Clinical Pathway for Surgical Removal of Stage 2 Liver Cancer

The patient presents with a confirmed diagnosis of Stage 2 hepatocellular carcinoma (HCC), characterized by multiple tumors or a single tumor with vascular invasion.
A comprehensive clinical evaluation is conducted, including a detailed medical history, physical examination, and assessment of liver function.
The patient is counseled on the diagnosis, treatment options, and the proposed surgical intervention, ensuring informed consent.

A thorough review of the patient’s medical history is performed, including comorbidities, prior treatments, and imaging studies.
Documentation of liver function, tumor size, location, and staging is confirmed using established criteria (e.g., BCLC staging system).

Complete blood count (CBC): To assess for anemia or thrombocytopenia.
Liver function tests (LFTs): Including ALT, AST, bilirubin, albumin, and INR to evaluate hepatic reserve.
Renal function tests: Creatinine and BUN to assess kidney function.
Alpha-fetoprotein (AFP) levels: As a tumor marker for HCC.
Viral hepatitis serology: To identify underlying hepatitis B or C infection, if not previously performed.
Coagulation profile: To evaluate bleeding risk and guide perioperative management.

Contrast-enhanced abdominal CT or MRI: To confirm tumor size, location, and vascular involvement.
Chest imaging (CT or X-ray): To rule out metastatic disease.
PET scan (if indicated): To assess for extrahepatic spread in select cases.

The case is presented to a multidisciplinary tumor board, including a hepatobiliary surgeon, medical oncologist, radiologist, and pathologist.
A consensus is reached on the surgical approach, considering tumor characteristics, liver function, and patient comorbidities.
The treatment plan, including risks, benefits, and alternatives, is discussed with the patient.

The patient is admitted to the hospital 24-48 hours prior to surgery.
Preoperative fasting is initiated.
Prophylactic antibiotics and venous thromboembolism (VTE) prophylaxis are administered as per protocol.
Anesthesia evaluation is performed to determine the appropriate anesthetic plan (general anesthesia or local/regional anesthesia, depending on patient factors).

Procedure: Partial hepatectomy or laparoscopic liver resection, depending on tumor location and size.
Intraoperative monitoring: Continuous hemodynamic monitoring, including arterial line and central venous pressure (CVP) monitoring.
Technique: The tumor is resected with clear margins, ensuring preservation of adequate functional liver parenchyma.
Intraoperative ultrasound: Used to confirm tumor margins and guide resection.
Hemostasis: Achieved using electrocautery, argon beam coagulation, or suturing.
Drain placement: A surgical drain may be placed near the resection site, depending on the extent of surgery.

The patient is transferred to the recovery room and subsequently to a private room for continuous monitoring.
Pain management is initiated using a multimodal approach (e.g., IV opioids, NSAIDs, or epidural analgesia).
Postoperative blood tests (CBC, LFTs, coagulation profile) are performed to monitor for complications such as bleeding or liver dysfunction.
Early ambulation and respiratory exercises are encouraged to prevent complications.

Postoperative imaging (CT or MRI): Performed if there is concern for residual disease or complications.
Pathology review: The resected specimen is sent for histopathological analysis to confirm clear margins and tumor characteristics.

The patient is discharged once stable, typically 5-7 days postoperatively, with detailed instructions on wound care, activity restrictions, and follow-up appointments.
A follow-up plan is established, including repeat imaging and blood tests (AFP levels) at 1 month postoperatively.

Regular surveillance imaging (every 3-6 months) and blood tests to monitor for recurrence.
Ongoing management of underlying liver disease (e.g., antiviral therapy for hepatitis B or C, lifestyle modifications for NAFLD).

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