Selection criteria for repeat hepatectomy in patients with recurrent hepatocellular carcinoma

Abstract

Objective: The purpose of this study was to evaluate prognostic factors in patients with recurrence after curative resection of hepatocellular carcinoma (HCC) and to identify selection criteria for repeat resection.

Summary background data: Recent studies have demonstrated that repeat hepatectomy is effective for treating intrahepatic recurrent HCC in selected patients. However, the prognostic factors in these patients have not been fully evaluated.

Methods: From October 1994 to December 2000, 334 patients underwent primary resection for HCC, and 67 received a 2nd hepatectomy for recurrent HCC. The survival results in these 67 patients were analyzed, and prognostic factors were determined using 38 clinicopathological variables. The prognosis and operative risk in 11 and 6 patients who received a 3rd and 4th resection were also evaluated.

Results: The overall 1-, 3-, and 5-year survival rates of the 334 patients after primary hepatectomy were 94%, 75%, and 56%, while those of the 67 patients after a 2nd resection were 93%, 70%, and 56%, respectively. There was no difference in survival (P = 0.64). All of the patients who underwent a 3rd or 4th are currently alive at a median follow-up of 2.5 and 1.4 years, respectively. The operative time and blood loss in the 2nd resection in patients who underwent a major primary resection were not different from those in patients who underwent minor hepatectomy at the 1st resection, and there were also no differences in these variables among the 2nd, 3rd, and 4th resections. In a multivariate analysis, absence of portal invasion at the 2nd resection (P = 0.01), single HCC at primary hepatectomy (P = 0.01), and a disease-free interval of 1 year or more after primary hepatectomy (P = 0.02) were independent prognostic factors after the 2nd resection. Twenty-nine patients with all 3 of these factors showed 3- and 5-year survival rates of 100% and 86%, respectively, after the 2nd resection.

Conclusions: Repeat hepatic resection is the treatment of choice for patients who have previously undergone resection of a single HCC at the primary resection and in whom recurrence developed after a disease-free interval of 1 year or more and the recurrent tumor had no portal invasion.

FIGURE 1. Comparison of overall survival rates between primary and 2nd hepatic resections, calculated from the primary and 2nd hepatectomies. There was no significant difference (P = 0.64; log-rank test).

FIGURE 2. Comparison of disease-free survival rates between primary and 2nd hepatic resections, calculated from the primary and 2nd hepatectomies. There was no significant difference (P = 0.06; log-rank test).

FIGURE 3. Comparison of survival after the 2nd resection between 29 patients with all 3 favorable prognostic factors (thick line) and 38 who lacked at least 1 of these factors (broken line). The median survival time in the former group (5.5 years) (95% confidence interval, 4.9–6.1) was significantly longer than that in the latter (3.4 years) (95% confidence interval, 2.6–4.3) (log-rank test; P < 0.01).