Treatment of Huge HCC: Extending the Indications for Liver Resection

Abstract

To the Editor, We read with great interest the article by Pandey et al. concerning the outcome of patients with huge hepatocellular carcinoma (HCC). The authors reported that liver resection in patients with large HCC (>10 cm) can be safely performed with a reasonable long-term survival. It is of clinical interest that the presence of small contralateral lesions was not considered a contraindication for surgery. The outcome of this group of patients is very poor if surgical resection cannot be performed. However, a fundamental question is deciding who should undergo liver resection. Usually liver resection is indicated for patients with large tumours with preserved liver function only if a radical liver resection can be performed. Nevertheless, we have recently reported that in patients with large HCC who have also controlateral small lesions, the resection of the large lesion followed by trans-arterial chemoembolization (TACE) may be associated to satisfactory long-term survival. In addition, the continuous progress of nonsurgical treatments such as TACE has improved the survival of patients with unresectable HCC. Previous studies have demonstrated that the treatment of local recurrences with TACE is effective in prolonging patients survival. Similarly, we have found that the treatment of residual HCC with TACE can be effective in improving the survival. Considering the benefits of multimodal therapy for patients with large HCC, even an R2 resection may be indicated. We believe that, in selected patients with large HCC and small contralateral lesions, the indications for liver resection should be reviewed.