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Is Liver Resection Justified in Advanced Hepatocellular Carcinoma? Results of An Observational Study in 464 Patients
Andrea Ruzzenente*1, Franco Capra2, Calogero Iacono1, Gianluca Piccirillo1, Marta Lunardi2, Stefano Pistoso3, Alessandro Valdegamberi1, Alfredo Guglielmi1
1Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy; 2Department of Internal Medicine, University of Verona Medical School, Verona, Italy; 3Department of Internal Medicine, Desenzano Hospital, Desenzano, Italy
Background and Objective: The role of liver resection of multinodular hepatocellular carcinoma (HCC) or with major vascular involvement is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced HCC.
Methods: 464 patients with HCC observed from 1991 to 2007 were included into the study. All the patients were evaluated for treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included into the study had no evidence of distant metastases.
Results: Median follow up time for surviving patients was 25 months (range 1-155. 260 patients were in Child-Pugh class A, 148 in class B and 18 in class C. 260 patients had sigle HCC, 79 patients had two HCCs, 37 three HCCs and 69 more than three HCCs. 136 (29.2%) patients were submitted to liver resection (LR), 232 (50.0 %) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), 8 (1.7 %) to liver transplantation (LT) and 88 (19.0 %) to supportive therapy (ST) Median survival time for all patients was 30.4 months (95% CI 24-36). Median survival time was 57 months for LR, 30 for LAT and 8 for ST, with a 5 year survival of 47 %, 20 % and 2.5 % respectively (p=0.001). 5-year survival for patients submitted to LT was 75 %. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC with a median survival time of 39, 36, 18 and 11 months for patients with single HCC, with 2 HCCs, with 3 HCCs and with more than 3 HCCs respectively (p=0.001). Survival for patients with single HCC was significatly longer in patients submitted to LR compare to LAT and ST with a median survival time of 57, 37 and 14 months respectively (p=0.001). Also in patients with multinodular HCCs (2-3 HCCs) LR showed the best results with a a median survival time of 59 months compared to 22 and 8 months for LAT and ST (p=0.001). In patients with more than 3 HCCs LR did not showed different results compared to LAT and ST. 66 patients had evidence of major vascular involvement, median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 19 and 52 months respectively. Survival for patients with major vascular involvement submitted to LR or LAT was significant longer compared to ST with a mean survival of 27, 30 and 12 respectively (p=0.001).
Conclusions: The present study shows that multinodular HCCs (2-3 nodules) can benefit from LR compared to LAT or ST. In patients with more than 3 HCCs or with major vascular involvement LR have similar results of LAT.
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