Towards a personalized approach to hepatic resection in cirrhotic patients

Vitale, Alessandro; Majno‐Hurst, Pietro

doi:10.1016/j.jhep.2019.09.005

Cited by 7 publications

(7 citation statements)

References 16 publications

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“…Optimal candidacy for LR relies on a multiparametric evaluation, which includes evaluation of residual liver function, grade of portal hypertension, volume of remaining parenchyma, and the possibility for adopting a laparoscopic/minimally invasive approach. (3,4,34) Moving beyond the original monoparametric BCLC model (forwarding single variables as absolute contraindications to surgery) distinctly provided further convenience for a right-to-left treatment stage migration. Moreover, the definition of "optimal surgical candidate" no more prevents the "suboptimal" cases from having access to LR, as long as they fit within a class with an acceptable risk of postoperative mortality and morbidity and the LR is expected to offer survival gain compared to the alternative options.…”

Section: Treatment Stage Migration Origin and Definitionmentioning

confidence: 99%

“…Moreover, the definition of “optimal surgical candidate” no more prevents the “suboptimal” cases from having access to LR, as long as they fit within a class with an acceptable risk of postoperative mortality and morbidity and the LR is expected to offer survival gain compared to the alternative options. ( 34 ) Similarly, the definition of “unresectable” intermediate‐stage patients clearly implies that hepatectomy may be considered an option (probably the first one) for certain such cases.…”

Section: Treatment Stage Migrationmentioning

confidence: 99%

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Treatment of Hepatocellular Carcinoma in the Precision Medicine Era: From Treatment Stage Migration to Therapeutic Hierarchy

et al. 2020

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Treatment allocation is extremely complex in patients with hepatocellular carcinoma (HCC) because this neoplasm arises, in most cases, in patients with cirrhosis and additional comorbidities. The “stage hierarchy” approach, which involves linking each stage (or substage) of the disease to a specific treatment, has become the main proposed treatment strategy for the clinical management of HCC, particularly in the West. The Barcelona Clinic Liver Cancer (BCLC) scheme serves as the main example of the application of this strategy. In an attempt to increase the plasticity of the “stage hierarchy” approach as well as its adaptability to the requirements of real‐world clinical practice, the latest versions of European and American guidelines have introduced certain relevant elements of flexibility, which were not intrinsic to the original BCLC scheme. These elements are as follows: the “treatment stage migration” strategy, which allows moving to another treatment (generally the one that is associated with the subsequent stage) if the approach linked with the current stage proves to be unfeasible, and the “treatment stage alternative” approach, which proposes further therapeutic options for each BCLC‐defined stage. In regard to most of the solid cancers, another potential strategy is to consider the treatment decision to be hierarchically dictated by the efficacy of each therapy with complete or partial independence from the tumor stage. This concept of “therapeutic hierarchy” has been historically endorsed by the Asia‐Pacific treatment algorithm as well as by the recent Italian multisociety guidelines. The present review provides a critical analysis of the different conceptual approaches to HCC management, highlighting their advantages and disadvantages and focusing on the remarkable differences between the stage‐guided and the hierarchical strategies.

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Section: Treatment Stage Migration Origin and Definitionmentioning

confidence: 99%

Section: Treatment Stage Migrationmentioning

confidence: 99%

Treatment of Hepatocellular Carcinoma in the Precision Medicine Era: From Treatment Stage Migration to Therapeutic Hierarchy

et al. 2020

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“…3 , taken by a recently published policy review 13 . In the specific LR setting, this is the best example of a multiparametric treatment decision for HCC patients 39 . This aspect is well described in the last guidelines of the European Association for the Study of the Liver 40 , introducing the multiparametric concept of ‘optimal surgical candidate’.…”

Section: Discussionmentioning

confidence: 99%

Liver resection versus radiofrequency ablation or trans-arterial chemoembolization for early-stage (BCLC A) oligo-nodular hepatocellular carcinoma: meta-analysis

Romano,

Busti,

Billato

et al. 2024

BJS Open

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Background The 2022 Barcelona Clinic Liver Cancer (BCLC) algorithm does not recommend liver resection (LR) in BCLC A patients with oligo-nodular (two or three nodules ≤3 cm) hepatocellular carcinoma (HCC). This sharply contrasts with the therapeutic hierarchy concept, implying a precise treatment order exists within each BCLC stage. This study aimed to compare the outcomes of LR versus radiofrequency ablation (RFA) or trans-arterial chemoembolization (TACE) in BCLC A patients. Methods A meta-analysis adhering to PRISMA guidelines and the Cochrane Handbook was performed. All RCT, cohort and case–control studies that compared LR versus RFA or TACE in oligo-nodular BCLC A HCC published between January 2000 and October 2023 were comprehensively searched on PubMed, Embase, the Cochrane Library and China Biology Medicine databases. Primary outcomes were overall survival (OS) and disease-free survival (DFS) at 3 and 5 years. Risk ratio (RR) was computed as a measure of treatment effect (OS and DFS benefit) to calculate common and random effects estimates for meta-analyses with binary outcome data. Results 2601 patients from 14 included studies were analysed (LR = 1227, RFA = 686, TACE = 688). There was a significant 3- and 5-year OS benefit of LR over TACE (RR = 0.55, 95% c.i. 0.44 to 0.69, P < 0.001 and RR 0.57, 95% c.i. 0.36 to 0.90, P = 0.030, respectively), while there was no significant 3- and 5-year OS benefit of LR over RFA (RR = 0.78, 95% c.i. 0.37 to 1.62, P = 0.452 and RR 0.74, 95% c.i. 0.50 to 1.09, P = 0.103, respectively). However, a significant 3- and 5-year DFS benefit of LR over RFA was found (RR = 0.70, 95% c.i. 0.54 to 0.93, P = 0.020 and RR 0.82, 95% c.i. 0.72 to 0.95, P = 0.015, respectively). A single study comparing LR and TACE regarding DFS showed a significant superiority of LR. The Newcastle–Ottawa Scale quality of studies was high in eight (57%) and moderate in six (43%). Conclusions In BCLC A oligo-nodular HCC patients, LR should be preferred to RFA or TACE (therapeutic hierarchy concept). Additional comparative cohort studies are urgently needed to increase the certainty of this evidence.

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“…The technical refinements, the implementation of laparoscopy as the standard of care for HR, the possibility to perform minimally invasive surgery, and improvements in postoperative management have increased the overall safety of HR during recent years, achieving a parallel reduction of resection-related mortality in "ideal patients" without CSPH from 10%-20% to a near-zero rate in hub centers [1,8,[34][35][36][37][38][39][40] . Moreover, much evidence confirms the superiority of HR in terms of oncological response over locoregional treatments for a similar number of nodules [41][42][43][44] .…”

Section: Clinically Significant Portal Hypertension and Hccmentioning

confidence: 99%

Hepatic venous pressure gradient in hepatic resection for hepatocellular carcinoma

Shalaby,

Burra,

Senzolo

2023

Hepatoma Res

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Liver transplantation is considered the gold standard for curative treatment of hepatocellular carcinoma (HCC) in patients with cirrhosis, but limited organ availability and high costs necessitate alternative options. Hepatic resection (HR) is preferred for select patients, providing tumor removal and prognostic information. However, HR has been associated with life-threatening complications, especially in the presence of clinically significant portal hypertension (CSPH). Current guidelines recommend HR only for patients with well-preserved liver function, normal bilirubin levels, good performance status, and no CSPH. However, advancements in surgical techniques and portal hypertension management are challenging these guidelines, potentially allowing the consideration of hepatic resection for HCC in cirrhotic patients with CSPH. Indeed, minimally invasive approaches improve safety and outcomes for selected CSPH patients and accurate assessment of CSPH allows risk stratification according to liver function, tumor location, and extent of resection. Thus, despite the negative impact of CSPH on HR outcomes, careful patient selection and minimally invasive techniques expand the potential for HR in CSPH patients. This comprehensive review examines the evidence on HR in HCC treatment for cirrhotic patients with CSPH, highlighting challenges in surgical decision-making, the importance of direct measurement of hepatic venous pressure gradient, and exploring the benefits and risks associated with HR. Moreover, it underscores the need for refined prediction models and algorithms to optimize patient selection and enhance surgical outcomes.

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Towards a personalized approach to hepatic resection in cirrhotic patients

Cited by 7 publications

References 16 publications

Treatment of Hepatocellular Carcinoma in the Precision Medicine Era: From Treatment Stage Migration to Therapeutic Hierarchy

Treatment of Hepatocellular Carcinoma in the Precision Medicine Era: From Treatment Stage Migration to Therapeutic Hierarchy

Liver resection versus radiofrequency ablation or trans-arterial chemoembolization for early-stage (BCLC A) oligo-nodular hepatocellular carcinoma: meta-analysis

Hepatic venous pressure gradient in hepatic resection for hepatocellular carcinoma

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