Management of Satellite Lesions in Hepatocellular Carcinoma: An Updated Review.

Satellite lesions, defined as microscopic or small macroscopic tumor nodules within 2 cm of a primary hepatocellular carcinoma (HCC), represent early intrahepatic dissemination and are strongly associated with aggressive tumor biology. This review synthesizes the current evidence regarding the biological basis, diagnostic challenges, prognostic relevance, and therapeutic approaches for managing satellite lesions in HCC. In published studies, satellite lesions were consistently linked to aggressive tumor behavior, including higher rates of microvascular invasion, multifocality, and early postoperative recurrence. Patients with satellite lesions experienced significantly reduced disease-free and overall survival compared to those with solitary tumors, although outcomes varied with tumor size, number, and liver function. In transplant-eligible cohorts, satellite lesions were associated with exceeding standard listing criteria and demonstrated increased post-transplant recurrence when identified on explant pathology. Radiologic detection showed moderate sensitivity but high specificity, influencing selection for resection, ablation, and transplant-based strategies. Satellite lesions are a critical marker of tumor aggressiveness in HCC and significantly influence surgical and transplant decision-making. Although resection may be appropriate for carefully selected patients with preserved liver function, recurrence rates remain high. The presence or suspicion of satellite lesions strongly impacts transplant candidacy, with most guidelines considering radiological satellites an indicator of advanced disease.