IS MINIMALLY-INVASIVE SURGERY AN ADDED-VALUE FOR PATIENTS WITH HEPATOCELLULAR CARCINOMA AND PORTAL VEIN HYPERTENSION UNDERGOING LIVER RESECTION? RESULTS OF AN INTERNATIONAL MULTI-INSTITUTIONAL ANALYSIS
Fabio Bagante*1, Andrea Ruzzenente1, Eliza W. W. Beal2, Simone Conci1, Katiuscha Merath2, Tommaso Campagnaro1, Guillaume Martel3, Sorin Alexandrescu4, Irinel Popescu4, Francesca Ratti5, Luca Aldrighetti5, Olivier Soubrane6, Hugo P. Marques7, Thomas J. Hugh8, George A. Poultsides9, Vincent Lam10, Calogero Iacono1, Alfredo Guglielmi1, Timothy M. Pawlik2
1Department of Surgery, University of Verona, Verona, Italy; 2Department of Surgery, The Ohio State University, Columbus, OH; 3Department of Surgery, University of Ottawa, Ottawa, ON, Canada; 4Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania; 5Department of Surgery, Ospedale San Raffaele, Milano, Italy; 6Department of Surgery, AP-HP, Beaujon Hospital, Clichy, France; 7Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal; 8Department of Surgery, The University of Sydney, School of Medicine, Sydney, New South Wales, Australia; 9Department of Surgery, Stanford University, Stanford, CA; 10Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
Background:Patients with hepatocellular carcinoma (HCC) and clinical sign of portal vein hypertension (CSPH, platelet count <100,000/mm3 and spleen size >12 cm) are denied surgery even if they fulfill all other criteria for classification as BCLC stage 0-A potentially resectable.
Methods:Propensity-score matching (PSM) was used to balance the clinico-pathological (age, gender, ASA classification, number and size of tumors, type of hepatectomy) difference between CSPH patients vs. non-CSPH patients and between patients undergoing open vs. MIS to compare short- and long-term outcomes.
Results:Among 1,556 patients who underwent surgery for HCC, 207 (13%) had CSPH while 1,349 (87%) did not have CSPH. Median age was 67 years and 75% (n=1,171) of patients was male. While 85% (n=1,326) of patients had a single HCC, 11% (n=170) and 4% (n=60) of patients has 2-3 and >3 tumors, respectively. The median tumor size was 4.8 cm. Serum AFP was <10, 10-500, and >500 in 32% (n=491), 31% (n=477), and 38% (n=588) of patients, respectively. HCC was well/moderately differentiated in 81% (n=1,256) of patients and poorly/undifferentiated in 19% (n=300) of patients. Minor and major hepatectomies were performed on 980 (63%) and 576 (37%) of patients, respectively. The median length-of-stay (LoS) was 6 days. While incidence of overall and severe (Clavien-Dindo ≥ 3) complications was 33% (n=489) and 8% (n=117), the incidence of 90-day mortality was 3% (n=52). Patient in the CSPH group had more often smaller HCC and underwent more often minor hepatectomies with MIS approach compared with no-CSPH patients (all p<0.05). After balancing of clinical-pathological variables with the PSM, the resulting groups of CSPH (n=192) and no-CSPH (n=192) patients had similar baseline characteristics (all p>0.2). There were no differences in terms of 90-day mortality, overall-, and severe (Clavien-Dindo ≥3) complications comparing the two matched groups (p>0.2). Moreover, there were no differences in terms of disease-free and overall survival between the two matched groups (p>0.2). After balancing with PSM the clinical-pathological variables of patients undergoing open and MIS, patients with CSPH and MIS had shorter LoS (p=0.002) with no differences in terms of 90-day mortality, overall- and sever complication, disease-free and overall survival compare to open resection patients (all p>0.2).
Discussion:While the current guidelines for the management of HCC patients suggest excluding patients with CSPH, in our series about one fourth of patients undergoing surgery had CSPH. When accurately selected, CSPH patients with HCC should not be excluded by surgical treatment because they can reach the same short- and long-term outcomes as non-CSPH patients. Moreover, MIS might result in better short-term outcomes (i.e. LoS) for CSPH patients undergoing surgery for HCC.
Back to 2019 Abstracts
