ABSTRACT
Hepatocellular carcinoma (HCC) is common in China. With the large number of HCC patients, experienced clinicians in managing this disease and the huge amounts of resources by the government to put into researches on HCC, the treatment of HCC in China has reached to the forefront of international standards in many aspects. The treatment of HCC can roughly be divided into three levels: (1) local treatment which includes liver resection, local ablative therapy and liver transplantation. The technical aspect of liver resection has become very matured. A recent study indicated that in HCC patients with microvascular invasion (MVI), anatomic liver resection resulted in significantly better long-term survival than non-anatomic liver resection. However, no significant difference could be found in HCC patients without MVI. As there are now models using preoperative data to predict presence or absence of MVI after surgery, surgeons can now decide on whether to use anatomic resection for a particular patient before surgery. Furthermore, medical evidences are accumulating on the effective and safe use of laparoscopic and robotic liver resection for selected HCC patients, which has less trauma and faster recovery compared with open hepatectomy. As the ability in predicting HCC recurrence improves, HCC patients predicted to have high risks of developing HCC recurrence can now be put into studies to investigate the treatment strategy for reducing recurrence after R 0 liver resection. There are now a lot of high level evidence studies on the use of local ablative therapy in treating HCC. Size of lesion is an important factor in choosing radiofrequency ablation (RFA) treatment alone (for diameter of HCC <2 cm), or RFA combined with transcatheter arterial chemoembolization (TACE) or percutaneous ethanol injection (for diameter of HCC with 3 to 5 cm), or to use surgery instead of RFA (for diameter of HCC >5 cm). Liver transplanta-tion has progressed rapidly in China. To supplement the Milan criteria, other criteria have been reported in China to select suitable candidates for liver transplantation beyond the Milan criteria. Furthermore, a lot of basic and clinical researches have been carried out attempting to improve the clinical outcomes of liver transplantation. (2) Regional therapies. The recent developments in TACE has focused on the use of increasingly highly selective canalization of branches of the hepatic artery to achieve bitter treatment outcomes and to decrease adverse treatment effects. Resin yttrium 90 microsphere has just been approved for clinical use in China. The indications of yttrium 90 microspheres are treatment for patients who are unsuitable to undergo TACE, failure of TACE, bridging therapy for HCC patients waiting for liver transplantation, and tumor downstaging followed by salvage liver resection. Recent developments in yttrium 90 microsphere therapies include radiation hepatectomy and ablative transarterial radioembolization. These two procedures can offer a chance of cure to patients who cannot undergo curative treatment because of poor general status, compromised liver function and unfavorable locations of HCC. (3) Systemic therapy. This is a rapidly advancing field in HCC management, which includes the use of chemotherapy, targeted therapy and immunotherapy. These therapies when used either alone, or in combination, have improved the long-term survival outcomes of patients with intermediate or late stages of HCC. A major hurdle to overcome for systemic therapy is related to the multiple gene mutations in HCC, which even with successful blockade of a tumor signal pathway, can lead to an alternate signal pathway being opened for tumor progression. In conclusions, management of HCC has rapidly improved through the enormous efforts put in by researchers in China and all around the world. It is my sincere hope that in the near future, HCC will become a very healable disease through tireless efforts of researchers.
ABSTRACT
Among locoregional treatments for hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) has been accepted as the most popular alternative to curative transplantation or resection, and it shows an excellent local tumor control rate and acceptable morbidity. The benefits of RFA have been universally validated by the practice guidelines of international societies of hepatology. The main advantages of RFA include 1) it is minimally invasive with acceptable morbidity, 2) it enables excellent local tumor control, 3) it has promising long-term survival, and 4) it is a multimodal approach. Based on these pros, RFA will play an important role in managing the patient with early HCC (smaller than 3 cm with fewer than four tumors). The main limitations of current RFA technology in hepatic ablation include 1) limitation of ablation volume, 2) technically infeasible in some tumors due to conspicuity and dangerous location, and 3) the heat-sink effect. Many technical approaches have been introduced to overcome those limitations, including a novel guiding modality, use of artificial fluid or air, and combined treatment strategies. RFA will continue to play a role as a representative ablative modality in the management of HCC, even in the era of targeted agents.