HCC Guidelines 2011

NCCN guidelines

NCCN Clinical Practice Guidelines in Oncology. Hepatobiliary Cancer. V2.2010; Available from: www.nccn.org.

• Imaging every 3–6 months for 2 years, then annually

• AFP, if initially elevated, every 3 months for 2 years, then every 6 months

Options:

• Sorafenib(Child–Pugh Class A [category 1] or B)

• Chemotherapy + RT only in the context of a clinical trial• Clinical trial• Locoregional therapy• RT (conformal or stereotactic) (category 2B)• Supportive care• Systemic or intra-arterial chemotherapy in clinical trial

Options:

• Sorafenib(Child–Pugh Class A [category 1] or B)

• Clinical trial• Locoregional therapy• RT (conformal or stereotactic) (category 2B)• Supportive care

• Sorafenib(Child–Pugh Class A [category 1] or B)

• Supportive care • Clinical trial

SurveillanceTreatmentClinical presentation

TransplantTransplantcandidate

• Inadequate hepatic reserve

• Tumor location

Evaluate whether patient is a candidate for transplant (See UNOS criteria under Surgical Assessment HCC-4)b Not a transplant

candidate

Extensive liver disease

Unresectable

Inoperable by perfomance status or comorbidity, local disease only

Metastatic disease

APASL guidelines

APASL recommendations on HCC, Omata M, et al. Hepatol Int. 2010;4:439–474

Sorafenib or systemic therapy trial

Confined to the liverMain portal vein patent

HCC

Extrahepatic metastasisMain portal vein tumor thrombus

Resectable Child–Pugh A/B Child–Pugh C

Yes No

Solitary tumor < 5 cm < 3 tumors < 3 cm

No venous invasion

Tumor > 5 cm > 3 tumors

Invasion of hepatic / portal vein branches

Child–Pugh A Child–Pugh B Child–Pugh C Child–Pugh A/B Child–Pugh C

Resection/RFA (for < 3 cm

HCC)

Local ablation Transplantation TACE Supportive care

Portal pressure/bilirubin

HCC

PEI/RFA Sorafenib

Stage 0PST 0, Child–Pugh A

Very early stage (0) 1 HCC < 2 cm

Carcinoma in situ

Early stage (A)1 HCC or 3 nodules

< 3 cm, PST 0

End stage (D)

Liver transplantation TACEResection Symptomatictreatment (20%)

Survival < 3 monthsCurative treatments (30%)5-year survival (40–70%)

Palliative treatments (50%)Median survival 11–20 months

Associated diseases

YesNo

3 nodules ≤ 3 cm

Increased

Normal

1 HCC

Stage DPST > 2, Child–Pugh C

Intermediate stage (B)Multinodular,

PST 0

Advanced stage (C) Portal invasion, N1, M1, PST 1–2

Stage A–CPST 0–2, Child–Pugh A–B

Adapted from Bruix J, Sherman M. Hepatology. In press 2010.Available from http://www.aasld.org. Last accessed September 2010.

Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711.

AASLD guidelines

Portal pressure/bilirubin

HCC

PEI/RFA Sorafenib

Stage 0PST 0, Child–Pugh A

Very early stage (0) 1 HCC < 2 cm

Carcinoma in situ

Early stage (A)1 HCC or 3 nodules

< 3 cm, PST 0

End stage (D)

Liver transplantation TACEResection Symptomatictreatment (20%)

Survival < 3 monthsCurative treatments (30%)5-year survival (40–70%)

Palliative treatments (50%)Median survival 11–20 months

Associated diseases

YesNo

3 nodules ≤ 3 cm

Increased

Normal

1 HCC

Stage DPST > 2, Child–Pugh C

Intermediate stage (B)Multinodular,

PST 0

Advanced stage (C) Portal invasion, N1, M1, PST 1–2

Stage A–CPST 0–2, Child–Pugh A–B

Adapted from Bruix J, Sherman M. Hepatology. In press 2010.Available from http://www.aasld.org. Last accessed September 2010.

Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711.

BCLC guidelines