Selection criteria for hepatic resection in intermediate-stage (BCLC stage B) multiple hepatocellular carcinoma

doi:10.1016/j.surg.2016.05.023

Surgery

Volume 160, Issue 5, November 2016, Pages 1227-1235

https://doi.org/10.1016/j.surg.2016.05.023 Get rights and content

Background

Several reports have suggested that hepatic resection provides a survival benefit in patients with hepatocellular carcinoma (HCC) at the intermediate stage of the Barcelona Clinic Liver Cancer classification (BCLC-B). The operative indications for multiple BCLC-B have not been established, however. The aim of this study was to clarify the survival benefit of hepatic resection for multinodular BCLC-B HCC.

Methods

We retrospectively analyzed 85 patients with BCLC-B HCC who underwent liver resection. To evaluate clinicopathologic factors and survival, we divided the patients into 3 types based on radiologic findings regarding tumor number and maximum tumor diameter: type 1, up to 3 lesions <5 cm; type 2, up to 3 lesions ≥5 cm or 4 nodules of any size; type 3, >4 nodules.

Results

Thirty-four patients were classified as type 1, 32 as type 2, and 19 as type 3. The 1-, 3-, and 5-year survival in type 1 were 97.1%, 87.4%, and 75.2%, respectively. Those in type 2 were 84.0%, 74.0%, and 63.0%, and those in type 3 were 64.9%, 55.7%, and 37.1%, respectively. The overall survival of type 1 patients was significantly better than that of type 3 patients. The prognosis of type 2 patients was worse than that of type 1 patients and better than that of type 3. Multivariate analysis identified radiologic tumor size and tumor number as independent prognostic factors.

Conclusion

Our findings suggest that hepatic resection should be considered a radical treatment for multinodular BCLC-B HCC. Our subclassification can be applied to select the initial treatment and when making decisions regarding hepatic resection of BCLC-B HCC with multiple nodules.

Section snippets

Patients

We retrospectively analyzed the HCC patients who underwent liver resection at Osaka University Hospital from January 1991 to December 2013. Among 792 patients, 85 (10.7%) were classified as BCLC-B. BCLC-B HCC comprises highly heterogeneous patients, and the benefit of hepatic resection varies. We diagnosed nodules as HCC based on radiologic vascular findings and elevation of tumor markers, α-fetoprotein (AFP) or protein-induced vitamin K absence or antagonist II (PIVKA-II). The typical

Patient characteristics

The clinicopathologic characteristics of the 85 patients (67 men, 18 women) evaluated in the present study are summarized in Table I. The median age was 65 years (range 45–84 years). Seventeen patients were positive for hepatitis B surface antigen, and 43 patients were positive for the hepatitis C virus antibody. Forty-three patients (50.6%) were diagnosed with liver cirrhosis. Indeed, the BCLC system was ordinarily designed for patients with cirrhosis. The preoperative median for serum AFP and

Discussion

In this study, we retrospectively analyzed 85 patients who underwent hepatic resection for BCLC-B HCC. Several reports have suggested that operative resection provides better long-term outcomes than TACE for BCLC-B HCC patients.7, 12 Most reports were retrospective studies and lack proper control groups. Others showed that an operation did not bring survival benefits compared with TACE. Selection criteria for hepatic resection have not been established, however, especially in multinodular

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A systematic search of MEDLINE (PubMed), Embase, Cochrane Library and Database for Systematic Reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases until December 2022 was conducted using free text and MeSH terms: hepatocellular carcinoma, portal vein tumor thrombus, portal vein thrombosis, vascular invasion, liver and/or hepatic resection, liver transplantation, and systematic review.
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This study retrospectively analyzed 161 HCC patients who underwent radical LR. Two methods, the least absolute shrinkage and selection operator and random survival forest analysis, were performed for radiomics signature (RS) construction. Univariate and multivariate stepwise Cox regression analyses were performed to establish a combined nomogram (RCN) of RS and clinical parameters and a clinical nomogram (CN). The performance of the models was assessed comprehensively using Harrell's concordance index (C-index), the calibration curve, and decision curve analysis. The discrimination accuracy of the models was compared using integrated discrimination improvement index (IDI). The risk stratification effect was assessed with Kaplan–Meier survival analysis and subgroup analysis.
The RCN achieved a C-index of 0.792/0.758 in the training/validation set, which was higher than the CN, RS, and BCLC stage system. The discriminatory accuracy of the RCN was improved when compared to the CN, RS, and BCLC staging systems (IDI > 0). Decision curve analysis reflected the clinical net benefit of the RCN. The RCN allows risk stratification of patients in different clinical subgroups.
The integrated model combining RS and clinical factors can more effectively predict RFS after LR of BCLC 0 to B stage HCC patients and can effectively stratify the prognostic risk.
Tumor burden in patients with early and intermediate-stage hepatocellular carcinoma undergoing liver resection: a retrospective multicenter study on clinical and oncological outcomes
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According to the Barcelona Clinic Liver Cancer (BCLC) staging system, liver resection (LR) is recommended for early-stage (BCLC-A) hepatocellular carcinoma (HCC) but not for intermediate-stage (BCLC-B). This study aimed to assess the outcomes of LR in these patients using a subclassification tumour burden score (TBS).
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Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada
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Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.
A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.
The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.
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According to the American Association for the Study of Liver Diseases guidelines, liver resection is not recommended for multiple hepatocellular carcinomas, although it is performed in Asian countries, including Japan. However, the maximum number, location, and recurrence types of tumors have not been reported in detail.
This retrospective study analyzed data for 1,170 patients who underwent surgical resection for hepatocellular carcinoma between October 2002 and December 2020 in a Japanese tertiary care hospital. Statistical analysis was performed to compare the surgical short-term and long-term outcomes among patients with >3 tumors and those with ≤3 tumors.
This study of patients who underwent liver resection identified 775 who had a single tumor and compared overall survival rates with 477 who had multiple hepatocellular carcinomas: 242 had 2 hepatocellular carcinomas, 79 had 3 hepatocellular carcinomas, and 74 had >3 hepatocellular carcinomas. The median survival times based on the number of tumors were 9.74 years for a single tumor, 6.36 years for 2 tumors, 7.21 years for 3 tumors, 3.31 years for 4 tumors, and 3.48 years for 5 tumors. The median survival time was significantly worse in patients with >3 tumors than in those with 3 tumors (P < .0001). Concerning the type of treatments for recurrence, the patients who underwent surgical treatment had significantly better survival after recurrence than patients who underwent other treatments (8.32 vs 3.19 years; P < .001).
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: The authors declare no conflicts of interest.

View full text

LiverSelection criteria for hepatic resection in intermediate-stage (BCLC stage B) multiple hepatocellular carcinoma

Background

Methods

Results

Conclusion

Section snippets

Patients

Patient characteristics

Discussion

Lancet

Hepatology

Gastroenterology

Surg Oncol

Eur J Surg Oncol

J Hepatol

Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012

Int J Cancer

Clinical significance of surgical resection of metastatic lymph nodes from hepatocellular carcinoma

Surg Today

Preoperative liver function assessments to estimate the prognosis and safety of liver resections

Surg Today

Diseases AAftSoL. Management of hepatocellular carcinoma: An update

Hepatology

Hepatic resection associated with good survival for selected patients with intermediate and advanced-stage hepatocellular carcinoma

Ann Surg

Liver resection for hepatocellular carcinoma on cirrhosis: Univariate and multivariate analysis of risk factors for intrahepatic recurrence

Ann Surg

Liver
Selection criteria for hepatic resection in intermediate-stage (BCLC stage B) multiple hepatocellular carcinoma