Table.

Currently Available Options for the Treatment of Hepatocellular Carcinoma

	Indications	Contraindications	Adverse Effects
Curative Treatments
Surgical resection	Solitary liver tumor Unilobar disease	Portal hypertension (hepatic venous pressure gradient ≥10 mm Hg) Decompensated cirrhosis (Child-Pugh B/C) Insufficient residual liver volume Extrahepatic disease Poor performance status	Hepatic decompensation Bleeding Wound infection Bile duct damage/biloma
Liver transplant	Solitary liver tumor ≤5 cm in size Up to 3 tumors, each ≤3 cm in size Decompensated cirrhosis	Macrovascular invasion of tumor Extrahepatic disease Severe comorbid disease (eg, severe cardiopulmonary disease) Poor performance status	Graft dysfunction/rejection Bleeding Wound infection Bile duct damage/biloma
Locoregional Treatments
Radiofrequency ablation/microwave ablationa	Liver tumor ≤4 cm in size	Macrovascular invasion of tumor Main portal vein obstruction Decompensated cirrhosis (Child-Pugh C) Biliary obstruction Proximity to vital structures (eg, bowel, diaphragm) not mitigated by open or laparoscopic technique	Fever Right upper quadrant pain Portal vein thrombosis Hepatic abscess Bleeding (eg, subcapsular hematoma, hemoperitoneum)
Transarterial chemoembolization	Lesions that are unresectable because of portal hypertension or lesion location Patients awaiting liver transplant (downstaging tumors for transplant eligibility, preventing tumor progression while listed) Decreasing tumor burden for resection	Macrovascular invasion of tumor (main portal vein) Main portal vein obstruction Decompensated cirrhosis (Child-Pugh C) Significant cardiac disease Significant renal insufficiency Biliary obstruction Poor performance status	Postembolization syndrome (fever, right upper quadrant pain, nausea, ileus, elevated liver enzymes) Hepatic decompensation Hepatic abscess Gastroduodenal ulceration Bile duct damage/biloma
Cryoablation	Liver tumor ≤5 cm in size	Decompensated cirrhosis (Child-Pugh B/C) Macrovascular invasion of tumor (main portal vein) Biliary obstruction Proximity to vital structures (eg, bowel, diaphragm, gallbladder, blood vessel)	Liver fracture Hemorrhage Coagulopathy Biliary fistula Hepatic abscess Myoglobinuria Cryoshock (multisystem organ failure)
Irreversible electroporation	Liver tumor ≤4 cm in size (proximity to vascular structures is not a barrier)	Pacemaker Cardiac arrhythmia Extensive extrahepatic metastases	Bleeding Fistula formation (eg, arteriovenous, biliary) Cardiac arrhythmia
Transarterial radioembolization	Lesions that are unresectable because of portal hypertension or lesion location Patients awaiting liver transplant (downstaging tumors for transplant eligibility, preventing tumor progression while listed) Patients with portal vein thrombosis Decreasing tumor burden for resection	Potential for >30 Gy radiation exposure to lung in a single session (99 mTc macroaggregated albumin scan with pulmonary shunt fraction >15%) Prior hepatic radiation Macrovascular invasion of tumor (main portal vein) Decompensated cirrhosis (Child-Pugh C) Significant cardiac disease Significant renal insufficiency Poor performance status Biliary obstruction	Hepatic decompensation Hepatic abscess Bile duct damage/biloma Gastroduodenal ulceration Postembolization syndrome (much milder than transarterial chemoembolization) Radiation-induced liver disease Radiation pneumonitis Lymphopenia
Radiotherapy	Unresectable lesions	Decompensated cirrhosis (Child-Pugh B/C) Inadequate liver volume outside of the treatment area Prior hepatic radiation	Gastroduodenal ulceration Right upper quadrant pain Radiation-induced liver disease Hepatic abscess Bile duct damage/biloma
Systemic Chemotherapies
Sorafenib	Unresectable lesions (Barcelona Clinic Liver Cancer stage C/D)	Known severe hypersensitivity to sorafenib	Diarrhea Weight loss Hand-foot-skin eruptions Hypophosphatemia Hypertension Cardiac ischemia
Regorafenib	Unresectable lesions (Barcelona Clinic Liver Cancer stage C/D) that have failed to respond to sorafenib	Known severe hypersensitivity to regorafenib	Same as sorafenib

^aAblative therapies are curative for small lesions; however, in larger lesions, they are considered bridge therapies.