Does Surgical Resection Have a Role in the Treatment of Large or Multinodular Hepatocellular Carcinoma?

Abstract

Several effective treatments are available for patients with small solitary hepatocellular carcinomas (HCCs). Conversely, the management of patients with large or multinodular HCCs is controversial, and the role of surgical resection is not well defined. Between 2000 and 2006, 51 patients with large or multinodular HCC underwent liver resection. Clinicopathologic and follow-up data were prospectively collected and retrospectively reviewed. The perioperative and long-term outcomes were analyzed. Univariate and multivariate analysis of prognostic factors were conducted. Although 20 patients had multinodular HCCs, 31 had large solitary tumors. Perioperative mortality occurred in eight patients and complications in 15. In patients with large solitary tumors, 5-year disease-free and overall survival were 41.3 per cent and 56.1 per cent, respectively. Those with multinodular HCCs demonstrated 5-year disease-free and overall survival rates of 0 per cent and 33.6 per cent, respectively. Liver resection can result in long-term survival in select patients with large or multinodular HCCs, even in select patients with impaired liver function. Large solitary HCCs seem to have better prognoses than multinodular tumors, with lower recurrence and higher survival rates after surgery. Randomized controlled trials comparing resection to other treatment modalities are indicated to determine optimal patient management.

Resection Strategies for Hepatocellular Carcinoma

“…80 Recent data from Japan and Italy demonstrated a 5-year survival of 58% and 33.6% for multinodular tumor after liver resection. 81,82 This contrasts to the outcome of those patients treated with TACE whose 5-year survival was around only 19%. 83 Resection strategies for multinodular tumors include major hepatectomy in one lobe combined with wedge resection for a smaller lesion in another lobe, or radiofrequency ablation (RFA) of centrally or deeply located tumors where resection would be difficult and involve removal of a large amount of nontumorous liver parenchyma.…”

Surgical treatment for large hepatocellular carcinoma: does size matter?

“…Specifically, a lower 5‐year survival of 8% was seen in the only series from the early 1990s, where experience in dealing with these tumours and identifying proper selection criteria was still evolving 32 . On the other hand, few studies reported 5‐year survivals of 55% to 70%, but with well‐selected patients that either had a single lesion or no cirrhosis 23,25,31 . Regarding the issue of recurrence in most studies, the 5‐year DFS ranged between 15% and 35%, with the only exception being studies with patients with single lesions and no cirrhosis showing DFS of 41% and 56%, respectively 23,31 .…”

“…On the other hand, few studies reported 5‐year survivals of 55% to 70%, but with well‐selected patients that either had a single lesion or no cirrhosis 23,25,31 . Regarding the issue of recurrence in most studies, the 5‐year DFS ranged between 15% and 35%, with the only exception being studies with patients with single lesions and no cirrhosis showing DFS of 41% and 56%, respectively 23,31 . These survival and recurrence figures may not seem very high, but are certainly acceptable if we consider that they are referring to patients with HCC over 10 cm that would be considered as unresectable by most centres.…”

“…The fact that the presence of cirrhosis predisposes to multicentricity means that this should not be considered as metastatic disease. The role of cirrhosis can explain the improved results in studies from Western centres as compared to some of the studies from Asia, where the number of cirrhotic patients is significantly higher 9,19,23,31 …”

Controversies and evidence of hepatic resection for hepatocellular carcinoma

“…This approach of stratifying patients by tumor size goes against a substantial body of evidence from studies in Western and Asian countries that hepatic resection can be safe and effective in patients with single and multinodular HCC, regardless of tumor size, so long as resection is feasible based on tumor location and preserved liver function [10] , [56] , [57] , [58] , [59] , [60] , [61] , [62] , [63] , [64] , [65] , [66] , [67] , [68] , [69] , [70] , [71] , [72] , [73] , [74] , [75] , [76] , [77] , [78] , [79] , [80] , [81] , [82] , [83] , [84] , [85] , [86] , [87] , [88] , [89] . This highlights the need to expand official indications for hepatic resection [20] , [21] , [22] .…”