Clinical

Major resection a good option for small liver malignancies in cirrhotic patients

Last Updated: 2003-12-19 16:44:43 -0400 (Reuters Health)

NEW YORK (Reuters Health) - For treatment of small, centrally located hepatocellular carcinoma in patients with cirrhosis and preserved liver function, major hepatic resection may prolong survival longer than more moderate surgery, researchers in Hong Kong suggest.

The role of major hepatic resection in these cases is controversial, with previous reports suggesting increased perioperative risk, limited regenerative capacity, and higher liver failure rate. However, these concerns are balanced by the benefits associated with removal of the portal venous drainage area of the tumor and better oncologic clearance, Dr. Ronnie Tung-Ping Poon and colleagues at Queen Mary Hospital explain in the Archives of Surgery for November.

Dr. Poon's team retrospectively analyzed outcomes for 218 cirrhotic patients with a solitary hepatocellular carcinoma (HCC) no more than 5 cm in diameter. Eight-four patients underwent major hepatic resection, with removal of 3 or more segments, while the remaining 134 had a minor hepatic resection.

Although postoperative mortality was higher in the major resection group (8.3% versus 3.0%), the difference did not reach statistical significance. Median survival was nonsignificantly higher in the major resection group (102.0 versus 72.3 months), while disease-free survival was significantly higher (59.0 versus 29.5 months).

Subgroup analyses revealed that major resection was associated with a two-fold longer survival compared with nonanatomic resections. Moreover, for tumors 3 to 5 cm in diameter, disease free (p < 0.001) and overall survival (p = 0.02) was better in the major resection group than in the minor resection group.

The authors note that patients chosen for major resection had an indocyanine green clearance at 15 minutes of up to 20%. This modality was preferred for those with centrally located tumors close to a major portal vein or hepatic vein. As a result, these patients had better preoperative liver function, and their tumors were significantly larger and more aggressive than those treated with minor resection.

"With appropriate case selection, meticulous operative technique and careful perioperative management," the authors write, "major hepatic resection could be performed as safely as minor hepatic resection in cirrhotic patients with small HCCs."

At the same time, segmentectomy is still preferred for peripherally located, completely respectable small tumors, they add. Prospective randomized trials are needed to confirm the advantages of major resection in selected groups over minor resection and liver transplantation.

Arch Surg 2003;138:1207-1213.