Updated 20 January 2006
The diagnosis of HCC is considered in a patient with a liver lesion more than 2 cm in size. Additional factors increasing the index of suspicion for HCC are an elevated alpha-fetoprotein, background of chronic hepatitis B or C infection, hemochromatosis, Wilson's disease, or alcoholic cirrhosis. Imaging studies should include an ultrasound and triphasic CT scan. Fine needle aspiration should not be carried out, for in many patients the decision to operate is based upon the clinical scenario and imaging studies. Patients with suspected HCC should be referred to a surgeon with expertise in hepatic resection, prior to fine needle aspiration.
Resection is potentially curative. Resectability will depend on size, number of lesions and their location, vascular invasion, and assessment of liver function. Resection may be possible in selected cases, even in the presence of cirrhosis. These patients, therefore, should be managed by a team familiar with this procedure and the potential complications. A properly planned resection should be accomplished with a low morbidity and mortality rate. Fibrolamellar hepatoma, a variant that is seen in young Caucasian patients, has a more indolent course and should be aggressively managed in a tertiary referral centre.
Multiple primary lesions and very large HCC involving both lobes are seldom resectable and are seldom treatable by transplantation. Unresectable or recurrent lesions can be considered for a number of palliative approaches including chemoembolization. alcohol injection, and radiofrequency ablation. On occasion, small primary lesions are managed by alcohol injection alone, in conjunction with close clinical follow-up. Some but not all of these local therapies are appropriate for patients who are poor surgical candidates. These techniques require expertise and patients should be referred to an appropriate centre.
Palliative systemic therapy with doxorubicin (Adriamycin) has been considered a standard of therapy with response rates of 10 to 20 % with usually partial responses, but with no evidence for survival benefit. As doxorubicin is metabolized by the liver, the dose needs to be reduced or discontinued with rising bilirubin levels and liver dysfunction. Single agent 5-flurouracil, capecitabine or gemcitabine may be better tolerated in such a situation but still with low objective response rates. Combination chemotherapy regimens results in higher response rates but at increased toxicities and unproven survival benefits, and are not usually recommended. Newer agents such as bevacizumab (Avastin), a monoclonal antibody against vascular endothelial growth factor (VEGF), or Thalidomide (an immune modifier or angiogenesis inhibitor) used alone or in combination with chemotherapy remain experimental.
Recent studies have suggested standard imaging studies such as CT may underestimate the pathologic responses to chemotherapy in patients who subsequently have surgical resections and have pathologic complete response. However the role of neoadjuvant systemic chemotherapy or even chemoembolization to "downstage" unresectable liver cancers remains to be further studied. When available, fit patients should be considered for clinical trials testing new therapeutic modalities or drugs. Discussion with a member of the GI Systemic Working Group may be helpful.
Radiotherapy is generally not used to treat hepatomas or other liver tumours. However, conformal radiation therapy is currently being evaluated. Palliative radiotherapy for painful bone or other metastases may be helpful.