title: Is there a standard for surgical therapy of hepatocellular carcinoma in healthy and cirrhotic liver? A comparison of eight guidelines.
abstract: OBJECTIVE
  Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis.
  
  
  METHODS
  We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines.
  
  
  RESULTS
  All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria.
  
  
  CONCLUSIONS
  Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.
authors.affiliation: Department of General and Visceral Surgery , University of Ulm , Ulm , Germany.
authors.forename: Giulia
authors.initials: G
authors.lastname: Manzini
authors.affiliation: Department of General and Visceral Surgery , University of Ulm , Ulm , Germany.
authors.forename: Doris
authors.initials: D
authors.lastname: Henne-Bruns
authors.affiliation: Health Care Research Group at the Hospital of General and Visceral Surgery, University Hospital of Ulm , Ulm , Germany.
authors.forename: Franz
authors.initials: F
authors.lastname: Porzsolt
authors.affiliation: Department of General and Visceral Surgery , University of Ulm , Ulm , Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Kremer
keywords: CIRRHOSIS; HEPATOCELLULAR CARCINOMA; LIVER TRANSPLANTATION; SURGICAL RESECTION