Treatment Strategies for Hepatocellular Carcinoma ⁻ a Multidisciplinary Approach

Abstract

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and its mortality is third among all solid tumors, behind carcinomas of the lung and the colon. Despite continuous advancements in the management of this disease, the prognosis for HCC remains inferior compared to other tumor entities. While orthotopic liver transplantation (OLT) and surgical resection are the only two curative treatment options, OLT remains the best treatment strategy as it not only removes the tumor but cures the underlying liver disease. As the applicability of OLT is nowadays limited by organ shortage, major liver resections ⁻ even in patients with underlying chronic liver disease ⁻ are adopted increasingly into clinical practice. Against the background of the oftentimes present chronical liver disease, locoregional therapies have also gained increasing significance. These strategies range from radiofrequency ablation and trans-arterial chemoembolization to selective internal radiation therapy and are employed in both curative and palliative intent, individually, as a bridging to transplant or in combination with liver resection. The choice of the appropriate treatment, or combination of treatments, should consider the tumor stage, the function of the remaining liver parenchyma, the future liver remnant volume and the patient's general condition. This review aims to address the topic of multimodal treatment strategies in HCC, highlighting a multidisciplinary treatment approach to further improve outcome in these patients.

Keywords: Hepatocellular carcinoma; liver cirrhosis; liver resection; liver transplantation; multimodal treatment.

Figure 1

Multidisciplinary HCC evaluation and treatment. (A) Progression of liver disease; (B) HCC stages according to BCLC; (C) Step-wise multidisciplinary management of patients with HCC; (D) Tools of modern liver surgery for HCC.

Figure 2

Systemic targeted therapy options for intermediate and advanced HCC. BCLC Stage B (multinodular) and Stage C (portal vein invasion or extrahepatic disease). Abbreviations: BSC—best supportive care, CPI—checkpoint inhibitor, E:H—evidence high; E:M—evidence medium, mAb—monoclonal Antibody, ORR—objective response rate, R:NA—recommendation: not available, R:SP—recommendation: strong positive, R:WP—recommendation: weak positive, TKI—tyrosine kinase inhibitor, VEGFR—vascular endothelial growth factor receptor. Recommendations derived from: European Association for the Study of the Liver, Hepatology, 2018 [13].