A Conceptual Classification of Resectability for Hepatocellular Carcinoma
Related Experiment Video
Updated: Aug 24, 2025
Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy
Published on: March 10, 2023
Tomoaki Yoh1, Takamichi Ishii1, Takahiro Nishio1
1Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan.
Insights
This study proposes a new classification for hepatocellular carcinoma (HCC) resectability, categorizing it into resectable, borderline resectable, and unresectable. This classification effectively stratifies survival outcomes and aids in treatment decisions for HCC patients.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Gastroenterology
Background:
- Defining resectability is crucial for hepatocellular carcinoma (HCC) within multidisciplinary treatment strategies.
- Current classifications may not adequately capture nuances in HCC resectability.
- Standardized criteria are needed to guide surgical and non-surgical management.
Purpose of the Study:
- To propose and validate a novel resectability classification system for HCC.
- To stratify HCC patients into distinct resectable, borderline resectable, and unresectable groups.
- To assess the clinical utility of this classification in predicting survival outcomes.
Main Methods:
- Proposed a three-tiered classification: resectable (R), borderline resectable (BR), and unresectable (UR)-HCC.
- Subdivided resectable groups based on indocyanine green clearance (ICG-Krem) and macrovascular invasion (MVI).
- Retrospectively analyzed 361 HCC patients treated between 2011-2017 to validate the classification.
Main Results:
- The classification identified 251 R-HCC, 46 BR-HCC, and 64 UR-HCC patients.
- ICG-Krem ≥0.05 correlated with reduced posthepatectomy liver failure (p=0.013).
- MVI presence was linked to worse overall survival (OS) (p<0.001).
- 3-5-year OS rates were significantly different: R-HCC (80.3%) vs. BR-HCC (68.3%) vs. UR-HCC (51.4% and 35.6%).
- BR-HCC independently predicted poorer OS (p<0.001) but showed survival benefit over UR-HCC (p<0.001).
Conclusions:
- The proposed HCC resectability classification effectively stratifies survival outcomes.
- This system can assist in determining optimal treatment strategies for HCC.
- The classification provides valuable prognostic information for patients with HCC.
Backgrounds:
In the era of multidisciplinary treatment strategy, resectability for hepatocellular carcinoma (HCC) should be defined. This study aimed to propose and validate a resectability classification of HCC.
Methods:
We proposed following the three groups; resectable-(R), borderline resectable-(BR), and unresectable (UR)-HCCs. Resectable two groups were sub-divided according to the value of indocyanine green clearance of remnant liver (ICG-Krem) and presence of macrovascular invasion (MVI); BR-HCC was defined as resectable HCCs with MVI and/or ICG-Krem≥0.03-<0.05, and R-HCC was the remaining. Consecutive patients with HCC who underwent liver resection (LR) and non-surgical treatment(s) (i.e., UR-HCC) between 2011 and 2017 were retrospectively analyzed to validate the proposed classification.
Results:
A total of 361 patients were enrolled in the study. Of these, R-, BR- and UR-HCC were found in 251, 46, and 64 patients, respectively. In patients with resected HCC, ICG-Krem≥0.05 was associated with decreased risk of clinically relevant posthepatectomy liver failure (p=0.013) and the presence of MVI was associated with worse overall survival (OS) (p<0.001). The 3-5-years OS rates according to the proposed classification were 80.3, and 68.3% versus 51.4, and 35.6%, in the R and BR groups, respectively (both p<0.001). Multivariate analysis showed BR-HCC was independently associated with poorer OS (p<0.001) after adjusting for known tumor prognostic factors. Meanwhile, BR-HCC was associated with benefit in terms of OS compared with UR-HCC (p<0.001).
Conclusion:
Our proposal of resectability for HCC allows for stratifying survival outcomes of HCC and may help to determine treatment strategy.
