Multidisciplinary management of recurrent and metastatic hepatocellular carcinoma after resection: an international expert consensus

Abstract

Hepatocellular carcinoma (HCC) is the sixth-most common cancer and the third leading cause of cancer-related death in the world. However, 40-70% patients eventually suffer from postoperative recurrence within 5 years. HCC recurrence after surgery severely affects prognosis of the patients. Nevertheless, there is an opportunity to improve patients' prognosis if doctors and researchers can recognize the importance of a standardized perioperative management and study it in clinical and pre-clinical settings. Hence, based on our own experience and published studies from other researchers, we develop this consensus regarding multidisciplinary management of locally recurrent and metastatic hepatocellular carcinoma after resection. This consensus consists of the entire course of recurrent hepatocellular carcinoma (RHCC) management, including prediction of recurrence, prevention, diagnosis, treatment and surveillance of RHCC. Consensus recommendations are presented with grades of evidences (Ia, Ib, IIa, IIb, III and IV), and strength of recommendations (A, B, C, D and E). We also develop a decision-making path for RHCC treatment, which can intuitively demonstrate the management for RHCC. It is hoped that we may make some effort to standardize the management of RHCC and ultimately understand how to improve outcomes.

Keywords: Recurrent hepatocellular carcinoma (RHCC); consensus; multidisciplinary management.

Figure 1

Chengdu system on multidisciplinary management for recurrent hepatocellular carcinoma. ^a, patients with a single resectable extrahepatic metastatic RHCC, could benefit from resection. ^b, “recurrent high risks” indicates recurrence interval from initial resection to recurrence, which is less than 1 year; presence of vascular invasion and/or multiple tumors in the initial HCC from operation findings or pathological reports. Except for the “Recurrent high risks” which is about the characteristics of initial HCC, other conditions all represent characteristics of RHCC. ^c, patients with PVTT are recommended to be treated according to Chinese Expert Consensus on multidisciplinary Diagnosis and Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus (2016 edition) (35). ^d, salvage liver transplantation could be performed based on patient’s tumor staging which is within specific enlistment criteria according to different liver transplantation centers. ECOG, Eastern Cooperative Oncology Group; RHCC, recurrent hepatocellular carcinoma; TACE, transarterial chemoembolization; PVTT, portal vein tumor thrombus.