Hepatocellular carcinoma: Surgical perspectives beyond the barcelona clinic liver cancer recommendations

Abstract

The barcelona clinic liver cancer (BCLC) staging system has been approved as guidance for hepatocellular carcinoma (HCC) treatment guidelines by the main Western clinical liver associations. According to the BCLC classification, only patients with a small single HCC nodule without signs of portal hypertension or hyperbilirubinemia should undergo liver resection. In contrast, patients with intermediate-advanced HCC should be scheduled for palliative therapies, even if the lesion is resectable. Recent studies report good short-term and long-term outcomes in patients with intermediate-advanced HCC treated by liver resection. Therefore, this classification has been criticised because it excludes many patients who could benefit from curative resection. The aim of this review was to evaluate the role of surgery beyond the BCLC recommendations. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%. Surgery also offers good long-term result in selected patients with multiple or large HCCs with a reported 5-year survival rate of over 50% and 40%, respectively. Although macrovascular invasion is associated with a poor prognosis, liver resection provides better long-term results than palliative therapies or best supportive care. Recently, researchers have identified several genes whose altered expression influences the prognosis of patients with HCC. These genes may be useful for classifying the biological behaviour of different tumours. A revision of the BCLC classification should be introduced to provide the best treatment strategy and to ensure the best prognosis in patients with HCC.

Keywords: Hepatocellular carcinoma; Liver resection; Hepatectomy; Barcelona clinic liver cancer; Surgical therapy

Core tip: The present review reports the results of surgery beyond the barcelona clinic liver cancer recommendations. Recent studies have reported that surgical resection can result in good short- and long-term survival in patients with early hepatocellular carcinoma (HCC) with portal hypertension and in patients with intermediate-advanced HCC. A careful preoperative evaluation, including liver function and remnant volume assessment, is mandatory before liver resection in HCC patients. An understanding of the biological behaviour of these tumours through molecular biology studies may be useful in choosing the optimal treatment strategy.