Diaphragmatic Involvement Should Not Preclude Curative-Intent Surgical Resection for Hepatocellular Carcinoma
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EDITORIAL – HEPATOBILIARY TUMORS
Diaphragmatic Involvement Should Not Preclude Curative-Intent Surgical Resection for Hepatocellular Carcinoma Aslam Ejaz, MD, MPH, and Timothy M. Pawlik, MD, MPH, PhD Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
Hepatocellular carcinoma (HCC) is an aggressive malignancy with an incidence that varies worldwide. In addition to underlying liver disease severity, treatment decisions for HCC often are dictated by tumor-related factors such as size, differentiation, and local invasion. We therefore read with interest the study by Orimo and colleagues1 regarding the impact of HCC diaphragmatic involvement on patients undergoing curative-intent surgical resection. The authors retrospectively analyzed a large cohort of 874 patients from Hokkaido University Hospital.1 Propensity score-matching was used to control for confounders to compare outcomes between patients undergoing hepatectomy for HCC who underwent diaphragmatic resection (DR) (5.3%) and those who did not. Perhaps not surprisingly, HCC with diaphragmatic involvement was associated with more advanced tumorrelated factors including higher alpha-fetoprotein (AFP) levels, larger tumor size, and higher incidence of portal and hepatic vein invasion. After control for these and other measurable confounders, DR was not found to be independently associated with short- or long-term outcomes after hepatectomy. In fact, patients who underwent DR had outcomes similar to those of individuals in the non-DR cohort. The aforementioned data were consistent with a previous report by Lin et al.,2 who reported on the safety of DR for HCC as well as with other studies on en bloc resection
Ó Society of Surgical Oncology 2020 First Received: 9 June 2020 A. Ejaz, MD, MPH e-mail: [email protected]
of different primary tumors combined with adjacent structures.3–6 For example, Kimchi et al.3 reported on the safety and efficacy of combined pancreaticoduodenectomy and extended right hemicolectomy for locally advanced pancreatic adenocarcinoma, sarcoma, and colon cancer. In a separate study, Hunter et al.4 similarly noted that patient survival after en bloc resection of colon cancer adherent to other organs was comparable with long-term outcomes after standard colectomy for nonadherent colorectal cancers. In addition, other studies have similarly noted comparable short- and long-term outcomes among patients undergoing cytoreduction with and without DR for gynecologic malignancies.5,6 Collectively, the data suggest that technical aspects of the case (i.e., need to resect adjacent structures such as the diaphragm) do not drive long-term outcomes. Rather, as expected, tumor-related rather than technical-related factors have an impact on prognosis. These data support an aggressive surgical approach to achieve complete tumor extirpation for well-selected patients who have locally advanced disease, including individuals with HCC and dia
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