Treatment Options

 

Surgery

Liver resection or transplantation offers the best chance of 5-year survival for carefully selected patients with HCC. Resection is usually reserved for patients with solitary HCCs without satellite lesions or major vascular invasion who have either no cirrhosis or Child class A cirrhosis with adequate hepatic functional reserve. In modern series reporting as-treated (as opposed to intent-to-treat) analyses, the 5-year survival rate among such patients approaches 50%, with perioperative mortality rates of less than 5%.Recurrences can occur locally (because of understaging of the primary lesion), metachronously (because of persistence of the carcinogenic injury within the residual liver), or distantly.

 

Liver transplantation can offer excellent outcomes (5-year survival rate of 70%) for patients with cirrhosis and inadequate functional reserve who satisfy the original Milan criteria (a single HCC ≤5 cm in diameter or up to three nodules £3 cm each).The high survival rates have led some to advocate expanding the Milan criteria to include additional patients; however, from an intention-to-treat perspective, doing so would lead to declines in overall survival rates as patients drop off the waiting list because of death or disease progression. Adjuvant therapies during the waiting period have not affected outcome. Moreover, the demand for livers for transplantation has already outstripped their availability.Living-donor transplantation is an option for some patients and has the potential to offset the imbalance between the supply and demand.

 

 

Radiation Therapy

Advances in the ability to quantify the radiation tolerance of the liver and parallel advances in diagnostic imaging, radiation therapy planning, techniques to account for the respiratory motion of the liver, techniques to target liver tumors by using image-guided therapy, and the increasing availability of stereotactic and charged-particle therapy have allowed the doses of focal radiation therapy to liver tumors to be escalated without increasing toxicity. This improved ability to deliver tumoricidal doses of radiation without increased toxicity has led to a resurgence of interest in using radiation therapy for the curative treatment of HCC, especially for tumors that cannot be resected and are not suitable for traditional liver-directed therapies.