Surgical therapy offers the only chance for long-term cure of patients with hepatocellular carcinoma. The role of partial and total hepatectomy with subsequent liver replacement was analyzed in a consecutive series of 198 patients. It was the aim of this study to compare both treatment modalities on the basis of various clinicopathological prognostic factors including the TNM system of pathological classification. One hundred thirty-one resections and 61 transplantations were performed for the following histological diagnoses: hepatocellular carcinoma without coexisting liver disease (86) or associated with various hepatic abnormalities (79), fibrolamellar carcinoma (19), and mixed hepatocholangiocellular carcinoma (8). Overall actuarial survival rates at 5 years were 35.8% following resection and 15.2% after transplantation, respectively. For partial hepatectomy, factors significantly associated with improved long-term outcome were: age 30-50 years, hepatocellular carcinoma without coexisting liver disease, fibrolamellar carcinoma, solitary tumor, unilobar location, absence of vascular invasion, portal vein thrombosis or extrahepatic spread, primary tumor categories pT 2/3, stage groups II/III, and curative operation (R0). Regarding total hepatectomy, the corresponding figures were: pT2, absence of portal vein thrombosis or extrahepatic spread (negative regional lymph nodes, no distant metastases), stage group II, and curative surgery. It could be clearly shown by uni- and multivariate analyses that the pTNM classification is of clinical value regarding the assessment of prognostic significance after resection and transplantation. A group of 13 patients had secondary resection (8) or transplantation (6) for intrahepatic tumor recurrence. Whereas in all resected patients cancer recurred again, 5 of 6 transplant recipients are alive and disease-free at 12-40 months. The results of this study demonstrate that liver resection is the treatment of choice for primary liver cancer while transplantation may be indicated, especially in cases of nonresectable or recurrent lesions. Thus, the therapeutic spectrum for hepatocellular carcinoma should include both partial and total hepatectomy, being integrated into one common concept.