How I manage my patients with hepatocellular carcinoma

In the late 1990s, the development of a standardized staging system for hepatocellular carcinoma (HCC) (Barcelona clinical liver cancer) using evidence-based data made it possible to stratify HCC patients to receive appropriate treatment with substantial clinical benefit. In the past, treatment failures were often because of faulty staging of tumour disease. This was the case for hepatic resection, as patient survival after surgery was endangered by tumour recurrence (70% at 5 years) as well as the risk of unresolved post-surgical hepatic decompensation, a complication that can be avoided by restricting resection to patients with low portal hypertension and normal serum bilirubin. It was also true for liver transplantation, whose outcome clearly improved when stringent patient selection criteria were adopted based on the volume and number of tumour nodules and venous invasion (so-called Milan criteria), resulting in <15% risk of tumour recurrence and a 75% 5-year survival rate. Switching from an empirical to an evidence-based patient selection approach improved the outcome of local ablation therapies, mainly because ideal candidates were identified, resulting in>50% 5-year survival rates, similar to those obtained with hepatic resection. While the prognosis is still poor in patients with advanced HCC, the recent availability of multikinase inhibitors has generated hope for improving survival in these patients.