title: Optimizing the management of patients with BCLC stage-B hepatocellular carcinoma: Modern surgical resection as a feasible alternative to transarterial chemoemolization.
abstract: OBJECTIVE
  To analyse the impact of liver resection (LR) in patients with Hepatocellular Carcinoma (HCC) within the Barcelona-Clinic-Liver-Cancer (BCLC)-B stage.
  
  
  METHODS
  Analysis of patients with BCLC-B HCC treated with LR or transarterial chemoembolization (TACE) between 2007 and 2012 in our hospital. Survival/recurrence analyses were performed by log-rank tests and Cox multivariate models. Further analyses were specifically obtained for the HCC subclassification (B1-2-3-4) proposed recently.
  
  
  RESULTS
  Eighty patients were treated (44-TACE/36-LR). Number of nodules was [1.8(1.1)], being multinodular in 50% of cases. Although resected patients had a higher hospital stay than those who underwent TACE (14 ± 13 vs 7 ± 6; P = 0.004), the rate and severity of complications was lower measured by Dindo-Clavien scale (P < 0.05). Overall survival was 40% with a median follow-up of 29.5 months (0.07-96.9). Five-years survival rates were 62.9%, 28.1% and 15.4%, respectively (P = 0.004) for B1, B2 and B3-4 stages. Cox model showed that only total bilirubin [OR = 2.055(1.23-3.44)] and BCLC subclassification B3-4 [OR = 2.439(1.04-5.7)] and B2 [OR = 2.79(1.35-5.77)] vs B1 were independent predictors of 5-years-survival. In B1 patients, surgical approach led a significant decrease in 5-years recurrence-rate (25% vs 60%; P = 0.018). In the surgical subgroup analysis, better results were observed if well/moderate differentiation combined with no microvascular-invasion (VI) in 5-years-survival (84.6%; P = 0.001) and -recurrence (23.1%; P = 0.041), respectively. These survival and recurrence trends were remarkable in B1 stages.
  
  
  CONCLUSIONS
  Management of Intermediate BCLC-B HCC stage should be more complex and include updated criteria regarding B-stage subclassifications, VI and tumour differentiation. Modern surgical resection would offer improved survival benefit with acceptable safety in selected BCLC-B stage patients.
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain. Electronic address: rubenciria@hotmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Ciria
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: P
authors.initials: P
authors.lastname: López-Cillero
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: A-B
authors.initials: AB
authors.lastname: Gallardo
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Cabrera
authors.affiliation: Unit of Hepatology and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofia, Cordoba, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Pleguezuelo
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: M-D
authors.initials: MD
authors.lastname: Ayllón
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Luque
authors.affiliation: Unit of Vascular and Interventional Radiology, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: L
authors.initials: L
authors.lastname: Zurera
authors.affiliation: Unit of Vascular and Interventional Radiology, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: J-J
authors.initials: JJ
authors.lastname: Espejo
authors.affiliation: Unit of Hepatology and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofia, Cordoba, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Rodríguez-Perálvarez
authors.affiliation: Unit of Hepatology and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofia, Cordoba, Spain.
authors.forename: J-L
authors.initials: JL
authors.lastname: Montero
authors.affiliation: Unit of Hepatology and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofia, Cordoba, Spain.
authors.forename: M
authors.initials: M
authors.lastname: de la Mata
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, CIBERehd, IMIBIC, University Hospital Reina Sofía, Cordoba, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Briceño
mesh_terms: D000368:Aged; D000903:Antibiotics, Antineoplastic / Q000627:therapeutic use*; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000628:therapy*; D016022:Case-Control Studies; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D018572:Disease-Free Survival; D004317:Doxorubicin / Q000627:therapeutic use*; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009378:Neoplasms, Multiple Primary / Q000628:therapy*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000903:Antibiotics, Antineoplastic; D004317:Doxorubicin
keywords: Barcelona Clinic Liver Cancer; Hepatocellular carcinoma; Liver resection; Transarterial chemoembolization