What is the recommended treatment approach for a patient with hepatocellular carcinoma (HCC), liver cirrhosis, and schistosomiasis, considering hepatic resection as an option?

Hepatic Resection for HCC in Cirrhosis with Schistosomiasis

Hepatic resection can be performed in patients with HCC, liver cirrhosis, and schistosomiasis if they meet strict criteria: Child-Pugh class A, absence of clinically significant portal hypertension (HVPG ≤10 mmHg or platelet count ≥100,000), adequate future liver remnant volume, and solitary tumor with preserved liver function. 1

Critical Assessment Parameters

The decision to proceed with hepatic resection requires multiparametric composite assessment to ensure perioperative mortality remains below 3% and morbidity below 20%: 1

• Liver function: Child-Pugh class A is mandatory; class B is an absolute contraindication to major resections (>2 segments) 1
• Portal hypertension status: Clinically significant portal hypertension (HVPG >10 mmHg) is not an absolute contraindication for limited resections with minimally invasive techniques, but major resections are contraindicated 1
• Tumor characteristics: Solitary HCC >2 cm when hepatic function is preserved and sufficient remnant liver volume can be maintained 1
• Performance status and comorbidities: Must be adequate to tolerate surgery 1

Schistosomiasis-Specific Considerations

While the guidelines do not specifically address schistosomiasis, this etiology presents unique challenges. Schistosomiasis-related cirrhosis often manifests with periportal fibrosis and portal hypertension, which may be more severe than hepatocellular dysfunction would suggest. 2

• Portal hypertension assessment is critical: Surrogate markers include esophageal varices, ascites, platelet count, and portal hypertensive gastropathy 3
• Hepatic venous pressure gradient measurement: If available, HVPG >10 mmHg contraindicates major resections 1
• Platelet count <100,000: Suggests clinically significant portal hypertension and increases surgical risk 1, 3

Treatment Algorithm by Tumor Size

Solitary HCC <2 cm

• Thermal ablation and resection are equally recommended without preference in compensated cirrhosis 1
• Ablation should be preferred when major hepatectomy would be required 1
• Minimally invasive resection is preferred if surgery is chosen 1

Solitary HCC >2 cm

• Hepatic resection is recommended when hepatic function is preserved and sufficient remnant liver volume can be maintained 1
• Anatomical resections are recommended, though this must be balanced against preservation of adequate hepatic function 1
• Minimally invasive approaches should be used for anterolateral and superficial locations 1

Multifocal HCC within Milan criteria (≤3 nodules ≤3 cm)

• Liver transplantation is the recommended first-line treatment 1, 3
• Resection may be considered in patients not suitable for transplant, but evidence is insufficient to recommend resection over locoregional therapies 1
• Multifocal tumors involving multiple segments require bridging or downstaging therapies before considering surgical resection 1

Absolute Contraindications to Resection

• Child-Pugh class C cirrhosis: Mortality risk is prohibitive 3
• Child-Pugh class B with major resection planned: Absolute contraindication for resections >2 segments 1
• Clinically significant portal hypertension with major resection planned: HVPG >10 mmHg contraindicates major resections 1
• Macrovascular invasion or extrahepatic disease: These are absolute contraindications to curative surgery 1

Alternative Treatment Options

If resection criteria are not met:

• Thermal ablation: For tumors up to 3 cm with up to three lesions 1
• Transarterial chemoembolization (TACE): Standard of care for intermediate stage HCC with preserved liver function (Child-Pugh A or B7 without ascites) 1
• Liver transplantation: For decompensated cirrhosis with HCC within accepted criteria 1, 3
• Systemic therapy with sorafenib: For advanced HCC with Child-Pugh A-B and adequate performance status 4

Perioperative Management

• Expected perioperative mortality: Should be 2-3% in cirrhotic patients 1
• Minimally invasive approaches: Should be performed whenever feasible in properly trained centers 1
• Neoadjuvant therapy: Not recommended outside prospective studies, as evidence of survival advantage is lacking 1
• Adjuvant therapy: Atezolizumab plus bevacizumab improves recurrence-free survival after resection, though longer-term follow-up is required 1, 3

Critical Pitfalls to Avoid

• Do not proceed with major resection in patients with Child-Pugh class B cirrhosis or clinically significant portal hypertension 1
• Do not overlook portal hypertension assessment: In schistosomiasis, portal hypertension may be disproportionate to hepatocellular dysfunction 2
• Do not use resection as a downstaging procedure for HCC beyond Milan criteria to meet liver transplantation eligibility 1
• Do not perform resection without adequate assessment of future liver remnant volume and function 1