For example, Maniaci et al have proposed an intensive surveillance protocol following surgery that includes CT and serum vitamin B12-binding protein levels every 3–6 months for the first 2–3 years postoperatively.54 In cases where serum vitamin B12-binding protein is elevated and CT scan is negative, the authors recommend PET/CT.54 

While this or other protocols have not been vigorously studied – and therefore cannot be endorsed – the data collectively suggest that close surveillance is warranted. If recurrence is detected, depending on the site and number of recurrent lesions, repeat surgical resection should be considered, as other treatment options are not effective.

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For example, Maniaci et al reported on ten patients with FLC treated with resection followed by close surveillance and re-excision, systemic chemotherapy, as well as radiotherapy for any relapses. This study showed a median overall survival of 9.3 years (95% confidence interval, 3.0–18.5) with two patients showing at least partial response to cisplatin and fluorouracil.54

For patients with FLC who present with unresectable disease, liver transplantation should be considered as 3-year survival following 75%–80% transplantation approaches.74 While transplantation may be used in cases of FLR, it is much more commonly indicated for HCC than FLC.70

This is likely due to the fact HCC is more common than FLC as well as the fact that regional lymph node metastasis (a relative contraindication to transplant) is more common in FLC (42.2%) compared with HCC (22.2%).70