HCC Guidelines 2011 1

NCCN guidelines Clinical presentation Treatment Surveillance Imaging every 3–6 months for 2 years, then annually AFP, if initially elevated, every 3 months for 2 years, then every 6 months Transplant candidate Evaluate whether patient is a candidate for transplant (See UNOS criteria under Surgical Assessment HCC-4)b Transplant Inadequate hepatic reserve Tumor location Options: Sorafenib (Child–Pugh Class A [category 1] or B) Chemotherapy + RT only in the context of a clinical trial Clinical trial Locoregional therapy RT (conformal or stereotactic) (category 2B) Supportive care Systemic or intra-arterial chemotherapy in clinical trial Not a transplant candidate Unresectable Extensive liver disease Options: Sorafenib (Child–Pugh Class A [category 1] or B) Clinical trial Locoregional therapy RT (conformal or stereotactic) (category 2B) Supportive care Inoperable by perfomance status or comorbidity, local disease only Sorafenib (Child–Pugh Class A [category 1] or B) Supportive care Clinical trial Metastatic disease NCCN Clinical Practice Guidelines in Oncology. Hepatobiliary Cancer. V2.2010; Available from: www.nccn.org.

Sorafenib or systemic therapy trial Resection/RFA (for < 3 cm HCC) APASL guidelines HCC Confined to the liver Main portal vein patent Extrahepatic metastasis Main portal vein tumor thrombus Resectable Child–Pugh A/B Child–Pugh C Sorafenib or systemic therapy trial Yes No Solitary tumor < 5 cm < 3 tumors < 3 cm No venous invasion Tumor > 5 cm > 3 tumors Invasion of hepatic / portal vein branches Resection/RFA (for < 3 cm HCC) Child–Pugh A Child–Pugh B Child–Pugh C Child–Pugh A/B Child–Pugh C Local ablation Transplantation TACE Supportive care APASL recommendations on HCC, Omata M, et al. Hepatol Int. 2010;4:439–474

AASLD guidelines HCC Portal pressure/ bilirubin PEI/RFA Sorafenib Stage 0 PST 0, Child–Pugh A Very early stage (0) 1 HCC < 2 cm Carcinoma in situ Early stage (A) 1 HCC or 3 nodules < 3 cm, PST 0 End stage (D) Liver transplantation TACE Resection Symptomatic treatment (20%) Survival < 3 months Curative treatments (30%) 5-year survival (40–70%) Palliative treatments (50%) Median survival 11–20 months Associated diseases Yes No 3 nodules ≤ 3 cm Increased Normal 1 HCC Stage D PST > 2, Child–Pugh C Intermediate stage (B) Multinodular, PST 0 Advanced stage (C) Portal invasion, N1, M1, PST 1–2 Stage A–C PST 0–2, Child–Pugh A–B Adapted from Bruix J, Sherman M. Hepatology. In press 2010. Available from http://www.aasld.org. Last accessed September 2010. Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711.

BCLC guidelines HCC Portal pressure/ bilirubin PEI/RFA Sorafenib Stage 0 PST 0, Child–Pugh A Very early stage (0) 1 HCC < 2 cm Carcinoma in situ Early stage (A) 1 HCC or 3 nodules < 3 cm, PST 0 End stage (D) Liver transplantation TACE Resection Symptomatic treatment (20%) Survival < 3 months Curative treatments (30%) 5-year survival (40–70%) Palliative treatments (50%) Median survival 11–20 months Associated diseases Yes No 3 nodules ≤ 3 cm Increased Normal 1 HCC Stage D PST > 2, Child–Pugh C Intermediate stage (B) Multinodular, PST 0 Advanced stage (C) Portal invasion, N1, M1, PST 1–2 Stage A–C PST 0–2, Child–Pugh A–B Adapted from Bruix J, Sherman M. Hepatology. In press 2010. Available from http://www.aasld.org. Last accessed September 2010. Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711.