Hepatocellular carcinoma (HCC) is responsible for a large proportion of cancer deaths worldwide. HCC is frequently diagnosed after the development of clinical deterioration at which time survival is measured in months. Long-term survival requires detection of small tumors, often present in asymptomatic individuals, which may be more amenable to invasive therapeutic options. Surveillance of high-risk individuals for HCC is commonly performed using the serum marker alfa-fetoprotein (AFP) often in combination with ultrasonography. Various other serologic markers are currently being tested to help improve surveillance accuracy. Diagnosis of HCC often requires more sophisticated imaging modalities such as CT scan and MRI, which have multiphasic contrast enhancement capabilities. Serum AFP used alone can be helpful if levels are markedly elevated, which occurs in fewer than half of cases at time of diagnosis. Confirmation by liver biopsy can be performed under circumstances when the diagnosis of HCC remains unclear.
Each year 500 000 to 1 million individuals are diagnosed with hepatocellular carcinoma (HCC) worldwide [1]. Incidence rates demonstrate dramatic geographic variability, ranging from < 5 new cases per 100 000 persons per year in developed western countries to > 100 per 100 000 persons per year in parts of south-east Asia and sub-Saharan Africa [2]. Although the United States is among regions of low incidence, a 70% increase in HCC has been observed over the past two decades, apparently related to the emergence of chronic hepatitis C [3]. The life expectancy of patients with HCC is poor, with a mean survival of 6-20 months and likely reflects the mortality/incidence ratio, which is close to 1 [4,5]. These figures have remained steady despite substantial progress in the diagnostic and therapeutic arena of HCC.
Removal of HCC by surgical means offers the best chance for possible cure. Criteria for such intervention have been refined over the last decade to optimize long-term survival in selected patients. Unfortunately < 20% of patients meet the criteria for resection at time of diagnosis [6]. The focus of much research revolves around diagnostic strategies to identify early HCC, defined by size of tumor and number of lesions. Diagnostic tools commonly used include the serum tumor marker alfa-fetoprotein (AFP), radiographic imaging, and liver biopsy. No universal guidelines for diagnosis exist, partly as a result of marked differences in the diagnostic approach between Eastern and Western institutions [7]; however, common themes do emerge which allow for important distinctions and conclusions to be made.