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. 2019 Sep 23;10(1):43–80. doi: 10.1016/j.jceh.2019.09.007
Consensus statements Level Grade
  • •

    In patients with a non-cirrhotic liver with HCC, resection is the treatment of choice provided an R0 resection can be carried out leaving an adequate liver remnant.

 II-2 Strong
  • •

    Of all ablative modalities, RFA is the preferred modality for HCC and has now replaced PEI as the most frequently used ablative therapy.

 I Strong
  • •

    In a cirrhotic patient, with resectable solitary HCC ≤2 cm (BCLC-0), the clinical outcome of RFA is comparable to LR. Hence, RFA should be offered as the first line treatment option, if the tumor is in favorable location.

 I Strong
  • •
    For resectable solitary tumor >2 cm in size:
    • ∘
      Liver transplantation should be considered as the preferred option for tumors within transplant criteria.
    • ∘
      Resection is a treatment option especially in patients with no clinically relevant portal hypertension (HVPG ≤ 10 mmHg and platelet count, ≥100,000), good liver function, and adequate liver remnant.
    • ∘
      If liver transplantation and resection cannot be done:
      • ▪
        RFA should be offered provided the tumor is < 3 cm and in favorable location
      • ▪
        RFA + TACE should be offered if tumor size is between 3 and 5 cm
 II-2 Strong
  • •
    Criteria for LT:
    • ∘
      Milan criteria (single tumor ≤5 cm or multiple tumors ≤3 nodules ≤3 cm in size, without vascular invasion) remain the gold standard for selection of patients with HCC for LT in the DDLT setting.
    • ∘
      In the DDLT setting, the UCSF criteria have been also validated in several studies and yield similar outcomes.
 II-1 Strong
  • •

    Liver transplantation is the best treatment option for adult patients with cirrhosis and HCC within Milan criteria

 II-1 Strong
  • •
    If LT is not an option for patients meeting Milan criteria:
    • ∘
      Combination of TACE plus RFA should be offered.
    • ∘
      Minor liver resection may be considered in these patients with mild portal hypertension when complete resection is possible with adequate FLR.
 II-1 Strong
  • •
    In patients beyond the Milan criteria:
    • ∘
      Liver transplantation may be considered if patient can be successfully downstaged into the Milan criteria using locoregional therapy.
      • ▪
        There is no standard, agreed-upon waiting period following downstaging to determine efficacy of downstaging and subsequent optimal timing for liver transplantation.
    • ∘
      If liver transplantation is not an option in these patients, feasibility of liver resection should be assessed, preferably in a multidisciplinary setting.
 II-3 Weak
  • •
    In countries where LDLT is predominant:
    • ∘
      Milan criteria may be too restrictive. Currently most LDLT centers follow beyond Milan criteria and have acceptable results.
    • ∘
      UCSF criteria have been the most validated expanded criteria (single nodule ≤6.5 cm or 2–3 nodules ≤4.5 cm and total tumor diameter ≤8 cm) for selection without compromising results.
 II-3 Strong
  • •

    Neoadjuvant or adjuvant therapies (including sorafenib) have not proven to improve outcome of patients successfully treated with curative resection or ablation.

 II-2 Strong
  • •

    Better survival outcomes are obtained after anatomical resection compared with non-anatomical resection in patients with early HCC, especially with small (<5 cm), solitary tumors, in patients with good liver function.

 II-2 Strong
  • •

    In experienced centers, LR may be considered via laparoscopic/minimally invasive approaches, especially for solitary tumors (≤5 cm) in favorable locations.

 II-3 Weak
  • •

    In the DDLT setting, where waiting time for liver transplantation is more than 6 months, bridging therapy may be recommended for those within Listing Criteria to reduce the chances of tumor progression during waiting period.

 II-3 Weak
  • •

    The choice of locoregional therapy for bridging therapy to be offered will depend on local availability of expertise and experience as well as patients ability to afford (in privately funded centers).

 II-3 Weak
  • •

    In a well-matched cohort, there is no difference in overall survival and disease-free survival of LT for HCC, with respect to the type of graft (Living vs. Deceased donor)

 II-2 Weak
  • •

    Major vascular invasion and extrahepatic metastases are an absolute contraindication for LT for HCC.

 II-2 Strong
  • •

    In LDLT predominant centers, primary liver transplantation is a better treatment strategy in a Child A cirrhotic with initially resectable and transplantable HCC (early HCC as per BCLC staging) compared with upfront resection ± salvage transplantation for recurrence.

 II-2 Weak
  • •

    CNIs promote tumor growth. High blood CNI level predisposes to early tumor recurrence. Hence, CNI minimization should be attempted in all patients transplanted for HCC taking care of risk of rejection.

 II-2 Strong
  • •

    mTOR inhibitors may delay the recurrence of HCC and improve overall recurrence-free survival. mTOR inhibitors can be used in patients transplanted for HCC.

 II-2 Weak