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Nonsurgical therapies for localized hepatocellular carcinoma: Radiofrequency ablation, percutaneous ethanol injection, thermal ablation, and cryoablation

Authors
Steven A Curley, MD, FACS
Keith E Stuart, MD
Jonathan M Schwartz, MD
Robert L Carithers, Jr, MD
Section Editor
Kenneth K Tanabe, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

Hepatocellular carcinoma (HCC) is an aggressive tumor that frequently occurs in the setting of cirrhosis. The patient's hepatic reserve often dictates therapeutic options (table 1). Treatment options are divided into surgical therapies (ie, resection, cryoablation, and orthotopic liver transplantation [OLT]), and nonsurgical therapies (ie, percutaneous ethanol injection [PEI], radiofrequency ablation [RFA], transarterial chemoembolization [TACE], radioembolization, radiation therapy [RT], and systemic therapy).

Treatment algorithms — A general approach to the treatment of 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 orthotopic liver transplantation. These issues and a general approach to treatment of HCC are discussed in detail elsewhere. (See "Overview of treatment approaches for hepatocellular carcinoma".)

Importance of comprehensive multidisciplinary care — A majority of patients with HCC have underlying liver disease, which may be related to infection with hepatitis B virus (HBV) and/or hepatitis C virus (HCV). Furthermore, patients who undergo any of these forms of therapy are at high risk for recurrent disease and of progression to liver failure. It is important that patients with more advanced liver disease have proper monitoring and assessment of their underlying liver disease, which may have a major impact on longer term survival. Prognostic scoring systems to assess the severity of underlying liver disease in patients undergoing treatment for HCC are discussed in detail elsewhere. (See "Staging and prognostic factors in hepatocellular carcinoma", section on 'Staging and prognostic scoring systems'.)

Comprehensive care of patients with cirrhosis includes antiviral therapy for HBV and HCV, immunization against hepatitis A and HBV (if indicated), and endoscopic screening and surveillance for varices. In addition, the wide variety of treatment options for these patients (surgical, interventional, medical, radiation) involves different types of specialists. Thus, the multidisciplinary team necessary to comprehensively evaluate and care for these patients requires significant breadth. (See "Epidemiology and etiologic associations of hepatocellular carcinoma" and "Cirrhosis in adults: Overview of complications, general management, and prognosis".)

This topic review will cover RFA, PEI, thermal methods of tumor ablation, and cryoablation for HCC. Other nonsurgical therapies for HCC (transarterial embolization, RT, and radioembolization) are discussed elsewhere, as are surgical resection, transplantation, and systemic therapy. (See "Nonsurgical therapies for localized hepatocellular carcinoma: Transarterial embolization, radiotherapy, and radioembolization" and "Surgical management of potentially resectable hepatocellular carcinoma" and "Liver transplantation for hepatocellular carcinoma" and "Systemic treatment for advanced hepatocellular carcinoma".)

                              

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