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HCC Guidelines and recommendation 2012

HCC Guidelines and recommendation 2012. Diagnostic algorithm . Mass/nodule on US. <1cm. 1-2cm. >2cm. 4-phase CT/Dynamic Contrast enhanced MRI. 4-phase CT or Dynamic Contrast enhanced MRI. Repeat US at 4 mo. 1 or 2 positive techniques*: HCC radiological Hallmarks**.

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HCC Guidelines and recommendation 2012

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  1. HCC Guidelines and recommendation 2012

  2. Diagnostic algorithm Mass/nodule on US <1cm 1-2cm >2cm 4-phase CT/Dynamic Contrast enhanced MRI 4-phase CT or Dynamic Contrast enhanced MRI Repeat US at 4 mo 1 or 2 positive techniques*: HCC radiological Hallmarks** 1 positive technique: HCC radiological Hallmarks** Growing/Changing Character Stable Yes No Yes No Investigate according to size HCC HCC Biopsy Biopsy Inconclusive Diagnostic algorithm and recall policy.*One imaging technique only recommended in centers of excellence with high-end radiological equipment.**HCC radiological hallmark: arterial hypervascularity and venous/late phase washout EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma Journal of Hepatology 2012 vol. 56 j 908–943 Available on: http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf

  3. Diagnostic algorithm New mass/nodule Ø < 1cm Ø ≥1cm US 3 months TC/RM/CEUS Growing Ø Typicalfeature (wash in/wash out) NO Sì NO Sì US 3 months (for 12 months) Othercontrastenhancedtechnique Sì Growing Ø Atypicalfeature Typicalfeature NO Biopsy US 6 months Otherdiagnosis No diagnosis HCC Raccomandazioni AISF per la gestione integrata del paziente con Epatocarcinoma; published on www.webaisf.org Available on: http://www.webaisf.org/media/16110/raccomandazioni-aisf-per-hcc.pdf Accessed on 30-March 2012 US, Ultrasound

  4. Clinical presentation Surveillance Treatment • Refer to liver transplant center • Consider brige therapy as indicated • Imaging every 3–6 months for 2 years, then every 6-12 months • AFP, if initially elevated, every 3-6 months for 2 years, then every 6-12 months • See relevant pathway (HCC-2 through HCC-7) if disease recurs Transplantcandidate Evaluate whether patient is a candidate for transplant (See UNOS criteria under Surgical Assessment HCC-5) • Inadequate hepatic reserve • Tumor location Not a transplant candidate • Options: • Sorafenib(Child–Pugh Class A [category 1] or B) • Chemotherapy + RT only in the context of a clinical trial • Locoregional therapy • RT (conformal or stereotactic) (category 2B) • Supportive care • Systemic or intra-arterial chemotherapy in clinical trial Unresectable Extensive liver disease • Options: • Sorafenib(Child–Pugh Class A [category 1] or B) • Clinical trial • Locoregional therapy • RT (conformal or stereotactic) (category 2B) • Supportive care Inoperable by perfomance status or comorbidity, local disease or local disease with minimal extrahepatic disease only • Sorafenib(Child–Pugh Class A [category 1] or B) • Supportive care • Clinical trial Metastatic disease NCCN Clinical Practice Guidelines in Oncology. Hepatobiliary Cancer. V2.2012; Available from: www.nccn.orgAccessed on 30-March 2012 .

  5. APASL guidelines HCC Confined to the liver Main portal vein patent Extrahepatic metastasis Main portal vein tumor thrombus Resectable Child–Pugh A/B Child–Pugh C Sorafenib or systemic therapy trial Yes No Solitary tumor < 5 cm < 3 tumors < 3 cm No venous invasion Tumor > 5 cm > 3 tumors Invasion of hepatic / portal vein branches Resection/RFA (for < 3 cm HCC) Child–Pugh A Child–Pugh B Child–Pugh C Child–Pugh A/B Child–Pugh C Local ablation Transplantation TACE Supportive care APASL recommendations on HCC, Omata M, et al. Hepatol Int. 2010;4:439–474

  6. Consensus-based treatment algorithm for HCC proposed by JSH HCC EXTRAHEPATIC SPREAD No Yes LIVER fUNCTION Child-Pugh A/B Child-Pugh C Child-Pugh B/C Child-Pugh A VASCULAR INVASION No Yes No Yes Single *1, *2 ≥4 1-3 NUMBER Within Milan*7 criteria or age ≤65 Exceeding Milan criteria or age >65 Hypovascular Early HCC*3 ≤3 cm >3 cm SIZE TREATMENT • Intensive • follow up • Ablation • Resection • Ablation • Resection • TACE • TACE+ • Ablation*4 • TACE*5 • HAIC*5 • Resection*6 • Ablation*6 • HAIC (Vp3,4)*8 • Sorafenib (vp3,4)*8 • TACE (Vp1,2)*9 • Resection(Vp1,2)*9 • Transplantation • TACE/ablation • for Child-Pugh C • Patient *10 Palliative care Sorafenib Sorafenib*5 (TACE refractory,child-pugh A) Kudo et al. Dig Dis 2011;29:339–364

  7. AASLD guidelines Symptomatictreatment HCC Stage 0PS 0, Child–Pugh A Stage A–CPS 0–2, Child–Pugh A–B Stage DPS > 2, Child–Pugh C Very early stage (0) 1 HCC < 2 cmCarcinoma in situ Early stage (A) 1 HCC or 3 nodules< 3 cm, PS 0 Intermediate stage (B) Multinodular,PS 0 Advanced stage (C) Portal invasion, N1, M1, PS 1–2 End stage (D) 1 HCC 3 nodules ≤ 3 cm Portal pressure/bilirubin Increased Associated diseases Normal No Yes Resection Liver transplantation RFA TACE Sorafenib Curative treatments Palliative treatments PS, performance status; TACE, transarterial chemoembolization. Adapted from Bruix J, Sherman M. HEPATOLOGY, Vol. 53, No. 3, 2011.Available on: http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf

  8. HCC guidelines HCC Stage 0PS 0, Child–Pugh A Stage A–CPS 0–2, Child–Pugh A–B Stage DPS > 2, Child–Pugh C Very early stage (0) 1 HCC < 2 cmCarcinoma in situ Early stage (A) 1 HCC or 3 nodules< 3 cm, PS 0 Intermediate stage (B) Multinodular,PS 0 Advanced stage (C) Portal invasion, N1, M1, PS 1–2 End stage (D) 1 HCC 3 nodules ≤ 3 cm Portal pressure/bilirubin Increased Associated diseases Normal No Yes Resection Liver transplantation PEI/RFA TACE Sorafenib BSC Curative treatments (30%) 5-year survival (40–70%) Target: 20% OS: 20 mo (45-14) Target: 40% OS: 11 mo (6-14) Target: 10% OS: <3 mo PS, performance status; TACE, transarterialchemoembolization; BSC, Best Supportive Care EASL–EORTC ClinicalPracticeGuidelines: Management of hepatocellular carcinoma Journal of Hepatology 2012 vol. 56 j 908–943 Available on: http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf .

  9. Levels of evidence and grade of raccomandation 1 Levels of evidence(NCI) Sorafenib Chemoembolization RF (<5 cm), RF/PEI (<2 cm) Adjuvant therapy after resection Resection OLT-Milan 2 LDLT Internal radiation Y90 OLT-extended Neoadjuvant therapy in waiting list Downstaging 3 External/palliative radiotherapy C B A C B A 1 (strong) 2 (weak) Grade of recommendation (GRADE) EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma Journal of Hepatology 2012 vol. 56 j 908–943 Available on: http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf

  10. Algorithm for resection in HCC patients Cirrhotic: patienteligible for liverresection MELD score 9 - 10 >10 <9 Serumsodiumlevel ≥ 140 mEq/L < 140 mEq/L Major hepatectomy(up to 4 segment) Segmentectomy or bisegmentectomy Segmentectomy or limitedresection Risk of IPLF>15% in alltypes of hepatectomy Raccomandazioni AISF per la gestione integrata del paziente con Epatocarcinoma; published on www.webaisf.org Available on: http://www.webaisf.org/media/16110/raccomandazioni-aisf-per-hcc.pdf Accessed on 30-March 2012

  11. Treatment algorithm for the repetition of TACE in intermediate stage HCC patients TACE candidate No portalveinthrombosis (acceptedsegmentalthrombosis) No extra-epatic spread; Child PughA or B7 cTACE or DEB-TACE Liverdeterioration, major complication* CR *** MRI or CT ** (at 1 month) No Resolution cTACE or DEB-TACE BSC Sì MRI or CT ** (at 1 month) MRI or CT Every 3 months ProgressionDisease (PD) *** or StableDisease(SD) *** PR *** Relapse*** New nodule Growth of target nodule or SD*** Consider other treatment (cTACE or DEB-TACE) Consider SORAFENIB * : each TACE; ** : with cTACE, MRI is preferred to CT *** : Response must be assessed by modified RECIST criteria [CR: Complete Response; PR: Partial Response; SD: Stable Disease; PD: Progression Disease]. Raccomandazioni AISF per la gestione integrata del paziente con Epatocarcinoma; published on www.webaisf.org Available on: http://www.webaisf.org/media/16110/raccomandazioni-aisf-per-hcc.pdf Accessed on 30-March 2012

  12. Trial design strategies and control groups EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma Journal of Hepatology 2012 vol. 56 j 908–943 Available on: http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711

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