Exclusive Interview with Prof. Ng Kwok Chai Kelvin from The Chinese University of Hong Kong
The Editorial Office of Hepatoma Research announced the recipients of the "Hepatoma Research 2024 Best Paper Awards" for outstanding articles published in Hepatoma Research between January 1, 2022, and December 31, 2022. The team from The Chinese University of Hong Kong received the award for their paper "Role of locoregional therapies in the management of patients with hepatocellular carcinoma". Upon the enthusiastic invitation of the editorial team, the corresponding author, Prof. Ng Kwok Chai Kelvin, shared his unique academic perspectives on locoregional therapies for HCC with us. Our Editorial Board member, Prof. Paolo De Simone, from the Department of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy, served as the interviewer.
Ng Kwok Chai Kelvin
Clinical Associate Professor (Honorary)
Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
Prof. Ng was appointed as Professor of Surgery in the Department of Surgery at The Chinese University of Hong Kong. He is a fellow of the Royal College of Surgeons of Edinburgh, the American College of Surgeons, and the College of Surgeons of Hong Kong. Additionally, he is a member of several international professional organizations, including the International Society of Digestive Surgery and International Hepato-Pancreato Biliary Association. Moreover, he serves as the treasurer of International Society of Digestive Surgery Asia-Pacific (ISDS AP) and Asia-Pacific Digestive Week Federation (APDWF). Prof. Ng’s main research interests focus on the management of liver cancer and liver resection. His clinical research in liver cancer spans from surgical management of early cancer to local ablation therapy for advanced disease. He is one of the few transplant surgeons in Hong Kong who can independently perform various types of liver transplants, including adult-to-adult living donor liver transplantation (LDLT) using a right liver graft with middle hepatic vein or a left liver graft using middle hepatic vein, adult-to-pediatric living donor liver transplantation, deceased donor liver transplantation (DDLT), and split-liver liver transplantation. His personal series of LDLT and DDLT is over 800 and 200, respectively. Throughout his career, Prof. Ng has actively presented at various international conferences, sharing unique academic insights and cutting-edge research findings.
Q1: What is the role of locoregional therapies in managing HCC with curative intent? How and for which patients can locoregional therapies achieve radicality?
Ng Kwok Chai Kelvin: In general, locoregional therapies for HCC can be classified as local ablative therapy using thermal energy and transarterial therapy. Local ablative therapy is potentially curative in intent, whereas transarterial therapy, e.g., TACE (transarterial chemoembolization), is only palliative in nature. Hence, when discussing curative locoregional therapies, we are referring to local ablative therapy. In our practice, radiofrequency ablation (RFA) and microwave coagulation (MWA) are the two common local ablative methods. In most practice guidelines (EASL and AASLD), local ablative therapy offers survival benefits comparable to hepatic resection, with a 5-year survival rate of up to 50 - 60% for early HCC. Whether RFA or MWA is better local ablation, there is no proven evidence, but MWA has faster ablation and bigger ablation than RFA. Local ablative therapy is especially good for small HCCs (< 5cm) that are deep-seated in the liver parenchyma and are away from major blood vessels. One potential problem of local ablative therapy is the occurrence of local recurrence of 5 - 7% at the ablative region. It is also good for patients with marginal liver functional reserve, i.e., Child’s B liver status.
Q2: There’s been a recent expansion of combination treatments with locoregional plus systemic therapies due to the anticipated magnification of efficacy versus either strategy alone. What’s your opinion? Is ablation plus immunotherapy better than simple ablation?
Ng Kwok Chai Kelvin: There have been recent advancements in using local ablation plus systemic therapy. Theoretically, it should achieve better tumor control than either strategy alone. It has been shown that local ablation can induce systemic immune response through local cytokine changes (IL - 6 & IL-10). Therefore, adding immunotherapy may be beneficial in terms of tumor control. However, there is still no large-scale study on this and the combination therapy is still on a trial basis.
Q3: What’s the role of locoregional therapies in managing patients with advanced HCC?
Ng Kwok Chai Kelvin: Advanced HCC is characterized by 1) multifocal disease inside the liver, 2) tumor invasion into the portal vein, and 3) extrahepatic HCC. Under the background of multifocal disease and portal vein tumor thrombus, there is a limited role of local ablative therapy since it cannot effectively control the tumor. For extrahepatic HCC, if the tumor load within the liver is not high, local ablation still has its role in local tumor control. However, the overall patient prognosis depends on the efficacy of systemic treatment.
Q4: Are locoregional therapies relevant to downstaging or bridging patients before liver transplantation in the setting of LDLT?
Ng Kwok Chai Kelvin: Yes, local ablative therapy is definitely an effective downstaging procedure or bridging procedure to LDLT. The only limitation is tumor size. These therapies are only effective for small HCCs (<5cm) and when the number of tumors is fewer than three. According to liver transplant guidelines in the US, local ablation and transarterial chemoembolization are incorporated into downstaging and bridging procedures for LDLT.
Q5: The crucial one: locoregional therapies or resection for early-stage HCC?
Ng Kwok Chai Kelvin: This question has been answered by several RCTs. In short, both treatments can achieve similar long-term survival (50-60% 5-year survival). Local ablative therapy is especially good for small HCCs (< 5cm), which are located deep within the liver parenchyma and distant from major blood vessels. However, one potential problem of local ablative therapy is the 5 - 7% occurrence rate at the ablative site. Therefore, in terms of tumor recurrence, local ablative therapy is inferior to hepatic resection. Nonetheless, the overall risk of local ablation is lower than that of hepatic resection (10% vs.20-30%), particularly with the percutaneous and minimally invasive approach. Hence, the choice should be individualized and discussed in multidisciplinary meetings.
Editor: Ada Zhong
Language Editor: Catherine Yang
Production Editor: Yan Zhang
Respectfully Submitted by the Editorial Office of Hepatoma Research
