Improving surgical treatments for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Curative-intent treatments offer the best long-term outcomes for selected patients. However, recurrence rates after resection approach 70% at 5 years, and access to transplantation remains limited by donor scarcity and stringent eligibility criteria. Emerging data reveal that recurrence is a reflection of underlying tumour biology, immune evasion and microenvironmental permissiveness. Advances in immunogenomic profiling, liquid biopsy and functional imaging are reshaping the concept of surgical eligibility, enabling biological risk stratification beyond conventional staging. At the same time, innovations in perioperative immunotherapy, graft preservation using machine perfusion and integrated multidisciplinary care are expanding the boundaries of curative treatment. These developments herald a shift from static criteria to dynamic, biology-driven paradigms that personalize surgical and transplant strategies. In this Review, we examine the evolving landscape of surgical treatment for HCC. We highlight the limitations of current selection frameworks, discuss how biological insights can inform resection and transplant decision-making and explore the role of perioperative and neoadjuvant therapies in reducing the recurrence of disease. Finally, we outline a future precision oncology model that integrates tumour genomics, immune phenotype and regenerative biology to improve outcomes in patients undergoing curative-intent treatment for HCC.