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

Association between the paracaval branches of the caudate lobe and the three major hepatic veins in liver casts: Locating the cranial boundary of the caudate lobe

According to Couinaud's definition, the cranial boundary of the caudate lobe is delineated by the three major hepatic veins. However, many branches of the caudate lobe go through the ceiling that is composed of these hepatic veins. The cranial boundary of the caudate lobe should be determined by employing the portal segmentation. We conducted a study based on the dissection of 37 colored resin liver casts to reveal the caudate branches of the liver. The paracaval portal vein branches (PCPvs) were defined as cranial portal branches from the main trunk or first-order branch of the portal vein distributed in front of the inferior vena cava, according to Kumon's classification. The PCVs were traced to reveal the cranial boundary of the caudate lobe. Results showed that in 18 cases (49%), the PCPvs reached the liver surface through the gap between the right and middle hepatic veins (type RM, n = 11), between the tiny branches of the middle hepatic vein (type M, n = 4), and between the middle and left hepatic veins (type ML, n = 3). The PCPvs did not reach the liver surface in 19 cases (type 0). No PCPvs reached the hepatic surface behind the right hepatic vein. Half of the PCPvs in the liver reached the hepatic surface beyond the boundary composed of the three major hepatic veins. Recognition of the PCPvs in the liver is indispensable to perform anatomically precise liver resections involving the major hepatic veins.

The successful posterior sectionectomy accompanied with caudate lobectomy for hepatocellular carcinoma located in segment 1 after LEN-TACE: a case report

Nowadays, the novel molecular targeting chemotherapy provides possibility of safe hepatectomy for progressive hepatocellular carcinoma (HCC). Further, combination of the conventional transarterial chemoembolization (TACE) may add an effect of tumor shrink. We present a successful radical hepatectomy for a large HCC located in segment 1 accompanied with the preoperative Lenvatinib (LEN)-TACE sequential treatment. We present a woman patient without any complaints who had a 7 cm-in-size of solitary HCC compressing vena cava and right portal pedicle. To achieve radical hepatectomy by tumor shrinking, LEN-TACE for 2 months. After confirming downsizing or devascularization of the HCC, we scheduled radical posterior sectionectomy combined with caudate lobectomy according to tumor location and expected future remnant liver volume from three-dimensional computed tomography simulation before surgery. Under the thoraco-abdominal incision laparotomy, we safely achieved scheduled radical hepatectomy without any vascular injuries. The postoperative course was uneventful and no tumor recurrence were observed for 1 year. Histological findings showed the Japan TNM stage III HCC with 70% necrosis. The multi-modal strategy of LEN-TACE followed by radical hepatectomy by confirming downsizing or devascularization in tumor is supposed to be useful and would be a preoperative chemotherapy option, and promising for curative treatment in HCC patients with progressive or large HCC, which may lead to safety by prevention surrounding major vascular injury.

Survival outcomes after caudate lobectomy for hepatocellular carcinoma: systematic review and meta-analysis

BACKGROUND

Caudate lobectomy (CLB) remains the most effective treatment for caudate lobe hepatocellular carcinoma (CL-HCC). However, there is controversy regarding the survival after CLB. This meta-analysis aims to investigate the survival outcomes following CLB for the treatment of CL-HCC.

METHODS

In line with PRISMA and MOOSE guidelines, a search for all eligible studies was performed. The pooled estimates of survival rates and hazard ratios (HRs) with their 95% confidence intervals (CIs) were calculated using fixed- or random-effects models.

RESULTS

Sixteen studies comprising 864 patients met the inclusion criteria. The pooled estimates of 3- and 5-year overall survival (OS) rates were 62.3% and 42.9% respectively and the pooled estimate of 3- and 5-year recurrence-free survival (RFS) rates were 39.3% and 24.4% respectively. CL-HCC showed inferior OS (HR:1.39, 95% CI: 0.91-1.88, P < 0.001) and RFS (HR:1.33, 95% CI: 1.10-1.56, P < 0.001) than other sites HCC. Isolated CLB showed better OS (HR:0.9, 95% CI:0.39-1.41, p < 0.001) and RFS (HR:0.76, 95% CI: 0.03-1.5, P = 0.04) than combined CLB.

CONCLUSIONS

The survival outcomes for CL-HCC after CLB are lower compared to other sites HCC. Isolated CLB offers better survival outcomes compared to combined CLB. However, choosing isolated or combined approaches should be prioritized according to patient and tumour characteristics.

A comprehensive study and extensive review of the Caudate lobe: The last piece of "Jigsaw" puzzle

Many liver surgeons have updated their understanding of the liver in recent years because of detailed studies on the liver anatomy and the rapid advances in laparoscopic liver surgery. Despite newer approaches, concepts and methods, research on the caudate lobe continues to be based on case reports and several persistent challenges concerning caudate lobe surgery that are worth discussing. Based on the literature and the author's experience, this study considers and addresses the challenges associated with caudate lobectomy encountered by most liver surgeons. We searched PubMed for relevant articles in English for 'caudate lobe', 'cholangiocellular carcinoma', 'laparoscopic caudate resection', 'right-side boundary of the caudate lobe' and 'assessment of hepatic functional reserve' published up to May 2022. This study reviewed the anatomical history of the caudate lobe, focusing on the challenges associated with caudate lobe-related surgical resection. Due to the unique anatomical position of the caudate lobe, surgical strategy for caudate lobe resection is particularly important, and the technical requirements for hepatobiliary surgeons are also extremely strict. Therefore, understanding the anatomical history of the caudate lobe and discussing the challenges associated with caudate lobectomy is essential.

A multicenter validation study for determining the condition of nonanatomical or minor anatomical hepatectomies satisfying technical difficulty of current high-level hepatectomy certificated by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND

The current high-level hepatectomy (HLH) is certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS), comprising only anatomical hepatectomies above Couinaud's segmentectomy. This multicenter study aimed to identify the conditions of non-HLH that satisfy equivalent technical difficulties to HLH.

METHODS

Between 2018 and 2021, 595 first open hepatectomies without biliary reconstruction (374 HLHs and 221 non-HLHs) were performed in the five institutions. Non-HLHs belonging to at least one of the three conditions; depth of hepatectomy ≥5 cm, number of resections ≥3 locations and at least one location with a depth of hepatectomy ≥3 cm, and hepatectomy involving the paracaval portion of the caudate lobe was proposed as the candidate for difficult non-HLH. The technical difficulty was estimated by the operative time and blood loss.

RESULTS

Difficult non-HLHs were neither associated with shorter operative time (373 min vs. 354 min, p = .184) nor lesser blood loss than those with HLHs (503 mL vs. 436 mL, p = .126). Postoperative complications such as Clavien-Dindo classification grade III or more were not significant between the two groups (18.6% vs. 13.4%, p = 0212).

CONCLUSIONS

Difficult non-HLHs were associated with no lesser technical difficulty than those with HLH.

Validity of the Algorithm for Liver Resection of Hepatocellular Carcinoma in the Caudate Lobe

BACKGROUND

We aimed to validate our algorithm for resecting Hepatocellular carcinoma (HCC) in the caudate lobe based on tumor location, tumor size, and indocyanine green clearance rate.

METHODS

Patients who underwent curative resections for solitary HCC in the caudate lobe were included. The surgical outcomes of patients with HCC in the caudate lobe were compared with those of patients with HCC in other sites of the liver.

RESULTS

After one-to-one matching, the caudate-lobe group (n = 150) had longer operation time, greater amount of bleeding, lower weight of resected specimens, and shorter distance between tumor and resection line than the other-sites group (n = 150), but the complication rates were not different between the groups (38.0% vs. 34.1%, P = 0.719). After a median follow-up period of 3.0 years (range, 0.3-16.2 years), the median overall survivals were 6.5 (95% confidence interval [CI], 5.3-7.9) and 7.5 years (95% CI, 6.3-9.7) in the caudate-lobe and other-site groups, respectively (P = 0.430). Median recurrence-free survivals in the caudate-lobe group (1.9 years; 95% CI, 1.4-2.7) had a tendency to be shorter than those in the other-sites group (2.3 years; 1.7-3.4) (P = 0.052).

CONCLUSIONS

Patients' survival and complication rates in the caudate-lobe group were comparable to those in the other-sites group; therefore, our algorithm for resecting HCC in the caudate lobe is of clinical use.

Isolated complete caudate lobectomy with Glissonean pedicle isolation using Takasaki's technique and right-left approach: preliminary experience from two case reports

Background

Tumors located in the caudate lobe may be primary tumor or metastases from other sites. Isolated caudate lobectomy (ICL) is a challenging procedure due to its complex structure and location. The access route to the caudate lobe has an important role in the success of the operation.

Methods

Based on the characteristics of the segment I location, which is the part of the liver located in front of the vena cava, below the hepatic veins, and cranial to the hilar plate, our approach aims to isolate the entire caudate lobe from these anatomical structures with the following steps: dissecting the caudate lobe from the hilar plate and isolating the caudate lobe from the IVC and from the hepatic veins along with parenchymal resection.

Results

We report two successful cases with the Glissonean pedicle transection method described by Takasaki and the combined right- and left-side approach: a 63-year-old female patient with a 46-mm-in-diameter HCC tumor and a 39-year-old female patient with a 45-mm lesion and the pathological result was focal nodular hyperplasia.

Conclusions

We found this to be a safe and effective approach, which can be applied to all cases of benign tumors or in the case of malignant tumors located entirely in the caudate lobe when extended hepatic resection is not possible due to poor liver function or small remnant liver volume.

Comparison of Hepatic Resection with Percutaneous Ablation for Hepatocellular Carcinoma in the Caudate Lobe Within Milan Criteria

PURPOSE

We aimed to compare the efficacy of hepatic resection and percutaneous ablation for resectable caudate HCC within Milan criteria and to investigate the prognostic factors.

METHODS

Between August 2006 and August 2020, a total of 67 eligible patients with resectable caudate HCC within Milan criteria in three centers were retrospectively analyzed and divided into hepatic resection group (n = 46) and percutaneous ablation group (n = 21). Recurrence-free survival (RFS) and overall survival (OS) rates were compared between groups of hepatic resection and percutaneous ablation for these resectable caudate HCC patients with Kaplan-Meier curves and log-rank test. Univariable and multivariable Cox regression analyses were performed to identify the prognostic factors of RFS and OS.

RESULTS

The 1-, 3-, and 5-year OS rates were 97.6%, 83.6%, and 71.5% for the hepatic resection group, and 89.4%, 58.5%, and 48.8% for the percutaneous ablation group (P = 0.032). The corresponding RFS rates were 77.6%, 47.9%, and 42.6% for the hepatic resection group, and 40.5%, 23.2%, and 15.4% for the percutaneous ablation group (P = 0.010). According to the univariable and multivariable analyses, tumor type (first recurrence) (HR = 3.54; 95%CI, 1.49-8.37; P = 0.004) was a significant independent prognostic factor of RFS for caudate HCC patients after resection or ablation, while total bilirubin (HR = 1.02; 95%CI, 1.01-1.04; P = 0.006) and treatment strategy (HR = 5.97; 95%CI, 1.48-24.12; P = 0.012) were significant independent prognostic factors of OS.

CONCLUSIONS

Hepatic resection appears to outperform percutaneous ablation for caudate HCC patients within Milan criteria.

Superselective Transarterial Chemoembolization for Unresectable or "Ablation Unsuitable" Hepatocellular Carcinoma in the Caudate Lobe: A Real World, Single-Center Retrospective Study

OBJECTIVES

To analyze the clinical outcomes of Transarterial chemoembolization (TACE) for unresectable or "ablation unsuitable" hepatocellular carcinoma (HCC) in the caudate lobe (CL) found at initial presentation in clinical practice.

METHODS

Fifty-eight patients with HCC-CL undergoing conventional TACE from January 2015 to January 2020 were enrolled in our medical center. Overall survival (OS), progression-free survival (PFS), tumor response rate and major complication rates were analyzed. Multivariate analyses for potential clinical and radiologic factors were performed by using the Cox proportional hazard model.

RESULTS

The median OS was 23 months (95%CI: 18.1-27.9), and the median PFS was 11 months (95%CI: 7.4-14.6). The 1-, 3-, and 5-years OS rates were 66.5%, 31.9% and 15.7%, respectively. The 0.5, 1-, and 3-years PFS rates were 60.3%, 44.5% and 6.3%, respectively. Objective response rate was 53.4% and disease control rate was 79.3%. The most serious complication was bile duct injury, with an incidence of 3.4%. Multivariable analysis revealed that total bilirubin, Barcelona Clinic Liver Cancer stage, nonselective chemoembolization and TACE session were four significant factors associated with OS.

CONCLUSIONS

Superselective TACE treatment might be associated with better survival benefits in unresectable or "ablation unsuitable" HCC in the CL without macroscopic vascular invasion (MVI) and adequate liver function, compared with the non-selective TACE group, and should be considered as an important reliable therapy for surgeons and interventional radiologists.

Laparoscopic liver resection for primary liver cancers originating in the paracaval portion of the caudate lobe: a preliminary retrospective analysis with 31 patients

Paracaval-originating cancers have been considered a contraindication for laparoscopic liver resection (LLR). This study aimed to explore the safety and feasibility of LLR in the treatment of paracaval-originating cancers. This study included 11 patients who underwent LLR and 20 who underwent open liver resection (OLR) for paracaval-originating cancers between May 2010 and November 2020. The outcomes of the procedures were retrospectively analyzed. There were no cases of perioperative death or conversion to laparotomy. The LLR group had an earlier postoperative feeding time, shorter postoperative hospital stay, and lower total bilirubin levels on the first day after surgery. No significant differences in the incidence of overall postoperative complications were noted between the LLR and OLR groups, but the incidence of grade IIIa complications was significantly higher in the LLR group than in the OLR group. Tumor recurrence occurred in 4 of 11 patients in the LLR group and in 11 of 20 patients in the OLR group. LLR for the treatment of paracaval-originating cancers is safe and feasible in selected patients.

Algorithm for Resecting Hepatocellular Carcinoma in the Caudate Lobe

OBJECTIVE

To propose an algorithm for resecting hepatocellular carcinoma (HCC) in the caudate lobe.

BACKGROUND

Owing to a deep location, resection of HCC originating in the caudate lobe is challenging, but a plausible guideline enabling safe, curable resection remains unknown.

METHODS

We developed an algorithm based on sublocation or size of the tumor and liver function to guide the optimal procedure for resecting HCC in the caudate lobe, consisting of 3 portions (Spiegel, process, and caval). Partial resection was prioritized to remove Spiegel or process HCC, while total resection was aimed to remove caval HCC depending on liver function.

RESULTS

According to the algorithm, we performed total (n = 43) or partial (n = 158) resections of the caudate lobe for HCC in 174 of 201 patients (compliance rate, 86.6%), with a median blood loss of 400 (10-4530) mL. Postoperative morbidity (Clavien grade ≥III b) and mortality rates were 3.0% and 0%, respectively. After a median follow-up of 2.6 years (range, 0.5-14.3), the 5-year overall and recurrence-free survival rates were 57.3% and 15.3%, respectively. Total and partial resection showed no significant difference in overall survival (71.2% vs 54.0% at 5 yr; P = 0.213), but a significant factor in survival was surgical margin (58.0% vs 45.6%, P = 0.034). The major determinant for survival was vascular invasion (hazard ratio 1.7, 95% CI 1.0-3.1, P = 0.026).

CONCLUSIONS

Our algorithm-oriented strategy is appropriate for the resection of HCC originating in the caudate lobe because of the acceptable surgical safety and curability.

The Clinical Efficacy of Surgical Removal of Hepatocellular Carcinoma in Caudate Lobe in the Chinese Population: A Case-control Study

Our aims were to compare the therapeutic efficacy of surgical resection of caudate lobe hepatocellular carcinoma and noncaudal lobe hepatocellular carcinoma in the Chinese population. The study group consisted of 220 patients undergoing caudate lobe hepatectomy during the period spanning from January 2003 to November 2017, and 220 patients with caudate lobe hepatectomy were selected as the control group. There were 142 cases (64.5%) of surgical margin of R0 in patients with caudate lobe liver cancer, and 178 cases (80.9%) of surgical margins in patients with noncaudal lobe liver cancer, and the difference was statistically significant (P<0.01) between the 2 groups. Compared with noncaudal lobe liver cancer patients, caudate lobe liver cancer patients had significantly longer operation time (186.65±81.36 vs. 118.85±69.23, P<0.01), longer vessel block time (29.93±11.96 vs. 22.76±10.74, P<0.01), more intraoperative blood loss (709.73±108.39 vs. 329.74±85.76, P<0.01), and there was no significant difference in the incidence of complications (53.4% vs. 46.6%, P>0.05). Significantly different therapeutic efficacy was found between the caudate lobe hepatocellular carcinoma group and the noncaudal lobe hepatocellular carcinoma group, which may be due to the lack of resection margin of caudate-leaf liver cancer surgery and more intraoperative bleeding.

Long-term clinical outcomes of patients receiving proton beam therapy for caudate lobe hepatocellular carcinoma

Hepatocellular carcinoma (HCC) located in the caudate lobe (caudate HCC) is rare; however, patients with this type of tumour have poorer prognoses than those with HCC in other segments. Despite many published reports on the clinical usefulness of proton beam therapy (PBT) for HCC, data on the clinical outcomes of patients undergoing PBT for caudate HCC remain scarce. Therefore, the present study aimed to investigate the outcomes of this group of patients. Thirty patients with caudate HCC who underwent definitive PBT between February 2002 and February 2014 were retrospectively analysed. The total irradiation doses ranged from 55 to 77 (median 72.6) Gy relative biological dose. The median follow-up period was 37.5 (range, 3.0-152.0) months. The overall survival (OS) rates at one, three and five years were 86.6%, 62.8% and 46.1%, respectively. According to univariate and multivariate analyses, Child-Pugh A (P < 0.01), having a single tumour (P = 0.02) and a low serum alpha-fetoprotein level (AFP; P < 0.01) were significant factors predicting longer survival. The local control (LC) rates at one, three and five years were 100%, 85.9% and 85.9%, respectively, while the corresponding progression-free survival (PFS) rates were 65%, 27.5% and 22%, respectively. No grade 3 or worse adverse events were observed. PBT is effective and safe for the treatment of caudate HCC, and should therefore be considered a feasible option for intervention in patients with this disease.

Parenchymal-sparing approaches for resection of tumors located in the paracaval portion of the caudate lobe of the liver-utility of limited resection and central hepatectomy

PURPOSE

Resection of liver cancer involving the paracaval portion (PC) of the caudate lobe is challenging because the PC is located deepest in the liver. This study aimed to elucidate the utility of two parenchymal-sparing approaches of limited resection and central hepatectomy for resecting tumors located in the PC.

METHODS

In 2018 and 2020, 12 out of 143 patients underwent hepatectomy for tumors located in the PC of the liver. In six patients, limited resection (LR) of the PC after full mobilization of the liver off the inferior vena cava (IVC) was performed for tumors excluding the hilar plate or large hepatic veins (large HVs), including major hepatic veins or thick short hepatic veins. In six patients, central hepatectomy (CH) using liver tunnel was performed for tumors involving or close to the hilar plate and/or large HVs.

RESULTS

During CH, the surgical view of the cranial side of the hilar plate was wide enough to perform combined resection of the large HVs in front of the IVC. Five of the six CHs were performed with resection of the LHVs. No LRs were accompanied with resection of the LHVs. The CH was associated with longer Pringle's time (76 min vs. 29.5 min, p = 0.015) and blood loss (1104 ml vs. 370 ml, p = 0.041). The preserved liver parenchyma volumes were 82% and 95% of the total liver volume after CH and LR, respectively.

CONCLUSION

Our parenchymal-sparing approach for resection of liver cancer located in the PC is feasible for curative resection.

Caudate Lobe Hepatocellular Carcinoma Treated with Sequential Transarterial Chemoembolization and Iodine 125 Seeds Implantation: A Single-Center Retrospective Study

Purpose

Resection of the hepatocellular carcinoma (HCC) in the caudate lobe (CL) is challenging even for accomplished surgeons. This retrospective study evaluated the safety and efficacy of transarterial chemoembolization (TACE) and iodine 125 seeds implantation (ISI) for unresectable or “ablation unsuitable” HCC-CL detected at the initial presentation in clinical practice.

Patients and Methods

A total of 20 HCC-CL patients undergoing sequential TACE and ISI from January 2014 to October 2018 were enrolled in this study. The overall survival (OS), progression-free survival (PFS), tumor response rate, and complication rates were analyzed and compared to non-caudate lobe (NCL) HCC patients. Multivariate analyses for potential clinical and radiological factors were performed using the Cox proportional hazard model.

Results

The technical success rate was 100%, as all the patients received 28 ISI treatments. The median OS was 35 months. The 1-, 3-, and 5-year OS rates were 100%, 63.2%, and 11.1%, respectively. The median PFS was 16 months. The objective response rate was 60.0%. The puncture tract bleeding (2/20) and pneumothorax (1/20) were the most common complications in operation, but no operation-related deaths occurred. One year after the surgery, biliary tract injury occurred in 1 patient, necessitating percutaneous biliary intervention. No statistical difference was observed between the CL and NCL groups. Multivariable analysis revealed that Barcelona Clinic Liver Cancer stage B and tumor size >3 cm were two significant factors associated with OS.

Conclusion

Sequential TACE and ISI were associated with the survival benefits in HCC-CL and should be considered as a reliable therapy for surgeons and interventional radiologists.

Laparoscopic anterior hepatic transection for resecting lesions originating in the paracaval portion of the caudate lobe (with videos)

BACKGROUND

The paracaval portion of the caudate lobe is located in the core of the liver. Lesions originating in the paracaval portion often cling to or even invade major hepatic vascular structures. The traditional open anterior hepatic transection approach has been adopted to treat paracaval-originating lesions. With the development of laparoscopic surgery, paracaval-originating lesions are no longer an absolute contraindication for laparoscopic liver resection. This study aimed to evaluate the safety and feasibility of laparoscopic anterior hepatic transection for resecting paracaval-originating lesions.

METHODS

This study included 15 patients who underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection between August 2017 and April 2020. The perioperative indicators, follow-up results, operative techniques and surgical indications were retrospectively evaluated.

RESULTS

All patients underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection. The median operation time was 305 min (220-740 min), the median intraoperative blood loss was 400 ml (250-3600 ml), and the median length of postoperative hospital stay was 9 days (5-20 days). No conversion to laparotomy or perioperative deaths occurred. Six patients had Clavien grade III-IV complications (III/IV, 5/1). Two patients developed tumor recurrence after 13 months and 8 months.

CONCLUSION

Although technically challenging, laparoscopic anterior hepatic transection is still a safe and feasible procedure for resecting paracaval-originating lesions in select patients.

Carbon ion radiotherapy for patients with hepatocellular carcinoma in the caudate lobe carbon ion radiotherapy for hepatocellular carcinoma in caudate lobe

AIM

The treatment of hepatocellular carcinoma in the caudate lobe (HCCCL) is technically challenging. We aimed to investigate the efficacy and toxicity of carbon ion radiotherapy (C-ion RT) for HCCCL.

METHODS

Patients with HCCCL treated with C-ion RT at our hospital between January 2011 and December 2018 were evaluated. The total dose was 52.8 or 60 Gy (relative biological effectiveness) in four or 12 fractions depending on the distance between the tumor and the gastrointestinal tract. The survival outcome, the presence or absence of recurrence (local recurrence, intrahepatic recurrence outside the irradiation field, or extrahepatic recurrence), and acute/late adverse events were evaluated.

RESULTS

Nine patients were included. The median tumor size was 3.4 cm, and the median follow-up duration was 18.3 months for all patients. No patient developed local recurrence during follow-up. Five patients subsequently developed intrahepatic recurrence outside the irradiation field and two had extrahepatic metastasis. Five patients died of hepatocellular carcinoma. No acute adverse events of grade ≥2 were observed. Two patients experienced grade 2 or 3 late adverse events, including obstructive jaundice, hepatic encephalopathy, ascites, and edema.

CONCLUSION

Carbon ion radiotherapy for HCCCL achieved excellent local control with acceptable adverse events and can thus be a curative treatment option for HCCCL.

Multi-Institutional Retrospective Study of Radiotherapy for Hepatocellular Carcinoma in the Caudate Lobe

Background: No studies evaluating the clinical outcomes of radiotherapy (RT) for hepatocellular carcinoma (HCC) in the caudate lobe have been available to date. The purpose of this study was to evaluate the effectiveness and safety of RT for HCC in the caudate lobe.

Material and Methods: Seventy patients with HCC in the caudate lobe treated with RT from a multi-institutional database were included in this study. The median equivalent dose in 2 Gy (EQD2) was 80.0 Gy₁₀ (range, 31.3–99.3), and freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) rates were evaluated.

Results: The median time of follow-up was 47.9 months (range, 3.4–127), and the 5-year FFLP, PFS, and OS rates were 80.6% [95% confidence interval (CI), 70.8–91.8], 13.8% (95% CI, 7.5–25.4), and 51.3% (95% CI, 39.9–66.1), respectively. In the multivariate analysis, the radiation dose was significantly associated with the FFLP rate [hazard ratio (HR), 0.57 per 10 Gy₁₀ increase, p = 0.001], and the status of FFLP was significantly associated with OS (HR, 2.694, p = 0.014). The overall rate of ≥grade 3 adverse events was 5.7% (4 of 70), and RT-related mortality was not observed.

Conclusion: RT for HCC in the caudate lobe showed promising FFLP and OS rates with safe toxicity profiles. These findings suggest that RT may be a promising treatment option for HCC in the caudate lobe.

Comparative analysis of radiofrequency ablation and resection for colorectal liver metastases in caudate lobe: a retrospective study

Objective: To assess the therapeutic efficiency of radiofrequency ablation (RFA) for colorectal liver metastases (CRLM) in the caudate lobe compared with that of surgical resection.Methods: After approved by institutional review board, we retrospectively reviewed 20 patients with caudate CRLM treated by RFA or resection between 2006 and 2017. Comparative analysis was performed based on the different therapies, including patient characteristics, therapeutic outcomes, recurrences, and survivals.Results: During the median follow-up of 7 years (range, 2 -11 years), no differences in complications and recurrences were found between RFA and surgery groups (p > .05). The median overall survival (OS) of patients after RFA and resection were 41 months (95% confidence interval (CI) 23.5-70.5) and 54 months (95% CI 31.1-77.7), respectively (p = .627, hazard radio (HR) 0.7, 95% CI 0.2-2.6). However, OS of resection group was better than that of RFA group for large caudate CRLMs (>3 cm) (p = .042, HR 4.4, 95% CI 0.6-32.6).Conclusions: RFA is a feasible, safe, and effective treatment for CRLM in the caudate. Surgical resection revealed superior outcomes in the treatment of caudate CRLMs, particularly in cases with a hepatic tumor size  >3 cm.

Stereotactic radiofrequency ablation of primary liver tumors in the caudate lobe

BACKGROUND

The encasement of the caudate lobe by a vascular ring of large vessels may apart from the technical difficulties in needle placement increase the probability of local recurrence after thermal ablation due to cooling effects. This single-center retrospective study evaluates the results after multiprobe stereotactic radiofrequency ablation (SRFA) of hepatocellular carcinoma (HCC) in the caudate lobe.

METHODS

Twenty patients underwent 24 multiple-probe SRFA sessions for the treatment of 24 HCCs in the caudate lobe. Eight of twenty patients had initially solitary tumors, the remaining 12 patients suffered from multifocal disease.

RESULTS

The median tumor size was 1.5 cm (range: 1-8 cm). After a mean follow-up of 21 months one local recurrence in the caudate lobe was observed resulting in a local recurrence rate of 4.2% (1/24). The overall survival rates at 1, 3, and 5 years from the date of the first SRFA were 95%, 59%, and 44%, respectively, with a median overall survival of 51.3 months. The disease-free survival after SRFA was 48%, 24% and 24%, at 1, 3 and 5 years, respectively. One patient suffering from Child C liver cirrhosis died due to septic shock 26 days after SRFA and one postinterventional complication required minimal invasive interventional treatment.

CONCLUSION

Multiprobe SRFA for HCC in the caudate lobe appears to be safe and feasible. The overall outcome is at least comparable to that of surgical resection, with low perioperative mortality and only minimal morbidity.

A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma

BACKGROUND

Surgical resection remains the only potentially curative therapy for hilar cholangiocarcinoma (CCC) patients. This meta-analysis aimed to review the current evidence on perioperative and long-term outcomes of routine caudate lobe resection (CLR) for surgical treatment of hilar CCC.

METHODS

A systematic literature search using MEDLINE, EMBASE and Cochrane databases was performed for studies providing comparative data on perioperative and long-term outcomes of patients undergoing resection for hilar CCC with and without CLR. The MINORS score was used for quality assessment. For time-to-event outcomes hazard ratios (HRs) and associated 95% CI were extracted from identified studies, whereas risk ratios (RRs) were calculated for overall morbidity, mortality, and resection margin status. Meta-analyses were carried out using random-effects models.

RESULTS

Eight studies involving 1350 patients met the inclusion criteria. The quality of the included studies was low to moderate. CLR resulted in significantly improved overall survival (HR 0.49; 95%CI 0.32-0.75, P < 0.01). Postoperative morbidity (RR 0.93; 95% CI 0.77-1.13; P = 0.48) and mortality (RR 1.01; 95% CI 0.42-2.41; P = 0.99) rates were comparable between both groups. Patients without concomitant CLR were at higher risk for residual tumor at the resection margin (RR 1.40; 95% CI 1.09-1.80; P = 0.01).

CONCLUSION

CLR is associated with improved long-term survival and negative tumor margins after resection of hilar CCC with no adverse impact on perioperative outcomes. CLR might provide the potential to become a standard-of-care procedure in the surgical management of hilar CCC.

Prognoses and Clinicopathological Characteristics for Hepatocellular Carcinoma Originating from the Caudate Lobe After Surgery

BACKGROUND

The aim was to evaluate the prognoses and clinicopathological characteristics of solitary hepatocellular carcinoma (HCC) originating from the caudate lobe (HCC-CL).

METHODS

We analyzed 584 patients with a solitary tumor <10 cm from January 1990 to November 2014. Patients were classified into a caudate lobe group (CL; n = 39) and a non-caudate lobe group (NCL; n = 545). We investigated the prognoses and clinicopathological characteristics of solitary HCC-CL. We compared the surgical procedures performed in these cases.

RESULTS

HCC-CL had a similar rate of portal venous invasion (PVI) as HCC-NCL (21% vs. 19%); however, the frequency of tumor thrombus at the first branch of the portal vein (PV) or extension to the trunk or the opposite side of the PV was significantly higher in HCC-CL (8% vs. 2%). HCC-CL had similar OS rates compared to HCC-NCL; however, HCC-CL showed significantly poorer RFS. Although there were no significant differences among the three surgical procedures, blood loss and complication rates tended to be higher in cases who underwent an isolated caudate lobectomy. Tumor size ≥5 cm, PVI, and liver fibrosis or cirrhosis (LF or LC) were independent unfavorable factors for both OS and RFS. PIVKA-II ≥120 mAU/ml was an independent unfavorable factor for RFS.

CONCLUSION

HCC-CL presented a poorer RFS rate. Patients with a tumor size ≥5 cm, PIVKA-II ≥120 mAU/ml, portal venous invasion, and LF or LC should be diligently followed up as these cases have a high risk of recurrence.

Ventral approach for resecting hepatocellular carcinoma in the caval portion of the caudate lobe

BACKGROUND

Resection of hepatocellular carcinoma located in the caudate lobe is challenging because this anatomical location is difficult to approach, especially the caval portion.

METHODS

We performed resection of the caval portion of the caudate lobe using a ventral approach combined with the resection of segment IV, VII, or VIII for hepatocellular carcinoma in 41 patients (extended segmentectomy group). As a control group, 138 patients with hepatocellular carcinoma who underwent segmentectomy for IV, VII, or VIII (segmentectomy group) were studied. We compared surgical outcomes, including postoperative morbidity and survival, between the 2 groups.

RESULTS

When compared with the segmentectomy group, platelet count was lower (12.8 × 10⁴/µL [range, 2.4-33.8] vs 14.8 × 10⁴/µL [3.2-41.4], P = .085), operation time was significantly longer (442 minutes [range, 184-710] vs 333 minutes [131-810], P < .001), blood loss was significantly greater (579 mL [range, 25-2688] vs 301 mL [10-3887], P = .001), and the percentage of patients with cirrhosis was greater (19 [46.3%] vs 41 [29.7%], P = .059) in the extended segmentectomy group. However, the morbidity rate (48.7% and 33.3%, P = .096) and median overall survival period (5.2 years; [95% confidence interval, 4.6-6.6] vs 6.2 years, [5.4-9.7], P = .203) were not significantly different between the 2 groups.

CONCLUSION

The ventral approach for the resection of hepatocellular carcinoma in the caval portion of the caudate lobe is a viable alternative to other approaches, especially in patients with insufficient liver function.

Treatment of Small Hepatocellular Carcinoma (≤2 cm) in the Caudate Lobe with Sequential Transcatheter Arterial Chemoembolization and Radiofrequency Ablation

PURPOSE

To evaluate technical feasibility and treatment results of sequential transcatheter arterial chemoembolization (TACE) and cone-beam computed tomography-guided percutaneous radiofrequency ablation (CBCT-RFA) for small hepatocellular carcinoma (HCC) in the caudate lobe.

MATERIALS AND METHODS

Institutional review board approved this retrospective study. Radiologic database was searched for the patients referred to perform TACE and CBCT-RFA for small caudate HCCs (≤2 cm) between February 2009 and February 2014. A total of 14 patients (12 men and 2 women, mean age; 61.3 years) were included. Percutaneous ultrasonography-guided RFA (pUS-RFA) and surgery were infeasible due to poor conspicuity, inconspicuity or no safe electrode pathway, and poor hepatic reserve. Procedural success (completion of both TACE and CBCT-RFA), technique efficacy (absence of tumor enhancement at 1 month after treatment), and complication were evaluated. Treatment results including local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), and progression-free survival (PFS) were analyzed.

RESULTS

Procedural success and technique efficacy rates were 78.6 % (11/14) and 90.9 % (10/11), respectively. Average follow-up period was 45.3 months (range, 13.4-64.6 months). The 1-, 3-, and 5-year LTP probabilities were 0, 12.5, and 12.5 %, respectively. IDR occurred in seven patients (63.6 %, 7/11). The 1-, 3-, and 5-year PFS probabilities were 81.8, 51.9, and 26 %, respectively. The 1-, 3-, and 5-year OS probabilities were 100, 80.8, and 80.8 %, respectively.

CONCLUSION

Combination of TACE and CBCT-RFA seems feasible for small HCC in the caudate lobe not amenable to pUS-RFA and effective in local tumor control.

Anterior hepatic parenchymal transection for complete caudate lobectomy to treat liver cancer situated in or involving the paracaval portion of the caudate lobe

BACKGROUND

Complete caudate lobectomy using the anterior hepatic parenchymal transection approach is a proper but technically demanding operation for tumors situated in or involving the paracaval portion of the caudate lobe. This study was intended to share our experience on this operation.

METHOD

Forty-nine consecutive patients who received complete caudate lobectomy using the anterior hepatic parenchymal transection approach were studied. The clinicopathologic and perioperative data, complications, and survival were analyzed.

RESULTS

Of the 49 patients, 15 (30.6 %) received isolated complete caudate lobectomy and 34 (69.4 %) received complete caudate lobectomy associated with segmentectomy IV. The median tumor size was 7.3 cm (2.4-18.0 cm), the operating time was 200 min (120-370 min), and the operative blood loss was 700 ml (200-3000 ml). The postoperative complication rate was 36.7 %. There was no perioperative death. Patients in the associated complete caudate lobectomy group had larger tumors (P<0.001), higher platelet counts (P=0.033), shorter operation time (P=0.004), and less patients with residual tumor (P=0.03) than those in the isolated complete caudate lobectomy group. There were no significant differences in cirrhosis, surgical resection margin, blood loss, postoperative complications, and prognosis between the two groups.

CONCLUSION

Complete caudate lobectomy using the anterior hepatic parenchymal transection approach was technically feasible and safe for patients with tumors situated in or involving the paracaval portion of the caudate lobe. Associated resection of segment IV can be used to facilitate the surgery and decrease the chance of local residual tumor.

Complete radiofrequency ablation of hepatolithiasis-associated cholangiocarcinoma and successful management of post-ablation bronchobiliary fistula

This report documented the use of radiofrequency ablation (RFA) in the treatment of hepatolithiasis-associated cholangiocarcinoma and cyanoacrylate glue in the management of post-ablation bronchobiliary fistula. A 47-year-old Chinese woman with 20 years history of extrahepatic and intrahepatic cholangiolithiasis and multiple hepatic segmentectomy, developed hepatolithiasis-associated cholangiocarcinoma. The tumor was successfully treated with RFA but patient developed bronchobiliary fistula. Cyanoacrylate glue was used for occluding the bronchobiliary fistula. CT scan at 3 months showed complete restoration of physiological separation between the biliary and bronchial system. Repeat CT scan showed complete tumor ablation with no signs of tumor recurrence 10 months after RFA. In conclusion, RFA may be a safe and effective treatment option for patients with hepatolithiasis-associated cholangiocarcinoma who are poor candidates for surgical resection. Protection of the integrity of the bile duct and diaphragm during RFA can minimize postoperative complications. In case of development of post-ablation bronchobiliary fistula, cyanoacrylate glue can be used to occlude the fistula, before surgical resection is considered.

Chemoembolization of extrahepatic collateral arteries for treatment of hepatocellular carcinoma in the caudate lobe of the liver

PURPOSE

This study was designed to evaluate the efficacy and safety in performing chemoembolization of extrahepatic collateral arteries (EHC) for hepatocellular carcinoma (HCC) located in the caudate lobe.

METHODS

Between January 2006 and November 2013, chemoembolization via EHC was performed in 35 patients with 35 caudate HCCs. Preprocedural and follow-up CT or MR scans, angiographic images, and medical records were reviewed retrospectively in consensus. Chi-square analysis was used to evaluate the relationship between tumor characteristics and type of EHC and that between tumor response and the characteristics of the tumor and chemoembolization.

RESULTS

In 31 (88.6 %) patients, EHCs supplying the caudate HCC originated from the right inferior phrenic artery (RIPA). The remaining four HCCs were supplied by the gastroduodenal artery, dorsal pancreatic artery, and right and left gastric arteries. Superselective catheterization of tumor-feeding vessels from the EHC was achieved in 27 patients (77.1 %). There were no major complications. Individual tumor response supplied by the EHC at follow-up contrast-enhanced CT were as follows: complete response (n = 18), partial response (n = 9), stable disease (n = 3), and progressive disease (n = 3). Non-RIPA EHCs were significantly more common in patients who had previously received chemoembolization via the RIPA (50 %) than those who had not (6.5 %; P = 0.01). There was no significant predictive factor associated with tumor response.

CONCLUSIONS

HCC in the caudate lobe can be supplied by several EHCs. Chemoembolization via these arteries can be performed safely and effectively.

Combination therapy of chemoembolization and radiofrequency ablation for the treatment of hepatocellular carcinoma in the caudate lobe

PURPOSE

To evaluate the clinical utility of radiofrequency (RF) ablation combined with chemoembolization in treatment of hepatocellular carcinoma (HCC) located in the caudate lobe.

MATERIALS AND METHODS

Between September 2000 and October 2011, 20 consecutive patients with single HCC measuring≤5 cm were treated with combination therapy of chemoembolization and RF ablation. Technical success was defined as completion of a planned electrode placement and ablation protocol. The effectiveness of the technique was defined as disappearance of tumor enhancement with an ablative margin of≥5 mm. Technical success, technique effectiveness, local tumor progression, overall and recurrence-free survival, and complications were evaluated.

RESULTS

RF electrodes were placed in planned sites of each tumor, and ablation was complete in all patients (technical success rate 100%). Tumor enhancement disappeared with sufficient ablative margins after 20 RF sessions in all patients (technique effectiveness rate 100%). Major and minor complication rates were 10.0% and 15.0%. Local tumor progression was found in 2 of 20 patients (10.0%) with local tumor progression rates of 6.3% at 1 year and 13.5% at 3 years and 5 years. Six patients died during the follow-up period (mean, 40.0 months; range, 2.0-110.5 months). Overall and recurrence-free survival rates were 94.4% and 70.8% at 1 year, 86.6% and 36.9% at 3 years, and 67.5% and 45.5% at 5 years.

CONCLUSIONS

RF ablation combined with chemoembolization is a safe and useful therapeutic option to treat HCCs located in the caudate lobe.

Choice of approach for hepatectomy for hepatocellular carcinoma located in the caudate lobe: Isolated or combined lobectomy?

AIM: To investigate the significance of the surgical approaches in the prognosis of hepatocellular carcinoma (HCC) located in the caudate lobe with a multivariate regression analysis using a Cox proportional hazard model.

METHODS: Thirty-six patients with HCC underwent caudate lobectomy at a single tertiary referral center between January 1995 and June 2010. In this series, left-sided, right-sided and bilateral approaches were used. The outcomes of patients who underwent isolated caudate lobectomy or caudate lobectomy combined with an additional partial hepatectomy were compared. The survival curves of the isolated and combined resection groups were generated by the Kaplan-Meier method and compared by a log-rank test.

RESULTS: Sixteen (44.4%) of 36 patients underwent isolated total or partial caudate lobectomy whereas 20 (55.6%) received a total or partial caudate lobectomy combined with an additional partial hepatectomy. The median diameter of the tumor was 6.7 cm (range, 2.1-15.8 cm). Patients who underwent an isolated caudate lobectomy had significantly longer operative time (240 min vs 170 min), longer length of hospital stay (18 d vs 13 d) and more blood loss (780 mL vs 270 mL) than patients who underwent a combined caudate lobectomy (P < 0.05). There were no perioperative deaths in both groups of patients. The complication rate was higher in the patients who underwent an isolated caudate lobectomy than in those who underwent combined caudate lobectomy (31.3% vs 10.0%, P < 0.05). The 1-, 3- and 5-year disease-free survival rates for the isolated caudate lobectomy and the combined caudate lobectomy groups were 54.5%, 6.5% and 0% and 85.8%, 37.6% and 0%, respectively (P < 0.05). The corresponding overall survival rates were 73.8%, 18.5% and 0% and 93.1%, 43.6% and 6.7% (P < 0.05).

CONCLUSION: The caudate lobectomy combined with an additional partial hepatectomy is preferred because this approach is technically less demanding and offers an adequate surgical margin.

New developments in the treatment of hepatic tumors

The International Association of Surgeons, Gastroenterologists and Oncologists (IASGO) hosted their annual world congress under the auspices of president Masatoshi Makuuchi from Japan and the general secretary Nicolas J Lygidakis. This year the congress was held in Tokyo, and the president was Wataru Kimura of Yamagata University. It is common knowledge that a major triple disaster struck Japan in March 2011. It was thought, for a time, that the congress would not take place, but the great courage and determination of the hosts allowed the conference to continue as scheduled. This congress was one of the most interesting hosted by the IASGO, evidenced by the presence of 909 participants from 59 countries, including invited speakers from Europe, America, Africa and Asia. The congress provided an opportunity to exchange knowledge of new techniques, methods of diagnosis and therapy. The program included symposiums, video presentations, free papers and poster presentations. This manuscript highlights presentations of the newest and most original material concerning the treatment of liver tumors, especially hepatocellular carcinoma.

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.