Report from the 26th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Hepatocellular and Biliary Tract Cancer, Saskatoon, Saskatchewan, 17–18 October 2024
Simple Summary
Abstract
1. Terms of Reference
1.1. Purpose
1.2. Participants
1.3. Target Audience
1.4. Basis of Recommendations
2. Question 1—What Are the Current Criteria for Curative Surgery and Transplant Candidacy in Patients with Hepatocellular Carcinoma?
2.1. Recommendations
- Patients should be assessed by a multidisciplinary team to review treatment options, ideally in a recurrent fashion. Representation of key specialties—ideally surgical, transplant, radiology, interventional radiology, hepatology, radiation and, medical oncology specialties—enriches rounds. Patients with liver-limited disease may be candidates for transplant and early involvement with transplant is advised.
- Achievement of adequate functional liver remnant and negative margins is key for all surgical resection cases. Resection may be considered for patients with compensated cirrhosis without clinically significant portal hypertension and an adequate functional liver remnant.
- Regarding transplant, criteria and exception points vary by province and by centre. Standardized national transplant criteria are needed.
- Vascular invasion and extrahepatic disease are general exclusion criteria while total tumour volume (TTV) and alpha-fetoprotein (AFP) criteria may vary by centre.
2.2. Summary of Evidence
3. Question 2—What Are the Current Indications and Modalities for Non-Surgical Liver-Directed Therapies in the Treatment of Hepatocellular Carcinoma?
3.1. Recommendations
- All patients should be discussed at multidisciplinary team rounds.
- For tumours ≤ 3 cm in size, the modality option depends upon the local expertise, which may include radiofrequency ablation (RFA), microwave ablation (MWA), and stereotactic body radiation therapy (SBRT).
- For intermediate risk disease, TARE or stereotactic ablative body radiotherapy (SABR) is preferred subject to availability. If TARE or SABR are not available, then TACE is an alternative option.
3.2. Summary of Evidence—An Interventional Radiology Perspective
3.3. Summary of Evidence—A Radiation Oncology Perspective
3.3.1. Introduction
3.3.2. Focal Radiotherapy
3.3.3. 3D-CRT
3.3.4. IMRT
3.3.5. SBRT
SBRT in HCC
SBRT in Advance HCC
3.3.6. Conclusions
4. Question 3—What Is the Optimal First-Line Systemic Treatment for HCC and Is There a Role for Combining Locoregional and Systemic Therapy?
4.1. Recommendations
- Combination therapy with bevacizumab + atezolizumab, or combination immunotherapy are preferred first-line options in patients with newly diagnosed advanced CP-A score HCC.
- First-line lenvatinib (preferred) or sorafenib can be considered in patients with a contraindication to immunotherapy. For select CP-B-7 patients, lenvatinib or durvalumab + tremelimumab (Durva/Treme) can be considered.
- A combination of local and systemic therapy in intermediate-risk HCC have shown promising results; however, mature data is required before incorporating this therapy into clinical practice.
4.2. Summary of Evidence
5. Question 4—What Are the Key Molecular Tests in Biliary Tract Cancer to Identify Actionable Mutations for Targeted Therapy?
5.1. Recommendations
- Patients need to be counselled prior to molecular testing, as mutations may not be actionable, or if drug access is limited. If targeted treatment is accessible, then the following tests can impact treatment decisions.
- Potential actionable mutations include IDH-1, HER 2 amplification, BRAF V600E, NTRK fusion gene, and RAS.
- DNA mismatch repair (MMR) testing is recommended for all patients.
- Other investigational markers may be used for clinical trial eligibility.
5.2. Summary of Evidence
- KRAS mutation
- BRAF mutation [38]
- Tumour protein p53 (TP53) mutation [35]
- Human epidermal growth factor receptor 2 (HER2) mutation [39]
- MMR mutation [40]
- Programmed death ligand 1 (PD-L1) [41]
6. Question 5—What Is the Role of Adjuvant Radiation Therapy for Patients with R1 Resections in Biliary Tract Cancer and How Should It Be Incorporated with Adjuvant Systemic Therapy?
6.1. Recommendations
- Evidence for adjuvant radiation therapy (ART) in this setting is based on small single-arm or phase II studies and is not strong. ART is not routinely recommended in this setting. If ART is to be administered, then priority should be given to administering systemic therapy first followed by ART (either alone or adjuvant chemoradiation (CRT)).
- All patients should be discussed at multidisciplinary team rounds.
- Patients should be considered for clinical trials if available.
6.2. Summary of Evidence
6.2.1. Introduction
6.2.2. Rationale for Adjuvant Radiation Therapy
6.2.3. Evidence Supporting Adjuvant Radiation Therapy
Intrahepatic Cholangiocarcinoma (ICC)
Extrahepatic Cholangiocarcinoma (ECC)
Gallbladder Cancer (GBC)
Clinical Guidelines and Recommendations
6.2.4. Challenges and Future Directions
6.2.5. Conclusions
7. Question 6—What Are the Optimal First- and Second-Line Systemic Treatments for Advanced Biliary Tract Cancer with or Without Molecular Profiling Information?
7.1. Recommendations
- Clinical trial participation should be encouraged when available.
- A combination of platinum, gemcitabine, and immunotherapy with durvalumab or pembrolizumab is the optimal systemic treatment, if available.
- The benefits of second-line therapy are limited, but fluoropyrimidine-based chemotherapy is preferred and could be combined with oxaliplatin or irinotecan-based treatment.
- Molecular testing does not alter first-line treatment options outside of a clinical trial.
- In the second-line setting, if targeted therapy is available, then it would be preferred over conventional second-line chemotherapy. Best supportive care is always an option.
7.2. Summary of Evidence
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Name | Specialty | Organization |
---|---|---|
Shahid Ahmed | Medical Oncologist | Saskatchewan Cancer Agency |
Blaire Anderson | Hepatobiliary/Transplant Surgeon | University of Alberta |
Brady Anderson | Medical Oncologist | Western Manitoba Cancer Centre |
Bryan Brunet | Radiation Oncologist | Saskatchewan Cancer Agency |
Haji Chalchal | Medical Oncologist | Allan Blair Cancer Centre |
Arun Elangovan | Radiation Oncologist | Saskatoon Cancer Centre |
Georgia Geller | Medical Oncologist | BC Cancer Victoria |
Vallerie Gordon | Medical Oncologist | CancerCare Manitoba |
Branawan Gowrishankar | Medical Oncologist | Cross Cancer Institute |
Edward Hardy | Medical Oncologist | BC Cancer/IHA |
Mussawar Iqbal | Medical Oncologist | Allan Blair Cancer Centre |
Duc Le | Radiation Oncologist | Saskatoon Cancer Centre |
Richard Lee-Ying | Medical Oncologist | Tom Baker Cancer Centre |
Shazia Mahmood | Radiation Oncologist | Saskatchewan Cancer Agency |
Karen Mulder | Medical Oncologist | Cross Cancer Institute |
Maged Nashed | Radiation Oncologist | CancerCare Manitoba |
Killian Newman | Interventional Radiologist | Foothills Medical Centre |
Maurice Ogaick | Hepatobiliary Surgeon | University of Saskatchewan |
Vibhay Pareek | Radiation Oncologist | CancerCare Manitoba |
Jennifer Rauw | Medical Oncologist | Cross Cancer Institute |
Deepti Ravi | GI/Liver Pathologist | Saskatchewan Health Authority |
Ralph Wong | Medical Oncologist | CancerCare Manitoba |
Adnan Zaidi | Medical Oncologist | Saskatoon Cancer Centre |
Clinical Questions (In Order of Discussion) | |
---|---|
1 | What are the current criteria for curative surgery and transplant candidacy in patients with hepatocellular carcinoma (HCC)? |
2 | What are the current indications and modalities for non-surgical liver-directed therapies in the treatment of HCC? |
3 | What is the optimal first-line systemic treatment for HCC and is there a role for combining locoregional and systemic therapy? |
4 | What are the key molecular tests in biliary tract cancer to identify actionable mutations for targeted therapy? |
5 | What is the role of adjuvant radiation therapy for patients with R1 resections in biliary tract cancer and how should it be incorporated with adjuvant systemic therapy? |
6 | What are the optimal first- and second-line systemic treatments for advanced biliary tract cancer with or without molecular profiling information? |
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Ravi, D.; Ahmed, S.; Anderson, B.; Anderson, B.; Brunet, B.; Chalchal, H.; Elangovan, A.; Geller, G.; Gordon, V.; Gowrishankar, B.; et al. Report from the 26th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Hepatocellular and Biliary Tract Cancer, Saskatoon, Saskatchewan, 17–18 October 2024. Curr. Oncol. 2025, 32, 398. https://doi.org/10.3390/curroncol32070398
Ravi D, Ahmed S, Anderson B, Anderson B, Brunet B, Chalchal H, Elangovan A, Geller G, Gordon V, Gowrishankar B, et al. Report from the 26th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Hepatocellular and Biliary Tract Cancer, Saskatoon, Saskatchewan, 17–18 October 2024. Current Oncology. 2025; 32(7):398. https://doi.org/10.3390/curroncol32070398
Chicago/Turabian StyleRavi, Deepti, Shahid Ahmed, Blaire Anderson, Brady Anderson, Bryan Brunet, Haji Chalchal, Arun Elangovan, Georgia Geller, Vallerie Gordon, Branawan Gowrishankar, and et al. 2025. "Report from the 26th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Hepatocellular and Biliary Tract Cancer, Saskatoon, Saskatchewan, 17–18 October 2024" Current Oncology 32, no. 7: 398. https://doi.org/10.3390/curroncol32070398
APA StyleRavi, D., Ahmed, S., Anderson, B., Anderson, B., Brunet, B., Chalchal, H., Elangovan, A., Geller, G., Gordon, V., Gowrishankar, B., Hardy, E., Iqbal, M., Le, D., Lee-Ying, R., Mahmood, S., Mulder, K., Nashed, M., Newman, K., Ogaick, M., ... Zaidi, A. (2025). Report from the 26th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Hepatocellular and Biliary Tract Cancer, Saskatoon, Saskatchewan, 17–18 October 2024. Current Oncology, 32(7), 398. https://doi.org/10.3390/curroncol32070398