How did you develop a clinical interest in HCC? Was there a particular clinical experience or patient encounter you had?
My interest in oncology started in medical school. When I decided to be a surgeon, the liver was the most challenging area to develop, and therefore any cancer affecting the liver, primary or secondary, was a natural consequence of my scientific and clinical research.
What pearls, pitfalls and/or tips do you have for physicians using your clinical decision tools (Milan Criteria, Metroticket Calculator, etc) at the bedside? Do you know of cases when recommendations have been applied, interpreted, or used inappropriately?
I think that a fool with a tool remains a fool. Tools such as calculators are instruments to ease decisions but are not able to replace personal judgment and multidisciplinary discussions. The tools we have developed in prognostication of liver cancer treated with transplantation may help in deciding on patient listing and priority but remain instruments to be balanced with many other parameters of disease and with the response to different therapies.
How do you use the tools in your own practice?
We use tools in daily practice and during multidisciplinary meeting with specialists of other areas. Tools and calculators are also very important when discussing and informing the patients and their families on the possible consequences of various therapies.
Do you have any thoughts on criticisms of the Milan Criteria as too restrictive and potentially excluding patients who might benefit from liver transplant?
The Milan Criteria were designed in a period of high disregard of cancer as a transplant indication. In fact, the Milan Criteria resuscitated the interest in liver transplantation as a cancer operation. As with any restrictive criteria, the drawback was the possible exclusion of tumor conditions that were potentially curable, although beyond the described limits. However, over the years, we have expanded the criteria with the Up-to-7 limits and in a more dynamic approach with the “Metroticket concept” of individualized prognosis, including alpha-fetoprotein (AFP) as a surrogate of tumor biology in the calculator available on MDCalc and published in Gastroenterology 2018.
Where are there deficits in HCC research?
HCC is a tumor in the interest of multiple fields - oncology, hepatology, surgery, interventional radiology, etc. This may generate some competition that does not always help. A more pragmatic and broad cooperation among different fields of research should be implemented in the case of liver cancer. Trial designs are not always optimal and this is a consequence of unbridged differences of different contesting groups (i.e., east-west, pharmacologic-non pharmacologic, hepatologic-oncologic etc.)
Is there any research you're working on now that you are particularly excited about?
Augmented reality in surgical oncology, immunotherapy and innovative loco-regional approaches to liver cancer, and expansion of the area of interest in transplant oncology.