Current and Future Challenges in the Surgical Treatment of Hepatocellular Carcinoma: A Review

Challenges in the treatment of hepatocellular carcinoma Hepatocellular carcinoma (HCC) represents one of the most frequent types of cancer worldwide. Surgery, although only a part of the armamentarium against HCC, represents the cornerstone in the management of this aggressive disease. This article will review the current and future challenges in the surgical management of HCC, with a special emphasis on the following areas: (1) the evolution of staging of the disease and the importance of the biological nature and behavior of HCC, (2) the effort to increase resectability, (3) technical innovations and the role of image-guided surgery, and, finally, (4) the role of liver transplantation in the continuum of care for these patients. Although by no means an exhaustive list, the issues mentioned above represent some of the most promising prospects for significant progress in the management of HCC.Key words: Hepatocellular carcinoma, Image-guided surgery, Liver transplantation, ResectabilityThe incidence of hepatocellular carcinoma (HCC) has risen significantly in the United States in the last decade, only to be surpassed by the increased incidence in East Asia and sub-Saharan Africa because of the high prevalence of hepatitis B in that area.^1,2 In other parts of the world, such as North America, Europe, and Japan, the main culprit appears to be the high prevalence of chronic hepatitis C infection, together with confounding factors, such as alcohol abuse, nonalcoholic steatohepatitis, obesity, and tobacco use.^3–5 The common theme is the association between liver cirrhosis and HCC, with 80% of HCC cases being in cirrhotic livers.⁶ Although the exact mechanism has not been fully elucidated yet, it may have to do with changes in the normal hepatic architecture seen in cirrhosis or with damage caused by the viral DNA in the cases of hepatitis infection, both representing a cancerous transformation signal.Given the complexity of the disease, it should come as no surprise that its treatment is multimodal and requires the cooperation of multiple specialties. Even so, surgery remains the cornerstone of the management of HCC, as it has the unique ability to provide a therapeutic option. The 2 main curative surgical therapies are liver resection and orthotopic liver transplantation (OLT). Even with careful patient selection, recurrence and metastatic disease remain the 2 main problems encountered in liver resection, with OLT having to deal with the additional obstacle of the limited number of available donors. Other treatments, such as chemoembolization or radiofrequency ablation, may be able to limit the disease in certain situations or act as bridging therapies, although overall the results cannot be compared with those of resection or OLT. The limitations mentioned above serve to underscore the challenges facing hepatic surgery, as well as to identify the areas where the research efforts should be focused. In this article, the areas that will be reviewed represent promising prospects for progress in the surgical management of HCC.