Multimodal treatment strategies in patients undergoing surgery for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the major health problems worldwide, and continues to grow because of its association with hepatitis B and C viruses. In patients with HCC, liver transplantation (LT) and liver resection are the only two curative treatment options. LT remains the best option since it not only removes the tumor, but also the underlying disease. The prerequisite for long-term success of LT for HCC depends on the tumor load and strict selection criteria with regard to the size and number of existing HCC lesions. The need to obtain the optimal benefit from a limited number of grafts has prompted the implementation of well-defined selection criteria that identify patients with early HCC who may benefit from better long-term outcome after LT. Unfortunately, LT can only be proposed in approximately 30% of patients with HCC due to limitations in donor graft availability. In this particular setting, open and laparoscopic surgical resection represent reasonable treatment modalities in noncirrhotic HCC patients. The decision-making process for liver resection should integrate the tumor stage, quality and function of the underlying liver parenchyma, volume of the future liver remnant, and general condition of the patient. In patients with favorable features (solitary tumor, compensated Child-Pugh A cirrhosis, no portal hypertension), the reported 5-year survival rates range between 50 and 70%. In specific cases, liver resection and LT may be combined in the same patient.