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. 2015 Apr;27(2):96–121. doi: 10.3978/j.issn.1000-9604.2015.03.03

Figure 2.

Figure 2

Consensus-based treatment algorithm for HCC proposed by JSH revised in 2010. Footnotes: *1, Treatment should be performed as if extrahepatic speed is negative, when extrahepatic spread is not regarded as a prognostic factor; *2, Sorafenib is the first choice of treatment in this setting as a standard of care; *3, Intensive follow-up observation is recommended for hypovascular nodules by the Japanese Evidence-Based Clinical Practice Guidelines. However, local ablation therapy is frequently performed in the following cases: (I) when the nodule is diagnosed pathologically as early HCC; (II) when the nodules show decreased uptake on Gd-EOB-DPTA MRI; (III) when the nodules show decreased portal flow by CTAP, since these nodules are known to frequently progress to the typical advanced HCC; *4, Even for HCC nodules exceeding 3 cm in diameter, combination therapy of TACE and ablation is frequently performed when resection is not indicated; *5, TACE is the first choice of treatment in this setting. HAIC using an implanted port is also recommended for TACE refractory patients. The regimen for this treatment is usually low-dose FP (5-FU + CDDP) or intra-arterial 5-FU infusion combined with systemic IFN therapy. Sorafenib is also a treatment of choice for TACE refractory patients with Child-Pugh A liver function; *6, Resection is sometimes performed even when numbers of nodules are over 4. Furthermore, ablation is sometimes performed in combination with TACE; *7, Milan criteria: tumor size ≤3 cm and tumor number ≤3; or solitary tumor ≤5 cm. Even when liver function is good (Child-Pugh A/B), transplantation is sometimes considered for frequently recurring HCC patients; *8, Sorafenib and HAIC are recommended for HCC patients with Vp3 (portal venous invasion at the first portal branch) or Vp4 (portal invasion at the main portal trunk); *9, Resection and TACE is frequently performed when portal invasion is minimum such as Vp1 (portal invasion at the third or more peripheral portal branch) or Vp2 (portal invasion at the second portal branch); *10, Local ablation therapy or subsegmental TACE is performed even for Child-Pugh C patients when transplantation is not indicated when there is no hepatic encephalopathy, no uncontrollable ascites, and a low bilirubin level (<3.0 mg/dL). However, it is regarded as an experimental treatment since there is no evidence of its survival benefit in Child-Pugh C patients. A prospective study is necessary to clarify this issue. Even in Child-Pugh A/B patients, transplantation is sometimes performed for relatively younger patients with frequently or early recurring HCC after curative treatments. HCC, hepatocellular carcinoma; JSH, Japan Society of Hepatology; CTAP, computed tomography arterial portography; TACE, transarterial chemoembolization; FU, fluorouracil; HAIC, hepatic arterial infusion chemotherapy. Reproduced with the permission from ref. (2).