The APASL Guideline published in 2010 were authored by a 25-member multi-disciplinary group comprising hepatologists, medical oncologists, surgeons and radiologists in the Asia-Pacific who first met at a monothematic conference on HCC in Bali in 2008.27 The APASL Guideline reflect the practices, not only of

major academic surgical centers in the Asia-Pacific, but its recommendations for surgical resection also mirrored that of some centers outside of the region that have dedicated HPB services (discussed below). These recommendations are a significant departure from those of the AASLD Guideline. The authors of the APASL guideline justified the more aggressive surgical approach on the basis of improved updated clinical outcomes from the published literature. Like the AASLD Guideline, Acalabrutinib nmr the APASL Guideline considers the presence of distant metastases and main portal vein and inferior vena cava involvement R788 concentration as definite contraindications

for liver resection in HCC.27 The number of tumors and the involvement of branch vasculature, however, were not considered contraindications. Bi-lobar HCC was also not considered a contraindication, and combined resection with radio-frequency ablation was specifically recommended in such cases.40,41 However, radio-frequency ablation was considered to be an acceptable alternative to resection for tumors less than 3 cm, even in CTP A patients, and this recommendation medchemexpress was largely based on a huge evidence base (but not from RCTs) generated in Japan. The philosophical premise was that if resection is technically feasible and safe, the long-term survival of resection is superior to current non-surgical therapies in such patients. In support of these recommendations, APASL noted that the reported long-term survival after resection for HCC with multi-focal nodules and/or vascular invasion is superior to that of the current mainstream alternative therapy, namely trans-arterial chemo-embolization

(TACE).35,36 Ng reported a 5-year OS of 39% after resection of large or multi-focal HCC.36 Ishizawa et al. reported a 58% 5-year OS for multifocal tumors and did not consider portal hypertension a contraindication to resection.42 Ikai et al. reported 5-year OS of 46% after resection in patients with vascular invasion.43 These results all compare well with TACE, where 2-year OS is between 24–63%, and there are no robust data on 5-year OS with TACE39,44 (Table 1). On the basis of these data, the patient would be best treated by resection if this is technically safe and feasible. A recent retrospective report from Asia similarly supports resection over TACE for stage BCLC B patients.45 Many academic surgical units in the West pursue a more aggressive surgical approach to HCC than might be suggested by the AASLD or BCLC Guidelines. These western views are well articulated by several recent reviews in the surgical literature. Truty et al.