Hepatocellular carcinoma remains a leading cause of cancer death worldwide. There are an increasing number of patients that do not meet traditional criteria for surgical resection as a result of historically poor outcomes. We define these oncologically high-risk patients as those with either one of these risk factors or a combination of them: Large (>5 cm) primary tumors, multinodular disease, and/or major vascular invasion. With appropriate selection and preparation, long-term survival is possible in this subset of patients after resection. This review focuses on the surgical treatment of these high-risk patients, focusing on our own institution's approach and methods as well as reviewing the literature pertinent to the support of our current practice.
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