What are the treatment options for hepatocellular carcinoma (HCC)?

From the Guidelines

Treatment options for hepatocellular carcinoma (HCC) should be guided by the most recent and highest quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life. According to the most recent study 1, multidisciplinary evaluation is essential to determine the optimal treatment approach for each patient. For early-stage HCC, surgical resection (partial hepatectomy) offers the best chance of cure by removing the tumor while preserving adequate liver function. Liver transplantation is ideal for patients with cirrhosis and small tumors (typically within Milan criteria: single tumor ≤5 cm or up to 3 tumors ≤3 cm each), eliminating both the cancer and underlying liver disease.

Some key points to consider in the treatment of HCC include:

• Liver resection can be considered as the treatment of choice for early-stage HCC patients with no cirrhosis 1
• Local ablative techniques are optimum for patients with early-stage HCC (BCLC 0 and BCLC A) in whom surgery is contraindicated 1
• TACE is the preferred treatment option for BCLC B patients 1
• For patients with BCLC C HCC, treatment options could be atezolizumab + bevacizumab or STRIDE regimen as first-line therapy 1
• Sorafenib or lenvatinib can be used as first-line alternatives for atezolizumab and/or bevacizumab 1

Advanced HCC may be treated with systemic therapies including sorafenib or lenvatinib as first-line options, with second-line alternatives including regorafenib, cabozantinib, and ramucirumab. Immunotherapy with checkpoint inhibitors like atezolizumab plus bevacizumab has become a preferred first-line regimen for advanced HCC 1. Radiation therapy may be used for symptom palliation or in combination with other treatments.

It's worth noting that the treatment of HCC is constantly evolving, and newer therapies such as checkpoint inhibitors are showing promising results 1. However, the choice of treatment should always be individualized and based on the patient's specific circumstances.

In terms of specific treatment recommendations, atezolizumab plus bevacizumab is a preferred first-line regimen for advanced HCC 1, and sorafenib or lenvatinib can be used as first-line alternatives 1. Regorafenib, cabozantinib, and ramucirumab are options for second-line therapy 1.

Ultimately, the goal of treatment should be to minimize morbidity, mortality, and improve quality of life, and treatment decisions should be made in consultation with a multidisciplinary team of experts 1.

From the FDA Drug Label

1.3 Hepatocellular Carcinoma LENVIMA is indicated for the first-line treatment of patients with unresectable hepatocellular carcinoma (HCC). The recommended dosage of LENVIMA is based on actual body weight: 12 mg for patients greater than or equal to 60 kg or 8 mg for patients less than 60 kg. Take LENVIMA orally once daily until disease progression or until unacceptable toxicity. 1.4 Hepatocellular Carcinoma CYRAMZA, as a single agent, is indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have an alpha fetoprotein (AFP) of ≥400 ng/mL and have been treated with sorafenib.

Treatment Options for Hepatocellular Carcinoma (HCC):

• First-line treatment: Lenvatinib (LENVIMA) is recommended for patients with unresectable HCC, with a dosage of 12 mg for patients ≥60 kg or 8 mg for patients <60 kg, taken orally once daily until disease progression or unacceptable toxicity 2.
• Second-line treatment: Ramucirumab (CYRAMZA) is recommended for patients with HCC who have an alpha fetoprotein (AFP) of ≥400 ng/mL and have been treated with sorafenib, as a single agent 3. Key Considerations:
• Patient selection and dosage adjustments should be based on individual patient needs and tolerability.
• Treatment should be continued until disease progression or unacceptable toxicity.

From the Research

Treatment Options for Hepatocellular Carcinoma (HCC)

• Early-stage HCC can be managed with therapies of curative intent, including:
  • Surgical resection 4, 5
  • Liver transplantation 6, 5, 4, 7
  • Ablative therapies, such as radiofrequency ablation (RFA) 5, 4
• Advanced HCC treatment options include:
  • Trans arterial chemoembolization (TACE) 6
  • Broad-spectrum tyrosine kinase inhibitors (TKIs), such as sorafenib and lenvatinib 6
  • Combination of immunotherapy and anti-angiogenesis therapy, namely atezolizumab and bevacizumab 6

Considerations for Treatment

• The management of HCC is directed primarily by the clinical stage, using staging systems such as the Barcelona-Clinic Liver Cancer system 5
• Treatment consideration should not only look at the oncological perspective but also the functional status of the liver parenchyma, i.e., the state of cirrhosis and presence of portal hypertension 4
• Factors that predict unsuitable results after treatment include tumor markers, inflammatory markers, imaging findings reflecting tumor biology, and liver functional reserve 8

Emerging Therapies

• Gene- and immune-based therapies, such as oncolytic viral vectors, nanoparticles, chimeric antigen receptor (CAR)-T cells, and clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 (CRISPR/Cas9), are being explored for the treatment of HCC 6
• Combination immunotherapies have been recently introduced and may overcome challenges in achieving optimal outcomes in the management of early-stage HCC 8