Clinical Outcomes for Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma (HCC) patients with >3 cm and/or multiple lesions can only expect a prolonged survival if they are eligible for a surgical treatment, e.g., resection or liver transplantation. Liver transplantation is the best option as it cures both the HCC and the underlying disease and is therefore associated with a better disease-free survival than resection. Yet, liver transplantation is selectively indicated because of graft shortage and is being offered to a limited number of patients with the best oncological prognosis, those entering the Milan criteria. Liver resection in the setting of chronic liver disease is a risky procedure, which calls for a stringent selection and preparation of the patients before surgery. Besides the stage of the tumor, the selection process is mainly based on the evaluation of the liver function reserve and the liver volume. When the patients are not good candidates for a surgical treatment, transarterial chemoembolization (TACE) is the treatment of choice. Because TACE is associated with a longer survival than symptomatic treatment in palliative cares, TACE has been used as a neoadjuvant treatment before surgery in order to reduce the recurrence rate. To date, no data support its use prior to surgery in patients deemed resectable up-front, but by downsizing the tumor in good responders, nonresectable patients may become resectable. In patients with a borderline liver function, portal vein embolization (PVE) is used to increase the future liver remnant volume without compromising the prognosis. Although there is some theoretical reason to use PVE cautiously in HCC patients, published data indicates that PVE offers an extension of the indication of liver resection for HCC. Finally, to counterbalance the potential side effects of PVE in the setting of HCC, it was thought to use a sequential arterioportal approach as both procedures may be synergistic. TACE may enhance the impact of PVE on regeneration and PVE may enhance the anticancer effect of TACE. There are very few series evaluating this sequence and none are prospective but, to date, it seems to be the best preoperative option before liver resection in HCC patients.