Treatment of Intermediate Stage Hepatocellular Carcinoma – from Guidelines and Beyond

Hepatocellular carcinoma (HCC) BCLC-B class is characterized by an extensive heterogeneity due to the wide range of liver function (Child Pugh A or B cirrhosis) and variable lesion number and size. With this regard, hepatologists must develop a better stratification of this HCC stage for patients to benefit from a better treatment allocation. Trans-arterial chemo-embolization (TACE) procedure is the most widely used therapeutic option for intermediate stage HCC. One therapy is not beneficial unless clinicians might predict its outcome. Along these lines, several predictive factors for the TACE success have emerged such as mRECIST criteria, HAP and mHAP, Munich and CHIP score. The overall survival (OS) after the TACE procedure is around 16 months and in rigorous selected candidates, might increase the survival up to 3 years. Nevertheless, in some BCLC B patients, other therapies have proved their benefit compared to TACE. Resection and liver transplantation when technically possible is associated with an increased OS versus TACE. Moreover, astounding results have arisen from the combination of TACE with radiofrequency ablation. However, the literature fails to support the use of multi-kinase inhibitors in combination with TACE. Selective internal radiation therapy (SIRT) also known as radioembolization (TARE) induces fewer side effects and maintains a better tumoral control than TACE, but it is less available worldwide and is less cost-efficient. In conclusion, navigating through all these treatment options, we believe that intermediate stage HCC has to be managed in a personalized way for each patient in order to have the best outcome.

Keywords: Hepatocellular carcinoma, Intermediate stage BCLC B, TACE