Treatment Modalities in HCC

Patients with early stage disease (solitary HCC nodule or up to 3 nodules ≤3cm, Child-Pugh A or B) should be identified and evaluated for curative-intent therapies (resection, liver transplant, RFA) by a multidisciplinary team
Pre-operative evaluation to:

determine the likelihood that disease is confined to the liver, and
determine if size/location of tumour and patient’s hepatic function permit resection
determine liver volumes including the Future Liver Remnant

May be used as an adjunct to major liver resection
initiates hypertrophy of the anticipated future liver remnant to enable an extended resection

potentially curative
optimal treatment for HCC in patients with adequate liver function
ideal patient: solitary HCC (or up to 3 lesions up to 3cm), confined to the liver, no radiographic evidence of invasion of hepatic vasculature, no portal hypertension, well-preserved hepatic function
anatomic resection preferred but non-anatomic resection may be necessary in patients with cirrhosis to preserve hepatic function
TNM stage IIIB, IIIC, IVA or IVB are considered incurable by resection

The Milan criteria are used to select patients with cirrhosis and HCC for liver transplantation
single lesion ≤5 cm
up to 3 lesions with a diameter ≤3 cm
no extrahepatic involvement
no major vessel involvement

Provides tumour control pending transplantation or as an adjunct or alternative to resection in patients with liver-limited disease
Selection of the appropriate therapy is best done through review at multi-disciplinary conference including input from interventional radiology, hepatobiliary surgery and medical oncology

To refer a patient for review at Provincial Liver Tumour Rounds, please see the referral process and complete the referral form.

Best outcomes when used with single tumours are centrally located, measure under 3 cm, and are distant from blood vessels (“heat sinks”) and major bile ducts.
For larger tumours, RFA is preferable to PEI.
RFA may be performed percutaneously (ultrasound, CT) or operatively (laparoscopic, open)

Minimally invasive procedure that involves direct injection of small tumours with ethanol
Less effective than RFA
May be used when RFA cannot be performed (eg tumours in a subcapsular location or adjacent to blood vessels)

Used for large unresectable tumours not amenable to other local therapy
Involves injection of a chemotherapeutic agent with or without lipiodol into the hepatic artery
Drug-eluting microspheres can also be used with potentially less toxicity and equal efficacy
Contraindicated in patients with portal vein thrombosis, decompensated cirrhosis (encephalopathy, jaundice, refractory ascites, or hepatorenal syndrome), extensive bilateral tumour burden, creatinine >180. Relative contraindications: platelets < 75, cardiac or lung disease, untreated varices, biliary occlusion, or tumour >10cm
TACE can be repeated, generally after prior response to TACE, to an area with progression
Bland partial embolization (i.e. without chemotherapy) can also be performed
Typically requires 2-3 days hospitalization. Post chemoembolization syndrome occurs in 80-90% of patients, characterized by self-limited fever, abdominal pain, nausea and vomiting, and elevated liver function tests
Follow-up to assess response: generally >=4-8 weeks post TACE with multiphasic CT or MRI liver.

lnvolves selective delivery of radioactive isotopes (eg yttrium-90 [⁹⁰Y]-tagged glass microspheres) to the tumour via the hepatic artery
For inoperable HCC
An alternative treatment for patients with contraindications to TACE, particularly portal venous thrombosis

Radiotherapy technique in which a limited number of high dose radiation fractions are delivered to a small, precisely-defined target
May be useful in patients with portal vein thrombus
Requires consultation with Radiation Oncologist experienced with SBRT

Systemic therapy is palliative-intent therapy indicated for patients with sufficient hepatic reserve and PS but no longer eligible for surgical or liver-directed therapies
Sorafenib

First-line standard of care based upon the 3 month median survival benefit demonstrated in the SHARP trial
oral multikinase inhibitor, used in patients with Child-Pugh A hepatic reserve, with ECOG PS 0-2. Not indicated for patients with Child Pugh B7 or worse hepatic reserve
Common adverse effects include diarrhea, hand-foot syndrome, fatigue, and weight loss

May be an options in patients ineligible for sorafenib or after sorafenib failure