Treatment for Advanced Hepatocellular Carcinoma: Current Standard and the Future

HCC staging is unique because liver function and functional status, in addition to tumor burden, are integral determinants of stage and prognosis. Although staging systems vary, parameters that define advanced stage HCC eligible for therapy include presence of portal vein tumor invasion and/or extrahepatic metastases, with relatively preserved liver function and functional status. Generally, systemic therapy trials excluded patients with Child Pugh class B and C cirrhosis, largely because of the competing risk for mortality with cirrhosis. Thus, for many therapies, there are little data on efficacy and tolerability in patients with more advanced liver disease. Systemic therapies may also be appropriate in those patients with unresectable HCC who are not eligible for or are unlikely to benefit from locoregional therapies, although the decision on timing of when to initiate systemic therapy in a patient with intermediate HCC who is eligible for recurrent locoregional therapy remains an open question. In this review, we discuss contemporary approaches and ongoing studies for the treatment of patients with advanced HCC.