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BackTable / Tumor Board / Article
Hepatocellular Carcinoma Surgery: Who, When, How?
Rajat Mohanka • Updated Aug 18, 2025 • 31 hits
Surgical management of hepatocellular carcinoma (HCC) hinges on nuanced decision-making across curative and palliative frameworks. While resection and transplant remain central to curative strategies, defining “cure” in patients with HCC requires careful patient communication and long-term surveillance. Surgical approach is influenced by tumor location, extent of liver disease, and anticipated future liver remnant (FLR), with anatomic resections, lobectomies, and trisegmentectomies tailored accordingly. Techniques like portal vein embolization and radiation lobectomy aim to increase FLR, though cirrhosis often limits success. Ultimately, multidisciplinary collaboration guides the balance between surgical intervention, locoregional therapy, and transplant prioritization.
Transplant and hepatobiliary surgeons Dr. John Seal and Dr. Gabriel Schnickel, with interventional radiologists Dr. Sid Padia and Dr. Sabeen Dhand, offer practical strategies for determining and bridging patients with HCC to surgical candidacy. This article features excerpts from the BackTable Tumor Board Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Tumor Board Brief
• Clinicians vary in how they define “curative” vs “palliative,” especially for cirrhotic HCC patients; transplant offers the closest proxy to cure but still requires continued surveillance.
• Transplant is preferred in patients with advanced cirrhosis, while resection is reserved for those with well-compensated liver function or de novo tumors.
• Surgical resection types include anatomic segmental resection, hemihepatectomy, and trisegmentectomy, selected based on tumor burden and future liver remnant.
• Future liver remnant assessment is critical; resection is contraindicated when FLR is insufficient due to cirrhosis or poor regenerative capacity.
• Radiation lobectomy and portal vein embolization can support hypertrophy of FLR but are less effective in cirrhotic HCC patients compared to those with colorectal metastases.
• Patient selection criteria for resection include ECOG status, age, AFP levels, tumor response to prior therapy, and peripheral tumor location.
Table of Contents
(1) Hepatocellular Carcinoma Surgery: Curative vs Palliative Treatment
(2) Surgical Resection Options in Hepatocellular Carcinoma
(3) Factors that Determine Surgical Candidacy & Success in HCC
Hepatocellular Carcinoma Surgery: Curative vs Palliative Treatment
Approaches to treating hepatocellular carcinoma vary depending on whether the intent is curative or palliative. While most clinicians agree that curative intent means eliminating all visible disease, it’s crucial to communicate to patients that even after a treatment with curative aim, recurrence remains a possibility. Long-term follow-up is essential, regardless of the initial response. For many patients with HCC, liver transplantation is considered the definitive goal. However, transplant does not guarantee a cure, further reinforcing the need for surveillance and individualized care.
Treatment decisions—particularly between resection and transplant—are guided by the degree of underlying liver dysfunction. Patients with extensive cirrhosis are typically poor candidates for resection and are better suited for transplant. In these cases, radioembolization can play an important role, offering outcomes similar to resection when surgery is not an option. Understanding these nuances helps inform not only which therapies are offered, but how physicians frame prognosis and follow-up with patients across the HCC care continuum.
[Dr. Sabeen Dhand]
…Let's just start off with what is the definition of curative and palliative? It can be a gray zone. What exactly does it mean to you, Gabe?
[Dr. Gabe Schnickel]
Sure. I think curative, in medicine and certainly in surgery, we always talk about measure everything in years. Once you get out to the five-year mark, I think everyone looks at that as being curative. When we approach surgery, we think about it as a curative approach versus palliative, where your intent is to clear and leave the patient with no evidence of disease.
[Dr. Sabeen Dhand]
Y-90 is considered palliative to most, Sid. Why is that?
[Dr. Sid Padia]
I agree with you, but that's not the approach. I don't disagree with those definitions because that's, I think, probably the more widely accepted definitions. I don't end up using those in my practice, particularly in the HCC population, because anytime we say cure, these patients assume they're never getting another cancer again. Unlike every other cancer, a woman has breast cancer, who doesn't have a family history of breast cancer, she gets a lumpectomy, radiation, her risk of getting breast cancer again is 1 in 11, just like the baseline population.
The risk of someone with alcohol-induced cirrhosis, we know that there's a good likelihood they'll get a new cancer. So when I started saying, "You're cured," and then they're like, "Why do I need Q3 month imaging?" Then they don't follow up with me. They're like, "I got another tumor." It's in the other side of the liver. It has nothing to do with what we did or a surgeon did. I got burned in the beginning. So I've just rephrased the way I've interacted with patients. I basically say, that tumor is dead or forever, right? There's always risk of new ones.
So I've used that because I've unfortunately miscommunicated the word "cure" to patients.
[Dr. John Seal]
Yeah, I never use it. That terminology, I don't know, do you all even use those terms? I never do. I think it's like, it's all a process to optimize the treatment options.
[Dr. Sid Padia]
Do you use it for transplant, though? That's the one time I say, okay, look, the real ultimate cure is getting a transplant, even though it's not zero.
[Dr. Sid Padia]
It's not zero, but it's so low, right?
[Dr. John Seal]
Whatever, Sid. It's just that I would hate-- because what are you going to tell them they're cured, and then you're going to tell them, "You have to get a scan every six months."
[Dr. Sid Padia]
"Why am I getting a scan?" Right.
[Dr. John Seal]
Yeah it's good news when you get the transplant. Is it cured? I'm delicate about that word term. I'm also very delicate about palliative care. You come in with a 18-cm tumor. We probably all have a case or two where there have been a great response. I'm not going to say all the stuff we're doing up front is palliative out of the gate. It's an interesting question, but I avoid both.
[Dr. Sid Padia]
There's conversation within the medical community, let's say the four of us. Then there's a different understanding with patients, right, of what cure means or palliation means. When the lay public or a patient hears the word "palliation", they think you are not treating them and you're just going to give them a bunch of oxycodone to treat their pain, right? That's what palliation means. So I think we need to be careful about what we discuss with each other. It's very different than what we discuss with patients because their understanding is very different than what I might come to understand.
[Dr. Sabeen Dhand]
Yeah. We kind of just said it earlier where transplant is the goal, right? We want to get to transplant. Now, the surgical approaches include resection and transplant. When do you decide just a resection only and the patient's not going to go to transplant? What are different things in your treatment strategy that select resection over transplant?
[Dr. John Seal]
I think there's some variability between practitioners…There's really a lot of factors. The first is really the extent of the underlying liver disease. You've got someone with no cirrhosis, de novo tumor that's clearly resectable. Those are the ones where I think resection is a really good option. Any time a tumor occurs in the context of cirrhosis, you have to physiologically think in your brain, there's a lot of damaged liver cells there and there's going to be an increased risk that they're going to form new tumors in the future.
You have to balance how you're going to approach that with what that risk will be. Transplant is not a free ride, right? Even if you want to get to transplant, you would hate to put them through a massive operation when you could have cured it with a little wedge resection or something like that. Then you have to look at the overall health of the patient. There are patients who you know transplant is not an option. Those, we push the envelope on resection a little bit more. You look at a number of factors that sort of dictate how big that operation is going to be and how you expect the patient will recover.
That metric has shifted a lot as the less invasive tools become a lot better. The things that you're achieving with Y-90 are really comparable to the outcomes of resection in a lot of cases. I think we have to think long and hard before we start operating on cirrhotic livers and doing big cases when there's a safer option and similar outcome.
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Surgical Resection Options in Hepatocellular Carcinoma
Surgical resection in hepatocellular carcinoma involves several approaches—anatomic resection, lobe resection (hemihepatectomy), and trisegmentectomy. The choice among these depends largely on the future liver remnant, which refers to the volume of functional liver expected to remain after surgery. Adequate FLR is critical to avoid liver failure post-resection, particularly in patients with underlying cirrhosis who may already have limited reserve.
The liver is divided into eight segments, each with its own vascular and biliary supply. Anatomic resection targets one or more of these segments based on vascular anatomy. Lobe resection involves removing either the right or left hepatic lobe, while trisegmentectomy includes a full lobe plus part of the adjacent lobe. For patients with insufficient FLR but otherwise curative potential, interventional techniques such as portal vein embolization or radiation lobectomy can be used to induce hypertrophy of the contralateral liver. These strategies help expand surgical options and improve outcomes in carefully selected patients.
[Dr. Sabeen Dhand]
Gabe, what would be, different types of surgical approaches as far as what are different resections for our listeners? What's a [trisegmentectomy]? What's anatomical, non-anatomical?
[Dr. Gabe Schnickel]
..when I think about who should get a resection and who should get a transplant, as John was saying, you have to think about the status of the underlying liver and then how much liver remnant, what's the future remnant going to be? We think about the extent of resection. Just for definition, you have your anatomic resection, when you're taking out an actual segment of liver that is based on the vascular anatomy. If you're taking out a whole, what we might call a lobe or a hemihepatectomy.
Which would be the right hemiliver or the left hemiliver, or you're doing a triseg, as you said, which means you're doing an extended hepatectomy. You're taking out all of the right and some of the left liver. Those operations for HCC are tricky because, again, most of these patients will have some underlying liver disease. I think it's around 80%, right, of patients with HCC will have cirrhosis. Those that don't might have some baseline underlying, whether it's fatty liver disease or they have hepatitis B or whatnot.
Those are all considerations that we have to keep in mind. As John said, it's really evolved over the past couple of decades when we think about transplant and when we think about resection.
[Dr. Sabeen Dhand]
You talked about FLR a little bit, the future liver remnant. Sid, are you doing many things to increase FLR in the setting of surgical resection?
[Dr. Sid Padia]
By FLR, you're meaning like a radiation lobectomy, right, to hypertrophy the other side. What we have seen over the last, let's say, five years when we started doing radiation lobectomy at UCLA, we did them for, I would say, predominantly two indications. Number one is HCC. Number two is metastatic colorectal cancer. For HCC, I would say that our results have not been as great as we and our hepatobiliary surgeons had hoped for. I think there is still this issue of, as you said, 80% of them have underlying cirrhosis.
The ones where we have done a successful radiation lobectomy for them to get to a curative intent surgical resection, it hasn't been as promising as we had hoped. Same thing with portal vein embolization. You do that portal vein embolization to get FLR hypertrophy in the HCC patient. They go to the operating room. There's too much cirrhosis. The tumor grew, et cetera. That's also a problem. In the CRC population, it's been a little bit different. What we've done is much more of a, I would say, staged and much more patient approach in terms of doing, let's say, a radiation lobectomy with the intent of future liver hypertrophy.
Factors that Determine Surgical Candidacy & Success in HCC
Surgical candidacy for hepatocellular carcinoma is influenced by a combination of patient-specific factors and tumor characteristics, making each case highly individualized. Key considerations include functional status (e.g., ECOG score), patient age, alpha-fetoprotein levels, and response to prior locoregional therapy. In patients with cirrhosis, the overarching goal is often to optimize them for transplant rather than resection. While radiation lobectomy can be used to promote hypertrophy of the future liver remnant, outcomes vary. Some centers report limited success with subsequent surgical resection, particularly when hypertrophy is inadequate or when a prolonged delay between radioembolization and surgery leads to fibrotic changes that complicate the procedure.
Tumor location also plays a critical role. Peripheral tumors are generally more amenable to resection, including minimally invasive approaches such as robotic surgery. In contrast, deeper tumors may require cutting through healthy liver tissue, prompting careful consideration of the risk-benefit ratio. In such cases, nonsurgical options like locoregional therapy may be preferable. Ultimately, both resection and transplant should remain on the table, with treatment decisions guided by tumor biology, liver function, and the patient’s overall condition.
[Dr. Sid Padia]
…after the local therapy, let's say we restage, and let's say you get a complete response and everything looks good, patient feels great. The question from our surgeons is, does this patient need a right hepatectomy? I don't know if we know the right answer to that. I think in the non-aggressive tumors, if it looks good, and let's say, as you mentioned, that the risk factors are a little high for a surgical recession, let's say they're 80. Let's say maybe they're not ECOG 0, they're ECOG 1, where your complication rate may be slightly higher than baseline.
Should we just hold off on those patients and see what their biology does? Is it possible that they may never need one?
[Dr. John Seal]
I feel like we're getting the answer to that question. It's really hard to do prospective trials, right, in surgery.
[Dr. John Seal]
I think probably several of us here have a cohort of patients we have in mind that we know they can't be transplanted and they're not great surgical candidates. We're like, we're just going to do radiation therapy and we watch them. Then three years later, you're seeing them in clinic. You're like, "Huh," that worked well for this patient in this context. Now when I have it in a patient where maybe there are some other options that aren't totally straightforward, it might give me a little hesitation to dive in and do the triseg on that patient.
[Dr. Sid Padia]
…Let's say you did a radiation lobectomy and you got great hypertrophy. Let's say I got great hypertrophy, but not a home run on the tumor. I got partial response. Would that push you then go, "You know what? Maybe this person, I'll push the limits." I'll push the limits in terms of resection. I might actually,-- maybe they're a higher risk because they're 78 years old, but it's worth it.
[Dr. Gabe Schnickel]
I think, yeah. Just the fact that hypertrophy, the data shows that the liver is actually going to respond and regenerate afterwards. That patient's probably more likely to tolerate a major resection. It's really helpful to see that response. That would give me a little bit more courage to step up in that marginal case and be willing to do the bigger resection for that patient.
[Dr. John Seal]
With the inverse being true and equally important, like, "Oh, you did all that and it didn't grow."
[Dr. Sid Padia]
I had one six months ago, radiation lobectomy. He was 79 years old. Procedure went great. No technical issues. I got a complete response. He got moderate ascites. Our hepatobiliary says there's no way I'm doing a right hepatectomy if you got ascites. Now his ascites went away after six months, but I said, "There's no way I'm doing a right hepatectomy on this guy if you got ascites after a radioembolization."
[Dr. Sabeen Dhand]
…What are some more characteristics when you look from a surgical perspective, say someone's presenting a case at Tumor Board, what are a lot of the patient characteristics that you look for that will make it a surgical candidate?
[Dr. Sid Padia]
…But we don't necessarily always go to surgery anymore. We go to surgery if there's certain risk factors, high AFP, there's a risk of them progressing, but there's a good proportion of patients where our surgeons have chosen to leave alone and just do a watchful wait.
[Dr. John Seal]
There are a number of things. Obviously, we have to always reference that the background is the extent of the cirrhosis, right? I think that as access and outcomes and transplant get better and better, then more of these people with advanced liver disease are just going to go straight to transplant. At least that's what I've seen in my practice over 10 years. I'm leaning more into transplant for a lot of these cases. The size of the lesion and location of lesion in a relatively healthy liver, I think, dictate that a lot.
A lot of progression with minimally invasive approaches really changes the recovery and the type of patients you can do these on. For lesions that are relatively small and on the periphery of the liver, those are the ones that I don't hesitate to do robotically, and those patients go home in one to three days. You can do that in the context of a much sicker patient and in bigger patients. We see a lot of obesity in the part of the country where we practice, and that becomes a really important tool if you can do it robotically or laparoscopically.
If it's really central and you have to take out a lot of healthy liver to get one little tumor, then that gives me a little bit of pause of, like, maybe I'm not going to take out 70% of your liver for a three-centimeter lesion, knowing what you all can do with the regional approaches.
[Dr. Gabe Schnickel]
I agree with your sentiments exactly. I think for me, it's evolved over time. I'm much more leaning into transplant in saving resection for either patients that are not cirrhotic or just very minimal, [Childs Pugh Score] A cirrhotic with a lesion that's really more on the periphery, where I'm not having to take the full right lobe. I'm really reluctant to do that, and I'll push them more towards transplant. The reality is, as we have evolved over the past five years, there are more livers available now, and I think the hesitation to save those donor livers for more patients, I think that's shifting.
Honestly, we don't have a lot of HCC patients on our list. They don't stay very long because we transplant them so quickly. I think definitely as the outcomes are getting better with transplant, leaning more towards transplant in general.
[Dr. John Seal]
…I think the most important thing to think about in those contexts is to always engage with the decision-making in a multidisciplinary setting so that you really get the perspectives from a lot of different people, and that all options are being considered at each step of the patient's treatment.
Podcast Contributors
Dr. John Seal
Dr. John Seal is a transplant and hepatobiliary surgeon with Ochsner Health in New Orlean, Louisiana.
Dr. Gabriel Schnickel
Dr. Gabriel Schnickel is a transplant and hepatobiliary surgeon and professor at UC San Diego in California.
Dr. Siddharth Padia
Dr. Sid Padia is an interventional radiologist at UCLA in Los Angeles, California.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
Cite This Podcast
BackTable, LLC (Producer). (2025, January 17). Ep. 7 – Surgery for HCC: What’s Its Role Today? [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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