Liver cancer. Hepatocellular Carcinoma
Whether or not adjuvant treatment protocols are going to improve the outcome from these trials, I think remains to be seen. Again, I think that if you don’t have a surgeon who understands the scheme of the segmental anatomy of the liver, then these operations are going to be fraught with a great deal of risk. But as every surgeon knows, that even if you restrict these resections to patients with child’s A cirrhosis, many of these patients very quickly act like child’s B or child’s C cirrhotics after they’ve had part of their liver wiped out. So the Spanish group proposed a couple of years ago that there were two variables that really were important in trying to determine which of these patients would deteriorate after surgical resection and which wouldn’t, and they settled on the fact that the bilirubin needed to be normal and that these patients should have hepatic venography done and they should have the absence of portal hypertension. These are perhaps the true indicators of how a patient may do. Concrete indicators rather than simply flying by the seat of ones pants. Finally, the thing that comes over and over on resection is that if the tumor size is greater than 4-5 centimeters in size, the one to two year recurrence rate is going to be prohibitive. So these patients have to have limited disease, to the best of your ability to determine them.
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Percutaneous ethanol injection, on the other hand, can be considered for patients with worse liver function but still the tumor size has to be limited and it usually is ineffective in patients with tumors larger than 5 centimeters in size but can be considered for patients with multiple lesions, 3 centimeters in size or less. The treatment has to be thorough, and this should be in quotation marks because it’s difficult to determine what thoroughness is in this case. The Spaniards not only used loss of enhancement on contrast CT but actually will vigorously biopsy these patients after several sessions of alcohol injection to try to determine if viable tissue remains. We don’t do that. We do use rapid contrast CT scan at our institution and as long as there is evidence of a bit of rim enhancement or a bit of enhancement at the edge of the tumor, then our radiologists will continue to aggressively inject these tumors until that enhancement it lost. I think we’ve had reasonably good results in using that as a gauge for how much longer to continue.
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But point of fact, in patients with isolated lesions smaller than 5 centimeters in size, the Castell’s paper from four or five years ago showed that patients who are thoroughly treated with alcohol injection do about as well as patients with surgical resection. This shows the recurrence rates, one group compared to another, and you will note that it is discouragingly high in both groups within 24 months of treatment, but there is no significant difference between the two and certainly after 36 months there is no significant difference. Both plats level out. Again, not unexpectedly, the survival rates of these patients is also somewhat poor but alcohol injection in these carefully selected patients tends to work about as well as surgical resection. So I think that even here, the case for surgical resection tends to become weaker and, as some authors have pointed out, those patients who tend to be good candidates for surgical resection are probably good candidates for orthotopic liver transplantation also. Certainly in our institution there is more of a trend in that direction.