Laparoscopic versus open liver resection for resectable HCC with BCLC stage B: a propensity score-matched analysis

Minimally invasive versus open liver resection for nonmetastatic hepatocellular carcinoma staged BCLC - B and - C: an Italian multicentric analysis

BACKGROUND

Recent papers report significant survival gain after liver resection in BCLC-B and -C HCC patients. The results of minimally invasive liver surgery (MILS) in such patients have not been widely investigated so far.

METHODS

Data regarding patients undergoing MILS or open liver resection (OLR) for HCC staged BCLC -B and -C were extracted from the HERCOLES database. An inverse probability of treatment weighting (IPTW) method was adopted to balance the confounders. The primary outcome was a composite endpoint including post-hepatectomy liver failure, severe postoperative complications and in-hospital mortality.

RESULTS

627 patients were included (459 undergoing OLR and 168 receiving MILS). After IPTW, no difference was found in the composite endpoint between MILS and OLR (OR 0.86 [95%CI 0.46-1-60]; p = 0.62). MILS reduced the risk of receiving intra-operative transfusions (OR 0.28 [95%CI 0.13-0.58]; p < 0.001) and of developing postoperative ascites (OR 0.56 [95%CI 0,32-0,98]; p = 0.039), with reduced length of stay (OR 0.82 [95%CI 0.66-1.01]; p = 0.045). The survival analysis showed no differences between MILS and OLR for both OS (p = 0.13) and DFS (p = 0.491).

CONCLUSION

MILS was shown to be safe and feasible for selected non-metastatic HCC patients staged BCLC B and C, reducing the risk of perioperative transfusions and postoperative ascites, and shortening the length of stay.

Novel techniques of liver segmental and subsegmental pedicle anatomy from segment 1 to segment 8

BACKGROUND

Laparoscopic anatomical liver resection has become more challenging because some subsegmental Glissonean pedicles are hard to dissect. Here, we introduce how to dissect every (sub) segmental Glissonean pedicle from the first porta hepatis and perform standardized (sub) segmentectomy [from segment 1 (S1) to S8].

AIM

To summarize our methods of laparoscopic anatomical segmental and subsegmental liver resection.

METHODS

The Glisson sheath and liver capsule were separated along the Laennec membrane. The Glissonean pedicle could be isolated and transected with little or no parenchymal damage through this extra-Glissonean dissection approach. The basin of the (sub) segment was determined by the ischemia demarcation line or indocyanine green staining. The hepatic vein or intersegmental vein was also used to guide the plane of parenchymal transection.

RESULTS

All segmental or subsegmental pedicles or even the pedicle of the cone unit could be dissected along the Laennec membrane using our novel technique through the first porta hepatis. The dorsal branches of S8, the branches of S4a and the paracaval portion branches (b/c vein) of the caudate lobe were the most difficult to dissect.

CONCLUSION

The novel techniques of liver segmental and subsegmental pedicle anatomy is feasible for laparoscopic liver resection and can help accurately guide (sub) segmentectomy from S1 to S8.

Risk factors and nomogram predictive models for postsurgical progression/hyperprogression recurrence in hepatocellular carcinoma with macroscopic vascular invasion

PURPOSE

This study aimed to develop postsurgical progression/hyperprogression recurrence (type III-IV recurrence) prediction models for hepatocellular carcinoma (HCC) patients with macroscopic vascular invasion (MaVI) and to guide treatment strategies in the accurate healthcare era.

PATIENTS AND METHODS

393 HCC patients with MaVI from two central hospitals made up the entire study population. In developmental (290 patients) and validation (103 patients) cohorts, all patients were randomized into one or the other. Two prediction models for type III-IV recurrence were developed, based on the findings of univariate and multivariate analysis in the development cohort, and multidimensional verification was carried out in both cohorts.

RESULTS

The postoperative recurrence rate of type III-IV in 393 HCC patients with MaVI was 70.9%. Young age, large tumor size (≥ 10 cm), node number, incomplete tumor capsule, postoperative complications, and high Ki67 index were the independent risk factors for relapse of type III-IV. In the development cohort, two nomograms (pre- and postoperative) had the Area Under the ROC curve (AUC) of 0.827 and 0.891, respectively. The two nomograms performed well, according to multidimensional verification methods such as clinical impact curves, decision curve analysis (DCA), and calibration curves. The validation cohort saw similar encouraging results. Both nomograms could separate patients into two distinct prognosis subgroups with ideal cutoff values of 170.3 presurgery and 175.0 postsurgery (both P < 0.05).

CONCLUSION

We constructed two novel and potentially clinically valuable models for predicting type III-IV recurrence. These two models can develop strategies for treating those suffering from HCC with MaVI owing to their strong prediction performance and availability.

Laparoscopic versus open liver resection for multiple hepatocellular carcinoma within and beyond the Milan criteria: An Eastern-Western propensity score-matched analysis

BACKGROUND

There is still little knowledge about the outcomes of laparoscopic liver resection (LLR) for multiple hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC within and beyond the Milan criteria, and in both BCLC-A and -B stage.

METHODS

Data regarding all consecutive patients undergoing liver resection for multiple HCC were retrospectively collected from Asian (South Korean) and European (Italian) referral HPB centers. The cases were propensity-score matched for age, BMI, center, extent of the resection, postero-superior location of the lesion, underlying liver condition, BCLB staging and the Milan criteria.

RESULTS

A total of 203 patients were included in the study: 27% of patients had undergone hemi-hepatectomy, 26.6% atypical resections, 20.6% sectionectomy and 16.2% segmentectomy. After PSM two cohorts of 57 patients were obtained, with no significant differences in all preoperative characteristics. The length of hospital stay was significantly lower after LLR (median 7 vs. 9 days, p < .01), with no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications and R1 resection rates. After a median follow-up of 61 (±7) months, there were no significant differences between OLR and LLR in both median OS (69 vs. 59 months, p = .74, respectively) and median DFS (12 vs. 10 months, p = .48, respectively).

CONCLUSION

LLR for multiple HCC can be safe and effective in selected cases and is able to shorten median hospital stay without affecting perioperative and long-term oncological outcomes.

Artificial Intelligence to Early Predict Liver Metastases in Patients with Colorectal Cancer: Current Status and Future Prospectives

BACKGROUND

Artificial Intelligence (AI)-based analysis represents an evolving medical field. In the last few decades, several studies have reported the diagnostic efficiency of AI applied to Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) to early detect liver metastases (LM), mainly from colorectal cancer. Despite the increase in information and the development of different procedures in several radiological fields, an accurate method of predicting LM has not yet been found. This review aims to compare the diagnostic efficiency of different AI methods in the literature according to accuracy, sensibility, precision, and recall to identify early LM.

METHODS

A narrative review of the literature was conducted on PubMed. A total of 336 studies were screened.

RESULTS

We selected 17 studies from 2012 to 2022. In total, 14,475 patients were included, and more than 95% were affected by colorectal cancer. The most frequently used imaging tool to early detect LM was found to be CT (58%), while MRI was used in three cases. Four different AI analyses were used: deep learning, radiomics, machine learning, and fuzzy systems in seven (41.18%), five (29.41%), four (23.53%), and one (5.88%) cases, respectively. Four studies achieved an accuracy of more than 90% after MRI and CT scan acquisition, while just two reported a recall rate ≥90% (one method using MRI and CT and one CT).

CONCLUSIONS

Routinely acquired radiological images could be used for AI-based analysis to early detect LM. Simultaneous use of radiomics and machine learning analysis applied to MRI or CT images should be an effective method considering the better results achieved in the clinical scenario.

Hepatocellular Carcinoma with Bile Duct Tumor Thrombus: A Case Report and Literature Review of 890 Patients Affected by Uncommon Primary Liver Tumor Presentation

Bile duct tumor thrombus (BDTT) is an uncommon finding in hepatocellular carcinoma (HCC), potentially mimicking cholangiocarcinoma (CCA). Recent studies have suggested that HCC with BDTT could represent a prognostic factor. We report the case of a 47-year-old male patient admitted to the University Hospital of Bari with abdominal pain. Blood tests revealed the presence of an untreated hepatitis B virus infection (HBV), with normal liver function and without jaundice. Abdominal ultrasonography revealed a cirrhotic liver with a segmental dilatation of the third bile duct segment, confirmed by a CT scan and liver MRI, which also identified a heterologous mass. No other focal hepatic lesions were identified. A percutaneous ultrasound-guided needle biopsy was then performed, detecting a moderately differentiated HCC. Finally, the patient underwent a third hepatic segmentectomy, and the histopathological analysis confirmed the endobiliary localization of HCC. Subsequently, the patient experienced a nodular recurrence in the fourth hepatic segment, which was treated with ultrasound-guided percutaneous radiofrequency ablation (RFA). This case shows that HCC with BDTT can mimic different types of tumors. It also indicates the value of an early multidisciplinary patient assessment to obtain an accurate diagnosis of HCC with BDTT, which may have prognostic value that has not been recognized until now.

Selecting the Best Approach for the Treatment of Multiple Non-Metastatic Hepatocellular Carcinoma

According to the Barcelona Clinic Liver Cancer (BCLC) staging system, the optimal strategy for patients with multiple HCC within the Milan Criteria is liver transplantation (LT). However, LT cannot be offered to all the patients due to organ shortages and long waiting lists, as well as because of the advanced disease carrying a high risk of poor outcomes. For early stages, liver resection (LR) or thermal ablation (TA) can be proposed, while trans-arterial chemoembolization (TACE) still remains the treatment of choice for intermediate stages (BCLC-B). Asian guidelines and the National Comprehensive Cancer Network suggest LR for resectable multinodular HCCs, even beyond Milan criteria. In this scenario, a growing body of evidence shows better outcomes after surgical resection when compared with TACE. Trans-arterial radioembolization (TARE) and stereotaxic body radiation therapy (SBRT) can also play an important role in this setting. Furthermore, the role of minimally invasive liver surgery (MILS) specifically for patients with multiple HCC is still not clear. This review aims to summarize current knowledge about the best therapeutical strategy for multiple HCC while focusing on the role of minimally invasive surgery and on the most attractive future perspectives.