Published online Aug 7, 2022. doi: 10.3748/wjg.v28.i29.3981
Peer-review started: February 1, 2022
First decision: February 24, 2022
Revised: March 9, 2022
Accepted: July 6, 2022
Article in press: July 6, 2022
Published online: August 7, 2022
Hepatocellular carcinoma (HCC) is the most frequent primary liver tumour and a leading cause of death. Despite follow-up programmes for cirrhotic patients, HCC is diagnosed in a multifocal form in up to 40% of the patients. Although being a heterogeneous group, the existing classifications consider together the patients with multifocal HCC and generally recommend Trans-Arterial ChemoEmbolization (TACE) as the main treatment. Considering the progress in perioperative care, a growing body of literature has started to propose liver resection (LR) in selected cases, which has shown the best long-term oncological results.
A consensus and detailed guidelines that also consider LR for these patients have not yet been proposed. Moreover, the characteristics of the patients that could benefit more from LR have still to be determined. Defining these aspects could help clinicians in patient management and potentially improve their prognosis.
A comparison between LR and TACE as the first main treatment in terms of post-procedural results and long-term oncological outcomes was performed in patients with multifocal HCC.
To reduce the influence of the well-known prognostic factors [i.e., Alpha-fetoprotein (AFP) levels as a dichotomous variable with a cut-off set at 400 ng/dL, presence or absence of cirrhosis, Child-Pugh and Model for End-Stage Liver Disease score, number, and diameter of lesions], a propensity score-matched analysis was performed. Two homogeneous groups (with a 1:1 ratio) were compared to assess the difference in short- and long-term post-procedural results.
After matching, 30 patients were eligible for the final analysis. Morbidity rates were 42.9% and 40% for LR and TACE, respectively (P = 0.876). Median overall survival (OS) was not different when comparing LR and TACE (53 mo vs 18 mo, P = 0.312), while disease-free survival (DFS) was significantly longer with LR (19 mo vs 0 mo, P = 0.0001). Subgroup analysis showed that patients in the Italian Liver Cancer (ITA.LI.CA) B2 stage, with AFP levels lower than 400 ng/mL, 2 lesions, and lesions bigger than 41 mm benefited more from LR in terms of DFS. Patients classified as ITA.LI.CA B3, with AFP levels higher than 400 ng/mL and more than 3 lesions appeared to receive more benefit from TACE in terms of OS. However, not all patients with multifocal HCC are amenable to treatment with LR or TACE. Consequently, only a small sample of patients resulted in being eligible for the analysis. Therefore, these results should be considered with caution and further studies are needed.
There are subgroups of patients with multifocal HCC that seem to benefit more from LR than TACE.
Further studies are needed to include LR in the guidelines as a potential treatment to be offered to specific subgroups of patients with multifocal HCC.