EWALT: East Meets West in a Multidisciplinary Setting to Improve the Management of Liver Tumors

To stimulate debate between the two medical cultures, Jacques Belghiti and Masatoshi Makuuchi organized the first biennial Eastern and Western meeting focusing on hepatocellular carcinoma in 1998. Following the inaugural meeting in Paris, meetings took place in Tokyo, Lodi (Italy), Hong Kong, Houston, Seoul, Paris once again, and then Tokyo in 2013. Since that first meeting, the epidemiology of liver tumors has changed, new local treatments have been introduced, and already existing treatments have evolved. Systemic therapies have taken their place in the treatment of patients, and basic sciences have gradually assumed a role in clinical practice. These changes and advances have sometimes been interpreted differently in Eastern and Western medical practice. This has further stimulated the scientific discussion between the two hemispheres, strengthened the rationale for these meetings, and justified their expansion into the field of hepatobiliary oncology. Therefore, a new acronym was introduced to indicate the expanded interest in primary and metastatic hepatobiliary tumors: EWALT (Eastern and Western Association for the Study of Liver Tumors). The first EWALT meeting took place in Milan in 2015; over two and a half days, experts from East and West discussed innovations in the diagnosis and treatment of hepatocellular carcinoma, colorectal liver metastases, and biliary and neuroendocrine tumors.

These biennial meetings were initiated by surgeons, but multidisciplinarity infused an indispensable added value to each event. Rather than the development of guidelines, the purpose of the meetings was to give a voice to innovation: physicians can debate and exchange ideas, make suggestions, and offer constructive criticism to promote the optimal treatment of liver tumors. The meetings represent a laboratory for finding and testing new ideas and also for building a common vocabulary among specialists. The latter should minimize the chance of misunderstandings that could otherwise be a potential source of erroneous conclusions. The most clinically relevant example of the lack of commonality is the absence of an accepted definition of resectability for hepatocellular carcinoma, not only among different specialist fields, but also among surgeons [1]. While many alternatives to surgery have their own roles in selected unresectable patients, the definition of resectability should be a unique and reliable concept. Furthermore, many well-designed studies regarding nonsurgical approaches [2,3,4] have evolved into flawed criteria of unresectability, and treatment guidelines based on these studies [5] are currently in use. Furthermore, as a final paradox, these guidelines refer their recommendations to the general population, thereby including resectable subjects.

At the other end of this spectrum, the “diffusion phenomenon” of new surgical techniques has allowed a technique such as the associating liver partition and portal vein ligation for staged hepatectomy to become a new standard of care without previous clarification of basic aspects regarding eligibility criteria [6].

Agreement regarding these issues is of utmost importance. Innovation and rigorous methodology are not antithetical if the different languages used by different specialists can have a common vocabulary that facilitates insightful answers based on solid and commonly agreed principles. EWALT is the ideal multidisciplinary and international setting for this. The proceedings of previous meetings were published in indexed journals and highlighted the discussions and conclusions [7,8,9,10]. The current issue of Liver Cancer summarizes the EWALT 2015 meeting in Milan. We look forward to convening again in Sendai in January 2017 for the second EWALT meeting.

Conflict of Interest

The authors state that no conflicts of interest exist.