# The Recent Development of the Surgical Treatment for Hepatocellular Carcinoma
## 3 Surgical Treatment of HCC within Milan Criteria  
For patients with HCC less than three in number and less than 3 cm in size or a single tumor less than 5 cm in size (equivalent to BCLC-A), liver resection and radiofrequency ablation (RFA) are recommended with equal weight in Asian countries [3; 4; 5]. On the other hand, in Western countries, liver resection is not recommended for patients with two or three tumors. Moreover, in cases with portal hypertension and high bilirubin levels, RFA or liver transplantation is recommended instead of liver resection [6; 7]. Certainly, liver transplantation is an ideal treatment that can eliminate unrecognized sites of intrahepatic spread as well as the possibility of de novo HCC arising from the diseased parenchyma. In general, the 10-year recurrence-free survival rate after liver transplantation is around 50-70%, which is extremely good compared to 30-50% for liver resection [2]. Due to severe shortage of liver graft and disease progression while on the waiting list, liver resection and transarterial chemoembolization (TACE) have been used as the second most effective treatment after transplantation. According to the nationwide survey in Japan, the five-year survival rate after liver resection for the HCC patients within the Milan criteria is about 70%. Liver resection may achieve long-term survival comparable to liver transplantation if appropriate treatment against recurrent HCC and resolution of the cause of hepatitis can be performed [9; 10]. In addition, recent reports from Western countries suggest the usefulness of liver resection for HCC patients within the Milan criteria for effective utilization of limited liver graft [2]. For increasing resectability with preventing postbepatectomy liver failure due to insufficient future liver remnant (FLR), portal vein embolization was performed as conventional approach [11]. As an alternative approach for FLR augmentation, associating liver partition and portal vein ligation for staged hepatectomy (ALLPS) has been popularized [12]. Most of the evidences focus on ALLPS procedure against colorectal liver metastases [13]. There are still few reports about the safety and efficacy of ALLPS for the treatment of HCC with liver cirrhosis, further studies are warranted [14; 15; 16]. On the other hand, RFA is an option for patients who cannot undergo hepatectomy. Currently, a large randomized controlled trial in Japan has shown that there is no significant difference in three-year recurrence-free survival between liver resection and RFA groups, and analysis of long-term prognosis is awaited [17]. HCC has a high recurrence rate even after curative treatment, with intrahepatic recurrence accounting for the majority of cases. The treatment strategy of intrahepatic recurrence is based on the same algorithm as for initial treatment. This means that the choice of treatment depends on the liver functional reserve and the biological features of the recurrent tumor [18; 19]. In a comparison of surgical treatment between repeat hepatectomyand salvage liver transplantation, many reports show that salvage liver transplantation has a good recurrence-free survival rate; however, there is no difference in five-year survival rate between the two groups [20; 21]. In view of the current donor shortage, repeat hepatectomy may be a useful option for recurrent HCC.