Long-Term Outcome After Resection of Huge Hepatocellular Carcinoma ≥10 cm: Single-Institution Experience with 471 Patients

Surgical outcome and risk scoring to predict survival after hepatic resection for hepatocellular carcinoma with portal vein tumor thrombosis

Backgrounds/Aims

The hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is classified as the advanced stage (BCLC stage C) with extremely poor prognosis, and in current guidelines is recommended for systemic therapy. This study aimed to evaluate the surgical outcomes and long-term prognosis after hepatic resection (HR) for patients who have HCC combined with PVTT.

Methods

We retrospectively analyzed 332 patients who underwent HR for HCC with PVTT at ten tertiary referral hospitals in South Korea.

Results

The median overall and recurrence-free survival after HR were 32.4 and 8.6 months, while the 1-, 3-, and 5-year overall survival rates were 75%, 48%, and 39%, respectively. In multivariate analysis, tumor number, tumor size, AFP, PIVKA-II, neutrophil-to-lymphocyte ratio, and albumin-bilirubin (ALBI) grade were significant prognostic factors. The risk scoring was developed using these seven factors-tumor, inflammation and hepatic function (TIF), to predict patient prognosis. The prognosis of the patients was well stratified according to the scores (log-rank test, p < 0.001).

Conclusions

HR for patients who have HCC combined with PVTT provided favorable survival outcomes. The risk scoring was useful in predicting prognosis, and determining the appropriate treatment strategy for those patients who have HCC with PVTT.

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.

Preoperative transarterial chemoembolization (TACE) + liver resection versus upfront liver resection for large hepatocellular carcinoma (≥5 cm): a systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for majority of primary liver cancer. Use of preoperative neoadjuvant transarterial chemoembolization (PN-TACE) may result in tumor shrinkage and improve resectability. This study aims to summarize the outcomes of PN-TACE versus upfront liver resection (Up-LR) in large HCC (≥5 cm).

METHODS

PubMed, Embase, The Cochrane Library, and Scopus were systematically searched till September 2022 for studies comparing PN-TACE versus Up-LR. The primary study outcomes were overall survival (OS), disease-free survival (DFS), and recurrence. Our secondary outcomes were postoperative morbidity and mortality.

RESULTS

There were 12 studies with 15 data sets including 3960 patients (PN-TACE n = 2447, Up-LR n = 1513). Majority (89.5%, n = 1250/1397) of patients had Child's A liver cirrhosis. Incidence of Child's B cirrhosis was higher in PN-TACE compared to Up-LR (Odds ratio (OR) 1.69, 95% CI: 1.18, 2.41, p = 0.004). Pooled hazard ratio (HR) for OS showed no significant difference between PN-TACE and Up-LR (HR 0.87, 95% CI: 0.64, 1.18, p = 0.37), but DFS was superior in PN-TACE (HR 0.79, 95% CI: 0.63, 0.99, p = 0.04). Subgroup analysis based on study design failed to show any significant effect in randomized controlled trials (n = 2/15 data sets). However, operating time (mean difference (MD) 31.94 min, 95% CI: 2.42, 61.45, p = 0.03) and blood loss (MD 190.93 ml, 95% CI: 10.22, 317.65, p = 0.04) were higher in PN-TACE. Intrahepatic and extrahepatic recurrence, post-operative morbidity and in-hospital mortality were comparable between PN-TACE and Up-LR.

CONCLUSION

In retrospective studies, PN-TACE resulted in superior DFS compared to Up-LR. However, this may be confounded by selection bias.

Management of early-stage hepatocellular carcinoma: challenges and strategies for optimal outcomes

Although hepatocellular carcinoma (HCC) is associated with a poor prognosis, management of early-stage HCC is often successful with highly efficacious treatment modalities such as liver transplantation, surgical resection, and radiofrequency ablation. However, unfavorable clinical outcomes have been observed under certain circumstances, even after efficient treatment. Factors that predict unsuitable results after treatment include tumor markers, inflammatory markers, imaging findings reflecting tumor biology, specific outcome indicators for each treatment modality, liver functional reserve, and the technical feasibility of the treatment modalities. Various strategies may overcome these challenges, including the application of reinforced treatment indication criteria with predictive markers reflecting tumor biology, compensation for technical issues with up-to-date technologies, modification of treatment modalities, downstaging with locoregional therapies (such as transarterial chemotherapy or radiotherapy), and recently introduced combination immunotherapies. In this review, we discuss the challenges to achieving optimal outcomes in the management of early-stage HCC and suggest strategies to overcome these obstacles.

Surgical resection for large hepatocellular carcinoma and those beyond BCLC: systematic review with proposed management algorithm

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for the sixth most common cancer and ranks third in mortality worldwide with inhomogeneity in terms of resection for advanced-stage disease.

METHODS

A systematic review of published literature using the PubMed, Medline, and Google Scholar databases from 1995 to 2020 was conducted to identify studies that reported outcomes of resection for solitary HCC > 10 cm, BCLC B/C, and multinodular HCC. Our aim was to assess overall survival for resection, identify poor prognostic factors, and to compare it to trans-arterial chemotherapy (TACE) where data was available.

RESULTS

Eighty-nine articles were included after a complete database search in the systematic review as per our predefined criteria. Analysis revealed a 5-year overall survival of 33.5% for resection of HCC > 10 cm, 41.7% for BCLC B, 23.3% for BCLC C, and 36.6% for multinodular HCC. Peri-operative mortality ranged from 0 to 6.9%. Studies comparing resection versus TACE for BCLC B/C had a survival of 40% versus 17%, respectively.

CONCLUSION

Our systematic review justifies hepatic resection wherever feasible for hepatocellular carcinomas > 10 cm, BCLC B, BCLC C, and multinodular tumors. In addition, we identified and proposed an algorithm with five poor prognostic criteria in this group of patients who may benefit from adjuvant TACE.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Clinical prognosis of surgical resection versus transarterial chemoembolization for single large hepatocellular carcinoma (≥5 cm): A propensity score matching analysis

Favorable prognostic factors and therapeutic strategies are important for patients with single large hepatocellular carcinoma (HCC). This retrospective study aimed to investigate the prognostic factors in patients with single large (≥5 cm) HCC with Child-Pugh (CP) class A patients and to recommend therapeutic strategies. Overall, 298 HCC patients with single and large (≥5 cm) tumors with CP class A, but without distant metastasis and macrovascular invasion were included, and their clinicopathological data, overall survival (OS), and progression-free survival (PFS) were recorded. OS and PFS was analyzed by the Kaplan-Meier method and Cox regression analysis. Propensity score matching (PSM) analysis was performed. The 298 HCC patients were 79.2% male and median age of 64 years. For the initial treatment, surgical resection (SR) and transarterial chemoembolization (TACE) was 50.8% and 49.2%, respectively. The OS and PFS were significantly higher in patients receiving SR than those receiving TACE before and after PSM. Furthermore, in multivariate analysis, cirrhosis (Hazard ratio [HR]: 2.04; 95% confidence interval [CI]: 1.35-3.03, p < 0.001, CP class A5/6 [HR: 4.01; 95% CI: 2.43-6.66, p < 0.001], and initial treatment [SR vs. TACE HR = 3.23; 95% CI: 2.13-5.01, p < 0.001]) remained significantly associated with mortality. Moreover, in multivariate analysis, CP class A5/6 (HR: 3.23; 95% CI: 1.89-5.88, p < 0.001), and initial treatment (Resection vs. TACE; HR = 4.17; 95% CI: 1.64-8.33, p = 0.039) remained significantly associated with recurrence. In conclusion, SR was associated with significantly higher OS and PFS rates than TACE before and after PSM for single large HCC patients.

Cirrhotic and non-cirrhotic huge hepatocellular carcinoma (≥ 10 cm): a comparative study of surgical management and follow-up treatment in a single institution

PURPOSE

Liver resection (LR) of huge hepatocellular carcinoma (HCC) has increasingly been regarded as a viable option of enhanced efficacy for patients, but most studies have focused on comparing various tumor sizes and the outcomes of surgery. The study aim was to evaluate the clinicopathologic characteristics and surgical outcomes of huge HCC with and without cirrhosis that underwent LR, and to delineate the treatment for recurrence.

METHODS

Sixty-three patients with huge HCC who underwent hepatectomy from 2010 to 2019 were enrolled and reviewed. Clinicopathological findings, surgical outcomes of the entire cohort, and differences between the cirrhotic and non-cirrhotic groups were analyzed.

RESULTS

Forty patients (60.3%) had huge HCC with cirrhosis. Clinicopathological findings were not different between the two groups, except tumor size ≥ 15 cm (40% in cirrhosis vs 17.4% in non-cirrhosis, p = 0.024) and major portal vein tumor thrombus were detected only in the cirrhosis group (11 patients, p = 0.006). Extended LR was performed in 13 cirrhotic patients (32.5%) and in 1 non-cirrhotic patient (4.4%) (p = 0.010). Operative data, postoperative complications including postoperative liver failure, and pattern of recurrence were not different between the two groups. For the entire cohort, mortality rate was 1.5%. The 1-, 3-, and 5-year overall survival rates (OS) were 81%, 54%, and 39%. Multivariate analysis showed resection margin ≥ 0.1 cm was a good prognostic factor for OS (HR 0.247 (p = 0.017)). For tumor recurrence, local ablative treatment for liver recurrence and resection for lung recurrence provided good long-term outcomes.

CONCLUSION

Although huge HCC with cirrhosis has been a more unfavorable tumor, LR still provided long-term survival with acceptable risk morbidity and mortality.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Impact of tumor size on hepatectomy outcomes in hepatocellular carcinoma: a nationwide propensity score matching analysis

Purpose

The aim of this study was to compare surgical outcomes after liver resection for hepatocellular carcinoma (HCC) according to tumor size using a large, nationwide cancer registry-based cohort and propensity score matching.

Methods

From 2008 to 2015, a total of 12,139 patients were diagnosed with liver cancer and registered in the Korean Primary Liver Cancer Registry. Patients without distant metastasis who underwent hepatectomy as a primary treatment were selected. We performed 1:1 propensity score matching between the small (<5 cm), large (≥5 cm and <10 cm), and huge (≥10 cm) groups.

Results

Overall, 265 patients in the small and large groups were compared, and 64 patients each in the large and huge groups were compared. The overall and progression-free survival rates were significantly lower in the large group than in the small group (P < 0.001 and P < 0.001, respectively). Overall survival tended to be poorer in the huge group than in the large group (P = 0.051). The progression-free survival rate was significantly lower in the huge group than in the large group (P = 0.002).

Conclusion

Although primary liver resection can be considered even in patients with huge HCC, greater caution with careful screening for recurrence is needed.

Chemoembolization for Single Large Hepatocellular Carcinoma with Preserved Liver Function: Analysis of Factors Predicting Clinical Outcomes in a 302 Patient Cohort

The purpose of this study was to define the role of transcatheter arterial chemoembolization (TACE) in patients with a single large hepatocellular carcinoma (HCC) and define the patient groups benefiting from TACE. Treatment-naïve patients with preserved liver function who received TACE as the first-line treatment for single large (>5 cm) HCC without macrovascular invasion and extrahepatic metastasis between 2007 and 2019 were retrospectively analyzed. Overall survival, progression-free survival, radiologic tumor response, complications, and predictors of survival were analyzed using multivariate analysis, and then a pretreatment risk-prediction model was created using the four predictive factors of tumor size, tumor type, ALBI grade, and ECOG performance status. Patients with scores of 0 (n = 54), 1-2 (n = 170), and 3-6 (n = 78) according to the model were classified as low-, intermediate-, and high-risk, respectively. The corresponding median OS values were 141, 55, and 28 months, respectively. The percentage of major complications increased as tumor size increased (4-21%). Asymptomatic, nodular HCC patients with a tumor size of 5-7 cm and ALBI grade 1 benefited the most from TACE. By contrast, the value of TACE in the treatment of single huge HCC (>10 cm) with high complication rates remains unclear.

Two novel online nomograms for predicting the survival of individual patients undergoing partial hepatectomy for huge hepatocellular carcinoma

BACKGROUND

A method for predicting prognosis of patients who undergo partial hepatectomy for huge hepatocellular carcinoma (HHCC, diameter ≥10 cm) is currently lacking. This study aimed to establish two online nomograms to predict the overall survival (OS) and disease-free survival (DFS) for patients undergoing resection for HHCC.

METHODS

The clinicopathologic characteristics and follow-up information of patients who underwent partial hepatectomy for HHCC at two medical centers were reviewed. Using a training cohort, a Cox model was used to identify the predictors of survival. Two dynamic nomograms for OS and DFS were developed and validated based on the data.

RESULTS

Eight and nine independent factors derived from the multivariate analysis of the training cohort were screened and incorporated into the nomograms for OS and DFS, respectively. In the training cohort, the nomogram achieved concordance indices (C-indices) of 0.745 and 0.738 in predicting the OS and DFS, respectively. These results were supported by external validation (C-indices: 0.822 for OS and 0.827 for DFS). Further, the calibration curves of the endpoints showed a favorable agreement between the nomograms' assessments and actual observations.

CONCLUSIONS

The two web-based nomograms demonstrated optimal predictive performance for patients undergoing partial hepatectomy for HHCC. This provides a practical method for a personalized prognosis based on an individual's underlying risk factors.

Efficacy of Liver Resection for Single Large Hepatocellular Carcinoma in Child-Pugh A Cirrhosis: Analysis of a Nationwide Cancer Registry Database

Background

Therapeutic strategies and good prognostic factors are important for patients with single large hepatocellular carcinoma (HCC). This retrospective study aimed to identify the prognostic factors in patients with single large HCC with good performance status and Child-Pugh A cirrhosis using a large national cancer registry database and to recommend therapeutic strategies.

Methods

Among 12139 HCC patients registered at the Korean Primary Liver Cancer Registry between 2008 and 2015, single large (≥ 5 cm) HCC patients with Eastern Cooperative Oncology Group (ECOG) performance status 0 and Child-Pugh score A were selected.

Results

Overall, 466 patients were analyzed. The 1-,2-,3-, and 5-year survival rates after initial treatment were 84.9%, 71.0%, 60.1%, and 51.6%, respectively, and progression-free survival rates were 43.6%, 33.0%, 29.0%, and 26.8%, respectively. Platelet count < 100 × 10⁹/L (P < 0.001), sodium level < 135 mmol/L (P = 0.002), maximum tumor diameter ≥ 10 cm (P = 0.001), and treatment other than resection (transarterial therapy vs. resection: P < 0.001, others vs. resection: P = 0.002) were significantly associated with poorer overall survival; sodium < 135 mmol/L (P = 0.015), maximum tumor diameter ≥ 10 cm (P < 0.001), and treatment other than resection (transarterial therapy vs. resection: P < 0.001, others vs. resection: P = 0.001) were independently associated with poorer progression-free survival.

Conclusion

Resection as an initial treatment should be considered when possible, even in patients with single large HCC with good performance status and mild cirrhosis. Caution should be exercised in patients with low platelet level (< 100 × 10⁹/L), low serum sodium level (< 135 mmol/L), and maximum tumor diameter ≥ 10 cm.

Prediction of Post-resection Prognosis Using the ADV Score for Huge Hepatocellular Carcinomas ≥13 cm

Background/Aims

Multiplication of α-fetoprotein, des-γ-carboxy prothrombin, and tumor volume (ADV score) is a surrogate marker for post-resection prognosis of hepatocellular carcinoma (HCC). This study aimed to validate the predictive power of the ADV score-based prognostic prediction model for patients with solitary huge HCC.

Methods

Of 3,018 patients, 100 patients who underwent hepatic resection for solitary HCC ≥13 cm between 2008 and 2012 were selected.

Results

The median tumor diameter and tumor volume were 15.0 cm and 886 mL, respectively. Tumor recurrence and overall survival (OS) rates were 70.7% and 66.0% at one year and 84.9% and 34.0% at five years, respectively. Microvascular invasion (MVI) was the only independent risk factor for disease-free survival (DFS) and OS. DFS and OS, stratified by ADV score with 1-log intervals, showed significant prognostic contrasts (P=0.007 and P=0.017, respectively). DFS and OS, stratified by ADV score with a cut-off of 8-log, showed significant prognostic contrasts (P=0.014 and P=0.042, respectively). The combination of MVI and ADV score with a cut-off of 8-log also showed significant prognostic contrasts in DFS (P<0.001) and OS (P=0.001) considering the number of risk factors. Prognostic contrast was enhanced after combining the MVI and ADV score.

Conclusions

The prognostic prediction model with the ADV score could reliably predict the risk of tumor recurrence and long-term patient survival outcomes in patients with solitary huge HCC ≥13 cm. The results of this study suggest that our prognostic prediction models can be used to guide surgical treatment and post-resection follow-up for patients with huge HCCs.

Liver resection versus transarterial chemoembolization for huge hepatocellular carcinoma: a propensity score matched analysis

To date, it is unclear which treatment modality, liver resection (LR) or transarterial chemoembolization (TACE) is the more appropriate for patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). The study aim was to compare, using propensity score matching, short- and long-term outcomes of patients with huge HCC who underwent potentially curative LR or TACE. Patients with huge HCC who had been managed at the Clinical Center by curative-intent LR or by palliative TACE between November 2001 and December 2018 were retrospectively identified. The morbidity and mortality rates and overall survival were compared between the groups before and after the propensity score matching. Independent predictors of long-term survival were determined by multivariate analysis. A total of 103 patients with huge HCC were included; 68 were assigned to the LR group and 35 to the TACE group. The overall morbidity rate was higher in the LR group than in the TACE group before matching (64.7% vs. 37.1%, p = 0.012), while there was no difference after matching (60% vs. 30%, p = 0.055). The major morbidity and 30-days mortality were similar between the groups before and after matching. The LR group was associated with longer overall survival than the TACE group before matching (p = 0.032) and after matching (p = 0.023). Total bilirubin and TACE treatment were independent prognostic factors associated with long-term survival. In patients with huge HCC, liver resection provides better long-term survival than TACE and should be considered as the initial treatment whenever possible.

Elevated serum alpha-fetoprotein levels are associated with poor prognosis of hepatocellular carcinoma after surgical resection: A systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

The relationship between the alpha-fetoprotein (AFP) level and the prognosis of hepatocellular carcinoma (HCC) after surgical resection remains unknown. This study aims to assess this relationship.

PATIENTS AND METHODS

PubMed and Web of Science were systematically utilised. Meta-analysis was conducted for the outcomes of the recurrence-free survival (RFS) and the overall survival (OS) by comparing the high AFP group with the low AFP group.

RESULTS

The studies included 61 manuscripts with 35,461 patients. The summary hazard ratio (HR) for RFS was 1.501 (95% CI 1.355-1.662; Z = 7.81, P < 0.00001) when comparing the high AFP group with the low AFP group. Sensitivity analysis only included adjusted HRs, with the summary HR being 1.563 (95% CI 1.381-1.768; Z = 7.10, P < 0.00001). The summary HR for OS was 1.565 (95% CI 1.439-1.701; Z = 10.52, P < 0.00001) when comparing two AFP groups. Sensitivity analysis showed that the summary HR was 1.611 (95% CI 1.456-1.782; Z = 9.24, P < 0.00001).

CONCLUSION

Our meta-analysis indicated that elevated serum AFP levels are associated with poor prognosis of HCC after surgical resection.

Transarterial Chemoembolization Combined With Hepatectomy for the Treatment of Intermediate-Stage Hepatocellular Carcinoma

Background

Transarterial chemoembolization (TACE) is currently the recommended treatment for intermediate-stage hepatocellular carcinoma (HCC). Liver resection (LR) may be an effective option, although recurrences are not uncommon. TACE prior to LR has been proposed as an even better alternative.

Methods

Patients with intermediate-stage HCC who underwent curative resection were enrolled between January 2007 and December 2015. We compared overall survival (OS) and recurrence-free survival (RFS) for the 2 groups using the Kaplan-Meier method, and we determined independent risk factors for death and recurrence using multivariate regression analyses.

Results

A total of 488 patients with HCC at BCLC B (265 patients with LR, 223 patients with TACE+LR) enrolled from our center. Mean follow-up was 40.2 (range, 3.0-128.7) months. For patients receiving TACE+LR and LR, estimated 1-, 3-, and 5-year OS rates were 90.6% and 73.3%, 61.7% and 43.5%, and 52.9% and 33.8%, respectively (all P < 0.001) and estimated 1-, 2-, and 3-year RFS rates were 54.6% and 39.4%, 41.4% and 29.4%, and 36.3% and 26.3%, respectively (P < 0.001, P = 0.002, and P = 0.008, respectively). Significant independent predictors of poor OS were more than 3 (vs. 3 or fewer) tumors (HR=2.19, 95% CI 1.69-2.84), non-anatomical (vs. anatomical) hepatectomy (HR=1.29, 95% CI 1.01-1.66), microscopic vascular invasion (HR=1.46, 95% CI 1.15-.90), cirrhosis (HR=2.41, 95%CI 1.88-3.01), and intraoperative blood transfusion (HR=1.29, 95% CI 1.01-1.66).

Conclusion

Preoperative TACE with LR may result in better oncological outcomes than either TACE or LR alone, without a substantial increase in morbidity, and could be considered an effective combination treatment for intermediate-stage HCC.

Development and validation of a prognostic model based on the albumin-to-fibrinogen ratio (AFR) and gamma-glutamyl transpeptidase-to-platelet ratio (GPR) in hepatocellular carcinoma patients

BACKGROUND

Our study aimed to formulate a nomogram based on the albumin-to-fibrinogen ratio (AFR) and gamma-glutamyl transpeptidase-to-platelet ratio (GPR) to predict the prognosis of hepatocellular carcinoma (HCC) patients after curative hepatic resection.

METHODS

A total of 825 HCC patients who underwent curative resection from 2008 to 2015 in West China Hospital of Sichuan University were divided into a training (n = 616) and a validation (n = 209) cohort. The AFR-GPR risk stratification was generated and confirmed by multivariate analysis. Nomograms for recurrence-free survival (RFS) and overall survival (OS) were constructed. The concordance indexes (C-index), calibration, and decision curve analysis (DCA) were used to assess the predictive performance and clinical benefits of the nomograms.

RESULTS

The AFR-GPR risk stratification was the independent prognostic factor for RFS (p = 0.044) and OS (p = 0.002) in the training cohort and integrated into the construction of nomograms. The C-indexes of RFS and OS in the training and validation cohorts were 0.654 (95%CI: 0.626-0.681)/0.699 (95%CI: 0.654-0.743) and 0.699 (95%CI: 0.668-0.729)/0.736 (95%CI: 0.684-0.787), respectively. Furthermore, the C-indexes of the nomograms were greater than those of other conventional staging systems.

CONCLUSION

Our nomograms based on the AFR-GPR risk stratification presented the more reliable, convenient and accurate prognostic predictions for HCC patients.

TACE-Sorafenib With Thermal Ablation Has Survival Benefits in Patients With Huge Unresectable Hepatocellular Carcinoma

Purpose

To investigate the effectiveness and safety of transarterial chemoembolization (TACE) combined with sorafenib and thermal ablation in patients with huge hepatocellular carcinoma (HCC).

Materials and Methods

This retrospective study examined 50 patients with huge unresectable HCC treated from January 2009 to December 2015. Among them, 28 cases received TACE-sorafenib treatment (TACE-sorafenib group), and 22 cases received TACE-sorafenib plus thermal ablation treatment (TACE-sorafenib-thermal ablation group). The Overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were compared.

Results

The median follow-up was 13.5 months (ranges 4.2 to 96.7 months). The median OS was significantly longer in the TACE-sorafenib-thermal ablation group than that in the TACE-sorafenib group (20.8 vs. 10.4 months, P=0.003). The median PFS of the ablation and no ablation groups were 4.3 vs. 7.1 months (P=0.546). The treatment modality was an independent predictor of OS (P=0.004). There were no notable drug-related high grade adverse events or permanent adverse sequelae.

Conclusion

TACE-sorafenib-thermal ablation provided extended OS to patients with huge unresectable HCC and could be a better choice than TACE-sorafenib.

Liquid Chromatography-Mass Spectrometry-Based Nontargeted Metabolomics Predicts Prognosis of Hepatocellular Carcinoma after Curative Resection

Assessment and prediction of prognostic risk in patients with hepatocellular carcinoma (HCC) would greatly benefit the optimal treatment selection. Here, we aimed to identify the critical metabolites associated with the outcomes and develop a risk score to assess the prognosis of HCC patients after curative resection. A total of 78 serum samples of HCC patients were analyzed by liquid chromatography-mass spectrometry to characterize the metabolic profiling. A novel network-based feature selection method (NFSM) was developed to define the critical metabolites with the most discriminant capacity to outcomes. The metabolites defined by NFSM was further reduced by Cox regression analysis to generate a prognostic metabolite panel-phenylalanine and choline. Furthermore, univariate and multivariate Cox regression analyses were applied to combine the metabolite panel with the presence of satellite nodes to generate a global prognostic index (GPI) score for overall survival assessment. Compared with the current clinical classification systems, including the Barcelona-clinic liver cancer stage, tumor-node-metastasis stage, and albumin-bilirubin grade, the GPI score presented comparable performance, according to the time-dependent receiver operating characteristic curves and was validated in an independent cohort, which suggested that metabolomics could serve as a helpful tool to stratify the HCC prognostic risk after operation.

Combined Transarterial Chemoembolization and External Beam Radiotherapy in a Patient with Recurrent Huge Hepatocellular Carcinoma after Hepatic Resection

The optimal treatment strategy for unresectable huge hepatocellular carcinoma (HCC) is yet to be established. Non-surgical monotherapy demonstrated insufficient oncologic outcomes in previously reported studies. To improve the clinical outcomes of unresectable huge HCC, combined locoregional treatments can be considered in selected cases. Here, we report a case of 58-year-old male patient who was treated with combined transarterial chemoembolization (TACE) and external beam radiotherapy for recurrent HCC after a previous hepatic resection. After combined TACE and radiotherapy for the intrahepatic lesion, two metastases were diagnosed in the pelvic bones and lung; each lesion was successfully treated with salvage radiotherapy. During the long-term follow-up period (around 8 years 7 months after combined TACE and radiotherapy for the recurrent huge HCC), no definite viable tumors were observed in any of the treated liver, bone, and lung lesions.

Efficacy of combined bland embolization and chemoembolization for huge (≥10 cm) hepatocellular carcinoma

INTRODUCTION

To assess the efficacy of combined therapy involving bland transarterial embolization using gelatin sponge particles (bland GS-TAE) followed by transarterial chemoembolization using lipiodol mixed with anticancer agents and GS particles (Lip-TACE) to reduce the adverse events and increase the therapeutic effect of Lip-TACE in the treatment of huge (≥10 cm) hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

Twenty-one consecutive patients with huge HCCs (≥10 cm in diameter) were enrolled in this study. First, bland GS-TAE was performed to reduce the tumor volume, and then Lip-TACE was performed to control the remaining tumor at intervals of around three weeks. Tumor response, survival, and adverse events of this combined therapy were assessed.

RESULTS

The tumor response was assessed three months after combined TACE, with complete response in 38.1% and partial response in 57.1% of cases. Severe adverse events were seen in two patients, acute cholecystitis and tumor rupture. The median survival time was 2.7 years, and the one-, two-, three-, and five-year overall survival rates were 76.2%, 66.7%, 42.9%, and 25.0%, respectively.

CONCLUSION

Combined therapy involving bland GS-TAE followed by Lip-TACE can be performed safety and may improve survival in patients with huge HCCs.

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.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Outcomes of conventional transarterial chemoembolization for hepatocellular carcinoma ≥10 cm

AIM

To retrospectively evaluate the outcomes of conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC) ≥10 cm.

METHODS

Twenty-five patients with naïve HCC ≥10 cm (mean maximum tumor diameter, 130 ± 27.6 mm; single [n = 12], 2-9 [n = 6], and ≥10 [n = 7]) without extrahepatic spread treated with cTACE were eligible. Five (20%) had vascular invasion. Two to three stepwise cTACE sessions using iodized oil ≤10 mL in one cTACE session were scheduled. When the tumor recurred, additional cTACE was repeated on demand, if possible. Overall survival (OS) rates were calculated using the Kaplan-Meier method. The prognostic factors were evaluated using uni- and multivariate analyses.

RESULTS

Stepwise cTACE sessions were completed for 20 (80%) patients, but could not be completed for four (16%). In the remaining (4%) patient, the whole tumor was embolized in one session. Additional treatment, mainly cTACE, was undertaken for 19 (76%) patients. The OS rates at 1, 3, and 5 years were 68, 34.7, and 23.1%, respectively. A tumor number of three was a significant prognostic factor (P = 0.020) and the 1-, 3-, and 4-year OS rates in patients with ≤3 and ≥4 tumors were 81.3 and 33.3, 55.6 and 11.1, and 38.9% and 0%, respectively. Whole tumor embolization and the serum level of protein induced by vitamin K absence or antagonist-II were also significant prognostic factors (P < 0.001 and P = 0.042, respectively). Bile duct complications requiring additional interventions developed in two (8%) patients.

CONCLUSION

Conventional TACE is safe and effective for huge HCCs, but has limited effects in cases with four or more tumors.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Prognostic Factors and Survival Outcomes of Surgical Resection of Huge Hepatocellular Carcinomas

INTRODUCTION

The aim of the study was to analyze the various prognostic factors that influence survival and clinical outcomes in patients undergoing liver resection for huge hepatocellular carcinomas.

MATERIALS AND METHODS

The records of patients who underwent curative surgery between 1991 and 2011 for huge hepatocellular carcinoma were analyzed. Various prognostic factors that influenced the survival were studied. The patients were followed up till November 2016.

RESULTS

The number of patients who underwent liver resection with huge hepatocellular carcinoma during the study period was 17; this included 14 males and 3 females. The median age of the study population was 52 years. The median serum AFP in the study population was 132.3 ng/ml (range 2 to 187,000 ng/ml). 41.2% of the patients were hepatitis B positive. The overall morbidity was 6%. The mortality rate was nil. The mean size of the resected specimen was 13.9 cm ± 3.6 cm. The overall recurrence rate was 76.5%. The local recurrence rate was 29.4%. The median time to recurrence was 8 months. The 5-year disease-free survival and overall survival of the study group were 26% and 32%, respectively. The factors that predicted an adverse survival outcome after the log-rank test for univariate analysis using life-table method were presence of lymphovascular invasion (p = 0.047), age ≤ 55 years (p = 0.021), and raised serum AFP (p = 0.041).

CONCLUSION

The factors that predict an adverse outcome after surgery in patients with huge hepatocellular carcinomas were the presence of lymphovascular invasion, raised serum AFP, and age ≤ 55 years.

Treatment strategies for locally advanced hepatocellular carcinoma

Liver cancer ranks fifth in incidence and fourth in overall cancer-related mortality, with approximately 854,000 new cases and 810,000 deaths per year worldwide. Hepatocellular carcinoma (HCC) accounts for 90% of these cases, and, over time, both the incidence and mortality of this cancer have been rising in many regions. Several staging systems are used to assess the extent of primary tumor, presence of metastasis, and underlying liver disease, and thereby aid in the definition of treatment strategies and prognosis for these patients. The consequence of this heterogeneity in HCC staging is that no consensual definition of advanced disease exists, and there is still ongoing debate on the optimal treatment for these patients. Patients with advanced tumors can be candidates for multiple therapies, ranging from potentially curative options such as transplantation and resection-to locoregional and systemic treatments; these should be evaluated on an individual basis by a multidisciplinary team. This paper provides an overview of treatment options for advanced stage HCC, based on a review of the latest relevant literature and the personal experience of the authors.

Prognostic Prediction Models for Resection of Large Hepatocellular Carcinoma: A Korean Multicenter Study

BACKGROUND

We developed a prognostic prediction model (PPM) using 4 factors for hepatic resection (HR) of large hepatic cellular carcinoma (HCC). Multiplication of α-fetoprotein (AFP), des-γ-carboxy prothrombin, and tumor volume (TV) (ADV score) is a surrogate marker for post-resection prognosis. This study intended to validate the predictive power of 4-factor PPM and to develop new ADV score-based PPM.

METHODS

A total of 526 patients who underwent HR for solitary HCC ≥ 8 cm were selected from 9 Korean institutions between 2008 and 2014.

RESULTS

Median tumor diameter and TV were 11.0 cm and 398 mL, respectively. Tumor recurrence and patient survival rates were 53.0 and 78.4% at 1 year and 70.2 and 49.3% at 5 years, respectively. Independent risk factors for both tumor recurrence and patient survival included AFP ≥ 100 ng/mL, hypermetabolic FDG-positron emission tomography (PET), microvascular invasion and satellite nodules, which comprised 4 factors of the PPM. Five subgroups based on the number of involved risk factors exhibited significant differences in tumor recurrence and patient survival. ADV score cutoff was set at 7log (ADV7log) after cluster prognostic analysis. Patient grouping according to combination of ADV7log and FDG-PET findings (ADV7log-PET) exhibited significant differences in tumor recurrence and patient survival, comparable to those of the 4-factor PPM.

CONCLUSIONS

Two PPMs using 4 risk factors and ADV7log-PET could reliably predict the risk of early HCC recurrence and long-term survival outcomes in patients who underwent HR for large HCC. We believe that these PPMs can guide surgical treatment for large HCCs from preoperative HR planning to post-resection follow-up.

A Nomogram Predicting Extrahepatic Metastases for Patients with Adjuvant Transarterial Chemoembolization after Hepatectomy

Background: Prognosis remains poor for hepatocellular carcinoma (HCC) patients with extrahepatic metastases (EHMs). This study aimed to develop a nomogram to predict EHMs in HCC patients who underwent adjuvant transarterial chemoembolization (TACE) following hepatectomy.

Methods: Data of 578 HCC patients who underwent TACE after hepatectomy at the Eastern Hepatobiliary Surgery Hospital was retrospectively reviewed. Cox regression analyses was used to select variables to construct the nomogram. Predictive accuracy and discriminative ability of the model were performed using concordance index (C-index), calibration curve and the area under time-dependent receiver operating characteristic (ROC) curve.

Results: Postoperative EHMs were detected in 89 and 31 patients in the training cohort (n = 453) and validation cohort (n = 125), respectively. Multivariate analysis showed that tumor size (HR, 1.099; 95% CI, 1.049-1.152), coarse beam type of tumor histopathological structure (HR, 2.382; 95% CI, 1.030-5.512), presence of satellite nodules (HR, 1.936; 95% CI, 1.156-3.244) and alpha-fetoprotein (AFP) (HR, 1.399; 95% CI, 1.098-1.783) were independent risk factors for EHMs (all p < 0.05). The nomogram incorporated these factors achieved good agreement between prediction and actual observation with a concordance index (C-index) of 0.73 (95% CI, 0.68 to 0.78) and 0.71 (95% CI, 0.63 to 0.79) in the training cohort and validation cohort, respectively. In addition, patients who had a nomogram score > 17 were considered to have higher risk for EHMs compared with those scored ≤ 12. Furthermore, the time-dependent area under the ROC curve indicated comparative stability and adequate discriminative ability of the model.

Conclusions: This novel nomogram can identify those with high risk of EHMs after adjuvant TACE following hepatectomy. The validation cohort showed a good performance, suggesting it could benefit surgeons on decision-making.

Surgical Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.

The effect of radiotherapy in liver-confined but non-resectable Barcelona Clinic Liver Cancer stage C large hepatocellular carcinoma

Background and aims

Clinical trials to determine the efficacy of radiotherapy (RT) in liver-confined but non-resectable Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) are scarce. We aimed to determine the benefit of RT in such tumors and investigated large HCC tumors.

Methods

HCC data from the Korea Central Cancer Registry recorded from 2008 to 2010 were used. A total of 593 patients met our inclusion criteria; 67 were treated with RT while the remainder made up the non-RT group. Fifty-two RT recipients underwent combination treatments within 4 weeks after the first RT treatment, and were defined as the combination RT group. We performed propensity score matching (PSM) to compare the RT or combination RT groups with the non-RT group. The endpoint was overall survival (OS).

Results

Median follow-up time for surviving patients was 48 months. After PSM, there was no difference in OS between the RT and non-RT groups or between the combination RT and non-RT groups. However, the combination RT group had a longer median survival time (MST) (10.7 vs. 6.9 months, respectively). Next, we conducted PSM between the combination RT and non-RT groups in patients with tumor sizes ≥10 cm; MST was significantly longer in the former group (10.1 vs. 5.4 months, respectively; bootstrap 95% confidence interval of the difference in MST: 0.2-11.8).

Conclusions

As a combined modality, RT is a plausible therapeutic option for liver-confined but non-resectable BCLC stage C large HCC patients.

The hepatectomy efficacy of huge hepatocellular carcinoma and its risk factors: A meta analysis

BACKGROUND

There has always been a controversy on the hepatectomy for huge hepatocellular carcinoma (HCC). Therefore, we aim to explore the hepatectomy efficacy of huge HCC and its risk factors.

METHODS

A systematic research was performed using PubMed, MedLine, Web of Knowledge, and Cochrane Library from their establishment to August 2017. The major endpoints were overall survival (OS) rate and recurrence-free survival (RFS) rate, and the secondary ones were the morbidity of complications and mortality of hepatectomy.

RESULTS

About 13 studies with a total of 7609 patients were included in this meta-analysis. The hepatectomy efficacy of huge HCC was inferior to non-huge HCC both in OS (hazard ratio [HR] = 2.18, 95% confidence interval [CI] = 1.90-2.50, P < .00001; I = 66%, P = .003) and RFS (HR = 1.97, 95% CI = 1.76-2.19, P < .00001; I = 74%, P = .0001). However, the risk difference[RD] of the 1-year, 3-year and 5-year OS tended to be acceptable (RD = -0.05, 95% CI = -0.11-0.00, P = .05; RD = -0.13, 95% CI = -0.21--0.05, P = .002; RD = -0.10, 95% CI = -0.19--0.01, P = .03; respectively). Moreover, there were also no significant differences between huge HCC and non-huge HCC in the morbidity of complication and mortality of hepatectomy (RD = 0.07, 95% CI = -0.09-0.23, P = .38; RD = -0.01, 95% CI = -0.00--0.03, P = .06; respectively). Related risk factors were measured to explore the differences, and the results showed that the level of alpha fetal protein (AFP) and the margin-positive rate were higher (standard mean difference [SMD] = 0.57, 95% CI = 0.26-0.88, P = .0003; odd radio[OR] = 32.52, 95% CI = 1.02-6.22, P = .04; respectively), the characteristic of huge HCC tended to be worse such as lower clinical or pathological stage, incomplete capsule and incorporate satellite metastases (OR = 2.91, 95% CI = 1.68-5.04, P = .001; OR = 3.99, 95% CI = 3.40-4.67, P < .00001; OR = 2.52, 95% CI = 1.66-3.83, P < .0001; respectively), and the rate of micorvascular invasion (MVI) including portal vein tumor thrombus (PVTT) were higher (OR = 3.36, 95% CI = 1.61-7.02, P = .001; OR = 2.75, 95% CI = 2.29-3.31, P < .00001; respectively) in the huge HCC.

CONCLUSION

The hepatectomy efficacy of huge HCC was inferior to non-huge HCC, but its survival benefits and feasibility were confirmed in this meta-analysis. In addition, higher level of AFP, positive margin, lower clinical or pathological stage, incomplete capsule, incorporate satellite metastasis and MVI were significantly correlated with poor OS.

Huge hepatocellular carcinoma greater than 10 cm in diameter worsens prognosis by causing distant recurrence after curative resection

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the impact of huge (≥10 cm) hepatocellular carcinoma (HCC) to the recurrence pattern and the prognosis after hepatectomy.

METHODS

574 patients who underwent hepatectomy by 17 surgeons (Open 536 and Laparoscopic 38) for HCC without major vascular invasion from 1990 to 2013 at single institute were retrospectively analyzed.

RESULTS

Huge tumor, age, HCV, multiple tumors and microscopic portal invasion are independent risk factors for overall survival (OS), and huge tumor, ICGR15 ≥16%, multiple tumors, moderate/poor histology, microscopic portal invasion and a positive pathological margin are risk factors for relapse-free survival (RFS). The 5-year OS and RFS of patients with huge HCC (n = 53) (42.9 and 14.2%) were significantly worse than those of patients with HCC <10 cm (n = 521) (71.3 and 33.1%). Huge tumor is an independent risk factor for initial extra-hepatic recurrence (Hazard ratio 7.86, P < 0.0001). The 5-year OS of patients with initial extra-hepatic recurrence (n = 55) was significantly worse than patients with intra-hepatic recurrence (n = 338) (16.8 vs. 50.5%).

CONCLUSIONS

Huge HCC (≥10 cm) is an independent risk factor due to a high risk for initial extra-hepatic recurrence. Future systemic adjuvant therapy is needed for these patients. J. Surg. Oncol. 2017;115:324-329. © 2016 Wiley Periodicals, Inc.

Prognostic factors after hepatic resection for the single hepatocellular carcinoma larger than 5 cm

Purpose

This study aimed to determine which factors affect the prognosis of hepatectomy for hepatocellular carcinoma (HCC) larger than 5 cm, including the prognostic difference between tumor sizes from 5–10 cm and larger than 10 cm.

Methods

The medical records of 114 patients who underwent hepatectomy for single HCC larger than 5 cm were reviewed and analyzed retrospectively.

Results

In the analysis of the entire cohort of 114 patients, the 5-year overall and diseases-free survival rates were 50% and 29%, respectively. In a comparison of survival rates between groups, tumor sizes of 5 to 10 cm and larger than 10 cm, the overall and disease-free survival rates were not significantly different, respectively (54% vs. 41%, P = 0.433 and 33% vs. 23%, P = 0.083). On multivariate analysis, positive hepatitis B, high prothrombin induced by vitamin K absence or antagonist-II levels over 200 mIU/mL, and vascular invasion (micro- and macrovascular invasion) were independent prognostic factors for recurrence after hepatic resection. However, tumor size larger than 10 cm was not significant for recurrence after resection.

Conclusion

This study shows that surgical resection of solitary HCC larger than 5 cm showed favorable overall survival. And there is no survival difference with tumors between 5–10 cm and larger than 10 cm.

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.

Changes in the types of liver diseases requiring hepatic resection: a single-institution experience of 9016 cases over a 10-year period

Backgrounds/Aims

To understand the changing demands for hepatic resection (HR), we collected data regarding HR performed in a tertiary centre over a period of 10 years.

Methods

We carried out extensive search of institutional databases to identify HR cases performed between January 2005 and December 2014. A study cohort of 9,016 patients were divided into 5 disease categories, namely hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), intrahepatic duct stone disease (IHDS), colorectal cancer liver metastasis (CRLM), and uncommon/rare diseases (URD).

Results

There were 5,661 (62.8%) HCC cases, followed by 1441 (16.0%) CRLM, 942 (10.5%) ICC, 638 (7.1%) IHDS and 334 (3.7%) URD. The number of annual HR cases gradually increased from 443 in 2005 to 1,260 in 2015. Annual HCC cases also gradually increased, but the annual proportion of HCC cases fluctuated narrowly between 58.3% and 70.2%. Annual CRLM cases increased rapidly, and their proportion increased progressively from 4.7% to 20.5%. Annual ICC cases increased slowly, and their annual proportion fluctuated between 7.2% and 15.6%. Annual IHDS cases decreased slowly, and their annual proportion decreased progressively from 17.2% to 3.4%, while annual URD cases fluctuated, with annual proportions varying between 2.3% and 5.6%.

Conclusions

Annual cases of HR increased over the last 10 years in a tertiary center probably due to a center-specific centralization effect. The number of CRLM cases increased rapidly; those of HCC and ICC increased gradually, and those of IHDS declined gradually. We believe that these results reflect real changes in the types of liver disease requiring HR.

Prognostic effect of preoperative sequential transcatheter arterial chemoembolization and portal vein embolization for right hepatectomy in patients with solitary hepatocellular carcinoma

Backgrounds/Aims

Both preoperative transcatheter arterial chemoembolization (TACE) alone and portal vein embolization (PVE) alone have a detrimental prognostic effect on the post-resection outcomes in patients with hepatocellular carcinoma (HCC). The main objective of this study was to assess the prognostic impact of preoperative TACE on the long-term survival outcomes in patients undergoing preoperative PVE and right liver resection for solitary HCC.

Methods

Patients who underwent macroscopic curative right liver resection of solitary HCC that lied between 3.0 and 7.0 cm (n=113) with or without preoperative TACE and PVE were selected for the study, making these subjects were divided into three groups; the TACE-PVE group (n=27), the PVE-alone group (n=13), and the control group (n=73). The subjects in the three groups were followed up for ≥36 months or until death.

Results

The 1-, 3-, 5-, and 10-year overall patient survival rates of all 113 patients were 96.5%, 88.2%, 81.3% and 65.0%, respectively. The 1-, 3-, 5-, and 10-year overall patient survival rates were 96.3%, 83.4%, 83.4% and 47.6% respectively in the TACE-PVE group; 84.6%, 76.9%, 57.7% and 19.2% respectively in the PVE-alone group; and 98.6%, 91.7%, 85.1% and 81.7% respectively in the control group (p=0.047). Patients were also sub-grouped according to tumor size, and those with a tumor of up to cutoff at 5 cm showed no prognostic difference (p=0.774), but tumor size >5 cm was associated with inferior patient survival only in the TACE-PVE group (p=0.018).

Conclusions

Preoperative sequential TACE and PVE appear to be compliant to the conventional oncological concept in addition to induction of the future remnant liver regeneration. Therefore, we suggest that preoperative TACE should be come first whenever preoperative PVE for major hepatectomy is planned, especially in patients with hypervascular HCC tumors.