Better survival after partial hepatectomy for resectable multiple hepatocellular carcinoma?

By Will Boggs MD

NEW YORK (Reuters Health) - For patients who have resectable multiple hepatocellular carcinoma (HCC), partial hepatectomy may offer better overall survival rates than transcatheter arterial chemoembolization (TACE), researchers from China report.

According to the Barcelona Clinic Liver Cancer staging system, patients with large multinodular tumors should undergo TACE, but some retrospective studies have suggested that partial hepatectomy provides better survival than TACE.

Dr. Hui Li from Second Military Medical University in Shanghai and colleagues undertook a randomized comparative trial to compare partial hepatectomy versus TACE in 180 patients with resectable multiple HCC, 173 of which completed the study.

Five of 62 patients with recurrent HCC (a recurrence rate of 68.9%) in the partial hepatectomy group underwent reoperation, 50 patients received local ablation, and five received sorafenib. Most of the patients in the TACE group underwent at least three treatment sessions at an interval of one session of TACE per 2-3 months.

Mortality after 30 and 90 days did not differ between the two treatments, according to the March 17 Journal of Hepatology online report.

Overall survival rates were consistently higher in the partial hepatectomy group than in the TACE group: 76.1% versus 51.8% at 1 year; 63.5% versus 34.8% at 2 years; and 51.5% versus 18.1% at 3 years.

Median overall survival was longer after partial hepatectomy (41 months) than after TACE (14 months), but there was substantial overlap of the ranges of overall survival (1-50 months for partial hepatectomy versus 5-47 months for TACE).

On multivariate analysis, significant predictors of better overall survival included partial hepatectomy versus TACE, two tumors versus more than two tumors, and female gender versus male gender.

"To achieve good results of partial hepatectomy," the researchers conclude, "patients should be carefully selected to minimize postoperative mortality and major morbidity."

While admitting the lower than usual survival rates after TACE in this study, the authors suggest that patients in earlier studies had less advanced HCC than the patients in their study.

Dr. Satoru Murata from Nippon Medical School in Tokyo, Japan, compared these results with a previously published Japanese study that found much better overall survival with TACE. He told Reuters Health via email, "If confined to Child-Pugh class A cases (a great deal of cases included in this Chinese study were classified as class A), 3 years survival rate reaches 56%, which is better than the survival rate in partial hepatectomy group in this Chinese study."

"Also, 5 year survival rate in our facility, although not published yet, is approximately 40%," Dr. Murata said. "So this fact means that clinical results obtained by TACE for HCC is technically, in other words, operator dependent. This article does not clarify the person who performed TACE and their experience. I strongly recommend to have experienced interventional radiologists perform TACE."

"Finally, the regimen of anticancer agents for TACE used in this study is uncommon," Dr. Murata said. "They mainly use large doses of 5-FU, and extremely small doses of cisplatin. However, mainstream of anticancer agents used in TACE worldwide is either doxorubicin, or platinum agents including cisplatin. This regimen is not common and authors should state why they chose the regimen."

"Other than the randomized design of the trial, there are few points that we can learn from this article, and I think it is not appropriate to change treatment strategy, only based on this study," Dr. Murata concluded.

Dr. Gagan K. Sood from Baylor College of Medicine and St. Luke's Liver Center in Houston, Texas, had other objections to the report. He told Reuters Health by email, "It is not fair to compare this group with TACE; median tumor size was more than >10 cm. TACE has best results with tumor size up to 5 cm."

"The study included a very small subset of highly select patients (180 patients out of cohort of 2500) with large tumor burden, who are not candidates for current curative treatment options," Dr. Sood explained. "In the US, because of screening guidelines, many patients are diagnosed at early stage and surgical resection, TACE, or RFA (radiofrequency ablation) are the options. Because of underlying cirrhosis and risk of recurrence, liver transplantation remains an option. But as transplantation is a limited resource, these options are worth considering."

Dr. Li did not respond to a request for comments.

SOURCE: http://bit.ly/1iEvvoO

J Hepatol 2014.