From the Guidelines
Hepatocellular carcinoma (HCC) management should be guided by the tumour stage, with treatment options including hepatic resection, orthotopic liver transplantation, percutaneous local ablation, transarterial chemoembolization (TACE), and oral therapy with sorafenib, as indicated by the Barcelona clinical liver cancer (BCLC) score 1. The BCLC score divides patients into five prognostic categories, each with a distinct treatment indication.
- For very early (BCLC 0) and early stage (BCLC A) tumours, hepatic resection, orthotopic liver transplantation, and percutaneous local ablation are strongly indicated, providing a survival rate of between 50 and 75% at year five 1.
- For patients with intermediate stage BCLC B, repeated treatments with TACE are advocated, with clinical benefits ranging from 16 to 22 months 1.
- For patients with advanced HCC (BCLC C), oral therapy with sorafenib may improve survival, especially in those who are in poor condition or do not respond to TACE 1. However, it is essential to note that most recommendations are based on uncontrolled studies and expert opinions rather than well-designed controlled trials, and up to one-third of patients do not fit recommendations due to advanced age, significant comorbidities, or strategic location of the nodule 1. In such cases, treatment of HCC beyond guidelines is often advocated, emphasizing the need for individualized care and consideration of patient-specific factors.
From the FDA Drug Label
OPDIVO, in combination with ipilimumab, is indicated for the treatment of adult patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib. The answer to HCC management is that nivolumab (OPDIVO), in combination with ipilimumab, is indicated for the treatment of adult patients with HCC who have been previously treated with sorafenib 2.
From the Research
HCC Management Overview
- Hepatocellular carcinoma (HCC) is a malignancy with increasing incidence in North America, often occurring in the setting of a cirrhotic liver 3.
- The Barcelona Clinic Liver Cancer (BCLC) staging system is preferred for HCC management, incorporating tumour characteristics, patient performance status, and liver function 3, 4, 5.
Treatment Options
- Transarterial chemoembolization (TACE) is the standard treatment for BCLC stage B (intermediate HCC) and can be used as bridge therapy for patients awaiting liver transplantation 5.
- Liver resection is traditionally proposed for early-stage HCC (BCLC-0/A), but can also be effective for intermediate-stage HCC (BCLC-B) with acceptable perioperative morbidity and mortality 6.
- Sorafenib represents the first-line treatment for patients with BCLC C stage HCC, and can be used in combination with TACE to delay tumor progression 5.
- Radiofrequency ablation (RFA) and transarterial radioembolization (TARE) are also viable treatment options for HCC, depending on the stage and patient characteristics 3, 5.
Patient Stratification and Subclassification
- The BCLC staging system has limitations, and subclassifications of BCLC B and C stages are needed to guide clinicians towards the most effective treatment option 4.
- Patient stratification systems should consider factors such as tumour burden, liver function, and performance status to select the best candidates for each treatment modality 5, 6.
- The presence of portal vein tumour thrombosis (PVT) and macrovascular invasion (MVI) can affect treatment outcomes and should be considered in patient stratification 4, 6.