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ESMO management and treatment adapted recommendations in the COVID-19 era: Hepatocellular carcinoma (HCC)

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

Patients with Hepatocellular Carcinoma in the COVID-19 era

The prognosis of patients with HCC largely depends on the stage of underlying liver disease. Measures for the care of patients with liver disease during the COVID-19 pandemic have recently been proposed by the European Association for the Studies of the Liver (EASL). These recommendations include patients with HCC [1].

Based on current evidence, patients with chronic liver disease and HCC and COVID-19 should be admitted for inpatient care.

 

Priorities for HCC patients

Outpatient visit priorities

High Priority

  • Patients with decompensated liver disease
  • Patients on the waiting list for liver transplantation
  • Patients with suspected HCC
  • Patients with proven HCC awaiting treatment initiation or modification
  • Patients showing moderate or severe side effects to treatment

Medium Priority

  • Patients with HCC-suspect lesions <1 cm
  • Patients showing response and tolerability to treatment (they may present by telemedicine/visits by phone)
  • Patients showing mild side effects to treatment
  • Second opinion

 Low Priority

  • Patients in long term remission >5 years (schedule blood tests and imaging close to home and report by telemedicine/by phone)
  • Patients in end-stage HCC (BCLC D, Child-Pugh C) without option for recompensation of liver function (best supportive care may be organised close to home by phone)

Priorities for HCC: Imaging

High Priority

  • Radiological diagnostic work-up of HCC-suspect lesions
  • Radiological assessment of treatment response
  • Radiological assessment of bone metastasis
  • Patients with decompensation of liver function

Medium Priority

  • HCC-suspect liver lesions <1 cm without progression

 Low Priority

  • HCC surveillance can be deferred based on available resources (including availability of therapeutic options in case of HCC diagnosis) at the centre and the individual risk assessment. Patients with increased risk, such as patients with elevated alpha-foetoprotein levels, advanced cirrhosis, chronic hepatitis B, NASH/diabetes, etc., may be prioritised if resources are limited
  • Patients in long term remission >5 years from HCC (schedule blood tests and imaging close to home and report by telemedicine/by phone)

Priorities for HCC: Surgical oncology

High Priority

  • Liver transplantation (listing prioritised for patients with poor short-term prognosis including those with acute/acute-on-chronic liver failure (ALF/ACLF), high model for end-stage liver disease (MELD) score (including exceptional MELDs) and HCC at the upper limits of the Milan criteria)
  • Surgical intentions with curative intent for patients with large or multifocal but still curatively resectable HCC lesions

Medium Priority

  • Listing for transplantation of patients with compensated liver disease and within the lower limits of Milan criteria
  • Curative surgical resection of small single HCC lesions

 Low Priority

-

 Priorities for HCC: Systemic treatment

High Priority

  • First and following line systemic treatments. However, if feasible, avoid outpatient visit appointments and plan follow-up assessments close to home and communication by telemedicine/by phone

Medium Priority

  • Experimental treatments with low probability for response

 Low Priority

  • Weekly blood tests unless clinical conditions and symptoms require them
  • Radiological evaluation by considering the patient’s risk/benefit ratio

Priorities for HCC: Radiation oncology

High Priority

  • Radiological treatments (e.g. TACE, SIRT/TARE) as bridging therapy for patients in stage BCLC A awaiting liver transplantation
  • Patients receiving radiological treatments with expected survival benefit in a palliative setting (stages BCLC B or C)

Medium Priority

  • Radiological treatment as bridging for liver transplantation in very early stage (BCLC 0)
  • Curative ablation of small single HCC lesions (≤2 cm)

 Low Priority

  • Delay all treatments with modest benefit expected

 

List of abbreviations: HCC, hepatocellular carcinoma; NASH, non-alcoholic steatohepatitis; SIRT, selective internal radiotherapy; TACE, transarterial chemoembolisation; TARE, transarterial radioembolisation.

1. Boettler T, Newsome PN, Mondelli MU et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Reports 2020 vol. 2.

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