Abstract
The treatment of hepatocellular carcinoma (HCC) is notoriously difficult. Either because of oncogenic behavior or the frequent association of cirrhosis, successful therapy is elusive, particularly in cirrhotic patients. Surgical removal has been the only modality that has produced long-term, disease-free survival. In a large series of patients from specialty institutions, median survival in those who underwent resection of HCC lesions has ranged from 30 to 70 months. Similarly, liver transplantation has been shown to be an effective treatment when HCC is favorable (limited in size and number), producing long-term survival in greater than 70% of patients. However, less information is known about community-based treatment of HCC. Reports from referral centers may not accurately reflect the community experience. We have retrospectively reviewed patients with HCC seen in surgical referral from three teaching hospitals in a medium-size urban community from 1995 to 2004 who were not felt to be candidates for liver transplantation and who were not sent to referral centers. We sought to examine their suitability for operation and resection. The study group comprised 61 patients, whose ages ranged from 35 to 83 years old. There were 44 patients (72%) with cirrhosis (Childs A, B, and C in 27, 15, and 2 patients, respectively), 21 from hepatitic C virus (HCV) infection. Three recognized staging systems were used that incorporated the estimation of hepatic reserve and tumor burden. Seven patients (11%) were deemed nonoperable (five advanced disease by imaging, two comorbidities). Of the 54 patients who underwent surgical procedures, 32 underwent resection (28 patients) or cryoablation (4 patients). The reasons for unresectability were unrecognized multifocality (ten patients), poor risk for major hepatectomy (five patients), portal vein/hepatic vein involvement (three patients), metastatic disease (two patients), and excessive blood loss prior to hepatectomy (two patients). Eleven of 17 (65%) noncirrhotic patients and 21 of 44 (48%) cirrhotic patients were resectable or ablatable. There were ten postoperative deaths: six following resection, two following cryoablation, and two following exploratory celiotomy. All deaths were in cirrhotic patients (Childs A in four patients, B in five patients, and C in one patient), 10 of 44 patients (23%); 3 of 11 (27%) patients died following segmentectomy and 3 of 9 (33%) following major hepatectomy. Seven deaths that occurred were in patients with HCV; (P = NS). From this series, the difficulty in surgically treating cirrhotic patients in an urban practice is evident. From 39 to 73% of patients had advanced local disease. Less than half were resectable and, for cirrhotic patients, the postoperative mortality was high, even after “minor” hepatectomies. Noncirrhotic patients fared somewhat better. While HCC in community practice can be treated surgically in the majority of noncirrhotic patients, cirrhotic patients are less likely candidates, and surgical treatment is associated with significant postoperative mortality. This frequently reflected advanced disease and HCV but may be associated with access to preventative and surveillance measures. Only those with optimum hepatic reserve and small tumor burden should be considered for surgical resection.
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El-Serag HB, Davila JA, Petersen NJ, McGlynn KA. The continued increase in the incidence of hepatocellular carcinoma in the United States: an update. Ann Intern Med 2003;139:817–823.
Farmer DG, Rosove MH, Shaked A, Busuttil RW. Current treatment modalities for hepatocellular carcinoma. Ann Surg 1994;219:236–247.
Tuttle-Newhall JE, Rutledge R, Johnson M, Fair J. A statewide, population-based, time series analysis of access to liver transplantation. Transplantation 1997;63:255–262.
McCormick PA, O’Rourke M, Carey D, Laffey M. Ability to pay and geographical proximity influence access to liver transplantation even in a system with universal access. Liver Transpl 2004;10:1422–1427.
Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005;242:540–547.
Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the esophagus for bleeding esophageal varices. Br J Surg 1973;60:646–654.
Green FL, Page DL, Fleming ID, et al., eds. AJCC Cancer Staging Manual, 6th ed. Berlin Heidelberg New York: Springer, 2002.
Okuda K, Ohtsuki T, Obata H, et al. Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients. Cancer 1985;56:918–928.
Llovet JM, Bru C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis 1999;19:329–338.
Fong Y, Sun RL, Jamagin W, Blumgart LH. An analysis of 412 cases of hepatocellular carcinoma at a western center. Ann Surg 1999;229:790–800.
Bismuth H, Houssin D, Ornowski J, Meriggi F. Liver resections in cirrhotic patients: a western experience. World J Surg 1986;10:311–317.
Nagao T, Inoue S, Goto S, et al. Hepatic resection for hepatocellular carcinoma: clinical features and long-term prognosis. Ann Surg 1987;205:33–40.
Nagorney DM, van Heerden JA, Ilstrup DM, Adson MA. Primary hepatic malignancy: Surgical management and determinants of survival. Surgery 1989;106:740–749.
Torzilli G, Makuuchi M, Inoue K, et al. No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. Arch Surg 1999;134:984–992.
Wayne JD, Lauwers GY, Ikai I, et al. Preoperative predictors of survival after resection of small hepatocellular carcinomas. Ann Surg 2002;235:722–731.
Adams R, Azoulay D, Castaing D, et al. Liver resection as a bridge to transplantation for hepatocellular carcinoma on cirrhosis: a reasonable strategy? Ann Surg 2003;238:508–519.
Llovet JM, Fuster J, Bruix J. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl 2004;10:S115–S120.
Teh SH, Christein J, Donohue J, et al. Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: model of end-stage liver disease (MELD) score predicts perioperative mortality. J Gastrointest Surg 2005;9:1207–1215.
De Carlis L, Giacomoni A, Pirotta V, et al. Surgical treatment of hepatocellular cancer in the era of hepatic transplantation. J Am Coll Surg 2003;196:887–897.
Poon RT, Fan ST, Lo CM, et al. Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified? Ann Surg 2002;236:602–611.
Mok K-T, Wang B-W, Lo G-H, et al. Multimodality management of hepatocellular carcinoma larger than 10 cm. J Am Coll Surg 2003;197:730–738.
Liu CL, Fan ST, Lo CM, Ng IO, Poon RT, Wong J. Hepatic resection for bilobar hepatocellular carcinoma: is it justified? Arch Surg 2003;138:100–104.
Pawlik TM, Poon RT, Abdallah EK, et al. Hepatectomy for hepatocellular carcinoma with major portal or hepatic vein invasion: results of a multicenter study. Surgery 2005;137:403–410.
Dimick JB, Pronovost PJ, Cowan JA Jr, Lipsett PA. Postoperative complication rates after hepatic resection in Maryland hospitals. Arch Surg 2003;138:41–46.
Helling TS. Ruminations of an ordinary hepatic surgeon: a journey through the pitfalls of major liver resection. J Gastrointest Surg 2002;6:625–629.
Laurent C, Blanc JF, Nobili S, et al. Prognostic factors and longterm survival after hepatic resection for hepatocellular carcinoma originating from noncirrhotic liver. J Am Coll Surg 2005;201:656–662.
Said A, Williams J, Holden J, Remington P, Musat A, Lucey MR. The prevalence of alcohol-induced liver disease and hepatitis C and their interaction in a tertiary care setting. Clin Gastroenterol Hepatol 2004;2:928–934.
Chapman WC, Wright JK, Awad JA, et al. Nashville experience with liver transplantation in Veterans Administration patients. J Surg Res 1997;67:79–83.
Sakai Y, Seki S, Nishiguchi S, et al. Homeless patients with hepatocellular carcinoma in Osaka City, Japan. Hepatogastroenterology 1999;46:1106–1110.
Maraj R, Kew MC, Hyslop RJ. Resectability rate of hepatocellular carcinoma in rural southern Africans. Br J Surg 1988;75:335–338.
Trevisani F, De NS, Rapaccini G, et al. Semiannual and annual surveillance of cirrhotic patients for hepatocellular carcinoma: effects on cancer stage and patient survival (Italian experience). Am J Gastroenterol 2002;97:734–744.
Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am 2003;85-A:27–32.
Kelz RR, Gimotty PA, Polsky D, Norman S, Fraker D, DeMichele A. Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer 2004;101:2187–2194.
Boxer LK, Dimick JB, Wainess RM, et al. Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States. Surgery 2003;134:142–145.
Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med 1994;331:444–449.
Anderson S, Nevins CL, Green LK, El-Zimaity H, Anand BS. Assessment of liver histology in chronic alcoholics with and without hepatitis C virus infection. Dig Dis Sci 2001;46:1393–1398.
Gao B. Interaction of alcohol and hepatitis viral proteins: implications in synergistic effect of alcohol drinking and viral hepatitis on liver injury. Alcohol 2002;27:69–72.
Farges O, Malassagne B, Flejou JF, Balzan S, Sauvanet A, Belghiti J. Risk of major liver resection in patients with underlying chronic liver disease: a reappraisal. Ann Surg 1999;229:210–221.
Eguchi H, Umeshita K, Sakon M, et al. Presence of active hepatitis associated with liver cirrhosis is a risk factor for mortality caused by posthepatectomy liver failure. Dig Dis Sci 2000;45:1383–1388.
Yoo HY, Thuluvath PJ. Outcome of liver transplantation in adult recipients: influence of neighborhood income, education, and insurance. Liver Transpl 2004;10:235–243.
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Helling, T.S., Woodall, C.E. Referrals for Surgical Therapy in Patients with Hepatocellular Carcinoma: A Community Experience. J Gastrointest Surg 11, 76–81 (2007). https://doi.org/10.1007/s11605-006-0073-z
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DOI: https://doi.org/10.1007/s11605-006-0073-z