Hepatocellular carcinoma (HCC) accounts for more than 90% of primary liver tumors and is therefore a major public health problem. It is the sixth most common cancer worldwide (800,000 new cases per year, 80% in developing countries) and the second leading cause of cancer deaths (750,000 deaths per year worldwide).
In 90% of cases, HCC develops in the context of chronic liver disease (chronic hepatitis and/or cirrhosis), which can be caused by viruses (HBV, HCV), metabolic disturbances (alcohol, metabolic syndrome associated with obesity and diabetes), or genetic diseases (e.g., hemochromatosis). Other factors, such as smoking or, in developing countries, exposure to aflatoxin B, also contribute to the occurrence of HCC.
The incidence of HCC is highest in South-East Asia and Central Africa, where the endemic prevalence of hepatitis B virus is responsible for 70% of cases. The incidence of HCC is increasing worldwide, particularly in Europe and the United States, due to hepatitis C virus infections, and both the obesity epidemic and metabolic syndromes associated with stearate non-alcoholic hepatitis (non-alcoholic steatohepatitis, NASH).
HCC can be detected in a variety of situations, such as routine screening for chronic liver disease, the presence of digestive symptoms, such as abdominal pain, palpation of a liver mass, weight loss, and anomalies in biological findings for hepatic function. Chronic liver disease and/or cirrhosis are often diagnosed at the same time as HCC. The diagnosis of HCC is based on non-invasive imaging (radiology) techniques, including CT or MRI with contrast injection, when combined with cirrhosis. HCC usually presents as a richly vascularized tumor located inside the liver. The diagnosis of HCC is also often made by examining a liver biopsy if imaging is atypical and/or in the absence of cirrhosis.
HCC is a complex disease for which the prognosis and therapeutic indication are influenced by multiple factors: hepatic function, stage of the cancer, and general condition of the patient.
Treatment is determined by the BCLC (Barcelona-Clinic Liver Cancer) stage of the HCC. Curative treatments are offered to patients at the earliest stages (BCLC 0 or A): surgical resection, percutaneous ablation and/or liver transplantation. More than 70% of patients with inoperable cancer (BCLC B or C) require chemoembolization, radioembolization, or systemic chemotherapy. HCC is one of the most chemically resistant cancers and the use of cytotoxic agents is frequently limited by poor liver function, which increases their toxicity. For the BCLC C stage, only antiangiogenic agents (sorafenib) have been shown to provide any benefit, albeit modest, in terms of survival, with side effects that may make it difficult to administer it to patients with impaired liver function. Encouraging results have been observed for some immunotherapies, which are currently being explored.