What are the first‑line curative treatment options and surveillance strategy for a patient with stage I hepatocellular carcinoma (solitary ≤2 cm tumor, no vascular invasion, Child‑Pugh A)?

Stage I Hepatocellular Carcinoma: First-Line Treatment and Surveillance

For a patient with stage I HCC (solitary ≤2 cm, no vascular invasion, Child-Pugh A), thermal ablation (radiofrequency or microwave) is recommended as first-line curative treatment, with surgical resection as an equally valid option depending on tumor location, extent of portal hypertension, and performance status. 1

Primary Treatment Selection Algorithm

Thermal Ablation (Preferred for Most Stage I Cases)

• Radiofrequency ablation (RFA) or microwave ablation are equally effective and recommended as first-line treatment for solitary HCC <2 cm in compensated cirrhosis (Child-Pugh A). 1
• The choice between ablation and resection is based on:
  • Tumor location (ablation preferred for centrally located tumors near major vessels) 1
  • Liver function and portal hypertension severity (ablation safer with clinically significant portal hypertension) 1, 2
  • Performance status and comorbidities 1
• RFA is specifically designated as first-line treatment for HCC ≤2 cm in diameter by Asian-Pacific guidelines 1

Surgical Resection (Alternative First-Line Option)

• Hepatic resection can be considered as an equally valid first-line option for solitary tumors <2 cm when:
  • Tumor is peripherally located 1
  • No clinically significant portal hypertension (HVPG ≤10 mmHg) 2
  • Adequate future liver remnant volume can be preserved 2
  • Expected perioperative mortality <3% and morbidity <20% 2
• Resection offers potential for complete pathologic assessment and may be preferred in younger patients suitable for potential salvage transplantation 3

Liver Transplantation Consideration

• Liver transplantation should be considered for patients meeting Milan criteria (which includes solitary ≤2 cm tumors) who have:
  • Child-Pugh B or C cirrhosis 1, 4
  • Child-Pugh A with oligonodular tumors in cirrhotic liver (poor prognosis with resection alone) 3
• Living donor liver transplantation can be considered using the same criteria as cadaveric transplantation 1

Critical Contraindications and Decision Points

Absolute Contraindications to Resection

• Child-Pugh class B or C cirrhosis with major resection planned 2
• Clinically significant portal hypertension (HVPG >10 mmHg) with major resection planned 2
• Inadequate future liver remnant volume 2

When to Choose Ablation Over Resection

• Tumor location near major vessels or in difficult surgical locations 1
• Presence of portal hypertension (even if compensated) 1
• Significant comorbidities limiting surgical candidacy 1
• Patient preference for less invasive approach 1

Alternative Ablation Technique

• Percutaneous ethanol injection can be considered only when thermal ablation is not technically feasible (lower efficacy, not preferred) 1

Neoadjuvant and Adjuvant Therapy

Emerging Evidence (Not Yet Standard)

• Adjuvant therapy with atezolizumab plus bevacizumab may improve recurrence-free survival after ablation, but longer-term follow-up is required before routine recommendation 1, 2
• This represents moderate-quality evidence with moderate strength recommendation 1

What NOT to Use

• Traditional systemic chemotherapy should be avoided - it shows only 10% response rate with no survival benefit and poor tolerance in early-stage disease 1, 5, 6
• Neoadjuvant therapy is not recommended outside prospective studies 2

Post-Treatment Surveillance Strategy

Surveillance Protocol

• Follow-up every 3-6 months with AFP determination and liver imaging (ultrasound, CT, or MRI) for the first 2 years 1, 5
• Imaging modality should be multiphasic CT or MRI for optimal recurrence detection 7
• Continue surveillance beyond 2 years as recurrence can occur late 3

Rationale for Intensive Surveillance

• Curative therapy can still be offered at recurrence in a significant proportion of patients 1
• Approximately 79% of patients with recurrence after resection of small HCC remain eligible for salvage transplantation 3
• Early detection of recurrence allows for potentially curative repeat interventions 3

Antiviral Therapy Integration

• For hepatitis B or C positive patients, antiviral therapy should be initiated or optimized based on viral replication status and degree of liver disease 1, 5
• Direct-acting antiviral therapy for hepatitis C should be integrated to reduce recurrence risk and improve liver function 5

Expected Outcomes

Survival Data

• 5-year overall survival rates of 70% are achievable with appropriate treatment of stage I HCC in Child-Pugh A patients 3
• Disease-free survival at 5 years ranges from 36-50% depending on tumor characteristics 3
• A considerable proportion of patients may survive without recurrence for 10 years 3

Common Pitfall to Avoid

• Do not perform major hepatic resection in patients with clinically significant portal hypertension - this dramatically increases perioperative mortality and should prompt consideration of ablation or transplantation instead 2
• Avoid incomplete resections - if complete resection cannot be achieved, ablation or transplantation should be considered 1