How to Choose Surgical Treatment of HCC

Surgical treatment has always been the first-line treatment for hepatocellular carcinoma (HCC). So, professor Paul B. S. Lai, from The Chinese University of Hong Kong, Hong Kong SAR, China, presented a report on surgical treatment of HCC.

Professor Lai pointed out that there were a number of different choices and sometimes patients might get confused when they were given rather different treatment options by different clinicians.

Firstly, for liver surgeons, the choice of treatment depends on the liver function, locations and number of tumors, presence or absence of co-morbidities and if there is extra-hepatic spread of tumor. In patients with acceptable risks for surgery, relatively good liver function and tumors located in a segment or a lobe of the liver, surgical resections by means of partial hepatectomy would be the first choice of treatment. However, surgical resections are not risk-free. Although patients nowadays rarely die of massive bleeding during surgery, mortalities are still possible (<5%) because of liver failure and sepsis after surgery. Furthermore, mortalities may be related to recurrence of disease and progression of liver cirrhosis in a longer term after initial curative surgical resections. The overall 5-year survival rate after liver resection has significantly been improved to around 50% in recent years.

Secondly, if there is no shortage of liver grafts and if the complications related to immunosuppression are excluded from consideration, liver transplantation would become a very viable treatment option for HCC. In patients with HCC confined to the liver, liver transplantation can treat both HCC as well as the underlying cirrhosis. From currently available data, for patients within the Milan Criteria, the 5-year survival has gone up to around 70%. However, liver graft shortage and healthcare resource implications are the major hurdles for liver transplantation to be more widely used as a standard treatment for HCC.

Thirdly, for unresectable or untransplantable HCC, local ablative therapy through percutaneous, laparoscopic or open means are also effective, particular for those tumors which are fewer in number and smaller in size. Local ablative therapy can be conducted using different energy platforms including radio-frequency ablation (RFA), microwave ablation (MA) or high intensity focused ultrasound (HIFU). Each of these modalities has its own advantages and limitations. The treatment decision may also be affected by availability of the expertise and the machines. Patient selection is also important in the consideration. Overall, for local diseases that are not resectable, local ablative therapy provides effective palliation and even cure for a smaller proportion of cases.

Finally, systemic chemotherapy and transarterial treatments in the form of trans-arterial chemo-embolization (TACE) or transarterial injection of lipiodol-ethanol mixture (LEM) are commonly used as palliative treatments in patients presented with unresectable tumours. In a selected group of patients, tumors may be down-staged so much so that surgical treatments like liver resections or transplantations may be possible.