HCC is the 4 th commonest and 2 nd most fatal cancer worldwide. It is strongly associated with hepatitis B and C, alcoholic liver disease and cirrhosis. Like most solid organ cancers, HCC is treated primarily by surgery. However, this is only possible in 5-15% of cases because of cirrhotic liver impairment, insufficient liver reserves, multifocal disease or extrahepatic involvement. When treatment is not possible, median survival is often 3 to 6 months. Attempts to prolong survival by other treatment methods ranging from systemic chemotherapy to ablation using radiofrequency (RFA) or alcohol have yet to show comparable results to surgery.

Types of Surgery
The liver is divided into distinct Couinard’s segments (Fig.1), each with its own inherent inflow and outflow vasculature. Removal of liver based on segments is termed anatomical resection, and range from single segmentectomy to the larger lobectomy or hemihepatectomy where several segments are removed together.

Anatomical resection reduces blood loss and obtains oncological clearance by removing a perfused segment. In contrast, non-anatomical resections are usually wedge removals of tumour with a margin of normal liver around it. Since this ignores the boundaries of segments, vascular control and oncologic clearance is less well defined. However, non-anatomical resections allow for greater parenchymal preservation, especially in the very cirrhotic patient.

Contraindications for surgery
Since surgery is currently the only treatment method that offers long-term survival in HCC, all attempts should be made to operate if possible. There are however several well-established contraindications to surgery. These include:

1.	Poor overall patient status precluding anaesthesia and surgery.
2.	Poor liver function status, usually Child’s C status.
3.	Extensive disease, e.g. diffuse or multifocal HCC, or extrahepatic metastases.
4.	Tumour extension into the main portal vein (MPV) or MPV thrombosis
5.	Tumour extension into the inferior vena cavae (IVC).

Results of Surgery
Resection for HCC is well established. Established hepatobiliary (HPB) surgery units report acceptable results with a mortality rates of less than 5% and long-term 5-year survival of close to 45% (Table 1).

Pushing the Limits
Understanding that surgery is currently the only method that offers long-term survival and that results of surgery in established HPB units are reasonable, various extended surgical indications have been included in attempts to improve patient survival and outcome. Factors like large tumour size (> 5cm), rupture, multifocal (but 3 or less nodules) and isolated metastases (with long disease-free intervals) are no longer definite contra-indications to surgery, and should be considered on a case-by-case basis. In our practice, the tumour size of resected HCC ranges from 1 cm to as large as 30 cm.

Combined techniques like resection with RFA allow for resection of multifocal HCC. In ruptured HCC, hepatic arterial embolisation in an emergent setting for control of bleeding, followed by staged resections have resulted in prolonged survival. Even with metastatic disease, especially to the adrenal glands, resection of isolated tumour may provide palliation and reasonably long-term survival.

A/P London Lucien Ooi
Head, Surgical Oncology
National Cancer Centre, Singapore