HJNO Jul/Aug 2023

HEALTHCARE JOURNAL OF NEW ORLEANS I  JUL / AUG 2023 55 Sukesh Manthri, MD Medical Oncologist Terrebonne General | Mary Bird Perkins Cancer Center postoperative adjuvant therapies. Postop- erative antiviral therapy improves outcomes after potentially curative treatment of HCC that is related to HBV or HCV and is rec- ommended for those with an active viral infection. The benefit of any other form of adjuvant therapy remains unproven and is not a standard approach. Unresectable liver-isolated disease Patients who are not candidates for resection because of tumor extent or underlying liver dysfunction may be candidates for one of the following options: • Liver transplantation (if they meet classic Milan criteria, are downstaged to within criteria, or have a potential living donor candidate). • Locoregional liver-directed therapies (e.g., thermal ablation, arterially- directed therapies [embolization and hepatic arterial infusion chemotherapy (HAIC)], and external beam radiation therapy [EBRT], including stereotactic body radiation therapy [SBRT]). • Systemic therapy. Liver transplantation: Liver transplan- tation is a potentially curative therapy for patients with HCC who are not surgical can- didates, typically because of the degree of underlying liver dysfunction. The waiting time for a donor organ can be long and var- ies significantly from region to region and country to country. Even among patients within the Milan criteria who have higher priority MELD exception scores, waiting times for a donor organ may be longer than one year. Bridging therapy is generally rec- ommended for patients with an estimated OVERVIEW OF TREATMENT OPTIONS Potentially resectable disease Patient selection for hepatic resection: Hepatic resection is a potentially curative therapy and the preferred treatment for eli- gible patients. The ideal patient for resection has a solitary potentially resectable HCC confined to the liver that shows no radio- graphic evidence of invasion of the hepat- ic vasculature and well-preserved hepatic function (Child-Pugh class A) without evi- dence of portal hypertension. Judging the resectability of a tumor is highly dependent on the skill, expertise, and comfort level of the surgeon and center. While most centers agree that Child-Pugh class B cirrhosis or portal hypertension are strong relative con- traindications to resection, limited resection might be feasible in selected patients. Resection versus ablation: Most patients who are eligible for resection are also candi- dates for thermal ablation. Thermal ablation is a less morbid procedure, and long-term outcomes may be similar, particularly for tumors <2 cm in size. The benefit of radiofre- quency ablation (RFA) relative to resection for potentially resectable HCC has been ad- dressed in several randomized trials, which have had mixed results; some conclude that surgery is superior, while others note simi- lar outcomes. AmericanAssociation for the Study of Liver Diseases suggests resection over RFA for adults with Child-Turcotte- Pugh class A cirrhosis, mainly if resection can be done using a laparoscopic approach, which reduces patient recovery time. Role of adjuvant therapy: The high re- currence rate of HCC after surgical resec- tion has prompted a search for effective Serummarkers The most commonly used serum marker for HCC is serum alpha-fetoprotein (AFP) concentration. AnAFP level of 20 ng/mL is a commonly-used threshold to trigger an evaluation for HCC in clinical practice. Se- rum AFP levels >400 ng/mL in a high-risk patient are nearly diagnostic of HCC, with a specificity of >95%. ElevatedAFP levels are not specific for HCC and may reflect viral hepatitis or decompensated liver disease. AFP had a sensitivity of approximately 60% and a specificity of approximately 80% for the detection of HCC. Because of low sensi- tivity and specificity, AFP is not used as the primary surveillance test for HCC. DIAGNOSTIC APPROACH For patients at high risk for developing HCC, the diagnosis can be made with dy- namic contrast-enhanced computed tomog- raphy (CT) or magnetic resonance imaging (MRI) tailored for liver lesion evaluation. For patients who have chronic, noncir- rhotic, nonviral liver disease and who have a suspicious liver lesion (of any size) on ul- trasound, we obtain a contrast-enhanced CT or MRI of the abdomen tailored for liver le- sion imaging andAFP for further evaluation. IMPORTANCE OF MULTIDISCIPLINARY CARE We strongly urge that patients with HCC (especially liver-localized HCC) be referred to specialized centers of excellence with multidisciplinary expertise so that the en- tire range of potentially available treatments can be offered, along with monitoring, as- sessment, and treatment of the underlying liver disease.