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cost [ 10 ]. Specifi cally, resection was more likely to be recommended over transplantation for patients with small solitary tumors, while patients with small multifocal lesion were much more likely to be referred for transplantation [ 11 ]. Pomfret EA
et al. [ 12 ] also mentioned that the application of liver transplantation at very early
stages of HCC development may be futile when treated in patients with wellcompensated cirrhosis and very early HCC (single tumour of <2 cm in size; T1
stage [ 13 , 14 ]). Due to the current issues about transplantation in China, this kind of
therapy may be excluded from our fi rst treatment of choice for small HCC.
Hepatectomy and ablation are another two treatment options available for small
HCC that will potentially have a positive impact on survival . Not surprisingly, resection and ablation have achieved excellent survival outcomes in this setting, in the
range of 60–70 % at 5 years [ 15 , 16 ]. Resection has generally been accepted as the
fi rst treatment of choice for HCC in many centers. It is recommended by surgeons
and allows for better local control, with an overall mortality rate less than 5 % in
cirrhotic patients and long-term survival up to >50 % after adequate anatomical
resections [ 17 , 18 ]. Anatomical hepatectomy is defi ned to preliminarily make blood
occlusion of hepatic segments and sectors where tumor located and then undergo
liver resection according to anatomical range. This approach resected the whole
tumor and the hepatic segments and sectors which its portal venous branches allocated. It may ensure the negative incisal margin and decrease the intrahepatic spread
of the tumor. After reforming the operation skill, our new approach is probably able
to precisely dissect the hepatic pedicle which the required resected segments are
affi liated and not need to excessively dissect more fi brous connective tissues of hilar
plate and gallbladder bed (Figs. 15.2 and 15.3 ), consequently, more normal liver are
remained by the skill. Previous study also revealed that precise hemihepatectomy
guided by middle hepatic vein resulted in fewer incidences of postoperative complications and had the potential to achieve more adequate tumor- free resection margin,
which may result in higher tumor-free survival rate [ 19 ]. For the nodules in the left
lateral lobe, laparoscopic hepatectomy may be another kind of surgical choice. In
addition, when patients’ performance status permitted, resection is still the fi rst-line
treatment for small nodules in right posterior and middle lobe. Therefore, surgical
resection was regarded as a fantastic treatment option for small HCC.
However, less than 30 % of patients with small HCC are eligible for surgery ,
mainly because of the multiplicity and heterogeneity of the lesions that often occurs
in a background of chronic liver disease, bad liver function, and deteriorating general condition [ 20 , 21 ]. So, many nonsurgical ablative methods have been devel-
oped, such as cryoablation, percutaneous ethanol injection (PEI), acetic acid
injection, radiofrequency ablation ( RFA ), microwave coagulation, and transcatheter
arterial chemoembolization ( TACE ) [ 22 ]. Among these modalities, Radiofrequency
(RFA) is now the fi rst-line technique for ablation [ 23 ]. Treatment strategy for HCC
is mainly decided according to the tumor size, tumor number, liver function and
performance status. For small HCC, liver function, which is evaluated by three parts
such as Child-Pugh grade, MELD score and the retention rate of ICG in 15 min
(R15), may play a pivotal role in guiding decision making. If a patient is diagnosed
as small HCC with bad liver function (MELD score >9 [
24 ] or ICG-R15 >20 %
15 Treatment Protocols for Small Hepatocellular Carcinoma (3 cm): RFA or Resection?
182
[ 25 ]), RFA will be considered as fi rst line probably. Nevertheless, there is still con-
troversy regarding the treatment choices for small HCC [ 26 ] although recent
advances in RFA technology have enabled clinicians to use RFA for larger tumors
[ 27 ]. While a robust trial appropriately comparing resection and ablation is still not
available [ 28 ], large case-control series and modelling studies support RFA as a
non-inferior [ 29 ] and more cost -effective [ 30 ] treatment for very early HCCs. Wakai
T et al. [ 31 ] proved that hepatectomy provides both similar local control and better
long-term survival for patients with HCC 4 cm in comparison with percutaneous
ablation. A nonrandomized prospective study suggested that resection is superior to
RFA in long-term survival [ 29 ]. Moreover, a recently reported randomized trial con-
fi rmed that in patients with small HCC, percutaneous RFA showed similar local
control and long-term survival compared with hepatectomy but are accompanied
with a lower complication rate and shorter hospital stay day [ 32 ].
Results
As far as we know, there have been rare randomized trials to compare the effi cacy
of RFA with that of surgical resection for an operable early-stage HCC in terms of
survival for HCCs 3 cm [ 33 , 34 ]. In our opinion, a new risk factor like gross
Fig. 15.2 Anatomical liver S4, 5, 8 resection . Boundary type of single nodular small HCC
Y. Qiu and Y. Mao
183
classifi cation should be added in to further help make decision in treatment choice
for small HCC. The concept of gross classifi cation for HCC was fi rst put forward in
1984 by Okuda K et al. [ 35 ]. According to those studies made by the Japanese
scholars, HCC nodules were divided into four groups based on the classifi cation in
The general rules for the clinical and pathological study of primary liver cancer ,
4th ed ., established by the Liver Cancer Study Group of Japan [ 36 ]: single nodular
type (Fig. 15.4 ), single nodular type with extranodular growth, confl uent multi-
nodular type and invasive type (Fig. 15.5 ). In total, 88 patients with small HCC
treated by RFA were divided into two groups on the basis of gross classifi cation
distinguished through preoperative imaging data. Our incipient results revealed that
the single nodular type group (SN) had signifi cantly better overall survival (OS) and
recurrence- free survival (RFS) than the non-single nodular type group (non-SN)
( P < 0.05) (Figs. 15.6 and 15.7 ). This signifi cance indicated that not all the patients
with small HCC are applicable for RFA treatment, so as to say, resection may be
more benefi cial for patients with the nonboundary type of small HCC.
Fig. 15.3 Anatomical liver S5 resection . Infi ltrating small HCC lesion
15 Treatment Protocols for Small Hepatocellular Carcinoma (3 cm): RFA or Resection?
184
Risk of Recurrence
One of the greatest problems plaguing potential curative treatment for HCC is the
high risk of recurrence (i.e., ablation and surgical resection ). Whichever modality
we choose to treat small HCC, recurrence and follow-up work should not be ignored.
Early recurrence due to dissemination is likely to have poorer prognosis than late
recurrence as it happens after resection. Tumor seeding due to tumor puncture for
diagnosis or ablation is the most important, as it is associated with a poor prognosis
among the patterns of recurrence [
37 , 38 ]. In current study, local recurrence was
found to be more frequent after RFA than after HR. Local recurrences after RFA
may be attributable to insuffi cient ablation of the primary tumor and/or the presence
of tumor venous invasion in the adjacent liver [ 22 ]. Solving these problems,
Fig. 15.4 Based on imaging examination, the macroscopic type was single nodular small HCC .
( a ) plain CT . ( b ) arterial phase. ( c ) portal phase CT computed tomography
Fig. 15.5 Based on imaging examination, the macroscopic type was invasive small HCC . ( a ) plain
CT . ( b ) arterial phase. ( c ) portal phase CT computed tomography
Y. Qiu and Y. Mao
185
prolongation of the follow-up time is needed and might be benefi cial for the comparison of the disease-free and overall survival rates between RFA and hepatectomy . Resection or TACE when indicated would be the great treatment of choice
against intrahepatic recurrences.
Conclusion
As previously stated, treatment decision in patients with small HCC should be individualized according to the parameters at fi rst diagnosis . Combined with current
research, three curative therapies (surgical resection , transplantation, RFA ) are effi cacious for small HCC. How to select an appropriate treatment seems to be a bit
vague in order to achieve a better prognosis. Shown in our results, gross classifi cation may play a pivotal role in therapy decision making for small HCC. In summary,
comprehensive diagnosis and treatment is essential for future survival in patients
with HCC. For these results to take place, all factors should be considered in
.00
SN
non-SN
non-SN-censored
SN-censored
0.0
0.2
0.4
0.6
0.8
1.0
20.00 40.00 60.00
Months after Surgery
Cum Recurrence-free Survival
Fig. 15.6 Recurrence-free survival curves for patients with small HCC treated by RFA between
SN and non-SN group ( P = 0.21)
15 Treatment Protocols for Small Hepatocellular Carcinoma (3 cm): RFA or Resection?
186
treating small HCC. Only by combination of the past clinical experience, the current
recommendations from guidelines and the latest research results will allow those
patients to achieve benefi ts.
Recommendations
• For Asian patients with HBV-related small HCC , we recommend the use of RFA
and resection to treat small HCC.
• For patients with Child-Pugh A and MELD score <9, resection should be consid-
ered. However, patients with MELD score >10, cirrhosis and portal hypertension
are tending to be treated with RFA .
• There is evidence for RFA to treat those patients with the boundary type of small
HCC in accordance with gross classifi cation .
• Specifi cally, infi ltrating hepatocellular carcinoma (iHCC) described as invasive
type in gross classifi cation was suggested to be treated with anatomical resection
due to the high recurrence rate if managed with RFA .
.00
non-SN
SN
non-SN-censored
SN-censored
Months after Surgery
Cum Overall Surgery
0.0
0.2
0.4
0.6
0.8
1.0
20.00 40.00 60.00 80.00 100.00
Fig. 15.7 Overall survival curves for patients with small HCC treated by RFA between SN and
non-SN group ( P = 0.19)
Y. Qiu and Y. Mao
187
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189© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_16
Chapter 16
Which Is the Better Predictor of Hepatic
Reserve Prior to Liver Resection: MELD
or the Child-Pugh Score?
Trevor W. Reichman and Humberto Bohorquez
Abstract Critical assessment of the hepatic reserve is essential prior to liver resec-
tion especially in patients with chronic liver disease. Development of liver dysfunction post resection can result in a signifi cant increase in associated complications
resulting in prolonged length of hospital stay and increased hospital costs. In addition, the development of liver failure is almost universally fatal unless the patient
can undergo liver transplantation. Several scoring systems have been identifi ed
which assess the degree of liver disease including the Child-Turcotte-Pugh scoring
system (CTP) and the Model for End Stage Liver Disease (MELD). Both of these
scoring systems have been used to predict mortality post liver resection. Based on
the current available literature, MELD appears to be the best predictor of postoperative liver dysfunction/failure in patients with cirrhosis, and patients with MELD
scores 9 should not be considered for hepatic resection. Other factors not included
in MELD such as platelet count, presence of portal hypertension, extent of liver
resection (and the resulting residual liver volume) and the presence of ascites should
also be considered when selecting patients with chronic liver disease to undergo
liver resection.
Keywords Hepatectomy • Liver resection • MELD • Child-Pugh Score • Liver failure • Cirrhosis
Introduction
Recent surgical advances in liver resection s have improved the safety and complication rates from this complex operation, and a hepatectomy is now a well-accepted
treatment for patients with both benign and malignant liver tumor s and metastatic
T. W. Reichman (*) • H. Bohorquez
Multi-Organ Transplant Institute, Department of Surgery , Ochsner Medical Center ,
1514 Jefferson Highway , New Orleans , LA 70121 , USA
e-mail:
treichman@ochsner.org
190
cancers to the liver. The presence of an adequate, healthy remnant liver is essential
in order to prevent postoperative liver dysfunction and/or liver failure after liver
resection and is especially critical in patients with known chronic liver disease. In
the case of hepatocellular cancer ( HCC ), >80 % of the patients diagnosed have
chronic liver disease [ 1 ]. With donor shortages across the globe, not all patients with
chronic liver disease can undergo transplantation for HCC [ 2 ]. Appropriate assess-
ment of the hepatic reserve is essential to avoiding post-operative liver dysfunction
and liver failure.
Liver Failure Following Liver Resection
Progression of liver dysfunction to liver failure is almost universally fatal unless the
patient can undergo liver transplant ation . Post- hepatectomy liver failure was
recently defi ned by the International Study Group of Liver Surgery (ISGLS) as the
inability of the liver to maintain its synthetic, excretory, and detoxifying functions,
which is manifested by an increased INR and hyperbilirubinemia on or after postoperative day 5 [ 3 ]. The reported rate of liver failure varies between 1.2 and 32 %
depending on the study population [ 3 ]. Liver dysfunction post liver resection ulti-
mately results in increased length of stay and increased hospital costs. Recently,
post operative liver dysfunction was also linked to post resection disease-free survival in patients undergoing resection for HCC [ 4 ].
Evaluation of the Degree of Chronic Liver Disease
It is well established that there is an increased risk performing surgery on patients
with chronic liver disease and cirrhosis . This increased risk derives from both factors associated with chronic liver disease (e.g. portal hypertension, ascites , thrombocytopenia, and coagulopathy) and also the potential exacerbation of liver
dysfunction secondary to general anesthesia and a laparotomy incision. Based on
several studies, mortality can be as high as 70–80 % in patients with advanced cirrhosis [ 5 , 6 ].
Based on this knowledge, it is not surprising that there is also an increased risk
in performing liver resections on patients with chronic liver disease. Accurate
assessment of the functional reserve is critical prior to liver resection especially in
patients with chronic liver disease. Two well-known scoring systems are the Model
for End Stage Liver Disease ( MELD ) and the Child-Turcotte-Pugh (CTP) scoring
system. The accuracy of these tests in predicting hepatic dysfunction post liver
resection is still debated.
The CTP score was initially reported in 1964 as a way to assess liver function in
patients with chronic liver disease and was later modifi ed by Pugh in 1973 [
7 , 8 ].
The current scoring system utilizes the serum bilirubin, serum albumin, prothromin
T.W. Reichman and H. Bohorquez