Hepatocellular carcinoma--cause, treatment and metastasis

In the recent decades, the incidence of hepatocellular carcinoma (HCC) has been found to be increasing in males in some countries. In China, HCC ranked second of cancer mortality since 1990s. Hepatitis B and C viruses (HBV and HCV) and dietary aflatoxin intake remain the major causative factors of HCC. Surgery plays a major role in the treatment of HCC, particularly for small HCC. Down-staging unresectable huge HCC to smaller HCC and followed by resection will probably be a new approach for further study. Liver transplantation is indicated for small HCC, however, some issues remain to be solved. Different modes of regional cancer therapy for HCC have been tried. Systemic chemotherapy has been disappointing in the past but the future can be promising. Biotherapy, such as cytokines, differentiation inducers, anti-angiogenic agents, gene therapy and tumor vaccine will probably play a role, particularly in the prevention of tumor recurrence. HCC invasiveness is currently the major target of study. Tremendous works have been done at the molecular level, which will provide clues for biomarker of HCC progression as well as targets for intervention.

Radiofrequency ablation in the treatment of liver metastases from colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the most common malignant tumour and the third leading cause of cancer deaths in USA. For advanced CRC, the liver is the first site of metastatic disease; approximately 50 % of patients with CRC will develop liver metastases either synchronously or metachronously within 2 years after primary diagnosis. Hepatic resection (HR) is the only curative option, but only 15-20% of patients with liver metastases from CRC (CRLMs) are suitable for surgical standard treatment. In patients with unresectable CRLMs downsizing chemotherapy can improve resectability (16%). Modern systemic chemotherapy represents the only significant treatment for unresectable CRLMs. However several loco-regional treatments have been developed: hepatic arterial infusion (HAI), cryosurgical ablation (CSA), radiofrequency ablation (RFA), microwave ablation and selective internal radion treatment (SIRT). During the past decade RFA has superseded other ablative therapies, due to its low morbidity, mortality, safety and patient acceptability.

OBJECTIVES

The objective of this study was to systematically review the role of radiofrequency ablation (RFA) in the treatment of CRLMs.

SEARCH METHODS

We performed electronic searches in the following databases:CENTRAL, MEDLINE and EMBASE. Current trials were identified through the Internet using the Clinical-Trials.gov site (to January 2, 2012) and ASCO Proceedings. The reference lists of identified trials were reviewed for additional studies.

SELECTION CRITERIA

Randomized clinical trials (RCTs), quasi-randomised or controlled clinical trials (CCTs) comparing RFA to any other therapy for CRLMs were included. Observational study designs including comparative cohort studies comparing RFA to another intervention, single arm cohort studies or case control studies have been included if they have: prospectively collected data, ten or more patients; and have a mean or median follow-up time of 24 months. Patients with CRLMs who have no contraindications for RFA. Patients with unresectable extra-hepatic disease were also included.Trials have been considered regardless of language of origin.

DATA COLLECTION AND ANALYSIS

A total of 1144 records were identified through the above electronic searching. We included 18 studies: 10 observational studies, 7 Clinical Controlled Trials (CCTs) and an additional 1 Randomized Clinical Trial (RCT) (abstract) identified by hand searching in the 2010 ASCO Annual Meeting. The most appropriate way of summarizing time-to-event data is to use methods of survival analysis and express the intervention effect as a hazard ratio. In the included studies these outcome are mostly reported as dichotomous data so we should have asked authors research data for each participant and perform Individual Patient Data (IPD) meta-analysis. Given the study design and low quality of included studies we decided to give up and not to summarize these data.

MAIN RESULTS

Seventeen studies were not randomised and this increases the potential for selection bias. In addition, there was imbalance in the baseline characteristics of the participants included in all studies. All studies were classified as having a elevate risk of bias. The assessment of methodological quality of all non-randomized studies included in meta-analysis performed by the STROBE checklist has allowed us to identify several methodological limits in most of the analysed studies. At present, the information from the single RCT included (Ruers 2010) comes from an abstract of 2010 ASCO Annual Meeting where the allocation concealment was not reported; however in original protocol allocation concealment was adequately reported (EORTC 40004 protocol). The heterogeneity regarding interventions, comparisons and outcomes rendered the data not suitable.

AUTHORS' CONCLUSIONS

This systematic review gathers information from several controlled clinical trials and observational studies which are vulnerable to different types of bias. The imbalance between characteristics of patients in the allocated groups appears to be the main concern. Only one randomised clinical trial (published as an abstract), comparing 60 patients receiving RFA plus CT versus 59 patients receiving CT alone, was identified. This study showed that PFS was significantly higher in the group that received RFA. However, it was not able to provide information on overall survival. In conclusion, evidence from the included studies are insufficient to recommend RFA for a radical oncological treatment of CRLMs.

Laparoscopic versus open liver resection for benign and malignant hepatic lesions in adults

BACKGROUND

Liver (hepatic) resection refers to removal of the whole liver, or one or more of its vascular segments. Elective liver resection is mainly performed for benign and malignant liver tumours. The operation can be performed as an open procedure or with a laparoscopic approach. With the advancement of laparoscopic skills and equipment, liver resection is selectively being carried out with this approach. A laparoscopic procedure is intended to be less severe, allowing for quicker healing, fewer complications, and a shorter hospital stay as the insult to the body is minimised. However, evidence about the efficacy of this approach when compared to an open procedure is still scattered. Current practice at different hepato-pancreato-biliary centres is based on the clinical judgement of experts in their field, which is highly insufficient in terms of evidence.

OBJECTIVES

To assess the benefits and harms of laparoscopic versus open liver resection for benign or malignant lesions on the liver in adult patients.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013. We also conducted searches of reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases.

SELECTION CRITERIA

We searched for randomised clinical trials of participants undergoing liver resection for benign or malignant lesions which reported on benefits and harms. We searched for quasi-randomised or observational studies for reports of harm.

DATA COLLECTION AND ANALYSIS

No data from randomised clinical trials could be collected.

MAIN RESULTS

Two authors performed study selection independently. We were not able to identify any randomised clinical trials that met the inclusion criteria of our review protocol. We identified two ongoing randomised clinical trials performed in Europe with data yet to be published. We retrieved a few observational studies (prospective and retrospective) with the searches for randomised clinical trials. They included a limited number of participants in whom laparoscopic and open liver resection was compared. Since these studies were non-randomised observational studies, the results for any adverse events are not included in the review as the risk of bias in such studies is high.

AUTHORS' CONCLUSIONS

No conclusions can be made at this time as no randomised clinical trials are available. In addition to the two ongoing randomised clinical trials for which results are expected to be published in the near future, well-designed, prospective, randomised clinical trials are needed in order to evaluate the benefits and harms of the laparoscopic procedure versus open liver resection.

Stage II surgical resection of hepatocellular carcinoma after TAE: a report of 38 cases

AIM: To evaluate the curative effect of stage II surgical resection of hepatocellular carcinoma after TAE.

METHODS: Thirty-eight patients with unresectable hepatocellular carcinoma were treated by transcatheter arterial embolization (TAE). When the sizes of tumors were markedly reduced after TAE, stage II surgical resections were performed.

RESULTS: Before TAE, the diameters of tumors were 12.84 cm ± 4.87 cm (x ± s), but reduced to 5.12 cm ± 1.82 cm (x ± s) after TAE (P < 0.001). Pathologic examination of the resected specimens revealed obvious necrosis in most cases. After surgery, 26 patients were alive, with the longest survival of 96 months, twelve died and 10 had tumor recurrence.

CONCLUSION: Patients in moderate and advanced stages of hepatocellular carcinoma after TAE should be treated surgically, but the indication must be controlled strictly.

Surgical management of neuroendocrine tumor-associated liver metastases: a review

Liver metastasis is common among patients who suffer from neuroendocrine tumors (NETs). Radical surgery is the standard treatment whenever possible but there is still controversies concerning the treatment strategies such as resection of the primary, role of debulking surgery, liver transplantation (LT) and neoadjuvant or adjuvant therapies. This article aims to review the current evidence available, together with some latest updates, focusing on the surgical management.

CRITICAL EVALUATION OF LONG-TERM RESULTS OF MALIGNANT HEPATIC TUMORS TREATED BY MEANS CURATIVE LAPAROSCOPIC HEPATECTOMY

BACKGROUND

Laparoscopic hepatectomy has presented great importance for treating malignant hepatic lesions.

AIM

To evaluate its impact in relation to overall survival or disease free of the patients operated due different hepatic malignant tumors.

METHODS

Thirty-four laparoscopic hepatectomies were performed in 31 patients with malignant neoplasm. Patients were distributed as: Group 1 - colorectal metastases (n=14); Group 2 - hepatocellular carcinoma (n=8); and Group 3 - non-colorectal metastases and intrahepatic cholangiocarcinoma (n=9). The conversion rate, morbidity, mortality and tumor recurrence were also evaluated.

RESULTS

Conversion to open surgery was 6%; morbidity 22%; postoperative mortality 3%. There was tumor recurrence in 11 cases. Medians of overall survival and disease free survival were respectively 60 and 46 m; however, there was no difference among studied groups (p>0,05).

CONCLUSION

Long-term outcomes of laparoscopic hepatectomy for treating hepatic malignant tumors are satisfactory. There is no statistical difference in relation of both overall and disease free survival among different groups of hepatic neoplasms.

Combined liver and multivisceral resections: A comparative analysis of short and long-term outcomes

BACKGROUND

En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver resections (MLRs).

OBJECTIVES

To compare the short and long-term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies.

METHODS

From a prospective database, a case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long-term survival.

RESULTS

Fifty-three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 [320-525] vs 360 [270-440] minutes, P = .005); higher estimated blood loss (600 [400-800] vs 400 [100-600] mL; P = .011); longer hospital stay (8 [6-14] vs 7 [5-9] days; P = .003); and higher postoperative mortality (9.4% vs 1.9%, P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio [OR], 1 organ = 1.8 [0.54-6.05]; OR ≥ 2, organs = 4.0 [0.35-13.84]) or perioperative mortality (OR, 1, organ = 5.2 [0.91-29.51]; OR ≥ 2, organs = 6.5 [0.52-79.60]). No differences in overall (P = .771) and disease-free survival (P = .28) were observed.

CONCLUSION

MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long-term outcomes.

Surgical treatment results of hepatocellular carcinoma in non-cirrhotic liver in southern Chile: case series with follow-up

BACKGROUND

Hepatocellular carcinoma is the most frequent primary tumour of the liver. Although often associated with chronic liver disease, it can also occur in non-cirrhotic livers. The aim of this study was to describe post-operative morbidity (POM), and survival of patients with hepatocellular carcinoma in non-cirrhotic liver treated surgically, and to identify variables associated with prognosis.

METHODS

Case series of patients who underwent surgery for hepatocellular carcinoma in non-cirrhotic liver at Clínica RedSalud Mayor de Temuco, Chile (2001-2017), were studied. The minimum follow-up time considered was 12 months. Principal outcomes were development of POM and survival. Other variables of interest were age, sex, tumour diameter, surgical time, hospital stay, follow-up time, need for surgical re-intervention, mortality, vascular and lymph node invasion and staging. Descriptive and analytic statistics were calculated.

RESULTS

A total of 32 patients were studied. They were characterized by a mean age of 67.3 ± 7.2 years, 62.5% of whom were men. Averages of tumour diameter, surgical time and hospitalization were 12.0 ± 2.6 cm, 114.4 ± 32.3 min and 7.2 ± 2.9 days, respectively. POM was 31.3%. There was no mortality and there were no re-interventions. The overall actuarial survival at 1, 2 and 3 years was 96.8%, 73.4% and 17.3%, respectively. Lower survival was verified in patients with vascular invasion, lymph node infiltration and stages III and IVa.

CONCLUSION

Despite the tumour diameter and extent of the resections, POM in patients with hepatocellular carcinoma in non-cirrhotic liver is moderate. However, its prognosis is poor. Vascular invasion, lymph node invasion and advances stages were associated with worse survival.