Operating on Large and Non-Cirrhotic HCC Without a Transplant Programme

For HCC after resection or an interventional procedure, MRI is favoured over repeated CT scans, both to limit cumulative radiation and contrast exposure and because MRI catches smaller lesions earlier, while they are still resectable or eligible for salvage transplant. Cholangiocarcinoma follow-up similarly relies on CT or MRI rather than ultrasound, alongside tumour markers, AFP and PIVKA-II for HCC, CA19-9 for cholangiocarcinoma.

Intent comes first. Even in India, transplant is offered at only a handful of government centres, with growth coming mainly from the private sector. Beyond intent, a new programme needs mentorship from teams already trained in transplant so that skills transfer gradually, buy-in across radiology, anaesthesia, critical care and hepatology rather than a purely surgeon-driven effort, and infrastructure including a strong interventional radiology service, phasic CT and MRI, and an apheresis machine for ABO-incompatible transplants. Management has to be fully behind the programme, because it takes far more time and effort than routine GI or hepatobiliary surgery.

Dr. George asked to review the actual scan before a specific recommendation, but for a resectable tumour around 3 to 3.5 centimetres, his general advice was not to force a diagnosis upfront: resect with a clear margin and send the specimen for histopathology. At that size, liver function or parenchymal loss is unlikely to be a concern, so surgery can proceed before, rather than after, a biopsy.

Hepatocellular carcinomas develop on a cirrhotic liver, which is like a fertile field: removing one tumour by resection or ablation does not remove the underlying tendency of that liver to produce another. Because the diseased liver stays in place after resection or ablation, these patients carry a higher ongoing risk of new tumours. A transplant removes the whole diseased liver and replaces it with one that does not carry that risk, which is why upfront transplant can be the better option even when a tumour looks resectable.

The first check is whether the background liver is cirrhotic or, from vertical hepatitis B or C transmission, essentially normal; a normal liver allows extended resection with portal vein embolisation to grow the future remnant. On a cirrhotic background, the priority is ruling out disease outside the liver, then grading any portal vein invasion from VP1 (a segmental branch) to VP4 (the main portal vein). Patients with VP1 or VP2 involvement and no extrahepatic disease can still be offered transplant, upfront or after downstaging with TACE, sometimes combined with SBRT for a portal vein tumour thrombus, aiming for 12 weeks of stable disease.

Because the underlying liver is healthy rather than diseased, it can tolerate a much larger resection. The rule of thumb is that a normal liver can lose up to about 80 percent of its volume and still regenerate enough function from the remaining 20 percent, which opens the door to extended resections, portal vein embolisation and staged procedures like ALPPS.

It is a minority of cases. In Dr. George's own caseload, roughly 5 out of every 100 HCC patients have a non-cirrhotic liver, typically from vertical transmission of hepatitis B or C, against 95 arising on a background of cirrhosis.

It is an option for a deep-seated tumour that cannot be resected without sacrificing too much liver tissue. It avoids removing parenchyma but depends on having a capable interventional radiologist available during surgery.

For patients with smaller lesions around 2 centimetres, the challenge is often less about the surgical decision itself and more about getting the patient medically optimised for the operation, a constraint that is common in settings without ready access to portal vein embolisation or extended resection expertise.