INTRODUCTION

Hepatocellular carcinoma (HCC) is an aggressive tumor that frequently occurs in the setting of cirrhosis. Although the mainstay of therapy is surgical resection, several other treatment modalities may also have a role. 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], radiation therapy [RT], and systemic therapy). Here we will discuss the nonsurgical liver-directed treatment options for patients with localized HCC. Surgical treatment options for localized disease, treatment of advanced disease, and the epidemiology, clinical manifestations, and diagnosis of HCC are reviewed separately. (See appropriate topic reviews).

Treatment algorithms — A general approach to the treatment of HCC is shown in the figure (figure 1). An alternative treatment algorithm is used by the Barcelona group (figure 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".)

Response assessment to locoregional therapies — Standard methods to assess treatment response (eg, unidimensional RECIST criteria [2], bidimensional perpendicular measurement using WHO criteria [3]) involve measurement of tumor dimensions before and after treatment. Methods such as these disregard the extent of necrosis, which is the end result of locoregional ablative therapies. Guidelines from the European Association for Study of the Liver (EASL) suggest that estimated reduction in viable tumor burden (nonenhanced areas using dynamic imaging techniques) be incorporated into definitions for response in this setting [4]:

• Complete response (CR) — Absence of enhanced tumor areas, reflecting complete necrosis
• Partial response (PR) — A >50 percent decrease in enhanced areas, reflecting partial tissue necrosis
• Progressive disease (PD) — An increase >25 percent in the size of ≥1 measurable lesion or appearance of a new lesion
• Stable disease — Any tumor response between PR and PD