Is less than 5 mm as the narrowest surgical margin width in central resections of hepatocellular carcinoma justified?

Phase 2 Evaluation of Neoadjuvant Intensity-Modulated Radiotherapy in Centrally Located Hepatocellular Carcinoma: A Nonrandomized Controlled Trial

Importance

Centrally located hepatocellular carcinoma (HCC) is a special type of HCC whose outcome is unsatisfactory when treated with surgery alone. No standard adjuvant or neoadjuvant treatment for this disease has been established that improves clinical outcomes.

Objective

To evaluate the effectiveness and safety of adding neoadjuvant intensity-modulated radiotherapy (IMRT) before surgery in patients with centrally located HCC.

Design, Setting, and Participants

This phase 2, single-center, single-group prospective nonrandomized controlled trial was conducted between December 16, 2014, and January 29, 2019, at the Cancer Institute and Hospital of the Chinese Academy of Medical Sciences in Beijing, China. The last follow-up was on July 30, 2021. Patients with centrally located HCC who underwent neoadjuvant IMRT and surgery were included in the analysis.

Interventions

Neoadjuvant IMRT followed by hepatectomy.

Main Outcomes and Measures

The primary end point was 5-year overall survival (OS). The secondary end points were tumor response to IMRT, 5-year disease-free survival (DFS), and treatment-related adverse events.

Results

Thirty-eight patients (mean [SD] age, 55.6 [9.3] years; 35 male [92.1%] individuals) completed the prescribed neoadjuvant IMRT without interruption. Radiographic tumor response to IMRT before surgery included partial response (16 [42.1%]) and stable disease (22 [57.9%]). Thirteen patients (34.2%) achieved major pathological response, of which 5 (13.2%) achieved pathologic complete response. With a median follow-up of 45.8 months, the median OS was not reached, and the OS rates were 94.6% at 1 year, 75.4% at 3 years, and 69.1% at 5 years. The median DFS was 45.8 months, and DFS rates were 70.3% at 1 year, 54.1% at 3 years, and 41.0% at 5 years. Radiotherapy-related grade 3 adverse events were observed in 3 patients (7.9%). Nineteen operative complications developed in 13 patients (34.2%), including grade I to II complications in 12 patients (31.6%) and grade IIIa complication in 1 patient (2.6%). No grade IIIb or higher operative complications were observed.

Conclusions and Relevance

Results of this trial suggest that neoadjuvant IMRT plus surgery is effective and well-tolerated in patients with centrally located HCC. These data may inform a future randomized clinical trial of this new treatment strategy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02580929.

Long-Term Outcome of Centrally Located Hepatocellular Carcinomas Treated by Radical Resection Combined With Intraoperative Electron Radiotherapy (IOERT)

Purpose

To explore the feasibility and safety of centrally located hepatocellular carcinoma (CL-HCC) treated by narrow-margin resection combined with intraoperative electron radiotherapy (IOERT).

Methods and Materials

From November 2009 to November 2016, 37 consecutive patients were treated with IOERT as adjuvant treatment during narrow-margin resection for CL-HCC. Long-term outcomes, adverse events for surgery, and acute and chronic toxicities were analyzed.

Results

The median follow-up was 57.82 months (range, 3.75-111.41 months). A total dose of 15 Gy (range 12 to 17Gy) (prescribed at the 90% isodose) was delivered with a 0.9cm (range 0.8-1.2 cm) median treatment depth targeting the narrow-margin. The 1-year, 3-year and 5-year OS rates were 91.39%, 88.34% and 88.34%, respectively. The 1-year, 3-year and 5-year DFS rates were 80.81%, 68.59% and 54.17%, respectively. In the univariate analysis, none of the treatment characteristics were predictive of overall survival. Fifteen (40.5%) patients suffered from a recurrence event. No patient had marginal recurrence. The 1-year, 3-year and 5-year intrahepatic recurrence rates were 19.75%, 25.92% and 39.58%, respectively. The 1-year, 3-year and 5-year extrahepatic recurrence rates were 2.7%, 5.95% and 9.87%, respectively. There was no 30-day surgical-related death. Three patients had grade 4, and 28 patients had grade 3 alanine aminotransferase (ALT) levels, and seven patients had grade 4, and 30 patients had grade 3 aspartate transaminase (AST) levels. All of them returned to normal within four months. There was no acute radiation-induced liver injury during follow-up. There were no acute or chronic toxicities associated with IOERT.

Conclusion

IOERT for narrow-margin CL-HCC may achieve good long-term survival outcomes, without significantly increasing acute and chronic toxicities. An IOERT dose of 15Gy may be the safest and most feasible. IOERT might be considered as an adjuvant therapy for CL-HCC patients with a narrow-margin.

Phase 2 Study of Adjuvant Radiotherapy Following Narrow-Margin Hepatectomy in Patients With HCC

BACKGROUND AND AIMS

Surgical resection is the primary treatment for HCC; however, it is associated with a high rate of recurrence and death. We conducted this phase 2 study to investigate the efficacy and safety of postoperative intensity-modulated radiotherapy (IMRT) for HCC after narrow-margin hepatectomy.

APPROACH AND RESULTS

We designed a single-arm, prospective phase 2 trial to evaluate overall survival (OS), disease-free survival (DFS), recurrence patterns, and toxicity in patients receiving adjuvant radiotherapy. The eligibility criteria included the following: pathological diagnosis of HCC after hepatectomy, with narrow pathological margins (< 1 cm); age > 18 years; and Eastern Cooperative Oncology Group performance status score of 0 or 1. Patients received IMRT within 4-6 weeks after surgical resection. This trial was registered at ClinicalTrials.gov (NCT01456156). Between 2008 and 2016, a total of 76 eligible patients who underwent narrow-margin resection were enrolled. The median follow-up duration was 70 months; the 3-year OS and DFS rates were 88.2% and 68.1%, respectively; and the 5-year OS and DFS rates were 72.2% and 51.6%, respectively. Intrahepatic recurrence was the primary recurrence pattern. No marginal recurrence was found. Intrahepatic, extrahepatic, and combined recurrences at the first relapse were found in 33, 5, and 1 patient, respectively. The most common radiation-related grade-3 toxicities were leukopenia (7.9%), elevated alanine aminotransferase (3.9%) and aspartate aminotransferase (2.6%) levels, and thrombocytopenia (1.3%). Classical or nonclassical radiation-induced liver disease was not noted.

CONCLUSIONS

Adjuvant radiotherapy is an effective, well-tolerated, and promising adjuvant regimen in patients with HCC who have undergone narrow-margin hepatectomy. Our trial provides evidence and a rationale for planning a future phase 3 trial.

State-of-the-art surgery for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most commonly diagnosed primary liver tumor with an increasing incidence worldwide. Management of patients with HCC is largely dictated by the presence of cirrhosis, disease stage, underlying liver function, and patient performance status.

PURPOSE

We provide an update on key aspects of surgical treatment options for patients with HCC. RESULTS & CONCLUSIONS: Liver resection and transplantation remain cornerstone treatment options for patients with early-stage disease and constitute the only potentially curative options for HCC. Selection of patients for surgical treatment should include a thorough evaluation of tumor characteristics and biology, as well as evidence-based use of various available treatment options to achieve optimal long-term outcomes for patients with HCC.

Effect of surgical margin on postoperative prognosis in patients with solitary hepatocellular carcinoma: A propensity score matching analysis

Objective: The effect of surgical margin (SM) on the postoperative prognosis of patients with solitary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the effect of SM on the postoperative prognosis of patients with solitary HCC by using propensity score matching (PSM).

Methods: Patients with solitary HCC who underwent liver resection were divided into a wide margin group (1.0 cm or more, group W) and a narrow margin group (< 1.0 cm, group N). Progression-free survival (PFS) and overall survival (OS) associated with the SM status and the factors influencing postoperative prognosis were evaluated.

Results: Before PSM, the indicators were not balanced between the two groups. PFS and OS were significantly lower in group N than group W. The factors affecting postoperative prognosis were international normalized ratio (INR), AST, capsule integrity, microvascular invasion, tumour embolus and tumour size. After PSM, data of both groups were balanced and comparable, and no significant differences in OS or PFS between the two groups. The INR in the above affecting factors was excluded.

Conclusion: For solitary HCC patients with negative SMs, SM size does not affect prognosis. INR, AST, capsule integrity, microvascular invasion, tumour embolus and tumour size are independent factors influencing the postoperative prognosis of solitary HCC patients.

Narrow-Margin Hepatectomy Resulted in Higher Recurrence and Lower Overall Survival for R0 Resection Hepatocellular Carcinoma

Purpose

To evaluate the impact of resection margin on recurrence pattern and survival for hepatocellular carcinoma (HCC) with narrow margin resection, with the aim to guide postoperative treatment.

Materials and Methods

Two hundred forty HCC patients after curative hepatectomy between 2014 and 2016 were reviewed retrospectively. The cases were divided into narrow-margin (width of resection margin <1cm, n=106) and wide-margin (width of resection margin ≥1cm, n=134) groups based on the width of resection margin. Recurrence pattern, recurrence-free survival (RFS), and overall survival (OS) were compared between the above two groups. An additional cohort of nine cases with positive margin plus post-operative stereotactic body radiotherapy (SBRT) was also analyzed for the recurrence pattern.

Results

Postoperative recurrence was found in 128 (53.3%) patients. The recurrence rate was significantly higher in narrow-margin group than that in wide-margin group (P=0.001), especially for the pattern of marginal recurrence (20.8 vs. 4.5%, P=0.003). The 1-, 2-, 3-year RFS rates for the narrow-margin and wide-margin groups were 55.8, 43.9, 36.9, and 78.7, 67.9, 60.2%, respectively, with significant difference between the two groups (P<0.001). Patients with narrow margin showed a tendency of decreased OS than those with wide margin (P<0.001). As comparison, the nine cases with positive margin treated with postoperative SBRT showed low recurrence rate and no marginal recurrence was found.

Conclusion

Patients with narrow resection margin were associated with higher recurrence rate and worse survival than those with wide resection margin. These patients may benefit from adjuvant local treatment, such as radiotherapy.

Impact on Oncological Outcomes and Intent-to-Treat Survival of Resection Margin for Transplantable Hepatocellular Carcinoma in All-Comers and in Patients with Cirrhosis: A Multicenter Study

BACKGROUND

The outcomes of liver resection (LR) with a narrow margin in patients with transplantable hepatocellular carcinoma (HCC) have not been studied. The aim was to assess whether narrow margin following up-front LR impacts the incidence, timing, pattern, and transplantability of tumor recurrence in patients with initially transplantable HCC.

METHODS

All initially transplantable HCC patients undergoing hepatectomy with either narrow (<10 mm) or wide (≥10 mm) margins from 2007 to 2016 at four Western university centers were compared in terms of recurrence, transplantability of recurrence, recurrence-free survival (RFS), and intention-to-treat overall survival (ITT-OS). Independent predictors of non-transplantability of recurrence were assessed.

RESULTS

This study included 187 patients (narrow group, n = 107 vs. wide group, n = 80). Recurrence was significantly more frequent in the narrow margin group (44% vs. 26%; p = 0.01) with a shorter RFS (p = 0.03). The transplantability of recurrence and ITT-OS were, however, not different between the two groups. The presence of satellite nodules on the resected specimens emerged as the sole independent predictor of non-transplantability of tumor recurrence. The stratification of the analysis according to the presence of cirrhosis achieved essentially the same results as in the whole study population.

CONCLUSIONS

Narrow margin was associated with a higher tumor recurrence rate and a shorter RFS for patients with initially transplantable HCC. However, transplantability of recurrence and long-term ITT-OS were not impaired.

Ideal Surgical Margin to Prevent Early Recurrence After Hepatic Resection for Hepatocellular Carcinoma

BACKGROUNDS AND AIMS

Postoperative early recurrence after hepatic resection for hepatocellular carcinoma (HCC) poses a challenge to surgeons, and the effect of a surgical margin is still controversial. This study aimed to identify an ideal margin to prevent early recurrence.

METHODS

A total of 226 consecutive patients who underwent primary curative hepatic resection for solitary and primary HCC were enrolled. The definition of early recurrence was determined using the minimum P value approach. Logistic regression analysis was used to identify the risk factors of early recurrence. The receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off of the surgical margin and early recurrence.

RESULTS

Recurrence within 8 months induced the poorest overall survival (P = 2×10^-15). ROC analysis showed that the optimal cut-off value of the surgical margin was 7 mm. The risk factors of early recurrence (≤ 8-month recurrence) were preoperative alpha-fetoprotein levels ≥ 100 ng/ml (Odds ratio [OR] 4.92 [2.28-10.77], P < 0.0001) and a surgical margin < 7 mm (OR 3.09 [1.26-8.85], P = 0.01) by multivariable analysis. The probability of early recurrence ranged from 5.0% in the absence of any factors to 43.5% in the presence of both factors. Among patients with alpha-fetoprotein levels ≥ 100 ng/ml, non-capsule formation, or microvascular invasion, there was a significant difference in 5-year overall survival between surgical margins of < 7 mm and ≥ 7 mm.

CONCLUSIONS

A > 7-mm margin is important to prevent early recurrence. Patients with HCC and alpha-fetoprotein levels > 100 ng/ml, non-capsule formation, or microvascular invasion may have a survival benefit from a ≥ 7-mm margin.

Effect of surgical margin on recurrence based on preoperative circulating tumor cell status in hepatocellular carcinoma

Background

High rates of recurrence after resection severely worsen hepatocellular carcinoma (HCC) prognosis. This study aims to explore whether circulating tumor cell (CTC) is helpful in determine the appropriate liver resection margins for HCC patients.

Methods

HCC patients who underwent liver resection were enrolled into training (n=117) or validation (n=192) cohorts, then classified as CTC-positive (CTC≥1) or CTC-negative (CTC=0). A standardized pathologic sampling method was used in the training cohort to quantify microvascular invasion (mVI) and the farthest mVI from the tumor (FMT).

Findings

CTC number positively correlated with mVI counts (r=0.655, P<0.001) and FMT (r=0.495, P<0.001). The CTC-positive group had higher mVI counts (P=0.032) and greater FMT P=0.008) than the CTC-negative group. In the CTC-positive group, surgical margins of >1 cm independently protected against early recurrence (training cohort, P=0.004; validation cohort, P=0.001) with lower early recurrence rates (training cohort, 20.0% vs. 65.1%, P=0.005; validation cohort, 36.4% vs. 65.1%, P=0.003) compared to surgical margins of ≤1 cm. No differences in postoperative liver function were observed between patients with margins >1 cm vs. ≤1 cm. Surgical margin size minimally impacted early postoperative HCC recurrence in CTC-negative patients when using 0.5 cm or 1 cm as the threshold.

Interpretations

Preoperative CTC status predicts mVI severity in HCC patients and is a potential factor for determining optimal surgical margin size to ensure disease eradication and conserve liver function. A surgical margin of >1 cm should be achieved for patients with positive CTC.

Funding

A full list of funding bodies that contributed to this study can be found in the Acknowledgement section.

"Logic-Based Medicine" Is More Feasible than "Evidence-Based Medicine" in the Local Treatment for Hepatocellular Carcinoma

The optimal type of surgery (e.g., anatomic or non-anatomic resection) or radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is still under debate despite numerous comparative studies based on overall survival. This debate continues not only because these endpoints are influenced by non-surgical factors, such as liver function, but because the definition of non-anatomic resection for HCC has remained unclear. The optimal surgery could be logically determined based on the mechanism of local intrahepatic metastasis, that is, the drainage of tumour blood flow (TBF), because HCC spreads locally through tumour blood flowing to the peri-tumourous liver parenchyma. Since TBF is clearly demonstrated by CT scan under hepatic arteriography, the surgical margin can be determined individually based on the drainage of TBF without deteriorating local curability. Controversy regarding RFA and surgery does not result from the curability of treatment itself but from the lack of scientific evidence on safety margins. Based on proper concepts and self-evident truths, an algorithm of loco-regional treatment for HCC is proposed.

Impact of narrow margin and R1 resection for hepatocellular carcinoma on the salvage liver transplantation strategy. An intention-to-treat analysis

BACKGROUND

No studies have investigated whether narrow margin is a risk factor for hepatocellular carcinoma recurrence outside transplantability criteria. The objective was to assess on an intent-to-treat (ITT) basis whether hepatectomy with narrow margin affects the outcomes in patients enrolled in the salvage liver transplantation (LT) strategy.

METHODS

From 2007 to 2016, patients enrolled in the salvage LT strategy were divided into 2 groups: narrow (<10 mm) vs. wide (≥10 mm) margin groups. R1 resection was defined as positive histologic margin involvement. Recurrence rate, transplantability rate of recurrence and ITT overall survival (ITT-OS) were evaluated.

RESULTS

A total of 81 patients were studied: 43 patients with narrow margin and 38 with wide margin. The recurrence rates, pattern and delay of recurrence, transplantability following recurrence, and ITT-OS were similar between the two groups. These results were maintained when comparing patients with R1 resection to those with R0 resection.

CONCLUSION

On an ITT basis, hepatectomy with narrow margin or R1 resection did not impair the transplantability of recurrence and survival of patients enrolled in the salvage LT strategy. Narrow margin and even R1 resection following hepatectomy in the setting of salvage LT strategy should not be the basis for altering the strategy.

Tropism of liver epithelial cells toward hepatocellular carcinoma in vitro and in vivo with altering gene expression of cancer stem cells

BACKGROUND

Rat liver epithelial (RLE) cells could inhibit the proliferation and invasiveness of hepatoma cells in vitro. This study is to understand the tropism and the effect of RLE cells on mouse hepatoma cells both in vitro and in vivo.

METHODS

RLE cells were isolated from new-born rats and characterized their stem cell markers. Co-culture and HCC mouse model was established to detect therapeutic effect of RLE cells.

RESULTS

RLE cells (including Thy-1⁺ RLE cells, Thy-1^- RLE cells, RLE cells) displayed a selective tropism toward ML-1 hepatoma cells both in vitro and in vivo. They altered the gene expression of some cancer stem cell markers in the liver tumor.

CONCLUSION

Liver epithelial cells have a selective tropism toward HCC in vitro and in vivo. They could alter the gene expression of cancer stem cells.

Prognostic impact of surgical margin in patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND

Surgical margin is an important prognostic factor in hepatectomy for patients with hepatocellular carcinoma (HCC). But the extent of surgical margins is still controversial. Our study was designed to systematically evaluate the prognosis of different width of resection margin.

METHODS

We conducted comprehensive searches of electronic databases including PubMed, MEDLINE, EMBASE, Cochrane, and the ISI Web of Science for relevant studies. A meta-analysis was performed by RevMan 5.3 software.

RESULTS

A total of 7 studies comprising 1932 patients were included. The patients with wider surgical margin were significantly higher than those with narrow surgical margin on 3-year overall survival (odds ratio [OR]: 1.58, 95% confidence interval (95% CI): 1.21-2.06, P = .0008), 5-year overall survival (OR: 1.76, 95% CI: 1.20-2.59, P = .004), 1-year disease-free survival (DFS)/recurrence-free survival (RFS) (OR: 1.43, 95% CI: 1.12-1.82, P = .005), 3-year DFS/RFS (OR: 1.66, 95% CI: 1.35-2.03, P < .00001), and 5-year DFS/RFS (OR: 1.69, 95% CI: 1.37-2.08, P < .00001). There was no significant difference in the 1-year overall survival rate for the 2 groups (OR: 1.24, 95% CI: 0.89-1.72, P = .20).

CONCLUSION

In comparison with the narrow surgical margin group (<1 cm), the wide surgical margin (≥1 cm) can significantly improve the prognosis in patients with HCC.

Wide versus narrow margins after partial hepatectomy for hepatocellular carcinoma: Balancing recurrence risk and liver function

BACKGROUND

The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved.

METHODS

A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 ("narrow") and >5 mm ("wide") as measured on final pathologic assessment.

RESULTS

One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85).

CONCLUSIONS

A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence.

Effect of surgical margin in R0 hepatectomy on recurrence-free survival of patients with solitary hepatocellular carcinomas without macroscopic vascular invasion

The study aimed to investigate the impact of different surgical margins on recurrence-free survival (RFS) of patients with solitary hepatocellular carcinoma (HCC) without macroscopic vascular invasion.The data of 586 selected patients who underwent curative hepatectomy for HCC between 2001 and 2012 were analyzed. The patients were divided into the anatomic resection and the nonanatomic resection groups according to the surgical approaches. Each group was further divided into group A (surgical margin <5 mm), group B (5 mm ≤ surgical margin < 10 mm), and group C (surgical margin ≥10 mm). Relationship between surgical margins and RFS in different groups was established by receiver operating characteristic curve and Kaplan-Meier analyses.The RFS of the anatomic resection group was significantly longer than that of the nonanatomic resection group (P = 0.026). There were no statistical differences in RFS between groups A, B, and C (PA VS B = 0.512, PA VS C = 0.272, PB VS C = 0.822, nA = 38, nB = 43, nC = 80) in the anatomic resection group while in the nonanatomic resection group, RFSs of groups B and C were longer than that of group A (PA VS B = 0.009, PA VS C = 0.000, PB VS C = 0.505, nA = 151, nB = 119, nC = 155).The analytic results suggest that if the patients with solitary HCC without macroscopic vascular invasion fall in the anatomic resection group, a minimal surgical margin (≥0 mm) is probably appropriate for hepatectomy; however, in cases of the nonanatomic resection, a surgical margin ≥5 mm should be regarded suitable for surgery of HCC.

Survival benefit with IMRT following narrow-margin hepatectomy in patients with hepatocellular carcinoma close to major vessels

BACKGROUND & AIMS

To investigate the role of post-operative intensity-modulated radiotherapy (IMRT) in patients receiving narrow-margin hepatectomy for hepatocellular carcinoma (HCC) located close to the major vessels.

METHODS

This exploratory study involved 181 HCC patients. Of them, 116 were treated with narrow-margin (<1.0 cm) hepatectomy. Thirty-three of the 116 underwent postoperative IMRT (Group A), while 83 did not receive radiotherapy (Group B). The remaining 65 patients underwent wide-margin (≥1.0 cm) hepatectomy (Group C). Prognosis and patterns of recurrence were assessed in the three groups.

RESULTS

The 3-year overall survival (OS) and disease-free survival (DFS) rates were 89.1 and 64.2% in Group A, 67.7 and 52.2% in Group B and 86.0 and 60.1% in Group C respectively. The OS and DFS of Group A and Group C patients surpassed those of Group B patients (Group A vs. B, P = 0.009 and P = 0.038; and Group C vs. B, P = 0.002 and P = 0.010). Patients in Groups A and C experienced significantly fewer early recurrences than did patients in Group B (P = 0.002). Furthermore, patients in Groups A and C experienced substantially fewer intrahepatic marginal (P = 0.048) and diffuse recurrences (P = 0.018) and extrahepatic metastases (P = 0.038) than did patients in Group B. No patient developed radiation-induced liver disease.

CONCLUSIONS

Post-operative IMRT following narrow-margin hepatectomy may be a favourable therapy for both its safety profile and clinical benefit in patients with HCC located close to the major vessels.

Central hepatectomy versus extended hepatectomy for liver malignancy: a matched cohort comparison

OBJECTIVE

To compare surgical outcomes between matched central hepatectomy (CH) and extended hepatectomy (EH) groups.

BACKGROUND

Surgical choices for centrally located liver tumours are limited. The traditional EH harbours substantial risks, whereas CH is an alternative parenchymal-sparing resection that may improve peri-operative morbidity.

METHODS

A review of 4661 liver resections at a single institution was performed. The cases (CH) were matched in a 1:1 ratio with EH controls.

RESULTS

The CH group was matched for demographic, tumour and laboratory factors with either right EH or combined (right/left) EH groups (n = 63 per group). Colorectal liver metastases were the most common diagnosis occurring in 70% of the patients. Higher intra-operative blood loss was observed in the right EH(P = 0.01) and combined EH groups (P < 0.01) compared with the CH group. There was a trend towards lower 90-day morbidity in the CH group (43%) compared with the right EH(59%, P = 0.1) and combined EH groups (56%, P = 0.2). The length of hospital stay was significantly longer in the control groups (P < 0.01 for both). The control groups had significantly higher post-operative bilirubin and International Normalized Ratio (INR) levels compared with the CH group. A post-operative bilirubin higher than 4 mg/dl was observed in 2% of the CH group compared with 39% of the right EH group (P < 0.01) and 52% of the combined EH group (P < 0.01). No differences in the rates of bile leak/biloma, post-hepatectomy liver failure or 90-day mortality were found.

CONCLUSIONS

CH, as compared with EH, was safe and associated with a shorter hospital stay and less post-operative liver dysfunction. CH should be considered in patients with centrally located tumours amenable to such a resection.

Patterns of cancer recurrence in localized resected hepatocellular carcinoma

BACKGROUND

Tumor resection in non-metastatic hepatocellular carcinoma (HCC) patients with adequate liver reserve offers a potential cure, but has a high 5-year recurrence rate. We analyzed the patterns of cancer relapse after partial hepatectomy to guide post-operative management.

METHODS

A total of 144 HCC patients (1996-2011) after partial hepatectomy were reviewed. Statistical correlations were determined using univariate and partition analyses.

RESULTS

A median follow-up of 20 months showed recurrence in 71 (49%) patients, and the median time to recurrence was 11.9 months. Vascular invasion (P<0.01) and number of lesions (P<0.01) predicted for recurrence. Histologic grade was not correlated with recurrence. Twenty-two (31%) patients developed both surgical margin (SM) and concurrent intrahepatic recurrences, and 28 (40%) had non-SM intrahepatic recurrences with no other signs of recurrence. On partition analysis, the risk of marginal recurrence in patients with SM <1 mm and SM ≥1 mm was 35% and 13.5% respectively. Approximately 57% of patients with intrahepatic recurrence had recurrence ≤2.5 cm from SM.

CONCLUSIONS

Intrahepatic recurrence after partial hepatectomy is common and is significantly associated with vascular invasion and tumor stage. About 57% of patients with intrahepatic relapse had a recurrence close (≤2.5 cm) to the SM. Additionally, patients with SM <1 mm have a higher recurrence rate and may benefit from adjuvant local therapy.

Central hepatectomy for centrally located malignant liver tumors: A systematic review

AIM: To study whether central hepatectomy (CH) can achieve similar overall patient survival and disease-free survival rates as conventional major hepatectomies or not.

METHODS: A systematic literature search was performed in MEDLINE for articles published from January 1983 to June 2013 to evaluate the evidence for and against CH in the management of central hepatic malignancies and to compare the perioperative variables and outcomes of CH to lobar/extended hemihepatectomy.

RESULTS: A total of 895 patients were included from 21 relevant studies. Most of these patients who underwent CH were a sub-cohort of larger liver resection studies. Only 4 studies directly compared Central vs hemi-/extended hepatectomies. The range of operative time for CH was reported to be 115 to 627 min and Pringle’s maneuver was used for vascular control in the majority of studies. The mean intraoperative blood loss during CH ranged from 380 to 2450 mL. The reported morbidity rates ranged from 5.1% to 61.1%, the most common surgical complication was bile leakage and the most common cause of mortality was liver failure. Mortality ranged from 0.0% to 7.1% with an overall mortality of 2.3% following CH. The 1-year overall survival (OS) for patients underwent CH for hepatocellular carcinoma ranged from 67% to 94%; with the 3-year and 5-year OS having a reported range of 44% to 66.8%, and 31.7% to 66.8% respectively.

CONCLUSION: Based on current literature, CH is a promising option for anatomical parenchymal-preserving procedure in patients with centrally located liver malignancies; it appears to be safe and comparable in both perioperative, early and long term outcomes when compared to patients undergoing hemi-/extended hepatectomy. More prospective studies are awaited to further define its role.

Cancer concepts and principles: primer for the interventional oncologist-part II

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.