In spite of recent achievement of treatment for advanced HCC, there are still hurdles to overcome. After the introduction of the molecular targeted agent (sorafenib) for advanced HCC, it seemed to be manageable disease by emerging new target agents. However, most clinical trials using new target agents were not successful for the past 10 years. Fortunately, two molecular targeted agents have been demonstrated the therapeutic efficacy by clinical trials. Regorafenib, which is used after sorafenib failure, is finally approved as the second-line agent. Lenvatinib, which has been shown to be non-inferior to sorafenib, is now waiting to be approved as the first-line agent. Moreover, new immunotherapy by using immune checkpoint inhibitors such as anti-PD-1/PD-L1 or CTLA-4 antibodies is currently under investigation in phase III studies with promising outcome. Therefore, emerging drugs may have significant changes in the treatment paradigm. However, high cost will be the hurdle to use in clinical practice in Asia. In addition, too advanced status HCC or rapid progressive HCC will be the hurdle.
Portal vein tumor thrombus (PVTT) is a quite common finding in advanced HCC with macrovascular invasion (MVI). Due to rapid progression, HCC with PVTT is usually inoperable and is associated with poor prognosis in spite of standard targeted treatment recommended by international guidelines. The recently updated AASLD guidelines point out that the selection of treatment may vary depending on the extent of MVI, but still no recommendation could be made. Many studies suggest alternative or more aggressive loco-regional treatment approaches could benefit selected patients. There are many alternative trial reports for HCC with PVTT using hepatic arterial infusion chemotherapy, external radiation therapy or selective internal radiation therapy. However, the level of evidence is not strong enough to accept any alternative strategy as international guidelines yet. The ideal strategy can be multimodal treatment using a combination of loco-regional therapy and personalized systemic therapy. |
