Introduction

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. The major clinical risk factor is the development of liver cirrhosis, and the most important risk factors for the development of cirrhosis are chronic infection with the hepatitis B and C viruses and chronic heavy alcohol consumption. The current increasing incidence of HCC is due to widespread dissemination of the hepatitis viruses. At present, there are over 200 million people around the world infected with hepatitis C, giving an incidence of around 3.3% of the world's population. Meanwhile, despite the introduction of hepatitis B vaccine, 5–6% of the world's population are chronic carriers of the disease. Most HCCs develop through a progressive pathway from premalignant nodular lesions to cancerous lesions in the cirrhotic liver. The progression takes an average of 2–4 decades from the time of initial infection to cirrhosis. Thereafter, the annual risk of HCC is 2–3% for hepatitis B, 1–7% for hepatitis C, and 1% for alcohol-induced cirrhosis.

Surgical resection is the current standard modality to achieve long-term survival. It may be offered to patients with single-lesion HCC and well-preserved hepatic function (e.g., Child A cirrhosis). Patients with Child B or C cirrhosis cannot tolerate loss of surrounding non-tumorous hepatic parenchyma during a local resection. Even some patients with Child A cirrhosis (e.g., those with signs of portal hypertension or hyperbilirubinemia) cannot tolerate this loss and are not candidates for local resection.