Management Consensus Guidelines for Hepatocellular Carcinoma: 2023 Update on Surveillance, Diagnosis, Systemic Treatment, and Posttreatment Monitoring by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

Abstract

Hepatocellular carcinoma (HCC) is the leading cause of cancer-related mortality in Taiwan. The Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan established HCC management consensus guidelines in 2016 and updated them in 2023. Current recommendations focus on addressing critical issues in HCC management, including surveillance, diagnosis, systemic treatment, and posttreatment monitoring. For surveillance and diagnosis, we updated the guidelines to include the role of protein induced by vitamin K absence or antagonist II (PIVKA-II) and gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in detecting HCCs. For systemic treatment, the updated guidelines summarize the multiple choices available for targeted therapy, immune checkpoint inhibitors, and a combination of both, especially for those carcinomas refractory to or unsuitable for transarterial chemoembolization. We have added a new section, posttreatment monitoring, that describes the important roles of PIVKA-II and EOB-MRI after HCC therapy, including surgery, locoregional therapy, and systemic treatment. Through this update of the management consensus guidelines, patients with HCC may benefit from optimal diagnosis, therapeutic modalities, and posttreatment monitoring.

Keywords: Diagnosis; Guideline; Hepatocellular carcinoma; Posttreatment monitoring; Surveillance; Systemic treatment.

Fig. 1.

Diagnostic algorithm for liver nodules. AFP, alpha-fetoprotein; CEUS, contrast-enhanced ultrasound; EOB-MRI, gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging; HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; MRI, magnetic resonance imaging; PIVKA-II, Protein induced by Vitamin K absence or antagonists-II; US, ultrasound. *Kupffer-phase contrast-enhanced ultrasound (CEUS) with Sonazoid, combined with the reinjection technique, can also be recommended as a primary test for HCC patients who have cirrhosis with very coarse liver parenchyma and renal dysfunction, if a liver nodule ≥1 cm is detected by B-Mode ultrasonography (Statement 1–3).

Fig. 2.

Treatment algorithms for hepatocellular carcinoma. C–P, Child-Pugh; DDLT, deceased donor liver transplantation; EHM, extrahepatic metastasis; HAIC, hepatic arterial infusion of chemotherapy; LA, local ablation (including PEI, RFA, and MWA); LDLT, living donor liver transplantation; MWA, microwave ablation; MVI, macrovascular invasion; PEI, percutaneous ethanol injection; RFA, radiofrequency ablation; RT, radiotherapy; SIRT, selective internal radiation therapy; TACE, transarterial chemoembolization; Tx, therapy; UCSF, University of California, San Francisco. *When the above treatments are infeasible.