Surgical resection represents the only potentially curative therapy for hepatocellular carcinoma. Resectability for any hepatic tumor, including HCC, is dependent on the patient’s ability to withstand a major surgical intervention, absence of extrahepatic disease, and anatomic respectability (Fig. 16.2). The results of surgical resection are influenced greatly by the preoperative liver functional status. Cirrhosis adversely influences surgical outcome in many ways, and often is the only determinant that results in an unresectable status. Because the liver parenchyma is cirrhotics is fibrotic and firm, retraction and isolation of intraparenchymal vessels is hazardous for the surgeon, and makes hemorrhage a particular concern during resection of HCC. Patients with cirrhosis also are likely to have thrombocytopenia form hypersplenism, further exacerbating the potential for hemorrhage. Finally, cirrhosis is associated with decreased regenerative capacity, increasing the risk of liver failure after partial resections. Therefore, hepatic resection for patients with cirrhosis carries a significantly higher operative risk than the risk for noncirrhotic patients. Hepatic function assessment is very important for patients before hepatic resections, especially for patients with hepatic cirrhosis. There are many complex methods of evaluating liver function to assist in patient selection. Assessment by Child-Pugh classification remains the most useful and most widely used in Western series, although the indocyanine green (ICG) retention rate is used commonly in Asia. Child-Pugh C status is considered to be a contraindication for most of surgeons. Liver transplantation is a better selection for these patients if they meet accepted criteria.

Total hepatectomy and liver transplantation is an attractive option for the patient with cirrhosis and cancer, because it may potentially cure both the underlying liver disease and the tumor. Generally well-accepted indications for liver transplant are Child-Pugh B or C patients with single HCC smaller than 5 cm in size, or fewer than three tumors all smaller than 3 cm. With these criteria, the recent series have found a 5-year survival of approximately 70 % with a 15 % chance for recurrence. However, the result of liver transplantation for HCC remains controversial. A recent article evaluated the outcome of patients undergoing liver resection with rumors that fit the criteria for liver transplantation. In this selected group of patients, overall survival at 5 year was 70 %, similar to outcome after liver transplantation [19].

Because a large majority of patients have live-only disease that is technically unresectable, other forms of therapy are needed for HCC. Because these tumors are so intensely vascular and are fed primarily by the hepatic artery (HA), embolization of the feeding arterial vessels has been shown to be one possible treatment option for these patients. On the other hand, hepatic artery embolization for big lesion of HCC may downstage to be resectable. Clinical practice shows that chemoembolization is a potentially viable option for patients with both unresectable and resectable disease, and additionally, it may have an advantage over conservative treatment.

Cryoablation is becoming an increasingly popular method for treating HCC. In this modality, probes that are cooled by liquid nitrogen or argon are introduced in tumors, followed by freezing under ultrasound guidance until adequate volume of tumor plus a 1-cm margin has been treated. Cryosurgery has great theoretical advantage in the treatment of tumors in cirrhotic patients, because very little nonmalignant parenchyma is damaged. Therefore, patients with cirrhosis are still often candidates for the procedure. The technique is useful for treating bilobar tumors, whether with cryosurgery alone or with cryosurgery plus resection. There are some reasons for limiting using of the technique in clinic. The first, this technique should undergo after general anesthesia and laparotomy, because it cannot be performed percutaneously. The second, big size of tumor cannot be treated with cryosurgery, which may increase complications. A number of published series clearly demonstrated the safety of such an ablative approach in experienced hands [20, 21].

Radiofrequency ablation (RFA) is an excellent alternative to cryosurgery and offers the advantage of percutaneous as well as intraoperative application. The disadvantage of RFA is that it is difficult to monitor under real-time US guidance, unlike cryosurgical ablation, because no distinct demarcation can be seen between viable tissue and RF-ablated tissue. One of the additional advantages of RFA is that it is useful in treating those patients with recurrent disease.

Percutaneous ethanol injection is a highly effective treatment for small HCC, with a 3-year survival of 60 % and a 5-year survival of 45 %. In this technique, absolute alcohol is injected into liver tumors percutaneously under CT or US guidance, which results in tissue necrosis. The technique will be applied for small lesion of HCC, although it is not the first choice for treatment of HCC.

Ablation of liver tumors by using microwave coagulation is a relatively new technique that will require further prospective trials before widely application. The advantages of this technique are the higher temperatures it can achieve in a shorter time and the ability to use multiple probes. The 5-year survival may arrive 47 % in some series [22].