Taiwan liver cancer association management consensus guidelines for intermediate-stage hepatocellular carcinoma

Abstract

Intermediate-stage hepatocellular carcinoma (HCC) encompasses a diverse patient population that requires individualized treatment strategies and a multidisciplinary approach. Recent advancements in systemic therapy have expanded the therapeutic options for intermediate-stage HCC, allowing for combination strategies such as systemic therapy with transarterial chemoembolization (TACE) and upfront systemic therapy for individuals deemed unsuitable for TACE. Additionally, the ongoing development of treatment modalities for intermediate-stage HCC has improved the potential for curative conversion and tumor downstaging. Nevertheless, consensus on the optimal management of intermediate-stage HCC remains limited. Thus, the primary aim of this study was to develop a set of consensus guidelines for the management of intermediate-stage HCC. To address this gap, the Taiwan Liver Cancer Association (TLCA) established a working group to develop a multidisciplinary strategy for managing intermediate-stage HCC. Here, we present eight consensus statements formulated by this expert panel, which outline criteria for TACE unsuitability, treatment recommendations based on TACE eligibility, and considerations for various modalities, including conventional TACE, drug-eluting bead TACE, and transarterial radioembolization, as well as the appropriate timing for initiating systemic therapy to enable curative conversion and downstaging. These statements provide specific, evidence-based recommendations for clinicians, addressing treatment pathways based on TACE eligibility and other key considerations for intermediate-stage HCC management. The development of this consensus guideline is intended to aid clinicians in selecting the most appropriate treatment pathway for intermediate-stage HCC, support personalized treatment planning, and ultimately enhance the feasibility of achieving curative conversion.

Keywords: Hepatocellular carcinoma; Immunotherapy; Intermediate stage; Systemic therapy; Transarterial chemoembolization.

Figure 1.

Overall treatment recommendation algorithm for intermediate-stage HCC. BCLC, Barcelona Clinic Liver Cancer; DEB-TACE, drug-eluting bead TACE; HCC, hepatocellular carcinoma; LRT, locoregional therapy; TACE, transarterial chemoembolization; TARE, transarterial radioembolization.

Figure 2.

Updated TLCA HCC treatment algorithm encompassing all disease stages. C-P, Child-Pugh; DDLT, deceased donor liver transplantation; EHM, extrahepatic metastasis; HAIC, hepatic arterial infusion chemotherapy; LA, local ablation; LDLT, living donor liver transplantation; MVI, macrovascular invasion; MWA, microwave ablation; RFA, radiofrequency ablation; RT, radiotherapy; TACE, transarterial chemoembolization; UCSF, University of California, San Francisco; WBC, white blood cells; SIRT, selective internal radiation therapy.