Bruix J and Sherman M (2005) Management of hepatocellular carcinoma. Hepatology 42: 1208–1236

Bruix and Sherman have published practice guidelines for the prevention, diagnosis, and management of hepatocellular carcinoma (HCC). They recommend ultrasonographic screening at 6 month intervals (determined by tumor growth rate) for those at high risk of developing HCC, namely patients with cirrhosis, including those on transplant waiting lists. They recommend ultrasonography because its sensitivity and specificity are superior to those of the available serological tests.

Ultrasonographically detected masses should be evaluated within structured diagnostic algorithms that vary according to the size of the mass. Lesions <1 cm in diameter should continue under surveillance, but at 3–6 month intervals for up to 2 years, to detect enlargement. If this does not occur, the patient can return to routine surveillance. Lesions >1 cm in diameter should be assessed by dynamic imaging modalities. If they show a nonspecific vascular profile, patients should undergo biopsy. By contrast, those with intense arterial uptake and delayed washout detected within a cirrhotic liver can be confidently diagnosed as HCC without a biopsy request.

The BCLC SYSTEM should be used to determine tumor stage and, thereby, what treatment ought to be given. Surgical resection for a single lesion can be considered for patients with good liver function, but adjuvant therapy before or after surgery is not recommended. Liver transplantation is recommended for those with one tumor ≤5 cm or up to three nodules <3 cm in size. Living donor liver transplantation can be offered to those at risk of exclusion from the waiting list because of tumor progression. The authors suggest no changes to the current priority system for patients awaiting transplantation, because no conclusive data exist yet on its effectiveness. For patients unable to undergo resection or transplantation, local ablation (preferably by radiofrequency) is recommended. Systemic or intra-arterial chemotherapy is an ineffective palliative treatment and should not be considered the standard of care. By contrast, randomized, controlled trials have indicated that TACE should be used as first-line palliative therapy for patients who can't undergo surgery or ablation and who don't have portal vein thrombosis or tumor metastasis.

The authors conclude that research is needed in several areas, especially in the identification of new biomarkers, the prevention of disease recurrence, the development of effective adjuvant therapies and the treatment of advanced HCC. As there is no effective treatment for advanced HCC, any new approach should be tested with placebo-controlled trials.