HCC treatments that improve survival include:

• surgery – resection or transplant
• local ablative therapies
• regional therapies
• localised therapies.

Surgery – resection or transplant

Only a small number of cases are suited to surgery. Established criteria for surgical intervention depend on the severity of liver disease and the presence of clinically significant portal hypertension. The size, number and position of the tumours, and residual liver volume, all need to be considered.

A resection may benefit patients with compensated liver disease. Laparoscopic surgical techniques produce better patient outcomes.

A liver transplant may benefit patients who also have cirrhosis, including those with decompensation, and patients with a tumour volume that is within accepted international guidelines.

Timeframe for starting treatment

Surgery should begin within four weeks of the MDM.

Training and experience required of the surgeon

Surgeon (Fellow of the Royal Australasian College of Surgeons (FRACS) or equivalent) with adequate training and experience in HPB surgery and institutional cross-credentialing and agreed scope of practice within this area.

Documented evidence of training and experience of the surgeon, including their specific experience with HCC and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• a clearly defined path to emergency care and advice after hours
• full support from other surgical specialties including vascular surgery, colorectal surgery, urological surgery and upper gastrointestinal surgery
• diagnostic imaging
• expert and timely interventional radiology
• pathology.

Evidence suggests that high-volume hospitals have better clinical outcomes for complex cancer surgery (Lu et al. 2014). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to a high-volume centre.

Local ablative therapies and regional therapies

Local ablative therapies used to treat HCC are:

• radiofrequency ablation
• microwave ablation
• percutaneous ethanol
• percutaneous acetic acid injections
• stereotactic radiation therapy
• image-guided cryoablation.

Local ablative therapies may have the following benefits:

• curative treatment in cases of advanced liver disease
• the downsizing of tumours before definitive treatment
• treatment of recurrent tumours
• improved length of survival and quality of life.

Regional therapies used to treat HCC are:

• transarterial chemoembolisation (TACE) – a type of chemotherapy that is injected directly into the liver along with a gel or small beads that are injected into the blood vessels surrounding the tumours
• transarterial embolisation (TAE) (as for TACE but without chemotherapy) – a rarely used alternative
• selective internal radiation therapy (SIRT) – a type of radiation and embolisation therapy where radioactive material is injected directly into the blood vessels supplying the tumours.

Regional therapies may have the following benefits:

• as a palliative treatment to slow down tumour growth (for early or advanced disease)
• for patients waiting for a transplant (shrinking of tumours)
• for patients with major vascular invasion (SIRT)
• for selected tumours using chemo-ablation therapy.

Timeframe for starting treatment

Local ablative therapies or regional therapies should begin within four weeks of the MDM.

Training and experience required of the appropriate specialists

• Interventional radiologist (FRANZCR or equivalent) with adequate training and experience with institutional credentialing and agreed scope of practice in liver cancer
• SIRT should only be performed by credentialled specialists
• European Board of Interventional Radiology (EBIR) certification, or equivalent standard, is recommended.

Documented evidence of training and experience of the radiologist, including their specific experience with liver ablation and procedures to be undertaken, should be available.

Health service unit characteristics

To provide safe and quality care for patients having regional or radiation therapy, health services should have these features:

• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation therapies delivered
• a treatment planning system
• trained medical physicists, experienced nuclear medicine technologists, radiation therapists and nurses with radiation therapy experience
• coordination for combined therapy with systemic therapy, especially where facilities are not collocated
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system

Localised therapies

Localised therapies are the most common treatment for early-stage HCC and are used with cure in mind. Localised therapies may be used in conjunction with surgery and may be thermal or chemical, depending on local expertise.

Localised therapies may benefit patients:

• with unresectable disease (due to the size, number or location of the tumour and severity of liver disease)
• with small tumour(s) (lesions 5 cm or smaller)
• awaiting liver transplant
• with small recurrent tumours (particularly after prior resection).

Localised therapies should be monitored by imaging four weeks after the procedure to assess the response and then at three-monthly intervals for two years, and six-monthly after that.

Timeframe for starting treatment

Localised therapies should begin within four weeks of the MDM.

Training and experience required of the appropriate specialists

• Interventional radiologist (FRANZCR or equivalent) with adequate training and experience in ablative therapies, with institutional credentialing and agreed scope of practice within this area
• EBIR or equivalent standard is recommended.

Documented evidence of training and experience of the radiologist, including their specific experience with localised therapies and procedures to be undertaken, should be available.