Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCT

Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCTJournal of HepatologyVol. 61Issue 1PreviewThe aim of this randomized comparative trial (RCT) is to compare partial hepatectomy (PH) with transcatheter arterial chemoembolization (TACE) to treat patients with resectable multiple hepatocellular carcinoma (RMHCC) outside of Milan Criteria. Full-Text PDF Target patients for partial hepatectomy and relationship between PLT and prognosis in BCLC B HCCJournal of HepatologyVol. 62Issue 3PreviewThe most common etiology of hepatocellular carcinoma (HCC) in China is hepatitis B virus infection, which is in marked contrast to the United Kingdom with common etiologies like alcoholism, non-alcoholic fatty liver disease, and hepatitis C virus infection. There is no doubt that a randomized comparative trial (RCT), involving a large number of patients with HCC, would provide a clearer answer to the point raised by Metussin et al., in their Letter to the Editor. Unfortunately, such a study would be difficult to carry out. Full-Text PDF Open Access Yin and colleagues are to be congratulated on having performed an RCT in such a challenging study population [[1]Yin L. Li H. Li A.J. Lau W.Y. Pan Z.Y. Zhou W.P. et al.Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCT.J Hepatol. 2014; 61: 82-88Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar]. The results are strongly supportive of surgery in preference to transarterial chemoembolization (TACE), in patients beyond Milan criteria at BCLC B. But, the findings must be viewed with caution before a similar approach is pursued in different patient populations. Firstly, the disease aetiology was almost exclusively due to chronic hepatitis B infection. A recent UK study showed that 70% of cases of HCC were due to alcoholic liver disease, fatty liver disease, and cryptogenic disease, so the patient groups between geographical locations are clearly very different and thus not comparable. Furthermore, the mean age in the far eastern population was 52 and 54 years for the partial hepatectomy patients and TACE patients, respectively. This compares with a median age of 69.9 years in the study from the Newcastle group [[2]Dyson J. Jacques B. Chattopadyhay D. Lochan R. Graham J. Reeves J.L. et al.Hepatocellular cancer: the impact of obesity, type 2 diabetes and a multidisciplinary team.J Hepatol. 2014; 60: 110-117Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. Excluding patients 70 years or older is likely to have introduced a selection bias to the study, since older patients are more likely to have significant co-morbidities that would preclude major liver resection. The normal platelet counts may also hint at low levels of significant portal hypertension, which is known to be associated with poorer outcomes following partial hepatectomy. Moreover, 22% of the surgical patients and 13% of the TACE patients were not cirrhotic, but for those patients who were cirrhotic, more Child-Pugh B patients were in the TACE group (although this approached, but did not reach statistical significance). Finally, the authors highlight the poorer than anticipated outcomes from TACE and the lack of access to drug eluted beads [3Llovet J.M. Real M.I. Montana X. Planas R. Coll S. Aponte J. et al.Arterial embolisation or chemoembolization vs. symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial.Lancet. 2002; 359: 1734-1739Abstract Full Text Full Text PDF PubMed Scopus (2911) Google Scholar, 4Burrel M. Reig M. Forner A. Barrufet M. de Lope C.R. Tremosini S. et al.Survival of patients with hepatocellular carcinoma treated by transarterial chemoembolisation (TACE) using Drug Eluting Beads. Implications for clinical practice and trial design.J Hepatol. 2012; 56: 1330-1335Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar, 5Dhanasekaran R. Kooby D.A. Staley C.A. Kauh J.S. Khanna V. Kim H.S. Prognostic factors for survival in patients with unresectable hepatocellular carcinoma undergoing chemoembolization with doxorubicin drug-eluting beads: a preliminary study.HPB (Oxford). 2010; 12: 174-180Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 6Takayasu K. Arii S. Ikai I. Omata M. Okita K. Ichida T. et al.Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8510 patients.Gastroenterology. 2006; 131: 461-469Abstract Full Text Full Text PDF PubMed Scopus (720) Google Scholar]. The lack of access to these treatments is understandable, but the questions remain: "Would the outcomes have been different had this been available"? In summary, the fact that Yin and colleagues were able to perform and complete this study is a major achievement, but due to the understandable difficulties in the methodology, it would be too early to suggest that BCLC B patients outside Milan should be offered surgery before TACE. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.