Clinically significant portal hypertension (CSPH) on early-stage HCC following hepatectomy: What's the impact?

https://doi.org/10.1016/j.ejso.2022.11.005Get rights and content

Abstract

Background and aim

The impact of currently clinically significant portal hypertension (CSPH) for patients with early-stage HCC after surgery remains controversial. The purpose of this study is to understand the specific effect of CSPH on patients with early-stage (BCLC A stage) HCC after surgery.

Methods

We collected data from 386 HCC patients treated at two centers from December 2009 to January 2017.224 patients (all treated by hepatectomy) were in BCLC stage A, of which, 122 had no CSPH, and 102 had CSPH. There were 162 patients in BCLC stage B (who underwent surgery, TACE, and conservative treatment). The prognosis of the CSPH and non-CSPH groups in BCLC stage A was compared using the Kaplan-Meier method. We used multivariate Cox regression to analyze prognostic factors in patients in BCLC stage A and compared the prognosis of the two groups with the BCLC stage B group.

Results

Among the 224 BCLC stage A patients after surgery, the overall survival (OS) and recurrence-free survival (RFS) of the CSPH group were worse than those of the non-CSPH group (P < 0.001, HR = 2.340[1.554–3.523]; P < 0.001, HR = 2.577[1.676–3.812]) The multivariate Cox proportional hazards model indicated that CSPH was an independent prognostic factor for OS and RFS in BCLC stage A patients. BCLC stage A patients with CSPH treated by hepatectomy had a comparable prognosis to BCLC B stage patients (P = 0.378), and the OS and RFS (P = 0.229; P = 0.077) in the CSPH (BCLC A) group were also comparable to BCLC stage B patients treated with surgery alone.

Conclusions

CSPH can affect the surgical prognosis of early-stage (BCLC stage A) HCC. BCLC stage A patients with CSPH have a prognosis comparable to patients with BCLC stage B. An additional stage, such as the BCLC stage A-B, can be considered.

Introduction

Hepatocellular carcinoma (HCC) is one of the most common cancers globally, and it causes a large number of deaths each year. Nearly 800,000 patients are diagnosed with liver cancer every year, and HCC accounts for about 90% of primary liver cancer. HCC develops in the setting of chronic liver disease, particularly in the setting of cirrhosis. Over 70% of HCC cases occur in patients with HBV infection in developing countries and the Asian continent [1,2]. Currently, hepatectomy is considered to be one of the best modalities to treat liver cancer when patients have a normal liver function [3,4]. However, there is debate as to whether HCC patients with clinically significant portal hypertension (CSPH) can be treated surgically and the prognosis for early-stage HCC patients with CSPH who undergo surgery is unclear.

The rate of HBV infection is relatively high in Asia, and many patients will develop cirrhosis secondarily. Portal hypertension occurs at a later stage of cirrhosis development. In most guidelines today, hepatectomy is generally not recommended for HCC with CSPH [[5], [6], [7]]. However, in the latest BCLC 2022 updates, they believed that hepatectomy can be considered for HCC patients with mild CSPH (but the specific portal venous pressure cut-off value is unknown) [8]. For patients with early stage liver cancer (BCLC stage A), current guidelines recommend radiofrequency ablation (RFA) or transcatheter arterial chemoembolization (TACE). However, many studies have shown that surgical treatment of early HCC is relatively better [[9], [10], [11], [12], [13]]. At present, the impact of CSPH on the surgical treatment of patients with early-stage liver cancer samely remains controversial. Some [[14], [15], [16]] believe that the surgical prognosis of patients with CSPH is much worse. While some researches [[17], [18], [19]] believed that portal hypertension does not significantly affect the postoperative prognosis of BCLC stage A patients. Therefore, hepatectomy may still be considered a reasonable treatment for HCC patients with CSPH, although the potential benefits of partial hepatectomy have not been fully described.

To date, no studies have been conducted to examine the specific impact of CSPH on the postoperative outcome of patients with early-stage liver cancer. Therefore, for the first time, we have conducted a multicenter prognostic study to determine the extent of the impact of CSPH on the postoperative outcome of early-stage HCC (BCLC stage A).

Section snippets

Patient selection

We collected data on 386 HCC patients treated at two centers from December 2009 to January 2017. According to the most recent BCLC staging system, 224 patients were in the BCLC stage A (122 without CSPH and 102 with CSPH), and they all received surgical treatment. The remaining 162 patients were in BCLC stage B and received either surgical treatment, TACE, or conservative treatment. We defined patients as having CSPH based on endoscopic evidence of esophageal or gastric varices or significant

Characteristics of the patients in BCLC stage A

All 224 HCC patients were in the BCLC stage A. All patients underwent radical hepatectomy. 102 patients (45.5%) had CSPH. In the non-CSPH group, there were 105 (86.1%) males and 17 (13.9%) females, 18 (14.8%) were older than 60 years and 104 (85.2%) were younger than 60 years; in the CSPH group, there were 85 (83.3%) males and 17 (16.7%) females, 20 (19.6%) were older than 60 years and 82 (80.4%) were younger than 60 years. Overall, the proportion of GGT only was not the same between the two

Discussion

At present, hepatectomy is considered a good option for HCC patients with normal liver function. Also with strict preoperative management of patients, using the strict selection criteria proposed by BCLC staging, patients can have a 5-year survival rate of over 50% after surgery [[24], [25], [26]]. However, there is no specific treatment recommended for HCC patients with CSPH in the BCLC staging and it is controversial whether surgical treatment is recommended for HCC patients with CSPH. An

Conclusion

In Conclusion, the surgical prognosis of patients with early-stage (BCLC stage A) HCC with CSPH was significantly worse than patients with early-stage liver cancer without CSPH and was comparable to that of patients with BCLC stage B. From a prognostic point of view, it may not be appropriate to classify patients with early HCC with CSPH as BCLC A. Of course, even if the prognosis becomes worse, surgical treatment is still the recommended modality. In conclusion, we believe that an additional

Credit author statement

Feng Xia: Conceptualization, Methodology, Software, Writing- Original draft preparation. Zhiyuan Huang: Conceptualization, Methodology. Qiao Zhang: Methodology, Software. Elijah Ndhlovu: Data curation, Writing- Reviewing and Editing. Xiaoping Chen: Supervision. Bixiang Zhang: Validation. Peng Zhu: Writing- Reviewing and Editing.

Funding statement

The research is funded by (1) Natural Science Foundation of Hubei Province [2019CFB433]. (2) Hengrui Hepatobiliary and Pancreatic Malignant Tumor Research Fund-Youth Research Fund [CXPJJH11800001-2018,306]. (3) Key project of science and technology in Hubei Province [2018ACA137]. (4) General Project of Health Commission of Hubei Province [WJ2021M108].

Conflict of interest disclosure

The authors have no conflicts of interest to declare.

Ethics approval statement

All methods were performed in accordance with the relevant guidelines and regulations. This retrospective observational study was approved by the Ethics Committee of the Wuhan Tongji Hospital and Zhongshan People's Hospital.

Patient consent statement

All patients provided written informed consent to the use and publication of their information.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due [This data involves other studies by our team] but are available from the corresponding author on reasonable request.

Declaration of competing interest

All authors declare no interest conflict.

Acknowledgments

Not Applicable.

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