Longterm favorable results of limited hepatic resections for patients with hepatocellular carcinoma: 20 years of experience

Surgical contribution to recurrence-free survival in patients with macrovascular-invasion-negative hepatocellular carcinoma

BACKGROUND

Macroscopic vascular invasion (MVI) is a well-known indicator of recurrence of hepatocellular carcinoma (HCC) even after curative hepatectomy, but the clinicopathologic and molecular features of the recurrence remain unclear in MVI-negative HCC.

STUDY DESIGN

Two hundred seven consecutive patients with confirmed primary MVI-negative HCC were retrospectively assessed after curative resection, with special emphasis on the importance of anatomically systematized hepatectomy. HCC tissues were also analyzed for genome-wide gene expression profile of each tumor using a microarray technique.

RESULTS

Univariant analysis of HCC recurrence revealed multiple tumors (p < 0.001), moderate to poor differentiation (p = 0.044), Child-Pugh B/C (p = 0.047), alpha-fetoprotein elevation (p = 0.007), and nonanatomic hepatectomy (p = 0.010) as risk factors. According to Cox hazard multivariant analysis, multiple tumors (p = 0.002), alpha-fetoprotein elevation (p < 0.001), and nonanatomic hepatectomy (p = 0.002) were identified as independent factors of the recurrence. In the recurrent cases after anatomic hepatectomy for HCC, local recurrence was significantly infrequent compared with those after nonanatomic hepatectomy (p < 0.001). Network expression analysis using cDNA microarray revealed distinct signaling pathways of epithelial-mesenchymal transitions are associated with recurrence after anatomically systematized hepatectomy.

CONCLUSIONS

Anatomically systematized hepatectomy might contribute to recurrence-free survival of HCC patients of HCC without MVI. Local recurrence could be mostly averted by anatomic hepatectomy, although specific epithelial-mesenchymal transitions signaling might regulate the biologic aggressiveness of HCC.

Revisiting the role of nonanatomic resection of small (< or = 4 cm) and single hepatocellular carcinoma in patients with well-preserved liver function

BACKGROUND

Anatomic resection of the liver in patients with hepatocellular carcinoma (HCC) is generally recommended. Several previous reports have described the potential superiority of anatomic resection. However, no clear evidence of long-term survival or other advantages compared with those achieved with limited resection exist. We evaluated the oncologic outcomes of nonanatomic resection performed as a primary treatment for small (<or=4 cm) and single HCC in patients with well-preserved liver function (Child-Pugh class A).

MATERIALS AND METHODS

From March 1998 to January 2005, 353 consecutive patients underwent resection of HCC. Among them, 167 patients with single and small (<or=4 cm) HCC and well-preserved liver function (Child-Pugh class A) were selected. Twenty-one patients (12.6%) underwent nonanatomic resection (Group NA) and 146 (82.4%) underwent anatomic resection (Group A). Patient factors, tumor factors, surgery factors, disease-free survival, and recurrence patterns were compared between the two groups.

RESULTS

There were no significantly different preoperative clinical characteristics between the two groups (Group NA versus Group A). Only the resection margin width (0.8 +/- 0.6 cm versus 2.0 +/- 1.4 cm, P < 0.001) and operative time (211.9 +/- 72.9 min versus 251 +/- 80.0 min, P = 0.036) were significantly different between the two groups. There was no difference in disease-free survival between the two groups, and platelet counts of less than 100,000/microL (P = 0.038), satellite nodules (P = 0.0164), and microscopic portal vein invasion (P < 0.001) were significant prognostic factors predicting disease-free survival in univariate analysis. Subsequent Cox-proportional hazards models revealed that both microscopic portal vein invasion (Exp {beta} = 3.281, P < 0.001) and platelet counts of less than 100,000/microL (Exp {beta} = 1.913, P = 0.012) adversely affected disease-free survival. Nonanatomic resection did not have adverse effects on early recurrence compared to anatomic resection (P = 0.805).

CONCLUSION

Our study showed that nonanatomic resection has no adverse effects on the oncologic outcomes of single and small (<or=4 cm) HCC in patients with well-preserved liver function (Child-Pugh class A).

The timing of liver transplantation after primary hepatectomy for hepatocellular carcinoma: a special reference to recurrence pattern and Milan criteria

INTRODUCTION

Hepatic resection (HR) is commonly applied as first-line treatment of hepatocellular carcinoma (HCC) even in the era of liver transplantation (LT).

METHODS

Outcomes and detailed recurrence pattern of 80 patients, who underwent curative HR for HCC were examined referring to Milan criteria.

RESULTS

(I) After HR for HCCs exceeding Milan criteria (n=41), recurrence within the criteria was observed in 13 patients (group-A) and recurrence not-meeting the criteria was observed in 22 patients (group-B). group-A showed better 3-year recurrence-free survival rate than group-B (85.7% vs. 23.9%, P<0.05). Tumor size more than or equal to 6 cm was identified as the significant factor for having recurrence as in group-A pattern (P<0.05). Among the patients in group-A, re-recurrence after treating recurrent HCC was observed in eight patients (61.5%) with increased rate of extra-Milan criteria recurrence at 12 months from the initial recurrence. (II) After HR for HCCs meeting Milan criteria (n=39), recurrences within the criteria was observed in 15 patients (group-C) and recurrence not-meeting the criteria was observed in five patients (group-D). The 3-year recurrence-free survival rate was 62.8% in group-C and 40.0% in group-D (P<0.05). Increased rate of extra-Milan re-recurrence was observed later than 12 months from the recurrence in group-C.

CONCLUSIONS

For HCCs not meeting Milan criteria, secondary LT after primary HR could be applied for a proportion of cases with less aggressiveness. For those meeting Milan criteria, primary LT should be the first therapeutic option. However, secondary LT could be offered for those with re-recurrence within criteria after primary HR.

Hepatocellular carcinoma: Defining the place of surgery in an era of organ shortage

Liver resection (LR) and transplantation offer the only potential chance of cure for patients with hepatocellular carcinoma (HCC). Historically, all patients were treated by hepatic resection. With the advent of liver transplantation (LT) patients with HCC were preferentially placed on the waiting list for LT. However, early experience with LT was associated with a high rate of tumour recurrence and poor long-term survival. The increasing scarcity of donor livers resulted in restrictions being placed on tumour size, and an improvement in patient survival. To date there have been no randomised clinical trials comparing LR to LT. We review the evidence supporting LR and/or LT for HCC and discuss the role of neoadjuvant therapy. The decision of whether to resect or transplant remains debatable and is often determined by centre experience, availability of LT and donor organs.