How I Do It: Triaging Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a malignancy that is increasing in incidence in the United States (4.9 per 100,000) with mortality rates that remain close to 50% at 1 year, despite improvement in programs aimed at the prevention of cirrhosis and early detection of liver cancer in high-risk patients. Liver cancer is now the third cause of cancer-related death. Diagnosis at an advanced stage excludes >85% of patients from curative surgical therapies. Medical therapy remains of limited benefit for nonsurgical patients. Sorafenib has shown the most promising results for palliative therapy in HCC patients, imparting a 10-week survival benefit in patients with advanced disease.

Liver-directed therapies provide alternatives to patients with HCC who are not considered surgical candidates. Radiofrequency ablation (RFA) has survival rates comparable with surgical resection in optimally selected patients with early disease; however, increasing size (>3 cm), multiple lesions (more than three), and central location limits application in patients with stage III disease and patients whose tumor location is adjacent to vascular structures or central bile ducts. Chemoembolization with single or multiple drugs mixed with ethiodized oil (cTACE) has the longest track record in the treatment of nonsurgical HCC patients and has been shown to improve survival in several randomized controlled trials compared with symptomatic treatment. Chemoembolization with drug-eluting beads (DEB) and selective internal radiation therapy (SIRT) with yttrium are newer therapies that appear to have similar efficacy and may be preferred in certain subpopulations. When to use them remains controversial because direct comparative evidence to guide choices is lacking.

This article presents several common scenarios of patients presenting with HCC to highlight the clinical and anatomical factors that lead to a treatment decision.

• Suggested Readings

• Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol 2009; 27 (9) 1485-1491
• Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis 2010; 30 (1) 61-74
• Lewandowski RJ, Kulik LM, Riaz A , et al. A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization. Am J Transplant 2009; 9 (8) 1920-1928
• Leoni S, Piscaglia F, Golfieri R , et al. The impact of vascular and nonvascular findings on the noninvasive diagnosis of small hepatocellular carcinoma based on the EASL and AASLD criteria. Am J Gastroenterol 2010; 105 (3) 599-609
• Lammer J, Malagari K, Vogl T , et al; PRECISION V Investigators. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol 2010; 33 (1) 41-52
• Llovet JM, Real MI, Montaña X , et al; Barcelona Liver Cancer Group. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet 2002; 359 (9319) 1734-1739
• Llovet JM, Ricci S, Mazzaferro V , et al; SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 2008; 359 (4) 378-390
• Lo CM, Ngan H, Tso WK , et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 2002; 35 (5) 1164-1171
• Mazzaferro V, Regalia E, Doci R , et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334 (11) 693-699
• McCarley JR, Soulen MC. Percutaneous ablation of hepatic tumors. Semin Intervent Radiol 2010; 27 (3) 255-260
• Salem R, Lewandowski RJ, Mulcahy MF , et al. Radioembolization for hepatocellular carcinoma using yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology 2010; 138 (1) 52-64
• Vauthey JN, Lauwers GY, Esnaola NF , et al. Simplified staging for hepatocellular carcinoma. J Clin Oncol 2002; 20 (6) 1527-1536
• Washburn K. Model for end stage liver disease and hepatocellular carcinoma: a moving target. Transplant Rev (Orlando) 2010; 24 (1) 11-17
• Yao FY, Xiao L, Bass NM, Kerlan R, Ascher NL, Roberts JP. Liver transplantation for hepatocellular carcinoma: validation of the UCSF-expanded criteria based on preoperative imaging. Am J Transplant 2007; 7 (11) 2587-2596