Surgical Treatment Strategies and Prognosis of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC is the fifth most common cause of mortality worldwide and the third cancer related cause and is responsible for about 1 million deaths yearly [1]. The ageadjusted worldwide incidence is 5.5-14.9 per 100.000 population. In some areas of the world, such as sub-Saharan Africa and Southeast Asia, HCC represents the first cause of cancer death with an incidence of 52 per 100.000. Furthermore, in Europe and USA, HCC incidence has progressively raised in the past decade representing a burden problem. HCC is one of the few cancers for which a number of risk factors are known in great detail [2, 3]. HCC is almost always (80%) associated with cirrhosis, at least in developed countries, and chronic hepatitis C and B infection, alcoholic cirrhosis and haemocromatosis are some of the established risk factors [4]. The metabolic syndrome related to hypertension, central obesity, diabetes and obesity has been identified as a new risk factor. As a result, screening programs have developed, with the use of ultrasound and α-fetoprotein (AFP), with a hope to increase the chances of diagnosing small HCC and unltimately increase the rate of curability. Definitive diagnosis relies on the demonstration of a typical vascular pattern per liver imaging techniques (triple-phase CT-scan or MRI) of tumors larger than 2 cm with arterial hypervascularity and venous wash- out. Nodules, smaller than 2 cm, should be rechecked every six months or, if highly suspect, subjected to needle biopsy. It’s likely that the study of tumor-specific tissue markers with prognostic value could introduce a systematic use of needle biopsy. Over the past 20 years, surgical treatment of hepatocellular carcinoma has seen an immense boost and improvement, with good survival outcomes and reduced morbidity and mortality.Liver resection (LR) and orthotopic liver transplantation (OLT) and ablative therapies are now considered the only potentially curative treatments for this cancer. LR has achieved improvement in survival within the past decade as a result of advances in diagnosis, surgical management of HCC and perioperative care. However, the long-term prognosis remains poor, and the 5-year overall survival rate ranges between 33% and 44%, with a 5-year cumulative recurrence rate of 80% to 100%. OLT could be viewed as the optimal treatment for HCC that is accompanied by advanced cirrhosis because of the widest possible resection margins for tumour and for a definitive cure of cirrhosis and its related complications. OLT for HCC performed within well-defined oncologic criteria (Milan criteria “reference”) has shown long-term results comparable with those of transplantation for non-HCC patients. However, the critical shortage of available donated organs, together with the increasing number of patients awaiting transplantation, makes this therapeutic option available to only a small percentage of patients. Owing to the limited organ supply, many liver transplant centers usually make a selection to resect patients with compensated liver cirrhosis, defined as Child–Pugh A chronic liver disease and resectable tumor and to reserve transplantation for those with impaired liver function (Child-Pugh class B-C) and small oligonodular HCC considered within the currently accepted criteria for transplantation. Radiofrequency and microwave ablation are relatively new percutaneous techniques in clinical use for HCC, that can produce tumour necrosis. Complete response rates are high in large series if tumour is less that 3 cm in diameter. This chapter will consider the main surgical techniques for the treatment of HCC in the light of the major guidelines currently available and of personal experience. Also, we will review HCC prognostic factors, and the particular situation of “large” HCC and the strategy for liver tumours located at the hepato-caval confluence.