Reviews and PerspectivesReviews in Basic and Clinical Gastroenterology and HepatologyEvidence-Based Diagnosis, Staging, and Treatment of Patients With Hepatocellular Carcinoma
Section snippets
Identification of Patients at Risk
The most significant risk factor for HCC is cirrhosis. Not all patients with cirrhosis are at equal risk for HCC, and HCC is not always found in patients with cirrhosis. There are no reliable data on the incidence of HCC in patients without cirrhosis. In addition to cirrhosis, other factors associated with increased risk include male sex, older age, persistent increase in alanine aminotransferase level, increased α-fetoprotein (AFP) level, and progressive impairment of liver function.9 However,
Diagnosis
Patients can be diagnosed with HCC based on imaging or biopsy analyses. The specific imaging patterns observed by magnetic resonance imaging or computed tomography analyses in nodules >10 mm in cirrhotic livers or livers of patients at high risk for HCC are intense uptake of contrast during the arterial phase followed by contrast washout in the venous or delayed phases.9, 43, 64, 65, 66, 67, 68 HCCs contain mostly arterial blood and are therefore brighter during the arterial phase than the
Staging
The Barcelona Clinic Liver Cancer (BCLC) system has been widely validated and is the most commonly used staging system for HCC (Figure 2).79, 80, 81, 82 It determines cancer stage and patient prognosis based on tumor burden, severity of liver disease, and the patient’s performance status. Very early and early-stage HCC (BCLC 0 or BCLC A) include patients with a solitary lesion or up to 3 nodules ≤3 cm (without macrovascular invasion or extrahepatic spread) with preserved liver function.
Molecular Markers of Risk, Diagnosis, and Determination of Prognosis and Treatment
Recent insights into mechanisms of HCC pathogenesis as well as studies of large sets of tumors and patients have identified factors that might be used in determining patients’ risk of HCC, their prognosis, or the best treatment. However, translation of findings from studies of cells and experimental models requires clinical trials. Most analyses have been based on retrospective studies of tumor and patient samples from tissue banks. Clinical information has been limited and does not incorporate
Treatment
The end point of treatment is to increase survival. Treatments should not be offered because they are technically possible.102 Treatment indications have been refined, and if patients are not candidates for first-line therapy as per stage, they can be given the treatment for a more advanced-stage tumor (treatment stage migration; see Figure 3).82
Radioembolization
Radioembolization is the intra-arterial injection of microspheres loaded with yttrium-90, a pure β-emitter with a short half-life (2.67 days) and a limited capacity to penetrate tissues (mean depth of penetration of 2.5 mm; maximum of 11 mm). Two types of yttrium-90 microspheres are commercially available: glass (TheraSphere; BTG, London, United Kingdom) and resin microspheres (SIR-Spheres; Sirtex SIR-Spheres Pty Ltd, Sidney, Australia).188 The efficacy of radioembolization has been assessed in
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Conflicts of interest The authors disclose the following: Morris Sherman has received consulting honoraria from Bayer, Daichii Sankyo, Merck, and Celsion. Jordi Bruix has consulted for for Gilead, Abbvie, Kowa, Bayer, BTG, Arqule, Terumo, BMS, Boehringer Ingelheim, Kowa, Novartis, OSI, Roche and Onxeo. Maria Reig has received consulting honorari from Bayer.
Funding CIBEREHD is supported by the Instituto de Salud Carlos III. J.B. and M.R. are supported by a grant from the Instituto de Salud Carlos III (PI14/00962 and PI15/00145). J.B. from AECC PI044031.