The European Society for Medical Oncology (ESMO) has published new guidelines for the management of hepatocellular carcinoma (HCC), with an expanded section on systemic treatments for advanced HCC.
While sorafenib remains the standard of care for advanced HCC and those with intermediate-stage disease not eligible for or progressing despite locoregional therapies, ESMO advises that lenvatinib can be considered as first-line therapy for advanced HCC without main portal vein invasion, clear bile duct invasion and at least 50 per cent tumour to total liver volume occupancy, pending European Medicines Agency (EMA) approval.
Regorafenib is the standard of care for advanced HCC after sorafenib failure in patients with well-preserved liver function and ECOG performance status (PS) 0-1. Cabozantinib can also be considered for progression after one or two systemic therapies, pending EMA approval.
Ramucirumab can be considered as second-line treatment in patients with baseline alpha-fetoprotein (AFP) of at least 400 ng/mL, well-preserved liver function and ECOG PS 0-1, pending EMA approval.
Nivolumab and pembrolizumab can be considered in patients who are intolerant to or have progressed on an approved tyrosine kinase inhibitor, pending EMA approval. However, the guidelines state that a definitive recommendation will be dependent on the future results of randomised trials.