Surgical treatment of hepatocellular carcinoma: Expert consensus statement

As the number of effective treatment options has increased, the management of patients with hepatocellular carcinoma has become complex. The most appropriate therapy depends largely on the functional status of the underlying liver. In patients with advanced cirrhosis and tumor extent within the Milan criteria, liver transplantation is clearly the best option, as this therapy treats the cancer along with the underlying hepatic parenchymal disease. As the results of transplantation has become established in patients with limited disease, investigation has increasingly focused on downstaging patients with disease outside of Milan criteria and defining the upper limits of transplantable tumors. In patients with well preserved hepatic function, liver resection is the most appropriate and effective treatment. Hepatic resection is not as constrained by tumor extent and location to the same degree as transplantation and ablative therapies. Some patients who recur after resection may still be eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial chemoembolization have been used primarily to treat patients with low volume irresectable tumors. Whether ablation of small tumors provides long term disease control that is comparable to resection remains unclear.