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

Preoperative Prediction of Microvascular Invasion with Gadoxetic Acid-Enhanced Magnetic Resonance Imaging in Patients with Single Hepatocellular Carcinoma: The Implication of Surgical Decision on the Extent of Liver Resection

Introduction

Microvascular invasion (MVI) is one of the most important prognostic factors for hepatocellular carcinoma (HCC) recurrence, but its application in preoperative clinical decisions is limited. This study aimed to identify preoperative predictive factors for MVI in HCC and further evaluate oncologic outcomes of different types and extents of hepatectomy according to stratified risk of MVI.

Methods

Patients with surgically resected single HCC (≤5 cm) who underwent preoperative gadoxetic acid-enhanced magnetic resonance imaging (MRI) were included in a single-center retrospective study. Two radiologists reviewed the images with no clinical, pathological, or prognostic information. Significant predictive factors for MVI were identified using logistic regression analysis against pathologic MVI and used to stratify patients. In the subgroup analysis, long-term outcomes of the stratified patients were analyzed using the Kaplan-Meier method with log-rank test and compared between anatomical and nonanatomical or major and minor resection.

Results

A total of 408 patients, 318 men and 90 women, with a mean age of 56.7 years were included. Elevated levels of tumor markers (alpha-fetoprotein [α-FP] ≥25 ng/mL and PIVKA-II ≥40 mAU/mL) and three MRI features (tumor size ≥3 cm, non-smooth tumor margin, and arterial peritumoral enhancement) were independent predictive factors for MVI. As the MVI risk increased from low (no predictive factor) and intermediate (1-2 factors) to high-risk (3-4 factors), recurrence-free and overall survival of each group significantly decreased (p = 0.001). In the high MVI risk group, 5-year cumulative recurrence rate was significantly lower in patients who underwent major compared to minor hepatectomy (26.6 vs. 59.8%, p = 0.027).

Conclusion

Tumor markers and MRI features can predict the risk of MVI and prognosis after hepatectomy. Patients with high MVI risk had the worst prognosis among the three groups, and major hepatectomy improved long-term outcomes in these high-risk patients.

Laparoscopic anatomic vs. nonanatomic liver resection for large hepatocellular carcinoma (≥5 cm) in the right lobe

OBJECTIVE

To determine the impacts and outcomes of laparoscopic anatomic liver resection (LAR) and laparoscopic nonanatomic resection (LNAR) in patients with large hepatocellular carcinoma (HCC) in the right lobe of the liver.

BACKGROUND

There are few comparative studies of LAR and LNAR for large HCC.

METHOD

Three hundred thirty-seven patients underwent liver resection for large HCC (≥5 cm) at Seoul National University Bundang Hospital, Seoul, Korea, between January 2004 and December 2022. After the exclusion of patients treated with open hepatic resection and those who had left-lobe or bilobar tumors, 94 patients were ultimately included. Patients were divided into LAR group (61 patients) and LNAR group (33 patients). After propensity score matching (PSM) with 1:1 matching, 31 patients were included in each group. The outcomes in the two groups were compared.

RESULTS

LAR group had longer operative time than LNAR group (333.7 ± 113.7 vs 210 ± 117.6 min, respectively, P < 0.001), wider safety margin (1.4 ± 1.5 vs 0.7 ± 0.7 cm, respectively, P = 0.015), and lower incidence of recurrence (25.8% vs. 54.8%, respectively, P = 0.021).

CONCLUSION

LAR required longer operative time, achieved wider safety margin, and had lower incidence of recurrence than LNAR.

Scientific Hepatectomy for Hepatocellular Carcinoma

With advances in imaging technology and surgical instruments, hepatectomy can be perfectly performed with technical precision for hepatocellular carcinoma (HCC). However, the 5-year tumor recurrence rates remain greater than 70%. Thus, the strategy for hepatectomy needs to be reappraised based on insights of scientific advances. Scientific evidence has suggested that the main causes of recurrence after hepatectomy for HCC are mainly related to underlying cirrhosis and the vascular spread of tumor cells that basically cannot be eradicated by hepatectomy. Liver transplantation and systemic therapy could be the solution to prevent postoperative recurrence in this regard. Therefore, determining the severity of liver cirrhosis for choosing the appropriate surgical modality, such as liver transplantation or hepatectomy, for HCC and integrating newly emerging immune-related adjuvant and/or neoadjuvant therapy into the strategy of hepatectomy for HCC have become new aspects of exploration to optimize the strategy of hepatectomy. In this new area, hepatectomy for HCC has evolved from a pure technical concept emphasizing anatomic resection into a scientific concept embracing technical considerations and scientific advances in underlying liver cirrhosis, vascular invasion, and systemic therapy. By introducing the concept of scientific hepatectomy, the indications, timing, and surgical techniques of hepatectomy will be further scientifically optimized for individual patients, and recurrence rates will be decreased and long-term survival will be further prolonged.

Impact of anatomic resection on long-term survival in patients with hepatocellular carcinoma with T1-T2 disease or microscopic vascular invasion

BACKGROUND

This study aimed to clarify potential candidates for anatomic resection (AR) among patients with pathological T1-T2 (pT1-T2) hepatocellular carcinoma (HCC) and to determine whether AR is effective for HCC with microscopic vascular invasion (MVI).

METHODS

We retrospectively analyzed 288 patients with pT1a (n = 50), pT1b (n = 134) or pT2 (n = 104) HCC who underwent curative-intent resection between 1990 and 2010. Surgical outcomes were compared between patients who underwent AR (n = 189) and those who underwent nonanatomic resection (NAR; n = 99) according to pT category and MVI status.

RESULTS

Patients who underwent AR were more likely to have good hepatic functional reserve and an aggressive primary tumor than those who underwent NAR. When patients were stratified according to pT category, AR had a more favorable impact on survival than NAR only in patients with pT2 HCC in univariate (5-year survival, 51.5% vs. 34.6%; p = 0.010) and multivariate analysis (hazard ratio 0.505; p = 0.014). However, AR had no impact on survival in patients with pT1a or pT1b HCC. In patients with MVI (n = 57), AR achieved better survival than NAR (5-year survival, 52.0% vs. 16.7%; p = 0.019) and was an independent prognostic factor (hazard ratio 0.335; p = 0.020). In patients without MVI (n = 231), there was no significant difference in survival between the two groups (p = 0.221).

CONCLUSION

AR was identified as an independent factor in improved survival in patients with pT2 HCC or HCC with MVI.

Conversion surgery for hepatocellular carcinoma with portal vein tumor thrombus after successful atezolizumab plus bevacizumab therapy: a case report

BACKGROUND

The treatment of hepatocellular carcinoma (HCC) requires diverse and multidisciplinary approaches. In recent years, new agents with good antitumor effects have emerged for systemic chemotherapy, and conversion surgery (CS) after systemic chemotherapy is expected to be an effective treatment strategy for unresectable HCC. We herein report a case of unresectable HCC with portal vein tumor thrombus (PVTT) in which atezolizumab plus bevacizumab therapy induced PVTT regression, followed by CS with R0 resection.

CASE PRESENTATION

The patient was a 79-year-old man with S2/S3 HCC who was referred to our department due to tumor re-growth and PVTT after two rounds of transcatheter arterial chemoembolization. The PVTT extended from the left portal vein to the main trunk, and it was determined that the resection of the left portal vein would be difficult to perform with R0 status. Based on the diagnosis of unresectable HCC, treatment with atezolizumab plus bevacizumab was initiated. After two courses of treatment, contrast-enhanced computed tomography showed that the PVTT had regressed to the peripheral side of the left portal vein, and R0 resection became possible. The patient developed grade 3 skin lesions as an immune-related adverse event, and it was determined that the continuation of chemotherapy would be difficult. Four weeks after the second course of atezolizumab plus bevacizumab administration, left lobectomy was performed. Intraoperative ultrasonography was used to confirm the location of the tumor thrombus in the left portal vein during the resection, and a sufficient surgical margin was obtained. The histopathological findings showed that primary tumor and PVTT were mostly necrotic with residues of viable tumor cells observed in some areas. The liver background was determined as A1/F4 (new Inuyama classification). The resection margins were negative, and R0 resection was confirmed. There were no postoperative complications. No recurrence was observed as of five months after surgery.

CONCLUSIONS

CS with atezolizumab plus bevacizumab therapy has potential utility for the treatment of unresectable HCC with PVTT.

All the Routes for Laparoscopic Liver Segment VIII Resection: A Comprehensive Review of Surgical Techniques

Liver surgery is highly demanding for anatomical, physiological and technical reasons, and minimally invasive approaches have been implemented at a slower rate. Today, laparoscopic liver resection is a standard of care in many occasions, yet specific operations remain particularly challenging and generally performed in open surgery. In particular, SVIII resection may be considered one of the most difficult due to anatomical characteristics including its sub-diaphragmatic position, the deep-lying Glissonean pedicle and the close contact with the inferior vena cava and right and middle hepatic veins. Many techniques have risen to overcome technical difficulties, and today laparoscopic SVIII resection has been demonstrated to be feasible. This review provides a complete picture of current approaches, focusing on all techniques reported so far with critical appraisal of each, discussing and explaining benefits and pitfalls.

Revisiting Surgical Strategies for Hepatocellular Carcinoma With Microvascular Invasion

Although liver resection (LR) and liver transplantation (LT) are widely considered as potentially curative therapies for selected patients with hepatocellular carcinoma (HCC); however, there is still high risk of tumor recurrence in majority of HCC patients. Previous studies demonstrated that the presence of microvascular invasion (MVI), which was defined as the presence of tumor emboli within the vessels adjacent to HCC, was one of the key factors of early HCC recurrence and poor surgical outcomes after LR or LT. In this review, we evaluated the impact of current MVI status on surgical outcomes after curative therapies and aimed to explore the surgical strategies for HCC based on different MVI status with evidence from pathological examination. Surgical outcomes of HCC patients with MVI have been described as a varied range after curative therapies due to a broad spectrum of current definitions for MVI. Therefore, an international consensus on the validated definition of MVI in HCC is urgently needed to provide a more consistent evaluation and reliable prediction of surgical outcomes for HCC patients after curative treatments. We concluded that MVI should be further sub-classified into MI (microvessel invasion) and MPVI (microscopic portal vein invasion); for HCC patients with MPVI, local R0 resection with a narrow or wide surgical margin will get the same surgical results. However, for HCC patients with MI, local surgical resection with a wide and negative surgical margin will get better surgical outcomes. Nowadays, MVI status can only be reliably confirmed by histopathologic evaluation of surgical specimens, limiting its clinical application. Taken together, preoperative assessment of MVI is of utmost significance for selecting a reasonable surgical modality and greatly improving the surgical outcomes of HCC patients, especially in those with liver cirrhosis.

Anatomic versus non-anatomic resection of hepatocellular carcinoma with microvascular invasion: A systematic review and meta-analysis

The efficacy of anatomical resection (AR) and non-anatomical resection (NR) in the treatment of hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI) remains unknown. This study compared the safety and outcomes of these surgical procedures. A systematic literature search was conducted. The main outcomes were overall survival (OS), disease-free survival (DFS). Overall hazard ratio (HR) was calculated from Kaplan-Meier plots and outcomes using random-effects models. There was no significant difference in postoperative complications between the AR and NR groups (risk ratio [RR]: 0.92, 95% confidence interval [CI]: 0.72-1.17, p = 0.496). OS was higher with AR at 1 year (RR: 0.66, 95% CI: 0.45-0.98, p = 0.037), 3 years (RR: 0.64, 95% CI: 0.50-0.82, p = 0.000), and 5 years (RR: 0.76, 95% CI: 0.65-0.89, p = 0.001). AR was associated with a higher OS rate (HR: 0.62, 95% CI: 0.47-0.82, p = 0.001). AR was associated with improved DFS at 1 year (RR: 0.65, 95% CI: 0.52 to 0.82, p = 0.000), 3 years (RR: 0.75, 95% CI: 0.66 to 0.86, p = 0.000), and 5 years (95% CI: 0.75 to 0.94, p = 0.002). Compared with NR, AR had significant advantages on overall HR of DFS (HR: 0.64, 95% CI: 0.45 to 0.91, p = 0.012). In conclusion, AR was associated with higher rates of OS and DFS in HCC patients with MVI. Thus, for well-presented liver function HCC patients which are predicted to have positive MVI, AR is recommended.

FXYD6 overexpression in HBV-related hepatocellular carcinoma with cirrhosis

Objective

The aim of this study was to investigate the expression of FXYD domain-containing ion transport regulator 6 (FXYD6) mRNA and protein in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) tissues with cirrhosis, the corresponding paracancerous tissues and the normal liver tissues, and to explore the clinical significance of FXYD6 expression in HBV-related HCC with cirrhosis.

Methods

The FXYD6 mRNA and protein were examined by semi-quantitative reverse transcription polymerase chain reaction and immunohistochemistry, respectively.

Results

The FXYD6 mRNA in HBV-related HCC tissues was significantly higher than that in the cirrhosis tissues or that in the normal liver tissues. The positive expression rate of FXYD6 protein was statistically higher in HBV-related HCC tissues than that in HBV-related cirrhosis or that in normal liver tissues. There was no significant correlation between the expression of FXYD6 protein and gender, age, histological differentiation, tumor diameter, tumor number, integrity of tumor capsule or not and alpha fetoprotein (AFP) concentration in serum, but the protein expression was associated with microvascular invasion, pathological stage, and early recurrence after operation within 1 year.

Conclusion

FXYD6 might be involved in hepatocyte carcinogenesis and tumor progression in HBV-related HCC with cirrhosis and indicated a poor prognosis.

Laparoscopically anatomical versus non-anatomical liver resection for large hepatocellular carcinoma

BACKGROUND

The role of laparoscopically anatomical resection (LAR) for hepatocellular carcinoma (HCC) remains unclear due to the more demanding technique required in laparoscopy. This study is to analyze the clinical impact of LAR compared to laparoscopically non-anatomical resection (LNAR) for HCC.

METHODS

All patients received laparoscopic hepatectomy for HCC (diameter 5-10 cm) from January 2015 to December 2018 were retrospectively enrolled in this study. Patients were divided into LAR and LNAR groups. The perioperative and oncological outcomes were evaluated based on propensity score matching (PSM) method.

RESULTS

After PSM, 51 patients in each group were enrolled. The operative time in LAR group was longer (240 vs 195.0 min, p = 0.012) and blood loss was more (200.0 vs 150.0 mL, p = 0.030) than those of LNAR group, respectively. The total complication rates were comparable between them (21.6% vs 17.6%, p = 0.500). The 3-year overall survival rates were 59.4% in LAR group and 38.7% in LNAR group, respectively (p = 0.045). The 3-year disease-free survival rates were 52.3% in LAR group and 27.0% in LNAR group, respectively (p = 0.042).

CONCLUSION

LAR could be feasibly performed with comparable perioperative outcomes and contributed to improve long-term survival in patients with HCC (diameter 5-10 cm) when compared to LNAR.

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

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

The Value of the C-Reactive Protein-to-Albumin Ratio is Useful for Predicting Survival of Patients with Child-Pugh Class A Undergoing Liver Resection for Hepatocellular Carcinoma

BACKGROUND

Although a recent study has shown that the C-reactive protein-to-albumin ratio (CAR) can predict the survival in patients with hepatocellular carcinoma (HCC), it is unclear whether CAR can predict the survival after surgery.

OBJECTIVE

To investigate the utility of CAR for prediction of postoperative survival among HCC patients with Child-Pugh class A.

METHODS

We retrospectively reviewed 239 patients with Child-Pugh class A who were newly diagnosed with HCC and received initial liver resection. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS), and their cutoff values were identified using receiver operating characteristic curve analyses. The cutoff value of CAR was 0.028. Kaplan-Meier analysis and the log-rank test were used for the comparison of OS and disease-free survival (DFS) between two CAR groups (>0.028/≤0.028).

RESULTS

Multivariate analysis using 16 clinical characteristics selected by univariate analyses revealed that CAR (>0.028/≤0.028) (HR, 3.211; 95% CI 1.065-9.680; P = 0.038) was significantly associated with OS, as well as anatomical resection (presence/absence) (HR, 0.275; 95% CI 0.119-0.635; P = 0.275). A significant difference in OS and DFS was observed between patients with low CAR (≤0.028) and patients with high CAR (>0.028).

CONCLUSIONS

CAR is a useful predictor of postoperative survival among HCC patients with Child-Pugh class A.

Vasculogenic mimicry in hepatocellular carcinoma contributes to portal vein invasion

Portal vein invasion (PVI) is common in hepatocellular carcinoma (HCC) and largely contributes to tumor recurrence after radical tumor resection or liver transplantation. Vasculogenic mimicry (VM) was an independent vascular system lined with tumor cells and associated with poor prognosis of HCC. The present study was conducted to evaluate the relationship between VM and portal vein invasion. A total of 44 HCC cases receiving anatomic liver resection were included in the study and were divided into groups with and without PVI. The prevalence of VM in each group was examined by CD34-PAS dual staining. The regulatory molecules of VM formation such as Notch1, Vimentin and matrix metalloproteinases (MMPs) were investigated by immunohistochemical staining. Analysis was performed to explore the association of PVI, VM and the VM regulatory molecules. PVI was found in 40.91% (18/44) cases and VM was found in 38.64% (17/44) cases in total samples. The incidence of VM was 72.22% (13/18) in PVI group while it was 15.38% (4/26) in non-PVI group (P<0.001), VM formation was positively correlated with PVI (r=0.574, P<0.001). The VM forming regulatory molecules such as Notch1, Vimentin, MMP-2 and MMP-9 were found to be correlated with PVI in HCC patients. Taken together, our results suggested that VM formation, alone with its regulatory molecules, is the promoting factor of PVI in hepatocellular carcinoma.

Clinicopathological Characteristics of Hepatocellular Carcinoma with Microscopic Portal Venous Invasion and the Role of Anatomical Liver Resection in These Cases

BACKGROUND

The aims of this study were to investigate predictive factors for microscopic portal venous invasion (mPVI) in hepatocellular carcinoma (HCC) and whether anatomical liver resection (ALR) was useful in such cases.

METHODS

We analyzed 852 patients with HCC without macroscopic portal venous invasion who were treated at our hospital between January 1990 and May 2014. These patients were stratified into a microscopic portal venous invasion group (mPVI group; n = 153) and non-microscopic portal venous invasion group (NmPVI group; n = 699).

RESULTS

PIVKA-II ≥100 mAU/ml, a tumor size ≥5 cm, a confluent lesion, and poor differentiation were found to be independent risk factors for mPVI. Among the mPVI group who had single HCC under 5 cm, serum albumin level <4.0 g/dl, PIVKA-II ≥100 mAU/ml, a positive surgical margin, and non-ALR (NALR) were independent unfavorable prognostic factors for overall survival (OS). PIVKA-II ≥100 mAU/ml, a positive surgical margin and NALR were independent unfavorable prognostic factors for relapse-free survival (RFS). ALR was significantly favorable factor for both OS and RFS of the mPVI group who had single HCC under 5 cm.

CONCLUSIONS

Even if no portal venous invasion is detectable in HCC patients preoperatively, a PIVKA-II ≥100 mAU/ml, tumor size ≥5 cm, and a confluent lesion indicate a high risk of mPVI. ALR should be considered for the patients with these characteristics because it is a favorable prognostic factor in these cases with mPVI.

Correlation between Resection Margin and Disease Recurrence with a Restricted Cubic Spline Model in Patients with Resected Hepatocellular Carcinoma

BACKGROUND

The relationship between resection margin (RM) and recurrence of resected hepatocellular carcinoma (HCC) is unclear.

METHODS

We reviewed clinical data for 419 patients with HCC. The oncologic outcomes were compared between 2 groups of patients classified according to the inflexion point of the restricted cubic spline plot.

RESULTS

The patients were divided according to an RM of <1 cm (n = 233; narrow RM group) or ≥1 cm (n = 186; wide RM group). The 5-year recurrence-free survival (RFS) rate was lower (34.8 vs. 43.8%, p = 0.042) and recurrence near the resection site was more frequent (4.7 vs. 0%, p = 0.010) in the narrow RM group. Patients with multiple lesions, or prior transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) were excluded from subgroup analyses. In patients with a 2-5 cm HCC, the 5-year RFS was greater in the wide RM group (54.4 vs. 32.5%, p = 0.036). Narrow RM (hazard ratio 1.750, 95% CI 1.029-2.976, p = 0.039) was independently associated with disease recurrence.

CONCLUSION

In patients with a single 2-5 cm HCC without prior TACE/RFA, an RM of ≥1 cm was associated with lower risk of recurrence after liver resection.

The prognostic correlation of AFP level at diagnosis with pathological grade, progression, and survival of patients with hepatocellular carcinoma

The purpose of this study was to conduct a comprehensive study of the clinical correlation between the alpha-fetoprotein (AFP) level at diagnosis and pathological grades, progression, and survival of patients with hepatocellular carcinoma (HCC). A total of 78,743 patients in Surveillance, Epidemiology, and End Results Program (SEER)-registered HCC was analyzed. The AFP test results for patients with HCC were mainly recorded as AFP-negative and AFP-positive. Logistic regression analysis revealed that the AFP level at diagnosis was an independent risk factor of pathological grade (odds ratio [OR], 2.559; 95% confidence interval [CI], 2.075-3.157; P < 0.001), TNM-7 stage (OR, 2.794; CI, 2.407-3.242; P < 0.001), and tumor size (OR, 1.748; 95% CI, 1.574-1.941; P < 0.001). Multivariable Cox regression analyses identified AFP level as an independent predictor of survival risk of patients with HCC who did not undergo surgery (hazard ratio [HR], 1.660; 95% CI, 1.534-1.797; P < 0.001), and those who underwent surgery (HR, 1.534; 95% CI, 1.348-1.745; P < 0.001). The AFP level at diagnosis was an independent risk predictor associated with pathological grade, progression, and survival. Further, surgery may not significantly reverse the adverse effects of AFP-positive compared with AFP-negative.

The preoperative globulin-to-albumin ratio, a novel inflammation-based prognostic system, predicts survival after potentially curative liver resection for patients with hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Although the globulin-to-albumin ratio (GAR) is useful for prognostication of patients with various cancers, its relationship with hepatocellular carcinoma (HCC) remains unclear. The study aims to investigate the relationship between GAR and postoperative survival among patients with HCC undergoing potentially curative liver resection (LR).

METHODS

We retrospectively reviewed 368 patients with newly diagnosed HCC who underwent initial and potentially curative LR. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS). Kaplan-Meier analysis and log-rank test were used to compare OS and disease-free survival (DFS).

RESULTS

The result of multivariate analysis using 25 clinical characteristics selected by univariate analysis revealed that the GAR (≥0.918/<0.918) was significantly associated with OS (hazard ratio [HR], 2.398; 95% confidence interval [CI], 1.012-5.683; P = 0.047), as well as platelet count (<14/≥14, ×10⁴ /mm³ ) and portal vein invasion (presence/absence). Kaplan-Meier analysis and log-rank test demonstrated that the OS and DFS of patients with a high GAR (>0.918) were significantly worse than that of patients with a low GAR (≤0.918).

CONCLUSIONS

The GAR is a useful predictor of postoperative survival among patients with HCC undergoing potentially curative LR.

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

BACKGROUND

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

METHODS

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

RESULTS

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p = 0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p = 0.115).

CONCLUSION

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

Anatomical versus non-anatomical liver resection for hepatocellular carcinoma exceeding Milan criteria

BACKGROUND

Liver resection is effective for hepatocellular carcinoma (HCC) exceeding the Milan criteria in selected patients. However, the benefit of anatomical resection (AR) versus non-anatomical resection (NAR) has not been clarified in this patient subgroup. This study aimed to compare outcomes between AR and NAR for HCC exceeding the Milan criteria.

METHODS

Data on consecutive patients with HCC exceeding the Milan criteria who underwent liver resection with curative intent over a recent 6-year interval were extracted from a prospective single-centre HCC database and examined retrospectively. The postoperative outcomes of patients were compared before and after propensity score matching.

RESULTS

Some 546 patients were included: 264 in the AR and 282 in the NAR group. In the original cohort, the AR group contained more patients with larger tumours, multiple tumours, macroscopic portal vein tumour thrombi, incomplete tumour capsules and microscopic vascular invasion. After propensity score matching, 177 pairs of patients were selected. The baseline data, including liver function and tumour burden, were similar in the matched groups. The 3-year recurrence-free survival rate was comparable between the matched NAR and AR groups (36·5 versus 28·5 per cent; P = 0·448). Similar results were observed for 3-year overall survival (57·5 versus 50·3 per cent; P = 0·385), recurrence patterns and early recurrence rates (57·6 per cent versus 59·9 per cent; P = 0·712).

CONCLUSION

AR and NAR achieved favourable and similar outcomes for HCC exceeding the Milan criteria in selected patients.