What is the recommended surgical treatment for hepatocellular carcinoma (HCC)?

Surgical Treatment for Hepatocellular Carcinoma

Surgical resection is the preferred first-line treatment for HCC in non-cirrhotic livers, while the choice between resection, transplantation, and ablation in cirrhotic patients depends on tumor size, liver function (Child-Pugh class), portal hypertension severity, and future liver remnant volume. 1

Treatment Algorithm Based on Clinical Scenario

For Non-Cirrhotic Liver

• Surgical resection is the definitive treatment regardless of tumor size, provided complete R0 resection can be achieved without causing postoperative liver failure 1
• 5-year survival rates reach 50-68% in experienced centers with perioperative mortality of 2-3% 1, 2

For Cirrhotic Liver with Compensated Function

Solitary HCC of Any Size

• Surgical resection is first-line treatment when all of the following criteria are met: 1
  • Child-Pugh class A liver function
  • Absence of clinically significant portal hypertension (no varices, ascites, or portal hypertensive gastropathy)
  • Adequate future liver remnant volume (≥20-40% of total liver volume) 2
  • Good performance status

Solitary HCC <2 cm

• Thermal ablation (radiofrequency or microwave) is recommended as first-line treatment alongside resection as an equally valid option 1
• The choice between ablation and resection depends on tumor location and extent of portal hypertension 1
• Liver transplantation is considered second-line in this scenario unless technical/anatomical factors limit ablation or resection efficacy 1

Multifocal HCC Within Milan Criteria

• Liver transplantation is the recommended first-line treatment (solitary tumor ≤5 cm or 2-3 nodules ≤3 cm) 1
• Living donor liver transplantation achieves 1-, 3-, and 5-year survival rates of 85%, 75%, and 70% respectively 1, 2

For Cirrhotic Liver with Decompensated Function

• Liver transplantation is the only recommended first-line treatment for patients with HCC within accepted criteria 1, 3
• Child-Pugh class C patients should NOT undergo resection due to prohibitive risk of postoperative liver failure 1, 2

Key Assessment Parameters

Liver Function Evaluation

• Child-Pugh classification is mandatory for surgical candidacy determination, based on bilirubin, albumin, prothrombin time, ascites, and encephalopathy 1
• Indocyanine green retention rate is used in East Asian centers to determine extent of safe resection 1
• MELD score assessment is essential for transplant prioritization 3

Portal Hypertension Assessment

• Clinically significant portal hypertension is a contraindication to resection 1
• Surrogate markers include esophageal varices, ascites, and portal hypertensive gastropathy 1
• Hepatic venous pressure gradient measurement provides objective assessment when available 1

Tumor-Related Contraindications

• Vascular invasion and extrahepatic metastases are absolute contraindications to liver transplantation 1
• Regional lymph node metastases are associated with decreased survival after resection 1

Special Surgical Considerations

Laparoscopic Approach

• Laparoscopic resection should be recommended in suitable patients with appropriate tumor location and surgeon expertise 1
• This approach offers reduced morbidity while maintaining oncological outcomes 1

Extended Indications for Resection

• Multifocal disease may be considered in highly selected patients not suitable for transplant 1
• Tumors with vascular invasion can be resected in highly selected cases, though outcomes are inferior 1
• Post-rupture HCC into peritoneal cavity may warrant emergency resection 1

Perioperative Management

Neoadjuvant Therapy for Transplant Candidates

• Patients listed for transplant should receive locoregional therapy while waiting if technically feasible 1, 3
• This reduces waiting list dropout from disease progression and provides information about tumor biology 1

Adjuvant Therapy Post-Resection

• Atezolizumab plus bevacizumab improves recurrence-free survival after resection, though longer-term follow-up data are still needed 1, 3
• Antiviral therapy is critical for HBV/HCV-related HCC to reduce postoperative decompensation and late recurrence 3

Critical Pitfalls to Avoid

• Do not perform extensive lobectomy or hemihepatectomy when limited resection suffices, as this unnecessarily compromises liver function and increases morbidity 4, 5
• Do not offer resection to Child-Pugh class C patients, as mortality risk is prohibitive 1, 2
• Do not proceed with transplantation in patients with macrovascular invasion or extrahepatic disease, as outcomes are universally poor 1
• Do not assume anatomical resection is always superior to non-anatomical resection, as margin adequacy and preservation of liver function are more critical than anatomical boundaries 6

Staging Framework

• The Barcelona Clinic Liver Cancer (BCLC) staging system should be used for treatment allocation, as it incorporates tumor burden, liver function, and performance status 1, 3
• This system has been extensively validated and is most widely used in Europe and the United States 1