How is hepatocellular carcinoma (HCC) treated?

Updated: Jan 31, 2021
  • Author: Luca Cicalese, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Management of hepatocellular carcinoma (HCC) is best performed in a multidisciplinary setting. Patients should be cooperatively managed by hepatologists, transplant and hepatobiliary surgeons, medical oncologists, interventional radiologists, and palliative care specialists. Specifically, this is crucial to ensure that patients who are candidates for liver transplantation are referred in a timely manner, while their tumors are within the Milan criteria. [38]

Treatment options for hepatocellular carcinoma depend on the following [49] :

  • Size, number, and location of tumors
  • Presence or absence of cirrhosis
  • Operative risk based on extent of cirrhosis and comorbid diseases
  • Overall performance status
  • Portal vein patency
  • Presence or absence of metastatic disease

Before instituting definitive therapy, it is best to treat the complications of cirrhosis, as follows:

  • Sodium restriciton, diuretics, and paracentesis for  ascites
  • Lactulose for encephalopathy
  • Ursodiol for pruritus
  • Sclerosis or banding for variceal bleeding

Surgical resection and liver transplantation provide the only chances of cure but have limited applicability. The main prognostic factors for resectability are tumor size and liver function. Only about 5% of hepatocellular carcinoma patients are suitable for transplantation; these patients may have a 5-year survival of greater than 75% with tumor recurrence rates as low as 15% at 5 years. [50]  

Thus, other treatments should be used to bridge patients to transplant or to delay recurrence if possible; these include resection; radiofrequency ablation (RFA); and, potentially, systemic therapy with sorafenib (or, if sorafenib fails, with regorafenib, nivolumab, lenvatinib, pembrolizumab, cabozantinib, or ramucirumab). In patients who experience a recurrence following resection or transplantation, aggressive surgical treatment appears to be associated with the best possible outcome. [51]

See also Hepatocellular Carcinoma Treatment Protocols.

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