Salvage Resection Following Reassessment of Resectability in Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) management is commonly guided by the Barcelona Clinic Liver Cancer (BCLC) staging system; however, surgical resectability cannot always be accurately defined by staging alone. We report a case highlighting how initial misclassification of resectability led to loss of an early curative opportunity, while subsequent expert reassessment enabled successful salvage surgery. A 67-year-old man with chronic hepatitis B virus (HBV) infection was diagnosed with a large solitary HCC confined to the right hepatic lobe. Liver function was preserved, and there was no radiological evidence of vascular invasion or extrahepatic disease at presentation. Despite these favorable features, upfront surgical resection was not pursued. The patient underwent right portal vein embolization (PVE), which resulted in adequate hypertrophy of the future liver remnant, confirming technical resectability. Nevertheless, surgery was deferred, and transarterial radioembolization (TARE) was performed. During this interval, tumor progression occurred, with the development of a tumor thrombus in the right hepatic vein extending into the inferior vena cava (IVC), meeting criteria for advanced-stage disease. Following referral to a specialized hepatobiliary center, multidisciplinary reassessment determined that curative surgery remained feasible despite macrovascular involvement. The patient underwent right hepatectomy with resection of the right hepatic vein and inferior vena cava thrombectomy. Complete tumor removal with negative margins was achieved. The postoperative course was uneventful, and follow-up imaging at six months demonstrated no evidence of recurrence. This case illustrates the limitations of rigid guideline-based decision-making in HCC and underscores the importance of individualized surgical evaluation in experienced hepatobiliary centers. Continuous reassessment of resectability, particularly after locoregional therapies, may reveal curative options even in patients classified as having advanced disease.