Table 1.

ILCA Guidance and EASL Position Paper on HCC treatment during the COVID‐19 pandemic

	ILCA 7 , 8	EASL 9
General matters	• Reduce hospital visits and use telemedicine to prevent hospital‐acquired COVID‐19 infection • Where visits cannot be avoided, use personal protective equipment in line with national guidance • When bridging therapy or active monitoring is offered in place of potentially curative interventions, patients should be closely monitored, including with imaging methods and measurement of AFP, to reduce their risk of progressing beyond criteria for transplant, resection or RFA • Where feasible, cancer therapy should be offered in a ‘COVID‐free’ institution	• Care should be maintained according to guidelines but consider minimal exposure to medical staff by telemedicine and telephone contacts wherever possible/required to avoid admission to hospital • Early admission is recommended for patients with COVID‐19
Surgical resection	• Select patients with lower risk of decompensation • Select patients without comorbidities that increase the risk of severe COVID‐19 Alternative/holding therapy: ablation if anesthetic capacity allows, Bridging TA(C)E, SBRT, bridging systemic therapy, active monitoring with imaging	NA
Transplant	• Temporary suspension of elective living donor transplantation may be considered to protect both the potential donor and recipient • Consider delayed transplant in patients on the transplant list with complete response to bridging therapy; however, the risk of delaying transplant in patients with viable tumors and/or significant liver dysfunction should be discussed with the patient Alternative/holding therapy: ablation if anesthetic capacity allows, bridging TA(C)E, bridging SBRT, bridging systemic therapy (excluding checkpoint inhibition given the risk of rejection), active monitoring with imaging	• Listing for transplantation should be restricted to patients with poor short‐term prognosis, including those with acute/acute‐on‐chronic liver failure, high MELD scores (including exceptional MELDs), and HCC at the upper limits of the Milan criteria, as transplantation activities/organ donations will likely be reduced in many countries and areas • Reduce the in‐hospital liver transplant evaluation program to that which is strictly necessary to shorten in‐hospital stay and reduce the number of consultations in other departments/clinics. Ophthalmologic, dermatologic, dental and neurologic consultations can be performed in local outpatient settings Before transplantation • Donors and recipients should be routinely tested for SARS‐CoV‐2 before transplantation • Consent for diagnostic and therapeutic procedures related to transplantation should include the potential risk of nosocomial COVID‐19 • Living‐donor transplantations should be considered on a case‐by‐case basis After transplantation • Emphasis on the importance of vaccination for Streptococcus pneumoniae and influenza • Stable patients should be tested at local laboratories, including measurement of drug levels • Immunosuppressive therapy should not be reduced, except under special circumstances after consultation with a specialist • In patients with COVID‐19, dose adjustment of calcineurin and/or mTOR inhibitors might be required depending on the antiviral therapy initiated
RFA	• Select patients at low risk due to tumor location • Select patients with highest chance of cure; single tumors <3 cm • Assess risks and benefits in patients with comorbidities that increase the risk of serious infection from COVID‐19 Alternative/holding therapy: TA(C)E, SBRT, systemic therapy, active monitoring with imaging	• RFA should be postponed whenever possible
TACE	• Select patients at lower risk of decompensation • Assess risks and benefits in patients with comorbidities that increase the risk of serious infection from COVID‐19 • Consider use of prognostic scores such as HAP or beyond‐seven criteria to select patients most likely to benefit • Consider use of TAE, DEB‐TACE, or TARE to reduce risk of immunosuppression Alternative therapy: systemic therapy, active monitoring with imaging	• TACE should be postponed whenever possible
Systemic therapy	• For patients in clinical trials, discussion with sponsors required to accommodate variations in follow‐up schedule, trial‐related procedures and treatment location • Select patients most likely to benefit, based on performance status, Child–Pugh score and comorbidities • First‐line sorafenib or lenvatinib to replace trial recruitment and minimize hospital visits • In regions where checkpoint inhibitors are approved, consider increased risks associated with attendance for infusion • Manage patients by telemedicine to avoid hospital visits Dispense drugs by mail, perform blood and urine tests, and measure BP locally in the community; consider omitting radiology response assessment and continue evaluating clinical progression by tolerance Alternative therapy: active monitoring (with imaging where appropriate), supportive palliative care	•Temporarily withdraw immune checkpoint inhibitor therapy・Decide whether to continue/reduce TKI in patients with non‐severe COVID‐19 on a case‐by‐case basis

AFP, alpha‐fetoprotein; BP, blood pressure; DEB‐TACE, drug‐eluting beads transarterial chemoembolization; EASL, European Association for the Study of the Liver; HAP; HCC, hepatocellular carcinoma; ILCA, International Liver Cancer Association; MELD, model for end‐stage liver disease; NA, not applicable; RFA, radiofrequency ablation; SBRT, stereotactic body radiotherapy; TACE, transarterial chemoembolization; TAE, transarterial embolization; TARE, transarterial radioembolization; TKI, tyrosine kinase inhibitor.