Surgical resection of early stage hepatocellular carcinoma: Balancing tumor biology with the host liver

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. In early stage HCC, current practice guidelines recommend surgical resection with 5-year overall survival (OS) rates approaching 60%. Due to heterogeneity of the patient population and underutilization of HCC screening, in the past only 10-37% of patients were eligible for surgical resection at the time of initial HCC diagnosis. With recent implementation of HCC screening programs resulting in earlier diagnosis, the number of patients that might be candidates for curative surgical resection has increased. Factors determining outcome following HCC diagnosis are complex and heterogenous in nature and treatment decisions should be based on both tumor- and patient-related factors. Tumor characteristics including tumor size, macrovascular invasion (MVI), and multifocality must be balanced against measures of liver dysfunction including portal hypertension, liver function, and future liver remnant (FLR) to assess the applicability of hepatic resection in patients newly diagnosed with HCC. The aim of this article is to review the indications for curative HCC surgical resection as it pertains to underlying tumor- and patient-related factors. We also discuss adjunctive therapies that may allow for an increased role for hepatic resection in HCC patients with early stage disease who are ineligible for upfront resection due to small liver remnant size.