From the Guidelines
Treatment options for hepatocellular carcinoma (HCC) depend on the cancer stage, liver function, and patient's overall health, with the Barcelona Clinic Liver Cancer (BCLC) staging system guiding treatment selection. For early-stage HCC, surgical resection or liver transplantation offers the best chance for cure 1. Ablation therapies like radiofrequency ablation (RFA) or microwave ablation can destroy small tumors (typically <3 cm) through heat.
Key Considerations
- For intermediate-stage disease, transarterial chemoembolization (TACE) delivers chemotherapy directly to the tumor while blocking its blood supply 1.
- Advanced HCC may be treated with systemic therapies including sorafenib or lenvatinib as first-line options, with second-line alternatives including regorafenib, cabozantinib, or immunotherapies like atezolizumab plus bevacizumab 1.
- Radiation therapy, including stereotactic body radiation therapy (SBRT), can target specific tumors.
- Treatment selection is typically made by a multidisciplinary team considering the BCLC staging system, with preservation of liver function being crucial since most HCC patients have underlying cirrhosis.
- Regular surveillance with imaging and alpha-fetoprotein testing is essential after treatment to monitor for recurrence.
BCLC Staging System
The BCLC staging system is a widely used classification system that takes into account the size and number of tumors, liver function, and the patient's overall health to guide treatment decisions.
- The system categorizes HCC into five stages: 0 (very early), A (early), B (intermediate), C (advanced), and D (end-stage).
- Each stage has specific treatment recommendations, ranging from surgical resection and liver transplantation for early-stage disease to systemic therapies and palliative care for advanced disease.
Recent Developments
Recent studies have led to the development of new treatment options for HCC, including molecular targeted agents, antibodies, and immune checkpoint inhibitors 1.
- Atezolizumab+bevacizumab therapy has become a first-line systemic treatment option for patients with advanced HCC who are ineligible for radical treatment or TACE.
- Ongoing research is focused on improving treatment outcomes and expanding the indications for each treatment, with a emphasis on personalized medicine and combination therapies.
From the FDA Drug Label
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. 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):
- For early-stage HCC, treatment options may include surgical resection, liver transplantation, or ablative therapies.
- For advanced HCC, treatment options may include:
- Lenvatinib (LENVIMA) as a first-line treatment
- Ramucirumab (CYRAMZA) as a single agent for patients with an alpha fetoprotein (AFP) of ≥400 ng/mL and who have been treated with sorafenib
- Other systemic therapies, such as sorafenib or regorafenib BCLC (Barcelona Clinic Liver Cancer) Staging System:
- A classification system used to stage HCC and guide treatment decisions
- Stages include:
- Very early stage (0): single tumor <2 cm, no vascular invasion, no extrahepatic spread
- Early stage (A): single tumor <5 cm or up to 3 tumors <3 cm, no vascular invasion, no extrahepatic spread
- Intermediate stage (B): multifocal tumor, no vascular invasion, no extrahepatic spread
- Advanced stage (C): vascular invasion, extrahepatic spread, or performance status 1-2
- Terminal stage (D): performance status 3-4, or severe liver dysfunction 2 3
From the Research
Treatment Options for Hepatocellular Carcinoma (HCC)
- For early-stage HCC, treatment options include liver transplantation, surgical resection, and local ablative techniques such as radiofrequency ablation (RFA) 4, 5, 6, 7.
- For advanced HCC, treatment options include transarterial chemoembolization (TACE), tyrosine kinase inhibitors (TKIs) like sorafenib and lenvatinib, immunotherapy, and anti-angiogenesis therapy 4, 5, 8.
- The Barcelona Clinic Liver Cancer (BCLC) classification system is used to stage HCC and guide treatment decisions, taking into account tumor size, number of tumors, liver function, and other factors 5, 6, 7.
BCLC Classification System
- The BCLC system categorizes HCC into five stages: very early, early, intermediate, advanced, and terminal 5, 6.
- Each stage has specific treatment recommendations, ranging from curative options like liver transplantation and surgical resection for early-stage HCC, to palliative care for advanced-stage HCC 5, 6.
Advanced Treatment Options
- Immunotherapy and anti-angiogenesis therapy, including pembrolizumab, bevacizumab, and atezolizumab, have shown promise in treating advanced HCC 4, 5, 8.
- Combination therapies, such as the combination of immune checkpoint inhibitors (ICIs) with targeted therapies or local ablative therapy, are being investigated to improve outcomes for patients with HCC 4, 5.
- Gene- and immune-based therapies, including oncolytic viral vectors, nanoparticles, and chimeric antigen receptor (CAR)-T cells, are also being explored as potential treatment options for HCC 8.