Portal hypertension should not be a contraindication of hepatic resection to treat hepatocellular carcinoma with compensated cirrhosis

Abstract

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. To the Editor: We read with great interest the article by Berzigotti et al.1 recently published in Hepatology. They observed that the presence of clinically significant portal hypertension (PH) negatively affects outcomes after hepatic resection (HR) to treat hepatocellular carcinoma (HCC) with compensated cirrhosis. Nevertheless, we believe that limitations in the study by Berzigotti et al.1 and results from our own medical center and elsewhere argue that PH should not be considered a contradiction of HR in such cases. Berzigotti et al.1 reported the outcomes of postoperative mortality and clinical decompensation, but they did not report the highly relevant outcomes of overall or disease‐free survival. Given that extending life expectancy is the goal of HR, the outcomes of long‐term overall and disease‐free survival are as clinically relevant, if not more so, than perioperative morbidity and mortality. In addition, Berzigotti et al.1 did not examine whether their results depended on Barcelona Clinic Liver Cancer (BCLC) stage or extent of hepatectomy (major or minor). This substantially limits their conclusions, given that numerous studies suggest that prognosis after HR depends strongly on BCLC stage. Although the results reported by Berzigotti et al.1 may lead clinicians to consider PH a contraindication for HR in HCC patients with compensated cirrhosis, we believe the weight of available evidence argues the opposite. A systematic literature search as well as retrospective study of more than 1,700 patients treated at our medical center between 2007 and 2010 revealed that median perioperative mortality during HR in HCC patients with PH is 6.7%.2 A previous retrospective study of more than 1,200 patients treated at our medical center between 2000 and 2007 found a median perioperative mortality of 10.3%,4 suggesting that improvements in surgical technique and perioperative care are lowering the mortality associated with HR. Our retrospective analysis further showed that long‐term survival of HCC patients with PH was higher after HR than after transarterial chemoembolization.4 In fact, such patients showed higher median overall and disease‐free survival at 1, 3, and 5 years after HR than did those with multinodular HCC or HCC involving macrovascular invasion.2 Retrospective subgroup analysis of our patients showed that short‐ and long‐term overall survival was similar in the presence or absence of PHT if the patients had early‐stage HCC or had undergone only minor hepatectomy, or if propensity score matching was used to eliminate baseline differences.3 Recurrence rates after HR were also similar in patients with or without PH.3 We suggest that despite being a negative prognostic factor, PH should not be regarded as an absolute contraindication to HR in HCC patients with compensated cirrhosis. Indeed, Berzigotti et al.1 seem to acknowledge this in their Conclusion section. We recommend that HR be considered a first‐line therapy for HCC patients with compensated cirrhosis, as well as for patients with early‐stage HCC and HCC patients scheduled to undergo minor hepatectomy, especially when liver transplantation and radiofrequency ablation are not indicated. In any event, PH should be measured directly whenever possible, given that not all patients diagnosed with PH using indirect methods actually fulfill the Barcelona group cutoff of ≥10 mmHg.5