Role of image-guided therapies in hepatocellular carcinoma

Treatment of hepatocellular carcinoma (HCC), even though fourth in frequency among all malignancies, have not yet achieved a general consensus.

HCC usually coexists with an underlying hepatic chronic disease, generally virus correlated. According to the stage, one disease will prevail over the other. For such reason, therapies should not worsen liver function.
HCC is an organ pathology, so the first nodule detected is only a prelude to others. A study on resected patients demonstrated that multicentricity is already present in 50% of early stages and that 93% of patients with single minute HCC (< 2 cm) presented other nodules within 5 years.

Being multicentric over time HCC needs multistep treatments, unless liver transplantation can be performed. In fact liver transplantation, curing both the diseases, is the only option able to offer a definitive cure.
However, because of the shortage of donors, the strict selection of recipients (Milano criteria), the high costs and the ethical reasons in some countries, liver transplantation is available only for a minority of patients.

The other treatments, as partial resection (according to a Japanese nationwide survey, only 1.6% of all resected patients presenting intrahepatic recurrence was re-resected) or percutaneous ablation techiques (PAT), can only prolong the survival achieving a definitive cure only locally. Several factors (site, size, number of nodules, age, liver function, type of vascularization, local expertise) lead to the treatment choice. Even though a general agreement was reached for the treatment of some presentations, no unequivocal evidence exists to establish the best treatment for borderline patients.
For instance, according to the Barcelona Liver Unit Classification, for patients presenting the very early stage (single nodule < 2 cm), for some presenting the early stage (single nodule ranging between 2 and 5 cm, or multiple till 3 nodules and till 3 cm), and for those with the intermediate stage (> 3 nodules without portal thrombosis and extrahepatic disease).
In such patients the controversy among the referral centers is about the choice between resection and PAT, among PAT, or  between transarterial chemoembolization (TACE) and no treatment .