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The treatment path in hepatocellular carcinoma.

The treatment approach for hepatocellular carcinoma (HCC) depends on the stage and extent of disease, the severity of the underlying liver disease, and the overall performance status of the patient. Treatment consists of 4 main strategies: surgery (eg, resection and liver transplant), locoregional procedures (eg, ablation and transarterial embolization), systemic therapies, and best supportive care. For patients with early-stage tumors, surgical treatment or ablation can be curative. Patients with intermediate-stage disease can be candidates for embolization, administered as either transarterial chemoembolization (TACE) or transarterial radioembolization (TARE). Systemic therapy is reserved for patients with advanced or unresectable disease. For the past decade, the multitargeted kinase inhibitor sorafenib has been the only agent approved for unresectable HCC. This approval was followed by several clinical trials investigating other multitargeted kinase inhibitors, but none showed any benefit over single-agent sorafenib. Most patients progress after treatment with first-line sorafenib. In April 2017, the US Food and Drug Administration approved regorafenib for patients with HCC who have been previously treated with sorafenib. In a phase 3 trial, regorafenib significantly improved overall survival vs placebo. A consideration with systemic treatments is the proactive management of adverse events, including toxicities associated with the drugs and progression of liver disease.