Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?

Abstract

Objective: To evaluate the perioperative outcomes and long-term survival of extended hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis.

Summary background data: Hepatic resection is a well-established treatment for HCC in cirrhotic patients with preserved liver function and limited disease. However, the role of extended hepatic resection (more than four segments) for HCC in cirrhotic patients has not been elucidated.

Methods: Between 1993 and 2000, 45 consecutive patients with histologically confirmed cirrhosis underwent right or left extended hepatectomy for HCC (group A). Perioperative outcomes and long-term survival of these patients were compared with 161 patients with HCC and cirrhosis who underwent hepatic resection of a lesser extent in the same period (group B). All clinicopathologic and follow-up data were collected prospectively.

Results: Group A patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than group B. However, the two groups were similar in overall morbidity and hospital mortality. There were no significant differences in the incidence of liver failure or other complications. The resection margin width was similar between the two groups. Despite significantly larger tumor size in group A compared with group B, long-term survival was comparable between the two groups.

Conclusions: Extended hepatic resection for HCC can be performed in selected cirrhotic patients with acceptable morbidity, mortality, and long-term survival that are comparable to those of lesser hepatic resection. Extended hepatectomy for large HCC extending from one lobe to the other or central HCC critically related to the hepatic veins is justifiable in cirrhotic patients with preserved liver function and adequate liver remnant.

Figure 1. An algorithm depicting the decision strategy used in selecting cirrhotic patients with hepatocellular carcinoma (HCC) for extended hepatectomy. Three Child-Pugh class B patients had extended hepatectomy in the early phase of the study period, but Child-Pugh class B or C liver function is now considered a contraindication for extended hepatectomy. ICG-R15, indocyanine green retention at 15 minutes; CT, computed tomography; USG, ultrasound.

Figure 2. Computed tomography scan shows a 16-cm right lobe hepatocellular carcinoma stretching the middle hepatic vein (arrows) towards the left side (A). There was portal hypertension with a moderately enlarged spleen. The tumor was resected by right extended hepatectomy (dotted line indicates the transection plane). Computed tomography scan shows substantial hypertrophy of the left lateral segment 2 months after surgery (B). Six months after surgery, the patient developed an intrahepatic recurrence, which was controlled by transarterial chemoembolization. By the time of data analysis, the patient remained alive 39 months after surgery.

Figure 3. Computed tomography scan shows a 5-cm hepatocellular carcinoma with irregular border straddling segments VIII and IV. The tumor was infiltrating around the middle hepatic vein near its junction with the inferior vena cava (A, arrow). Scan at a 10-mm lower cut shows that the tumor was encroaching on the left hepatic vein (B, arrow). Intraoperative ultrasound confirmed similar findings. In addition, it revealed a tumor thrombus in the middle hepatic vein and tumor infiltration into the caudate lobe. The tumor was resected by left extended hepatectomy and caudate lobectomy. By the time of data analysis, the patient was alive without recurrence 46 months after surgery.

Figure 4. Cumulative overall survival curves of group A (n = 45) and group B (n = 161) patients (P = .44).

Figure 5. Cumulative disease-free survival curves of group A (n = 42) and group B (n = 153) patients (P = .48).