Hepatocellular carcinoma: Where are we?

Abstract

Hepatocellular carcinoma (HCC) is the second cause of death due to malignancy in the world, following lung cancer. The geographic distribution of this disease accompanies its principal risk factors: Chronic hepatitis B virus and hepatitis C virus infection, alcoholism, aflatoxin B1 intoxication, liver cirrhosis, and some genetic attributes. Recently, type II diabetes has been shown to be a risk factor for HCC together with obesity and metabolic syndrome. Although the risk factors are quite well known and it is possible to diagnose HCC when the tumor is less than 1 cm diameter, it remains elusive at the beginning and treatment is often unsuccessful. Liver transplantation is thus far considered the best treatment for HCC as it cures HCC and the underlying liver disease. Using the Milan criteria, overall survival after liver transplantation for HCC is about 70% after 5 years. Many attempts have been made to go beyond the Milan Criteria and according to recent works reasonably good results have been achieved by using a histochemical marker such as cytokeratine 19 and the so-called "up to seven criteria" to divide patients into categories according to their risk of relapse. In addition to liver transplantation other therapies have been proposed such as resection, tumor ablation by different means, embolization and chemotherapy. An important step in the treatment of advanced HCC has been the introduction of sorafenib, the first oral, systemic drug that has provided significant improvement in survival. Treatment of HCC patients must be multidisciplinary and by using the different approaches discussed in this review it is possible to offer prolonged survival and quite good and sometimes even excellent quality of life to many patients.

Keywords: Chemoembolization; Chemotherapy; Epidemiology; Hepatocellular carcinoma; Liver cancer; Liver transplantation; Percutaneous ethanol injection; Radiofrequency ablation; Treatment.

Figure 1

Staging and possible strategy to treat patients with hcc and liver cirrhosis. PS: Performance status according to ECOG; BCLC: Barcelona clinic liver cancer; HVPG: Hepatic vein portal gradient; BSC: Best supportive care; CP: Child-Pugh score; CK19: Cytokeratin 19; S2: Patients beyond Milan Criteria (see text). References[73-75,79,123].