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Staging Strategy and Treatment for Patients With HCC

Staging Strategy and Treatment for Patients With HCC. HCC. PST 0-2, Child-Pugh A-B. PST 0, Child-Pugh A. PST > 2, Child-Pugh C. Very early stage. Early stage. Intermediate stage. Advanced stage. Terminal stage. Single < 2 cm. Single or 3 nodules. Multinodular, PST 0. Portal invasion,.

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Staging Strategy and Treatment for Patients With HCC

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  1. Staging Strategy and Treatment for Patients With HCC HCC PST 0-2, Child-Pugh A-B PST 0, Child-Pugh A PST > 2,Child-Pugh C Very early stage Early stage Intermediate stage Advanced stage Terminalstage Single < 2 cm Single or 3 nodules Multinodular, PST 0 Portal invasion, ≤ 3 cm, PST 0 N1, M1, PST 1-2 Single 3 nodules ≤ 3 cm Portal pressure/bilirubin Associated Increased diseases Normal No Yes Resection Liver transplant RFA/PEI TACE Sorafenib Curative treatments Palliative treatments Symptomatic Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects.Semin Liver Dis. 2010;30(1):61-74

  2. BCLC Staging and Treatment Strategy HCC Okuda 1-2, PS 0-2, Child-Pugh A-B PS 0, Child-Pugh A Okuda 3, PS > 2,Child-Pugh C Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminalstage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Single 3 nodules ≤ 3 cm Portal pressure/bilirubin Associated Increased diseases Normal No Yes Symptomatic (20%); survival < 3 mos Resection Liver transplantation RFA/PEI TACE Sorafenib Curative treatments (30%); 5-yr survival: 40%-70% RCTs (50%); 3-yr survival: 10%-40% Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

  3. BCLC Staging System HCC Stage 0 Stage A-C Stage D Okuda 3, PS > 2,Child-Pugh C Okuda 1-2, PS 0-2, Child-Pugh A-B PS 0, Child-Pugh A Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminalstage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

  4. Liver Transplantation for HCC:Milan Criteria (Stage 1 and 2) • 5-yr survival with transplantation: ~ 70% • 5-yr recurrent rates: < 15% Single tumor, not > 5 cm Up to 3 tumors, none > 3 cm + Absence of macroscopic vascular invasion, absence of extrahepatic spread Mazzaferro V, et al. N Engl J Med. 1996;334:693-699. Llovet JM. J GastroenterolHepatol. 2002;17(suppl 3):S428-S433.

  5. Candidates for RFA/PEI • Includes individuals who are not candidates for surgery • Radiofrequency ablation generally preferred over percutaneous ethanol injection • Necrotic effect more predictable across tumor sizes • Meta-analyses suggest survival benefit with radiofrequency ablation vs percutaneous ethanol injection Bruix J, et al. AASLD HCC guidelines. July 2010.

  6. BCLC Staging and Treatment Strategy HCC Okuda 1-2, PS 0-2, Child-Pugh A-B PS 0, Child-Pugh A Okuda 3, PS > 2,Child-Pugh C Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminalstage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Single 3 nodules ≤ 3 cm Unresectable HCC Portal pressure/bilirubin Associated Increased diseases Normal No Yes Symptomatic (20%); survival < 3 mos Resection Liver transplantation RFA/PEI TACE Sorafenib Curative treatments (30%); 5-yr survival: 40%-70% RCTs (50%); 3-yr survival: 10%-40% Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

  7. Arterial Embolization for HCCMeta-analysis of 6 RCTs (2-Yr Survival) Random Effects Model, OR (95% CI) Author, Journal Yr Patients, n Lin, Gastroenterology 1988 63 GETCH, NEJM 1995 96 Bruix, Hepatology 1998 80 Pelletier, J Hepatol 1998 73 Lo, Hepatology 2002 79 Llovet, Lancet 2002 112 Overall 503 0.1 0.5 1 2 10 100 0.01 Z = -2.3 P = .017 Median survival: ~ 20 mos Favors Treatment Favors Control Llovet JM, et al. Hepatology. 2003;37:429-442.

  8. Contraindications to TACE • Extrahepatic tumor spread • Lack of portal blood flow • Portal vein thrombosis, portosystemic anastomoses or hepatofugal flow • Advanced liver disease (Child-Pugh Class B or C) • Clinical symptoms of end-stage cancer Bruix J, et al. AASLD HCC guidelines. July 2010.

  9. BCLC Staging and Treatment Strategy HCC Okuda 1-2, PS 0-2, Child-Pugh A-B PS 0, Child-Pugh A Okuda 3, PS > 2,Child-Pugh C Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminalstage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Single 3 nodules ≤ 3 cm Portal pressure/bilirubin Associated Increased diseases Normal No Yes RFA/PEI TACE Sorafenib Resection Liver transplantation Symptomatic (20%); survival < 3 mos Curative treatments (30%); 5-yr survival: 40%-70% RCTs (50%); 3-yr survival: 10%-40% Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

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