Patient selection, resection, and outcomes for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an aggressive malignancy of the liver that most often arises in patients with cirrhosis and other chronic liver diseases. Worldwide, it is the sixth most common cancer and the third most common cause of cancer-related death. Median survival is poor, ranging from 6 to 20 months. Definitive treatment options for HCC are surgical resection, ablation, or transplantation. The selection of patients for surgical resection is based on clinical findings, laboratory data, and imaging. Although a number of staging systems exist, all have their limitations. A multidisciplinary approach to patient selection for surgery that includes the input of an experienced liver surgeon assures optimal outcomes. Sound understanding of liver segmentation, modern surgical techniques, and the use of intraoperative ultrasound have led to a reported perioperative mortality rate below 3%, blood transfusion requirements of less than 10%, and 5-year survival rates of at least 50%. Advances in laparoscopic technique and technology have expanded the indications for a safe and oncologically appropriate minimally invasive resection. Deciding which treatment option to employ depends on tumor resectability and the degree of underlying liver disease, which is present in 80% to 85% of patients with HCC; however, despite these surgical advances, a high recurrence rate of 70% in patients with cirrhosis and a survival rate of 65% to 80% in well-selected transplant patients are expected. This article will focus on the evaluation and selection of patients for surgical intervention, considerations in selecting the appropriate type of resection, and expected outcomes following liver resection.