Update on the Diagnosis and Treatment of Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma (HCC) is the fourth-leading cause of cancer-related mortality worldwide and the fastest-rising cause of cancer-related death in the United States. Given the strong association between tumor stage and prognosis, HCC surveillance is recommended in high-risk patients, including patients with cirrhosis from any etiology. The diagnosis can be made based on characteristic imaging findings, with histologic confirmation primarily reserved for patients with atypical imaging findings. Over the last 2 decades, the treatment landscape for HCC has experienced significant advances. Curative therapies, including liver transplantation and surgical resection, are available to patients with early-stage HCC; however, recent data have expanded the potentially eligible patient population. Locoregional therapies, including transarterial chemoembolization and transarterial radio-embolization, continue to be standard therapies for patients with intermediate-stage disease. The greatest advances have been observed for patients with advanced HCC, where there are now multiple first- and second-line options that can prolong survival by up to 2 years when used sequentially. The increasing complexity of HCC treatment options underlies the necessity for multidisciplinary care, which has been associated with increased survival. This article reviews data on best practices for early detection and diagnosis of HCC and the current status of treatment options.

Keywords: Hepatocellular carcinoma; LI-RADS; diagnosis; immunotherapy; screening; treatment.

Figure 1.

BCLC treatment recommendations according to BCLC stage, including additional evidence-based therapies. BCLC, Barcelona Clinic Liver Cancer; ECOG, Eastern Cooperative Oncology Group; LT, liver transplantation; PS, performance status; SBRT, stereotactic body radiation therapy; TACE, transarterial chemoembolization; TARE, transarterial radioembolization. ^aThese therapies have not yet been incorporated into guidelines but are evidence-based.

Figure 2.

Timeline of major phase 3 clinical trials of first-line treatments for advanced hepatocellular carcinoma by year of publication or presentation at a national meeting. HAIC, hepatic arterial infusion chemotherapy; HR, hazard ratio; OS, overall survival; PFS, progression-free survival; TTP, time to progression. ^aMedian survival not yet reached. Results reported are after a median follow-up of 8.6 months.