Multimodal therapy concepts in hepatocellular carcinoma

HCC is the most severe complication of liver cirrhosis. For the majority of patients the chances of cure are still limited. The recent experience in liver transplantation for HCC in the authors unit and in other centers allows the definition of a subgroup of patients, with small tumors (up to 3.0 cm, or 5 cm if solitary), no more than 3 nodules, and the absence of portal vein tumor thrombus. In these patients, liver transplantation offers a disease-free survival that is better than after liver resection, and similar to the survival of liver transplantation for benign liver disease. Patients with contraindications to transplantation, patients in whom a long waiting-time before transplantation is anticipated, and patients in countries with limited access to transplantation can be treated with a palliative intent (because of de novo tumors) by liver resection. Depending on liver function and local expertise, percutaneous ethanol injection (PEI) can be equally effective for small HCC. Other forms of treatment currently being evaluated, such as radio-frequency, thermal destruction or cyro-therapy, offer advantages similar to PEI without the need for multiple sessions. Further progress will probably come from a wider use of screening to detect a larger proportion of treatable lesions, and from strategies to prevent carcinogenesis in the cirrhotic liver, and possibly from innovative treatments such as gene therapy to alter the tumor biology.