Chapter 088. Hepatocellular Carcinoma (Part 6) Hepatocellular Carcinoma: Treatment Most HCC patients have two liver diseases, cirrhosis and HCC, each of which is an independent cause of death. The presence of cirrhosis usually places constraints on resection surgery, ablative therapies, and chemotherapy. Thus patient assessment and treatment planning have to take the severity of the nonmalignant liver disease into account. The clinical management choices for HCC can be complex (Fig. 88-1). The natural history of HCC is highly variable. Patients presenting with advanced tumors (vascular invasion, symptoms, extrahepatic spread) have a median survival of ~4 months, with or without treatment. Treatment results from the literature are difficult to interpret. Survival is not always a measure of the efficacy of therapy because of the adverse effects on survival of the underlying liver disease. A multidisciplinary team, including a hepatologist, interventional radiologist, surgical oncologist, transplant surgeon, and medical oncologist, is important for the comprehensive management of HCC patients. Figure 88-1 Treatment approach to patients with hepatocellular carcinoma. The initial clinical evaluation is aimed at assessing the extent of the tumor and the underlying functional compromise of the liver by cirrhosis. Patients are classified as having resectable disease, unresectable disease, or as transplantation candidate s. Abbreviations: OLTX, orthotopic liver transplantation; TACE, transarterial chemoembolization; PEI, percutaneous ethanol injection; RFA, radiofrequency ablation; LN, lymph node. Child's A/B/C refers to the Child- Pugh classification of liver failure. Stages I and II HCC Early-stage tumors are successfully treated using various techniques, including surgical resection, local ablation (thermal or radiofrequency), and local injection therapies (ethanol or acetic acid). Because the majority of patients with HCC suffer from a field defect in the cirrhotic liver, they are at risk for subsequent multiple primary liver tumors. Many will also have significant underlying liver disease and may not tolerate major surgical loss of hepatic parenchyma; they may be eligible for orthotopic liver transplant (OLTX) in the future. An important principle in treating early-stage HCC is to use liver-sparing treatments and to focus on treatment of both the tumor and the cirrhosis. Surgical Excision The risk of major hepatectomy is high (5–10% mortality) due to the underlying liver disease and the potential for liver failure. Preoperative portal vein occlusion can sometimes be performed to cause atrophy of the HCC-involved lobe and compensatory hypertrophy of the noninvolved liver, permitting safer resection. Intraoperative ultrasound is useful for planning the surgical approach. In cirrhotic patients, any major liver surgery can result in liver failure. The Child- Pugh classification of liver failure (Chap. 295) is a reliable prognosticator for tolerance of hepatic surgery, and only Child A patients should be considered for surgical resection. Child B and C patients with stages I and II HCC should be referred for OLTX if appropriate, as should patients with ascites or a recent history of variceal bleeding. Although open surgical excision is the most reliable, the patient may be better served with a laparoscopic approach to resection, using RFA or percutaneous ethanol injection (PEI). No adequate comparisons of these different techniques have been undertaken, and the choice of treatment is usually based on physician skill. Local Ablation Strategies Radiofrequency ablation (RFA) uses heat to ablate tumors. The maximum size of the probe arrays allows for a 7-cm zone of necrosis, which would be adequate for a 3- to 4-cm tumor. The heat reliably kills cells within the zone of necrosis. Treatment of tumors close to the main portal pedicles can lead to bile duct injury and obstruction. This limits the tumors that are anatomically suited for this technique. RFA can be performed percutaneously with CT or ultrasound guidance, or by laparoscopy with ultrasound guidance. . Chapter 088. Hepatocellular Carcinoma (Part 6) Hepatocellular Carcinoma: Treatment Most HCC patients have two liver diseases,. management of HCC patients. Figure 88-1 Treatment approach to patients with hepatocellular carcinoma. The initial clinical evaluation is aimed at assessing the extent of the tumor