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.
The 2018 edition of the Chinese Society of Clinical Oncology Guidelines for the Management of Primary Liver Cancer, published for the first time by the Chinese Society of Clinical Oncology, is based on the 2017 edition of the Primary Liver Cancer Practice Guidelines, with reference to the 2018 edition of EASL and AASLD guidelines, and with the addition of literature from some Chinese scholars.
Hepatocellular carcinoma in China differs markedly from those in Europe and the United States in terms of etiology, epidemiological features, molecular biological behavior, clinical presentation and staging, and treatment strategies.
What are the 2018 American Association for the Study of Liver Diseases (AASLD) liver cancer guideline updates?
What are the 2018 European Association for the Study of the Liver (EASL) liver cancer guideline updates?
Differences between primary liver cancer screening and Europe and the US
Screening for high-risk individuals requires serum AFP, liver ultrasound, and is recommended at least every 6 months. However, in patients with positive ultrasound or serum AFP, dynamic enhanced multiphasic CT or MR of the abdomen is emphasized.
Diagnosis of primary liver cancer differs from Europe and the United States
In China, the diagnostic criteria are more stringent, with dynamic-enhanced MRI/ CT scans for the general population. When there are high-risk factors, patients with nodules again have different recommendations based on nodule size (no higher than 1 cm, 1 to 2 cm, no lower than 2 cm). This differs from the European definition of 1 cm only. In the absence of nodules, there are different recommendations based on whether the serum AFP is positive.
Primary liver cancer
Differences in the treatment of primary liver cancer from Europe and the United States
The CSCO guidelines also differ from European and US guidelines in the treatment of primary liver cancer.
Surgical treatment
The indications for surgery in China are significantly broader than in Europe and the United States. For patients with hepatocellular carcinoma who are able to perform surgery in the early or mid-stage, the guidelines advocate early hepatectomy or liver transplantation (Milan criteria), with secondary recommendations using the UCSF criteria.
Both criteria are widely accepted internationally and confirmed by the results of large randomized controlled clinical trials, resulting in a relatively high level of recommendation. The criteria specifically mentioned in the notes require further expert effort to provide a high level of evidence.
Highlights of adjuvant therapy
A postoperative adjuvant therapy recommendation has been added to the European and American guidelines, and “Sophora” can be used as a postoperative adjuvant therapy for hepatic resection. In addition, the CSCO guidelines recommend TACE, immunomodulators (e.g., α-interferon, thymidine α1), chemotherapy and targeted therapy, and sorafenib alone or in combination with chemotherapy.
Local treatment of hepatocellular carcinoma
Recommended treatments include radiofrequency ablation, microwave ablation, cryotherapy, and anhydrous ethanol injection therapy. Radiofrequency ablation is the most important local treatment for early and mid-stage.
For stage I patients: no single tumor larger than 5 cm in diameter or no more than 3 tumor nodes and no larger than 3 cm in maximum tumor diameter, no vascular, bile duct, or adjacent organ invasion and no distant metastases, and a Child-Pugh grade A or B liver function, multi-point coverage or combined TACE should be used.
Given that most patients with advanced hepatocellular carcinoma die from intrahepatic lesion progression despite extrahepatic metastases, aggressive local lesion control on top of systemic therapy is important, and the guidelines recommend TACE for patients with advanced disease.
Radiotherapy
Radiotherapy is controversial in Europe and the United States, and SBRT and radionuclide immunotherapy are included in our guidelines, but more evidence is needed for these treatments.
Systemic therapy
For first-line treatment of advanced hepatocellular carcinoma, the targeted drug recommendations are the same as in Europe and the United States, with lenvatinib recommended for first-line treatment of hepatocellular carcinoma due to the publication of the study results and its availability in China.
The difference is that based on the results of the EACH study, the Chinese guidelines approved chemotherapy with the FOLFOX4 regimen with a primary indication of Child-Pugh grade A or better grade B (no greater than 7) liver function.
The second-line treatment strategy for advanced hepatocellular carcinoma is to recommend regorafenib, PD-L1 monoclonal antibody (including nabumab, pembrolizumab, etc.) in patients with Child-Pugh grade A or better grade B liver function (no greater than 7).