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Systemic treatment for advanced hepatocellular carcinoma

Author
Keith E Stuart, MD
Section Editor
Richard M Goldberg, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

Hepatocellular carcinoma (HCC) is an aggressive tumor that frequently occurs in the setting of chronic liver disease and cirrhosis. It is typically diagnosed late in the course of patients with chronic liver disease [1]. The patient's hepatic reserve, as indicated by the Child-Pugh (CP) classification, often dictates therapeutic options (table 1).

Treatment options for HCC are divided into surgical therapies (ie, resection, cryoablation, and liver transplantation) and nonsurgical therapies, which may be liver-directed (ie, percutaneous ethanol injection, radiofrequency ablation, transarterial chemoembolization, radiation and radioembolization) or systemic (chemotherapy, molecularly targeted therapy, hormone therapy). A general approach to the treatment of HCC is shown in the figure (algorithm 1). An alternative treatment algorithm has been proposed by the Barcelona group (algorithm 2) [2].

Attempts to generate algorithmic approaches to the treatment of HCC are difficult since new treatments and indications for various treatments are evolving rapidly. Furthermore, therapeutic approaches tend to vary based upon the available expertise as well as variability in the criteria for hepatic resection and liver transplantation. These issues and a general approach to treatment of HCC are discussed in detail elsewhere. (See "Overview of treatment approaches for hepatocellular carcinoma".)

Here we will discuss systemic treatment approaches for patients with advanced, unresectable HCC for whom liver-directed therapy is not appropriate. Surgical treatment, liver-directed nonsurgical therapies, and the epidemiology, clinical manifestations, and diagnosis of HCC are reviewed separately. (See appropriate topic reviews.)

GENERAL CONSIDERATIONS

Palliative chemotherapy has not been used routinely for patients with advanced HCC for a number of reasons:

                                           

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