Clinical practice guideline and real-life practice in hepatocellular carcinoma: A Korean perspective

Abstract

Hepatocellular carcinoma (HCC) is a major cause of death in many countries, including South Korea. To provide useful and sensible advice for clinical management of patients with HCC, the Korean Liver Cancer Association and National Cancer Center Korea Practice Guideline Revision Committee have recently revised the practice guidelines for HCC management. However, there are some differences between practice guidelines and real-life clinical practice. In this review, we describe some key recommendations of the 2022 version of practice guidelines and the real-life clinical situation in South Korea, together with discussion about efforts needed to reduce the difference between guidelines and real-life clinical practice.

Keywords: Clinical practice guideline; Diagnosis; Hepatocellular carcinoma; Surveillance; Treatment.

Figure 1.

Diagnostic algorithm of HCC. HCC, hepatocellular carcinoma; CHB, chronic hepatitis B; CHC, chronic hepatitis C; CT, computed tomography; MRI, magnetic resonance imaging; APHE, arterial phase hyperenhancement; US, ultrasonography. *The radiological hallmarks for diagnosing “definite” HCC on multiphasic contrast-enhanced CT or MRI are APHE with washout appearance in the portal venous, delayed, or hepatobiliary phase. These criteria should be applied only to a lesion that does not show either marked T2 hyperintensity or targetoid appearance on diffusion-weighted images or contrast-enhanced images. For a second-line imaging modality, contrast-enhanced US (blood-pool contrast agent or Kupffer cell-specific contrast agent) for a “definite” diagnosis of HCC is APHE with mild and late (≥60 seconds) washout. These criteria should be applied only to a lesion that does not show either rim or peripheral globular enhancement in the arterial phase. ^†For diagnosis of “probable” HCC, ancillary imaging features are applied as follows. There are two categories of ancillary imaging features, those favoring malignancy in general (mild-to-moderate T2 hyperintensity, restricted diffusion, threshold growth) and those favoring HCC in particular (enhancing or non-enhancing capsule, mosaic architecture, nodule-in-nodule appearance, fat or blood products in the mass). For nodules without APHE, “probable” HCC can be assigned only when the lesion fulfills at least one item from each of the two categories of ancillary imaging features. For nodules with APHE but without washout appearance, “probable” HCC can be assigned when the lesion fulfills at least one of the aforementioned ancillary imaging features. Adopted from 2022 KLCA-NCC HCC guidelines [1].

Figure 2.

Best and alternative first-line treatment options in 2022 KLCA-NCC Korea guidelines for patients with HCC, Child-Pugh class A, no portal hypertension, and Eastern Cooperative Oncology Group performance status 0–1. KLCA-NCC, Korean Liver Cancer Association and National Cancer Center; HCC, hepatocellular carcinoma; mUICC, modified Union for International Cancer Control; VI, vascular or bile duct invasion; RFA, radiofrequency ablation; cTACE, conventional transarterial chemoembolization; TARE, transarterial radioembolization; Other local ablation included percutaneous ethanol injection, microwave ablation, and cryoablation; Vp, portal vein invasion; LT, liver transplantation; DEB-TACE, drug eluting bead-TACE; TACE included cTACE and DEB-TACE; HAIC, hepatic arterial infusion chemotherapy. Adopted from 2022 KLCA-NCC HCC guidelines [1].

Figure 3.

Treatment algorithm of systemic therapies for hepatocellular carcinoma. AFP, alpha-fetoprotein. ^*If patients have absolute or relative contraindications for immune-checkpoint inhibitors or bevacizumab, multiple tyrosine kinase inhibitors such as sorafenib or lenvatinib should be recommended. Adopted from 2022 KLCA-NCC HCC guidelines.