Published online May 28, 2015. doi: 10.4254/wjh.v7.i9.1184
Peer-review started: September 6, 2014
First decision: September 28, 2014
Revised: January 18, 2015
Accepted: February 9, 2015
Article in press: February 11, 2015
Published online: May 28, 2015
Processing time: 257 Days and 1.8 Hours
Intermediate stage, or stage B according to Barcelona Clinic Liver Cancer classification, of hepatocellular carcinoma (HCC) comprises a heterogeneous population with different tumor burden and liver function. This heterogeneity is confirmed by the large variability of treatment choice and disease-relate survival. The aim of this review was to highlight the existing evidences regarding this specific topic. In a multidisciplinary evaluation, patients with large (> 5 cm) solitary HCC should be firstly considered for liver resection (LR). When LR is unfeasible, locoregional treatments are evaluable therapeutic options, being transarterial chemoembolization (TACE), the most used procedure. Percutaneous ablation can be an evaluable treatment for large HCC. However, the efficacy of all ablative procedures decrease as tumor size increases over 3 cm. In clinical practice, a combination treatment strategy [TACE or transarterial radioembolization (TARE)-plus percutaneous ablation] is “a priori” preferred in a relevant percentage of these patients. On the other hands, sorafenib is the treatment of choice in patients who are unsuitable to surgery and/or with a contraindication to locoregional treatments. In multifocal HCC, TACE is the first-line treatment. The role of TARE is still undefined. Surgery may have also a role in the treatment of multifocal HCC in selected cases (patients with up to three nodules, multifocal HCC involving 2-3 adjacent liver segments). In some patients with bilobar disease the combination of LR and ablative treatment may be a valuable option. The choice of the best treatment in the patient with intermediate stage HCC should be “patient-tailored” and made by a multidisciplinary team.
Core tip: Intermediate stage, or stage B according to Barcelona Clinic Liver Cancer classification, of hepatocellular carcinoma (HCC) comprises a heterogeneous population with different tumor burden and liver function. This heterogeneity is confirmed by the large variability in treatment and survival, the choice of the best treatment in the patient with intermediate stage HCC is a difficult task. A multisciplinary evaluation of each intermediate stage HCC patient is recommended for planning the best therapeutic strategy and this review was aimed to discuss about the existing evidences regarding this topic. Due to the heterogeneity of intermediate HCC, the use of different therapies (combination treatment) is likely the best choice in most of the cases offering the opportunity of a treatment tailored to the single patient.