Management of hepatocellular carcinoma

Abstract

Purpose: Hepatocellular carcinoma (HCC), a common cause for cancer-related death, is increasing worldwide. Over the past decade, survival and quality of life of HCC patients have significantly improved due to better prevention strategies, early diagnosis, and improved treatment options. We performed this narrative review to synthesize current status on the HCC management.

Methods: Literature search for publications especially over the last decade, which has changed the paradigm on the management of HCC.

Results: Hepatitis B vaccination and treatment of chronic hepatitis B and C are important measures for HCC prevention. Screening and surveillance for HCC using ultrasonogram and alpha-fetoprotein estimation are directed toward cirrhotics and hepatitis B patients at high risk of HCC. If detected at an early stage, curative treatments for HCC can be used such as tumor resection, ablation and liver transplantation. HCC patients without curative options are managed by loco-regional therapies and systemic chemotherapy. Loco-regional treatments include trans-arterial chemoembolization, radioembolization and combinations of loco-regional plus systemic therapies. Currently, sorafenib is the only FDA-approved systemic therapy and newer better chemotherapeutic agents are being investigated. Palliative care for terminally ill patients with metastatic disease and/or poor functional status focusses on comfort care and symptom control.

Conclusions: In spite of significant advancement in HCC management, its incidence continues to rise. There remains an urgent need to continue refining understanding of HCC and develop strategies to increase utilization of the available preventive measures and curative treatment modalities for HCC.

Fig. 1

Algorithm for screening, surveillance and diagnosis of hepatocellular carcinoma

Fig. 2

Evolutional change in the proportion of blood supply (portal venous supply shown in blue vs. hepatic arterial supply shown in red) with changing liver histology from cirrhosis to regenerative nodule to dysplastic nodule to HCC. Patients with a poorly differentiated HCC are supplied almost entirely by hepatic artery

Fig. 3

Classical radiological imaging findings of HCC on dynamic 4-phase CT scan with enhancement of the lesion during the arterial phase, washout of contrast in the portal venous and delayed phases

Fig. 4

Algorithm for management of HCC based on the Barcelona Classification of Liver Cancer

Fig. 5

The outcome of HCC treated by resection, with the worst survival in patients with portal hypertension (platelet count <150,000) and high bilirubin (>1.1 mg/dL), the best survival in those without these factors and intermediate survival in patients with one of these factors

Fig. 6

CT scan imaging showing pre- and post-TACE treatment of the HCC. TACE achieves necrosis of the tumor as shown by reduced area of arterial enhancement (mRECIST criteria)