Goal-directed minimally invasive treatment of hepatocellular carcinoma across the disease course: a scenario-based clinical framework

Abstract

Minimally invasive treatment for hepatocellular carcinoma (HCC) is evolving from isolated procedures into a longitudinal pathway linking local control, liver-function preservation, and future treatment options. This review synthesizes recent evidence on positioning these therapies according to treatment intent, technical feasibility, biologic selection, and integration with systemic therapy. The evidence is organized into five scenarios: curative-intent treatment, bridging or downstaging to transplantation, unresectable liver-dominant disease, post-recurrence salvage, and transition to systemic therapy. Randomized studies in mixed liver-tumor populations support faster recovery after laparoscopic resection, whereas HCC-specific randomized data have not demonstrated a survival advantage for surgery over radiofrequency ablation (RFA) for small tumors; this does not establish equivalence. Robotic platforms may extend minimally invasive surgery to selected complex cases. RFA remains the benchmark for small tumors, while microwave ablation and combined locoregional approaches extend the boundary of local radicality. Navigation, software-based margin assessment, and real-time imaging are also moving ablation toward a closed-loop quality-control model. In unresectable liver-dominant disease, selected transarterial chemoembolization (TACE)-based sequences and combinations have improved progression-free survival or disease control in trial-defined populations, but LEAP-012 and EMERALD-1 have not demonstrated an overall-survival benefit. Candidate selection extends beyond tumor geometry to tumor biology and host reserve, although artificial intelligence, biomarkers, histotripsy, and experimental platforms remain at different stages. The central challenge is no longer expansion of technical capability alone. It is disciplined sequencing: choosing the right local therapy for the right patient at the right point in the disease course without prematurely exhausting liver reserve.

Keywords

Hepatocellular carcinoma / minimally invasive treatment / liver resection / ablation / transplantation / locoregional therapy / treatment transition / liver reserve

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