Should surgery be carried out in patients with hepatocellular carcinoma with portal hypertension?

Abstract

We read with great interest the meta-analysis by Berzigotti et al. 1 This study revealed that clinically significant portal hypertension (CSPH) significantly increased the 3-and 5-year mortality rates and risks of clinical liver decompensation after surgery on hepatocellular carcinoma (HCC) patients with cirrhosis and portal hypertension. We appreciate their hard work in coming up with this systematic review and meta-analysis. However, as hepatic surgeons, we would like to raise the following points:1. Postoperative outcomes should include not only long-term (e.g., recurrence and survival), but also short-term outcomes (e.g., postoperative morbidity and mortality). This meta-analysis hardly touches on sufficient variables of short-term outcomes or recurrence as study endpoints. 2. We consider the investigators' conclusion on the absolute necessity to use hepatic venous pressure gradient (HVPG) in the diagnosis of CSPH debatable. HVPG is an invasive procedure performed by blood vessel. Given that endoscopic finding of varices is sufficient to diagnose CSPH, 2 why is a lessinvasive procedure of endoscopy not used as the first-line diagnostic modality for CSPH? 3. We agree with the investigators that: "Even if the presence of CSPH should not be regarded as an absolute contraindication to surgery, our results demonstrate that it has to be considered a major negative prognostic factor," which was also admitted by other scholars. 3-5 However, we would like to point out that the majority of clinicians may be more interested in understanding the prognostic difference between surgery and other treatment modalities (e.g., transcatheter arterial chemoembolizaion or sorafenib), provided that they are comparable for this specific, but not uncommon, group of patients. A prospective study, or even better, a prospective, randomized trial would be required.

Measurement of Portal Pressure and its Application in the Clinical Setting

“…47 Similarly, several other reports argue that HVPG > 10 mm Hg should not be considered an absolute contraindication to resection. 42,[48][49][50][51] Response to Therapy for Portal Hypertension…”

HVPG signature: A prognostic and predictive tool in hepatocellular carcinoma

“…A meta-analysis demonstrated that the presence of CSPH evaluated by direct or surrogate measurements was significantly associated with the higher risk of 3- and 5-year mortality and of hepatic decompensation after HR for HCC [ 7 ]. But these results were not regarded as convincing evidence mainly due to the differences of definitions or evaluations of CSPH, BCLC stage and endpoints in studies included [ 15 , 16 ].…”

“…The EASL and AASLD guidelines for the management of HCC consider CSPH to be a contraindication for HR [ 2 , 3 ] due to the higher risk of postoperative liver decompensation based on the reports of BCLC group [ 4 , 5 ]. However, there is no consensus regarding how CSPH should be evaluated in the decision-making process, but most researches hold the view that CSPH should not be considered an absolute contraindication to HR [ 12 , 15 , 16 , 19 ].…”

“…There are also other noninvasive of HVPG, such as imaging-derived strategies of CT angiography [ 34 , 35 ] and MR imaging, which are not described in detail. Due to differences of definitions or evaluation methods of CSPH and different results, it is hard to get the conclusion that which kind of measurement is better [ 12 ], and additional data are still needed [ 16 ].…”

Controversies and evidence of hepatic resection for hepatocellular carcinoma

“…This reflects remarkable advances in radiological technology [13] , [14] , surgical techniques, and perioperative care. However, some liver care centers and official guidelines in the West do not recommend hepatic resection for such patients [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] .…”