Abstract
Primarymalignant tumor of the liver, hepatocellular carcinoma (HCC) occurs almost always with an underlying chronic liver disease, commonly but not necessarily at cirrhosis stage. In developed countries, chronic hepatitis C and nonalcoholic fatty liver disease frequently associated with metabolic syndrome are the major risk factors for HCC, thus explaining its increasing incidence in the recent years. Liver transplantation, liver resection and radiofrequency ablation are the three potentially curative therapeutic possibilities available for the treatment of HCC. The choice of treatment depends on the following factors: a nontumorous liver, age, comorbidities of the patient, and size and number of the lesions. Liver transplantation (LT) appears to be the best theoretical treatment for removing all lesions with optimal margins and treating the underlying liver disease at the same time. However, graft shortage and stringent selection criteria for oncological reasons hamper its use in all patients. More than 10 years after their adoption by the transplant community, Milan criteria remain the corner stone of the indications of LT for HCC. Liver resection (LR) is an alternative option, particularly to treat HCC without cirrhosis or as a bridging therapy to LT. However, its significant operative risk and high rate of recurrence need to be considered before treatment. Radiofrequency ablation helps in the treatment of early-stage HCC with lower morbidity than LR, but its efficiency is impaired by the size of the lesion. Although LT offers the best chance for cure it is not suitable for all patients, and indications of treatment is still a matter of debate. Recent advances in molecular biology of the tumor and non-tumorous liver should help to better assess prognosis and thus to refine indications.
Résumé
Première tumeur maligne primitive du foie, le carcinome hépatocellulaire (CHC) survient presque toujours dans le cadre d’une hépatopathie chronique sous-jacente souvent, mais pas nécessairement à un stade de cirrhose. Dans les pays à haut niveau socio-économique, l’hépatite chronique virale C et le syndrome métabolique par l’intermédiaire de la stéatose hépatique souvent associée en sont les principaux facteurs de risque, ce qui explique l’augmentation de l’incidence du CHC ces dernières années. La transplantation hépatique (TH), la résection et la destruction par radiofréquence constituent les trois seules options thérapeutiques potentiellement curatives. Le choix du traitement repose sur le foie non tumoral, en particulier l’existence d’une cirrhose, l’âge et les comorbidités du patient et enfin la taille et le nombre des lésions. En permettant une exérèse de l’ensemble des lésions avec des marges maximales tout en traitant dans lemêmetemps lamaladie hépatique sous-jacente, la TH apparaît comme la meilleure option. Néanmoins, la pénurie de greffons et des critères de sélection stricts ne la rendent pas applicable à l’ensemble des patients. Encore aujourd’hui, plus de dix ans après leur adoption, les critères de Milan restent le socle des indications de TH pour CHC. La résection hépatique est une alternative possible en particulier en l’absence de cirrhose ou comme traitement d’attente avant TH mais s’accompagne d’un risque opératoire et un taux de récidive significatif. Enfin, la destruction par radiofréquence peut permettre de traiter des « petits » CHC avec une morbiditémoindre que la résection, mais son efficacité est limitée par la taille de la lésion. Sachant que la TH est lemeilleur traitement, mais qu’il n’est pas applicable à tous, les indications de traitement restent encore débattues. L’amélioration de l’évaluation du pronostic par les progrès récents de la biologie moléculaire de la tumeur et de son environnement péritumoral devrait permettre de préciser les indications.
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Adam, R., Allard, M.A. Chirurgie du carcinome hépatocellulaire: de l’exérèse à la transplantation: indications actuelles et futures. Oncologie 14, 164–173 (2012). https://doi.org/10.1007/s10269-012-2133-1
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DOI: https://doi.org/10.1007/s10269-012-2133-1