Hepatocellular Carcinoma: Surgical Management and Evolving Therapies

HCC is the second leading cause of cancer death worldwide. The majority of cases arise within the background of liver cirrhosis and are most commonly related to chronic hepatitis B and C viral infection. Surgical resection, liver transplantation, and tumour ablation are potentially curative modalities in cases of localized, non-metastatic, hepatocellular carcinoma. Systemic sorafenib has been shown to be marginally effective in slow disease progression in patients whose cirrhosis is so severe that they are not candidates for liver directed therapy and in those with metastatic disease. Several large prospective and retrospective studies have demonstrated transplantation to provide better long term outcomes than resection in patients with small volume carcinoma. Other small retrospective series have demonstrated similar outcomes for patients with well matched tumour characteristics and compensated cirrhosis. There is not even level one evidence to guide the choice of modality to be used in individual cases and treatment algorithms vary widely among high volume centres. Newer and emerging techniques and approaches such as laparoscopic liver resection and living donor transplantation continue to evolve and impact choice of treatment in absence of well-controlled comparative trials. For locally advanced disease and in patients with significant cirrhosis, interventional technologies such as transarterial chemoembolization or transarterial radioembolization can provide disease control or result in tumour regression and hypertrophy in the future liver remnant and may allow interval resection or down-staging to liver transplantation. Improving transarterial, surgical, and transplant techniques continue to expand the surgical and interventional options for managing localized HCC and are driving a shift towards aggressive multimodality therapy in patients with localized hepatoma.