Volume 69, Issue 1, Pages 182-236 (July 2018) EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma  Peter R. Galle, Alejandro Forner, Josep M. Llovet, Vincenzo Mazzaferro, Fabio Piscaglia, Jean-Luc Raoul, Peter Schirmacher, Valérie Vilgrain Peter R. Galle, Alejandro Forner, Josep M. Llovet, Vincenzo Mazzaferro, Fabio Piscaglia, Jean-Luc Raoul, Peter Schirmacher, Valérie Vilgrain  Journal of Hepatology  Volume 69, Issue 1, Pages 182-236 (July 2018) DOI: 10.1016/j.jhep.2018.03.019 Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 1 Incidence rates of primary liver cancer according to geographical distribution in Europe. Total numbers per country and age-adjusted incidence rates per 100,000 of liver cancer in Europe in 2012. The colour intensity is proportional to the magnitude of incidence. Available from: http://globocan.iarc.fr. Data refer to all primary liver cancers (hepatocellular carcinoma, intrahepatic cholangiocarcinoma and liver cancer of mixed differentiation). Source: GLOBOCAN 2012, IARC -29.11.2017 Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 2 Diagnostic algorithm and recall policy in cirrhotic liver. ∗Using extracellular MR contrast agents or gadobenate dimeglumine. ∗∗Using the following diagnostic criteria: arterial phase hyperenhancement (APHE) and washout on the portal venous phase. ∗∗∗Using the following diagnostic criteria: arterial phase hyperenhancement (APHE) and mild washout after 60s. ∗∗∗∗Lesion <1 cm stable for 12 months (three controls after four months) can be shifted back to regular six months surveillance. ∗∗∗∗∗Optional for centre-based programmes. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 3 Modified BCLC staging system and treatment strategy. 1“Preserved liver function” refers to Child-Pugh A without any ascites, considered conditions to obtain optimal outcomes. This prerequisite applies to all treatment options apart from transplantation, that is instead addressed primarily to patients with decompensated or end-stage liver function. 2PS 1 refers to tumour induced (as per physician opinion) modification of performance capacity. 3Optimal surgical candidacy is based on a multiparametric evaluation including compensated Child-Pugh class A liver function with MELD score <10, to be matched with grade of portal hypertension, acceptable amount of remaining parenchyma and possibility to adopt a laparoscopic/minimally invasive approach. The combination of the previous factors should lead to an expected perioperative mortality <3% and morbidity <20% including a postsurgical severe liver failure incidence <5%. 4The stage migration strategy is a therapeutic choice by which a treatment theoretically recommended for a different stage is selected as best 1st line treatment option. Usually it is applied with a left to right direction in the scheme (i.e. offering the effective treatment option recommended for the subsequent more advanced tumour stage rather than that forecasted for that specific stage). This occurs when patients are not suitable for their first line therapy. However, in highly selected patients, with parameters close to the thresholds defining the previous stage, a right to left migration strategy (i.e. a therapy recommended for earlier stages) could be anyhow the best opportunity, pending multidisciplinary decision. 5As of 2017 sorafenib has been shown to be effective in first line, while regorafenib is effective in second line in case of radiological progression under sorafenib. Lenvatinib has been shown to be non-inferior to sorafenib in first line, but no effective second line option after lenvatinib has been explored. Cabozantinib has been demonstrated to be superior to placebo in 2nd or 3rd line with an improvement of OS from eight months (placebo) to 10.2 months (ASCO GI 2018). Nivolumab has been approved in second line by FDA but not EMA based on uncontrolled phase II data. ASCO, American Society of Clinical Oncology; BCLC, Barcelona Clinic Liver Cancer; EMA, European Medicines Agency; FDA, Food and Drug Administration; MELD, model for end-stage liver disease; PS, performace status; OS, overall survival. Modified with permission from87. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 4 Multi-parametric assessment of the risk of liver decompensation after LR for HCC in cirrhosis. Simplified decisional algorithm identifying high (red), intermediate (yellow) and low (green) risk of liver decompensation, according to a hierarchic interaction of the three main determinants of liver insufficiency: portal hypertension, extent of resection and liver function. HCC, hepatocellular carcinoma; LR, liver resection. Adapted from348 with permission. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 5 Principles of anatomic vs. non-anatomic liver resection for HCC. (A) Anatomic resection (A-A1) removes entirely the tumour-bearing portal branches bordered by the landmark veins, while non-anatomic resection (B-B1) is any other type of resection in which the tumour-bearing 3rd order portal region is not fully removed. (B) After non-anatomic resection of HCC some part of the tumour-bearing portal region is left, which is at high risk of tumour recurrence This picture is reproduced from Shindoh J et al. J Hepatol 2016 (with permission). HCC, hepatocellular carcinoma; MHV, middle hepatic vein; P8v, ventral branch of P8; P8d, dorsal branch of P8; PRPM, right para-median pedicle; RHV, right hepatic vein; V8i, intermediate vein for segment VIII. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 6 Principles of mini-invasive/laparoscopic liver resection for HCC. HCC, hepatocellular carcinoma. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 7 Computation of HCC nodules treated with neo-adjuvant therapies in light of liver transplantation. Post-treatment stage migration of this HCC according to commonly used criteria for transplant selection is indicated (see also text). HCC, hepatocellular carcinoma. Example of multifocal (three nodules) HCC presented for transplant consideration after neo-adjuvant treatments (downstaging). On last pre-LT imaging, tumour nodules are considered as fully necrotic (black) or still vital if presenting even minimal amount of enhanced tumour tissue (white). For transplant consideration this case should be rated as a two nodules HCC of 4.5 cm and 2.5 cm in size, with decrease in AFP from 150 to 45 ng/ml. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 8 Models governing decision-making on prioritisation of liver transplant candidates with cirrhosis and HCC. HCC, hepatocellular carcinoma. Adapted from,437 with permission. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 9 Representation of EASL recommendations for treatment according to levels of evidence and strength of recommendation (adaptation of the GRADE system). LDLT, living donor liver transplantation; LT, orthotopic liver transplantation; MW, microwave; PEI, percutaneous ethanol injection; RF, radiofrequency ablation. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 10 Understanding non-inferiority results in advanced HCC. It is estimated that RCT testing drugs head-to-head to sorafenib in first line might have three potential results a) drug is superior to sorafenib if the HR (95% CI) boundaries do not cross the unity (no example so far). b) The drugs are non-inferior compared to sorafenib, if the HR (95% CI) boundaries fall between 1 and 1.08 (lenvatinib case), and C) the drug is inferior to sorafenib if the HR (95% CI) boundaries cross the 1.08 upper limit for non-inferiority (linifanib and brivanib cases). Also, the negative results of Y-90 vs. sorafenib are shown. To claim non-inferiority a specific trial needs to be conducted. (Modified from Llovet, CCR 2014). ∗These treatments are inferior or inconclusive. If the RCT have been designed for superiority (i.e. Y90 vs. sorafenib) a specific RCT with non-inferiority design is needed to claim non-inferiority. HCC, hepatocellular carcinoma; HR, hazard ratio; RCT, randomised controlled trial. Journal of Hepatology 2018 69, 182-236DOI: (10.1016/j.jhep.2018.03.019) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions