Abstract
Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and its mortality is third among all solid tumors, behind carcinomas of the lung and the colon. Despite continuous advancements in the management of this disease, the prognosis for HCC remains inferior compared to other tumor entities. While orthotopic liver transplantation (OLT) and surgical resection are the only two curative treatment options, OLT remains the best treatment strategy as it not only removes the tumor but cures the underlying liver disease. As the applicability of OLT is nowadays limited by organ shortage, major liver resections—even in patients with underlying chronic liver disease—are adopted increasingly into clinical practice. Against the background of the oftentimes present chronical liver disease, locoregional therapies have also gained increasing significance. These strategies range from radiofrequency ablation and trans-arterial chemoembolization to selective internal radiation therapy and are employed in both curative and palliative intent, individually, as a bridging to transplant or in combination with liver resection. The choice of the appropriate treatment, or combination of treatments, should consider the tumor stage, the function of the remaining liver parenchyma, the future liver remnant volume and the patient’s general condition. This review aims to address the topic of multimodal treatment strategies in HCC, highlighting a multidisciplinary treatment approach to further improve outcome in these patients.
Highlights
Liver cancer is currently estimated to be the sixth most commonly diagnosed cancer and the fourth leading cause of cancer-related deaths worldwide, accounting for 841,000 new cases and 782,000 deaths annually [1]
Some 90% of all Hepatocellular carcinoma (HCC) have a known underlying etiology, first and foremost, viral cirrhosis [4], but a major shift in the spectrum of etiology is predicted for the decades, with a declining burden of chronic hepatitis C disease due to widespread introduction of modern direct-acting antiviral drugs and a rise of non-alcoholic fatty liver disease (NAFLD)-associated carcinomas related to the worldwide obesity epidemic [5]
While the Barcelona Clinic Liver Cancer (BCLC) classification constitutes a milestone in clinical decision-making, nowadays, the traditional BCLC stage-based therapy boundaries have blurred; liver resection (LR) is applied in advanced HCC, trans-arterial therapies can aid bridging of early tumors, while new ablative strategies are employed in the treatment of larger HCCs with good results [10,11]
Summary
Liver cancer is currently estimated to be the sixth most commonly diagnosed cancer and the fourth leading cause of cancer-related deaths worldwide, accounting for 841,000 new cases and 782,000 deaths annually [1]. The majority of HCC diagnoses are made at tumor stages that are beyond curative treatment, with palliative care as the only remaining option [6]. While the BCLC classification constitutes a milestone in clinical decision-making, nowadays, the traditional BCLC stage-based therapy boundaries have blurred; LR is applied in advanced HCC, trans-arterial therapies can aid bridging of early tumors, while new ablative strategies are employed in the treatment of larger HCCs with good results [10,11]. The biology of HCC with underlying liver disease necessitates a multidisciplinary cooperation and individual patient evaluation to achieve maximal oncological radicality without significantly compromising liver function. This review aims to illustrate the scope of state-of-the-art treatments and treatment combinations for HCC, with a strong clinical focus on emerging multimodal and multidisciplinary therapies
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