2019 Chinese clinical guidelines for the management of hepatocellular carcinoma: updates and insights

Abstract

Importance: Approximately half of newly-diagnosed hepatocellular carcinoma (HCC) cases in the world occur in China, with hepatitis B virus (HBV) infection being the predominant risk factor. Recently, the guidelines for the management of Chinese HCC patients were updated. Objective:The past decade has witnessed a great improvement in the management of hepatocellular carcinoma (HCC). This study reviews the recommendations in the 2019 Chinese guidelines and makes comparison with the practices from the Western world. Evidence Review: The updated recommendations on the surveillance, diagnosis, and treatment algorithm of HCC in the 2019 Chinese guidelines were summarized, and comparisons among the updated Chinese guidelines, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines were made. Findings: Besides imaging and pathological diagnoses, novel biomarkers like the seven-micro-RNA panel are advocated for early diagnoses and therapeutic efficacy evaluation in the updated Chinese guidelines. The China liver cancer (CNLC) staging system, proposed in the 2017 guidelines, continues to be the standard model for patient classification, with subsequent modifications and updates being made in treatment allocations. Compared to the Barcelona Clinic Liver Cancer (BCLC) system, the CNLC staging system employs resection, transplantation, and transarterial chemoembolization (TACE) for more progressed HCC. TACE in combination with other regional therapies like ablation or with systemic therapies like sorafenib are also encouraged in select patients in China. The systemic treatments for HCC have evolved considerably since lenvatinib, regorafenib, carbozantinib, ramucirumab and immune checkpoint inhibitors (ICIs)were first prescribed as first-line or second-line agents. Conclusions and Relevances: Novel biomarkers, imaging and operative techniques are recommended in the updated Chinese guideline. More aggressive treatment modalities are suggested for more progressed HBV-related HCC in China.

Overview of Prognostic Systems for Hepatocellular Carcinoma and ITA.LI.CA External Validation of MESH and CNLC Classifications

“…Finally, the CNLC staging system [ 9 , 10 ] represents the chart endorsed by the National Health and Family Planning Commission of the People’s Republic of China for HCC surveillance, diagnosis, staging and treatment ( Table 3 ). These recommendations, released in 2017 and updated in 2019, are a management summary regarding all the aspect of HCC patients delineated by a multidisciplinary panel of more than 50 experts, including surgeons, oncologists, hepatologists, interventional radiologists etc.…”

“…It has several similarities with the BCLC system, but it supports more aggressive treatment options for advanced HCC stages. For example, the CNCL system indicates liver resection in patients belonging to Ia, Ib, and IIa categories, that correspond to the BCLC B stage with 2–3 nodules >3 cm, and also for select patients classified in IIb and IIIa stage (multinodular and locally advanced HCC) [ 9 , 10 , 11 ]. The updated 2019 CNCL version [ 11 ] is reported in the Table 3 .…”

“…Third, in order to concretely apply the comparison rules previously described to the need of clinical practice, we have performed a formal comparison between the most recent prognostic systems proposed for each of the above mentioned three categories, using a large Italian database. In particular, we have compared the Taiwanese Model to Estimate Survival for HCC (MESH) [ 8 ] score for the prognostic scores category, the Chinese Liver Cancer (CNLC) classification [ 9 , 10 , 11 ] for the staging systems category, and the Italian Liver Cancer (ITA.LI.CA) prognostic score and staging system [ 12 ] for the combined prognostic systems category. The Cancer of the Liver Italian Program score [ 13 , 14 ] and the Barcelona Clinic Liver Cancer (BCLC) classification [ 15 ] are also taken as reference for the prognostic scores and the staging systems categories, respectively.…”

Survival Benefit of Hepatic Arterial Infusion Chemotherapy over Sorafenib in the Treatment of Locally Progressed Hepatocellular Carcinoma

“…Currently, MTAs are the standard treatment for TACE-refractory HCC and advanced HCC according to worldwide treatment guidelines [ 24 , 25 , 26 , 27 ]. However, not all patients with HCC benefit from treatment with MTA.…”

HBV Infection Promotes The Occurrence and Development of Hepatocellular Carcinoma Through Impairing The Inhibitory Effect of PPP2R5A on MAPK/AKT/WNT Signaling Pathway

“…China has a high incidence of hepatocellular carcinoma (HCC), while the vast majority of HCC are associated with HBV infection [1][2][3]. In recent years, the anti-HCC effects of molecular targeted drugs have attracted more and more attention and become one of the hot spots in anti-tumor research.…”