Hepatocellular Carcinoma

The answer first

Hepatocellular carcinoma (HCC) is a primary malignancy of the hepatocyte that arises, in the great majority of cases, on the background of cirrhosis. It is the sixth most common cancer worldwide and the third leading cause of cancer-related death. Its incidence is rising, driven by the non-alcoholic fatty liver disease (NAFLD/MASLD) epidemic in Western populations alongside persistent HBV and HCV burdens globally [1].

The single organising principle: HCC management is driven by the Barcelona Clinic Liver Cancer (BCLC) staging system, which links tumour burden, liver function (Child-Pugh score) and performance status (ECOG) to a treatment allocation. Know the BCLC algorithm and you know HCC. Everything else — surveillance, LI-RADS imaging, the systemic therapy ladder — feeds into the staging decision [2][1].

The treatment ladder, by stage: [1]

• BCLC 0 (very early) and BCLC A (early) — curative: resection, thermal ablation (RFA or MWA), or liver transplant (within Milan criteria).
• BCLC B (intermediate) — transarterial chemoembolisation (TACE) for multinodular disease without vascular invasion.
• BCLC C (advanced) — systemic therapy: first-line atezolizumab plus bevacizumab (for Child-Pugh A), or sorafenib or lenvatinib as single-agent TKI alternatives; second-line regorafenib, cabozantinib, or ramucirumab.
• BCLC D (terminal) — best supportive care. [1]

DWE high-yield: The answer to almost every HCC management question is "apply the BCLC stage." A cirrhotic patient with a single lesion under 5 cm, Child-Pugh A and ECOG 0 is BCLC A — curative therapy (resection, ablation, or transplant). A patient with portal vein invasion is BCLC C — systemic therapy. A patient with Child-Pugh C and no transplant option is BCLC D — best supportive care [2][1].

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References7Show ledgerHide ledger

1. [1]Llovet JM, Kelley RK, Villanueva A, et al. Hepatocellular carcinoma Nat Rev Dis Primers, 2021.PMID 33479224
2. [2]Marrero JA, Kulik LM, Sirlin CB, et al. Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases Hepatology, 2018.PMID 29624699
3. [3]Singal AG, Pillai A, Tiro J Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis PLoS Med, 2014.PMID 24691105
4. [4]Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma N Engl J Med, 2008.PMID 18650514
5. [5]Finn RS, Qin S, Ikeda M, et al. Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma N Engl J Med, 2020.PMID 32402160
6. [6]Kudo M, Finn RS, Qin S, et al. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial Lancet, 2018.PMID 29433850
7. [7]Bruix J, Qin S, Merle P, et al. Regorafenib for patients with hepatocellular carcinoma who progressed on sorafenib treatment (RESORCE): a randomised, double-blind, placebo-controlled, phase 3 trial Lancet, 2017.PMID 27932229