Hepatocellular carcinoma: early-stage management challenges

Abstract

Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.

Keywords: Barcelona clinic liver cancer; cirrhosis; hepatectomy; hepatic resection; hepatitis; hepatocellular carcinoma; liver transplantation; locoregional therapy; radiofrequency ablation; staging; surveillance; transarterial chemoembolization.

Figure 1

HCV global burden and rising incidence of HCC in the USA. Notes: (A) HCV global statistics from adapted by permission from Macmillan Publishers Ltd: Nat Rev Gastroenterol Hepatol, Thrift AP, El-Serag HB, Kanwal F, Global epidemiology and burden of Hcv infection and Hcv-related disease, 2017;14(2):122–132, copyright 2016. (B) Projected HCC incidence data reprinted with permission ©2016 American Society of Clinical Oncology. All rights reserved. Petrick JL, Kelly SP, Altekruse SF, McGlynn KA, Rosenberg PS. Future of hepatocellular carcinoma incidence in the United States forecast through 2030. J Clin Oncol. 2016;34(15):1787–1794. Abbreviations: HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Figure 2

Early-stage HCC treatment algorithm. Abbreviations: CPS, Child–Pugh score; DCE-MRI, dynamic contrast-enhanced magnetic resonance imaging; FLR, future liver remnant; HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; MELD, model end-stage liver disease; PEI, percutaneous ethanol injection; PVE, portal vein embolization; RFA, radiofrequency ablation; TACE, transarterial chemoembolization.