Management of Hepatocellular Carcinoma: Prevention, Surveillance, Diagnosis, and Staging

More than 600 000 people die from hepatocellular carcinoma each year. Worldwide, research on the disease needs to be intensified in both the medical and pharmaceutical fields, with a focus on providing help to geographic areas where resources are limited. Treatment approaches depend on the stage of the disease at diagnosis and on access to complex treatment regimens. However, advanced disease is not curable, and treating these patients is expensive and only marginally effective for increasing quality-adjusted life-years. Although the Milan criteria are often used to determine which patients will benefit from liver transplantation, many centers have their own criteria for patient selection. According to criteria developed by Başkent University in Ankara, Turkey, patients with hepatocellular carcinoma and a cirrhotic liver but without extrahepatic disease should be candidates for liver transplant when possible, and living-donor liver transplant should be considered as an alternative rescue therapy for many of these patients. Tumor size and number should not be the sole criteria for excluding liver transplant. Although significant vascular invasion and extrahepatic dissemination definitely indicate major tumor dissemination, until sensitive tests for measuring circulating tumor cells are developed, we continue to recommend liver transplant regardless of tumor size and number. Various locoregional therapies for hepatocellular carcinoma are used before transplant to prevent tumor progression and to decrease the risk of recurrence after transplant. In turn, response to locoregional therapy to decrease tumor stage in hepatocellular carcinoma may be an indicator of tumor behavior and may determine a patient's selection for liver transplant. The delivery of healthcare services for hepatocellular carcinoma could be improved by developing centers of excellence. Concentrating medical care in this way can lead to an increased level of expertise so that resections are performed by surgeons who understand liver disease and the limitations of these and other procedures.