Management of hepatocellular in the United States
Ali A Mokdad1, Caitlin A Hester1, Amit G Singal2
1Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390, USA.
Insights
Hepatocellular carcinoma (HCC) management varies by stage, from liver transplant for early stages to systemic therapy for advanced disease. Future directions focus on molecular pathways and genetic targets for improved hepatocellular carcinoma treatment.
Area of Science:
- Hepatology
- Oncology
- Gastroenterology
Background:
- Hepatocellular carcinoma (HCC) presents a significant global health challenge, with rising incidence in the United States.
- Patient outcomes for HCC are highly variable due to tumor heterogeneity and underlying liver dysfunction.
Purpose of the Study:
- To outline the current staging and management strategies for Hepatocellular carcinoma (HCC) based on the Barcelona Clinic Liver Cancer (BCLC) system.
- To review established and emerging therapeutic options for different stages of HCC.
Main Methods:
- The Barcelona Clinic Liver Cancer (BCLC) staging system categorizes HCC into stages 0/A, B, C, and D.
- Treatment modalities discussed include liver transplant, resection, ablation, transarterial chemoembolization (TACE), transarterial radioembolization (90Y-TACE), and systemic therapies (sorafenib, regorafenib).
Main Results:
- For BCLC 0/A HCC, liver transplant is optimal; resection and ablation are alternatives.
- BCLC B HCC is managed with TACE, with 90Y-TACE as a viable alternative.
- Advanced BCLC C HCC is treated with sorafenib, with regorafenib as second-line therapy. Ongoing trials explore novel agents and checkpoint inhibitors.
- Terminal BCLC D HCC receives best supportive care.
Conclusions:
- Current HCC management is stage-dependent, utilizing a range of locoregional and systemic treatments.
- Future advancements in Hepatocellular carcinoma treatment will likely stem from understanding molecular pathways and identifying actionable genetic aberrations.
Abstract:
Hepatocellular carcinoma (HCC) is a major cause of cancer burden globally. In the United States, the incidence of HCC is forecast to continue to rise for the next 15 years. Patients with HCC vary markedly owing to heterogeneous tumor characteristics and concomitant liver dysfunction. In the United States and Europe, HCC is staged and managed according to the Barcelona Clinic Liver Cancer (BCLC) system. For very early and early stage HCC, or BCLC 0/A, liver transplant is the optimal treatment option. Liver resection and radiofrequency or microwave ablation are alternative treatment options. For intermediate stage HCC, or BCLC B, transarterial chemoembolization (TACE) is the standard of care. An alternative locoregional therapy, transarterial radioembolization using yttrium-90, has shown comparable outcomes with TACE and may be used in patients for whom TACE is contraindicated. For advanced stage HCC, or BCLC C, systemic chemotherapy with sorafenib, a multikinase inhibitor, is the only evidence-based treatment option available. Another multikinase inhibitor, regorafenib, was recently approved as a second-line therapy for this patient group. Randomized clinical trials investigating other agents in enriched patient groups and novel therapeutics including checkpoint inhibitors are underway. Patient with prohibitive performance status and/or end stage liver dysfunction are classified terminal stage HCC, or BCLC D, and are managed with best supportive care. The future direction for the management of HCC will rely on continuing efforts to uncover molecular pathways and actionable genetic aberrations in HCC.
