Clinical efficacy and predictors of outcomes of repeat hepatectomy for recurrent hepatocellular carcinoma - a systematic review

Survival benefit of second line therapies for recurrent hepatocellular carcinoma: repeated hepatectomy, thermoablation and second-line transplant referral in a real life national scenario

BACKGROUND

Despite second-line transplant(SLT) for recurrent hepatocellular carcinoma(rHCC) leads to the longest survival after recurrence(SAR), its real applicability has never been reported. The aim was to compare the SAR of SLT versus repeated hepatectomy and thermoablation(CUR group).

METHODS

Patients were enrolled from the Italian register HE.RC.O.LE.S. between 2008 and 2021. Two groups were created: CUR versus SLT. A propensity score matching (PSM) was run to balance the groups.

RESULTS

743 patients were enrolled, CUR = 611 and SLT = 132. Median age at recurrence was 71(IQR 6575) years old and 60(IQR 53-64, p < 0.001) for CUR and SLT respectively. After PSM, median SAR for CUR was 43 months(95%CI = 37 - 93) and not reached for SLT(p < 0.001). SLT patients gained a survival benefit of 9.4 months if compared with CUR. MilanCriteria(MC)-In patients were 82.7% of the CUR group. SLT(HR 0.386, 95%CI = 0.23 - 0.63, p < 0.001) and the MELD score(HR 1.169, 95%CI = 1.07 - 1.27, p < 0.001) were the only predictors of mortality. In case of MC-Out, the only predictor of mortality was the number of nodules at recurrence(HR 1.45, 95%CI= 1.09 - 1.93, p = 0.011).

CONCLUSION

It emerged an important transplant under referral in favour of repeated hepatectomy or thermoablation. In patients with MC-Out relapse, the benefit of SLT over CUR was not observed.

Prognosis of repeat hepatectomy for liver transplantable hepatocellular carcinoma recurrence after hepatectomy: a Retrospective Cohort Study with the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO)

PURPOSE

Factors affecting the prognosis of repeat hepatectomy for transplantable hepatocellular carcinoma (HCC) recurrence after hepatectomy remain unclear. We aimed to clarify the prognostic factors for transplantable hepatocellular carcinoma recurrence after hepatectomy.

METHODS

We included 1758 primary and 486 repeat hepatectomies out of 2244 for HCC performed between 2006 and 2017 using the Hiroshima Study Group for Clinical Oncology and Surgery database. We first compared survival rates of primary and repeat hepatectomy patients. Subsequently, prognostic factors were analyzed in patients who underwent a repeat hepatectomy for transplantable hepatocellular carcinoma recurrence after hepatectomy (defined as age < 70 years at the time of recurrence and recurrent tumor morphology that meets the Milan criteria).

RESULTS

The 5-year overall survival rate (OS) after repeat hepatectomy was 63.2%, while the 5-year recurrence-free survival rate (RFS) was 23.7%. RFS demonstrated significant inferiority in the repeat hepatectomy group than in the primary hepatectomy group; however, OS did not present a notable difference between the two cohorts. In the transplantable recurrence group, mALBI grade 2b, max tumor size > 20 mm, and multiple tumors were independent prognostic risk factors for overall survival. Patients with two or more risk factors had a significantly lower survival rate (only 30.6% at 5 years) compared to those with one or fewer risk factors (81.8% at 5 years).

CONCLUSIONS

We identified the risk factors involved in post-hepatectomy survival for patients with transplantable recurrence after hepatectomy. The results are a potential indicator of whether salvage liver transplantation should be considered during repeat hepatectomy.

Ablative strategies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is the fifth leading cause of cancer death worldwide and the third leading cause of all diseases worldwide. Liver transplantation, surgical resection and ablation are the three main curative treatments for HCC. Liver transplantation is the optimal treatment option for HCC, but its usage is limited by the shortage of liver sources. Surgical resection is considered the first choice for early-stage HCC, but it does not apply to patients with poor liver function. Therefore, more and more doctors choose ablation for HCC. However, intrahepatic recurrence occurs in up to 70% patients within 5 years after initial treatment. For patients with oligo recurrence after primary treatment, repeated resection and local ablation are both alternative. Only 20% patients with recurrent HCC (rHCC) indicate repeated surgical resection because of limitations in liver function, tumor location and intraperitoneal adhesions. Local ablation has become an option for the waiting period when liver transplantation is unavailable. For patients with intrahepatic recurrence after liver transplantation, local ablation can reduce the tumor burden and prepare them for liver transplantation. This review systematically describes the various ablation treatments for rHCC, including radiofrequency ablation, microwave ablation, laser ablation, high-intensity focused ultrasound ablation, cryablation, irreversible electroporation, percutaneous ethanol injection, and the combination of ablation and other treatment modalities.

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.

An alternative option of the retroperitoneal laparoscopic approach for limited hepatectomy for recurrent hepatocellular carcinoma at the transected edge after previous hepatectomy

Laparoscopic hepatectomy is safely performed with minimal invasiveness on patients with recurrent liver tumors after previous hepatectomy. However, it is still difficult to dissect and expose the operative field at the transected edge or plane after open right hepatectomy, even for limited resection by a laparoscopic approach, due to severe adhesion to the surrounding peritoneum or organs. We herein applied the retroperitoneal laparoscopic approach to limited resection of the dorsal surface at the transected edge of Couinaud's segment 6 after previous repeated hepatectomies in a patient with recurrent hepatocellular carcinoma (HCC) by avoiding severe intra-abdominal adhesion. We safely resected recurrent HCC via the retroperitoneal space. This approach is a useful and alternative option for laparoscopy which minimizes the dissecting time and avoids organ injury on the right side of the transected area of the liver after hepatectomy in patients with liver malignancies.

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.

Treatment of recurrent hepatocellular carcinoma following liver resection, ablation or liver transplantation

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and causes one third of cancer related deaths world-wide. Approximately one third of patients with HCC are eligible for curative treatments that include hepatic resection, liver transplantation or imaging guided tumor ablation. Recurrence rates after primary therapy depends on tumor biology and pre-treatment tumor burden with early recurrence rates ranging from 30%-80% following surgical resection and ablation. HCC recurs in over ten percent following liver transplantation for HCC. Treatment modalities for tumor recurrence following resection and ablation include repeat liver resection, salvage liver transplantation, locoregional therapies, and systemic chemotherapy/immunotherapy. Locoregional and immune mediated therapies are limited for patients with tumor recurrence following liver transplantation given potential immune related allograft rejection. Given the high HCC recurrence rates after primary tumor treatment, it is imperative for the clinician to review the appropriate treatment strategy for this disease entity. This article will review the current literature regarding HCC recurrence after primary curative therapies and will discuss the relevant future trends in the HCC field.

Application of hazard functions to investigate recurrence after curative-intent resection for hepatocellular carcinoma

BACKGROUND

Defining patterns and risk of recurrence can help inform surveillance strategies and patient counselling. We sought to characterize peak hazard rates (pHR) and peak time of recurrence among patients who underwent resection of hepatocellular carcinoma (HCC).

METHODS

1434 patients who underwent curative-intent resection of HCC were identified from a multi-institutional database. Hazard, patterns, and peak rates of recurrence were characterized.

RESULTS

The overall hazard of recurrence peaked at 2.4 months (pHR: 0.0384), yet varied markedly. The incidence of recurrence increased with Barcelona Clinic Liver Cancer (BCLC) stage 0 (29%), A (54%), and B (64%). While the hazard function curve for BCLC 0 patients was relatively flat (pHR: <0.0177), BCLC A patients recurred with a peak at 2.4 months (pHR: 0.0365). Patients with BCLC B had a bimodal recurrence with a peak rate at 4.2 months (pHR: 0.0565) and another at 22.8 months. The incidence of recurrence also varied according to AFP level (≤400 ng/mL: 52.6% vs. >400 ng/mL: 36.3%) and Tumor Burden Score (low: 73.7% vs. medium: 50.6% vs. high: 24.2%) (both p < 0.001).

CONCLUSION

Recurrence hazard rates for HCC varied substantially relative to both time and intensity/peak rates. TBS and AFP markedly impacted patterns of hazard risk of recurrence.

Surgical Strategies for Recurrent Hepatocellular Carcinoma after Resection: A Review of Current Evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, and both liver resection and liver transplantation are considered potentially curative options. However, high recurrence rates affect the prognosis depending both on the primary HCC pathology characteristics or on the type and time of the relapse. While great attention has been usually posted on treatment algorithms for the first HCC, treatment algorithms for recurrent HCC (rHCC) are lacking. In these cases, surgery still represents a curative option with both redo hepatectomy and/or salvage liver transplantation, which are considered valid treatments in selected patients. In the current era of personalised medicine with promises of new systemic-targeted immuno-chemotherapies, we wished to perform a narrative review of the literature on the role of surgical strategies for rHCC.

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.

Laparoscopic repeat hepatectomy versus conventional open repeat hepatectomy for recurrent hepatocellular carcinoma: A systematic review and meta-analysis

Background

Repeat hepatectomy has been proven to be an effective treatment in patients with recurrent hepatocellular carcinoma (RHCC). However, for RHCC, it is still controversial whether laparoscopic hepatectomy is superior to conventional ones. The present meta-analysis was carried out to investigate the safety and overall effect of laparoscopic repeat hepatectomy (LRH) to open repeat hepatectomy (ORH) for patients with RHCC.

Methods

A meta-analysis was registered at PROSPERO, and the registration number is CRD42021257569. PubMed, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before 25 April 2022. Data on operative times, bleeding volume, overall complications, 90-day mortality, blood transfusion, length of stay, overall survival rate, and long-term recurrence-free survival rate were subjected to meta-analysis.

Results

Overall, we identified nine studies of LRH versus ORH enrolling a total of 945 patients (460 and 485 underwent LRH and ORH, respectively). The present meta-analysis revealed non-significant differences in operative time, blood transfusion, overall complications, 90-day mortality, 3-year overall survival rate, 5-year overall survival rate, and long-term recurrence-free survival rate between the two groups. Alternatively, comparing LRH with ORH, LRH has less bleeding volume (p < 0.001) and a shorter length of stay (p = 0.005).

Conclusion

LRH is a feasible and effective treatment strategy for RHCC.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier CRD42021257569.

Surgical resection versus radiofrequency ablation for early recurrent hepatocellular carcinoma

BACKGROUND

Surgical resection (SR) and radiofrequency ablation (RFA) are reasonable treatment options for early recurrent hepatocellular carcinoma (rHCC), but it is still uncertain which treatment is better. The purpose of this study was to compare the therapeutic effects of SR and RFA on patients with early rHCC.

METHODS

This study enrolled 168 patients with early rHCC who underwent SR or RFA. The progression-free survival (PFS), overall survival (OS), and complications between the treatment groups for the total and propensity score-matched (PSM) cohorts were compared.

RESULTS

Before PSM, the 1-, 3-, 5-year OS (94.8%, 63.0%, 36.1% vs. 93.8%, 58.5%, 35.4%, P  = 0.580) and PFS (50.7%, 22.7%, 12.0% vs. 68.8%, 30.3%, 15.9%, P  = 0.224) were similar in RFA group and the SR group. After PSM, the 1-, 3-, 5-year OS (95.5%, 71.1%, 53.3% vs. 95.5%, 58.0%, 42.1%, P  = 0.285) and PFS (50%, 36.4%, 27.3% vs. 68.2%, 25.6%, 12.8%, P  = 0.999) were similar in the RFA group and the SR group. For patients with early recurrent tumors ≤3 cm, RFA and SR could achieve similar curative effects. However, SR was superior to RFA in terms PFS for patients with early recurrent tumors >3 cm, but the OS was similar. For all patients, RFA had significantly fewer complications and shorter hospitalization time compared with SR.

CONCLUSION

SR achieves better tumor control compared with RFA for patients with early rHCC (>3 cm) after SR. RFA had significantly fewer complications and shorter hospitalization time compared with SR for all patients.

Comparison of the efficacy and safety of repeated hepatectomy and radiofrequency ablation in the treatment of primary recurrent liver cancer: a meta-analysis

Background

Since there is still controversy about the comparison of the efficacy and safety of RH and RFA in the treatment of recurrent liver cancer, we conducted a meta-analysis to compare the efficacy and safety, in order to provide evidence-based evidence for future research and clinical treatment.

Methods

We searched PubMed, Embase, and Cochrane Library from the establishment of the database to Feb 2021. We included studies that reported liver cancer patients underwent repeated hepatectomy (RH) or radiofrequency ablation (RFA), and we excluded duplicate publications, research without full text, incomplete information, or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. The STATA 15.1 was used to analyze the data.

Results

The pooled results show that the 3-year and 5-year overall survival (OS) rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (odds ratio (OR) = 1.95, 95% confidence interval (CI):1.47–2.60, P ≤ 0.001; OR = 1.65, 95% CI: 1.12–2.43, P = 0.012). Similarly, the pooled results show that the 3-year and 5-year disease-free survival (DFS) rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (OR = 1.73, 95% CI: 1.30–2.31, P ≤ 0.001; OR = 1.84, 95% CI: 1.38–2.49, P ≤ 0.001). However, there is no significant difference in the 1-year OS and DFS rate of repeated hepatectomy group and radiofrequency ablation group. Additionally, the pooled results show that the postoperative Clavien-Dindo (CD) grade II or higher complication rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (OR = 2.80, 95% CI: 1.37–5.75, P = 0.005).

Conclusion

Based on the pooled results of 8 existing retrospective studies, RH has a higher OS rate and DFS rate in the treatment of recurrent liver cancer, while the postoperative complication rate of RFA is lower. When survival is the primary goal, RH should be the first choice for recurrent liver cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02649-4.

Nomograms for Predicting Hepatocellular Carcinoma Recurrence and Overall Postoperative Patient Survival

Background

Few studies have focused on the prognosis of patients with hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage 0‒C in terms of early recurrence and 5-years overall survival (OS). We sought to develop nomograms for predicting 5-year OS and early recurrence after curative resection of HCC, based on a clinicopathological‒radiological model. We also investigated whether different treatment methods influenced the OS of patients with early recurrence.

Methods

Retrospective data, including clinical pathology, radiology, and follow-up data, were collected for 494 patients with HCC who underwent hepatectomy. Nomograms estimating OS and early recurrence were constructed using multivariate Cox regression analysis, based on the random survival forest (RSF) model. We evaluated the discrimination and calibration abilities of the nomograms using concordance indices (C-index), calibration curves, and Kaplan‒Meier curves. OS curves of different treatments for patients who had recurrence within 2 years after curative surgery were depicted and compared using the Kaplan–Meier method and the log-rank test.

Results

Multivariate Cox regression revealed that BCLC stage, non-smooth margin, maximum tumor diameter, age, aspartate aminotransferase levels, microvascular invasion, and differentiation were prognostic factors for OS and were incorporated into the nomogram with good predictive performance in the training (C-index: 0.787) and testing cohorts (C-index: 0.711). A nomogram for recurrence-free survival was also developed based on four prognostic factors (BCLC stage, non-smooth margin, maximum tumor diameter, and microvascular invasion) with good predictive performance in the training (C-index: 0.717) and testing cohorts (C-index: 0.701). In comparison to the BCLC staging system, the C-index (training cohort: 0.787 vs. 0.678, 0.717 vs. 0.675; external cohort 2: 0.748 vs. 0.624, 0.729 vs. 0.587 respectively, for OS and RFS; external cohort1:0.716 vs. 0.627 for RFS, all p value<0.05), and model calibration curves all showed improved performance. Patients who underwent surgery after tumor recurrence had a higher reOS than those who underwent comprehensive treatments and supportive care.

Conclusions

The nomogram, based on clinical, pathological, and radiological factors, demonstrated good accuracy in estimating OS and recurrence, which can guide follow-up and treatment of individual patients. Reoperation may be the best option for patients with recurrence in good condition.

Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature

Recurrence following curative-intent hepatectomy for colorectal cancer liver metastasis, hepatocellular carcinoma, or cholangiocarcinoma is unfortunately common with a reported incidence as high as 75%. Various treatment modalities can improve survival following disease recurrence. A review of the literature was performed using PubMed. In addition to systemic therapy, liver-directed treatment options for recurrent liver disease include repeat hepatectomy, salvage liver transplantation, radiofrequency or microwave ablation, intra-arterial therapy, and stereotactic body radiation therapy. Repeat resection can be consider for patients with limited recurrent disease that meets resection criteria, as this therapeutic approach can provide a survival benefit and is potentially curative in a subset of patients. Salvage liver transplantation for recurrent hepatocellular carcinoma is another option, which has been associated with a 5-year survival of 50%. Salvage transplantation may be an option in particular for patients who are not candidates for resection due to underlying liver dysfunction but meet criteria for transplantation. Ablation is another modality to treat patients who recur with smaller tumors and are not surgical candidates due to comorbidity, liver dysfunction, or tumor location. For patients with inoperable disease, transarterial chemoembolization, or radioembolization with Yttrium-90 are liver-directed intra-arterial therapy modalities with relatively low risks that can be utilized. Stereotactic body radiation therapy is another palliative treatment option that can provide a response and local tumor control for smaller tumors.

The effect of the robotic platform in hepatectomy after prior liver and non-liver abdominal operations: a comparative study of clinical outcomes

Improvements in outcomes after primary hepatectomy have increased the eligibility of patients for reoperative hepatectomies, but this can be fraught with technical difficulties, particularly via a minimally invasive approach. The robotic approach provides superior visualization, articulated instrumentation, platform stability, and increased dexterity when compared to conventional laparoscopy. We sought to investigate the effect brought by the robotic system in the outcome of these operations. We followed 234 patients who underwent robotic liver resection from 2012 to 2021 for retrospective analysis. Patients were classified as: no prior abdominal operation, prior abdominal operation(s), and prior liver resection. Cohorts were compared by one-way ANOVA and 2 × 3 contingency table analyses. For illustrative purposes, data are presented as median (mean ± SD). Significance was accepted at p < 0.05. Of the 234 patients studied, 114 underwent primary hepatectomy, 105 had a prior laparoscopic or open abdominal operation (cholecystectomy, herniorrhaphy, colectomy, and appendectomy), and 15 had a redo hepatectomy. Demographic and preoperative ASA, MELD, neoplasm size, and extent of liver resection were similar among the cohorts. There were no statistically significant differences between the three cohorts for all outcome variables including blood loss, operative duration, intensive care unit length of stay, overall length of stay, morbidity, mortality, and readmission rate. There were no differences in morbidity nor mortality between patients undergoing primary nor reoperative robotic hepatectomy. The advantages afforded by the robotic platform may have contributed to the equalization of outcomes.

Clinical stages of recurrent hepatocellular carcinoma: A retrospective cohort study

BACKGROUND

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide, and has relatively high recurrence rates. Few studies have been published on the clinical stages of recurrent HCC.

AIM

To assess the applicability of the Barcelona Clinic Liver Cancer (BCLC) staging for recurrent HCC and the need to establish clinical stage criteria for recurrent HCC.

METHODS

The clinicopathological data of 81 patients with recurrent HCC who were admitted to the Hospital of Guangxi Zhuang Autonomous Region from January 2013 to December 2017 were collected. The patients were divided into three groups according to the BCLC staging system as follows: (1) Group A with BCLC stage A, 51 patients; (2) Group B with BCLC stage B, 14 patients; and (3) Group C with BCLC stage C, 16 patients. The median time to tumor recurrence and the median overall survival were compared.

RESULTS

The median time to tumor recurrence in groups A, B, and C was 16 ± 1.5 mo, 10 ± 2.8 mo, and 6 ± 0.5 mo, respectively, with a statistically significant difference among them (χ² = 70.144, P < 0.05); no statistically significant difference was noted between group A and group B (χ² = 2.659, P > 0.05), although there were statistically significant differences between group A and group C and between group B and group C (χ² = 62.110, and 19.972, P < 0.05). The median overall survival in groups A, B, and C were 42 ± 5.1 mo, 22 ± 3.1 mo, and 13 ± 1.8 mo, respectively, with a statistically significant difference among them (χ² = 38.949, P < 0.05); there were statistically significant differences between group A and group B, group A and group C, and group B and group C (χ² = 9.577, 37.172, and 7.183, respectively; P < 0.05).

CONCLUSION

There are different prognoses in recurrent HCC patients according to the BCLC staging. Therefore, BCLC staging is applicable to recurrent HCC and it is essential to formulate clinical stage criteria for recurrent HCC.

Anatomic Resection for Hepatocellular Carcinoma: Prognostic Impact Assessed from Recurrence Treatment

BACKGROUND

The oncologic advantage of anatomic resection (AR) for primary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the clinical advantages of AR for primary HCC by using propensity score-matching and by assessing treatment strategies for recurrence after surgery.

METHODS

The study reviewed data of patients who underwent AR or non-anatomic resection (NAR) for solitary HCC (≤ 5 cm) in two institutions between 2004 and 2017. Surgical outcomes were compared between the two groups in a propensity score-adjusted cohort. The time-to-interventional failure (TIF), defined as the elapsed time from resection to unresectable/unablatable recurrence, also was evaluated.

RESULTS

The inclusion criteria were met by 250 patients: 77 patients (31%) with AR and 173 patients (69%) with NAR. In the propensity score-matched populations (AR, 67; NAR, 67), the 5-year recurrence-free survival (RFS) for AR was better than for NAR (62% vs 35%; P = 0.005). No differences, however, were found in the 5-year overall survival between the two groups (72% vs 78%; P = 0.666). The 5-year TIF rates for the NAR group (60%) also were similar to those for the AR group (66%) (P = 0.413). In the cohort of 67 patients, curative repeat resection or ablation therapy was performed more frequently for the NAR patients (42%) than for the AR patients (10%) (P < 0.001).

CONCLUSION

For solitary HCC, AR decreases recurrence after the initial hepatectomy. However, aggressive curative-intent interventions for recurrence compensate for the impaired RFS, even for patients undergoing NAR.

Intrahepatic recurrence of hepatocellular carcinoma after resection: an update

Hepatocellular carcinoma recurrence occurs in 40-70% of patients after hepatic resection. Despite the high frequency of hepatocellular cancer relapse, there is no established guidance for the management of such cases. The evaluation of prognostic factors that indicate a high risk of recurrence after surgery such as the tumor number and size and the presence of microvascular invasion may guide the therapeutic strategy and point out which patients should be strictly monitored. Additionally, the administration of adjuvant treatment or ab initio liver transplantation in selected patients with high-risk characteristics could have a significant impact on the prevention of relapse and overall survival. Once the recurrence has occurred in the liver remnant, the available therapeutic options include re-resection, salvage liver transplantation and locoregional treatments, although the therapeutic choice is often challenging and should be based on the characteristics of the recurrent tumor, the patient profile and most importantly the timing of relapse. Aggressive combination treatments are often required in challenging cases of early relapse. The results of the above treatment strategies are reviewed and compared to determine the optimal management of patients with recurrent hepatocellular cancer following liver resection.

A prediction model of major complications after radiofrequency ablation for recurrent hepatocellular carcinoma patients

BACKGROUND

Postoperative major complications are potentially fatal to recurrent hepatocellular carcinoma (RHCC) patients. We aimed to construct a prediction model of major complications after RFA for RHCC patients.

METHODS

We retrospectively reviewed the medical records of 407 RHCC patients who underwent RFA as second treatment. Patients were divided into two groups according to the date of RFA: training cohort (277 patients treated in 2010-2016) and validation cohort (130 patients treated in 2017-2019). 23 clinicopathological variables were recorded and analyzed. The logistic regression model was used to build a prediction model.

RESULT

Major complications developed in 3.6 % of RHCC patients after RFA. In the multivariate analysis, tumor adjacent vessels (p = 0.004) and hepatitis C (p = 0.022) were associated with postoperative complications. The prediction model was described as follow: Risk score (major complication) = 5.180 + 3.391*tumor location+3.389*hepatic etiology, the Youden index was 0.642, the best cut-off value of the model was 8.57 (sensitivity, 78.57 %, specificity, 84.03 %). The area under the receiver operating characteristic curve of the predictive model was 0.85 (95 % CI, 0.82 to 0.88). The validation of the model demonstrated acceptable results, the sensitivity was 80.00 %, specificity was 98.40 %.

CONCLUSIONS

This study developed a simple and reliable prediction model of postoperative major complications after RFA for RHCC patients.

Repeat hepatic resection VS radiofrequency ablation for the treatment of recurrent hepatocellular carcinoma: an updated meta-analysis

BACKGROUND

This paper evaluates the efficacy and safety of repeat hepatic resection and radiofrequency ablation in the treatment of recurrent hepatocellular carcinoma.

MATERIAL AND METHODS

We retrieved and collected all relevant articles from the inception to 8 March 2020. After data extraction, we conducted meta-analysis and carried out the heterogeneity test, sensitivity analysis, and publication bias test to evaluate reliability.

RESULTS

A total of 12 studies with 1746 patients (rHR 837, RFA 909) were included. rHR was similar to RFA in a one-year overall survival rate (OS), while rHR was superior to RFA in 3- and 5-year OS and 1-, 3-, and 5-year disease-free survival rates (DFS), but the procedure-related complications of RFA were significantly less than those of rHR. Among the subgroups with Milan criteria, rHR was similar to RFA in 1-, 3-, and 5-year OS and 1-year DFS, but superior to RFA in 3- and 5-year DFS.

CONCLUSIONS

RFA is the first choice for recurrent HCC meeting Milan criteria. When it does not meet the Milan criteria, minimally invasive treatment should not be carried out at the cost of survival, and rHR should be the first choice.

Prognostic Nomogram for Patients with Hepatocellular Carcinoma After Thermal Ablation

PURPOSE

To develop an effective prognostic nomogram for patients with hepatocellular carcinoma (HCC) after thermal ablation.

METHODS

A total of 772 patients with intrahepatic primary or recurrent HCC who underwent radiofrequency ablation or microwave ablation between March 2011 and October 2016 were included. 602 patients (mean age, 56.0 ± 11.9 years; 495 male/107 female) were included in the primary cohort to establish a prognostic nomogram. Significant prognostic factors for overall survival (OS) identified by Cox univariate and multivariate regression analyses were used to construct the nomogram. The remaining 170 patients (mean age, 55.9 ± 11.9 years; 145 male/25 female) were used to validate the predictive accuracy of the nomogram.

RESULTS

During a mean follow-up period of 26 months (range 1-85 months), the median OS periods were 48.6 months and 44.0 months for the primary and validation cohorts. The 1-, 3-, and 5-year OS rates were 85.5%, 61.4%, and 43.3% in the primary cohort and 84.7%, 59.6%, and 43.3% in the prospective validation cohort, respectively. Multivariate analysis found that pre-ablation treatment, AFP, CEA, CA19-9, ALBI grade, tumor number, and tumor size (hazard ratio > 1, P < 0.05) were independent risk factors for OS. A nomogram was developed based on these seven variables. The calibration curve for predicting the probability of survival showed a good agreement between the nomogram and actual observation both in the primary (concrete index: 0.699) and validation cohorts (concrete index: 0.734).

CONCLUSIONS

This simple nomogram based on seven variables including ALBI grade offers personalized prognostic data for HCC patients after ablation.

LEVEL OF EVIDENCE

Level 4, case series.

A Multi-Institutional Retrospective Study of Repeated Stereotactic Body Radiation Therapy for Intrahepatic Recurrent Hepatocellular Carcinoma

PURPOSE

Through this multi-institutional study, we aimed to retrospectively evaluate the safety and efficacy of repeated stereotactic body radiation therapy (SBRT) for intrahepatic recurrent hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Between 2005 and 2017, 709 patients with 835 HCCs underwent SBRT; those treated with repeated SBRT were eligible. The median prescribed dose was 40 Gy in 5 fractions.

RESULTS

Eighty-one patients with 189 tumors underwent repeated SBRT (≥ 2 courses [median 2 times; range, 2-5 times]). The median follow-up periods from the first to the second SBRT were 41.5 (range, 12-99) and 20 (range, 1-81) months, respectively. The median interval between the first and second SBRT was 18 (range, 3-74) months. The 5-year local recurrence rate was 6.3% (95% confidence interval [CI], 2.3%-13.4%). The 5-year overall survival (OS) and liver-related death rates from the first SBRT were 60.4% (95% CI, 47.0%-73.8%) and 32.9% (95% CI, 20.3%-46.0%), respectively, and the 3-year rates from the second SBRT were 61.0% (95% CI, 49.9%-75.2%) and 34.5% (95% CI, 20.6%-48.9%), respectively. The frequency of grade 3 toxicity was not significantly different between the first and second SBRT (first: 11% [95% CI, 5.2%-20%]; second: 15% [95% CI, 7.9%-24%]; P = .48). Among 39 patients with no intrahepatic recurrence for 1 year after the first and second SBRT, the deterioration in liver function after the first and second SBRT was not significantly different; the albumin-bilirubin score increased 1 year after the first versus second SBRT (first, 0.143 ± 0.23; second, 0.195 ± 0.38; P = .48). Multivariate analysis revealed that the intrahepatic recurrence-free interval was the only significant factor for OS.

CONCLUSIONS

Repeated SBRT for intrahepatic recurrent HCC resulted in high local control with safety and a satisfactory OS comparable with that of other curative local treatments for patients with well-preserved liver function.

An overview of stereotactic body radiation therapy for hepatocellular carcinoma

Introduction: According to several guidelines, stereotactic body radiation therapy (SBRT) for early hepatocellular carcinoma (HCC) can be considered an alternative to other modalities, such as resection, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE), or when these therapies have failed or are contraindicated. This article reviews the current status of SBRT for the treatment of HCC.Areas covered: From the results of many retrospective reports, SBRT is a promising modality with an excellent local control of almost 90% at 2-3 years and acceptable toxicities. Currently there are no randomized trials to compare SBRT and other modalities, such as resection, RFA, and TACE, but many retrospective reports and propensity score matching have shown that SBRT is comparable to the different modalities. Repeated SBRT for intra-hepatic recurrent HCC also resulted in high local control with safety and satisfactory overall survival, which were comparable to those of other curative local treatments.Expert opinion: Despite the good results of SBRT, the conclusions of the comparisons of SBRT and other modalities are still controversial. Further studies, including randomized phase III studies to define that patients are more suitable for each curative local treatment, are needed.

Efficacy of surgical microwave ablation for recurrent hepatocellular carcinoma after curative hepatectomy

BACKGROUND

Little evidence exists regarding postrecurrence survival after microwave ablation for recurrent hepatocellular carcinoma (HCC) after curative hepatectomy; we aimed to evaluate the feasibility of surgical microwave ablation.

METHODS

In this retrospective review, we enrolled patients who underwent curative hepatectomy for primary HCC in our department and had intrahepatic recurrence. We analyzed overall survival according to treatment modality to clarify the prognostic factors for survival.

RESULTS

Of 257 patients, 119 had intrahepatic recurrence. Three patients underwent repeat hepatectomy; 75 patients underwent surgical microwave ablation, and 34 patients underwent transcatheter arterial chemoembolization or hepatic arterial infusion chemotherapy. The median postrecurrence survival time and 5-year postrecurrence survival after surgical microwave ablation were 37.4 months and 55.4%, respectively. The major complication rate (Clavien-Dindo classification IIIa or above) after surgical microwave ablation was 5.3% with no mortality. Multivariate analysis showed that microvascular invasion at primary tumors, and recurrent tumors within 3 cm and 3 nodules were independent prognostic factors for overall survival after surgical microwave ablation for recurrent HCC.

CONCLUSION

Our results suggested that surgical microwave ablation is safe and feasible for recurrent intrahepatic HCC after curative hepatectomy. Close follow-up and further curative treatment could be important for improving postrecurrence survival.

Repeat hepatectomy for patients with early and late recurrence of hepatocellular carcinoma: A multicenter propensity score matching analysis

BACKGROUND

Repeat hepatectomy is a feasible treatment modality for intrahepatic recurrence after hepatectomy of hepatocellular carcinoma, yet the survival benefit remains ill-defined. The objective of the current study was to define long-term, oncologic outcomes after repeat hepatectomy among patients with early and late recurrence.

METHODS

Patients undergoing curative-intent repeat hepatectomy for recurrent hepatocellular carcinoma were identified using a multi-intuitional database. Early and late recurrence was defined by setting 1 year after initial hepatectomy as the cutoff value. Patient clinical characteristics, overall survival, and disease-free survival were compared among patients with early and late recurrence before and after propensity score matching.

RESULTS

Among all the patients, 81 had early recurrence and 129 had late recurrence from which 74 matched pairs were included in the propensity score matching analytic cohort. Before propensity score matching, 5-year overall survival and disease-free survival after resection of an early recurrence were 41.7% and 17.9%, respectively, which were worse compared with patients who had resection of a late recurrence (57.0% and 39.4%, both P < .01). After propensity score matching, 5-year overall survival and disease-free survival among patients with early recurrence were worse compared with patients with late recurrence (41.0% and 19.2% vs 64.3% and 43.2%, both P < .01). After adjustment for other confounding factors on multivariable Cox-regression analysis, early recurrence remained independently associated with decreased overall survival and disease-free survival (hazard ratio 2.22, 95% confidence interval 1.35-3.34, P = .001; hazard ratio 1.86, 95% confidence 1.26-2.74, P = .002).

CONCLUSION

Repeat hepatectomy for early recurrence was associated with worse overall survival and disease-free survival compared with late recurrence. These data may help inform patients and selection of patients being considered for repeat hepatectomy of recurrent hepatocellular carcinoma.

Postoperative recurrent factors and therapeutic and preventive strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. The recurrence rate is about 50% at 3 years and over 70% at 5 years after hepatectomy for HCC. The high recurrence rate seriously affects the curative effect and long-term survival of patients with HCC, and is the primary cause of death after operation. Postoperative recurrence of HCC is a complex multi-step, multi-factorial process involving three factors: the body, microenvironment, and tumor tissue, which include body immunity, local pH value, interstitial pressure, vascular osmotic pressure, inflammatory reaction, tumor cell adhesion, extracellular matrix degradation, cell migration, cell proliferation, and tumor angiogenesis. HCC recurrence is closely related to abnormal gene expression and related molecular function changes, but the molecular mechanism has not been fully elucidated. How to treat the recurrence of HCC after operation directly affects the prognosis of patients with HCC, and treatments include reoperation, liver transplantation, local minimally invasive treatment, radiotherapy, molecular targeted drugs, immunotherapy, and traditional Chinese medicine treatment. It is difficult to cure or control tumor progression by a single therapy. Two or more therapeutic methods need to be combined organically to achieve a synergistic therapeutic effect. According to the specific situation of patients with HCC, it is key to analyze the individual characteristics of patients, to combine the clinical experience of clinicians and the best evidence, to adopt the individualized treatment plan, and to choose the appropriate treatment methods. For HCC patients with high-risk factors for recurrence, selecting the appropriate treatment is important to reduce the recurrence of HCC after operation and prolong the survival of patients.

Comparison of clinical outcomes of laparoscopic versus open surgery for recurrent hepatocellular carcinoma: a meta-analysis

BACKGROUND

The purpose of this study is to compare the clinical outcomes of laparoscopic liver resection versus open liver resection for recurrent hepatocellular carcinoma (RHCC).

METHODS

Published studies which investigated laparoscopic versus open liver resection for RHCC were identified, and meta-analysis was used for statistical analysis.

RESULTS

Six studies were analyzed by meta-analysis method, and cumulative 335 cases were included in this study. Laparoscopic liver resection was performed in 145 cases, and open liver resection was performed in 190 cases. Meta-analysis showed that there was no difference in operative time and 90-day mortality between the laparoscopic group and the open group (p = 0.06 and p = 0.06 respectively); Nevertheless, compared with the open group, the laparoscopic group resulted in significantly lower rate of in-hospital complication (p < 0.0001), much less blood loss (p < 0.0001) and shorter postoperative hospital stay (p = 0.002).

CONCLUSION

Laparoscopic liver resection for RHCC offers a benefit of lower in-hospital complication rate, less blood loss, shorter postoperative hospital stay, while similar operative time and 90-day mortality as the open liver resection. Laparoscopic liver resection is feasible with satisfactory postoperative outcomes and can be a safe alternative treatment strategy to open procedure for RHCC.

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.

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.

Restaging Patients With Hepatocellular Carcinoma Before Additional Treatment Decisions: A Multicenter Cohort Study

Prognostic assessment of patients with hepatocellular carcinoma (HCC) at the time of diagnosis remains controversial and becomes even more complex at the time of restaging when new variables need to be considered. The aim of the current study was to evaluate the prognostic utility of restaging patients before proceeding with additional therapies for HCC. Two independent Italian prospective databases were used to identify 1,196 (training cohort) and 648 (validation cohort) consecutive patients with HCC treated over the same study period (2008-2015) who had complete restaging before decisions about additional therapies. The performance of the Italian Liver Cancer (ITA.LI.CA) prognostic score at restaging was compared with that of the Barcelona Clinic Liver Cancer, Hong Kong Liver Cancer, and Cancer of the Liver Italian Program systems. A multivariable Cox survival analysis was performed to identify baseline, restaging, or dynamic variables that were able to improve the predictive performance of the prognostic systems. At restaging, 35.3% of patients maintained stable disease; most patients were either down-staged by treatment (27.2%) or had disease progression (37.5%). The ITA.LI.CA scoring system at restaging demonstrated the best prognostic performance in both the training and validation cohorts (c-index 0.707 and 0.722, respectively) among all systems examined. On multivariable analysis, several variables improved the prognostic ability of the ITA.LI.CA score at restaging, including progressive disease after the first treatment, Model for End-Stage Liver Disease at restaging, and choice of nonsurgical treatment as additional therapy. A new ITA.LI.CA restaging model was created that demonstrated high discriminative power in both the training and validation cohorts (c-index 0.753 and 0.745, respectively).

CONCLUSION

Although the ITA.LI.CA score demonstrated the best prognostic performance at restaging, other variables should be considered to improve the prognostic assessment of patients at the time of deciding additional therapies for HCC.

Metformin induces miR-378 to downregulate the CDK1, leading to suppression of cell proliferation in hepatocellular carcinoma

Metformin is one of the extensively and most commonly used oral antihyperglycemic agents, but it has been shown to exert antineoplastic effects in many cancer cells. Recent studies have confirmed that metformin has an antitumor effect on hepatocellular carcinoma (HCC). However, the molecular mechanism underlying this effect needs to be further studied.

Long-term outcomes in elderly patients with resectable large hepatocellular carcinoma undergoing hepatectomy

BACKGROUND

In contrast to the feasibility of hepatectomy for resectable large hepatocellular carcinoma (HCC, >5 cm) in the younger patients, the concerns of benefits for the elderly patients remain in practice. This study aimed to evaluate the long-term outcomes and safety after hepatectomy in elderly patients with resectable large HCC compared with younger patients.

METHODS

Between 2003 and 2014, a total of 2211 HCC patients were reviewed using a prospective database and 257 patients with resectable large HCC undergoing hepatectomy were included: 79 elderly patients with age ≥70 years and 178 younger patients with age <70 years. The last follow-up was assessed in December 2017. The complications, long-term outcomes and risk factors of disease-free and overall survival were analysed.

RESULTS

The 1-, 3-, 5- and 7-year overall survival rates in the elderly and younger groups were 76%, 55%, 48%, and 42% and 79%, 57%, 51%, and 49%, respectively (P = 0.319). The 1-, 3-, 5-, and 7-year disease-free survival rates in the elderly and younger groups were 60%, 40%, 38%, and 27% and 54%, 36%, 32%, and 32%, respectively (P = 0.633). The analysis of post-operative outcomes of interest, including hospital stay and hospital death and hepatectomy-related complications in both groups revealed no significant difference. Serum albumin and AJCC TNM stage were independent risk factors for survival. Serum alpha-fetoprotein, tumour number and AJCC TNM stage predicted HCC recurrence.

CONCLUSIONS

Our results suggested that hepatectomy can achieve comparable long-term outcomes in the selected younger and elderly patients with resectable large HCC.

Impact of Preoperative Hepatitis B Virus Levels on Prognosis After Primary and Repeat Hepatectomies for Hepatocellular Carcinoma Patients-a Retrospective Study

BACKGROUND

Chronic HBV plays an important role in hepatocellular carcinoma pathogenesis. Previously, most studies have been focusing on HBV DNA levels before the primary curative hepatectomy. However, the association of virus level before repeat hepatectomy with the degrees of inflammation and fibrosis on histopathology and prognosis has not been surveyed.

METHODS

From January 2002 to December 2009, all patients who were seropositive for hepatitis B surface antigen (HBsAg) were enrolled and assigned into four groups based on their HBV DNA levels before the primary and repeat hepatectomies. The cancer prognoses of these four groups of patients after the first and second operations were assessed and compared. The disease-free survival and overall survival were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify risk factors for the primary and repeat hepatectomies.

RESULTS

For the 385 patients in this study, a low level of serum HBV DNA before repeat hepatectomy, but not primary hepatectomy, was significantly associated with improvement in prognosis, in terms of tumor recurrence, liver fibrosis, and liver-related mortality.

CONCLUSION

The levels of HBV DNA before hepatectomies were crucial prognostic risk factors of HBV-related hepatocellular carcinoma patients. Surveillance of serum HBV DNA levels at multiple time points, rather than at a single time point, and antiviral therapy to suppress the virus to a low level had beneficial effects for these patients.

Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: An intent-to-treat analysis

The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The longterm outcomes of a second resection for recurrent HCC have improved. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage. Liver Transplantation 23 1553-1563 2017 AASLD.

Evolution and revolution of laparoscopic liver resection in Japan

Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta‐analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high‐volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi‐hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of “de principe liver transplant” (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Strategic overview on the best treatment option for intrahepaitc hepatocellular carcinoma recurrence

INTRODUCTION

The long-term survival after hepatectomy for HCC remains unsatisfactory because of the high incidence of recurrence. The cumulative 5-year recurrence rate ranged from 60-100% in previous studies and majority of them remains intrahepatic recurrence. The therapeutic modalities commonly used for primary tumors, including surgical resection, liver transplantation, TACE, local ablative therapy and radiotherapy have been used to treat recurrent tumors in the liver remnant and the outcomes with the heterogeneous therapeutic options are reviewed. It is important to note that the level of evidence for most therapeutic options is limited to cohort investigations with few RCTs and most were limited due to enrollment of various tumor stages and did not compare treatment modalities for specific tumor stages.

AREAS COVERED

A literature search for recurrent HCC was performed using Medline and PubMed up to May 2016. Expert commentary: The long term survival results after re-resection for recurrent HCC were favourable and aggressive management of postoperative intrahepatic recurrence remains the most important strategy in prolonging the survival of patients after resection of HCC.

Primary liver resection for patients with cirrhosis and hepatocellular carcinoma: the role of surgery in BCLC early (A) and intermediate stages (B)

AIM

This study aims to report the outcomes following primary liver resection (PLR) in patients with cirrhosis including stratification according to the Barcelona Clinic Liver Cancer (BCLC) classification.

METHODS

Patients with cirrhosis and hepatocellular carcinoma (HCC) who had PLR between 2000 and 2013 were examined. Overall survival (OS), disease-free survival (DFS) and recurrence rate (RR) were analysed. Management after recurrence was reviewed as well as comparison to a series of 116 patients listed directly for liver transplant.

RESULTS

Seventy-one patients underwent PLR. Median follow-up was 40 months. The 1-, 3- and 5-year OS and DFS for the series were 77, 69 and 61 % and 69, 39 and 28 % respectively. Overall recurrence was 59 % (44/71) and only 36 % (15/44) of those patients had a further potentially curative procedure. The 1-3-5-year OS and DFS in the BCLC-A (44 patients) were 86, 78 and 68 % and 78, 48 and 44 % respectively. The RR in BCLC-A was 45 % (20 patients) with half (11 patients) suitable for further treatment with curative intent. The 1-3-5-year OS and DFS in the BCLC-B (17 patients) were 81, 74 and 60 % and 58, 29 and 7 % respectively. The overall RR in BCLC-B was 76 % (13 patients).

CONCLUSION

Recurrence following PLR for HCC in patients with cirrhosis is high with only a third of patients suitable for further potentially curative procedures. For patients with BCLC-A (or within Milan criteria), PLR provided a 68 % 5-year OS with 44 % of them free of disease. Surgery can offer satisfactory OS in carefully selected patients in the BCLC-B stage.

Autologous adipose tissue‑derived mesenchymal stem cells are involved in rat liver regeneration following repeat partial hepatectomy

Adipose tissue-derived mesenchymal stem cells (ADSCs) have been considered to be attractive and readily available adult mesenchymal stem cells, and they are becoming increasingly popular for use in regenerative cell therapy, as they are readily accessible through minimally invasive techniques. The present study investigated whether autologous ADSC transplantation promoted liver regeneration following a repeat partial hepatectomy in rats. The rats were divided into three groups as follows: 70% partial hepatectomy (PH) group; repeat PH (R-PH) group and R-PH/ADSC group, subjected to R-PH and treated with autologous ADSCs via portal vein injection. In each group, the rats were sacrificed at different time points postoperatively in order to evaluate the changes in liver function and to estimate the liver regenerative response. The expression of proliferating cell nuclear antigen (PCNA) labeling index in the liver was measured using immunohistochemistry. The expression levels of hepatocyte growth factor (HGF) mRNA were measured using reverse transcription polymerase chain reaction. The results showed that regeneration of the remaining liver following R-PH was significantly promoted by ADSC transplantation, as shown by a significant increase in liver to body weight ratio and the PCNA labeling index at 24 h post-hepatectomy. Additionally, ADSC transplantation markedly inhibited the elevation of serum levels of alanine aminotransferase, aspartate aminotransferase and total bilirubin, increased HGF content and also attenuated hepatic vacuolar degeneration 24 h postoperatively. Furthermore, the liver was found to almost fully recover from hepatocellular damage due to hepatectomy among the three groups at 168 h postoperatively. These results indicated that autologous ADSC transplantation enhanced the regenerative capacity of the remnant liver tissues in the early phase following R-PH.

The Feasibility of Third or More Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma

OBJECTIVES

To investigate the feasibility and prognostic benefits of third or more hepatectomy (third or more Hx) for recurrent hepatocellular carcinoma.

BACKGROUND

Second hepatectomy (second Hx) has been accepted as an effective treatment of recurrent hepatocellular carcinoma after first hepatectomy (first Hx). However, the feasibility and efficacy of third or more Hx have not been adequately assessed.

METHODS

Data were reviewed from 1340 patients with hepatocellular carcinoma who underwent curative hepatectomy. Among them, 941, 289, and 110 underwent first Hx, second Hx, and third or more Hx, respectively. Surgical outcomes and long-term survival were compared among the groups.

RESULTS

Surgical duration was significantly longer in third or more Hx (median, 6.4 hours) than in second Hx (median, 5.9 hours). Postoperative bile leakage and wound infection were more frequently observed in third or more Hx versus second Hx (12.5% vs 6.2%, [P = 0.04] and 2.9% vs 0.4% [P = 0.03], respectively). Three and 5-year disease-free survival rates were 36.8% and 27.1% in first Hx, 24.4% and 17.9 % in second Hx, and 26.1% and 12.8% in third or more Hx, respectively (P < 0.01 [first Hx vs third Hx], P = 0.95 [second Hx vs third or more Hx]). The 5-year overall survival rates from each resection were similar among the groups (65.3%, 60.5%, 68.2%, respectively). The 5- and 10-year overall survival rates from initial hepatectomy in patients who received third or more Hx were 91.4% and 75.5%, respectively.

CONCLUSIONS

Third or more Hx is technically demanding in terms of surgical duration and morbidity compared with second Hx. However, aggressive repeat resection offers a survival similar to second Hx, leading to cumulative long-term survival from initial resection.

Ablation for recurrent hepatocellular carcinoma: a systematic review of clinical efficacy and prognostic factors

BACKGROUND

Hepatocellular carcinoma (HCC) typically recurs following primary treatment. The primary objective of this systematic review was to evaluate the safety and efficacy of ablative therapies for recurrent HCC. The secondary objective was to identify any factors associated with prognosis following ablation for recurrent disease.

METHODS

A systematic search of the literature published between January 2000 and December 2013 was undertaken using the PubMed, Medline and Scopus databases. Reference lists from selected studies were manually searched to ensure complete capture of any relevant data.

RESULTS

A total of 19 studies were included in the review. The median age of patients undergoing ablation for recurrent HCC was 58 years (range 52-69 years) and 85 % of patients had cirrhosis (range 56-100 %). HCC recurred as a single nodule in 79 % of those treated with ablation (range 46-100 %). There were few significant complications associated with any form of ablation. Sufficient data were only available to allow analysis of survival outcomes following radiofrequency ablation (RFA). After RFA the median, 1, 3 and 5-year survivals were 84 % (73-99 %), 51 % (42-84 %) and 40 % (28-83 %), respectively. The only factor consistently associated with overall survival following ablation for recurrence was the alpha-fetoprotein (AFP) level.

CONCLUSION

Comparable survival figures from previously published systematic reviews suggest that hepatic resection is the most effective treatment for recurrent HCC. However, ablation can be a safe and effective option for the majority of patients with recurrent disease who are unsuitable for surgery. Elevated levels of AFP suggest a poorer prognosis following ablation.