Comparable surgical outcomes after downstaging of unresectable hepatocellular carcinoma - a propensity score analysis

Abstract

INTRODUCTION: This study aims to explore whether hepatectomy after downstaging of unresectable hepatocellular carcinoma (HCC) provides similar long-term survival to upfront surgery. METHOD: This was a retrospective study from a university hospital from 1991–2014. Data was retrieved from a prospectively collected database. All HCC patients who had unresectable, nontransplantable and nonablatable tumors received palliative treatment. Hepatectomy was offered if tumors became resectable after downstage therapy. Outcomes of them were compared to patients who had upfront hepatectomy; matching was performed using propensity score analysis in 1:6 ratio using criteria: Child grade, 7th UICC staging and lymphovascular permeation. RESULTS: 44 patients had hepatectomy after downstage therapy (Transarterial chemoembolization alone in 37, sorafenib alone = 2, selective internal radiation therapy alone = 1, combination = 4). Median time from downstage treatment to surgery was 10 (3–61) months. Baseline characteristics were comparable including age, sex, hepatitis B infection, comorbid disease and Child grade. Operative outcomes were also similar; major hepatectomy (54.9 vs. 50% in upfront and downstage group respectively, p = 0.54), blood loss (0.96 vs. 1L, p = 0.76) and operative time (406 vs. 436 mins, p = 0.34). Pathological characteristics including tumor size, number, differentiation, cirrhosis and lymphovascular permeation didn't differ but downstaged patients were more likely to have bilobar disease (17.4 vs. 36.4%, p = 0.004). Overall complication (26.5 vs. 40.9%, p = 0.05) and hospital mortality (1.5 vs. 0%, p = 0.92) were comparable. Overall and disease free survivals were similar. CONCLUSION: Outcomes and survivals in downstage group were comparable to those who had upfront hepatectomy. Regular evaluation for treatment response and resectability is warranted.