Locoregional therapies for hepatocellular carcinoma: A critical review from the surgeon's perspective

Abstract

Objective: This article reviews the current results of various locoregional therapies for hepatocellular carcinoma (HCC), with special reference to the implications for surgeons. Summary Background Data: Resection or transplantation is the treatment of choice for HCC, but most patients are not suitable candidates. The past decade has witnessed the development of a variety of locoregional therapies for HCC. Surgeons are faced with the challenge of adopting these therapies in the management of patients with resectable or unresectable HCC. Methods: A review of relevant English-language articles was undertaken based on a Medline search from January 1990 to August 2001. Results: Retrospective studies suggested that transarterial chemoembolization is an effective treatment for inoperable HCC, but its perceived benefit for survival has not been substantiated in randomized trials, presumably because its antitumor effect is offset by its adverse effect on liver function. Nonetheless, it remains a widely used palliative treatment for HCC not amenable to resection or ablative therapies, and it also plays an important role as a treatment of postresection recurrence and as a pretransplant therapy for transplantable HCC. Better patient selection, selective segmental chemoembolization, and treatment repetition tailored to tumor response and patient tolerance may improve its benefit-risk ratio. Transarterial radiotherapy is a less available alternative that produces results similar to those of chemoembolization. Percutaneous ethanol injection has gained wide acceptance as a safe and effective treatment for HCCs 3 cm or smaller. Uncertainty in tumor necrosis limits its potential as a curative treatment, but its repeatability allows treatment of recurrence after ablation or resection of HCC that is crucial to prolongation of survival. Cryotherapy affords a better chance of cure because of predictable necrosis even for HCCs larger than 3 cm, but its use is limited by a high complication rate. There has been recent enthusiasm for heat ablation by microwave, radiofrequency, or laser, which provides predictable necrosis with a low complication rate. Preliminary data indicated that radiofrequency ablation is superior to ethanol injection in the radicality of tumor ablation. The advent of more versatile radiofrequency probes has allowed ablation of HCCs larger than 5 cm. Recent studies have suggested that combined transarterial embolization and heat ablation is a promising strategy for large HCCs. Thus far, no randomized trials comparing various thermoablative therapies have been reported. It is also uncertain whether a percutaneous route, laparoscopy, or open surgery affords the best approach for these therapies. Thermoablative therapies have been combined with resection or used to treat postresection recurrence, and they have also been used as a pretransplant therapy. However, the value of such strategies requires further evaluation. Conclusions: Advances in locoregional therapies have led to a major break-through in the management of unresectable HCC, but the exact role of the various modalities needs to be defined by randomized studies. Novel thermoablative techniques provide the surgeon with an exciting opportunity to participate actively in the management of unresectable HCC. Locoregional therapies are also useful adjuncts in the management of patients with resectable or transplantable disease. Hence, surgeons must be equipped with the latest knowledge and techniques of ablative therapy to provide the most appropriate treatment for the wide spectrum of patients with HCC.