Salvage surgery following downstaging of unresectable hepatocellular carcinoma

Abstract

Objective: We reported here a series of 49 patients with unresectable hepatocellular carcinoma (HCC) who underwent nonsurgical treatment to downstage the disease followed by salvage surgery, their long-term outcome, and pattern of recurrence.

Summary background data: Most HCC patients present with unresectable disease and are treated with chemotherapy or intra-arterial therapy with a palliative intent. Occasionally, there are good responses to treatment so that salvage surgery becomes feasible afterward. However, long-term outcomes of these patients are seldom reported.

Methods: Patients with unresectable hepatocellular carcinoma, from September 1993 to June 2002, who received salvage surgery after downstaging by systemic chemotherapy, intra-arterial yttrium-90 microspheres, or sequential treatment were included in this study. Systemic chemotherapy consisted of combination doxorubicin, cisplatin, interferon-alpha and 5-fluorouracil (5-FU), or single-agent doxorubicin. The choice of treatment was according to stage of disease and contemporary clinical trial protocol. Survival, recurrence pattern, and surgical outcome were studied.

Results: There were 49 patients in this study with 40 males and 9 females, age ranged from 12 to 69 years. Forty patients (81.6%) were hepatitis B positive. Thirty-two patients had combination chemotherapy alone (65.3%), 8 patients had single agent chemotherapy alone (16.3%), 4 patients received intra-arterial yttrium-90 microspheres alone (8.2%), and 5 patients received sequential therapy (10.2%). Twenty-eight (57.1%) patients received major hepatic resection. Thirteen patients (26.5%) had complete necrosis of the tumor after treatment. Twenty-one patients (42.9%) had recurrence after surgery, and 14 of them were intrahepatic recurrence. The median survival was 85.9 months. The 1-year, 3-year, and 5-year survival rates were 98%, 64%, and 57%, respectively.

Conclusions: Salvage surgery after successful downstaging can provide long-term control of disease in a small proportion of patients with unresectable hepatocellular carcinoma.

FIGURE 1. Overall survival for the whole group of patients (n = 49).

FIGURE 2. Survival of patients with initially unresectable HCC because of extensive bilobar liver involvement (n = 34), main portal vein tumor thrombus (n = 7), or extrahepatic metastases (n = 8).

FIGURE 3. Survival of patients with different degrees of tumor necrosis to the therapy before surgery: 100% necrosis (n = 15); 51% to 99% necrosis (n = 28), and 0% to 50% necrosis (n = 6).

FIGURE 4. Survival of patients with initial therapy being PIAF alone (n = 32), yttrium-90 (n = 4), doxorubicin (n = 8), and sequential therapy (n = 5).