Clinical Implication Based on

Updated APASL Guidelines for

Small HCC Management
Rino Alvani Gani

Hepatobiliary Division, Department of Internal Medicine

Cipto Mangunkusumo National General Hospital
Faculty of Medicine, Universitas Indonesia
Jakarta, Indonesia
 Outline

•Introduction

Diagnosis

Surveillance

Management
 Outline

•Introduction

Diagnosis

Surveillance

Management
 Epidemiology of
Hepatocellular Carcinoma
•Liver cancer: the 6th most common cancer

Asia-Pacific region
• Main contributor of global HCC cases
• Incidence stay the same in 20-years
• HBV and HCV is the mainstay etiology
• Incidence increased by combination of multiple risk
factors (HBV, HCV, HIV infection, alcohol, DM)

Omata M, et al. Hepatol Int 2017.

 Small Hepatocellular Carcinoma
HCC lesion with median diameter 2 cm (range 1-6 cm)
Vague

Distinctly
nodular

nodular
Early HCC Well- to moderately
Well-differentiated differentiated
Fibrous capsule ↓ Capsulated
Involve portal tracts Portal tracts
involvement ↓

(A) Vaguely nodular HCC (arrow) sized 1.2 cm in the liver of 53-year (A) Distinctly nodular HCC (arrow) sized 1.0 cm in the liver of 47-year
old man with chronic hepatitis B and cirrhosis. old man with chronic hepatitis B and cirrhosis.
(B) The trabecular arrangement of the neoplastic cells and fatty (B) The trabecular pattern of growth. The tumor encapsulated by
change. The cancerous cells invade the portal tract (star). fibrous tissue (star).

Omata M, et al. Hepatol Int 2017. | Hytiroglou P, et al. Gastroenterol Clin N Am 2007.
 Outline

•Introduction

Diagnosis

Surveillance

Management
Diagnosis Algorithm of HCC
Typical lesions:
arterial phase
enhancement,
wash-out in vein
and delayed-
phase

Atypical lesions
of small lesions
or early stage?

Omata M, et al. Hepatol Int 2017.

 Small HCC Dysplastic Nodules

Two dysplatic nodules (arrows) at

approximately 1.0 cm in size.

Gd-EOB-DTPA- CT arterial
enhanced MRI portography/CT Contrast-enhanced
hepatic angiography US (CEUS)
FIRST-LINE (CTAP/CTHA)

Omata M, et al. Hepatol Int 2017.

 Outline

•Introduction

Diagnosis

Surveillance

Management
 Monitoring every 6-month with US and AFP

High-risk
Population
to Monitor

Omata M, et al. Hepatol Int 2017.

 Outline

•Introduction

Diagnosis

Surveillance

Management
 Options on HCC Management
• Liver resection
•Invasive
• Liver transplantation
• Microwave ablation (MWA)

LOCAL
•Minimal • Radiofrequency ablation (RFA)
invasive • Ethanol injection
• Transarterial chemoembolization (TACE)
•Non- • Stereotactic body radiotherapy (SBRT)
• Sorafenib or regorafenib

SYS
invasive

Omata M, et al. Hepatol Int 2017.

 Options on HCC Management

• Liver resection (LR)

• First-line for CP A

• Liver transplantation (LT)

• First-line for CP B and C
Omata M, et al. Hepatol Int 2017.
 Options on HCC Management
•Microwave ablation (MWA)
• ≤3 lesions, ≤3 cm in size, CP A or B
•Radiofrequency ablation (RFA)
• First-line for ≤2 cm lesions, CP A or B
•Ethanol injection
• Treatment of choice for very small lesions; RFA alternative
•Transarterial chemoembolization (TACE)
• First-line for unresectable, large, or multifocal lesions without
vascular invasion or extrahepatic metastasis

Omata M, et al. Hepatol Int 2017.

 Options on HCC Management

•Stereotactic body radiotherapy

(SBRT)
• Alternative if other local treatment failed

•Sorafenib or regorafenib

• Recommended for advanced-stage disease

Omata M, et al. Hepatol Int 2017.

Previous Treatment Algorithm
APASL 2010

Omata M, et al. Hepatol Int 2010.

Previous Treatment Algorithm
APASL 2010

Omata M, et al. Hepatol Int 2010.

Updated Treatment Algorithm
APASL 2017

Omata M, et al. Hepatol Int 2017.

Updated Treatment Algorithm
APASL 2017

Omata M, et al. Hepatol Int 2017.

 Point of Change
in Small HCC Management
APASL 2010 APASL 2017

• Liver resection is best option • Decision of resectability

for small HCC <5 cm should be discussed
• Post-LR 5-year survival: interdisciplinary
70% • Complication: post-LR liver
• Post-LR 5-year recurrence: failure  require liver
50-80% functional reserve and liver
volume evaluation
• RFA considered as:
• First-line for <2 cm
• Alternative for <3 cm

Omata M, et al. Hepatol Int 2010. | Omata M, et al. Hepatol Int 2017.
Resection vs RFA for Small HCC

Tumor
recurrence,
overall survival,
and disease-
free survival
rates were not
much different

Ng KKC, et al. Br J Surg 2017.

Resection vs RFA for Small HCC

Tumor
recurrence,
overall survival,
and disease-
free survival
rates were not
much different

Ng KKC, et al. Br J Surg 2017.

 Metaanalysis Resection vs RFA
1 year

3 year

Xu XL et al. Radiology 2018

 Summary and Conclusions
• Surveillance is crucial to performed amongst high-risk
population. The earlier to be found, the sooner the
therapy can be given, the lower the burden of disease
that will arise.
• Therapy upon small HCC should be individualized.
Decision to resect or ablate should be adjusted
according to patients’ condition and capability of each
center.
• Liver resection and RFA have its own advantages and
disadvantages; the tumor recurrence and survival rate
seemed to be similar in small HCC cases.
Thank You