1. Epidemiology & First option of treatment
Do Young Kim
Department of Internal Medicine,
Yonsei University College of Medicine

2. Epidemiology

3. High HCC incidence in Eastern Asia
Source:
GLOBOCAN 2008

4. Top 10 Cancer incidence in Korea: 2012

5. HCC; incidence and prevalence
Source: 2012
National Cancer Statistics (2014)

6. Trend of age-standardized incidence of HCC
( )

7. Trends of incidence and mortality in HCC
(Age-standardized)
Source: National Cancer Statistics (2013)

8. 5-year survival rates of major cancers in Korea
The 5-year survival rate is still very poor, and the median survival time of HCC patients is only about 2-years.
Thus, the incidence rate of HCC is almost equals to the mortality rate.
Stomach Lung Colon Liver Thyroid Breast Ut. Cx Biliary Pancreas Prostate

9. Korean nationwide
HCC registry data

10. Courtesy of Dr. Lim YS

11. Methods Total HCC Registry (2003-2005) 31,521 Random Sample Sample (N)
5,252
16.7%
Abstraction Possible
4,630
14.7%
88.2%
Real Abstraction*
4,522
14.3%
86.1%
KLCSG Voluntary Report
Report (N)
Analysis (%)
Total Report
4,578
14.5%
Analysis Possible*
4,311
13.7%
94.4%
* Exclusions for miss-Dx, duplication, miss-data
Courtesy of Dr. Lim YS

12. HCC characteristics - Age & Gender-
P = 0.41 %
Random
Voluntary P
Age
57.1 ± 10.8
56.8 ± 10.7
0.14
100 80
Female 60
Male 40 20
Random
Voluntary
Courtesy of Dr. Lim YS

13. Liver function & Tumor stage
Child-Pugh Class
TNM Stage (UICC v.6)
P<0.001
P<0.001
100%
100%
80%
80% IV
60%
60% C
III B II
40% A
40% I
20%
20% 0% 0%
Random
Voluntary
Random
Voluntary
Courtesy of Dr. Lim YS

14. Cause & Treatment Associated Disease First Treatment P<0.001
100%
100%
80%
80%
Systemic Tx
60%
Others
60%
EBRT
Alcohol
Transarterial Tx
HCV
Local Ablation
40%
HBV
40% LT
Resection
20%
20% 0% 0%
Random
Voluntary
Random
Voluntary
Courtesy of Dr. Lim YS

15. Overall survival Survival Years after Diagnosis Voluntary Reporting
(median surv. 29 mo.) %
100
Random Statutory
(median surv. 17 mo.) 80
66.6% 60
53.6%
44.6%
Survival
54.9%
38.6% 40
32.9%
42.5%
35.0%
31.1%
29.6% 20
P<0.001 1 2 3 4 5
Years after Diagnosis
Courtesy of Dr. Lim YS

16. First option of treatment

17. HCC staging: AASLD guidelines (updated 2010)
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
HCC
Portal pressure/ bilirubin
Adapted from Bruix J, Sherman M. Hepatology Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf.
Llovet JM, et al. J Natl Cancer Inst. 2008;100:698–711.
AASLD = American Association for the Study of Liver Diseases; PEI = percutaneous ethanol injection;
PST = Performance Status test; RFA = radiofrequency ablation.

18. 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
Yes No
Solitary tumor ≤ 5 cm
≤ 3 tumors ≤ 3 cm
No venous invasion
Tumor > 5 cm > 3 tumors
Invasion of hepatic/portal vein branches
Child–Pugh A
Child–Pugh B
Sorafenib or systemic therapy trial
Resection/RFA (for < 3 cm HCC)
Local ablation
Transplantation
TACE
Supportive care
APASL recommendations on HCC. Omata M, et al. Hepatol Int. 2010;4:439–74.

19. Japan Society of Hepatology: consensus-based treatment algorithm for HCC
Extrahepatic spread No
Yes
Liver function
Child–Pugh A/B
Child–Pugh C
Child–Pugh B/C
Child–Pugh A
Vessel invasion No
Yes No
Yes
Number
Single
1–3
4 or more
Within Milan criteria and age ≤ 65
Within Milan criteria and age ≤ 65
Exceeding Milan criteria or age > 65
Hypovascular early HCC
Size
≤ 3 cm
> 3 cm
Intensive follow-up Ablation
Resection Ablation
Resection TACE (TACE + ablation)
TACE HAIC
(resection + ablation)
Transplantation (TACE/ablation for Child–Pugh C patients)
Sorafenib
HAIC
TACE
Resection
Transplantation (TACE/ablation for Child–Pugh C patients)
Palliative care
Sorafenib
Treatment
Sorafenib
(TACE refractory)
TAI = hepatic arterial infusion chemotherapy.
Kudo M, et al. Dig Dis. 2011;29:339–364.

20. First-line treatment option in each mUICC stage

21. Single, less than 2cm HCC, Child-A, no or minimal portal hypertension
(BCLC-0)
Resection vs. RFA; many studies
LT?

22. Single, more than 2cm HCC
(BCLC-A)
In case within Milan criteria

23. Multiple, less than 2cm HCC
(BCLC-A or B)
In case above Milan criteria

24. Single, less than 2cm HCC with vascular invasion (BCLC-C)
According to Western guidelines
Unusual presentation. Practically TACE preferred,
Resection vs. TACE?

25. Multiple, more than 2cm HCC (BCLC-B or A)
Mostly TACE,
LT or RFA: limitedly applied

26. Hong Kong Liver Cancer (HKLC) classification
Yau T, et al. Gastroenterology 2014

27. Single, more than 2cm HCC with vascular invasion (BCLC-C)
Which modality is the best for this kind of HCC?
No data

28. Multiple, less than 2cm HCC with vascular invasion (BCLC-C)
Resection
TACE may be preferred because of small tumor size

29. Advanced HCC without extrahepatic spread (BCLC-C)
Only sorafenib has evidence.

30. Competitor (I)

31. Competitor (II)

32. Competitor (III)
Gastroenterology 2010

33. HCC with extrahepatic spread
(BCLC-C)

34. Conclusions HCC incidence in Korea is slightly decreasing.
Still a major cancer related with significant mortality
Prognosis is being improved due to proper management
Selection of first treatment option does not always depend on evidence.
Guideline are just guidelines.
Heterogeneity of HCC presentation makes it difficult to keep algorithm for selecting treatment option.

35. Thank you for attention