Medical Management of Hepatocellular Carcinoma

The possibility of effective treatment of hepatocellular carcinoma (HCC), one of the most common cancers worldwide, largely depends on its detection at an early stage before symptoms develop. Screening patients with known cirrhosis, in whom the overall annual incidence of HCC development is of the order of 1–6% (1 ,2 ), has the potential to improve the detection rate of such asymptomatic tumors. Such an approach is limited, however, by the fact that cirrhosis is unrecognized prior to presentation with HCC in up to two-thirds of patients in areas with a high incidence of this tumor, such as Asia, and in nearly half of those from low-incidence areas, such as the United Kingdom (3 ,4 ). Furthermore, the sensitivity of commonly employed screening tools, such as the serum α-fetoprotein (AFP) level and hepatic ultrasonography, is suboptimal for detecting small tumors (5 ). In addition, HCC may arise in noncirrhotic patients with chronic hepatitis or carriage of hepatitis B virus in the absence of histological abnormality (6 ,7 ). The fibrolamellar variant, which does not produce AFP, also arises in an otherwise normal liver and would not, therefore, be detected by conventional screening programs. Consequently, most patients continue to present with large HCCs that are not amenable to either of the potentially curative surgical options of resection or orthotopic liver transplantation (OLT). Resection is also precluded when lesions, even if small, are sited in an anatomically unsuitable central position or if hepatic functiona