Published online Apr 18, 2016. doi: 10.4254/wjh.v8.i11.513
Peer-review started: September 11, 2015
First decision: October 27, 2015
Revised: February 18, 2016
Accepted: March 24, 2016
Article in press: March 25, 2016
Published online: April 18, 2016
Hepatocellular carcinoma (HCC) is the main common primary tumour of the liver and it is usually associated with cirrhosis. The barcelona clinic liver cancer (BCLC) classification has been approved as guidance for HCC treatment algorithms by the European Association for the Study of Liver and the American Association for the Study of Liver Disease. According to this algorithm, hepatic resection should be performed only in patients with small single tumours of 2-3 cm without signs of portal hypertension (PHT) or hyperbilirubinemia. BCLC classification has been criticised and many studies have shown that multiple tumors and large tumors, as wide as those with macrovascular infiltration and PHT, could benefit from liver resection. Consequently, treatment guidelines should be revised and patients with intermediate/advanced stage HCC, when technically resectable, should receive the opportunity to be treated with radical surgical treatment. Nevertheless, the surgical treatment of HCC on cirrhosis is complex: The goal to be oncologically radical has always to be balanced with the necessity to minimize organ damage. The aim of this review was to analyze when and how liver resection could be indicated beyond BCLC indication. In particular, the role of multidisciplinary approach to assure a proper indication, of the intraoperative ultrasound for intra-operative restaging and resection guidance and of laparoscopy to minimize surgical trauma have been enhanced.
Core tip: According to the barcelona clinic liver cancer (BCLC) classification liver resection should be performed only in patients with small single hepatocellular carcinoma of 2-3 cm without signs of portal hypertension (PHT). Nevertheless, many studies have shown that patients with multiple and large hepatocellular carcinoma, as like as those with macrovascular infiltration and PHT, could benefit from liver resection. Consequently BCLC algorithm should be updated and revised. The aim of this review was to analyze when and how liver resection could be indicated beyond BCLC indications. In this perspective, the role of multidisciplinary approach, of intraoperative ultrasound and of laparoscopy have been enhanced.