RECENT MODALITIES IN SURGICAL MANAGEMENT OF HEPATOCELLULAR CARCINOMA (HCC)

Abstract

HCC is a difficult to treat and extremely complex malignant disease. Epidemiological data confirms an increasing number of new cases each year and this rise will persist due to the burden linked to HCV and obesity. The anatomy of the liver, particularly the rich network of intrahepatic vascular structures draining into the hepatic veins, allows easy intrahepatic and extrahepatic tumour progression. The scenario of locally advanced tumour development within a compromised yet vital organ has implications for all aspects of management, including diagnosis, staging and treatment. Since the number of new HCC cases being diagnosed each year is nearly equal to the number of deaths from this cancer, it is clear that the international scientific community and healthcare systems worldwide have no efficient answer to HCC. There are marked differences between countries in providing disparate quality of healthcare considering screening and surveillance programs; available treatment modalities and drugs; reimbursement of specific treatment options by the state-funded health insurance. In many countries, worldwide liver transplantation is not a therapeutic option. In countries with national LT program, the donor pool is a serious obstacle for treating more patients. Surveillance programs, so essential for the diagnosing an early stage HCC, are lacking in many countries. The experiencefrom Japan clearly confirms importance of a successful surveillance program. The only treatments currently with a recognized role for curative management are resection and liver transplantation. These are inapplicable for most patients, owing to the inability to leave a functional remnant of liver (resection) and the shortage of donor livers (transplantation). Unfortunately, both procedures are associated with high intrahepatic and/or extrahepatic relapses. Liver resection and TACE are the two treatment modalities offered to HCC patients even in underdeveloped countries. Since treatment allocation should be decided by a multidisciplinary board involving hematologists, pathologists, radiologists, liver surgeons and oncologists guided by individualized-based medicine, HCC patients should be managed in high-volume, tertiary, university centers. This approach is important to achieve the best possible outcome from a variety of potentially useful therapies and for research purposes. Different combination therapies tested in various studies failed to demonstrate a real benefit in terms of overall survival. This is mainly due to the complexity of the disease and due to the extremely heterogeneous patient populations included in clinical trials. The consensus conference on LT for HCC has shown that many controversies remained unanswered due to the lack of evidence. Therefore, high-quality randomized trials with better patient stratification are mandatory in the future to find patient populations that can benefit from certain treatment modalities. Basic research in HCC carcinogenesis is equally important. Combinations of different treatment modalities should be more exploited in order to improve survival and the quality of life of HCC patients. In the management of HCC patients, several recommendations are important: (1) to establish a national surveillance program in as many countries as possible;(2) to further improve treatment modalities for patients on the waiting list for LT;(3) to improve the safety of liver resection and to reduce the recurrence rates following resection;(4) to investigate further and to upgrade results of the TACE treatment modality;(5) to continue research on novel molecular therapies; and (6) to continue research on novel molecular markers for better patient selection for various treatment modalities.