Carcinoma
hepatocelular:
Estadio
inicial
Alejandro
Forner
BCLC
Group.
Liver
Unit.
Hospital
Clínic.
CIBERedh.
University
of
Barcelona
VI
CURSO
DE
RESIDENTES
AEEH
Barcelona,
10-‐11
Noviembre
2017
Question
#1
Respecto
al
hepatocarcinomaen
estadio
inicial,
señale
usted
la
respuesta
incorrecta:
1.-‐ Es
posible
su
diagnóstico
mediante
técnicas
de
imagen
sin
necesidad
de
realizar
una
biopsia
2.-‐ Con
los
tratamientos
disponibles
es
posible
obtener
una
supervivencia
a
5
años
superior
al
50%
3.-‐ Es
aceptable
una
mortalidad
intraoperatoriadel
5%
en
aquellos
pacientes
afectos
de
CHC
inicial
tratados
mediante
resección
quirúrgica
4.-‐ La
función
hepática
es
un
parámetro
fundamental
para
elegir
la
mejor
opción
terapéutica.
Early
stage
(A)
Single
or
3
nodules
<
3cm
Preserved
liver
function*,
PS
0
Portal
pressure
Bilirubin
Solitary 3
nodules
≤3cm
Associated
diseasesIncreased
No Yes
Potential
candidate
for
liver
transplantation
No Yes
Normal
Effective treatmentswith impact on survival
Intermediate
stage
(B)
Multinodular
Preserved
liver
function*,
PS
0
Advanced
stage
(C)
Portal
invasion
Extrahepatic spread
Preserved
liver
function*,
PS
1-‐2
HCC
Terminal
stage
(D)
End-‐stage
liver
function**
PS
3-‐4
Very
early
stage
(0)
Single<
2cm
Preserved
liver
function*,
PS
0
Tr
ea
tm
en
t
Pr
og
no
si
s
*This
term
includes
a
heterogeneous
group
of
patients
with
different
degree
of
liver
function
reserve
that
has
to
be
carefully
evaluated.
For
most
treatment
options,
compensated
liver
disease
(Child-‐Pugh
A
without
ascites)
is
requested
to
obtain
optimal
outcomes.
The
sole
option
that
may
be
applied
irrespective
of
liver
function
is
liver
transplant.
Most
of
them
are
compensated
and
fitting
into
the
Chilld-‐Pugh
stage
A.**Patients
with
end
stage
cirrhosis
due
to
heavily
impaired
liver
function
(Child-‐Pugh
C
or
earlier
stages
with
predictors
of
poor
prognosis,
high
MELD
score)
should
be
considered
for
liver
transplantation.
In
them
HCC
may
become
a
contraindication
if
exceeding
the
enlistment
criteria.
***Currently sorafenib
followed by regorafenib has
been shown to
be
effective.
lenvatinib has
been shown to
be
non-‐inferior
to
sorafenib,
but no
effective second line
option after lenvatinib has
been
explored.
Chemoembolization Systemictherapy***TransplantResectionAblation Ablation
BSC
>5 years >2.5
years >1
year 3
months
Su
rv
iv
al
BCLC
Staging
and
Treatment
Strategy,
2017
Forner
A,
Reig ME,
Bruix J.
Lancet.
2017.
Accepted.
>5 years
Early
stage
(A)
Single
or
3
nodules
<
3cm
Preserved
liver
function*,
PS
0
Portal
pressure
Bilirubin
Solitary 3
nodules
≤3cm
Associated
diseasesIncreased
No Yes
Potential
candidate
for
liver
transplantation
No Yes
Normal
Effective treatmentswith impact on survival
HCC
Very
early
stage
(0)
Single<
2cm
Preserved
liver
function*,
PS
0
Tr
ea
tm
en
t
Pr
og
no
si
s
*This
term
includes
a
heterogeneous
group
of
patients
with
different
degree
of
liver
function
reserve
that
has
to
be
carefully
evaluated.
For
most
treatment
options,
compensated
liver
disease
(Child-‐Pugh
A
without
ascites)
is
requested
to
obtain
optimal
outcomes.
The
sole
option
that
may
be
applied
irrespective
of
liver
function
is
liver
transplant.
Most
of
them
are
compensated
and
fitting
into
the
Chilld-‐Pugh
stage
A.**Patients
with
end
stage
cirrhosis
due
to
heavily
impaired
liver
function
(Child-‐Pugh
C
or
earlier
stages
with
predictors
of
poor
prognosis,
high
MELD
score)
should
be
considered
for
liver
transplantation.
In
them
HCC
may
become
a
contraindication
if
exceeding
the
enlistment
criteria.
***Currently sorafenib
followed by regorafenib has
been shown to
be
effective.
lenvatinib has
been shown to
be
non-‐inferior
to
sorafenib,
but no
effective second line
option after lenvatinib has
been
explored.
TransplantResectionAblation Ablation
Su
rv
iv
al
Forner
A,
Reig ME,
Bruix J.
Lancet.
2017.
Accepted.
Natural
history:
Unknown
Survival:
12-‐65%
at
3
years
BCLC
Staging
and
Treatment
Strategy,
2017
EASL–EORTC
Clinical
Practice
Guidelines.
J
Hepatol.
2012:56(4);908-‐43
3
2
1
2
(weak) 1
(strong)
Grade
of
recommendation
Levels
of
evidence
Sorafenib
Chemoembolization
RF
>5 years
Portal
pressure
Bilirubin
Potential
candidate
for
liver
transplantation
No Yes
Normal
Effective treatmentswith impact on survival
HCC
Very
early
stage
(0)
Single<
2cm
Preserved
liver
function*,
PS
0
Tr
ea
tm
en
t
Pr
og
no
si
s
*This
term
includes
a
heterogeneous
group
of
patients
with
different
degree
of
liver
function
reserve
that
has
to
be
carefully
evaluated.
For
most
treatment
options,
compensated
liver
disease
(Child-‐Pugh
A
without
ascites)
is
requested
to
obtain
optimal
outcomes.
The
sole
option
that
may
be
applied
irrespective
of
liver
function
is
liver
transplant.
Most
of
them
are
compensated
and
fitting
into
the
Chilld-‐Pugh
stage
A.**Patients
with
end
stage
cirrhosis
due
to
heavily
impaired
liver
function
(Child-‐Pugh
C
or
earlier
stages
with
predictors
of
poor
prognosis,
high
MELD
score)
should
be
considered
for
liver
transplantation.
In
them
HCC
may
become
a
contraindication
if
exceeding
the
enlistment
criteria.
***Currently sorafenib
followed by regorafenib has
been shown to
be
effective.
lenvatinib has
been shown to
be
non-‐inferior
to
sorafenib,
but no
effective second line
option after lenvatinib has
been
explored.
ResectionAblation
Su
rv
iv
al
Forner
A,
Reig ME,
Bruix J.
Lancet.
2017.
Accepted.
BCLC
Staging
and
Treatment
Strategy,
2017
Tumor
cell invasion into the portal
vein
and
minute
intrahepatic metastases in
the vicinity of
the tumor
are
observed in
27%
and
10%
of
distinctly nodular
small
HCCs,
respectively,
but not observed in
indistinctly nodular
small HCCs
Prognostic
scoring
systems
for
HCC
Very
early
HCC
KojiroM,
Roskams T.
Semin Liver
Dis.
2005;25:133-‐142.
Hasegawa K
et
al.
J
Hepatol 2013;58:724-‐729.
Patients
CP-‐A
(n=785)
5-‐year
survival:
83.9%
Si
ng
le
tu
m
or
<
2c
m
CP-‐A
and
platelet
>150,000/mm3 (n=66)
5-‐year
survival:
81%
Roayaie S.
et
al.
Hepatology 2013:57(4):1426-‐35.
Overall
Survival
Rate
(%)
Study No.
of
patients 1
year 3
year 5
year
Lencioni et
al.
2005
Child-‐Pugh
A 144 100% 76% 51%
Child-‐Pugh
B 43 89% 46% 31%
Tateishi et
al.
2005
Chil
