Non surgical management in advanced hepatocellular carcinoma.

Abstract

Hepatocellular carcinoma (HCC) is major global health problem. Although there are widespread applications of surveillance programs to detect an early stage HCC, a significant proportion of patients are still diagnosed as non-resectable HCC. According to the Barcelona Clinic Liver Cancer (BCLC) staging, patients with cancer related symptoms, macrovascular invasion (either segmental or portal invasion) or extrahepatic spread (lymph node involvement or metastases were defined as advanced HCC. Untreated HCC with advanced stage had poor prognosis, the median survival was 3 - 6 months. Sorafenib, multikinase inhibitor, was the first molecular target agent and had supported evidence for survival benefits and now it has become the first-line treatment in patients with advanced HCC. Development and progression of HCC had heterogeneity of molecular events and complex mechanisms. Combination treatment with molecular target agents targeting different pathways may be other option. Other treatment modalities for advanced HCC include external beam radiotherapy, ⁹⁰Yittrium radio-embolization, transarterial chemoembolization (TACE), drug-eluting-beat and chemotherapy. High-dose external radiation directed to the tumor or portal vein thrombosis (PVT) in combination with regional chemotherapy or TACE, has good outcome. Previous data of ⁹⁰Yittrium radio-embolization in patients with PVT were interesting; however, they need further studies to support. Each treatment modality has different levels of evidences to support. This review provides an updated overview of the diagnosis and non-surgical management of advanced HCC.