Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.
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There are differences in opinion regarding the application of external beam radiotherapy in the treatment of hepatocellular carcinoma. Some major guidelines state that external beam radiotherapy is yet to attain a sufficient level of evidence. However, caution should be exercised when attempting to understand the clinical need for external beam radiotherapy solely based on the level of evidence. Previously, external beam radiotherapy had low applicability in the treatment of hepatocellular carcinoma before computed tomography-based planning was popularized. Modern external beam radiotherapy can selectively target tumor cells while sparing normal liver tissues. Recent technologies such as stereotactic body radiotherapy have enabled more precise treatment. The characteristics of hepatocellular carcinoma differ significantly according to the regional etiology. The main cause of hepatocellular carcinoma is the hepatitis B virus. It is commonly diagnosed as a locally advanced tumor but with relatively preserved hepatic function. The majority of these hepatocellular carcinoma cases are found in the East Asian population. Hepatocellular carcinoma caused by hepatitis C virus or other benign hepatitis tends to be diagnosed as a less locally aggressive tumor but with deteriorated liver function. The Western world and Japan tend to have patients with such causes. External beam radiotherapy has been more commonly performed for the former, although the use of external beam radiotherapy in the latter might have more concerns with regard to hepatic toxicity. This review discusses the above subjects along with perspectives regarding external beam radiotherapy in recent guidelines.
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The incidence of hepatocellular carcinoma (HCC) is geographically heterogeneous depending on the underlying liver disease. Moreover, the decisions and recommendations about standard treatments differ between countries, especially between the East and the West. Because of the complexity of treatment decisions for the management of HCC, a multidisciplinary approach is recommended to maximize the therapeutic efficacy. External beam radiotherapy (RT) has been increasingly used to manage HCC when recommended treatments cannot be applied in real-world clinical practice. However, Western guidelines for the management of HCC do not recommend RT as a treatment option due to the lack of clinical evidence. RT has often been used more in Eastern countries than in Western countries; hence, it is necessary to review both Eastern and Western guidelines for HCC treatment regarding the recommendations about RT. In this study, the comments and potential roles of external beam RT are summarized from several treatment guidelines for the management of HCC.
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The accurate evaluation of response to treatment is a key aspect in cancer therapy, because an objective response may become
a surrogate marker of improver survival. For cytotoxic drugs, tumor response evaluation according to the World Health
Organization (WHO) criteria or the Response Evaluation Criteria in Solid Tumors (RECIST) guideline offers simple approaches
based on the size of the lesions. However, considering the nature of locoregional therapy or new cytostatic agent for
hepatocellular carcinoma (HCC), which do not decrease the size of the tumor but induce tumor necrosis, original WHO or
RECIST criteria will not reflect clinical benefit exactly. Recently, modified RECIST assessment is proposed by AASLD-JNCI
guidelines. Given that complete necrosis was well correlated with better survival, modified RECIST criteria consider changes in
tumor viability, which can be measured as the area of arterial enhancement, with maintaining overall response assessment similar
to RECIST. The proposed modified RECIST assessment is expected to provide a reliable method for assessing tumor response in
HCC clinical trials.
Hepatocellular carcinoma (HCC) usually appears in the setting of underlying liver disease. Therefore, HCC should be
managed in multidisciplinary settings. Under these circumstances, several practice guidelines were introduced around the world.
Clinically useful practice guidelines should be based on evidences, but socio-economic and medical status of the country should
be considered as well. In this review, 6 well-known global practical guidelines (BCLC-AASLD, NCCN, 2 from Japan, APASL,
Korean) were compared in terms of resection and liver transplantation (LT). BCLC-AASLD from Europe and the United States
stressed more on LT for the patients within Milan criteria. However, the guidelines from the Asia had more extended indication
of liver resection. The number of living donor LT in Korea is the highest in the world. Under this circumstance, indication of LT
for HCC in Korea is inevitably being expanded. Compared to other guidelines, therefore, Korean guideline allowed a limited
expansion of indication for HCC into patients with Child A and/or living donor LT with outside Milan HCC. However, to make
more practical guidelines, high quality evidence from Korea and validation study of current Korean guideline are needed.