•Liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis should be considered after careful patient selection.
•Patient characteristics, tumor pattern, liver function and surgical approach should be considered as selection criteria.
•Nomograms to predict surgical risks and survival may help in treatment allocation.
Background & AimsTreatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival.
MethodsPatients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed.
ResultsA total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm3, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed.
ConclusionsLiver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes.
Lay summaryLiver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.
总共包括253名患者,其中57.3%的患者术前血小板计数<100,000 / mm3,43.5%的患者术前腹水,56.9%的患者患有门脉高压。轻度肝切除最常见(84.6%),而122例(48.2%)通过微创手术(MIS)进行。 90天死亡率为4.3%,其中6名患者(2.3%)因肝衰竭而死。一百零八名患者(42.7%)经历了并发症,其中最常见的是腹水(37.5%)。接受大面积肝切除术的患者具有更高的90天死亡率(10.3%比3.3%; p = 0.04)和发病率(69.2%比37.9%; p <0.001)。接受开放性肝切除术的患者的发病率高于接受MIS的患者(52.7%vs. 31.9%; p = 0.001)。建立了手术风险的预测模型(https://childb.shinyapps.io/morbidity/)。 5年总生存率为47%,56.9%的患者复发。构建了总生存期(https://childb.shinyapps.io/survival/)和无病生存期(https://childb.shinyapps.io/DFsurvival/)的预测模型。
结论
晚期肝硬化(Child-Pugh B评分)的肝癌肝切除术与术后并发症高发生率相关。但是,由于在这种情况下治疗方法的局限性,最近的研究表明,在准确选择患者后,结果令人鼓舞。在我们的国际多中心研究中,我们提供3种临床模型来预测肝切除术后的手术风险和长期存活率,目的是改善治疗分配并最终改善临床结果。
关键字:
肝细胞癌,肝切除,晚期肝硬化,Child-Pugh B