Facilitating Care for Patients With Early Stage Hepatocellular Carcinoma
In patients with very early hepatocellular carcinoma, percutaneous ablation or liver resection are the recommended first line therapies.
A proposed algorithm to facilitate the decision-making process of clinical care for patients with very early stage hepatocellular carcinoma (HCC) provides optimal personalized treatment strategies for these patients, according to a review published in the Journal of Hepatology.
The current evidence that compares curative options for patients with very early HCC is poor due to small sample sizes and lack of solid subgroup analyses. Therefore, Alessandro Vitale, MD, PhD, from the Department of Surgery, Oncology, and Gastroenterology at the University of Padua in Italy, and colleagues reviewed the data on the management of early HCC from randomized and nonrandomized comparative studies, prognostic studies, and simulation effectiveness studies to define optimal personalized treatment strategies for this patient population.
“In this era of ‘precision medicine,'” the authors of the review wrote, “a ‘personalized approach' to very early HCC should be based on not only the traditional EBM [evidence based medicine] model, but also all the data from the literature that could be extracted for the individual patient setting. This way, the therapeutic decision could be made in the context of individual, patient-specific cases.”
The investigators proposed an algorithm to facilitate the decision-making process of clinical care for patients with very early HCC. “The aim of the algorithm is not to represent a definitive treatment guideline, but rather to provide a readily available guide to the clinician as an example of a personalized approach to very early HCC based on the available evidence.”
They note 3 considerations:
- Comparative efficacy studies show that liver resection offers better disease-free survival than radiofrequency ablation at the price of higher postoperative morbidity. Larger comparative effectiveness studies show that the difference in disease-free survival translates into a significantly higher long-term survival after liver resection compared with radiofrequency ablation among well-selected patients with very early HCC.
- Laparoscopic ablation has the potential to overcome some limits of percutaneous ablation, particularly in patients with very early HCC in high risk locations.
- Liver transplantation has the lowest survival benefit among patients with very early HCC compared with patients who have HCC in more advanced stages.
Based on these considerations, liver resection is most likely justified as first-line therapy only when the risk of postoperative liver decompensation is comparable to that of nonresection approaches. Laparoscopic surgery is preferred when the tumor is in the surface of the liver or close to extra-hepatic organs
In addition, transplantation is recommended only as a second-line therapy in case of tumor recurrence or liver failure after ablation or liver resection due to scarce donor resources and competition with patients with high transplant benefit
The authors of the study note that although very early HCC may be the easiest stage of HCC to treat, clinical expertise can make a distinct difference in outcomes for these patients. Personalized treatment of very early HCC should integrate individual clinical expertise with the best available clinical evidence from systematic research.
Vitale A, Peck-Radosavljevic M, Giannini EG, et al. Personalized treatment of patients with very early hepatocellular carcinoma. J Hepatol. 2017;66:412-423. doi: 10.1016/j.jhep.2016.09.012