Etiology, natural history and treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is linked to environmental, dietary and lifestyle factors. Patients with cirrhosis and chronic carriage of hepatitis B virus (HBV) are at risk for HCC at annual rates of 3%. HCC risk is particularly high in patients with evidence of cirrhosis and histological markers of increased liver cell proliferation. In addition, thrombocytopenia, prolonged prothrombin time and over 55 years of age also predict the development of HCC. Treatment options are defined according to the presence or absence of cirrhosis, number and size of tumors, and degree of hepatic decompensation. Hepatic resection is the primary intervention for these few patients with tumor but surrounding normal liver tissue and well preserved hepatic function. Under such circumstances, the cumulative 5-year survival is approximately 45%. Liver transplantation (OLT) provides long term survivals (90% at 5 years) in patients with a HCC discovered by chance as a minute nodule and of 75% in patients with viral cirrhosis and a single <5 cm tumor or fewer than three <3 cm nodes. Since liver transplantation cannot be offered to most patients with HCC, hepatic resection remains the primary therapeutic option; 5-year survival of 50% is anticipated in patients with compensated cirrhosis and <5 cm of tumor and 75% for those with moderate portal hypertension and normal serum bilirubin values. Ultrasound-guided tumor injection with absolute ethanol or tumor thermoablation with radiofrequency provide similar survival rates but with fewer complications. Whether arterial chemoembolization benefits patients with HCC remains controversial.