Abstract
The poor prognosis of hepatocellular carcinoma (HCC) was partly a result of the majority of unresectable HCCs in clinical patients. Fortunately, with the progress of regional cancer therapies and multimodality treatment, some of the localized unresectable HCCs were converted to resectable ones. During the period 1960–1994, 72 of the 663 patients with surgically verified unresectable HCCs have been converted to resectable. Successful cytoreduction with median diameter reduced from 10 cm to 5 cm was mainly a result of the triple or double combination treatment with hepatic artery ligation, hepatic artery cannulation with infusion, radioimmunotherapy, and fractionated regional radiotherapy. The interval between the first operation and the sequential resection was 5 months. The operative mortality was 1.4% for sequential resection, and the 5-year survival was 62.1%. Analysis of factors influencing sequential rescction rate revealed HCCs that were single nodule, well encapsulated, situated at right lobe or hepatic hilum, associated with micronodular cirrhosis, and treated with triple or double combination modalities had higher sequential resection rate as compared to their counterparts. Analysis of factors influencing survival after sequential resection revealed that HCCs with a solitary tumor confined in one lobe, without tumor embolus, and without residual cancer in specimen of sequential resection, had longer survival. It is suggested that localized unresectable, solitary, well encapsulated, right lobe or hilar HCC, associated with micronodular cirrhosis, will be good candidates for cytoreduction and sequential resection; and HCCs with unilateral involvement, without tumor embolus, and with complete necrosis of tumor after multimodality treatment favored better prognosis.
Résumé
Le mauvais pronostic des carcinomes hépatocellulaires (CHC) est en partie dû à l'impossibilité de réséquer chirurgicalement la plupart de ces cancers. Il est à espérer, cependant, qu'avec les progrès des thérapies locorégionales et multidisciplinaires, un certain nombre de ces cancers a priori non résécables, deviennent résécables. Pendant la période 1960–1994, 72 des 663 patients ayant un CHC, vérifiés non résécables chirurgicalement, ont été ainsi traités. On a réussi ainsi à diminuer le diamètre moyen de ces tumeurs de 10 à 5 cm, essentiellement en combinant la ligature en aval de l'artère hépatique, la perfusion directe dans cette artère en amont, une immunoradiothérapie et une radiothérapie régionale fractionnée. L'intervalle entre la première intervention et la résection séquentielle a été de 5 mois. La mortalité opératoire a été de 1.4% pour la résection séquentielle et la survie à 5 ans de 62.1% Les nodules simples, bien encapsulés, situés au lobe droit ou au hile, associés à une cirrhose micronodulaire, et traités avec plusieurs de ces tactiques thérapeutiques, avaient un taux de résecabilité plus élevé par rapport aux autres tumeurs. La survie a été meilleure lorsque la résection a intéressé une tumeur unique dans un seul lobe, sans embolie tumorale, et sans cancer résiduel dans la pièce de résection. On suggère que les CHC localisés, solitaires, bien encapsulés du lobe droit ou du hile, associés à une cirrhose micronodulaire mais chirurgicalement non résécables, sont susceptibles de le devenir avec une technique de cytoréduction. Le pronostic des tumeurs unilatérales, sans embolie tumorale et avec une nécrose tumorale complète est meilleur après traitement multidisciplinaire.
Resumen
El mal pronóstico del carcinoma hepatocelular (CHC) se debe, por lo menos en parte, a que en la mayoría de los pacientes el tumor se presenta como una lesión no resecable. Afortunadamente, con el avance en las terapias regionales del cácer y los tratamientos multimodales, algunos de los CHCs no resecables pueden ser convertidos a resecables. En el período 1960–1994, 72 de 663 pacientes con CHCs quirúrgicamente no resecables han sido convertidos a resecables. Se logró una citorreducción exitosa con una disminución promedio del diámetro de 10 cm a 5 cm, fundamentalmente como resultado de un tratamiento combinado doble o triple con ligadura de la arteria hepática, canulación e infusión de la arteria hepática, radioinmunoterapia y radioterapia regional fraccionada. El intervalo entre la primera operación y la resección secuencial fue de cinco meses. La mortalidad operatoria fue 1.4% para la resección secuencial consobrevida a 5 años de 62.1%. El análisis de los factores que influyen sobre la tasa de resección secuencial reveló que un nódulo único, bien encapsufado, ubicados en el lóbulo derecho o en el hilio hepático, asociado con cirrosis micronodular, tratado con modalidades ombinadas dobles o triples, exhibe una tasa de resección secuencial más alta que la observada en el resto de los casos. El análisis de los factores que influyen sobre la sobrevida luego de la resección secuencial reveló que un tumor solitario confinado a un lóbulo, libre de trombos tumorales, sin cáncer residual en el espécimen de la resección secuencial, exhibe la más larga supervivencia. Se sugiere que los CHCs localizados no resecables, solitarios, bien encapsulados, ubicados en el lóbulo derecho o en la región hiliar y asociados con cirrosis micronodular, son buenos candidatos para citorreducción y resección secuencial; y la lesión unilateral, libre de tumor embólico, con necrosis completa del tumor luego de tratamiento multimodal tiende a un mejor pronóstico.
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Tang, ZY., Yu, YQ., Zhou, XD. et al. Cytoreduction and sequential resection for surgically verified unresectable hepatocellular carcinoma: Evaluation with analysis of 72 patients. World J. Surg. 19, 784–789 (1995). https://doi.org/10.1007/BF00299771
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DOI: https://doi.org/10.1007/BF00299771