Hepatocellular carcinoma: a review

Abstract

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and is a leading cause of cancer-related death worldwide. In the United States, HCC is the ninth leading cause of cancer deaths. Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, incidence and mortality continue to rise. Cirrhosis remains the most important risk factor for the development of HCC regardless of etiology. Hepatitis B and C are independent risk factors for the development of cirrhosis. Alcohol consumption remains an important additional risk factor in the United States as alcohol abuse is five times higher than hepatitis C. Diagnosis is confirmed without pathologic confirmation. Screening includes both radiologic tests, such as ultrasound, computerized tomography, and magnetic resonance imaging, and serological markers such as α-fetoprotein at 6-month intervals. Multiple treatment modalities exist; however, only orthotopic liver transplantation (OLT) or surgical resection is curative. OLT is available for patients who meet or are downstaged into the Milan or University of San Francisco criteria. Additional treatment modalities include transarterial chemoembolization, radiofrequency ablation, microwave ablation, percutaneous ethanol injection, cryoablation, radiation therapy, systemic chemotherapy, and molecularly targeted therapies. Selection of a treatment modality is based on tumor size, location, extrahepatic spread, and underlying liver function. HCC is an aggressive cancer that occurs in the setting of cirrhosis and commonly presents in advanced stages. HCC can be prevented if there are appropriate measures taken, including hepatitis B virus vaccination, universal screening of blood products, use of safe injection practices, treatment and education of alcoholics and intravenous drug users, and initiation of antiviral therapy. Continued improvement in both surgical and nonsurgical approaches has demonstrated significant benefits in overall survival. While OLT remains the only curative surgical procedure, the shortage of available organs precludes this therapy for many patients with HCC.

Clinical outcomes of direct-acting antiviral therapy in patients with compensated hepatitis C virus-related cirrhosis

“…It is known that the risk of hepatocellular carcinoma increases in advanced stage of fibrosis, in patients with comorbidities such as diabetes mellitus, and in older age [17,18] . The reason why there are different outcomes in terms of cancer development depending on the treatment received could be explained by the fact that patients with more advanced liver disease and with comorbidities are now being treated with direct acting antivirals, as they were not considered suitable for interferon based therapies before due to the possibility of dangerous side effects.…”

Hepatocellular carcinoma in the setting of Interferon-free treatment for chronic HCV hepatitis - experience of a single center

“…There are several variables associated with an increased risk of developing HCC after SVR, such as advanced liver fibrosis, older age, alcohol abuse, metabolic diseases (especially diabetes mellitus) and the persistence of hepatic inflammation [18,19] . A variant in genotype 1b HCV core protein Gln70 (His 70) may also be incriminated in the increase of HCC incidence [20] .…”

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“…2,8,9 In developed countries, the rising incidence of HCC is related to high rates of alcohol consumption and obesity. 2,10 Failure to recognize groups at risk in the population or to expand social awareness about risk factors have been leading factors in the long delays in diagnosing HCC. It is well known that the more advanced stage the HCC, the fewer curative treatment options are available, the higher the costs of treatment, and the worse the survival outcomes.…”

“…1 This cancer commonly arises against a background of chronic liver disease. 2 As a result, a patient with HCC requires multidisciplinary care. Treatment options vary widely based on tumor burden and metastases.…”