Liver cancer information
This slide, I think, depicts why we have a bias and that is because we think we are accomplishing something with preoperative chemo-embolization and when we look at the alpha-fetoprotein levels, when Denise looked at the alpha-fetoprotein levels on patients pretreatment, following chemo-embolization at the time of OLT ( orthotopic liver transplant), there was a fairly dramatic drop in the alpha-fetoprotein indicating that chemo-embolization was certainly accomplishing something in these patients and in six months after OLT remained quite low.
Let’s look then at transarterial embolization, or chemo-embolization, not necessarily in a setting of patients who are transplant candidates. This very important paper from Spain came out last year in Hepatology, where they looked at the probability of progression of the initial presenting tumor in patients who were treated with transarterial embolization without chemotherapy added. As you can see, the probability that the tumor would progress over a very short time was really quite high in both groups and there was no significant difference in either group, either embolized or the group that were treated “symptomatically”. As you might expect, the survival curves also fail to show an advantage from transarterial embolization. This nice paper from the French group several years ago in Hepatology had looked at the effect of chemo-embolization, first as a control group and actually suggested that the group who were chemo-embolized did worse than the patients who were treated symptomatically, although the differences were not significant. So I think there has now developed over the last decade or so a general feeling that embolization, whether or not it’s accompanied by chemotherapy, is not a particularly effective way to treat hepatocellular carcinoma. Several papers, including this paper, showed a fairly significant anti-tumoral effect from the treatment but it does not affect survival in these patients. So even though we are somewhat excited about the use of this modality in patients who are waiting on the liver transplant list, there seems to be little reason for enthusiasm in patients who are otherwise untreatable. I would furthermore point out that there is no significant difference between us in studies that are shown in comparison between chemo-embolization and simply arterial embolization. Head-to-head, there is no advantage, one over the other.
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Let’s talk now about surgical resection. Surgical resection continues to come up I think, not only with regard to those patients who don’t have cirrhosis and therefore can undergo segmental or subsegmental resection, but also in regions of this country where waiting lists for liver transplantation may exceed two years. Fortunately United Network of Organ Sharing has made it possible for patients with hepatocellular carcinoma to be listed as a status II-b, which brings some of them into the operating room sooner than they might have otherwise been able to be operated on, but we are still concerned about these long waits until some groups continue to consider patients with reasonably well-maintained liver function for resection. It requires, certainly, a good knowledge of subsegmental anatomy and I think that one of the reasons that we’ve progressed in our ability to operate on these patients is our modern hepatobiliary surgeons have a very good knowledge of subsegmental anatomy and the use of inflow or vascular occlusion in a relatively dry field.