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Treatment Modalities in HCC

Primary Surgical Therapies

  • 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
  • Pre-operative portal vein embolization (PVE)
    • May be used as an adjunct to major liver resection
    • initiates hypertrophy of the anticipated future liver remnant to enable an extended resection
  • Liver 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
  • Tumour rupture:
    • embolization or emergency surgery may be used to control bleeding.
    • following staging, some patients may have long-term benefit from resection
  • Liver transplantation:
    • 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

Loco-Regional Liver Directed Therapies

  • 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

How to Refer Hepatocellular Cancer (HCC) Patients to Provincial Liver Tumour Rounds (VGH/BCC)

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

  • Radiofrequency Ablation (RFA):
    • 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)
  • Percutaneous Ethanol Injection (PEI)
    • 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)
  • Transarterial Chemoembolization (TACE):
    • 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.
  • Transarterial Radioembolization (TARE)
    • 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
  • Stereotatic Ablative Radiotherapy (SABR) aka SBRT:
    • 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

System Therapy

  • 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
  • Doxorubicin
    • May be an options in patients ieligible for sorafenib or after sorafenib failure
  • No proven role for systemic therapy in the neoadjuvant or adjuvant setting

SOURCE: Treatment Modalities in HCC ( )
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