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Assessment of tumor response in patients receiving systemic and nonsurgical locoregional treatment of hepatocellular cancer

Authors
Keith E Stuart, MD
Shams I Iqbal, MD
Section Editor
Richard M Goldberg, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

Hepatocellular carcinoma (HCC) is an aggressive tumor that frequently occurs in the setting of underlying liver disease, particularly cirrhosis. The two factors that are most important in determining a patient's prognosis and potential treatment options are tumor mass/location and the patient's hepatic reserve. Patients with unresectable tumors who do not fulfill criteria for liver transplantation are typically managed with nonsurgical locoregional therapy (percutaneous needle-based ablation techniques, transarterial therapies, and/or radiation therapy [RT]) or systemic therapy (molecularly targeted agents, such as sorafenib or conventional cytotoxic chemotherapy). (See "Surgical management of potentially resectable hepatocellular carcinoma", section on 'Preoperative assessment' and "Liver transplantation for hepatocellular carcinoma", section on 'Requirements for listing and management while on the wait list'.)

The antitumor effect of many nonsurgical locoregional treatment modalities and many systemic therapies is not accurately reflected by conventional bidimensional tumor measurements on radiographic studies. Accurate assessment of response requires evaluation of tumor size and other features, including the ablative margin, tumor viability and vascularity (as reflected by contrast enhancement), and early detection of residual/recurrent tumor and new areas of tumor involvement.

This topic review will cover the alternative methods of tumor assessment used for HCC that is treated either by nonsurgical local means or systemic therapy. Antitumor efficacy of specific nonsurgical locoregional treatments and systemic therapy is covered elsewhere. (See "Nonsurgical therapies for localized hepatocellular carcinoma: Transarterial embolization, radiotherapy, and radioembolization" and "Nonsurgical therapies for localized hepatocellular carcinoma: Radiofrequency ablation, percutaneous ethanol injection, thermal ablation, and cryoablation" and "Systemic treatment for advanced hepatocellular carcinoma".)

TREATMENT ALGORITHMS AND GENERAL APPROACH TO THE PATIENT WITH HCC

An algorithmic approach to the treatment of patients with hepatocellular cancer (HCC) is shown in the figure (algorithm 1). An alternative treatment algorithm is used by the Barcelona group (algorithm 2) [1]. However, attempts to generate algorithmic approaches to the treatment of HCC are difficult since new treatments and indications for various treatments are evolving rapidly. Furthermore, therapeutic approaches tend to vary based upon the available expertise, as well as variability in the criteria for hepatic resection and liver transplantation. These issues are discussed in detail elsewhere. (See "Overview of treatment approaches for hepatocellular carcinoma".)

In general, the optimal treatment for early stage HCC is surgical resection or liver transplantation. Patients with unresectable tumors that are outside of usual criteria for liver transplantation (the Milan criteria) are typically managed with nonsurgical locoregional therapy or systemic therapy. Nonsurgical locoregional therapy may also be used as a bridge to liver transplantation or to downstage tumors that initially exceed usual transplantation criteria. (See "Surgical management of potentially resectable hepatocellular carcinoma" and "Liver transplantation for hepatocellular carcinoma", section on 'Requirements for listing and management while on the wait list' and "Liver transplantation for hepatocellular carcinoma", section on 'Bridging therapy'.)

                           

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Literature review current through: Nov 2016. | This topic last updated: Tue May 03 00:00:00 GMT 2016.
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