Surgical resection of primary hepatocellular carcinoma extending to adjacent organ(s)

Combined resection for hepatocellular carcinoma with diaphragmatic invasion: a systematic review and meta-analysis

INTRODUCTION

According to the Staging System of Barcelona Clinic Liver Cancer (BCLC), diaphragmatic invasion (DI) is generally considered to be a manifestation of advanced hepatocellular carcinoma (HCC) with nearly no cure. However, some studies have indicated that combined liver and diaphragmatic resection may be a reasonably safe treatment option for HCC patients with diaphragmatic invasion. In this article, we conduct a systematic review to compare the short- and long-term surgical outcomes between HCC patients without diaphragmatic involvement who underwent hepatectomy alone and HCC patients with diaphragmatic involvement who underwent combined liver and diaphragmatic resection.

EVIDENCE ACQUISITION

PubMed, Web of Science, Embase and Cochrane library databases were searched. All related studies were checked. Hazard ratios (HR) with 95% confidence intervals were calculated for the comparison of cumulative overall survival (OS) and recurrence free survival (RFS). Odds ratios (OR) with 95% CI were calculated for the comparison of overall postoperative morbidity and mortality.

EVIDENCE SYNTHESIS

Seven studies met the inclusion criteria were included. There was no significant difference between the single hepatectomy group and combined liver and diaphragmatic resection group in the overall survival and recurrence free survival. Subgroup analysis showed a statistically significantly higher overall survival in HCC patients with diaphragmatic fibrous adhesion (DFA) compared with the DI group. However, there was no statistically significant difference in OS between the DI group and the single hepatectomy group.

CONCLUSIONS

For HCC patients with diaphragmatic involvement, combined liver and diaphragmatic resection might be considered no matter whether its diaphragmatic invasion or not.

Resection of T4 hepatocellular carcinomas with adjacent structures, is it justified?

BACKGROUND

T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s). This study aims to assess whether such combined resection for T4 HCC is justifiable.

METHODS

Adult patients with T4 HCC were divided into three groups. Group 1: tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion; group 2: same as group 1 but histopathologically confirmed tumor adhesion; group 3: tumor resection only. Group comparisons were made.

RESULTS

Totally 144 patients were included in the study. There were 71, 14 and 59 patients in groups 1, 2 and 3, respectively. The groups were comparable in demographics, complication and survival. Ten hospital deaths occurred (5, 0 and 5 in groups 1, 2 and 3, respectively; P=0.533). The 5-year overall survival (hospital mortality excluded) was 17.8% in group 1, 14.3% in group 2, and 28.9% in group 3 (P=0.191). The 5-year disease-free survival was 10.4% in group 1 and 14.5% in group 3 (no data for group 2 yet) (P=0.565). On multivariate analysis, macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival.

CONCLUSIONS

Combined resection achieved survival outcomes similar to tumor resection only. Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection. At centers with the required expertise, combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

BACKGROUND

The impact of diaphragmatic invasion in patients with colorectal liver metastases (CRLMs) remains poorly evaluated. We aimed to evaluate feasibility and safety of laparoscopic right hepatectomy (LRH) with or without diaphragmatic resection for CRLM.

METHODS

From 2002 to 2012, 52 patients underwent LRH for CRLM. Of them, 7 patients had combined laparoscopic partial diaphragmatic resection ("diaphragm" group). Data were retrospectively collected and short and long-term outcomes analyzed.

RESULTS

Operative time was lower in the control group (272 vs 345 min, P = .06). Six patients required conversion to open surgery. Blood loss and transfusion rate were similar. Portal triad clamping was used more frequently in the "diaphragm" group (42.8% vs 6.6%, P = .02). Maximum tumor size was greater in the "diaphragm" group (74.5 vs 37.1 mm, P = .002). Resection margin was negative in all cases. Mortality was nil and general morbidity similar in the 2 groups. Specific liver-related complications occurred in 2 patients in the "diaphragm" group and 17 in the control group (P = .69). Mean hospital stay was similar (P = 56). Twenty-two (42.3%) patients experienced recurrence. One-, 3-, and 5-year overall survival after surgery in "diaphragm" and control groups were 69%, 34%, 34%, and 97%, 83%, 59%, respectively (P = .103). One- and 3-year disease-free survival after surgery in "diaphragm" and control groups were 57%, 47% and 75%, 54%, respectively (P = .310).

CONCLUSION

LRH with en-bloc diaphragmatic resection could be reasonably performed for selected patients in expert centers. Technical difficulties related to diaphragmatic invasion must be circumvented. Further experience must be gained to confirm our results.

Results of en bloc resection for hepatocellular carcinoma extending to adjacent organs

BACKGROUND

To curatively resect hepatocellular carcinoma (HCC) with adjacent organ extension, the combined resection of these organs is inevitable. We analyzed the safety and effectiveness of en bloc resection for HCC extending to adjacent organs.

METHODS

From December 2002 to May 2006, we compared the surgical outcomes of patients with HCC extending to adjacent organs with those of closely matched, randomly selected patients with HCC without adjacent organ extension.

RESULTS

We included 42 patients whose HCC extended to adjacent organs and 126 patients whose HCC did not extend to adjacent organs. There was no significant difference in survival, operative morbidity or mortality between the groups. In patients with HCC extending to adjacent organs, histopathological examination of the specimen revealed true tumour invasion in 13 and adhesion in 29 patients. Those with tumour invasion were more likely to have a high incidence of capsule infiltration, microvascular invasion and early intrahepatic recurrence (≤ 1 yr after hepatectomy). The 5-year overall survival of patients with tumour invasion was 11.5%, whereas that of patients with tumour adhesion was 38.1% (p = 0.033).

CONCLUSION

En bloc resection is a safe and effective therapy for HCC extending to adjacent organs. Tumour invasion to adjacent organs exhibits a more aggressive clinical behaviour and is associated with worse survival than tumour adhesion.

One stage resection of spontaneous rupture of hepatocellular carcinoma in the triangular ligament with diaphragm invasion: case report and review of the literature

A spontaneous rupture of hepatocellular carcinoma (HCC) can lead to extensive hemorrhage and is a rare but life-threatening event. A 58-year-old male patient with no history of trauma presented at our institution with severe epigastric pain and abdominal distension for 6 h. His blood pressure was a 60/40 mmHg, and pulse rate was 132/min. Abdominal contrast enhanced computed tomography (CT) imaging revealed a ruptured mass under the left diaphragm and fluid collection in the upper abdomen, flanks and pelvic cavity. Exploratory laparotomy confirmed the presence of an active bleeding tumor in the triangular ligament invading into the diaphragm. The tumor was resected with an appropriate diaphragm margin. The resected tumor was 5 cm in diameter and pathologically identified as hepatocellular carcinoma with a negative surgical margin. This case report shows that ruptured hepatocellular carcinoma should be considered in the differential diagnosis of non-traumatic hemoperitoneum. And it is necessary to set a surgical plan for unpredictable HCC rupture with direct diaphragm invasion.

Surgical impacts of an en bloc resection of the diaphragm for hepatocellular carcinoma with gross diaphragmatic involvement

PURPOSE

Diaphragmatic involvement is relatively uncommon in patients undergoing a hepatectomy for hepatocellular carcinoma (HCC). The aim of this study was to evaluate the short- and long-term surgical impacts of HCC with gross diaphragmatic involvement in patients undergoing an en bloc resection of the diaphragm.

METHODS

Between 1990 and 2007, 911 patients with HCC underwent a hepatectomy at our institution. Twenty-seven patients (3.0%) had had gross involvement of the diaphragm. Thirteen patients (1.4%) had undergone an en bloc resection of the diaphragm, and 14 (1.5%) had received only a blunt dissection. The short-term surgical impacts (surgical morbidity and mortality) and long-term surgical impacts (overall and disease-free survival) were compared between the groups.

RESULTS

In patients with an en bloc resection of the diaphragm as compared with those who received a blunt dissection, the values of total bilirubin and the indocyanine green retention rate at 15 min were significantly better (P < 0.01 and P = 0.04, respectively), and the rate of positivity for the hepatitis B antigen was significantly higher (P = 0.02). The positive rates of microscopic fibrocapsular invasion (P = 0.03), microscopic vascular invasion (P = 0.04), and Ki-67 immunostaining (P = 0.04) were significantly higher in patients with an en bloc resection of the diaphragm. There were no significant differences in the short-term and long-term surgical impacts between the groups.

CONCLUSION

An en bloc resection of the diaphragm in patients with gross diaphragmatic involvement of HCC is therefore justified, since there are no significant differences in short- or long-term surgical impacts in comparison with the patients receiving blunt dissection.

Application of tumor-node-metastasis staging 2002 version in locally advanced hepatocellular carcinoma: is it predictive of surgical outcome?

BACKGROUND

Locally advanced (pT3-4N0M0) hepatocellular carcinoma (HCC) is a heterogeneous group of tumors, which consists of four different categories, including HCC with "multiple tumors more than 5 cm", "major vascular invasion", "invasion of adjacent organs", and "perforation of visceral peritoneum". The aim of our study was to verify whether the 2002 version of the Tumor-Node-Metastasis staging system could predict surgical outcomes in patients with locally advanced HCC.

METHODS

We retrospectively reviewed 298 patients with pT3-4N0M0 HCC who underwent hepatic resection from 1993 to 2000 in an academic tertiary hospital. Overall survival (OS) and cumulative recurrence rate (CRR) of the four categories of locally advanced HCC patients were compared.

RESULTS

In multivariate analysis, major vascular invasion was identified as the most significant factor (HR = 3.291, 95% CI 2.362-4.584, P < 0.001) followed by cirrhosis status on OS, and was found to be the only independent factor of CRR (HR = 2.242, 95% CI 1.811-3.358, P < 0.001) in patients with locally advanced HCC. Among the four categories of locally advanced HCC, OS was significantly worse, and CRR was significantly higher in patients with HCC with major vascular invasion (pT3) than with multiple tumors more than 5 cm (pT3); or tumor invasion of adjacent organs (pT4); or perforation of visceral peritoneum (pT4). No significant differences were observed in OS or CRR between the latter three groups of patients.

CONCLUSIONS

HCC with major vascular invasion, which are classified as pT3 under the current TNM staging, have the worst prognosis when compared with the other categories of pT3-4 disease. There is a need to redefine the T classification and to stratify locally advanced HCC.

Successful en bloc resection of primary hepatocellular carcinoma directly invading the stomach and pancreas

Multivisceral surgical resection for cure was successfully performed in a 70-year-old man suffering from a primary hepatocellular carcinoma (HCC) associated with direct invasion to the stomach and pancreas. The patient presented with gastric outlet obstruction, upper abdominal pain and a history of chronic liver disease due to hepatitis B virus (HBV) infection. Upper gastrointestinal (GI) endoscopy revealed an infiltrating tumor protruding through the gastric wall and obliterating the lumen. Computer tomograghy (CT) and magnetic resonance imaging (MRI) scan demonstrated a 15-cm tumor in the left lateral segment of the liver with invasion to the stomach and pancreas. Alpha-foetoprotein (AFP) levels and liver function tests were normal. The patient underwent an en bloc left hepatectomy, total gastrectomy, distal pancreatectomy with splenectomy and radical lymphadenectomy. Pathology revealed a poorly differentiated, giant cell HCC involving the stomach and pancreas. Disease-free margins of resection were achieved. The patient’s postoperative course was uneventful. Sixteen months after surgery, he has no recurrence or distal metastasis. Direct invasion of HCC into the GI tract is rarely encountered. Complete surgical resection should be considered in selected patients with an appropriate hepatic functional reserve.

Direct invasion to the colon by hepatocellular carcinoma: Report of two cases

Although hepatocellular carcinoma (HCC) is a common tumor, direct invasion of the gastrointestinal tract by HCC is uncommon. Recently, we encountered two cases of HCC with direct invasion to the colon. The first patient was a 79-year-old man who underwent transarterial chemo-embolization (TACE) for HCC 1.5 years prior to admission to our hospital. Computed tomography (CT) showed a 7.5-cm liver tumor directly invading the transverse colon. Partial resection of the liver and transverse colon was performed. The patient survived 6 mo after surgery, but died of recurrent HCC. The second patient was a 69-year-old man who underwent TACE and ablation for HCC 2 years and 7 months prior to being admitted to our hospital for melena and abdominal distension. CT revealed a 6-cm liver tumor with direct invasion to the colon. The patient underwent partial resection of the liver and right hemicolectomy. The patient recovered from the surgery. But, unfortunately, he died of liver failure due to liver cirrhosis one month later. Although the prognosis of HCC that has invaded the colon is generally poor due to the advanced stage of the disease, surgical resection may be a favorable treatment option in patients with a good general condition.

Recurrent hepatocellular carcinoma after hepatic resection: prognostic factors and long-term outcome

AIM

The prognosis of patients with recurrent hepatocellular carcinoma (HCC) after hepatic resection varies widely. This study analyzed long-term survival and prognostic factors of patients with recurrent HCC after hepatectomy.

METHODS

From July 1991 to December 2000, 623 patients underwent hepatic resection for HCC. Of those, 347 (56.5%) patients had tumour recurrence, and 286 patients with follow-up time more than 24 months after recurrence were enrolled. Twenty-seven clinicopathologic factors underwent both univariate and multivariate analysis.

RESULTS

Of these 286 patients, survival times after tumour recurrence were mean 672+/-619 days; median 468 days; and, range 10-3753 days. The overall 1-, 3-, 5-, and 10-year post-recurrence survival rates were 61.5, 33.4, 18.2, and 9.0%, respectively. Seventy (24.5%) patients were alive at the time of study, and 10 of the 34 patients who underwent re-resection were disease-free. By Cox regression analysis, multiple initial tumours (relative risk (RR) 1.428), recurrent multiple (RR 1.372), extrahepatic recurrence (RR 2.434), recurrent tumour size >2 cm (RR 1.926), post-hepatectomy period until recurrence <1 year (RR 1.769), and non-resectional treatment of recurrent tumours (RR 3.527) were independent prognostic factors for post-recurrent survival rates.

CONCLUSIONS

In patients with recurrent HCC after hepatectomy, both initial and recurrent tumour factors influenced their prognosis. Early detection of recurrent tumours is important. Re-resection correlated with better post-recurrent survival rates.

Simplified staging for hepatocellular carcinoma

PURPOSE

The current American Joint Committee on Cancer (AJCC) staging system for hepatocellular carcinoma (HCC) fails to stratify patients adequately with respect to prognosis.

PATIENTS AND METHODS

The ability of the currently proposed tumor (T) categories to effectively stratify the survival of 557 patients who underwent complete resection for HCC at four centers was examined. Independent predictors of survival were combined into a new staging system.

RESULTS

Using the current AJCC T classification, patients with T1 and T2 tumors had similar 5-year survivals (P =.6). In addition, the survival of patients with multiple bilobar tumors (T4) matched that of T3 patients (P =.5). Independent predictors of death were major vascular invasion (P <.001), microvascular invasion (P =.001), severe fibrosis/cirrhosis of the host liver (P =.001), multiple tumors (P =.007), and tumor size greater than 5 cm (P =.01). Based on our results, a simplified stratification is proposed: (a) patients with a single tumor and no microvascular invasion, (b) patients with a single tumor and microvascular invasion or multiple tumors, none more than 5 cm, and (c) patients with either multiple tumors, any more than 5 cm, or tumor with major vascular invasion (P <.001). Severe fibrosis/cirrhosis had a negative impact on survival within all categories. The survival of patients with lymph node involvement matched that of patients with major vascular invasion (P =.3).

CONCLUSION

The current AJCC staging system for HCC is unnecessarily complex. We propose a simplified model of stratification that is based on vascular invasion, tumor number, and tumor size and incorporates the effect of fibrosis on survival.

Surgical treatment and outcome in patients with a hepatocellular carcinoma greater than 10 cm in diameter

BACKGROUND

Hepatocellular carcinoma (HCC) over 10 cm in diameter at the time of diagnosis continues to account for a number of patients undergoing hepatic resection. This study evaluated the clinicopathological features and outcome following surgery for large HCC.

METHODS

Forty patients with a large HCC (greater than 10 cm) (group 1) resected between 1991 and 1996 were studied retrospectively. They were compared with 245 patients who had smaller HCCs (10 cm or less) (group 2).

RESULTS

No patient in group 1 had hepatitis C infection compared with 22.9 per cent in group 2 (P=0.001). Patients in group 1 were significantly younger, had higher alpha-fetoprotein levels (16750 versus 1864 ng/ml; P < 0.001), better liver function, a higher incidence of multiple tumours (27 of 40 versus 42.0 per cent; P=0.003) and venous invasion (35 of 40 versus 52.2 per cent; P < 0.001), and underwent more major resections (37 of 40 versus 26.5 per cent; P < 0.001) than those in group 2. Morbidity and mortality rates and hospital stay were comparable in the two groups. For group 1, the 1-, 3- and 5-year disease-free survival rates were 42, 30 and 28 per cent respectively. Multiple tumours, venous invasion and impaired liver function were factors associated with recurrence.

CONCLUSION

Large HCC had specific clinicopathological features. In selected patients, resection is safe and offers the chance of long-term disease-free survival.

Prognostic significance of surgical margin in hepatocellular carcinoma resection: an analysis of 165 Childs' A patients

BACKGROUND AND OBJECTIVES

The clinical significance of the width of the surgical margin in the resection of hepatocellular carcinoma (HCC) has yet to be clarified.

METHODS

Childs' A patients (165) who underwent resections of HCC were studied. Patients were divided into a wide margin group (1.0 cm or more, group W, n = 85), and a narrow margin group (< 1.0 cm, group N, n = 80).

RESULTS

Multivariate analysis showed that preoperative alpha-fetoprotein level (P = 0.0202), venous invasion (P = 0.0226), surgical margin (P = 0.0012), and TNM stage (P = 0.0023) were significant predictors of disease-free survival. By the log-rank test, the disease-free survival rate of the group W patients was significantly higher than that of the group N patients (P = 0.0007). Group N had a higher percentage of patients undergoing minor resection (wedge resection or subsegmentectomy) (44% vs. 26%, P = 0.016) and had a higher percentage of patients with centrally located tumor (62% vs. 29%, P = 0.000) than group W.

CONCLUSIONS

The results of this study indicated the significant influence of surgical margin on HCC recurrence after resection. Minor resection and centrally located tumor are factors related to a narrow surgical margin.