What are the management options for liver cancer?

Management of Hepatocellular Carcinoma (HCC)

The Barcelona Clinic Liver Cancer (BCLC) staging system should be used to guide treatment decisions for hepatocellular carcinoma, incorporating tumor burden, liver function, and performance status to determine optimal management strategies. 1

Diagnosis and Staging

Diagnosis of HCC relies on a combination of imaging and, in some cases, histopathology:

• In cirrhotic patients:

  • Lesions showing typical enhancement pattern (hypervascular with washout) on dynamic contrast-enhanced CT/MRI can be diagnosed as HCC without biopsy 1
  • Lesions not showing typical features require biopsy for confirmation 1

• In non-cirrhotic patients:

  • Diagnosis should be based on pathology (biopsy) 1

Proper staging is essential and should include:

• TNM classification for tumor staging 1
• Child-Pugh classification for liver function assessment
• ECOG performance status evaluation 2

Treatment Algorithm Based on BCLC Stage

Very Early Stage (BCLC 0) and Early Stage (BCLC A)

For single tumors ≤5 cm or up to 3 nodules ≤3 cm each, without vascular invasion:

1. Surgical resection is the first-line treatment for:

   • Non-cirrhotic patients 1
   • Cirrhotic patients with preserved liver function (Child-Pugh A), normal bilirubin, and no portal hypertension 2

2. Liver transplantation is optimal for:

   • Patients meeting Milan criteria (single tumor ≤5 cm or up to 3 tumors ≤3 cm) with cirrhosis 1, 2
   • Patients with decompensated cirrhosis (Child-Pugh C) 1
   • 5-year survival rates up to 70-80% 1

3. Ablative techniques for patients not suitable for surgery:

   • Radiofrequency ablation (RFA) for tumors ≤3 cm 2
   • Percutaneous ethanol injection (PEI) as an alternative 1, 2

Intermediate Stage (BCLC B)

For multinodular tumors without vascular invasion or extrahepatic spread:

• Transarterial chemoembolization (TACE) is the standard treatment 1, 2
• Not recommended for patients with decompensated cirrhosis, vascular invasion, or extrahepatic spread 2

Advanced Stage (BCLC C)

For patients with vascular invasion, extrahepatic spread, or ECOG 1-2:

• Systemic therapy is the standard approach:
  • Sorafenib is the first-line treatment for patients with Child-Pugh A liver function 2, 3
  • Lenvatinib is FDA-approved for first-line treatment of unresectable HCC 4
  • These treatments typically extend survival by approximately 3 months 3

Terminal Stage (BCLC D)

For patients with severe liver dysfunction (Child-Pugh C) or poor performance status (ECOG 3-4):

• Best supportive care is recommended 1
• Early referral to palliative care services alongside any active treatment 1
• Holistic assessment of physical, psychological, social, and emotional needs 1

Special Considerations

Downstaging

• Patients with tumor burden beyond standard criteria may be considered for liver transplantation after successful downstaging 1
• TACE can be instrumental in downstaging before liver transplantation 1

Bridging Therapy

• Patients listed for transplant should be considered for neoadjuvant locoregional therapy while on the waiting list 1
• This reduces waiting list dropout due to disease progression and provides information about tumor biology 1

Palliative Care

• All patients with advanced HCC should have early referral to palliative care services 1
• A single fraction of radiotherapy to the liver may be considered for pain control when other treatments are not indicated 1

Multidisciplinary Approach

Treatment decisions should be made by a multidisciplinary team including hepatologists, surgeons, oncologists, radiologists, and interventional radiologists 1, 2

Common Pitfalls to Avoid

1. Delayed diagnosis: Implement surveillance with ultrasound for high-risk patients to detect HCC at earlier stages
2. Inappropriate treatment selection: Always consider liver function and performance status, not just tumor characteristics
3. Overlooking palliative care: Early integration improves quality of life for advanced cases
4. Neglecting underlying liver disease: Manage underlying conditions (viral hepatitis, alcohol use) alongside HCC treatment
5. Missing recurrence: Regular follow-up is essential as HCC has high recurrence rates even after curative treatments

The management of HCC continues to evolve with emerging therapies and updated criteria for various treatment modalities, making a multidisciplinary approach essential for optimal patient outcomes.