Description: 
 A patient being surveilled for untreated hepatitis C presents to your clinic for a newly identified liver mass. Hepatocellular carcinoma (HCC) accounts for ~90% of new liver cancers and infection by hepatitis B and hepatitis C viruses are the main risk factors. Non-alcoholic steatohepatitis associated with metabolic syndrome and diabetes mellitus, however, have contributed to HCC becoming the fastest growing solid organ tumor in the United States. In this episode from the Surgical Oncology team at Behind the Knife, join the discussion on a surgeons approach to this growing patient population.

Learning Objectives: 
In this episode, we review risk factors for hepatocellular carcinoma, key steps in the diagnostic work-up with a focus on pre-operative planning for hepatectomy in cirrhotic patients. We will cover interventions available preoperatively, options and considerations once in the operating room, as well as treatment strategies and shifting paradigms following successful resection. 

Hosts: 
Adam Yopp, MD, FACS (@AdamYopp) is an Assistant Professor of Surgery at the UT Southwestern Medical Center and is Chief of the Division of Surgical Oncology. He also serves as Surgical Director of the Liver Tumor Program.

Caitlin Hester, MD (@CaitlinAHester) is a 2nd Year Complex General Surgical Oncology Fellow at the MD Anderson Cancer Center.

Gilbert Murimwa, MD (@GilbertZMurimwa) is a PGY-3 General Surgery Resident at the UT Southwestern Medical Center and a research fellow in the Hamon Center for Therapeutic Oncology Research.

Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis
J Am Coll Surg. 2011 Apr;212(4):638-48; discussion 648-50. doi: 10.1016/j.jamcollsurg.2011.01.004. PMID: 21463803 
https://pubmed.ncbi.nlm.nih.gov/21463803/

Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology
J Natl Compr Canc Netw. 2021 May 1;19(5):541-565. doi: 10.6004/jnccn.2021.0022.
PMID: 34030131
https://pubmed.ncbi.nlm.nih.gov/34030131/

Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma
Br J Surg. 2006 Sep;93(9):1091-8. doi: 10.1002/bjs.5341. PMID: 16779884
https://pubmed.ncbi.nlm.nih.gov/16779884/

Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis
J Clin Anesth. 2021 Aug 1;75:110467. doi: 10.1016/j.jclinane.2021.110467. Online ahead of print. PMID: 34343737
https://pubmed.ncbi.nlm.nih.gov/34343737/

Portal vein embolization: rationale, technique and future prospects
Br J Surg. 2001 Feb;88(2):165-75. doi: 10.1046/j.1365-2168.2001.01658.x.
PMID: 11167863
https://pubmed.ncbi.nlm.nih.gov/11167863/

Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant
J Am Coll Surg. 2013 Feb;216(2):201-9. doi: 10.1016/j.jamcollsurg.2012.10.018. Epub 2012 Dec 7. PMID: 23219349 
https://pubmed.ncbi.nlm.nih.gov/23219349/

IMbrave 050: a Phase III trial of atezolizumab plus bevacizumab in high-risk hepatocellular carcinoma after curative resection or ablation
Future Oncol. 2020 May;16(15):975-989. doi: 10.2217/fon-2020-0162. Epub 2020 Apr 30.
PMID: 32352320
https://pubmed.ncbi.nlm.nih.gov/32352320/

Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection Is Associated With Increased Survival in Patients With a History of Hepatocellular Carcinoma
Gastroenterology. 2019 Nov;157(5):1253-1263.e2. doi: 10.1053/j.gastro.2019.07.040. Epub 2019 Jul 30. PMID: 31374215
https://pubmed.ncbi.nlm.nih.gov/31374215/