Comparison of Patterns and Outcomes of Liver Resection for Hepatocellular Carcinoma: East vs West

Surgical resection is the standard option and treatment of choice for localized hepatocellular carcinoma (HCC).1Jemal A. Bray F. Center M.M. et al.Global cancer statistics.CA Cancer J Clin. 2011; 61: 69-90Crossref PubMed Scopus (30254) Google Scholar, 2Kishi Y. Hasegawa K. Sugawara Y. et al.Hepatocellular carcinoma: current management and future development-improved outcomes with surgical resection.Int J Hepatol. 2011; 2011: 728103Crossref PubMed Google Scholar Difference in candidate selection and surgical practice of liver resection for HCC has been widely acknowledged between Eastern and Western centers.3Roayaie S. Jibara G. Tabrizian P. et al.The role of hepatic resection in the treatment of hepatocellular cancer.Hepatology. 2015; 62: 440-451Crossref PubMed Scopus (242) Google Scholar, 4Vibert E. Ishizawa T. Hepatocellular carcinoma: Western and Eastern surgeons' points of view.J Visc Surg. 2012; 149: e302-e306Crossref PubMed Scopus (8) Google Scholar However, direct comparisons between the 2 regions are still lacking, especially those that identify the differences in their surgical safety and long-term efficacy. This study aimed to compare the patterns and outcomes of liver resection for HCC between 2 large centers in the East and the West. We retrospectively collected the data from patients who underwent curative resection for HCC in 1 department of Eastern Hepatobiliary Surgery Hospital of Shanghai, China (the East group; n = 1229) and the Mount Sinai Hospital of New York (the West group; n = 268) from year 2000 to 2011. Patients’ characteristics, operative variables, perioperative outcomes, overall survival (OS), and time-to-recurrence (TTR) were compared between the 2 groups. Propensity score matching analysis was used to minimize bias related to patient selection and confounding variables. Multivariate Cox proportional hazards regression analyses were performed to identify independent predictors of OS and TTR after propensity matching. In the entire cohort, the East group had significantly worse liver function (higher Child-Pugh scores) and HCCs with more advanced stage (multiple tumors or tumors with vascular invasion or poorer differentiation), whereas the preoperative mortality and overall and major morbidity were comparable between the 2 groups (all P > .05). After confounding variables were balanced, the propensity score matching analysis created 239 pairs of patients from both groups. After matching, the West group had significantly more anatomic resections (69.5% vs 33.9%; P < .001) and major hepatectomies (38.1% vs 27.2%; P = .011), and the East group had shorter operative time (120 ± 38 vs 143 ± 51 min; P < .001). Preoperative and perioperative mortality and morbidity were comparable between the 2 groups (all P > .05). In the matched cohort, the OS and TTR rates were comparable between the East and West groups (P = .396 and P = .979), respectively. The 1-, 3-, and 5-year OS and TTR rates in the East and West groups before and after propensity match are shown in Figure 1. In this brief report, we did not identify significant difference in hospital mortality and morbidity (both overall and major), and long-term OS and TTR in patients undergoing liver resection for HCC between the 2 large hepatic surgical centers in the East and the West, although distinct patterns in patient characteristics and operative variables existed between 2 centers. The safety and efficacy of liver resection for HCC are comparable between the 2 centers that could be regarded as representatives of the East and the West: The Eastern Hepatobiliary Surgery Hospital is the largest hepatic surgery center in Asia with more than 4000 hepatic resections exclusively for HCC annually,5Yang T. Li L. Zhong Q. et al.Risk factors of hospital mortality after re-laparotomy for post-hepatectomy hemorrhage.World J Surg. 2013; 37: 2394-2401Crossref PubMed Scopus (11) Google Scholar and the Mount Sinai Hospital is 1 of the largest hepatic surgery centers in the United States with more than 350 hepatic resections and transplantations for HCC per year.6Franssen B. Alshebeeb K. Tabrizian P. et al.Differences in surgical outcomes between hepatitis B- and hepatitis C-related hepatocellular carcinoma: a retrospective analysis of a single North American center.Ann Surg. 2014; 260: 650-656Crossref PubMed Scopus (66) Google Scholar In the entire cohort of this study, patients in the East group had significantly poorer OS and shorter TTR than those in the West group. However, after subsequent propensity matching analysis, both the OS and TTR in the East and West groups were completely comparable. This indicates that the great gap of prognostic risk between the 2 centers observed in the entire cohort is caused by the differences in patient characteristics, rather than differences in surgical practice between the 2 centers. The independent predictors identified for poor OS and short TTR could be viewed as a validation of the restrictive criteria embodied in Western guidelines, notably those developed by the Barcelona Clinic Liver Cancer Program, in which surgery is only recommended for patients in whom optimal outcomes can be achieved, whereas surgery is viewed as the preferred treatment whenever technically feasible in Eastern countries and suboptimal results in high-risk patients are acceptable.7Romagnoli R. Mazzaferro V. Bruix J. Surgical resection for hepatocellular carcinoma: moving from what can be done to what is worth doing.Hepatology. 2015; 62: 340-342Crossref PubMed Scopus (20) Google Scholar Thus, a more comprehensive guideline with more tolerability is needed. The generalizability of our findings may be limited by its retrospective nature, the limited centers involved to represent the East and West, and the different surgical indications adopted among different centers. More global multicenter prospective studies with larger scale and higher patient volume on this issue are warranted. This work has been presented in the 9th Annual Conference of International Liver Cancer Association (Paris, France, September 4–6, 2015) as an oral communication and the 7th Asia-Pacific Primary Liver Cancer Expert Meeting (Hong Kong, China, July 8–10, 2016) as Best Oral Presentation.