2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

a 5-year survival rate of 70% following liver resection for
HCC. In those with portal hypertension, however, the rate of
5-year survival is 50% and even lower in the setting of an
abnormal bilirubin. Similar results have been reported from
Western and other Asian centers. Survival rates as high as
60% at 5 years may be achieved in Child class A patients
with well-encapsulated tumors of 2 cm in diameter, which
are equivalent to results following liver transplantation.
Unfortunately, few patients (� 10%) meet these selection
criteria. 28 Furthermore, recurrence after resection is common,
occurring in up to 80% of the patients at 5 years.
Approximately two-thirds of recurrences occur within 2
years after treatment; these are considered early recurrence
by convention. 29
The factors associated with early recurrence are vascular
invasion, tumor size (only 25% of patients with HCC of less
than 2 cm have vascular invasion), satellite nodules, alphafetoprotein
levels, nonanatomic resection, and extent of
underlying disease. There has been some debate as to
whether tumor recurrence 2 or more years following resection
represents a true recurrence of the initial lesion or a de
novo HCC in the oncogenic cirrhotic liver. Risk factors
associated with late recurrence include presence of cirrhosis,
active hepatitis, vascular invasion, moderate or poorly differentiated
HCC, and multinodularity. 29 Genomic analyses
to better define recurrence risk based on primary tumor
characteristics and molecular evaluation of the cirrhotic
liver may be valuable for prognostication in the future, 30
and future research will show whether neoadjuvant therapy
with radiation, retinoids, chemoembolization, interferon, or
sorafenib (an inhibitor of several tyrosine protein kinases
[VEGFR, PDGFR, Raf]) leads to delayed recurrence. Despite
the fact that recurrence following resection of HCC is a poor
prognosticator, there is evidence that some patients will
benefit from aggressive surgical approaches if recurrence
Authors’ Disclosures of Potential Conflicts of Interest
Author
Employment or
Leadership
Positions
Consultant or
Advisory Role
Claudius Conrad*
Kenneth K. Tanabe Best Doctors;
Covidien; Health
Advances; LEK
Consulting;
UpToDate
*No relevant relationships to disclose.
1. Duffy JP, Hiatt JR, Busuttil RW. Surgical resection of hepatocellular
carcinoma. Cancer J. 2008;14:100-110.
2. Bruix J, Hessheimer AJ, Forner A, et al. New aspects of diagnosis and
therapy of hepatocellular carcinoma. Oncogene. 2006;25:3848-3856.
3. Davila JA, Morgan RO, Shaib Y, et al. Hepatitis C infection and the
increasing incidence of hepatocellular carcinoma: a population-based study.
Gastroenterology. 2004;127:1372-1380.
4. El-Serag HB, Mason AC. Risk factors for the rising rates of primary liver
cancer in the United States. Arch Intern Med. 2000;160:3227-3230.
5. Duffy JP, Vardanian A, Benjamin E, et al. Liver transplantation criteria
for hepatocellular carcinoma should be expanded: a 22-year experience with
467 patients at UCLA. Ann Surg. 2007;246:502-509; discussion 509-511.
6. Schindl MJ, Redhead DN, Fearon KC, et al. The value of residual liver
volume as a predictor of hepatic dysfunction and infection after major liver
resection. Gut. 2005;54:289-296.
7. Johnson TN, Tucker GT, Tanner MS, et al. Changes in liver volume from
birth to adulthood: a meta-analysis. Liver Transpl. 2005;11:1481-1493.
268
occurs. It is our practice to offer patients regional therapy—
occasionally including resection—for recurrent HCC when
the recurrence is limited to the liver. If recurrence occurs, it
has been reported that multimodality therapy including
transarterial chemoembolization, percutaneous ablations,
and surgery results in an overall 5-year survival rate of 20%.
Conclusion
Surgical resection, ablation, and liver transplantation
offer the highest likelihood of long-term survival or cure in
carefully selected patients. A multidisciplinary approach by
a team consisting of surgical oncologists, transplant surgeons,
medical oncologists, interventional radiologists, radiation
oncologists, social workers, and other ancillary staff
provides best outcomes. Advances in surgical techniques,
technology, and understanding of liver anatomy allow experienced
liver surgeons to perform resections that are safer
than before, and resections are available to more patients
than before. Whereas neoadjuvant therapy has not been
shown to convert unresectable tumors to resectable ones,
preoperative portal vein embolization can increase the FLR
and convert patients from unresectable to resectable. Ablative
techniques can be valuable adjuncts in the surgical
therapy of patients with HCC. And in some instances
ablation can be the sole local treatment modality during an
open or laparoscopic operation, recognizing that ablation is
similarly effective as resection for early HCC. Improvements
in surgical techniques have contributed to decreased perioperative
morbidity and mortality. Important prognostic factors
associated with survival after resection include vascular
invasion, satellite nodules, and extent of underlying liver
disease. Further improvements in survival after hepatectomy
for HCC will depend on strategies for early detection as
well as effective neoadjuvant or adjuvant therapies.
Stock
Ownership Honoraria
REFERENCES
Springer
Science and
Business Media
Research
Funding
AstraZeneca
Expert
Testimony
CONRAD AND TANABE
Other
Remuneration
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