Treatment of high-burden hepatocellular carcinoma: an oncologist perspective

Hepatocellular carcinoma (HCC) is recognized as a major global healthcare burden. Although there have been tremendous improvements in cancer screening and treatment, HCC mortality rate remains high. Many patients with HCC present late to medical attention and thus are not candidates for curative treatment. They typically have high tumor burden at presentation showing heterogeneity in anatomical factors and biochemical profile. Despite the relatively poor prognosis for these patients, significant improvements can still be made in survival if the optimal treatment modality is chosen. Currently, there is no international consensus on how to manage this group of heterogeneous, high-burden HCC. In this article, we will address this question by reviewing the latest available evidences. Our definition of “high-burden HCC” will be based on three factors: size, number of tumors and the presence of macrovascular invasion. The different treatment modalities, namely surgery, intra-arterial therapy, radiotherapy and systemic therapy, and their respective supportive evidences, will be discussed. In the end, we will summarize with our views on the future direction of research priorities for the management of high-burden HCC.