Comparison of Surgical Resection and Systemic Treatment for Hepatocellular Carcinoma with Vascular Invasion: National Cancer Database Analysis

Abstract

<b><i>Introduction:</i></b> Small studies from outside of the USA suggest excellent outcomes after surgical resection for hepatocellular carcinoma (HCC) with vascular invasion. The study aims to (1) compare overall survival after surgical resection and systemic therapy among patients with HCC and vascular invasion and (2) determine factors associated with receipt of surgical resection in a US population. <b><i>Methods:</i></b> HCC patients with AJCC clinical TNM stage 7th T3BN0M0 diagnosed between 2010 and 2017 from the National Cancer Database were analyzed. Cox and logistic regression analyses identified factors associated with overall survival and receipt of surgical resection. <b><i>Results:</i></b> Of 11,259 patients with T3BN0M0 HCC, 325 (2.9%) and 4,268 (37.9%) received surgical resection and systemic therapy, respectively. In multivariable analysis, surgical resection was associated with improved survival compared to systemic therapy (adjusted hazard ratio: 0.496, 95% confidence interval: 0.426–0.578) with a median survival of 21.4 and 8.1 months, respectively. Superiority of surgical resection was observed in noncirrhotic and cirrhotic subgroups and propensity score matching and inverse probability of treatment weighting adjusted analysis. Asians were more likely to receive surgical resection, whereas Charlson comorbidity ≥3, elevated alpha-fetoprotein, smaller tumor size, care in a community cancer program, and the South or West region were associated with a lower likelihood of surgical resection. <b><i>Conclusion:</i></b> HCC patients with vascular invasion may benefit from surgical resection compared to systemic therapies. Demographic and clinical features of HCC patients and region and type of treating facility were associated with surgical resection versus systemic treatment.

Characteristics and outcomes of hepatocellular carcinoma patients with macrovascular invasion following surgical resection: a meta-analysis of 40 studies and 8,218 patients

“…Therefore, surgery may be a viable alternative option in the setting of segmental or 2nd order PVTT ( 25 ). Our data is in line with a recent study by Govalan et al ( 10 ) which was published after our search was performed. The authors evaluated 11,259 HCC patients with American Joint Commission on Cancer (AJCC) 7 th clinical stage TNM ( 26 ) T 3B N 0 M 0 and demonstrated that those who underwent resection had a median OS of 21 versus 8 months in those that received systemic therapy.…”

“…More recently, data from Asia and the US suggest a survival benefit with surgical resection in well selected HCC patients with MVI (10)(11)(12). However, available data are heterogenous likely due in part to the inclusion of patients with tumor thrombus that involved different anatomic levels of the vasculature in different studies.…”

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

“…However, recent retrospective studies have shown that the OS of hepatic resection was better than that of non-surgical treatment modalities, such as TACE, radiation therapy, or sorafenib, unless the main portal trunk or contralateral branch was involved. [349][350][351][352][353][354] In addition, according to a Korean multicenter study and a Korea-Japan joint study, the 5-year survival rate after hepatic resection for HCC with bile duct invasion was 32.0-43.6%, which was fairly appreciable, and aggressive hepatic resection including bile duct resection was helpful to improve survival. 355,356 Therefore, even for HCC that has invaded blood vessels or bile ducts, hepatic resection can be selectively considered if the patient's general condition is tolerable.…”

“…Generally, tumor invasion to the major hepatic veins or major portal veins has been considered as a contraindication of hepatic resection. However, recent retrospective studies have shown that the OS of hepatic resection was better than that of non-surgical treatment modalities, such as TACE, radiation therapy, or sorafenib, unless the main portal trunk or contralateral branch was involved [ 349 - 354 ]. In addition, according to a Korean multicenter study and a Korea-Japan joint study, the 5-year survival rate after hepatic resection for HCC with bile duct invasion was 32.0–43.6%, which was fairly appreciable, and aggressive hepatic resection including bile duct resection was helpful to improve survival [ 355 , 356 ].…”

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

“…However, recent retrospective studies have shown that the OS of hepatic resection was better than that of non-surgical treatment modalities, such as TACE, radiation therapy, or sorafenib, unless the main portal trunk or contralateral branch was involved. [349][350][351][352][353][354] In addition, according to a Korean multicenter study and a Korea-Japan joint study, the 5-year survival rate after hepatic resection for HCC with bile duct invasion was 32.0-43.6%, which was fairly appreciable, and aggressive hepatic resection including bile duct resection was helpful to improve survival. 355,356 Therefore, even for HCC that has invaded blood vessels or bile ducts, hepatic resection can be selectively considered if the patient's general condition is tolerable.…”