Target patients for partial hepatectomy and relationship between PLT and prognosis in BCLC B HCC
Authors: Yin Lei, Lau Wan Yee, Zhou Wei Ping
Journal: Journal of Hepatology (2014)

Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCTJournal of HepatologyVol. 62Issue 3PreviewYin and colleagues are to be congratulated on having performed an RCT in such a challenging study population [1]. The results are strongly supportive of surgery in preference to transarterial chemoembolization (TACE), in patients beyond Milan criteria at BCLC B. But, the findings must be viewed with caution before a similar approach is pursued in different patient populations. Firstly, the disease aetiology was almost exclusively due to chronic hepatitis B infection. A recent UK study showed that 70% of cases of HCC were due to alcoholic liver disease, fatty liver disease, and cryptogenic disease, so the patient groups between geographical locations are clearly very different and thus not comparable. Full-Text PDF Open AccessPartial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond the Milan criteria: A randomized controlled trialJournal of HepatologyVol. 62Issue 3PreviewWe read with interest the article by Yin et al. [1], in which they highlighted that partial hepatectomy (PH) was superior to transcatheter arterial chemoembolization (TACE) for patients with resectable multiple hepatocellular carcinoma (HCC) beyond the Milan criteria. However, their findings may need further improvement based on the following two viewpoints. Full-Text PDF Open AccessPartial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCTJournal of HepatologyVol. 61Issue 1PreviewThe aim of this randomized comparative trial (RCT) is to compare partial hepatectomy (PH) with transcatheter arterial chemoembolization (TACE) to treat patients with resectable multiple hepatocellular carcinoma (RMHCC) outside of Milan Criteria. Full-Text PDF The most common etiology of hepatocellular carcinoma (HCC) in China is hepatitis B virus infection, which is in marked contrast to the United Kingdom with common etiologies like alcoholism, non-alcoholic fatty liver disease, and hepatitis C virus infection. There is no doubt that a randomized comparative trial (RCT), involving a large number of patients with HCC, would provide a clearer answer to the point raised by Metussin et al., in their Letter to the Editor. Unfortunately, such a study would be difficult to carry out. Although in our study there were more Child-Pugh B patients in the TACE group, there was no significant difference between the 2 groups. In response to the criticisms about the exclusion from our study of patients 70 years or older, this RCT was conducted on a selected group of patients, who were suitable to undergo both partial hepatectomy (PH) and TACE, and chronological age of over 70 years alone has never been a contraindication to these treatments in our center. Clinical practice guidelines for HCC state that drug-eluting beads (DEB) had similar response rates when compared with conventional TACE [[1]European Association for the Study of the LiverEuropean Organisation for Research and Treatment of CancerEASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma.J Hepatol. 2012; 56: 908-943Abstract Full Text Full Text PDF PubMed Scopus (4843) Google Scholar]. However, DEB is recommended for its less systemic adverse events. Although many clinical studies on DEB have been reported, the benefits on survival of DEB, when compared with conventional TACE, remain controversial. Until now, there has not been any clinical comparative trial which compares DEB with PH on survival in patients with BCLC B stage HCC. A study [[2]Wiggermann P. Sieron D. Brosche C. Brauer T. Scheer F. Platzek I. et al.Transarterial chemoembolization of child-A hepatocellular carcinoma: drug-eluting bead TACE (DEB TACE) vs. TACE with cisplatin/lipiodol (cTACE).Med Sci Monit. 2011; 17: CR189-CR195Crossref PubMed Google Scholar] showed a mean survival of 21.7 months in patients treated with DEB-TACE, which was less than the 41 months in the PH group in our study. The two studies used similar criteria to enroll patients. Our study suggested that PH would produce better overall survival than DEB. It is controversial to perform partial hepatectomy (PH) on hepatocellular carcinoma (HCC) patients with severe cirrhosis. Thus, at the beginning of the study, severe cirrhosis and a low platelet (PLT) were considered as exclusion criteria of the study. In our study, the receiver operating characteristic curve for PLT showed an optimal cut-off value of 121 × 109/L in detecting death (area under the ROC curve = 0.415). In our study, univariate analysis using the Log-rank test showed the variable for PLT <121 × 109/L could not be entered into multivariate analysis, according to our pre-set criteria (χ2 = 3.287, p = 0.07). In response to the criticism by Pang et al., in their Letter to the Editor, we carried out another multivariate analysis to include PLT. The result was still the same as with our previous conclusions: the type of treatment, number of tumor, and gender were independent risk factors associated with overall survival (OS). PLT was not an independent risk factor (HR, 0.743; 95% CI, 0.485 to 1.136, p = 0.170). Dr. Qing Pang and his associates stated in their letter that patients with a high preoperative PLT had significantly worse OS and recurrence free survival (RFS). This statement was based on a small sample size, retrospective clinical study, which was recently reported [[1]European Association for the Study of the LiverEuropean Organisation for Research and Treatment of CancerEASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma.J Hepatol. 2012; 56: 908-943Abstract Full Text Full Text PDF PubMed Scopus (4843) Google Scholar]. A careful look at this retrospective study [[3]Shen S.L. Fu S.J. Chen B. Kuang M. Li S.Q. Hua Y.P. et al.Preoperative aspartate aminotransferase to platelet ratio is an independent prognostic factor for hepatitis B-induced hepatocellular carcinoma after hepatic resection.Ann Surg Oncol. 2014; 21: 3802-3809Crossref PubMed Scopus (93) Google Scholar] showed aspartate amino-transferase to platelet ratio (APRI) but not PLT, to be associated with poor prognosis in patients with HCC. On multivariate analysis, APRI (not PLT) and other 3 factors were associated with both poor DFS and OS. Thus, APRI and PLT should not be confused. Further studies are required to determine the relationship between PLT with prognosis of HCC. As TACE is not a curative therapy, and residual diseases are commonly left after TACE, it is difficult to use DFS in the TACE group. As clinical practice guidelines for HCC suggest OS to be used as a primary endpoint for randomized comparative trials in HCC research [[1]European Association for the Study of the LiverEuropean Organisation for Research and Treatment of CancerEASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma.J Hepatol. 2012; 56: 908-943Abstract Full Text Full Text PDF PubMed Scopus (4843) Google Scholar], we did not compare the RFS between the two groups. All the enrolled patients in our study had multiple tumors; it is not surprising that the recurrence rate was high in the PH group. However, the OS curves clearly showed better survival outcomes of patients who received PH. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.