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Should We Reappraise the Role of Surgery?

Mircea Chirica, MD; Olivier Scatton, MD; Pierre-Philippe Massault, MD; Thomas Aloia, MD; Bruto Randone, MD; Bertrand Dousset, MD; Paul Legmann, MD; Olivier Soubrane, MD

Arch Surg. 2008;143(6):538-543.

Hypothesis  A subset of patients with stage IVA hepatocellular carcinoma (HCC) and preserved liver function may benefit from hepatic resection.

Design  Retrospective review of a prospectively collected database.

Setting  An academic tertiary care hepatobiliary unit.

Patients  Twenty patients who underwent surgical treatment for stage IVA HCC between July 1998 and October 2004 were identified from the database.

Intervention  Intraoperative ablation of HCC nodules was combined with resection in 6 patients (30%) to increase resectability. Three patients also underwent resection of extrahepatic tumors. Five patients (25%) had macroscopic invasion of the portal vein and 2 patients (10%) underwent thrombectomy of the vena cava.

Main Outcome Measures  Intraoperative data, recurrence, and long-term survival rates were analyzed.

Results  Postoperative mortality and morbidity were 5% and 30%, respectively. The median number of resected tumors per patient was 3, and the median diameter of the largest tumor was 60 mm. With a median follow-up of 23 months, 14 patients (70%) developed recurrence. Treatment of recurrence was possible in 10 patients and included transarterial chemoembolization in 7 patients (35%), of whom 2 (10%) had radiofrequency ablation first, and systemic chemotherapy in 3 patients (15%). Median survival time was 32 months, and the actuarial 1-, 3-, and 5-year survival rates were 73%, 56%, and 45%, respectively.

Conclusions  Long-term survival can be achieved using an aggressive surgical approach in select patients with advanced HCC. Patients with stage IVA HCC should be followed up by a multidisciplinary team because recurrence is common and sequential treatments may prolong survival.

Author Affiliations: Departments of Hepatobiliary Surgery and Transplantation (Drs Chirica, Scatton, Massault, Randone, Dousset, and Soubrane) and Radiology (Dr Legmann), Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Université Paris Descartes, Paris, France; and Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas (Dr Aloia).

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Arch Surg. 2008;143(6):543.
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