The role of hepatic resection in the treatment of hepatocellular cancer

Abstract

Current guidelines recommend surgical resection as the primary treatment for a single hepatocellular cancer (HCC) with Child's A cirrhosis, normal serum bilirubin, and no clinically significant portal hypertension. We determined how frequently guidelines were followed and whether straying from them impacted survival. BRIDGE is a multiregional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. A total of 8,656 patients from 20 sites were classified into four groups: (A) 718 ideal resection candidates who were resected; (B) 144 ideal resection candidates who were not resected; (C) 1,624 nonideal resection candidates who were resected; and (D) 6,170 nonideal resection candidates who were not resected. Median follow‐up was 27 months. Log‐rank and Cox's regression analyses were conducted to determine differences between groups and variables associated with survival. Multivariate analysis of all ideal candidates for resection (A+B) revealed a higher risk of mortality with treatments other than resection. For all resected patients (A+C), portal hypertension and bilirubin >1 mg/dL were not associated with mortality. For all patients who were not ideal candidates for resection (C+D), resection was associated with better survival, compared to embolization and “other” treatments, but was inferior to ablation and transplantation. Conclusions: The majority of patients undergoing resection would not be considered ideal candidates based on current guidelines. Not resecting ideal candidates was associated with higher mortality. The study suggests that selection criteria for resection may be modestly expanded without compromising outcomes, and that some nonideal candidates may still potentially benefit from resection over other treatment modalities. (Hepatology 2015;62:440–451

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“…(1) The authors raise the important issue of primary mouse hepatocyte (PMH) dedifferentiation in culture. We considered this and looked for RIPK3 in "freshly isolated PMH" multiple times in phosphate-buffered saline-treated mice and mice treated with acetaminophen (APAP) for 3 hours.…”

“…We read with interest the article by Roayaie et al (1) regarding the surgical management of hepatocellular carcinoma (HCC) within the Bridge database. As reported by the authors, about two-thirds of resected patients were not ideal candidates for surgery according to published guidelines; in particular, 37% had portal hypertension (PH), and 7% were Child-Pugh B-C.…”

Hepatic surgeons are like the child who rescued dying fishes

“…This conclusion was based on an international multicenter study by Roayaie et al, (1) which reported a 5-year overall survival rate of >30% in the suboptimal group. This group of patients accounted for nearly 70% of all the patients who underwent hepatic resection during the study period.…”

“…Although the current European and American guidelines for HCC do not recommend hepatic resection for patients with intermediate or advanced HCCs, with Child B liver function, or concurrent portal hypertension, many hepatic surgeons around the world still operate on such patients on a selective basis provided the perioperative mortality and morbidity rates are estimated to be low. (1)(2)(3) In real life, a significant proportion of these patients would also choose surgical resection because of the potential cure despite a high tumor recurrence rate after resection.…”

Assessment of treatment efficacy in hepatocellular carcinoma: Response rate, delay in progression or none of them

“…Surgical resection is the favored option for advanced HCC before any other treatment option [4]. However, options that delay tumor progression in the absence of a major tumor burden reduction such as treatment with sorafenib [5] or regorafenib [6] are seen as less appealing even if survival -the most valued endpoint -may be similar or even better.…”