What is the management strategy for patients with Hepatocellular Carcinoma (HCC) and cirrhosis, particularly for grading systems starting with 'A', such as the Albumin-Bilirubin (ALBI) score?

Management of HCC with Cirrhosis: ALBI and Other 'A' Grading Systems

The Barcelona Clinic Liver Cancer (BCLC) staging system is the recommended framework for managing patients with hepatocellular carcinoma (HCC) and cirrhosis, with treatment decisions guided by tumor burden, liver function assessment (using Child-Pugh classification or ALBI score), and performance status. 1, 2

Liver Function Assessment in HCC

ALBI Score (Albumin-Bilirubin)

• ALBI Grade 1: Albumin ≥4.0 g/dL - Best prognosis (median survival 46.7 months with radioembolization) 3
• ALBI Grade 2: Albumin 3.5-3.9 g/dL - Intermediate prognosis (median survival 19.1 months) 3
• ALBI Grade 3: Albumin <2.8 g/dL - Poor prognosis (median survival 8.8 months) 3

The ALBI score outperforms traditional Child-Pugh classification in survival prognosis for HCC patients, with albumin being the main driver of survival prediction 3, 4.

Child-Pugh Classification

• Child-Pugh A: Well-preserved liver function
• Child-Pugh B: Moderate liver dysfunction
• Child-Pugh C: Severe liver dysfunction

Treatment Algorithm Based on BCLC Staging and Liver Function

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

1. Surgical Resection: First-line for solitary tumors with very well-preserved liver function

   • Normal bilirubin AND either HVPG ≤10 mmHg OR platelet count ≥100,000 1
   • Anatomical resections preferred 1
   • Expected perioperative mortality: 2-3% 1

2. Liver Transplantation: First-line for patients with:

   • Single tumor ≤5 cm OR ≤3 nodules ≤3 cm (Milan criteria) 1, 2
   • Not suitable for resection due to portal hypertension or multifocal disease
   • 5-year survival up to 80% 2

3. Ablative Therapies: For patients not eligible for surgery

   • Radiofrequency ablation (RFA): Preferred for tumors <5 cm 1
   • Percutaneous ethanol injection (PEI): Alternative for small tumors <2 cm 1

Intermediate Stage (BCLC B)

• Transarterial Chemoembolization (TACE): Standard treatment 1
• Contraindicated in patients with decompensated cirrhosis (Child-Pugh C) or ECOG PS ≥2 1

Advanced Stage (BCLC C)

• Systemic Therapy: For patients with preserved liver function (Child-Pugh A) 2
• Monitor albumin levels during treatment, as chronological changes in albumin (ALBS grade) predict prognosis 4

Terminal Stage (BCLC D)

• Best Supportive Care: For patients with end-stage liver function (Child-Pugh C) or poor performance status (ECOG 3-4) 1, 2

Special Considerations

Monitoring During Treatment

• Closely monitor liver function during treatment, as both HCC progression and treatments can cause decompensation 5
• Albumin levels at 1 month after starting systemic therapy can predict outcomes better than baseline levels 4

Multidisciplinary Approach

• Treatment decisions should be made by a team including hepatologists, surgeons, oncologists, radiologists, and interventional radiologists 1, 2
• Regular assessment of both tumor response and liver function is essential 5

Recurrence Management

• High recurrence rates even after curative treatments
• In case of recurrence, reassess using BCLC staging and treat accordingly 1

Pitfalls to Avoid

1. Overestimating liver reserve: Even Child-Pugh A patients may have significant portal hypertension that increases surgical risk
2. Underestimating the importance of albumin: Albumin is more predictive of outcomes than bilirubin in HCC patients 3, 4
3. Delaying multidisciplinary evaluation: Early referral to specialized centers improves outcomes
4. Focusing only on tumor control: Management of cirrhosis complications is equally important for survival and quality of life 5

The ALBI score provides a more objective assessment of liver function than Child-Pugh classification and should be incorporated into treatment decision-making for HCC patients with cirrhosis 3.