الفهرس 
ANATOMY OF THE LIVEROnly 14 pages are availabe for public view
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Abstract
The recent development of a large number of therapeutic options provides patients with HCC the opportunity for more effective management, but it also poses major challenges to hepatic surgeons. Surgeons are increasingly confronted with the dilemma of selecting the best option among resection, transplantation, transarterial therapies, and local ablative therapies for a patient with HCC localized to the liver. A critical appraisal of the data aids in the appropriate choice of therapy.
Although a few retrospective studies have suggested that the surival results after TACE or PEI may be coparable to that after hepatectomy for respectable HCCs, the uncertainty of tumor necrosis with such techniques renders them a second choice after resection.
Cryotherapy or hyperthermic ablation using MCT, laser, or RFA produces a more predictable area of necrosis that encompasses not only the tumor tissue but also the capsule and a margin of surrounding liver tissue. Even though these new modalities can produce complete necrosis in 80% to 90% of HCCs less than 5 cm, it is difficult to ensure complete ablation. Further, satellite nodules are frequently present around the main tumor and can be cleared only by an anatomic resection. The possibility of needle track tumor seeding with percutaneous ablative therapies further jeopardizes the chance of cure. Hence, it is unlikely that these thermoablative therapies can replace resection as the curative treatment for HCC.
Hepatic resection is the first choice treatment for HCC when the tumor is cofined to the liver and the main portal vein is patent. Liver transplantation is the treatment of choice for patients with small HCCs < 5 cm and Child’s C cirrhosis. For patients with large or multifocal HCCs and reasonable liver function, TACE is considered an effective treatment.
Surgical resection of HCC, can result in significant long-term survival benefit in 20% to 35% of patients. Unfortunatly, only 5% to 15% of newly diagnosed HCC undergo a potentially curative resection. Patients with disease confined to the liver may not be candidates for resection because of multifocal disease, proximity of the tumor to key vascular or biliary structures that precludes a margin-negative resectin, or inadequate functional hepatic reserve related to coexistent cirrhosis.
For patients with solitary HCCs smaller than 5 cm or multiple small tumors up to three in number, local ablation should be offered when surgical resection or transplantation is not possible. PEI has been the standard therapy for small HCCs, but hyperthermic ablation by MCT or RFA is superior in the radicality of tumor ablation. PEI remain a useful treatment for lesions located in areas unsafe for hyperthermic ablation, such as those near major bile duct or hilar structures.
Cryotherapy offers effective necrosis of large HCCs and has the advantage that the ablation process can be monitored precisely by real time US. However, the complications of cryoshock phenomenon and bleeding from the cracking of liver parenchyma have rendered it a less popular choice than heat ablation.
Numerous chemotherapeutic regimens have been tested for use against HCC. However, HCC is highly resistant to chemotherapy. Because the results of systemic chemotherapy are far from optimal, regional delivery of chemotherapy has been attempted. Hepatic tumors derive their blood supply mainly from the hepatic artery. Infusion of chemotherapy directly into the hepatic artery may allow increased effective dose at the tumor with fewer systemic side effects.
Hepatocellular carcinoma
Imaging & liver function assessment
Tumor confined to the liver & main portal vein patent Extrahepatic metastasis & main portal vein tumor thrombus
Resectable
Unresectable
Systemic therapy such as chemotherapy or RFA
cResectionc
Tumor ≤ 5 cm
Tumor number ≤ 3
No venous invasion Tumor > 5 cm
> 3 tumors
Invasion of hepatic or portal veins
Child’s C Child’s A / B Child’s C
Transplantation Supportive treatmentd
Child’s A / B TAI or TACEf
Tumor favorable for thermal ablation Tumor unfavorable for
thermal ablation
RFA or MCT PEIj
Fig (23): Algorithm for management of HCC.
This figure summarizes the role of various modalities in the management of HCC. MCT=Microwave coagulation therapy; PEI = Percutaneous ethanol injection; RFA=Radiofrequency ablation; TACE = Transarterial chemoembolization; TAI = Transarterial infusion (Ronnie et al., 2002).