Liver Cancer
Hepatocellular carcinoma is one of the more common causes of cancer deaths worldwide. Not unexpectedly, the highest incidence of this disease is in hepatitis B endemic areas, although I think we all are expecting more of an impact from hepatitis C over the next few decades. As everyone knows, cirrhosis is a premalignant condition and as many patients in this country and around the world progress to cirrhosis it is somewhat unpredictable, I think, how much of a problem hepatocellular carcinoma is going to become, but I suspect it’s going to be more significant.
Cancer treatment
Surgical resection exists in those patients with well maintained liver function. Percutaneous ethanol injection, if you have a radiologist with a steady hand. Of course, orthotopical re-transplantation for a selected group of patients, chemo-embolization, transarterial chemo-embolization, or simply transarterial embolization without chemotherapy, and experimental medical therapy which is coming to the fore. And I’m not going to say much about this because currently there is little applicability with regard to these modalities. One reason why hepatocellular carcinoma, for example, may be somewhat resistant to treatment is because of the discovery of the multi-chemo resistant drug, or P-53 mutations, but all the patients with hepatoma don’t have P-53 mutations so simply inserting a wild-type P-53 is not necessarily going to help these patients. And then of course gene therapy. I think we are unfortunately away from routine applicability from any of these modalities.
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Liver transplantation for hepatoma initially gave poor results, unacceptable results, because these early studies basically included patients with advanced disease. I think that after this initial attempt, most people in the transplant community became disappointed and disillusioned about transplanting for this disease. However, after 1990 we began to understand that we simply had to be more selective in who was transplanted for hepatocellular carcinoma. Candidates are those people who have small tumors and of course poor liver function. In other words, people who would probably be headed for the transplant list even if they didn’t have a hepatoma. We are concerned about this issue of so-called field cancerization therapy, similar to scirrhous lung carcinoma, and that is; what happens if we actually perform a subsegmental or segmental resection for a patient who has hepatitis B, hepatitis C or hemochromatosis when we leave behind the fertile field that led to the development of that cancer, and it will likely lead to the development of another cancer? This issue of arising alpha-fetoprotein without detectable hepatocellular carcinoma tells us that this is a patient who should be moving toward a transplant program, likely. And finally, what is the role of preoperative chemo-embolization in these patients? I would submit to you that although we at Mayo are generally pro chemo-embolization, we have only preliminary data to suggest that it’s helpful.