Overview of treatment algorithm for hepatocellular carcinoma

PVE: portal vein embolization; TACE: transcatheter arterial chemoembolization; PVTT: portal vein tumor thrombus; HAIC: hepatic arterial infusional chemotherapy; TARE: transarterial radioembolization; SBRT: stereotactic body radiation therapy; RFA: radiofrequency ablation; HCC: hepatocellular carcinoma.

* Selected patients with Child-Pugh class B cirrhosis may be amenable to limited resection.

¶ Bridging therapy refers to the administration of local treatment (typically RFA or TACE) while awaiting orthotopic liver transplantation in order to reduce risk of progressing beyond Milan criteria.

Δ In the United States, patients with underlying chronic liver disease (cirrhosis, hepatitis C virus infection) are potentially eligible for orthotopic liver transplant if they fulfill the Milan criteria (ie, solitary HCC ≤5 cm in diameter or up to three separate lesions none of which is larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases). Patients who meet extended liver transplantation criteria may undergo downstaging therapy (eg, RFA, arterially-directed therapies) followed by reassessment for liver transplantation.

◊ Options for initial systemic therapy include participation in a clinical trial (preferred), atezolizumab plus bevacizumab, durvalumab plus tremelimumab, sorafenib, or lenvatinib (refer to UpToDate text).