Parissa Tabrizian

OBJECTIVE: We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol. BACKGROUND: Very little is known about the prognosis of HCC that recurs after resection and the outcomes associated with treatments applied to recurrent tumors. METHODS: A total of 661 HCC patients undergoing resection from January 1988 to January 2011 were reviewed to identify those with recurrence. Single recurrences with preserved liver function, and no portal hypertension were treated with resection. Patients with multiple intrahepatic tumors or poor liver function and no major comorbidities were listed for transplantation. Patients with up to 3 tumors, each 4 cm or smaller, and not eligible for transplantation, received ablation. Patients not eligible for ablation received embolization. Other treatments such as systemic therapy and radiation were used in remaining patients, but not in a systematic manner. RESULTS: Recurrent HCC developed in 356 (54%) patients at a median time of 22 months from primary resection. Median survival from time of recurrence to death was 21 months. Variables independently associated with survival from recurrence included time from primary resection to recurrence, alpha-fetoprotein more than 100 ng/mL at recurrence, recurrent tumor larger than 3 cm, BCLC stage at recurrence, and type of treatment rendered for the recurrence. All variables except treatment modality were significantly correlated with characteristics of the original primary tumor. CONCLUSIONS: Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation. Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors.

Current guidelines recommend surgical resection as the primary treatment for a single hepatocellular cancer (HCC) with Child's A cirrhosis, normal serum bilirubin, and no clinically significant portal hypertension. We determined how frequently guidelines were followed and whether straying from them impacted survival. BRIDGE is a multiregional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. A total of 8,656 patients from 20 sites were classified into four groups: (A) 718 ideal resection candidates who were resected; (B) 144 ideal resection candidates who were not resected; (C) 1,624 nonideal resection candidates who were resected; and (D) 6,170 nonideal resection candidates who were not resected. Median follow‐up was 27 months. Log‐rank and Cox's regression analyses were conducted to determine differences between groups and variables associated with survival. Multivariate analysis of all ideal candidates for resection (A+B) revealed a higher risk of mortality with treatments other than resection. For all resected patients (A+C), portal hypertension and bilirubin >1 mg/dL were not associated with mortality. For all patients who were not ideal candidates for resection (C+D), resection was associated with better survival, compared to embolization and “other” treatments, but was inferior to ablation and transplantation. Conclusions : The majority of patients undergoing resection would not be considered ideal candidates based on current guidelines. Not resecting ideal candidates was associated with higher mortality. The study suggests that selection criteria for resection may be modestly expanded without compromising outcomes, and that some nonideal candidates may still potentially benefit from resection over other treatment modalities. (H epatology 2015;62:440–451