British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults

Abstract

Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.

Keywords: CANCER; CANCER SUSCEPTIBILITY; CHRONIC LIVER DISEASE; MOLECULAR ONCOLOGY; SURGICAL ONCOLOGY.

Figure 1

European age-standardised incidence rates of liver cancer in the UK from 1993 to 2018.

Figure 2

Average number of new cases of liver cancer per year and age-specific incidence rates per 100,000 population, UK from 2016 to 2018.

Figure 3

Investigation of focal lesion on ultrasound scan.

Figure 4

Imaging characteristics of hepatocellular carcinoma. (A) Arterial phase T1-weighted MR image demonstrates a large tumour with arterial hyperenhancement (white arrow) and perilesional shunting, resulting in wedge-shaped hyperenhancement within the surrounding parenchyma (black arrow). In the portal venous phase (B) there is early washout, more clearly visible in the delayed phase (C), in which a pseudocapsule is also visible (black arrow). (D)-(F) represent corresponding CT phases 4 months later. Washout is equivocal in the portal phase at CT (E), but more obvious in the 4 min delayed phase (F). This demonstrates the importance of including a delayed-phase acquisition, since washout may not be present in many tumours in the portal phase at CT.

Figure 5

First- and second-line systemic therapy for advanced hepatocellular carcinoma. *Bevacizumab biosimilar and trial conducted exclusively in China. **Following sorafenib. ***If α-fetoprotein ≥400 ng/mL.

Figure 6

UK treatment algorithm for hepatocellular carcinoma (HCC). EHS, extrahepatic disease spread; LT, liver transplantation; MVI, macrovascular tumour infiltration; PS, performance status; SABR, stereotactic ablative radiotherapy; SIRT, selective internal radiation therapy; TACE, transarterial chemoembolisation. *Sorafenib can be considered in PS=2. **Turnour <3 cm. ***Disease confined to one lobe. ****Solitary tumour, branch portal vein thrombosis, no EHS. *****No ascites, PS=0.