Photo Credit: Myboxpra
Liver resection in patients with multifocal hepatocellular carcinoma leads to longer survival compared to tumor ablation.
Patients with multifocal hepatocellular carcinoma (MHCC) who undergo liver resection (LR) surgery tend to live longer after the procedure than those who have tumor ablation (TA).
“LR provides better outcomes if a transplant option is unavailable,” senior study author Hassan Aziz, MD, and his coauthors wrote in the Journal of Surgical Oncology.
“Patients with MHCC often have very poor survival outcomes. The incidence of MHCC is increasing, and close to 30,000 new cases are expected to be diagnosed in 2030,” Dr. Aziz explains. “The options for patients with stage T2 MHCC are generally transplant, resection, or ablation. Although transplant is often considered superior, the scarcity of organs limits their availability, so for many patients, resection or ablation remain the most likely options.”
Retrospective Study of Nationwide Data
The researchers identified patients in the National Cancer Database who were diagnosed with nonmetastatic T2 MHCC between 2004 and 2015. The study team generated Kaplan‐Meier survival curves to compare 10‐year overall survival (OS) between patients with LR to those with TA, stratifying the analyses based on lymphovascular invasion, resection margin status, and Charlson-Deyo score. They used Cox proportional hazard models in their multivariable analyses.
Overall, 991 patients received LR, and 234 received TA. Most participants were male, White, aged 60 years or older, and both groups had similar clinicodemographic traits. In patients who underwent LR, 84% had negative margins, and 17% had lymphovascular invasion.
30-Day OS Higher After TA; 10-Year OS Higher After LR
At 30 days, 5.4% of patients with LR died, including 7.3% of those with a Charlson-Deyo score of 2 or higher, while all those who received TA survived (P<0.001; Figure). Conversely, at 10 years, the OS after LR was 27.5% (95% CI, 24.4-30.8) versus 14.7% (95% CI, 9.8-20.7; P<0.001) after TA.
In stratified analysis, survival benefit was statistically significant only in patients with negative resection margin, no lymphovascular invasion, and a Charlson-Deyo score of 1 or lower. In multivariable Cox analysis, LR was independently linked with improved survival compared with TA (HR, 0.80; 95% CI, 0.67-0.95; P<0.009).
The authors call for well-powered prospective studies to confirm these findings.
Challenges and Progress
“The results bring up an interesting dilemma,” Dr. Aziz says. “Although patients who undergo resection appear to have better long-term survival, this benefit comes with a higher upfront risk of possible complications from surgery.”
He urges physicians to use these results, along with their patients’ comorbidities and tumor characteristics, to have more meaningful discussions with them about the survival benefits and perioperative risks of both treatment strategies.
“Our findings can help ensure that patients have enough knowledge to make informed decisions about their care that align with their preferences and values,” he adds.
“An important issue is who gets access to care and what the barriers to treatment are,” Dr. Aziz notes. “Approximately 60% of patients in our study were non-Hispanic White, despite liver cancer incidence being much higher among minority populations.”
The treatment picture may change over time, he says. Improved ablation techniques might eventually yield outcomes comparable to or better than resection, and molecular or genetic markers may be identified that can help differentiate which patients will benefit from which treatment.
“Managing MHCC can be challenging,” Dr. Aziz advises. “Patients should be treated at specialized centers experienced in managing this complex disease. For every patient, the pros and cons of each treatment should be discussed with a multidisciplinary team from surgery, hepatology, oncology, radiology, social work, and other specialties.”
