Identifying optimal candidates for liver resection or transarterial chemoembolisation in patients with unresectable hepatocellular carcinoma

Abstract

Background: Recommended as the first-line treatment for advanced unresectable hepatocellular carcinoma (HCC), sorafenib has been shown to prolong median overall survival (OS) for patients. However, advanced HCC sees high heterogeneity across patient groups. Recently, a growing number of studies have indicated surgical resection and transarterial chemoembolisation (TACE) to perform well in patients with portal vein tumor thrombosis (PVTT). The aim of this study was to compare the outcomes of liver resection and TACE and to identify prognostic factors related to OS for BCLC stage C patients with performance status (PS) 1 who have a single tumor but no vascular invasion or extrahepatic spread.Methods: A total of 323 consecutive patients in BCLC stage C with PS 1 who had only one tumor and no vascular invasion or extrahepatic spread were enrolled in this retrospective study, regardless of tumor size.Survival analyses were performed using the Kaplan-Meier analysis, and statistical differences between the TACE and sorafenib groups were examined by the log-rank test. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.Results: Based on the Kaplan-Meier curves, patients treated with surgical resection showed a better OS than those who underwent TACE, with OS at 1, 3, and 5 years (85.7%, 48.8%, and 33.3% vs. 66.6%, 21.8%, and 13.4%, respectively; log-rank P<0.001). Univariate and multivariate analyses demonstrated that tumor size, albumin, bilirubin, Child-Pugh score, and treatment method were significant prognostic factors for OS.According to the subgroup analyses based on tumor size, there were significant differences in OS among overall subsets between patients who underwent hepatectomy and those who underwent TACE therapy.Conclusions: Liver resection had a better prognostic performance than TACE and should be put forward as an alternative treatment modality to TACE for BCLC stage C patients with PS 1 who have a single tumor and no vascular invasion or extrahepatic spread.

Treatment of Barcelona Clinic Liver Cancer Stage C hepatocellular carcinoma: liver resection versus TACE and beyond

“…In advanced HCC with PVTT and a mean tumour size of 7cm, A-TARE had a significantly longer survival than cTARE (45.3 vs. 18.2 months, P=0.003) (21). These are impressive results considering the patients in Zhao et al treated with surgical resection had a median survival of 19.5 months with tumours 5cm or greater (1). Similar to the criteria for surgery, in A-TARE, a majority of the liver can be ablated as long as the future liver remaining is >40% in Child Pugh A5, A6 or B7 patients (21).…”

“…This issue of Annals of Translational Medicine provides a thought-provoking study by Zhao and colleagues "Identifying optimal candidates for liver resection or TACE in patients with unresectable hepatocellular carcinoma" (1). This retrospective study adds to the current literature in treating hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage C patients.…”

“…In comparison, the study by Zhao et al was performed in China where endemic hepatitis B virus (HBV) infection is the main attributable factor for HCC (1). Many physicians in Asia take a more aggressive treatment approach than the BCLC staging classification such as the Hong Kong Liver Cancer (HKLC) classification, particularly with a broader use of surgical resection in identified subsets of BCLC Stage B and C patients (5).…”

“…Firstly, TACE was administered every 6 weeks during the first year and every 6 to 8 weeks thereafter, depending on their liver function. The study did not quantify the average number of TACE per patient or whether they continued to administer TACE even with non-viable or TACE-resistant HCC (1). At our institution, we perform multiphase imaging approximately 4 weeks after TACE to assess for residual viable tumour using the LI-RADS criteria.…”

Liver resection is always a good choice for hepatocellular carcinoma (HCC) patients regardless of Barcelona Clinic Liver Cancer (BCLC) stage: the therapeutic hierarchy

“…For all these reasons, the BCLC "stage hierarchy" approach (3), linking each HCC stage to a specific treatment, has been exceeded firstly by the concept of "treatment stage migration" strategy (4), which allows moving to another treatment in a bidirectional way (the previous or the subsequent one in BCLC classification, according to each single case), and more recently by the theory of "therapeutic hierarchy" (5), historically endorsed by the Asia-Pacific guidelines (6) as well as by Italian guidelines (7). Accordingly, Zhao et al recently published a study in Ann Transl Med entitled "Identifying optimal candidates for liver resection or TACE in patients with unresectable hepatocellular carcinoma" (8). This study aimed to compare the post-treatment outcomes after liver resection (LR) or transarterial chemoembolization (TACE) to recognize prognostic factors related to overall survival (OS) for BCLC stage C patients with PS 1 having single tumor and without vascular invasion or extrahepatic spread.…”