Management of hepatocellular carcinoma

Management of hepatocellular carcinoma requires a multidisciplinary approach and should be undertaken in a specialised unit. The choice of therapy is based on the number, size and location of tumours, the presence of vascular invasion or metastatic disease, the severity of underlying liver disease, and the performance status of the patient. These factors are incorporated into staging systems (eg Barcelona Clinic Liver Cancer system) that are used to guide the approach to treatment.

Liver transplantation  offers the best long-term recurrence-free survival rate, and should be considered for patients fulfilling certain criteria (eg Milan criteria: a single tumour less than 5 cm in diameter, or up to three tumours less than 3 cm in diameter).

Surgical resection may be offered to patients with compensated cirrhosis who do not have portal hypertension. While patients who undergo surgical resection of hepatocellular carcinoma remain at risk of recurrence (60 to 70% have recurrent or new tumours by 5 years), overall survival is similar for surgical resection and liver transplant.

Nonsurgical therapies are available for patients with hepatocellular carcinoma that is not suitable for surgical resection or liver transplantation. These therapies are used to ablate a tumour or control its growth, and offer improved survival in patients with hepatocellular carcinoma and compensated cirrhosis (Child–Pugh class A). Nonsurgical therapies delivered by experienced interventional radiologists include percutaneous ablation, transarterial chemoembolisation and transarterial radioembolisation. Stereotactic body radiotherapy is also being used more frequently.

Drug therapy may be used in patients with advanced-stage hepatocellular carcinoma and compensated cirrhosis (Child–Pugh class A), if other forms of treatment are not suitable. Drugs that may be used include oral multikinase inhibitors (eg lenvatinib, sorafenib), immunotherapy (eg atezolizumab) and antiangiogenic therapy (eg bevacizumab). These drugs have been shown to prolong survival in patients with advanced disease. For current information, see the Australian recommendations for the management of hepatocellular carcinoma: A consensus statement, available online.

Supportive care only is appropriate for patients with decompensated cirrhosis and advanced hepatocellular carcinoma. Advance care planning and palliative care referral are recommended for patients with advanced-stage hepatocellular carcinoma.