Gastroenterology

Gastroenterology

Volume 122, Issue 6, May 2002, Pages 1609-1619
Gastroenterology

Hepatocellular carcinoma: Diagnosis and treatment

https://doi.org/10.1053/gast.2002.33411Get rights and content

Abstract

Hepatocellular carcinoma is the most frequent primary malignancy of the liver and appears to be rising in incidence in the United States and other developed westerm countries. Imaging studies play a key role in diagnosis of hepatocellular carcinoma, and more and more commonly, patients are being diagnosed at an asymptomatic stage. The use of triphasic computed tomography scanning and improved magnetic resonance imaging equipment and protocols has led to greater sensitivity and specificity for these techniques in diagnosis of hepatocellular carcinoma. Accurate staging of hepatocellular carcinoma is important in determining prognosis and in helping decide the best treatment for each patient. No one staging system appears optimal, but important factors to be considered are the size of the tumor, severity of underlying liver disease, and the functional status of the patient. Liver transplantation has grown in importance as a treatment for hepatocellular carcinoma but may be limited by availability of donor organs and long waiting times. This situation may be improved by greater use of living donor liver transplantation. Hepatic resection remains an important treatment modality for hepatocellular carcinoma, particularly in the absence of cirrhosis. Tumor ablation by alcohol injection or radiofrequency ablation is associated with favorable outcomes and may be considered a potentially curative treatment. Early diagnosis of hepatocellular carcinoma remains a key goal in improving the poor prognosis of this form of liver cancer. Identifying hepatocellular carcinoma at an early stage is often associated with having better treatment options for patients with small, asymptomatic tumors.

GASTROENTEROLOGY 2002;122:1609-1619

Section snippets

Clinical features

The classic clinical features of HCC include right upper quadrant pain and weight loss. Other clinical scenarios that suggest this diagnosis include worsening liver function in a patient known to have cirrhosis, acute abdominal catastrophe from rupture of a liver tumor with intra-abdominal bleeding, and some rare extrahepatic manifestations. More and more commonly though, patients are being diagnosed with HCC at an asymptomatic stage while they are being evaluated for liver transplantation or

Staging of HCC

After making the diagnosis of HCC, the next step in the management of the patient is staging. The goal of cancer staging is to separate patients into different groups based on their predicted survival to help determine the most appropriate treatment modality. Patients within a particular stage should have a homogenous survival that is clearly different from the survival in other stages. HCC is different from other cancers because survival is not predominantly based on biology of the tumor, but

Liver transplantation

OLT is theoretically the best treatment for HCC because it results in the widest possible resection margins for the cancer, removes the remaining liver tissue that is at risk for the development of de novo cancer, and restores hepatic function. Unfortunately, the limited availability of donor organs with the resulting delay to transplantation makes OLT less effective and less available to individual patients. Living donor transplantation eliminates many of these obstacles if the patient has a

Hepatic resection

Liver resection treats HCC by surgically removing the portion of the liver involved with cancer. It is second only to transplantation in its ability to effectively eliminate the cancer, but has the disadvantage of not eliminating remaining portions of the liver at risk for malignant transformation and neither does it improve hepatic function. For patients without cirrhosis who have technically resectable cancers and no evidence of vascular invasion or spread outside of the liver, resection is

Summary and conclusions

HCC remains a major problem worldwide and appears to be increasing in developed Western countries. Recent advances in diagnosis include the use of 3-phase spiral CT scanning and progress in the use of magnetic resonance imaging. Better imaging has allowed more frequent diagnosis of HCC when tumors are still small. Smaller tumors are more amenable to potentially curative treatments, such as resection, ablation, and liver transplantation. Liver transplantation has become established as an

References (54)

  • HB El-Serag et al.

    Rising incidence of hepatocellular carcinoma in the United States

    N Engl J Med

    (1999)
  • F Trevisani et al.

    Clinical and pathologic features of hepatocellular carcinoma in young and older Italian patients

    Cancer

    (1996)
  • GA Krinsky et al.

    Dysplastic nodules and hepatocellular carcinoma: sensitivity of digital subtraction hepatic arteriography with whole liver explant correlation

    J Comput Assist Tomogr

    (2000)
  • WJ Miller et al.

    Malignancies in patients with cirrhosis: CT sensitivity and specificity in 200 consecutive transplant patients

    Radiology

    (1994)
  • GA. Krinsky

    Hepatocellular carcinoma and dysplastic nodules in patients with cirrhosis: prospective diagnosis with MR imaging and explantation correlation

    Radiology

    (2001)
  • J Collier et al.

    Screening for hepatocellular carcinoma

    Hepatology

    (1998)
  • Y Sato et al.

    Early recognition of hepatocellular carcinoma based on altered profiles of alpha-fetoprotein

    N Engl J Med

    (1993)
  • E Longchampt et al.

    Accuracy of cytology vs. microbiopsy for the diagnosis of well-differentiated hepatocellular carcinoma and macroregenerative nodule. Definition of standardized criteria from a study of 100 cases

    Acta Cytol

    (2000)
  • L Sobin et al.

    TMN classification of malignant tumours

  • JM Llovet et al.

    Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastasis classification does not have prognostic power

    Hepatology

    (1998)
  • JW Marsh et al.

    Is the pathologic TNM staging system for patients with hepatoma predictive of outcome?

    Cancer

    (2000)
  • V Mazzaferro et al.

    Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

    N Engl J Med

    (1996)
  • K Okuda et al.

    Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients

    Cancer

    (1985)
  • JM Llovet et al.

    Prognosis of hepatocellular carcinoma: the BCLC staging classification

    Semin Liver Dis

    (1999)
  • F Farinati et al.

    How should patients with hepatocellular carcinoma be staged? Validation of a new prognostic system

    Cancer

    (2000)
  • JM Llovet et al.

    Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials

    Hepatology

    (1999)
  • CLIP investigators

    A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients: the Cancer of the Liver Italian Program (CLIP) investigators

    Hepatology

    (1998)
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    Address requests for reprints to: Adrian M. Di Bisceglie, M.D., Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University School of Medicine, 3635 Vista Avenue, St. Louis, Missouri 63110.

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