Treatment of Stage IVA Hepatocellular Carcinoma

Abstract

Hypothesis: A subset of patients with stage IVA hepatocellular carcinoma (HCC) and preserved liver function may benefit from hepatic resection. Design: Retrospective review of a prospectively collected database. Setting: An academic tertiary care hepatobiliary unit. Patients: Twenty patients who underwent surgical treatment for stage IVA HCC between July 1998 and October 2004 were identified from the database. Intervention: Intraoperative ablation of HCC nodules was combined with resection in 6 patients (30%) to increase resectability. Three patients also underwent resection of extrahepatic tumors. Five patients (25%) had macroscopic invasion of the portal vein and 2 patients (10%) underwent thrombectomy of the vena cava. Main Outcome Measures: Intraoperative data, recurrence, and long-term survival rates were analyzed. Results: Postoperative mortality and morbidity were 5% and 30%, respectively. The median number of resected tumors per patient was 3, and the median diameter of the largest tumor was 60 mm. With a median follow-up of 23 months, 14 patients (70%) developed recurrence. Treatment of recurrence was possible in 10 patients and included transarterial chemoembolization in 7 patients (35%), of whom 2 (10%) had radiofrequency ablation first, and systemic chemotherapy in 3 patients (15%). Median survival time was 32 months, and the actuarial 1-, 3-, and 5-year survival rates were 73%, 56%, and 45%, respectively. Conclusions: Long-term survival can be achieved using an aggressive surgical approach in select patients with advanced HCC. Patients with stage IVA HCC should be followed up by a multidisciplinary team because recurrence is common and sequential treatments may prolong survival.

Historical Comparison of Overall Survival after Hepatic Resection for Patients With Large and/or Multinodular Hepatocellular Carcinoma

“…Relatively high recurrence rate is one of the hallmarks of HCC, and aggressive treatment of recurrence using repeat HR, RFA, or TACE can offer satisfactory OS. 26 , 27 The recurrence rate in our cohort was significantly higher among patients with >3 tumors (83%) than among patients with 2 to 3 tumors or with a single large tumor. Patients with >3 tumors are also less likely to be eligible for a second resection, which helps explain why they showed the lowest OS in our study.…”

Refusal of Cancer-Directed Surgery Strongly Impairs Survival of Patients with Localized Hepatocellular Carcinoma

“…The use of CDS as a cornerstone treatment of early-stage HCC has evolved over the last 20 years; significant advances in preoperative evaluation, surgical techniques, and postoperative care have reduced the perioperative morbidity and mortality associated with liver surgery [11–15]. Mortality after hepatectomy has dropped from approximately 25% in the 1960s to less than 3% today and investigators from high-volume centers report 0% mortality [18].…”

Application of tumor-node-metastasis staging 2002 version in locally advanced hepatocellular carcinoma: is it predictive of surgical outcome?

“…For hepatic resection, the presence of distant metastasis is generally considered a contraindication[22]. In contrast, in view of the lack of other effective treatment options, surgical resection especially in eastern countries, is still advocated as the treatment of choice for patients with locally advanced HCC which is classified as pT3-4N0M0[22-24]. Ishizawa et al demonstrated that partial hepatectomy provided survival benefits for patients with multiple tumors with Child-Pugh class A cirrhosis[25].…”