What are the guidelines for hepatocellular carcinoma (liver cancer) treatment?

From the Guidelines

Liver cancer treatment guidelines involve a multidisciplinary approach based on cancer stage, liver function, and patient health status, with the most recent and highest quality evidence recommending personalized surveillance and treatment strategies 1. The treatment of hepatocellular carcinoma (HCC) requires a comprehensive approach, taking into account the patient's overall health, liver function, and cancer stage.

• For early-stage HCC, surgical resection or liver transplantation offers the best chance of cure, with patients having small tumors (≤5 cm) and preserved liver function being ideal candidates for resection, while transplantation is preferred for those with cirrhosis and tumors meeting Milan criteria (single tumor ≤5 cm or up to 3 tumors ≤3 cm each) 1.
• For unresectable early-stage disease, local ablation therapies like radiofrequency ablation (RFA) or microwave ablation are effective, typically requiring 1-3 sessions depending on tumor size.
• Intermediate-stage patients benefit from transarterial chemoembolization (TACE), usually performed every 2-3 months until maximum response.
• Advanced HCC is treated with systemic therapies, including first-line options like sorafenib (400 mg twice daily) or lenvatinib (8-12 mg daily based on weight), and second-line options such as regorafenib (160 mg daily for 3 weeks on, 1 week off) or immunotherapies like atezolizumab plus bevacizumab, as recommended by the most recent guidelines 1. These treatments work by targeting cancer cell growth pathways or enhancing immune response against tumors.
• Supportive care is essential throughout treatment, including pain management, nutritional support, and monitoring for complications.
• Regular imaging every 2-3 months helps assess treatment response, and therapy should be adjusted based on response and tolerability, with a focus on personalized treatment strategies and multidisciplinary care 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 guidelines for hepatocellular carcinoma (liver cancer) treatment with lenvatinib are:

• First-line treatment: Lenvatinib is indicated for the first-line treatment of patients with unresectable hepatocellular carcinoma (HCC) 2. Note that the label does not provide detailed treatment guidelines, such as dosage or duration of treatment, but rather indicates the approved use of lenvatinib for this condition.

From the Research

Treatment Options for Hepatocellular Carcinoma (HCC)

• Surgical resection is considered for patients with early-stage HCC, but most patients are diagnosed at an advanced stage and are unresectable 3
• Criteria for unresectability include uncontrolled extrahepatic disease, extensive intrahepatic tumor growth, insufficient remnant liver volume, and severe co-morbid disease 3
• Downstaging of HCC can be achieved through transarterial chemoembolization (TACE) or local tumor ablation using ethanol injection, cryosurgery, and radiofrequency 3

Systemic Treatment for Advanced HCC

• Sorafenib and lenvatinib are approved for first-line treatment of patients with advanced HCC 4
• Atezolizumab plus bevacizumab has been shown to be effective in first-line treatment, and regorafenib, cabozantinib, ramucirumab, nivolumab, pembrolizumab, and ipilimumab plus nivolumab are approved for second-line treatment 4, 5
• The selection of second-line systemic treatment should be based on factors such as effectiveness, safety, tolerability, patient quality of life, and individual patient characteristics 4

Surgical Strategies for HCC

• Liver resection provides a potential cure for HCC, but the risks and benefits must be considered on an individual basis 6
• The principles of surgical resection include margin-negative resections with preservation of adequate function of the residual liver 6
• Onco-surgical strategies such as portal vein embolization and parenchymal-sparing resections can increase the number of patients eligible for curative liver resection 6

Sequential Treatment After First-Line Failure

• There is a lack of data on sequential regimens after atezolizumab/bevacizumab failure, but lenvatinib has shown better progression-free survival and comparable overall survival to sorafenib in a real-world study 7
• Future studies are needed to optimize second-line treatment for patients with advanced HCC after first-line failure 7