyone has it, not everyone does it, but it's an important option.
[Dr. Sabeen Dhand]
How about around here in San Diego?
[Dr. Gabe Schnickel]
We do living donor as well down in San Diego and I think that's a great option as John mentioned. But we've also leaned into the use of machine perfusion and normal thoracic regional perfusion to access livers that previously were not being used for transplant. With that, we've been able to make more organs available for our patients on our list and transplanted at a much lower MELD. So those patients that have HCC get a nice set of exception points on our list and we're able to actually transplant them pretty quickly.
We really leaned into that and that's really definitely shifted, at least from my perspective, leaning again on those marginal cases, our waiting time after they get their points. So six months after listing, it's less than three months until they get transplanted. That allows us to lean into transplant for marginal cases where if your wait time is three years and I think the literature bears this out, you're certainly at risk of tumor progression and falling off the list despite Sid's best efforts.
We're really reliant on the IOs, the interventionalists, to maintain those patients on the list and to keep them from progressing and falling off the list because their tumor gets outside of the Milan criteria that John mentioned.
[Dr. Sabeen Dhand]
Sid, do you find any trouble with–
[Dr. Sid Padia]
As you said, it's hard because when I see a patient, I make the assumption, whether it's right or wrong, this guy's never getting a transplant. I play to that. If he gets a transplant, great, I didn't lose anything, but I make the assumption that he's never going to get one. What I do is I play for like, okay, what do I need to do in terms of a local regional therapy standpoint, whether it's do nothing, do an ablation, do a TACE, do a Y-90, send them for an SBRT, et cetera, to get you the most number of years possible with the assumption that somehow you're not going to get a transplant, even if you are eligible.
You may not get an organ. You may start drinking again. You may lose your insurance. You may have family issues. You may move out of state, etc. We've had all those patients we thought they were transplant candidates and it didn't happen for them. It becomes tough, not necessarily on day one, but to plan the next treatment for when they get inevitably the next tumor. That's what we try to do now is play that long game. This is where I think concepts like radiation segmentectomy came about.
This is where we're very aggressive on our thermal ablations. This is why chemoembolization has largely fallen out of favor, I think, not only at our place, but I would argue at most transplant centers because chemoembolization works great within the first six months. Then when we look at the recurrence rates at 12, 24, and 36 months, there is a very real recurrence rate. It's fine if you're going to get a transplant in six months, in a way. It's not fine if I'm playing the long game of 36 months or 48 months and finding these recurrences and then I have to come up with a plan B.
[Dr. Sabeen Dhand]
On the other side of the situation, and what comes up in my clinic a lot, is a patient who doesn't want surgery. That's an option and they're like, "oh no, doctor's too much, it's too big of a surgery. I'd want the minimally invasive option." How do you approach those patients, Gabe?
[Dr. Gabe Schnickel]
That's a great question. I think it's really incumbent on the surgeons, and I'd be interested to see John's opinion on this, really to put all the options on the table. I think it's really those options have shifted over time to the point where, when it comes to, okay, you can have a resection that's going to be for me and an open surgery, or you can go to interventional radiology and they're going to give you a TARE or radiation segmentectomy that's going to be really a durable option for them that's really probably not that different than what I'm going to accomplish.
In that patient population that doesn't want a big surgery or, for whatever reason or perhaps their functional status isn't great, it's really a legitimate-- It's hard for me to say that surgery is the right answer for them, whereas it used to be, I feel like pretty clear cut that that was the gold standard.
[Dr. Sid Padia]
At the same time, Sabeen, as an interventional radiologist, if I have a patient who goes, "I don't want surgery." Actually, what more happens, "I don't want chemo." That's 99% of people.
[Dr. John Seal]
Lucky for you. You got the one cancer.
[Dr. Sid Padia]
Exactly. Let's say they say, "There's no way I'm getting cut open," etc. My best-- what I'd like to do is I'd be like, "I'm going to have you meet with our guys. Meet with my hepatobiliary surgeons, let them talk to you about it. If you still don't want it, fine, it's still your choice because they can describe it way better than I can. They can also weigh the risks and benefits way better for a surgical resection or a transplant, a hundred times better than I can." Especially when our surgeons, just like you guys individualize it for each person that we look at based on your specific risk factors, you're a disaster and you don't want surgery.
Or the exact opposite. "They can do that. I'm not very good at that when it comes to surgery." I tell patients, just have a conversation with them. You're not buying into anything. You just have to have a conversation with our surgeons and then you can make the-- at the end of the day, it's still your decision."
[Dr. Sabeen Dhand]
John, you mentioned a robotic approach to surgery. Now, does that increase the amount of patient selection that you have and more patients are–
[Dr. John Seal]
It hasn't really increased the number. Really has to do with that sort of algorithm I described loosely before, which is if you've got-- I do left-sided liver resections robotically. I'm not quite a Gen Z, so all the kids coming out of residency, they need to robot everything, and I have to teach them how to make an incision. That's how that goes. I feel comfortable doing all the left side. Anything that shows up on the left side, I think it's safe to do that robotically. In some people's hands, even trisegmentectomies and big operations are really safe.
Again, I think one of the themes we're picking up on is every part of the country, every set of providers has a little niche of how they've adapted to their local environment and how they're trying to take care of their patients. If you have a jet and infinite amount of money, then I know where to send you. The person's going to do the most aggressive robotic surgery out there. If you want to stay at home, then it's like, oh, this is what I'm comfortable doing. The reality is, I don't know if it's true for you, but we used to do God-awful incisions for surgeries.
I do all liver resections through a little midline.
[Dr. Sabeen Dhand]
Midline.
[Dr. Sid Padia]
With a chevron, yes.
[Dr. John Seal]
We still do. Anyway, that's a sore subject. Our practice is still that for the transplant, but for a liver resection, it's a midline incision and the recovery is really quick and it isn't as morbid as patients often think. The indications for it are shifting and for a patient who has something that we can do robotically, the recovery is really really fast. It's a great tool to have for the right patient.
(5) Bridging Patients with HCC to Surgical Therapies
[Dr. Sabeen Dhand]
Got it. We touched on downstaging and bridging a little bit. Sid, are all your patients getting bridged to surgery per se, or?
[Dr. Sid Padia]
Surgery or transplant, either one you're saying?
[Dr. Sabeen Dhand]
Yeah, either one.
[Dr. Sid Padia]
If someone comes in with an HCC, if they're a good surgical candidate, they very well may get surgical resection. Just like all of you guys, we have a multidisciplinary tumor board. It is quite collaborative. Of course, nowadays it's all web-based and not in-person for the last, since March of 2020. I don't know if it's ever going to go back, If someone is a good surgical candidate, they're going to go straight to a surgical resection. If someone is a good transplant candidate, they are going to get bridged with some form of local regional therapy to get to an eventual OLT.
How they get bridged is, I would still say, a matter of debate. Our practice, we typically lean on a percutaneous thermal ablation or radio embolization. Those are our two main weapons that I would say we use in 98% to 99% of the cases.
[Dr. Sabeen Dhand]
Same in your institutions, too?
[Dr. Gabe Schnickel]
Yeah, I definitely would move towards Y-90 pretty substantially. I think we really liked microwave for a while because we thought it was really more durable. You're going to get a longer treatment effect. Then there was the data on TACE, then thermal ablation. Now really, far and away, it's Y-90 at our institution for sure. That's the bridge and the downstage. Downstaging is almost always going to involve some Y-90 because obviously that tumor burden is pretty high and the response is going to be probably more significant with a Y-90.
[Dr. Sabeen Dhand]
John, you mentioned-- I always thought that the Y-90 helps with the resection, but you said that it can actually make the surgery more difficult.
[Dr. John Seal]
It's funny, this came up in another session. If you're in surgery to cut out cancer, then it helped, it got you to be there to cut out cancer, right? In that sense, it did.
[Dr. Sabeen Dhand]
From the technical sense.
[Dr. John Seal]
Yeah, so from the technical sense, it depends how crazy you get, but a really aggressive segmentectomy causes a lot of scarring, whether it's a resection or transplant. It's not something I want to complain about because it means someone's there and they're getting this treatment. I don't know, it's very rarely like a big deal, right? It's just annoying.
[Dr. Sabeen Dhand]
It's something to think about, though.
[Dr. Gabe Schnickel]
I had to create a dot phrase called unblocked diaphragm resection. Thanks to the Y-90.
[Dr. Sabeen Dhand]
There you go. Isotope.
[Dr. Sid Padia]
We did our first radiation segmentectomy in 2011. This was when I was at University of Washington. It was segment 7 tumor right up against the IVC. Seven or eight months later, patient gets a liver transplant. Liver transplant was done typically, 3:30 AM.
[Dr. John Seal]
Yeah, sure. Not anymore, but, you're right.
[Dr. Sid Padia]
At that time, right? Now you guys have better preservation techniques, right?
[Dr. John Seal]
Fair enough.
[Dr. Sid Padia]
The surgeon calls me, who was amazing and wonderful person, at 3:30 in the morning, just dropping F-bombs going, "What have you done here?" The challenge of the segment 7, it was adhering to the IVC. This is the first time they're going into a patient who had gotten a radiation segmentectomy and was completely stuck in the IVC tour and massive blood loss. Patient did fine, fortunately, but that was their first experience with it. I agree, at two different institutions, the surgeons in my experience, especially, tell me what you guys think, certain specific locations are worse than others, right?
What I've noticed anecdotally, again, I'm not the one in the operating room, the ones near the IVC where you're causing the right hepatic lobe or the caudate to get stuck to the IVC or the ones in the porta hepatis. Those seem to be the sore points for you guys.
[Dr. Gabe Schnickel]
Yeah, the diaphragm, it's not a huge deal because he's taken out part of the diaphragm is not that troublesome. The stomach, like the left side that gets the stomach stuck up there, that's really annoying. It's more annoying. I'm sure the surgeons have taken your name in vain several times.
[Dr. Sid Padia]
It's fine, no problem.
[Dr. Gabe Schnickel]
Again, to second John's point, you got them there.
[Dr. John Seal]
You got them to that.
[Dr. Gabe Schnickel]
That's what matters.
[Dr. John Seal]
The times where it's really, if you have Y-90 radiation changes plus X, Y, Z, that's when it gets tricky. If you have really bad portal hypertension and really bad varices and a bunch of adhesions from Y-90, that can be a little bit of a bloodbath. Fortunately, anesthesia has also improved over the past 30 years and they can usually keep up and there's a lot of things you can do to temporize that. Then we deal with really extreme obesity and that, when you're trying a really, really deep hole and you're trying to chisel it up,-
[Dr. Gabe Schnickel]
That's a bad combination.
[Dr. John Seal]
-that's not fun, too.
[Dr. Sid Padia]
Do you think it's also experience-based in the fact that, just to be more specific, the more you guys resect patients who have had prior radioembolization, the easier it gets, or let's just say the less challenging it gets?
[Dr. Gabe Schnickel]
I think you come to the OR more prepared. As I said, I created that diaphragm dotphrase.
[Dr. John Seal]
No doubt for this.
[Dr. Gabe Schnickel]
Now I don't try and get it off the diaphragm anymore. I just plan to take the diaphragm with it and so that saves me a lot of grief, a lot of headaches. You just know what to expect and it makes things easier, and you know why it's stuck there. You're like, "Oh, Sid was here. Great, thanks, Sid, yeah."
[Dr. Sabeen Dhand]
I know, like I said, you think of any techniques that we should be aware about or something to try helping our surgeons out with this?
[Dr. Sid Padia]
No I mean it's a double-edged sword, right? Because you want to get them to the OR, if you're talking about a surgical resection or transplant. So every time I've thought about this, and again, with our wait time, like do I do a chemoembolization, which may have-- we don't actually know this, which may have a lower adhesion risk, but then the recurrence rate at 9 to 12 months is 50%. I'm not really cool with that. I'd rather get them with some adhesions and then when they explant the liver, there's no active tumor. I think that's a better end result. So we've just bitten the bullet and done it that way.
[Dr. John Seal]
The elephant in the room is the wait time. If you can do that pretty quickly, then those radiation changes are usually relatively manageable. I did a transplant last week, a guy who'd been treated, downstaged over a huge period of time, and that's when I just-- I'm going to get that dot phrase. You're just like, I just took everything that was attached and I put it in a bucket and then I put everything back together.
(6) Maintaining Continuity of Care between the Patients’ Providers
[Dr. Sabeen Dhand]
What about patients who are referred to you from the community? I'm talking from personal experience, too. How do you keep the loop in those physicians in the community, the oncologist, the operator, how do you keep a full loop going that everyone knows what's going on? Or does the patient really just get into your center and then the care gets taken care of over there?
[Dr. Gabe Schnickel]
From my perspective, it's a little bit tricky. I think that could always do a better job communicating. I might get a patient that comes to my cancer clinic and then I see that, oh, this is actually a patient better served by transplant. Then I'll present them to our tumor board and then they go from there. I'll connect them with hepatology and then they get sucked into the system. Once you get into the transplant system, then we take over. I'm sure some community physicians get a little bit put off by the lack of communication, like, "What happened to that patient I sent you? Am I ever going to see them again?"
That's definitely something, at least from my perspective, we could be a little bit more deliberate about. I'm not sure how it works on your end, Sid.
[Dr. Sid Padia]
We absolutely, just to be honest, suffer from a little bit of arrogance. We're a tertiary care, quaternary care center, honestly similar to where both of you work, right? The thought, whether it's right or wrong, is that we do it better. I don't necessarily agree with the fact that we do it better. So the challenge is this. I live in West LA. Just to be brutally honest, we have referrers who send us patients who've gotten local regional therapy. When you look at their local regional therapy, it is absolutely exceptional.
It's perfectly done. Then we'll get another one and it's the exact opposite. Sometimes it's hard to tell who did what because I may not know that person.
[Dr. Sabeen Dhand]
Stop talking about me like that.
[Dr. Sid Padia]
Actually, ironically, the few patients we've gotten from his center, you look at, you're like, "That's exactly what I would have done. This looks perfect." So the challenge is how do you make this blanket policy at UCLA to say they should all return back to the community because we have gotten burned on that where centers just don't do it the way we would prefer in terms of a local regional therapy standpoint. Sabeen, what would you like us to do about that? I can't say, for Sabeen, it's okay to send it back to Sabeen, but for the next doctor, no, we should do this at UCLA.
For doctor number three, we should do it this way. That's what it becomes hard for us to do.
[Dr. Sabeen Dhand]
Yeah, to be honest, I think it relies on the community doctors to actually start to get to know you guys and develop a communication because I don't ever expect if it's someone I don't know, they're not going to call me. You guys are busy, but if I refer someone to you, Sid, then I'm already talking to you and I'm talking to other surgeons in your program. I think it takes from the community side, that effort, and then that you can continue the loop of communication.
[Dr. Sid Padia]
I would also say, maybe this is somewhat unique, like if a community, let's say an interventional radiologist were to contact our hepatobiliary surgeons, Fady Kaldas, Vatche Agopian, and say, "Hey, look, I got this. How would you guys normally prefer doing this?" They would be very open and honest. They would be very conversational about it and not speak from a point of arrogance or bravado. They would be like, "Okay, what you're doing is fine. Just keep in touch, right? Here's my e-mail."
They'll give you their e-mail address. They'll give you their cell phone number. They're very easy. Honestly, they're incredibly easy to communicate with. So I would encourage, number one, if you're in the community and you're not at a transplant center, contact your local transplant center, get in touch with a transplant coordinator. That's probably the easiest intake and be like, "Hey, look, can I just set up like a 20-minute Zoom meeting with your guys, just so I can get an idea of what they prefer?"
You may find a transplant center that's like, "We'd hate Y-90. We only want our patients getting TACE. If you start doing Y-90, we don't want anything to do with your patients," or it might be the exact opposite. You don't know, right? Because there's a little bit of personal preference and you could probably learn a lot by doing that. It builds relationships between academic and community centers, which I think is sorely needed.
[Dr. Sabeen Dhand]
I know that's a good point. Feedback from any surgeons, if I ever get it, it's helpful.
[Dr. John Seal]
Yeah, again, if you got us a surgery, then that's the bottom line. I think we have to lean a little bit. We don't have anyone at the table here, but we have to lean a little bit into the health systems. We have to build them in a way that there can be better integration. There aren't community transplant surgeons, right?
[Dr. Sabeen Dhand]
Yeah, exactly.
[Dr. John Seal]
It's like, no, this requires this whole behemoth of regulatory stuff. We only exist in certain places. So one of the things that we've done is we have sort of, not a wide-open policy, but because as you alluded to earlier, we had these virtual tumor boards. We just invite people all over the state and you can-
[Dr. Sid Padia]
Join on.
[Dr. John Seal]
You present the patient and like, "Oh, this is what's going on." When you get into not straightforward Y-90 cases, we are a little picky because I think you can do that wrong and we want the best for the patient. We can have that conversation and figure out how that needs to happen. Also, patients-- I don't know how it is. I'm blown away by this. New Orleans is 600,000 people, super small, and there's people who live over a bridge. They will not come over the bridge. You're like, "What is going on? It's the big city," and like, "Oh, wow, no."
We have to also meet patients where they are. That's the trend and we got to work with our partners in those communities to do what they can there.
[Dr. Gabe Schnickel]
I love this virtual tumor board idea. This is fantastic. If you can incorporate the community into the tertiary academic center, that's great.
[Dr. Sabeen Dhand]
That's really cool.
[Dr. John Seal]
It requires some tiptoeing because, I don't know what yours is like, but ours is on a Tuesday morning and we're already doing 26 cases.
[Dr. Sabeen Dhand]
Yeah. How do you have time to add the community?
[Dr. John Seal]
We're not ready to upload that. It's sort of been like you have a patient that comes and you identify that this provider in this community is looking for better resources and if we can provide that. They have two or three cases a year that come to us. It's like, yeah, we can make it easy for you. We should do better at that. We have lots of tools. We need our administrators to think more creatively about how to connect those dots.
[Dr. Sabeen Dhand]
I think that's a good point to close on. That was awesome. Any last remarks?
(7) Role of Checkpoint Inhibitors in Bridging Patients to Liver Transplant
[Dr. Sid Padia]
Yeah, can I run one question by you guys? There's a couple of trials now and there's medical oncology pushing the limits in terms of bridging or downstaging to OLT with immune checkpoint inhibitors. What are your thoughts on that?
[Dr. Gabe Schnickel]
That's I feel like part of the next frontier, which is really interesting. I think we were one of the earlier centers to report some really negative outcomes in patients transplanted after immunotherapy. You have to really tread lightly. I do think it's an important tool that can be used effectively to downstage folks. It shouldn't be used for maintenance, I think, but downstaging potentially. You have to be very thoughtful about how you transplant them afterwards because you're completely changing their immune system.
That change lasts for longer than you think. The outcomes or the potential for catastrophic outcomes after transplant are significant. Yeah, you just have to be thoughtful about it. I'm interested to hear what John's practice is and what you think about that.
[Dr. John Seal]
Yes, we're very case-by-case. We always like to learn from other people who've tried things. I appreciate those reports.
[Dr. John Seal]
This is such an annoying phrase, but it is true. Biology is king or queen, however, you want to phrase it. What that really is going to do is it's going to shrink it. The pictures look better, but have we really changed the biology of the tumor? For us, that really critical period is that first three months off of it and just to see what the tumor is doing. If we see active tumor biology in a short window off of that immunotherapy, then I don't know that those are great candidates.
Because I do think you need that big buffer to get the immune system, the washout period. We've learned that, too. We are not using it a ton. I think we probably have, three or four cases a year that we're doing it. They don't all make it. There's also the denominator that doesn't always get reported, which is the people don’t get downstaged.
[Dr. Sid Padia]
Who don't get it. Right.
[Dr. John Seal]
No one writes those papers. It's a tool. It's evolving. It's exciting to have something else because we have had nothing. It's just like, cut it out as quick as you can. Burn it, fry it, and cut it out. It's like, oh, let's be a little less caveman about it.
[Dr. Sabeen Dhand]
Thank you all for coming and, dropping this knowledge. Thank you.
[Dr. Gabe Schnickel]
Thanks, I had a lot of fun.
[Dr. John Seal]
Thanks for having us.
[Dr. Sid Padia]
Good times.
[Dr. Sabeen Dhand]
Bye.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, January 17). Ep. 7 – Surgery for HCC: What’s Its Role Today? [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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