TREATMENT OF HEPATOCELLULAR-CARCINOMA IN CIRRHOSIS PATIENTS

Hepatocellular carcinoma accounts for 90% of the primary malignant liv er tumours. Most cases occur in cirrhotic livers. Management decisions should not be based on the stage of the tumour extension but rather o n the functional situation of the liver. The first therapetic option w hich should be considered is surgical resection if the case presents w ith a single tumour (or less than 4 tumours for some teams) without de tectable metastasis nor intraportal thrombosis and if the liver remain ing after surgery will be sufficient for normal hepatic functions. The disadvantage of resection is the high risk of recurrence in the long term. Liver transplantation cannot be proposed if the hepatocellular c arcinoma has produced clinical signs but it can be a possibility in ca se of a resectable tumour in the framework of a prospective protocol c omparing transplantation and resection. Intra-arterial injection of 13 1-iodine linked lipiodol is the only effective treatment in case of po rtal thrombosis. Chemoembolization of non-resectable hepatocellular ca rcinoma has led to spectacular tumour response but its effect on survi val has not been demonstrated by randomized studies. For tumours less than 3 cm in diameter, even multifocal alcoholization has provided enc ouraging results. Although a randomized study of questionable quality suggested tamoxifen could be effective, there is no current indication for this drug. External radiotherapy may be a possibility in the futu re, especially with proton irradiation. Thus the current management of hepatocellular carcinoma is in a difficult, even paradoxical, situati on since there is a wide therapeutic choice (resection, alcoholization , transplantation) for the rare cases with small tumours but almost no possibilities for the more severe cases most frequently encountered.