Liver Cancer Treatment: Resection vs. Transplant—Which Option is Best?
"Navigating the complexities of liver cancer treatment: a comprehensive comparison of hepatic resection and liver transplantation for optimal outcomes."
When facing a diagnosis of liver cancer, also known as hepatocellular carcinoma (HCC), understanding the available treatment options is crucial. Among the most effective approaches are hepatic resection (HR), which involves surgically removing the cancerous portion of the liver, and liver transplantation (LT), where the diseased liver is replaced with a healthy one.
Both HR and LT offer the potential for a cure, but they are not suitable for all patients. The choice between these two depends on several factors, including the stage and size of the tumor, the overall health of the liver, and the presence of underlying liver disease such as cirrhosis. Determining the best course of action requires a comprehensive evaluation by a team of specialists.
This article will explore the recent advances in both hepatic resection and liver transplantation for hepatocellular carcinoma, providing insights into patient selection, surgical techniques, and outcomes. By understanding the nuances of each procedure, patients and their families can make informed decisions in consultation with their healthcare providers.
Progress in Understanding Liver Cancer
Research has greatly improved understanding of liver cancer pathogenesis, early detection, diagnosis, staging, and treatment. Molecular aberrations driving both hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) have been identified. Molecular studies have also identified adult hepatocytes as a cell of origin for liver cancer, helping frame research into carcinogenesis and therapeutic options.
Hepatic Resection: When Removing the Tumor is an Option
Hepatic resection is often the preferred treatment for HCC when the tumor is confined to the liver and the remaining liver function is adequate. The goal of HR is to remove the tumor completely while preserving as much healthy liver tissue as possible. This approach is particularly effective for single, smaller tumors in livers without advanced cirrhosis.
- Tumor Size and Location: Smaller tumors located in easily accessible areas of the liver are ideal for resection.
- Liver Function: Patients must have sufficient liver function to tolerate the removal of a portion of their liver. This is assessed through various liver function tests, including the indocyanine green retention rate (ICG-R15).
- Absence of Cirrhosis: While HR can be performed in patients with mild cirrhosis, it is generally not recommended for those with advanced cirrhosis due to the increased risk of complications.
- Overall Health: Patients must be in good overall health to undergo major surgery.
Recent HCC Reviews
Recent reviews address HCC from several angles, including etiology, surveillance, diagnostic approaches, molecular features, and current treatment modalities. A December 2025 review describes HCC as the third leading cause of cancer-related mortality worldwide and notes a shift in disease burden from viral hepatitis toward non-viral causes such as alcohol-related liver disease (ALD) and metabolic dysfunction-associated steatotic liver disease (MASLD). A May 2026 review focuses on the current and emerging treatment landscape for advanced HCC, including molecular-targeted and immuno-oncology monotherapies.
Treatment Resistance and Recurrence
HCC treatment remains challenging because of treatment resistance and high tumor recurrence rates. A 2023 review notes that early-stage HCC is treated with liver resection and other surgical therapies, but recurrence remains a major concern. A 2023 management review also describes how advances in systemic and locoregional therapies have made it possible to downstage some patients for resection, underscoring that treatment pathways can change as disease is managed.
Transplant Selection and Tumor Risk
Transplant selection criteria matter because patients outside the Milan criteria had reported microvascular invasion rates of 37.2% and 50.0%, compared with 13.6% among patients within the criteria; both comparisons were statistically significant (P < 0.001). One analysis argues that a 50% five-year survival rate after liver transplantation for HCC is too low as a threshold for considering transplant indications. Locoregional therapy has also been described as a way to distinguish potentially transplantable patients with advanced HCC.
Making Informed Decisions for Liver Cancer Treatment
Both hepatic resection and liver transplantation play crucial roles in the management of hepatocellular carcinoma. HR offers a chance for cure when the tumor is resectable and liver function is adequate, while LT provides an option for patients with advanced disease or underlying cirrhosis.
Multidisciplinary HCC Management
Expert discussion at the 24th World Gastrointestinal Cancer Congress (WGICC) in Barcelona in July 2022 emphasized that a multidisciplinary approach is mandatory for optimal HCC diagnosis and staging. The discussion framed treatment planning as a coordinated process that considers curative and therapeutic options, including surgery, embolisation, and ablation. A 2026 practical recommendations article reports that immune-based options have become the foundation of systemic HCC therapies and notes innovations in surgical techniques, including robotic approaches.
Personalized Treatment and Changing Risk
A 2024 review describes HCC management as potentially involving personalized treatment plans that may include surgical resection, liver transplantation, minimally invasive techniques, immunotherapy, or targeted therapy. The same review emphasizes early detection and accurate diagnosis as parts of this approach. Another review reports that HCC incidence is rising, especially among younger populations, and links HCC commonly to chronic liver disease and longstanding inflammation.
Advanced Disease and Global Burden
Many patients with HCC present at an advanced stage and are unsuitable for curative treatments, according to a 2026 review of systemic therapy for advanced disease. HCC accounts for up to 80% of primary liver cancer cases in that source, while another review estimates that it constitutes around 90% of liver cancer cases. These sources therefore differ on the proportion of liver cancers attributed to HCC; both describe it as the most common type of primary liver cancer.
Learning from Real-World Care
Real-world longitudinal observational studies can help clarify the long-term safety and effectiveness of kinase inhibitors and immunotherapies used for advanced HCC. A 2025 non-interventional retrospective study enrolled patients with Barcelona Clinic Liver Cancer (BCLC) stage B or C unresectable or advanced/metastatic HCC, diagnosed between January 2017 and December 2019. Its design reflects how real-world treatment patterns and outcomes can be examined in patients whose disease is not amenable to resection.
The decision between HR and LT should be made in consultation with a multidisciplinary team of experts, including surgeons, hepatologists, and oncologists. These specialists can assess the individual patient's situation and recommend the most appropriate treatment strategy.
Ongoing research continues to refine the selection criteria and surgical techniques for both HR and LT, offering hope for improved outcomes and prolonged survival for patients with liver cancer. A multi-modality treatment strategy, especially for patients with advanced HCC, provides new fields of investigation for diverse indications of HR and LT.