Advanced hepatocellular carcinoma and sorafenib: Diagnosis, indications, clinical and radiological follow-up

Table 1 Main loco-regional therapies in advanced hepatocellular carcinoma treatment

Loco-regional therapies
TACE is the most common used loco-regional treatment in patients with unresectable HCC, without macrovascular invasion or extrahepatic spreads (BCLC stage B)
The use of TACE in advanced HCC is controversial: some authors affirm its better efficacy in term of survival benefit, than the best supportive care in HCC with extrahepatic spreads and macrovascular invasion. Some other ones recommend to be careful and suggest its use only in selected patients with Child A cirrhosis and segmental portal vein thrombosis
TACE can be a valid alternative for advanced HCC patients who are not compliant with oral therapies or have severe side effects or could not have access to sorafenib because of health authorities or high cost
In advanced HCC, TARE shows survival rates similar to sorafenib and TACE, especially in patients with portal vein thrombosis
TARE contraindication: important arterial shunt to gastrointestinal tract or lung, any contraindication to catheterization

TACE: Trans-arterial chemo-embolization; TARE: Trans-arterial Radio Embolization; HCC: Hepatocellular carcinoma; BCLC: Barcelona clinic liver cancer.

Table 2 Main systemic therapies in advanced hepatocellular carcinoma treatment

Systemic therapies
The only drug approved for the treatment of advanced HCC. Patients treated with sorafenib have longer OS then placebo group in the two largest studies
The efficacy of this treatment is linked to liver function: Child B patients have much lower survival than Child A ones (5.5 mo vs 11.3 mo). Child C patients have very poor prognosis and seem not to be suitable for sorafenib therapy (1.6 mo)
Patient treated with sorafenib has longer survival than those treated with sunitinib. No difference in OS has been found comparing sorafenib treatment to brivanib
Some combination therapies have been proposed, but none of these has shown superiority compared to sorafenib alone
At now there is no therapeutic plan approved as second line in advanced HCC pretreated with sorafenib
Some drugs as capecitabine, brivanib, sunitinib, everolimus have been tested in monotherapy, moreover some combination therapies as erlotinib with sorafenib, and gemcitabine with oxaliplatin have been evaluated as second line options, but all of them have not given significant results
Many studies are still in progress and some interesting, but preliminary results have been obtained in patients with high expression of c-met in treatment with brivanib

HCC: Hepatocellular carcinoma; OS: Overall survival.