**6. Surgical therapies for HCC**

#### **6.1 Surgical resection for Hepatocellular carcinoma**

Surgical resection is contraindicated in patients with decompensated liver disease or Child's B-C classifications. In patients with Child's A cirrhosis and lack of portal hypertension, resection can be offered as an alternative to transplantation. The advantages of resectional therapy over liver transplantation include: no waiting time, no need for long-term

In Percutaneous Ethanol Injection (PEI), ultrasound guidance is used to deliver ethanol over 4-8 sessions performed 1-2 times per week. Its mechanism of action is inducing local tumor necrosis as a result of cellular dehydration, protein denaturalization, and chemical occlusion of tumor vessels (Pompili, 2005). PEI is most effective in treating nodules <3 cm and is overall better tolerated than TACE. However, its major limitation is a high local recurrence rate, which can reach up to 43%. Other limitations include a long treatment time. Overall, RFA has better outcomes than PEI and is better tolerated. In one study, the overall 1-2 year survival rates were higher among patients treated with RFA versus PEI were 86% and 64% versus 77% and 43% respectively (Lencioni, 2010). PEI has similar limitations but less

efficacy than RFA and is infrequently used in North America for treatment of HCC.

lung shunt < 16%, and ECOG performance < 2 (Carr, 2004).

\$4,047 for treatment and consultation (Wigg, 2010).

**6.1 Surgical resection for Hepatocellular carcinoma** 

**5.6 External Beam Radiation Therapy** 

**6. Surgical therapies for HCC** 

Treatment with Yttrium glass microspheres occurs when a catheter is placed in the hepatic artery and the Therasphere vial, which is comprised of silica containing Yttrium, is rapidly injected. The intent is to deliver 125–150 Gy (12,500 –15,000 rads) of radiation to the tumor or tumors. In a study of 65 patients treated from August 2000 to August 2003, 42 patients (64.6 %) had a significant decrease in tumor size within 4 months. The median survival among Okuda stage I patients was 649 days in historical comparison to a median of 244 days. The median survival among Okuda stage II patients was 302 days in historical comparison to a median of 64 days (Carr, 2004). A benefit of this procedure is that it is generally better tolerated than TACE. Drawbacks are potential radiation to other organ systems and elevated cost. Also, it is also contraindicated in patients with severe liver synthetic dysfunction. To be eligible for treatment, a patient must be relatively wellcompensated, with a bilirubin < 2.0 mg/dL, creatinine < 2.0 mg/dL, platelets > 60 K/L, a

External Beam Radiation Therapy (EBRT) occurs when radiation is delivered to a tumor after the placement of fiducial markers, which are markers are implanted via sterilized needles under ultrasound or CT guidance. Some clinical reports have demonstrated response rates to EBRT ranging from 80-87.5 for small HCC. EBRT may achieve a 10-12 log decrease in tumor, compared to up to 6 logs associated with chemotherapy. An advantage is that EBRT can be delivered to multiple lesions regardless of the proximity of the tumor or tumors to major hepatic vessels or bile ducts. Another advantage is that it is less costly than procedures such as treatment with Yttrium glass Microspheres: an estimation of EBRT is

Surgical resection is contraindicated in patients with decompensated liver disease or Child's B-C classifications. In patients with Child's A cirrhosis and lack of portal hypertension, resection can be offered as an alternative to transplantation. The advantages of resectional therapy over liver transplantation include: no waiting time, no need for long-term

**5.4 Percutaneous Ethanol Injection (PEI)** 

**5.5 Yttrium microspheres** 

immunosuppression, can be offered to older patients, cost and transplant can be reserved as a salvage therapy. However, liver transplantation can cure not only HCC but also cures the cirrhosis in the remnant liver. Therefore, cancer recurrence in the remnant liver is a significant disadvantage for the resected patients. Poor prognostic factors identified after liver resection for HCC are microvascular invasion, positive margins and older age groups (>65 years old).When resection was offered to patients within Milan criteria, patients with solitary tumors (5 cm or less) had a significantly better 5-year survival rate of 70% versus 46% in patients with 2-3 tumors less than 3 cm (Fan, 2011).In a meta-analysis of the medline database, the 1, 3 and 5 year survivals for liver resection of HCC were 80%, 55% and 37%, respectively. In the same study, liver transplantation for HCC carried a 1, 3 and 5 year survivals of 80%, 70% and 62%,respectively (Morris-Stiff, 2009).
