Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2022; 28(29): 3981-3993
Published online Aug 7, 2022. doi: 10.3748/wjg.v28.i29.3981
Evaluating the best treatment for multifocal hepatocellular carcinoma: A propensity score-matched analysis
Matteo Risaliti, Ilenia Bartolini, Claudia Campani, Umberto Arena, Carlotta Xodo, Valentina Adotti, Martina Rosi, Antonio Taddei, Paolo Muiesan, Amedeo Amedei, Giacomo Batignani, Fabio Marra
Matteo Risaliti, Ilenia Bartolini, Claudia Campani, Umberto Arena, Carlotta Xodo, Valentina Adotti, Martina Rosi, Antonio Taddei, Paolo Muiesan, Amedeo Amedei, Giacomo Batignani, Fabio Marra, Department of Experimental and Clinical Medicine, AOU Careggi, Florence 50134, Italy
Author contributions: All authors contributed to the conceptualization and design of the study; Risaliti M, Bartolini I and Campani C wrote the original draft; all authors contributed to critical revision of the article and final approval of the version to be published; Amedei A, Batignani G and Marra F supervised the work.
Institutional review board statement: The study was approved by the Ethical Committee Area Vasta Centro (Florence), No. 12254/22.
Informed consent statement: All study participants or their legal guardian provided informed written consent for personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Fabio Marra, MD, Professor, Department of Experimental and Clinical Medicine, AOU Careggi, Largo Brambilla 3, Florence 50134, Italy. fabio.marra@unifi.it
Received: February 1, 2022
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
Processing time: 182 Days and 11.6 Hours
Abstract
BACKGROUND

Hepatocellular carcinoma (HCC) is a common tumour often diagnosed with a multifocal presentation. Patients with multifocal HCC represent a heterogeneous group. Although Trans-Arterial ChemoEmbolization (TACE) is the most frequently employed treatment for these patients, previous data suggested that liver resection (LR) could be a safe and effective procedure.

AIM

To compare LR and TACE in patients with multifocal HCC in terms of procedure-related morbidity and oncologic outcomes.

METHODS

All patients with multifocal HCC who underwent LR or TACE as the first procedure between May 2011 and March 2021 were enrolled. The decision to perform surgery or TACE was made after a multidisciplinary team evaluation. Only patients in Child-Pugh class A or B7 and stage B (according to the Barcelona Clinic Liver Cancer staging system, without severe portal hypertension, vascular invasion, or extrahepatic spread) were included in the final analysis. Propensity score matching was used to adjust the baseline differences between patients undergoing LR and the TACE group [number and diameter of lesions, presence of cirrhosis, alpha-fetoprotein (AFP) levels, and Model for End-Stage Liver Disease score]. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS). The outcomes of LR and TACE were compared using the log-rank test.

RESULTS

After matching, 30 patients were eligible for the final analysis, 15 in each group. Morbidity rates were 42.9% and 40% for LR and TACE, respectively (P = 0.876). Median OS was not different in the LR and TACE groups (53 mo vs 18 mo, P = 0.312), while 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, less than 3 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 with more than 3 lesions, appeared to receive more benefit from TACE in terms of OS.

CONCLUSION

In a small cohort of patients with multifocal HCC, LR confers longer DFS compared with TACE, with similar OS and post-procedural morbidity.

Keywords: Hepatocellular carcinoma; Multifocal hepatocellular carcinoma; Liver resection; Trans-arterial chemoembolization; Guidelines; Liver tumour management

Core Tip: Hepatocellular carcinoma (HCC) is a leading cause of death and often presents in a multifocal form. Trans-Arterial ChemoEmbolization (TACE) is the most frequently employed treatment for this patient category. As patients with multifocal HCC are a heterogeneous group, previous data suggested that liver resection (LR) could be a safe and effective procedure. A propensity score-matched analysis has been performed to compare LR and TACE in terms of post-procedure morbidity and survival. Despite the limited number of patients, LR conferred longer disease-free survival with similar overall survival compared to TACE. Subgroup analyses identified the patients benefiting more from a specific treatment.