Benefiting from promising advances in the treatment of hepatocellular carcinoma with targeted agents and immune checkpoint inhibitors, the American association for the study of liver diseases (AASLD), the European association for the study of the liver (EASL), and the Chinese society of clinical oncology (CSCO) have updated their guidelines for the management of hepatocellular carcinoma in 2018. The American association for the study of liver diseases (AASLD), the European association for the study of the liver (EASL), and the Chinese society of clinical oncology (CSCO) have updated their guidelines for the management of hepatocellular carcinoma in 2018.
Common to all three is a greater emphasis on multidisciplinary treatment (MDT) than in the previous edition, meaning that the clinical management of hepatocellular carcinoma should be a multidisciplinary effort involving hepatology, diagnostic radiology, pathology, transplantation surgery, surgical oncology, radiation intervention, medical oncology, radiation oncology, and nursing to improve patient survival. thereby improving the survival benefit for patients.
In April 2018, the AASLD published the 2018 edition of the Clinical Practice Guidelines for Hepatocellular Carcinoma online. The new guidelines are based on new evidence-based evidence from recent years, using the GRADE grading system to assess the quality of evidence and strength of recommendations, and provide a comprehensive update and supplement to the 2010 guidelines.
How are patients with liver disease monitored?
The new guidelines emphasize that cirrhosis due to hepatitis B, hepatitis C, alcohol, and non-alcoholic fatty liver disease (NAFLD) has the highest risk of hepatocellular carcinoma and must be monitored regularly.
As in the 2010 edition, ultrasound is recommended every 6 months and is no longer negated by serum alpha fetoprotein (AFP) co-testing. Regular monitoring is not recommended for patients with Child-Pugh class C cirrhosis, except for those awaiting liver transplantation.
Regular monitoring is not recommended for patients with hepatitis C without cirrhosis or for patients with NAFLD. CT and MRI imaging are not recommended for routine monitoring in patients with cirrhosis, except when ultrasound is highly suspicious but inconclusive.
How is hepatocellular carcinoma diagnosed and what is the prognosis?
For the diagnosis of hepatocellular carcinoma in patients with cirrhosis, the new version of the guideline recommends contrast-contrast multistage CT or MRI imaging. Routine biopsy of each indeterminate node is not recommended. The diagnosis should be clarified with a review of an ultrasound finding of no less than 1 cm or a concurrent AFP of no less than 20 ng/ml.
Liver biopsy should be considered for clarification in the absence of typical features of hepatocellular carcinoma but in the presence of suspected hepatocellular carcinoma or other malignant lesions.
For patients without cirrhosis, the diagnosis cannot be made solely on the basis of imaging, and a liver biopsy is required to confirm the diagnosis. For hepatocellular carcinoma that cannot be confirmed by conventional histology, the histologic markers GPC3, HSP70, and GS can be used to differentiate between highly heterogeneous hyperplasia and hepatocellular carcinoma.
For prognostic determination, the new version of the guideline continues to recommend BCLC staging for the evaluation of patients with hepatocellular carcinoma.
Treatment of hepatocellular carcinoma
In the treatment of hepatocellular carcinoma, the following updates were made to the new version of the guideline.
Hepatectomy
The new guidelines recommend surgical resection over local ablative therapy for resectable hepatocellular carcinoma in Child-Pugh grade A cirrhosis in early stages (stage 0 or A). Surgical resection is preferred for resectable hepatocellular carcinoma without cirrhosis or for resectable hepatocellular carcinoma with good liver function and no significant portal hypertension.
Local ablation therapy
For local ablation of hepatocellular carcinoma, the new guidelines consider thermal ablation to be superior to alcohol injection, especially for tumors up to 3 cm in diameter. Monitoring with enhanced CT or MRI is required every 3 to 6 months after ablation therapy.
Stereotactic body radiation therapy (SBRT) can be an alternative to thermal ablation, and is not recommended as a routine adjuvant therapy after radical resection or ablative therapy.
Liver transplantation
The new version of the guidelines has stricter rules for liver transplantation for hepatocellular carcinoma in patients with cirrhosis.
- In patients with stage T1 hepatocellular carcinoma with cirrhosis awaiting liver transplantation, imaging follow-up is recommended for observation.
- Local therapy is recommended during the waiting period for patients with hepatocellular carcinoma meeting the Milan criteria stage T2.
- For patients with hepatocellular carcinoma beyond Milan criteria stage T3, liver transplantation is recommended after downstaging treatment to reach Milan criteria.
TACE
Transcatheter arterial chemo embolization (TACE), transcatheter arterial radio-therapy is recommended for patients with BCLC-stage B hepatocellular carcinoma who are not candidates for surgical resection and liver transplantation. nbsp;embolization (TARE) and local treatments such as external irradiation radiotherapy.
TACE combined with sorafenib has no clinical benefit over TACE alone for hepatocellular carcinoma and is not recommended.
Systemic therapy
The new guideline recommends systemic therapy for patients with BCLC-stage C, progressive hepatocellular carcinoma with vascular invasion and/or metastasis, with sorafenib preferred as first-line therapy and lenvatinib also as first-line therapy.
For patients who progress after sorafenib treatment, regorafenib and nabumab may be chosen as second-line therapy. There is no information to support the choice of regorafenib or nabumab as second-line therapy after progression on lenvatinib therapy.