Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial

[Diagnosis of and therapy for hepatocellular carcinoma]

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence-and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

Family history of hepatocellulcar carcinoma is not associated with its patients' prognosis after hepatectomy

BACKGROUND

Family history of liver cancer is a major risk factor for hepatocellular carcinoma (HCC). In this study, we investigated the prognosis of patients with HCC with or without family history.

METHODS

Data for 1,313 patients who underwent hepatectomy as initial treatment for HCC between 2000 and 2008 at a tertiary cancer center hospital were retrieved from a prospective database. A positive family history was defined as a self-reported history of HCC in first-degree relatives. Clinicopathologic characteristics were compared by family history. Kaplan-Meier method and Cox proportional hazards regressions were applied for overall survival (OS) and disease-free survival (DFS).

RESULTS

Of 1,313 patients, 169 patients (12.9%) had first-degree relatives with a history of HCC. There were no significant differences between patients with or without family history in basic clinicopathologic characteristics. In either whole group or each stage according to the TNM staging system, first-degree family history was not associated with survival in all patients, hepatitis B virus-positive patients, as well as male patients. Multivariate analysis revealed that first-degree family history was not a prognostic factor, either for OS or DFS.

CONCLUSION

A first-degree family history of HCC is not associated with its patients' prognosis after hepatectomy.

Long-term outcomes after curative resection for patients with macroscopically solitary hepatocellular carcinoma without macrovascular invasion and an analysis of prognostic factors

The long-term outcome and prognostic factors after curative in patients with single hepatocellular carcinoma (HCC) without macrovascular invasion are still unclear. The objective of this study is to evaluate the effect of curative resection on survival and analyze the prognostic clinicopathologic factors, especially the presence of microvascular invasion (MVI), in these patients. Two hundred and sixty consecutive patients with single HCC without macrovascular invasion who underwent curative resection from December 2004 to December 2007 were retrospectively reviewed in this study. Survival rates were calculated by using the Kaplan-Meier method. Univariate and multivariate analyses of 14 clinicopathologic factors were performed to determine the significant prognostic factors. No patient died within 1 month after the operation. The 1-, 3-, and 5-year overall survival rates after curative resection were 96.54, 83.46, and 74.01%, respectively. Multivariate analysis revealed that only the presence of MVI was an independent negative prognostic factor affecting overall survival. The 1-, 3-, and 5-year disease-free survival rates were 79.62, 62.69, and 56.01%, respectively. The presence of MVI was the only independent unfavorable prognostic factor for disease-free survival. According to our analysis, patients with single HCC without macrovascular invasion after curative resection can be expected to have considerable long-term survival. The presence of MVI was an independent negative prognostic factor for both overall survival and disease-free survival. To improve the prognosis, these patients should be followed up more carefully and might be good candidates for adjuvant therapy.

Cancer concepts and principles: primer for the interventional oncologist-part II

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

A survival benefit of major hepatectomy for hepatocellular carcinoma identified by preoperative [18F] fluorodeoxyglucose positron emission tomography in patients with well-preserved hepatic function

AIMS

Hepatic resection can cure hepatocellular carcinoma (HCC). However, the optimal extent of resection remains controversial. Major hepatectomy could minimize a tumor recurrence, but it is harmful due to decreased hepatic functional reserve. [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scans are known as their reflection tumor differentiation and biological activity in HCC. To evaluate a benefit of major hepatectomy for HCC, we performed this retrospective analysis in patients with well-preserved hepatic function, and further analyzed in the subset identified by preoperative FDG-PET.

METHODS

We reviewed the medical records of 189 patients with HCC who underwent curative resection between August 2004 and December 2010 at two institutes. All patients underwent anatomical resection, either by major or minor hepatectomy.

RESULTS

Median overall survival did not differ significantly between the major and minor hepatectomy groups (29.4 versus 26.3 months, p = 0.269). However, the major hepatectomy group had a better recurrence-free survival (24.5 versus 19.9 months, p = 0.004). On multivariate analysis, the presence of intrahepatic metastasis independently predicted overall survival (p = 0.009), but other examined variables did not. Overall survival and recurrence-free survival were significantly better following major hepatectomy rather than minor hepatectomy in patients whose preoperative FDG-PET indicated that the maximum standardized uptake value of the tumor (SUVtumor) was ≥4 and the tumor-to-nontumor SUV ratio (TNR) was ≥1.5.

CONCLUSIONS

Our findings suggest that preoperative FDG-PET may be useful in identifying patients with favorable hepatic reserve who are most likely to benefit from major rather than minor hepatectomy.

Surgical therapy for hepatocellular carcinoma: formulating a rational approach

Hepatocellular carcinoma is one of the most common malignancies worldwide, and its incidence continues to rise in the United States. Partial hepatectomy and liver transplantation remains the mainstay of treatment for localized disease and provides significant improvement in long-term survival, as well as the potential for cure. The indications and criteria for resection and transplantation are well established, but continue to undergo significant modification over time. Surgical resection is the primary therapeutic modality in patients with well-compensated liver disease, and transplantation is highly effective in early-stage tumors in patients with severe underlying liver disease. The relative role for each of these modalities must be tailored to individual patients based on a rational approach designed to balance quality of life, organ allocation, and patient survival.

Outcomes of central bisectionectomy for hepatocellular carcinoma

BACKGROUND

Central bisectionectomy (resection of Couinaud segments IV, V and VIII) for malignant or benign disease poses a technical challenge to the surgeon but if feasible, has significant benefits in terms of conserving liver volume and options for future intervention. This study reviews a cohort of patients who underwent this procedure; outlines the indications, optimal operative technique as well as both short- and long-term outcomes.

METHODS

A retrospective review of a prospectively maintained database was performed. Pre-operative clinicopathological data, operative details and post-operative outcomes including overall and disease-free survival were analysed.

RESULTS

Between 1989 and 2009, 21 patients underwent a central bisectionectomy. All procedures were performed for hepatocellular carcinoma (HCC). All patients underwent a R0 resection with a median resection margin of 5 mm (1-15 mm). The 1-, 3- and 5-year disease-free survivals were 65%, 34.8% and 34.8%, and the corresponding overall survival rates were 90.5%, 66.8% and 66.8%, respectively.

CONCLUSION

These data support the use of a central bisectionectomy in selected cases in the management of HCC. With the use of a meticulous operative technique and adherence to surgical oncological principles, satisfactory long-term outcomes were achievable.

Survival comparison between surgical resection and percutaneous radiofrequency ablation for patients in Barcelona Clinic Liver Cancer early stage hepatocellular carcinoma

AIM

To compare the survival outcome between surgical resection (SR) and radiofrequency ablation (RFA) for Barcelona Clinic Liver Cancer (BCLC) early stage hepatocellular carcinoma (HCC).

METHODS

The retrospective study enrolled eighty-two patients with newly diagnosed BCLC early HCC (single nodule, size ≦3 cm, and Child-Pugh class A) treated either surgically (n = 46) or with RFA (n = 36) from year 2004 to 2009. The patients' survival outcomes were compared.

RESULTS

There were no significant differences in overall survival (OS) rates between SR and RFA (p = 0.204). The 3- and 5-year disease-free survival (DFS) rates were 65.8 % and 53.7 % respectively, in the SR group, which were significantly higher than those in the RFA group (34.8 % and 14.9 % respectively) (p = 0.009 and p = 0.001). In subgroup analysis, the DFS was similar between RFA and SR in patients with presentation of lower platelet count (≦100,000/mL) and smaller tumor size (tumor size ≦1 cm). Multivariate analysis showed SR as a procedure type was a significant predictive factor for DFS [HR = 2.26 (CI 1.462-5.227), p = 0.002].

CONCLUSION

SR yielded similar OS but better DFS when compared to RFA for patients with BCLC early HCC (single nodule, ≦3 cm and Child-Pugh class A). In subgroup patients with lower platelet count (≦100,000/mL) and smaller tumor size (tumor size ≦1 cm), DFS was similar between both treatments.

Management of hepatocellular carcinoma: Enlightening the gray zones

Management of hepatocellular carcinoma (HCC) has been continuously evolving during recent years. HCC is a worldwide clinical and social issue and typically a complicates cirrhosis. The incidence of HCC is increasing, not only in the general population of patients with cirrhosis, but particularly in some subgroups of patients, like those with human immunodeficiency virus infection or thalassemia. Since a 3% annual HCC incidence has been estimated in cirrhosis, a bi-annual screening is generally suggested. The diagnostic criteria of HCC has recently had a dramatic evolution during recent years. HCC diagnosis is now made only on radiological criteria in the majority of the cases. In the context of cirrhosis, the universally accepted criteria for HCC diagnosis is contrast enhancement in arterial phase and washout in venous/late phase at imaging, the so called “typical pattern”. However, recently updated guidelines slightly differ in diagnostic criteria. Apart from liver transplantation, the only cure of both HCC and underlying liver cirrhosis, all the other treatments have to match with higher rate of HCC recurrence. The latter can be classified into curative (resection and percutaneous ablation) and palliative treatments. The aim of this paper was to review the current knowledge on management of HCC and to enlighten the areas of uncertainty.

Safety of liver resection for hepatocellular carcinoma after sorafenib therapy: a multicenter case-matched study

BACKGROUND

Liver resection can be considered in some hepatocellular carcinoma (HCC) patients who received sorafenib. The lack of clinical data about safety of resection after sorafenib treatment led us to assess its potential impact on perioperative course in a multicentric study.

METHODS

From 2008 to 2011, a total of 23 HCC patients who underwent liver resection after treatment with sorafenib (sorafenib group) were compared with 46 HCC patients (control group) matched for age, gender, underlying liver disease, tumor characteristics and type of resection. Patients received sorafenib for a median duration of 1 (range 0.2-11) months and drug was interrupted at least 7 days before surgery. End points were intraoperative (operative time, vascular clamping, blood loss and transfusion), and postoperative outcomes focusing on recovery of liver function.

RESULTS

In the sorafenib group, HCC was developed on F4 cirrhosis in 48 % and the rate of major resection was 44 %. Surgical procedure duration (280 vs. 240 min), transfusion rate (26 vs. 15 %), blood loss (400 vs. 300 mL) and vascular clamping (70 vs. 74 %) were similar in the two groups. Mortality was zero in the sorafenib group and one (2.1 %) in the control group (p = 1.000). The incidence of postoperative complications was 44 % in the sorafenib group and 59 % in the control group (p = 0.307). Recovery of liver function was similar in the two groups in terms of prothrombin time (90 vs. 81 %, p = 0.429) and bilirubin level (16 vs. 24 μmol/L, p = 102) at postoperative day 5.

CONCLUSIONS

No adverse effect of preoperative administration of sorafenib was observed during and immediately after liver resection for HCC.

Frequency, risk factors and survival associated with an intrasubsegmental recurrence after radiofrequency ablation for hepatocellular carcinoma

BACKGROUND

In the treatment of hepatocellular carcinoma (HCC), hepatic resection has the advantage over radiofrequency ablation (RFA) in terms of systematic removal of a hepatic segment.

METHODS

We enrolled 303 consecutive patients of a single naïve HCC that had been treated by RFA at The University of Tokyo Hospital from 1999 to 2004. Recurrence was categorized as either intra- or extra-subsegmental as according to the Couinaud's segment of the original nodule. To assess the relationship between the subsegments of the original and recurrent nodules, we calculated the kappa coefficient. We assessed the risk factors for intra- and extra-subsegmental recurrence independently using univariate and multivariate Cox proportional hazard regression. We also assessed the impact of the mode of recurrence on the survival outcome.

RESULTS

During the follow-up period, 201 patients in our cohort showed tumor recurrence distributed in a total of 340 subsegments. Recurrence was categorized as exclusively intra-subsegmental, exclusively extra-subsegmental, and simultaneously intra- and extra-subsegmental in 40 (20%), 110 (55%), and 51 (25%) patients, respectively. The kappa coefficient was measured at 0.135 (95% CI, 0.079-0.190; P<0.001). Multivariate analysis revealed that of the tumor size, AFP value and platelet count were all risk factors for both intra- and extra-subsegmental recurrence. Of the patients in whom recurrent HCC was found to be exclusively intra-subsegmental, extra-subsegmental, and simultaneously intra- and extra-subsegmental, 37 (92.5%), 99 (90.8%) and 42 (82.3%), respectively, were treated using RFA. The survival outcomes after recurrence were similar between patients with an exclusively intra- or extra-subsegmental recurrence.

CONCLUSIONS

The effectiveness of systematic subsegmentectomy may be limited in the patients with both HCC and chronic liver disease who frequently undergo multi-focal tumor recurrence.

Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis

BACKGROUND

Laparoscopic hepatectomy (LH) has been proposed as a safe and feasible treatment option for liver diseases. However, the short- and long-term outcomes of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) have not been adequately assessed. Thus, as another means of surgical therapy for hepatocellular carcinoma (HCC), we assessed the feasibility of performing LH as the standard procedure for disease in the left lateral lobe and peripheral right segments for HCC in selected patients.

METHODS

Literature search included PubMed, Embase, Science Citation Index, SpringerLink, and secondary sources, from inception to March 2012, with no restrictions on languages or regions. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed by the Q statistic. Subgroup and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of study quality.

RESULTS

A total of 1238 patients (LH 485, OH 753) from 15 studies were included. The pooled odds ratios for postoperative morbidity and incidence of negative surgical margin in LH were found to be 0.37 (95 % confidence interval [CI] 0.27-0.52; P < 0.01) and 1.63 (95 % CI 0.82-3.22; P = 0.16), respectively, compared with OH. Blood loss was significantly decreased in the LH (weighted mean difference -224.63; 95 % CI -384.87 to -64.39; P = 0.006). No significant difference was observed between the both groups for long-term outcomes of overall survival and recurrence-free survival.

CONCLUSIONS

In patients with solitary left lateral lobe/right peripheral subcapsular tumors treated with minor resection, this meta-analysis demonstrated that compared to OH, LH may have short-term advantages in terms of blood loss and postoperative morbidity for HCC. Both procedures have similar long-term outcomes. It may be time to consider changing the standard procedures for treatment of HCC in the left lateral lobe and peripheral subcapsular right segments in selected patients.

Tailoring the area of hepatic resection using inflow and outflow modulation

The performance of hepatic surgery without a parenchyma-sparing strategy carries significant risks for patient survival because of the not negligible occurrence of postoperative liver failure. The key factor of modern hepatic surgery is the use of the intraoperative ultrasound (IOUS), not only to stage the disease, but more importantly to guide resection with the specific aim to maximize the sparing of the functional parenchyma. Whether in patients with hepatocellular carcinoma and underlying liver cirrhosis, or in patients with colorectal liver metastasis, IOUS allows the performance of the so-called “radical but conservative surgery”, which is the pivotal factor to offer a chance of cure to an increasing proportion of patients, who until few years ago were considered only for palliative care. Using some new IOUS-guided surgical maneuvers, which are based on the liver inflow and outflow modulations, more precise anatomically subsegmental- and segmental-oriented resections can be effectively performed. The present work describes the rationale and the surgical technique for a precise tailoring of the area of hepatic resection using the most recent attainments in IOUS. Such important technical achievements should be a fundamental part of the surgical armamentarium of the modern liver surgeon.

Hepatic resection for hepatocellular carcinoma based on tumor hemodynamics

Survival or disease-free survival is not considered an appropriate surrogate outcome for the locoregional curability (i.e. surgical margin) of hepatectomy for hepatocellular carcinoma because these are greatly influenced by non-metastatic factors like multicentric carcinogenesis (MC) or liver function. Hepatocellular carcinoma metastasizes by hematogenous seeding; therefore, the tumor blood flow (TBF) drainage area is a high-risk area for intrahepatic metastasis, and can be identified by computed tomography under hepatic arteriography and completely resected as part of the surgical margin. The TBF pattern is classified into marginal, portal vein or hypovascular types. Partial hepatectomies were mostly performed in patients with marginal or hypovascular type, whereas anatomical surgery was frequently performed in those with portal vein type. Pathologically, nodules inside the TBF drainage area were moderately or poorly differentiated carcinomas, suggesting intrahepatic metastasis. In contrast, those outside the drainage area were frequently solitary and contained well-differentiated carcinoma, which is consistent with MC. The pattern of tumor recurrences after TBF-based hepatectomy is divided into two distinct groups - "a few nodules" and "many nodules in multiple segments or extrahepatic" - indicating that intrahepatic recurrences develop from MC and from circulating tumor cells in peripheral blood, respectively. Anatomical resection has not shown a survival benefit over that of TBF-based partial hepatectomy. TBF-based hepatectomy enables us to preserve liver function without compromising locoregional curability.

Surgical resection for small hepatocellular carcinoma in cirrhosis: the Eastern experience

Detection of small Hepatocarcinoma (HCC) by screening of high-risk populations is important to increase the percentage of patients suitable for curative treatment, which would lead to prolongation of the mean survival of patients with HCC. It should be remembered that small HCC is not always necessarily equivalent to early HCC as defined histologically. With recent advances in diagnostic imaging modalities, including contrast-enhanced ultrasonography and magnetic resonance imaging with liver-specific contrast enhancement, accurate differential diagnosis of early HCCs from dysplastic nodules has become possible. Because a certain proportion of small HCCs is known to show microscopic vascular invasion, surgical resection would be the treatment of first choice. To minimize potential microscopic invasion, anatomic resection and/or resection with a wide margin should be performed, while preserving liver function to the maximum extent possible. Surgical resection, however, cannot prevent multicentric occurrence of HCC, which remains a major issue precluding curative treatment of HCC.

Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

BACKGROUND

Despite the accumulation of favorable results from laparoscopic liver resection (LLR), centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava (IVC) are still considered contraindications for LLR. We evaluated the feasibility and safety of LLR for centrally located tumors.

METHODS

Of the 182 patients who underwent LLR for benign or malignant tumors between September 2003 and June 2010, the clinical outcomes of 13 patients with tumors within 1 cm or less of the major vascular structures, including the hilum, major hepatic veins, and IVC, were retrospectively analyzed. The perioperative outcomes of the patients were compared with those of the 23 patients who underwent open liver resection for tumors with similar criteria in terms of location and size during the same period.

RESULTS

Anatomic liver resection, including left and right hepatectomy, central bisectionectomy, right anterior and posterior sectionectomy, and extended S4 segementectomy, was performed in 10 patients. The remaining 3 patients underwent subsegmentectomy for tumors located in the Spiegel lobe of the caudate. There was no open conversion or postoperative mortality. Compared with the open group, the laparoscopic group showed similar rates of intraoperative transfusion, postoperative complications, and operative time. However, the laparoscopic group spent less time in the hospital postoperatively and had shorter resection margins. After a median follow-up of 34.3 months, there were no statistically significant differences between the 2 groups in reference to the overall survival rates and the disease-free survival rates.

CONCLUSION

This study shows that LLR can be safely performed in selected patients with centrally located tumors close to the liver hilum, the major hepatic veins, or the IVC that were previously considered to be contraindications for LLR. Recent technical developments in the performance of laparoscopic major liver resection may have contributed to the successful application of LLR for centrally located tumors.

Current concepts in hepatic resection for hepatocellular carcinoma in cirrhotic patients

Hepatocellular carcinoma (HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with liver cirrhosis. Liver resection is considered the most potentially curative therapy for HCC patients when liver transplantation is not an option or is not immediately accessible. This review is aimed at investigating the current concepts that drive the surgical choice in the treatment of HCC in cirrhotic patients; Eastern and Western perspectives are highlighted. An extensive literature review of the last two decades was performed, on topics covering various aspects of hepatic resection. Early post-operative and long-term outcome measures adopted were firstly analyzed in an attempt to define an optimal standardization useful for research comparison. The need to avoid the development of post-hepatectomy liver failure represents the “conditio sine qua non” of surgical choice and the role of the current tools available for the assessment of liver function reserve were investigated. Results of hepatic resection in relationship with tumor burden were compared with those of available competing strategies, namely, radiofrequency ablation for early stages, and trans-arterial chemoembolization for intermediate and advanced stages. Finally, the choice for anatomical versus non-anatomical, as well as the role of laparoscopic approach, was overviewed. The literature review suggests that partial hepatectomy for HCC should be considered in the context of multi-disciplinary evaluation of cirrhotic patients. Scientific research on HCC has moved, in recent years, from surgical therapy toward non-surgical approaches and most of the literature regarding topics debated in the present review is represented by observational studies, whereas very few well-designed randomized controlled trials are currently available; thus, no robust recommendations can be derived.

Roles played by chemolipiodolization and embolization in chemoembolization for hepatocellular carcinoma: single-blind, randomized trial

BACKGROUND

The aim of our study was to compare the efficacy and safety of: 1) transarterial chemolipiodolization with gelatin sponge embolization vs chemolipiodolization without embolization, and 2) chemolipiodolization with triple chemotherapeutic agents vs epirubicin alone.

METHODS

A single-blind, three parallel arm, randomized trial was conducted at three clinical centers with patients with biopsy-confirmed unresectable hepatocellular carcinoma. Arm 1 received triple-drug chemolipiodolization and sponge embolization, whereas Arm 2 received triple-drug chemolipiodolization only. Patients in arm 3 were treated with single-drug chemolipiodolization and sponge embolization. We compared overall survival and time to progression. Event-time distributions were estimated by the Kaplan-Meier method. All statistical tests were two-sided.

RESULTS

From July 2007 to November 2009, 365 patients (Arm 1: n = 122; Arm 2: n = 121; Arm 3: n = 122) were recruited. The median tumor size was 10.9cm (range = 7-22cm), and 34.5% had macrovascular invasion. The median survivals and time to progression in Arm 1, Arm 2, and Arm 3 were 10.5 and 3.6 months, 10.1 and 3.1 months, and 5.9 and 3.1 months, respectively. Survival was statistically significantly better in Arm 1 than in Arm 3 (P < .001), whereas there was no statistically significant difference between Arm 1 and Arm 2 (P = .20). Objective response rates were 45.9%, 29.7%, and 18.9% for Arm 1, Arm 2, and Arm 3, respectively.

CONCLUSIONS

Chemolipiodolization played an important role in transarterial chemoembolization, and the choice of chemotherapy regimen may largely affect survival outcomes. However, the removal of embolization from chemoembolization might not statistically significantly decrease survival.

Salvage liver transplantation for recurrent hepatocellular carcinoma within UCSF criteria after liver resection

Background

Salvage liver transplantation (SLT) is restricted to patients who develop hepatocellular carcinoma (HCC) recurrence within Milan criteria (MC). Little is known about outcomes for SLT in patients with recurrent HCC within University of California San Francisco (UCSF) criteria after liver resection (LR).

Methods

Between January 2001 and December 2011, 380 patients with HCC meeting UCSF criteria, 200 of which were resected (LR group) from a perspective of SLT in case of recurrence, and 180 directly underwent LT (PLT). We compared patient characteristics, perioperative and long-term outcomes between SLT and PLT groups. We also assessed the outcome of LR and PLT groups.

Results

Among the 200 patients in LR group, 86 (43%) developed HCC recurrence and 15/86 (17%) of these patients presented HCC recurrence outside UCSF criteria. Only 39 of the 86 patients underwent SLT, a transplantation rate of 45% of patients with HCC recurrence. Compared with PLT group, LR group showed lower overall survival rate (P = 0.005) and higher recurrence rate (P = 0.006). Although intraoperative blood loss and required blood transfusion were more frequent in SLT group, the perioperative mortality and posttransplant complications were similar in SLT and PLT groups. The overall survival and recurrence rates did not significantly differ between the two groups. When stratifying by graft type in the SLT group, overall survival and recurrence rates did not significantly differ between deceased donor LT (DDLT) and living donor LT (LDLT) groups. In the subgroup analysis by MC, similar results were observed between patients with recurrent HCC meeting MC and patients with recurrent HCC beyond MC but within UCSF criteria.

Conclusion

Our single institution experience demonstrated that prior hepatectomy and SLT for recurrent HCC within UCSF criteria was feasible and SLT could achieve the same outcome as PLT.

Are Tumor Exposure and Anatomical Resection Antithetical during Surgery for Hepatocellular Carcinoma? A Critical Review

Hepatic resection is the most potentially curative local therapy for patients with hepatocelluar carcinoma (HCC). However, the high rate of postoperative recurrence, 50-70% at 3 years, remains a major concern. Such recurrences usually occur in the liver owing to the high propensity of HCC to invade the portal vein branches and the underlying liver cirrhosis, which is the ideal background for HCC development. Two pivotal surgical techniques are commonly used to reduce such recurrences: anatomical resection (AR) and achievement of negative margins. However, controversies exist about the definition of anatomical resection and the requisite width of negative margins. Consequently, a consensus on these issues is far from being achieved in the specialized surgical community. Review of the literature and author's discernment support AR for HCC larger than 2cm, and tumor exposure when the tumor is in contact with major vessels. Therefore, tumor exposure is not a contradiction to an AR properly carried out.

A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma

BACKGROUND & AIMS

The aim of this study was to compare the efficacy of radiofrequency ablation (RFA) with surgical resection (RES) in the treatment of small hepatocellular carcinoma (HCC).

METHODS

A total of 168 patients with small HCC with nodular diameters of less than 4 cm and up to two nodules were randomly divided into RES (n=84) and RFA groups (n=84). Outcomes were carefully monitored and evaluated during the 3-year follow-up period.

RESULTS

The 1-, 2-, and 3-year survival rates for the RES and RFA groups were 96.0%, 87.6%, 74.8% and 93.1%, 83.1%, 67.2%, respectively. The corresponding recurrence-free survival rates for the two groups were 90.6%, 76.7%, 61.1% and 86.2%, 66.6%, 49.6%, respectively. There were no statistically significant differences between the two groups in overall survival rate (p=0.342) or recurrence-free survival rate (p=0.122). Multivariate analysis demonstrated that the independent risk factors associated with survival were multiple occurrences of tumors at different hepatic locations (relative risk of 2.696; 95% CI: 1.189-6.117; p=0.018) and preoperative indocyanine green retention rate at 15 min (ICG-15) (relative risk of 3.853; 95% CI: 1.647-9.015; p=0.002).

CONCLUSIONS

In patients with small hepatocellular carcinomas, percutaneous RFA may provide therapeutic effects similar to those of RES. However, percutaneous RFA is more likely to be incomplete for the treatment of small HCCs located at specific sites of the liver, and open or laparoscopic surgery may be the better choice.

Liver resection and transplantation in hepatocellular carcinoma

Liver resection is the most available, efficient treatment for patients with hepatocellular carcinoma. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the most important factors that have led to reduced mortality, with an expected 5 year survival of 70%. Impairment of liver function and the risk of tumor recurrence lead to consideration of liver transplantation (LT) as the ideal treatment for removal of the existing tumor and the preneoplastic underlying liver tissue. However, LT, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. Limited availability of grafts as well as the risk and the cost of the LT procedure has led to considerable interest in combined treatment involving resection and LT. An increasing amount of evidence has shown that initial liver resection in transplantable patients with a single limited tumor and good liver function is a valid indication. Histological analysis of specimens allows identification of the subgroup of patients who could benefit from follow-up with LT in case of recurrence.

Hepatocellular carcinoma: natural history, current management, and emerging tools

Hepatocellular carcinoma (HCC) is the most common primary liver tumor and represents the third-leading cause of cancer-related death in the world. The incidence of HCC continues to increase worldwide, with a unique geographic, age, and sex distribution. The most important risk factor associated with HCC is liver cirrhosis, with the majority of cases caused by chronic infection with hepatitis B (HBV) and C (HCV) viruses and alcohol abuse, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Primary prevention in the form of HBV vaccination has led to a significant decrease in HBV-related HCC, and initiation of antiviral therapy appears to reduce the incidence of HCC in patients with chronic HBV or HCV infection. Additionally, the use of ultrasonography enables the early detection of small liver tumors and forms the backbone of recommended surveillance programs for patients at high risk for the development of HCC. Cross-sectional imaging studies, including computed tomography and magnetic resonance imaging, represent further noninvasive techniques that are increasingly employed to diagnose HCC in patients with cirrhosis. The mainstay of potentially curative therapy includes surgery – either resection or liver transplantation. However, most patients are ineligible for surgery, because of either advanced disease or underlying liver dysfunction, and are managed with locoregional and/or systemic therapies. Randomized controlled trials have demonstrated a survival benefit with both local therapies, either ablation or embolization, and systemic therapy in the form of the multikinase inhibitor sorafenib. Despite this, median survival remains poor and recurrence rates significant. Further advances in our understanding of the molecular pathogenesis of HCC hold promise in improving the diagnosis and treatment of this highly lethal cancer.

Hepatocellular carcinoma: Western and Eastern surgeons' points of view

Hepatocellular carcinoma (HCC) is the third leading cause of cancer mortality worldwide. Developed on a pathological liver in 90% of cases, theoretically liver transplantation (LT) is its best treatment because it cures both malignancy and cause of malignancy, the underlying pathological liver. Cadaveric donors are the main source of liver in Western countries as France and living donors are the rules in Eastern countries as Japan. Because organ shortage could impact choices in HCC treatments, it was interesting to compare a Western and Eastern surgeon's points of view about treatment of HCC to assess if the source of organs has modified therapeutic strategies. Hence, aim of this work was to compare points of view of two hepatobiliary and transplant surgeons specialized in the treatment of HCC in France and Japan concerning five keys points that are decisive to choose one of the two curative treatments in HCC on pathological liver: liver resection or LT. These questions included the definition of an oncological treatment of HCC, the assessment of liver function, the treatment of HCC recurrences, the incidence of pathological information on therapeutic strategy and potential future therapeutics strategies.

Management of HCC

Hepatocellular carcinoma (HCC) is a highly prevalent and lethal neoplasia, the management of which has significantly improved during the last few years. A better knowledge of the natural history of the tumor and the development of staging systems that stratify patients according to the characteristics of the tumor, the liver disease, and the performance status, such as the BCLC (Barcelona Clinic Liver Cancer) system, have led to a better prediction of prognosis and to a most appropriate treatment approach. Today curative therapies (resection, transplantation, ablation) can improve survival in patients diagnosed at an early HCC stage and offer a potential long-term cure. Patients with intermediate stage HCC benefit from chemoembolization and those diagnosed at advanced stage benefit from sorafenib, a multikinase inhibitor with antiangiogenic and antiproliferative effects. In this article we review the current management in HCC and the new advances in this field.

Influence of ablative margin on local tumor progression and survival in patients with HCC ≤4 cm after laser ablation

BACKGROUND

Ablation of the normal hepatic parenchyma surrounding the tumor (ablative margin [AM]) is necessary to prevent local tumor progression.

PURPOSE

To assess the prognostic value of the ablative margin in patients with HCC ≤4 cm treated with US-guided laser ablation.

MATERIAL AND METHODS

A cohort of 116 patients (53 women and 63 men, age range 42-82 years) with 132 HCC nodules ≤4 cm completely ablated by US-guided laser ablation was retrospectively analyzed. Rates of local tumor progression were compared using different ablative margin cut-offs (≥2.5, 5.0, 7.5, and 10.0 mm). Survival probability curves were obtained with the Kaplan-Meier method.

RESULTS

The mean period of follow-up was 42 months (range 3-114 months). Local tumor progression was identified in 24 out of 132 lesions (18%), with an average time to progression of 24 months (range 6-36 months). A significant difference in local tumor progression was observed only if the ablative margin was ≥7.5 mm (7% vs. 23%, P = 0.020). Survival curves of patients with or without an ablative margin ≥7.5 mm were not different (P = 0.665; mean survival time 43.8 ± 3.1 and 46.8 ± 6.1 for an AM < or ≥7.5 mm, respectively).

CONCLUSION

An ablative margin ≥7.5 mm turned out to be useful in preventing local tumor progression but did not affect long-term survival in patients with HCC ≤4 cm treated with laser ablation.

Radiofrequency ablation versus hepatic resection for the treatment of hepatocellular carcinomas 2 cm or smaller: a retrospective comparative study

PURPOSE

To compare retrospectively the effects of percutaneous radiofrequency (RF) ablation with those of hepatic resection in the treatment of hepatocellular carcinoma (HCC) measuring 2 cm or smaller.

MATERIALS AND METHODS

This study was approved by the institutional ethics committee, and all patients provided written informed consent before treatment. From December 2003 to December 2008, 145 patients with a resectable HCC measuring 2 cm or smaller were studied. Sixty-six patients had a central HCC (located at least 3 cm from the liver capsule). As an initial treatment, 71 patients were treated with percutaneous RF ablation and 74 with surgical resection. Of the patients with central HCC, 37 underwent percutaneous RF ablation and 29 underwent surgical resection. Survival curves were constructed with the Kaplan-Meier method and compared by using the log-rank test. The relative prognostic significance of the variables for predicting overall survival rates was assessed with multivariate Cox proportional hazards regression analysis. Complications were observed clinically when patients were admitted and assessed by telephone interview after patients were discharged.

RESULTS

One death was considered to be related to treatment after surgical resection. Major complications occurred significantly more often in the surgical resection group (38 of 74 patients) than in the RF ablation group (14 of 71 patients) (P = .009). The 1-, 3-, and 5-year overall survival rates were 98.5%, 87.7%, and 71.9%, respectively, with RF ablation and 90.5%, 70.9%, and 62.1% with surgical resection (P = .048). The corresponding recurrence-free survival rates were 76.4%, 65.2%, and 59.8% with RF ablation and 75.6%, 56.1%, and 51.3% with surgical resection (P = .548). At subgroup analysis of patients with central HCC, 1-, 3-, and 5-year overall survival rates were 96.6%, 93.0%, and 79.9% with RF ablation and 92.0%, 71.6%, and 61.5% with surgical resection (P = .020). The corresponding recurrence-free survival rates were 86.5%, 74.0%, and 67.0% with RF ablation and 68.0%, 40.0%, and 40.0% with surgical resection (P = .033). For patients with peripheral HCC, 1-, 3-, and 5-year overall survival rates were 97.3%, 83.3%, and 65.1% with RF ablation and 87.8%, 68.4%, and 62.9% with surgical resection (P = .464). The corresponding recurrence-free survival rates were 68.7%, 59.2%, and 54.9% with RF ablation and 82.9%, 66.6%, and 52.9% with surgical resection (P = .351).

CONCLUSION

The efficacy and safety of percutaneous RF ablation were better than those of surgical resection in patients with HCC measuring 2 cm or smaller, especially those with central HCC.

Liver hypertrophy and accelerated growth of implanted tumors in nonembolized liver of rabbit after left portal vein embolization

BACKGROUND

Portal vein embolization (PVE) has become a standard preoperative procedure to promote hypertrophy of the future remnant liver to reduce postoperative liver failure. Whether PVE accelerates tumor growth is still controversial. We developed a left PVE procedure and investigated its effect on liver hypertrophy and tumor growth in a rabbit liver tumor model.

MATERIALS AND METHODS

VX2 tumors were implanted in both the external left and right middle lobe (the bilateral group) or in the external left lobe only (the unilateral group) of rabbit liver. Both groups were further divided into a PVE or a sham/control group. Tumor volume and tumor growth rate as volume relative increase were determined by ultrasound. Liver volume-to-body weight index, an index for liver volume, was compared. Serum HGF was measured by ELISA.

RESULTS

In the bilateral PVE group, tumor volume and relative increase value in the nonembolized lobe were significantly (71% and 65%, respectively) greater than those in the control group at 5 d post-PVE. In the unilateral PVE group, liver volume-to-body weight index of the nonembolized lobes was significantly increased by 17%. Increase of serum HGF level after PVE was correlated well with both tumor growth and liver hypertrophy.

CONCLUSIONS

Left PVE promoted both the growth of implanted tumors and liver hypertrophy in the nonembolized liver, in which serum HGF might play an important role.

Prognostic impact of marginal resection for patients with solitary hepatocellular carcinoma: evidence from 570 hepatectomies

BACKGROUND

During resection of a hepatocellular carcinoma, surgeons encounter occasionally a situation where marginal resection is inevitable because of a close association between the hepatocellular carcinoma and major vasculature and/or underlying impaired liver function. We investigated the impact of marginal resection on recurrence-free survival after a resection of a solitary hepatocellular carcinoma.

METHODS

The data of 570 patients who underwent macroscopically curative hepatectomy for a solitary hepatocellular carcinoma in our institution between 1990 and 2007 were analyzed. Marginal resection and non-marginal resection were defined as a cancer-negative surgical margin of ≤ 1 mm and a surgical margin of >1 mm, respectively. The macroscopic appearance of the hepatocellular carcinoma was classified as the simple nodular type or non-simple nodular type based on the classification of the Liver Cancer Study Group of Japan, and patients were categorized into 4 groups: group A, simple nodular type with cirrhosis; group B, simple nodular type without cirrhosis; group C, non-simple nodular type with cirrhosis; and group D, non-simple nodular type without cirrhosis.

RESULTS

The surgical margins were diagnosed as cancer-positive in 31 patients, as marginal resection in 165 patients, and as non-marginal resection in 374 patients. The marginal resection group showed a better recurrence-free survival than the positive surgical margin group (P = .001), and also a worse recurrence-free survival than the non-marginal resection group (P = .003). In groups A, B, and C, the recurrence-free survival rates were similar between marginal resection and non-marginal resection patients (P = .458), while in group D, marginal resection was a significant poor prognostic factor of recurrence-free survival in both univariate and multivariate analyses.

CONCLUSION

Marginal resection is acceptable in group A, B, and C patients, because it did not negatively affect postoperative recurrence-free survival.

Is wider surgical margin justified for better clinical outcomes in patients with resectable hepatocellular carcinoma?

BACKGROUND/PURPOSE

Surgical resection for hepatocellular carcinoma (HCC) is regarded as a curable treatment; however, the postoperative recurrence still poses a challenge to surgeons. The effect of surgical margin on long-term outcome is still controversial, although it has been considered as the treatment-related risk factor for recurrence. A precise assessment of the effects of surgical margin on clinical outcome is required to clarify the issue.

METHODS

A retrospective study was conducted on 407 patients with microscopically complete resection of HCC; they were divided into three groups with surgical margin negative by 1-5 mm (Group A, n = 156), 6-10 mm (Group B, n = 109), and wider than 10 mm (Group C, n = 142). The groups were compared for clinicopathologic characteristics, perioperative features, postoperative recurrence, and long-term outcome.

RESULTS

The median follow-up time for all patients was 72.97 months. Recurrence rates were similar among these groups. There was no significant difference in the overall 1-, 3-, and 5-year actual survival rates for the groups on the log-rank test (p = 0.073). After controlling the independent risks for disease-free survival, there was also no significant difference in the 1-, 3-, and 5-year disease-free survival rates for the groups (p = 0.354). The patients with wider surgical margin had worse perioperative outcomes; more patients in this group needed blood transfusion (p < 0.001) and more patients suffered from postoperative complications (p = 0.020). They also had higher in-hospital mortality rate than that of other groups (1.41% vs. 0.64%).

CONCLUSION

No superiority was seen in patients with wider surgical margin in either perioperative features or long-term outcome.

Survival comparison between surgical resection and radiofrequency ablation for patients in BCLC very early/early stage hepatocellular carcinoma

BACKGROUND & AIMS

To compare the survival between surgical resection (SR) and radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) very early/early stage.

METHODS

Between 2002 and 2009, patients with newly diagnosed BCLC very early/early stage HCC who received SR or RFA were enrolled. Medical records were reviewed. The cumulative overall survival (OS) and disease-free survival (DFS) were compared.

RESULTS

A total of 605 patients, including 143 very early (SR: 52; RFA: 91) and 462 early stages (SR: 208; RFA: 254) were enrolled. For very early stage, the 3- and 5-year OS rates were 98% and 91.5% for SR, and 80.3% and 72% for RFA, respectively (p=0.073). The 3- and 5-year DFS rates were 62.1% and 40.7% for SR, and 39.8% and 29.3% for RFA, respectively (p=0.006). Either multiple adjustment by Cox model or match analysis based on propensity score showed no significant difference in OS between the two groups. For early stage, the 3- and 5-year OS rates were 87.8% and 77.2% for SR, and 73.5% and 57.4% for RFA, respectively (p=0.001). The 3- and 5-year DFS rates were 59.9% and 50.8% for SR, and 28.3% and 14.1% for RFA, respectively (p<0.001). After adjusting covariates, there was no significant difference in OS between the two groups. However, SR was superior to RFA in DFS.

CONCLUSIONS

For HCC patients in BCLC very early/early stage, there was no significant difference in OS between SR and RFA. However, SR yielded better DFS than RFA.

Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: an intention-to-treat analysis

Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by "salvage transplantation" (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio [HR] 2.38 [range, 1.10-7.29]), satellite nodules (HR 2.46 [range, 1.01-6.68]), tumor size > 3 cm (HR 1.34 [range, 1.03-3.12]), poorly differentiated tumor (HR 3.18 [range, 1.31-7.70]), and liver cirrhosis (HR 1.90 [range, 1.04-3.12]).

CONCLUSION

The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors.

Surgical and oncologic outcomes following laparoscopic versus open liver resection for hepatocellular carcinoma: A meta-analysis

AIM

  Laparoscopic hepatectomy has become a common method for treatment of hepatocellular carcinoma (HCC) nowadays, but the oncologic risks of laparoscopic liver resection for HCC are still under investigation. We performed a meta-analysis to quantitatively compare surgical and oncologic outcomes of patients with HCC undergoing laparoscopic versus open hepatectomy.

METHODS

  Systematic review and meta-analysis of studies comparing laparoscopic with open liver resection for HCC. Two authors independently assessed study quality and extracted data. All data were analyzed using RevMan 5.

RESULTS

  Ten studies comprising 627 patients were eligible for inclusion. The overall rate of conversion to open surgery was 6.6%. The laparoscopic group had significantly less blood loss by 223.17 mL (95% confidence interval [CI]: -331.81, -114.54; P < 0.0001), fewer need for transfusions (odds ratio [OR]: 0.42, 95% CI: 0.22, .079; P = 0.007), shorter hospital stay by 5.05 days (95% CI: -7.84, -2.25; P = 0.0004) and fewer postoperative complications (OR: 0.50; 95% CI: 0.32, 0.77; P = 0.002). No significant differences were found concerning surgery margin (weighted mean differences [WMD], 0.55; 95% CI: -0.71, 1.80; P = 0.39), resection margin positive rate (OR, 0.63; 95% CI: 0.25, 1.54; P = 0.31) and tumor recurrence (OR, 0.79; 95% CI: 0.49, 1.27; P = 0.33). In the 244 patients that underwent laparoscopic hepatectomy of all 10 studies included, no patients developed tumor recurrence at the site of resection margin, peritoneal dissemination or trocar-site metastases.

CONCLUSIONS

  On currently available evidence, laparoscopic resection appears not to affect oncologic outcomes and increase tumor recurrence. It also offers less blood loss, decreased rate of intraoperative transfusion and shorter lengths of hospital stay. Laparoscopic resection is a safe and feasible choice for selected patients with HCC.

Predictors for microinvasion of small hepatocellular carcinoma ≤ 2 cm

BACKGROUND

Hepatocellular carcinoma (HCC) ≤ 2 cm in diameter is considered to have a low potential for malignancy.

METHODS

A retrospective review was undertaken of 149 patients with primary solitary HCC ≤ 2 cm who underwent initial hepatic resection between 1994 and 2010. The independent predictors of the microinvasion (MI) such as portal venous, hepatic vein, or bile duct infiltration and/or intrahepatic metastasis were identified by multivariate analysis. Prognosis of patients with HCC ≤ 2 cm accompanied by MI was compared to that of patients with HCC ≤ 2 cm without MI.

RESULTS

Forty-three patients with HCC ≤ 2 cm had MI in patients (28.9%). Three independent predictors of the MI were revealed: invasive gross type (simple nodular type with extranodular growth or confluent multinodular type), des-γ-carboxy prothrombin (DCP) >100 mAU/ml, and poorly differentiated. Disease-free survival rates of patients with HCC ≤ 2 cm with MI (3 year 44%) were significantly worse than those for HCC ≤ 2 cm without MI (3 year 72%). This disadvantage of disease-free survival rate of patients with HCC ≤ 2 cm with MI could be dissolved by hepatic resection with a wide tumor margin of ≥ 5 mm (P = 0.04).

CONCLUSIONS

Even in cases of HCC ≤ 2 cm, patients who are suspected of having invasive gross type tumors in preoperative imaging diagnosis or who have a high DCP level (>100 mAU/ml) are at risk for MI. Therefore, in such patients, hepatic resection with a wide tumor margin should be recommended.

Prognostic factors after liver resection for hepatocellular carcinoma: a single-center experience from China

BACKGROUND

This study aimed to clarify the risk factors for survival and recurrence of hepatocellular carcinoma (HCC) in a cohort of Chinese HCC patients after hepatectomy and to compare 6 developed staging systems.

METHODS

A retrospective analysis was performed on 165 consecutive patients. The Kaplan-Meier method was used to calculate survival. Postoperative prognostic factors were evaluated using univariate and multivariate analyses. The overall predictive power of each staging system was evaluated by the area under the receiver operating characteristic curve.

RESULTS

The overall survival rates of 1, 3, and 5 years were 81.2%, 58.6%, and 56.7%, respectively, and the corresponding disease-free survival rates were 52.9%, 23.3%, and 15.5%, respectively. α-fetoprotein level and blood transfusion were correlated significantly with patients' overall survival, and portal vein thrombosis and tumor size (>5 cm) were correlated significantly with poor disease-free survival.

CONCLUSIONS

The French staging system is better for predicting the prognosis of HCC patients receiving surgical treatment.

A special recurrent pattern in small hepatocellular carcinoma after treatment: Bile duct tumor thrombus formation

AIM: To investigate the clinicopathologic features of bile duct tumor thrombus (BDTT) occurrence after treatment of primary small hepatocellular carcinoma (sHCC).

METHODS: A total of 423 patients with primary sHCC admitted to our hospital underwent surgical resection or local ablation. During follow-up, only six patients were hospitalized due to obstructive jaundice, which occurred 5-76 mo after initial treatment. The clinicopathologic features of these six patients were reviewed.

RESULTS: Six patients underwent hepatic resection (n = 5) or radio-frequency ablation (n = 1) due to primary sHCC. Five cases had an R1 resection margin, and one case had an ablative margin less than 5.0 mm. No vascular infiltration, microsatellites or bile duct/canaliculus affection was noted in the initial resected specimens. During the follow-up, imaging studies revealed a macroscopic BDTT extending to the common bile duct in all six patients. Four patients had a concomitant intrahepatic recurrent tumor. Surgical re-resection of intrahepatic recurrent tumors and removal of BDTTs (n = 4), BDTT removal through choledochotomy (n = 1), and conservative treatment (n = 1) was performed. Microscopic portal vein invasion was noted in three of the four resected specimens. All six patients died, with a mean survival of 11 mo after BDTT removal or conservative treatment.

CONCLUSION: BDTT occurrence is a rare, special recurrent pattern of primary sHCC. Patients with BDTTs extending to the common bile duct usually have an unfavorable prognosis even following aggressive surgery. Insufficient resection or ablative margins against primary sHCC may be a risk factor for BDTT development.

Identification of MACC1 as a novel prognostic marker in hepatocellular carcinoma

Background

Metastasis-associated in colon cancer-1 (MACC1) is a newly identified gene that plays a role in colon cancer metastasis through upregulation of c-MET proto-oncogene (c-MET). However, the value of MACC1 as a potential biomarker for hepatocellular carcinoma (HCC) remains unknown.

Methods

MACC1 mRNA expression in 128 HCC tissues was examined by quantitative polymerase chain reaction. To show the potential correlation of MACC1 and c-MET, c-MET was also analysed.

Results

MACC1 was more highly expressed in HCC than in non-HCC tissues (P = 0.009). High MACC1 expression was significantly increased in cases with high alpha fetoprotein (AFP) (P = 0.025). A positive correlation was found between MACC1 and c-MET mRNAs (r = 0.235, P = 0.009). Both univariate and multivariate analyses revealed that MACC1 expression was associated with overall survival (OS) and disease-free survival (DFS). Moreover, stratified analysis showed that tumour-node-metastasis (TNM) stage I patients with high MACC1 levels had shorter OS and DFS than those with low MACC1.

Conclusions

MACC1 may identify low- and high-risk individuals with HCC and be a valuable indicator for stratifying the prognosis of TNM stage I patients. MACC1 may serve as a novel biomarker for HCC.

Prognosis of patients undergoing hepatectomy for solitary hepatocellular carcinoma originating in the caudate lobe

BACKGROUND

Operative and nonoperative treatment for hepatocellular carcinoma (HCC) originating in the caudate lobe is regarded as challenging because of its deep location in the liver and possibly worse prognosis than HCC in other sites in the liver. The objective of this study is to investigate the clinicopathologic factors and survival of patients who underwent hepatectomy for solitary HCC originating in the caudate lobe.

METHODS

A retrospective review of 783 patients who underwent curative hepatectomy for solitary HCC between 1988 was performed. Clinicopathologic factors and survival rate of 46 (5.9%) patients with HCC originating in the caudate lobe were compared with those of 737 (94%) patients with HCC arising in other sites.

RESULTS

The clinical backgrounds of patients with HCC in the caudate lobe and in other sites were comparable. Hepatectomy for HCC in the caudate lobe was associated with greater operative time and blood loss than for HCC in other sites of the liver. Pathologically, HCC in the caudate lobe was associated with less frequent intrahepatic metastasis, lesser operative margins, and more frequent tumor exposure than HCC in other sites. Overall and disease-free 5-year survival rates of the 46 patients with solitary HCC in the caudate lobe were 76% and 45%, respectively; no significant difference was observed in the overall or disease-free survival rates between the 2 groups (P = .07 and P = .77, respectively). Resection of HCC in the paracaval portion of the caudate lobe (n = 27) was associated with more frequent anatomic resection, greater operative time and blood loss, and a lesser operative margin than HCC in the Spiegel lobe or caudate process (n = 19).

CONCLUSION

Resection for HCC in the caudate lobe, especially in the paracaval portion, remains technically demanding. The prognosis of patients with solitary HCC in the caudate lobe, however, was as good as that of patients with solitary HCC in other sites in the liver.

Laparoscopic resection vs. open liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: a case-matched study

BACKGROUND

Studies that compare laparoscopic to open liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients are rare and may have suffered from low patient numbers. This work was designed to determine the impact of laparoscopic resection on postoperative and long-term outcomes in a large series of cirrhotic patients with hepatocellular carcinoma (HCC) compared with open resection.

METHODS

From 2002 to 2009, 36 patients with chronic liver disease with complicating HCC were selected for laparoscopic resection (laparoscopic group, LG). The outcomes were compared with those of 53 patients who underwent open hepatectomy (open group, OG) during the same period in a matched-pair analysis. The two groups were similar in terms of tumor number and size and number of resected segments.

RESULTS

Morbidity and mortality rates were similar in the two groups (respectively 25 and 0% in LG vs. 35.8 and 7.5% in OG; p = 0.3). Severe complications were more frequent in OG (13.2%) than in LG (2.8%; p = 0.09). Despite similar portal hypertension levels, complications related to ascites (namely evisceration or variceal bleeding) were fatal in 4 of 12 affected patients in OG but 0 of 5 cases in LG (p = 0.2). The mean hospitalization durations were 6.5 ± 2.7 days and 9.5 ± 4.8 days in LG and OG, respectively (p = 0.003). The surgical margins were similar in the two groups. Although there was a trend toward better 5-year overall survival in LG (70 vs. 46% in OG; p = 0.073), 5-year disease-free survival was similar (35.5 vs. 33.6%).

CONCLUSIONS

Laparoscopic resection of HCC in patients with chronic liver disease has similar results to open resection in terms of postoperative outcomes, surgical margins, and long-term survival.

Improving Outcomes with Surgical Resection and Other Ablative Therapies in HCC

With rising incidence and emergence of effective treatment options, the management of hepatocellular carcinoma (HCC) is a complex multidisciplinary process. There is still little consensus and uniformity about clinicopathological staging systems. Resection and liver transplantation have been the cornerstone of curative surgical treatments with recent emergence of ablative techniques. Improvements in diagnostics, surgical techniques, and postoperative care have lead to dramatically improved results over the years. The most appropriate treatment plan has to be individualised and depends on a variety of patient and tumour-related factors. Very small HCCs discovered on surveillance have the best outcomes. Patients with advanced cirrhosis and tumours within Milan criteria should be offered transplantation. Resection is best for small solitary tumours with preserved liver function. Ablative techniques are suitable for low volume tumours in patients unfit for either resection or transplantation. The role of downstaging and bridging therapy is not clearly established.

Vitamin analogues in chemoprevention of hepatocellular carcinoma after resection or ablation--a systematic review and meta-analysis

OBJECTIVE

While hepatic resection or local ablative therapy may provide a potentially curative treatment for hepatocellular carcinoma (HCC), more than half of these patients develop recurrent HCC within 5 years after treatment. Thus identification of any therapy which can decrease or delay the incidence of recurrence will improve the results of treatment. However, no chemopreventive agent has been approved for HCC.

METHODS

A MEDLINE database, Embase, Cancerlit (National Cancer Institute), and CBM (Chinese Biomedical Database) search from 1990 to 2009 was performed to identify relevant articles using the keywords "hepatocellular carcinoma," "vitamin analogue," and "chemoprevention." Additional papers were identified by a manual search of the references from the key articles. The fixed effect model was used for a meta-analysis.

RESULTS

Oral administration of acyclic retinoids (vitamin A analogue), and menatetrenone (vitamin K2 analogue) have been tested as chemopreventive agents after hepatic resection or local ablative therapy for HCC. There were one and four randomised, controlled trials (RCTs) which evaluated the efficacy of polyprenoic acid and menatetrenone, respectively. All studies were conducted in Japan. One RCT showed the preventive effect of polyprenoic acid in lowering the incidence of HCC recurrence after hepatic resection or percutaneous ethanol injection, and this effect lasted up to 199 weeks after randomization (or 151 weeks after completion of retinoid administration). Four RCTs evaluated the preventive efficacy of menatetrenone on HCC recurrence after hepatic resection or local ablative therapy. The results of three studies, as well as the meta-analysis of all four studies, showed significantly better tumour recurrence-free survival. The beneficial effect on the overall survival was less definite.

CONCLUSION

There is evidence to suggest that chemopreventive therapy after partial hepatectomy or local ablative therapy is beneficial in prolonging disease-free survival, but the evidence is less for an effect on the overall survival. To confirm the beneficial role of vitamin A or K analogues in the chemoprevention of HCC further and larger randomised trials are now required.

Conventional Surgical Treatment of Hepatocellular Carcinoma

Liver resection remains the standard therapy for solitary hepatocellular carcinoma in patients with preserved hepatic function. In well-selected patients, 5-year survival rates are good and can approach that of liver transplantation for early-stage disease. Patient selection is critical to optimizing therapeutic benefit, and the health of the native liver must be considered in addition to tumor characteristics. Hepatic recurrence after resection is common. The difficulty lies in deciding which patients with chronic liver disease and small solitary tumors are best served by resection and which should proceed with transplant evaluation; this is the focus of this article.