2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

tion. Advanced computer-based image reconstruction
provides a virtual three-dimensional model for accurate
quantitative assessment of areas at risk for devascularization
or venous congestion, thus influencing the extent of
resection or need for vascular reconstruction. Liver volumetry
using axial images from two-dimensional CT scans is
used to build a virtual model of the liver to measure the
future liver remnant (FLR) as a predictor of postoperative
hepatic dysfunction. 6 The following formula for the estimation
of the total liver volume (TLV) in adults was found to be
the most precise 7 :
TLV (cm 3 ) ��794.41 � 1267.28 � body-surface area (m 2 )
Preoperative portal vein embolization of the branches
supplying the portion of the liver to be resected may be used
to induce hypertrophy to increase the FLR and reduce the
risk of morbidity and mortality. This is particularly helpful
if the future remnant volume is below 40% in a noncirrhotic
liver or below 60% in a cirrhotic liver. 8 This technique allows
liver regeneration (and therefore an increase in FLR) to take
place before definitive major liver resection. Failure of the
liver to undergo hypertrophy and regenerative hyperplasia
in response to portal vein embolization should be a warning
sign of a decreased ability of the liver to regenerate and an
increased risk of liver failure after liver resection. Portal
vein ligation (rather than percutaneous embolization) can
KEY POINTS
● A multidisciplinary approach to patient selection for
surgery that includes the input of an experienced
liver surgeon is necessary for optimal surgical outcomes,
which are a perioperative mortality rate below
3%, blood transfusion requirements in less than 10%
of cases, and 5-year survival rates of 50%.
● Underlying liver disease is present in more than 80%
of patients with hepatocellular carcinoma. Thorough
preoperative clinical, laboratory, and imaging assessment
is necessary to optimize patient selection and
avoid small-for-size future liver remnant leading to
liver failure.
● Intraoperative ultrasound with full liver mobilization
is an essential component of every liver cancer operation.
Anterior approach, hanging maneuver, and
diverse parenchymal transaction devices have improved
surgical outcome.
● Laparoscopic resection is a viable alternative to open
resection with an improved perioperative period and
similar oncologic outcomes. A laparoscopic approach
may decrease morbidity of salvage liver transplantation.
● Risk factors associated with early recurrence are
tumor size, microvascular invasion, satellite nodules,
alpha-fetoprotein levels, and nonanatomical resection.
Risk factors associated with late recurrence
include presence of cirrhosis, active hepatitis, vascular
invasion, moderate or poor differentiation, and
multinodularity.
266
Table 1. Overall and Disease-Free Survival Rates after
Resection According to Prognostic Factors a
Prognosticator Factor 5-yr OS (%) 5-yr DFS (%)
Cirrhosis HCC and cirrhosis 23–48 22–36
HCC, no cirrhosis 44–58 24–45
Tumor Size HCC � 3 cm 55–78 30–51
HCC � 5 cm 41–67 21–44
HCC � 5 cm 29–56 22–23
Number of lesions Single 35–68 19–46
Multiple 21–58 6–25
Abbreviations: DFS, disease-free survival; HCC, hepatocellular carcinoma;
OS,overall survival.
a Adapted from Rahbari and colleagues. 30 The three most important prognosticators
for long-term survival after liver resection for HCC are the absence or
degree of liver cirrhosis; size of the lesion below 3 cm, below 5 cm, or above 5
cm; and the presence of single or multiple lesions.
also be performed laparoscopically in a safe manner and
may be particularly useful in patients undergoing staging
laparoscopy to rule out disseminated disease. 9 Before any
regional therapy including resection or transplantation,
chest imaging should be performed to rule out distant
metastases.
In addition to imaging and clinical evaluation, laboratory
studies (total bilirubin, albumin, International normalized
ratio) provide information required to determine Child-Pugh
classification. Patients with class A cirrhosis may be good
surgical candidates, whereas almost no patients with class B
cirrhosis are appropriate for resection. Thrombocytopenia,
especially when combined with splenomegaly, is generally a
sign of portal hypertension and excludes a patient from
consideration of resection (though liver transplantation remains
a potential option). Preoperative percutaneous biopsy
to confirm a diagnosis of HCC is not typically required for
lesions that meet radiographic criteria for HCC in the
setting of underlying liver disease.
Advances in Operative Techniques
CONRAD AND TANABE
It is well-accepted that HCC resection should be performed
with at least 1-cm margins and sound oncologic
principles (avoidance of tumor spillage). Controversy exists
as to whether there is a survival benefit of anatomic resections
according to the Couinaud classification of liver segmentation
over nonanatomic resection. A series from an
Asian center demonstrated significantly improved survival
of the group that underwent resection according to
Couinaud classification over nonanatomic resection: 66%
compared with 35%, p � 0.01 for 5-year survival, and 34%
compared with 16%, p � 0.006 for disease-free survival. 10 A
comparison of the outcome with anatomic and nonanatomic
resection for HCC, using a nationwide Japanese database of
72,744 patients, demonstrated an improved disease-free
survival rate with anatomic resection but no difference in
the overall survival rate. When survival was stratified by
tumor size, the disease-free survival rate was significantly
improved with an anatomic resection for HCC with a diameter
of 2 to 5 cm (p � 0.0005). 11 This finding was not
confirmed by Western studies, where only tumor size and
presence of vascular invasion affected survival. 12
Full liver mobilization and ultrasound examination allow
full ultrasonic inspection of the liver and delineation of the
intrahepatic anatomy and may spare the patient from undergoing
a potentially noncurative operation or one in which
a tumor is unknowingly left behind. Depending on the