Resection bests chemoembolization in selected liver cancer patients

Last Updated: 2018-03-28

By Marilynn Larkin

NEW YORK (Reuters Health) - Resection offers survival benefits in carefully selected patients with intermediate-to-advanced hepatocellular carcinoma (HCC), researchers in Korea suggest.

"East Asian countries, which account for more than 50% of the worldwide HCC prevalence, recommend primary hepatic resection for a broader spectrum of HCC patients" than practice guidelines from Europe and the U.S., according to Dr. Ji Hoon Kim and colleagues at Korea University Medical Center in Seoul.

The one randomized controlled trial, published in 2014 (http://bit.ly/2GjxJP4), that compared resection with transarterial chemoembolization (TACE) found that surgery was more effective in certain patients with more severe liver cancer, the authors noted.

To investigate further, they conducted a meta-analysis comparing survival outcomes of 5,986 patients after primary resection and TACE, as reported in the randomized controlled trial, five propensity-score matching non-randomized trials and 12 additional nonrandomized trials.

As reported in Hepatology, online March 14, the researchers found significant survival benefits for resection over TACE in Barcelona Clinical Liver Cancer (BCLC) stage-B/C patients (hazard ratio: 0.59).

Both stage-B and stage-C patients showed significantly better overall survival with resection compared to TACE (HR, 0.53 and HR: 0.67, respectively).

Five-year survival after primary surgery was significantly higher than after TACE in BCLC stage-B/C, stage-B, and BCLC stage-C patients (odds ratios: 2.71, 2.77, and 3.03, respectively; all P < 0.00001).

Survival benefits persisted across subgroup, sensitivity, and meta-regression analyses, they noted; nonetheless, "significant heterogeneity remained."

"This meta-analysis suggests that surgical resection provides survival benefits in patients with intermediate to advanced stage HCC," the authors conclude. However, they add, "the results should be interpreted with caution," and "well-designed randomized studies evaluating the benefits of PH as an extended indication are required."

Dr. Anton Bilchik, chief of gastrointestinal research at John Wayne Cancer Institute and chief of general surgery at Providence Saint John's Health Center in Santa Monica, California, told Reuters Health, "Primary liver resection has typically been reserved for patients with liver cancer and well preserved liver function (Child-Turcotte-Pugh A)."

"For more severe liver dysfunction (CTP B and C), treatments generally include systemic therapy, embolization or liver transplantation," he said by email.

"This study demonstrates that liver resection can be performed in some of these patients with better survival than embolization," he noted. "This is promising because it offers more therapeutic options for patients that typically have a very poor prognosis."

However, he added, "It is important to recognize that most patients with primary liver cancer who have poor liver function will not be candidates for a liver resection because of inadequate liver reserve. Therefore, this study applies to a subset of patients who may benefit from resection."

"Also, hepatitis B is more prevalent in the East and hepatitis C in the West," he said. "The majority of patients in this study had hepatitis B and (it is not known) whether the same benefit shown in this study will apply to patients with hepatitis C."

Dr. Theodore Welling, director of the liver tumor program at Perlmutter Cancer Center at NYU Langone Health in New York City, said he "generally agrees with the conclusion, but not because the study is a large advancement . . . (The authors) freely admit that the studies from which they are drawing their analysis have significant case bias and treatment selection."

"It has been known for quite a while that resection offers the best hope for cure or durability of tumor response in HCC patients," he said in an email to Reuters Health.

"The caveat," he said, "is that the patient needs to be a resection candidate based on a combination of tumor burden, liver disease burden, anatomical location, and tumor biology-related factors."

"Patients with intermediate and potentially advanced HCC would stand to benefit more from resection as compared to TACE, presuming they can get resected," Dr. Welling concluded.

Dr. Kim did not respond to requests for a comment.

SOURCE: http://bit.ly/2E31K3o

Hepatology 2018.