Current status of surgical treatment for hepatocellular carcinoma

The therapeutic modalities for hepatocellular carcinoma (HCC) have diversified during the past decades, and in particular, the treatment has mainly been concentrated on small HCC of 3 cm or less. Therefore, it has become very important for surgeons to be able to identify the clinical indications for liver resection in HCC. We reviewed data on liver resection for HCC using the National Primary Hepatic Cancer follow-up survey report of the Liver Cancer Study Group of Japan, indicating problem associated with liver resection for HCC. As a result, the indications of surgical treatment for HCC are as follows: (1) In patients with HCC of 3 cm or less in diameter, a solitary HCC indicates liver resection. However, priority should be given to medical treatment such as percutaneous transhepatic ethanol injection therapy, microwave coagulative necrosis therapy for multiple HCC and patients with clinical states II or III. (2) HCC between 3 cm and 5 cm in diameter is a good indicator for liver resection. Solitary HCC indicates liver resection as a first choice. (3) HCC greater than 5 cm diameter eter and cases with tumor stages II or III indicate liver resection. (4) There are limits to treating HCC with tumor thrombus in the second branch of the portal vein (Vp2) and tumor thrombus in the first branch, the trunk of the portal vein or in a branch on the opposite side (Vp3) only by liver resection. (5) HCC with tumor thrombus in the right, middle or left hepatic vein trunk, posterior inferior hepatic vein trunk or short hepatic vein (Vv2) and with tumor thrombus in the inferior vena cava (Vv3) are indicators for liver resection. A limited resection according to Glissons structure and with a negative surgical margin can be performed in HCC of 5 cm or less, however an extended resection is required for HCC greater than 5 cm. Furthermore, the extent of liver resection should be considered according to the hepatitis virus. Finally, it was emphasized that effective measures against the postoperative recurrence was essential in order to improve the outcome of HCC.