Surgical treatment for hepatocellular carcinoma in era of multidisciplinary strategies

Abstract

Hepatocellular carcinoma (HCC) remains a significant global health challenge, with over 800,000 new cases diagnosed annually. This comprehensive review examines current surgical approaches and emerging multidisciplinary strategies in HCC treatment. While traditional surgical criteria, such as the Barcelona Clinic Liver Cancer (BCLC) staging system, have been relatively conservative, recent evidence from high-volume Asian centers supports more aggressive surgical approaches in carefully selected patients. The review discusses the evolution of selection criteria, including the new "Borderline Resectable HCC" classification system, which provides more explicit guidance for surgical decision-making. Technical innovations have significantly enhanced surgical precision, including three-dimensional simulation, intraoperative navigation systems, and the advancement of minimally invasive approaches. The review evaluates the ongoing debate between anatomical versus non-anatomical resection and examines the emerging role of robotic surgery. In liver transplantation, expanded criteria beyond the Milan criteria show promising outcomes, while the integration of novel biomarkers and imaging techniques improves patient selection. The role of preoperative and adjuvant therapies is increasingly important, with recent trials demonstrating the potential of immune checkpoint inhibitors combined with anti-VEGF agents in both settings. Despite these advances, postoperative recurrence remains a significant challenge. The review concludes that successful HCC treatment requires a personalized approach, integrating surgical expertise with emerging technologies and systemic therapies while considering individual patient factors and regional variations in practice patterns.

Keywords: Hepatocellular carcinoma; Immunotherapy; Liver surgery; Minimally invasive surgery; Transplantation.

Fig. 1

Treatment algorithm for hepatocellular carcinoma (HCC). This figure extracts parts related to surgical treatment. a illustrates the overall decision-making process for selecting between resection or transplantation in American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL), which based on Barcelona Clinic Liver Cancer (BCLC) staging system. b highlights Japanese Society of Hepatoligy (JSH) guidelines, emphasizing that surgical treatment (shown in black with white text) is applicable to a broader range of conditions compared to other criteria. a was modified from reference 10 and 17. b was modified from reference 16

Fig. 2

Novel classification criteria for oncologically borderline resectable HCC. The classification system for HCC resectability proposed in reference 22 was reorganized into a flow chart format consistent with conventional criteria