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Advanced HCC Systemic Therapy — RACP Adult Medicine MCQ

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ModerateMedical OncologyAdvanced HCC Systemic TherapyRACP Adult Medicine

A 62-year-old man with hepatocellular carcinoma beyond Milan criteria (single tumour 8 cm, no vascular invasion) and Child-Pugh A cirrhosis is not a transplant candidate. What is the first-line systemic therapy?

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Correct answer: A — Lenvatinib

For advanced HCC (BCLC stage C) or intermediate HCC not amenable to locoregional therapy, the first-line systemic treatment has shifted from sorafenib to atezolizumab + bevacizumab based on the IMbrave150 trial (superior OS and PFS compared to sorafenib). This combination is now the standard first-line treatment and is PBS-listed in Australia. Patients must be screened for oesophageal varices before starting bevacizumab (risk of variceal bleeding – treat varices first if present). Sorafenib or lenvatinib are alternatives if immunotherapy is contraindicated (e.g., autoimmune disease, transplant recipients).

Reference: Cancer Council Australia – 2020 – HCC Guidelines; PBS – 2025 – Atezo/Bev HCC Listing