When to perform hepatic resection for intermediate-stage hepatocellular carcinoma

Authors

  • Alessandro Cucchetti,

    Corresponding author
    1. Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum–University of Bologna, Bologna, Italy
    • Address reprint requests to: Alessandro Cucchetti, M.D., Policlinico Sant'Orsola-Malpighi, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy. E-mail: aleqko@libero.it; fax: +39-051-304902.

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  • Benjamin Djulbegovic,

    1. Division of Evidence-based Medicine, Department of Internal Medicine, University of South Florida and H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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  • Athanasios Tsalatsanis,

    1. Division of Evidence-based Medicine, Department of Internal Medicine, University of South Florida and H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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  • Alessandro Vitale,

    1. Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy
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  • Iztok Hozo,

    1. Department of Mathematics and Actuarial Science, Indiana University Northwest, Gary, IN
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  • Fabio Piscaglia,

    1. Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum–University of Bologna, Bologna, Italy
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  • Matteo Cescon,

    1. Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum–University of Bologna, Bologna, Italy
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  • Giorgio Ercolani,

    1. Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum–University of Bologna, Bologna, Italy
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  • Francesco Tuci,

    1. Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy
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  • Umberto Cillo,

    1. Department of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy
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  • Antonio Daniele Pinna

    1. Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum–University of Bologna, Bologna, Italy
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  • Potential conflict of interest: Dr. Cillo consults and advises Novartis and advises Astellas. Dr. Piscaglia advises, is on the speakers' bureau of, and received grants from Bayer.

Abstract

Transcatheter arterial chemoembolization (TACE) is the first-line therapy recommended for patients with intermediate hepatocellular carcinoma (HCC). However, in clinical practice, these patients are often referred to surgical teams to be evaluated for hepatectomy. After making a treatment decision (e.g., TACE or surgery), physicians may discover that the alternative treatment would have been preferable, which may bring a sense of regret. Under this premise, it is postulated that the optimal decision will be the one associated with the least amount of regret. Regret-based decision curve analysis (Regret-DCA) was performed on a Cox's regression model developed on 247 patients with cirrhosis resected for intermediate HCC. Physician preferences on surgery versus TACE were elicited in terms of regret; threshold probabilities (Pt) were calculated to identify the probability of survival for which physicians are uncertain of whether or not to perform a surgery. A survey among surgeons and hepatologists regarding three hypothetical clinical cases of intermediate HCC was performed to assess treatment preference domains. The 3- and 5-year overall survival rates after hepatectomy were 48.7% and 33.8%, respectively. Child-Pugh score, tumor number, and esophageal varices were independent predictors of survival (P < 0.05). Regret-DCA showed that for physicians with Pt values of 3-year survival between 35% and 70%, the optimal strategy is to rely on the prediction model; for physicians with Pt <35%, surgery should be offered to all patients; and for Pt values >70%, the least regretful strategy is to perform TACE on all patients. The survey showed a significant separation among physicians' preferences, indicating that surgeons and hepatologists can uniformly act according to the regret threshold model. Conclusion: Regret theory provides a new perspective for treatment-related decisions applicable to the setting of intermediate HCC. (Hepatology 2015;61:905–914)

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