Journal of Liver Cancer

Special Contribution

Expert survey on systemic therapy indications for hepatocellular carcinoma in Korea: bridging clinical practice and reimbursement criteria: Hyun Yang, Soon Sun Kim, Seong Hee Kang, Jieun Kwon, Do Young Kim, Eunju Kim, Hyun Phil Shin, Jeong Il Yu, Jeong-Ju Yoo, Eileen L. Yoon, Sangheun Lee, Young Eun Chon, Janghan Jung, Jaekyung Cheon, Woosun Choi, Seul Ki Han, Ji Eun Han, Moon Haeng Hur, Hyun Woong Lee, Hyung Joon Kim; J Liver Cancer. 2025;25(2):160-168. Published online July 7, 2025; DOI: https://doi.org/10.17998/jlc.2025.07.02

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This survey aimed to collect expert opinions from multidisciplinary specialists involved in the management of hepatocellular carcinoma (HCC) in Korea regarding real-world criteria for systemic therapy indications. In response to discrepancies between national reimbursement policies and clinical decision-making, members of the Korean Liver Cancer Association and Korean Association for the Study of the Liver participated in a web-based survey from February 4 to 14, 2025. A total of 89 respondents, primarily experienced clinicians, provided their views on major clinical scenarios including infiltrative HCC, bilobar multifocal disease, huge tumors, vascular invasion, extrahepatic metastasis, and transarterial chemoembolization (TACE) refractoriness. There was high agreement for including infiltrative HCC (69.7%), suspected portal vein invasion (70.8%), and TACE refractoriness (82.0%) as systemic therapy indications. TACE refractoriness, in particular, aligns with current guideline definitions. Additionally, over half of respondents (51.7%) supported extrahepatic metastasis under similar conditions. Notably, multidisciplinary discussion was emphasized across scenarios, but many respondents also favored allowing primary physician discretion in select cases. This report provides consolidated expert input to inform future updates to reimbursement policies and promote alignment with real-world clinical practice. These findings may help bridge the gap between national coverage criteria and clinical decision in systemic therapy for HCC.

Citations

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Real-world outcomes of lenvatinib versus sorafenib as the second-line therapy after atezolizumab plus bevacizumab in patients with hepatocellular carcinoma: a large-scale multicenter study in Korea
Min Ji Lee, Subin Lim, Jae Yong Shim, Mi Na Kim, DongKyu Kim, Kyu‑pyo Kim, Kang Mo Kim, Baek‑Yeol Ryoo, Won‑Mook Choi, Hyun‑Jeong Kim, Seung‑Hoon Lee, Gaeun Kang, Mira Kang, Won Chul Cha, Jung Yong Hong, Woo Kyoung Jeong, Sung Kyung Ju, Jung‑Hyun Won, Doi
Hepatology International.2026;[Epub] CrossRef

Case Reports

Multiple Hepatic Metastasis and Lymphatic Metastasis of Solid Pseudopapillary Neoplasm of Pancreas: Kim, You Gyung , Kim, Byung Ik , Kim, Seul Ki , Kim, Hak Soo , Kim, Hong Ju , Cho, Yong Kyun , Jeon, Yu Gyu; J Liver Cancer. 2018;18(2):168-174. Published online September 30, 2018; DOI: https://doi.org/10.17998/jlc.18.2.168

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Solid pseudo-papillary neoplasm (SPN) of pancreas is a rare epithelial neoplasm of pancreas with a low malignant potential, occurs most commonly in young females. Here, we report a rare case of woman who has severe hepatomegaly due to multiple hepatic metastases of SPN of pancreas. At the time of diagnosis, a SPN was detected at only pancreas and there was no evidence of metastasis. So, she received subtotal pancreatectomy and total splenectomy. After 2 years of follow up, multiple small hepatic metastases were presented. In spite of three times of radiofrequency ablation, the burden of hepatic metastasis has increased continuously and multiple intra-abdominal lymph nodes metastases were detected, and ascites and peripheral edema occurred. However, because of benign feature of SPN and extremely rare incidence of recurrence and metastasis, there is no specific treatment guideline for metastatic SPN. Through multidisciplinary care service, we planned to do radiotherapy followed by a transarterial chemoembolization (TACE). But the patient could not have a scheduled radiation therapy due to deterioration of liver function. So changing the strategy of treatment, followed by TACEs were done alone. Although the size of SPN is not reduced, the extent of SPN and complication of SPN (ascites, peripheral edema, abdominal pain and so on) are being controlled.

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Solid Pseudopapillary Epithelial Neoplasm of the Pancreas in the Paediatric Population: A Report of Two Cases
Ravi Maharaj, Nahmorah J Bobb, Christo Cave, Keshan V Ramnarace, Jamar Critchlow
Cureus.2022;[Epub] CrossRef

A Case of Achieving Complete Remission with Stereotactic Body Radiation Therapy in Patients with Hepatocellular Carcinoma with Macrovascular Invasion after Repeated Transarerial Chemoembolization: Sang Youn Hwang, Seon-Mi Lee, Jong Woo Im, Ki Jeong Jeon, Sang Bu Ahn, Eun Kyeong Ji, Jin-Young Park, Cheol-Won Choi Choi, Gwang-Mo Yang; J Liver Cancer. 2016;16(2):123-128. Published online September 30, 2016; DOI: https://doi.org/10.17998/jlc.16.2.123

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Abstract PDF: Transarterial chemoembolization (TACE) is the worldwide procedure performed for patients with various stage hepatoceullar carcinoma (HCC), but is not yet considered as curative treatment because of relatively high local recurrence rate. Moreover, many clinicians frequently experience treatment failure (incomplete necrosis or stage progression etc.) after repeated TACE, but no clear guidelines have been recommended about salvage treatment modalities for this situation. Recently, studies for combination of radiation therapy and TACE for HCC with TACE refractoriness have been tried and reported better therapeutic efficacy. Based on above suggestions, we herein offer our experience of a patient with macrovascular invasion developed after repeated TACE that achieve complete remission by stereotactic body radiation therapy. Further study, maybe regarding a combination of locoregional and systemic therapy, is necessary on how to manage HCC patients with TACE refractoriness.

A Case of Unresectable Hepatocellular Carcinoma Treated by Repeated Transcatheter Arterial Chemoembolization Using DC beads® Followed with Resection: Jeong-Yeop Song, Young Seok Kim, Jae Myeong Lee, Soo Ji Jin, Kyu Sung Choi, Yun Nah Lee, Sang Hyune Kim, Sung Won Jeong, Jae Young Jang, Sae Hwan Lee, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):65-69. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.65

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Abstract PDF: In patients with unresectable hepatocellular carcinoma (HCC) and no anti-cancer treatment, the prognosis is quite poor. But in some cases, repeated sessions of transcatheter arterial chemoembolization (TACE) reduce the tumor size even to resectable, and post-TACE resection may prolong the survival time. We present a case of 50-year-old HBV carrier woman with abdominal distension. The diagnosis was huge HCC with intrahepatic metastasis. Repeated intra-arterial injections of adriamycin mixed lipiodol or DC beads® (100-300/300-500/500-700 μm, ©BIOCOMPATIBLES UK LTD) were instituted through ten sessions for 13 months. The tumor size became reduced with a partial response after 10th TACE and post-TACE resection was performed. No visible HCCs and decreased tumor markers were noted on the examinations 3 months after the resection.

Review Article

Transarterial Chemoembolization with Drug-Eluting Beads for Hepatocellular Carcinoma: Myeong Jun Song; Journal of the Korean Liver Cancer Study Group. 2012;12(2):88-92. Published online September 30, 2012

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Abstract PDF: Transarterial chemoembolization (TACE) has been widely used as a standard treatment for HCC patients who are not suitable candidates for curative treatments and as a bridge to liver transplantation. The rationale for TACE is that the intra-arterial chemotherapy using lipiodol and chemotherapeutic agents, followed by selective vascular embolization, will result in a strong cytotoxic effect combined with ischemia (conventional TACE). Recently, drug-eluting beads (DC Bead®) for the transcatheter treatment of HCC have been developed to deliver higher doses of chemotherapeutic agent and to prolong contact time with the tumor. DC Bead® has the ability to actively sequester doxorubicin hydrochloride from solution and release it in a controlled and sustained fashion. Treatment with DC Bead® has been shown to substantially diminish the amount of chemotherapeutic agent that reaches the systemic circulation compared with conventional, lipiodol-based regimens, significantly reducing drug-related adverse events. In this article, we describe the treatment efficacy and safety of TACE with the drug-eluting bead for the treatment of hepatocellular carcinoma and discuss future therapeutic possibilities.

Case Reports

A Patient of Hepatocellular Carcinoma Performed Hepatectomy after Tumor Downing Sizing with Transcatheter Arterial Chemoembolization: Seul Ki Min, Sang Gyune Kim, Young Seok Kim, Sae Whan Lee, Soung Won Jeong, Jae Young Jang, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2011;11(1):40-45. Published online February 28, 2011

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Abstract PDF: Hepatocellular carcinoma (HCC) is the third most common cancer in korean population. Surgical management is the mainstay of HCC. Surgical resection and liver transplantation shows the best outcomes in well-selected patients. But few patients are possible to benefit from surgical resection or liver transplantation. The majority of cases of HCC are unresectable, but there are no proven treatment modalities for these cases. In small number of articles showed the favorable result of adjuvant chemotherapy, and transcatheter arterial chemoembolization (TACE) for unresectable HCCs. But there are some drawbacks, such as small number of sample size and variablity of study design at each studies. Hereby we report a patients of HCC, who was performed hepatectomy after tumor down sizing with TACE.

A Case of Atypical Imaging Finding for Hepatocellular Carcinoma: Sang-Hyung Cho, Seong-Hoon Kim, Hyun-Jung Jang, Hong-Suk Park, Woo-Jin Lee, Sang-Jae Park, Joong-Won Park, Eun-Kyung Hong, Chang-Min Kim; Journal of the Korean Liver Cancer Study Group. 2003;3(1):77-79. Published online July 31, 2003

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Abstract PDF: A　62-year-old male was referred to our hospital for further evaluation and treatment due to hepatocellular carcinoma. He was performed to TACE once. Threre was no evidence of abnormal finding except HBs Ag positive. We performed four times of TACE. Another hepatic mass was found on Liver CT which was observed in delyed phase not in arterial phase, portal phase. We diagnosed hepatocellular carcinoma by sono-guided Liver biopsy and radiofrequency ablation was performed because of no response to further TACE. There wad no evidence of recurring during 3-month follow-up.

A Case of Hepatocellular Carcinoma with Dramatic Therapeutic Response in Stage Ⅳa (T4N0M0): Hye Won Chung, Jae Youn Cheong, Kun Hoon Song, Kwang Hyub Han, Young Myoung Moon, Byoung Ro Kim, Jin Sil Seong, Myoung Jin Kim, Do Yun Lee, Young Nyun Park; Journal of the Korean Liver Cancer Study Group. 2001;1(1):89-92. Published online June 30, 2001

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Abstract PDF: A 52 year-old-female patient was admitted due to right upper quadrant abdominal pain and right shoulder pain for 1 month. She had no history of previous medical problem before admission. At admission, physical findings revealed that she had 2 FB palpable hepatomegaly and others were not remarkable. Laboratory findings revealed that HBsAg and HBeAG were positive enhanced at arterial phase involving entire right lobe and S4, and thrombus at main portal vein. Clinically she was diagnosed advanced hepatocellular carcinoma(HCC) and TNM stage was T4N0M0, stage Ⅳa. She was treated with transarterial chemoembolization(TACE) for 2 cycles and radiation therapy. After TACE and radiation therapy, the tumor size decreased and the main portal vein thrombus was disappeared. Then, she underwent extended right lobectomy of the liver. Pathology of operative specimen revealed well-encapsulated HCC at Edmonsons grade Ⅱ, near total necrosis. Normal liver tissue showed sinusoidal congestion, mild periportal fibrosis, and veno-occlusive disease. Two years after the operation, there had been no sign of recurrence and follow-up CT scan showed sign of recurrence at S2. He underwent percutaneous Holmium injection 3 times and TACE 4 times, and so far he survived for 6 years and 10 months. He is currently under observation at out patient department.

A Case of Hepatocellular Carcinoma: Curative Resection after Repeated Transcatheter Arterial Chemoembolization: Jae Hyuk Do, Joon Won Park, Hyung Joon Kim, Hyung Jin Shim, Byung Chul Yoo, Sung Il Park, Sil Moo Park; Journal of the Korean Liver Cancer Study Group. 2001;1(1):110-113. Published online June 30, 2001

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Abstract PDF: A 57 year-old-male, who had a 40-year history of chronic alcohol dirnking, was referred to general weakness and jaundice for 1 month. Physical findings revealed that he had jaundice and spider angioma on anterior chest wall. The serum chemistries showed the total bilirubin 9.3 mg/dL and direct bilirubin level 6.1 mg/dL. The serum level of AST/ALT/AP was 130/192/494 IU/L. And the serum level of AFP was 18225.7 ng/ml. abdomen CT scan revealed the huge ill-defined hypodense mass was involving segment 2 and 3. The main portal vein and left portal vein were involved by this mass. Abdominal ultrasonography (US) showed huge echogenic mass in hilar portion of bile duct and tumor thrombosis in main and left portal vein. ERCP showed intraluminal-filling defect in CHD and complete obstruction of left IHD. We had a diagnosis this mass as hepatocellular carcinoma by US guided gun biopsy. Transcatheter arterial chemoembolization (TACE) was selected as the treatment due to TNM stage Ⅳa. After three times repeated TACE tumor decreased in size, regression of left portal vein invasion and normalization of jaundice, as a result, curative left lobectomy could be performed.

A Case of Hepatocellular Carcinoma with Rapid Growing after TACE: Chang Min Cho, Seung Yup Lee, Young Tak Kim, Young Hak Lee, Won Young Tak, Young Oh Kweon, Sung Kook Kim, Yong Hwan Choi, Joon Mo Chung; Journal of the Korean Liver Cancer Study Group. 2001;1(1):129-132. Published online June 30, 2001

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Abstract PDF: A 33 year-old-female patient with hepatocellular carcinoma(HCC) was admitted due to right upper quadrant abdominal pain for 1 week. One month ago, she had been diagnosed hepatocellular carcinoma by percutaneous liver biopsy. MRI showed low signal intensity on T1-weighted image and high signal intensity in T2-weighted image on S 8 about 5 cm in diameter without portal vein thrombosis. She was treated with TACE(transheaptic arterial chemoemboilzation) and discharged. Two weeks later, follow-up computed tomography showed marginal lipiodol washout lesion on segment 8 about 2 cm in diameter. So she was admitted for the 2nd TACE. At admission physical findings revealed that she had mild tenderness on right upper quadrant with jaundice. Total bilirubin was 3.3 mg/dL, AST/ALT was 82/128 IU/L, and AFP was 1,210 ng/mL. Abdomen CT revealed diffuse attenuating mass lesion on segment 8 with intraperitoneal fluid collection with contrast enhancement suggesting HCC rupture.

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