Current management strategies for hepatocellular carcinoma.

Hepatocellular carcinoma is the third leading cause of cancer death worldwide, and its frequency is expected to increase. The possibility of identifying early stage curative cancer has supported the recommendation of surveillance by hepatic ultrasonography every 6 months in individuals with an annual incidence of cancer that exceeds 1.5%. Computerized tomography or magnetic resonance imaging is diagnostic if contrast uptake within the nodule is demonstrated in the arterial stage and washout is evident. Liver tissue examination is warranted in indeterminate nodules larger than 1 cm, and stromal invasion is the pathological hallmark. The Barcelona Clinic Liver Cancer staging system indicates the most appropriate evidence-based therapy. Liver resection is preferred for nodules <2 cm in the absence of portal hypertension or hyperbilirubinemia, and liver transplantation is the choice in patients without cirrhosis or with Child-Pugh A or B cirrhosis who have portal hypertension or hyperbilirubinemia. Radiofrequency ablation should be performed if transplantation is not an option and the total number of nodules is less than 3 and all are smaller than 3 cm. Intermediate or advanced stage cancer, defined by multinodularity, macrovascular invasion or extrahepatic spread, should be palliated by transarterial chemoembolization, treatment with sorafenib, or symptomatic care. Early referral to a tertiary care center is encouraged if there are deficiencies in diagnostic or therapeutic expertise or resources. In regions with limited resources, strong preventive measures must be instituted and at least hepatic resection or tumor ablation must be developed.