2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Keywords: Carcinoma, hepatocellular; Diagnosis; Guidelines; Management.

Fig. 1. Crude death rate and age-standardized death rate in Korea in calendar years 1999 to 2013.

Fig. 2. Annual number of liver cancer deaths, liver disease deaths and LTs in Korea during calendar years 1999 to 2013.

LT = liver transplantation

Fig. 3. Typical hallmarks of HCC (arrows) on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid MRI.

A. T2-weighted image. B. Diffusion-weighted image. C. Non-contrast image. D. Arterial phase image. E. Portal phase image. F. Delayed phase image. G. Hepatobiliary phase image. HCC = hepatocellular carcinoma, MRI = magnetic resonance imaging

Fig. 4. Diagnostic algorithm and recall policy in patients with high risk of HCC.

^*Major imaging features for “definite” diagnosis of HCC are defined as arterial phase hyperenhancement with washout in portal venous, delayed or hepatobiliary phases. These criteria should be applied only to lesion which does not show either marked T2 hyperintensity or targetoid appearance on diffusion-weighted images or contrast-enhanced sequence on contrast-enhanced US as second line exams, major imaging features include arterial hyperenhancement and mild washout with late onset (≥ 60 seconds), ^†In nodule(s) with some but not all of aforementioned major imaging features of HCC, category of “probable” HCC can be assigned only when lesion fulfills at least one item from each of following two categories of ancillary imaging features. Two categories which make up ancillary imaging features are findings favoring malignancy in general (mild-to-moderate T2 hyperintensity, restricted diffusion, hepatobiliary phase hypointensity, interval growth) and those favoring HCC in particular (non-enhancing capsule, mosaic architecture, nodule-in-nodule appearance, fat or blood products in mass). These criteria should be applied only to lesion which shows neither marked T2 hyperintensity nor targetoid appearance on diffusion-weighted images or contrast-enhanced sequences. CHB = chronic hepatitis B, CHC = chronic hepatitis C, CT = computed tomography, ECF = extracellular fluid, EOB = gadolinium ethoxybenzyl diethylenetriamine pentaacetate, LC = liver cirrhosis, US = ultrasonography

Fig. 5. First-line treatment recommendations from 2018 Korean Liver Cancer Association-National Cancer Center, Korea Practice Guidelines for Patients with HCC, Child-Pugh class A, no portal hypertension, and Eastern Cooperative Oncology Group 0–1.

EBRT = external beam radiation therapy, LRT = locoregional therapy, LT = liver transplantation, mUICC = modified Union for International Cancer Control, other LRT = percutaneous ethanol injection, microwave ablation, and cryoablation, RFA = radiofrequency ablation, TACE = transarterial chemoembolization, TARE = transarterial embolization, VI = vascular or bile duct invasion, Vp = portal vein invasion