Selecting the Best Approach for the Treatment of Multiple Non-Metastatic Hepatocellular Carcinoma

Abstract

According to the Barcelona Clinic Liver Cancer (BCLC) staging system, the optimal strategy for patients with multiple HCC within the Milan Criteria is liver transplantation (LT). However, LT cannot be offered to all the patients due to organ shortages and long waiting lists, as well as because of the advanced disease carrying a high risk of poor outcomes. For early stages, liver resection (LR) or thermal ablation (TA) can be proposed, while trans-arterial chemoembolization (TACE) still remains the treatment of choice for intermediate stages (BCLC-B). Asian guidelines and the National Comprehensive Cancer Network suggest LR for resectable multinodular HCCs, even beyond Milan criteria. In this scenario, a growing body of evidence shows better outcomes after surgical resection when compared with TACE. Trans-arterial radioembolization (TARE) and stereotaxic body radiation therapy (SBRT) can also play an important role in this setting. Furthermore, the role of minimally invasive liver surgery (MILS) specifically for patients with multiple HCC is still not clear. This review aims to summarize current knowledge about the best therapeutical strategy for multiple HCC while focusing on the role of minimally invasive surgery and on the most attractive future perspectives.

Laparoscopic versus open liver resection for multiple hepatocellular carcinoma within and beyond the Milan criteria: An Eastern‐Western propensity score–matched analysis

“…Recent studies have already revealed how selected patients with multiple resectable HCC included in BCLC-B stage can undergo surgery better results than TACE. [6][7][8][9][10][11] Thus, latest NCCN, APASL and ESMO guidelines recommend surgery in such selected cases. However, whether LLR is safely feasible for patients with multiple HCC is still under debate.…”

“…Recent studies have already revealed how selected patients with multiple resectable HCC included in BCLC‐B stage can undergo surgery with better results than TACE 6–11 . Thus, latest NCCN, APASL and ESMO guidelines recommend surgery in such selected cases.…”

“…7 Nonetheless, it has been widely reported that referral HPB centers perform LR in selected HCC patients also for BCLC-B and BCLC-C patients, as well as for patients with multiple HCC. 8,9 Indeed, some trials have indicated that liver resection may offer better oncological outcomes than TA or TACE. 10,11 Accordingly, the latest guidelines from the National Comprehensive Cancer Network (NCCN) and from the Asian Pacific Association for the Study of the Liver (APASL) recommend LR also in cases of multiple resectable nonmetastatic HCCs.…”

“…Indeed, for more than three nodules, as well as when one of the nodules is larger than 3 cm, patients are staged as Barcelona Clinic Liver Clinic staging system (BCLC)‐B, and they are recommended to undergo transarterial chemoembolization (TACE) according to current European guidelines 7 . Nonetheless, it has been widely reported that referral HPB centers perform LR in selected HCC patients also for BCLC‐B and BCLC‐C patients, as well as for patients with multiple HCC 8,9 . Indeed, some trials have indicated that liver resection may offer better oncological outcomes than TA or TACE 10,11 .…”

Clinical outcome of surgical resection for multifocal T2-T3 hepatocellular carcinoma up to 3 nodules: a comparative analysis with a single nodule

“…Previous studies comparing hepatic resection with TACE in the intermediate stage reported that OS after surgical resection was significantly better than that in the TACE groups (23.9-60% vs. 12-41.6%). 14 - 16 In addition, recent studies have also shown that liver resection has a favorable survival rate compared to non-surgical treatment in multinodular HCCs with ≤3 nodules. 4 , 14 , 18 …”