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*Only for medical professionals to read and compare the 2020 version of the CSCO guideline with the European and American guidelines to understand more suitable diagnosis and treatment plans for liver cancer patients in China.
Primary liver cancer is one of the common malignant tumors in my country.
The latest data show that in 2020, 900,000 new cases of liver cancer will occur globally, and China will account for 45.
6%; and the deaths will be 830,000, and China will account for 47%.
The etiology, epidemiological characteristics, molecular biological behaviors, clinical manifestations and treatment strategies of liver cancer in my country are significantly different from those in Europe and the United States.
Therefore, while being in line with international standards, my country’s national conditions should be fully considered and clinical guidelines suitable for Chinese patients should be formulated.
.
On April 24, 2021, at the Chinese Society of Clinical Oncology (CSCO) Guidelines Conference, Professor Ming Zhao from the Interventional Department of Sun Yat-sen University Cancer Hospital compared the 2020 version of the CSCO Guidelines for the diagnosis and treatment of primary liver cancer and the European and American guidelines for the diagnosis and treatment of liver cancer.
, To provide reference and reference for the formulation of the 2021 CSCO guidelines for diagnosis and treatment of primary liver cancer.
Surveillance In terms of liver cancer surveillance, the European Society for the Study of Liver Diseases (EASL) guidelines have developed detailed screening and control standards, including improving the screening process, including high-risk populations in the scope of screening, and actively controlling chronic liver diseases.
Figure 1.
Recommendations of the EASL guidelines for liver cancer monitoring are for the value of alpha-fetoprotein (AFP) in liver cancer monitoring.
At present, many guidelines and recommendations are not uniform.
The 2020 CSCO guidelines recommend that high-risk groups check serum AFP and other tumor markers at least every 6 months.
In the case of low international recognition of AFP, this proposal has improved the status of AFP in liver cancer surveillance.
Figure 2.
NCCN guidelines for liver cancer monitoring recommendations.
In the 2021 edition of the National Comprehensive Cancer Network (NCCN) guidelines, the recommendations for liver cancer monitoring are changed from ultrasound ± AFP in the 2020 guidelines to ultrasound + AFP.Figure 3.
CSCO guidelines for liver cancer monitoring recommended diagnosis In terms of liver cancer diagnosis, EASL guidelines suggest that for patients with liver cirrhosis, liver cancer diagnosis can be based on non-invasive and/or pathology, and hepatocellular carcinoma (HCC) without a background of liver cirrhosis The diagnosis needs to be confirmed by pathology.
In the choice of imaging diagnostic methods, enhanced magnetic resonance imaging (MRI) and X-ray computed tomography (CT) are recommended.
Figure 4.
The EASL guidelines recommend the NCCN guidelines for the diagnosis of liver cancer.
It is proposed that only when the diameter of liver ultrasound nodules exceed 1 cm, AFP, CT and MRI can be used to diagnose liver cancer.
Figure 5.
NCCN guidelines for liver cancer diagnosis recommendation 2020 version of the CSCO guidelines further subdivide the population: for 1~2cm nodules, at least two positive imaging tests are required to make a clinical diagnosis of liver cancer; for nodules> 2cm , As long as one kind of imaging test is positive, it can be clinically diagnosed as liver cancer.
Figure 6.
CSCO guidelines for the recommended staging of liver cancer diagnosis The 2018 version of the EASL guidelines adopts the BCLC staging, which is mainly based on six factors: the number, size, vascular invasion, extrahepatic metastasis, Child-Push classification, and physical status (PS) score of liver tumors.
Comprehensively determine the tumor stage, divided into 5 stages of 0-D stage.
Figure 7.
Recommendations of the EASL guideline for liver cancer staging The 2021 version of the NCCN guideline still uses the TNM staging system.
This staging system has certain guiding significance for surgeons to choose an appropriate treatment plan.
Figure 8.
NCCN guidelines for liver cancer staging recommendations The 2020 version of the CSCO guidelines for liver cancer staging is the Chinese liver cancer staging scheme (CNLC) for grade I experts, grade II recommendations for BCLC staging and TNM staging, and grade III recommendations for JSH staging and APASL Staging.
Figure 9.
CSCO guidelines recommended treatment for liver cancer staging▌ The diameter of the tumor treated by local ablation is the focus of ablation therapy, because as the diameter of the tumor increases, the necrosis rate of ablation therapy will decrease.
In the EASL guidelines, for tumors with a diameter of less than 2 cm, the highest recommended ablation method is radiofrequency ablation (RFA).
Figure 10.
Recommendations of the EASL guidelines for liver cancer ablation treatment The SURF study reported at the 2019 American Society of Clinical Oncology (ASCO) annual meeting confirmed that for liver cancer with a diameter ≤ 3cm, ablation treatment is not inferior to surgical treatment.
The 2021 NCCN guidelines recommend ablation therapy for liver cancer ≤3 cm.
For tumors of 3 to 5 cm in a suitable location, ablation combined with transarterial chemoembolization (TACE) is recommended.
Figure 11.
NCCN guidelines for liver cancer ablation treatment recommendations CSCO guidelines for liver cancer ablation treatment recommendations are extended compared with NCCN guidelines: single tumor diameter ≤ 5 cm, or tumor nodules ≤ 3, the largest tumor diameter ≤ 3 cm, you can choose Ablation treatment.
Figure 12.
CSCO guidelines for liver cancer ablation treatment recommendations▌ Surgical treatment EASL guidelines suggest that the residual liver volume, tumor location, portal hypertension, surgical resection mortality and complications should be considered during surgical resection.
For patients without a background of cirrhosis, surgical resection is the first choice.
Figure 13.
Recommendations of the EASL guidelines for surgical resection of liver cancer The 2021 NCCN guidelines propose that surgical resection should consider portal hypertension, tumor location, residual liver volume, and liver function.
It also emphasizes multidisciplinary collaboration (MDT), and it is recommended to consult a liver disease expert to jointly assess whether the patient is suitable for surgical resection.
Figure 14.
NCCN guidelines for liver cancer surgical resection recommendations The Hong Kong Liver Cancer (HKLC) guidelines for liver cancer surgical resection concepts are similar to those in mainland China, including stage IIb liver cancer, even liver cancer with small blood vessel infiltration, into the scope of surgical resection.
Figure 15.
Recommendations of HKLC guidelines for surgical resection of liver cancer In the 2020 version of the CSCO guidelines, surgical resection of stage Ia and Ib liver cancer is 1A evidence, and stage IIa and IIb liver cancer may benefit from surgery, and it is also category 1A evidence.
Multiple tumors can also be removed surgically.
Figure 16.
The CSCO guidelines recommend the surgical resection of liver cancer.
In terms of liver transplantation, the EASL guidelines have carried out a detailed analysis, including the indications and contraindications suitable for transplantation, waiting period treatment, and the principle of priority allocation. Figure 17.
Recommendations of the EASL guidelines for liver transplantation The 2021 edition of the NCCN guidelines specifically emphasizes AFP in liver transplantation, because AFP is a poor prognostic indicator.
In addition, for patients with Child-Push Class A, if they are suitable for transplantation and can also be surgically removed, then surgical resection or liver transplantation needs to be considered.
Figure 18.
NCCN Guidelines for Liver Transplantation Recommendations The 2020 version of the CSCO Guidelines still considers Milan standards as liver transplantation standards as Level I recommendations, UCSF standards as Level II recommendations, and domestic standards as Level III recommendations.
Figure 19.
CSCO guidelines for liver transplantation recommendations ▌ Radiotherapy In terms of radiotherapy, the highest level of evidence recommended in the EASL guidelines is 90Y microsphere therapy.
90Y microsphere therapy is an important means of bridging treatment of liver transplantation for patients with BCLC-A liver cancer.
In BCLC-B and BCLC-C stage liver cancer patients, 90Y microsphere therapy did not show an overall survival advantage compared with sorafenib.
Figure 20.
Recommendations of the EASL guidelines for radiotherapy for liver cancer The 2021 edition of the NCCN guidelines separates radiotherapy for liver cancer from local treatments, suggesting that radiotherapy has more room for development in the future.
Figure 21.
NCCN Guidelines Recommendations for Radiotherapy for Liver Cancer The 2020 version of the CSCO Guidelines recommends stereotactic radiotherapy (SBRT), TACE combined radiotherapy, and bridging therapy before liver transplantation to delay disease progression as a level II expert recommendation.
Figure 22.
CSCO guidelines for liver cancer TACE recommendation▌ TACE has developed over many years, and TACE has become an important means of liver cancer treatment.
In the EASL guidelines, TACE occupies an important position.
Figure 23.
The EASL guideline recommends TACE for liver cancer.
The NCCN guideline lists TACE treatment as a transarterial treatment category.
Updates in transarterial therapy include: radiotherapy dose ≥205Gy may be related to patient survival benefit; 90Y microsphere therapy is not better than sorafenib in the treatment of advanced liver cancer; deembolization endpoint may be selected by the treatment.
Figure 24.
NCCN guidelines recommending TACE for liver cancer.
In the CSCO guidelines, TACE is recommended for patients with stage Ia and IIb liver cancer.
For patients with stage IIb, TACE combined with sorafenib can be selected for treatment.
Figure 25.
CSCO guidelines for liver cancer TACE recommendations ▌ system therapy In recent years, advanced liver cancer treatment research has progressed rapidly.
The EASL guidelines suggest that in the first-line treatment of advanced liver cancer, sorafenib has shown significant efficacy, and lenvatinib is not inferior to sorafenib.
Regorafenib and cabozantinib are recommended for second-line treatment.
Figure 26.
EASL Guidelines for Systemic Treatment of Advanced Liver Cancer Recommendations The 2020 American Society for the Study of Liver Diseases (AASLD) consensus recommended the first-line treatment plan for advanced liver cancer is atilizumab combined with bevacizumab, and the second-line treatment plan is sorafil Ni and lenvatinib.
Figure 27.
The AASLD consensus recommendation for the systemic treatment of advanced liver cancer The 2021 NCCN guidelines recommend sorafenib, lenvatinib, and atilizumab combined with bevacizumab as first-line treatment recommendations, but at the same time emphasizes the use of ati Before treatment with livizumab and bevacizumab, the bleeding risk of the patient needs to be assessed.
Figure 28.
NCCN guidelines for systemic treatment of advanced liver cancer recommendations.
In the 2020 version of the CSCO guidelines, for liver function Child-Push grade A or better grade B (≤7 points) advanced liver cancer, the first-line treatment level I expert recommendation includes Sola Systemic chemotherapy based on fenib and oxaliplatin, lenvatinib, donafenib, and atilizumab combined with bevacizumab, the second-line treatment level I recommendation includes regorafenib, PD-1 Mab and apatinib.
Figure 29.
CSCO guidelines recommended for systemic treatment of advanced liver cancer.
Conclusion: Liver cancer has a strong heterogeneity.
The etiology, molecular biological behavior and clinical manifestations of liver cancer in my country are very different from those in Europe and the United States.
The 2020 version of the CSCO liver cancer diagnosis and treatment guidelines fully considers national conditions, covers the latest developments, and is in line with international standards in diagnosis and treatment technology, and leads international guidelines in AFP monitoring and MDT.
A number of clinical studies on liver cancer are currently underway, and we look forward to bringing more diagnosis and treatment programs suitable for Chinese patients.
Primary liver cancer is one of the common malignant tumors in my country.
The latest data show that in 2020, 900,000 new cases of liver cancer will occur globally, and China will account for 45.
6%; and the deaths will be 830,000, and China will account for 47%.
The etiology, epidemiological characteristics, molecular biological behaviors, clinical manifestations and treatment strategies of liver cancer in my country are significantly different from those in Europe and the United States.
Therefore, while being in line with international standards, my country’s national conditions should be fully considered and clinical guidelines suitable for Chinese patients should be formulated.
.
On April 24, 2021, at the Chinese Society of Clinical Oncology (CSCO) Guidelines Conference, Professor Ming Zhao from the Interventional Department of Sun Yat-sen University Cancer Hospital compared the 2020 version of the CSCO Guidelines for the diagnosis and treatment of primary liver cancer and the European and American guidelines for the diagnosis and treatment of liver cancer.
, To provide reference and reference for the formulation of the 2021 CSCO guidelines for diagnosis and treatment of primary liver cancer.
Surveillance In terms of liver cancer surveillance, the European Society for the Study of Liver Diseases (EASL) guidelines have developed detailed screening and control standards, including improving the screening process, including high-risk populations in the scope of screening, and actively controlling chronic liver diseases.
Figure 1.
Recommendations of the EASL guidelines for liver cancer monitoring are for the value of alpha-fetoprotein (AFP) in liver cancer monitoring.
At present, many guidelines and recommendations are not uniform.
The 2020 CSCO guidelines recommend that high-risk groups check serum AFP and other tumor markers at least every 6 months.
In the case of low international recognition of AFP, this proposal has improved the status of AFP in liver cancer surveillance.
Figure 2.
NCCN guidelines for liver cancer monitoring recommendations.
In the 2021 edition of the National Comprehensive Cancer Network (NCCN) guidelines, the recommendations for liver cancer monitoring are changed from ultrasound ± AFP in the 2020 guidelines to ultrasound + AFP.Figure 3.
CSCO guidelines for liver cancer monitoring recommended diagnosis In terms of liver cancer diagnosis, EASL guidelines suggest that for patients with liver cirrhosis, liver cancer diagnosis can be based on non-invasive and/or pathology, and hepatocellular carcinoma (HCC) without a background of liver cirrhosis The diagnosis needs to be confirmed by pathology.
In the choice of imaging diagnostic methods, enhanced magnetic resonance imaging (MRI) and X-ray computed tomography (CT) are recommended.
Figure 4.
The EASL guidelines recommend the NCCN guidelines for the diagnosis of liver cancer.
It is proposed that only when the diameter of liver ultrasound nodules exceed 1 cm, AFP, CT and MRI can be used to diagnose liver cancer.
Figure 5.
NCCN guidelines for liver cancer diagnosis recommendation 2020 version of the CSCO guidelines further subdivide the population: for 1~2cm nodules, at least two positive imaging tests are required to make a clinical diagnosis of liver cancer; for nodules> 2cm , As long as one kind of imaging test is positive, it can be clinically diagnosed as liver cancer.
Figure 6.
CSCO guidelines for the recommended staging of liver cancer diagnosis The 2018 version of the EASL guidelines adopts the BCLC staging, which is mainly based on six factors: the number, size, vascular invasion, extrahepatic metastasis, Child-Push classification, and physical status (PS) score of liver tumors.
Comprehensively determine the tumor stage, divided into 5 stages of 0-D stage.
Figure 7.
Recommendations of the EASL guideline for liver cancer staging The 2021 version of the NCCN guideline still uses the TNM staging system.
This staging system has certain guiding significance for surgeons to choose an appropriate treatment plan.
Figure 8.
NCCN guidelines for liver cancer staging recommendations The 2020 version of the CSCO guidelines for liver cancer staging is the Chinese liver cancer staging scheme (CNLC) for grade I experts, grade II recommendations for BCLC staging and TNM staging, and grade III recommendations for JSH staging and APASL Staging.
Figure 9.
CSCO guidelines recommended treatment for liver cancer staging▌ The diameter of the tumor treated by local ablation is the focus of ablation therapy, because as the diameter of the tumor increases, the necrosis rate of ablation therapy will decrease.
In the EASL guidelines, for tumors with a diameter of less than 2 cm, the highest recommended ablation method is radiofrequency ablation (RFA).
Figure 10.
Recommendations of the EASL guidelines for liver cancer ablation treatment The SURF study reported at the 2019 American Society of Clinical Oncology (ASCO) annual meeting confirmed that for liver cancer with a diameter ≤ 3cm, ablation treatment is not inferior to surgical treatment.
The 2021 NCCN guidelines recommend ablation therapy for liver cancer ≤3 cm.
For tumors of 3 to 5 cm in a suitable location, ablation combined with transarterial chemoembolization (TACE) is recommended.
Figure 11.
NCCN guidelines for liver cancer ablation treatment recommendations CSCO guidelines for liver cancer ablation treatment recommendations are extended compared with NCCN guidelines: single tumor diameter ≤ 5 cm, or tumor nodules ≤ 3, the largest tumor diameter ≤ 3 cm, you can choose Ablation treatment.
Figure 12.
CSCO guidelines for liver cancer ablation treatment recommendations▌ Surgical treatment EASL guidelines suggest that the residual liver volume, tumor location, portal hypertension, surgical resection mortality and complications should be considered during surgical resection.
For patients without a background of cirrhosis, surgical resection is the first choice.
Figure 13.
Recommendations of the EASL guidelines for surgical resection of liver cancer The 2021 NCCN guidelines propose that surgical resection should consider portal hypertension, tumor location, residual liver volume, and liver function.
It also emphasizes multidisciplinary collaboration (MDT), and it is recommended to consult a liver disease expert to jointly assess whether the patient is suitable for surgical resection.
Figure 14.
NCCN guidelines for liver cancer surgical resection recommendations The Hong Kong Liver Cancer (HKLC) guidelines for liver cancer surgical resection concepts are similar to those in mainland China, including stage IIb liver cancer, even liver cancer with small blood vessel infiltration, into the scope of surgical resection.
Figure 15.
Recommendations of HKLC guidelines for surgical resection of liver cancer In the 2020 version of the CSCO guidelines, surgical resection of stage Ia and Ib liver cancer is 1A evidence, and stage IIa and IIb liver cancer may benefit from surgery, and it is also category 1A evidence.
Multiple tumors can also be removed surgically.
Figure 16.
The CSCO guidelines recommend the surgical resection of liver cancer.
In terms of liver transplantation, the EASL guidelines have carried out a detailed analysis, including the indications and contraindications suitable for transplantation, waiting period treatment, and the principle of priority allocation. Figure 17.
Recommendations of the EASL guidelines for liver transplantation The 2021 edition of the NCCN guidelines specifically emphasizes AFP in liver transplantation, because AFP is a poor prognostic indicator.
In addition, for patients with Child-Push Class A, if they are suitable for transplantation and can also be surgically removed, then surgical resection or liver transplantation needs to be considered.
Figure 18.
NCCN Guidelines for Liver Transplantation Recommendations The 2020 version of the CSCO Guidelines still considers Milan standards as liver transplantation standards as Level I recommendations, UCSF standards as Level II recommendations, and domestic standards as Level III recommendations.
Figure 19.
CSCO guidelines for liver transplantation recommendations ▌ Radiotherapy In terms of radiotherapy, the highest level of evidence recommended in the EASL guidelines is 90Y microsphere therapy.
90Y microsphere therapy is an important means of bridging treatment of liver transplantation for patients with BCLC-A liver cancer.
In BCLC-B and BCLC-C stage liver cancer patients, 90Y microsphere therapy did not show an overall survival advantage compared with sorafenib.
Figure 20.
Recommendations of the EASL guidelines for radiotherapy for liver cancer The 2021 edition of the NCCN guidelines separates radiotherapy for liver cancer from local treatments, suggesting that radiotherapy has more room for development in the future.
Figure 21.
NCCN Guidelines Recommendations for Radiotherapy for Liver Cancer The 2020 version of the CSCO Guidelines recommends stereotactic radiotherapy (SBRT), TACE combined radiotherapy, and bridging therapy before liver transplantation to delay disease progression as a level II expert recommendation.
Figure 22.
CSCO guidelines for liver cancer TACE recommendation▌ TACE has developed over many years, and TACE has become an important means of liver cancer treatment.
In the EASL guidelines, TACE occupies an important position.
Figure 23.
The EASL guideline recommends TACE for liver cancer.
The NCCN guideline lists TACE treatment as a transarterial treatment category.
Updates in transarterial therapy include: radiotherapy dose ≥205Gy may be related to patient survival benefit; 90Y microsphere therapy is not better than sorafenib in the treatment of advanced liver cancer; deembolization endpoint may be selected by the treatment.
Figure 24.
NCCN guidelines recommending TACE for liver cancer.
In the CSCO guidelines, TACE is recommended for patients with stage Ia and IIb liver cancer.
For patients with stage IIb, TACE combined with sorafenib can be selected for treatment.
Figure 25.
CSCO guidelines for liver cancer TACE recommendations ▌ system therapy In recent years, advanced liver cancer treatment research has progressed rapidly.
The EASL guidelines suggest that in the first-line treatment of advanced liver cancer, sorafenib has shown significant efficacy, and lenvatinib is not inferior to sorafenib.
Regorafenib and cabozantinib are recommended for second-line treatment.
Figure 26.
EASL Guidelines for Systemic Treatment of Advanced Liver Cancer Recommendations The 2020 American Society for the Study of Liver Diseases (AASLD) consensus recommended the first-line treatment plan for advanced liver cancer is atilizumab combined with bevacizumab, and the second-line treatment plan is sorafil Ni and lenvatinib.
Figure 27.
The AASLD consensus recommendation for the systemic treatment of advanced liver cancer The 2021 NCCN guidelines recommend sorafenib, lenvatinib, and atilizumab combined with bevacizumab as first-line treatment recommendations, but at the same time emphasizes the use of ati Before treatment with livizumab and bevacizumab, the bleeding risk of the patient needs to be assessed.
Figure 28.
NCCN guidelines for systemic treatment of advanced liver cancer recommendations.
In the 2020 version of the CSCO guidelines, for liver function Child-Push grade A or better grade B (≤7 points) advanced liver cancer, the first-line treatment level I expert recommendation includes Sola Systemic chemotherapy based on fenib and oxaliplatin, lenvatinib, donafenib, and atilizumab combined with bevacizumab, the second-line treatment level I recommendation includes regorafenib, PD-1 Mab and apatinib.
Figure 29.
CSCO guidelines recommended for systemic treatment of advanced liver cancer.
Conclusion: Liver cancer has a strong heterogeneity.
The etiology, molecular biological behavior and clinical manifestations of liver cancer in my country are very different from those in Europe and the United States.
The 2020 version of the CSCO liver cancer diagnosis and treatment guidelines fully considers national conditions, covers the latest developments, and is in line with international standards in diagnosis and treatment technology, and leads international guidelines in AFP monitoring and MDT.
A number of clinical studies on liver cancer are currently underway, and we look forward to bringing more diagnosis and treatment programs suitable for Chinese patients.
