When is surgery indicated over liver transplant in a cirrhotic patient with Hepatocellular Carcinoma (HCC)?

Surgical Management of HCC in Cirrhotic Patients: Resection vs. Transplantation

Liver resection should be the first-line treatment for cirrhotic patients with HCC when the patient has well-preserved liver function, no significant portal hypertension, and sufficient future liver remnant volume can be maintained. 1

Patient Selection Criteria for Resection over Transplantation

Favorable for Resection:

• Liver Function Parameters:

  • Child-Pugh A cirrhosis 1
  • Carefully selected Child-Pugh B patients may be candidates for minor resections 1
  • Absence of significant portal hypertension (or minimal portal hypertension) 1
  • Adequate future liver remnant volume 1

• Tumor Characteristics:

  • Solitary HCC of any size when liver function is maintained 1
  • Peripheral location amenable to minor resection 1
  • Tumors in anterolateral and superficial locations (especially suitable for laparoscopic approach) 1

• Patient Factors:

  • Good performance status 1
  • Minimal comorbidities 1
  • Non-cirrhotic liver (absolute indication for resection over transplant) 1

Favor Transplantation Instead:

• Decompensated cirrhosis (Child-Pugh B with significant portal hypertension or Child-Pugh C) 1
• Multiple tumors within Milan criteria (one lesion < 5 cm or up to three lesions each < 3 cm) 1
• Central tumors requiring major hepatectomy in a cirrhotic liver 1
• Tumors with macrovascular invasion or extrahepatic spread (contraindication for transplant) 1

Surgical Approach Considerations

• Laparoscopic resection should be preferred when technically feasible, especially for anterolateral and superficial tumors 1
• Minimally invasive approaches result in:
  • Reduced intraoperative blood loss
  • Faster postoperative recovery
  • No compromise to oncological outcomes 1

Special Scenarios

1. Very early HCC (< 2 cm):

   • Both resection and thermal ablation are recommended first-line options 1
   • Transplantation considered second-line for these small tumors 1

2. Multifocal disease:

   • Transplantation preferred if within Milan criteria 1
   • Resection may be considered for multifocal disease in patients not suitable for transplant 1

3. Post-resection recurrence:

   • Patients with high-risk pathological findings (microvascular invasion, poor differentiation) may be considered for salvage transplantation 1

Important Caveats and Pitfalls

• Do not perform major resections (>2 segments) in patients with significant portal hypertension or Child-Pugh B cirrhosis 1
• Avoid resection as a downstaging procedure for HCC beyond Milan criteria to meet transplantation eligibility 1
• Beware of high recurrence rates after resection (50-70% within 5 years) 1
• Consider future liver remnant volume carefully to prevent post-hepatectomy liver failure 1
• Do not overlook metabolic-related conditions in patients with MASLD (metabolic-associated steatotic liver disease) and HCC, as they may experience higher perioperative morbidity 1

Post-Resection Management

• Adjuvant therapy after resection is not recommended based on current evidence 1
• Close surveillance for recurrence is essential given the high recurrence rates 1

By following these guidelines, clinicians can appropriately select cirrhotic HCC patients who would benefit from resection over transplantation, optimizing both short-term surgical outcomes and long-term survival.