Chinese experience with hepatectomy for huge hepatocellular carcinoma

Adjuvant Transarterial Chemoembolization Plus Immunotherapy for Huge Hepatocellular Carcinoma: A Propensity Score Matching Cohort Study

Purpose

The prognosis of patients with huge hepatocellular carcinoma (huge HCC, diameter ≥10 cm) is poor owing to the high early recurrence rate. This study aimed to explore the clinical value of postoperative adjuvant transarterial chemoembolization (PA-TACE) plus programmed cell death-1 (PD-1) inhibitors for huge HCC.

Patients and Methods

Data from consecutive huge HCC patients treated with hepatectomy during June 2017 and July 2022 were retrospectively collected. Baseline differences were balanced between huge HCC patients who underwent PA-TACE with (AIT group) or without PD-1 inhibitors (AT group) by propensity-score matching (PSM). We compared recurrence-free survival (RFS), overall survival (OS) and recurrence patterns between the two groups. Independent risk factors for RFS and OS were confirmed by Cox regression analysis, and subgroup analysis was also conducted.

Results

A total of 294 patients were enrolled, and 77 pairs of patients in the AIT and AT groups were matched by PSM. The 1-year and 2-year RFS were 49.9% and 35.7% in the AIT group compared to 24.7% and 15.5% in the AT group respectively (p<0.001). The 1-year and 2-year OS were 83.6% and 66.9% in the AIT group compared to 50.6% and 36.8% in the AT group respectively (p<0.001). There were no significant differences in recurrence patterns between the two groups. Multivariable analysis demonstrated that combined therapy of PA-TACE plus PD-1 inhibitors was a protective factor related to both RFS and OS.

Conclusion

PA-TACE plus PD-1 inhibitors could improve survival outcomes for huge HCC patients.

A simple preoperative model to predict overall survival of patients undergoing liver resection for hepatocellular carcinoma ≥10 cm

BACKGROUND

Studies have rarely reported on preoperative predictors of prognosis of patients undergoing liver resection (LR) for HCC ≥10 cm. We developed a simple model to predict overall survival (OS) of these patients.

METHODS

We enrolled 305 patients with HCC ≥10 cm undergoing LR. Cirrhosis and imaging-defined AJCC stage were used to develop a preoperative model. Patients were divided into three groups based on the Kaplan-Meier estimator.

RESULTS

Group 1 included patients with AJCC stage 1 and no cirrhosis (n = 86), group 2 those with AJCC stage 1 and cirrhosis plus those with AJCC stage 2 or 3 and no cirrhosis (n = 166), and group 3 those with AJCC stage 2 or 3 and cirrhosis (n = 51). The five-year OS of group 1, 2, and 3 was 55%, 32%, and 25%, respectively (p < 0.001). With group 1 as the reference, multivariate analysis of OS showed that group 2 (HR = 2.043; 95% CI = 1.332-3.134; p = 0.001) and group 3 (HR = 2.740; 95% CI = 1.645-4.564; p < 0.001) were independent predictors of OS.

CONCLUSION

We developed a simple model to predict OS of patients undergoing LR for HCC ≥10 cm.

CT radiomics nomogram for the preoperative prediction of severe post-hepatectomy liver failure in patients with huge (≥ 10 cm) hepatocellular carcinoma

Background

This study aimed to establish a radiomics-based nomogram for predicting severe (grade B or C) post-hepatectomy liver failure (PHLF) in patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC).

Methods

One hundred eighty-six patients with huge HCC (training dataset, n = 131 and test dataset, n = 55) that underwent curative hepatic resection were included in this study. The least absolute shrinkage and selection operator (LASSO) approach was applied to develop a radiomics signature for grade B or C PHLF prediction using the training dataset. A multivariable logistic regression model was used by incorporating radiomics signature and other clinical predictors to establish a radiomics nomogram. Decision tree analysis was performed to stratify the risk for severe PHLF.

Results

The radiomics signature consisting of nine features predicted severe PHLF with AUCs of 0.766 and 0.745 for the training and test datasets. The radiomics nomogram was generated by integrating the radiomics signature, the extent of resection and the model for end-stage liver disease (MELD) score. The nomogram exhibited satisfactory discrimination ability, with AUCs of 0.842 and 0.863 for the training and test datasets, respectively. Based on decision tree analysis, patients were divided into three risk classes: low-risk patients with radiomics score < -0.247 and MELD score < 10 or radiomics score ≥ − 0.247 but underwent partial resections; intermediate-risk patients with radiomics score < − 0.247 but MELD score ≥10; high-risk patients with radiomics score ≥ − 0.247 and underwent extended resections.

Conclusions

The radiomics nomogram could predict severe PHLF in huge HCC patients. A decision tree may be useful in surgical decision-making for huge HCC hepatectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02459-0.

Long-Term Outcomes of Transarterial Radioembolization for Large Single Hepatocellular Carcinoma: A Comparison to Resection

The surgical treatment for large hepatocellular carcinoma (HCC) remains controversial due to a high risk of recurrence after resection. This study aimed to compare long-term outcomes of transarterial radioembolization (TARE) with resection for patients with large HCC. Methods: This retrospective cohort study included a total of 557 patients who were initially treated with either resection (the resection group, n = 500) or TARE (the TARE group, n = 57) for large (≥5 cm) single nodular HCC at two tertiary centers in Korea. Patients with major portal vein tumor thrombosis or extrahepatic metastasis were excluded. The primary endpoint was overall survival (OS), and secondary endpoints were time to progression (TTP), time to intrahepatic progression (TTIP), and safety. Results: The resection group were younger (median, 60 years vs. 69 years) with smaller tumor size (median, 7.0 cm vs. 10.0 cm) (all P<0.05). After baseline characteristics were balanced using inverse probability of treatment weighting (IPTW), the TARE group showed comparable OS (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.40-2.43; P = 0.97), TTP (HR, 1.10; 95% CI, 0.55-2.20; P = 0.80), and TTIP (HR, 1.45; 95% CI, 0.72-2.93; P = 0.30) to the resection group. TARE was not an independent risk for OS (adjusted-HR, 1.04; 95% CI, 0.42-2.59; P = 0.93), TTP (adjusted-HR, 0.98; 95% CI, 0.50-1.95; P = 0.96), or TTIP (adjusted-HR, 1.30; 95% CI, 0.65-2.58; P = 0.46). The TARE group showed shorter hospital stay and fewer adverse events than the resection group. Conclusion: TARE showed comparable OS, TTP, and TTIP with better safety profile compared to surgical resection for large single nodular HCC.

Long-term outcomes after hepatectomy of huge hepatocellular carcinoma: A single-center experience in China

BACKGROUND

Currently, hepatectomy remains the first-line therapy for hepatocellular carcinoma (HCC). However, surgery for patients with huge (>10 cm) HCCs is controversial. This retrospective study aimed to explore long-term survival after hepatectomy for patients with huge HCC.

METHODS

The records of 188 patients with pathologically confirmed HCC who underwent curative hepatectomy between 2007 and 2017 were reviewed; patients were divided into three groups according to tumor size: huge (>10 cm; n = 84), large (5-10 cm; n = 51) and small (<5 cm; n = 53) HCC. Kaplan-Meier analysis was used to assess overall survival (OS) and disease-free survival (DFS), and log-rank analysis was performed for pairwise comparisons among the three groups. Risk factors for survival and recurrence were analyzed using the Cox proportional hazard model.

RESULTS

The median follow-up period was 20 months. Although the prognosis of small HCC was better than that of huge and large HCC, OS and DFS were not significantly different between huge and large HCC (P = 0.099 and P = 0.831, respectively). A family history of HCC, poor Child-Pugh class, vascular invasion, diolame, pathologically positive margins, and operative time ≥240 min were identified as independent risk factors for OS and DFS in a multivariate model. Tumor size (>10 cm) had significant effect on OS, and postoperative antiviral therapy and postoperative complications also had significant effects on DFS.

CONCLUSIONS

Huge HCC is not a contraindication of hepatectomy. Although most of these patients experienced recurrence after surgery, OS and DFS were not significantly different from those of patients with large HCC after resection.

Systematic review of the outcomes of surgical resection for intermediate and advanced Barcelona Clinic Liver Cancer stage hepatocellular carcinoma: A critical appraisal of the evidence

AIM

To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas (HCC).

METHODS

A systematic review of the published literature was performed using the PubMed database from 1^st January 1999 to 31^st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer (BCLC) stage B or C HCC. The primary end point was to determine the overall survival (OS) and disease free survival (DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve (i.e., Child’s A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC (defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.

RESULTS

We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to (1) BCLC stage B or C HCC, (2) Size of HCC and (3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7% (range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0% (range 0.0-42.0). The collective median 5-year OS of both stages was 27.9% (0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR (95%CI) = 1.00 (0.76-1.31)] and mortality [RR (95%CI) = 1.15 (0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.

CONCLUSION

Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.

Better Long-Term Prognosis: Comparison Between Surgery and TACE as Initial Treatment for Operable Huge HCCs (≥10 cm) After More Than 5 Years of Follow Up

The objective of this study was to research the long-term survival difference between surgery and transarterial chemoembolization (TACE) for operatable hepatocellular carcinoma (HCC) ≥10 cm. Little data are available comparing surgical resection with nonsurgical treatment in the management of very large HCCs (≥10 cm). We proposed to directly compare patients' 5-year survival rates after surgical resection or TACE of these tumors. Between January 2004 and June 2009, 16 patients with HCCs ≥ 10 cm underwent hepatic resection, and 9 received TACE. The patients were followed for 5 years or longer. The median follow-up period was 55.6 months. The median survival time was significantly longer in the resection group than in the TACE group (30.2 versus 9.33 months; P = 0.05). The 1-, 3-, and 5-year survival rates for patients in the resection group also were significantly better than for patients in the TACE group (operative group: 57.8%, 36.1%, and 28.9%, TACE group: 33.3%, 11.1%, and 0%, respectively). Surgical resection as initial treatment for resectable HCCs ≥10 cm has a better long-term survival outcome than does TACE.

Optimizing stage of single large hepatocellular carcinoma: A study with subgroup analysis by tumor diameter

This study aims to refine the designation for single hepatocellular carcinoma (HCC) >5 cm by comparing the postresection prognosis of these patients with those who have a single-tumor ≤5 cm and those with stage B.Patients with a single-tumor were classified into subgroups based on diameter. Of the 1132 patients analyzed, 426 had a single-tumor >2 and ≤5 cm; 229, a single-tumor >5 and ≤8 cm; 52, a single-tumor >8 and < 10 cm; 150, a single-tumor ≥10 cm; and 275, stage B.Hospital mortality and complications increased with tumor size among the single-tumor subgroups and median survival decreased with increasing of tumor size. Overall survival (OS) among patients with a single-tumor >5 cm was significantly lower than among patients with a single-tumor >2 and ≤5 cm (P ≤ .001), but significantly higher than among patients with clearly stage B (P ≤ .001). Patients with a single-tumor >5 and ≤8 cm showed lower OS than patients with a single-tumor >2 and ≤5 cm (P < .001). Patients with a single-tumor >8 and <10 cm or a single-tumor ≥10 cm showed lower OS than patients with a single-tumor >5 and ≤8 cm (P = .033 and .006), and similar OS to patients with stage B (P = .323).Patients with a single-tumor >5 and ≤8 cm may be assigned to a new stage between early and intermediate. Patients with a single-tumor >8 cm may be assigned to intermediate stage.

Long-term survival of patients undergoing liver resection for very large hepatocellular carcinomas

BACKGROUND

This study aimed to assess long-term survival after liver resection for huge hepatocellular carcinoma (HCC).

METHODS

Patients with stage I-III HCC who underwent hepatectomy from 2002 to 2010 were identified retrospectively from prospective national databases and followed until December 2012. Patients were assigned into four groups according to tumour size: less than 3·0 cm (small), 3·0-4·9 cm (medium), 5·0-10·0 cm (large) and over 10·0 cm (huge). The primary endpoint was overall survival. The Kaplan-Meier method and Cox proportional hazards model were used for survival analysis.

RESULTS

A total of 11 079 patients with HCC (mean(s.d.) age 59·7 (12·0) years) were eligible for this study. Median follow-up was 72·5 months. Patients with huge HCC had the worst prognosis; overall survival rates for patients with small, medium, large and huge HCC were 72·0, 62·1, 50·8 and 35·0 per cent respectively at 5 years, and 52·6, 41·8, 35·8 and less than 20·0 per cent at 10 years (P < 0·001). Multivariable analysis showed that tumour size affected long-term survival (hazard ratio (HR) 1·31, 1·55 and 2·38 for medium, large and huge HCC respectively versus small HCC). Prognostic factors for huge HCC were surgical margin larger than 0·2 cm (HR 0·70; P = 0·025), poor differentiation (HR 1·34; P = 0·004), multiple tumours (HR 1·64; P < 0·001), vascular invasion (HR 1·52; P = 0·008), cirrhosis (HR 1·37; P = 0·013) and the use of nucleoside analogues (HR 0·69; P = 0·004).

CONCLUSION

Huge HCCs have a worse prognosis than smaller HCCs after liver resection. A wide resection margin and antiviral therapy with nucleoside analogues may be associated with favourable long-term survival.

Selective Inflow Occlusion Technique Versus Intermittent Pringle Maneuver in Hepatectomy for Large Hepatocellular Carcinoma: A Retrospective Study

Selective inflow occlusion (SIO) maneuver preserved inflow of nontumorous liver and was supposed to protect liver function. This study aims to evaluate whether SIO maneuver is superior to Pringle maneuver in patients undergoing partial hepatectomy with large hepatocellular carcinomas (HCCs). Between January 2008 and May 2012, 656 patients underwent large HCC resections and were divided into 2 groups: intermittent Pringle maneuver (IP) group (n = 336) and SIO group (n = 320). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed. In comparison to the IP maneuver, the SIO maneuver significantly decreased intraoperative blood loss (473 vs 691  mL, P = 0.001) and transfusion rates (11.3% vs 28.6%, P = 0.006). The rate of major complication between the 2 groups was comparable (22.6% vs 18.8%, P = 0.541). Patients with moderate/severe cirrhosis, total bilirubin > 17  μmol/L, or HBV DNA> = 104  copy/mL in SIO group resulted in lower major complication rates. The SIO maneuver is a safe and effective technique for large HCC resections. In patients with moderate/severe cirrhosis, total bilirubin > 17  μmol/L, or HBV DNA> = 104  copy/mL, the SIO technique is preferentially recommended.

Subclassification of patients with solitary hepatocellular carcinoma based on post-hepatectomy survival: a large retrospective study

Official guidelines group together all cases of solitary hepatocellular carcinoma (HCC) without macroscopic vascular invasion, regardless of tumor size. Here, we examined whether this is justified based on overall survival (OS) after hepatic resection (HR). Patients with newly diagnosed solitary HCC treated by initial HR from January 2004 to October 2013 were classified into six groups based on tumor size (in 2-cm increments). Combining adjacent categories with similar OS led to three groups: ≤5 cm (n = 426), >5 and ≤8 cm (n = 229), and >8 cm (n = 202). Among all patients, median survival time was 62 months, and OS was 95 % at 1 year, 73 % at 3 years, and 54 % at 5 years. Patients in the ≤5 cm group showed significantly higher OS (P < 0.001) and lower tumor recurrence (P = 0.004) than those in the >5 and ≤8 cm group, who in turn showed significantly higher OS (P = 0.003) and lower tumor recurrence (P = 0.021) than those in the >8 cm group. Our results suggest that patients with solitary HCC should be subclassified based on tumor size for more accurate prognosis. We propose defining solitary HCC tumors >5 and ≤8 cm as "large" and tumors >8 cm as "huge".

Prognostic Nomograms for Pre- and Postoperative Predictions of Long-Term Survival for Patients Who Underwent Liver Resection for Huge Hepatocellular Carcinoma

BACKGROUND

Liver resection is an effective treatment in select patients with huge hepatocellular carcinoma (HCC, diameter ≥10 cm). This study aimed to develop nomograms for pre- and postoperative predictions of overall survival (OS) for these patients.

STUDY DESIGN

There were 464 consecutive patients who underwent liver resection for huge HCC at the Eastern Hepatobiliary Surgery Hospital (EHBH) between January 2008 and December 2009. They were collected and divided into a training cohort (n = 310) and an internal validation cohort (n = 154). Another 90 patients who were operated on at the Fujian Medical University (FMU) between January 2008 and April 2010 served as an external validation cohort. The surgical morbidity, mortality, time to recurrence, and OS were observed. Two prognostic nomograms were developed based separately on the data obtained before and after surgery. Discrimination and predictive accuracy of the models were measured using concordance index (C-index), calibration curves, and validation study.

RESULTS

The postoperative 4-year tumor recurrence and OS rates were, respectively, 79.0% and 41.2% in the patients from the EHBH and 78.8% and 37.6% in those from the FMU. Independent predictors of OS on multivariable analysis using pre- and postoperative data were respectively incorporated into the 2 nomograms. In the training cohort, calibration curves for the probability of 4-year postoperative survival fitted well. The C-indexes of the pre- and postoperative nomograms in predicting OS were 0.75 (95% CI 0.72 to 0.78) and 0.78 (95% CI 0.75 to 0.81), respectively. The internal and external validation studies optimally supported these results.

CONCLUSIONS

The 2 nomograms achieved accurate pre- or postoperative predictions of long-term survival for patients with huge HCC after liver resection.

Above 5 cm, size does not matter anymore in patients with hepatocellular carcinoma

BACKGROUND

Solitary hepatocellular carcinoma (HCC) is a good candidate for surgical resection. However, the significance of the size of the tumor in solitary HCC remains unclear.

OBJECTIVE

The aim of this study was to evaluate the impact of tumor size on overall and recurrence-free survival of patients with solitary HCC.

MATERIALS

We retrospectively reviewed 616 patients with histologically confirmed solitary HCC who underwent curative surgical resection between 1994 and 2010. The characteristics and prognosis of patients with HCC were analyzed stratified by tumor size.

RESULTS

A total of 403 patients (65 %) had tumors <5 cm, 172 (28 %) had tumors between 5 and 10 cm, and 41 (7 %) had tumors >10 cm. The incidence of microvascular invasion, satellite nodules, and advanced tumor grade significantly increased with tumor size. The 5-year overall and recurrence-free survival rates of HCC <5 cm were 69.6 % and 32 %, respectively, which were significantly better than those of HCC between 5 and 10 cm (58 % and 26 %, respectively) and HCC >10 cm (53 % and 24 %, respectively). On multivariate analysis, cirrhosis (p = 0.0307), Child-Pugh B (p = 0.0159), indocyanine green retention rate at 15 min >10 % (p = 0.0071), microvascular invasion (p < 0.0001), and satellite nodules (p = 0.0009) were independent predictors of poor survival, whereas tumor size >5 cm was not.

CONCLUSION

Although recurrence rates are high, surgical resection for solitary HCC offers good overall survival. Tumor size was not a prognostic factor. Solitary large HCC >10 cm would be a good candidate for hepatectomy as well as solitary HCC between 5 and 10 cm.

Hepatectomy for hepatocellular carcinoma larger than 10 cm: preoperative risk stratification to prevent futile surgery

OBJECTIVES

Appropriate patient selection is important to achieving good outcomes and obviating futile surgery in patients with huge (≥10 cm) hepatocellular carcinoma (HCC). The aim of this study was to identify independent predictors of futile outcomes, defined as death within 3 months of surgery or within 1 year from early recurrence following hepatectomy for huge HCC.

METHODS

The outcomes of 149 patients with huge HCCs who underwent resection during 1995-2012 were analysed. Multivariate logistic regression analysis was performed to identify preoperative independent predictors of futility.

RESULTS

Independent predictors of 3-month mortality (18.1%) were: total bilirubin level >34 μmol/l [P = 0.0443; odds ratio (OR) 16.470]; platelet count of <150 000 cells/ml (P = 0.0098; OR 5.039), and the presence of portal vein tumour thrombosis (P = 0.0041; OR 5.138). The last of these was the sole independent predictor of 1-year recurrence-related mortality (17.2%). Rates of recurrence-related mortality at 3 months and 1 year were, respectively, 6.3% and 7.1% in patients with Barcelona Clinic Liver Cancer (BCLC) stage A disease, 12.5% and 14% in patients with BCLC stage B disease, and 37.8% (P = 0.0002) and 75% (P = 0.0002) in patients with BCLC stage C disease.

CONCLUSIONS

According to the present data, among patients submitted to hepatectomy for huge HCC, those with a high bilirubin level, low platelet count and portal vein thrombosis are at higher risk for futile surgery. The presence of portal vein tumour thrombosis should be regarded as a relative contraindication to surgery.

The safety and adequacy of resection on hepatocellular carcinoma larger than 10 cm: A retrospective study over 10 years

BACKGROUND/PURPOSE

Current treatment options for HCC≥10 cm (huge HCC) are limited. Otherwise, the margin status is known as a prognostic factor. Our aim was to determine the safety, effectiveness, and risk factors for overall survival and disease-free survival for these patients.

METHODS

A total of 211 consecutive patients from 2000/08 to 2010/12 were enrolled. Characteristics of patients, tumors, and treatment were compared between the huge group (HCCs; ≥10 cm, n = 23; 11%) and those with smaller group (HCC; <10 cm n = 188; 89%). Disease-free survival (DFS), overall survival (OS), and risk factors were analyzed.

RESULTS

Median follow up was 37 months. Patients with huge HCC were more likely to be symptomatic, positive for preoperative portal vein thrombosis, longer surgical time, more blood loss and transfusions, and significantly shorter median OS and DFS. Both groups had similar postoperative mortality and morbidity rates. In the huge HCC, multivariate analysis identified two significant determinants of DFS (preoperative portal vein thrombosis on imaging and tumor-free margin less than 1 mm) and two significant determinants of OS (age over 80 and preoperative portal vein thrombosis). Even with positive margins, it still had no impact on OS. For DFS, 1 mm free margins appeared to be adequate.

CONCLUSION

Tumor-free margin is an independent risk factor for recurrence but has no impact on OS. Surgical margin >1 mm is adequate in patients with tumors ≥10 cm. Postoperative close follow up, especially of distant metastasis, and appropriate treatment of recurrence by a multidisciplinary approach may improve prognosis.

Hepatic resection as a safe and effective treatment for hepatocellular carcinoma involving a single large tumor, multiple tumors, or macrovascular invasion

This systematic review examined whether the available evidence justifies using hepatic resection (HR) during later stages of hepatocellular carcinoma (HCC), which contravenes treatment guidelines but is current practice at many medical centers.Official guidelines and retrospective studies recommend different roles for HR for patients with large/multinodular HCC or with HCC involving macrovascular invasion (MVI).Several databases were systematically searched for studies examining the safety and efficacy of HR for treating HCC involving a single large tumor (>5 cm) or multiple tumors, or for treating HCC involving MVI.We identified 50 studies involving 14, 808 patients that investigated the use of HR to treat large/multinodular HCC, and 24 studies with 4389 patients that investigated HR to treat HCC with MVI. Median in-hospital mortality for patients with either type of HCC was significantly lower in Asian studies (2.7%) than in non-Asian studies (7.3%, P < 0.001). Median overall survival (OS) was significantly higher for all Asian patients with large/multinodular HCC than for all non-Asian patients at both 1 year (81% vs 65%, P < 0.001) and 5 years (42% vs 32%, P < 0.001). Similar results were obtained for median disease-free survival at 1 year (61% vs 50%, P < 0.001) and 5 years (26% vs 24%, P < 0.001). However, median OS was similar for Asian and non-Asian patients with HCC involving MVI at 1 year (50% vs 52%, P = 0.45) and 5 years (18% vs 14%, P = 0.94). There was an upward trend in 5-year OS in patients with either type of HCC.HR is reasonably safe and effective at treating large/multinodular HCC and HCC with MVI. The available evidence argues for expanding the indications for HR in official treatment guidelines.

Outcomes of Hepatic Resection for Large Hepatocellular Carcinoma: Special Reference to Postoperative Recurrence

Safety and efficacy of hepatic resection for large hepatocellular carcinomas (HCCs 10 cm or greater in diameter) remain controversial. Surgical results of patients with HCCs 10 cm or greater (n = 24) who underwent hepatic resection over an 11-year period were compared with those of patients with HCCs less than 10 cm (n = 291). There was no significant difference in mortality between the two groups ( P > 0.99). Overall 5-year survival rate was 44.6 per cent among patients with HCCs 10 cm or greater and 70.5 per cent among those with HCCs less than 10 cm ( P = 0.010); however, there was no significant difference in disease-free survival rate between the two groups ( P = 0.16). Incidence of synchronous intra- and extrahepatic recurrence was higher in patients with HCCs 10 cm or greater than in those with HCCs less than 10 cm ( P = 0.0012). Macrovascular invasion alone was an independent risk factor for poor prognosis (hazard ratio [HR],: 11.1) and recurrence (HR, 6.02) after hepatic resection for HCCs 10 cm or greater, which was correlated with synchronous intra- and extrahepatic recurrence. Hepatic resection for large HCCs is safe and efficacious. However, incidence of synchronous intra- and extrahepatic recurrence is high, especially in patients with macrovascular invasion.

Hepatectomy for huge hepatocellular carcinoma: single institute's experience

BACKGROUND

The surgical resection of huge hepatocellular carcinoma (HCC) is still controversial. This study was designed to introduce our experience of liver resection for huge HCC and evaluate the safety and outcomes of hepatectomy for huge HCC.

METHODS

A total of 258 hepatic resections for the patients with huge HCC were analysed retrospectively from December 2002 to December 2011. The operative outcomes were compared with 293 patients with HCC >5.0 cm but <10.0 cm in diameter. Prognostic factors for long-term survival were evaluated by univariate and multivariate analyses.

RESULTS

The 1-, 3-, 5-year overall survival rates after liver resection were 84, 62, and 33 %. Overall survival and disease-free survival in huge HCC group and HCC >5.0 cm but <10.0 cm group were similar (P = 0.751, P = 0.493). Solitary huge HCC group has significantly a more longer overall and disease-free survival time than nodular huge HCC (P = 0.026, P = 0.022). Univariate and multivariate analysis revealed that the types of tumour, vascular invasion, and UICC stage were independent prognostic factors for overall survival (P = 0.047, P = 0.037, P = 0.033).

CONCLUSIONS

Hepatic resection can be performed safely for huge HCC with a low mortality and favorable survival outcomes. Solitary huge HCC has the better surgical outcomes than nodular huge HCC.

Clinical characteristics and survival of European patients with resectable large hepatocellular carcinomas

PURPOSE

Large hepatocellular carcinoma (HCC) presents on cirrhosis or in the absence of cirrhosis. Prognostic factors include both tumor and liver factors. Evaluate clinical and tumor characteristics of a group of large resected HCC in European patients.

METHODS

Data for patients with HCC >7 cm who underwent liver resection between 1992 and 2011 were analyzed. Patients were dichotomized into those with tumor diameters of 7-10 cm or >10 cm and their characteristics and outcomes were compared.

RESULTS

A total of 65 hepatectomies for HCC ≥7 cm were performed. Severe fibrosis or cirrhosis was present in 41.5 % of patients. Thirty-seven (56.9 %) patients had HCC ≥10 cm. Mortality and morbidity rates were 1.5 % and 37.5 %, respectively. Preoperative blood platelet levels and serum alkaline phosphatase (ALKP) levels showed significant differences between the groups. The 3-year survival was 43.5 % and 17.4 % for patients with tumors 7-10 and ≥10 cm, respectively.

CONCLUSIONS

Patients with large size HCC and preserved liver function can be resected with low operative risk. ALKP levels and platelet counts were higher in the larger tumors. Given these patterns of clinical and biochemical characteristics, this group of tumors may be a selected subset of large HCCs and might potentially benefit from surgical resection.

Role of the 1-month protocol transarterial chemoinfusion in detecting intrahepatic metastasis after resection of large hepatocellular carcinoma greater than 10 cm

Backgrounds/Aims

Tumor recurrence is very common after hepatic resection of hepatocellular carcinoma (HCC) ≥10 cm. The purpose of this study was to validate the prognostic significance of the preoperative alkaline phosphatase (ALP) level and early intrahepatic metastasis in HCC patients who underwent resection of large HCC.

Methods

Clinical data of 100 large HCC patients who underwent liver resection were retrospectively reviewed. All of them underwent protocol transarterial chemoinfusion (TACI) at 1 month.

Results

Median tumor diameter was 13.8 cm, and 94% were single lesions. Systematic and non-systematic resections were performed in 91% and 9%, respectively, with R0 resection achieved in 84%. Overall 1-, 3- and 5-year survival rates were 76%, 38.5%, and 30.4%, respectively. Univariate analyses on patient survival revealed that intrahepatic metastasis on 1-month protocol TACI was the only significant risk factor (p=0.002). Mean ALP values according to the intrahepatic metastasis on 1-month protocol TACI were 124.6±76.9 IU/L and 145.1±92.6 IU/L, which did not show a statistical difference (p=0.23).

Conclusions

In patients with large HCC, 1-month protocol TACI combined with hepatic resection may contribute to the early detection and timely treatment of potentially preexisting metastatic lesions.

Functional liver reserve parameters predictive for posthepatectomy complications

BACKGROUND

Posthepatectomy complications have markedly decreased with advances in techniques and management; however, surgical risk to patients with injured livers is still not negligible. We evaluated several preoperative parameters of functional liver reserve tests in patients with various liver diseases as predictors of posthepatectomy complications. A comprehensive evaluation of preoperative liver functions is necessary for the prediction of the risk of posthepatectomy complications.

METHODS

Over a 10-y period, we examined 442 patients who underwent hepatectomy for liver and biliary diseases. The patients' background liver diseases included chronic viral liver diseases in 211 patients, obstructive jaundice in 29 patients, and normal liver in 202 patients. Hepatectomy-related postoperative complications (i.e., long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 115 (26%) patients. A multivariate logistic analysis was performed to detect the predictive parameters, and a multivariate linear regression analysis was performed to derive a predictive formula for complications.

RESULTS

A univariate analysis identified 15 significant parameters associated with hepatectomy-related complications, and eight parameters (i.e., presence of chronic hepatic injury, clearance index by technetium-99 m galactosyl human serum albumin liver scintigraphy of ≥ 0.60, total bilirubin level of >1 mg/dL, serum hyaluronic acid level of ≥ 75 ng/mL, major hepatectomy, blood loss of ≥ 950 mL, operating time of ≥ 500 min, and combined resection of another organ or major vessel) were independent predictive factors identified in the multivariate analysis. Clearance index by technetium-99 m galactosyl human serum albumin liver, bilirubin level, hyaluronic acid level, and major hepatectomy were the parameters included in the predictive formula.

CONCLUSIONS

In the present study, we present a comprehensive formula based on the predictive parameters for hepatic complications for prospective assessment to avoid posthepatectomy morbidity.

The effect of alkaline phosphatase and intrahepatic metastases in large hepatocellular carcinoma

BACKGROUND

Hepatectomy is the standard treatment for HCC. However, large HCC poses a difficult challenge because of the technical complexity of surgical resection and the fear of postoperative hepatic decompensation. We analyzed the outcome and prognostic factors in patients with large hepatocellular carcinoma (HCC ≥10 cm) after surgery.

METHODS

We retrospectively investigated the medical records of 91 patients who had undergone hepatectomy between January 2006 and June 2010. A survival analysis was performed utilizing the Kaplan-Meier method and prognostic factors were evaluated using Cox regression analysis.

RESULTS

Of the 91 patients evaluated, most tumors were associated with hepatitis B virus (HBV). The median tumor size was 12.3 cm (range, 10 to 21 cm), with microvascular invasion present in most patients. The postoperative mortality rate was 2.2%. The median disease-free survival and overall survival were six months and 41 months. The one-year, two-year, and three-year disease-free survival rates were 33.5%, 29.3%, and 18.8%, respectively. The one-year, two-year, and three-year overall survival rates were 73.9%, 63.7%, and 54.8%, respectively. Of the 89 surviving patients, 69 patients (77.5%) developed HCC recurrence during the mean follow-up period of 23.4 ± 15.9 months. On multivariate analysis, the statistically significant factors that predicted HCC recurrence were ALP ≥ 80 IU/mL (P = 0.009) and intrahepatic metastases (P = 0.013).

CONCLUSIONS

Our study suggests that preoperative ALP levels (≥ 80 IU/L) and intrahepatic metastases could be utilized to monitor and predict recurrence in HCC patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of hepatectomy for huge solitary hepatocellular carcinoma

BACKGROUND

To evaluate the surgical outcome of patients with huge solitary hepatocellular carcinoma (HCC, ≥10 cm in diameter) without major vascular invasion.

METHODS

We retrospectively studied 177 patients with huge HCC (≥10 cm in diameter) who underwent hepatectomy from 1990 to 2008. Surgical outcomes and clinicopathological characteristics were compared among 54 patients with solitary HCC without a major portal vein tumor thrombus (MPVT), 53 patients with multiple HCCs without MPVT, and 70 patients who have HCC with MPVT.

RESULTS

The mean tumor size and indocyanine green retention rate at 15 min showed no significant difference among patients groups. The overall 5-year survival rate was significantly higher in patients with solitary HCC (79%) than in patients with multiple HCCs (31%, P < 0.0001) and MPVT (17%, P < 0.0001). In patients who underwent curative surgery, the 5-year disease-free survival rate was significantly higher in patients with solitary HCC (48%) than in patients with multiple HCCs (12%, P = 0.0008) and MPVT (12%, P = 0.0003). Multivariate analysis showed solitary HCC to be a significant independent prognostic factor for overall survival and disease-free survival.

CONCLUSIONS

Patients with solitary HCC without MPVT show a favorable surgical outcome even for tumor size ≥10 cm in diameter.

Systematic review of actual 10-year survival following resection for hepatocellular carcinoma

BACKGROUND

Hepatic resection is a potentially curative therapy for hepatocellular carcinoma (HCC), but recurrence of disease is very common. Few studies have reported 10-year actual survival rates following hepatic resection; instead, most have used actuarial measures based on the Kaplan-Meier method. This systematic review aims to document 10-year actual survival rates and to identify factors significant in determining prognosis.

METHODS

A comprehensive search was undertaken of MEDLINE and EMBASE. Only studies reporting the absolute number of patients alive at 10 years after first resection for HCC were included; these figures were used to calculate the actual 10-year survival rate. A qualitative review and analysis of the prognostic factors identified in the included studies were performed.

RESULTS

Fourteen studies, all of which were retrospective case series, including data on 4197 patients with HCC were analysed. Ten years following resection, 303 of these patients were alive. The 10-year actual survival rate was 7.2%, whereas the actuarial survival quoted from the same studies was 26.8%. Positive prognostic factors included better hepatic function, a wider surgical margin and the absence of satellite lesions.

CONCLUSIONS

The actual long-term survival rate after resection of HCC is significantly inferior to reported actuarial survival rates. The Kaplan-Meier method of actuarial survival analysis tends to overestimate survival outcomes as a result of censorship of data and subgroup analysis.

Efficacy and safety of right hemihepatectomy through the right retrohepatic tunnel

We wished to study the efficacy and safety of the retrograde ligation of short hepatic veins (SHVs) and the right hepatic vein (HV) through the retrohepatic tunnel in patients who underwent hemihepatectomy due to large hepatic carcinoma in the right lobe of the liver. Right hemihepatectomy was performed in 23 patients with tumors larger than 8 cm in diameter. The liver was separated at the secondary porta, and the interspace between right HVs and middle HVs was expanded. The right hepatic portal vein and hepatic artery were freed and ligated, followed by the retrograde dissection of SHVs and the right HV along the right retrohepatic space anterior to the inferior vena cava. A blocking belt was set at the left side of the midline, after which the right liver was cut off. The procedure was successfully completed in all patients. The average amount of intraoperative blood loss was 640 ml. The change in hepatic function was observed on the third postoperative day. Twenty-two patients exhibited satisfactory results; one patient died from postoperative hepatic failure. In conclusion, this procedure can be safely performed in most hemihepatectomy patients with liver tumors.

Outcome of Hepatectomy for Huge Hepatocellular Carcinoma

PURPOSE

In spite of the recent improved results of hepatectomy for huge hepatocellular carcinomas (HCC), the prognosis of patients with huge HCCs is still poor compared to that of patients with small HCCs. This study was performed to compare the results of hepatectomy between patients with huge HCCs and those with small HCCs, to identify the prognostic factors in patients with huge HCCs, and to determine the preoperative selection criteria.

METHODS

We retrospectively analyzed 51 patients who underwent hepatectomy, between July 1994 and February 2009 at Dankook University Hospital. Patients with HCC≥10 cm were classified in large (L) group and others were classified in small (S) group. The clinicopathological features, operative procedures, and postoperative outcome were compared between both groups and various prognostic factors were investigated in group L.

RESULTS

Eleven patients were classified in group L. Tumor size, vascular invasion, and tumor stage were higher in group L. Postoperative morbidity was higher in group L, but mortality was not different between the groups. Disease-free survivals were significantly lower in group L than in group S (36.4%, and 24.2% vs. 72.0%, and 44.0% for 1- and 3-year), but overall survival rates were similar in both groups (45.5%, and 15.2% in group L vs. 60.3%, and 41.3% in group S for 3- and 5-year). Presence of satellite nodules was the only prognostic factor in multivariate analysis after surgery for huge HCC.

CONCLUSION

Regardless of tumor size, huge HCCs deserve consideration for surgery in patients with preserved liver function. Furthermore, the effect of surgery could be maximized with appropriate selection criteria, such as huge HCC without satellite nodules.

Outcomes of hepatic resection for huge hepatocellular carcinoma (≥ 10 cm in diameter)

BACKGROUND

The object of the current study was to review the outcomes of hepatic resection for hepatocellular carcinoma (HCC) ≥ 10 cm.

METHODS

Between 1995 and 2007, fifty-three patients with HCC ≥ 10 cm underwent hepatic resection, and clinical data were compared to those of patients with non-surgical treatment (n = 12). Surgical results for HCC ≥ 10 cm were compared to those of patients with HCC < 10 cm (n = 412). The independent poor prognostic factors of the patients with HCC ≥ 10 cm were identified.

RESULTS

Overall survival was significantly better in patients with hepatic resection for HCC ≥ 10 cm than in those with non-surgical treatment (P < 0.01). Survival rates of patients with hepatic resection for HCC ≥ 10 cm were 35% at 5 years. Morbidity and mortality rate were statistically equal. The independent poor prognostic factors of patients with hepatic resection for HCC ≥ 10 cm were revealed: T4 status, macroscopic tumor thrombus in portal vein (VP+), and the use of intra-operative transfusion.

CONCLUSION

Hepatic resections for HCC ≥ 10 cm are safe and efficacious. Minimizing intra-operative blood loss and the establishment of an effective systemic treatment for patients with HCC ≥ 10 cm in T4 appear to be critical.

Surgical treatment for hepatocellular carcinoma

Surgery is the most important therapeutic approach for patients with hepatocellular carcinoma. We have reviewed patients' survival after resection for hepatocellular carcinoma in 17 series since 2000, each including more than 100 patients. Median survival rates were 80% (range 63-97%) at 1 year, 70% (34-78%) at 3 years and 50% (17-69%) at 5 years. Such wide ranges of survival rates are attributed mainly to differences in the hepatocellular carcinoma stage among studies, but the survival rate is obviously much better for early hepatocellular carcinomas. Today, liver resection is an established treatment for hepatocellular carcinoma owing to minimal surgical mortality and improved survival. Liver transplantation is one of the best treatments for hepatocellular carcinoma in patients who meet the selection criteria. Further studies are needed to establish suitable criteria for transplantation in patients with hepatocellular carcinoma. For patients who are not candidates for liver resection or transplantation, percutaneous ablation is the best treatment option. However, no randomized controlled clinical trial has compared the results of ablation with those of surgical therapy for hepatocellular carcinoma, and none of the ablation techniques have been shown to offer a definitive survival advantage. A treatment algorithm based on published evidence is now available, which helps us to select the most suitable therapeutic option for individual patients, depending on tumor characteristics and liver functional reserve. This review paper summarizes the current status of the surgical management of hepatocellular carcinoma.

Safety and efficacy of partial hepatectomy for huge (≥10 cm) hepatocellular carcinoma: a systematic review

Huge (≥10 cm) hepatocellular carcinoma (HCC) is not uncommon at clinical presentation, and the surgical outcomes of such tumors are poor. This systematic review aimed to assess the safety and efficacy of partial hepatectomy for huge HCC. We performed a search on Medline and PubMed databases for all relevant studies published prior to December 2009. After exclusions, 21 studies remained for appraisal and data extraction. All studies were classified as level-4 evidence. The median overall perioperative morbidity and mortality rates were 29.2% (range: 13.6-72%) and 3.5% (range: 0-18.2%), respectively. The overall median survival since the partial hepatectomy was 20.7 months (range: 10.1-32 months), with median 1-, 3- and 5-year survival of 60.7% (range: 41-72.2%), 34% (range: 0-60.3%) and 28.6% (range: 0-54%), respectively. The median disease-free survival since the partial hepatectomy was 11.3 months (range: 5.5-32 months), with median 1-, 3- and 5-year disease-free survival rates of 48.7% (range: 32-65.4%), 27.5% (range: 14.1-49%) and 20.7% (range: 9.5-43%), respectively. Partial hepatectomy can be performed safely and is associated with long-term survival in a subset of patients with huge HCC, but the evidence of benefit is currently weak.

Perioperative liver function in hepatectomy: evaluation and influencing factors

Hepatectomy is currently still the major treatment for hepatocellular carcinoma. Although hepatectomy has become safer because of progress made in surgical techniques, it is still frequently associated with the development of postoperative liver insufficiency. Therefore, investigation of factors influencing perioperative liver function in hepatectomy and intraoperative evaluation of residual liver function can help surgeons predict post-hepatectomy outcome and select appropriate postoperative rehabilitation treatment.

Resection of a giant hepatocellular carcinoma weighing over ten kilograms

The authors report a giant hepatocellular carcinoma (HCC) with a diameter over 30 cm and weight over 10 kg that was resected completely. A 62-year-old man was admitted because of continuous abdominal uplift. A computed tomography scan demonstrated that the entire abdomen was filled with a giant tumor containing both cystic and solid components with a size of 29 cm × 22 cm. The huge tumor was successfully resected without any complication, such as massive hemorrhage or visceral injuries. The size and weight of the tumor were 35 cm × 30 cm × 15 cm and 10 050 g, respectively. Pathological examination showed that the tumor was a well-differentiated HCC, and α-fetoprotein was positive. Postoperative syndrome, characterized by hypovolemic shock, diarrhea and urine retention, was observed and induced by abdominal decompression. This syndrome was resolved with expectant treatment. The patient was still alive without recurrence after a 27-mo follow-up.

Prognostic determinants for survival after resection/ablation of a large hepatocellular carcinoma

BACKGROUND

Liver resection of large hepatocellular carcinomas (HCC), measuring at least 10 cm remains a controversial debate. Multiple studies on HCCs treated with surgical resection and/or ablation had shown variable results with 5-year survival rates ranging from 0% to 54.0%. The aim of this study was to evaluate the survival of patients with HCCs measuring at least 10 cm and to identify the potential prognostic variables affecting the outcome.

METHODS

Retrospective analysis was performed on the prospectively updated HCC database. A total of 44 patients with tumours measuring 10 cm or more were 'curatively' treated with surgical resection with or without ablation. Patient demographics, clinical, surgical, pathology and survival data were collected and analysed.

RESULTS

Thirty-one patients received surgical resection alone. Thirteen other patients were treated with a combination of surgical resection and ablation. The median follow-up duration was 14.5 months. The overall median survival at 1, 3 and 5 years were 66.4%, 38.1% and 27.8%, respectively. The median time to tumour recurrence was 10.7 months and the 1, 3 and 5-year disease-free survival were 49.6%, 23.9% and 19.1%, respectively. Univariate analysis demonstrated cirrhosis, microvascular invasion, poor tumour differentiation and ethnicity to adversely affect survival. For overall survival, only cirrhosis, poor tumour differentiation and ethnicity were significant on multivariate analysis. Portal vein tumour thrombus, microvascular invasion and ethnicity were identified on univariate analysis to significantly affect disease-free survival.

CONCLUSION

Surgical treatment offers good survival to patients with large HCCs (> or = 10 cm). Both cirrhosis and poor tumour differentiation are independent variables prognostic of adverse survival.

Adaptation of hepatectomy for huge hepatocellular carcinoma

BACKGROUND/PURPOSE

We retrospectively identified prognostic factors in patients with huge hepatocellular carcinoma (HCC) more than 10 cm in diameter and established a clinical strategy for such patients at our institution.

METHODS

Three-hundred and twenty patients with HCC underwent hepatectomy. Twenty-nine of them were diagnosed with HCC 10 cm or more in diameter (group L). Two hundred and ninety-one patients were diagnosed with HCC less than 10 cm (group S). The overall and disease-free survival rates in the two groups were compared, and the prognostic factors in group L were analyzed.

RESULTS

The overall 3-and 5-year survival rates in group L were 33.6% and 33.6%, and these rates in group S were 61.4% and 45.0%, respectively. The difference between the two groups was significant (P=0.0048). The disease-free survival rates in group L (3-year, 21.5%; 5-year, 21.5%) were also significantly worse than those in group S (3-year, 37.1%; 5-year, 25.4%; P=0.0022). Background liver (cirrhosis vs no cirrhosis) (P=0.0380) and TNM stage according to the Liver Cancer Study Group of Japan (stage II or III vs stage IV; P=0.0308) were significantly associated with prognosis by multivariate analyses.

CONCLUSIONS

Hepatic resection is a safe and effective treatment for huge HCC of more than 10 cm in diameter. However, we suggest that cirrhotic patients with huge HCC with the presence of both macrovascular invasion and multiple tumors may not be appropriate candidates for hepatic resection.

Role of hepatitis B virus genotypes and quantitative HBV DNA in metastasis and recurrence of hepatocellular carcinoma

Identification of risk factors for recurrence and metastasis of HCC is important for the prognosis of HCC surveillance in chronic HBV infection. In this article, 125 HCC patients recruited were followed up prospectively for tumor metastasis and recurrence for a median of 104 (10-130) weeks. HBV DNA level was detected by LightCycler-based real-time fluorescence quantitative polymerase chain reaction-restriction system. HBV genotypes were determined by using PCR restriction-fragment length polymorphism. BCP and PC mutations were performed by PCR and direct sequencing of amplified products. Among 125 HCC patients, 19 patients were excluded because of the lack of follow-up data and the remaining 106 patients were followed up of 2 years and entered into analysis. Sixty-nine patients had tumor metastasis or recurrence during the follow-up and the cumulative probability of HCC metastasis or recurrence was 65.1%. On multivariate analysis, genotype C and HBV DNA level were the risk factors for HCC recurrence or metastasis. The incidence of recurrence or metastasis increased with baseline HBV DNA level in a dose-response relationship ranging from 22% for HBV DNA level of less than 3 log10 copies/ml to 80% for HBV DNA level of 5 log10 copies/ml or greater (P = 0.012). Fifty-seven (74.0%) and 12 (41.4%) patients had metastasis or recurrence in patients with genotype C and B, respectively. The adjusted OR of recurrence or metastasis for genotype C compared with genotype B was 9.755 (P = 0.009). In conclusion, elevated HBV DNA level and genotype C are strong risk predictors of HCC metastasis or recurrence.

Positron emission tomography/computer tomography in guidance of extrahepatic hepatocellular carcinoma metastasis management

Hepatocellular carcinoma (HCC) is one of the most common primary cancers in the world. Surgery is the gold standard for treatment of patients with HCC. Recurrence and metastasis are the major obstacles to further improve the prognosis of HCC. Most recurrences are intrahepatic. However, 30% of the recurrences are extrahepatic. The role of resection in intrahepatic recurrences is widely accepted. The role of resection in extrahepatic HCC recurrence and metastasis is not well established. 18F fluorodeoxyglucose (18F-FDG) positron emission tomography/computer tomography (PET/CT) is useful in detecting distant metastasis from a variety of malignancies and shows superior accuracy to conventional imaging modalities in identification of intrahepatic and extrahepatic metastasis. We present one patient with one new isolated omental lymph node metastasis, who had a history of huge HCC resected six years ago. The metastatic focus was identified with 18 F-FDG PET/CT and resected. The follow-up revealed good prognosis with a long-term survival potential after resection of the omental lymphatic metastasis.

Long term outcome and prognostic factors for large hepatocellular carcinoma (10 cm or more) after surgical resection

BACKGROUND

Surgical resection is the standard treatment for hepatocellular carcinoma (HCC). However, the role of surgery in treatment of large tumors (10 cm or more) is controversial. We have analyzed, in a single centre, the long-term outcome associated with surgical resection in patients with such large tumors.

METHODS

We retrospectively investigated 166 patients who had undergone surgical resection between July 1995 and December 2006 because of large (10 cm or more) HCC. Survival analysis was done using the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate analyses.

RESULTS

Of the 166 patients evaluated, 80% were associated with viral hepatitis and 48.2% had cirrhosis. The majority of patients underwent a major hepatectomy (48.2% had four or more segments resected and 9% had additional organ resection). The postoperative mortality was 3%. The median survival in our study was 20 months, with an actuarial 5-year and 10-year overall survival of 28.6% and 25.6%, respectively. Of these patients, 60% had additional treatment in the form of transarterial chemoembolization, radiofrequency ablation or both. On multivariate analysis, vascular invasion (P < 0.001), cirrhosis (P = 0.028), and satellite lesions/multicentricity (P = 0.006) were significant prognostic factors influencing survival. The patients who had none of these three risk factors had 5-year and 10-year overall survivals of 57.7% each, compared with 22.5% and 19.3%, respectively, for those with at least one risk factor (P < 0.001).

CONCLUSIONS

Surgical resection for those with large HCC can be safely performed with a reasonable long-term survival. For tumors with poor prognostic factors, there is a pressing need for effective adjuvant therapy.

Outcome of patients with huge hepatocellular carcinoma after primary resection and treatment of recurrent lesions

BACKGROUND

Tumour recurrence is common after hepatic resection of hepatocellular carcinomas (HCCs) greater than 10 cm in diameter. This study evaluated the outcome of patients with huge HCC after primary resection and treatment of recurrent lesions.

METHODS

A retrospective review was undertaken of clinical data for 100 patients with huge HCC who underwent liver resection.

RESULTS

Mean(s.d.) tumour diameter was 13.3(3.0) cm; 80 per cent were single lesions. Systematic and non-systematic resections were performed in 80 and 20 per cent of patients respectively, with R0 resection achieved in 86 per cent. Overall 1-, 3- and 5-year disease-free survival rates were 43, 26 and 20 per cent respectively. Risk factors for HCC recurrence were resection margin less than 1 cm and macrovascular invasion. Extensive tumour necrosis of 90 per cent or more after preoperative transarterial chemoembolization was not a prognostic factor. Some 85 per cent of patients with recurrence received various treatments, and these patients had a longer post-recurrence survival than those who were not treated. Overall 1-, 3- and 5-year survival rates were 66, 44 and 31 per cent respectively.

CONCLUSION

In patients with huge HCC, hepatic resection combined with active treatment for recurrence resulted in longer-term survival. Frequent protocol-based follow-up appears to be beneficial for the early detection and timely treatment of recurrence.

Surgical treatment of hepatocellular carcinoma with cirrhotic esophageal varices and hypersplenism: a 184 case report

In treating hepatocellular carcinoma (HCC) patients with advanced cirrhosis, one of the most difficult problems is concomitant esophageal varices and hypersplenism. Whether these conditions should be treated surgically in association with HCC resection is still in debate. To elucidate whether esophageal devascularization or splenectomy is beneficial when simultaneously performed with liver resection in HCC patients with both varices and hypersplenism, HCC patients (n = 184) with esophageal varices and hypersplenism received one of the three treatments: simultaneous liver resection and esophageal devascularization (Group I, n = 41); simultaneous liver resection and splenectomy (Group II, n = 61); liver resection only (Group III, n = 82). The incidences of postoperative complications of the three groups were 31.7%, 29.5% and 24.4%, respectively, with no significant difference among them. The 5-year tumor-free survival rates for the group I, group II and group III were 34.1%, 36.1% and 37.8%, respectively. Variceal bleeding caused death by only 4.2% in group I, but by 14.3% in group II and 23.2% in group III. The survival rates in the group I and the group II were comparable to those in the group III, however, the recurrences of postoperative fatal variceal bleeding in group I and group II were significantly lower than those in group III. The results suggest that HCC patients with esophageal varices and hypersplenism should undergo hepatic resection plus esophageal devascularization or splenectomy if radical resection of HCC can be expected.

Long-term outcome of resection of large hepatocellular carcinoma

BACKGROUND

The role of hepatectomy in the treatment of large hepatocellular carcinoma (HCC) is still controversial. This retrospective study evaluated whether the long-term outcome of hepatectomy for large HCC improved over 14 years in one centre.

METHODS

Data from 2102 patients who underwent hepatectomy for large HCC were collected prospectively and divided into two time intervals for analysis: before end of December 1996 (group 1) and after December 1996 (group 2). Clinicopathological data for the two groups were compared, and factors associated with long-term prognosis were further analysed.

RESULTS

Cumulative 1-, 3- and 5-year overall survival rates were 71.2, 58.8 and 38.7 per cent respectively in group 2, and were significantly better than respective rates of 67.8, 50.7 and 27.9 per cent in group 1. Cumulative 1-, 3- and 5-year disease-free survival rates were 61.5, 38.6 and 23.8 per cent respectively in group 2, and 56.5, 34.7 and 18.9 per cent in group 1. There was a significant difference in median survival time after recurrence between groups 2 and 1 (17 and 10 months respectively; P = 0.043).

CONCLUSION

Hepatic resection in patients with large HCC has improved overall and disease-free survival during the past decade at this institute. Long-term survival can be improved significantly by aggressive treatment of recurrent tumours.

Effects of Location and Extension of Portal Vein Tumor Thrombus on Long-Term Outcomes of Surgical Treatment for Hepatocellular Carcinoma

BACKGROUND

The role of surgical resection and thrombectomy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is controversial. This study aimed to evaluate the effects of the location and extent of PVTT on the long-term outcomes of surgical treatment for HCC.

METHODS

A total of 438 patients with HCC and PVTT underwent liver resection with or without thrombectomy. These 438 patients were divided into 2 groups: in group A, PVTT was located in the hepatic resection area or protruded into the first branch of the main portal vein beyond the resection line for < 1 cm (286 patients), and in group B, PVTT extended into the main portal vein (152 patients). Concomitant thrombectomy was performed in 147 patients (51.4%) of group A and in all patients of group B.

RESULTS

PVTT recurrence within 6 months after surgery in group B was significantly higher than that in group A: 76.9% vs. 11.3%. Remnant liver recurrence within 1 year after surgery was 45.0% in group A and 78.8% in group B. The cumulative 1-, 2-, 3-, and 5-year overall survival rates were 58.7%, 39.9%, 22.7%, and 18.1% for group A and 39.5%, 20.4%, 5.7%, and 0% for group B, respectively. The overall survivals were significantly better in group A than group B (P < .02).

CONCLUSIONS

Liver resection with thrombectomy yielded better outcomes in the HCC patients with PVTT confined to the first or second branch of the main portal vein compared with PVTT extending into the main portal vein.

Modified technique of hepatic vascular exclusion: effect on blood loss during complex mesohepatectomy in hepatocellular carcinoma patients with cirrhosis

BACKGROUND

Hepatic veins remain patent during complete inflow occlusion (CIO) and bleeding from them may continue. Occlusion of the inferior vena cava (ICV) during CIO may reduce blood loss from hepatic veins. This study was designed to compare the overall outcomes after application of CIO with or without occlusion of the ICV below the liver in complex mesohepatectomy for hepatocellular carcinoma (HCC) patients with cirrhosis.

MATERIALS AND METHODS

One hundred and eighteen (118) patients were randomly assigned to CIO or a modified technique of hepatic vascular exclusion (MTHVE). Hemodynamic parameters were evaluated and the amount of blood loss, measurement of liver enzymes, and postoperative progress were recorded.

RESULTS

Blood loss during liver transection in CIO groups was significantly greater than that in MTHVE group (P=0.046). Thus, incidence of blood transfusion was significantly greater in patients of the CIO group (P=0.041). There were no significant differences in liver enzyme changes, bilirubin, or morbidity in the postoperative period between the two groups.

CONCLUSIONS

CIO with occlusion of the ICV below the liver is a safe, effective, and feasible technique during mesohepatectomy in HCC patients with cirrhosis. Excellent results were obtained with minimized bleeding, limited hepatic function damage, and low rate of postoperative complications.