Systematic Reviews
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jun 27, 2018; 10(6): 433-447
Published online Jun 27, 2018. doi: 10.4254/wjh.v10.i6.433
Systematic review of the outcomes of surgical resection for intermediate and advanced Barcelona Clinic Liver Cancer stage hepatocellular carcinoma: A critical appraisal of the evidence
Ye Xin Koh, Hwee Leong Tan, Weng Kit Lye, Juinn Huar Kam, Adrian Kah Heng Chiow, Siong San Tan, Su Pin Choo, Alexander Yaw Fui Chung, Brian Kim Poh Goh
Ye Xin Koh, Hwee Leong Tan, Juinn Huar Kam, Alexander Yaw Fui Chung, Brian Kim Poh Goh, Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore 169608, Singapore
Weng Kit Lye, Center for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
Adrian Kah Heng Chiow, Siong San Tan, Department of General Surgery, Hepatopancreatobiliary Service, Changi General Hospital, Singapore 529889, Singapore
Su Pin Choo, Department of Medical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
Brian Kim Poh Goh, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
Author contributions: Koh YX, Tan HL, Lye WK, Kam JH, Chiow AKH, Tan SS, Choo SP, Chung AYF and Goh BKP were all critically involved in the design of the study, article review, manuscript drafting and final approval of the version to be published; all authors are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflict-of-interest statement: There are no conflicts of interest to declare for any of the authors.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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/
Correspondence to: Ye Xin Koh, MBBS, MMed, FRCS, Associate Consultant, Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. koh.ye.xin@singhealth.com.sg
Telephone: +65-65767751 Fax: +65-62209363
Received: November 30, 2017
Peer-review started: November 30, 2017
First decision: December 27, 2017
Revised: February 10, 2018
Accepted: March 3, 2018
Article in press: March 3, 2018
Published online: June 27, 2018
Abstract
AIM

To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas (HCC).

METHODS

A systematic review of the published literature was performed using the PubMed database from 1st January 1999 to 31st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer (BCLC) stage B or C HCC. The primary end point was to determine the overall survival (OS) and disease free survival (DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve (i.e., Child’s A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC (defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.

RESULTS

We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to (1) BCLC stage B or C HCC, (2) Size of HCC and (3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7% (range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0% (range 0.0-42.0). The collective median 5-year OS of both stages was 27.9% (0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR (95%CI) = 1.00 (0.76-1.31)] and mortality [RR (95%CI) = 1.15 (0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.

CONCLUSION

Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.

Keywords: Barcelona Clinic Liver Cancer, Hepatocellular carcinoma, Hepatectomy, Milan criteria

Core tip: This is a systematic review of the current literature reporting the surgical outcomes of liver resection for Barcelona Clinic Liver Cancer (BCLC) Stage B and C hepatocellular carcinomas (HCC). Based on this review, there is robust evidence that indications for primary surgical resection of HCC should be extended to include BCLC stage B lesions in selected patients. There is a need for further studies that stratify BCLC stage C lesions and potentially extend surgical indications for resectable lesions.