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Liver resection for HCC with cirrhosis: surgical perspectives out of EASL/AASLD guidelines
L Capussotti1, A Ferrero, L Viganò
1Department of Surgery, Ospedale Mauriziano Umberto I, Largo Turati 62, Torino, Italy. lcapussotti@mauriziano.it
Insights
Current liver cancer guidelines exclude many patients from surgery. Expanding hepatectomy indications could improve outcomes for advanced hepatocellular carcinoma (HCC) patients, offering better survival than other treatments.
Area of Science:
- Hepatobiliary Surgery
- Hepatocellular Carcinoma (HCC) Treatment
- Surgical Oncology
Background:
- Current European Association for the Study of the Liver (EASL)/American Association for the Study of Liver Diseases (AASLD) guidelines for hepatocellular carcinoma (HCC) restrict liver surgery indications.
- These restrictive guidelines exclude patients with large tumors, portal vein thrombosis, or portal hypertension, potentially limiting access to curative treatment.
- Many patients excluded by current guidelines could potentially benefit from radical resection, a procedure frequently performed in surgical centers.
Purpose of the Study:
- To evaluate the efficacy of liver resection for advanced hepatocellular carcinoma (HCC) beyond current guideline limitations.
- To investigate whether expanding hepatectomy indications could improve long-term outcomes for patients ineligible for transplantation or interstitial treatments.
- To assess the potential role of liver resection in selected patients with portal hypertension.
Main Methods:
- Review of outcomes for liver resection in patients with advanced HCC, including those with multinodular disease or beyond standard criteria.
- Comparison of survival results after liver resection versus non-curative therapies such as transarterial chemoembolization (TACE) and conservative treatments.
- Analysis of data regarding liver resection in patients with varying degrees of portal hypertension.
Main Results:
- Liver resection can achieve good long-term outcomes in selected cases of advanced HCC, significantly better than non-curative therapies.
- For multinodular HCC beyond Milan criteria, liver resection, especially for cases with two nodules, offers better survival than TACE or conservative management.
- While guidelines exclude patients with portal hypertension, selected individuals with mild portal hypertension may be candidates for liver resection.
Conclusions:
- Current guidelines for HCC treatment should be reconsidered to include the positive results of liver resection for advanced disease.
- Expanding indications for hepatectomy is warranted to ensure patients who could benefit from radical therapy are not excluded.
- Further research is needed to clarify the role of liver resection in patients with portal hypertension, potentially offering an alternative to transplantation.
Abstract:
EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.
