Extent of liver resection influences the outcome in patients with cirrhosis and small hepatocellular carcinoma

doi:10.1067/msy.2002.121892

Surgery

Volume 131, Issue 3, March 2002, Pages 311-317

https://doi.org/10.1067/msy.2002.121892 Get rights and content

Abstract

Background. The long-term outcome after resection of hepatocellular carcinoma (HCC) is influenced by parameters related to the tumor and the underlying liver disease. However, the extent of the resection, which can be limited or anatomical (including the tumor and its portal territory), is controversial. Methods. Among 64 Child-Pugh A patients with cirrhosis who underwent curative liver resection for small HCC (≤ 4 cm) between 1990 and 1996, 34 patients underwent limited resection with a margin width of at least 1 cm, and 30 patients underwent anatomic resection of at least 1 liver segment with complete removal of the portal area containing the tumor. The 2 groups were comparable in terms of epidemiologic and pathologic parameters. The major end points were: (1) in-hospital mortality and morbidity; (2) overall and disease-free survival; and (3) rate and topography of recurrence. Results. The 30-day mortality (6% vs 7%) and morbidity (52% vs 47%) rates after limited and anatomic liver resection were not statistically different. The 5- and 8-year overall survival rates after limited versus anatomic resection were, respectively, 35% versus 54% (P <.05) and 6% versus 45% (P <.05). The 5- and 8-year disease-free survival rates were, respectively, 26% versus 45% and 0% versus 21% (P <.05). Local recurrence was more frequently observed after limited resections than after anatomic resections (50% vs 10%, P <.05). Conclusions. In patients with cirrhosis and a small HCC, anatomic resection achieves better disease-free survival than limited resection without increasing the postoperative risk. Therefore, anatomical resection should be the treatment of choice and considered as the reference surgical treatment compared with other treatments. (Surgery 2002;131:311-7.)

Section snippets

Patient selection

From January 1990 (availability of hepatitis C serology at our institution) to December 1996 (period for appropriate follow-up), data from 193 patients with HCC who underwent liver resection had been reviewed. Among 92 patients with a small HCC (4 cm or less), 28 patients were excluded for 1 or more of the following reasons: absence of cirrhosis, severely impaired liver function (Child-Pugh score B and C), palliative liver resection, resection margin < 1 cm, ruptured tumor, multiple tumors, and

Operative variables

The number of patients who underwent resection under Pringle's maneuver was not statistically different between limited (30/34, 88%) and anatomic resection groups (25/30, 83%). The mean total duration of vascular clamping between limited and anatomic resection groups was not significantly different: 35 ± 19 minutes (range 6-75 minutes) versus 30 ± 15 minutes (range 5-75 minutes). Intraoperative bleeding was not significantly different between limited and anatomic groups (670 ± 773 mL vs 844 ±

Discussion

This study showed that in selected patients with cirrhosis and Child-Pugh score A, all presenting a small HCC (≤ 4 cm), anatomic resections, and attempted removal of the tumor and its portal territory achieved better long-term and disease-free survival than those who underwent limited resections, without increasing the postoperative risk.

It is known that major factors influencing survival after resection of HCC include liver function, tumor characteristics, underlying liver disease, and type of

Conclusion

This study showed that anatomic resections, including the tumor and its adjacent portal territory, improve overall and disease-free survivals of patients with cirrhosis presenting a small HCC. Therefore, we suggest considering this oncologic surgical concept as standard treatment for small HCC in patients with cirrhosis with good liver function. Consequently, in our institution, when anatomical resection does not seem possible because of either the tumor location or the degree of the liver

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Cited by (277)

International Hepato-Pancreato-Billiary Association (IHPBA) registry study on COVID-19 infections in HPB surgery patients
2024, HPB
In response to the pandemic, the International Hepato-Pancreato-Biliary Association (IHPBA) developed the IHPBA-COVID Registry to capture data on HPB surgery outcomes in COVID-positive patients prior to mass vaccination programs. The aim was to provide a tool to help members gain a better understanding of the impact of COVID-19 on patient outcomes following HPB surgery worldwide.
An online registry updated in real time was disseminated to all IHPBA, E-AHPBA, A-HPBA and A-PHPBA members to assess the effects of the pandemic on the outcomes of HPB procedures, perioperative COVID-19 management and other aspects of surgical care.
One hundred twenty-five patients from 35 centres in 18 countries were included. Seventy-three (58%) patients were diagnosed with COVID-19 preoperatively. Operative mortality after pancreaticoduodenectomy and major hepatectomy was 28% and 15%, respectively, and 2.5% after cholecystectomy. Postoperative complication rates of pancreatic procedures, hepatic interventions and biliary interventions were respectively 80%, 50% and 37%. Respiratory complication rates were 37%, 31% and 10%, respectively.
This study reveals a high risk of mortality and complication after HPB surgeries in patient infected with COVID-19. The more extensive the procedure, the higher the risk. Nonetheless, an increased risk was observed across all types of interventions, suggesting that elective HPB surgery should be avoided in COVID positive patients, delaying it at distance from the viral infection.
The appropriate method of hepatectomy for hepatocellular carcinoma within University of California San Francisco (UCSF) criteria through neural network analysis
2023, HPB
This study aimed to find effective treatments for the patient within UCSF criteria.
This study enrolled 1006 patients meeting UCSF criteria, undergoing hepatic resection (HR), divided into two groups: single tumor group and multiple tumors group. We compared and analyzed the risk factors between these two groups’ long-term outcomes, through log-rank test, cox proportional hazards model and using neural network analysis to identify the independent risk factors.
The 1-, 3-, and 5-year OS rates in single tumor were significantly higher than multiple tumors (95.0%, 73.2% and 52.3% versus 93.9%, 69.7% and 38.0%, respectively, p < 0.001). The 1-, 3- and 5-year RFS rates were 90.3%, 60.7%, and 40.1% in single tumor and 83.4%, 50.7% and 23.8% in multiple tumors, respectively (p < 0.001). And tumor type, anatomic resection and MVI were the independent risk factors for the patient within UCSF criteria. MVI was the most important risk factor affecting OS and RFS rates in neural network analysis. The method of hepatic resection and the number of tumors were also affected OS and RFS rates.
Anatomic resections should be applied to patients within UCSF criteria, especially for patients with single MVI negative tumours.
Paradigm shift: should preoperative 3D reconstruction models become mandatory before hepatectomy for hepatocellular carcinoma (HCC)? Results of a multicenter prospective trial
2023, HPB
A preoperative surgical strategy before hepatectomy for hepatocellular carcinoma is fundamental to minimize postoperative morbidity and mortality and to reach the best oncologic outcomes. Preoperative 3D reconstruction models may help to better choose the type of procedure to perform and possibly change the initially established plan based on conventional 2D imaging.
A non-randomized multicenter prospective trial with 136 patients presenting with a resectable hepatocellular carcinoma who underwent open or minimally invasive liver resection. Measurement was based on the modification rate analysis between conventional 2D imaging (named “Plan A”) and 3D model analysis (“Plan B”), and from Plan B to the final procedure performed (named “Plan C”).
The modification rate from Plan B to Plan C (18%) was less frequent than the modification from Plan A to Plan B (35%) (OR = 0.32 [0.15; 0.64]). Concerning secondary objectives, resection margins were underestimated in Plan B as compared to Plan C (−3.10 mm [−5.04; −1.15]).
Preoperative 3D imaging is associated with a better prediction of the performed surgical procedure for liver resections in HCC, as compared to classical 2D imaging.
Anatomic versus non-anatomic resection of hepatocellular carcinoma with microvascular invasion: A systematic review and meta-analysis
2021, Asian Journal of Surgery
Citation Excerpt :
Several studies have reported that AR is associated with better overall survival (OS) and disease-free survival (DFS) in HCC patients.5 AR involves resecting a segment or subsegment of the liver, including major branches of the portal vein and hepatic arteriovenous system,6 and allows for effective removal of the entire tumor burden and hepatic areas at high risk of intrahepatic micrometastasis or MVI.7 However, to reduce the risk of vascular invasions and subnodules, a greater surface area of liver tissue is sacrificed in AR, which is unfavorable in patients with underlying liver disease.8
The efficacy of anatomical resection (AR) and non-anatomical resection (NR) in the treatment of hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI) remains unknown. This study compared the safety and outcomes of these surgical procedures. A systematic literature search was conducted. The main outcomes were overall survival (OS), disease-free survival (DFS). Overall hazard ratio (HR) was calculated from Kaplan–Meier plots and outcomes using random-effects models. There was no significant difference in postoperative complications between the AR and NR groups (risk ratio [RR]: 0.92, 95% confidence interval [CI]: 0.72–1.17, p = 0.496). OS was higher with AR at 1 year (RR: 0.66, 95% CI: 0.45–0.98, p = 0.037), 3 years (RR: 0.64, 95% CI: 0.50–0.82, p = 0.000), and 5 years (RR: 0.76, 95% CI: 0.65–0.89, p = 0.001). AR was associated with a higher OS rate (HR: 0.62, 95% CI: 0.47–0.82, p = 0.001). AR was associated with improved DFS at 1 year (RR: 0.65, 95% CI: 0.52 to 0.82, p = 0.000), 3 years (RR: 0.75, 95% CI: 0.66 to 0.86, p = 0.000), and 5 years (95% CI: 0.75 to 0.94, p = 0.002). Compared with NR, AR had significant advantages on overall HR of DFS (HR: 0.64, 95% CI: 0.45 to 0.91, p = 0.012). In conclusion, AR was associated with higher rates of OS and DFS in HCC patients with MVI. Thus, for well-presented liver function HCC patients which are predicted to have positive MVI, AR is recommended.
A commentary on “Anatomic versus non-anatomic resection for hepatocellular carcinoma, do we have an answer? A meta-analysis” [Int. J Surg. 2020; 80:243-255]
2021, International Journal of Surgery
Comparison of anatomic and non-anatomic resections for very early-stage hepatocellular carcinoma: The importance of surgical resection margin width in non-anatomic resection
2021, Surgical Oncology
Citation Excerpt :
However, a western study of two centers has reported that AR for HCC of diameter ≤2 cm is associated with better outcome [3]. Other researchers have also found AR to be beneficial for early-stage HCC [7,22–24]. Most of the studies were retrospective, and the results were potentially confounded by selection bias.
The superiority of anatomic resection (AR) over non-anatomic resection (NAR) for very early-stage hepatocellular carcinoma (HCC) has remained a topic of debate. Thus, this study aimed to compare the prognosis after AR and NAR for single HCC less than 2 cm in diameter.
Consecutive patients with single HCC of diameter less than 2 cm who underwent curative hepatectomy between 1997 and 2017 were included in this retrospective study.
In total, 159 patients were included in this study. Of these, 52 patients underwent AR (AR group) and 107 patients underwent NAR (NAR group). No significant differences were noted in recurrence-free survival (RFS) and overall survival (OS) between the AR and NAR groups (P = 0.236 and P = 0.363, respectively). Multivariate analysis revealed that low preoperative platelet count and presence of satellite nodules were independent prognostic factors of RFS and OS. Wide surgical resection margin did not affect RFS (P = 0.692) in the AR group; however, in the NAR group, RFS was found to be higher with surgical resection margin widths ≥1 cm than with surgical resection margin widths <1 cm (P = 0.038).
Prognosis was comparable between the NAR and AR groups for very early-stage HCC with well-preserved liver function. For better oncologic outcomes, surgeons should endeavor in keeping the surgical resection margin widths during NAR ≥1 cm.

View all citing articles on Scopus

^*: Reprint requests: Jacques Belghiti, MD, Department of Hepatobiliary and Digestive Surgery, Beaujon Hospital, 92 118 Clichy Cédex, France.

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Original CommunicationsExtent of liver resection influences the outcome in patients with cirrhosis and small hepatocellular carcinoma*

Abstract

Section snippets

Patient selection

Operative variables

Discussion

Conclusion

Am J Surg

Gastroenterology

Surgery

Lancet

Percutaneous ethanol injection in the treatment of hepatocellular carcinoma in cirrhosis. A study on 207 patients

Cancer

Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis

Ann Surg

Radiofrequency ablation of porcine liver in vivo: effects of blood flow and treatment time on lesion size

Ann Surg

Liver resection versus transplantation for hepatocellular carcinoma in cirrhotic patients

Ann Surg

Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

N Engl J Med

Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation

Hepatology

An analysis of 412 cases of hepatocellular carcinoma at a Western center

Ann Surg

The prognostic significance of surgical margin in liver resection of patients with hepatocellular carcinoma

Arch Surg

Retrospective analysis of type of hepatic resection for hepatocellular carcinoma

Br J Surg

Prognostic factors affecting long-term outcome after liver resection for hepatocellular carcinoma: results in a series of 100 Italian patients

Cancer

Surgical margin and recurrence after resection of hepatocellular carcinoma in patients with cirrhosis. Further evaluation of limited hepatic resection

Ann Surg

Original Communications
Extent of liver resection influences the outcome in patients with cirrhosis and small hepatocellular carcinoma*