2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Keywords: Carcinoma; Diagnosis; Guidelines; Management; hepatocellular.

Fig. 1

Crude death rate and age-standardized death rate in the Korea in calendar years 1999 to 2013.

Fig. 2

Annual number of liver cancer deaths, liver disease deaths and liver transplantations in the Korea during calendar years 1999 to 2013.

Fig. 3

Typical hallmarks of hepatocellular carcinoma (arrow) on Gd-EOB-DTPA (gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid) magnetic resonance imaging. (A) T2-weighted image, (B) diffusion-weighted image, (C) non-contrast image, (D) arterial phase image, (E) portal phase image, (F) delayed phase image, and (G) hepatobiliary phase image.

Fig. 4

Diagnostic algorithm and recall policy in patients with a high risk of hepatocellular carcinoma (HCC). CHB, chronic hepatitis B; CHC, chronic hepatitis C; LC, liver cirrhosis; US, ultrasonography; CT, computed tomography; MRI, magnetic resonance imaging; ECF, extracellular fluid; EOB, gadolinium ethoxybenzyl diethylenetriamine pentaacetate. *The major imaging features for “definite” diagnosis of HCC are defined as arterial phase hyperenhancement with washout in the portal venous, delayed or hepatobiliary phases. These criteria should be applied only to a lesion which does not show either marked T2 hyperintensity or targetoid appearance on diffusion-weighted images or contrast-enhanced sequence on contrast-enhanced US as second line exams, major imaging features include arterial hyperenhancement and mild wash-out with late onset (≥60 seconds); ^†In nodule(s) with some but not all of the aforementioned major imaging features of HCC, the category of “probable” HCC can be assigned only when the lesion fulfills at least one item from each of the following two categories of ancillary imaging features. The two categories which make up ancillary imaging features are findings favoring malignancy in general (mild-to-moderate T2 hyperintensity, restricted diffusion, hepatobiliary phase hypointensity, interval growth) and those favoring HCC in particular (non-enhancing capsule, mosaic architecture, nodule-in-nodule appearance, fat or blood products in the mass). These criteria should be applied only to a lesion which shows neither marked T2 hyperintensity nor a targetoid appearance on diffusion-weighted images or contrast-enhanced sequences.

Fig. 5

First-line treatment recommendations from the 2018 KLCA-NCC, Korea Practice Guidelines for Patients with hepatocellular carcinoma, Child-Pugh class A, no portal hypertension, and ECOG 0–1. KLCA, Korean Liver Cancer Association; NCC, National Cancer Center; ECOG, Eastern Cooperative Oncology Group; mUICC, modified Union for International Cancer Control; VI, vascular or bile duct invasion; RFA, radiofrequency ablation; TACE, transarterial chemoembolization; LRT, locoregional therapy; other LRT includes percutaneous ethanol injection, microwave ablation, and cryoablation; EBRT, external beam radiation therapy; LT, liver transplantation; TARE, transarterial embolization; Vp, portal vein invasion.