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Modern trends in the management of hepatocellular carcinoma.

No treatment of proven validity in hepatocellular carcinoma (HCC) has yet been found, with the exception of surgery in a small subset of patients. Furthermore, there is a paucity of phase I and II trials and of phase III prospective randomized trials. Radiation therapy is not considered very effective, even as a palliative procedure, but there has been renewed interest in this modality, with several ongoing trials attempting to establish optimal doses, fractionation and effectiveness. Chemotherapy, single or combination, has not increased the survival of patients with HCC, although there have been unquestionable, even spectacular, responses to chemotherapy. Adriamycin seems the most effective agent with approximately 25% objective responses. The regional administration of drugs and/or interruption of arterial supply, in this malignancy with a pattern of local confinement, yields quite high response rates but no increase in survival. Several trials with combined therapeutic modalities are now in progress. Furthermore, there have been important advances in nuclear medicine, in the totally implantable pump, in the understanding of pharmacokinetics and in microspheres, monoclonal antibodies, etc. It is remarkable that there have been so few randomized trials in such a common malignancy. To obtain valuable results any future studies should randomize patients into "treatment" and "no treatment" groups and stratify patients according to prognostic factors. It seems, however, that the combination of local and systemic treatment is the most promising answer to this virulent and fatal disease.