Treatment strategies for advanced hepatocellular carcinoma: Sorafenib vs hepatic arterial infusion chemotherapy

Figure 1 Treatment strategy for advanced hepatocellular carcinoma according to the hepatic arterial infusion chemotherapy score to assess continuous treatment. The score (range, 0-3) was calculated as follows: Child-Pugh score before hepatic arterial infusion chemotherapy (HAIC) (A = 0, B = 1), alpha-fetoprotein (AFP) response (yes = 0, no = 1), and des-gamma-carboxy prothrombin (DCP) response (yes = 0, no = 1). For patients with a score ≤ 1, HAIC treatment would be continued, while for patients with a score ≥ 2, a second-line therapy such as sorafenib and/or participation in a new clinical trial would be a better option. ¹The AFP and DCP responses were assessed 2 wk after HAIC induction; a positive response is defined as a reduction of ≥ 20% from baseline. ACTH: Arterial infusion chemotherapy.

Figure 2 Patient with complete response treated with hepatic arterial infusion chemotherapy using low-dose cisplatin combined with a 5-fluorouracil (low-dose FP)-based regimen. A: This 44-year-old man had massive hepatocellular carcinoma (HCC) (16 cm in diameter) with tumor thrombosis in the right portal vein (Vp3) and the inferior vena cava (Vv3) on dynamic computed tomography; B: After one course of hepatic arterial infusion chemotherapy (HAIC), the liver tumor markedly decreased; however, as slight tumor vascularity remained, the patient was assessed as having partial response at that time; C, D: Three tumor markers [alpha-fetoprotein (AFP), des-γ-carboxyprothrombin (DCP), and AFP L3] decreased after HAIC (AFP from 7145 ng/mL to 12.7 ng/mL, DCP from 233460 mAU/mL to 51 mAU/mL, AFP L3 from 58.1% to 3.1%). The patient’s Child-Pugh classification improved from B (8 points) to A (5 points). Thus, hepatic resection was performed, and histological findings showed no viable tumor cells (C, D). Finally, the patient was considered to have a complete response; E: The patient has been treated with nucleic acid analogs after the operation, and Child-Pugh A has been maintained. The patient is alive without HCC recurrence 148 mo after HAIC treatment.

Figure 3 Draft proposal of a treatment strategy for advanced hepatocellular carcinoma. (1) For advanced hepatocellular carcinoma (HCC) patients without macroscopic vascular invasion and Child-Pugh A, the first-line treatment should be sorafenib, while second-line treatments should be either regorafenib or hepatic arterial infusion chemotherapy (HAIC); (2) For advanced HCC patients with macroscopic vascular invasion and Child-Pugh A, the first-line treatment should be HAIC, and the second-line treatments should be either sorafenib or experimental treatment in clinical trials; (3) For advanced HCC patients with Child-Pugh B, the first-line treatment should be HAIC, and the second-line treatment should be clinical trials.