Combined liver resection and transarterial chemoembolization versus liver resection alone for the management of solitary large exophytic hepatocellular carcinoma with extrahepatic arterial supply: is two always better than one?

Purpose
Does the control of extrahepatic arterial feeders with preoperative transarterial chemoembolization (TACE) in large exophytic hepatocellular carcinoma improve surgical and oncological outcomes compared with surgery alone?
Patients and methods
A total of 545 patients were assessed for eligibility, and 108 patients fulfilled the inclusion criteria and were assigned to either upfront surgery (group I) or surgery after TACE (group II).
Results
Patients in both groups had no significant difference with respect to age (=0.573), sex (=0.464), α-fetoprotein (=0.313), American Society of Anesthesiologists score (=0.820), and Child–Pugh score (=0.577). The mean tumor size was comparable (9.8±2.2 cm in group I vs. 10.3±2.3 cm in group II, =0.265). In group I, four patients underwent major hepatectomy, whereas 48 patients underwent minor hepatectomy. In group II, 54 patients underwent 121 TACE sessions with a mean of number of 2±0.8 session (range: 1–4 sessions). The mean interval between first TACE and surgery was 45±10.7 days (range: 12–72 days). Surgery after TACE had significantly higher rate of perihepatic adhesions (=0.006), longer operative time (<0.0001), increased blood loss (=0.035), and longer hospital stay (=0.020) compared with upfront surgery but with comparable outcomes regarding in-hospital and 30-day morbidity (=0.819). After a mean follow-up of 14.3±5.9 months, both groups had similar disease-free survival, with none of the tumors in both groups showed local recurrence. There was no significant difference in the type, time of recurrence following resection, or the mean numbers of new (de-novo) tumors detected in both groups (2.22±1.60 and 2.54±1.69 in groups I and II, respectively).
Conclusion
In patients with solitary large exophytic hepatocellular carcinoma, combined hepatic resection plus TACE is associated with increased perihepatic adhesions, increased operative time, blood loss, and postoperative hospital stay compared with liver resection alone. Preoperative TACE has no additional oncological benefit, with no reduction in recurrence rate or improvement in disease-free survival.