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Surgical treatment of hepatocellular carcinoma: Experience with liver resection and transplantation in 198 patients

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Abstract

Surgical therapy offers the only chance for long-term cure of patients with hepatocellular carcinoma. The role of partial and total hepatectomy with subsequent liver replacement was analyzed in a consecutive series of 198 patients. It was the aim of this study to compare both treatment modalities on the basis of various clinicopathological prognostic factors including the TNM system of pathological classification. One hundred thirty-one resections and 61 transplantations were performed for the following histological diagnoses: hepatocellular carcinoma without coexisting liver disease (86) or associated with various hepatic abnormalities (79), fibrolamellar carcinoma (19), and mixed hepatocholangiocellular carcinoma (8). Overall actuarial survival rates at 5 years were 35.8% following resection and 15.2% after transplantation, respectively. For partial hepatectomy, factors significantly associated with improved long-term outcome were: age 30–50 years, hepatocellular carcinoma without coexisting liver disease, fibrolamellar carcinoma, solitary tumor, unilobar location, absence of vascular invasion, portal vein thrombosis or extrahepatic spread, primary tumor categories pT 2/3, stage groups II/III, and curative operation (R0). Regarding total hepatectomy, the corresponding figures were: pT2, absence of portal vein thrombosis or extrahepatic spread (negative regional lymph nodes, no distant metastases), stage group II, and curative surgery. It could be clearly shown by uni- and multivariate analyses that the pTNM classification is of clinical value regarding the assessment of prognostic significance after resection and transplantation. A group of 13 patients had secondary resection (8) or transplantation (6) for intrahepatic tumor recurrence. Whereas in all resected patients cancer recurred again, 5 of 6 transplant recipients are alive and disease-free at 12–40 months. The results of this study demonstrate that liver resection is the treatment of choice for primary liver cancer while transplantation may be indicated, especially in cases of nonresectable or recurrent lesions. Thus, the therapeutic spectrum for hepatocellular carcinoma should include both partial and total hepatectomy, being integrated into one common concept.

Résumé

La chirurgie présente la seule chance de guérison à long terme des patients ayant un carcinome hépatocellulaire. Le rôle de la résection hépatique ou de l'ablation complète du foie suivie d'une transplantation du foie a été analysé dans une série consécutive de 198 patients. Le but de cette étude était de comparer les deux modalités thérapeutiques en se basant sur les différents facteurs clinicopathologiques de pronostic y compris la classification TNM. Cent trente et une résections et 61 transplantations ont été réalisées d'après les diagnostics histologiques suivants: carcinome hépatocellulaire sur foie sain (n =86) ou carcinome sur foie malade (n=79), carcinome fibrolamellaire (n=19), et hépatocholangiocarcinome (n=8). La survie actuarielle globale à 5 ans était respectivement de 35.8% après résection et de 15.2% après transplantation. En ce qui concerne la résection, les facteurs associés améliorant de façon significative la survie à distance étaient: âge de 30 à 50 ans, carcinome hépatocellulaire sur foie sain, carcinome fibrolamellaire, tumeur unique, localisation à un seul lobe, absence d'envahissement vasculaire, de thrombose de la veine porte et de dissémination extrahépatique, tumeurs primitives de catégories pT 2/3, stade II/III, et intervention à visée curative. En ce qui concerne l'ablation complète du foie suivie de transplantation, les facteurs favorables correspondants étaient: stade pT2, absence de thrombose de la veine porte et de dissémination extrahépatique (absence d'envahissement hépatique local et de métastases à distance), stade II, et chirurgie à visée curative. Il a été ainsi clairement démontré par l'analyse uniet multifactorielle que la classification pTNM a une valeur clinique pour établir le pronostic après résection partielle ou transplantation. Treize autres patients ont eu une résection secondaire (n=8) ou une transplantation secondaire (n=6) pour récidive intrahépatique de leur carcinome hépatocellulaire. Alors que chez tous les patients ayant eu une simple résection le cancer a récidivé, 5 sur 6 des patients ayant eu une transplantation étaient vivants et sans maladie apparente à 12–40 mois. Les résultats de cette étude prouvent que la résection hépatique est le traitement de choix du cancer primitif du foie alors que la transplantation est indiquée particulièrement en cas de tumeur non résécable ou en cas de récidive. Ainsi, l'éventail thérapeutique pour le carcinome hépatocellulaire comprend à la fois la résection hépatique partielle et l'ablation totale du foie suivie de transplantation.

Resumen

El tratamiento quirúrgico ofrece la única posibilidad de curación a largo plazo de pacientes con carcinoma hepatocelular. En el presente artículo se analizan el rol de la hepatectomía parcial y de la hepatectomía total con el subsiguiente reemplazo del hígado en una serie consecutiva de 198 pacientes. El objeto del estudio fue comparar tales modalidades terapéuticas con base en diversos factores clinicopatológicos de pronóstico, incluso el sistema TNM de clasificación patológica. Cien treinta y uno resecciones y 61 trasplantes fueron realizados en pacientes con los siguientes diagnósticos histológicos: carcinoma hepatocelular sin enfermedad hepática coexistente (86) o asociado con variadas anormalidades hepáticas (79), carcinoma fibrolamelar (19), y carcinoma mixto hepatocolangiocelular (8). Las tasas globales de supervivencia actuarial a 5 años fueron 35.8% después de resección y 15.2% después de trasplante. En los casos de hepatectomía parcial, los factores asociados con mejor sobrevida a largo plazo fueron: edad de 30–50 años, carcinoma hepatocelular sin enfermedad hepática coexistente, carcinoma fibrolamelar, tumor solitario, ubicación unilobar, ausencia de invasión vascular, trombosis de la vena porta o extensión extrahepática, tumor primario de categoría pT 2/3, estadios II/III, y resección curativa (RO). En los casos con hepatectomía total los factores correspondientes fueron: pT2, ausencia de trombosis de la vena porta y de extensión extrahepática (ganglios linfáticos regionales negativos, no metástasis distantes), estadio II, y cirugía curativa. Mediante el análisis uniy multivariable se pudo demostrar con claridad que la clasificación pTNM es de utilidad en relación a la valoración de lo significativo del pronóstico después de la resección del trasplante. Un grupo de 13 pacientes fue sometido a resección secundaria (8) o trasplante (6) por recurrencia intrahepática del tumor. En tanto que se presentó nueva recurrencia del tumor en la totalidad de los pacientes con resección, 5 de los 6 pacientes trasplantados están vivos y libres de enfermedad a los 12–40 meses. Los resultados del estudio demuestran que la resección hepática es el tratamiento de escogencia en el cáncer primario del hígado en tanto que el trasplante puede estar indicado especialmente en pacientes con lesiones no resecables o con lesiones recurrentes. Por lo tanto, la terapia para carcinoma hepatocellular debe incluir ambas modalidades, la hepatectomía parcial y la total, integradas en un concepto común.

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  1. Klinik für Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Kontanty-Gutschow-Str. 8, 3000, Hannover 61, Germany

    Burckhardt Ringe M.D., Rudolf Pichlmayr M.D., Christian Wittekind M.D. & Günter Tusch M.S.

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  1. Burckhardt Ringe M.D.
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  2. Rudolf Pichlmayr M.D.
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  3. Christian Wittekind M.D.
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Ringe, B., Pichlmayr, R., Wittekind, C. et al. Surgical treatment of hepatocellular carcinoma: Experience with liver resection and transplantation in 198 patients. World J. Surg. 15, 270–285 (1991). https://doi.org/10.1007/BF01659064

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