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Ng KKC, Chok KSH, Chan ACY, Cheung TT, Wong TCL, Fung JYY, Yuen J, Poon RTP, Fan ST, Lo CM. Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma. Br J Surg 2017; 104:1775-1784. [PMID: 29091283 DOI: 10.1002/bjs.10677] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/22/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Hepatic resection and radiofrequency ablation (RFA) are treatment options for early-stage hepatocellular carcinoma (HCC). Whether tumour recurrence and long-term survival favour either treatment has not been established. This randomized trial aimed to test the hypothesis that RFA is superior to hepatic resection in terms of lower tumour recurrence rate and better long-term survival.
Methods
Patients with early-stage HCC (solitary tumour no larger than 5 cm; or no more than 3 tumours, each 3 cm or smaller) were randomized into hepatic resection and RFA groups. Demographic and clinical characteristics, and short- and long-term outcome measures were compared between groups. Primary and secondary outcome measures were overall tumour recurrence and survival respectively.
Results
Clinicopathological data were similar in the two groups, which each contained 109 patients. The RFA group had a shorter treatment duration, less blood loss and shorter hospital stay than the resection group. Mortality and morbidity rates were similar in the two groups. The overall tumour recurrence rate was similar in the resection and RFA groups (71·3 versus 81·7 per cent respectively). The 1-, 3-, 5- and 10-year overall survival rates were 94·5, 80·6, 66·5 and 47·6 per cent respectively in the resection group, compared with 95·4, 82·3, 66·4 and 41·8 per cent in the RFA group (P = 0·531). Corresponding disease-free survival rates were 74·1, 50·9, 41·5 and 31·9 per cent in the resection group, and 70·6, 46·6, 33·6 and 18·6 per cent in the RFA group (P = 0·072).
Conclusion
RFA for early-stage HCC is not superior to hepatic resection, in terms of tumour recurrence, overall survival and disease-free survival. Registration number: HKUCTR-10 (http://www.hkuctr.com).
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Affiliation(s)
- K K C Ng
- Department of Surgery, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - K S H Chok
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - A C Y Chan
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - T T Cheung
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - T C L Wong
- Department of Surgery, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - J Y Y Fung
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Department of Medicine, University of Hong Kong, Hong Kong, China
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - J Yuen
- Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - R T P Poon
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
| | - S T Fan
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Liver Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - C M Lo
- Department of Surgery, University of Hong Kong, Hong Kong, China
- State Key Laboratory for Liver Research, University of Hong Kong, Hong Kong, China
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
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Liu QY, Lai DM, Liu C, Zhang L, Zhang WD, Li HG, Gao M. A special recurrent pattern in small hepatocellular carcinoma after treatment: Bile duct tumor thrombus formation. World J Gastroenterol 2011; 17:4817-24. [PMID: 22147984 PMCID: PMC3229632 DOI: 10.3748/wjg.v17.i43.4817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinicopathologic features of bile duct tumor thrombus (BDTT) occurrence after treatment of primary small hepatocellular carcinoma (sHCC).
METHODS: A total of 423 patients with primary sHCC admitted to our hospital underwent surgical resection or local ablation. During follow-up, only six patients were hospitalized due to obstructive jaundice, which occurred 5-76 mo after initial treatment. The clinicopathologic features of these six patients were reviewed.
RESULTS: Six patients underwent hepatic resection (n = 5) or radio-frequency ablation (n = 1) due to primary sHCC. Five cases had an R1 resection margin, and one case had an ablative margin less than 5.0 mm. No vascular infiltration, microsatellites or bile duct/canaliculus affection was noted in the initial resected specimens. During the follow-up, imaging studies revealed a macroscopic BDTT extending to the common bile duct in all six patients. Four patients had a concomitant intrahepatic recurrent tumor. Surgical re-resection of intrahepatic recurrent tumors and removal of BDTTs (n = 4), BDTT removal through choledochotomy (n = 1), and conservative treatment (n = 1) was performed. Microscopic portal vein invasion was noted in three of the four resected specimens. All six patients died, with a mean survival of 11 mo after BDTT removal or conservative treatment.
CONCLUSION: BDTT occurrence is a rare, special recurrent pattern of primary sHCC. Patients with BDTTs extending to the common bile duct usually have an unfavorable prognosis even following aggressive surgery. Insufficient resection or ablative margins against primary sHCC may be a risk factor for BDTT development.
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Xiao EH, Guo D, Bian DJ. Effect of preoperative transcatheter arterial chemoembolization on angiogenesis of hepatocellular carcinoma cells. World J Gastroenterol 2009; 15:4582-6. [PMID: 19777619 PMCID: PMC2752005 DOI: 10.3748/wjg.15.4582] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effects of four types of preoperative transcatheter arterial chemoembolization (TACE) on angiogenesis of hepatocellular carcinoma (HCC) cells.
METHODS: A total of 136 patients with HCC underwent liver resection. One to five courses of TACE prior to liver resection were performed in 79 patients (TACE group), in which one to four courses of chemotherapy alone were performed in 11 patients (group A); one to five courses of chemotherapy combined with iodized oil were performed in 33 patients (group B); one to three courses of chemotherapy combined with iodized oil and gelatin sponge were performed in 23 patients (group C); one to three courses of chemotherapy combined with iodized oil, ethanol and gelatin sponge were performed in 12 patients (group D). The other 57 patients only received liver resection (non-TACE group). The microvessels were marked by CD31. The expression of CD31 and vascular endothelial growth factor (VEGF) protein were detected by immunohistochemical methods.
RESULTS: The mean microvessel density (MVD) in HCC cells was significantly higher in groups A, B, C and D than in the non-TACE group (P < 0.05). The expression of VEGF protein in HCC cells were significantly higher in groups A, B, C and D than in the non-TACE group (P < 0.05). MVD and the expression of VEGF protein were positively correlated. Mean MVD and the expression of VEGF protein were closely related to the number of courses of TACE and the interval of TACE.
CONCLUSION: Four different types of preoperative TACE regimens enhanced angiogenesis in HCC cells by up-regulating the expression of VEGF protein. It is necessary to repress angiogenesis of liver cancer after TACE.
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Kang SY, Kim HJ, Yoon SS, Lee DS. Prognostic Factors and Clinicopathologic Features after Resection of Small Hepatocellular Carcinoma (≤2 cm). JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.76.2.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sang-Yoon Kang
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Hong-Jin Kim
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sung-Su Yoon
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Dong-Shik Lee
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, Korea
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Ezaki T, Ikegami T, Maeda T, Yamada T, Ishida T, Hashizume M, Maehara Y. Prognostic value of thymidine phosphorylase activity in liver tissue adjacent to hepatocellular carcinoma. Int J Clin Oncol 2005; 10:171-6. [PMID: 15990964 DOI: 10.1007/s10147-005-0488-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Accepted: 03/16/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Measurement of thymidine phosphorylase (TP) activity in normal liver tissue adjacent to hepatocellular carcinoma (HCC) may predict multicentric recurrence a long time after an operation. The authors investigated this activity in 92 patients with HCC who had a single HCC equal to or less than 5 cm. METHODS Fresh samples (tumors with adjacent normal tissues) were collected from 92 patients with HCC who underwent curative hepatic resection. The levels of TP activity in nonfixed, fresh, and frozen HCC specimens with adjacent noncancerous liver tissue were biochemically measured by using an enzyme-linked immunosorbent assay method. RESULTS Patients who had a high TP level in normal liver tissue had significantly earlier recurrence (median disease-free survival, 819 days; 95% confidence interval [95% CI], 478-1044 days) compared with patients who had a low TP level (median disease-free survival, 1376 days; lower limit of 95% CI, 921 days; P = 0.0171). Multivariate analysis showed that patients who had a low TP level in adjacent liver tissue had a 0.387-fold higher risk of postoperative recurrence compared with patients who had a high TP level (P = 0.0067). CONCLUSION TP activity in normal liver tissue adjacent to HCC is related to tumor occurrence and may predict postoperative tumor recurrence.
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Affiliation(s)
- Takahiro Ezaki
- Department of Disaster and Emergency Medicine, Graduate School of Medical Science, Kyushu University, Fukuoka 812-8582, Japan.
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Ezaki T, Ikegami T, Ishida T, Aimitsu S, Mori M, Fujihara M. Significance of thymidine phosphorylase in HCC with chronic liver disease for long-term postoperative recurrence. J Surg Oncol 2003; 83:173-9; discussion 179. [PMID: 12827687 DOI: 10.1002/jso.10259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the significance of thymidine phosphorylase (TP) levels in HCC. The authors investigated the TP activity of HCC and adjacent normal liver tissue in 70 HCC patients, and the prognostic significance of the TP levels. METHODS We obtained fresh samples (tumors with adjacent normal tissues) from 70 patients with HCC who have undergone curative hepatic resection. The levels of TP activity in unfixed, fresh, frozen HCC tissue, together with adjacent normal liver tissue specimens, were determined by the enzyme-linked immunosorbent assay (ELISA) method. RESULTS The mean TP activity in HCC was approximately 1.5-fold higher than that in adjacent liver tissues (P = 0.0013). Disease-free survival rates for patients with low and high TP levels in HCC were not significantly different. Although disease-free survival rates for low and high TP levels in adjacent normal liver tissue were also not significantly different, disease-free survival for patients with low and high TP levels in adjacent normal liver tissue, excluding cases of postoperative recurrence within 700 days of hepatectomy, showed a significant difference (P = 0.0494). The group with high TP activity in adjacent liver tissue showed more frequent postoperative recurrence in the long-term than that with low TP activity. CONCLUSIONS Measurement of TP activity of adjacent normal liver tissue to HCC may allow us to predict metachronous long-term postoperative recurrence.
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Affiliation(s)
- Takahiro Ezaki
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan. t.ezaki@
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Zhang LH, Qin LX, Ma ZC, Ye SL, Liu YK, Ye QH, Wu X, Huang W, Tang ZY. Allelic imbalance regions on chromosomes 8p, 17p and 19p related to metastasis of hepatocellular carcinoma: comparison between matched primary and metastatic lesions in 22 patients by genome-wide microsatellite analysis. J Cancer Res Clin Oncol 2003; 129:279-86. [PMID: 12734753 DOI: 10.1007/s00432-002-0407-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2002] [Accepted: 11/19/2002] [Indexed: 11/28/2022]
Abstract
To understand the molecular mechanisms of metastasis in hepatocellular carcinoma (HCC), it is necessary to identify the accumulating genetic alterations during its progression as well as those responsible for the acquisition of metastatic potential in cancer cells. In our previous study, using comparative genomic hybridization (CGH), we found that loss on chromosome 8p is more frequent in metastatic lesions than in matched primary tumors of HCC. Thus, 8p deletion might contribute to HCC metastasis. To narrow the location of metastasis-related alteration regions, we analyzed 22 primary and matched metastatic lesions of HCC by genome-wide microsatellite analysis. Common regions with high levels of allelic imbalance (AI) were identified on 17p, 8p11-cen, 8p21-23, 4q32-qter, 4q13-23, 16q, and 1p33. Regions with increased AI in metastatic lesions were 8p23.3, 8p11.2, 17p11.2-13.3, 4q21-22, 4q32-qter, 8q24.1, 9p11, 9q31, 11q23.1, 13q14.1-31, 13q32-qter, 16p13.3, 16q13, 16q22, and 19p13.1, and these were considered to be related to the metastasis phenotype. Among them, loss on 8p was again proved to be related to progression and metastasis of HCC, and 8p23.3 and 8p11.2 were two likely regions harboring metastasis-related genes. It was also shown for the first time in HCC that AI of 19p13.1 might also be related to metastatic potential. These results provide some candidate regions for further study to identify putative genes suppressing metastasis of HCC.
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Affiliation(s)
- Lian-Hai Zhang
- Liver Cancer Institute, Fudan University, 136 Yi Xue Yuan Road, 200032, Shanghai, China
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Nakajima T, Moriguchi M, Mitsumoto Y, Katagishi T, Kimura H, Shintani H, Deguchi T, Okanoue T, Kagawa K, Ashihara T. Simple tumor profile chart based on cell kinetic parameters and histologic grade is useful for estimating the natural growth rate of hepatocellular carcinoma. Hum Pathol 2002; 33:92-9. [PMID: 11823978 DOI: 10.1053/hupa.2002.30194] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Thirty-four untreated hepatocellular carcinomas (HCCs) with known growth rates were classified into 5 groups on a tumor profile chart based on their doubling time (DT), Ki-67-positive index (Ki-67-PI), apoptotic index (Apo-I), and histologic grade. The slow-growing HCCs (DT > 100 days) consisted of well-differentiated tumors with slight cell kinetic imbalance and were divided into groups A and B. Group A had Apo-I values <3%, and most tumors had Ki-67-PI values <10%, whereas group B had Apo-I values of 3 per thousand to 10 per thousand and Ki-67-PI values of 10% to 20%. The HCCs with intermediate growth rates, which had Ki-67-PI values similar to those of the tumors in group B, were divided into groups C and D based on differences in cell kinetics: group C consisted of well-differentiated tumors, most of which had Apo-I values <3 per thousand, and group D consisted of moderately or poorly differentiated tumors with Apo-I values between 10 per thousand and 20 per thousand. The rapidly growing tumors (DT < 50 days, group E) had higher Ki-67-PI values than other groups and a wide range of Apo-I values. Rapidly growing tumors were mostly moderately or poorly differentiated, with a large cell kinetic imbalance in favor of cell production. This grouping system is useful for approximating the growth rate of HCCs in a clinical setting, even when only histologic parameters are available.
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Affiliation(s)
- Tomoki Nakajima
- Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Shiina S, Teratani T, Obi S, Hamamura K, Koike Y, Omata M. Percutaneous ethanol injection therapy for liver tumors. ACTA ACUST UNITED AC 2001; 13:95-106. [PMID: 11369522 DOI: 10.1016/s0929-8266(01)00123-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Percutaneous ethanol injection therapy (PEIT) has been widely practiced in the treatment of liver tumors, especially of hepatocellular carcinoma (HCC). Histopathologic examinations, findings in imaging modalities and serum tumor marker levels have shown a remarkable anticancer effect of this procedure. In addition, PEIT has achieved considerably high long-term survival rates. For small HCC, PEIT has been generally accepted as an alternative to surgery. Here we will describe PEIT from the viewpoints of patient selection, technique, various evaluation procedures of efficacy, long-term results, side effects and complications, and relationship with other therapies.
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Affiliation(s)
- S Shiina
- Department of Gastroenterology, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, 113 8655, Tokyo, Japan.
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Minata M, Nishida N, Komeda T, Azechi H, Katsuma H, Nishimura T, Kuno M, Ito T, Yamamoto Y, Ikai I, Yamaoka Y, Fukuda Y, Nakao K. Postoperative detection of alpha-fetoprotein mRNA in blood as a predictor for metastatic recurrence of hepatocellular carcinoma. J Gastroenterol Hepatol 2001; 16:445-51. [PMID: 11354284 DOI: 10.1046/j.1440-1746.2001.02461.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND We tested for the presence of alpha-fetoprotein (AFP) mRNA by using nested RT-PCR in the peripheral blood of hepatocellular carcinoma (HCC) patients who had undergone curative surgery, and investigated the occurrence of intrahepatic and/or extrahepatic metastasis thereafter, to reveal the optimal timing of blood sampling for the prediction of metastatic recurrence. METHODS Twenty-nine patients with HCC, who had been operated on were analyzed with RT-PCR at several points during the clinical course, and examined for metastatic recurrence for 3-28 months (mean = 18.7 months) after surgery. RESULTS The presence of AFP mRNA before surgery was significantly correlated with the tumor size (P = 0.017). Metastatic recurrence was associated with the postoperative detection of AFP mRNA (P < 0.001), but not with the preoperative and/or perioperative detection. Furthermore, AFP mRNA was detected in some cases that showed low serum AFP levels at recurrence. The recurrence-free period after the detection of AFP mRNA varied from 1 to 12 months. CONCLUSIONS The postoperative detection of AFP mRNA is useful for the prediction of metastatic recurrence, and long-term follow up with this method should be conducted.
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Affiliation(s)
- M Minata
- Department of Medicine and Clinical Science, Kyoto University Graduate School of Medicine, Japan
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Tung-Ping Poon R, Fan ST, Wong J. Risk factors, prevention, and management of postoperative recurrence after resection of hepatocellular carcinoma. Ann Surg 2000; 232:10-24. [PMID: 10862190 PMCID: PMC1421103 DOI: 10.1097/00000658-200007000-00003] [Citation(s) in RCA: 648] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the current knowledge on the risk factors for recurrence, efficacy of adjuvant therapy in preventing recurrence, and the optimal management of recurrence after resection of hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA The long-term prognosis after resection of HCC remains unsatisfactory as a result of a high incidence of recurrence. Prevention and effective management of recurrence are the most important strategies to improve the long-term survival results. METHODS A review of relevant English articles was undertaken based on a Medline search from January 1980 to July 1999. RESULTS Pathologic factors indicative of tumor invasiveness such as venous invasion, presence of satellite nodules, large tumor size, and advanced pTNM stage, are the best-established risk factors for recurrence. Active hepatitis activity in the nontumorous liver and perioperative transfusion also appear to enhance recurrence. Recent molecular research has identified tumor biologic factors such as the proliferative and angiogenic activities of the tumor as new risk factors for recurrence. There is a lack of convincing evidence for the efficacy of neoadjuvant or adjuvant therapy in preventing recurrence. Retrospective studies suggested that postoperative hepatic arterial chemotherapy might improve disease-free survival, but results were conflicting. For the management of postoperative recurrence, studies have consistently indicated that surgical resection should be the treatment of choice for localized recurrence, be it in the liver remnant or extrahepatic organs. Transarterial chemoembolization and percutaneous ethanol injection are widely used to prolong survival in patients with unresectable intrahepatic recurrence, and combined therapy with these two modalities may offer additional benefit. CONCLUSIONS Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to prevention. Minimal surgical manipulation of tumors to prevent tumor cell dissemination, avoidance of perioperative blood transfusion, and suppression of chronic hepatitis activity in the liver remnant are strategies that may be useful in preventing recurrence. The efficacy of postoperative adjuvant regional chemotherapy deserves further evaluation. New concepts on the influence of tumor biologic factors such as angiogenic activity on recurrence of HCC suggest a potential role of novel approaches such as antiangiogenesis for adjuvant therapy in the future. Currently, the most realistic approach in prolonging survival after resection of HCC is early detection and aggressive management of recurrence. Randomized trials are needed to define the roles of various treatment modalities for recurrence and the benefit of multimodality therapy.
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Affiliation(s)
- R Tung-Ping Poon
- Centre of Liver Diseases, Department of Surgery, The University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam Road, Hong Kong, China.
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Influence factors to recurrence of hepatocellular carcinoma after surgical resection. Chin J Cancer Res 2000. [DOI: 10.1007/bf02983440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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