The diagnosis and treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) has continued to rise in recent years. This increase has been attributed to alcohol-induced liverdiseases, metabolic syndrome, and the rising number of hepatitis B and C viral infections.

Pertinent publications (2000-2011) were retrieved by a systematic Medline search. In seven different subject areas, 41 key questions were defined; 15 of them were answered on the basis of a primary search. In addition, original-source guidelines that are currently available from around the world were assessed and utilized with the aid of a systematic instrument for the evaluation of guidelines (DELBI).

All patients with chronic liver disease should undergo ultrasonography every six months for the early detection of HCC. Measurement of the alphafetoprotein (AFP) concentration is not obligatory, as this test is relatively insensitive when used for early detection. If ultrasonography reveals a mass, a tomographic imaging study with contrast should be obtained; the latter may reveal a characteristic pattern of contrast enhancement that can be accepted as definitive evidence of HCC. Fine-needle biopsy has a sensitivity and specificity of over 90% for the diagnosis of HCC. Any patient in whom HCC has been diagnosed should be referred to a center where potentially curative treatments (surgery, transplantation, local ablation) can be considered. Radiofrequency ablation (RFA) is now performed instead of percutaneous ethanol instillation. For patients with advanced tumors, sorafenib should only be offered to those in Child-Pugh stage A. This drug has been found to prolong mean overall survival from 7.9 to 10.7 months.

HCC poses particular diagnostic and therapeutic challenges that are best met with an interdisciplinary management approach.