Hepatocellular carcinoma (HCC) is the most common form of liver cancer, often developing in individuals with underlying chronic liver disease like cirrhosis. While HCC can be a challenging diagnosis, surgical intervention stands as a primary and often curative treatment for carefully selected patients. The decision to pursue surgery involves a thorough evaluation, balancing the potential for cure with the complexities of the procedure and the patient’s overall health.
Deciding on Surgery
Determining suitability for HCC surgery involves a multidisciplinary team, including hepatologists, surgeons, and oncologists. They assess several factors, such as the tumor’s characteristics, the liver’s health, and the patient’s general physical condition. Tumor size, number, and location are important considerations; for instance, a single tumor less than 5 cm or up to three tumors, each less than 3 cm, without macroscopic vascular invasion or spread outside the liver, are often favorable for surgery.
Liver health is another significant factor, as HCC frequently develops in a liver already affected by conditions like cirrhosis. Liver function is assessed using tools like the Child-Pugh score, with Child-Pugh class A indicating good liver function, preferred for surgical candidates. The patient’s overall health and performance status also play a role in the decision-making process, ensuring they can tolerate the demands of surgery and recovery.
Two main surgical approaches are employed for HCC: liver resection and liver transplantation. Liver resection involves removing the portion of the liver containing the tumor while leaving healthy liver tissue. This approach is preferred for patients with smaller tumors, good liver function, and no signs of portal hypertension. The extent of the resection depends on the tumor’s size and position, ranging from a small segment to an entire lobe.
Liver transplantation, conversely, involves replacing the diseased liver with a healthy donor liver. This option is considered for patients with early-stage HCC who meet specific criteria, such as the Milan criteria, which includes a single lesion 5 cm or smaller, or up to three lesions, none larger than 3 cm, without vascular invasion or extrahepatic metastasis. The benefits of transplantation include removing both the tumor and the underlying liver disease; however, challenges include donor organ availability and the need for lifelong immunosuppression to prevent rejection of the new organ.
The Surgical Experience
Before undergoing HCC surgery, thorough pre-operative preparation optimizes patient health. This includes detailed imaging, such as CT or MRI scans, to precisely map the tumor and assess the liver’s anatomy. Blood tests evaluate liver function, blood clotting ability, and overall health. Cardiac evaluations ensure the patient’s heart can withstand the stress of surgery.
Breathing and leg exercises are advised to minimize the risk of post-operative complications like chest infections and blood clots. Stopping smoking several weeks before surgery can significantly improve recovery. Nutritional status is assessed and optimized, as maintaining protein synthesis is important for recovery.
During surgery, general anesthesia is administered, ensuring the patient is unconscious and pain-free. The duration of a liver resection varies, typically 2 to 4 hours, depending on the extent of tissue removed. Surgeons work to remove the cancerous tissue with a margin of healthy liver, while preserving sufficient remaining liver volume to maintain function.
Following the procedure, patients are moved to a recovery unit (ICU or high dependency unit) for close monitoring. Pain management is a priority, with painkillers administered through various methods, including patient-controlled analgesia (PCA) pumps. Early mobilization, often within 12 hours, is encouraged to prevent complications and aid recovery. Several tubes for drainage and nourishment are gradually removed as patients recover.
Recovery and Long-Term Outlook
Recovery from HCC surgery continues at home, with timelines varying by surgery type. For liver resection, it can take weeks to months for full recovery, with a hospital stay usually lasting 5 to 10 days. Avoid heavy lifting or strenuous activities for at least 8 to 12 weeks to allow the wound to heal and the liver to regenerate. Fatigue is common, and gradual increases in activity, such as walking, are recommended.
Long-term follow-up care is a long-term commitment and important to monitor for cancer recurrence. Regular appointments involve physical examinations, blood tests (including alpha-fetoprotein (AFP) levels), and imaging scans (CT or MRI). Initially, appointments may be every 3 to 6 months for the first two years, then every 6 to 12 months. The frequency and type of surveillance depend on individual risk factors and the specific surgery performed.
Long-term considerations after HCC surgery vary by intervention type. After liver resection, the remaining liver regenerates, often returning to its original size within weeks. However, underlying liver disease often persists, increasing the risk of new tumors in the remaining liver. Transplant recipients require lifelong immunosuppressant medications to prevent organ rejection, which carry side effects and increase the risk of infections or other cancers.
Despite potential recurrence, successful HCC surgery offers a good long-term outlook and improved quality of life. Five-year overall survival rates after resection range from 40% to 70%, depending on factors. For transplant recipients, 5-year overall survival rates exceed 70% when Milan criteria are met. Adherence to medical advice, including regular surveillance and managing underlying liver conditions, is paramount for best long-term outcomes.