The first 60 days: Intermediate hepatocellular carcinoma (BCLC B)
Intermediate hepatocellular carcinoma is several tumours inside a working liver, too many to cut out but with no spread beyond it. The standard treatment for two decades has been chemoembolisation through the hepatic artery, and trials now show that adding immunotherapy and anti-angiogenic drugs to it delays progression. Below, week by week, is what OnCo's record of Intermediate hepatocellular carcinoma (BCLC B) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Chemoembolisation or radioembolisation as a bridge, then liver transplantation.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: High burden or diffuse disease.
- SurgeonNamed in the standard of care for: Well-defined nodules, preserved liver function, Within transplant criteria after downstaging.
- Medical oncologistNamed in the standard of care for: Well-defined nodules, preserved liver function, TACE plus systemic therapy, High burden or diffuse disease, Within transplant criteria after downstaging.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Well-defined nodules, preserved liver function.
- Transplant and cell therapy teamNamed in the standard of care for: Within transplant criteria after downstaging.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Transarterial chemoembolisation, conventional or with drug-eluting beads, repeated on demand; radioembolisation as an alternative.
Durvalumab with bevacizumab (EMERALD-1) or lenvatinib with pembrolizumab (LEAP-012) added to TACE, where approved; durvalumab-tremelimumab with TACE after EMERALD-3.
Systemic therapy as for advanced disease (atezolizumab-bevacizumab or durvalumab-tremelimumab) instead of embolisation.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Tumour number and size, Child-Pugh and ALBI liver function before and after each embolisation, Alpha-fetoprotein response, Modified RECIST response on contrast imaging, Absence of macrovascular invasion and extrahepatic spread), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Multinodular HCC in a cirrhotic liver within the up-to-seven criteria, Well-defined nodules suitable for TACE, Diffuse or infiltrative bilobar HCC.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Well-defined nodules, preserved liver function
- For my situation (well-defined nodules, preserved liver function), which of the standard options do you recommend and why?Guideline options include: Transarterial chemoembolisation, conventional or with drug-eluting beads, repeated on demand; radioembolisation as an alternative.
TACE plus systemic therapy
- For my situation (tace plus systemic therapy), which of the standard options do you recommend and why?Guideline options include: Durvalumab with bevacizumab (EMERALD-1) or lenvatinib with pembrolizumab (LEAP-012) added to TACE, where approved; durvalumab-tremelimumab with TACE after EMERALD-3.
- Am I a candidate for Durvalumab, Bevacizumab, Lenvatinib or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of EMERALD-1 and LEAP-012 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
High burden or diffuse disease
- For my situation (high burden or diffuse disease), which of the standard options do you recommend and why?Guideline options include: Systemic therapy as for advanced disease (atezolizumab-bevacizumab or durvalumab-tremelimumab) instead of embolisation.
- Am I a candidate for Atezolizumab, Bevacizumab, Durvalumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of IMbrave150 and HIMALAYA apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Within transplant criteria after downstaging
- For my situation (within transplant criteria after downstaging), which of the standard options do you recommend and why?Guideline options include: Chemoembolisation or radioembolisation as a bridge, then liver transplantation.
Any stage
- Are there clinical trials I could join, for example of EMERALD-3, TACE + immunotherapy/anti-VEGF, Radioembolisation (TARE / SIRT, yttrium-90), Durvalumab?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “No overall survival gain yet shown for TACE combinations”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Which patients should skip embolisation and go straight to systemic therapy”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Intermediate hepatocellular carcinoma (BCLC B): the full pageIntermediate hepatocellular carcinoma is several tumours inside a working liver, too many to cut out but with no spread beyond it. The standard treatment for two decades has been chemoembolisation through the hepatic artery, and trials now show that adding immunotherapy and anti-angiogenic drugs to it delays progression.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Bridging therapy: Treatment given to keep a fast-growing cancer in check during the weeks between deciding on CAR-T (or transplant) and actually receiving it, while the cells are being manufactured or a donor found.
- BCLC staging: The liver-cancer staging system that combines tumour size, liver function and fitness to recommend treatment: ablation or surgery, transplant, TACE, or drugs.
- TACE (transarterial chemoembolisation): Threading a catheter into the artery feeding a liver tumour and injecting chemotherapy plus particles that block the blood supply, starving and poisoning it at once.
Every term links to the glossary.