الفهرس 
Other treatment modalitiesOnly 14 pages are availabe for public view
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Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third most common cause of cancer mortality among patients with cirrhosis worldwide. Approximately 549,000 cases diagnosed per year. Its aggressiveness and extensive dissemination lead to poor prognosis.
The liver was morphologically divided into left and right lobes utilizing the line of attachment of falciform ligament and the fissures for the ligamentum teres and ligamentum venosum on its surfaces. But the study of the functional (surgically) anatomy of the liver allows us to describe left and right livers, each divided into four hepatic segments, based upon the distribution of the portal pedicles and the location of the hepatic veins. During the past decades, the differentiated liver surgery with its countless new developments especially liver resection and LDLT are firmly based on our good knowledge of the functional anatomy of the liver.
The liver is a large, chemically reactant pool of cells that have a high rate of metabolism, sharing substrates and energy from one metabolic system to another, processing, and synthesizing multiple substrates that are transported to other areas of the body, and performing myriad other metabolic functions. It helps maintain homeostasis, metabolizes wastes, drugs, and toxins, and plays a key immunology role, such as the filtration of pathogens from the bowel.
The adult liver exhibits a remarkable potential to restore its cellular mass in response to all types of liver injury by hepatocytes hyperplasia and proliferation following the removal of liver mass.
Annual incidence rates for hepatocellular carcinoma of 2 to 4 cases per 100,000 population in North and South America, north and central Europe, and Australia compare with intermediate rates of up to 20 cases per 100,000 in countries bordering the Mediterranean. The highest annual incidence rates are found in Korea, Taiwan, Mozambique, and southeast China, approaching 150 per 100,000.
Any agent leading to chronic liver damage, and ultimately cirrhosis-which is present in patients with HCC estimates vary between 90% and 95%- should be seen as a risk factor for HCC. The prevalence of HCC worldwide parallels that of hepatitis B virus (HBV) or hepatitis C virus (HCV) cases with approximately 3-10 percent annual risk of HCC development.
Patients with cirrhosis due to genetic hemochromatosis, alcoholic, autoimmune hepatitis, primary biliary cirrhosis and Wilson’s disease have a very low risk of HCC development. Patients with other metabolic diseases including hereditary tyrosinemase, &-1 antitrypsin deficiency, porphyria cutaneatarda, glycogen storage disease 1 and 3, citrullinemia, and aciduria are also at a slightly increased risk of developing HCC.
Approximately 7 percent of HCCs arise without cirrhosis excluding the fibrolamellar variant, patients with viral liver disease or the rarely occurring hemochromatosis.
HCC originates from epithelial cells with different architectural patterns and cytological variants and frequently occur in combination. There are also different staging systems, the most common are TNM classification, Okuda classification, Child-Pugh, CLIP, and BCLC staging systems.
Patients with HCC often remain asymptomatic until very late in the course of the disease, and HCC is only discovered by screening (ultrasound and AFP) in individuals at risk of the disease. The diagnosis of HCC does not depend up on laboratory findings as liver function test and tumor markers. But also on non-invasive methods as ultrasound, computed tomography, magnetic resonant imaging and hepatic angiography have upper hand in the diagnosis of HCC. These methods allow better preoperative staging of patients, therefore more appropriate surgical treatment. Fine needle aspiration biopsy offers the sure diagnosis of HCC in some cases.
The selection of the best treatment in patients with HCC is the result of the evaluation of several factors, among which the most relevant are the status of the under lying liver and the tumor stage. Surgical resection is the first choice in the treatment of HCC; which can be offered to 15-30% of patients with HCC and the average 5-year survival rate can now be achieved in 40% of patients. The liver transplantation is valuable in treating patients who meet the Milan criteria and have no evidence of vascular invasion or metastasis. The 5-year survival rate after transplantation for patients fulfilling these criteria is 75%.
Several other therapeutic methods (non surgical) are discussed with emphasis on expected survival rates and overall indications. It should be emphasized that, whereas in many instances one therapy may appear superior to another, treatment must be individualized. Individualized treatment or in a combination is particularly relevant for possible side effects of therapies, patients with underlying liver disease, tumor characteristics, and overall patient performance status.
These methods treatment includes percutaneous ethanol injection or acetic acid injection or thermally by radiofrequency thermal ablation (RFA), microwave-heat induced thermal ablation, laser induced thermal ablation, or cryotherapy (which can be applied percutaneous, laparoscopically or after laparotomy), transcatheter chemo-embolization (TACE), radio and chemotherapy.
Therapeutic goals of the modalities vary from potentially curative to palliative in patients with irresectable HCC and from directed therapy to systemic therapy. The effectiveness of these methods is still under trial.