Post-Treatment Follow-up and Recurrence Prevention in Primary Liver Cancer

Non-cirrhotic HCC is uncommon in Dr. George's own caseload, around 5 patients in every 100 he sees, but for exactly this group his unit is far more aggressive: extended resections, portal vein embolisation, and even ALPPS, a staged hepatectomy, are all options, because a normal liver can lose as much as 80 percent of its volume and still regenerate enough function from what remains.

HCC has a characteristic imaging signature, so biopsy is reserved for genuine diagnostic dilemmas. An arterially enhancing lesion with venous washout on a properly phased triphasic CT is treated as diagnostic in around 95 percent of cases; MRI is used when the CT is inconclusive. Around 40 percent of HCC patients have an elevated AFP, meaning 60 percent do not, so diagnosis relies on radiology rather than tumour markers.

No. Dr. George has operated on perihilar cholangiocarcinoma patients with bilirubin as high as 30 to 35. Surgical practice has also evolved: where extended resections once left only the left lateral section or right posterior sector achievable, his unit now more often does a left- or right-with-caudate resection with extended bile duct resection, preserving more liver parenchyma. Preoperative biliary drainage, usually percutaneous (PTBD) rather than endoscopic nasobiliary drainage, is reserved for patients with cholangitis or those planned for portal vein embolisation.

Alpha-fetoprotein is the marker primarily elevated in hepatocellular carcinoma. CA19-9 comes primarily from the biliary system and can rise somewhat in cirrhotic patients, but not to a high degree, so it remains the more specific marker for cholangiocarcinoma.

After HCC resection on a normal liver, patients are generally placed on lenvatinib long-term. After transplant, there is no separate adjuvant chemotherapy; instead, immunosuppression is adjusted to tacrolimus plus everolimus rather than the standard tacrolimus and mycophenolate, since everolimus is associated with a lower recurrence risk. For cholangiocarcinoma with nodal or vascular invasion, patients are referred to medical oncology for cisplatin or gemcitabine-based adjuvant therapy, usually once they have recovered, six to twelve weeks later, from preoperative jaundice and cholangitis.

MRI reduces cumulative radiation exposure and the risk of contrast-induced nephropathy compared to repeated CT scans, and it is better at catching smaller lesions early enough that resection or salvage transplant is still possible. The underlying cirrhotic liver still carries a risk of producing new tumours after resection or ablation, so this surveillance continues indefinitely.

Instead of the standard combination of tacrolimus and mycophenolate, transplant recipients are switched to tacrolimus and everolimus, since everolimus has been associated with a lower risk of post-transplant recurrence.

Patients who undergo resection on a normal liver are generally placed on lenvatinib over the long term, distinct from the immunosuppression adjustment used after transplant.

AFP and PIVKA-II are tracked for HCC, while CA19-9 is tracked for cholangiocarcinoma, alongside imaging with CT or MRI rather than ultrasound, which is not sensitive enough to catch recurrence at an early stage.