Real Life Treatment of Hepatocellular Carcinoma: Impact of Deviation from Guidelines for Recommended Therapy

  • Alkhatib, Alzhraa (Oncology, National Liver Institute, Menoufiya University) ;
  • Gomaa, Asmaa (Hepatology, National Liver Institute, Menoufiya University) ;
  • Allam, Naglaa (Hepatology, National Liver Institute, Menoufiya University) ;
  • Rewisha, Eman (Hepatology, National Liver Institute, Menoufiya University) ;
  • Waked, Imam (Hepatology, National Liver Institute, Menoufiya University)
  • Published : 2015.11.04


Background: Real life management of hepatocellular carcinoma occasionally deviates from guidelines for recommended therapy. Aims: To evaluate how frequent this deviation happens in our center and assess its impact on outcome. Materials and Methods: The treatment of 770 patients (87% males, mean age 57.8 years) was analyzed and the effect of deviation on outcome over 36 months was examined. Results: Of Barcelona Clinic liver cancer stages 0 and A patients, 65.8% received resection, ablation, liver transplantation or transarterial chemoembolisation for unresectable tumors more than 5 cm in diameter, and 34.2% received treatment recommended for later stages. Of stage B patients, 62.2% received recommended therapy, 34.3% of patients received supportive therapy or sorafenib and 3.5% received upward treatment stage migration. Among stage C patients, 7.6% received sorafenib, and most (79.2%) were given supportive care. Deviation from recommended therapy occurred in 34.2%, 37.7%, and 92.4% in stages 0-A, B and C. Survival of stage 0-A patients who received downwards treatment stage migration was lower than those who received recommended treatment (p <0.001). Upward treatment stage migration in stages B, C and D did not improve survival compared to those who received recommended treatment. Conclusions: Deviation from recommended therapy had a negative impact on survival in Barcelona Clinic liver cancer stage A patients.


AASLD guidelines;barcelona clinic liver cancer;hepatocellular carcinoma;survival


  1. Borzio M, Sacco R (2013). Nonadherence to guidelines in the management of hepatocellular carcinoma: an Italian or universal phenomenon? Future Oncol, 9, 465-7.
  2. Bruix J, Sherman M, Llovet JM, et al (2001). Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona- 2000 EASL conference. J Hepatol, 35, 421-30.
  3. Bruix J, Sherman M (2005). AASLD practice guidelines. management of hepatocellular carcinoma. Hepatol, 42, 1208-36.
  4. Bruix J, Sherman M (2011). Management of hepatocellular carcinoma: an update. american association for the study of liver diseases (AASLD) practice guideline. Hepatol, 53, 1020-35.
  5. Cabrera R, Nelson DR (2010). Review article: the management of hepatocellular carcinoma. Aliment Pharmacol Ther, 31, 461-76.
  6. D'Avola D, Inarrairaegui M, Pardo F, et al (2011). Prognosis of hepatocellular carcinoma in relation to treatment across BCLC stages. Ann Surg Oncol, 18, 1964-71.
  7. De Lope CR, Tremosini S, Forner A, Reig M, Bruix J (2012). Management of HCC. J Hepatol, 56, 75-87.
  8. European Association For The Study Of The Liver (2012). European organisation for research and treatment of cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol, 56, 908-43.
  9. Forner A, Reig ME, de Lope CR, Bruix J (2010). Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis, 30,61-74.
  10. Jaka H, Mshana SE, Rambau PF, et al (2014). Hepatocellular carcinoma: clinicopathological profile and challenges of management in a resource-limited setting. World J Surg Oncol, 2014, 12, 246.
  11. Kaplan E, Meier P (1958). Nonparametric estimation from incomplete observations. J Am Stat Assoc, 53, 457-81.
  12. Kim SE, Lee HC, Kim KM, et al (2011). Applicability of the BCLC staging system to patients with hepatocellular carcinoma in Korea: analysis at a single center with a liver transplant center. Korean J Hepatol, 17, 113-9.
  13. Abdelaziz AO, Elbaz TM, Shousha HI, et al (2014). Survival and prognostic factors for hepatocellular carcinoma: an egyptian multidisciplinary clinic experience. Asian Pac J Cancer Prev, 15, 3915-20.
  14. Benson AB 3rd, Abrams TA, Ben-Josef E, et al (2009). NCCN clinical practice guidelines in oncology: hepatobiliary cancers. J Natl Compr Canc Netw, 7, 350-91.
  15. Borzio M, Fornari F, De Sio I, et al (2013). Adherence to AASLD guidelines for the management of hepatocellular carcinoma: results of an Italian field-practice multicenter study. Future Oncol, 9, 283-94.
  16. Llovet JM, Ricci S, Gane E, et al (2008). Sorafenib in advanced hepatocellular carcinoma. N Engl J Med, 359, 378-90.
  17. Oken MM, Creech RH, Tormey DC, et al (1982). Toxicity and response criteria of the eastern cooperative oncology group. Am J Clin Oncol, 5, 649-55.
  18. Omata M, Lesmana LA, Tateishi R, et al (2010). Asian pacific association for the study of the liver consensus recommendations on hepatocellular carcinoma. Hepatol Int, 4, 439-74.
  19. Parikh P, Malhotra H, Jelic S (2008). ESMO guidelines working group. hepatocellular carcinoma: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol, 19, 27-8.
  20. Pinter M, Hucke F, Graziadei I, et al (2012). Advanced-stage hepatocellular carcinoma: transarterial chemoembolization versus sorafenib. Radiol, 263, 590-9.
  21. Radu P, Ioana G, Iancu C, et al (2013). Treatment of hepatocellular carcinoma in a tertiary romanian center. deviations from BCLC recommendations and influence on survival rate. J Gastrointestin Liver Dis, 22, 291-7.
  22. Ruzzenente A, Capra F, Pachera S, et al (2009). Is liver resection justified in advanced hepatocellular carcinoma? results of an observational study in 464 patients. J Gastrointest Surg, 13, 1313-20.
  23. Ryder SD, British Society of Gastroenterology (2003). Guidelines for the diagnosis and treatment of hepatocellular carcinoma (HCC) in adults. Gut, 52, iii1-8. 10.1136/gut.52.suppl_3.iii1
  24. Song P, Tobe RG, Inagaki Y, et al (2012). The management of hepatocellular carcinoma around the world: a comparison of guidelines from 2001 to 2011. Liver Int, 32, 1053-63.
  25. Su Cheng-Hao, Lin Y , Cai L (2013). Genetic factors, viral infection, other factors and liver cancer: an update on current progress. Asian Pac J Cancer Prev, 14, 4953-60.

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