2019 Chinese clinical guidelines for the management of hepatocellular carcinoma: updates and insights

Abstract

Importance: Approximately half of newly-diagnosed hepatocellular carcinoma (HCC) cases in the world occur in China, with hepatitis B virus (HBV) infection being the predominant risk factor. Recently, the guidelines for the management of Chinese HCC patients were updated.

Objective: The past decade has witnessed a great improvement in the management of hepatocellular carcinoma (HCC). This study reviews the recommendations in the 2019 Chinese guidelines and makes comparison with the practices from the Western world.

Evidence review: The updated recommendations on the surveillance, diagnosis, and treatment algorithm of HCC in the 2019 Chinese guidelines were summarized, and comparisons among the updated Chinese guidelines, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines were made.

Findings: Besides imaging and pathological diagnoses, novel biomarkers like the seven-micro-RNA panel are advocated for early diagnoses and therapeutic efficacy evaluation in the updated Chinese guidelines. The China liver cancer (CNLC) staging system, proposed in the 2017 guidelines, continues to be the standard model for patient classification, with subsequent modifications and updates being made in treatment allocations. Compared to the Barcelona Clinic Liver Cancer (BCLC) system, the CNLC staging system employs resection, transplantation, and transarterial chemoembolization (TACE) for more progressed HCC. TACE in combination with other regional therapies like ablation or with systemic therapies like sorafenib are also encouraged in select patients in China. The systemic treatments for HCC have evolved considerably since lenvatinib, regorafenib, carbozantinib, ramucirumab and immune checkpoint inhibitors (ICIs)were first prescribed as first-line or second-line agents.

Conclusions and relevances: Novel biomarkers, imaging and operative techniques are recommended in the updated Chinese guideline. More aggressive treatment modalities are suggested for more progressed HBV-related HCC in China.

Keywords: Clinical practice guidelines; diagnosis; hepatocellular carcinoma (HCC); treatment algorithm.

Figure 1

Comparisons of staging and treatment algorithms of HCC among 2018 EASL, 2018 AASLD, and 2019 Chinese guidelines. BCLC, Barcelona Clinic Liver Cancer; EASL, European Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; CNLC, China liver cancer staging; OLT, orthotopic liver transplantation; TACE, transarterial chemoembolization; TARE, transarterial radioembolization; TKIs, tyrosine kinase inhibitors; PD-1, programmed cell death-1; SBRT, stereotactic body radiation therapy; RT, radiation therapy; UCSF, University of California San Francisco; FOLFOX4, infusional fluorouracil, leucovorin, and oxaliplatin regimen.