What is the gold standard and treatment of choice for primary liver (hepatic) cancer?

Hepatic Resection is the Gold Standard Treatment for Primary Liver Cancer

Hepatic resection is the first-line treatment and gold standard for primary liver cancer (hepatocellular carcinoma) in patients with solitary tumors and well-preserved liver function. 1, 2

Treatment Selection Based on BCLC Staging

• For early-stage HCC (BCLC 0 and A), surgical resection is the treatment of choice, achieving 5-year survival rates of 60-80% in well-selected candidates 1, 2
• Resection is specifically recommended for patients with:
  • Solitary tumors with very well-preserved liver function 1
  • Normal bilirubin with either hepatic venous pressure gradient ≤10 mmHg or platelet count ≥100,000 1
  • No evidence of portal hypertension 1
• Anatomical resections are preferred when technically feasible to achieve better oncological outcomes 1
• For non-cirrhotic patients (5% of cases in Western countries, 40% in Asia), major resections can be performed with low complication rates and acceptable outcomes (5-year survival: 30-50%) 1

Alternative Treatment Options

• Liver transplantation should be considered for patients who meet Milan criteria (single tumor ≤5 cm or up to three nodules ≤3 cm) but have decompensated cirrhosis 1, 2
• Radiofrequency ablation (RFA) is an alternative for single nodules <2 cm (BCLC stage 0) or for early-stage patients who are not candidates for resection 1
• For intermediate-stage HCC (BCLC B), transarterial chemoembolization (TACE) is the standard of care 1, 2
• For advanced HCC (BCLC C), systemic therapy with atezolizumab plus bevacizumab is the current preferred first-line treatment, with sorafenib or lenvatinib as alternatives 3, 4

Preoperative Assessment and Surgical Planning

• Future liver remnant (FLR) calculation is crucial before major resections, with minimum requirements of ≥20% for normal liver, ≥30% for chronic liver disease, and ≥40% for cirrhotic liver 2
• Portal vein embolization may be considered when FLR is inadequate to induce hypertrophy of the future liver remnant 2, 1
• Expected perioperative mortality for liver resection in cirrhotic patients is 2-3% in experienced centers 1

Post-Treatment Monitoring and Recurrence Management

• Tumor recurrence is the major complication after resection, with recurrence rates as high as 50-60% at 5 years 1
• Follow-up should consist of clinical evaluation and dynamic CT or MRI studies every 3 months for the first 2 years and every 6 months thereafter 1, 2
• In case of recurrence, patients should be reassessed by BCLC staging and retreated accordingly 1

Important Considerations and Pitfalls

• Neo-adjuvant or adjuvant therapies have not proven to improve outcomes for patients treated with resection 1
• For patients requiring downstaging before definitive therapy but for whom surgery is not an option due to resource constraints, locoregional therapies rather than neoadjuvant chemotherapy are preferred 1
• Response assessment should be based on dynamic CT or MRI studies using modified RECIST criteria 1, 3
• Antiviral therapy is important for patients with HBV or HCV-related HCC to reduce the risk of postoperative decompensation and prevent late recurrence 2

Based on the most recent and highest quality evidence, hepatic resection remains the gold standard treatment for primary liver cancer in patients with preserved liver function and resectable disease.