Surgical Candidacy in Advanced HCC

Anthony El-Khoueiry, MD:The question is, “What makes a patient a good resection candidate?” I would start by saying that the 2 curative modalities that are established in the treatment of hepatocellular carcinoma are liver transplantation and surgical resection. Given the limited supply of organs, and given the long-term impact of having a liver transplant, surgical resection remains a very viable option for patients.

However, surgical resection is limited by various factors. The main limitation to surgical resection is the availability of, or the amount of, residual liver that will be left behind that is healthy enough to sustain life. So, having advanced cirrhosis, or having significant portal hypertension, will preclude the patient from having surgical resection. In other words, the patient has to have well-preserved liver function—generally, Child-Pugh grade A cirrhosis with limited or no signs of portal hypertension. So, depending on the institution, things like a normal bilirubin level may be regarded as a requirement for resection; a platelet count that’s within the normal range or above 100,000 would be a requirement; and the absence of glaring signs of portal hypertension, such as esophageal varices, would be a requirement.

Another limitation to surgical resection is the size of the tumor and its relationship to blood vessels in the liver. These are technical decisions that have to be made by an experienced surgeon to determine whether or not it would be appropriate to do a resection, and not affect vital vasculature in the liver. A third limitation is whether or not there is vascular invasion. So, if the hepatocellular carcinoma invades the portal vein or the inferior vena cava, these are thought to be poor prognostic markers, and the outcomes after surgical resection would be poor. These patients are usually not sent for surgical resection.

Now there are some relative contraindications, but these, again, are relative and depend on institutional practice, the context, and the availability of other treatment options. Having multifocal disease is also considered a relative contraindication to surgical resection, because the risk of recurrence increases with the increasing number of lesions in the liver.

Transcript edited for clarity.

February 2014

• A 63-year old male with HBV
• ECOG=0
• Child-Pugh A; platelet count 230,000 cells/mcL
• Bilirubin 1.0 mg/dL; Albumin 3.5 g/dL
• CT scan revealed liver lesions, 1 is 2-cm; 1 is 5-cm both in the right lobe
• No extrahepatic disease
• Biopsy confirmed HCC diagnosis
• AFP=5400 IU/ml
• Tumors were resected with RO margin

August 2016

• Imaging showed recurrence in the liver, metastatic disease in the lungs
• Therapy was initiated with sorafenib 400 mg BID
• Therapy was well-tolerated

April 2017

• Radiographic progression with multiple lung metastases
• ECOG=0
• Therapy with regorafenib initiated at 160 mg
• Starting dose was well-tolerated, patient experienced some fatigue