HCC is the most common primary liver cancer and is often diagnosed at an advanced stage making surgery difficult. Treatment depends on tumor stage and liver function. The Child-Turcotte-Pugh classification and MELD score evaluate liver function. Future liver remnant volume must be sufficient post-surgery. Hepatic resection is only recommended for early stage HCC meeting Milan criteria with a normal liver. Liver transplantation allows for the widest resection margins but is reserved for select patients.

1. By
Dr E Aravind

2.  Most common primary liver malignancy
 Most common of the solid organ cancers
 Surgery is potentially curative
 But discovered at a stage too advanced
for complete excision
 Highly resistant to chemotherapy,
limiting options for palliative treatment.

3.  Difficulties in treatment due to
 Usually asymptomatic at early stages
 Associated with cirrhosis
 Intravascular or intrabiliary extension
 Important aspect of the morbidity,
mortality, and long-term outcome of liver
resection depends on patient selection
 Treatment depends on tumor stage and
the functional status of the liver

5.  Classified into three distinct patterns of
growth that are associated with
resectability
 Hanging type
 Pushing type
 Infiltrative type

6. TUMOR STAGE
 Done by triphasic CT
 Number
 Size
 Presence of satellite nodules
 Tumor invasion of the portal vein, its branches,
or the inferior vena cava;
 To exclude any extrahepatic metastasis; for
surgical planning,
 Clarify the relationship of the tumors with the
intrahepatic vascular and biliary structures
 MRI is contrast is contrindicated

7. EVALUATION OF LIVER FUNCTION
 Accurate evaluation of the liver
functional reserve is therefore crucial to
avoid postoperative hepatic insufficiency
 Child-Turcotte-Pugh(Child) classification
is used for evaluation of liver function

8.  partial hepatectomy is offered only to
patients who are Class A
 Most favourable Class B patients.
 Class C patients are only offered
supportive care,

9.  Indocyanine green (ICG) clearance test
 ICG retention rate at 15 minutes (ICG R15)
of 10% to 20% is considered the upper limit
 Hepatic venous pressure gradient
(HVPG)
 indirect measure of portal hypertension
 >10 mm Hg - unresolved hepatic
decompensation

10.  Model for End-Stage Liver Disease
(MELD) score
 MELD = 3.78×ln[serum bilirubin (mg/dL)] +
11.2×ln[INR] + 9.57×ln[serum creatinine
(mg/dL)] + 6.43×aetiology(0: cholestatic or
alcoholic, 1: otherwise)
 Scores of <9 predict both low mortality and
reduced morbidity after hepatic resection

11. FUTURE LIVER REMNANT
 Actual total liver volume (TLV), defined
as the volume of the patients liver
measured directly on CT images minus
tumor volume
 Estimated liver volume, an alternative
method by which the total liver volume is
calculated by a formula that relies on a
linear correlation between TLV and body
weight or body surface area in healthy
subjects

12.  Portal vein embolization (PVE)
 In candidates for hepatic resection with
insufficient future liver re
 FLR is <40% of TLV
 Contraindications to PVE include tumor
invasion of the portal vein

13. Prognostic staging models
 Barcelona Clinic Liver Cancer (BCLC)
 Early,
 Intermediate,
 Advanced,
 Terminal

14.  Hepatic resection is indicated only in
patients with early stage HCC defined
by
 Milan criteria
○ single tumors ≤5 cm in maximal dimension or
no more than three tumors each ≤3 cm in
maximal dimension
 Normal clinical performance status
 Preserved liver function (bilirubin levels <1
mg/dL, absence of portal hypertension, and
Child-Pugh class A status)

15.  Site of tumor
 Hepatic segments involved
 Feasibility when all tumor nodules can
be technically excised with negative
margins while maintaining an
adequately functioning hepatic remnant,
 Clinical performance statusis >50% to
60% and systemic comorbidity is
compensated

16.  Contraindications for resection
 Extrahepatic disease,
 Tumor thrombus in the inferior vena cava,
 Involvement of the common hepatic artery
and portal vein trunk

19. Total Hepatectomy and Liver
Transplantation.
 Allows for tumor resection with the
widest possible margins, and permits
removal of diseased and tumorigenic
parenchyma that may contain
microscopic metastatic disease and be
predisposed to the formation of
additional primary tumors.