Multidisciplinary Management of Hepatocellular Carcinoma

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Hepatocellular carcinoma is a challenging disease to treat because of its association with cirrhosis, variable biologic behavior, and variable morphology and because of the variations in local expertise and resources available. The expertise of multiple specialties is required for optimal treatment, which must be individualized. Multidisciplinary and multimodality approaches can be successful for converting patients with unresectable disease into surgical candidates and can stabilize disease as patients await liver transplantation. Regional and local ablation treatment strategies provide effective palliation and possibly prolong survival in nonsurgical candidates, with novel combinations of therapies showing promising results. Interventional radiologists can and should play a lead role in the multidisciplinary management of this disease and in the development of future treatment strategies.

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CHALLENGE OF HCC

Many factors contribute to the difficulty in treating HCC. First, the presence and degree of co-existing cirrhosis are variables that affect all potential treatment options. Liver function in patients with HCC may be anywhere in the spectrum from normal to severely decompensated. Cirrhosis is present in up to 90% of all HCC cases (4, 5). In the United States, the percentage of HCC patients with Child-Pugh C cirrhosis varied from 4% in a series of patients selected for surgery to 47% in

MULTIDISCIPLINARY APPROACHES TO RESECTION AND TRANSPLANTATION

In general, surgical management (resection or transplantation) is considered the ideal treatment for HCC. Advances in surgical technique and perioperative care have decreased operative morbidity and mortality, even in patients with cirrhosis (10). With proper patient selection, postresection 5-year survival rates of at least 35% have been reported (11). After resection, however, the remaining cirrhotic liver is at high risk for the subsequent development of HCC. Seventy percent of patients

NONSURGICAL TREATMENT OPTIONS

Although multidisciplinary approaches to HCC can improve outcomes for resection and OLT, most patients are unsuitable for surgical therapies at presentation owing to tumor stage, degree of cirrhosis, or both. Therefore, nonsurgical therapies play a central role in this disease (21).

Regional and local ablation techniques are detailed elsewhere in this supplement. Percutaneous ethanol injection (PEI) has a well-documented role in the treatment of small HCC, with results that compare favorably

MULTIDISCIPLINARY CARE OF THE PATIENT WITH HCC

As seen earlier, the integration of multiple therapies has allowed more HCC patients to be treated with transplantation or resection by achieving greater response rates. The choice and sequence of therapies must be individualized with the dual goals of preservation of liver function and maximal tumor response in this patient population with varying degrees of compromised liver function. The invasive therapies must then be melded with preventative approaches, antiviral therapy, surveillance,

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    Neither author has identified a conflict of interest.

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