Recent advances in the treatment of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide and continues to have a poor prognosis. Despite surveillance efforts, most tumors are diagnosed at late stages. Surgical resection, liver transplantation, and local ablative therapies such as radio frequency ablation offer the chance of a cure for tumors detected at an early stage in well selected patients. The role of adjuvant or neoadjuvant therapy is being investigated, but there is no clear evidence supporting its routine use at this time. Some have proposed expanding size criteria for transplantation or downstaging tumors detected beyond an early stage, although any benefits must be weighed against the harms to others on the waiting list. For intermediate-stage HCC, transarterial chemoembolization is the mainstay of treatment but is only possible in a minority of patients. The role of radiation therapy for these patients continues to be refined with recent advances in technology minimizing its toxicity to surrounding nonmalignant liver. For patients with advanced HCC, sorafenib is the first systemic therapy to significantly prolong survival and is now considered standard of care for patients with Child A cirrhosis and good performance status. Ongoing trials are evaluating the role of other targeted therapies in patients with advanced HCC.