Navigating the Therapeutic Pathway and Optimal First-Line Systemic Therapy for Hepatocellular Carcinoma in the Era of Immune Checkpoint Inhibitors

Hepatocellular carcinoma (HCC) remains a prevalent form of cancer with a poor prognosis and requires systemic therapies for most advanced cases. In this review, we summarize considerations for selecting treatment options for HCC, particularly with regard to immune checkpoint inhibitors (ICIs). Traditional chemotherapy has been surpassed by molecular-targeted therapies and ICIs, such as cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), programmed death-1 (PD-1), and programmed death-ligand 1 (PD-L1) inhibitors, which enhance the immune response against tumors. The European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD) guidelines recommend atezolizumab/bevacizumab (Atez/Bev) and tremelimumab/durvalumab (Dur/Tre) as first-line treatments for unresectable HCC, along with alternatives, such as sorafenib and lenvatinib. Atezolizumab and bevacizumab have demonstrated superior efficacy but require the monitoring of bleeding risk and adverse events, such as proteinuria. Tremelimumab and durvalumab offer alternatives for patients at high risk of anti-Vascular Endothelial Growth Factor (anti-VEGF)-related complications. In cases where ICIs are contraindicated, lenvatinib and sorafenib serve as additional options, with lenvatinib demonstrating longer progression free survival (PFS) in clinical trials. It is important to consider that each treatment has specific side effects or contraindications, and the choice of medication should be based not only on the therapeutic efficacy of the drug, but also on the patient's health status, liver function, and tumor characteristics.