New frontiers in liver resection for hepatocellular carcinoma

Abstract

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Keywords: ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; BCLC, Barcelona Clinic liver cancer; CSPH, clinically significant portal hypertension; DFS, disease-free survival; GSA, galactosyl serum albumin; HCC; HCC, hepatocellular carcinoma; HVGP, hepatic venous pression gradient; ICG, indocyanine green; ICG-R15, hepatic clearance of ICG 15 minutes after its intravenous administration; IL-6, interleukin 6; LR, liver resection; LSM, liver stiffness measurement; Laparoscopy; Liver resection; MELD, model for end-stage liver disease; NAFLD, non-alcoholic fatty liver disease; OS, overall survival; PVL, portal vein ligation; PVTT, tumour-related portal vein thrombosis; RFA, radiofrequency ablation; SSM, spleen stiffness measurement; Surgery; TACE, transarterial chemoembolisation.

Fig. 1

Current indications for liver surgery according to EASL, AASLD and APASL guidelines. Indications of treatment by liver surgery for hepatocellular carcinoma differ according to the guidelines. EASL guidelines recommend surgery in case of solitary lesion without vascular invasion, in well compensated patients with an MELD score <10. For AASLD guidelines, all potential resectable solitary tumours <5 cm, with or without vascular invasion, and multifocal <5 cm tumours should undergo surgery in the absence of impaired liver function. APASL guidelines enlarge the indication to all resectable tumours even those with vascular invasion and in patients with decompensated cirrhosis (Child-Pugh B). The presence of portal hypertension is not an absolute contraindication but must be balanced with liver function and the extent of the hepatectomy. MELD, model for end-stage liver disease.

Fig. 2

Standard assessment to determine if HCC is suitable for liver resection. To determine if liver resection is appropriate, it is necessary to consider tumour burdens but also liver function, extent of hepatectomy and the expected volume of the future liver remnant, as well as the presence of portal hypertension and the comorbidities of the patients. HVGP, hepatic venous gradient pressure; IGC₁₅, hepatic clearance of indocyanine green 15 minutes after its intravenous administration; LSM, liver stiffness measurement; MELD, model for end-stage liver disease score; SSM, spleen stiffness measurement.