Locoregional management of hepatocellular carcinoma: Surgical and ablation therapies

The selection of an appropriate treatment strategy for patients with HCC depends on careful tumor staging and assessment of the underlying liver disease (Fig. 5). All patients with localized HCC (involvement of one single lobe, no vascular invasion or extrahepatic disease) should be evaluated for the potentially curative therapeutic options of partial hepatectomy or OLT. Candidates for partial hepatectomy must have no liver disease or Child's A cirrhosis, normal portal pressure, and normal serum bilirubin. For patients not meeting these criteria, OLT should be considered if there is a solitary lesion smaller than 5 cm in diameter or fewer than three lesions smaller than 3 cm. Local ablative therapies such as PEI, RFA, and TACE offer palliation for patients for whom surgical approaches are contraindicated. Percutaneous alcohol injection and RFA are minimally invasive and can be used on an outpatient basis, usually for tumor nodules smaller than 3 cm. When these therapies are used for small tumors, the survival rates can be similar to those achieved by partial hepatectomy. Transcatheter arterial chemoembolization may be used as an interim treatment for patients waiting for OLT. Although TACE is often used for the palliation of large tumors, significant survival benefits have not yet been demonstrated for this indication.