From the Guidelines
The recommended treatment approach for hepatocellular carcinoma (HCC) greater than 10 cm is a multimodal strategy, prioritizing systemic therapy with options such as atezolizumab plus bevacizumab, sorafenib, or lenvatinib for unresectable cases with vascular invasion or extrahepatic spread, as suggested by the most recent guidelines 1.
Treatment Considerations
When considering treatment for HCC greater than 10 cm, several factors must be taken into account, including the patient's liver function, performance status, and presence of vascular invasion or extrahepatic spread.
- Liver function is a critical determinant, with Child-Pugh A patients being ideal candidates for more aggressive treatments.
- Performance status, as measured by the ECOG category, should be less than 2 for patients to be considered for intra-arterial therapies.
- The presence of vascular invasion or extrahepatic spread significantly influences the treatment approach, often necessitating systemic therapy.
Locoregional Therapies
Locoregional therapies, such as transarterial chemoembolization (TACE) and radioembolization with Yttrium-90 microspheres, may be considered for patients with intermediate-stage HCC and limited tumor burden, as indicated by the British Society of Gastroenterology guidelines 1.
- TACE is the standard of care for patients with intermediate-stage HCC, with the best candidates having limited tumor burden and preserved liver function.
- However, for large-volume intrahepatic disease, such as HCC greater than 10 cm, the evidence for TACE or TAE is not strong, and systemic therapy or selective internal radiation therapy (SIRT) may be considered as first-line treatment.
Systemic Therapy
Systemic therapy plays a crucial role in the management of unresectable HCC, especially in cases with vascular invasion or extrahepatic spread.
- First-line options include atezolizumab plus bevacizumab, sorafenib, and lenvatinib, with the choice of therapy depending on the patient's performance status, liver function, and comorbidities.
- The combination of TACE with systemic therapy, such as multikinase inhibitors or immune checkpoint inhibitors, is not recommended due to insufficient evidence, as stated in the guidelines 1.
Multidisciplinary Approach
The treatment decision for HCC greater than 10 cm should be made by a multidisciplinary tumor board, considering all relevant factors and available treatment options.
- A careful assessment of the patient's condition and a tailored approach are essential to optimize outcomes and minimize morbidity and mortality.
- Neoadjuvant approaches to downstage tumors before definitive treatment may be necessary for large HCCs, which present unique challenges due to their size and potential for vascular invasion.
From the Research
Treatment Approaches for HCC Greater Than 10 cm
- The optimal treatment choice for hepatocellular carcinoma (HCC) is dictated by multiple variables such as tumor burden, liver function, and patient's health status 2.
- For patients with intermediate stage HCC, transarterial chemoembolization (TACE) is considered the first-line treatment 2, 3, 4.
- TACE is a minimally invasive, catheter-based technique that allows for targeted delivery of chemotherapy to tumor sites while occluding tumor-feeding blood vessels 3.
- The increasing incidence and mortality of HCC, in addition to the late-stage presentation of most HCC patients, demonstrates the need to expand the role of locoregional therapies in the treatment of HCC, including TACE 3.
Patient Selection for TACE
- Patient selection for TACE is crucial, and careful assessment of an individual patient's benefit/risk ratio is recommended before any TACE session is considered to ensure optimal long-term outcomes in intermediate HCC 4.
- Intermediate HCC represents a broad and heterogeneous group of patients, not all of whom will benefit from TACE, and some patients may benefit from early switch to systemic therapies rather than continuing retreatments with TACE 4.
- TACE can produce survival benefits without adversely affecting hepatic functional reserve if applied correctly 4.
Combination Therapies
- Combinations of TACE and other local or systemic therapies have several theoretical advantages, and many clinical trials have been conducted to evaluate the effectiveness of TACE in combination with local treatment or systemic therapy 5.
- TACE has also been used as a preoperative adjuvant chemotherapy in patients with HCC to improve survival and as a bridging therapy before liver transplantation to downstage HCC 5.