Image-guided ablation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is increasingly diagnosed at an early, asymptomatic stage owing to surveillance of high-risk patients. Patients with early stage HCC require careful diagnostic and therapeutic management. Diagnostic confirmation of small nodules detected in cirrhotic livers may be challenging. It is very difficult to distinguish well-differentiated tumors from non-malignant hepatocellular nodules on biopsy specimens. Careful assessment of lesion vascularity – through the use of state-of-the-art dynamic imaging techniques – can provide a reliable non-invasive diagnosis. Given the complexity of the disease, multidisciplinary assessment of tumor stage, liver function and physical status is required for proper therapeutic planning. Patients with early stage HCC should be considered for any of the available curative therapies, including surgical resection, liver transplantation and percutaneous image-guided ablation. Resection is currently indicated among patients with solitary HCC and extremely well-preserved liver function, who have neither clinically significant portal hypertension nor abnormal bilirubin. Liver transplantation benefits patients who have decompensated cirrhosis and one tumor smaller than 5 cm or up to three nodules smaller than 3 cm, but donor shortage greatly limits its applicability. This difficulty might be overcome by living donation; that, however, is still at an early stage of clinical application. Image-guided percutaneous ablation is the best therapeutic choice for nonsurgical patients with early stage HCC. Although ethanol injection has been the seminal percutaneous technique, radiofrequency ablation has emerged as the most effective method for local tumor destruction and is currently used as the primary ablative modality at most institutions.