Diagnosis and treatment of hepatocellular carcinoma: An update

Abstract

Hepatocellular carcinoma (HCC) is one of the most common malignancies leading to high mortality rates in the general population; in cirrhotic patients, it is the primary cause of death. The diagnosis is usually delayed in spite of at-risk population screening recommendations, i.e., patients infected with hepatitis B or C virus. Hepatocarcinogenesis hinges on a great number of genetic and molecular abnormalities that lead to tumor angiogenesis and foster their dissemination potential. The diagnosis is mainly based on imaging studies such as computed tomography and magnetic resonance, in which lesions present a characteristic classical pattern of early arterial enhancement followed by contrast medium "washout" in late venous phase. On occasion, when imaging studies are not conclusive, biopsy of the lesion must be performed to establish the diagnosis. The Barcelona Clinic Liver Cancer staging method is the most frequently used worldwide and recommended by the international guidelines of HCC management. Currently available treatments include tumor resection, liver transplant, sorafenib and loco-regional therapies (alcoholization, radiofrequency ablation, chemoembolization). The prognosis of hepatocarcinoma is determined according to the lesion's stage and in cirrhotic patients, on residual liver function. Curative treatments, such as liver transplant, are sought in patients diagnosed in early stages; patients in more advanced stages, were not greatly benefitted by chemotherapy in terms of survival until the advent of target molecules such as sorafenib.

Keywords: Catheter ablation; Hepatocellular carcinoma; Liver transplant; Sorafenib; Surveillance.

Figure 1

Contrast - enhanced computed tomography and Dynamic contrast-enhanced magnetic resonance imaging. A: Classical imaging pattern of hepatocellular carcinoma in contrast-enhanced computed tomography; A1: Simple phase, hypodense lesion in segment VII; A2: Arterial phase; A3: Enhanced portal; A4: 3 min late-phase washout; B: Diagnostic dynamic-contrast magnetic resonance imaging with classical pattern; B1: Simple phase; B2: Portal phase; B3: late-phase washout.

Figure 2

Diagnostic algorithm for hepatocellular carcinoma in Western countries. Modified from Bruix et al[6], with permission of the author and John Wiley and Sons. CT: Computed tomography; MRI: Magnetic resonance imaging.

Figure 3

Diagnosis algorithm for hepatocellular carcinoma in Eastern countries. Modified from Omata et al[51], with permission of the author and Springer. HCC: Hepatocellular carcinoma; CT: Computed tomography; MRI: Magnetic resonance imaging; SPIO: Super paramagnetic iron oxide; CEUS: Contrast-Enhanced Ultrasonography.

Figure 4

Barcelona Clinic Liver Cancer staging system and treatment strategy.