Liver & Hepatobiliary — treatment notes

4Liver & Hepatobiliary

Snapshot. HCC (hepatocellular carcinoma) arises in cirrhosis → Child-Pugh / ALBI (albumin-bilirubin) score gates therapy; staged by BCLC (Barcelona Clinic Liver Cancer). Biliary tract cancers (gallbladder / cholangiocarcinoma) — gene-profile everyone at diagnosis: HER2, FGFR2, IDH1 open targeted options later in the pathway.

Workup

HCC: multiphasic CT/MRI (LI-RADS [liver-imaging reporting and data system] — often diagnostic without biopsy in cirrhosis), AFP (alpha-fetoprotein), Child-Pugh/ALBI. Biliary: biopsy mandatory, CA 19-9 (a biliary tumour marker — interpret only after relieving any obstruction), MRCP (MR cholangiopancreatography), NGS at diagnosis (HER2 / FGFR2 / IDH1).

Treatment by setting

Setting	Treatment
HCC — EARLY BCLC 0/A — solitary or oligonodular, preserved liver function	Resection (partial hepatectomy), transplant, or ablation transplant within Milan criteria SBRT as an alternative local option stereotactic body radiotherapy — when ablation / surgery is unsuitable
HCC — INTERMEDIATE BCLC B — multinodular, preserved liver function, no vascular invasion/extrahepatic spread	TACE ± Y90 transarterial chemoembolisation · yttrium-90 radioembolisation
HCC — ADVANCED BCLC C — vascular invasion / extrahepatic spread, Child-Pugh A	Atezolizumab + bevacizumab (IMbrave150) PD-L1 inhibitor + anti-VEGF · ⚠ do an EGD for varices FIRST (upper endoscopy) Or durvalumab + tremelimumab — the STRIDE regimen (HIMALAYA) the choice when varix / bleeding risk makes bevacizumab unattractive Later-line → lenvatinib / sorafenib / regorafenib / cabozantinib VEGFR tyrosine kinase inhibitors
Biliary — RESECTED R0/R1 resection	Adjuvant capecitabine ×6 months (BILCAP)
Biliary — ADVANCED unresectable/metastatic; HER2/FGFR2/IDH1 wild-type or pending	Gemcitabine + cisplatin + durvalumab (TOPAZ-1) or + pembrolizumab (KEYNOTE-966) 2nd line — biomarker-matched FGFR2 fusion → pemigatinib / futibatinib · IDH1-mutant → ivosidenib · HER2-amplified → zanidatamab (a BISPECIFIC HER2 antibody — binds two HER2 epitopes at once, unlike trastuzumab; approved 2024) or trastuzumab deruxtecan

Watch

Bevacizumab → variceal/GI bleed, proteinuria, hypertension. Dexamethasone (steroid for liver-capsular pain) → immunosuppression — HSV (herpes simplex virus) reactivation flag; consider antiviral ± PJP (pneumocystis pneumonia) prophylaxis if prolonged. Durvalumab+tremelimumab carries a higher immune-related hepatitis/colitis rate than atezo+bev — check LFTs before every cycle, doubly so in a cirrhotic liver.