Recent advances in the surgical management of hepatocellular carcinoma

Abstract

The incidence of hepatocellular carcinoma (HCC) is increasing, despite effective antiviral treatment for hepatitis B (HBV) and C virus infection and the application of preventive measures such as vaccination at birth against HBV infection. This is mainly due to the increase in metabolic syndrome and its hepatic components, nonalcoholic fatty liver disease and steatohepatitis. Liver resection and transplantation are the main treatment options, offering long-term survival and potential cure. In this review, the recent advances in the surgical management of HCC are presented. More specifically, the role of liver resection in the intermediate and advanced stages, according to the Barcelona Clinic Liver Cancer classification, is analyzed. In addition, the roles of minimally invasive surgery and of living-related liver transplantation in the management of patients with HCC are discussed. Finally, recent data on the role of molecular markers in the early diagnosis and recurrence of HCC are presented. The management of HCC is complex, as there are several options for each stage of the disease. In order for, each patient to get the maximum benefit, an individualized approach is suggested, in specialized liver units, where cases are discussed in multidisciplinary tumor boards.

Keywords: Hepatocellular carcinoma; intermediate and advanced stage; living-related liver transplantation; minimally invasive surgery; surgical management.

Figure 1

Portal vein tumor thrombosis classification according to the liver study group of Japan HCC, hepatocellular carcinoma; HBV, hepatitis B; HCV, hepatitis C; NAFLD, nonalcoholic fatty liver disease; MILR, minimally invasive liver surgery; LDLT, living donor liver transplantation; LT, liver transplantation; BCLC, Barcelona Clinic Liver Cancer; TACE, transarterial chemoembolization; PV, portal vein; LLR, laparoscopic liver resection; MC, Milan criteria; UCSF criteria, the University of California, San Francisco criteria; MELD, model for end-stage liver disease; DDLT, deceased donor liver transplantation; SFSS, small-for-size syndrome; AFP, α-fetoprotein; AASLD, American Association for the Study of Liver Diseases; EASL, European Association for the Study of the Liver

Figure 2

Autophagy reduction contributes to tumor initiation, and increased autophagy allows cancer cells to survive under stress conditions. The function of autophagy in liver cancer is a topic of concern, and it plays multiple roles in different situations. In normal liver cells, basal autophagy is involved in maintaining liver homeostasis. Once hepatocellular carcinoma (HCC) is established, autophagy plays a promotional role in tumor development, metastasis, and therapeutic resistance. Thus, appropriate autophagy inhibition could effectively suppress HCC growth and metastasis. However, in targeted HCC therapy, the role of autophagy is uncertain, for either inhibition or promotion, according to the different characteristics of agents. Autophagy induction at the tumor development stage promotes resistance to cancer therapy, while inhibition of autophagy promotes cancer cell death during cancer therapy