Review
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. May 28, 2015; 7(9): 1184-1191
Published online May 28, 2015. doi: 10.4254/wjh.v7.i9.1184
Intermediate hepatocellular carcinoma: How to choose the best treatment modality?
Giovan Giuseppe Di Costanzo, Raffaella Tortora
Giovan Giuseppe Di Costanzo, Raffaella Tortora, Department of Transplantion, Liver Unit, Cardarelli Hospital, 80131 Napoli, Italy
Author contributions: Both authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; both authors also contributed to drafting the article, revising it critically for important intellectual content and final approval of the version to be published.
Conflict-of-interest: The authors have declared no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Giovan Giuseppe Di Costanzo, Department of Transplantation, Liver Unit, Cardarelli Hospital, Via A Cardarelli 9, 80131, Naples, Italy. ggdicostanzo@libero.it
Fix: +39-081-7472208
Received: September 5, 2014
Peer-review started: September 6, 2014
First decision: September 28, 2014
Revised: January 18, 2015
Accepted: February 9, 2015
Article in press: February 11, 2015
Published online: May 28, 2015
Processing time: 257 Days and 1.8 Hours
Abstract

Intermediate stage, or stage B according to Barcelona Clinic Liver Cancer classification, of hepatocellular carcinoma (HCC) comprises a heterogeneous population with different tumor burden and liver function. This heterogeneity is confirmed by the large variability of treatment choice and disease-relate survival. The aim of this review was to highlight the existing evidences regarding this specific topic. In a multidisciplinary evaluation, patients with large (> 5 cm) solitary HCC should be firstly considered for liver resection (LR). When LR is unfeasible, locoregional treatments are evaluable therapeutic options, being transarterial chemoembolization (TACE), the most used procedure. Percutaneous ablation can be an evaluable treatment for large HCC. However, the efficacy of all ablative procedures decrease as tumor size increases over 3 cm. In clinical practice, a combination treatment strategy [TACE or transarterial radioembolization (TARE)-plus percutaneous ablation] is “a priori” preferred in a relevant percentage of these patients. On the other hands, sorafenib is the treatment of choice in patients who are unsuitable to surgery and/or with a contraindication to locoregional treatments. In multifocal HCC, TACE is the first-line treatment. The role of TARE is still undefined. Surgery may have also a role in the treatment of multifocal HCC in selected cases (patients with up to three nodules, multifocal HCC involving 2-3 adjacent liver segments). In some patients with bilobar disease the combination of LR and ablative treatment may be a valuable option. The choice of the best treatment in the patient with intermediate stage HCC should be “patient-tailored” and made by a multidisciplinary team.

Keywords: Hepatocellular carcinoma; Percutaneous ablation; Hepatectomy; Chemoembolization; Liver transplantation; Combination therapy

Core tip: Intermediate stage, or stage B according to Barcelona Clinic Liver Cancer classification, of hepatocellular carcinoma (HCC) comprises a heterogeneous population with different tumor burden and liver function. This heterogeneity is confirmed by the large variability in treatment and survival, the choice of the best treatment in the patient with intermediate stage HCC is a difficult task. A multisciplinary evaluation of each intermediate stage HCC patient is recommended for planning the best therapeutic strategy and this review was aimed to discuss about the existing evidences regarding this topic. Due to the heterogeneity of intermediate HCC, the use of different therapies (combination treatment) is likely the best choice in most of the cases offering the opportunity of a treatment tailored to the single patient.