title: Surgery for Intermediate and Advanced Hepatocellular Carcinoma: A Consensus Report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014).
abstract: BACKGROUND
  The Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy does not recommended surgery for treating BCLC stage B and C hepatocellular carcinoma (HCC). However, numerous Asia-Pacific institutes still perform surgery for this patient group. This consensus report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting aimed to share opinions and experiences pertaining to liver resection for intermediate and advanced HCCs and to provide evidence to issue recommendations for surgery in this patient group.
  
  
  CONCLUSIONS
  Thirteen experts from five Asia-Pacific regions were invited to the meeting; 10 of them (Japan: 2, Taiwan: 3, South Korea: 2, Hong Kong: 1, and China: 2) voted for the final consensus. The discussion focused on evaluating the preoperative liver functional reserve and surgery for large tumors, multiple tumors, HCCs with vascular invasion, and HCCs with distant metastasis. The feasibility of future prospective randomized trials comparing surgery with transarterial chemoembolization for intermediate HCC and with sorafenib for advanced HCC was also discussed. The Child-Pugh score (9/10 experts) and indocyanine green retention rate at 15 min (8/10) were the most widely accepted methods for evaluating the preoperative liver functional reserve. All (10/10) experts agreed that portal hypertension, tumor size >5 cm, portal venous invasion, hepatic venous invasion, and extrahepatic metastasis are not absolute contraindications for the surgical resection of HCC. Furthermore, 9 of the 10 experts agreed that tumor resection may be performed for patients with >3 tumors. The limitations of surgery are associated with a poor liver functional reserve, incomplete tumor resection, and a high probability of recurrence.
  
  
  CONCLUSIONS
  Surgery provides significant survival benefits for Asian-Pacific patients with intermediate and advanced HCCs, particularly when the liver functional reserve is favorable. However, prospective randomized controlled trials are difficult to conduct because of technical and ethical considerations.
authors: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan (ROC).
authors: Ming-Chih
authors: MC
authors: Ho
authors: Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
authors: Kiyoshi
authors: K
authors: Hasegawa
authors: Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors: Xiao-Ping
authors: XP
authors: Chen
authors: Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
authors: Hiroaki
authors: H
authors: Nagano
authors: Department of Surgery, Asan Medical Center, Seoul, Republic of Korea.
authors: Young-Joo
authors: YJ
authors: Lee
authors: Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC).
authors: Gar-Yang
authors: GY
authors: Chau
authors: Department of Liver Surgery and Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
authors: Jian
authors: J
authors: Zhou
authors: Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan (ROC).
authors: Chih-Chi
authors: CC
authors: Wang
authors: Department of Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea.
authors: Young Rok
authors: YR
authors: Choi
authors: Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China.
authors: Ronnie Tung-Ping
authors: RT
authors: Poon
authors: Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
authors: Norihiro
authors: N
authors: Kokudo
keywords: Hepatocellular carcinoma; Outcome; Staging system; Surgery