The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021

Abstract

Background and Objective Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used. Methods In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018. Key Content and Findings The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence. Conclusions Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.

Clinical practice guidelines and real-life practice on hepatocellular carcinoma: the Hong Kong perspective

“…The HKLC Staging System is recommended as the staging system of choice in the Hong Kong Consensus Guidelines. 5 The HKLC Staging was developed in 2014 with data from 3856 HCC patients in Hong Kong. The rationale for developing the HKLC Staging was to account for the high HBV prevalence and generally more aggressive treatment approach in Hong Kong.…”

“…For limited extrahepatic metastasis and bilobar disease, the predominant HCC lesion can be resected, while the extrahepatic metastasis or contralateral liver lobe nodules can be managed by resection or ablation. 5 Local ablation is recommended as an alternative to resection in Child-Pugh A/B patients with HCC <3cm. The options of radiofrequency ablation (RFA), microwave ablation (MWA), highintensity focused ultrasound (HIFU), and cryoablation are all suitable, whereas percutaneous ethanol injection is less preferred due to lower complete ablation rates and higher recurrence rates.…”

“…The options of radiofrequency ablation (RFA), microwave ablation (MWA), highintensity focused ultrasound (HIFU), and cryoablation are all suitable, whereas percutaneous ethanol injection is less preferred due to lower complete ablation rates and higher recurrence rates. 5…”

“…Liver transplantation is recommended by the Hong Kong Consensus in patients with poor liver function, as it can treat both HCC and cirrhosis. 5 The guidelines recommend patient selection for transplant by the University of California San Francisco (UCSF) criteria -Solitary tumor <6.5cm; or <3 tumor nodules with largest lesion <4.5cm with total tumor diameter <8.0 cm. 27 For patients waitlisted for transplant, options of bridging therapy include local ablation, transarterial chemoembolization (TACE), transarterial radioembolization (TARE) and stereotactic body radiation therapy (SBRT).…”

“…The management framework of HCC in Hong Kong is depicted in Figure 1. The key guidelines covered include (1) Recommendations on Prevention and Screening for Liver Cancer for Health Professionals (Published in 2018); 4 (2) The Hong Kong Liver Cancer (HKLC) Staging system (Published in 2014); 3 (3) The Hong Kong Consensus Statement on the Management of Hepatocellular Carcinoma (Hong Kong Consensus) (Published in 2022); 5…”