Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2021; 13(10): 1439-1449
Published online Oct 27, 2021. doi: 10.4254/wjh.v13.i10.1439
Clinical outcomes of patients with two small hepatocellular carcinomas
Anh Duy Pham, Karl Vaz, Zaid S Ardalan, Marie Sinclair, Ross Apostolov, Sarah Gardner, Ammar Majeed, Gauri Mishra, Ning Mao Kam, Kurvi Patwala, Numan Kutaiba, Niranjan Arachchi, Sally Bell, Anouk T Dev, John S Lubel, Amanda J Nicoll, Siddharth Sood, William Kemp, Stuart K Roberts, Michael Fink, Adam G Testro, Peter W Angus, Paul J Gow
Anh Duy Pham, Karl Vaz, Zaid S Ardalan, Marie Sinclair, Ross Apostolov, Sarah Gardner, Ning Mao Kam, Kurvi Patwala, Michael Fink, Adam G Testro, Peter W Angus, Paul J Gow, The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
Zaid S Ardalan, Ammar Majeed, John S Lubel, William Kemp, Stuart K Roberts, Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
Marie Sinclair, Ammar Majeed, Niranjan Arachchi, Sally Bell, Anouk T Dev, Amanda J Nicoll, Siddharth Sood, William Kemp, Stuart K Roberts, Michael Fink, Adam G Testro, Peter W Angus, Paul J Gow, The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
Marie Sinclair, Ross Apostolov, Sally Bell, Siddharth Sood, Michael Fink, Adam G Testro, Peter W Angus, Paul J Gow, The University of Melbourne, Parkville 3010, Victoria, Australia
Ammar Majeed, John S Lubel, William Kemp, Stuart K Roberts, Central Clinical School, Monash University, Melbourne 3004, Victoria, Australia
Gauri Mishra, Sally Bell, Anouk T Dev, Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
Numan Kutaiba, Department of Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
Numan Kutaiba, Department of Radiology, Eastern Health, Box Hill 3128, Victoria, Australia
Niranjan Arachchi, Department of Gastroenterology, Western Health, Footscray 3011, Victoria, Australia
Amanda J Nicoll, Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
Siddharth Sood, Department of Gastroenterology, Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
Author contributions: All authors contributed to data collection, drafting and/or review of the manuscript.
Institutional review board statement: Institutional ethics committee approval was obtained from participating sites prior to commencement at each centre.
Informed consent statement: No signed consent form was required from individual patients included in this study, as deemed by our institutional ethics board.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at karl.vaz@austin.org.au. Consent was not obtained but the presented data are anonymized and risk of identification is low.
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: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Karl Vaz, MBBS, Doctor, The Victorian Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg 3084, Victoria, Australia. karl.vaz@austin.org.au
Received: April 25, 2021
Peer-review started: April 25, 2021
First decision: June 15, 2021
Revised: June 19, 2021
Accepted: September 2, 2021
Article in press: September 2, 2021
Published online: October 27, 2021
Abstract
BACKGROUND

Management of single small hepatocellular carcinoma (HCC) is straightforward with curative outcomes achieved by locoregional therapy or resection. Liver transplantation is often considered for multiple small or single large HCC. Management of two small HCC whether presenting synchronously or sequentially is less clear.

AIM

To define the outcomes of patients presenting with two small HCC.

METHODS

Retrospective review of HCC databases from multiple institutions of patients with either two synchronous or sequential HCC ≤ 3 cm between January 2000 and March 2018. Primary outcomes were overall survival (OS) and transplant-free survival (TFS).

RESULTS

104 patients were identified (male n = 89). Median age was 63 years (interquartile range 58-67.75) and the most common aetiology of liver disease was hepatitis C (40.4%). 59 (56.7%) had synchronous HCC and 45 (43.3%) had sequential. 36 patients died (34.6%) and 25 were transplanted (24.0%). 1, 3 and 5-year OS was 93.0%, 66.1% and 62.3% and 5-year post-transplant survival was 95.8%. 1, 3 and 5-year TFS was 82.1%, 45.85% and 37.8%. When synchronous and sequential groups were compared, OS (1,3 and 5 year synchronous 91.3%, 63.8%, 61.1%, sequential 95.3%, 69.5%, 64.6%, P = 0.41) was similar but TFS was higher in the sequential group (1,3 and 5 year synchronous 68.5%, 37.3% and 29.7%, sequential 93.2%, 56.6%, 48.5%, P = 0.02) though this difference did not remain during multivariate analysis.

CONCLUSION

TFS in patients presenting with two HCC ≤ 3 cm is poor regardless of the timing of the second tumor. All patients presenting with two small HCC should be considered for transplantation.

Keywords: Hepatocellular carcinoma, Liver cancer, Prognosis, Transplantation, Transplant-free survival

Core Tip: Transplant-free survival in patients with 2 small hepatocellular carcinomas is poor, whether presenting synchronously or sequentially, and so should be considered for transplantation.