The true incidence of HCC in Israel is not known. Following the large waves of immigration from Mediterranean countries in the early 1950's and 1960's and more recently from Russia, the number of hepatitis B and C patients has risen several folds in Israel. As a result it is estimated that there are approximately 80,000 hepatitis B virus carriers and about 40,000-50,000 hepatitis C virus carriers in the total Israeli population. In a recent survey conducted by the late Professor Baruch Modan and Professor Daniel Shouval in 22 hospitals in Israel, it was established that there should be about 5,000 patients with cirrhosis of the liver annually, of whom only 10% seek medical advice in hospitals during each year. Among these patients there is an annual HCC incidence of 5%. Thus the expected number of patients who are developing liver tumors is in the range of 200-300 per year. Most of these patients are currently identified at a late stage of their neoplastic disease when treatment is often unsuccessful. Indeed, the Liver Clinic at Hadassah University Hospital has focused in recent years on the early detection, evaluation and treatment of patients with HCC, and as a result the number of referrals of patients with primary liver tumors is rising.

The prognosis of HCC is dismal. Until the 1990's the median survival of patients with HCC has been around 4-10 months from the time of diagnosis depending on the initial presentation of a unifocal or multifocal tumor in the liver, respectively. The only treatment believed to be effective in such patients was surgical resection of small tumors. However, due to the natural history and the multifocal nature of HCC in the Mediterranean area, the number of patients presented with small liver tumors in Israel is small. Patients with HCC (about 80-90%) usually have chronic liver disease and cirrhosis in the background and tumor diameter at clinical presentation ranges between 5-10 cm. Better screening programs for patients with chronic liver disease and cirhosis should enable earlier detection of tumors and as a result increase efficiency of treatment. Most patients with HCC require a multi disciplinary team effort for early detection, treatment and follow-up. The most frequent treatment modalities currently available for patients with HCC are percutaneous intralesional alcohol injection (PEI), transcutaneous arterial chemoembolization (TACE) into the hepatic artery that feeds the tumor and radiofrequency ablation (RFA). Alcohol injection is a treatment that has been developed in Japan and in Italy and it is especially useful in patients with small HCC tumors. Intralesional alcohol injection into tumors with a diameter of <3cm will provide adequate palliation with a 3 year survival rate of 60-70% and a 5 year survival rate of 50-60% which is equivalent or even better as compared with surgical resection reported from Japan. Chemoembolization is based on the injection of poppyseed oil (lipoidol) into the hepatic artery which feeds the liver tumor in suspension together with a chemotherapeutic agent such as adriamycin or mitomycin. This injection into the hepatic artery is taken up by the tumorous liver cells. The lipiodol contains iodine, which also serves as a contrast material, and therefore the uptake and reaction to this mixture within the tumor can be followed by imaging such as a CT scan examination of the liver without acutally injecting any contrast materials. After injection of a suspension of lipiodol and adriamycin, the hepatic artery is occluded temporarily by gel foam. This treatment, when given to patients with small to intermediate size tumors, will provide palliation for a significant number of patients who are unresectable surgically or who are not suitable for alcohol injection. The treatment was developed in Japan and has been adopted by a large number of centers in Europe and in the United States, and requires the presence of an experienced invasive radiologist. At Hadassah Hospital Dr. Anthony Verstandig has gained very valuable experience in performing selective and non-selective chemoembolizations, in a large number of patients (see later). As a result, Dr. Verstandig became the main expert in Israel for this procedure. Patients with HCC have benefited from the experience of Drs. A. Verstandig, A. Blum, T. Sassoon and I. Krichun's skills over the years in the treatment of hundreds of patients with hepatocellular carcinoma. It is important to note that each year there are approximately 4000 patient visits in the Liver Clinic at Hadassah and about 70% of them are carriers of hepatitis C virus. These patients require careful follow-up and when followed, 5-10% of them will develop tumors after the fifth decade of life.

During the years 1989-1998 approximately 300 patients have been evaluated at Hadassah for primary hepatocellular carcinoma. Among these patients, one-third was referred for repeated chemoembolization or intralesional alcohol injection. About 271 chemoembolizations were performed on these 100 patients, mainly through injection of lipiodol and adryamicin into the hepatic artery. Sixteen patients have also undergone surgical resection of the tumor (performed either by Professor Eid or Dr. Jurim) after receiving chemoembolization. Eight patients received both alcohol injection and chemoembolization. In about 2/3 of the patients the size of the tumor was reduced. In 2/3 of the patients with elevated alpha-fetoprotein there was a significant decrease in the level of the tumor marker. The median survival of 100 patients was 19 months. However, in those patients with the preserved hepatic functions as graded by the Okuda Classification 1 (a total of 57 patients), the median survival was 30 months. (!) This figure is an increase of 300% in survival as compared with data from 1980-1984 in the Liver Unit when no chemoembolization was used. The side effects associated with chemoembolization are relatively mild. Most patients develop fever after the procedure and abdominal pain, which usually subsides within two weeks. There was one death associated with chemoembolization as a result of liver failure. Currently, new patients with HCC are detected during routine follow-up of patients with hepatitis B or C, or are referred by other centers. At this time, the number of patients surviving more than 3 years after diagnosis of HCC is rising. Recently Dr. E. Blum of the Department of Radiology introduced a new treatment modality for hepatocellular carcinoma called radiofrequency ablation (RAF). This technology involved the introduction of a special needle into the center of a liver tumor which receives a high input of thermal energy leading to tumor cell necrosis. This treatment modality is an important new addition to the spectrum of therapeutic options for HCC patients.

At this point in time 2-4 patients are referred to the Liver Unit each week with suspected or diagnosed HCC, who require further evaluation and treatment. The Hadassah University Medical Center can today provide all necessary solutions for paliation of this intractatable tumor which include: alcohol injection, chemoembolization, radiofrequency ablation, cryosurgery, surgical resection and liver transplantation.

Through the efforts of the Department of Oncology a similar team is expected to use the same tools for diagnosis and treatment of metastatic liver disease.

Aim:Establishment of a multidisciplinary team of experts who will include hepatologists, oncologists, surgeons, invasive radiologists, hepatologists, and a social worker for diagnosis and management of patients with liver tomors.

Participants in this multidepartmental project will include:
Prof. Daniel Shouval, Liver Unit
Dr. Yizhar Levi, Liver Unit
Dr. Ayala Hubert, Department of Oncology
Dr. Anthony Ferstendig, Department of Radiology
Dr. Alan Blum, Department of Radiology
Prof. Y. Lipson Department of Radiology
Prof. Y. Bar-Ziv, Department of Radiology,
Dr. Orit Pappo, Department of Pathology,
Prof. Achmed Eid, Department of Surgery
Dr. Gideon Zamir, Department of Surgery
A designated social worker

This team is already actively involved in the care of patients with primary hepatocellular carcinoma and meeting regularly to review new patients referred to our clinic