Surgical treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world, and cirrhosis is a risk factor for HCC. Resection is indicated for those unilobar tumors without vascular invasion and metastases in the liver and preserved liver function. Small HCC (< 2 cm) without microvascular invasion is associated with a 5-year recurrence rate as high as 50% to 60%, whereas liver transplantation is indicated for those within the Milan criteria (solitary tumor ≤ 5 cm or two or three nodules ≤ 3 cm) who have decompensated cirrhosis. The 1-, 3-, and 5-year survival rates of living donor liver transplantation for HCC are 85%, 75%, and 70%, respectively. This review summarizes the scientific evidence supporting the clinical practice recommendations for patients with HCC, and it discusses surgical treatment of HCC.

Is hepatic resection better than transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis?

Background

The management of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains controversial. We compared the outcomes of hepatic resection (HR) and transarterial chemoembolization (TACE).

Methods

Comprehensive online databases search was performed. Comparative studies measuring survival in HCC patients with PVTT undergoing HR versus TACE were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for overall survival (OS) at 1, 3, and 5 years. Study quality and heterogeneity was assessed.

Results

Six studies comprising 1,320 patients were included. HR was done in 526 (39.8%) patients and TACE in 794 (60.2%) patients. Meta-analysis of all included studies showed improved OS in HR compared to TACE patients at 1-year (OR: 1.49, 95% CI: 1.16-1.92, P=0.002), 3-year (OR: 3.33, 95% CI: 1.55-7.12, P=0.002) and 5-year (OR: 3.91, 95% CI: 1.42-10.77, P=0.008). Survival benefit conferred by HR was 7-33 months. This benefit was mostly noted in tumors with PVTT types I and II and those with single lesions. Age, ECOG status, and STROBE score did not contribute to differences in survival.

Conclusions

Long-term survival outcomes of HCC with PVTT are superior in patients undergoing hepatectomy compared to TACE. Further experience with randomized clinical trials may be warranted to confirm these findings.

Anatomical versus Non-anatomical Resection for Hepatocellular Carcinoma with Microscope Vascular Invasion: A Propensity Score Matching Analysis

Background: The benefits of anatomical resection (AR) and non-anatomical resection (NAR) on hepatocellular carcinoma (HCC) patients with microscope vascular invasion (MVI) remain unknown. We aimed to investigate the prognostic outcomes of AR and NAR for HCC patients with MVI. Study Design: A total of 362 consecutive HCC patients diagnosed with MVI after hepatic resection between February 2005 and December 2013 were included in this study. The patient outcomes were compared, and a 1:2 propensity score matching (PSM) analysis was applied to eliminate selection bias. Results: Before PSM, compared to the NAR group, the AR group contained more patients that exceeded the Milan criteria, with larger, unilobar tumors and higher AST levels. After PSM, 100 patients were classified into the propensity-matched AR group (PS-AR), while 170 were classified into the propensity-matched NAR group (PS-NAR). Baseline data, including liver function and tumor burden measurements, were similar in the matched groups. The respective 1-, 3- and 5-year overall survival (OS) rates were 78.9%, 56.9%, and 51.5% in the PS-AR group and 76.2%, 53.0%, and 42.4% in the PS-NAR group (P = 0.301). The 1-, 3- and 5-year disease-free survival (DFS) rates were 51.1%, 44.7% and 42.0% in the PS-AR group and 44.9%, 34.3% and 26.4% in the PS-NAR group, respectively (P = 0.039). Multivariate analysis identified AR (P=0.025) as an independent favorable prognostic factor for DFS in HCC patients with MVI. Conclusions: Anatomical resection was superior to non-anatomical resection for improving DFS in hepatocellular carcinoma patients with microscope vascular invasion.

Current topics in the surgical treatments for hepatocellular carcinoma

Treatment strategy for hepatocellular carcinoma (HCC) requires optimal selection of therapies based on various factors related to tumor condition and liver functional reserve. Although several evidence-based guidelines have been proposed for the treatment of HCC, the criteria and range of indications differ among these guidelines according to the circumstances of each country. In European nations and the USA, patients with the Barcelona Clinic Liver Cancer stage 0-A are subjects for surgical resection, whereas in Asian countries, even those with the intermediate stage are regarded as surgical candidates. Furthermore, since the recent introduction and rapidly widely spreading use of laparoscopic liver resection, this technique has become an important treatment option for surgical resection. In this review article, we overview the current topics of treatment of HCC with a special focus on surgical therapy.

Survival benefit of hepatic resection versus transarterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus: a systematic review and meta-analysis

Background

No consensus treatment has been reached for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Hepatic resection (HR) and transarterial chemoembolization (TACE) have been recommended as effective options, but which is better remains unclear. This meta-analysis is to compare the effectiveness of HR and TACE for HCC with PVTT patients.

Methods

The PubMed, EMBASE, Cochrane Library, VIP, Wan Fang, and Sino Med databases were systematically searched for comparing HR and TACE treating PVTT.

Results

Twelve retrospective studies with 3129 patients were included. A meta-analysis of 11 studies suggested that the 1-, 2-, 3-, and 5-year overall survival (OS) rates (OR = 0.48, 95% CI = 0.41–0.57, I² = 37%, P < 0.00001; OR = 0.21, 95% CI = 0.12–0.38, I² = 43%, P < 0.00001; OR = 0.35, 95% CI = 0.28–0.44, I² = 53%, P < 0.00001; OR = 0.28, 95% CI = 0.14–0.54, I² = 72%, P = 0.0001, respectively) favored HR over TACE. In a subgroup analysis, HR had better 1-, 2-,3, 5-year OS for type I PVTT (OR = 0.33, 95% CI = 0.17–0.64, I² = 20%, P = 0.001; OR = 0.32, 95% CI = 0.16–0.63, I2 = 0%, P = 0.001; OR = 0.18, 95% CI = 0.09–0.36, I2 = 0%, P < 0.00001; OR = 0.07, 95% CI = 0.01–0.32, I2 = 0%, P = 0.0006, respectively) and better 1-, 3-, and 5-year OS for type II PVTT (OR = 0.37, 95% CI = 0.20–0.70, I² = 59%, P = 0.002; OR = 0.22, 95% CI = 0.13–0.39, I² = 0%, P < 0.00001; OR = 0.16; 95% CI = 0.03–0.91; I² = 51%, P = 0.04, respectively). There was no difference in 1-, 3-, or 5-year OS between HR and TACE for type III PVTT (OR = 0.86, 95% CI = 0.61–1.21, I² = 0%, P = 0.39; OR = 0.83, 95% CI = 0.42–1.64, I² = 0%, P = 0.59; OR = 0.59, 95% CI = 0.06–-6.04, I² = 65%, P = 0.66, respectively).

Conclusions

HR may lead to longer OS for some selected HCC patients with PVTT than TACE, especially for type I or II PVTT, with less difference being observed for type III or IV PVTT.

A double blinded prospective randomized trial comparing the effect of anatomic versus non-anatomic resection on hepatocellular carcinoma recurrence

BACKGROUND

The aim of this study was to determine the effect of anatomic resection (AR) versus non-anatomic resection (NAR) on recurrence rates in patients with hepatocellular carcinoma (HCC).

METHODS

Eligible patients were randomized to AR or NAR from January 2006 to July 2007 at a single center. The primary outcome was the 2-year recurrence-free survival (RFS). Secondary outcomes were postoperative complications, time to first recurrence, 1-, 3-, and 5-year RFS, and overall survival (OS).

RESULTS

Fifty-three (51%) and 52 (50%) patients underwent NAR and AR, respectively. A larger proportion of patients achieved margins ≥20 mm in the AR group (52% vs. 30%; P = 0.023). Complications (blood loss, transfusion requirement, and hospital stay) were similar between the two groups. Median follow-up was 33 (range, 2-77) months. Incidence of local recurrence at 2 years was 30% and 59% in the AR and NAR groups, respectively. Median time to first local recurrence in the AR group was significantly longer than in the NAR group (53 vs. 10 months, P = 0.010). There was no difference in overall RFS between the two groups (P = 0.290).

DISCUSSION

AR decreased the 2-year local recurrence rate and increased the time to first local recurrence compared to NAR in patients with HCC.

Clinical Impact of Anatomical Liver Resection for Hepatocellular Carcinoma with Pathologically Proven Portal Vein Invasion

BACKGROUND

Portal vein invasion (PVI) is known to be a poor prognostic factor for hepatocellular carcinoma (HCC) patients. Anatomical liver resection (ALR) is a preferable procedure for treating HCC. However, the effect of ALR for HCC with PVI has not been fully evaluated. The aim of this study is to investigate the survival benefit of ALR for HCC patients with or without pathologically proven portal vein invasion (pPVI).

METHODS

Curative hepatic resection was performed for a single HCC in 313 patients. The patients were divided into two groups according to the absence or presence of pPVI (absence: n = 216, presence: n = 97). These groups were then subclassified by the surgical procedures employed (ALR or non-ALR), and the clinical characteristics and stratified prognoses were compared according to the surgical procedure between the subgroups. Uni- and multivariate analyses were performed to explore the significant prognostic factors.

RESULTS

Among the patients without pPVI, there was no significant difference in postoperative survival between the groups. However, among the patients with pPVI, both the 5-year overall and recurrence-free survival rates in the ALR group were significantly higher than those in the non-ALR group (46.1 % vs. 16.3 %; p = 0.0019 and 33.8 % vs. 0 %; p = 0.0010). Multivariate analyses revealed that tumor differentiation and intraoperative blood loss (IOB) were associated with postoperative survival in patients without pPVI. On the other hand, in patients with pPVI, ALR, serum AFP level, and IOB were associated with postoperative survival.

CONCLUSION

ALR confers a survival benefit for HCC patients with pPVI.

Precise diagnosis and treatment of hepatolithiasis

Hepatolithiasis is a complex condition and the lesion is extensive. It is necessary to introduce the notion of precise surgery during the diagnosis and treatment of hepatolithiasis because the commonly used clinical methods have their limitations. A variety of technical means should be comprehensively applied to improve the levels of precise diagnosis and treatment, and individualized treatment strategy should be used. In addition, surgeons must attach great importance to the latest achievements of precise medicine, biomedical and intelligent technology.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies.

DATA SOURCES

PubMed database was searched for relevant articles in English on the issue of HCC management.

RESULTS

Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.

CONCLUSION

Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Hepatocellular carcinoma: From diagnosis to treatment

Primary liver cancer is the sixth most common cancer overall and the second most common cause of cancer mortality worldwide. Hepatocellular carcinoma accounts for up to 90% of all primary hepatic malignancies and represents a major international health problem. While surgical resection and transplantation are the cornerstone of therapy in early-stage hepatocellular carcinoma, locoregional therapy and sorafenib are beneficial in those with more advanced disease or those who are not surgical candidates. At times, the integration of both surgical and locoregional therapy may be necessary. Hence, hepatocellular carcinoma requires a multidisciplinary approach to determine the most appropriate treatment as well as the timing of various treatments for optimal outcomes.

Multiple Tumors Located in the Same Section Are Associated with Better Outcomes After Hepatic Resection for HCC Patients Meeting the Milan Criteria

The impact of the tumor location on the outcome after hepatic resection (HR) in multifocal hepatocellular carcinoma (HCC) is still poorly understood. The aim of this study was to compare the short- and long-term outcomes of HR patients with multifocal tumors meeting the Milan criteria and tumors located in the same or different sections. A total of 219 consecutive HR patients with multifocal tumors meeting the Milan criteria were divided into group SS (n = 97; same section) and group DS (n = 122; different sections) according to their anatomical location (Couinaud's segmentation). The prognostic predictors were evaluated, and a subgroup analysis was performed. The 1-, 3-, and 5-year overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in group SS than group DS. The subgroup analysis showed that patients with two tumors in the same section and patients undergoing en bloc resection had better OS and RFS. A multivariate analysis revealed that tumors located in different sections and macrovascular invasion were independent predictors of poor prognosis. In HCC patients with multifocal tumors meeting the Milan criteria, tumors located in the same hepatic section may lead to better long-term survival and lower HCC recurrence rates than tumors in different sections after HR.

Predictive value of quantitative contrast-enhanced ultrasound in hepatocellular carcinoma recurrence after ablation

AIM: To investigate the relationship between contrast-enhanced ultrasound (CEUS), basic fibroblast growth factor (bFGF), endothelin-1 (ET-1), and hepatocellular carcinoma (HCC) recurrence after ablation.

METHODS: A total of 51 HCC patients (38 males and 13 females) who received radiofrequency ablation in our hospital from June 2012 to July 2014 were enrolled in this study. The patients were divided into two groups: recurrence group and non-recurrence group. Routine abdominal examination was first performed in the horizontal position. Then the patients underwent CEUS and immunohistochemical staining before receiving radiofrequency ablation. All patients were followed-up every three months for one year. The results of CEUS and serum tumor marker levels were evaluated and combined together to estimate HCC recurrence and metastasis. Patients were divided into two groups: recurrence group and non-recurrence group. Quantitative parameters of CEUS and tumor expression levels of bFGF and ET-1 were compared between the two groups, respectively. Binary logistic regression analysis was used to analyze the relationship between CEUS quantitative parameters, expression levels of ET-1 and bFGF, and HCC recurrence after ablation.

RESULTS: Based on the quantitative parameters of CEUS before patients received radiofrequency ablation, the levels of tumor rise time (tRT), tumor time to peak (tTTP), tumor peak intensity (tPI) and tumor-parenchymal peak intensity (t-pPI) in the recurrence group were significantly lower than those in the non-recurrence group (16.6 ± 6.1 vs 23.2 ± 7.0, P = 0.000; 41.2 ± 10.2 vs 59.6 ± 14.2, P = 0.000; 23.8 ± 6.7 vs 31.4 ± 6.4, P = 0.000; 7.1 ± 3.4 vs 14.6 ± 7.4, P = 0.000; respectively). The expression levels of bFGF in the recurrence group were significantly higher than those in the non-recurrence group (P < 0.05). Levels of tTTP showed a significant inverse correlation with the level of bFGF in tumors (r = -0.312, P = 0.037). The Binary logistic regression analysis results revealed that the levels of tRT, tTTP, tPI and the level of bFGF were associated with HCC recurrence after radiofrequency ablation (P < 0.05).

CONCLUSION: CEUS is a noninvasive and effective method for evaluating the angiogenesis of HCC, and predicting its recurrence and prognosis.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Does Establishing a Safety Margin Reduce Local Recurrence in Subsegmental Transarterial Chemoembolization for Small Nodular Hepatocellular Carcinomas?

Objective

To test the hypothesis that a safety margin may affect local tumor recurrence (LTR) in subsegmental chemoembolization.

Materials and Methods

In 101 patients with 128 hepatocellular carcinoma (HCC) nodules (1-3 cm in size and ≤ 3 in number), cone-beam CT-assisted subsegmental lipiodol chemoembolization was performed. Immediately thereafter, a non-contrast thin-section CT image was obtained to evaluate the presence or absence of intra-tumoral lipiodol uptake defect and safety margin. The effect of lipiodol uptake defect and safety margin on LTR was evaluated. Univariate and multivariate analyses were performed to indentify determinant factors of LTR.

Results

Of the 128 HCC nodules in 101 patients, 49 (38.3%) nodules in 40 patients showed LTR during follow-up period (median, 34.1 months). Cumulative 1- and 2-year LTR rates of nodules with lipiodol uptake defect (n = 27) and those without defect (n = 101) were 58.1% vs. 10.1% and 72.1% vs. 19.5%, respectively (p < 0.001). Among the 101 nodules without a defect, the 1- and 2-year cumulative LTR rates for nodules with complete safety margin (n = 52) and those with incomplete safety margin (n = 49) were 9.8% vs. 12.8% and 18.9% vs. 19.0% (p = 0.912). In multivariate analyses, ascites (p = 0.035), indistinct tumor margin on cone-beam CT (p = 0.039), heterogeneous lipiodol uptake (p = 0.023), and intra-tumoral lipiodol uptake defect (p < 0.001) were determinant factors of higher LTR.

Conclusion

In lipiodol chemoembolization, the safety margin in completely lipiodolized nodule without defect will not affect LTR in small nodular HCCs.

Binocular Goggle Augmented Imaging and Navigation System provides real-time fluorescence image guidance for tumor resection and sentinel lymph node mapping

The inability to identify microscopic tumors and assess surgical margins in real-time during oncologic surgery leads to incomplete tumor removal, increases the chances of tumor recurrence, and necessitates costly repeat surgery. To overcome these challenges, we have developed a wearable goggle augmented imaging and navigation system (GAINS) that can provide accurate intraoperative visualization of tumors and sentinel lymph nodes in real-time without disrupting normal surgical workflow. GAINS projects both near-infrared fluorescence from tumors and the natural color images of tissue onto a head-mounted display without latency. Aided by tumor-targeted contrast agents, the system detected tumors in subcutaneous and metastatic mouse models with high accuracy (sensitivity = 100%, specificity = 98% ± 5% standard deviation). Human pilot studies in breast cancer and melanoma patients using a near-infrared dye show that the GAINS detected sentinel lymph nodes with 100% sensitivity. Clinical use of the GAINS to guide tumor resection and sentinel lymph node mapping promises to improve surgical outcomes, reduce rates of repeat surgery, and improve the accuracy of cancer staging.

Optimizing the management of patients with BCLC stage-B hepatocellular carcinoma: Modern surgical resection as a feasible alternative to transarterial chemoemolization

OBJECTIVE

To analyse the impact of liver resection (LR) in patients with Hepatocellular Carcinoma (HCC) within the Barcelona-Clinic-Liver-Cancer (BCLC)-B stage.

METHODS

Analysis of patients with BCLC-B HCC treated with LR or transarterial chemoembolization (TACE) between 2007 and 2012 in our hospital. Survival/recurrence analyses were performed by log-rank tests and Cox multivariate models. Further analyses were specifically obtained for the HCC subclassification (B1-2-3-4) proposed recently.

RESULTS

Eighty patients were treated (44-TACE/36-LR). Number of nodules was [1.8(1.1)], being multinodular in 50% of cases. Although resected patients had a higher hospital stay than those who underwent TACE (14 ± 13 vs 7 ± 6; P = 0.004), the rate and severity of complications was lower measured by Dindo-Clavien scale (P < 0.05). Overall survival was 40% with a median follow-up of 29.5 months (0.07-96.9). Five-years survival rates were 62.9%, 28.1% and 15.4%, respectively (P = 0.004) for B1, B2 and B3-4 stages. Cox model showed that only total bilirubin [OR = 2.055(1.23-3.44)] and BCLC subclassification B3-4 [OR = 2.439(1.04-5.7)] and B2 [OR = 2.79(1.35-5.77)] vs B1 were independent predictors of 5-years-survival. In B1 patients, surgical approach led a significant decrease in 5-years recurrence-rate (25% vs 60%; P = 0.018). In the surgical subgroup analysis, better results were observed if well/moderate differentiation combined with no microvascular-invasion (VI) in 5-years-survival (84.6%; P = 0.001) and -recurrence (23.1%; P = 0.041), respectively. These survival and recurrence trends were remarkable in B1 stages.

CONCLUSIONS

Management of Intermediate BCLC-B HCC stage should be more complex and include updated criteria regarding B-stage subclassifications, VI and tumour differentiation. Modern surgical resection would offer improved survival benefit with acceptable safety in selected BCLC-B stage patients.

Appropriate treatment strategies improve survival of hepatocellular carcinoma patients with portal vein tumor thrombus

AIM: To evaluate the survival benefits of different treatment strategies for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) and to determine the prognosis factors.

METHODS: Between 2007 and 2009, 338 HCC patients treated for PVTT were retrospectively studied. The patients were divided into 4 groups that underwent different treatments: the conservative treatment group (n = 75), the transarterial chemoembolization (TACE) group (n = 86), the hepatic resection group (n = 90), and the hepatic resection associated with postoperative TACE group (n = 87). Survival rates were determined using the Kaplan-Meier method and differences between the groups were identified through log-rank analysis. Cox’s proportional hazard model was used to identify the risk factors for survival.

RESULTS: The mean survival periods for patients in the conservative treatment, TACE, hepatic resection and hepatic resection associated with postoperative TACE groups were 3.8, 7, 8.2 and 15.1 mo, respectively. Significant differences were observed in the survival rates. For the surgical resection associated with postoperative TACE group, the survival rates after 1, 2 and 3 years were 49%, 37% and 19%, respectively. These results were significantly higher than those of the other groups (P < 0.05). Meanwhile, the 1, 2 and 3 year survival rates for the surgical resection group were 28%, 20% and 15%, whereas those for the TACE group were 17.5%, 0% and 0%, respectively. These values significantly increased after hepatic resection compared with those after TACE (P < 0.05).

CONCLUSION: Surgical resection is the most effective therapeutic strategy for HCC patients with PVTT and results in high hepatic functional reserve. For patients who can tolerate the procedure, postoperative TACE is necessary to prevent recurrence and prolong the survival period.

Recent advances in the surgical treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The treatment of HCC is complex and complicated by the severity of associated chronic liver disease, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC, with an expected 5-year survival of 38%-61% depending on the stage of the disease. Improved liver function assessment, increased understanding of segmental liver anatomy from advanced imaging studies, and surgical technical progress are important factors that have led to reduced mortality in patients with HCC. The indication for LR may be expanded due to emerging evidences from laparoscopic hepatectomies and combined treatments with newly developed chemotherapies. Liver transplantation (LT) is considered as an ideal treatment for removal of existing tumors and the injured/preneoplastic underlying liver tissue with impaired liver function and the risk of multicentric carcinogenesis that results from chronically injured liver. However, LT is restricted to patients with minimal risk of tumor recurrence under immunosuppression. The expansion of criteria for LT in HCC patients is still under trial and discussion. Limited availability of grafts, as well as the risk and the cost of transplantation have led to considerable interest in expansion of the donor pool, living donor-related transplantation, and combined treatment involving LR and LT. This highlight presents evidence concerning recent studies evaluating LR and LT in HCC patients. In addition, alternative therapies for the treatment of early stage tumors and the management of patients on transplant waiting lists are discussed.

New insights in hepatocellular carcinoma: from bench to bedside

Hepatocarcinogenesis is a multistep process involving different genetic alterations that ultimately lead to malignant transformation of the hepatocyte. The liver is one of the main targets for different metastatic foci, but it represents an important and frequent locus of degeneration in the course of chronic disease. In fact, Hepatocellular carcinoma (HCC) represents the outcome of the natural history of chronic liver diseases, from the condition of fibrosis, to cirrhosis and finally to cancer. HCC is the sixth most common cancer in the world, some 630,000 new cases being diagnosed each year. Furthermore, about the 80% of people with HCC, have seen their clinical history developing from fibrosis, to cirrhosis and finally to cancer. The three main causes of HCC development are represented by HBV, HCV infection and alcoholism. Moreover, metabolic disease [starting from Non Alcoholic Fatty Liver Disease (NAFLD), Non Alcoholic Steatohepatitis (NASH)] and, with reduced frequency, some autoimmune disease may lead to HCC development. An additional rare cause of carcinogenetic degeneration of the liver, especially developed in African and Asian Countries, is represented by aflatoxin B1. The mechanisms by which these etiologic factors may induce HCC development involve a wide range of pathway and molecules, currently under investigation. In summary, the hepatocarcionogenesis results from a multifactorial process leading to the common condition of genetic changes in mature hepatocytes mainly characterized by uncontrolled proliferation and cell death. Advances in understanding the mechanism of action are fundamental for the development of new potential therapies and results primarily from the association of the research activities coming from basic and clinical science. This review article analyzes the current models used in basic research to investigate HCC activity, and the advances obtained from a basic and clinical point of view.

Current management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and leading cause of death among patients with cirrhosis. Treatment guidelines are based according to the Barcelona Clinic Liver Cancer staging system. The choice among therapeutic options that include liver resection, liver transplantation, locoregional, and systemic treatments must be individualized for each patient. The aim of this paper is to review the outcomes that can be achieved in the treatment of HCC with the heterogeneous therapeutic options currently available in clinical practice.

Comparison of microwave ablation and surgical resection for treatment of hepatocellular carcinomas conforming to Milan criteria

BACKGROUND AND AIM

To compare the efficacy of microwave ablation (MWA) and surgical resection (RES) in the treatment of hepatocellular carcinoma (HCC) conforming to Milan criteria.

METHODS

Two hundred twenty-four patients met the inclusion criteria and were enrolled in the study. One hundred and seventeen patients received MWA, and 107 patients underwent RES. The primary endpoints were overall survival (OS) and disease-free survival (DFS).

RESULTS

The 1-, 3-, and 5-year OS rates were 94%, 70%, 52% for the MWA group and 94%, 72%, 60% for the RES group (P = 0.513). The corresponding DFS rates for the two groups were 77%, 38%, 18% and 85%, 57%, 31% (P = 0.005). In subgroup analyses of patients with solitary HCC ≤ 3 cm, there were no significant differences in OS rates and DFS rates between the two groups (P = 0.577 and P = 0.140). For patients with solitary HCC 3 to 5 cm, there was no significant differences in OS rates between the two groups (P = 0.820), the DFS rates was significantly higher in the RES group than in the MWA group (P = 0.014).

CONCLUSIONS

MWA results in lower DFS rates than RES for HCC conforming to Milan criteria. However, the OS rates are comparable between the two therapies. For solitary HCC ≤ 3 cm, MWA is as effective as RES.

Liver resection and transplantation in hepatocellular carcinoma

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

Recent advances in liver resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The association of HCC with chronic liver disease (CLD) is well known and making treatment complex and challenging. The treatment of HCC must take into consideration, the severity of CLD, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the important factors that have led to reduced mortality, with an expected 5 year survival of 38–61% depending on the stage of the disease. However, the procedure is applicable to <30% of all HCC patients, and 80% of the patients after LR recurred within 5 years. There are recent advances and prospects in LR for HCC in several aspects. Three-dimensional computed tomography imaging assisted preoperative surgical planning facilitates unconventional types of LR. Emerging evidences of laparoscopic hepatectomy and prospects for the use of newly developing chemotherapies as a combined therapy may lead to expanding indication of LR. LR and liver transplantation could be associated rather than considered separately with the current concepts of “bridging LR” and “salvage transplantation.”

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.

METHODS: Between January 2002 and December 2010, 268 consecutive HCC patients, including 110 and 158 patients that underwent AR and NAR, respectively, were retrospectively enrolled in this study. Forty-four patients from each group were selected and matched using logistic multivariate analysis followed by propensity score analysis.

RESULTS: In the whole analysis set, the histological background of the liver, liver function, and tumor marker levels differed significantly among the groups. Although the overall survival (OS) and recurrence-free survival rates of the two groups did not differ significantly in the whole analysis set, the OS of the AR group was significantly longer than that of the NAR group after propensity matching (76.2 ± 6.3 mo vs 58.9 ± 6.3 mo; P = 0.0039). Although AR (HR = 0.456, P = 0.039) was found to be a prognostic factor in the univariate analysis, only vascular invasion (HR = 0.228, P = 0.002) and the hepatocyte growth factor level (HR = 52.366, P = 0.035) were subsequently found to be independent prognostic factors.

CONCLUSION: AR conveys a survival advantage over NAR in specific subpopulations of HCC patients with tumors of less than 5 cm in diameter, single tumor, and good liver function.

Identification of Zinc Finger, MYM-type 2 (ZMYM2) as a regulator of sorafenib resistance in hepatocellular carcinoma cell lines

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is an aggressive malignancy with a very complex molecular process. There is no successful therapy for advanced HCC at present. Recently, sorafenib has been used as a systemic therapy to improve survival in patients with advanced HCC, but increasing reports of recurrence or non-responsiveness indicate the limitations of sorafenib as a therapeutic agent. Therefore, identification of genes involved in sorafenib resistance is important to effectively treat advanced HCC.

METHODS

We performed a genomic screening with a short-hairpin RNA library cassette on HCC cell lines to find genes relating resistance to sorafenib.

RESULTS

Zinc finger, MYM type 2 (ZMYM2) was sequenced after three successive screens in vitro as a challengeable target. The inhibition of ZMYM2 resulted in sorafenib-resistance in formerly sensitive HCC cell lines. Immunohistochemical comparison of tumor and non-tumor regions showed stronger ZMYM2 staining intensities in non-tumor regions than in tumor regions.

CONCLUSION

ZMYM2 may play an important role in sorafenib resistance.

Intraoperative detection of liver tumors aided by a fluorescence goggle system and multimodal imaging

Real-time image guidance in the operating room is needed to improve instantaneous surgical decisions. Toward this goal, we utilized a new fluorescence goggle system and a near-infrared fluorescent dye approved for human use, indocyanine green, to demonstrate the feasibility of detecting liver tumors intraoperatively. The fluorescence goggle provided successful imaging of multifocal breast cancer metastases in mouse liver. Diffused tumor deposits as small as 0.8 mm in diameter were detected, which were not obvious without the fluorescence goggle. A combination of surface-weighted fluorescence imaging and deep tissue-sensitive ultrasound imaging allowed comprehensive image guidance with the fluorescence goggle system for tumor resection in a rabbit VX2 liver metastasis model. This multimodal detection and guided surgical intervention strategy using ultrasonic imaging and real-time intraoperative fluorescence guidance is a promising and innovative technology platform for improving surgical outcome of human patients with primary or metastatic liver cancer.

Real-time fluorescence image-guided oncologic surgery

Medical imaging plays a critical role in cancer diagnosis and planning. Many of these patients rely on surgical intervention for curative outcomes. This requires a careful identification of the primary and microscopic tumors, and the complete removal of cancer. Although there have been efforts to adapt traditional-imaging modalities for intraoperative image guidance, they suffer from several constraints such as large hardware footprint, high-operation cost, and disruption of the surgical workflow. Because of the ease of image acquisition, relatively low-cost devices and intuitive operation, optical imaging methods have received tremendous interests for use in real-time image-guided surgery. To improve imaging depth under low interference by tissue autofluorescence, many of these applications utilize light in the near-infrared (NIR) wavelengths, which is invisible to human eyes. With the availability of a wide selection of tumor-avid contrast agents, advancements in imaging sensors, electronic and optical designs, surgeons are able to combine different attributes of NIR optical imaging techniques to improve treatment outcomes. The emergence of diverse commercial and experimental image guidance systems, which are in various stages of clinical translation, attests to the potential high impact of intraoperative optical imaging methods to improve speed of oncologic surgery with high accuracy and minimal margin positivity.

First in-human intraoperative imaging of HCC using the fluorescence goggle system and transarterial delivery of near-infrared fluorescent imaging agent: a pilot study

Surgical resections remain the primary curative interventions for hepatocellular carcinoma (HCC). However, lack of real-time intraoperative image guidance confines surgeons to subjective visual assessment of the surgical bed, leading to poor visualization of small positive nodules and the extension of diffuse HCC. To address this problem, we developed a wearable fluorescence imaging and display system (fluorescence goggle) for intraoperative imaging of HCCs in human patients. In this pilot study, both intravenous (IV) and transarterial hepatic (TAH) delivery of indocyanine green (ICG) were explored to facilitate fluorescence goggle-mediated HCC imaging. The results show that all primary tumors in patients (n = 4) who received TAH delivery of ICG were identified successfully by the fluorescence goggle. In addition, 6 satellite tumors were also detected by the goggle, 5 of which were neither identifiable via preoperative magnetic resonance imaging (MRI) and computed tomography (CT) nor by visual inspection and palpation. In the group (n = 5) that received ICG intravenously, only 2 of 6 tumors visible by preoperative MRI or CT were identified with the fluorescence goggle, demonstrating the limitation of this delivery route for a non-tumor-selective imaging agent. Comparative analysis shows that the HCC-to-liver florescence contrast detected by the goggle was significantly greater in patients that received TAH than IV delivery of ICG (P = 0.013). This pilot study demonstrates the feasibility of using the fluorescence goggle to identify multifocal lesions and small tumor deposits using TAH ICG delivery in HCC patients.

Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching

BACKGROUND

Laparoscopic liver resection (LR) for hepatocellular carcinoma (HCC) is usually applied to superficial and left-side small lesions. Therefore, well designed comparative studies about the results of LR versus open liver resection (OR) for HCC are difficult and still uncommon. The aim of this study was to compare the perioperative and long-term oncologic outcomes of LR versus OR for HCC between well-matched patient groups.

METHODS

Between January 2000 and March 2012, 205 patients (43 with intent-to-treat with LR, 162 OR) underwent primary liver resection of less than three segments for HCC in our center. To select a comparison group, propensity score matching (PSM) was used at 1:1 ratio with covariates of baseline characteristics, including tumor characteristics. Outcomes were compared between the matched groups.

RESULTS

The two groups were well balanced by PSM and 29 patients were matched respectively. In LR, there was more non-anatomical resection (65.5 vs. 34.5 %; p = 0.012), less postoperative ascites (0.0 vs. 17.2 %; p = 0.025), and shorter hospital stay (7.69 ± 2.94 vs. 13.38 ± 7.37 days; p < 0.001). With the exception of these, there were no significant differences in perioperative and long-term outcomes. The 1-, 3- and 5-year survivals were 100, 100 and 92.2 % in LR, and 96.5, 92.2 and 87.7 % in OR (p = 0.267), respectively. The 1-, 3- and 5-year disease-free survivals were 81.7, 61.7 and 54.0 % in LR, and 78.6, 60.9 and 40.1 % in OR, respectively (p = 0.929).

CONCLUSIONS

The outcome of LR for HCC was technically feasible and safe in selected patients, and LR showed similar perioperative and long-term oncologic outcomes when compared with OR matched with PSM.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of central bisectionectomy for hepatocellular carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of hepatocellular carcinoma: Enlightening the gray zones

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

Hepatic resection for hepatocellular carcinoma based on tumor hemodynamics

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

Liver resection and transplantation in hepatocellular carcinoma

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

Management of HCC

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

Contrast-enhanced ultrasound in abdominal imaging

The administration of a contrast agent is considered an essential tool to evaluate abdominal diseases using Ultrasound. The most targeted organ is the liver, especially to characterize focal liver lesions and to assess the response to percutaneous treatment. However, the expanding abdominal indications of contrast-enhanced ultrasound make this technique an important tool in the assessment of organ perfusion including the evaluation of ischemic, traumatic, and inflammatory diseases.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

PURPOSE

The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence.

METHODS

A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model.

RESULTS

Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay.

CONCLUSIONS

AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.

Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

PURPOSE

The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence.

METHODS

A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model.

RESULTS

Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay.

CONCLUSIONS

AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.