Question 1

You mentioned recurrence rates even after surgery. Can you expand on that?

Dr. Ashish George · Accepted Answer

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.

Question 2

The majority of HCC patients present late, with very large lesions up to 10 centimetres, and liver transplant isn't available in most of our countries. What criteria should guide resection in that setting?

Dr. Ashish George · Accepted Answer

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.

Question 3

We see a lot of non-cirrhotic HCC, mainly hepatitis B, often resectable at 2 centimetres, but we struggle to get these patients optimised for surgery.

Dr. Ashish George · Accepted Answer

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.

Question 4

How do you make a diagnosis of HCC, and is liver biopsy common?

Dr. Ashish George · Accepted Answer

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.

Question 5

In cholangiocarcinoma, is there a bilirubin cut-off above which you would not operate?

Dr. Ashish George · Accepted Answer

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.

Question 6

Between CA19-9 and alpha-fetoprotein, which is more specific?

Dr. Ashish George · Accepted Answer

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.

Question 7

After surgery, does the patient take any anti-cancer drugs, and if so, which ones?

Dr. Ashish George · Accepted Answer

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.

Question 8

A patient developed deranged bilirubin and liver enzymes following a Pringle manoeuvre during hepatectomy, later requiring ERCP stenting. Is this a common complication of the Pringle manoeuvre?

Dr. Ashish George · Accepted Answer

No, this is not typical of the Pringle manoeuvre itself. Needing a stent afterwards points to bile duct involvement: a narrowed biliary confluence after a right hepatectomy, a bile leak that progressed to a stricture after a hepaticojejunostomy, or compromised duct vascularity following preoperative radiotherapy. The Pringle manoeuvre alone may raise liver enzymes, but it should not cause obstructive jaundice.

Question 9

What is the guidance on follow-up for HCC and cholangiocarcinoma to prevent recurrence?

Dr. Ashish George · Accepted Answer

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.

Question 10

What does it take to have a transplant-capable centre?

Dr. Ashish George · Accepted Answer

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.

Question 11

A 60-year-old female patient presented with right upper quadrant pain for three months. Investigations suggested a hydatid cyst, but the CT findings raised the possibility of a different tumour, and the lesion hadn't changed over two months.

Dr. Ashish George · Accepted Answer

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.

Management of Primary Liver Cancers

Questions Doctors Asked Dr. Ashish George