**2.1 Multidisciplinary evaluation**

The multidisciplinary unit is a highly specialized and dedicated team, composed of hepatobiliary and transplants surgeons, hepatologists, radiologists, pathologists, oncologists, interventional radiologists and supportive care specialists (**Figure 1**) [28]. The aim of the unit is to discuss complex patients, developing the best possible care plan for every different case. First of all, liver status and disease shall always be evaluated and taken into account, assessing them according to Child-Pugh (CTP), MELD or MELD-Na scores [5, 14, 29]. CTP score seems to have a higher specificity than MELD in patients undergoing resective surgery (**Table 2**) [13]. Other important factors are preoperative platelet count, INR and hepatic venous pressure gradient (HVPG) [5, 30]. Cirrhotic patients eligible for hepatic resection should have ideally HPVG < 10 mmHg and platelet count ≥100,000/ml [5].

In addition to Child-Pugh and MELD scores, in borderline liver function, indocyanine green kinetics and cholinesterase/bilirubin ratio are useful to improve patients selection [5].

Thanks to multidisciplinary discussions in international meetings, many HCC staging systems have been proposed during the years [31]. The Cancer of the Liver Italian Program (CLIP) score and Barcelona Clinic Liver Cancer (BCLC) staging classification are the most comprehensive and commonly used systems to stage HCC patients. They consider the liver status and function, physical status, cancerrelated symptoms and number and extension of lesions. Patients are classified in six stages (CLIP score) or five stages (BCLC), each linked with a specific survival rate and treatment algorithm (**Table 3**, **Figure 2**) [32].

According to BCLC criteria, liver resection is indicated in BCLC stage A patients only, but several studies show that it could provide long-term survival with reduced intraoperative mortality in selected BCLC stage B patients (**Figure 3**) [33–36]. Patients having singular large nodule (>5 cm) and/or lateralized multinodular tumor and a very well-preserved liver function are considered

**79**

**Table 3.**

*HCC in Cirrhotic and Non-cirrhotic Liver: Timing to Surgery and Outcome - State of the Art*

Serum bilirubin (mg/dl) 2.0 2-3 >3.0 Serum albumin (g/dl) >3.5 2.8-3.5 <2.8

Hepatic encephalopathy None Mild to moderate (grade1 or 2) Severe (grade 3

Ascites None Mild to moderate (diuretic responsive) Severe (grade 3

**Points 1 2 3**

1-4 4-6 >6

or 4)

or 4)

Massive or extension > 50%

resectable stage B patients [38]. In order to achieve a parenchyma-sparing surgery, these patients may benefit from combining surgery with intraoperative ablation

Ultrasonography (US) has a primary role in HCC screening. US sensitivity ranges

from 63 (for small lesions) to 94%, whereas specificity from 52 to 98% [41–43]. US is highly operator-dependent. Machine quality, tumor size and localization, liver echotexture and abdomen characteristic influence the diagnostic accuracy of

Six-month US is relevant in detecting early-stage HCC in high-risk patients [45]. US detection of small HCC nodules in cirrhotic livers is arduous due to altered

If combined with serum marker alpha-fetoprotein (AFP), it allows further unidentified lesions' detection in 6–8% of the cases [47]. AFP alone is a weak screening test (Se 39–64%, Sp 76–91%, cut-off 20 mg/ml) [41], since high AFP levels could be also related to inflammatory status (exacerbation of underlying chronic liver disease or hepatitis), and it is not increased in about 20% of HCC

Child-Pugh score A B C Alpha-fetoprotein <400 ng/ml ≥400 ng/ml —

**Points 0 1 2**

> Multinodular and extension ≤ 50%

Absent Present —

*DOI: http://dx.doi.org/10.5772/intechopen.86638*

(RF/MW) [39, 40].

*Child-Pugh scoring system.*

**Table 2.**

**Child-Pugh score Parameters**

Prothrombin time Seconds prolonged

5–6 points Child-Pugh A 7–9 points Child-Pugh B 10–15 points Child-Pugh C

the exam [44].

echotexture [46].

**CLIP score Parameters**

Portal vein thrombosis

*Maida et al. [31].*

*CLIP score evaluation system.*

**2.2 US evaluation of liver disease**

Tumor morphology Uninodular and

extension ≤ 50%

#### **Figure 1.** *Composition of liver multidisciplinary units. Source: Siddique et al. [28].*

*HCC in Cirrhotic and Non-cirrhotic Liver: Timing to Surgery and Outcome - State of the Art DOI: http://dx.doi.org/10.5772/intechopen.86638*


#### **Table 2.**

*Liver Disease and Surgery*

patients selection [5].

**2. Planning and timing surgery**

**2.1 Multidisciplinary evaluation**

The multidisciplinary unit is a highly specialized and dedicated team, composed of hepatobiliary and transplants surgeons, hepatologists, radiologists, pathologists, oncologists, interventional radiologists and supportive care specialists (**Figure 1**) [28]. The aim of the unit is to discuss complex patients, developing the best possible care plan for every different case. First of all, liver status and disease shall always be evaluated and taken into account, assessing them according to Child-Pugh (CTP), MELD or MELD-Na scores [5, 14, 29]. CTP score seems to have a higher specificity than MELD in patients undergoing resective surgery (**Table 2**) [13]. Other important factors are preoperative platelet count, INR and hepatic venous pressure gradient (HVPG) [5, 30]. Cirrhotic patients eligible for hepatic resection should

have ideally HPVG < 10 mmHg and platelet count ≥100,000/ml [5].

and treatment algorithm (**Table 3**, **Figure 2**) [32].

*Composition of liver multidisciplinary units. Source: Siddique et al. [28].*

In addition to Child-Pugh and MELD scores, in borderline liver function, indocyanine green kinetics and cholinesterase/bilirubin ratio are useful to improve

According to BCLC criteria, liver resection is indicated in BCLC stage A patients only, but several studies show that it could provide long-term survival with reduced intraoperative mortality in selected BCLC stage B patients (**Figure 3**) [33–36]. Patients having singular large nodule (>5 cm) and/or lateralized multinodular tumor and a very well-preserved liver function are considered

Thanks to multidisciplinary discussions in international meetings, many HCC staging systems have been proposed during the years [31]. The Cancer of the Liver Italian Program (CLIP) score and Barcelona Clinic Liver Cancer (BCLC) staging classification are the most comprehensive and commonly used systems to stage HCC patients. They consider the liver status and function, physical status, cancerrelated symptoms and number and extension of lesions. Patients are classified in six stages (CLIP score) or five stages (BCLC), each linked with a specific survival rate

**78**

**Figure 1.**

*Child-Pugh scoring system.*

resectable stage B patients [38]. In order to achieve a parenchyma-sparing surgery, these patients may benefit from combining surgery with intraoperative ablation (RF/MW) [39, 40].

#### **2.2 US evaluation of liver disease**

Ultrasonography (US) has a primary role in HCC screening. US sensitivity ranges from 63 (for small lesions) to 94%, whereas specificity from 52 to 98% [41–43].

US is highly operator-dependent. Machine quality, tumor size and localization, liver echotexture and abdomen characteristic influence the diagnostic accuracy of the exam [44].

Six-month US is relevant in detecting early-stage HCC in high-risk patients [45]. US detection of small HCC nodules in cirrhotic livers is arduous due to altered echotexture [46].

If combined with serum marker alpha-fetoprotein (AFP), it allows further unidentified lesions' detection in 6–8% of the cases [47]. AFP alone is a weak screening test (Se 39–64%, Sp 76–91%, cut-off 20 mg/ml) [41], since high AFP levels could be also related to inflammatory status (exacerbation of underlying chronic liver disease or hepatitis), and it is not increased in about 20% of HCC

