ASO Author Reflections: Is Hepatectomy Plus Diaphragmatic Resection for Hepatocellular Carcinoma with Diaphragmatic Invo
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Is Hepatectomy Plus Diaphragmatic Resection for Hepatocellular Carcinoma with Diaphragmatic Involvement Justified? Tatsuya Orimo, MD PhD, Toshiya Kamiyama, MD PhD FACS, and Akinobu Taketomi, MD PhD FACS Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
PAST
PRESENT
Hepatic resection is the accepted treatment for hepatocellular carcinoma (HCC), but the validity of a hepatectomy combined with diaphragmatic resection for treating HCC with diaphragmatic involvement is still unclear. Although a peripherally located large HCC, in particular located in segment VII or VIII of the liver, is prone to diaphragmatic involvement, it is difficult during an operation to discriminate between the histological invasion of the diaphragm and a strictly fibrous adhesion only.1, 2 In addition, HCCs with gross diaphragmatic involvement tend to have abundant blood flow from the surrounding mesenteries and diaphragm.3 Thus, when a HCC tumor is suspected to have infiltrated the diaphragm, a hepatectomy combined with diaphragmatic resection is thought to be important to avoid such intraoperative bleeding risk or tumor rupture, because a forcible dissecting approach to the diaphragm typically triggers bleeding from the surface of the tumor. Infiltration of the diaphragm of HCC is common in advanced cases, such as those harboring very large tumors. However, no prior study has matched the clinicopathological background of these patients, and this has caused a selection bias.
A total of 874 HCC patients who underwent liver resection between 1999 and 2018 were enrolled in our study, and these cases were divided into two groups: 46 HCC patients with diaphragmatic resection (DR group) and 828 HCC patients without diaphragmatic resection (nonDR group). Because the DR group cases were pathologically more advanced than those in the non-DR group, we applied 1:1 propensity score matching (PSM) to these subjects to match the clinicopathological features. There was no statistically significant difference between the two groups in terms of perioperative outcomes, overall survival, or relapse-free survival in these matched cohorts. Multivariate analyses of the matched HCC patients revealed that neither diaphragmatic invasion nor diaphragmatic resection was found to be a prognostic factor for either overall survival or relapse-free survival. The most frequent site of recurrence in the non-DR group was the liver, whereas the most frequent site of recurrence in the DR group was the lung before and after PSM.4
Ó Society of Surgical Oncology 2020 First Received: 18 May 2020 T. Orimo, MD PhD e-mail: [email protected]
FUTURE The short- and long-term surgical outcomes of DR and non-DR HCC patients are similar under a matched clinicopathological background. A hepatectomy combined with diaphragmatic resection is therefore an acceptable treatment for HCC with diaphragmatic involvement. However, HCC that requires diaphragmatic resection tends
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