Management of small hepatocellular carcinoma in cirrhotic patients: resection versus ablative therapies

Abstract

Hepatocellular carcinoma (HCC), the most prevalent liver cancer type, has a heterogeneous molecular and physiological basis with several contributing factors. Cirrhosis is the number one underlying factor for HCC, accounting for approximately 80% of cases. The recent advances in diagnostics and screening have led to a substantial increase in the number of patients diagnosed at an early stage with small HCC. The gold-standard curative treatments for early-stage HCC are thermal ablation or resection. HCC treatment is particularly challenging in cirrhotic patients due to liver dysfunction and their being prone to portal hypertension. Thus, choosing between thermal ablation and resection remains an unresolved debate that requires balancing radical removal of the tumor with preserving adequate functioning liver tissue. This review aims to explore the distinct etiology of HCC in cirrhotic patients and how it contributes to the development of malignancy. It also seeks to explore how cirrhosis affects the response to available treatment approaches by comparing the gold-standard methods used, ablation vs resection, taking into account recent evidence on liver cell preservation, portal hypertension consequences, and microvascular invasion, along with novel radiomics tools. To provide evidence-based recommendations for enhancing small HCC management in cirrhotic patients.