Journal of Liver Cancer

Recommendation and Guideline

Surgical treatment of hepatocellular carcinoma: an expert consensus-based practical recommendation from the Korean Liver Cancer Association: Min-Su Park, Jai Young Cho, Eunju Kim, Hee Young Na, YoungRok Choi, Na Reum Kim, Young-In Yoon, Boram Lee, Eun Sun Jang, Yun Kyung Jung, Kyung Sik Kim; J Liver Cancer. 2025;25(2):140-159. Published online September 22, 2025; DOI: https://doi.org/10.17998/jlc.2025.08.05

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Compared with other treatments, surgical resection is an effective treatment method with the lowest local recurrence rate and the highest survival rate for hepatocellular carcinoma (HCC). To achieve excellent results after surgical treatment, it is essential to carefully select patients who are suitable for hepatic resection and minimize postoperative complications and liver function decline through standardized surgical methods and pre- and postoperative management. However, domestic and international treatment guidelines only broadly recommend the application of hepatic resection for HCC with a single tumor and good liver function. Hence, practical treatment guidelines are required that can be standardized and used according to the varying clinical environments, including indications for hepatic resection, preoperative evaluation, basic principles of hepatic resection, minimally invasive hepatic resection, pre- and postoperative patient management, surgical treatment considerations in specific infection situations, and follow-up after surgical resection. Accordingly, an expert group from the Korean Liver Cancer Association Research Committee has developed practical recommendations based on expert consensus regarding the surgical treatment of HCC through a Delphi study.

Citations

Citations to this article as recorded by

Radiotherapy for Liver-Confined Hepatocellular Carcinoma in Elderly Patients with Comorbidity
Sun Hyun Bae, Young Seok Kim, Sang Gyune Kim, Jeong-Ju Yoo, Jae Myeong Lee, Sanghyeok Lim, Jae Hong Jung, Chan Kyu Kim
Cancers.2025; 18(1): 91. CrossRef

Special Contribution

Impact of the 2024 medical-policy conflict on hepatocellular carcinoma management in Korea: Soon Sun Kim, Hyun Yang, Jieun Kwon, Eunju Kim, Jeong Il Yu, Janghan Jung, Woosun Choi, Ji Eun Han, Moon Haeng Hur, Bo Hyun Kim, Sung Hyun Kim, Jeong Han Kim, Haeryoung Kim, Pyoung-Jae Park, Hyun Phil Shin, Su Jong Yu, Ki Tae Yoon, Sang Min Yoon, Minjong Lee, Jai Young Cho, Jin-Young Choi, Do Young Kim, June Sung Lee, Mi-Sook Kim, Kyung Sik Kim; J Liver Cancer. 2025;25(2):169-177. Published online September 2, 2025; DOI: https://doi.org/10.17998/jlc.2025.09.01

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Abstract PDF: In 2024, a nationwide conflict between the South Korean government and the medical community, the medical-policy conflict, profoundly impacted healthcare delivery. This study aimed to evaluate the changes in the management of hepatocellular carcinoma (HCC) following this crisis. We analyzed retrospective real-world data from university hospitals in the Seoul Metropolitan Area, supplemented with national healthcare data from the Health Insurance Review and Assessment Service. The analytical variables included changes in workforce composition, initial treatment modalities, HCC stage distribution, quality indicators for HCC care, regional and institutional variations in care delivery, and liver transplantation (LT) volume. A comparison between 2023 and 2024 revealed a marked decline in the number of medical trainees, a rise in the proportion of physician assistants, a 28.9% reduction in newly initiated HCC treatments, and an increased rate of stage IV diagnoses. Several quality indicators, including rates of multidisciplinary care and patient education, declined. The volume of LTs decreased by approximately 20% nationwide, with some regions ceasing LT procedures. The results suggest that serious disruptions occurred in HCC care following the conflict. The significant decrease in initial treatment and number of LT procedures, more advanced stages at diagnosis, and declining quality metrics indicate the emergence of healthcare gaps. Without the recovery of the clinical workforce and the reestablishment of a stable healthcare delivery system, the management of serious diseases such as HCC will remain structurally vulnerable. National-level efforts are urgently required to address regional disparities and restore essential medical services.

Editorial

Congratulatory remarks: Kyung Sik Kim; J Liver Cancer. 2024;24(2):119-119. Published online September 13, 2024; DOI: https://doi.org/10.17998/jlc.2024.09.10

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Original Article

Confirmation of HIF-1α Independent Pathway in the Progression of HepG2 Cells by Hypoxic Condition: Sang Woo Lee, Jae Uk Chong, Seon Ok Min, Kyung Sik Kim; J Liver Cancer. 2016;16(1):31-37. Published online March 31, 2016; DOI: https://doi.org/10.17998/jlc.16.1.31

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Abstract PDF: Background/Aims
When hepatocellular carcinoma (HCC) is exposed to hypoxic condition, HIF-1α is activated and results in angiogenesis and increased tumor burden. Although inhibition of HIF-1α may reduce tumor growth, there are some limitations to control tumor growth completely. For a more effective therapy for HCC, we investigated HIF-1α independent pathway related tumor growth with angiogenesis.
Methods
We cultured HepG2 cells (HCC cell line) in both normoxia and hypoxia conditions. These cells were divided into three groups: a echinomycin treated group, a echinomycin and quinazoline treated group and a control group without any treatments. Growth morphologies of cells were observed with a microscope after 24 hours. Immunocytochemistry assay was done to detect the angiogenesis during inhibition of HIF-1α and/or NF-κB in hypoxia condition, and compared with results in normoxia condition.
Results
In normoxia, the expression of HIF-1α on tumor growth was not found. In hypoxia, inhibition of HIF-1α reduced the tumor growth compared to the control group. But, inhibition of both HIF-1α and NF-κB did not show apparent reduction of tumor growth as shown in HIF- 1α only group.
Conclusions
Signaling pathways related to cancer cell growth exist through a vast network. Inhibition of one target molecule may result in over-expression of other molecules related to the tumor growth. For an effective therapy in blocking of the tumor growth, more comprehensive understanding of the network related to signaling pathways on tumor growth is necessary. (J Liver Cancer 2016;16:31-37)

Case Reports

A Case of Concurrent Liver Resection and Splenectomy in Patients with Hepatocellular Carcinoma and Decompensated Liver Cirrhosis: Sung Hoon Kim, JIn Hong Lim, Sang Hoon Ahn, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2011;11(2):160-164. Published online September 30, 2011

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Abstract PDF: Hepatocellular carcinoma (HCC) develops on chronic liver disease and often accompanies portal hyperternsion. Portal hypertension induces hypersplenism with splenomegaly. Because hypersplenism results in pancytopenia, especially thrombocytopenia, it is not easy to decide the hepatic resection for many surgeons in patients with HCC and hypersplenism. Although liver transplantation is the most ideal treatment for HCC and hypersplenism, liver resection has been performed commonly because of donor shortage. Splenectomy has performed to control intractable varices as a Hassab’s operation (=decongestion of upper gastric marginal veins and splenectomy). Recently, as a development of surgical techniques and equipments, especially laparoscopic surgery, splenectomy has been performed safely and easily. Some studies reported that splenectomy improved the liver function. Splenectomy in patients with HCC expanded the indication of liver resection and increased disease free survival (DFS). However, portal vein thrombosis (PVT) is a one of well-recognized complications of splenectomy and recent prospective study reported the 50% rate of PVT in non-cirrhotic splenectomized patients. Some studies reported that splenectomy with simultaneously or staged liver resection was performed safely without a significant complication and operative mortality. We experienced a case that underwent simultaneously liver resection and splenectomy and then recovered without complication. The further study may be needed to evaluate the role of splenectomy in patients with HCC and hypersplenism.

A Case of Early and Massive Recurred Hepatocellular Carcinoma in Patients with Ruptured Hepatocellular Carcinoma Underwent Staged-Surgical Resection: Sung Hoon Kim, Jin Hong Lim, Sang Hoon Ahn, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2011;11(2):155-159. Published online September 30, 2011

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Abstract PDF: The rupture of hepatocellular carcinoma (HCC) has been uncommon complication. Because the diagnosis of early HCC has been increase due to development of imaging modality and surveillance program, the incidence of ruptured HCC has been decreased. The paradigm of treatment for ruptured HCC has shifted from surgical hemostasis to transcatheteric chemoembolization (TACE) at acute phase. After the control of acute phase, the definitive treatment for HCC is still debate. However, many studies have advocated staged-liver resection. Some studies reported that the patients underwent staged-liver resection showed a similar survival rate compared with survival rate in patient with non-ruptured HCC. The staged-liver resection was usually performed in the patients with well-preserved liver function. The decision of optimal time for surgery after TACE and surgical indications for ruptured HCC after any other primary treatment are controversy. We experienced a cases of early and massive recurrence HCC in patients with well-preserved liver function and the rupture of HCC. The further study may be needed to decide the optimal time of surgery after TACE and surgical indication for rutprued-HCC.

Review Article

2009 Treatment Guideline for Hepatocellular Carcinoma: Surgical Resection and Liver Transplantation: Sung Hoon Kim, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):6-10. Published online June 30, 2010

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Abstract PDF: The effort we are trying to set up the treatment guideline for hepatocellular carcinoma has produced various guidelines after drawing a conclusion from Barcelona EASL meeting in 2000. Especially in Korea, the Korean Liver Cancer Study Group and the National Cancer Center have collaborated on making treatment guideline for hepatocellular carcinoma in the early stage of setting up the guideline, 2003, and it was a great help to treatment, study and education. However, a need of revision had been raised due to many changes in the latest treatments and an accumulation of international and domestic experience. After the proposal of amending the treatment guideline for Hepatocellular carcinoma in the Cancer Control Forum of the National Cancer Control Planning Board on October 17th, 2008, “2009 Guideline” has been reported in the Conference of the Korean Liver Cancer Study Group held on June 27th, 2009. When revising the guideline, there are some suggestions of continuous modification to reflect evidence based medical knowledge, and recently there are some debates about the drawback of the surgical field which was not handled in EASL and AASLD Guidelines. Therefore, it will broaden your understanding of liver surgical resection and liver transplantation and it will also be a place for the discussion of disputable issues.

Case Reports

A Case of Early Recurred Hepatocellular Carcinoma with Initial Expectation of Good outcome by Surgical Resection: Jung Min Lee, Jun Yong Park, Do Young Kim, Kyung Sik Kim, Young Nyun Park, Myeong-Jin Kim, Chae Yoon Chon, Kwang-Hyub Han; Journal of the Korean Liver Cancer Study Group. 2009;9(1):41-44. Published online June 30, 2009

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Abstract PDF: Hepatocellular carcinoma (HCC) is one of the cancers with poor prognosis as HCC develops on base of cirrhosis in majority cases, which requires multidisciplinary approach. If feasible, however, surgical resection is the choice of treatment, and many previous studies and guidelines offered appropriate indications for surgical resection; firstly, preservation of liver function should be confirmed with traditional Child-Pugh classification or more recently with Indocyanine Green retention test or absence of portal hypertension. Secondly, several variables about the size, number, and vascular invasion of tumor should be taken into consideration. It is suggested that to lessen the risk of recurrence gross vascular invasion be absent and the number of tumor be single. Regarding the size of tumor, although risk of dissemination increases with size, some tumors may grow as a single mass and thus the size of tumor is not a clear-cut limiting factor. Based on above suggestions, we herein offer our experience of a patient with initial hopeful expectation of good outcome with surgical resection, but who eventually turned out to result in disseminated tumor recurrence. Further study, maybe regarding a combination of adjuvant or neoadjuvant transarterial chemoembolization/chemotherapy or radiotherapy, is necessary on how to manage such patient.

A Case of Hepatocellular Carcinoma in a Pregnant Patient in Twenties: Kang Kook Choi, Young Ju Hong, Sae Byeol Choi, Nam Joon Yi, Shin Hwang, Young Nyun Park, Jin Sub Choi, Kyung Suk Suh, Chae Yoon Chon, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2009;9(1):76-81. Published online June 30, 2009

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Abstract PDF: Hepatocellular carcinoma (HCC) in pregnancy is very rare. The cirrhosis which is present in the majority of patients with HCC induces infertility. The diagnostic methods and treatment modalities in HCC during pregnancy are different from those of usual types of other HCC. A 26-year-old, 32th-gestational-week pregnant female was sent to our hospital because of abnormal liver function test. A 1.5cm sized mass was identified in segment 6 of liver which was compatible to AJCC stage I. She did not have any other medical history except Hepatitis B Virus carrier and the HBs Ag of her mother also was positive. At the 40th gestational week, the female baby was delivered uneventfully. And then she underwent the transarterial chemoembolization (TACE) following the Rt. Hemihepatectomy. Since she underwent a surgical resection, the tumors have been recurred in the remnant liver only. Whenever the tumors were founded, the aggressive surgical approaches were performed including 3 times of hepatic resection with TACE or TACI. She is still alive with good general condition and normal liver function for 9 years since the first diagnosis was made. Therefore an extremely rare case of hepatocellular carcinoma in pregnancy is treated successfully because of aggressive therapies.

Review Article

Hepatic Resection Following Adjuvant Treatments in Hepatocellular Carcinoma: Sae-Byeol Choi, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2008;8(1):32-38. Published online June 30, 2008

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Abstract PDF: The optimal treatment of hepatocellular carcinoma has become increasingly complex with myriad of available treatment options. Although recently the liver transplantation has been accepted the best treatment for survival, the shortage of donor limits the extension of this procedures. As the neoadjuvant chemotherapy is being increasingly employed to downsize colorectal metastasis, the clinical trials have been extended to the hepatocellular carcinoma. Therefore we reviewed the use of liver resection following tumor downstaging with chemotherapeutic agents and Radiation therapy to treat unresectable HCC. Key Words: Hepatic resection․Downstaging․Transarterial chemoembolization․Radiation

Case Reports

A Case of Curative Resection of Advanced Hepatocellular Carcinoma After Localized Concurrent Chemo-Radiation Therapy: Wonseok Kang, Ki Tae Yoon, Jun Yong Park, Do Young Kim, Sang Hoon Ahn, Chae Yoon Chon, Kyung Sik Kim, Young Nyun Park, Jin Sil Seong, Kwang Hyub Han; Journal of the Korean Liver Cancer Study Group. 2008;8(1):98-101. Published online June 30, 2008

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Abstract PDF: Most patients with advanced hepatocellular carcinoma (HCC) are not suitable candidates for surgical treatment at the time of diagnosis because of poor liver function, extensive tumor involvement of the liver, vascular involvement, and/or intra/extrahepatic metastasis. We attempted localized concurrent chemo-radiation therapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC) in patients having locally advanced HCC with vascular involvement and preserved hepatic function. We report a case of locally advanced HCC patient who became surgically resectable by downstaging after localized CCRT followed by HAIC. Localized CCRT was performed with a total radiation dose of 4,500 cGy (180 cGy × 25 times) and hepatic arterial infusion of 5-fluorouracil (5-FU, 500 mg/day) via implantable port system during the first and the last weeks of the radiotherapy. Following localized CCRT, the patient was scheduled to receive HAIC with 5-FU (500 mg/m2 for 5 hours, days 1～3) and cisplatin (60 mg/m2 for 2 hours, day 2) every 4 weeks. Marked contraction of HCC was noted on follow up computerized tomography (CT) and positron emission tomography (PET) after localized CCRT and HAIC, and subsequently surgical resection with curative aim was performed. The patient is in complete remission status without recurrence to date.

Two cases of Vessel invasion of Hepatocellular carcinoma: Sae Byeol Choi, Jae Yeon Seok, Kyung Sik Kim, Young Nyun Park, Kwang-Hyub Han, Jong Tae Lee; Journal of the Korean Liver Cancer Study Group. 2007;7(1):71-76. Published online June 30, 2007

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Abstract PDF: Despite growing information on the clinical behavior of hepatocellular carcinoma(HCC), the histologic features associated with survival are not well characterized. Several different staging systems are suggested for use in predicting the prognosis of HCC. American Joint Committee on Cancer/International Union Against Cancer Staging System (AJCC/UICC) 6th edition divided T stages according to vessel invasion, T1 without microvessel invasion, T2 showing microvessel invasion and T3 showing major vessel invasion. The vessel invasion is generally considered a poor prognostic factor for HCC. Our report of the two patients with HCC run along similar terms. The patient diagnosed HCC with microvessel invasion underwent left lateral sectionectomy. Although the presence of microvessel invasion was found, this patient has survived without any recurrence for over 5 years now. The other patient underwent S8 segmentectomy and lived 10 years disease-free. After 10 years, although an intrahepatic recurred HCC successfully treated with local therapy, the recurred and newly developed multiple lesions were found again leading to a decision to perform operation. The HCC invaded into the portal vein and constituted portal vein thrombosis. The patient expired after 3 months postoperatively due to intrahepatic dissemination of the tumor. Therefore the impact of the vascular invasion on long-term survivors remains to be determined.

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