Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma

Abstract

Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.

Keywords: Hepatocellular carcinoma; clinical management; consensus recommendations; diagnosis; percutaneous ethanol injection; prognosis; radiofrequency ablation; screening; staging; surgical resection; systemic chemotherapy; transarterial chemotherapy; transplantation.

FIGURE 1

Diagnostic algorithm for suspected hepatocellular carcinoma (hcc). Adapted from the 2010 American Association for the Study of Liver Diseases guidelines. us = ultrasonography; mdct = multi-detector computed tomography; mri = magnetic resonance imaging; ct = computed tomography.

FIGURE 2

Management of hepatocellular carcinoma (hcc) in a patient with cirrhosis. Modified from the 2010 American Association for the Study of Liver Diseases guidelines and the Alberta hcc Algorithm . bclc= Barcelona Clinic Liver Cancer; pvi= portal vein invasion; N1 = nodes positive; M1 = metastasis; ht= portal hypertension; lt= liver transplantation; ecog= Eastern Cooperative Oncology Group; pvt= portal vein thrombosis; rfa= radiofrequency ablation; tace= transarterial chemoembolization.