Selection criteria for resection in hepatocellular carcinoma: Can we expand them?

Abstract

Potential conflict of interest: Nothing to report. To the Editor: We read with interest the article by Roayaie et al.1 regarding the surgical management of hepatocellular carcinoma (HCC) within the Bridge database. As reported by the authors, about two‐thirds of resected patients were not ideal candidates for surgery according to published guidelines; in particular, 37% had portal hypertension (PH), and 7% were Child‐Pugh B‐C. However, factors traditionally associated with poor outcome, such as PH and bilirubin >1 mg/dL, were not correlated with survival if taken separately. Therefore, the authors suggest that selection criteria might be safely expanded to include patients with moderately elevated bilirubin or PH, highlighting the importance of considering both PH and liver function when assessing patients for resection. We recently published the results of a well‐characterized cohort of HCC patients (n = 48) undergoing liver resection at our center between 2010 and 2014.2 Patients underwent a hepatic venous pressure gradient (HVPG) and indocyanine green clearance measurement as part of the protocol used to assess resectability. All subjects were Child‐Pugh A5 and had a performance status of 0. Median HVPG was 6 mm Hg (range 2‐15), and 11 (23%) patients had HVPG ≥10 mm Hg but preserved liver function, defined as indocyanine green retention at 15 minutes of <15%. Four (8%) had bilirubin >1 mg/dL. In line with Roayaie et al., we found no correlation between PH and survival. Moreover, we have also explored the role of the albumin–bilirubin (ALBI) score, a newly developed HCC prognostic score in patients undergoing assessment for liver resection.3 In our cohort (n = 67) ALBI was the only factor significantly correlated with survival, independently of Child‐Pugh score and HVPG. Interestingly, of resected patients, only two (4%) were classified as ALBI 2, suggesting that ALBI 2 patients are unlikely to be considered suitable candidates for resection. In conclusion, we agree that current selection criteria for resection in HCC can be expanded to include patients with moderate PH, provided that an accurate assessment of liver function is performed. In this setting, indocyanine green clearance measurement appears to be a reliable method to evaluate liver function and ALBI score can identify patients who are unlikely to be suitable candidates for resection.