Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. May 27, 2021; 13(5): 476-492
Published online May 27, 2021. doi: 10.4240/wjgs.v13.i5.476
Liver resection for hepatocellular carcinoma larger than 10 cm: A multi-institution long-term observational study
Chao-Wei Lee, Ming-Chin Yu, Chih-Chi Wang, Wei-Chen Lee, Hsin-I Tsai, Feng-Che Kuan, Chun-Wei Chen, Yi-Chung Hsieh, Hsing-Yu Chen
Chao-Wei Lee, Ming-Chin Yu, Wei-Chen Lee, Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Guishan 333, Taoyuan, Taiwan
Chao-Wei Lee, Ming-Chin Yu, Wei-Chen Lee, Hsin-I Tsai, Chun-Wei Chen, Yi-Chung Hsieh, College of Medicine, Chang Gung University, Guishan 333, Taoyuan, Taiwan
Chao-Wei Lee, Ming-Chin Yu, Hsin-I Tsai, Hsing-Yu Chen, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Guishan 333, Taoyuan, Taiwan
Ming-Chin Yu, Department of Surgery, New Taipei Municipal Tu-Cheng Hospital (Built and Operated by Chang Gung Medical Foundation), Tu-Cheng 236017, New Taipei City, Taiwan
Chih-Chi Wang, Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
Chih-Chi Wang, Division of General Surgery, Department of Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
Hsin-I Tsai, Department of Anesthesiology, Linkou Chang Gung Memorial Hospital, Guishan 333, Taoyuan, Taiwan
Feng-Che Kuan, Department of Hematology and Oncology, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
Chun-Wei Chen, Yi-Chung Hsieh, Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Guishan 333, Taoyuan, Taiwan
Hsing-Yu Chen, Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Taoyuan Chang Gung Memorial Hospital, Guishan 33378, Taoyuan, Taiwan
Hsing-Yu Chen, School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Guishan 333, Taoyuan, Taiwan
Author contributions: Lee CW designed the study, conducted the research, and drafted the manuscript; Yu MC, Wang CC, and Lee WC performed the operations, formulated the concept, supervised the study, and revised the manuscript; Tsai HI and Kuan FC confirmed the statistics, interpreted the data, and revised the manuscript; Chen CW and Hsieh YC collected the data and analyzed the results; Chen HY coordinated the entire study, performed the statistics, and approved the manuscript; All authors read and approved the final manuscript.
Supported by Chang Gung Memorial Hospital, No. CMRPG3J1691.
Institutional review board statement: This study was approved by the Institutional Review Boards (No. 202000608B0) of Chang Gung Memorial Hospital. For retrospective study, informed consent was waived according to our institutional guideline.
Conflict-of-interest statement: Authors have no conflicts of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hsing-Yu Chen, MD, Associate Professor, Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Taoyuan Chang Gung Memorial Hospital, No. 123 Dinghu Road, Guishan District, Guishan 33378, Taoyuan, Taiwan. b8705016@gmail.com
Received: January 29, 2021
Peer-review started: January 29, 2021
First decision: March 6, 2021
Revised: March 13, 2021
Accepted: April 28, 2021
Article in press: April 28, 2021
Published online: May 27, 2021
Processing time: 111 Days and 22.6 Hours
Abstract
BACKGROUND

The treatment of hepatocellular carcinoma (HCC) ≥ 10 cm remains a challenge.

AIM

To consolidate the role of surgical resection for HCC larger than 10 cm.

METHODS

Eligible HCC patients were identified from the Chang Gung Research Database, the largest multi-institution database, which collected medical records of all patients from Chang Gung Memorial Foundation. The surgical outcome of HCC ≥ 10 cm (L-HCC) was compared to that of HCC < 10 cm (S-HCC) (model 1). The survival of L-HCC after either liver resection or transarterial chemoembolization (TACE) was also analyzed (model 2). The long-term risks of all-cause mortality and recurrence were assessed to consolidate the role of surgery for L-HCC.

RESULTS

From January 2004 to July 2015, a total of 32403 HCC patients were identified from the Chang Gung Research Database. Among 3985 patients who received liver resection, 3559 (89.3%) had S-HCC, and 426 had L-HCC. The L-HCC patients had a worse disease-free survival (0.27 for L-HCC vs 0.40 for S-HCC) and overall survival (0.18 for L-HCC vs 0.45 for S-HCC) than the S-HCC after liver resection (both P < 0.001). However, the surgical and long-term outcome of resected L-HCC had improved dramatically in the recent decades. After adjusting for covariates, surgery could provide a better outcome for L-HCC than TACE (adjusted hazard ratio of all-cause mortality: 0.46, 95% confidence interval: 0.38-0.56 for surgery). Subgroup analysis stratified by different stages showed similar trend of survival benefit among L-HCC patients receiving surgery.

CONCLUSION

Our study demonstrated an improving surgical outcome for HCC larger than 10 cm. Under selected conditions, surgery is better than TACE in terms of disease control and survival and should be performed. Due to inferior survival, a subclassification within T1 stage should be considered. Future studies are mandatory to confirm our findings.

Keywords: Hepatocellular carcinoma; 10 cm; Liver resection; Transarterial chemoembolization; Chang Gung Research Database

Core Tip: By analyzing the data from one of the largest clinical databases worldwide, the current study demonstrated an improving surgical outcome for hepatocellular carcinoma ≥ 10 cm. Under selected conditions, surgery is better than transarterial chemoembolization in terms of disease control and survival. Due to inferior survival for HCC ≥ 10 cm, a subclassification within T1 stage should be considered.