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EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma

      Abbreviations:

      HCV (Hepatitis C virus), SNP (Single nucleotide polymorphism), PEG (Polyethylene glycol), HALT-C (Hepatitis C antiviral long-term treatment against cirrhosis), EPIC (Evaluation of PegIntron in control of hepatitis C cirrhosis), CT (Computed tomography), MR (Magnetic resonance), MRI (Magnetic resonance imaging), EpCAM (Epithelial cell adhesion molecule), PPV (Positive predictive value), qRT-PCR (Real-time reverse-transcription polymerase chain reaction), CUPI (Chinese university prognostic index), CLIP (Cancer of the Liver Italian program), SHARP (Sorafenib hepatocellular carcinoma assessment randomised protocol)

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      Introduction

      EASL–EORTC Clinical Practice Guidelines (CPG) on the management of hepatocellular carcinoma (HCC) define the use of surveillance, diagnosis, and therapeutic strategies recommended for patients with this type of cancer. This is the first European joint effort by the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) to provide common guidelines for the management of hepatocellular carcinoma. These guidelines update the recommendations reported by the EASL panel of experts in HCC published in 2001 [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ]. Several clinical and scientific advances have occurred during the past decade and, thus, a modern version of the document is urgently needed.
      The purpose of this document is to assist physicians, patients, health-care providers, and health-policy makers from Europe and worldwide in the decision-making process according to evidence-based data. Users of these guidelines should be aware that the recommendations are intended to guide clinical practice in circumstances where all possible resources and therapies are available. Thus, they should adapt the recommendations to their local regulations and/or team capacities, infrastructure, and cost–benefit strategies. Finally, this document sets out some recommendations that should be instrumental in advancing the research and knowledge of this disease and ultimately contribute to improve patient care.
      The EASL–EORTC CPG on the management of hepatocellular carcinoma provide recommendations based on the level of evidence and the strength of the data (the classification of evidence is adapted from National Cancer Institute [

      National Cancer Institute. PDQ® levels of evidence for adult and pediatric cancer treatment studies. Bethesda, MD: National Cancer Institute. Date last modified 26/August/2010. <http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/healthprofessional/>; 2011 [accessed 01.03.11].

      ]) (Table 1A) and the strength of recommendations following previously reported systems (GRADE systems) (Table 1B).
      Table 1ALevels of evidence according to study design and end-points National Cancer Institute: PDQ Levels of Evidence for Adult and Pediatric Cancer Treatment Studies. Bethesda

      National Cancer Institute. PDQ® levels of evidence for adult and pediatric cancer treatment studies. Bethesda, MD: National Cancer Institute. Date last modified 26/August/2010. <http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/healthprofessional/>; 2011 [accessed 01.03.11].

      .
      National Cancer Institute: PDQ® Levels of Evidence for Adult and Paediatric Cancer Treatment Studies. Bethesda, MD: National Cancer Institute. Date last modified 26/August/2010. Available at: http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/HealthProfessional. Accessed <March 1st, 2011>.
      The randomized, double-blinded controlled clinical trial (1i) is the gold standard of study design. Meta-analyses of randomized studies are placed in the same category of strength of evidence as are randomized studies.
      ∗∗This category includes trials in which treatment allocation was made by birth date, chart number (so-called quasi randomized studies) or subset analyses of randomized studies (or randomized phase II studies).
      ∗∗∗All other prospective (cohort studies) or retrospective studies (case–control studies, case series).
      #These end-points may be subjected to investigator interpretation. More importantly, they may, but do not automatically, translate into direct patient benefit such as survival or quality of life. Nevertheless, it is rational in many circumstances to use a treatment that improves these surrogate end-points while awaiting a more definitive end-point to support its use.
      Table 1BGrading evidence and recommendations (adapted from GRADE system).

      Epidemiology, risk factors, and prevention

      Figure thumbnail fx8

      Epidemiology

      The burden of cancer is increasing worldwide. Each year there are 10.9 million new cases of cancer and 6.7 million cancer-related deaths. The most commonly diagnosed cancers are lung, breast, and colorectal while the most common causes of cancer death are lung, stomach, and liver [
      • Parkin D.M.
      • Bray F.
      • Ferlay J.
      • Pisani P.
      Global cancer statistics, 2002.
      ,

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      ]. Liver cancer is the sixth most common cancer (749,000 new cases), the third cause of cancer-related death (692,000 cases), and accounts for 7% of all cancers [

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      ]. HCC represents more than 90% of primary liver cancers and is a major global health problem.
      The incidence of HCC increases progressively with advancing age in all populations, reaching a peak at 70 years [
      • El-Serag H.B.
      • Mason A.C.
      Rising incidence of hepatocellular carcinoma in the United States.
      ]. In Chinese and in black African populations, the mean age of patients with the tumor is appreciably younger. This is in sharp contrast to Japan, where the incidence of HCC is highest in the cohort of men aged 70–79 years [
      • Tanaka H.
      • Imai Y.
      • Hiramatsu N.
      • Ito Y.
      • Imanaka K.
      • Oshita M.
      • et al.
      Declining incidence of hepatocellular carcinoma in Osaka, Japan from 1990 to 2003.
      ]. HCC has a strong male preponderance with a male to female ratio estimated to be 2.4 [

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      ].
      The pattern of HCC occurrence has a clear geographical distribution, with the highest incidence rates in East Asia, sub-Saharan Africa, and Melanesia, where around 85% of cases occur [
      • Parkin D.M.
      • Bray F.
      • Ferlay J.
      • Pisani P.
      Global cancer statistics, 2002.
      ,

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      ]. In developed regions, the incidence is low with the exception of Southern Europe where the incidence in men (10.5 age-standardized incidence rates per 100,000) is significantly higher than in other developed regions [
      • Bosetti C.
      • Boffetta P.
      • Lucchini F.
      • Negri E.
      • La Vecchia C.
      Trends in mortality from hepatocellular carcinoma in Europe, 1980–2004.
      ] (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Incidence rates of primary liver cancer according to geographical distribution in Europe. Age-adjusted incidence rates per 100,000 of liver cancer in Europe in 2008. The color intensity is proportional to the magnitude of incidence. M, males; F, females. (Data from: Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr.)
      There is a growing incidence of HCC worldwide. Overall, the incidence and mortality rates were of 65,000 and 60,240 cases in Europe and 21,000 and 18,400 cases in the United States in 2008, respectively. It is estimated that by 2020 the number of cases will reach 78,000 and 27,000, respectively [

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      ]. People infected with HCV in Europe during the period 1940–60 and in the United States of America (USA) one decade later led to the current increase of HCC incidence. In Europe, the incidence and mortality rates reported are heterogeneous. HCC mortality during the last decades increased in males in most of the countries (i.e. Austria, Denmark, Germany, Greece, Ireland, Portugal, Norway, Spain, Switzerland, and United Kingdom), but decreased in others (Finland, France, Italy, Netherlands, and Sweden) [
      • Bosetti C.
      • Boffetta P.
      • Lucchini F.
      • Negri E.
      • La Vecchia C.
      Trends in mortality from hepatocellular carcinoma in Europe, 1980–2004.
      ]. In the United States, the rate of HCC deaths appears to have increased by about 40% over the period 1990–2004, whereas the overall rate of cancer deaths has declined by about 18% during this same period [
      • Jemal A.
      • Siegel R.
      • Ward E.
      • Hao Y.
      • Xu J.
      • Murray T.
      • et al.
      Cancer statistics, 2008.
      ]. Besides the emergence of liver disease due to hepatitis C, this growth in incidence may be also due to an increase in HBV-related HCC, particularly among immigrants from endemic countries. Conversely, in Japan, a country where the impact of HCV-related HCC was first noticed after World War II, there has been an apparent decline in the incidence of this neoplasm for the first time since 1990 [
      • Tanaka H.
      • Imai Y.
      • Hiramatsu N.
      • Ito Y.
      • Imanaka K.
      • Oshita M.
      • et al.
      Declining incidence of hepatocellular carcinoma in Osaka, Japan from 1990 to 2003.
      ]. Finally, the impact of universal infant vaccination against HBV has decreased the rate of HBV-related HCC in endemic countries. So far, this has been observed among children in Taiwan, but it is expected to become more apparent as these vaccinated children grow into adults [
      • Chang M.H.
      • You S.L.
      • Chen C.J.
      • Liu C.J.
      • Lee C.M.
      • Lin S.M.
      • et al.
      Taiwan Hepatoma Study Group. Decreased incidence of hepatocellular carcinoma in hepatitis B vaccinees: a 20-year follow-up study.
      ].

      Etiology and risk factors

      Approximately 90% of HCCs are associated with a known underlying risk factor (Table 2). The most frequent factors include chronic viral hepatitis (types B and C), alcohol intake and aflatoxin exposure. In Africa and East Asia, the largest attributable fraction is due to hepatitis B (60%) whereas in the developed Western world, only 20% of cases can be attributed to HBV infection, while chronic hepatitis C appears to be the major risk factor [
      • Parkin D.M.
      • Bray F.
      • Ferlay J.
      • Pisani P.
      Global cancer statistics, 2002.
      ]. Worldwide, approximately 54% of cases can be attributed to HBV infection (which affects 400 million people globally) while 31% can be attributed to HCV infection (which affects 170 million people), leaving approximately 15% associated with other causes.
      Table 2Geographical distribution of main risk factors for HCC worldwide.
      Updated from Llovet et al.
      • Llovet J.M.
      • Burroughs A.
      • Bruix J.
      Hepatocellular carcinoma.
      , according to IARC data

      IARC. <http://www-dep.iarc.fr/>; 2011 [accessed 01.11.11].

      . AAIR, age-adjusted incidence rate.
      Cirrhosis is an important risk factor for HCC, and may be caused by chronic viral hepatitis, alcohol, inherited metabolic diseases such as hemochromatosis or alpha-1-antitrypsin deficiency, and non-alcoholic fatty liver disease. All etiologic forms of cirrhosis may be complicated by tumor formation, but the risk is higher in patients with hepatitis infection. Overall, one-third of cirrhotic patients will develop HCC during their lifetime [
      • Sangiovanni A.
      • Prati G.M.
      • Fasani P.
      • Ronchi G.
      • Romeo R.
      • Manini M.
      • et al.
      The natural history of compensated cirrhosis due to hepatitis C virus: a 17-year cohort study of 214 patients.
      ]. Long-term follow-up studies have demonstrated that approximately 1–8% per year of patients with cirrhosis develop HCC (e.g. 2% in HBV-infected cirrhotic patients and 3–8% in HCV-infected cirrhotic patients) [
      • Ioannou G.
      • Splan M.
      • Weiss N.
      • McDonald G.
      • Beretta L.
      • Lee S.
      Incidence and predictors of hepatocellular carcinoma in patients with cirrhosis.
      ]. In general, features of liver disease severity (low platelet count of less than 100 × 103, presence of esophageal varices), in addition to older age and male gender, correlate with HCC development among patients with cirrhosis [
      • Lok A.S.
      • Seeff L.B.
      • Morgan T.R.
      • Di Bisceglie A.M.
      • Sterling R.K.
      • Curto T.M.
      • et al.
      Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease.
      ]. Recent studies have shown that liver cancer incidence increases in parallel to portal pressure as directly measured [
      • Ripoll C.
      • Groszmann R.J.
      • Garcia-Tsao G.
      • Bosch J.
      • Grace N.
      • Burroughs A.
      • et al.
      Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis.
      ] or in parallel to the degree of liver stiffness as measured by transient elastography [
      • Masuzaki R.
      • Tateishi R.
      • Yoshida H.
      • Goto E.
      • Sato T.
      • Ohki T.
      Prospective risk assessment for hepatocellular carcinoma development in patients with chronic hepatitis C by transient elastography.
      ,
      • Jung K.S.
      • Kim S.U.
      • Ahn S.H.
      • Park Y.N.
      • Kim do Y.
      • Park J.Y.
      • et al.
      Risk assessment of hepatitis B virus-related hepatocellular carcinoma development using liver stiffness measurement (FibroScan).
      ].
      Several studies have identified HBV-related factors as key predictors of HCC development in patients with chronic hepatitis B infection [
      • Lok A.S.
      Prevention of hepatitis B virus-related hepatocellular carcinoma.
      ]. Hepatitis B virus e antigen (HBeAg) seropositivity [
      • Yang H.I.
      • Lu S.N.
      • Liaw Y.F.
      • You S.L.
      • Sun C.A.
      • Wang L.Y.
      • et al.
      Taiwan Community–Based Cancer Screening Project Group. Hepatitis B e antigen and the risk of hepatocellular carcinoma.
      ], high viral load [
      • Chen C.J.
      • Yang H.I.
      • Su J.
      • Jen C.L.
      • You S.L.
      • Lu S.N.
      • et al.
      REVEAL-HBV Study Group. Risk of hepatocellular carcinoma across a biological gradient of serum hepatitis B virus DNA level.
      ], and genotype C [
      • Yu M.W.
      • Yeh S.H.
      • Chen P.J.
      • Liaw Y.F.
      • Lin C.L.
      • Liu C.J.
      • et al.
      Hepatitis B virus genotype and DNA level and hepatocellular carcinoma: a prospective study in men.
      ] are independent predictors of HCC development. In addition, hepatitis B viral load correlates with the risk of progression to cirrhosis [
      • Iloeje U.H.
      • Yang H.I.
      • Su J.
      • Jen C.L.
      • You S.L.
      • Chen C.J.
      Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer–In HBV (the REVEAL–HBV) Study Group. Predicting cirrhosis risk based on the level of circulating hepatitis B viral load.
      ]. Similarly, in a recent meta-analysis, HCV genotype 1b is claimed to increase the risk of HCC development [
      • Raimondi S.
      • Bruno S.
      • Mondelli M.U.
      • Maisonneuve P.
      Hepatitis C virus genotype 1b as a risk factor for hepatocellular carcinoma development: a meta-analysis.
      ].
      Dietary exposure to aflatoxin B1, derived from the fungi Aspergillus flavus and A. parasiticus, is an important co-factor for HCC development in some parts of Africa and Asia. These molds are ubiquitous in nature and contaminate a number of staple foodstuffs in tropical and subtropical regions. Epidemiologic studies have shown a strong correlation between the dietary intake of aflatoxin B1, TP53 mutations and incidence of HCC, specifically in HBV-infected individuals [
      • Hsu I.C.
      • Metcalf R.A.
      • Sun T.
      • Welsh J.A.
      • Wang N.J.
      • Harris C.C.
      Mutational hotspot in the p53 gene in human hepatocellular carcinomas.
      ]. Regarding other risk factors, patients with hemochromatosis develop HCC in up to 45% of cases [
      • Deugnier Y.M.
      • Guyader D.
      • Crantock L.
      • Lopez J.M.
      • Turlin B.
      • Yaouanq J.
      • et al.
      Primary liver cancer in genetic hemochromatosis: a clinical, pathological, and pathogenetic study of 54 cases.
      ], most often with a background of cirrhosis, and HCC is well documented as a complication of cirrhosis associated with alpha-1-antitrypsin deficiency [
      • Perlmutter D.H.
      Pathogenesis of chronic liver injury and hepatocellular carcinoma in alpha-1-antitrypsin deficiency.
      ]. HCC develops occasionally in patients with Wilson’s disease, but only in the presence of cirrhosis [
      • Polio J.
      • Enriquez R.E.
      • Chow A.
      • Wood W.M.
      • Atterbury C.E.
      Hepatocellular carcinoma in Wilson’s disease. Case report and review of the literature.
      ].
      Obesity, diabetes and fatty liver disease have come to be recognized as a cause of HCC [
      • El-Serag H.B.
      • Richardson P.A.
      • Everhart J.E.
      The role of diabetes in hepatocellular carcinoma: a case–control study among United States Veterans.
      ,
      • Marrero J.
      • Fontana R.
      • Fu S.
      • Conjeevaram H.
      • Su G.
      • Lok A.
      Alcohol, tobacco and obesity are synergistic risk factors for hepatocellular carcinoma.
      ], although the mechanisms by which these overlapping conditions contribute to cancer development remain elusive. Cirrhosis due to non-alcoholic steatohepatitis may give rise to HCC but it appears that these factors may also be additive to chronic viral hepatitis [
      • Marrero J.
      • Fontana R.
      • Fu S.
      • Conjeevaram H.
      • Su G.
      • Lok A.
      Alcohol, tobacco and obesity are synergistic risk factors for hepatocellular carcinoma.
      ]. Epidemiologic evidence of a link between cigarette smoking and the occurrence of HCC was traditionally conflicting [
      • El-Serag H.B.
      • Richardson P.A.
      • Everhart J.E.
      The role of diabetes in hepatocellular carcinoma: a case–control study among United States Veterans.
      ], but recent evidence support that smoking is a clear co-factor [
      • Trichopoulos D.
      • Bamia C.
      • Lagiou P.
      • Fedirko V.
      • Trepo E.
      • Jenab M.
      • et al.
      Hepatocellular carcinoma risk factors and disease burden in a European cohort: a nested case–control study.
      ]. Heavy smokers have a higher risk than non-smokers. In the general population, the incidence of HCC is increased among patients with HIV infection compared to controls, and HIV appears to be an additive co-factor, exacerbating the risk of HCC in patients with chronic viral hepatitis [
      • Marcellin P.
      • Pequignot F.
      • Delarocque-Astagneau E.
      • Zarski J.P.
      • Ganne N.
      • Hillon P.
      • et al.
      Mortality related to chronic hepatitis B and chronic hepatitis C in France: evidence for the role of HIV coinfection and alcohol consumption.
      ].
      Identification of mutations in germline DNA that define patients at high risk of developing cancer has become a challenge for surveillance programs and chemopreventive strategies. This is the case of mutations in BRCA1 or BRCA2 and increased risk of breast or ovarian cancer [
      • Miki Y.
      • Swensen J.
      • Shattuck-Eidens D.
      • Futreal P.A.
      • Harshman K.
      • Tavtigian S.
      • et al.
      A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1.
      ] or in genes involved in DNA mismatch repair and hereditary colon cancer [
      • Marra G.
      • Boland C.R.
      Hereditary nonpolyposis colorectal cancer: the syndrome, the genes, and historical perspectives.
      ]. In HCC, a recent case–control study found a significant association between an epidermal growth factor (EGF) gene polymorphism and the risk of HCC [
      • Tanabe K.K.
      • Lemoine A.
      • Finkelstein D.M.
      • Kawasaki H.
      • Fujii T.
      • Chung R.T.
      • et al.
      Epidermal growth factor gene functional polymorphism and the risk of hepatocellular carcinoma in patients with cirrhosis.
      ], while another study suggests genetic predisposition of SNPs at loci involved in immune response [
      • Clifford R.J.
      • Zhang J.
      • Meerzaman D.M.
      • Lyu M.S.
      • Hu Y.
      • Cultraro C.M.
      • et al.
      Genetic variations at loci involved in the immune response are risk factors for hepatocellular carcinoma.
      ]. These findings require validation by independent investigators.

      Prevention

      Primary prevention of HCC can be achieved with universal vaccination against HBV infection [
      • Chang M.H.
      • You S.L.
      • Chen C.J.
      • Liu C.J.
      • Lee C.M.
      • Lin S.M.
      • et al.
      Taiwan Hepatoma Study Group. Decreased incidence of hepatocellular carcinoma in hepatitis B vaccinees: a 20-year follow-up study.
      ]. Vaccination against hepatitis B is recommended to all newborns and high risk groups, following the recommendations of the World Health Organization [

      World Health Organization. Hepatitis B vaccines. Weekly epidemiological record of the World Health Organization 2009;84;405–420.

      ]. Since perinatal or early postnatal transmission is an important cause of chronic HBV infections globally, the first dose of hepatitis B vaccine should be given as soon as possible after birth, even in low-endemicity countries (those with prevalence of HBsAg carriers <2%). Vaccination is also recommended in age-specific cohorts (young adolescents) and people with risk factors for acquiring HBV infection (i.e. health workers, travellers to areas where HBV-infection is prevalent, injecting drug users, and people with multiple sex partners).
      Antiviral treatment for patients with chronic hepatitis B and C infection should follow the recommendations from existing EASL guidelines [
      • European Association for the Study of the Liver
      EASL Clinical Practice Guidelines: management of chronic hepatitis B.
      ,
      • European Association for the Study of the Liver
      EASL Clinical Practice Guidelines: management of hepatitis C virus infection.
      ]. Interferon, lamivudine, adefovir, entecavir, telbivudine and tenofovir are now available for HBV treatment, but long-term follow-up data assessing their effect in secondary prevention are only available with interferon and lamivudine. Observational studies assessing the effect of interferon showed a potential effect in reduction of HCC incidence [
      • Niederau C.
      • Heintges T.
      • Lange S.
      • Goldmann G.
      • Niederau C.M.
      • Mohr L.
      • et al.
      Long-term follow-up of HBeAg-positive patients treated with interferon alfa for chronic hepatitis B.
      ], but this was not confirmed by Asian case-controlled studies [
      • Yuen M.F.
      • Sablon E.
      • Hui C.K.
      • Yuan H.J.
      • Decraemer H.
      • Lai C.L.
      Factors associated with hepatitis B virus DNA breakthrough in patients receiving prolonged lamivudine therapy.
      ]. Similarly, a randomized controlled trial (RCT) assessing the effect of lamivudine showed a significant reduction in HCC incidence. Nonetheless, there are some concerns regarding the effects obtained in this study as prevention of HCC occurrence was not the primary end-point of the study, and because the marginal effect obtained disappeared once adjusted for co-variables [
      • Liaw Y.F.
      • Sung J.J.
      • Chow W.C.
      • Farrell G.
      • Lee C.Z.
      • Yuen H.
      • et al.
      Cirrhosis Asian Lamivudine Multicentre Study Group. Lamivudine for patients with chronic hepatitis B and advanced liver disease.
      ]. As a result, it appears prudent to conclude that surveillance for HCC should be maintained in those patients who already qualified before starting the treatment.
      In hepatitis C viral infection, the results of a meta-analysis of retrospective studies suggest that the risk of HCC is reduced among patients with HCV who achieve a sustained virological response (SVR) with antiviral therapy with interferon–ribavirin [
      • Singal A.G.
      • Volk M.L.
      • Jensen D.
      • Di Bisceglie A.M.
      • Schoenfeld P.S.
      A sustained viral response is associated with reduced liver-related morbidity and mortality in patients with hepatitis C virus.
      ]. Once cirrhosis is established, there is no conclusive evidence that anti-viral therapy can prevent or delay the occurrence of HCC [
      • Nishiguchi S.
      • Kuroki T.
      • Nakatani S.
      • Morimoto H.
      • Takeda T.
      • Nakajima S.
      • et al.
      Randomised trial of effects of interferon-alpha on incidence of hepatocellular carcinoma in chronic active hepatitis C with cirrhosis.
      ,
      • Valla D.C.
      • Chevallier M.
      • Marcellin P.
      • Payen J.L.
      • Trepo C.
      • Fonck M.
      • et al.
      Treatment of hepatitis C virus-related cirrhosis: a randomized, controlled trial of interferon alfa-2b versus no treatment.
      ]. Maintenance therapy with PEG–interferon in cirrhotic patients has not significantly decreased the incidence of HCC according to the HALT-C [
      • Lok A.S.
      • Everhart J.E.
      • Wright E.C.
      • Di Bisceglie A.M.
      • Kim H.Y.
      • Sterling R.K.
      • et al.
      HALT-C Trial Group. Maintenance peginterferon therapy and other factors associated with hepatocellular carcinoma in patients with advanced hepatitis C.
      ,
      • Di Bisceglie A.M.
      • Stoddard A.M.
      • Dienstag J.L.
      • Shiffman M.L.
      • Seeff L.B.
      • Bonkovsky H.L.
      • et al.
      HALT-C Trial Group. Excess mortality in patients with advanced chronic hepatitis C treated with long-term peginterferon.
      ] and EPIC studies [
      • Bruix J.
      • Poynard T.
      • Colombo M.
      • Schiff E.
      • Burak K.
      • Heathcote E.J.
      • et al.
      EPIC3 Study Group. Maintenance therapy with peginterferon alfa-2b does not prevent hepatocellular carcinoma in cirrhotic patients with chronic hepatitis C.
      ]. Additional studies are required to test the potential preventive effect of combination with new protease inhibitors (boceprevir, telaprevir) in cirrhotic patients .
      Table 3Recommendations for HCC surveillance: categories of adult patients in whom surveillance is recommended.
      Evidence 3A; strength B1;
      ∗∗evidence 3D; strength B1;
      ∗∗∗evidence 1B; strength A1 for Asian patients; evidence 3D; strength C1 for Western patients;
      ∗∗∗∗evidence 3D; strength B1 for Asian patients; evidence 3D; strength B2 for Western patients.

      Surveillance

      Figure thumbnail fx9
      Surveillance consists of the periodic application of a diagnostic test to subjects at risk for developing a given disease. Its usefulness and applicability are influenced by several factors, such as the incidence of the surveyed disease in the target population, the availability of efficient diagnostic test(s) at bearable costs and their acceptability by the target population, and the availability of treatments and their effectiveness [
      • Prorok P.C.
      Epidemiologic approach for cancer screening. Problems in design and analysis of trials.
      ]. The aim of surveillance is to obtain a reduction in disease-related mortality. This is usually achieved through an early diagnosis (stage migration) that, in turn, enhances the applicability and cost–effectiveness of curative therapies. Stage migration, however, cannot serve as a surrogate for the main end-point, which is patient survival.
      HCC is a condition which lends itself to surveillance as at-risk individuals can readily be identified because of the presence of underlying viral hepatitis or other liver diseases. In fact, in the Western world, HCC arises in a cirrhotic background in up to 90% of cases [
      • El-Serag H.B.
      Hepatocellular carcinoma.
      ], and cirrhosis itself is a progressive disease that affects patient survival. The presence of cirrhosis then influences the chances for anti-tumoral treatment and affects their results, thus rendering early diagnosis of HCC even more crucial. Moreover, many available treatments can have an adverse impact on cirrhosis, and the exact cause of death, which could be either the underlying disease or HCC, cannot be clearly defined in some instances. For this reason, a reduction in overall mortality represents a more appropriate end-point to assess the efficacy of surveillance.

      Target populations

      Cirrhotic patients

      Decision analysis and cost–effectiveness models suggest that an intervention is considered cost-effective if it provides gains of life expectancy of at least 3 months with a cost lower than approximately US$ 50,000 per year of life saved [
      • Laupacis A.
      • Feeny D.
      • Detsky A.S.
      • Tugwell P.X.
      How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations.
      ]. Cost–effectiveness studies indicate that an incidence of 1.5%/year or greater would warrant surveillance of HCC in cirrhotic patients [
      • Sarasin F.P.
      • Giostra E.
      • Hadengue A.
      Cost–effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child–Pugh class A cirrhosis.
      ], irrespective of its etiology [
      • Sangiovanni A.
      • Prati G.M.
      • Fasani P.
      • Ronchi G.
      • Romeo R.
      • Manini M.
      • et al.
      The natural history of compensated cirrhosis due to hepatitis C virus: a 17-year cohort study of 214 patients.
      ,
      • Yang H.I.
      • Lu S.N.
      • Liaw Y.F.
      • You S.L.
      • Sun C.A.
      • Wang L.Y.
      • et al.
      Taiwan Community–Based Cancer Screening Project Group. Hepatitis B e antigen and the risk of hepatocellular carcinoma.
      ,
      • Fattovich G.
      • Stroffolini T.
      • Zagni I.
      • Donato F.
      Hepatocellular carcinoma in cirrhosis: incidence and risk factors.
      ,
      • Yoshida H.
      • Shiratori Y.
      • Moriyama M.
      • Arakawa Y.
      • Ide T.
      • Sata M.
      • et al.
      Interferon therapy reduces the risk for hepatocellular carcinoma: national surveillance program of cirrhotic and noncirrhotic patients with chronic hepatitis C in Japan. IHIT Study Group. Inhibition of hepatocarcinogenesis by interferon therapy.
      ]. It may also be possible to identify cirrhotic patients at low risk of developing HCC [
      • Sangiovanni A.
      • Del Ninno E.
      • Fasani P.
      • De Fazio C.
      • Ronchi G.
      • Romeo R.
      • et al.
      Increased survival of cirrhotic patients with a hepatocellular carcinoma detected during surveillance.
      ,
      • Ganne-Carrié N.
      • Chastang C.
      • Chapel F.
      • Munz C.
      • Pateron D.
      • Sibony M.
      • et al.
      Predictive score for the development of hepatocellular carcinoma and additional value of liver large cell dysplasia in Western patients with cirrhosis.
      ,
      • Velázquez R.F.
      • Rodríguez M.
      • Navascués C.A.
      • Linares A.
      • Pérez R.
      • Sotorríos N.G.
      • et al.
      Prospective analysis of risk factors for hepatocellular carcinoma in patients with liver cirrhosis.
      ] and hence exclude them from surveillance, thereby saving costs although this approach is not proven yet. Conversely, the presence of advanced cirrhosis (Child–Pugh class C) prevents potentially curative therapies from being employed, and thus surveillance is not cost-effective in these patients [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ,
      • Trevisani F.
      • Santi V.
      • Gramenzi A.
      • Di Nolfo M.A.
      • Poggio P.D.
      • Benvegnù L.
      For the Italian Liver Cancer (ITA.LI.CA.) group. Surveillance for early diagnosis of hepatocellular carcinoma: is it effective in intermediate/advanced cirrhosis?.
      ]. As an exception, patients on the waiting list for liver transplantation, regardless of the liver functional status, should be screened for HCC in order to detect tumors exceeding conventional criteria and to help define priority policies for transplantation. Finally, although it seems intuitive that surveillance might not be cost-effective above a certain age cut-off, the lack of data prevents the adoption of any specific recommendation.

      Non-cirrhotic subjects

      Patients with chronic HBV infection are at risk of HCC development even in the absence of cirrhosis. In these cases, the recommended cut-off of annual incidence above which surveillance should be recommended cannot be applied. The cut-off of annual incidence in these patients is ill-defined, albeit expert opinion indicates that it would be warranted if HCC incidence is at least 0.2%/year [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma: an update.
      ,
      • Di Bisceglie A.M.
      Issues in screening and surveillance for hepatocellular carcinoma.
      ]. Thus, cost–benefit modeling is needed in this scenario. The incidence of HCC in adult Asian or African active HBV carriers or with a family history of HCC exceeds this value, whereas HCC incidence ranges from 0.1% to 0.4%/year in Western patients with chronic HBV infection [
      • Fattovich G.
      • Bortolotti F.
      • Donato F.
      Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors.
      ,
      • Sánchez-Tapias J.M.
      • Costa J.
      • Mas A.
      • Bruguera M.
      • Rodés J.
      Influence of hepatitis B virus genotype on the long-term outcome of chronic hepatitis B in western patients.
      ]. Viral load also appears to increase the risk of developing HCC. In Asian patients, serum HBV-DNA above 10,000 copies/ml was associated with an annual risk above 0.2%/year [
      • Chen C.J.
      • Yang H.I.
      • Su J.
      • Jen C.L.
      • You S.L.
      • Lu S.N.
      • et al.
      REVEAL-HBV Study Group. Risk of hepatocellular carcinoma across a biological gradient of serum hepatitis B virus DNA level.
      ].
      Unfortunately, there is scanty and sometimes contradictory information on the incidence of HCC in patients with chronic hepatitis C without cirrhosis. Data from Japan would suggest that patients with mild fibrosis have a yearly HCC incidence of 0.5% [
      • Yoshida H.
      • Shiratori Y.
      • Moriyama M.
      • Arakawa Y.
      • Ide T.
      • Sata M.
      • et al.
      Interferon therapy reduces the risk for hepatocellular carcinoma: national surveillance program of cirrhotic and noncirrhotic patients with chronic hepatitis C in Japan. IHIT Study Group. Inhibition of hepatocarcinogenesis by interferon therapy.
      ]. A recent study from the United States has pointed out that HCC does occur in patients with chronic hepatitis C and bridging fibrosis in the absence of cirrhosis (Metavir F3) [
      • Lok A.S.
      • Seeff L.B.
      • Morgan T.R.
      • Di Bisceglie A.M.
      • Sterling R.K.
      • Curto T.M.
      • et al.
      Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease.
      ]. The fact that the transition from advanced fibrosis and cirrhosis cannot be accurately defined led the EASL guidelines to recommend surveillance also for patients with bridging fibrosis [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ]. This panel also endorses such a policy. In this respect, transient elastography appears to be a promising tool able to stratify patients at different HCC risks [
      • Masuzaki R.
      • Tateishi R.
      • Yoshida H.
      • Goto E.
      • Sato T.
      • Ohki T.
      Prospective risk assessment for hepatocellular carcinoma development in patients with chronic hepatitis C by transient elastography.
      ,
      • Martínez S.M.
      • Crespo G.
      • Navasa M.
      • Forns X.
      Noninvasive assessment of liver fibrosis.
      ].
      Information about the incidence of HCC in patients with non-viral chronic liver disease without cirrhosis, such as non-alcoholic and alcoholic steatohepatitis, autoimmune liver disease, genetic hemochromatosis, α1-antitripsin deficiency, and Wilson disease is limited [
      • Deugnier Y.M.
      • Guyader D.
      • Crantock L.
      • Lopez J.M.
      • Turlin B.
      • Yaouanq J.
      • et al.
      Primary liver cancer in genetic hemochromatosis: a clinical, pathological, and pathogenetic study of 54 cases.
      ,
      • Perlmutter D.H.
      Pathogenesis of chronic liver injury and hepatocellular carcinoma in alpha-1-antitrypsin deficiency.
      ,
      • Polio J.
      • Enriquez R.E.
      • Chow A.
      • Wood W.M.
      • Atterbury C.E.
      Hepatocellular carcinoma in Wilson’s disease. Case report and review of the literature.
      ,
      • Bosch F.X.
      • Ribes J.
      • Díaz M.
      • Cléries R.
      Primary liver cancer: worldwide incidence and trends.
      ]. However, available evidence suggests that HCC usually arises in these contexts once cirrhosis is established [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ]. Certainly, patients with metabolic syndrome or non-alcoholic steatohepatitis leading to cirrhosis should undergo surveillance [
      • Yasui K.
      • Hashimoto E.
      • Komorizono Y.
      • Koike K.
      • Arii S.
      • Imai Y.
      Characteristics of patients with nonalcoholic steatohepatitis who develop hepatocellular carcinoma.
      ], whereas the risk of HCC development is not established in non-cirrhotic individuals.

      Treated viral chronic hepatitis

      Recent advances in therapy have led to relatively high rates of viral clearance or suppression among those patients being treated for chronic hepatitis B or C. Successful treatment, leading to sustained virological response in chronic hepatitis C, and HBeAg seroconversion or sustained HBV-DNA suppression in chronic hepatitis B, decreases, but does not eliminate the risk of HCC [
      • Craxì A.
      • Cammà C.
      Prevention of hepatocellular carcinoma.
      ,
      • Bruno S.
      • Stroffolini T.
      • Colombo M.
      • Bollani S.
      • Benvegnù L.
      • Mazzella G.
      • et al.
      Italian Association of the Study of the Liver Disease (AISF). Sustained virological response to interferon-alpha is associated with improved outcome in HCV-related cirrhosis: a retrospective study.
      ,
      • Sung J.J.
      • Tsoi K.K.
      • Wong V.W.
      • Li K.C.
      • Chan H.L.
      Meta-analysis: treatment of hepatitis B infection reduces risk of hepatocellular carcinoma.
      ,
      • Lampertico P.
      • Viganò M.
      • Manenti E.
      • Iavarone M.
      • Sablon E.
      • Colombo M.
      Low resistance to adefovir combined with lamivudine: a 3-year study of 145 lamivudine-resistant hepatitis B patients.
      ]. Surveillance should be offered to treated patients with chronic hepatitis B who remain at risk of HCC development due to baseline factors, or to those with HCV-induced advanced fibrosis or cirrhosis, even after achieving sustained virological response.

      Surveillance tests

      Tests that can be used in HCC surveillance include serological and imaging examinations. The imaging test most widely used for surveillance is ultrasonography (US). US has an acceptable diagnostic accuracy when used as a surveillance test (sensitivity ranging from 58% to 89%; specificity greater than 90%) [
      • Bolondi L.
      Screening for hepatocellular carcinoma in cirrhosis.
      ,
      • Kim C.K.
      • Lim J.H.
      • Lee W.J.
      Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients.
      ]. A recent meta-analysis including 19 studies has showed that US surveillance detected the majority of HCC tumors before they presented clinically, with a pooled sensitivity of 94%. However, US was less effective for detecting early-stage HCC, with a sensitivity of only 63% [
      • Singal A.
      • Volk M.L.
      • Waljee A.
      • Salgia R.
      • Higgins P.
      • Rogers M.A.
      • et al.
      Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.
      ]. In contrast, in a recent Japanese cohort including 1432 patients, careful US surveillance performed by highly skilled operators resulted in an average size of the detected tumors of 1.6 ± 0.6 cm, with less than 2% of the cases exceeding 3 cm [
      • Sato T.
      • Tateishi R.
      • Yoshida H.
      • Ohki T.
      • Masuzaki R.
      • Imamura J.
      • et al.
      Ultrasound surveillance for early detection of hepatocellular carcinoma among patients with chronic hepatitis C.
      ].
      The widespread popularity of US also relies on the absence of risks, non-invasiveness, good acceptance by patients and relatively moderate cost. Nonetheless, US detection of HCC on a cirrhotic background is a challenging issue. Liver cirrhosis is characterized by fibrous septa and regenerative nodules. These features produce a coarse pattern on US, which may impair identification of small tumors. Because of these limitations, the performance of US in early detection of HCC is highly dependent on the expertise of the operator and the quality of the equipment. Thus, special training for ultrasonographers is recommended. The recent introduction of US contrast agents has not proven to increase the ability of US to detect small HCC tumors [
      • Lencioni R.
      • Piscaglia F.
      • Bolondi L.
      Contrast-enhanced ultrasound in the diagnosis of hepatocellular carcinoma.
      ].
      There are no data to support the use of multidetector CT or dynamic MR imaging for surveillance. Practical experience suggests that the rate of false-positive results that will trigger further investigation is very high and non-cost-effective. These circumstances are overcome in the setting of the waiting list for liver transplantation where CT scan or MRI are alternatives to US. These techniques should be also considered when obesity, intestinal gas, and chest wall deformity prevent an adequate US assessment. Even in these circumstances, radiation risk due to repeated exposure to CT scan and high cost of MR make debatable their use in long-term surveillance.
      Serological tests that have been investigated or are under investigation for early diagnosis of HCC include alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP) – also known as prothrombin induced by Vitamin K Absence II (PIVKA II) – the ratio of glycosylated AFP (L3 fraction) to total AFP, alpha-fucosidase, and glypican 3 [
      • Lok A.S.
      • Seeff L.B.
      • Morgan T.R.
      • Di Bisceglie A.M.
      • Sterling R.K.
      • Curto T.M.
      • et al.
      Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease.
      ,
      • Marrero J.A.
      • Su G.L.
      • Wei W.
      • Emick D.
      • Conjeevaram H.S.
      • Fontana R.J.
      • et al.
      Des-gamma carboxyprothrombin can differentiate hepatocellular carcinoma from nonmalignant chronic liver disease in American patients.
      ]. AFP is the most widely tested biomarker in HCC. It is known that persistently elevated AFP levels are a risk factor for HCC development and can be used to help define at-risk populations [
      • Tsukuma H.
      • Hiyama T.
      • Tanaka S.
      • Nakao M.
      • Yabuuchi T.
      • Kitamura T.
      • et al.
      Risk factors for hepatocellular carcinoma among patients with chronic liver disease.
      ]. Of note is that AFP has been mostly tested in the diagnostic mode rather than for surveillance. This is relevant, since its performance as a diagnostic test cannot be extrapolated to the surveillance setting. As a serological test for surveillance, AFP has a suboptimal performance. One randomized study [
      • Chen J.G.
      • Parkin D.M.
      • Chen Q.G.
      • Lu J.H.
      • Shen Q.J.
      • Zhang B.C.
      • et al.
      Screening for liver cancer: results of a randomised controlled trial in Qidong, China.
      ] and one population-based observational study [
      • McMahon B.J.
      • Bulkow L.
      • Harpster A.
      • Snowball M.
      • Lanier A.
      • Sacco F.
      • et al.
      Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study.
      ] reached opposite results. The latter study provides rationale for testing AFP in special populations or health care environments when US is not readily available [
      • McMahon B.J.
      • Bulkow L.
      • Harpster A.
      • Snowball M.
      • Lanier A.
      • Sacco F.
      • et al.
      Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study.
      ]. However, when combined with US, AFP levels are only able to provide additional detection in 6–8% of cases not previously identified by US. Reasons for the suboptimal performance of AFP as a serological test in the surveillance mode are twofold. Firstly, fluctuating levels of AFP in patients with cirrhosis might reflect flares of HBV or HCV infection, exacerbation of underlying liver disease or HCC development [
      • Di Bisceglie A.M.
      • Sterling R.K.
      • Chung R.T.
      • Everhart J.E.
      • Dienstag J.L.
      • Bonkovsky H.L.
      • et al.
      HALT-C Trial Group. Serum alpha-fetoprotein levels in patients with advanced hepatitis C: results from the HALT-C Trial.
      ]. Secondly, only a small proportion of tumors at an early stage (10–20%) present with abnormal AFP serum levels, a fact that has been recently correlated with a molecular subclass of aggressive HCCs (S2 class, EpCAM positive) [
      • Yamashita T.
      • Forgues M.
      • Wang W.
      • Kim J.W.
      • Ye Q.
      • Jia H.
      • et al.
      EpCAM and alpha-fetoprotein expression defines novel prognostic subtypes of hepatocellular carcinoma.
      ,
      • Villanueva A.
      • Minguez B.
      • Forner A.
      • Reig M.
      • Llovet J.M.
      Hepatocellular carcinoma: novel molecular approaches for diagnosis, prognosis, and therapy.
      ,
      • Hoshida Y.
      • Nijman S.M.
      • Kobayashi M.
      • Chan J.A.
      • Brunet J.P.
      • Chiang D.Y.
      • et al.
      Integrative transcriptome analysis reveals common molecular subclasses of human hepatocellular carcinoma.
      ]. When used as a diagnostic test, AFP levels at a value of 20 ng/ml show good sensitivity but low specificity, whereas at higher cut-offs of 200 ng/ml the sensitivity drops to 22% with high specificity [
      • Trevisani F.
      • D’Intino P.E.
      • Morselli-Labate A.M.
      • Mazzella G.
      • Accogli E.
      • Caraceni P.
      • et al.
      Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HbsAg and anti-HCV status.
      ].
      All other serum markers have usually been evaluated, alone or in combination, in a diagnostic rather than surveillance setting. Moreover, their diagnostic performance has often been assessed at an HCC prevalence remarkably higher than that expected in the context of surveillance [
      • Pateron D.
      • Ganne N.
      • Trinchet J.C.
      • Aurousseau M.H.
      • Mal F.
      • Meicler C.
      • et al.
      Prospective study of screening for hepatocellular carcinoma in Caucasian patients with cirrhosis.
      ]. In the latter setting, DCP, measured with a first generation assay, did not offer substantial advantages with respect to AFP [
      • Koike Y.
      • Shiratori Y.
      • Sato S.
      • Obi S.
      • Teratani T.
      • Imamura M.
      • et al.
      Des-gamma-carboxy prothrombin as a useful predisposing factor for the development of portal venous invasion in patients with hepatocellular carcinoma: a prospective analysis of 227 patients.
      ]. In addition, DCP levels have been associated to portal vein invasion and advanced tumoral stage, a fact that prevents the usage of this marker for early detection [
      • Koike Y.
      • Shiratori Y.
      • Sato S.
      • Obi S.
      • Teratani T.
      • Imamura M.
      • et al.
      Des-gamma-carboxy prothrombin as a useful predisposing factor for the development of portal venous invasion in patients with hepatocellular carcinoma: a prospective analysis of 227 patients.
      ]. A similar situation occurs with AFP-L3 fraction levels [
      • Sterling R.K.
      • Jeffers L.
      • Gordon F.
      • Sherman M.
      • Venook A.P.
      • Reddy K.R.
      • et al.
      Clinical utility of AFP-L3% measurement in North American patients with HCV-related cirrhosis.
      ]. At present, none of these tests can be recommended to survey patients at risk of developing HCC. Several markers, such as fucosylated proteins, are currently under investigation [
      • Wang M.
      • Long R.E.
      • Comunale M.A.
      • Junaidi O.
      • Marrero J.
      • Di Bisceglie A.M.
      • et al.
      Novel fucosylated biomarkers for the early detection of hepatocellular carcinoma.
      ].
      In conclusion, US can be seen as the most appropriate test to perform surveillance. The combination with AFP is not recommended, as the 6–8% gain in the detection rate does not counterbalance the increase in false positive results, ultimately leading to an about 80% increase in the cost of each small HCC diagnosed [
      • Singal A.
      • Volk M.L.
      • Waljee A.
      • Salgia R.
      • Higgins P.
      • Rogers M.A.
      • et al.
      Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.
      ,
      • Zhang B.
      • Yang B.
      Combined alpha fetoprotein testing and ultrasonography as a screening test for primary liver cancer.
      ].

      Surveillance efficacy

      Two randomized controlled trials have been published on HCC surveillance. In one population-based study cluster randomization (randomizing entire villages) was performed comparing surveillance (US and AFP measurements every 6 months) versus no surveillance in a population of Chinese patients with chronic hepatitis B infection, regardless of the presence of cirrhosis [
      • Zhang B.H.
      • Yang B.H.
      • Tang Z.Y.
      Randomized controlled trial of screening for hepatocellular carcinoma.
      ]. Despite suboptimal adherence to the surveillance program (55%), HCC-related mortality was reduced by 37% in the surveillance arm as a result of increased applicability of resection in detected cases. The other AFP-based surveillance study carried out in Qidong (China) in high-risk individuals (males, HBsAg+) did not identify differences in overall survival [
      • Chen J.G.
      • Parkin D.M.
      • Chen Q.G.
      • Lu J.H.
      • Shen Q.J.
      • Zhang B.C.
      • et al.
      Screening for liver cancer: results of a randomised controlled trial in Qidong, China.
      ].
      Other types of evidence include population and non-population-based cohorts and cost–effectiveness analysis, which mostly reinforce the benefits of regular US schemes [
      • Trevisani F.
      • Santi V.
      • Gramenzi A.
      • Di Nolfo M.A.
      • Poggio P.D.
      • Benvegnù L.
      For the Italian Liver Cancer (ITA.LI.CA.) group. Surveillance for early diagnosis of hepatocellular carcinoma: is it effective in intermediate/advanced cirrhosis?.
      ,
      • Singal A.
      • Volk M.L.
      • Waljee A.
      • Salgia R.
      • Higgins P.
      • Rogers M.A.
      • et al.
      Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.
      ,
      • Barbara L.
      • Benzi G.
      • Gaiani S.
      • Fusconi F.
      • Zironi G.
      • Siringo S.
      • et al.
      Natural history of small untreated hepatocellular carcinoma in cirrhosis: a multivariate analysis of prognostic factors of tumor growth rate and patient survival.
      ,
      • Ebara M.
      • Ohto M.
      • Shinagawa T.
      • Sugiura N.
      • Kimura K.
      • Matsutani S.
      • et al.
      Natural history of minute hepatocellular carcinoma smaller than three centimetres complicating cirrhosis. A study in 22 patients.
      ,
      • Sheu J.C.
      • Sung J.L.
      • Chen D.S.
      • Yang P.M.
      • Lai M.Y.
      • Lee C.S.
      • et al.
      Growth rate of asymptomatic hepatocellular carcinoma and its clinical implications.
      ,
      • Makuuchi M.
      • Kokudo N.
      • Arii S.
      • Futagawa S.
      • Kaneko S.
      • Kawasaki S.
      • et al.
      Development of evidence-based clinical guidelines for the diagnosis and treatment of hepatocellular carcinoma in Japan.
      ,
      • Trinchet J.C.
      • Chaffaut C.
      • Bourcier V.
      • Degos F.
      • Henrion J.
      • Fontaine H.
      • et al.
      Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities.
      ,
      • Santagostino E.
      • Colombo M.
      • Rivi M.
      • Rumi M.G.
      • Rocino A.
      • Linari S.
      • et al.
      A 6-month versus a 12-month surveillance for hepatocellular carcinoma in 559 hemophiliacs infected with the hepatitis C virus.
      ,
      • Thompson Coon J.
      • Rogers G.
      • Hewson P.
      • Wright D.
      • Anderson R.
      • et al.
      Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis.
      ]. However, these studies are heterogeneous as far as stage and etiology of liver disease, and surveillance protocols. Moreover, almost all suffer from methodological biases such as lead-time bias (apparent improvement of survival due to an anticipated diagnosis) and length time bias (over-representation of slower-growing tumors). While the latter is unavoidable in this type of study, lead-time bias can be minimized using correction formulas. When this was done, the advantage of surveillance remained [
      • Trevisani F.
      • Cantarini M.C.
      • Morselli Labate A.M.
      • De Notariis S.
      • Rapaccini G.
      • Farinati F.
      • et al.
      Surveillance for hepatocellular carcinoma in elderly Italian patients with cirrhosis. Effects on cancer staging and patients survival.
      ].

      Surveillance interval

      The ideal interval of surveillance for HCC should be dictated by two main features: rate of tumor growth up to the limit of its detectability, and tumor incidence in the target population. Based on available knowledge on mean HCC volume doubling time [
      • Barbara L.
      • Benzi G.
      • Gaiani S.
      • Fusconi F.
      • Zironi G.
      • Siringo S.
      • et al.
      Natural history of small untreated hepatocellular carcinoma in cirrhosis: a multivariate analysis of prognostic factors of tumor growth rate and patient survival.
      ,
      • Ebara M.
      • Ohto M.
      • Shinagawa T.
      • Sugiura N.
      • Kimura K.
      • Matsutani S.
      • et al.
      Natural history of minute hepatocellular carcinoma smaller than three centimetres complicating cirrhosis. A study in 22 patients.
      ,
      • Sheu J.C.
      • Sung J.L.
      • Chen D.S.
      • Yang P.M.
      • Lai M.Y.
      • Lee C.S.
      • et al.
      Growth rate of asymptomatic hepatocellular carcinoma and its clinical implications.
      ]; a 6-month interval represents a reasonable choice. Considering, though, that inter-patient variability is so huge, a shorter 3-month interval has been proposed by Japanese guidelines [
      • Makuuchi M.
      • Kokudo N.
      • Arii S.
      • Futagawa S.
      • Kaneko S.
      • Kawasaki S.
      • et al.
      Development of evidence-based clinical guidelines for the diagnosis and treatment of hepatocellular carcinoma in Japan.
      ,
      • Nouso K.
      • Tanaka H.
      • Uematsu S.
      • Shiraga K.
      • Okamoto R.
      • Onishi H.
      • et al.
      Cost–effectiveness of the surveillance program of hepatocellular carcinoma depends on the medical circumstances.
      ]. However, the unique randomized study comparing 3 versus 6-month based programs failed to detect any differences [
      • Trinchet J.C.
      • Chaffaut C.
      • Bourcier V.
      • Degos F.
      • Henrion J.
      • Fontaine H.
      • et al.
      Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities.
      ]. On the other hand, cohort comparisons of 6 versus 12-month schemes provide similar results [
      • Sangiovanni A.
      • Del Ninno E.
      • Fasani P.
      • De Fazio C.
      • Ronchi G.
      • Romeo R.
      • et al.
      Increased survival of cirrhotic patients with a hepatocellular carcinoma detected during surveillance.
      ,
      • Santagostino E.
      • Colombo M.
      • Rivi M.
      • Rumi M.G.
      • Rocino A.
      • Linari S.
      • et al.
      A 6-month versus a 12-month surveillance for hepatocellular carcinoma in 559 hemophiliacs infected with the hepatitis C virus.
      ], while retrospective studies identified better performance of the 6-month interval in terms of stage migration (small HCC amenable for curative treatments) [
      • Trevisani F.
      • De Notariis S.
      • Rapaccini G.
      • Farinati F.
      • Benvegnù L.
      • Zoli M.
      • et al.
      Semiannual and annual surveillance of cirrhotic patients for hepatocellular carcinoma: effects on cancer stage and patients survival (Italian experience).
      ] and survival [
      • Santi V.
      • Trevisani F.
      • Gramenzi A.
      • Grignaschi A.
      • Mirici-Cappa F.
      • Del Poggio P.
      • et al.
      Italian Liver Cancer (ITA.LI.CA) Group. Semiannual surveillance is superior to annual surveillance for the detection of early hepatocellular carcinoma and patient survival.
      ]. Meta-analysis of prospective studies has shown that the pooled sensitivity of US-based surveillance decreases from 70% with the 6-month program to 50% with the annual program [
      • Singal A.
      • Volk M.L.
      • Waljee A.
      • Salgia R.
      • Higgins P.
      • Rogers M.A.
      • et al.
      Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.
      ].
      Finally, cost–effectiveness studies have shown that semi-annual US-based surveillance improves quality-adjusted life expectancy at a reasonable cost [
      • Andersson K.L.
      • Salomon J.A.
      • Goldie S.J.
      • Chung R.T.
      Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis.
      ]. In light of available knowledge, a 6-month scheduled surveillance appears the preferable choice. Further trials in this setting would be difficult to implement.

      Recall policy

      Figure thumbnail fx10
      Recall policy is crucial for the success of surveillance procedures. It consists of a defined algorithm to be followed when surveillance tests show an abnormal result. This definition must take into account the ideal target of surveillance, i.e. the identification of HCC at a very early stage (2 cm or less), when radical treatments can be applied with the highest probability of long-term cure [
      • Llovet J.M.
      • Burroughs A.
      • Bruix J.
      Hepatocellular carcinoma.
      ]. In case of HCC, abnormal US results are either a newly detected focal lesion or a known hepatic lesion that enlarges and/or changes its echo pattern [
      • Lencioni R.
      • Llovet J.M.
      Modified RECIST (mRECIST) assessment for hepatocellular carcinoma.
      ].
      Pathology studies show that the majority of nodules smaller than 1 cm, that can be detected in a cirrhotic liver, are not HCCs [
      • Roskams T.
      Anatomic pathology impact on prognosis and response to therapy.
      ]. Thus, a tight follow-up is recommended in these cases (Fig. 2). An accepted rule is to consider any nodule larger than about 1 cm as an abnormal screening result warranting further investigation [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma: an update.
      ]. These new nodules should trigger the recall strategy for diagnosis with non-invasive or invasive (biopsy) criteria, as described in the section of diagnosis. If a diagnosis cannot be reached with non-invasive criteria due to atypical radiological appearance, then biopsy is recommended. If even biopsy provides inconclusive results, then a tight follow-up every 4 months is recommended. A second biopsy can be considered in case of growth or change in the enhancement pattern. Upon detection of a suspicious nodule, the recommended policy is to evaluate the patient in a referral center with appropriate human and technical resources [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma: an update.
      ].
      Figure thumbnail gr2
      Fig. 2Diagnostic algorithm and recall policy. One imaging technique only recommended in centers of excellence with high-end radiological equipment. ∗∗HCC radiological hallmark: arterial hypervascularity and venous/late phase washout.

      Diagnosis

      Figure thumbnail fx11
      Nowadays, early HCC diagnosis is feasible in 30–60% of cases in developed countries and this enables the application of curative treatments. In fact, while tumors less than 2 cm in diameter represented <5% of the cases in the early nineties in Europe, currently they represent up to 30% of cases in Japan. This trend is expected to continue growing in parallel to the wider implementation of surveillance policies in developed countries [
      • Llovet J.M.
      • Bruix J.
      Novel advancements in the management of hepatocellular carcinoma in 2008.
      ]. However, detection of these minute nodules of ∼2 cm poses a diagnostic challenge as they are difficult to characterize by radiological or pathological examination [
      • Bolondi L.
      • Gaiani S.
      • Celli N.
      • Golfieri R.
      • Grigioni W.F.
      • Leoni S.
      • et al.
      Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma.
      ,
      • Forner A.
      • Vilana R.
      • Ayuso C.
      • Bianchi L.
      • Solé M.
      • Ayuso J.R.
      • et al.
      Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma.
      ,
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ].
      Proper definition of nodules as pre-neoplastic lesions or early HCC has critical implications. Dysplastic lesions should be followed by regular imaging studies, since at least one-third of them develop a malignant phenotype [
      • Terasaki S.
      • Kaneko S.
      • Kobayashi K.
      • Nonomura A.
      • Nakanuma Y.
      Histological features predicting malignant transformation of nonmalignant hepatocellular nodules: a prospective study.
      ,
      • Borzio M.
      • Fargion S.
      • Borzio F.
      • Fracanzani A.L.
      • Croce A.M.
      • Stroffolini T.
      • et al.
      Impact of large regenerative, low grade and high grade dysplastic nodules in hepatocellular carcinoma development.
      ]. Conversely, early tumors are treated with potentially curative procedures – albeit expensive – such as resection, transplantation and percutaneous ablation. Thus, there is an urgent need to identify better tools to characterize these lesions. Otherwise, the cost–effectiveness of the recall policies applied within surveillance programs will be significantly undermined.

      Non-invasive diagnosis

      Accurate diagnosis of small liver nodules is of paramount importance. Until 2000, diagnosis was based on biopsy. This approach had some limitations related to feasibility due to location and risk of complications, such as bleeding or needle-track seeding [
      • Stigliano R.
      • Marelli L.
      • Yu D.
      • Davies N.
      • Patch D.
      • Burroughs A.K.
      Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome? Seeding risk for percutaneous approach of HCC.
      ]. In addition, achieving accuracy in differentiating between high-grade dysplastic nodules and early HCCs was complex, since stromal invasion, the most relevant criteria, is difficult to recognize even for an expert pathologist [
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ]. In 2001, a panel of experts on HCC convened in Barcelona by EASL reported for the first time non-invasive criteria for HCC based on a combination of imaging and laboratory findings [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ]. In principle, a unique dynamic radiological behavior (contrast up-take in the arterial phase by CT, MRI, angiography or US) represented the backbone of radiological diagnosis of early HCC. In cirrhotic patients with nodules >2 cm, coincidental findings by two imaging techniques were considered diagnostic, or alternatively, one imaging technique along with AFP levels above 400 ng/ml. In all other circumstances biopsy was mandatory. In 2005, the EASL panel of experts and the American Association for the Study of Liver Diseases (AASLD) guidelines adopted a new HCC radiological hallmark, i.e. contrast uptake in the arterial phase and washout in the venous/late phase [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma.
      ]. Non-invasive diagnosis was established by one imaging technique in nodules above 2 cm showing the HCC radiological hallmark and two coincidental techniques with nodules of 1–2 cm in diameter (CT, MRI and US-contrast). AFP levels were dropped from the diagnostic scheme [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma.
      ]. Recent updated AASLD guidelines have proposed that one imaging technique (CT or MRI) showing the HCC radiological hallmark suffices for diagnosing tumors of 1–2 cm in diameter [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma: an update.
      ].
      In order to update the EASL guidelines for non-invasive diagnostic criteria of HCC, two questions are posed. First, what data provides reliable non-invasive diagnostic accuracy for nodules of 1–2 cm in diameter taking into account that the recommendations apply to a wide range of expert physicians and radiologists. And second, what imaging techniques can be used. Regarding the first issue, two prospective studies have shown that using 2 imaging techniques is an approach with high PPV and specificity [
      • Forner A.
      • Vilana R.
      • Ayuso C.
      • Bianchi L.
      • Solé M.
      • Ayuso J.R.
      • et al.
      Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma.
      ,
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma.
      ]. In one study including 89 consecutive cases of nodules between 0.5 and 2 cm detected within surveillance programs in cirrhotic patients showed that non-invasive criteria are accurate for the diagnosis of HCC, with a specificity of 100% [
      • Forner A.
      • Vilana R.
      • Ayuso C.
      • Bianchi L.
      • Solé M.
      • Ayuso J.R.
      • et al.
      Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma.
      ]. Unfortunately, such an absolute specificity had the downside of a low sensitivity of 30%, meaning that two-thirds of nodules required pathological confirmation. The other study suggested that the use of a sequential algorithm would maintain an absolute specificity but increase the sensitivity, with significant savings in terms of liver biopsy procedures for nodules of 1–2 cm [
      • Sangiovanni A.
      • Manini M.A.
      • Iavarone M.
      • Romeo R.
      • Forzenigo L.V.
      • Fraquelli M.
      • et al.
      The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis.
      ]. A retrospective study reporting diagnostic accuracies of MRI in large series of transplanted patients showed an overall false positive rate exceeding 10% when using one imaging technique [
      • Yu N.C.
      • Chaudhari V.
      • Raman S.S.
      • Lassman C.
      • Tong M.J.
      • Busuttil R.W.
      • et al.
      CT and MRI improve detection of hepatocellular carcinoma, compared with ultrasound alone, in patients with cirrhosis.
      ]. Finally, a recent prospective study, testing the accuracy of imaging techniques in nodules between 1 and 2 cm detected by ultrasound, showed false positive diagnosis – mostly due to high grade dysplastic nodules – above 10% with either 1 or 2 imaging techniques, with a specificity of 81% and 85%, respectively [
      • Sersté T.
      • Barrau V.
      • Ozenne V.
      • Vullierme M.P.
      • Bedossa P.
      • Farges O.
      • et al.
      Accuracy and disagreement of CT and MRI for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: role of biopsy.
      ]. Hence, the non-invasive diagnosis of 1–2 cm lesions remains a challenging issue, with no unequivocal data in prospective validation studies. While the panel considers incorporating the 1 technique rule in order to have a consistent approach in the field, a more cautious application of this rule is recommended in suboptimal settings, where the technology at disposal or the local skills are not at the high-end level. In these circumstances, we recommended to use two coincidental techniques, since the negative consequences of high rates of false-positive diagnosis offset the benefit. Additional prospective studies to confirm the accuracy of this approach are recommended in order to support a more strong recommendation at the 1A level.
      Regarding which imaging techniques should be used, it has to be pointed out the fact that the HCC radiological hallmark is based on the tumor vascular dynamic performance. This limits the usage of US-contrast – since US microbubbles are confined to the intravascular space – as opposed to iodinated contrast-CT or gadolinium-based MR imaging, in which standard contrast agents are rapidly cleared from the blood pool into the extracellular space. A recent study showed that lesions other than HCC, i.e. cholangiocarcinoma, displayed homogeneous contrast uptake at US-contrast followed by washout, i.e. the vascular pattern assumed to represent the hallmark of HCC [
      • Rimola J.
      • Forner A.
      • Reig M.
      • Vilana R.
      • de Lope C.R.
      • Ayuso C.
      • et al.
      Cholangiocarcinoma in cirrhosis: absence of contrast washout in delayed phases by magnetic resonance imaging avoids misdiagnosis of hepatocellular carcinoma.
      ]. Thus, latest generation CT and/or MRI following reported protocols are recommended for non-invasive diagnosis of HCC [
      • Lencioni R.
      • Cioni D.
      • Della Pina C.
      • Crocetti L.
      • Bartolozzi C.
      Imaging diagnosis.
      ]. On the other hand, recent advances in the use of perfusion CT or MRI with liver-specific contrast agents have not so far provided solid data to support their use as alternate criteria.
      It is important to point out that the HCC radiological hallmark only occurs in a small proportion of patients with tiny tumors (1–2 cm) [
      • Bolondi L.
      • Gaiani S.
      • Celli N.
      • Golfieri R.
      • Grigioni W.F.
      • Leoni S.
      • et al.
      Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma.
      ], and thus biopsy or tissue biomarkers will be required in most instances. Delaying diagnosis beyond 2 cm leads to increased levels of treatment failure or recurrence, since it is known that satellites and microscopic vascular invasion rise exponentially beyond this size cut-off [
      • Roskams T.
      Anatomic pathology impact on prognosis and response to therapy.
      ]. Therefore, it is crucial to provide reliable tools for a final diagnosis before the 2 cm cut-off.

      Pathological diagnosis

      Pathological diagnosis of HCC is based on the definitions of the International Consensus Group for Hepatocellular Neoplasia [
      • International Consensus Group for Hepatocellular Neoplasia
      Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia.
      ] and is recommended for all nodules occurring in non-cirrhotic livers, and for those cases with inconclusive or atypical imaging appearance in cirrhotic livers. Sensitivity of liver biopsy depends upon location, size and expertise, and might range between 70% and 90% for all tumor sizes. Pathological diagnosis is particularly complex for nodules between 1 and 2 cm [
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ]. Morphological criteria alone still pose problems for the differential diagnosis of high-grade dysplastic nodules versus early HCC, especially because the pathological hallmark of HCC, stromal invasion, can be absent or difficult to identify in biopsy specimens [
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ]. In a prospective study, first biopsy was reported positive in ∼60% of cases for tumors less than 2 cm [
      • Forner A.
      • Vilana R.
      • Ayuso C.
      • Bianchi L.
      • Solé M.
      • Ayuso J.R.
      • et al.
      Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma.
      ]. Thus, a positive tumor biopsy is clinically useful to rule in a diagnosis of HCC, but a negative biopsy does not rule out malignancy. The risk of tumor seeding after liver biopsy is 2.7% with a median time interval between biopsy and seeding of 17 months [
      • Silva M.A.
      • Hegab B.
      • Hyde C.
      • Guo B.
      • Buckels J.A.
      • Mirza D.F.
      Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis.
      ].
      Tissue markers might provide a more across-the-board standardized diagnosis of these tumors. Distinct technologies such as genome-wide DNA microarray, qRT-PCR, proteomic and inmunostaining studies have been used in an attempt to identify markers of early diagnosis of HCC. Few studies, however, include a thorough analysis of several markers in a training-validation scheme and with a sufficient number of samples [
      • Villanueva A.
      • Minguez B.
      • Forner A.
      • Reig M.
      • Llovet J.M.
      Hepatocellular carcinoma: novel molecular approaches for diagnosis, prognosis, and therapy.
      ]. A study conducted in 128 human samples described a 13-gene signature able to identify HCC lesions with high diagnostic accuracy [
      • Colombat M.
      • Paradis V.
      • Bièche I.
      • Dargère D.
      • Laurendeau I.
      • Belghiti J.
      • et al.
      Quantitative RT-PCR in cirrhotic nodules reveals gene expression changes associated with liver carcinogenesis.
      ]. Similarly, a three-gene signature (the genes that encode GPC3, LYVE1, and survivin) has been proposed as an accurate molecular tool (>80% accuracy) to discriminate between dysplastic nodules and small HCCs (<2 cm) [
      • Llovet J.M.
      • Chen Y.
      • Wurmbach E.
      • Roayaie S.
      • Fiel M.I.
      • Schwartz M.
      • et al.
      A molecular signature to discriminate dysplastic nodules from early hepatocellular carcinoma in HCV cirrhosis.
      ]. The performance of this signature was externally validated in a different set of samples [
      • Llovet J.M.
      • Chen Y.
      • Wurmbach E.
      • Roayaie S.
      • Fiel M.I.
      • Schwartz M.
      • et al.
      A molecular signature to discriminate dysplastic nodules from early hepatocellular carcinoma in HCV cirrhosis.
      ,
      • Wurmbach E.
      • Chen Y.B.
      • Khitrov G.
      • Zhang W.
      • Roayaie S.
      • Schwartz M.
      • et al.
      Genome-wide molecular profiles of HCV-induced dysplasia and hepatocellular carcinoma.
      ].
      The diagnostic performance of some markers of early HCC identified by genomic studies has been prospectively assessed by immunohistochemistry, a low-cost technique. By examining the tissue, the pathologist can select a representative tumor sample without necrosis or inflammation and define the cell type expressing protein markers and the specific pattern. A promising marker is GPC3, which shows a sensitivity of 68–72% with a specificity superior to 92% [
      • Di Tommaso L.
      • Franchi G.
      • Park Y.N.
      • Fiamengo B.
      • Destro A.
      • Morenghi E.
      • et al.
      Diagnostic value of HSP70, glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis.
      ,
      • Capurro M.
      • Wanless I.R.
      • Sherman M.
      • Deboer G.
      • Shi W.
      • Miyoshi E.
      • et al.
      Glypican-3: a novel serum and histochemical marker for hepatocellular carcinoma.
      ]. Similarly, combinations of different protein markers – HSP70, GPC3, and GS – in 105 hepatocellular nodules performed acceptably (sensitivity and specificity of 72% and 100%, respectively) [
      • Di Tommaso L.
      • Franchi G.
      • Park Y.N.
      • Fiamengo B.
      • Destro A.
      • Morenghi E.
      • et al.
      Diagnostic value of HSP70, glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis.
      ], and were afterwards validated in two larger series [
      • Di Tommaso L.
      • Destro A.
      • Seok J.Y.
      • Balladore E.
      • Terracciano L.
      • Sangiovanni A.
      • et al.
      The application of markers (HSP70 GPC3 and GS) in liver biopsies is useful for detection of hepatocellular carcinoma.
      ,

      Tremosini S, Forner A, Boix L, Rimola J, Rodríguez de Lope C, Reig M, et al. Biopsy diagnosis of hepatocellular carcinoma <2 cm: prospective validation of glypican 3, heat-shock protein 70 and glutamine synthetase staining in fine needle biopsy samples. ILCA book of abstracts; 2011.

      ]. The International Consensus Group of Hepatocellular Neoplasia has adopted the recommendation to define a pathological diagnosis of HCC if at least two of these markers are positive [
      • International Consensus Group for Hepatocellular Neoplasia
      Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia.
      ]. Additional staining can be considered to assess neovascularisation (CD34) or potential progenitor cell origin (Keratin 19, EpCAM) [
      • Roskams T.
      Anatomic pathology impact on prognosis and response to therapy.
      ,
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ,
      • Durnez A.
      • Verslype C.
      • Nevens F.
      • Fevery J.
      • Aerts R.
      • Pirenne J.
      • et al.
      The clinicopathological and prognostic relevance of cytokeratin 7 and 19 expression in hepatocellular carcinoma. A possible progenitor cell origin.
      ]. In particular, keratin 19 (K19), a progenitor cell/biliary marker, at a cut-off of 5% of positive tumor cells with immunohistochemistry, has been shown to correlate with poorest outcome [
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ,
      • Durnez A.
      • Verslype C.
      • Nevens F.
      • Fevery J.
      • Aerts R.
      • Pirenne J.
      • et al.
      The clinicopathological and prognostic relevance of cytokeratin 7 and 19 expression in hepatocellular carcinoma. A possible progenitor cell origin.
      ,
      • Kim H.
      • Choi G.H.
      • Na D.C.
      • Ahn E.Y.
      • Kim G.I.
      • Lee J.E.
      • et al.
      Human hepatocellular carcinomas with “Stemness”-related marker expression: keratin 19 expression and a poor prognosis.
      ]. Moreover, K19 recognizes biliary features in mixed forms of HCC/cholangiocarcinoma, which are not always detected on hematoxylin–eosin stain.

      Assessment of disease extension

      Assessment of tumor extension is critical for defining staging and treatment strategy. Several studies with pathological correlation have shown that dynamic contrast-enhanced MRI and 4-phase multidetector CT are the most effective imaging techniques for detecting tumors smaller than 2 cm. However, underestimation of 25–30% is expected even with the best state-of-the-art technology [
      • Colli A.
      • Fraquelli M.
      • Casazza G.
      • Massironi S.
      • Colucci A.
      • Conte D.
      • et al.
      Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review.
      ,
      • Burrel M.
      • Llovet J.M.
      • Ayuso C.
      • Iglesias C.
      • Sala M.
      • Miquel R.
      • et al.
      MRI angiography is superior to helical CT for detection of HCC prior to liver transplantation: an explant correlation.
      ]. Pre-specified protocols should define the amount and rate of contrast given, the precise individualized timing of the image acquisition and image reconstruction with minimum slice thickness. Lipiodol contrast staining should not be used. Contrast-enhanced ultrasound is unable to compete with CT and MRI in terms of accuracy for detection of lesions. Bone scintigraphy can be used for evaluating bone metastases. PET-based imaging is not accurate to stage early tumors. Pre-operative staging prior to liver transplantation should include abdominal dynamic CT or MRI, chest CT and bone scintigraphy.

      Staging systems

      Figure thumbnail fx12
      Cancer classification is intended to establish prognosis and enable the selection of the adequate treatment for the best candidates. In addition, it helps researchers to exchange information and design clinical trials with comparable criteria. In patients with HCC, unlike most solid tumors, the coexistence of two life-threatening conditions such as cancer and cirrhosis complicates prognostic assessments [
      • Llovet J.M.
      • Burroughs A.
      • Bruix J.
      Hepatocellular carcinoma.
      ,
      • D’Amico G.
      • Garcia-Tsao G.
      • Pagliaro L.
      Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.
      ]. Thus, staging systems for this cancer should be designed with data coming from two sources. First, prognostic variables obtained from studies describing the natural history of cancer and cirrhosis. Second, treatment-dependent variables obtained from evidence-based studies providing the rationale for assigning a given therapy to patients in a given subclass.
      Based on data reporting the natural history of the disease, the main clinical prognostic factors in HCC patients are related to tumor status (defined by number and size of nodules, presence of vascular invasion, extrahepatic spread), liver function (defined by Child–Pugh’s class, bilirubin, albumin, portal hypertension, ascites) and general health status (defined by ECOG classification and presence of symptoms) [
      • Okuda K.
      • Ohtsuki T.
      • Obata H.
      • Tomimatsu M.
      • Okazaki N.
      • Hasegawa H.
      • et al.
      Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients.
      ,
      • The Cancer of the Liver Italian Program (CLIP) Investigators
      A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients.
      ,
      • Llovet J.M.
      • Bustamante J.
      • Castells A.
      • Vilana R.
      • Ayuso M.del C.
      • Sala M.
      • et al.
      Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials.
      ,
      • Villa E.
      • Moles A.
      • Ferretti I.
      • Buttafoco P.
      • Grottola A.
      • Del Buono M.
      • et al.
      Natural history of inoperable hepatocellular carcinoma: estrogen receptors’ status in the tumor is the strongest prognostic factor for survival.
      ,
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ]. Etiology has not been identified as an independent prognostic factor.
      Tissue and serum biomarkers predicting prognosis have been less explored in HCC patients. Strict rules for incorporating prognostic or predictive markers into clinical practice have been published [
      • Simon R.M.
      • Paik S.
      • Hayes D.F.
      Use of archived specimens in evaluation of prognostic and predictive biomarkers.
      ]. According to these rules, acceptable biomarkers should be obtained from randomized investigations, as is the case with KRAS status and response to cetuximab in colon cancer. Only in particularly compelling circumstances can prognostic or predictive markers tested in cohort studies be adopted in clinical practice. The panel recommends to incorporate biomarkers for the management of HCC when the following requirements are met: (1) demonstrate prognostic prediction in properly powered randomized studies or in training and validation sets from cohort studies; (2) demonstrate independent prognostic value in mutivariate analysis, including known clinico-pathological predictive variables; and (3) confirmation of results using the same technology in an external cohort reported by independent investigators. None of the biomarkers tested so far fulfil these criteria in HCC, but four just require external validation by independent groups: gene signatures or biomarkers from the tumor (EpCAM signature, G3-proliferation subclass, and miR-26a) [
      • Yamashita T.
      • Forgues M.
      • Wang W.
      • Kim J.W.
      • Ye Q.
      • Jia H.
      • et al.
      EpCAM and alpha-fetoprotein expression defines novel prognostic subtypes of hepatocellular carcinoma.
      ,
      • Ji J.
      • Shi J.
      • Budhu A.
      • Yu Z.
      • Forgues M.
      • Roessler S.
      • et al.
      MicroRNA expression, survival, and response to interferon in liver cancer.
      ,
      • Villanueva A.
      • Hoshida Y.
      • Battiston C.
      • Tovar V.
      • Sia D.
      • Alsinet C.
      • et al.
      Combining clinical, pathology, and gene expression data to predict recurrence of hepatocellular carcinoma.
      ] and adjacent tissue (poor-survival signature) [
      • Hoshida Y.
      • Villanueva A.
      • Kobayashi M.
      • Peix J.
      • Chiang D.Y.
      • Camargo A.
      • et al.
      Gene expression in fixed tissues and outcome in hepatocellular carcinoma.
      ]. Regarding serum markers, AFP levels, VEGF and Ang2 have been shown to have independent prognostic value in large cohorts of untreated advanced tumors [
      • Llovet J.M.
      • Peña C.
      • Shan M.
      • Lathia C.
      • Bruix J.
      Biomarkers predicting outcome of patients with advanced hepatocellular carcinoma (HCC) randomized in the phase III SHARP trial. Presidential plenary session, AASLD 59th annual meeting, San Francisco.
      ]. The prognostic relevance of high AFP levels has been scarcely reported in controlled investigations [
      • Llovet J.M.
      • Bruix J.
      Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival.
      ], but has been shown to predict risk of drop-out in patients on the waiting list for liver transplantation (cut-off of 200 ng/ml, or by increases of >15 ng/ml) [
      • Vibert E.
      • Azuolay D.
      • Hoti E.
      • Iacopinelli S.
      • Samuel D.
      • Salloum C.
      • et al.
      Progression of alphafetoprotein before liver transplantation for hepatocellular carcinoma in cirrhotic patients: a critical factor.
      ,
      • Toso C.
      • Trotter J.
      • Wei A.
      • Bigam D.L.
      • Shah S.
      • Lancaster J.
      • et al.
      Total tumor volume predicts risk of recurrence following liver transplantation in patients with hepatocellular carcinoma.
      ], response to local ablation [
      • N’Kontchou G.
      • Mahamoudi A.
      • Aout M.
      • Ganne-Carrié N.
      • Grando V.
      • Coderc E.
      • et al.
      Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic factors in 235 Western patients with cirrhosis.
      ], response to loco-regional therapies [
      • Riaz A.
      • Kulik L.
      • Lewandowski R.J.
      • Ryu R.K.
      • Giakoumis Spear G.
      • Mulcahy M.F.
      • et al.
      Radiologic–pathologic correlation of hepatocellular carcinoma treated with internal radiation using yttrium-90 microspheres.
      ] and in the outcome of advanced tumors (cut-off of 200 ng/ml [
      • Llovet J.M.
      • Peña C.
      • Shan M.
      • Lathia C.
      • Bruix J.
      Biomarkers predicting outcome of patients with advanced hepatocellular carcinoma (HCC) randomized in the phase III SHARP trial. Presidential plenary session, AASLD 59th annual meeting, San Francisco.
      ]; 400 ng/ml [
      • The Cancer of the Liver Italian Program (CLIP) Investigators
      A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients.
      ,
      • Vora S.R.
      • Zheng H.
      • Stadler Z.K.
      • Fuchs C.S.
      • Zhu A.X.
      Serum alpha-fetoprotein response as a surrogate for clinical outcome in patients receiving systemic therapy for advanced hepatocellular carcinoma.
      ]). The heterogeneity of the above studies prevents the formulation of a clear recommendation, but it is advised to test levels >200 and/or >400 ng/ml as prognostic factors of poor outcome in research investigations.
      Several staging systems have been proposed to provide a clinical classification of HCC. In oncology, the standard classification of cancer is based on the TNM staging. In HCC, the 7th TNM edition in accordance with the AJCC [
      ], which was obtained from the analysis of a series of patients undergoing resection, has several limitations [
      • Llovet J.M.
      • Bruix J.
      • Fuster J.
      • Castells A.
      • García-Valdecasas J.C.
      • Grande L.
      • et al.
      Liver transplantation for treatment of small hepatocellular carcinoma: the TNM classification does not have prognostic power.
      ]. First, pathological information is required to assess microvascular invasion, which is only available in patients treated by surgery (∼20%). In addition, it does not capture information regarding liver functional status or health status. One-dimensional systems, such as the Okuda staging and the Child–Pugh classification, albeit popular, serve purposes distinct to class prediction in HCC patients. Among more comprehensive staging systems, five have been broadly tested, three European (the French classification [
      • Chevret S.
      • Trinchet J.C.
      • Mathieu D.
      • Rached A.A.
      • Beaugrand M.
      • Chastang C.
      A new prognostic classification for predicting survival in patients with hepatocellular carcinoma. Groupe d’Etude et de Traitement du Carcinome Hépatocellulaire.
      ], the Cancer of the Liver Italian Program (CLIP) classification [
      • The Cancer of the Liver Italian Program (CLIP) Investigators
      A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients.
      ], and the Barcelona-Clínic Liver Cancer (BCLC) staging system [
      • Llovet J.M.
      • Brú C.
      • Bruix J.
      Prognosis of hepatocellular carcinoma: the BCLC staging classification.
      ,
      • Llovet J.M.
      • Di Bisceglie A.M.
      • Bruix J.
      • Kramer B.S.
      • Lencioni R.
      • Zhu A.X.
      • et al.
      Design and endpoints of clinical trials in hepatocellular carcinoma.
      ]) and two Asian (the Chinese University Prognostic Index (CUPI score) [
      • Leung T.W.
      • Tang A.M.
      • Zee B.
      • Lau W.Y.
      • Lai P.B.
      • Leung K.L.
      • et al.
      Construction of the Chinese University Prognostic Index for hepatocellular carcinoma and comparison with the TNM staging system, the Okuda staging system, and the Cancer of the Liver Italian Program staging system: a study based on 926 patients.
      ] and the Japan Integrated Staging (JIS), which was recently refined including biomarkers (AFP, DCP AFP-L-3) (bm-JIS) [
      • Kitai S.
      • Kudo M.
      • Minami Y.
      • Haji S.
      • Osaki Y.
      • Oka H.
      • et al.
      Validation of a new prognostic staging system for hepatocellular carcinoma: a comparison of the biomarker-combined Japan Integrated Staging Score, the conventional Japan Integrated Staging Score and the BALAD Score.
      ]). The CUPI and CLIP scores largely subclassify patients at advanced stages, with a small number of effectively treated patients. Overall, few of the most used systems or scores have been externally validated (BCLC, CUPI, CLIP, and bm-JIS), only two include the three types of prognostic variables (BCLC, CUPI) and only one assigns treatment allocation to specific prognostic subclasses (BCLC).
      The current EASL–EORTC GP guidelines endorse the Barcelona-Clínic Liver Cancer (BCLC) classification for several reasons [
      • Llovet J.M.
      • Brú C.
      • Bruix J.
      Prognosis of hepatocellular carcinoma: the BCLC staging classification.
      ,
      • Llovet J.M.
      • Di Bisceglie A.M.
      • Bruix J.
      • Kramer B.S.
      • Lencioni R.
      • Zhu A.X.
      • et al.
      Design and endpoints of clinical trials in hepatocellular carcinoma.
      ]. It includes prognostic variables related to tumor status, liver function and health performance status along with treatment-dependant variables obtained from cohort studies and randomized trials. It has been externally validated in different clinical settings [
      • Marrero J.
      • Fontana R.J.
      • Barrat A.
      • Askari F.
      • Conjeevaram H.S.
      • Su G.L.
      • et al.
      Prognosis of hepatocellular carcinoma: comparison of 7 staging systems in an American cohort.
      ,
      • Cillo U.
      • Vitale A.
      • Grigoletto F.
      • Farinati F.
      • Brolese A.
      • Zanus G.
      • et al.
      Prospective validation of the Barcelona Clinic Liver Cancer staging system.
      ,
      • Guglielmi A.
      • Ruzzenente A.
      • Pachera S.
      • Valdegamberi A.
      • Sandri M.
      • D’Onofrio M.
      • et al.
      Comparison of seven staging systems in cirrhotic patients with hepatocellular carcinoma in a cohort of patients who underwent radiofrequency ablation with complete response.
      ]. This is an evolving system that links tumor stage with treatment strategy in a dynamic manner enabling the incorporation of novel advancements in the understanding of the prognosis or management of HCC. In this regard, the seminal classification reported in 1999 [
      • Llovet J.M.
      • Brú C.
      • Bruix J.
      Prognosis of hepatocellular carcinoma: the BCLC staging classification.
      ] was updated with the incorporation of stage 0 (very early HCC) and chemoembolization for intermediate HCC in 2003 [
      • Llovet J.M.
      • Burroughs A.
      • Bruix J.
      Hepatocellular carcinoma.
      ], and further modified in 2008 to incorporate sorafenib as first-line treatment option in advanced tumors [
      • Llovet J.M.
      • Di Bisceglie A.M.
      • Bruix J.
      • Kramer B.S.
      • Lencioni R.
      • Zhu A.X.
      • et al.
      Design and endpoints of clinical trials in hepatocellular carcinoma.
      ]. As discussed below, further refinements in class stratification (for instance to incorporate biomarkers) or treatment allocation resulting from positive high-end trials are expected in the following years. The BCLC classification was first endorsed by the EASL [
      • Bruix J.
      • Sherman M.
      • Llovet J.M.
      • Beaugrand M.
      • Lencioni R.
      • Burroughs A.K.
      • et al.
      EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.
      ], and thereafter by the AASLD guidelines for the management of HCC [
      • Bruix J.
      • Sherman M.
      Management of hepatocellular carcinoma: an update.
      ].

      BCLC classification: outcome prediction and treatment allocation

      The Barcelona-Clínic Liver Cancer (BCLC) classification divides HCC patients in 5 stages (0, A, B, C and D) according to pre-established prognostic variables, and allocates therapies according to treatment-related status (Fig. 3). Thus, it provides information on both prognostic prediction and treatment allocation. Prognosis prediction is defined by variables related to tumor status (size, number, vascular invasion, N1, M1), liver function (Child–Pugh’s) and health status (ECOG). Treatment allocation incorporates treatment dependant variables, which have been shown to influence therapeutic outcome, such as bilirubin, portal hypertension or presence of symptoms-ECOG.
      Figure thumbnail gr3
      Fig. 3Updated BCLC staging system and treatment strategy, 2011.

      Early stages

      Very early HCC (BCLC stage 0) is defined as the presence of a single tumor <2 cm in diameter without vascular invasion/satellites in patients with good health status (ECOG-0) and well-preserved liver function (Child–Pugh A class). Nowadays, 5–10% of patients in the West are diagnosed at this stage while in Japan the figure is almost 30% due to the widespread implementation of surveillance programs [
      • Kudo M.
      Review of 4th Single Topic Conference on HCC. Hepatocellular carcinoma: international consensus and controversies.
      ]. From pathological studies, though, two subclasses of tumors have been defined: vaguely nodular type – size around 12 mm without local invasiveness – and the distinctly nodular type – mean size 16 mm which might show local invasiveness. Vaguely nodular types are very well-differentiated HCCs that contain bile ducts and portal veins, have ill-defined nodular appearance and, by definition, do not have invaded structures. Distinctly nodular type show local metastases surrounding the nodule in 10% of cases, and microscopic portal invasion in up to 25% [
      • Roskams T.
      Anatomic pathology impact on prognosis and response to therapy.
      ,
      • Roskams T.
      • Kojiro M.
      Pathology of early hepatocellular carcinoma: conventional and molecular diagnosis.
      ]. Therefore, some tumors smaller than 2 cm are prone to locally disseminate, but others behave as carcinoma in situ and those are defined as Stage 0. Recent data have shown a 5-year survival in 80–90% of patients with resection and liver transplantation and in 70% with local ablation [
      • Takayama T.
      • Makuuchi M.
      • Hirohashi S.
      • Sakamoto M.
      • Yamamoto J.
      • Shimada K.
      • et al.
      Early hepatocellular carcinoma as an entity with a high rate of surgical cure.
      ,
      • Roayaie S.
      • Blume I.N.
      • Thung S.N.
      • Guido M.
      • Fiel M.I.
      • Hiotis S.
      • et al.
      A system of classifying microvascular invasion to predict outcome after resection in patients with hepatocellular carcinoma.
      ,

      Roayaie S, Llovet JM, Obeidat K, Labow D, Sposito C, Pellegrinelli A, et al. Hepatic resection for hepatocellular carcinoma <2 cm in diameter. Hepatology, in press.

      ,
      • Livraghi T.
      • Meloni F.
      • Di Stasi M.
      • Rolle E.
      • Solbiati L.
      • Tinelli C.
      • et al.
      Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: is resection still the treatment of choice?.
      ]. Whether patients at very early stage can be offered local ablation as a first line treatment option is a topic of controversy. No RCT addressing this issue have been reported so far and comparison of cohort studies suffers from selection bias.
      Early HCC (BCLC stage A) is defined in patients presenting single tumors >2 cm or 3 nodules <3 cm of diameter, ECOG-0 and Child–Pugh class A or B. Median survival of patients with early HCC reaches 50–70% at 5 years after resection, liver transplantation or local ablation in selected candidates [
      • Llovet J.M.
      • Bruix J.
      Novel advancements in the management of hepatocellular carcinoma in 2008.
      ,
      • Arii S.
      • Yamaoka Y.
      • Futagawa S.
      • Inoue K.
      • Kobayashi K.
      • Kojiro M.
      • et al.
      Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan.
      ]. The natural outcome of these cases is ill-defined due the scarcity of reported data, but it is estimated to be a median survival of around 36 months. An improvement in survival is universal when applying the so-called treatment-dependent variables in the selection of candidates.
      Tumor status is defined by size of the main nodule and multicentricity (single 2–5 cm, 3 nodules ⩽3 cm), each of these categories showing significantly different outcomes. As discussed below, single tumors beyond 5 cm are still considered for surgical resection as first option, because if modern MRI is applied in pre-operative staging, the fact that solitary large tumors remain single and with no macrovascular involvement – which might be common in HBV-related HCC – reflects a more benign biological behavior.
      Variables related to liver function are relevant for candidates to resection. Absence of clinically relevant portal hypertension and normal bilirubin are key predictors of survival in patients with single tumors undergoing resection [
      • Llovet J.M.
      • Fuster J.
      • Bruix J.
      Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation.
      ]. Similarly, Child–Pugh class A is the strongest prognostic variable in patients undergoing local ablation, along with tumor size and response to treatment [
      • Sala M.
      • Llovet J.M.
      • Vilana R.
      • Bianchi L.
      • Solé M.
      • Ayuso C.
      • et al.
      Barcelona Clínic Liver Cancer Group. Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma.
      ]. Since liver transplantation may potentially cure both the tumor and the underlying liver disease, variables mostly related with HCC have been clearly established as prognostic factors (single tumors ⩽5 cm or 3 nodules ⩽3 cm), defining the so-called Milan criteria.

      Intermediate-advanced HCC

      Prognosis of HCC was assumed to be poor for unresectable cases, with a median survival of less than 1 year. Analysis of heterogeneous outcomes within 25 RCT (2 year survival 8–50%) [
      • Llovet J.M.
      • Bustamante J.
      • Castells A.
      • Vilana R.
      • Ayuso M.del C.
      • Sala M.
      • et al.
      Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials.
      ,
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ,
      • Llovet J.M.
      • Bruix J.
      Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival.
      ,
      • Lopez P.M.
      • Villanueva A.
      • Llovet J.M.
      Systematic review: evidence-based management of hepatocellular carcinoma – an updated analysis of randomized controlled trials.
      ] leads to the identification of at least three subgroups of patients with unresectable HCC: the intermediate, advanced and end-stage classes, according to the BCLC classification.
      Intermediate HCC (BCLC stage B): Untreated patients at an intermediate stage – BCLC B class (multinodular asymptomatic tumors without an invasive pattern) present a median survival of 16 months [
      • Llovet J.M.
      • Bruix J.
      Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival.
      ,
      • Llovet J.M.
      • Bruix J.
      Molecular targeted therapies in hepatocellular carcinoma.
      ], or 49% at 2 year [
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ]. Chemoembolization extends the survival of these patients to a median of up to 19–20 months according to RCT and meta-analysis of pooled data [
      • Llovet J.M.
      • Bruix J.
      Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival.
      ]. Nonetheless, outcome prediction is heterogeneous for BCLC B subclass patients, and has been reported to range from around 36–45 months [
      • Takayasu K.
      • Arii S.
      • Ikai I.
      • Omata M.
      • Okita K.
      • Ichida T.
      • et al.
      Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8510 patients.
      ,
      • Varela M.
      • Real M.I.
      • Burrel M.
      • Forner A.
      • Sala M.
      • Brunet M.
      • et al.
      Chemoembolization of hepatocellular carcinoma with drug eluting beads: efficacy and doxorubicin pharmacokinetics.
      ,

      Burrel M, Reig M, Forner A, Barrufet M, Rodríguez de Lope C, Tremosini S, et al. Survival of patients with hepatocellular carcinoma treated by transarterial chemoembolization (TACE) using DC beads. Implications for clinical practice and trial design. J Hepatol, in press.

      ] for the best responders to chemoembolization in recent series, to 11 months for the worst scenario of untreated candidates (placebo arm of the SHARP trial-BCLC B patients) [
      • Llovet J.M.
      • Ricci S.
      • Mazzaferro V.
      • Hilgard P.
      • Gane E.
      • Blanc J.F.
      • et al.
      SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma.
      ]. A recent meta-analysis of RCT assessing outcome of patients in the control arm suggests that ascites – which contraindicates TACE treatment – is the worst prognostic factor for this subclass [
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ].
      Advanced HCC (BCLC stage C): Patients with cancer related-symptoms (symptomatic tumors, ECOG 1–2), macrovascular invasion (either segmental or portal invasion) or extrahepatic spread (lymph node involvement or metastases) bear a dismal prognosis, with expected median survival times of 6 months [
      • Llovet J.M.
      • Bustamante J.
      • Castells A.
      • Vilana R.
      • Ayuso M.del C.
      • Sala M.
      • et al.
      Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials.
      ,
      • Llovet J.M.
      • Bruix J.
      Molecular targeted therapies in hepatocellular carcinoma.
      ], or 25% at 1 year [
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ]. Nonetheless, it is obvious that this outcome varies according to the liver functional status and other variables. For instance, patients with preserved liver function (Child–Pugh’s A class) have a median survival of 7 months [
      • Llovet J.M.
      • Ricci S.
      • Mazzaferro V.
      • Hilgard P.
      • Gane E.
      • Blanc J.F.
      • et al.
      SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma.
      ], while those with severe liver impairment (Child–Pugh’s B class) present 5 months of median life expectancy. In 2006, there was no FDA-approved first line treatment for patients with advanced HCC. This scenario has changed as a result of the data reported showing survival benefits from patients receiving sorafenib – a multi tyrosine kinase inhibitor – in advanced cases [
      • Llovet J.M.
      • Ricci S.
      • Mazzaferro V.
      • Hilgard P.
      • Gane E.
      • Blanc J.F.
      • et al.
      SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma.
      ]. The results of this RCT represent a breakthrough in the management of HCC, as it is discussed in the molecular targeted therapies section of this document. Overall median survival in the sorafenib arm was 10.7 months, ranging from 14.7 months in BCLC B and 9.5 months in BCLC C patients.
      End-stage HCC: Patients with end-stage disease are characterized by presenting with tumors leading to a very poor Performance Status (ECOG 3–4), which reflects a severe tumor-related disability. Their median survival is 3–4 months [
      • Llovet J.M.
      • Brú C.
      • Bruix J.
      Prognosis of hepatocellular carcinoma: the BCLC staging classification.
      ] or 11% at 1-year [
      • Cabibbo G.
      • Enea M.
      • Attanasio M.
      • Bruix J.
      • Craxì A.
      • Cammà C.
      A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma.
      ]. Similarly, Child–Pugh C patients with tumors beyond the transplantation threshold also have a very poor prognosis.

      Concept of treatment stage migration

      A proportion of patients in each stage do not fulfil all the criteria for the treatment allocation. In those cases, it is advised to offer the patient the next most suitable option within the same stage or the next prognostic stage. For instance, patients at BCLC A failing local ablation should be offered chemoembolization. Similarly, patients at BCLC B stage non-responding to chemoembolization – at least two cycles of treatment – should be offered sorafenib, as reported in the SHARP trial [
      • Llovet J.M.
      • Ricci S.
      • Mazzaferro V.
      • Hilgard P.
      • Gane E.
      • Blanc J.F.
      • et al.
      SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma.
      ,
      • Raoul J.L.
      • Sangro B.
      • Forner A.
      • Mazzaferro V.
      • Piscaglia F.
      • Bolondi L.
      • et al.
      Evolving strategies for the management of intermediate-stage hepatocellular carcinoma: Available evidence and expert opinion on the use of transarterial chemoembolization.
      ].

      Refinement of BCLC classification

      Some studies challenged the capacity of BCLC to properly provide a fine stratification of patients for trial design. These studies mostly included patients at BCLC C stage of the disease [
      • Huitzil-Melendez F.D.
      • Capanu M.
      • O’Reilly E.M.
      • Duffy A.
      • Gansukh B.
      • Saltz L.L.
      • et al.
      Advanced hepatocellular carcinoma: which staging systems best predict prognosis?.
      ]. The panel of experts acknowledges that the range of survival reported for patients at BCLC B (from 45 months to 11 months) and C (from 11 months to 5 months) deserves to be addressed. Further stratification of patients within each class according to liver function (Child–Pugh A versus B, or ascites), prognostic molecular biomarkers or prognostic variables (ECOG, cancer invasiveness) should be explored.

      Molecular classification of HCC

      Molecular classification of cancer should aid in understanding the biological subclasses and drivers of the disease and optimize benefits from molecular therapies and enrich trial populations. Few molecular classifications have been proposed in cancer. One such is the case of breast cancer, where Her2/nu status discriminates subgroups of patients with different outcome and treatment response to trastuzumab [
      • Slamon D.J.
      • Leyland-Jones B.
      • Shak S.
      • Fuchs H.
      • Paton V.
      • Bajamonde A.
      • et al.
      Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2.
      ]. Similarly, EGFR mutational status in non-small cell lung cancer identifies a subgroup of responders to tyrosine kinase inhibitors [
      • Tsao M.S.
      • Sakurada A.
      • Cutz J.C.
      • Zhu C.Q.
      • Kamel-Reid S.
      • Squire J.
      • et al.
      Erlotinib in lung cancer – molecular and clinical predictors of outcome.
      ]. More recently, the fact that a subgroup of patients with melanoma and BRAF mutations respond to specific B-RAF inhibitors has defined a new paradigm and subclass in the management of this cancer [
      • Flaherty K.T.
      • Puzanov I.
      • Kim K.B.
      • Ribas A.
      • McArthur G.A.
      • Sosman J.A.
      • et al.
      Inhibition of mutated, activated BRAF in metastatic melanoma.
      ].
      In HCC, no molecular subclass has been reported as responding to specific targeted therapy. Nonetheless, clear advancements in the understanding of the pathogenesis and molecular subclasses of the disease occurred during the last decade. From the biological standpoint, different tumoral classes have been characterized including a Wnt subclass, a proliferation class (with two subclasses: S1-TGF-beta and S2-EpCAM positive) and an inflammation class [
      • Yamashita T.
      • Forgues M.
      • Wang W.
      • Kim J.W.
      • Ye Q.
      • Jia H.
      • et al.
      EpCAM and alpha-fetoprotein expression defines novel prognostic subtypes of hepatocellular carcinoma.
      ,
      • Hoshida Y.
      • Villanueva A.
      • Kobayashi M.
      • Peix J.
      • Chiang D.Y.
      • Camargo A.
      • et al.
      Gene expression in fixed tissues and outcome in hepatocellular carcinoma.
      ,
      • Boyault S.
      • Rickman D.S.
      • de Reyniès A.
      • Balabaud C.
      • Rebouissou S.
      • Jeannot E.
      • et al.
      Transcriptome classification of HCC is related to gene alterations and to new therapeutic targets.
      ,
      • Chiang D.Y.
      • Villanueva A.
      • Hoshida Y.
      • Peix J.
      • Newell P.
      • Minguez B.
      • et al.
      Focal gains of VEGFA and molecular classification of hepatocellular carcinoma.
      ]. Samples obtained from different parts of a given neoplastic nodule showed identical class stratification in 95% of cases [
      • Villanueva A.
      • Hoshida Y.
      • Battiston C.
      • Tovar V.
      • Sia D.
      • Alsinet C.
      • et al.
      Combining clinical, pathology, and gene expression data to predict recurrence of hepatocellular carcinoma.
      ]. Equally relevant, gene profiling of adjacent non-tumoral tissue defines two subgroups of patients with good and poor outcome [
      • Hoshida Y.
      • Villanueva A.
      • Kobayashi M.
      • Peix J.
      • Chiang D.Y.
      • Camargo A.
      • et al.
      Gene expression in fixed tissues and outcome in hepatocellular carcinoma.
      ]. Thus, a portrait of the field effect is currently available, although further studies are required to confirm the prognostic significance of these subclasses, and whether specific drivers within them can provide the rationale for a more stratified medicine.

      Treatment

      Figure thumbnail fx13
      In oncology, the benefits of treatments should be assessed through randomized controlled trials and meta-analysis. Other sources of evidence, such as non-randomized clinical trials or observational studies are considered less robust. Few medical interventions have been thoroughly tested in HCC, in contrast with other cancers with a high prevalence worldwide, such as lung, breast, colorectal and stomach cancer. As a result, the strength of evidence for most interventions in HCC is far behind the most prevalent cancers worldwide. The level of evidence for efficacy according to trial design and end-points for all available treatments in HCC and the strength of recommendations according to GRADE are summarized in Fig. 4.
      Figure thumbnail gr4
      Fig. 4Representation of EASL–EORTC recommendations for treatment according to levels of evidence (NCI classification
      [

      National Cancer Institute. PDQ® levels of evidence for adult and pediatric cancer treatment studies. Bethesda, MD: National Cancer Institute. Date last modified 26/August/2010. <http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/healthprofessional/>; 2011 [accessed 01.03.11].

      ]
      ) and strength of recommendation (GRADE system). RF, radiofrequency ablation; PEI, percutaneous ethanol injection; OLT, orthotopic liver transplantation; LDLT, living donor liver transplantation.
      In principle, recommendations in terms of selection for different treatment strategies are based on evidence-based data in circumstances where all potential efficacious interventions are available. Multidisciplinary HCC teams including hepatologists, surgeons, oncologists, radiologists, interventional radiologists, pathologists and translational researchers are encouraged to apply these guidelines. Strategic recommendations should be adapted to local regulations and/or team capacities and cost–benefit strategies.

      Resection

      Figure thumbnail fx14
      Surgery is the mainstay of HCC treatment. Resection and transplantation achieve the best outcomes in well-selected candidates (5-year survival of 60–80%), and compete as the first option in patients with early tumors on an intention-to-treat perspective [
      • Llovet J.M.
      • Schwartz M.
      • Mazzaferro V.
      Resection and liver transplantation for hepatocellular carcinoma.
      ,
      • Mazzaferro V.
      • Bhoori S.
      • Sposito C.
      • Bongini M.
      • Langer M.
      • Miceli R.
      • et al.
      Milan criteria in liver transplantation for HCC: an evidence-based analysis on 15 years of experience.
      ]. Hepatic resection is the treatment of choice for HCC in non-cirrhotic patients (5% of cases in the West, 40% in Asia) [
      • Belghiti J.
      • Hiramatsu K.
      • Benoist S.
      • Massault P.
      • Sauvanet A.
      • Farges O.
      Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.
      ,
      • Lang H.
      • Sotiropoulos G.C.
      • Dömland M.
      • Frühauf N.R.
      • Paul A.
      • Hüsing J.
      • et al.
      Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis.
      ], where major resections can be performed with low rates of life-threatening complications and acceptable outcome (5-year survival: 30–50%).
      Modern standards of HCC resection in cirrhotic patients are defined by the panel as follows: expected 5-year survival rates of 60%, with a peri-operative mortality of 2–3% and blood transfusion requirements of less than 10% [
      • Llovet J.M.
      • Bruix J.
      Novel advancements in the management of hepatocellular carcinoma in 2008.
      ,
      • Roayaie S.
      • Blume I.N.
      • Thung S.N.
      • Guido M.
      • Fiel M.I.
      • Hiotis S.
      • et al.
      A system of classifying microvascular invasion to predict outcome after resection in patients with hepatocellular carcinoma.
      ,
      • Poon R.T.
      • Fan S.T.
      • Lo C.M.
      • Liu C.L.
      • Lam C.M.
      • Yuen W.K.
      • et al.
      Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?.
      ,
      • Mazzaferro V.
      • Romito R.
      • Schiavo M.
      • Mariani L.
      • Camerini T.
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      ,
      • Ishizawa T.
      • Hasegawa K.
      • Aoki T.
      • Takahashi M.
      • Inoue Y.
      • Sano K.
      • et al.
      Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma.
      ]. In fact, peri-operative mortality has decreased from 15% in the 1980s to 3–5% in the majority of referral units. Some centers have reported zero peri-operative mortality [
      • Llovet J.M.
      • Schwartz M.
      • Mazzaferro V.
      Resection and liver transplantation for hepatocellular carcinoma.
      ,
      • Makuuchi M.
      • Sano K.
      The surgical approach to HCC: our progress and results in Japan.
      ]. Blood loss is significantly associated with patient outcome and may be controlled both by selecting patients with preserved liver functional reserve and by applying intermittent inflow occlusion during the hepatic parenchymal transection. Nowadays the selection of candidates for resection has been refined, and both the surgical technique – pre-resection imaging planning, ultrasonic dissector, intermittent Pringle maneuvre, low central venous pressure maintenance, etc. – and immediate post-operative management have been optimized. These strategies have led to a decrease in blood transfusion from 80% to 90% to less than 10% in two decades [
      • Makuuchi M.
      • Sano K.
      The surgical approach to HCC: our progress and results in Japan.
      ]. In addition, the implementation of anatomic resections according to Couinaud has ensured a surgical approach based on sound oncologic principles, although associated with modest decrease in early recurrence [
      • Arii S.
      • Tanaka S.
      • Mitsunori Y.
      • Nakamura N.
      • Kudo A.
      • Noguchi N.
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      Surgical strategies for hepatocellular carcinoma with special reference to anatomical hepatic resection and intraoperative contrast-enhanced ultrasonography.
      ]. Anatomic resections aiming at 2 cm margins provide better survival outcome than narrow resection margins <1 cm [
      • Shi M.
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      • Lin X.J.
      • Zhang Y.Q.
      • Chen M.S.
      • Zhang C.Q.
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      Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial.
      ] and are recommended only in case that the maintenance of appropriate function to the remnant liver volume is ensured. Retrospective studies linking anatomic resections and better outcome should be interpreted with caution, due to the propensity of performing wider interventions in patients with well-preserved liver function. Thus, caution should be exercised as the surgical effort is aimed at preservation of adequate hepatic reserve through tailoring of the procedures to individual patients and tumor characteristics – i.e. body size, central versus peripheral location of tumor nodule and solitary large HCC (versus infiltrating tumor types).
      Selection of the ideal candidates involves an adequate assessment of the liver functional reserve and tumor extension. The refinement of assessment of liver function has moved from the gross determination of Child–Pugh class to a more sophisticated measurement of indocyanine green retention rate at 15 min (ICG15) [
      • Makuuchi M.
      • Kosuge T.
      • Takayama T.
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      • Kakazu T.
      • Miyagawa S.
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      ] or hepatic venous pressure gradient (HVPG) ⩾10 mmHg as a direct measurement of relevant portal hypertension [
      • Bruix J.
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      • Fuster J.
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      ]. This concept of portal hypertension as prognostic factor in patients undergoing resection has recently been validated in Asia [
      • Ishizawa T.
      • Hasegawa K.
      • Aoki T.
      • Takahashi M.
      • Inoue Y.
      • Sano K.
      • et al.
      Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma.