What are the treatment options for a patient with Hepatocellular Carcinoma (HCC)?

Treatment Options for Hepatocellular Carcinoma (HCC)

Treatment for hepatocellular carcinoma must be stratified based on tumor stage, liver function, and patient performance status, with surgical options offering the only curative potential for early-stage disease. 1

Treatment Algorithm Based on Disease Stage

Early Stage HCC (BCLC 0/A)

• Localized Resectable Tumors (T1, T2, T3, selected T4; N0; M0):

  • First option: Surgical resection (partial hepatectomy) for patients without cirrhosis [II, A] 1
  • For patients with cirrhosis:
    • Surgical resection if adequate hepatic functional reserve
    • Liver transplantation for patients meeting Milan criteria (single tumor ≤5 cm or 2-3 tumors ≤3 cm) 1

• Local Ablative Techniques (when surgery not feasible):

  • Radiofrequency ablation (RFA) for tumors ≤3 cm 1
  • Microwave ablation (MWA)
  • Percutaneous ethanol injection for tumors near critical structures 1

Intermediate Stage HCC (BCLC B)

• Localized Unresectable Tumors:
  • First option: Total hepatectomy with liver transplantation if meeting criteria [II, A] 1
  • Alternative options [IV, B] 1:
    • Transarterial chemoembolization (TACE) for patients with adequate hepatic reserve and multifocal HCC
    • Percutaneous ethanol injection for patients with <3-4 tumor nodules, maximum 5 cm
    • Radiofrequency ablation for tumors <5 cm and/or fewer than four

Advanced Stage HCC (BCLC C)

• Systemic Therapy Options:
  • First-line: Lenvatinib for unresectable HCC 2
  • Second-line: Regorafenib for patients previously treated with sorafenib 3
  • Sorafenib (extends survival by approximately 2.8 months) 1

Terminal Stage HCC (BCLC D)

• Best supportive care for Child-Pugh C patients exceeding transplant criteria 1

Treatment Selection Based on Liver Function

Child-Pugh A and Selected B

• Eligible for specific treatment options including resection, transplantation, ablation, or TACE 1

Child-Pugh C

• Only supportive care unless meeting transplantation criteria 1

Important Considerations

1. Multidisciplinary Approach: Treatment should be planned by a multidisciplinary team 1

2. Staging Assessment:

   • Chest X-ray/CT scan and abdominal CT/MRI for baseline staging 1
   • TNM staging along with BCLC classification which incorporates liver function 1

3. Follow-up After Treatment:

   • Patients who undergo curative resection should be followed every 3-6 months with AFP determination and liver imaging for at least 2 years 1
   • Early detection of recurrence may allow for additional curative therapy

Common Pitfalls to Avoid

1. Delaying Treatment Decision: HCC is an aggressive cancer that often presents at advanced stages. Prompt treatment initiation is critical for improved outcomes 4

2. Overlooking Liver Function: Treatment selection must consider not only tumor characteristics but also underlying liver function, as many patients have concurrent cirrhosis 1

3. Inappropriate Patient Selection for Procedures:

   • Resection in patients with poor liver function can lead to liver failure
   • TACE in patients with vascular invasion can worsen liver function

4. Neglecting Antiviral Therapy: For patients with hepatitis B or C, appropriate antiviral therapy should be considered to prevent further liver damage 1

5. Underestimating Systemic Therapy Benefits: Even modest survival benefits (2-3 months) from systemic therapies are significant in this aggressive disease 5

The treatment landscape for HCC continues to evolve, with newer targeted therapies showing promise. However, early detection remains crucial as curative options are primarily available only for early-stage disease.