Adherence to AASLD guidelines for the treatment of hepatocellular carcinoma in clinical practice: Experience of the Bologna Liver Oncology Group

Published:March 17, 2014DOI:



      Few data exist on real-life adherence to international guidelines for the treatment of hepatocellular carcinoma. We analysed the rate of adherence to American Association for the Study of Liver Diseases guidelines, to identify reasons for discrepancy with treatments performed in our centre.


      227 consecutive cirrhotics with a first hepatocellular carcinoma diagnosis (2005–2010) were retrospectively evaluated and stratified based on Barcelona Clinic Liver Cancer system: 126 early, 50 intermediate, 40 advanced, and 11 end stage.


      Early hepatocellular carcinomas were theoretically eligible for resection (n = 27), liver transplantation (n = 36), and percutaneous treatment (n = 63). In practice, 15/27 (55.5%), 31/36 (86.1%), and 22/63 (34.9%) respectively were treated as recommended. Reasons for discrepancy were age/comorbidity, tumour location, ultrasound visibility, surgical contraindications. Transarterial chemoembolisation was performed in 25/126 early hepatocellular carcinomas (19.8%), resection in 11/63 early hepatocellular carcinomas eligible for percutaneous treatment (17.5%). Transarterial chemoembolisation was excluded in 16/50 intermediate hepatocellular carcinomas (32%). Resection or transarterial chemoembolisation was performed in 6/40 advanced hepatocellular carcinomas (15%).


      Overall, 60% of patients were treated according to American Association for the Study of Liver Diseases guidelines. Approximately 28% of hepatocellular carcinomas were “under-treated” and 7% treated more aggressively than recommended. Peculiarities of individual patients can lead the multidisciplinary team to personalise real-life treatments.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Digestive and Liver Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bruix J.
        • Sherman M.
        Management of hepatocellular carcinoma.
        Hepatology. 2005; 42: 1208-1236
        • Forner A.
        • Reig M.E.
        • de Lope C.R.
        • et al.
        Current strategy for staging and treatment: the BCLC update and future prospects.
        Seminars in Liver Disease. 2010; 30: 61-74
        • Llovet J.M.
        • Brú C.
        • Bruix J.
        Prognosis of hepatocellular carcinoma: the BCLC staging classification.
        Seminars in Liver Disease. 1999; 19: 329-338
        • Cammà C.
        • Di Marco V.
        • Cabibbo G.
        • et al.
        Survival of patients with hepatocellular carcinoma in cirrhosis: a comparison of BCLC, CLIP and GRETCH staging systems.
        Alimentary Pharmacology and Therapeutics. 2008; 28: 62-75
        • Bruix J.
        • Sherman M.
        • American Association for the Study of Liver Diseases
        Management of hepatocellular carcinoma: an update.
        Hepatology. 2011; 53: 1020-1022
        • Bolondi L.
        • Burroughs A.
        • Dufour J.F.
        • et al.
        Heterogeneity of patients with intermediate (BCLC B) Hepatocellular Carcinoma: proposal for a subclassification to facilitate treatment decisions.
        Seminars in Liver Disease. 2012; 32: 348-359
        • European Association for the Study of the Liver
        • European Organisation for Research and Treatment of Cancer
        EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma.
        Journal of Hepatology. 2012; 56: 908-943
        • Llovet J.M.
        • Ricci S.
        • Mazzaferro V.
        • et al.
        Sorafenib in advanced hepatocellular carcinoma.
        New England Journal of Medicine. 2008; 359: 378-390
        • Kim S.E.
        • Lee H.C.
        • Kim K.M.
        • et al.
        Applicability of the BCLC staging system to patients with hepatocellular carcinoma in Korea: analysis at a single center with a liver transplant center.
        Korean Journal of Hepatology. 2011; 17: 113-119
        • Cunningham S.C.
        • Tsai S.
        • Marques H.P.
        • et al.
        Management of early hepatocellular carcinoma in patients with well-compensated cirrhosis.
        Annals of Surgical Oncology. 2009; 16: 1820-1831
        • Chen C.H.
        • Hu F.C.
        • Huang G.T.
        • et al.
        Applicability of staging systems for patients with hepatocellular carcinoma is dependent on treatment method-analysis of 2010 Taiwanese patients.
        European Journal of Cancer. 2009; 45: 1630-1639
        • Farinati F.
        • Sergio A.
        • Baldan A.
        • et al.
        Early and very early hepatocellular carcinoma: when and how much do staging and choice of treatment really matter? A multi-center study.
        BMC Cancer. 2009; 9: 33
        • Borzio M.
        • Fornari F.
        • De Sio I.
        • et al.
        Adherence to American Association for the Study of Liver Diseases guidelines for the management of hepatocellular carcinoma: results of an Italian field practice multicenter study.
        Future Oncology. 2013; 9: 283-294
        • Brandi G.
        • Biasco G.
        • Mirarchi M.G.
        • et al.
        A phase I study of continuous hepatic arterial infusion of Irinotecan in patients with locally advanced hepatocellular carcinoma.
        Digestive and Liver Disease. 2011; 43: 1015-1021
        • Sangro B.
        • Carpanese L.
        • Cianni R.
        • et al.
        Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation.
        Hepatology. 2011; 54: 868-878
        • Brandi G.
        • de Rosa F.
        • Bolondi L.
        • et al.
        Durable complete response of hepatocellular carcinoma after metronomic capecitabine.
        Tumori. 2010; 96: 1028-1030
        • Iavarone M.
        • Cabibbo G.
        • Piscaglia F.
        • et al.
        Field-practice study of sorafenib therapy for hepatocellular carcinoma: a prospective multicenter study in Italy.
        Hepatology. 2011; 54: 2055-2063
        • Santi V.
        • Buccione D.
        • Di Micoli A.
        • et al.
        The changing scenario of hepatocellular carcinoma over the last two decades in Italy.
        Journal of Hepatology. 2012; 56: 397-405
        • Mirici-Cappa F.
        • Gramenzi A.
        • Santi V.
        • et al.
        Treatments for hepatocellular carcinoma in elderly patients are as effective as in younger patients: a 20-year multicentre experience.
        Gut. 2010; 59: 387-396
        • Tremosini S.
        • Reig M.
        • de Lope C.R.
        • et al.
        Treatment of early hepatocellular carcinoma: towards personalized therapy.
        Digestive and Liver Disease. 2010; 42: S242-S248
        • Bargellini I.
        • Sacco R.
        • Bozzi E.
        • et al.
        Transarterial chemoembolization in very early and early hepatocellular carcinoma patients excluded from curative treatment: a prospective cohort study.
        European Journal of Radiology. 2012; 81: 1173-1178
        • Cabibbo G.
        • Genco C.
        • Di Marco V.
        • et al.
        Predicting survival in patients with hepatocellular carcinoma treated by transarterial chemoembolisation.
        Alimentary Pharmacology and Therapeutics. 2011; 34: 196-204
        • Golfieri R.
        • Cappelli A.
        • Cucchetti A.
        • et al.
        Efficacy of selective transarterial chemoembolization in inducing tumor necrosis in small (<5 cm) hepatocellular carcinomas.
        Hepatology. 2011; 53: 1580-1589
        • Golfieri R.
        • Renzulli M.
        • Mosconi C.
        • et al.
        Hepatocellular carcinoma responding to superselective transarterial chemoembolization: an issue of nodule dimension.
        Journal of Vascular and Interventional Radiology. 2013; 24: 509-517
        • Ruzzenente A.
        • Valdegamberi A.
        • Campagnaro T.
        • et al.
        Hepatocellular carcinoma in cirrhotic patients with portal hypertension: is liver resection always contraindicated.
        World Journal of Gastroenterology. 2011; 17: 5083-5088
        • Cucchetti A.
        • Ercolani G.
        • Vivarelli M.
        • et al.
        Is portal hypertension a contraindication to hepatic resection.
        Annals of Surgery. 2009; 250: 922-928
        • AISF Expert Panel
        • AISF Coordinating Committee
        Position paper of the Italian Association for the Study of the Liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma. Italian Association for the Study of the Liver (AISF).
        Digestive and Liver Disease. 2013; 45: 712-723
        • Kudo M.
        • Izumi N.
        • Kokudo N.
        • et al.
        Management of hepatocellular carcinoma in Japan: Consensus-Based Clinical Practice Guidelines proposed by the Japan Society of Hepatology (JSH) 2010 updated version.
        Digestive Diseases. 2011; 29: 339-364