General Surgery
Surgical management of HCC removes liver cancer while keeping enough healthy liver to live on. In a 230-patient trial, resection beat ablation for five-year survival.
Hepatocellular carcinoma, HCC, grows from the liver's own cells, mostly in livers scarred by hepatitis B, hepatitis C, alcohol or fatty liver disease. Resection, ablation and transplant can each cure an early tumor, and the right choice depends on the tumor and on how well the rest of the liver works. Send your CT or MRI, blood tests and any biopsy report, and our liver team will tell you which treatment gives you the best chance.
75.7% vs 54.8%
Five-year survival, resection against ablation, 230-patient trial
63.1% vs 41.5%
Five-year survival after resection, with or without hepatitis B antiviral tablets
41.7%
Cancer back within five years after resection in the same trial
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Review of your scans before you book
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Hepatocellular carcinoma surgery means removing the part of the liver that holds the cancer, by open or keyhole surgery, with a margin of healthy tissue around it. The liver left behind has to keep you alive. In a healthy liver that leaves room for large resections, while a cirrhotic liver tolerates far less, and most HCC grows in cirrhotic livers. Every plan starts there.
Resection, ablation or transplant
For a small single tumor, resection and ablation compete directly. Two randomized trials from China tested them head to head.
PLAT was as effective as surgical resection in the treatment of solitary and small HCC.
Randomized trial of 180 patients, Annals of Surgery, 2006
The Chen trial
Chen and colleagues randomized 180 patients with a single tumor up to five centimeters to ablation or resection. Four-year survival reached 67.9 percent after ablation and 64.0 percent after resection, with no significant difference, and complications came more often and more severely after surgery. Nineteen of the 90 patients assigned to ablation withdrew consent before treatment.
Why the trials disagree
The two trials enrolled different tumors, followed patients for different lengths of time and lost different numbers of patients before treatment. Size matters most. Small tumors under three centimeters, deep in the liver, suit ablation best, while larger tumors and tumors lying against big vessels, which carry heat away from the needle and leave cancer cells alive at the edge, favor resection.
Two trials, two answers
Side by side, the results look like this.
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Resection against ablation in two randomized trials
| Measure |
Chen, 180 patients, 2006 |
Huang, 230 patients, 2010 |
| Tumors included |
Single, up to 5 cm |
Within the Milan criteria |
| Survival, resection |
64.0 percent at four years |
75.7 percent at five years |
| Survival, ablation |
67.9 percent at four years |
54.8 percent at five years |
| Verdict |
No significant difference |
Resection better |
Who suits resection
Liver function comes first
Resection suits patients with good liver function, Child-Pugh class A, no fluid in the abdomen, a normal or near-normal bilirubin and no high pressure in the portal vein. Our liver tumor removal page explains how we measure liver volume and pressure before surgery.
When resection outlasts ablation
Tumors within the Milan criteria
- One tumor up to five centimeters.
- Or up to three tumors, none larger than three centimeters.
- No invasion of the large blood vessels.
- No spread outside the liver.
The Huang trial
Huang and colleagues randomized 230 patients within these limits to resection or ablation and followed them for five years. Five-year survival reached 75.7 percent after resection. After ablation, 54.8 percent. Recurrence, 41.7 against 63.5 percent.
Overall survival and recurrence-free survival were significantly lower in the RFA group than in the RES group.
Randomized trial of 230 patients, Annals of Surgery, 2010
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Huang trial, survival year by year, 230 patients
| Year |
Resection |
Ablation |
| One |
98.3 percent |
87.0 percent |
| Three |
92.2 percent |
69.6 percent |
| Five |
75.7 percent |
54.8 percent |
When transplant fits better
A tumor within the Milan criteria in a liver with poor function or high portal pressure points to transplant. Our page on liver transplant for hepatocellular carcinoma covers that path.
Preventing the cancer from coming back
Follow-up runs for life, because the liver that grew one cancer keeps the conditions that grew it, and a second tumor found at one centimeter on a routine scan still has every treatment open to it.
1
First two years
A CT or MRI and the AFP blood marker every three months, when most early recurrences appear.
2
Years three to five
Scans every six months.
3
After five years
Ultrasound every six months for life.
4
Treatment of the cause
Antiviral tablets for hepatitis B or C, no alcohol, and weight and diabetes control for fatty liver.
Our data indicate that sorafenib is not an effective intervention in the adjuvant setting for hepatocellular carcinoma following resection or ablation.
STORM trial of 1,114 patients, Lancet Oncology, 2015
Drug treatment after surgery
The STORM trial found the same time without recurrence with sorafenib or placebo after resection or ablation, 33.3 against 33.7 months. The IMbrave050 trial gave atezolizumab with bevacizumab for a year to 334 high-risk patients and found fewer recurrences at an interim analysis, with severe side effects in 41 percent against 13 percent under surveillance. Its authors called for longer follow-up of survival, and our oncologists discuss it with high-risk patients case by case.
The operation
Anatomical resection
For HCC we remove whole liver segments along their blood supply, since the cancer spreads through the small portal vein branches of the segment it grows in.
1
Anesthesia and access
General anesthesia, then keyhole ports or an incision under the right ribs.
2
Ultrasound on the liver
The surgeon maps the tumor, the vessels and any small second tumor the scans missed.
3
Dividing the liver
The segment comes out along its natural borders, with low pressure in the main vein to limit bleeding.
4
Checks and closure
Bile and blood leaks checked, a drain placed when needed.
Keyhole liver surgery
Tumors near the surface and in the front and left segments come out by keyhole surgery, with less pain and a shorter stay. Deep tumors near the main veins, and livers with advanced cirrhosis, need open surgery.
Recovery
Three to seven nights in hospital. Walking starts on the first day, eating on the second, and the drain comes out once the fluid runs clear. A cirrhotic liver regrows more slowly than a healthy one, so tiredness lasts longer, and fluid in the abdomen sometimes builds up for a few weeks and needs water tablets. Normal activity returns at four to six weeks.
Hepatitis, recurrence and the stay in Istanbul
Removing the tumor leaves the cause behind. Hepatitis B, hepatitis C, alcohol and fatty liver disease go on damaging the remaining liver after a perfect operation, and the treatment that follows surgery decides much of what happens in the next ten years, as much as the operation itself.
Treating hepatitis B after surgery
Huang and colleagues randomized 200 patients after complete removal of a hepatitis B related HCC to antiviral tablets or no antiviral treatment. Five-year survival reached 63.1 percent with antivirals against 41.5 percent without, mainly by preventing late recurrences.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Antiviral tablets after resection of hepatitis B related HCC, 200 patients
| Outcome at five years |
Antiviral |
No antiviral |
| Survival |
63.1 percent |
41.5 percent |
| Free of recurrence |
46.1 percent |
27.1 percent |
In patients with hepatitis B-related HCC, adefovir antiviral therapy reduced late HCC recurrence and significantly improved overall survival after R0 hepatic resection.
Randomized trial of 200 patients, Annals of Surgery, 2015
Hepatitis C and fatty liver
Modern hepatitis C tablets clear the virus in nearly every patient, and we start them after surgery when the virus remains. For fatty liver disease, weight loss, diabetes control and no alcohol protect the remaining liver.
- A CT or MRI of the liver with contrast, under two months old.
- Blood tests, bilirubin, albumin, INR, platelets and AFP.
- Hepatitis B and C results, with the viral load.
- Any biopsy or endoscopy report.
Recurrence stays common
Even after a complete resection, HCC returns within five years in four of ten patients, because the liver that grew one cancer can grow another. A new tumor found early can still be treated with repeat resection, ablation or a transplant, which explains the strict scan schedule.
The stay in Istanbul
Plan ten to fourteen days in Istanbul after a keyhole resection and two to three weeks after an open one. Our surgeon confirms fitness to fly before you leave, and a companion can sleep in your room. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, and follow-up after you return home runs through them, with the pathology report, the scan schedule and the antiviral plan sent to your doctor. The cost depends on the size of the resection, keyhole or open surgery and the length of stay, and the estimate after the free review lists each.
Our tumor board
Liver surgeons, hepatologists, interventional radiologists and oncologists review every case together and choose between resection, ablation, transplant and other treatments in a written plan, before you travel.
Hepatocellular carcinoma surgery FAQ
Is surgery better than ablation for liver cancer?
For tumors within the Milan criteria, one trial of 230 patients found better five-year survival after resection. Another trial of small single tumors found no difference, and ablation suits small, deep tumors.
Can I have liver cancer surgery with cirrhosis?
Yes, with good liver function and normal portal pressure. Poor function points to transplant.
Will the cancer come back after surgery?
In four of ten patients within five years in the Huang trial. Regular scans find a new tumor early, when it can still be treated.
Do I need chemotherapy after HCC surgery?
Standard chemotherapy does not help, and sorafenib failed in the STORM trial. Antiviral treatment for hepatitis B improved survival.
How long is the stay in Istanbul?
Ten days to three weeks, depending on keyhole or open surgery.
References
- Huang J, Yan L, Cheng Z, et al. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Annals of Surgery. 2010;252(6):903-912.
- Chen MS, Li JQ, Zheng Y, et al. A prospective randomized trial comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular carcinoma. Annals of Surgery. 2006;243(3):321-328.
- Bruix J, Takayama T, Mazzaferro V, et al. Adjuvant sorafenib for hepatocellular carcinoma after resection or ablation (STORM): a phase 3, randomised, double-blind, placebo-controlled trial. Lancet Oncology. 2015;16(13):1344-1354.
- Qin S, Chen M, Cheng AL, et al. Atezolizumab plus bevacizumab versus active surveillance in patients with resected or ablated high-risk hepatocellular carcinoma (IMbrave050): a randomised, open-label, multicentre, phase 3 trial. Lancet. 2023;402(10415):1835-1847.
- Huang G, Lau WY, Wang ZG, et al. Antiviral therapy improves postoperative survival in patients with hepatocellular carcinoma: a randomized controlled trial. Annals of Surgery. 2015;261(1):56-66.
