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. 2015 Mar;4(2):85-95.
doi: 10.1159/000367730.

Clinical Practice Guidelines for Hepatocellular Carcinoma Differ between Japan, United States, and Europe

No authors listed

Clinical Practice Guidelines for Hepatocellular Carcinoma Differ between Japan, United States, and Europe

No authors listed. Liver Cancer. 2015 Mar.
No abstract available

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Figures

Fig. 1
Fig. 1
AASLD practice guidelines for HCC surveillance and diagnosis [1]. MDCT=multidetector CT; US=ultrasound. Modified with permission from Bruix J et al. [1].
Fig. 2
Fig. 2
EASL-EORTC practice guidelines for HCC surveillance and diagnosis [2]. aOne imaging technique only recommended in centers of excellence with high-end radiological equipment. bHCC radiological hallmarks: arterial hypervascularity and venous/late phase washout. Modified with permission from EASL-EORTC. [2].
Fig. 3
Fig. 3
Japanese evidence-based clinical practice guidelines for HCC: surveillance and diagnostic algorithm [6]. AFP=alpha-fetoprotein; DCP=des-gamma carboxyprothrombin (also known as PIVKA-II). Optional testing=EOB-MRI, CEUS, CT angiography or tumor biopsy. aCT/MRI are used for some patients even if the nodule(s) are not visualized using ultrasound because of poor visualization capability. Contrast-enhanced ultrasound may be considered for patients with renal impairment and/or allergies to contrast media of CT/MRI. Modified with permission from Kokudo N et al. [6].
Fig. 4
Fig. 4
Consensus-based surveillance and diagnostic algorithm for HCC (Proposed by Liver Cancer Study Group of Japan 2014 [19]). Gd-EOB-DTPA=gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced; DN=dysplastic nodule. SPIO=superparamagnetic iron oxide; CTAP=CT during arterial portography; CTHA=CT during hepatic arteriography. Optional examinations such as SPIO MRI, CTAP, CTHA and highly sensitive tumor marker measurement are recommended in difficult to diagnose cases. aCavernous hemangioma may show hypointensity on equilibrium (transitional) phase of dynamic Gd-EOB-DTPA MRI (pseudo-washout). Cavernous hemangioma should be excluded by other sequences of MRI and/or other imaging modalities. bCavernous hemangioma usually shows hypointensity on hepatobiliary phase of Gd-EOB-DTPA MRI. Cavernous hemangioma should be excluded by other sequences of MRI and/or other imaging modalities. cBiopsy may be considered for confirmation. Modified with permission from Kudo M et al. [19].
Fig. 5
Fig. 5
AASLD/EASL-EORTC treatment algorithm for HCC (1, 2). PST=performance status; CLT=cadaveric liver transplantation; LDLT=living donor liver transplantation; RF/PEI=radiofrequency ablation/percutaneous ethanol injection; OS=overall survival; mo=months; Target 20% means expected target population is 20%. The numbers in parentheses after the overall survival in months indicate the OS range of reported series. Modified with permission from Bruix J et al. and EASL-EORTC.[1,2].
Fig. 6
Fig. 6
Japanese evidence-based clinical practice guidelines for hepatocellular carcinoma: treatment algorithm [6]. aThe Child-Pugh classification may also be used when non-surgical treatment is considered. bCan be selected for tumors with a diameter of ≤3 cm. cOral administration and/or hepatic arterial infusion are available. dA single tumor ≤5 cm or 2-3 tumors ≤3 cm in diameter. ePatients aged ≤65 years. Modified with permission from Kokudo N et al. [6].
Fig. 7
Fig. 7
JSH/Liver Cancer Study Group of Japan consensus-based treatment algorithm for HCC revised in 2014 [19]. HAIC=hepatic arterial infusion chemotherapy. aTreatment should be performed as if extrahepatic spread is negative, when extrahepatic spread is not regarded as a prognostic factor. bSorafenib is the first choice of treatment in this setting as a standard of care. cIntensive follow-up observation is recommended for hypovascular nodules by the Japanese Evidence-Based Clinical Practice Guidelines. However, local ablation therapy is frequently performed in the following cases: 1) when the nodule is diagnosed pathologically as early HCC, 2) when the nodules show decreased uptake on hepatobiliary-phase Gd-EOB-MRI, 3) when the nodules show decreased portal flow by CTAP or 4) decreased uptake is shown on Kupffer phase of Sonazoid-enhanced US, since these nodules are known to frequently progress to typical hypervascular HCC. dEven for HCC nodules exceeding 3 cm in diameter, combination therapy of TACE and ablation is frequently performed when resection is not indicated. eTACE is the first choice of treatment in this setting. HAIC using an implanted port is also recommended for TACE-refractory patients. The regimen for this treatment is usually low-dose FP [5-fluorouracil (5FU) + cisplatin] or intraarterial 5FU infusion combined with systemic interferon therapy. Sorafenib is also a treatment of choice for TACE-refractory patients with Child-Pugh A liver function. fResection is sometimes performed even when the number of nodules is >4. Furthermore, ablation is sometimes performed in combination with TACE. gMilan criteria: tumor size ≤3 cm and tumor number ≤3; or solitary tumor ≤5 cm. Even when liver function is good (Child-Pugh A/B), transplantation is sometimes considered for frequently recurring HCC patients. hSorafenib and HAIC are recommended for HCC patients with Vp1,2 (minor portal vein invasion) and Vp3 (portal invasion at the 1st portal branch). Sorafenib is not recommended for HCC patients with Vp4 (portal invasion at the main portal branch), whereas HAIC is recommended for such patients with tumor thrombus in the main portal branch. iResection and TACE are frequently performed when portal invasion is minimum, such as Vp1 (portal invasion at the 3rd or more peripheral portal branch) or Vp2 (portal invasion at the 2nd portal branch). jLocal ablation therapy or subsegmental TACE is performed even for Child-Pugh C patients when transplantation is not indicated when there is no hepatic encephalopathy, no uncontrollable ascites, and a low bilirubin level (<3.0 mg/dl). Although it is a well-accepted treatment in the routine clinical setting, there is no evidence of its survival benefit in Child-Pugh C patients. A prospective study is necessary to clarify this issue. Even in Child-Pugh A/B patients, transplantation is sometimes performed for relatively younger patients with frequently or early recurring HCC after curative treatments. Modified with permission from Kudo M et al. [19].
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References

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    1. European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56:908–943. - PubMed
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