Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, ON.
Princess Margaret Cancer Centre, Toronto, ON.
Curr Oncol. 2020 Apr;27(2):e106-e114. doi: 10.3747/co.27.5891. Epub 2020 May 1.
Practice guidelines based on a systematic review of the literature regarding the nonsurgical management of hepatocellular carcinoma (hcc) in North America are lacking. Resection and transplantation are the foundations for cure of hcc; however, most patients are diagnosed at an advanced stage, precluding those curative treatments. A number of local or regional therapies are used and are followed by systemic therapy for advanced or progressive disease. Other treatments are available, but their efficacy, compared with those standards, is not well known.
First, systematic review questions were developed. Literature searches of the medline, embase, and Cochrane library databases (January 2000 to July 2018 or January 2005 to July 2018 depending on the question) were conducted; in addition, abstracts from the 2018 annual meeting of the American Society of Clinical Oncology were reviewed. A practice guideline was drafted that was then scrutinized by internal and external reviewers.
Seventy-seven studies were included in the guideline: no guidelines, two systematic reviews, and seventy-five primary studies published in full (including one pooled analysis). Five recommendations were developed.
There is no evidence for or against the use of local or regional interventions other than transarterial chemoembolization for the treatment of intermediate- or advanced-stage hcc. Furthermore, there is no evidence to support the addition of sorafenib to any local or regional therapy. Sorafenib or lenvatinib are recommended for first-line systemic treatment of intermediate-stage hcc. Regorafenib or cabozantinib provide survival benefits when given as second-line treatment. Antiviral treatment is recommended in individuals with advanced hcc who are positive for the hepatitis B surface antigen.
北美的肝细胞癌（HCC）非手术治疗缺乏基于文献系统评价的实践指南。切除术和肝移植是 HCC 治愈的基础；然而，大多数患者在晚期被诊断出来，排除了这些治愈性治疗方法。许多局部或区域治疗方法被应用，然后在晚期或进展性疾病时采用系统治疗。还有其他治疗方法，但与这些标准相比，其疗效尚不清楚。
首先，制定了系统评价问题。对 medline、embase 和 Cochrane 图书馆数据库进行了文献搜索（根据问题的不同，搜索时间为 2000 年 1 月至 2018 年 7 月或 2005 年 1 月至 2018 年 7 月）；此外，还审查了 2018 年美国临床肿瘤学会年会的摘要。起草了一份实践指南，然后由内部和外部审查者进行审查。
指南中纳入了 77 项研究：没有指南，两项系统评价，七十五项完整发表的原始研究（包括一项汇总分析）。制定了五项建议。
除了经动脉化疗栓塞术之外，没有证据支持或反对使用局部或区域干预措施来治疗中晚期 HCC。此外，没有证据支持在任何局部或区域治疗中添加索拉非尼。索拉非尼或仑伐替尼被推荐用于中晚期 HCC 的一线系统治疗。regorafenib 或 cabozantinib 作为二线治疗可提供生存获益。对于乙型肝炎表面抗原阳性的晚期 HCC 患者，建议进行抗病毒治疗。
