Topic: Multidisciplinary Management of HCC

Hepatocellular carcinoma (HCC) is a globally significant malignancy known for its clinical and biological diversity, often leading to a poor prognosis. Predicting outcomes and selecting treatment strategies for HCC patients is incredibly challenging due to the prognostic influence of underlying liver disease and the high incidence of clinical frailty. Moreover, over the past two decades, advancements in HCC treatments have significantly improved, adding further complexity to disease management. For these reasons, in recent years, there has been increasing support for treatment decisions made by expert multidisciplinary tumour boards, which can provide personalised therapeutic approaches tailored to each patient's unique characteristics. The intricate management of HCC, at both early and advanced stages, necessitates multidisciplinary expertise due to advancements in diagnosis, staging, and treatment options. A patient-centred approach involves evaluating various clinical and psychosocial factors on a case-by-case basis, including comorbid conditions, patient insight and preferences, and the impact of treatment on the patient's quality of life. This Special Issue of Hepatoma Research focuses on the crucial field of multidisciplinary management of HCC. A novel framework for a personalised multiparametric and expert multidisciplinary approach to HCC has been recently proposed in The Lancet Oncology, the multiparametric therapeutic hierarchy (MTH) scheme. The MTH proposal has three main components: the ordinal therapeutic hierarchy concept (left vertical axis), the multiparametric expert decision component (horizontal axis), and the converse therapeutic hierarchy part (right vertical axis). The multiparametric expert decision component (horizontal axis) was explicitly designed for expert multidisciplinary tumour boards. It indicates, in fact, a comprehensive, evidence-based checklist of all variables to be systematically considered by an expert tumour board in the multidisciplinary decision-making process (patient fitness, critical tumour features beyond simple tumour stage, liver function parameters, technical feasibility and availability, cost and resources available for each treatment). Moreover, it considers the balance of treatment benefits/harms, society's values and preferences, resource use, feasibility, acceptability, and equity (in the unfeasibility variable).

While many robust studies support the ordinal therapeutic hierarchy concept (left vertical axis), the quality of the evidence supporting the multiparametric expert decision (horizontal axis) seems more heterogeneous and suffers indirectness. This Special Issue aims to describe each component of the multiparametric expert decision axis, the evidence available, and proposals to increase the quality of this evidence. From this perspective, dedicated reviews will be designed for each axis component: fitness, critical tumour features, liver function, and treatment feasibility. A narrative review will also discuss the converse therapeutic hierarchy concept, another crucial component of the MTH proposal that merits further prospective studies. Other critical points that will be addressed in this Special Issue include how an HCC multidisciplinary expert team should be composed, the prognostic impact of multidisciplinary tumour board evaluation in HCC patients, and the potential role of artificial intelligence and novel biomarkers in the multidisciplinary evaluation of HCC patients. This Special Issue aims to stimulate discussion about these crucial aspects of multidisciplinary HCC expert management, encouraging continued research and innovation in HCC treatment to bridge the gap between expert multidisciplinary decisions and evidence-based medicine.

Potential topics include, but are not limited to, the following:
1. The concept of Multiparametric Therapeutic Hierarchy;
2. The role of “fitness” in the multiparametric, multidisciplinary, and expert evaluation of HCC patients;
3. The role of “critical tumour features” in the multiparametric, multidisciplinary, and expert evaluation of HCC patients;
4. The role of “liver function” in the multiparametric, multidisciplinary, and expert evaluation of HCC patients;
5. The role of “treatment feasibility” in the multiparametric, multidisciplinary, and expert evaluation of HCC patients;
6. The concept of Converse Therapeutic Hierarchy;
7. How should an HCC multidisciplinary expert team be composed and evaluated? 
8. The prognostic impact of multidisciplinary tumour board evaluation in HCC patients;
9. The potential role of artificial intelligence in the multidisciplinary evaluation of HCC patients;
10. Potential role of novel biomarkers in the multidisciplinary evaluation of HCC patients;
11. Bridging the gap between expert multidisciplinary decisions and evidence-based medicine.


Figure 1. Multiparametric therapeutic hierarchy

The concept of converse therapeutic hierarchy is represented with a dashed and faded arrow since the evidence supporting this concept is still weak. AFP = alpha-fetoprotein. PIVKA-II = Protein Induced by Vitamin-K Absence-II. LDLT = living donor liver transplantation. DCD = donor after circulatory death. DBD = donor after brain death. MELD = model for end-stage liver disease. CRPH = clinically relevant portal hypertension. TACE = transarterial chemoembolisation. PVT = portal vein thrombosis.

REFERENCES
1. Vitale A, Cabibbo G, Iavarone M, et al (2023) Personalised management of patients with hepatocellular carcinoma: a multiparametric therapeutic hierarchy concept. Lancet Oncol 24:e312–e322.
2. Trevisani F, Vitale A, Kudo M, Kulik L, Park J-W, Pinato DJ, Cillo U (2024) Merits and boundaries of the BCLC staging and treatment algorithm: Learning from the past to improve the future with a novel proposal. J Hepatol 80:661–669.

30 Sep 2024