ETIOLOGY, SCREENING, AND TREATMENT OF HEPATOCELLULAR CARCINOMA

MANAGEMENT OF CHRONIC LIVER DISEASE

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ETIOLOGY, SCREENING, AND TREATMENT OF HEPATOCELLULAR CARCINOMA Salim I. Khakoo, MBBS, BSc, MRCP, Leonie F. L. Grellier, MBBS, BSc, MRCP, Paresh N. Soni, MMed, FCP(SA), Sattya Bhattacharya, MS, FRCS, and Geoffrey M. Dusheiko, FCP(SA), FRCP

ETIOLOGY

Hepatocellular carcinoma (HCC) is a disease of multifactorial etiology; the development of a carcinoma in a given individual is a multistep process and the result of an accumulation of risks. Fundamental to these changes are genetic alterations, resulting in uncontrolled cellular proliferation and dedifferentiation. Many factors may therefore contribute to the final common pathway of HCC. The most important predisposing factor is cirrhosis. Cirrhosis

Cirrhosis underlies the development of HCC in most, but certainly not all, cases. This has been highlighted as one of the risk factors most commonly associated with HCC.77In a Japanese population, the 3-year cumulative risk of developing HCC was 3.8% in patients with chronic hepatitis without cirrhosis but 12.5% if cirrhosis was Similar incidence rates are reported from Italy.Ix In both populations, chronic viral hepatitis was the predominant underlying cause for liver disease, and in the Japanese population it was demonstrated that the presence of either hepatitis B surface antigen (HBsAg) or antibody to hepatitis C virus (anti-HCV) were associated with a significantly higher risk of developing HCC. HCC occurs relatively rarely in primary biliary cirrhosis, autoimmune hepatitis, and Wilson’s disease. Therefore, although cirrhosis is clearly associated with the development of HCC, other cofactors are likely to be

From the University Departments of Medicine (SIK,LFLG, PNS, GMD) and Surgery (SB), Royal Free Hospital and School of Medicine, London, United Kingdom

MEDICAL CLINICS OF NORTH AMERICA

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VOLUME 80 NUMBER 5 SEPTEMBER 1996

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involved, and these may be related to increases in hepatocellular proliferation,@ which lead to the activation of oncogenes, such as rus, c-myc, c-erb-2, c - j ~ nas ’~~ well as the accumulation of genetic abnormalities. These abnormalities may occur as mutations in tumor suppressor genes (such as P53 and the retinoblastoma gene).8O Loss of heterozygosity of these alleles may lead to the cell’s possessing only an inactivated allele or mutant allele, thus forming another step in carcinogenesis. Allele losses have been documented on several chromosomes in HCC.21

Hepatitis B Virus Infection

Epidemiologic data have shown that the cause of HCC varies according to geographic region. Incidence rates for HCC are highest in areas where hepatitis B virus (HBV) infection is endemic, such as the Far East and sub-Saharan Africa, in comparison to the United States, where HBV infection is much less common.12 Two main mechanisms have been postulated to account for HBV as a direct cause in the development of HCC, independent of the increased cell turnover associated with chronic viral infection and persisting necroinflammatory damage. The first is the integration of HBV at sites within the host genome, which are critical for the control of cell cycling. Initial studies demonstrated the integration of HBV DNA into the host genome in up to 90% of HBsAg-positive patients with HCC6,l 3 It was therefore suggested that these integrated sequences might disrupt tumor suppressor genes or switch on candidate oncogenes, by disrupting their regulatory elements. No common integration site for the HBV genome, however, has been and integrated HBV DNA has not been consistently found in the vicinity of known oncogenes. Isolated case reports of HBV integration at significant sites, such as at the second intron of the cyclin A gene,14othe retinoic acid receptor gene,’35and on chromosome 17 (the chromosome on which the gene for P53 is found), have been reported, but these are exceptions. The second mechanism by which HBV may cause HCC involves transactivation of host oncogenes by either the HBx protein or a truncated protein derived from the pre-SZ/S region of the HBV genome, which may also possess transactivating activity. Both of these regions of the HBV genome have been shown to be commonly integrated into the host genome, the former predominantly truncated at the 3’ end. Research has focused on the HBx gene product. The X gene product is a transcriptional transactivator of RNA polymerase I1 and 111 promoters, but this activity does not seem to require the 11 carboxyl terminal amino acid residues of the molecule.11oBecause the X gene product lacks intrinsic DNA binding activity? *5 it has been suggested that it interacts with cellular transcription machinery, via activation of cellular kinases. As such, it has been shown to activate the proto-oncogenes c-fos and c - j ~ n ” ~this ; activation may occur via a Ha-rus-dependent and Raf-1-dependent signal transduction pathway.86Furthermore, messenger RNA from the HBx gene has been shown to accumulate preferentially in tumorous tissue in HCC from patients negative for HBsAg but whose genome contains integrated HBV sequences.1ozFurther interest in the role of the HBx protein has been stimulated by the finding that it can bind to the P53 tumor suppressor gene.Io2Thus, the cause of HCC in HBsAgpositive patients could be a combination of processes generalized to chronic liver disease and those specific for HBV infection; however, despite epidemiologic and molecular evidence implicating HBV as a directly oncogenic virus, this is currently far from proven.

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Hepatitis C Virus Infection

HCC is commonly associated with hepatitis C virus (HCV) infection. The proportion of cases of HCC associated with HCV infection is essentially geographically determined and dependent on the local incidence of HCV infection, ranging from 75% in Spain9 to less than 20% in the United States.134In Japan, where incidence rates of chronic HBV and chronic HCV infection are similar, the incidence of HCC was higher in patients with chronic HCV than in those with chronic HBV infection (10.4% versus 3.9%).125 The pathogenesis of HCV-associated HCC is at present unclear but may be due to the hepatocellular regenerative activity seen in long-term chronic infection. Molecular mechanisms whereby HCV has a direct oncogenic role are hard to postulate because the virus does not integrate into the host genome and is not known to exert any effects on host cellular control. In a series of 13 cases of HCC in HCV RNA-positive, noncirrhotic livers, 4 had detectable HBV in the livers and 2 others were positive for anti-HBc, despite being HBsAg-negative.ls The possible role of HBV coinfection in other cases of HCV-related HCC is demonstrated by the high prevalence of past or active HBV infection in these patients in the South African (75%) and Japanese (82%) populations.125Alcohol ingestion may be another co-factor in HCC development; in a Japanese cohort, the cumulative 10-year rate of HCC development in patients with well-established cirrhosis was 19% in alcoholics, 57% in patients with chronic HCV infection, and 81% in alcoholic patients with chronic HCV infe~ti0n.I~~ Genetic Hemochromatosis

The incidence of HCC in this condition has been calculated to be as high as with a relative risk of greater than 200 for its development in patients with cirrhosis.88Although HCC in genetic hemochromatosis is strongly linked to the development of cirrhosis, cirrhosis per se is not an absolute prerequisite, and HCC can rarely develop on the background of a fibrotic, noncirrhotic l i ~ e r . 6 ~ Attention has focused on iron-free foci in the liver as being sites for HCC development. In a study of 185 hemochromatosis patients, such foci were found in 14 (7.6%) patients, and in 10, dysplastic changes were seen in the liver. Twelve patients with iron-free foci were followed up, and HCC developed in 6, as compared to 2 out of 24 matched control patients.zoThe pathogenesis may be related directly to iron, although a link with alcoholism has also been

Other Metabolic Disorders

Although these causes of HCC are rare in comparison with chronic viral hepatitis, individuals affected by the following disorders do have a significant risk of developing HCC. Glycogen storage disease type 1 is associated with a particularly high incidence of hepatic adenomas and subsequent carcinomas in patients surviving into adulthood, even in those adequately treated with appropriate dietary therapy.68Interestingly, these tumors are not associated with hepatic cirrhosis, and endocrine or metabolic mechanisms for tumor development have been postulated. Hereditary tyrosinemia caused by fumarylacetoacetate hydrolase deficiency

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is a severe life-threatening condition, resulting in liver failure usually within the first year of life. Those who survive have a high incidence of HCC, which may be difficult to diagnose because of the presence of macronodular cirrhosis and the high alpha-fetoprotein (AFP) levels found in this disease in the absence of HCC. HCC is associated with the porphyrias, and of this group of disorders, the closest association is with porphyria cutanea tarda. The data are confounded by the high incidence of HCV infection found in this population and its relationship to alcoholism and iron overload.33The contribution of the underlying porphyria to carcinogenesis is therefore at present unclear. Other metabolic disorders associated with the development of HCC include alpha,-antitrypsin deficiency, in which the most common association is with the PiZZ phenotype,3oWilson’s disease (although this is rare), hypercitrullinemia (again in the absence of cirrhosis), and a single case report in a man with hereditary fructose intolerance. Alcohol

Excessive alcohol ingestion may be considered a risk factor for the development of HCC in areas where HCC is relatively uncommon, and where alcoholic liver disease is a major etiologic factor in the development of cirrhosis. Although alcohol was thought to be a cofactor in the development of HCC in a cohort of vinyl chloride at present there is little further evidence that alcohol per se is carcinogenic. Epidemiologic studies do not confirm an excess of HCC in alcoholic cirrhosis compared with cirrhosis of other causes, and laboratory studies demonstrate only a cocarcinogenic role via its effect on the P-450 mixed function oxidase system, causing enhanced activation of chemical ca~cinogens,”~ the in vivo role of which is unclear. Aflatoxin B and the P53 Tumor Suppressor Gene

Aflatoxin B is a mycotoxin derived predominantly from inappropriately stored grain. Epidemiologic data point to a role of aflatoxin B in the development of HCC. Subsequent molecular studies have demonstrated a specific effect of this mycotoxin on the P53 tumor suppressor gene. This gene, located on the short arm of chromosome 17 (17p13), encodes a phosphoprotein that has a DNA-binding activity and a transcriptional transactivating function. Following exposure to DNA-damaging agents, P53 accumulates intracellularly and inhibits DNA replication and cell growth, thus allowing time for DNA repair or cytolys ~ s . ~ ~

Aflatoxin B1 is metabolized by the hepatic microsomal enzymes to a reactive intermediate AF B1-23 oxide. This selectively binds to guanine residues in cellular DNA, and the adduct these two molecules form is excised and replaced preferentially by a thymidine residue. In HCCs occurring in areas of high aflatoxin ingestion, this guanine-to-thymidine mutation is commonly found at the third base of codon 249 in the P53 tumor suppressor gene but not in 13s Furthermore, regions where food aflatoxin levels are low or undete~table.~~. susceptibility to the development of HCC in areas of high aflatoxin exposure may be genetically related to the genotype of the detoxification genes epoxide hydrolase and glutathione S-transferase Ml.7s

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SCREENING AND DIAGNOSIS

Patients with clinically apparent HCC survive for only a few weeks or months. The majority of patients present too late for effective treatment and have tumors that are unresectable, because of extensive involvement of the liver, invasion of the hepatic or portal veins, the presence of metastases, or advanced hepatocellular disease." It is possible, however, to detect small tumors by regular screening and thereby improve the prognosis. Successful treatment of HCC by liver transplantation or targeted chemotherapy depends on the identification of early disease. There has, therefore, been growing interest in the use of screening programs in presymptomatic patients who are at high risk for the development of tumor. Such patients may have better synthetic liver function, smaller tumors, and, therefore, a better prognosis.62 Studies carried out in Asia have indicated that early detection of HCC may be achievable by real-time ultrasonography and AFP meas~rement.'~~ Other studies in white patients have been disappointing and have failed to demonstrate any conclusive benefit in terms of identifying potentially resectable tumors.16,24, 103 Another variable that reduces the effectiveness of screening programs is the prevalence of silent cirrhosis in patients with HCC. In areas of the world where HCC is common because of viral hepatitis, the prevalence of silent cirrhosis within a cohort of HCC sufferers may approach 56%. Such patients are obviously missed in a screening program. To make a significant impact on early detection of HCC in these countries, better population screening for HBV and HCV must occur to reduce the number of patients with unidentified cirrhosi~.'~~ It is difficult to assess accurately the effectiveness of screening programs for HCC because adequate controlled studies using disease-specific mortality as an end point have never been performed. Follow-up of some cohorts has been short, which may introduce lead-time bias into the analysis of results. From the data available, some assumptions can be drawn about the accuracy of diagnostic tests available. The usefulness of this information when applied to a given population, however, may vary depending on geographic and ethnic differences that affect the incidence and growth characteristics of HCC. It is reasonable to screen those patients who are at highest risk. This includes men with chronic viral hepatitis of any cause and is probably most important in those with cirrhosis and macronodular nodules, which are visible on ultrasonography. There is less evidence that screening patients with cirrhosis resulting from nonviral causes has appreciable benefit. The cost of screening is high when applied to a large patient population and is further increased by investigation of non-HCC-related nodules. Alpha-Fetoprotein and Other Tumor Markers

Early detection of HCC in patients infected with viral hepatitis may be 41 Both this test and ultrasound screening, the most achieved by AFP screening.25, commonly used screening tests, however, are associated with significant falsepositive and false-negative rates. It appears from a number of studies that ultrasound is more reliable than AFP as an initial screening test. A study from Italy followed 147 patients with Child's A cirrhosis prospectively over an 8-year period. Screening was performed by 6-monthly AFP levels and ultrasound examinations. Thirty tumors were detected on follow-up by ultrasound at a time

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when AFP levels were within normal levels. The authors suggest that more frequent scanning should be performed in patients with intermediate values of AFP.17 A study conducted in North America in which 1069 chronic carriers of HBV were followed with either AFP or ultrasound for the development of HCC found that the sensitivity and specificity of a raised serum AFP of 20 pg/L was 64% and 91%. This compared to a sensitivity and specificity for ultrasound of 79% and 94?'0."~ It may be concluded from studies such as these that although ultrasound is more sensitive for detecting early lesions, missed lesions may be picked up by closely monitoring the trend in AFP levels in an individual patient together with frequent imaging. By combining AFP and ultrasound in this way, costeffectiveness may be improved. False-positive elevations in AFP levels may be found in patients with flares of viral hepatitis and may result in an invasive search for tumor tissue. Isoelectric focusing of sera from patients may identify variant forms of AFP more commonly associated with tumor. There is some evidence that variant AFP bands I11 and IV may be found with HCC as opposed to nontumorous nodules.1° Unfortunately, serum AFP levels may be normal or only modestly raised in the presence of HCC, and, therefore, alternative tumor markers are being sought. Lectin-reactive AFP and plasma urokinase-type plasminogen activator have both been proposed, but it is not clear whether the added expense of these markers lz2 Serum des-gammais reflected in an increase in sensitivity or specifi~ity.~~, carboxyprothrombin (DCP), or prothrombin induced by vitamin K absence or antagonist I1 (PIVKA-11),appears to be elevated in patients with large or multiple tumors; however, it is arguable that these tumors would be detectable on routine ultrasound screening.54

Imaging

The presence of small or large hypoechoic nodules on ultrasound scanning is associated with a higher risk of the development of tumor when compared to nonnodular cirrhotic li~ers.2~ Unfortunately the presence of such nodules may reduce the specificity of ultrasound scanning because tumorous tissue is much harder to distinguish in this setting. The sensitivity of enhanced computed tomography (CT) scanning may be poor (around 56%) in early HCC because often the tumors are isodense with respect to surrounding liver tissue and are, therefore, poorly delineated.lZ6Characteristic features of HCC on imaging are a peritumoral fibrous capsule, an intratumoral mosaic appearance, and hypervascularity; however, these features are frequently not seen in tumors smaller than 2 cm in diameter. Spiral CT scanning using intra-arterial contrast is useful in detecting hypervascular tumors and appears to increase sensitivity in tumors less than 1 cm (87%), a figure comparable or slightly better than standard contrast-enhanced magnetic resonance (MR) (64y0).~~ Lipiodal angiography followed by CT appears to be one of the most sensitive modalities available to detect small HCCS.~~,It has a sensitivity of about 93% to 97% in both Asian and white patients. Lipiodol ultrafluid is a lipid compound containing 475 mg of iodine per milliliter (38% by weight). It is derived by the iodination of poppy seed oil and has been used for many years as a lymphographic contrast medium. This is available commercially as Lipiodol

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(Laboratoire Guerbet, Aulnay-sous-Bois, France). In 1979, Nakakuma and associatesS2injected Lipiodol into the hepatic artery and demonstrated selective retention in foci of HCC. This has proven to be a sensitive technique, which can image a 2-mm HCC, and is useful in patients who are candidates for Iz7 Following intrahepatic arterial injection of the substance, a CT scan surgery.26, of the liver is performed 10 to 14 days later, when the Lipiodol has cleared from the nonneoplastic liver parenchyma but is retained by HCC. Lipiodol retention, however, can occur in cirrhosis, at the sites of previous liver or in focal nodular hyperplasia?* The precise mechanisms of Lipiodol retention remain undetermined. There is much debate as to whether Lipiodol binds specifically to a population of malignant cells, is simply embolic in the microvasculature of the tumor circulation, or fails to clear from the tumor because of a lack of Kupffer cells. The technique plays an important role in determining whether tumors are resectable or should be managed with chemotherapy and provides a vehicle for the delivery of chemotherapeutic agents such as epirubicin or radioactive iodine (1311). MR is increasingly being used to establish the diagnosis of HCC. It appears to be useful in distinguishing HCC from some tumorlike conditions such as adenomatous hyperplasia and cavernous hemangioma.y5It also appears to be superior to CT scanning as a second-line noninvasive investigation, both in terms of sensitivity and in the reduction of ionizing radiation to which the patient is exposed.lYMore invasive investigations, however, such as LipiodolCT and digital subtraction angiography may not be avoidable in patients in whom an accurate record of vascular supply and number of lesions is necessary (e.g., pretransplantation). Chondroitin sulfate iron colloid used as an MR contrast agent may improve the sensitivity of this technique further (to 92%), although paradoxically it appears to be less favorable in tumors smaller than 1 cm in diameter.52It may also be useful in assessing the degree or differentiation within a Fast low-angle shot sequences, which detect fatty metamorphosis in HCC, and iron oxide-enhanced MR imaging also appear to improve accuracy of diagn0~is.I~~ (See also the article by Rubin and Mitchell.) Biopsy

There is debate whether directed fine-needle biopsy is indicated in tumors that show the characteristic features of HCC on imaging and that are accompanied by a typical rise in serum AFP levels. There is a small but well-established risk of tumor seeding along a percutaneous needle tract.4y,'50In those tumors that show a peritumoral fibrous capsule, an intratumoral mosaic appearance, and hypervascularity, treatment arguably should be given without the need for a biopsy. In general, however, in situations in which reasonable doubt exists, ultrasound-guided or CT-guided percutaneous biopsy or, preferably, fine-needle aspiration should be carried out when a suspicious nodule is discovered. The influence of preoperative biopsy on survival remains undetermined, but fineneedle aspiration of the tumor is perhaps preferable to reduce malignant cellular dissemination along the biopsy track. It should, therefore, be avoided if a confident diagnosis can be made using other means. TREATMENT

The mainstay of therapy for HCC apparently confined to the liver is ablation of the primary tumor, either by surgical removal or by in situ destruction.

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Unfortunately, only a minority of patients present with such localized lesions, although screening programs in endemic areas have increased the proportion of treatable cases. Even with successful treatment of the primary lesion, however, only a minority of patients are cured. The options for surgical removal of HCC include partial liver resection and orthotopic liver transplantation (OLT). Both these treatment modalities have theoretic advantages and disadvantages. Before the decision about partial liver resection or liver transplantation, a complete assessment of the tumor and liver function is essential, including tumor size, multifocality, presence or absence of extrahepatic metastases, cause of liver disease, and nontumorous liver function. For staging the clinical status of patients with HCC, Okuda and colleague^^^ proposed considering tumor size, ascites, serum bilirubin level, and serum albumin level, which indirectly assess the functioning hepatic mass and the severity of the underlying cirrhosis. Clearance of indocyanine green is thought to be an indicator of reserve liver function and may predict patient survival; however, this probably offers little advantage over clinical assessment, such as the Child's clas~ification."~

Surgical Treatments Hepatic Resection

The usual treatment of choice for patients with a small asymptomatic HCC is surgical resection. Local wedge-shaped resection or segmentectomy is the operation of choice for a small HCC and offers a hope of cure.65The key appears to be to remove the tumor completely with a 1-cm resection margin, while preserving as much hepatic parenchyma as possible. Whenever feasible, surgical removal is the best treatment for patients with a larger HCC. An increasing number of patients with a small HCC have been treated at an asymptomatic stage. The incidence of small or asymptomatic lesions is highest in Japan, where successful screening programs are now established. The Liver Cancer Study Group of Japan (LCSGJ) has the largest experience in treating patients with HCC by hepatic resection.' More than 2200 patients underwent hepatic resection between 1978 and 1987 in Japan, representing 21% of all patients diagnosed. The postoperative mortality was between 2% and 11%, with an overall 3-year survival rate of 46%. The best survival results were for patients with a single tumor less than 2 cm in diameter, for whom the 5-year survival rate was 60.5%. Tumor number, infiltration of cancer cells into the fibrous capsule, portal vein invasion by the tumor, and tumor growth pattern were important factors that affected the prognosis. Overall, although recurrence rates in patients with asymptomatic tumors are disappointing, most recent series report a 1-year survival rate between 55% and 80% and a 5-year survival rate between 25% and 39%. Five-year survival rates of 67% have been reported in China, favoring the likelihood that, at least in certain patients, the tumors are unicentric and undisseminated at diagnosis.131, I5l Most surgeons report lower 5-year survival rates (loo/, to 20%) in cirrhotic patients with tumors greater than 5 cm.65,96 A number of factors limit the success of surgical resection. Resection of liver tissue in cirrhotic patients with portal hypertension presents unique difficulties, and considerable expertise and experience are required to limit perioperative rn~rtality.'~~ Surgery can be aided by intraoperative diagnostic ultrasound. The incidence of the complications of surgical resection, particularly bleeding, coagu-

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lopathy, hepatic failure, jaundice, ascites, leakage of bile, and renal dysfunction, is much higher in cirrhotic patients. Multiple additional neoplastic lesions invisible to preoperative screening have been found in up to 20% of resected specimen^.^ The tumor may arise multicentrically, and other foci in the liver are liable to malignant transformation after surgical removal of a discernible cancer. The major factors determining survival in patients who have had tumors resected are tumor recurrence and death from underlying liver dysfunction. Survival rates are usually higher in patients with smaller tumors ( 5 2 cm), negative resection margins, encapsulated tumors without intracapsular invasion of tumor cells, and sufficient hepatic functional reserve (Child’s or Ptigh class 64, 96, lm, 137 Other features that favorably influence the outcome of surgical resection include tumor location, well-differentiated histologic grade, lack of vascular invasion, and the fibrolamellar variant of HCC. Thus, the ideal candidate for hepatic resection is someone less than 65 years old, well-nourished, with Child’s class A liver status, who has an encapsulated tumor smaller than 2 cm and no portal vein infiltration. In 223 consecutive patients with HCC seen in Milan in 5 years, however, only 8% fit these selection ~riteria.’~ Adjuncts to Surgery

Measures such as the preoperative administration of Lipiodol with emulsified doxorubicin (Adriamycin), mitomycin, or cisplatin, with or without transcatheter arterial embolization (TAE) to necrose tumor before resection, may be adjuncts to surgery. Data to support this approach, however, are still awaited. Orthotopic Liver Transplantation

The major advantage of OLT is that it removes both detectable and undetectable tumor together with all the preneoplastic lesions present in the cirrhotic liver. Removal of the diseased liver also reduces the risk of morbidity and mortality from portal hypertension. Major disadvantages include the shortage of donor organs, high cost of the procedure, stringent criteria for patient selection, early mortality in HBV-infected patients, and high risk of early tumor recurrence because of immunosuppression. Under the influence of immunosuppression necessary to maintain function of a liver graft, the growth rate of HCC is accelerated, with mean tumor doubling times of about 37 days in recurrent tumors after transplantation, compared with 274 days in patients with recurrence after The overall patient survival following OLT has improved markedly since the introduction of cyclosporin A and accurate criteria for patient selection. In most studies, the best long-term survival rates were for patients in whom HCC was not the primary indication for OLT, but was discovered by chance during examination of the explanted liver. In a review of 429 patients treated with OLT for HCC from liver transplantation centers throughout the world between 1968 and 1991, Penn105 analyzed patients in three groups: the usual variety (85%), HCCs discovered as incidental findings after OLT for some other liver disorder (7%), and fibrolamellar HCCs (8%). For usual HCC, tumor recurrence occurred in 39%; 33% occurred in the first 6 months, 58% in first year, 76% in the first 18 months, and 84% in the first 24 months. At 2 years, the overall survival rate, with and without tumor, was 30%, and at more than 5 years, it dropped to 18%. Most of the deaths in the

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2-year and 5-year interval were caused by recurrent tumor. For incidental HCC, 13% had recurrences and 57% of patients, with and without tumor, were alive at 2 years and 5 years after OLT. Similar 1- to 5-year survival rates have been reported in resected versus transplanted patients.47 In a series from Pittsburgh comparing 76 patients with HCC treated with subtotal hepatic resection and 105 patients following OLT treated with cyclosporin A-steroid therapy during a 10-year period, the 5-year survival rate was 32.9% for hepatic resection versus 35.6% for OLT?7 The survival rates of the resection group, however, were significantly lower than those of the OLT group when HCC was associated with cirrhosis, but they were similar when HCC was not associated with cirrhosis ( P =0.02). In a small series from the King's College group, the actuarial 3-year survival rate was 40% for hepatic resection compared to 63% for OLT for tumors less than 8 crn.l3O The difference in the survival curves, however, was not statistically significant. A French study comparing survival rates with and without recurrence after resection or OLT showed an overall survival rate of 45% for OLT compared to 25% for resection.7*The recurrence probability in the OLT group increased from 0% to 25% within the first 12 months, then remained at 25% until month 48. In the resection group, the recurrence probability increased from 0% to 78% regularly during the 48 months. Data from the European Transplant and Cincinnati Transplant Tumor Registers indicate a 30% 2-year survival rate.lo5 Liver transplantation is more expensive than segmental resection, is not available in many centers, and necessitates lifelong immunosuppression. Compounding the problem is that HBV or HCV viremia recurs in a high proportion of carriers. Although hepatitis B immunoglobulin (HBIG) may limit this risk, it adds a considerable amount to the cost.66, Results with new antiviral agents such as lamivudine or famciclovir indicate that HBV recurrence may be reduced by treatment with these agents. (See the article by Fried.) Patients undergoing transplantation for the fibrolamellar variant of HCC may also have a better prognosis. Because the group at risk for this variant has not been identified, however, the tumor is rarely detected when asymptomatic. Based on these data, OLT would appear to be a rational form of therapy for patients with both end-stage liver disease and a small HCC because the operation removes both the diseased liver and the malignancy, and long-term survival is possible. In both transplanted and resected patients, the tumor, nodes, and metastases (TNM) classification has been found to be useful in assessing prognosis and, therefore, raises the issue of whether pretransplant laparoscopic staging with regional lymph node biopsy should become routine. Unfortunately, the detection of nodal micrometastases is often inaccurate and poorly p r e d i ~ t i v e . ~ ~ The effectiveness of adjuvant perioperative chemotherapy has not yet been adequately evaluated. In a pilot study from Dallas of HCC confined to the liver, 20 patients were treated with OLT and preoperative, intraoperative, and postoperative doxorubicin at a dose of 10 mg/m* weekly.lZ3The actuarial disease-free survival was 74% at 1 year, 61% at 2 years, and 54% at 3 years. Seventeen of the patients completed the planned course of chemotherapy of 200 mg/m2, and the most common side effect was leukopenia (14 patients). In another study of adjuvant chemotherapy from UCLA,9725 patients were treated for 6 months after OLT with intravenous fluorouracil, doxorubicin, and cisplatin. Overall, long-term survival in the protocol patients was 46% at 3 years, im-

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proved over rates in historic controls of 5.8% at 3 years (P=O.OOOl). Overall recurrence rate was 20%. Devascularization Transcatheter arterial embolization (TAE) of the hepatic arterial bed is another approach that has been tried with some success.69The rationale for this is based on the observation that HCCs receive their blood supply predominantly from the hepatic artery. Substances used for TAE include gelatin sponge (Gelfoam), polyvinyl alcohol (Ivalon), steel coils, degradable starch microspheres, and plastic or metal microspheres. TAE has been used effectively for palliation of unresectable or recurrent Malignant cells in the tumor, however, are not fully eradicated, leading to eventual recurrence. The procedure is generally accepted to be contraindicated in patients with occlusion of the main trunk of the portal vein. TAE is frequently associated with pain, fever, and malaise, which is usually self-limiting. More serious complications include septicemia, cholecystitis, pancreatitis, gastroduodenal hemorrhage, and, in 1% of patients, rupture of the tumor. Chernotherapy

Current systemic chemotherapeutic regimens for the treatment of HCC are of limited benefit, and less than 25% of patients have partial responses. Conventional systemic chemotherapy with cytotoxic agents, singly or in combination, has been associated with disappointing long-term s~rvival.’~,31,Io4 The failure to achieve impressive results with systemic and local treatments has led to an increasing interest in targeted therapies delivered via the hepatic artery. Selective hepatic arterial infusion of cytotoxic agents alone has been associated with a higher response rate and better survival figures than systemic therapy.Io4Although this modality has the potential advantage of achieving a better response with a lower dose (and, consequently, less dose-related morbidity), it does not ensure prolonged retention and gradual release of the drug within the tumor. Radiotherapy The value of external beam radiotherapy for treating HCC is limited by the relative radiosensitivity of the normal liver. Whole liver irradiation at 35 Gy is associated with a high incidence of radiation hepatitis. An acceptable maximum dose for a healthy liver ranges between 20 and 35 Gy, delivered in daily fractions of 200 ~ G y , but 4 ~ in a cirrhotic liver even such doses are associated with a high incidence of hepatic failure. Targeted Therapies An increasing variety of targeted or delivered therapies have been employed in an attempt to improve the palliation of inoperable HCC. These include not only arterial devascularization, arterial infusion chemotherapy, and TAE,

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but also delivered therapies, for example, Lipiodol-targeted chemotherapy or radiotherapy, Lipiodol-targeted chemotherapy with TAE, and intratumor injection of ethanol or local freezing or warming of the lesions. The authors still require firm evidence from controlled trials that any of these treatments significantly improves survival, but some appear to offer clinical benefit. TranscatheterArterial Embolization and Chemoembolization

This procedure is performed by selectively embolizing the feeding hepatic artery with particles of Gelfoam or Ivalon sponge soaked in solutions of mitomycin C, doxorubicin, or cisplatin (chemoembolization). Injections can be repeated at 2-monthly intervals. The effect of this is to induce immediate HCC tissue necrosis because most HCCs derive their blood supply from the hepatic artery. An increase in the concentrations of tumor-specific enzymes suggests selective tumor damage.% The procedure is indicated for unresectable HCC but can be combined with subsequent hepatic resection in suitable patients. Good 1-year survival (78%) rates have been observed in Okuda stage I patients. Viable cells may remain undamaged in the capsule and periphery of the tumor, and neovascularization occurs, resulting in recurrence. Portal vein thrombosis precludes the procedure, and it should not be undertaken in patients with Child’s class C cirrhosis. Pain and fever occur commonly. Significantly improved survival rates at 3 years have been noted for patients with recurrence after resection who underwent TAE compared with those who were not embolized (45% versus O%).58,128 Emergency TAE can also be used for the treatment of acute intraperitoneal hemorrhage of HCC. Lipiodol-Targeted Chemotherapy

In this procedure, a chemotherapeutic agent is linked to Lipiodol by emulsification and injected by selective hepatic arteriography into the HCC (lipiodolizution). Lipiodol alone has no antitumor effect129and has to be combined with a cytotoxic substance or a radioisotope to achieve therapeutic results. Such therapies have consistently yielded better response rates than systemic or intra96 arterial chemotherapy using cytotoxic agents Cytotoxic agents used in conjunction with Lipiodol include doxorubicin, epirubicin, aclarubicin, 5-fluorouracil, mitomycin, cisplatin, and SMANCS (a semisynthetic macromolecular compound consisting of neocarzinostatin and two chains of synthetic copolymers of styrene and maleic acid). It is believed, but not proven, that the activity of cytotoxic agents delivered in this way is prolonged by the persistent retention of the Lipiodol within the tumor. Tumor necrosis is demonstrable after Lipiodiol chemotherapy injection but may not be complete.61 Some studies have demonstrated tumor shrinkage and greater survival following infusion of Lipiodol and anticancer agents, including doxorubicin, mitomycin, cisplatin, and SMANCS, than after systemic chern~therapy.~~, Many favorable studies are cited in the Japanese medical literature. Other studies have not noted benefit and have not found a difference in the pharmacokinetics of intraarterial doxorubicin and doxorubicin linked to Lipiodol.w,51 Demonstrated efficacy against HCC, ease of conjugation to the lipid vehicle, and acceptable toxicity are the considerations that determine the selection of these cytotoxic agents. Several trials have used doxorubicin or cisplatin, and it has been suggested that the latter may confer a greater survival benefit.55In a study at the Royal Free Hospital, each patient received 40 to 120 mg (30 to 75

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mg/m2) of epirubicin dissolved in 10 mL of 60% sodium meglumine diatrizoate (Urografin 290) and emulsified with 10 mL of Lipiodol using an ultrasonic agitator. The cumulative 1-year survival in this group was 3 8 0 , but survival compared to historical controls was improved only in Okuda stage I and I1 patients?O The side effects of the procedure appear acceptable in patients without severe decompensated liver disease. Hepatic arterial administration of Lipiodol alone has not been associated with any significant adverse effects. Thus, apart from the hazards of hepatic artery cannulation, the complications of Lipiodolbased chemotherapy depend largely on the systemic and hepatic toxic effects of the specific cytotoxic agent used. A large proportion of patients suffer some pyrexia, nausea and abdominal discomfort, and raised serum aminotransferase levels, which are usually self-limiting. Leukopenia occurs rarely. Alopecia is very rarely seen. Gastric mucosal lesions, pancreatitis, cholecystitis, jaundice, and pulmonary edema have been reported by others. The authors have observed fatal hepatocellular failure in patients who had advanced liver disease (Child’s class C cirrhosis) at the time of treatment. Anomalies of the celiac vascular tree may prevent hepatic artery cannulation, and treatment in patients with portal vein thrombosis carries the risk of producing liver infarction. The treatment merits further evaluation as an adjunctive therapy before (or after) surgical resection, as 70% 5-year survival rates have been reported when 53 lipiodolization is followed by hepatic

Transcatheter Oily Chemoembolizafion Lipiodol-targeted chemotherapy has been combined with TAE; this involves first injecting Lipiodol chemotherapy into the hepatic artery and then occluding the vessels by embolization, with the aim of preventing washout of the chemotherapeutic agents. Subsequent treatments can be given, depending on clinical, biochemical, and radiologic response. The procedure has been termed trunscatheter oily chemoembolization. in 1985 reported on a group of 97 patients who Ohishi and received Lipiodol-based chemotherapy followed by TAE with gelatin sponge. Subsequently, TAE has been combined with Lipiodol-targeted chemotherapy in several trials. The results may be superior to those obtained by TAE a10ne.9~ Takayasu and reported a randomized trial wherein intra-arterial Lipiodol-doxorubicin chemotherapy followed by gelatin sponge embolization obtained significantly better results than were achieved in a comparable group with Lipiodol-doxorubicin alone. The contraindications and potential complications outlined for TAE apply to transcatheter oily chemoembolization as well. The procedure is indicated for treatment of unresectable tumor, and controlled trials have indicated a therapeutic effect: Vetter and colleagues139have reported 1- and 2-year survival rates of 59% and 39% for French patients treated with intra-arterial injection of Lipiodoldoxorubicin emulsion followed by embolization with gelatin sponge particles, compared to 0% for untreated patients. Nearly all the trials achieve 1-year survival rates of 25% to 60%. The addition of gelatin sponge embolization to intra-arterial Lipiodol-based chemotherapy does not appear to add to the morbidity or mortality and may confer a slightly greater survival benefit. The presence of a good hepatic reserve improves the prognosis. The procedure has been claimed to be more effective than lipiodolization alone, but comparative studies have not been done, and better results are found in patients with Okuda

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stage I and I1 disease. This procedure has also been combined with subsequent surgical rese~tion.4~ The side effects and limitations of the treatment are the same as those of Lipiodol-targeted chemotherapy and TAE combined, and the procedure is contraindicated in patients with Child’s class C cirrhosis. Although a majority of the reports are from the Far East, there have been some studies from Europe and Africa. In several trials, multiple drugs or drug combinations were used, and it was not possible to assess the effects of each regimen separately. Most centers have used more than one cycle of treatment, but although some have administered multiple doses routinely, others have varied their schedules according to the degree of Lipiodol retention in the lesion or according to tumor response. The criteria to determine the number and frequency of cycles need to be clearly defined. Nevertheless, from these results, it would be reasonable to conclude that Lipiodol-based chemotherapy and transcatheter oily chemoembolization can be carried out with an acceptable degree of safety at centers accustomed to treating such patients. Procedure-related morbidity and deaths are well documented, and hepatic failure is a common cause of mortality. Patients with Child’s class C cirrhosis and poor hepatic reserve, advanced (Okuda stage 111) tumor, and thrombosis of the main trunk of the portal vein are particularly poor candidates for these treatments, and it would be useful to consider these as standard contraindications. Targeted Radiotherapy: Radioactive Microspheres

Targeted therapy using hepatic arterial injection of microspheres impregnated with yttrium-90 (”Y) has been attempted with some success. Although high levels of intralesional activity have been achieved, not all studies have reported a decrease in tumor size.”, 27, 4o Among the major complications of this therapy are leaching of from the microspheres, causing myelosuppression, and spillage of microspheres into the splanchnic or pulmonary beds, leading to gastrointestinal bleeds and lung fibrosis. The composition and size of the microspheres may have an important role in determining the efficacy and complication^.^^ Lipiodol Radiotherapy

By replacing part of the iodine component of lipiodol with the radioactive isotope l3II, or by using 90Y microspheres, radiotherapy can be selectively delivered to HCC.”, Each technique focuses a potentially tumoricidal dose of radiation into the malignant tissue without exceeding the safe dose for the surrounding hepatic parenchyma. Plasma levels of the isotope reach a plateau within 48 hours and remain low, thus reducing the possibility of tcxicity to other tissues, particularly bone marrow. Biodistribution studies7,*, 46, 72, lo7 have shown that after hepatic arterial injection, nearly all the activity is concentrated in the liver and the lungs, with the major component in the liver. Systemic levels of radioactivity are negligible. On average, activity within an HCC is four times that in surrounding normal tissue, and in metastases it is two times the level achieved in normal tissue. Half-life of activity in the tumor is over 4.5 days. Despite its iodine content, there is no significant localization of Lipiodol in the thyroid. In the authors’

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experience, it has not proven necessary to block the thyroid gland by administering iodide preparations before Lipiodol injection. No changes in biodistribution have been demonstrated on reinjection 4 weeks after the first dose of Lipiodol. Retention of the isotope within the liver, coupled with a biologic half-life of 1311 of up to 8 days, results in sustained irradiation of tumor foci allowing the treatment to be given infrequently. The uptake of l3lI Lipiodol in an animal tumor model and in humans has been measured and shown to have a significantly longer half-life in tumor than in normal tissue, resulting in almost complete necrosis of the tumor?1,92,100 The authors have used gamma camera radiography in studies to confirm selective accumulation in tumor. Early reports from clinical trials in HCC have been encouraging, with a reduction in tumor size and ascites and symptomatic improvement in the majority of patients. Toxicities to bone marrow, thyroid, and lung have not been reported. Larger trials with Lipiodol-targeted radiotherapy in HCC are currently in progress in several European centers, including the authors' center. The early reports on the therapeutic use of 1311-Lipiodolhave come from France, Japan, and South Korea.8,57, More recently, a French multicenter phase I1 trial has been reported.ImFifty patients (47 cirrhotics) with unresectable Okuda stage I or stage I1 HCC were given one to three injections of l3II-labeledLipiodol, with doses ranging from 21 to 100 mCi. The treatment was well tolerated. Symptomatic pain relief was achieved in 9 of 11 patients, and the AFP levels fell in 22 of 29 patients in whom it was initially raised. Decrease in tumor size was seen in 28 of 45 cases (62%), and it remained static in 5 (14%). Actuarial survival at 1 year was 50% and 19% in patients with Okuda stage I and stage 11. Yo0 and colleagues147 have achieved impressive responses, with a reduction in tumor size in 89% of patients with small tumors (<4 cm in diameter). No radiation-related complications involving the thyroid, lungs, or bone marrow have been reported. At the Royal Free Hospital, the authors have used I3'ILipiodol in 26 patients with unresectable HCC, with results comparable to those achieved with Lipiodol-epirubicin.4 Arrest or diminution in tumor size was noted in 68% of patients. Four patients died of liver failure within 4 weeks of therapy. Treatment-related morbidity was comparable to that in patients treated with Lipiodol-epirubicin. The incidence of pyrexia was lower, and there were no instances of bone marrow suppression. The authors have carried out a prospective, randomized comparison in 28 patients of Lipiodol-epirubicin (n = 17) versus Lipi~dol-~~lI (n = 11) and found no significant difference between the two modalities, but the numbers in this study are small, and further prospective, randomized comparisons between transcatheter oily chemoembolization and 1311-Lipiodolare indicated. One minor problem with this form of treatment is the need for radiation shielding of the patient for a few days to reduce the radioactivity risk after administration of treatment exceeding 800 kBq.

lntratumor Injection of Ethanol For small tumors less than 3 cm in size, percutaneous injection of alcohol directly into the lesion under radiologic guidance has been attempted with encouraging results.n, llR This leads to coagulative necrosis of the tumor. It is indicated for patients with up to three tumors of 3 cm or less in size. Response rates are lower in those with larger tumors or poor hepatic function. The technique can also be used intraoperatively. The technique has been advocated

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particularly for patients whose tumors are yesectable but who are unfit for surgery.lLh It has been suggested that survival in Japanese patients with small HCC is comparable if they are treated by percutaneous ethanol injection or resection. Several authors have advocated alcohol injectiofis for patients whose lesions are technically resectable but who are unfit for surgery. Sixty percent 4-year surviviil rates have been reported. Tumor recurrence from persisting malignant cells, however, remains a potential problem, and it remains to be clarified how many injections should be administered to a given lesion and what volumes of alcohol should be used. Complications of the procedure include pain, fever, and intrahepatic or intraperitoneal hemorrhage. Unfortunately, viable malignant cells that persist within the capsule lead to recurrences. It has not been established how many injections are needed or how much ethanol should be injected to optimize results. Acetic acid has also been used. In a large retrospective series from Italy, 1108 patients with single, small lesions (<5 cm) and with Child’s class A or B cirrhosis were treated with resection or percutaneous ethanol injection or were given no treatment.70Patients treated with resection or percutaneous ethanol ihjection had the same 3-year survival rates in the two Child classes (75% for Child’s A and 40% for Child’s B), suggesting that percutaneous ethanol injection is an alternative to resection in this category of patients. Ethanol injection is the cheapest treatment modality and is widely available. Other Treatments

Other treatments yet to find widespread acceptance include cryotherapy, which has been used in treating superficial tumor deposits at laparotomy,38,‘09 and laser hyperthermia.2zDirect intratumoral injection of in animals has been associated with a reduction in tumor size and prolonged survival.@Iy2Iridium implantation has been used for palliation of malignant biliary obstruction, but its low beta energy and range make it a poor choice for intratumoral injection in the liver. Molecular Approaches to Therapy

Recombinant adenoviruses can deliver foreign genes to parenchymal liver cells in vitro and in vivo with high efficiency. The thymidine kinase gene of herpes simplex virus (HSV-tk), a suicide gene, converts the protoxic nucleoside analogue ganciclovir (GCV) to a highly toxic phosphorylated GCV that acts as a chain terminator of DNA synthesis and an inhibitor of DNA polymerase, selectively killing dividing cells. Studies have successfully used the recombinant adenovirus vehicle to transfer HSV-tk to HCC cell lines and to confer susceptibility to GCV.44,lU6 When AdCMVtk-infected cells were mixed with uninfected cells, a bystander killing effect in vitro was observed. It has also been shown that the 0.3 kb promoter sequence of the human AFP gene is sufficient for selective expression of the HSV-tk gene in AFP-producing HCC cells and thereby sensitizes these cells to GCV.* (See also the article by Nunes and Raper.) lmmunotherapy

Monoclonal antibodies specific for HCC have been raised with a degree of success. Intravenous administration of radiolabeled antibody has shown good

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tumor l o ~ a l i z a t i o nbut ~ ~autoradiography of the treated tissues revealed patchy localization of the isotope. The value of monoclonal antibodies conjugated to isotopes, cytotoxics, or ricin is being investigated, as are other techniques of targeted treatment. The most developed therapeutic approach, that of l3]I antiferritin with chemotherapy and external beam irradiation, has led to partial remissions in selected patients.2yHCC cells have a high level of ferritin, and trials of polyclonal antiferritin antibodies labeled with 1311 or '"Y have yielded impressive remission ratesY8Cross-reactivity with ferritin in other organs and bone marrow toxicity caused by are among the problems associated with this technique. Perhaps other adjunctive treatments such as tamoxifen,28 interferon,h3intratumoral injection of interleukin-2,36cryosurgery, or radiofrequency h~perthermia'~~ may be effective in the treatment of small, satellite or recurrent lesions and could offer useful palliation #or recurrent lesions.

PREVENTION

Prevention of HCC should be aimed at prevention of the underlying liver disease or attenuation of disease in patients with chronic liver disease.

Viral Hepatitis

Currently the biggest impact should be on HBV-related HCC because the HBV vaccine is both safe and confers greater than 90% protection against HBV infection in areas endemic for HBV infe~ti0n.l~~ Success in some countries may be limited, however, by financial constraints, poor primary care infrastructure, and disinclination to be ~accinated.'~~ With respect to HCV, screening of blood products initially for surrogate markers and subsequently for anti-HCV has led to a significant decrease in posttransfusion hepatitis in the United States from 0.45% to 0.03% per Further reductions in the incidence of HCV infection could be achieved by targeting intravenous drug users and implementing sterile needle and syringe exchange programs. Vaccination for HCV is beset by methodologic difficulties because of the sequence heterogeneity of the virus. Alternative strategies, such as peptide or DNA vaccines that generate cytotoxic lymphocytes rather than antibodies may therefore be required. AFP therapy has been shown in some prospective studies to have a protective effect on the development of HCC in patients with chronic hepatitis C and B cirrh0sis,8~but more prospectively collected data are necessary before this approach can be routinely advocated. (See also the article by Katkov.)

Other Liver Diseases Hemochromatosis should be treated with phlebotomy to prevent progressive liver disease. If cirrhosis has already supervened, however, it is not clear that de-ironing a patient reduces the risk. In glycogen storage disease type 1, development of multiple hepatic adenomas may supervene despite intensive dietary manipulation. These have a high likelihood of becoming malignant, and, hence, at this stage perhaps prophylactic liver transplantation should be considered. Similarly, in hereditary tyrosinemia, the probability of HCC is so

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et a1

high after the age of 2 years that prophylactic liver transplantation should be considered.

CONCLUSIONS The prognosis of large HCC is poor, and only palliative treatment is available. Small tumors are amenable to several modes of treatment, including liver transplantation, resection, or alcohol injection, with acceptable 5-year survival rates. Although the value of screening for HCC has yet to be shown, these data, coupled with the recognition of at-risk groups, and useful diagnostic techniques might encourage the clinician to screen at-risk patients in the clinic. New imaging techniques such as ultrasonographic angiography enhanced with C02 microbubbles, or color Doppler u l t r a s ~ u n d "may ~ clarify the intratumoral blood flow of small tumors.60 Several modes of treatment of large HCC are being investigated that promise to improve the prognosis of this otherwise devastating tumor. Each of these modalities appears to be of potential benefit in palliating HCC. The endpoints used to judge the relative efficacies of the different regimens need clarification, however. Diminution in tumor size indicative of response to the treatment and fall in AFP levels are acceptable parameters of therapeutic efficacy for initial trials, but in the long-term, the duration of survival and the quality of palliation achieved are the main yardsticks to measure one modality against another. Until the optimal form of treatment for small HCC can be selected based on the intrinsic biology, vascularity and extent of the tumor, and underlying liver function, the choice of treatment will depend on local expertise and interest. Multimodal treatment for patients with risk factors of recurrence needs to be evaluated in controlled trials. In the future, the worldwide incidence of HCC should be reduced by immunization against HBV and, it is hoped, HCV.

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