Surgical therapy is currently the only option for curative (“curative”) treatment of primary hepatocellular carcinoma (hepatocellular carcinoma, abbreviated HCC, or carcinoma hepatocellulare):
- First-line therapy is total hepatectomy (complete removal of the liver) and orthotopic liver transplantation for simultaneous therapy of hepatocellular carcinoma and underlying disease (feasible in less than 5% of patients).See also Classification/Milan criteria (Milan criteria).
- Liver resection (surgical partial liver removal) may be reasonable in stage I to III. However, the presence of other nonmalignant liver diseases must be considered. In patients with cirrhosis, this means that liver function must be sufficiently good. There must also be no higher-grade portal hypertension (portal hypertension; portal vein hypertension), no bilirubin elevation (> 2 mg/dl), no splenomegaly (splenomegaly) or thrombocytopenia (< 100/nl; platelet deficiency).
- Approximately 75% of all cases are inoperable at the time of diagnosis.
- Local-ablative (local, tumor-destroying) procedures are used to bridge the gap until liver transplantation (LTx) can be performed (for more information, see “Further therapy/Conventional non-surgical therapy methods); Indication: when the tumor can neither be removed surgically nor treated locally-ablatively.
- Radiofrequency ablation (RFA, RFTA, RITA) or / and drug therapy with the tyrosine kinase inhibitor sorafenib.
- Transarterial chemoembolization (TAE, TACE) or /and drug therapy with the tyrosine kinase inhibitor sorafenib.
- Percutaneous ethanol injection (PEI) – by means of a fine needle, 95% alcohol is injected into the tumor under ultrasound or CT vision.
The exact procedure for hepatocellular carcinoma depends on the stage of the disease as well as the presence of other non-malignant liver diseases such as cirrhosis (see above). HCC <2 cm
- Radiofrequency ablation (RFA, RFTA, RITA), with iodine-125 implantation if necessary; for small liver carcinomas (diameter: up to 3 cm) is equivalent to surgical liver resection (partial liver removal) in terms of effectiveness, prolongation of life, and chances of cure (cure is possible).
- Percutaneous ethanol injection
- Surgical liver resection
HCC > 2 cm, no vascular infiltration.
- Liver resection
- Radiofrequency ablation
- Orthotopic liver transplantation
Multiple tumor nodules (unilobar)/vascular infiltration.
- Transarterial chemoembolization (TAE, TACE).
Tumor bilobaric, no vascular infiltration.
- Transarterial chemoembolization (TAE, TACE) with orthotopic liver transplantation (in patients who respond to therapy).
Further notes
- According to a meta-analysis (168 studies; 9,527 cases), laparoscopic liver resection (LLR) is a compelling procedure associated with a low mortality rate (0.39%) and few complications.
- Comparison of liver resection (LR) with liver transplantation (LTX) in terms of morbidity (disease incidence) and mortality (death rate) in patients with early hepatocellular carcinoma (HCC) with compensated cirrhosis showed no significant differences at 1 and 3 years; only at 5 years did LTX show a higher survival rate than LR (66.67 versus 60.35 percent).
- Transarterial chemoembolization (TAE, TACE) patients treated with acetylsalicylic acid (ASA) at the time of TAE had lower post-embolization bilirubin levels compared with patients not treated with ASA: 1 day (0.9 vs. 1.3), 1 month (0.9 vs. 1.2), and 1 year (0.8 vs. 1.0); ASA-treated patients also lived longer (57 versus 23 months).
- HCC recurrence (recurrence of disease): there was no difference in survival in the overall group between repeat liver resection (partial liver removal) and radiofrequency ablation (for description, see “Hepatocellular Carcinoma/Additional Therapy/Conventional Nonoperative Therapies”). In a subgroup, patients had elevated AFP > 200 ng/ml or recurrent tumors > 3 cm in diameter, survival was longer after surgical therapy.It is possible that this is why repeat liver resection is more appropriate for these patients, as they are aggressive tumors due to elevated AFP levels.
