1. Locally-Advanced HCC:
Great Debates & Updates in GI Malignancies
Debate:
Locally-Advanced HCC:
Surgery is Optimal
Michael A. Choti, MD
Department of Surgery
UT Southwestern Medical Center
Dallas, Texas

2. Disclosures Beyer Healthcare: research, consultant
Bristol Mayer Squibb: research, consultant

3. Treatment Options for HCC
CURATIVE THERAPIES:
Liver Resection
Liver Transplantation
Tumor Ablation
PALLIATIVE THERAPIES:
Chemoembolization
Chemotherapy
Radiation Therapy

4. Management of HCC No cirrhosis Child A Extrahepatic Spread Locally
Unresectable
Resectable
No cirrhosis
Resectable
Child A
T1 or T2
(1/5 or 3/3 rule)
with poor
liver function
(Child, B or C)
Biopsy to confirm
Small
(<5cm)
Large
(>5cm)
RFA
PEI
Palliative TACE or
Systemic
Chemotherapy
Supportive Care
TACE/Y90
Resection
RFA
Total Hepatectomy
or Supportive
Care

7. Operative Mortality for HCC:
More Recent Series
Author n % Cirr % Mort
Torzilli (99) % %
Midorikawa (99) % %
Fong (99) % %
Fan (99) % %

8. Results of Hepatectomy for HCC
Author n 1-year surv (%) year surv (%)
Fong (1999)
Llovett (1999)
nl bili, no portal HT
Takayama (2000)
Arii (2000)
Stage 1,<2cm
Stage 1, 2-5cm Stage 2, <2cm
Stage 2, 2-5cm
Grazi (2001)
Wayne (2002)

9. Milan/UNOS Criteria for Transplantation
Single lesion of ≤ 5cm or
2 or 3 lesions, none > 3cm
No gross vascular invasion
No regional nodal or distant metastases

10. BCLC Staging System for HCC

11. BCLC Staging System for HCC
A early single <5-cm or
3 nodules <3-cm each
B intermediate Large, multi-nodular
C advanced vascular invasion and/or
extrahepatic disease

12. Liver Resection vs Intraarterial therapy?
Framing the Debate
Resectable Disease
Child A
Anatomically resectable
Outside Milan criteria
Locally Advanced
Large size
Multifocal disease
Major vascular invasion
Nodal involvement
Liver Resection vs Intraarterial therapy?

13. Liver Resection for Multiple HCCs
367 TACE
404 BSC
Retrospective cohort comparison
National Taiwan University
1065 patients with multiple HCCs
Ho et al. Ann Surg Onc (2009)

15. Resection vs TACE for Multiple HCCs: RCT
2 TUMORS
>2 TUMORS

16. Multifocal HCC Prognosis and management can vary based on biology
Satellitosis
Multifocal (field defect)
Intrahepatic metastases

17. Liver Resection for HCC Invading Major Portal and/or Hepatic Veins
no portal vein involvement
distal to second trunk
within second trunk
first branch
main portal trunk

18. Liver Resection for HCC with Major Vein Involvement
Large retrospective cohort study from Japan (94-11)
Among 1523 HCC resections, major venous involvement:
153 portal vein
21 hepatic vein
13 IVC
Mortality 2-5%
Acceptable long-term outcome
Worse survival with IVCTT
Kokudo et al. J Hepatology (2014)

19. Liver Resection for Node Positive HCC
positive hilar nodes

20. Potentially Resectable But Locally Advanced?
Liver Resection
TACE/Y-90/SRT or
Liver Resection
TACE/Y-90/SRT
followed by
Defines biology and improves patient selection
Response can improve resectability

22. Thank You