[Treatment of hepatocellular carcinoma in the presence of liver cirrhosis].

Hepatocellular carcinoma accounts for 90% of the primary malignant liver tumours. Most cases occur in cirrhotic livers. Management decisions should not be based on the stage of the tumour extension but rather on the functional situation of the liver. The first therapeutic option which should be considered is surgical resection if the case presents with a single tumour (or less than 4 tumours for some teams) without detectable metastasis nor intraportal thrombosis and if the liver remaining 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 carcinoma has produced clinical signs but it can be a possibility in case of a resectable tumour in the framework of a prospective protocol comparing transplantation and resection. Intra-arterial injection of 131-iodine linked lipiodol is the only effective treatment in case of portal thrombosis. Chemoembolization of nonresectable hepatocellular carcinoma has led to spectacular tumour response but its effect on survival has not been demonstrated by randomized studies. For tumours less than 3 cm in diameter, even multifocal alcoholization has proved encouraging 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 future, especially with proton irradiation. Thus the current management of hepatocellular carcinoma is in a difficult, even paradoxical, situation 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.