Treatment Strategy to Improve Long-Term Survival for Hepatocellular Carcinoma Smaller than 5 cm: Major Hepatectomy vs Minor Hepatectomy

The extent of hepatectomy for solitary hepatocellular carcinoma (HCC) < 5 cm is controversial. This is a retrospective review of patients with solitary HCC < 5 cm, who underwent liver resection in a tertiary referral centre in Hong Kong between January 1989 and December 2009. Baseline demographics, liver function, peri-operative outcomes, and overall survival were compared. A total of 348 cirrhotic patients with a solitary HCC < 5 cm underwent either major hepatectomy (n = 93) or minor hepatectomy (n = 255). Child-Pugh status did not differ, 98.9 vs. 96.1 % (p = 0.319); all patients who underwent major and minor hepatectomy were classified as Child-Pugh status A. Patients who underwent major hepatectomy had a larger median tumor size (4.0 vs. 2.5 cm, p < 0.001) and they also had more advanced stage of disease (stage I/II/IIIa: 10.8/55.9/33.3 vs. 26.7/52.9/20.4 %, p = 0.002). Median operative time for major hepatectomy was significantly longer (415 vs. 248 min, p < 0.001) and entailed greater blood loss (0.9 vs. 0.5 l, p < 0.001). Despite larger tumor size and more advanced stage of disease in the major hepatectomy group, hospital mortality (5.4 vs. 2.0 %, p = 0.185), complication rates (30.1 vs. 23.1 %, p = 0.234), and transfusion rate (10.8 vs. 11.4 %, p = 0.862) were the same between the two groups. Overall survival was significantly better for those who underwent major hepatectomy, with a median survival of 147.5 vs. 92.1 months (p = 0.043), and they had a better 5- and 10-year disease-free survival rate (57.3 vs. 40.2, 38.1 vs. 18.9 %, p = 0.003). In subgroup analysis, the 10-year survival for patients with stage II HCC and tumor < 5 cm was 68.6 vs. 36.6 % in those who received minor hepatectomy alone (p = 0.027). Major hepatectomy provided better long-term survival benefit in patients with HCC < 5 cm, particularly in those with stage II disease.