Hepatocellular carcinoma and cholangiocarcinoma: an update

Abstract

Hepatocellular carcinoma (HCC) is the third most common cause of cancer worldwide and is rising in incidence. Ultrasound is the preferred modality for screening high-risk patients for HCC because it detects clinically significant nodules, widespread availability and lower cost. HCC does not require a biopsy for diagnosis if specific imaging criteria are fulfilled. Transarterial chemoembolization (TACE) is the most common modality used to treat HCC followed by ablation. Cholangiocarcinoma (CCA) is increasing in incidence and the second most common primary malignancy of the liver. There is no effective screening strategy for CCA although magnetic resonance imaging and carbohydrate antigen 19-9 (CA 19-9) are commonly used without proven benefit. Therapy for CCA is challenging and resection, when possible, is the mainstay of therapy. Gemcitabine in combination with cisplatin or biologics may offer a modest survival benefit. Liver transplantation for CCA is associated with reasonable survival in select cases. Molecular diagnostics offer the potential to develop personalized approaches in the management of HCC and CCA.

Keywords::

• ablation
• bile duct cancer
• chemotherapy
• cirrhosis
• liver cancer
• resection
• transplant
• treatment

Financial & competing interests disclosure

MW Russo has been a speaker and consultant for Bayer. DA Iannitti has been a Consultant for Coviden, Baxter and angiodynamics. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The incidence of hepatocellular carcinoma (HCC) is rising largely due to the aging population of baby boomers with hepatitis C and the prevalence of obesity and cirrhosis associated with non-alcoholic fatty liver disease.

• Ultrasound every 6 months with or without alpha-fetoprotein is the preferred screening modality for individuals at risk for HCC.

• The diagnosis of HCC in a cirrhotic liver can be made on contrast-enhanced cross-sectional imaging alone for lesions greater than 2 cm that have late arterial enhancement and portal venous washout.

• Transarterial chemoembolization is the most commonly used treatment for HCC in cirrhotic patients because most patients are not resection candidates due to location of the tumor and the presence of underlying liver dysfunction. In practice, most patients undergo combination therapy with two or more of the available therapies, including transarterial chemoembolization, ablation, radioembolization or systemic therapy. More data are needed on the efficacy and safety of combination therapy.

• HCC and cholangiocarcinoma (CCA) are relatively chemo- and radioresistant. Although some progress has been made in targeted therapy against HCC with the development of sorafenib, there has been little progress against CCA with only modest, if any benefit with gemcitabine alone or in combination with other therapeutics. Photodynamic therapy may improve outcomes in select patients and should be considered in treatment algorithms.

• Liver transplantation for HCC has been well studied and widely used in select patients with success. The role of liver transplantation for CCA has not been as widely studied and although select patients may benefit from transplant results need to be reproduced before widespread implementation.

• Molecular diagnostics, such as genomic sequencing or microarray profiling, have the potential to develop targeted therapy against specific pathways in the pathogenesis of HCC and CCA and research in this area should be supported.