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      Tratamiento del carcinoma hepatocelular Translated title: Treatment of hepatocellular carcinoma

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          Abstract

          El carcinoma hepatocelular aparece en el 90% de los casos sobre una cirrosis hepática. Su alta prevalencia está relacionada con el ascenso de la infección por el virus de la hepatitis C a nivel mundial. De hecho, en el 80% de los casos el tumor se desarrolla en hepatopatías causadas por este virus. El tratamiento quirúrgico, resección o trasplante hepático, continúa siendo de elección pero son pocos los casos en los que está indicado. Las terapias ablativas percutáneas, como inyección de alcohol o radiofrecuencia, son la otras opciones terapéuticas con intención radical cuando el tumor no es tributario de resección o trasplante. Desafortunadamente, tan sólo un 15-20% pueden beneficiarse de estos tratamientos con intención curativa. La quimioembolización constituye una alternativa cuando las opciones previas están contraindicadas aunque sus beneficios sobre la supervivencia continúan siendo controvertidos. Los nuevos fármacos, como tamoxifeno, interferon y quimioterapia no han conseguido demostrar ningún efecto sobre la sintomatología o la supervivencia.

          Translated abstract

          Hepatocellular carcinoma develops in more of 90% of patients in the setting of cirrhosis. The increasing prevalence seems related with the wide-spread distribution of hepatitis C virus infection, as 80% of cases arise on chronic infection caused by this agent. Either conventional resection or orthotopic liver transplantation are often curative but suitable for few patients, If the surgical approach is not adequate, percutaneous ablation using ethanol injection or radiofrequency current may be considered. However, only 15-20% of patients can benefit from these therapies. Chemoembolization is considered when the previous options are contra-indicated but benefits on survival are still a matter of debate. The impact of new agents as tamoxifen, interferon o diverse chemotherapies on both survival and symptoms also remains to be stablished.

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          Most cited references46

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          Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure.

          Although resection of hepatocellular carcinoma complicating cirrhosis is restricted to patients with preserved liver function, postoperative hepatic decompensation develops in some patients. The aim of this study was to determine the value of increased portal pressure in the development of postoperative hepatic decompensation. Twenty-nine cirrhotic patients with Child-Pugh's class A disease and hepatocellular carcinoma (all except one < 5 cm) scheduled to undergo resection were evaluated by conventional criteria and by a systemic and hepatic hemodynamic study. Predictors of decompensation were assessed among a series of 44 clinical, analytical, tumoral, and hemodynamic parameters. Eleven patients had unresolved decompensation 3 months after surgery. Bilirubin and blood ureic nitrogen levels, platelet count, wedged hepatic venous pressure, hepatic venous pressure gradient, and indocyanine green intrinsic clearance were significantly associated with unresolved decompensation, but only hepatic venous pressure gradient was significant, in the multivariate analysis (P = 0.0001; odds ratio, 1.90; 95% confidence interval, 1.12-3.22). The preoperative gradient of patients with unresolved decompensation was higher than that of patients without it (13.9 +/- 2.4 and 7.4 +/- 3.5 mm Hg, respectively; P < 0.001). Cirrhotics with increased portal pressure are at high risk of hepatic decompensation after resection of hepatocellular carcinoma. Surgical resection should therefore be restricted to patients without portal hypertension.
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            Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions.

            To study local therapeutic efficacy, side effects, and complications of radio-frequency (RF) ablation in the treatment of medium and large hepatocellular carcinoma (HCC) lesions in patients with cirrhosis or chronic hepatitis. One-hundred fourteen patients who were under conscious sedation or general anesthesia had 126 HCCs greater than 3.0 cm in diameter treated with RF by using an internally cooled electrode. Eighty tumors were medium (3.1-5.0 cm), and 46 were large (5.1-9.5 cm). The mean diameter for all tumors was 5.4 cm. At imaging, 75 tumors were considered noninfiltrating, and 51 were considered infiltrating. Complete necrosis was attained in 60 lesions (47.6%), nearly complete (90%-99%) necrosis in 40 lesions (31.7%), and partial (50%-89%) necrosis in the remaining 26 lesions (20.6%). Medium and/or noninfiltrating tumors were treated successfully significantly more often than large and/or infiltrating tumors. Two major complications (death, hemorrhage requiring laparotomy) and five minor complications (self-limited hemorrhage, persistent pain) were observed. The single death was due to a break in sterile technique rather than to the RF procedure itself. RF ablation appears to be an effective, safe, and relatively simple procedure for the treatment of medium and large HCCs.
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              Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection.

              To define indications for percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and cirrhosis. Survival rates were determined in 746 patients who had undergone PEI (567 men, 179 women; mean age, 64.3 years; mean follow-up, 36 months). In patients with Child A (n = 293), B (n = 149), or C (n = 20) cirrhosis and single HCCs 5 cm or smaller, the 3-5 year survival rate was 47%-79%, 29%-63%, and 0%-12%, respectively. In patients with Child A cirrhosis, it was 36%-68% for multiple HCCs (n = 121), 30%-53% for single HCCs larger than 5 cm (n = 28), and 0%-16% for advanced HCC (n = 16). Treatment was associated with a 1.7% rate of severe complications and a 0.1% mortality rate. PEI proved safe, effective, and repeatable and had a low cost. Survival after PEI was comparable to that after surgery, probably because of a balancing between greater radicality of surgery and absence of early mortality and liver damage of PEI.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                ami
                Anales de Medicina Interna
                An. Med. Interna (Madrid)
                Arán Ediciones, S. L. (Madrid )
                0212-7199
                October 2002
                : 19
                : 10
                : 43-48
                Affiliations
                [1 ] Hospital Universitario Dr. Peset Spain
                Article
                S0212-71992002001000010
                966fece2-066b-4208-ac70-01ddb5604367

                http://creativecommons.org/licenses/by/4.0/

                History
                Categories
                MEDICINE, GENERAL & INTERNAL

                Internal medicine
                Cirrhosis,Treatment,Hepatocellular carcinoma,Carcinoma hepatocelular,Cirrosis hepática,Tratamiento

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