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Majority of HCC patients undergoing resection are not ideal candidates

In a recent study, patients with hepatocellular carcinoma who underwent resection were not found to be ideal candidates, according to current guidelines.

“Patients who are ideal candidates for surgery do not always get offered resection for reasons that are not always clear (lack of knowledge regarding guidelines or lack of surgical expertise),” Sasan Roayaie, MD, of North Shore-LIJ Health Systems, New York, told Healio.com/Hepatology. “In these patients, surgery offers the best chance for long term survival and use of other therapies was associated with worse outcome.”

Sasan Roayaie

Roayaie and colleagues analyzed data of 8,656 patients from 20 clinical sites enrolled in the BRIDGE study, a multi-regional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. The patients were divided into four groups: 718 ideal resection candidates who underwent resection; 144 ideal resection candidates who did not undergo resection; 1,624 non-ideal resection candidates who underwent resection; and 6,170 non-ideal resection candidates who did not undergo resection.

“Log-rank and Cox's regression analyses were conducted to determine differences between groups and variables associated with survival,” the researchers wrote.

The researchers sought to determine how frequently current EASL/AASLD guidelines for HCC were followed and whether following them affected overall survival.

Researchers found that of all the patients, 80% met criteria as ideal candidates and underwent resection. However, only one-third of patients who underwent resection met criteria as appropriate candidates for the procedure.

“These proportions varied considerably among the three different regions contributing patients,” the researchers wrote. “The most common area in which people strayed from the guidelines was by inclusion of patients with a performance status [greater than] zero, followed by resection of patients with [portal hypertension].”

“Some patients who would not be considered as ideal candidates according to the guidelines may still safely undergo resection,” Roayaie said. “These would be patients with slightly elevated bilirubin or moderate portal hypertension. However, the choice for surgery and extent of resection must be made by a true expert.”

Data from three multivariate analyses showed that all ideal candidates for resection had a twofold higher risk of mortality with treatments other than resection. Among only the resected patients, portal hypertension and a bilirubin level greater than 1 mg/dL were not associated with mortality. Among patients who were not ideal candidates for resection, resection was associated with better survival compared with embolization and other forms of treatment. However, this was inferior to ablation and transplantation, according to the research.

Possibly expanding criteria could influence survival, according to the research.

“Expansion of criteria to include more-severe liver dysfunction, advanced tumor characteristics or compromised performance status was associated with a significant detrimental effect on survival,” the researchers wrote.

Roayaie stated: “Results with resection may be better than chemoembolization and/or transplant for patients with multiple tumors even though the results with surgery are lower for these patients than what is achieved in ideal resection candidates.”

The researchers concluded: “Our study suggests that the current AASLD/EASL criteria might be expanded to include patients with either moderate [portal hypertension] or slightly elevated total bilirubin [greater than] 1 mg/dL, but not both, without any appreciable increase in mortality. However, expansion of criteria along other lines, such as tumor characteristics, liver function, and performance status, is associated with significantly lower survival. Finally, for patients who do not meet AASLD/EASL criteria for surgery, resection may still be associated with longer survival, when compared to embolization and “other” treatments, and shorter survival, in comparison to ablation and transplantation, when controlling for other relevant factors.” – by Melinda Stevens

Disclosures: Roayaie reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.