Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. Most patients still present late in the course of the disease so that curative therapy is rarely possible. Strategies developed to improve the prognosis include primary prevention, directed at the underlying liver diseases, secondary prevention by cancer surveillance and early intervention, and more effective therapies. Only childhood vaccination against hepatitis B (HBV) infection has been clearly documented to reduce the incidence of HCC. Eradication of the hepatitis B and C viruses by interferon in noncirrhotic patients may reduce the incidence of HCC. Removal of iron by phlebotomy in noncirrhotic patients with genetic hemochromatosis will largely prevent HCC. Many physicians offer secondary prevention by surveillance and early intervention involving repeated abdominal ultrasound and serial serum α-fetoprotein estimations in order to identify early malignant lesions, but such strategies have yet to be proven to reduce mortality from HCC. Nonetheless, early detection would seem to offer a greater chance for application of potentially curative therapy. Different surveillance strategies may be necessary in different patient groups. For example, in chronic hepatitis C the increased risk of HCC seems to be confined to patients with established cirrhosis, whereas even noncirrhotic patients with HBV have a substantially increased risk of HCC. In high-risk patients, such as those with cirrhosis following chronic viral hepatitis, several factors can be identified which appear to confer additional risk. Examples are hepatocyte dysplasia found on biopsy, or non-neoplastic vascular nodules on computed tomography scanning. The management of such patients needs urgent resolution. Potentially curative treatment options include resection, liver transplantation, and alcohol injection or radiofrequency ablation. Resection in ideal candidates may provide up to 60% survival at 5 years. Liver transplantation may result in a 5-year survival of up to 70%. However, the shortage of organ donors means that tumor progression while on the waiting list will disqualify some patients, while others will die before an organ becomes available. Local ablation has been reported to be as effective as resection and is applicable to a larger proportion of patients. Of the palliative forms of therapy only chemoembolization has been shown to provide a significant improvement in life-span, although other forms of adjuvant and palliative therapy are under investigation.