Hepatocellular carcinoma and evidence-based surgery

Abstract

Transplantation cannot be considered the most important therapeutic procedure for hepatocellular carcinoma (HCC). In France, no more than 2% of patients with HCC undergo a transplantation. Randomized controlled trial must assess the benefit to risk ratio of various potentially “curative” treatment procedures (transplantation, resection, radio-frequency ablation).

Key Words: Hepatocellular carcinoma; Evidence based medicine

TO THE EDITOR

Rampone et al[1] stated that hepatocellular carcinoma (HCC) still remains a considerable challenge for surgeons and that transplantation is the most important therapeutic procedure. However, facts seem different for an evidence-based medicine adept[2].

There is a challenge for the patient because yet no randomized controlled trial (RCT) has assessed the benefit to risk ratio of various potentially “curative” treatment procedures (transplantation, resection, radio-frequency ablation). RCT is feasible. Benefit of chemoembolization to patients with unresectable HCC and sorafenib in a palliative indication are evidence-based from RCT. Recruiting is not an issue since HCC is the fifth most common cause of cancer.

Transplantation cannot be considered the most important therapeutic approach. In France with 66 000 000 inhabitants, 7500 inhabitants die of HCC per year. In 2007, 1061 transplantations were performed for various conditions and 6% of the candidates died while on waiting list due to the shortage of organs[3]. In Europe, 15% of transplantations are performed for HCC[4]. Therefore, in France, no more than 2% of patients with HCC undergo a transplantation. Nevertheless, more than one out of four exceeds the Milan criteria, a situation which does not improve the results[4]. Again, data are missing, and the national agency in charge of transplantation does not publish survival after transplantation according to indications. However, they exist.