Figure 2.
A) BCLC treatment algorithm with new systemic agents. Treatment strategy in the management of HCC is guided by the Barcelona Clinic Liver Cancer (BCLC) staging system, which consists of five stages depending on tumour burden features, liver function and performance status. Asymptomatic patients with low tumour burden and good liver function (BCLC 0/A) should be treated with local curative treatments (resection, ablation or transplantation, depending on the presence of portal hypertension, number of nodules and liver function). Asymptomatic patients with multinodular disease and adequate liver function (BCLC B) should receive chemoembolization and patients with portal thrombosis or extrahepatic spread (BCLC C) should be treated with systemic therapies. HCC, Hepatocellular carcinoma; ECOG PS, Eastern Cooperative Oncology Group performance status; LT, liver transplantation; M1, distant metastasis; N1, lymph node metastasis; SBRT, Stereotactic Body Radiation Therapy; TACE, Transarterial Chemoembolization; TARE; Transarterial Radioembolization. Adapted with permission from [ref. 23], Wiley. #: Based on high level of evidence studies. ##: Based on low/moderate level of evidence studies. *: see Figure 2b. [AU: we have initiated the collection of permissions to adapt and re-use parts of this figure]
B) Treatment strategy for HCC with systemic therapies. Green: Regulatory approved regimes based on phase III studies. Orange: positive combinations vs sorafenib, but drugs not yet approved. Yellow: treatments that got FDA accelerated approval based on phase II studies. (*) Around 70–80% of patients are expected to receive this regime. (**) COSMIC-312 phase III trial reported superior PFS for the combination of cabozantinib plus atezolizumab versus sorafenib, but final analysis on benefit on OS is not yet available94. BCLC, Barcelona Clinic Liver Cancer; ECOG PS, Eastern Cooperative Oncology Group performance status; PD, Progressive Disease.