Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Abstract

The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.

Meta-Analysis of Postoperative Adjuvant Hepatic Artery Infusion Chemotherapy Versus Surgical Resection Alone for Hepatocellular Carcinoma

“…But there are several disadvantages in adjuvant TACE. On the one hand, the anti-recurrence efficacy of adjuvant TACE remains controversial, especially in Europe and the United States ( 4 ); on the other hand, TACE was reported to induce recurrence via upregulation of hypoxia-inducible factor-1a and vascular endothelial growth factor related to embolization ( 35 , 36 ). HAIC might be an alternative to TACE in the following aspects: 1) HAIC could significantly increase the total dose of chemotherapy and prolong the exposure time of high-concentration chemotherapy drugs, and 2) HAIC could prevent adverse events related to embolization such as embolization syndrome and ectopic embolism.…”

“…With the development of surgical techniques and advances in perioperative management, great progress has been acquired in the prognosis of patients receiving SR. However, since the 5-year recurrence rate following SR is beyond 70% ( 3 , 4 ), the long-term prognosis of HCC patients remains discouraging. Therefore, strategies intended to decrease the postoperative recurrence rate are badly warranted in clinical practice.…”

“…Numerous kinds of treatments following SR have been tried to prevent or reduce the recurrence rates, including transarterial chemoembolization (TACE), antiviral therapy, Huaier granule, interferon-α, cytokine-induced killers, and sorafenib ( 2 , 5 ). But the anti-recurrence efficacy of most of the strategies has not been recognized universally, except for antiviral therapy ( 4 ). Hepatic artery infusion therapy (HAIT) followed by surgery has been confirmed in a meta-analysis to improve the overall survival (OS) and disease-free survival (DFS) of patients not candidates for transplantation ( 6 ).…”

Clinical Evaluation of Ramucirumab for the Treatment of Hepatocellular Carcinoma (HCC): Place in Therapy

“…Currently, ramucirumab is the only therapy specifically tested in a biomarker (AFP)-selected HCC population, with a recommendation only for patients with AFP ≥ 400 ng/mL. 11 , 42 , 43 Other available molecular targeted systemic therapies for advanced HCC include sorafenib, lenvatinib, regorafenib, and cabozantinib, all of which are multikinase inhibitors, and more recently the combination of atezolizumab and bevacizumab. While bevacizumab targets VEGF, ramucirumab is the only VEGF receptor (VEGFR-2) antagonist approved for HCC.…”

“…The most current guidelines favor the atezolizumab plus bevacizumab combination over sorafenib, a multi-tyrosine kinase inhibitor (TKI) that had so far been the standard first-line systemic therapy for patients with advanced HCC. 10 , 11 While regorafenib was considered the next-line therapy for patients with disease progression on sorafenib, the most recent National Comprehensive Cancer Network (NCCN) clinical guidelines have also supported the use of ramucirumab in the second-line setting for advanced HCC. 12…”