Primary Liver Cancers with a Focus on (HCC) Hepatocellular Carcinoma

Hepatocellular cancer (HCC) and cholangiocarcinoma represent the most common forms of liver cancer with the former accounting for over 80% of cases1 . Cholangiocarcinomas arise from the bile ducts and will not be discussed in this article however should be highlighted as a rising cause of liver cancer. Indeed the numbers of new cases and deaths from liver cancer are expected to increase by more than 55% by 20401. This highlights the urgent need for national strategies and international collaboration to deal with this impending disease burden. The management of HCC has seen remarkable changes in the past 5 years. Up until 2017 sorafenib was the only drug available to patients with advanced HCC. We now have two new standard immune checkpoint inhibitor (ICI) combinations in the first line setting, demonstrating superiority over sorafenib while lenvatinib represents a further oral therapy. A number of additional oral tyrosine kinase inhibitors have shown benefit in the second line setting. It is now inevitable that these agents will be integrated earlier in the management of HCC, with trials in the adjuvant and neoadjuvant setting ongoing. How countries will cope with the cost of these new therapies has not been addressed and highlights continued global disparities in cancer care.

Hepatocellular carcinoma is the 3rd most common cause of cancer related mortality world-wide with an estimated 5 year survival rate of 18%. The majority of HCC arise on a background of chronic liver disease with 80-90% of patients having underlying liver cirrhosis. HCC most commonly occurs in the 6th decade and occurs more frequently in males. The spectrum of underlying liver disease varies globally with a predominance of hepatitis B and C in Asia while alcohol and non-alcoholic fatty liver disease (NAFLD) dominate in Western Societies. Less common causes of HCC include haemochromatosis, alpha-1antitrypsin deficiency and drug induced liver injury.