Surgery for Intermediate and Advanced Hepatocellular Carcinoma: A Consensus Report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014)

Ming-Chih Ho; Kiyoshi Hasegawa; Xiao-Ping Chen; Hiroaki Nagano; Young-Joo Lee; Gar-Yang Chau; Jian Zhou; Chih-Chi Wang; Young Rok Choi; Ronnie Tung-Ping Poon; Norihiro Kokudo

doi:10.1159/000449336

Surgery for Intermediate and Advanced Hepatocellular Carcinoma: A Consensus Report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014)

Liver Cancer. 2016 Oct;5(4):245-256. doi: 10.1159/000449336. Epub 2016 Sep 14.

Authors

Affiliations

¹ Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan (ROC).
² Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
³ Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
⁴ Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
⁵ Department of Surgery, Asan Medical Center, Seoul, Republic of Korea.
⁶ Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC).
⁷ Department of Liver Surgery and Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
⁸ Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan (ROC).
⁹ Department of Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea.
¹⁰ Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China.

Abstract

Background: The Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy does not recommended surgery for treating BCLC stage B and C hepatocellular carcinoma (HCC). However, numerous Asia-Pacific institutes still perform surgery for this patient group. This consensus report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting aimed to share opinions and experiences pertaining to liver resection for intermediate and advanced HCCs and to provide evidence to issue recommendations for surgery in this patient group.

Summary: Thirteen experts from five Asia-Pacific regions were invited to the meeting; 10 of them (Japan: 2, Taiwan: 3, South Korea: 2, Hong Kong: 1, and China: 2) voted for the final consensus. The discussion focused on evaluating the preoperative liver functional reserve and surgery for large tumors, multiple tumors, HCCs with vascular invasion, and HCCs with distant metastasis. The feasibility of future prospective randomized trials comparing surgery with transarterial chemoembolization for intermediate HCC and with sorafenib for advanced HCC was also discussed. The Child-Pugh score (9/10 experts) and indocyanine green retention rate at 15 min (8/10) were the most widely accepted methods for evaluating the preoperative liver functional reserve. All (10/10) experts agreed that portal hypertension, tumor size >5 cm, portal venous invasion, hepatic venous invasion, and extrahepatic metastasis are not absolute contraindications for the surgical resection of HCC. Furthermore, 9 of the 10 experts agreed that tumor resection may be performed for patients with >3 tumors. The limitations of surgery are associated with a poor liver functional reserve, incomplete tumor resection, and a high probability of recurrence.

Key messages: Surgery provides significant survival benefits for Asian-Pacific patients with intermediate and advanced HCCs, particularly when the liver functional reserve is favorable. However, prospective randomized controlled trials are difficult to conduct because of technical and ethical considerations.

Keywords: Hepatocellular carcinoma; Outcome; Staging system; Surgery.