Conversion of unresectable to resectable liver cancer: an approach and follow-up study

In the last decade, significant improvement has been achieved in the treatment of hepatocellular cancer by combining therapies from different disciplines, and using effective biologic response modifiers to improve response to existing therapy. While operative resection remains the only curative modality, a select group of patients with unresectable fibrolamellar or nodular variant, can be converted from unresectable status to resectable by combining chemotherapy and radiotherapy. We reviewed the recent experience with intra-arterial chemotherapies and use of external beam radiotherapy and isotopic immunoglobulin-directed radiotherapy in the treatment of unresectable hepatocellular cancer. While significant tumor response can be achieved with these therapies they are short-lived, and long-term survival is poor. When combined with operative resection, however, a significant survival advantage is achieved. The expected survival of the unresectable patient is then altered from 18 to 24 months for chemotherapy or radiation alone, or when used in combination, to 44 months for patients converted to resectable status. We conclude that the need for more effective chemotherapy is imperative, and the major role for chemotherapy or radiotherapy in hepatocellular cancer is to convert an unresectable patient to resectable status.