Hepatectomy After Conversion Therapy for Initially Unresectable HCC: What is the Difference?

Abstract

Purpose: Conversion therapy gives some patients with initially unresectable hepatocellular carcinoma (HCC) access to surgery. The purpose of this study was to evaluate the safety and efficacy of hepatectomy after conversion therapy and how it differed from those who undergoing direct hepatectomy.

Patients and methods: From January 2018 to April 2022, 745 patients underwent hepatectomy for HCC were enrolled. Among them, 41 patients of unresectable HCC underwent hepatectomy after conversion therapy. A demographically and clinically comparable cohort was created from the remaining patients in a 1:1 ratio using propensity score matching.

Results: The median duration of conversion therapy was 108 (42-298) days, 8 patients achieved complete response (CR) and 33 achieved partial response (PR). Conversion therapy resulted in some degree of myelosuppression, but liver function index remained good. Compared with the direct hepatectomy group, the conversion group had more blood loss (600 mL vs 400 mL, p=0.015), longer operative time (270 min vs 240 min, p=0.02), higher blood transfusion rates, and longer hospital stay (8 days vs 11 days, p<0.001). Patients in the conversion group had significantly more complications of any grade (82.9% vs 51.2%, p=0.002) and grade 3/4 (26.8% vs 4.9%, p=0.013), and 6 patients developed post-hepatectomy liver failure (PHLF). There were no deaths in either group. All patients achieved R0 resection, 6 (6/41, 14.6%) achieved pathological complete response (pCR), 14 achieved major pathologic responses (MPR). During a median follow-up of 12.8 months, 14 patients in the conversion group experienced recurrence or metastasis, no deaths.

Conclusion: Hepatectomy after conversion therapy was more difficult than direct hepatectomy, but accurate preoperative assessment could ensure the safety of the surgery. The damage of liver function after conversion therapy was more severe than expected, PHLF should be prevented and treated. Hepatectomy was effective and necessary, postoperative pathological examination could provide guidance for adjuvant therapy.

Keywords: conversion therapy; hepatectomy; hepatocellular carcinoma; pathological complete response; post-hepatectomy liver failure.

Conflict of interest statement

The authors report no conflicts of interest in this work.

© 2022 Luo et al.

Figures

Figure 1

The flowchart of article.

Figure 2

Effects of conversion therapy on biochemical indexes of patients and comparison between preoperative and direct hepatectomy groups. Group A: Patients in the conversion group before receiving treatment; Group B: Patients in the conversion group before undergoing hepatectomy; Group C: Patients in direct hepatectomy group. *P

Figure 3

Comparison of postoperative complications between the two groups.

Figure 4

A 51-year-old male patient was diagnosed multiple HCC with maximum tumor diameter 14.7*11.6cm (BCLC B stage). Patients received 4 cycles of HAIC combined with systemic therapy (lenvatinib 8 mg/day and camrelizumab 200 mg every 3 weeks for 5 cycles). After 110 days of conversion therapy, the patient underwent S5, S6, S7 segments hepatectomy. H&E staining of the surgically resected specimen showed a pCR. (A) after entering the abdominal cavity, mild abdominal adhesion was observed; (B) gallbladder inflammation was obvious; (C) section of the liver after tumor resection; (D) resected specimen; (E) H&E staining of resected specimen (magnification ×100); (F) H&E staining of resected specimen (magnification ×200).

Figure 5

A 46-year-old male patient was diagnosed with giant HCC (24*15.2cm) involving the left lobe and right anterior segment of liver with left portal vein tumor thrombus (BCLC C stage). Patients received 6 cycles of HAIC combined with systemic therapy (lenvatinib 12 mg/day and camrelizumab 200 mg every 3 weeks for 6 cycles). After 166 days of conversion therapy, the patient underwent hepatectomy. The Operative programme was planned through 3D reconstruction preoperatively, and an extended left hemihepatectomy was performed. HAIC combined with camrelizumab and lenvatinib was continued as adjuvant therapy after surgery, and no tumor recurrence was observed until August 2022. (A) (B) Prior treatment MRI; (C) Preoperative CT; (D) Preoperative 3D reconstructed images; (E) CT image at 1 month after surgery; (F) CT image at 13 months after surgery.