Primary carcinoma of the liver: improvement in sight?

Hospital variation in use of prophylactic drains following hepatectomy

BACKGROUND

Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use.

METHODS

Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed.

RESULTS

Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level.

CONCLUSION

Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.

Validation of the Modified Tnm-Izumi Classification for Hepatocellular Carcinoma

AIMS AND BACKGROUND

The clinical value of the UICC TNM classification and the Izumi TNM modification regarding prognosis after hepatic resection was evaluated.

METHODS

Between January 1993 and December 1998, survival and disease-free survival were analyzed in 53 cirrhotic patients (40 males, 13 females; mean age, 65 years; range, 43-81) who underwent hepatic resection for HCC.

RESULTS

The 1-, 3-, and 5-year overall survivals were: 89%, 54%, and 50%, with disease-free survivals of 70%, 38%, and 28%, respectively. The difference between stages 1 and 2 or stages 3 and 4A using the UICC TNM classification was not significant with respect to survival or disease-free survival. Conversely, the Izumi TNM modification showed a significant difference between each stage with respect to survival and disease-free survival. In a multivariate analysis the lack of micro/macro vascular invasion was predictive of long-term outcome.

CONCLUSIONS

Our results show that the UICC TNM classification for hepatocellular carcinoma is inadequate. The Izumi modified TNM staging system is superior in assessing prognosis for surgical HCC patients.

Adverse effects of preoperative hepatic artery chemoembolization for resectable hepatocellular carcinoma: A retrospective comparison of 138 liver resections

During the past 8 years we have treated 268 patients with primary hepatocellular carcinoma (HCC); total extirpation of the tumor was carried out in 138. Thirty-one of the patients with resectable HCCs had already been treated with transcatheter arterial embolization (TAE) of the liver before they were referred to us. The clinical values of preoperative TAE were retrospectively evaluated for those 31 patients and for the remaining 107 patients without TAE. There were no substantial differences between the two study groups in the clinical and histopathologic backgrounds. No differences were observed in the extent of liver resection, estimated blood loss during surgery, and operation time. During surgery, however, troublesome intra-abdominal complications relevant to TAE were encountered in 15 patients, and detection of tumors was impossible, even with intraoperative ultrasonography, in five patients in the group with TAE. Such findings were not present in any of the patients without TAE. Postoperative morbidity and mortality rates were similar in the two groups. There was no significant difference in the rate of recurrence of tumor in the liver, but the recurrence time was significantly shorter in the group with TAE. TAE did not improve the long-term survival rates in patients either with or without cirrhosis. Results of our study seem to indicate that preoperative TAE is meaningless in the treatment of resectable HCCs and therefore should be avoided, particularly in patients with advanced cirrhosis of the liver.

Imaging: focus on hepatocellular carcinoma and liver transplantation

The choice of management for the patient with HCC hinges on precise localization and staging of the disease process. All the major imaging modalities are employed to achieve this end. US is frequently the initial means of detection of the lesion. Since percutaneous needling may lead to tumour dissemination, the temptation to proceed to imaging-guided biopsy should be resisted until a full evaluation has been completed and it is clear that neither curative surgery nor transplantation is a therapeutic option. CT scanning is considered to be superior to ultrasound both in detection and staging of the disease. A variety of modifications to the technique, including CT arterio-portography and lipiodol-CT, is used to obtain optimum results. The role of MRI has not yet been established but initial results suggest that this may be the optimum means of scanning the patient following percutaneous or intra-arterial therapy. Angiography is generally performed prior to resection and may be combined with the delivery of chemotherapeutic and embolic agents pre-operatively or as a definitive palliative procedure. Imaging-guided percutaneous alcohol is also a useful palliative measure where the lesion is small. In the majority of cases, resection is not feasible. In a selected few liver transplantation is an option. Imaging requirements of the potential liver transplant candidate depend on the nature of the underlying liver problem. A general assessment including a chest X-ray and US with Doppler imaging of the hepatic vascular structures is sufficient in the majority. In children with complex structural anomalies and in patients with bile duct disease or tumours, the full range of investigations is required. US, cholangiography CT and angiography may all be required in the diagnosis and management of post-transplant complications.

Criteria for safe hepatic resection

BACKGROUND

To lower morbidity after hepatic resection, the authors examined the influence of predictor variables including: age, sex, preoperative risk factors, serum total bilirubin level, plasma retention rate of indocyanine green at 15 minutes, underlying liver disease, operative blood loss, operation time, amount of whole blood transfused, vascular occlusion time, surgical procedure employed, and extent of hepatic resection.

PATIENTS AND METHODS

Between January 1990 and December 1992, 172 patients underwent hepatic resection based on our own criteria for hepatectomy, including the presence or absence of ascites, serum total bilirubin level, and the plasma retention rate of indocyanine green at 15 minutes in patients with chronic liver disease. The morbidity rate was 37.2%, and the hospital and operative mortality rates were 2.3% and 0.6%.

RESULTS

The multiple logistic model revealed that the risk of morbidity was increased by longer operation time, major hepatic resection, and preoperative cardiovascular disease.

CONCLUSIONS

Shortening the operation time without increasing operative blood loss and further modalities for making major hepatectomy safer are future problems to be addressed.

Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma

BACKGROUND

Experience with hepatocellular carcinoma (HCC) is limited in the West and factors affecting outcome after resection are not clearly defined.

METHODS

Between 1970 and 1992, 106 patients (including 74 Caucasians, 31 Orientals, and 1 black) underwent hepatic resection for HCC at Memorial Sloan-Kettering Cancer Center. Clinical and histopathologic factors of outcome were analyzed.

RESULTS

Cirrhosis was present in 33% and 95% were Child-Pugh A. Operative mortality was 6%, 14% in cirrhotics versus 1% in non-cirrhotics (P = 0.013). Orientals had a higher prevalence of cirrhosis (68% versus 19%) (P < 0.0001) and smaller tumors (mean 8.7 cm versus 11.0 cm) (P = 0.028) compared to Caucasians. Overall survival was 41% and 32% at 5 and 10 years, respectively. By univariate analysis, survival was greater in association with the following: absence of vascular invasion (69% versus 28%, P = 0.002); absence of symptoms (66% versus 38%, P = 0.014); solitary tumor (53% versus 28%, P = 0.014); negative margins (46% versus 21%, P = 0.022); small tumor (< or = 5 cm) (75% versus 36%, P = 0.027); and presence of tumor capsule (69% versus 35%, P = 0.047). Ethnic origin, cirrhosis, necrosis and grade did not affect survival. By multivariate analysis, only vascular invasion predicted outcome (P = 0.0025, risk ratio 2.9).

CONCLUSIONS

One third of patients resected for HCC can be expected to survive long-term. Except for a higher incidence of cirrhosis in Orientals, no major histopathologic or prognostic differences were noted between Orientals and Caucasians undergoing resection. Early cirrhosis (Child-Pugh A) did not adversely affect survival. Vascular invasion predicted long-term outcome.

Trends in morbidity and mortality of hepatic resection for malignancy. A matched comparative analysis

OBJECTIVE

The authors define more clearly the trends in morbidity and mortality after hepatic resection for malignant disease in matched patient groups during two discrete time periods.

SUMMARY BACKGROUND DATA

Recent reports have shown improvement in operative morbidity and mortality associated with hepatic resection; however, results often included resections for benign disease and trauma. Furthermore, specific factors contributing to the improvement in operative risks between the last two decades have not been defined.

METHODS

A retrospective matched comparative analysis was conducted of patients with primary and metastatic hepatic malignancy resected with curative intent between two periods (1976 to 1980 and 1986 to 1990). Eighty-one patients met our inclusion criteria in the early period; this group was matched with 81 patients from the latter period by the following four parameters: age, gender, type of malignant disease, and extent of resection. Records of these two patient groups were abstracted for clinical presentation, co-morbid factors, operative techniques, and perioperative morbidity and mortality.

RESULTS

The authors found a significant decrease in operative morbidity, median perioperative transfusion, and length of hospital stay in the latter period (1986 to 1990). The incidence of postoperative subphrenic abscess and intra-abdominal hemorrhage was significantly lower during this period. Operative mortality rate was similar for both periods, 4.9% and 1.2%, respectively (p > 0.05).

CONCLUSION

Hepatic resection for malignant disease currently can be performed with a low morbidity and mortality in the hands of trained and experienced hepatic surgeons; operative risks of hepatic resection should not deter its application in the treatment of primary and metastatic malignant disease of the liver.

Postoperative adjuvant hepatic arterial infusion of Lipiodol containing anticancer drugs in patients with hepatocellular carcinoma

Vascular invasion and intrahepatic metastasis by hepatocellular carcinoma are important factors predisposing to tumor recurrence. Recurrences of this malignancy occur frequently in residual liver, and its prevention is one of the most important factors in obtaining better surgical survival. Fifty patients who underwent hepatectomy for invasive hepatocellular carcinoma with vascular invasion and/or intrahepatic metastases were studied to evaluate the effect of adjuvant bolus hepatic arterial infusion of iodized poppyseed oil (Lipiodol) containing anticancer drugs in preventing recurrence and in prolonging survival. Patients were assigned to two treatment groups. Twenty-three of the fifty patients received adjuvant bolus infusion of Lipiodol containing doxorubicin and mitomycin C, whereas 27 patients received no therapy. The disease-free survival rate for the patients who received adjuvant therapy was significantly better (p < 0.05) than that for those who did not when measured at 172, 516, 688 and 860 days after hepatectomy, and the disease-free survival curve for patients with adjuvant therapy was significantly (p = 0.0237) better than that without adjuvant therapy. The cumulative survival rates and curves were not significantly different between the two groups. While adjuvant hepatic arterial infusion of Lipiodol containing anticancer drugs was effective in improving disease-free survival, the effect was not satisfactory. Further trials of adjuvant chemotherapy are required to improve the surgical survival of hepatocellular carcinoma patients.

Hepatoma registry of the Western world. Repeat Hepatic Resection Registry

The western HCC registry comprised data from 322 patients who underwent hepatic resection for HCC over a 50-year period. The majority of patients had lesions > 4 cm and were symptomatic at presentation. Lesions were mostly unicentric. Cirrhosis was not a prevalent problem, unlike the East. In the most recent decade, 1980-1989, we noted a significant decrease in operative mortality from 19% to 10% overall, and 15% to 4% in the noncirrhotic group. We identified four variables that resulted in poorer postresectional outcome: cirrhosis, regional nodal disease, multicentric disease, and tumor-free resectional margin < 1 cm. Although these factors are associated with a poorer outcome after resection, whether they should serve as contraindications to surgery should be determined by individual surgeons, taking into account the patient's overall status, concomitant risk factors, and treatment objectives.

Hepatic resections for primary liver cancer

The medical records of 399 patients who underwent hepatic resection between January 1981 and December 1990 were reviewed. Information regarding the results of the hepatic resection in terms of the operative indication, operative procedure, operative morbidity, and mortality was abstracted. As of the end of 1990, a total of 402 hepatic resections had been completed, including those of 319 primary malignancies, 4 secondary malignancies, 2 gallbladder carcinomas, 42 cases of intrahepatic cholelithiasis, and 35 benign masses. Major hepatic resections were performed on 117 patients (29%), of whom 60 (51%) had histologically proven liver cirrhosis. Minor hepatic resections were performed on the remaining 285 patients (71%). Sepsis was the most frequent complication, which manifested primarily as wound infection (71 cases) or intra-abdominal infection (25 cases). Nonfatal hepatic failure occurred in nine patients with cirrhosis and one patient without cirrhosis. There were 38 operative deaths among the 402 hepatic resections, for an overall operative mortality of 9.4%; 25 of those deaths were due to hepatic failure after the operation, accounting for 66% of the total operative mortality. There was an increasing frequency of hepatic resection during the last 5 years. The indication for resection due to hepatocellular carcinoma increased from 87 to 195 cases. The cumulative data show a decrease in the incidence of complications and the operative mortality rate. In the most recent period, nonlethal postoperative complications occurred in 135 of 286 patients (47%). The overall 1-, 3-, and 5-year survival rates for 172 patients, excluding cases of operative mortality, palliative resection, and re-resection, were 71.0%, 39.8%, and 28.3%, respectively.

[Liver resections for primary liver malignancies. Personal results and analysis of the literature]

In a retrospective study we analysed 50 resections for primary liver tumors performed between 1 July 1979 and 31 December 1991 at the Department of Surgery of the University of Cologne. The mean resectability rate was 28%. Hospital mortality after resection was 22% and could be reduced to 4% during the last 4 years. The overall survival rates after 1, 3 and 5 years were 55%, 30% and 24% respectively. The surgical radicality is the most important prognostic factor. In a review of the literature the results of 8,725 resections for primary liver malignancies published between 1980 and 1992 were analyzed. The mean resectability rate was 32 +/- 17%. The hospital mortality after resection could be reduced from 15 +/- 5% (resections before 1970) to 6 +/- 2% (resections after 1980). The overall survival rates after 1, 3 and 5 years were 66 +/- 17%, 39 +/- 15% and 27 +/- 10%, respectively. Apart from a lower hospital mortality in Asian studies (4% vs. 7%) the resection rates and long-term results of Asian, American and European studies were similar. Long-term prognosis predominantly depended on the surgical radicality and on the size and extension of the tumor at the point of resection. The effectivity of an adjuvant tumor therapy is not analyzed sufficiently.

Effects of preoperative transcatheter hepatic arterial chemoembolization for hepatocellular carcinoma. The relationship between postoperative course and tumor necrosis

BACKGROUND

The effects of preoperative transcatheter arterial chemoembolization (TAE) for hepatocellular carcinoma (HCC) remain a matter of controversy.

METHODS

Seventy-two patients with HCC were entered in the study; the patients did not have the risk factors for disease recurrence of tumor larger than 5 cm in diameter, the presence of venous invasion, or intrahepatic metastasis. Only patients with 3 years of follow-up after curative resection were selected. Forty-six underwent TAE (Group I) and 26 did not undergo TAE (Group II). Group I was divided into three subgroups according to the degree of tumor necrosis: IA, complete necrosis; IB, partial necrosis; and IC, no necrosis. Group II was divided into two subgroups: IIB, partial necrosis; and IIC, no necrosis.

RESULTS

Preoperative TAE did not improve the average disease-free survival rates of the group as a whole. For patients undergoing TAE, the survival rate of Group IB was significantly worse than that of Groups IA or IC. The survival rate of Group IB was worse than that of Group II, but the difference was not significant. In Group II, the survival of Group IIB was worse than that of Group IIC. Histologically, residual tumor cells lacking mutual contact were detected in some patients in Group IB.

CONCLUSION

These results indicate that partial tumor necrosis caused by preoperative TAE or spontaneous tumor necrosis per se might facilitate postoperative disease recurrence. This may occur because in patients with partial necrosis, the remaining tumor cells are less firmly attached and more likely to be dislodged into the bloodstream during hepatic resection.

Evaluation of preoperative transcatheter arterial embolization in the treatment of resectable primary liver cancer

The effects of preoperative transcatheter arterial embolization (TAE) and intra-arterial injection of Lipiodol were retrospectively evaluated in patients with resectable hepatocellular carcinoma experienced during two different periods of time. In the TAE study, there were 31 patients with TAE and 107 patients without TAE. In the Lipiodol study, 60 patients had received Lipiodol injection and 68 patients served as controls. Curative hepatic resection was performed in all cases. As such preceding treatments had been performed at other hospitals, two comparing groups were fairly randomized in both the TAE and the Lipiodol study. Preoperative TAE did not influence the postoperative morbidity and mortality rates, cause of late death, and long-term survival rate in overall patients, but seemed to produce a better survival in noncirrhotic patients. Antitumor effect by Lipiodol injection was found in that the cancer free survival rate was significantly better in the group with Lipiodol injection. However, the overall 5-year survival rate was significantly better in the group without Lipiodol (67%) than in the group with Lipiodol (26%). The present study may indicate that preoperative TAE or Lipiodol injection should not be routinely performed. Such treatments may produce a substantial benefit only in selected patients with good hepatic functional reserve.

Survival after hepatic resection for malignant tumours

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.

Liver transplantation for hepatocellular carcinoma: clinical results and future aspects

The treatment of unresectable hepatocellular carcinoma (HCC) by liver transplantation remains controversial. In our series, the 5-year survival value for 87 patients who underwent transplantations between 1972 and 1990 was 19.6%. There was no difference in the long-term survival of patients who had underlying cirrhosis and those who did not. In patients with early-stage tumors the long-term prognosis was improved, the 5-year survival in stage II disease being 55.6% according to UICC criteria. Even in some cases of more advanced tumour stage, good long-term results were obtained. In a review of the recent literature, we evaluated prognostic factors to work out criteria for a more differentiated indication for liver transplantation. Resection of increased radicality--which will keep its place as the therapy of choice--and transplantation should be performed complementarily. Further developments will reveal the value of multimodal therapeutic strategies, including chemo-embolisation, chemotherapy and immunotherapy.

Elective and emergency hepatic resection. Determinants of operative mortality and morbidity

To determine the reasons for improved mortality and morbidity rates after major hepatic resection, five variables were analyzed retrospectively in 300 patients operated on over a 27-year period: (1) the indication for surgery, (2) the surgical approach, (3) the urgency with which surgery was performed, (4) the nature of the surgical procedure, and (5) the experience of the surgeon. The operative mortality rate decreased from 19% between 1962 and 1979 to 9.7% between 1980 and 1988 (p less than 0.05). The operative mortality rates for patients undergoing resection for benign hepatic neoplasms was 3.4%; for metastatic tumors, 6.3%; for primary hepatic malignancies, 19%; and for trauma, 33%. Fifty-seven percent of operations before 1980 were performed through a thoracoabdominal exposure as compared with 19% after 1980. Overall a thoracoabdominal exposure of the liver was associated with a 20% mortality rate as compared with 8.6% for operations with abdominal exposure of the liver (p less than 0.02). Elective operations accounted for 65% of hepatic resections before 1980, as compared with 90% after 1980, and were associated with an 8.8% mortality rate as compared with 30.7% for urgent and emergency operations (p less than 0.001). Segmental and wedge resections were associated with a 5.3% mortality rate as compared with 14.7% for major hepatic resections (p less than 0.05), but this difference did not affect overall operative mortality rates because there was no change in the proportion of major hepatic resections after 1980. Surgical experience was not a determinant of operative mortality or morbidity rates in elective operations. Although there was no reduction in the complication rate after 1980, there was a reduction in postoperative stay from 26 days before 1980 to 16 days after 1980 (p less than 0.001). A reduction in the incidence of postoperative sepsis and a change in its management was associated with improved operative mortality rates.

Experience with 225 hepatic resections for hepatocellular carcinoma over a 4-year period

During the past 4 1/2 years, we have performed hepatic resection on 225 patients with hepatocellular carcinoma (HCC). These patients included 171 men and 54 women, whose ages ranged from 29 to 84 years with an average of 60 years. Underlying cirrhosis of the liver was found in 67% of the patients and chronic hepatitis in 27%. Patients undergoing hepatic resection were classified into five groups according to curability as follows: Group A, resection of the tumor-bearing segment and one additional segment; Group B, complete resection of the tumor with more than 1.0 cm free surgical margin; Group C, complete resection of the tumor with less than 1.0 cm free surgical margin; Group D, incomplete resection of the tumor; Group E, surgical approach for advanced HCC with tumor thrombi in the main trunk or the first branch of the portal vein and/or the inferior vena cava, with multiple daughter nodules in both lobes and with tumor recurrence. The number of patients in Groups A, B, C, D, and E was 12 (5%), 83 (37%), 58 (26%), 14 (6%) and 58, (26%), respectively. There were 4 deaths (2.4%) among the 167 patients in Groups A to D within 30 days after operation and 12 deaths (20.7%) in Group E. The 3-year survival rate of Groups A, B, C, D, and E was 100%, 74%, 21%, 0%, and 35%, respectively.

Surgical treatment of hepatocellular carcinoma: experience with liver resection and transplantation in 198 patients

Surgical therapy offers the only chance for long-term cure of patients with hepatocellular carcinoma. The role of partial and total hepatectomy with subsequent liver replacement was analyzed in a consecutive series of 198 patients. It was the aim of this study to compare both treatment modalities on the basis of various clinicopathological prognostic factors including the TNM system of pathological classification. One hundred thirty-one resections and 61 transplantations were performed for the following histological diagnoses: hepatocellular carcinoma without coexisting liver disease (86) or associated with various hepatic abnormalities (79), fibrolamellar carcinoma (19), and mixed hepatocholangiocellular carcinoma (8). Overall actuarial survival rates at 5 years were 35.8% following resection and 15.2% after transplantation, respectively. For partial hepatectomy, factors significantly associated with improved long-term outcome were: age 30-50 years, hepatocellular carcinoma without coexisting liver disease, fibrolamellar carcinoma, solitary tumor, unilobar location, absence of vascular invasion, portal vein thrombosis or extrahepatic spread, primary tumor categories pT 2/3, stage groups II/III, and curative operation (R0). Regarding total hepatectomy, the corresponding figures were: pT2, absence of portal vein thrombosis or extrahepatic spread (negative regional lymph nodes, no distant metastases), stage group II, and curative surgery. It could be clearly shown by uni- and multivariate analyses that the pTNM classification is of clinical value regarding the assessment of prognostic significance after resection and transplantation. A group of 13 patients had secondary resection (8) or transplantation (6) for intrahepatic tumor recurrence. Whereas in all resected patients cancer recurred again, 5 of 6 transplant recipients are alive and disease-free at 12-40 months. The results of this study demonstrate that liver resection is the treatment of choice for primary liver cancer while transplantation may be indicated, especially in cases of nonresectable or recurrent lesions. Thus, the therapeutic spectrum for hepatocellular carcinoma should include both partial and total hepatectomy, being integrated into one common concept.

Hepatic arterial embolization with microencapsulated mitomycin C for unresectable hepatocellular carcinoma in cirrhosis

From 1986 to 1988, 35 patients with a hepatoma judged either inoperable or unresectable because of coexistent cirrhosis were treated with hepatic arterial embolization of mitomycin C microcapsules. Five of these 35 patients (14.5%) could not be treated because of inability to selectively cannulate the hepatic artery and were therefore excluded from the evaluation (feasibility rate, 86%). There were 24 men and six women with a median age of 57 years (range, 47 to 79) who could be classified as Okuda I (14 pts) or Okuda II (16 pts) and Child Class A:18 and Child Class B:12 in the remaining patients. A median dose of 0.5 mg mitomycin C/kg was administered to each subject and the treatment was repeated at 5 to 6 week intervals. Seventy courses were administered to these 30 patients (median, two courses/patient; range, 1 to 4). Minor complications were frequent (63%) but always either resolved spontaneously or after appropriate medical treatment. Neither severe renal nor hepatic toxicity was observed. No specific treatment related mortality was observed. When alpha-fetoprotein levels and tumor volume were assessed to evaluate the response to treatment using established criteria for identifying a response, an objective response was found in 43% of the cases treated. The actuarial median survival was 7 months and the 1-year actuarial survival was 36% (51% for those rated as Child Class A and 0% for those identified as Child Class B, P = 0.04 and 78% rated as Okuda Types I and 0% Okuda type II, P = 0.0001). The excellent quality of life and the increased survival rate experienced after mitomycin C microcapsule embolization suggest that this treatment modality can be used successfully in patients seen in the West who have unresectable hepatoma.

Androgen receptor in hepatocellular carcinoma as a prognostic factor after hepatic resection

Androgen receptors (AR) in the cytosol of hepatocellular carcinoma (HCC) were assayed in 45 unselected patients in whom radical hepatic resection was performed. Thirty-one patients had detectable amounts of ARs in tumors, ranging from 2.3 to 82.6 fmol/mg protein with the dissociation constants (Kd) of 4.1 - 30.9 x 10(-10) M. The receptor was not found in the remaining 14 cases. AR negative HCCs were significantly more common among women and nonalcoholic patients. Otherwise, there were no significant difference in the clinicopathologic background between patients with AR positive HCCs and those with AR negative tumors. Three patients died of liver failure in the former group, whereas two died in the latter; one patient died of liver failure and the other died of pneumonia (results were not statistically significant). Excluding those five operative deaths, the recurrence rates were 67.9% in the group of patients with AR positive HCCs and 33.3% in the group of patients with AR negative tumors (0.1 less than p less than 0.05). The 5-year survival rate was significantly better (p less than 0.05) in patients with AR negative HCCs (62.2%) than in those with the positive tumors (17.3%). In light of the current results and previous experimental works by others, it is likely that testosterones enhance the growth and invasiveness of human HCC, which is mediated by AR in the tumor.

Liver resection for hepatocellular carcinoma: results from 150 consecutive patients

During the past 6 years, 150 consecutive hepatic resections were performed for hepatocellular carcinoma on 129 male and 21 female patients. Their ages ranged from 17 years to 78 years, with an average of 57.0 years. All but two patients had an underlying parenchymal disease of the liver; 131 had liver cirrhosis, 16 chronic hepatitis, and one liver fibrosis. The operations performed were extended right lobectomy in 10 cases, right lobectomy in 13, left lobectomy in 5, left lateral segmentectomy in 11, other segmentectomies in 31, and partial wedge resection in 80 instances. The operative and in-hospital mortality rates were 6.0% and 12.0% respectively. In the 122 patients with curative resection, the 1-, 3- and 5-year survival rates were 75.2%, 49.0% and 30.0% respectively. The 1- and 3-year survival rates were 14.3% and 7.1% in the 28 patients with palliative resection. The tumor size and Child's classification generally reflected the survival rate.

Role of surgery in the treatment of primary carcinoma of the liver: a 31-year experience

During the 31 year period 1954 to 1985, 225 major hepatic resections have been performed for symptomatic primary carcinoma of the liver, of which right hepatic lobectomy was performed in 115, extended right hepatic lobectomy in 11, trisegmentectomy in 2, left hepatic lobectomy in 94, and middle hepatectomy in 3. In addition there were 107 partial hepatic resections for 89 asymptomatic small hepatocellular carcinomas. In the 225 patients undergoing major hepatic resection, the operative mortality was 8.0 per cent. In the 107 patients undergoing partial hepatic resection, the operative mortality was 5.6 per cent. Of the total of 314 hepatic resections for primary carcinoma of the liver, 309 were undertaken for hepatocellular carcinoma and the remaining 5 were carried out for cholangiocarcinoma. All hepatic resections in this series were performed with the finger fracture technique without controlling the hepatic hilar vessels, hepatic ducts or hepatic veins outside the liver, although hepatic clamping and the Pringle manoeuvre were also used in selective cases. Of 207 cases who survived major hepatic resection, 119 cases died within one year after the operation, mainly due to recurrence of cancer in the remaining residual lobe, lung metastasis or late hepatic failure. The 5 year survival rate is 18.0 per cent, 12 patients are still alive and well after more than 5 years and the longest survival is 23 years. Of the 89 patients with small asymptomatic hepatocellular carcinomas, 28 died within one to four years of surgery because of a second new growth.

Liver resection in malignant disease

As more surgeons become familiar with the techniques of hepatic resection and the mortality and morbidity decrease, the indications for resection of malignant disease within the liver broadens. The preoperative assessment of malignant liver lesions, as well as the definition of resectability, are outlined. Indications for operative intervention as well as the results obtained are covered. The personal experience of the authors at the Royal Postgraduate Medical School Hepatobiliary Unit, Hammersmith Hospital, in dealing with malignant lesions of the liver is detailed with respect to procedures performed and postoperative morbidity and mortality. Hepatocellular carcinoma, hilar cholangiocarcinoma, and metastatic colon carcinoma are discussed in detail. The authors' experience with each of these diseases is presented.

Second hepatic resection for recurrent hepatocellular carcinoma

During the last 5 years, radical hepatic resection was performed in 91 patients with hepatocellular carcinoma (HCC). Thirty-one of them had tumour recurrence in the remaining liver during the follow-up period. Second hepatic resection was carried out on nine of them 4-38 months after the first hepatectomy. The ages of these patients ranged from 39 to 65 years with an average of 53.7. There were six men and three women. Eight patients had underlying cirrhosis of the liver and one chronic active hepatitis. Six patients are alive, four being free of HCC and two with disease, for 15-45 months after the first operation. Two patients died of systemic cancer dissemination. The remaining patient had tumour recurrence in the liver again and died of hepatic failure after the third laparotomy. The survival rate of these nine patients was significantly better than that of twenty-two patients who were treated by other palliative methods. The present result shows that a second hepatic resection is a possible and meaningful method of treatment for the patients with recurrent HCCs in the liver remnant.

Characteristics of fibrolamellar hepatocellular carcinoma. A study of nine cases and a review of the literature

Clinical and laboratory data for nine patients with hepatocellular fibrolamellar carcinoma treated at our institution have been summarized with emphasis on the relevance of plasma neurotensin levels as a tumor marker. The mean age of the patients was 22 years. Seven underwent hepatic resection, and two of these had later surgical removal of recurrent disease. Plasma neurotensin levels were initially elevated in five of the seven patients in whom it was measured. Neurotensin levels were within normal limits in three of four patients with recurrent disease, but were elevated in one patient who also had elevated plasma neurotensin levels preoperatively. In addition, a review of 80 patients reported since 1980 was performed. The mean age of these patients was 23 years, and only 6 percent were older than 50. The male to female ratio was 3:4. Eight percent were positive for hepatitis B antigen and 11 percent had elevated alpha-fetoprotein levels. Four percent had cirrhosis of the liver. The resectability rate was 58 percent. Five year survival for patients who underwent hepatic resection was 56 percent. Patients treated nonsurgically had a median survival of 13 months, and none of these patients lived for 5 years. Fibrolamellar hepatoma seems to be a distinct clinical entity that mainly occurs in young patients. The prognosis in patients treated with a curative resection is good. Plasma neurotensin levels may be of value as a tumor marker, but further studies are necessary to substantiate this theory.

Large hepatocellular cancers: hepatic resection or liver transplantation?

Thirteen patients with primary hepatocellular cancer were studied to outline criteria for resectability in patients with large liver tumours. The mean age was 34 and the mean tumour diameter 13 cm (range 7-18 cm). Five of the tumours had a diameter of 15 cm or more. Extensive radiological investigations showed that seven of the patients had tumours of both right and left lobes of the liver, 10 had evidence of vascular invasion, and three had evidence of extrahepatic spread. Only two of the patients underwent a classically described formal hepatic resection, the rest having extensive resections crossing major anatomical planes. In no instance did the vascular invasion preclude resection, and extrahepatic spread could be verified in only one patient. The traditional criteria of resectability--that is, tumours located to one main lobe of the liver without vascular invasion and extrahepatic spread--can and should be extended. Resection may be preferable to transplantation even in patients with large primary liver tumours.

One hundred hepatic resections. Indications and operative results

The indications and operative results of hepatic resections were investigated in 100 consecutive patients over the past 20 years. There were 61 hepatocellular carcinoma, 13 hepatolithiasis, and 26 other miscellaneous diseases. An overall hospital mortality rate was 25%. It was 26, 0, and 35% in patients with hepatocellular carcinoma, hepatolithiasis, and other diseases, respectively. There was not any significant difference between survived and deceased cases in their preoperative laboratory data. The volume of operative blood loss in deceased cases was significantly larger than that in survived cases, so the influence of operative blood loss on morbidity and mortality was investigated. The incidences of postoperative bleeding, hepatic insufficiency, pulmonary insufficiency, and hospital death were significantly higher in patients whose operative blood loss exceeded 5000 ml. These results indicate that operative blood loss is one of the critical factors that decide the operative prognosis.

Hepatic resection in the treatment of hepatocellular carcinoma: report of 60 cases

During the last 3 years and 9 months, hepatic resections were carried out on 60 patients with hepatocellular carcinoma (HCC). The resections were radical in 44 and palliative in 16 cases. Simultaneous operations were performed for oesophageal varices in 11 (9 prophylactic and 2 therapeutic) and for cholelithiasis in 9 patients. Fifty-nine patients had underlying hepatic disease; 52 had cirrhosis and 7 chronic hepatitis. Operative mortality rate within 1 month was 10 per cent and overall hospital mortality rate was 16.7 per cent. Excluding operative and hospital deaths, 76.8 per cent of patients who had radical excision and 18.8 per cent with palliative resections are alive. The result indicates that HCCs are frequently resectable even in the presence of liver cirrhosis provided that they are discovered at a relatively early stage.

Fibrolamellar hepatoma

We found the clinical features of fibrolamellar hepatoma similar to those of nonfibrolamellar hepatoma with the exception of patient age. Although the histopathologic findings of fibrolamellar hepatoma are distinct and easily recognizable, we found that fibrolamellar hepatomas may be histologically heterogeneous. The overall length of survival of patients with fibrolamellar hepatoma was greater than that of patients with nonfibrolamellar hepatoma, but the survival resection was similar, regardless of histologic characteristics. Differences in overall survival between histologic subtypes probably reflects differences in the rate of resectability between fibrolamellar and nonfibrolamellar hepatomas.

Hepatic resection for primary liver malignancy

The results of hepatic resection for patients with primary liver malignancy seen at our clinic during the past 21 years are reported. Of 92 patients, 57 had cirrhosis in addition to hepatocellular carcinoma, and 49 (53 percent) underwent hepatic resection of various degrees from partial resection to trisegmentectomy. Resectability rates of the liver were 52 percent in 77 patients with hepatocellular carcinoma, including 19 in whom the tumor was less than 5 cm in diameter, and 60 percent in 15 patients with other malignant tumors; operative mortality rates were 15 percent in the former and 0 percent in the latter. Cumulative survival rates of all patients who underwent hepatic resection, excluding death within one month, were 55 percent at one year, 29 at 3 and 5 years. In patients with hepatocellular carcinoma, survival rates of 15 those who had a curative resection of the tumor were 87 percent at one year and 47 percent at 3 or 5 years, there was a significant difference in survival curves between those with tumors less than 5 cm and more than 5 cm (p less than 0.05). On the other hand, survival rates of all patients with other malignant tumors were 78 percent at one year and 37 percent at 5 years. These results indicate the importance of performing hepatic resection for patients with small hepatocellular carcinoma associated with cirrhosis and those with other malignant tumors.

Experience with 150 liver resections

One hundred fifty liver resections were performed with an operative mortality rate of 4%. Indications for liver resections were 43 primary liver malignancies, 43 metastatic liver tumors, and 64 benign liver diseases. The 3-year actuarial survival rate after treatment of primary liver malignancy was 56%, and that after treatment of metastatic liver tumors was 66%. All but one of 59 patients with benign disease who survived operation were alive without development of late symptoms or complications.