Liver Transplantation and Surgery in the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the second cause of cancer–related deaths worldwide constitutes a major global health problem. Although our understanding of the molecular pathogenesis of hepatocellular HCC has improved, detected driver mutations are not yet sufficiently reliable therapeutic targets. The modern management of HCC is conceived only within multidisciplinary schemes. Current systemic therapies are not curative and surgical treatments remain the only potential curative treatments for selected patients with early stage HCC. The role of parenchyma sparing liver resection for appropriately selected patients may vary in different environments according to organ availability,and liver resection remains a reliable curative method for HCC. Meta-analyses have shown that clinical outcomes of surgical resection are superior to ablative treatments in early stage HCC. Liver transplantation is still the standard treatment for patients with early stage HCC. Lately the Milan Criteria are considered too restrictive, still recognizing that the extension of transplantation criteria beyond Milano criteria increases the risk of HCC recurrence. Resection, ablation, transarterial embolization and trans-arterial radiation are commonly applied to bridge patients to transplant. Despite enormous advances in the therapy of HCC treatments at present, there are currently no genuine breakthroughs for patients with HCC. The Clinical Trials Planning Meeting (CTPM) in HCC convened by the American Society of Clinical Oncology identified the key knowledge gaps in HCC and define clinical research priorities. Major improvements in survival provided by multimodal treatments witnessed in other cancers are not yet available for HCC because effective systemic treatment modalities for HCC are still lacking. Integration of bio-genetic tumor information into current tested treatment schemes and truly multimodal surgery-based treatment schemes will enable the recruitment of less selected patients in larger numbers to curative treatments.