A Snapshot of the Effective Indications and Results of Surgery for Hepatocellular Carcinoma in Tertiary Referral Centers: Is It Adherent to the EASL/AASLD Recommendations? An Observational Study of the HCC East-West Study Group

Objective:The aim of this study was to investigate in a retrospective setting the patients' profile and results of those undergoing surgery for hepatocellular carcinoma (HCC) in high-volume surgical centers throughout the world. Background:Whether surgery for HCC is a suitable approach and for which subset of patients is still controversial. The EASL/AASLD (European Association for the Study of Liver Disease/American Association for the Study of Liver Disease) guidelines, based on the Barcelona Clinic Liver Cancer (BCLC) classification, leave little room for hepatic resection; inversely, other reports promote its wider application. Methods:On the basis of the network “Hepatocellular Carcinoma: Eastern & Western Experiences,” data for 2046 consecutive patients resected for HCC in 10 centers were collected. According to the BCLC classification, 1012 (50%) were BCLC 0-A, 737 (36%) BCLC B, and 297 (14%) BCLC C. Analysis of overall survival and disease-free survival and multivariate analysis of prognostic factors were performed. Findings.The 90-day mortality rate was 2.7%. Overall morbidity was 42%. After a median follow-up of 25 months (range, 1–209 months), the 1-, 3-, and 5-year overall survival rates were 95%, 80%, and 61% for BCLC 0-A; 88%, 71%, and 57% for BCLC B; and 76%, 49%, and 38% for BCLC C (P = 0.000). The 1-, 3-, and 5-year disease-free survival rates were as follows: 77%, 41%, and 21% for BCLC 0-A; 63%, 38%, and 27% for BCLC B; and 46%, 28%, and 18% for BCLC C (P = 0.000). The multivariate analysis identified bilirubin, cirrhosis, esophageal varices, tumor size, and macrovascular invasion to be statistical and independent prognostic factors for overall survival. Conclusions:This large multicentric survey shows that surgery is in current practice widely applied among patients with multinodular, large, and macrovascular invasive HCC, providing acceptable short- and long-term results and justifying an update of the EASL/AASLD therapeutic guidelines in this sense.

[1]  J. Bruix,et al.  Management of hepatocellular carcinoma: An update , 2011, Hepatology.

[2]  T. Livraghi,et al.  Is it time to reconsider the BCLC/AASLD therapeutic flow‐chart? , 2010, Journal of surgical oncology.

[3]  Bachir Taouli,et al.  Pretreatment assessment of hepatocellular carcinoma: expert consensus statement. , 2010, HPB : the official journal of the International Hepato Pancreato Biliary Association.

[4]  J. Bruix,et al.  Current Strategy for Staging and Treatment: The BCLC Update and Future Prospects , 2010, Seminars in liver disease.

[5]  G. Torzilli,et al.  A New Systematic Small for Size Resection for Liver Tumors Invading the Middle Hepatic Vein at its Caval Confluence: Mini-Mesohepatectomy , 2010, Annals of surgery.

[6]  M. Vivarelli,et al.  Is Portal Hypertension a Contraindication to Hepatic Resection? , 2009, Annals of surgery.

[7]  J. Bruix,et al.  Major achievements in hepatocellular carcinoma , 2009, The Lancet.

[8]  S. Paggi,et al.  Sorafenib in Advanced Hepatocellular Carcinoma , 2008 .

[9]  G. Torzilli,et al.  Hepatectomy for stage B and stage C hepatocellular carcinoma in the Barcelona Clinic Liver Cancer classification: results of a prospective analysis. , 2008, Archives of surgery.

[10]  M. Latteri,et al.  Survival of patients with hepatocellular carcinoma in cirrhosis: a comparison of BCLC, CLIP and GRETCH staging systems , 2008, Alimentary pharmacology & therapeutics.

[11]  P. Legmann,et al.  Treatment of stage IVA hepatocellular carcinoma: should we reappraise the role of surgery? , 2008, Archives of surgery.

[12]  M. Makuuchi,et al.  Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma. , 2008, Gastroenterology.

[13]  Sheng-Nan Lu,et al.  The efficacy of treatment schedules according to Barcelona Clinic Liver Cancer staging for hepatocellular carcinoma - Survival analysis of 3892 patients. , 2008, European journal of cancer.

[14]  G. Torzilli,et al.  Systematic Extended Right Posterior Sectionectomy: A Safe and Effective Alternative to Right Hepatectomy , 2008, Annals of surgery.

[15]  Singal Amit,et al.  Screening for hepatocellular carcinoma. , 2008, Gastroenterology & hepatology.

[16]  M. Sherman,et al.  Screening for hepatocellular carcinoma , 2007, Hepatology research : the official journal of the Japan Society of Hepatology.

[17]  E. Cholongitas,et al.  Transarterial Therapy for Hepatocellular Carcinoma: Which Technique Is More Effective? A Systematic Review of Cohort and Randomized Studies , 2007, CardioVascular and Interventional Radiology.

[18]  D. Nagorney,et al.  Predictive indices of morbidity and mortality after liver resection. , 2006, Annals of surgery.

[19]  P. Zapater,et al.  Comparison of staging systems to predict survival in hepatocellular carcinoma , 2006, Liver international : official journal of the International Association for the Study of the Liver.

[20]  A. Muratore,et al.  Portal Hypertension: Contraindication to Liver Surgery? , 2006, World Journal of Surgery.

[21]  J. Marrero Staging systems for hepatocellular carcinoma: should we all use the BCLC system? , 2006, Journal of hepatology.

[22]  Alessandro Vitale,et al.  Prospective validation of the Barcelona Clinic Liver Cancer staging system. , 2006, Journal of hepatology.

[23]  J. Bruix,et al.  Management of hepatocellular carcinoma , 2005, Hepatology.

[24]  M. Makuuchi,et al.  "Radical but conservative" is the main goal for ultrasonography-guided liver resection: prospective validation of this approach. , 2005, Journal of the American College of Surgeons.

[25]  T. Pawlik,et al.  Critical appraisal of the clinical and pathologic predictors of survival after resection of large hepatocellular carcinoma. , 2005, Archives of surgery.

[26]  J. Marrero,et al.  Prognosis of hepatocellular carcinoma: Comparison of 7 staging systems in an American cohort , 2005, Hepatology.

[27]  T. Pawlik,et al.  Is Hepatic Resection for Large or Multinodular Hepatocellular Carcinoma Justified? Results From a Multi-Institutional Database , 2005, Annals of Surgical Oncology.

[28]  N. Demartines,et al.  Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey , 2004, Annals of Surgery.

[29]  M. Makuuchi,et al.  One thousand fifty-six hepatectomies without mortality in 8 years. , 2003, Archives of surgery.

[30]  H. El‐Serag Hepatocellular carcinoma: an epidemiologic view. , 2002, Journal of clinical gastroenterology.

[31]  Pietro Andreone,et al.  Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. , 2002, Radiology.

[32]  Ramon Planas,et al.  Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial , 2002, The Lancet.

[33]  Jacques Ferlay,et al.  Estimating the world cancer burden: Globocan 2000 , 2001, International journal of cancer.

[34]  L Pagliaro,et al.  Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. , 2001, Journal of hepatology.

[35]  L. Ellis,et al.  Underlying liver disease, not tumor factors, predicts long-term survival after resection of hepatocellular carcinoma. , 2001, Archives of surgery.

[36]  M. Makuuchi,et al.  Selection Criteria for Hepatectomy in Patients with Hepatocellular Carcinoma and Portal Vein Tumor Thrombus , 2001, Annals of surgery.

[37]  M. Makuuchi,et al.  No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. , 1999, Archives of surgery.

[38]  S. Fan,et al.  Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. , 1999, Annals of surgery.

[39]  J. Bruix,et al.  Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. , 1996, Gastroenterology.

[40]  V. Mazzaferro,et al.  Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. , 1996, The New England journal of medicine.

[41]  J. Concato,et al.  Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. , 1995, Journal of clinical epidemiology.

[42]  E. McFadden,et al.  Toxicity and response criteria of the Eastern Cooperative Oncology Group , 1982, American journal of clinical oncology.

[43]  K. Inokuchi,et al.  The General rules for recording endoscopic findings on esophageal varices , 1980, The Japanese journal of surgery.

[44]  R. Pugh,et al.  Transection of the oesophagus for bleeding oesophageal varices , 1973, The British journal of surgery.

[45]  J. Bruix,et al.  Management of HCC. , 2012, Journal of hepatology.

[46]  L. Capussotti,et al.  Liver resection for HCC with cirrhosis: surgical perspectives out of EASL/AASLD guidelines. , 2009, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[47]  L. Mariani,et al.  Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. , 2009, The Lancet. Oncology.

[48]  J. Bruix,et al.  Prognostic Prediction in Patients with Hepatocellular Carcinoma , 2005, Seminars in liver disease.

[49]  M. Makuuchi,et al.  The Brisbane 2000 terminology of liver anatomy and resections. , 2000 .

[50]  J. Bruix,et al.  Prognosis of Hepatocellular Carcinoma: The BCLC Staging Classification , 1999, Seminars in liver disease.