Hepatocellular carcinoma (HCC) is the fifth most common
malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing
tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with
cirrhosis, a condition that increases the risk of performing potentially curative surgical
therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and
perioperative care. As such, the operative mortality rate for
hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the
malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial
hepatectomy or total
hepatectomy followed by
liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic
metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without
cirrhosis can tolerate extensive resections, and partial
hepatectomy should be considered first. For Child class B and C patients with a small HCC,
liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated
cirrhosis. Living donor
liver transplantation should be considered using the same criteria as that used for cadaveric
transplantation.