Treatment of hepatocellular carcinoma: Beyond international guidelines

Research output: Contribution to journalArticle

46 Citations (Scopus)

Abstract

The management of hepatocellular carcinoma (HCC) is decided according to evidence-based recommendations generated by international societies: according to these recommendations, the tumour stage, as determined by the Barcelona clinical liver cancer (BCLC) score, divides patients into five prognostic categories, each with a distinct treatment indication. Radical therapies such as hepatic resection, orthotopic liver transplantation and percutaneous local ablation are strongly indicated in patients with very early and early stage tumours (BCLC O and A), a choice which mainly depends on a combination of tumour volume, status of underlying liver disease, the presence of comorbidities and the patient's age. Although radical therapies provide a survival rate of between 50% and 75% at year five in well selected patients, tumour recurrence is frequent following resection and ablation compared to transplantation (70% vs. 10% respectively), which has the additional advantage of preventing morbidity and mortality from portal hypertension. Generally, while radical therapies are contraindicated in patients with a large tumour burden, such as those with intermediate stage BCLC B, survival in the subset of these patients with well compensated cirrhosis may improve from 16 to 20 months, on average, following repeated treatments with transarterial chemoembolization (TACE). Survival may also improve in patients who are in poor condition or who do not respond to TACE and in those with an advanced HCC (BCLC C) following oral therapy with the multikinase inhibitor sorafenib. However, because most recommendations are based on uncontrolled studies and expert opinions rather than well designed, high powered randomized controlled trials, treatment criteria need to be adapted to special groups because real life cohorts do not match the selection criteria suggested by the guidelines. Indeed, up to one-third of patients with early stage tumours who are unfit for radical therapy because of advanced age, the presence of significant comorbidities or a strategic location of the nodule, are forced to receive palliative care. BCLC A patients with moderate portal hypertension and certain BCLC B patients could still be eligible for hepatic resection if a chance for 50% survival at 5 years is still perceived as being cost-effective by both the patient and caregivers.

Original languageEnglish
Pages (from-to)129-138
Number of pages10
JournalLiver International
Volume35
Issue numbers1
DOIs
Publication statusPublished - Jan 1 2015

Fingerprint

Hepatocellular Carcinoma
Guidelines
Liver Neoplasms
Therapeutics
Portal Hypertension
Tumor Burden
Survival
Comorbidity
Neoplasms
Liver
Expert Testimony
Palliative Care
Liver Transplantation
Patient Selection
Caregivers
Liver Diseases
Fibrosis
Survival Rate
Randomized Controlled Trials
Transplantation

Keywords

  • BCLCA staging
  • Chemoembolization
  • Hepatic resection
  • Liver transplantation
  • Local ablation
  • Sorafenib

ASJC Scopus subject areas

  • Hepatology
  • Medicine(all)

Cite this

Treatment of hepatocellular carcinoma : Beyond international guidelines. / Colombo, Massimo; Sangiovanni, Angelo.

In: Liver International, Vol. 35, No. s1, 01.01.2015, p. 129-138.

Research output: Contribution to journalArticle

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