Treatment algorithm for intermediate and advanced stage hepatocellular carcinoma: Korea

The practice guideline for hepatocellular carcinoma (HCC) in Korea was revised in 2009. It was based on clinical evidence. The treatment algorithm was divided into curative and noncurative treatments. According to Barcelona Clinic Liver Cancer (BCLC) staging, the curative treatment group included early stage HCC (BCLC-A), and the noncurative treatment group consisted of intermediate and advanced stages of HCC (BCLC-B, C). The intermediate stage of HCC stands for noncurative disease, and therefore surgical resection and radiofrequency ablation are not considered as primary treatment modalities. Transarterial chemoembolization (TACE) forms the backbone of the treatment for intermediate stage HCC with Child-Pugh A cirrhosis. Patients in whom complete necrosis is not achieved or early recurrence after TACE develops should receive individualized treatments such as systemic treatment or combined radiation therapy (RT). Liver transplantation (LT) can be carried out for intermediate stage HCCs. However, the long-term survival rate after LT for intermediate stage HCCs is inferior to that of early stage HCCs because intermediate stage HCCs exceed the Milan criteria. In patients with Child-Pugh C liver function, LT would be better than TACE in terms of survival gain if the tumor burden is acceptable by expert opinion standards. The treatment algorithm becomes very complicated when it comes to advanced stage HCC. Sorafenib, a multikinase inhibitor with antiangiogenic and antiproliferative properties, has been shown to prolong the median overall survival and the median time to radiological progression compared to placebo in randomized controlled trials (RCTs) and has become the current standard of care for patients with advanced-stage tumors not suitable for surgical or locoregional therapies. RT is in the process of becoming a modality with a high efficacy and minimum side effects for HCC treatment, with recent improvements in equipment as well as radiation methods. However, to discover whether RT is really beneficial in the treatment of large-sized intermediate and advanced stage HCC, prospective RCTs should be carried out.