Management of hepatocellular carcinoma: Enlightening the gray zones

Abstract

Management of hepatocellular carcinoma (HCC) has been continuously evolving during recent years. HCC is a worldwide clinical and social issue and typically a complicates cirrhosis. The incidence of HCC is increasing, not only in the general population of patients with cirrhosis, but particularly in some subgroups of patients, like those with human immunodeficiency virus infection or thalassemia. Since a 3% annual HCC incidence has been estimated in cirrhosis, a bi-annual screening is generally suggested. The diagnostic criteria of HCC has recently had a dramatic evolution during recent years. HCC diagnosis is now made only on radiological criteria in the majority of the cases. In the context of cirrhosis, the universally accepted criteria for HCC diagnosis is contrast enhancement in arterial phase and washout in venous/late phase at imaging, the so called "typical pattern". However, recently updated guidelines slightly differ in diagnostic criteria. Apart from liver transplantation, the only cure of both HCC and underlying liver cirrhosis, all the other treatments have to match with higher rate of HCC recurrence. The latter can be classified into curative (resection and percutaneous ablation) and palliative treatments. The aim of this paper was to review the current knowledge on management of HCC and to enlighten the areas of uncertainty.

Keywords: Hepatocellular carcinoma; Management; Orthotopic liver transplantation; Surgery; Trans-arterial chemoembolization.

Figure 1

Typical hepatocellular carcinoma at magnetic resonance imaging: contrast enhancement in arterial phase (A) and washout in venous (B)/late (C) phase.

Figure 2

Multi-nodular hepatocellular carcinoma. A: Basal and arterial computed tomography (CT) phase; B: Venous and late CT phase.

Figure 3

A new typical hepatocellular carcinoma found at computed tomography during follow up another hepatocellular carcinoma treated with radiofrequency ablation (central lesion). Note that also in the treated lesion there is a marginal area of vital hepatocellular carcinoma.