Liver resection for hepatocellular carcinoma in a hepatitis B endemic area

Surgical resection versus liver transplant for patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is a major worldwide health problem, involving more than half a million new patients yearly, with a different incidence in different parts of the world. Hepatocellular carcinoma develops in about 80% of cirrhotic patients, and cirrhosis is considered the strongest predisposing factor for it. Surgical resection and liver transplantation are conventional treatment modalities that can offer long-term survival for patients with hepatocellular carcinoma.

OBJECTIVES

To assess the benefits and harms of surgical resection compared with those of liver transplantation in patients with hepatocellular carcinoma.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (SCI-EXPANDED) at ISI Web of Science (last search February 2013). We also searched the abstracts from annual meetings of the American Society of Clinical Oncology, the American Association for the Study of Liver Diseases (AASLD), and the European Association for the Study of the Liver (EASL), provided through The Cochrane Hepato-Biliary Group until February 2013.

SELECTION CRITERIA

Randomised clinical trials comparing surgical resection and hepatic transplantation.

DATA COLLECTION AND ANALYSIS

The search strategies were run and two authors individually evaluated whether the retrieved studies fulfilled the inclusion criteria.

MAIN RESULTS

No randomised clinical trials comparing surgical resection and liver transplantation as the major methods of treating hepatocellular carcinoma were found.

AUTHORS' CONCLUSIONS

There are no randomised clinical trials comparing surgical resection and liver transplantation for hepatocellular carcinoma treatment.

Cirrhosis and microvascular invasion predict outcomes in hepatocellular carcinoma

BACKGROUND

Liver resection (LR) and liver transplantation (LT) are two modalities offering potential for cure in patients with hepatocellular carcinoma (HCC). The objective of this study was to evaluate the long-term survival of patients with HCC treated with LT and LR and to analyse variables influencing these outcomes.

METHODS

Patients referred to the South Australian Liver Transplant Unit and Hepatopancreatobiliary Unit at Flinders Medical Centre from January 1992 to September 2009 with a diagnosis of HCC who underwent LT or LR were included in the study. Histopathological parameters analysed included size, number and grade of tumour, microscopic vascular invasion and presence or absence of cirrhosis in remnant liver.

RESULTS

Eighty-five patients with a median age of 58 years (range 26-85 years) underwent LT or LR. Median follow-up was 40 months in both groups. Overall, 5-year actuarial survival for all patients with HCC in both groups was 55%. LR patients were significantly older (P < 0.001) than LT patients. Their tumours were larger (P < 001) and more often solitary (P < 0.001) compared with the LT group. In multivariate analysis, age >60 (P < 0.02), histopathological evidence of vascular invasion (P < 0.02) and presence of cirrhosis (P < 0.02) were associated with a significantly reduced survival. Patients without vascular invasion and cirrhosis had an actuarial 5-year survival >70%.

CONCLUSIONS

Our study indicates that LT (within University of California, San Francisco criteria) and LR can lead to acceptable long-term survival outcomes in patients with HCC. Microscopic vascular invasion and cirrhosis were the most significant prognostic factors impacting on survival.

Hepatic incidentaloma: the rule of tens

OBJECTIVES

Hepatic incidentalomas (HI) are asymptomatic lesions detected incidentally during investigations for other pathologies. This prospective series outlines the management and outcomes of 121 HI managed over 7 years.

METHODS

Data were recorded prospectively on 121 patients referred between 2003 and 2010 for assessment of HI out of 1081 patients referred for a hepatic resection. Patients were reviewed in multidisciplinary meetings and investigated with tumour markers and radiological investigations. HI were classified as hypo- or hypervascular depending on arterial phase CT scan findings. Univariate and multivariate analysis was performed to define predictive factors for malignancy.

RESULTS

Forty HI were hypovascular, 35 were benign (18 cysts, 12 focal fatty sparing, 1 fetal lobulation and 4 solitary necrotic nodules) and 5 cholangiocarcinomas (all resected)]. Eighty-one HI were hypervascular, 72 were benign [40 focal nodular hyperplasia (FNH), 8 adenoma and 24 hemangiomas) and 9 cancers (5 HCC, 4 metastases: 7 resected). Male gender [relative risk (RR) 2.70, confidence interval (CI) 1.69-3.51], age >45 years (RR 3.15, CI 2.71-3.89), tumour diameter >4 cm (RR 3.35, CI 3.13-4.01) and late (8 min) enhancement on magnetic resonace imaging (MRI) (RR 4.15, CI 3.01-4.79) were predictive of malignancy.

CONCLUSIONS

HI constitute 10% of practice volume. 10% of hyper and hypovascular incidental lesions are malignant. Most can be treated aggressively after diagnosis.

Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria

BACKGROUND

Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome.

METHODS

Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant.

RESULTS

In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P= 0.04). The recurrence rate was higher in group B (P= 0.002).

CONCLUSIONS

Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score.

Hepatocellular carcinoma: Defining the place of surgery in an era of organ shortage

Liver resection (LR) and transplantation offer the only potential chance of cure for patients with hepatocellular carcinoma (HCC). Historically, all patients were treated by hepatic resection. With the advent of liver transplantation (LT) patients with HCC were preferentially placed on the waiting list for LT. However, early experience with LT was associated with a high rate of tumour recurrence and poor long-term survival. The increasing scarcity of donor livers resulted in restrictions being placed on tumour size, and an improvement in patient survival. To date there have been no randomised clinical trials comparing LR to LT. We review the evidence supporting LR and/or LT for HCC and discuss the role of neoadjuvant therapy. The decision of whether to resect or transplant remains debatable and is often determined by centre experience, availability of LT and donor organs.