Surgical options for treatment of hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is a primary parenchymal cancer of the liver. Currently, only one-fifth of HCC patients are suitable for liver resection, the mainstay of surgical treatments for HCC, at presentation of the disease. Only half of the patients, except those with early tumor stage, will survive after liver resection. Adequate functional liver reserve is essential for even short-term survival. With improvement in tumor surveillance for viral hepatitis carriers, HCC identified at early stages is amenable to liver transplantation. This radical surgical extirpation of HCC provides the best chance of cure with longterm survival over 80%. Not only is tumor clearance complete, the cirrhotic liver, a premalignant organ, is replaced. The success of liver transplantation for HCC depends on careful selection of recipients. Potential recipients should be patients with a low chance of extrahepatic spread. Contrary to the common belief that HCC with microvascular invasion is a contraindication to liver transplantation, HCC patients with tumors within the ‘Up-to-7’ criteria have a 5-year survival rate of 80% irrespective of such invasion. On the other hand, liver resection for the same lesions only entails dismal survival. Salvage transplantation, however, has low applicability and a higher recurrence rate. Living donor liver transplantation potentially provides more liver grafts for transplantation, but it causes the donors inevitable risk. This risk is, however, lowered by the application of the left liver as graft with accumulation of experience in handling the left liver which is often small for size. Lowering the donor risk without increasing the recipient risk improves the donor/recipient risk/benefit ratio, and hence substantiates liver transplantation as a primary treatment for potentially resectable HCC. However, this is an ethical challenge which has to be validated by clinical data. For patients with tumors beyond acceptable criteria for liver transplantation or resection, ablative therapies by radiofrequency (RFA), microwave, and high-intensity focused ultrasound (HIFU) are often feasible options.Microwave ablation is faster and can treat HCC up to 7 cm in size. HIFU is non-invasive but this procedure often takes hours to complete and requires general anaesthesia of the patient. These treatments are now carried out under clinical trial settings and producing promising results.