Current surgical treatment strategies for hepatocellular carcinoma in North America

Table 1 American liver tumor study group modified tumor-node-metastasis staging classification for hepatocellular carcinoma

Tumor classification	Definition	Stage	Criteria
T0, N0, M0	No tumor found
T1	1 nodule < 2.0 cm	Stage I	T1 lesion
T2	1 nodule 2-5 cm, 2 or 3 nodules each less than 3 cm	Stage II	T2 lesion
T3	1 nodule > 5 cm, 2 or 3 nodules, at least 1 > 3 cm	Stage III	T3 lesion
T4a	≥ 4 nodules, any size	Stage IVa1	T4a
T4b	T2, T3 or T4a plus gross intrahepatic, portal or hepatic vein involvement as indicated by CT, MRI or US	Stage IVa2	T4b
N1	Regional (porta hepatis) node involvement	Stage IVb	Any N1 or M1
M1	Metastatic disease including extrahepatic portal or hepatic vein involvement

HCC: Hepatocellular carcinoma; CT: Computed tomography; MRI: Magnetic resonance imaging; US: Ultrasound; TNM: Tumor node metastasis.

Table 2 Current indications of commonly used treatment options for hepatocellular carcinoma

	Current indications
Hepatic resection	Treatment of choice in patients with resectable disease and absence of cirrhosis
	Indicated in selected patients with limited disease and early cirrhosis (Child-Pugh A)
	Limited role as a bridge to OLT
OLT	Standard therapy for patients with HCC and Cirrhosis within Milan criteria
	OLT may be indicated in select patients with tumors outside Milan criteria but within UCSF criteria
	Indicated in select patients with stage III and IV HCC downstaged to within Milan criteria with use of neo-adjuvant therapy
Non resectional ablative therapies (RFA, microwave, TACE, TAE, HIFU etc.)	Indicated as primary therapy only in patients with HCC who are not candidates for curative resection or OLT
	Increasingly used alone or in combination as bridging therapy in patients awaiting OLT or to downstage stage advanced stage disease to within Milan criteria
	Established role in palliative treatment of HCC (not discussed in this paper)

HCC: Hepatocellular carcinoma; OLT: Orthotopic liver transplant; UCSF: University of California San Francisco.

Table 3 Overview of the common modalities used in the treatment of hepatocellular carcinoma

Treatment modality	Advantages	Disadvantages
Hepatic resection	Readily accessible	Not indicated for patients with advanced cirrhosis
	No waiting period	High recurrence rates (> 50% at 5 yr)
	5 yr survival of > 50% in carefully selected patients	Risk of post operative haptic failure
	Peri-operative mortality < 5%	Does not address risk of cancer in residual liver
	Not limited by tumor size
OLT	Low rate of recurrence in carefully selected patients	Restricted by size and number of lesions
	Post transplant survival rates similar to patients with OLT for all other causes	Risk of dropout while on wait list (38% drop out rate after 12 mo)
TACE/TAE	Indicated for treatment in patients not candidates for resection or OLT	Low curative potential when used alone with high recurrence rates
	Effective role as bridge for transplantation	Efficacy decreased for large sized tumors
	Established role in downstaging HCC to make patients OLT eligible	Does not address risk of cancer in residual liver
	Evidence of survival benefit after OLT when used as neo-adjuvant therapy in select patients
	Relatively low morbidity
RFA	Highly effective for HCC ≤ 3 cm	Decreased effectiveness in HCC ≥ 4 cm with high recurrence rates
	Effective bridge for OLT by decreasing drop out rate on wait list	May be limited by proximity of HCC to vascular pedicels
	Established role in downstaging HCC to make patients OLT eligible	Does not address risk of cancer in residual liver
	Relatively low morbidity and mortality

HCC: Hepatocellular carcinoma; OLT: Orthotopic liver transplantation; TACE: Transarterial chemoembolization; TAE: Transarterial embolization; RFA: Radiofrequency ablation.