Surgical Management of Large Hepatocellular Carcinoma: The First Single-Center Study From Western India

Abstract

Background: Majority of patients with large size HCC (>10 cm) are not offered surgery as per Barcelona Clinic Liver Cancer (BCLC) criteria and hence, their outcomes are not well studied, especially from India, owing to a lower incidence. Aim: To analyze outcomes of surgery for large HCCs. Methods: This retrospective observational study included all patients who underwent surgery for large HCC from January 2007 to December 2017. The entire perioperative and follow up data was collected and analyzed. Results: Nineteen patients were included. Ten were non-cirrhotic; 16 were BCLC grade A; one BCLC grade B; and two were BCLC C. Two cirrhotic and three non-cirrhotic underwent preoperative sequential trans-arterial chemoembolization and portal vein embolization. Right hepatectomy was the most commonly done procedure. The postoperative 30-day mortality rate was 5% (1/19). Wound infection and postoperative ascites was seen in seven patients each. Postoperative liver failure was seen in five. Two cirrhotic and two non-cirrhotic patients had postoperative bile leak. The hospital stay was 11.9±5.4 days (median 12 days). Vascular invasion was present in four cirrhotic and five non-cirrhotic patients. The median follow-up was 32 months. Five patients died in the follow-up period. Seven had recurrence and median recurrence free survival was 18 months. The cumulative recurrence free survival was 88% and 54%, whereas the cumulative overall survival was 94% and 73% at one and three years respectively. Both were better in non-cirrhotic; however, the difference was not statistically significant. The recurrence free survival was better in patients without vascular invasion and the difference was statistically significant (p=0.011). Conclusion: Large HCC is not a contraindication for surgery. Vascular invasion if present, adversely affects survival. Proper case selection can provide the most favorable survival with minimal morbidity.

Non-cirrhotic hepatocellular carcinoma in chronic viral hepatitis: Current insights and advancements

“…NCHCC usually presents at late stage, with a large tumor size, extrahepatic metastases, and heavy tumor burden. Symptoms may include malaise, fatigue, weight loss, abdominal pain, gastrointestinal bleeding and distension, even though often patients are asymptomatic[ 77 - 79 ].…”

“…However, little has been reported in the non-cirrhotic setting. Wagle et al [ 79 ] retrospectively noted ten NCHCC patients with outcomes with LRT and surgery. One patient underwent trans-arterial embolization and three underwent sequential TACE-portal vein embolization.…”

Primary Tumor Lymphovascular Invasion Negatively Affects Survival After Colorectal Liver Metastasis Resection?

“…The main prognostic factors for overall survival after hepatic resection of colorectal metastasis are based on classical papers published between 1960 and 2000 9,10,13,18,21 . However, more recent publications failed to demonstrate adequate accuracy of these variables in current population 13,21,27 . Much of this disparity is attributed to widespread and improvement in chemotherapy, better patient selection and advancements in surgical techniques.…”

“…Whenever feasible, liver resection presents with a 5-year overall survival between 24% and 64% in comparison with 10% to 11% of systemic chemotherapy alone 1 , 9 , 10 , 13 , 19 , 21 , 22 , 23 , 30 . Currently, patients with technically resectable nodules, a sufficient liver remnant, no or limited extra-hepatic disease and those considered fit to be submitted to major abdominal surgery are considered candidates for resection, though this accounts for only 20% of all metastatic patients 22 , 27 .…”

Comprehensive Review of Hepatocellular Carcinoma in India: Current Challenges and Future Directions

“…Therefore, a higher chance of survival with minimal morbidity can be achieved through proper case selection, such as a single tumor with no gross vascular invasion, good PS, liver remnant augmentation by sequential TACE with portal vein embolization, good preoperative planning, and adherence to hepatic surgery principles. 42 The INASL suggests that LR needs to be considered in experienced centers, particularly for solitary tumors (≤ 5 cm) located in favorable regions, using laparoscopic/minimally invasive techniques using a wide surgical margin (≥ 1 cm) for better prognosis. 11 However, there is a high risk of recurrence after resection.…”