Selection criteria for hepatic resection in patients with large hepatocellular carcinoma larger than 10 cm in diameter

Investigating the Influence of Preoperative Trans Arterial Embolization (TAE) and Predictive Potential of Circulating Tumor Cells (CTCs) in Prognosis of Hepatocellular Carcinoma

Introduction

Circulating tumor cells are a promising biomarker in many malignancies. CTC dissemination during the operative procedure can lead to disease recurrence. The effect of preoperative transarterial embolization on the release of CTCs and miRNA panels and oncological outcomes in large hepatocellular carcinomas has been evaluated.

Materials and methods

The study included non-metastatic HCC >5 cm in size, that were completely resected after TAE (n = 10). Blood was collected pre-TAE, post-TAE, postoperative (day 2,30 and 180) and analyzed for the presence of CTC and miRNA (miR-885-5p, miR-22-3p, miR-642b-5p). The samples were subjected to CTC enrichment, isolation and staining using the markers CD45, EpCAM, and cytokeratin (CK). The data was analyzed using Gene Expression Suite software.

Results

The CTC enumeration resulted in three groups: Group 1- CTC present at both pre-TAE and postoperative day 30 (n = 4), Group 2- CTC present at pre-TAE and clearing at postoperative day 30 (n = 2), Group 3- No CTC detected at any stages (n = 3). Group 2 patients had better survival compared with the other groups. Downregulation of miRNA 22-3p also had favorable prognostic implications.

Conclusion

Although preoperative TAE does not seem to impact CTC shedding, CTC clearance may prove to be a valuable biomarker in prognosticating HCC. A larger study to evaluate the significance of CTCs as a prognostic marker is warranted to further evaluate these findings.

Prognostic significance of MRI features in patients with solitary large hepatocellular carcinoma following surgical resection

OBJECTIVE

To assess the prognostic impact of preoperative MRI features on outcomes for single large hepatocellular carcinoma (HCC) (≥ 8 cm) after surgical resection.

MATERIAL AND METHODS

This retrospective study included 151 patients (mean age: 59.2 years; 126 men) with a single large HCC who underwent gadoxetic acid-enhanced MRI and surgical resection between 2008 and 2020. Clinical variables, including tumor markers and MRI features (tumor size, tumor margin, and the proportion of hypovascular component on hepatic arterial phase (AP) (≥ 50% vs. < 50% tumor volume) were evaluated. Cox proportional hazards model analyzed overall survival (OS), recurrence-free survival (RFS), and associated factors.

RESULTS

Among 151 HCCs, 37.8% and 62.2% HCCs were classified as ≥ 50% and < 50% AP hypovascular groups, respectively. The 5- and 10-year OS and RFS rates in all patients were 62.0%, 52.6% and 41.4%, 38.5%, respectively. Multivariable analysis revealed that ≥ 50% AP hypovascular group (hazard ratio [HR] 1.7, p = 0.048), tumor size (HR 1.1, p = 0.006), and alpha-fetoprotein ≥ 400 ng/mL (HR 2.6, p = 0.001) correlated with poorer OS. ≥ 50% AP hypovascular group (HR 1.9, p = 0.003), tumor size (HR 1.1, p = 0.023), and non-smooth tumor margin (HR 2.1, p = 0.009) were linked to poorer RFS. One-year RFS rates were lower in the ≥ 50% AP hypovascular group than in the < 50% AP hypovascular group (47.4% vs 66.9%, p = 0.019).

CONCLUSION

MRI with ≥ 50% AP hypovascular component and larger tumor size were significant factors associated with poorer OS and RFS after resection of single large HCC (≥ 8 cm). These patients require careful multidisciplinary management to determine optimal treatment strategies.

CLINICAL RELEVANCE STATEMENT

Preoperative MRI showing a ≥ 50% arterial phase hypovascular component and larger tumor size can predict worse outcomes after resection of single large hepatocellular carcinomas (≥ 8 cm), underscoring the need for tailored, multidisciplinary treatment strategies.

KEY POINTS

MRI features offer insights into the postoperative prognosis for large hepatocellular carcinoma. Hypovascular component on arterial phase ≥ 50% and tumor size predicted poorer overall survival and recurrence-free survival. These findings can assist in prioritizing aggressive and multidisciplinary approaches for patients at risk for poor outcomes.

Nomogram and calculator for predicting the prognosis of patients with giant hepatocellular carcinoma

OBJECTIVES

This study aimed to explore the factors affecting the overall survival (OS) of giant hepatocellular carcinoma (G-HCC) patients and establish a nomogram and an Internet-based OS calculator for evaluating the OS of G-HCC patients.

RESEARCH DESIGN AND METHODS

A total of 2445 G-HCC patients were searched in the SEER database. The independent variables affecting OS of G-HCC patients were determined by univariate and multivariate analyses, and a nomogram and Internet-based OS calculator were established. The accuracy of the nomogram was evaluated by the C-index, the AUC curve, and calibration curve.

RESULTS

Grade, surgery, radiotherapy, chemotherapy, T-staging, M-staging, AFP, and fibrosis were identified as independent variables affecting OS. These variables were included in the nomogram model and Internet-based OS calculator to evaluate OS in G-HCC patients. The C-indices and AUC of the nomogram are better than AJCC-staging system. Similarly, the calibration curves revealed that the actual survival was consistent with nomogram-based survival.

CONCLUSION

The nomogram and Internet-based OS calculator are superior to the traditional AJCC-staging system in the reliability and convenience of prognosis assessment for G-HCC patients, which is more conducive for clinicians to predict the survival of G-HCC patients and make the best treatment strategy.

Hepatic Arterial Infusion Chemotherapy vs Transcatheter Arterial Chemoembolization as Adjuvant Therapy Following Surgery for MVI-Positive Hepatocellular Carcinoma: A Multicenter Propensity Score Matching Analysis

Background

Microvascular invasion (MVI) is a significant pathological feature in hepatocellular carcinoma (HCC), adjuvant hepatic arterial infusion chemotherapy (a-HAIC) and adjuvant transcatheter arterial chemoembolization (a-TACE), are commonly used for HCC patients with MVI. This study aims to evaluate the efficacies of two adjuvant therapies after surgical treatment for HCC, compare them, and identify the significant factors.

Methods

Clinical data from two randomized controlled trials involving HCC patients with MVI after surgical treatment were retrospectively reviewed. Propensity score matching (PSM) analysis was performed to balance baseline differences between patients who received a-HAIC or a-TACE, and control groups who underwent hepatectomy alone. Disease-free survival (DFS) and overall survival (OS) rates were compared.

Results

In total of 549 patients were collected from two randomized controlled trials. Using the PSM and Kaplan-Meier method, the median DFS of the a-HAIC, a-TACE, and control groups was 63.2, 21.7, and 11.2 months (P<0.05). The a-HAIC group show significantly better 1-, 3-, and 5-year OS rates compared to the a-TACE and control groups (96.3%, 80.0%, 72.8% vs 84.4%, 57.0%, 29.8% vs 84.5%, 62.8%, 53.4%, P<0.05). But the OS rates of a-TACE and control groups showed no significant difference (P=0.279). Multivariate analysis identified a-HAIC (HR=0.449, P=0.000) and a-TACE (HR=0.633, P=0.007) as independent protective factors. For OS, a-HAIC (HR=0.388, P=0.003) was identified as an independent protective factor, too.

Conclusion

Compared to a-TACE and the control group, a-HAIC demonstrated greater benefits in preventing tumor recurrence and improving survival in HCC patients with MVI.

Resection Versus Transplant for Hepatocellular Carcinoma: How to Offer the Best Modality

Liver resection and liver transplantation are the mainstay of treatment for patients with hepatocellular carcinoma. Patient comorbidities, tumor resectability, and perioperative morbidity and mortality risk, specifically of post-hepatectomy liver failure, are determining factors when deciding between liver resection and liver transplantation in patients who do not have an obvious contraindication to either treatment. Liver resection is preferred in patients without cirrhosis, and it may be a reasonable choice in patient with cirrhosis but preserved liver function and no portal hypertension if the size and function of the future liver remnant are appropriate, especially if organ availability is scarce.

Hepatocellular Carcinoma: Surgical Management and Evolving Therapies

Hepatocellular carcinoma (HCC) is the fifth most common cancer in men and the eighth most common cancer in women worldwide. It is also the second leading cause of cancer death worldwide, with 780,000 deaths in 2018. Seventy-two percent of HCC cases occur in Asia, 10% in Europe, 8% in Africa, 5% in North America, and 5% in Latin America (Singal et al. in J Hepatol 72(2):250-261, 2020 [1]).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Liver resection for large and huge hepatocellular carcinoma: Predictors of failure, recurrence patterns, and prognoses

BACKGROUND

Characteristic symptoms and signs are often absent in patients with hepatocellular carcinoma (HCC). As a result, many patients are not diagnosed until their tumors have grown to large (> 5cm) or huge sizes (> 10cm). Liver resection has traditionally been reserved for patients with small HCC, but more recently it is being used for patients with large and huge tumors. The aim of this study was to determine risk predictors of recurrence, patterns of recurrence, and survival rates for large and huge HCC patients who underwent curative liver resection.

MATERIALS AND METHODS

We retrospectively identified a subgroup of patients who underwent liver resection for HCC with diameters 5 cm or larger. Overall survival (OS) and recurrence-free survival (RFS) rates were calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were performed to investigate potential risk factors for recurrence and death.

RESULTS

Among 897 patients, the median follow-up was 48 (range, 5-140) months. The 1-, 3-, and 5-year RFS rates were 51.6%, 36.1%, and 30.1%, respectively, and OS rates were 80.2%, 55.4%, and 47.7%, respectively. Significant independent predictors of recurrence were preoperative satellite nodule (HR = 2.25; 95% CI, 1.17-4.31; p = .02), preoperative AFP levels above 400 ng/ml (HR = 1.23; 95% CI, 1.04-1.45; p = .01), resection margins of 1 cm or less (HR = 1.21; 95% CI, 1.00-1.46; p = .047), cirrhosis (HR = 2.64; 95% CI, 2.13-3.28; p < .001), and microvascular invasion (HR = 1.71; 95% CI, 1.45-2.20; p < .001). All of these except narrow resection margin were also independent risk factors of OS.

CONCLUSIONS

Hepatic resection for patients with large and huge HCC without hepatic vascular invasion, extrahepatic metastases, or severe chronic liver disease results in acceptable long-term outcomes.

Does size matter for resection of giant versus non-giant hepatocellular carcinoma? A meta-analysis

BACKGROUND

Research on long-term survival after resection of giant (≥ 10 cm) and non-giant hepatocellular carcinoma (HCC) (< 10 cm) has produced conflicting results.

AIM

This study aimed to investigate whether oncological outcomes and safety profiles of resection differ between giant and non-giant HCC.

METHODS

PubMed, MEDLINE, EMBASE, and Cochrane databases were searched. Studies designed to investigate the outcomes of giant vs non-giant HCC were included. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were postoperative complications and mortality rates. All studies were assessed for bias using the Newcastle–Ottawa Scale.

RESULTS

24 retrospective cohort studies involving 23747 patients (giant = 3326; non-giant = 20421) who underwent HCC resection were included. OS was reported in 24 studies, DFS in 17 studies, 30-d mortality rate in 18 studies, postoperative complications in 15 studies, and post-hepatectomy liver failure (PHLF) in six studies. The HR was significantly lower for non-giant HCC in both OS (HR 0.53, 95%CI: 0.50-0.55, P < 0.001) and DFS (HR 0.62, 95%CI: 0.58-0.84, P < 0.001). No significant difference was found for 30-d mortality rate (OR 0.73, 95%CI: 0.50-1.08, P = 0.116), postoperative complications (OR 0.81, 95%CI: 0.62-1.06, P = 0.140), and PHLF (OR 0.81, 95%CI: 0.62-1.06, P = 0.140).

CONCLUSION

Resection of giant HCC is associated with poorer long-term outcomes. The safety profile of resection was similar in both groups; however, this may have been confounded by reporting bias. HCC staging systems should account for the size differences.

Dual-Applicator MR Imaging-Guided Microwave Ablation with Real-Time MR Thermometry: Phantom and Porcine Tissue Model Experiments

PURPOSE

To investigate the effect of simultaneous use of dual applicators on the image quality of real-time magnetic resonance (MR) thermometry and to characterize the dual-applicator treatment zone pattern during MR imaging-guided microwave ablation (MWA).

MATERIALS AND METHODS

MWA experiments were performed on a 1.5-T MR scanner with 2 commercial microwave systems (902-928 MHz). Phantom experiments were first performed to evaluate the effect of dual-applicator MWA on the image quality of MR. Then, porcine tissue model experiments were conducted with real-time MR thermometry using either a single applicator or dual applicators inserted 2.6, 3.6, and 4.6 cm apart. Fiberoptic thermal probes were used to measure the temperature changes at the tissue surface.

RESULTS

Simultaneous use of dual applicators resulted in a decrease in the relative signal-to-noise ratio (SNR) in the MR thermometry images to 55% ± 2.9% when compared with that of a single applicator (86.2% ± 2.0%). Despite the lower SNR, the temperature and ablation zone maps were of adequate quality to allow visualization of the ablation zone(s). The extents of increase in the temperature at the tissue surface using dual applicators (19.7 °C ± 2.6 °C) and a single applicator (18.2 °C ± 3.3 °C) were not significantly different (P = .40). Treatment zones were significantly larger (P < .05) in dual-applicator ablations (29.4 ± 0.4, 39.9 ± 0.6, and 42.6 ± 0.9 cm² with 2.6-, 3.6-, and 4.6-cm spacing, respectively) at the end of the ablation procedure than in the single-applicator MWA (18.6 ± 0.9 cm²).

CONCLUSIONS

MR imaging-guided dual-applicator MWA produced larger ablation zones while allowing adequate real-time MR thermometry image quality for monitoring the evolution of the treatment zone.

Preoperative transcatheter arterial chemoembolization and prognosis of patients with solitary large hepatocellular carcinomas (≥5 cm): Multicenter retrospective study

OBJECTIVES

Large hepatocellular carcinoma (LHCC) is prone to short-term recurrence and poor long-term survival after hepatectomy, and there is still a lack of effective neoadjuvant treatments to improve recurrence-free survival (RFS) and overall survival (OS). We retrospectively analyzed the efficacy of preoperative transcatheter arterial chemoembolization (TACE) in solitary LHCC (≥5 cm).

MATERIALS AND METHODS

A multicenter medical database was used to analyze preoperative TACE's effects on RFS, OS, and perioperative complications in patients with solitary LHCC who received surgical treatment from January 2005 to December 2015. The patients were divided into Group A (5.0-9.9 cm) and Group B (≥10 cm), with 10 cm as the critical value, and the effect of preoperative TACE on RFS, OS and perioperative complications was assessed in each subgroup.

RESULTS

In the overall population, patients with preoperative TACE had better RFS and OS than those without preoperative TACE. However, after stratifying the patients into the two HCC groups, preoperative TACE only improved the survival outcomes of patients with Group B (≥10 cm). Multivariate Cox-regression analysis showed that lack of preoperative TACE was an independent risk factor for RFS and OS in the overall population and in Group B but not in Group A.

CONCLUSIONS

Preoperative TACE is beneficial for patients with solitary HCC (≥10 cm).

Laparoscopic versus open hepatectomy for large hepatocellular carcinoma: a single center propensity-score-matching comparative analysis of perioperative outcomes and long-term survival

BACKGROUND

Although the benefits of laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC) in most circumstances are evident, the benefits for large HCC are contentious. This study aimed to compare the perioperative outcomes and survival after LH versus open hepatectomy (OH) in large HCC patients.

METHODS

An analysis of prospectively maintained database included 215 hepatectomies for large HCC (diameter ≥ 5 cm). The operative and survival outcomes were compared between the LH group (n = 109) and the OH group (n = 106). Propensity score matching (PSM) 1:1 included 70 patients in each group. The entire cohort multivariable analyses were performed to identify the factors associated with surgical complications and suboptimal recurrence-free survival (RFS).

RESULTS

After PSM, baseline characteristics and the extent of liver resection were similar in both groups. The LH group had a shorter hospital stay than the OH group (7 vs 9.5 days, p = 0.001). The R0 resection rate, complication rate, overall survival, and RFS were similar between the groups. The multivariate analyses revealed two independent factors predicting surgical complication (major resection; p < 0.001 and large volume blood loss; p = 0.042), and 3 independent factors predicting suboptimal RFS including R1 resection (p = 0.011), multifocal HCC (p = 0.005), and microvascular invasion (p = 0.001). LH was not associated with surgical complication and suboptimal RFS.

CONCLUSION

Our study highlights the benefits of LH by improving the perioperative outcomes, without long-term survival inferiority in selected large HCC patients compared with conventional OH. LH can be an attractive option for large HCC treatment.

Guiding Value of Circulating Tumor Cells for Preoperative Transcatheter Arterial Embolization in Solitary Large Hepatocellular Carcinoma: A Single-Center Retrospective Clinical Study

Background

Large hepatocellular carcinoma (LHCC) is highly malignant and prone to recurrence, leading to a poor long-term prognosis for patients. There is an urgent need for measures to intervene in postoperative recurrence. Preoperative Transcatheter Arterial Embolization (TACE) is an effective treatment. However, there is a lack of reliable preoperative indicators to guide the application of preoperative TACE. We, therefore, investigated whether the preoperative status of circulating tumor cells (CTCs) could be used to guide preoperative TACE for HCC treatment.

Methods

This study recruited 361 HCC patients and compared recurrence-free survival (RFS) and overall survival (OS) in patients treated with TACE prior to surgery and those not treated with TACE. Patients were divided into CTC-positive group and CTC-negative group according to CTC status, and the effect of preoperative TACE on RFS and OS was compared in each subgroup.

Results

In CTC-positive patients, preoperative TACE reduces early recurrence and improves long-term survival. However, HCC patients did not benefit from preoperative TACE for the overall population and CTC-negative patients.

Conclusions

Preoperative CTC testing is a reliable indicator of whether HCC patients received TACE preoperatively. CTC positivity was associated with early tumor recurrence, and preoperative TACE could reduce early recurrence and long-term prognosis in CTC-positive patients.

A preoperative nomogram for predicting long-term survival after resection of large hepatocellular carcinoma (>10 cm)

BACKGROUND

It has previously been demonstrated that a fraction of patients with hepatocellular carcinoma (HCC) > 10 cm can benefit from liver resection. However, there is still a lack of effective decision-making tools to inform intervention in these patients.

METHODS

We analysed a comprehensive set of clinical data from 234 patients who underwent liver resection for HCC >10 cm at the National Cancer Institute of Peru between 1990 and 2015, monitored their survival, and constructed a nomogram to predict the surgical outcome based on preoperative variables.

RESULTS

We identified cirrhosis, multifocality, macroscopic vascular invasion, and spontaneous tumour rupture as independent predictors of survival and integrated them into a nomogram model. The nomogram's ability to forecast survival at 1, 3, and 5 years was subsequently confirmed with high concordance using an internal validation. Through applying this nomogram, we stratified three groups of patients with different survival probabilities.

CONCLUSION

We constructed a preoperative nomogram to predict long-term survival in patients with HCC >10 cm. This nomogram is useful in determining whether a patient with large HCC might truly benefit from liver resection, which is paramount in low- and middle-income countries where HCC is often diagnosed at advanced stages.

Preoperative transarterial chemoembolization for barcelona clinic liver cancer stage A/B hepatocellular carcinoma beyond the milan criteria: a propensity score matching analysis

BACKGROUND

Debate continues about the benefits of preoperative transarterial chemoembolization (TACE) for treatment of hepatocellular carcinoma (HCC). This study aimed to assess the impact of preoperative TACE on long-term outcomes after curative resection for HCC beyond the Milan criteria.

METHODS

Patients who underwent HCC resection exceeding the Milan criteria without macrovascular invasion between 2015 and 2018 were identified (n = 393). Short- and long-term outcomes were compared between patients who underwent preoperative TACE and patients who did not before and after propensity score matching (PSM). Factors associated with recurrence after resection were analyzed.

RESULTS

100 patients (25.4%) underwent preoperative TACE. Recurrence-free survival (RFS) and overall survival (OS) were comparable with patients who underwent primary liver resection. 7 patients (7.0%) achieved total necrosis with better RFS compared with patients who had an incomplete response to TACE (P=0.041). PSM created 73 matched patient pairs. In the PSM cohort, preoperative TACE improved RFS (P=0.002) and OS (P=0.003). The maximum preoperatively diagnosed tumor diameter (HR 3.230, 95% CI: 1.116-9.353; P=0.031) and hepatitis B infection (HR 2.905, 95%CI: 1.281-6.589; P=0.011) were independently associated with favorable RFS after HCC resection.

CONCLUSION

Preoperative TACE made no significant difference to perioperative complications and was correlated with an improved prognosis after surgical resection for patients with HCC beyond the Milan criteria.

Liver resection for hepatocellular carcinoma larger than 10 cm: A multi-institution long-term observational study

BACKGROUND

The treatment of hepatocellular carcinoma (HCC) ≥ 10 cm remains a challenge.

AIM

To consolidate the role of surgical resection for HCC larger than 10 cm.

METHODS

Eligible HCC patients were identified from the Chang Gung Research Database, the largest multi-institution database, which collected medical records of all patients from Chang Gung Memorial Foundation. The surgical outcome of HCC ≥ 10 cm (L-HCC) was compared to that of HCC < 10 cm (S-HCC) (model 1). The survival of L-HCC after either liver resection or transarterial chemoembolization (TACE) was also analyzed (model 2). The long-term risks of all-cause mortality and recurrence were assessed to consolidate the role of surgery for L-HCC.

RESULTS

From January 2004 to July 2015, a total of 32403 HCC patients were identified from the Chang Gung Research Database. Among 3985 patients who received liver resection, 3559 (89.3%) had S-HCC, and 426 had L-HCC. The L-HCC patients had a worse disease-free survival (0.27 for L-HCC vs 0.40 for S-HCC) and overall survival (0.18 for L-HCC vs 0.45 for S-HCC) than the S-HCC after liver resection (both P < 0.001). However, the surgical and long-term outcome of resected L-HCC had improved dramatically in the recent decades. After adjusting for covariates, surgery could provide a better outcome for L-HCC than TACE (adjusted hazard ratio of all-cause mortality: 0.46, 95% confidence interval: 0.38-0.56 for surgery). Subgroup analysis stratified by different stages showed similar trend of survival benefit among L-HCC patients receiving surgery.

CONCLUSION

Our study demonstrated an improving surgical outcome for HCC larger than 10 cm. Under selected conditions, surgery is better than TACE in terms of disease control and survival and should be performed. Due to inferior survival, a subclassification within T1 stage should be considered. Future studies are mandatory to confirm our findings.

An overview in management of hepatocellular carcinoma in Hong Kong using the Hong Kong Liver Cancer (HKLC) staging system

In Hong Kong, liver cancer is the fifth most common cancer and the third most common cause of cancer deaths. The prevalence of hepatitis B is high in Hong Kong because of the high rate of hepatitis B virus infection, and chronic hepatitis B has remained the leading cause of hepatocellular carcinoma in the city, accounting for 80% of all cases in the period from 1992 to 2016. In view of the different etiologies of hepatocellular carcinoma around the world, a group of liver experts in Hong Kong developed the Hong Kong Liver Cancer staging system in order to provide more aggressive treatment guidance (predominantly a wider use of surgical resection) for Asian patients of hepatocellular carcinoma. In this article focussing on the Hong Kong Liver Cancer staging system, we briefly reviewed the screening criteria adopted in Hong Kong for liver resection, local ablation, transcatheter arterial chemoembolization, transcatheter arterial radioembolization, stereotactic body radiation therapy, and systemic therapy.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Hepatectomy Combined with Diaphragmatic Resection for Hepatocellular Carcinoma with Diaphragmatic Involvement: A Propensity Score-Matched Analysis

PURPOSE

We evaluated the short- and long-term surgical outcomes of hepatectomy combined with diaphragmatic resection for hepatocellular carcinoma (HCC) with diaphragmatic involvement.

METHODS

We retrospectively reviewed the surgical outcomes of HCC patients with diaphragmatic resection (DR group) and HCC patients without diaphragmatic resection (non-DR group). We applied 1:1 propensity score matching (PSM) to these subjects.

RESULTS

The study included 46 patients in DR group and 828 patients in non-DR group. The DR group cases were pathologically more advanced, and both overall and relapse-free survival among the patients in this group with pathological diaphragmatic invasion were similar to cases with pathological diaphragmatic fibrous adhesion. There were 40 patients from each group subjected to PSM. In these matched cohorts, there was no statistically significant difference between the two groups regarding perioperative outcomes, overall survival, and relapse-free survival. Multivariate analyses of our matched HCC patients revealed that alpha-fetoprotein expression and tumor size were independent prognostic factors for overall survival and poor differentiation for relapse-free survival, whereas neither diaphragmatic invasion nor diaphragmatic resection were prognostic indicators. The most frequent site of recurrence in non-DR group was the liver, whereas the most frequent site of recurrence in DR group was the lung before and after PSM.

CONCLUSIONS

The short- and long-term surgical outcomes of DR HCC cases are equivalent to their non-DR counterparts under a matched clinicopathological background. Hepatectomy combined with DR is an acceptable treatment for HCC with either diaphragmatic fibrous adhesion or diaphragmatic invasion.

Preoperative transcatheter arterial chemoembolization for surgical resection of huge hepatocellular carcinoma (≥ 10 cm): a multicenter propensity matching analysis

BACKGROUND AND AIMS

Surgical resection for hepatocellular carcinoma (HCC) is potentially curative, but long-term survival remains unsatisfactory. There is currently no effective neoadjuvant or adjuvant therapy for HCC. We sought to evaluate the impact of preoperative transcatheter arterial chemoembolization (TACE) on long-term prognosis after surgical resection of huge HCCs (≥ 10 cm).

METHODS

Using a multicenter database, consecutive patients who underwent curative-intent resection for huge HCC without macrovascular invasion between 2004 and 2014 were identified. The association between preoperative TACE with perioperative outcomes, long-term overall survival (OS), and recurrence-free survival (RFS) was assessed before and after propensity score matching (PSM).

RESULTS

Among the 377 enrolled patients, 88 patients (23.3%) received preoperative TACE. The incidence of perioperative mortality and morbidity was comparable among patients who did and did not undergo preoperative TACE (3.4% vs. 2.4%, p= 0.704, and 33.0% vs. 31.1%, p= 0.749, respectively). PSM analysis created 84 matched pairs of patients. In examining the entire cohort as well as the PSM cohort, median OS (overall cohort: 32.8 vs. 22.3 months, p= 0.035, and PSM only: 32.8 vs. 18.1 months, p= 0.023, respectively) and RFS (12.9 vs. 6.4 months, p= 0.016, and 12.9 vs. 4.1 months, p= 0.009, respectively) were better among patients who underwent preoperative TACE vs. patients who did not. After adjustment for other confounding factors on multivariable analyses, preoperative TACE remained independently associated with a favorable OS and RFS after the resection of huge HCC.

CONCLUSION

Preoperative TACE did not increase perioperative morbidity or mortality, yet was associated with an improved OS and RFS after liver resection of huge HCC (≥ 10 cm).

Transplantation versus liver resection in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common solid cancers in the world. Its treatment strategies have evolved significantly over the past few decades but the best treatment outcomes remain in the surgical arena. Especially for early HCCs, the options are abundant. However, surgical resection and liver transplantation provide the best long-term survival. In addition, there are evidence the ablative therapy such as radiofrequency ablation, could provide equivalent outcome as compared to resection. However, HCC is a unique malignancy as the majority of patients develop this cancer in the background of cirrhotic livers. As such, the treatment consideration should not only look at the oncological perspective but also the functional status of the liver parenchyma, i.e., the state of cirrhosis and presence of portal hypertension. Even with the most widely adopted staging systems for HCC such as the Barcelona Clinic Liver Cancer (BCLC) staging system and many other staging systems, none of them are ideal in including the various considerations for patients with HCCs. In this article, the key issues between choosing surgical resection and liver transplantation are discussed. A comprehensive review of the current surgical options are outlined in order to explore the pros and cons of each option.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Optimizing hepatectomy for hepatocellular carcinoma in Asia-patient selection and special considerations

Hepatocellular carcinoma (HCC) is a common affliction in Asia. The treatment of HCC depends on the tumor status as well as the underlying liver function. Resection is the cornerstone of surgical management of HCC. For those unfit to undergo resection, local ablative therapy is a viable alternative. For patients with multiple small unresectable HCCs, liver transplantation offers another option, having the simultaneous benefit of removing the cancer in addition to replacing the pre-malignant and cirrhotic liver together. However, the paucity of liver grafts limits the applicability of this operation. In assessing for the appropriate treatment, the traditional TNM staging is not widely applied to HCC. Conventionally, doctors in the West have relied on the Barcelona staging system. Asian surgeons, on the other hand, have long adopted a more aggressive approach for their patients. Borne out of the need for a system which better suited Asian patients, the Hong Kong guidelines have been established. For the surgical resection of HCC, considerations must take into account issues regarding the tumor, the underlying liver and the patient. For the tumor, the size, the presence vascular invasion and presence of extra-hepatic metastasis will determine operability. Another important issue is the liver function and, by extension, the estimated residual liver volume after resection. Thirdly, patient factors i.e., fitness to undergo general anesthesia must be properly assessed. With improved surgical technique and better patient selection, peri-operative morbidity and long-term survival results after operation have improved drastically over the past decades.

Resection for hepatocellular cancer: overpassing old barriers

Several recent studies have shown that the selection limits commonly used for patients with hepatocellular cancer (HCC) potentially requiring a liver resection (LR) are too restrictive. The present review aims at investigating the studies showing that LR is no longer a treatment suitable only for highly selected patients, but also for patients selectively presenting one-to-more negative factors. Several specific variables have been investigated, none of them showing to be an absolute contraindication for LR: age; single vs. multiple diseases; the dimension of the nodule; hyperbilirubinemia; clinically relevant portal hypertension; Child-Pugh status; macrovascular invasion. As a consequence, LR for the treatment of HCC-on-cirrhosis is a safe and effective procedure not only in "ideal cases", but also for selected patients presenting risk factors. The presence of only one of these factors does not represent an absolute contraindication for LR. On the opposite, the contemporaneous presence of risk factors should contraindicate the procedure. Further studies investigating the "borderline" cases are required, mainly looking at the possible decisive role of laparoscopy in this setting.

Proton therapy for hepatocellular carcinoma: Current knowledges and future perspectives

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death, as few patients can be treated with currently available curative local modalities. In patients with HCC where curative modalities are not feasible, radiation therapy (RT) has emerged as an alternative or combination therapy. With the development of various technologies, RT has been increasingly used for the management of HCC. Among these advances, proton beam therapy (PBT) has several unique physical properties that give it a finite range in a distal direction, and thus no exit dose along the beam path. Therefore, PBT has dosimetric advantages compared with X-ray therapy for the treatment of HCC. Indeed, various reports in the literature have described the favorable clinical outcomes and improved safety of PBT for HCC patients compared with X-ray therapy. However, there are some technical issues regarding the use of PBT in HCC, including uncertainty of organ motion and inaccuracy during calculation of tissue density and beam range, all of which may reduce the robustness of a PBT treatment plan. In this review, we discuss the physical properties, current clinical data, technical issues, and future perspectives on PBT for the treatment of HCC.

Hong Kong Consensus Statements for the Management of Unresectable Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is highly prevalent in Hong Kong due to the high prevalence of chronic hepatitis B infection. Liver cancer is the fourth most common cancer and the third most common cause of cancer death. Due to the high case load, there is a high level of local expertise in treating HCC, and the full spectrum of treatment modalities is available. This document summarizes how these modalities should be used based on the latest evidence.

SUMMARY

In 2 meetings held in early 2017, a multidisciplinary group of Hong Kong clinicians, including liver surgeons, interventional radiologists, clinical oncologists, and medical oncologists, met to update local consensus statements for management of HCC. These statements are based on the latest evidence and give detailed guidance on how to deploy these modalities, in particular for cases of HCC which are not suited to surgical resection.

KEY MESSAGES

These statements give detailed information on how to decide if a patient is a candidate for resection, methods to improve candidacy for resection, and guidance for use of various nonsurgical interventions to manage patients ineligible for resection.

Evaluating clinical and prognostic implications of Glypican-3 in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most deadly cancers worldwide. In patients with HCC, histopathogical differentiation is an important indicator of prognosis; however, because determination of HCC differentiation is difficult, the recently described immunohistochemical (IHC) marker glypican3 (GPC3) might assist in HCC prognostication.The goal of our study was to investigate GPC3's IHC staining pattern and define the relationship between its expression and patients' clinicopathologic features and overall survival. We retrieved clinical parameters from 101 pathologically diagnosed HCC patients' medical records and classified these patients into 4 clinical score categories (0–3) based on increasing GPC3 staining intensity and the percentage of stained tumor cells in their resection and biopsy specimens. Histopathological samples were well, moderately, and poorly differentiated in 33, 22, and 12 patients, respectively, and the GPC3 expression rate was 63%, 86%, and 92%,respectively. The median overall survival was 49.9 months (confidence interval (CI): 35.3–64.6 months) for clinical scores 0–1 and 30.7 months (CI: 19.4–41.9 months) for clinical scores 2–3. This difference was not statistically significant (P = .06) but showed a strong trend. In conclusion, a greater GPC3 expression is associated with a worse HCC prognosis and may be a promising prognostic marker.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of cavitron ultrasonic surgical aspirator (CUSA) and bipolar radiofrequency device (Habib-4X) based hepatectomy for hepatocellular carcinoma on tumour recurrence and disease-free survival

Background

The aim of this study was to evaluate the oncological outcomes of hepatocellular carcinoma patients undergoing liver resection using cavitron ultrasonic surgical aspirator (CUSA) or radiofrequency (RF) based device Habib-4X.


Study Design

We prospectively analyzed the data of 280 patients who underwent liver resection for hepatocellular carcinoma at our institution from 2010–2012 with follow up till August 2016. The CUSA was used in the 163 patients whilst Habib-4X in 117 patients. The end points of analysis were oncological outcomes as disease recurrence, disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan–Meier method, which has been compared with all other existing literature on the survival study.

Results

Compared with CUSA the reported incidence of recurrence was significantly lower, in Habib-4X group; p < 0.01. The median DFS was significantly better in Habib-4X group than CUSA group (50.80 vs 45.87 months, p = 0.03). The median OS was better in Habib-4X group than CUSA group (60.57 vs 57.17 months, p = 0.12) though the lesser difference in OS between the groups might be explained by the use of palliative therapies as TACE, percutaneous RFA, etc. in case of recurrence.

Conclusions

RF based device Habib-4X, is safe and effective device for resection of hepatocellular carcinoma, in comparison to CUSA with better oncological outcomes, i.e., significantly lesser tumour recurrence and better DFS. This could be explained on the basis of systemic and local immunomodulatory effect involving induction of kupffer cells and effector CD-8 T cells that help in minimizing postoperative complications and bring more advantageous oncological outcomes.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A retrospective analysis of long term outcomes in patients undergoing hepatic resection for large (>5 cm) hepatocellular carcinoma

AIM

The treatment of large (>5 cm) hepatocellular carcinoma (HCC) remains controversial. The aim of this study was to report short and long term outcomes and analyze the factors associated with long term survival for patients who underwent hepatic resection for large HCC.

METHODS

All patients who underwent hepatic resection for large HCC at the department of Hepato-Pancreato-Biliary Surgery of the First Affiliated Hospital of Anhui Medical University between August 2005 and December 2011 were identified and included for analysis. Demographic and operative data, pathological findings and post-operative outcomes were entered into a computer database. Prognostic factors were analyzed by univariate and multivariate analysis.

RESULTS

Ninety-nine patients were included for analysis. Two patients died within 30 days of surgery secondary to hepatic failure. The 1-, 3-, 5-year disease-free survival and overall survival rates following hepatic resection were 67%, 49%, 37% and 77%, 56%, 43%, respectively. Poor histological grade was the only independent predictor of a reduced 5-year disease-free survival. Spontaneous tumor rupture and tumor recurrence were independent predictors of a reduced 5-year overall survival.

CONCLUSIONS

For selected patients with large HCC, hepatic resection can be performed safely and effectively with moderate expectation of long term survival. True cure however remains rare.

Hepatic resection versus transarterial chemoembolization for patients with Barcelona Clinic Liver Cancer intermediate stage Child-Pugh A hepatocellular carcinoma

The present study aimed to compare the overall and recurrence-free survival rates following hepatic resection (HR) and transcatheter arterial chemoembolization (TACE) in patients with Barcelona Clinic Liver Cancer (BCLC) classified intermediate-stage Child-Pugh A hepatocellular carcinoma (HCC). A total of 443 patients were examined, among whom 274 underwent HR, whereas 169 received TACE. The overall survival, recurrence-free survival between groups and subgroups, and risk factors with respect to mortality and recurrence, were analyzed. The 1-, 3- and 5-year overall and recurrence-free survival rates were 70, 46 and 37% and 73, 52, and 37%, respectively after HR, compared with 38, 15, and 12% and 44, 25 and 16%, respectively after TACE. Overall and recurrence-free survival rates were significantly increased following HR compared with TACE. Subgroup analysis in the multi-nodule group showed that the 1-, 3- and 5-year overall survival rates were 68, 38 and 30% after HR, compared with 36, 10 and 0% following TACE. In the solitary tumor group, 1-, 3- and 5-year overall survival rates were 71, 50 and 38% after HR, and 41, 22 and 15% after TACE. The overall survival rate after HR was significantly increased compared with that after TACE in the solitary tumor and multi-nodule groups. The risk factors for mortality include solitary tumor diameter >10 cm, multi-nodules, serum albumin level ≥35 g/l, prothrombin time >13 sec, alphafetoprotein levels >400 ng/ml, and patients with hepatitis B virus. Solitary tumor diameter >10 cm, multi-nodules, and hepatitis B virus (P<0.001) were found to be associated with higher recurrence of HCC. Overall and recurrence-free survival rates were improved after HR compared with those after TACE in BCLC stage B, Child-Pugh A, HCC patients.

Surgery for Intermediate and Advanced Hepatocellular Carcinoma: A Consensus Report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014)

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy does not recommended surgery for treating BCLC stage B and C hepatocellular carcinoma (HCC). However, numerous Asia-Pacific institutes still perform surgery for this patient group. This consensus report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting aimed to share opinions and experiences pertaining to liver resection for intermediate and advanced HCCs and to provide evidence to issue recommendations for surgery in this patient group.

SUMMARY

Thirteen experts from five Asia-Pacific regions were invited to the meeting; 10 of them (Japan: 2, Taiwan: 3, South Korea: 2, Hong Kong: 1, and China: 2) voted for the final consensus. The discussion focused on evaluating the preoperative liver functional reserve and surgery for large tumors, multiple tumors, HCCs with vascular invasion, and HCCs with distant metastasis. The feasibility of future prospective randomized trials comparing surgery with transarterial chemoembolization for intermediate HCC and with sorafenib for advanced HCC was also discussed. The Child-Pugh score (9/10 experts) and indocyanine green retention rate at 15 min (8/10) were the most widely accepted methods for evaluating the preoperative liver functional reserve. All (10/10) experts agreed that portal hypertension, tumor size >5 cm, portal venous invasion, hepatic venous invasion, and extrahepatic metastasis are not absolute contraindications for the surgical resection of HCC. Furthermore, 9 of the 10 experts agreed that tumor resection may be performed for patients with >3 tumors. The limitations of surgery are associated with a poor liver functional reserve, incomplete tumor resection, and a high probability of recurrence.

KEY MESSAGES

Surgery provides significant survival benefits for Asian-Pacific patients with intermediate and advanced HCCs, particularly when the liver functional reserve is favorable. However, prospective randomized controlled trials are difficult to conduct because of technical and ethical considerations.

Major Liver Resection for Large and Locally Advanced Hepatocellular Carcinoma

Optimal management of large and locally advanced hepatocellular carcinoma (HCC) remains a clinical challenge especially in patients with chronic liver disease (CLD). We present our experience of major liver resection for large and locally advanced HCC. Prospectively collected data of patients with large and locally advanced HCC who underwent major liver resection between March 2011 and May 2015. The outcome measures of interest were the characteristics of tumor, surgical outcome, and overall as well as disease-free survival. Eighteen patients (14 male) with median age of 59 years (20 to 73 years) with good performance status underwent resection. Fifteen patients were in Child Pugh class A and three in class B. On contrast-enhanced computed tomography (CECT) scan, four patients had lobar/segmental portal vein involvement, two patients had bilobar disease, and one had biliary obstruction. Seven patients underwent extended resection (>5 segments), five right hepatectomy, two modified right hepatectomy, one modified right hepatectomy with wedge resection of segment six, two left hepatectomy, and one left lateral sectionectomy. On histopathology, 12 were solitary and six were multiple, the median tumor diameter was 9 cm (5-18 cm). All 18 patients had R0 resection. Eight patients had cirrhosis, six had fibrosis, and four had chronic hepatitis. Vascular invasion was noticed in 12 and out of these, six had large-vessel embolization. Morbidity according to Clavien-Dindo class was grades 1-11, grades 2-5, grade 3B-1, and grades 5-1. After a median follow-up of 32 months (6-54 months), the overall survival at 1 and 3 years was 83 and 54 %, respectively. The disease-free survival at 1 and 3 years was 75 and 54 % respectively. In carefully selected patients with large and locally advanced HCC, acceptable perioperative and medium term outcomes can be achieved with major liver resection.

Multisciplinary management of patients with liver metastasis from colorectal cancer

Colorectal cancer (CRC) is one of the leading causes of cancer-related death. Surgery, radiotherapy and chemotherapy have been till now the main therapeutic strategies for disease control and improvement of the overall survival. Twenty-five per cent (25%) of CRC patients have clinically detectable liver metastases at the initial diagnosis and approximately 50% develop liver metastases during their disease course. Twenty-thirty per cent (20%-30%) are CRC patients with metastases confined to the liver. Some years ago various studies showed a curative potential for liver metastases resection. For this reason some authors proposed the conversion of unresectable liver metastases to resectable to achieve cure. Since those results were published, a lot of regimens have been studied for resectability potential. Better results could be obtained by the combination of chemotherapy with targeted drugs, such as anti-VEGF and anti-EGFR monoclonal antibodies. However an accurate selection for patients to treat with these regimens and to operate for liver metastases is mandatory to reduce the risk of complications. A multidisciplinary team approach represents the best way for a proper patient management. The team needs to include surgeons, oncologists, diagnostic and interventional radiologists with expertise in hepatobiliary disease, molecular pathologists, and clinical nurse specialists. This review summarizes the most important findings on surgery and systemic treatment of CRC-related liver metastases.

Future remnant liver function estimated by combining liver volumetry on magnetic resonance imaging with total liver function on (99m)Tc-mebrofenin hepatobiliary scintigraphy: can this tool predict post-hepatectomy liver failure?

INTRODUCTION

Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy with a high mortality rate and is likely to happen in insufficient liver remnant. We hypothesize that assessment of the estimated future liver remnant function (eFLRF), combining future remnant liver volume (FLRV) with total liver function (TLF), is an accurate formula for prediction of PHLF.

METHODS

88 patients undergoing hepatectomy were included. The ratio of the future liver remnant volume (FLRV%) was measured on MRI. TLF was estimated by liver clearance of (99m)Technetium (Tc)-mebrofenin on hepatobiliary scintigraphy (HBS). eFLRF was calculated by multiplying FLRV% by TLF. Cut-off values of FLRV% and eFLRF predicting PHLF, were defined by receiver-operating-characteristic (ROC) analysis.

RESULTS

PHLF occurred in 12 patients (13%). Perioperative mortality was 5/12 (41%). Multivariate analysis showed that FLRV% cut off at 40% was not an independent predictive factor. eFLRF cut off at 2.3%/min/m(2) was the only independent predictive factor for PHLF. For FLRV% vs. eFLRF, positive predictive value was 41% vs. 92% and Odds Ratio 26 vs. 836.

CONCLUSION

FRLF measured by combining FLRV% and TLF is a more valuable tool to predict PHLF than FLRV% alone. The cutoff of eFLRF can be used in clinical decision making.

Systematic Review of Single Large and/or Multinodular Hepatocellular Carcinoma: Surgical Resection Improves Survival

BACKGROUND

The role of surgical resection for patients with single large (≥5 cm) and/or multinodular (≥2) hepatocellular carcinoma (HCC) is still controversial. This systematic review was performed to evaluate the safety and efficacy of resection for patients with single large and/or multinodular HCC.

MATERIALS AND METHODS

Databases (the PubMed, Web of Science, Embase, and Cochrane databases) were systematically searched to identify relevant studies exploring the safety and efficacy of resection for single large and/or multinodular HCC, published between January 2000 and December 2014. Perioperative morbidity and mortality, overall survival, and disease-free survival of the resection group were calculated. In addition, these outcome variables were also calculated for the control group in the included studies.

RESULTS

One randomized controlled trial and 42 non- randomized studies involving 9,580 patients were eligible for analysis. Eight (1,594 patients) of the 43 studies also reported the outcomes of transarterial chemoembolization (TACE). Although 51.4% of patients featured cirrhosis, 90.7% of them demonstrated Child-Pugh A liver function in the resection group. The median rates of morbidity (24.5%) and mortality (2.5%) after resection were significantly higher than that of TACE (11.0%, P<0.001; 1.9%, P<0.001). However, patients who underwent resection had significantly higher median one-, three-, and five-year overall survival (76.1%, 51.7%, and 37.4%) than those who underwent TACE (68.3%, 31.5%, and 17.5%, all P<0.001). The median 1-, 3-, and 5-year DFS rates after resection were 58.3%, 34.6%, and 24.0%, respectively.

CONCLUSIONS

Although tumor recurrence after resection for patients with single large and/ or multinodular HCC continues to be a major problem, resection should be considered as a strategy to achieve long-term survival.

Repeated Radiofrequency Ablation Combined With Ablated Lesion Elimination and Transarterial Chemoembolization Improves the Outcome of Solitary Huge Hepatocellular Carcinomas 10 m or Larger

This study investigated the effectiveness of a new strategy, repeated radiofrequency (RF) ablation combined with ablated lesion elimination following transarterial chemoembolization (TACE)/transarterial embolization (TAE), for solitary huge hepatocellular carcinoma (SHHCC) 10 cm or larger. From July 2008 to October 2015, 39 consecutive patients with SHHCC were screened. Of these, 12 were treated with TACE/TAE and repeated RF ablation (TACE/TAE + RF ablation group) and the remaining 27 patients were treated with the aforementioned new strategy (new strategy group). Local tumor progression (LTP)-free survival, intrahepatic distant recurrence (IDR)-free survival, and overall survival (OS) rates were obtained using the Kaplan-Meier method. Univariate and multivariate analyses were performed on several clinicopathological variables to identify factors affecting long-term outcome and intrahepatic recurrence. Correlation analysis was also performed. The 1-, 2-, and 3-year LTP-free survival rates and OS rates were significantly higher in the new strategy group than in the TACE/TAE + RF ablation group (82.9% vs 58.3%, 73.9% vs 29.2%, 18.5% vs 9.7%, P = 0.002; 92.0% vs 75.0%, 84.0% vs 33.3%, 32.7% vs 16.7%, P = 0.025). However, there was no significant difference between the 2 groups in the 1-, 2-, and 3-year IDR-free survival rates (P = 0.108). Using univariate analysis, alpha-fetoprotein (AFP > 200 ng/mL), ablative margin (AM > 1.0 cm), and well-differentiated cells were found to be significant factors for predicting LTP, IDR, and OS. Surgical elimination was found to be a significant factor only for predicting OS. In multivariate analyses, AFP (>200 ng/mL), AM (>1.0 cm), and well-differentiated cells were found to be significant independent factors linked to LTP, IDR, and OS. Correlation analysis indicated that AM > 1.0 cm was strongly associated with surgical elimination (P < 0.001, correlation coefficient = 0.877). For patients with SHHCC who were initially excluded from surgery, the new strategy including repeated RF ablation combined with ablated lesion elimination following TACE/TAE should now be considered as an alternative treatment.

Comparative analysis of current guidelines for the treatment of hepatocellular carcinoma

Hepatocellular carcinoma is one of the most common malignancies and represents a unique challenge for physicians and patients. Treatment patterns are not uniform between areas despite efforts to promote a common protocol. Even if most hepatologists worldwide adopt the Barcelona Clinic Liver Cancer staging system, Asian and North American physicians are also independently making an effort to expand the indications of each treatment, combining therapies for better outcomes. Also, new therapeutic techniques have emerged and an increasing number of studies are trying to include these paradigm shifts into newer treatment guidelines. Controversial and diverging points in the current international guidelines are emphasized and discussed. Unanswered questions are also analyzed to identify the most needed and promising future perspectives.

Determination of Resectability

The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.

Hepatic resection provided long-term survival for patients with intermediate and advanced-stage resectable hepatocellular carcinoma

Background

Hepatic resection has the highest local controllability that results in long-term survival for hepatocellular carcinoma (HCC). This study aimed to investigate the role of hepatic resection in selected patients of intermediate and advanced stage.

Methods

Clinical, pathological, and outcome data of 542 consecutive patients were retrospectively analyzed from a single center. The Kaplan-Meier method was used to estimate survival. Postoperative prognostic factors were evaluated using univariate and multivariate analyses.

Results

The 1-, 3-, and 5-year overall survival rates were 89.0, 64.3, and 53.0 %, respectively. The 1-, 3-, and 5-year disease-free survival rates were 72.2, 44.5, and 34.2 %, respectively. Preoperative α-fetoprotein level >400 ng/mL, macroscopic vascular invasion, microscopic portal vein thrombosis, multiple tumor nodules, and the largest tumor size >5 cm were significantly correlated with overall survival. When these clinical risk factors were used in a postoperative staging system, assigning one point for each factor, the total score was precisely predictive of long-term survival. For patients with surgery plus adjuvant TACE (transarterial chemoembolization), the median overall survival was 56 months (range 1–110 months) and the 5-year OS rate was 48.5 %.

Conclusions

Hepatic resection is efficient and safe for HCC patients of intermediate and advanced stage. The adjuvant TACE should be recommended for HCC patients with poor risk factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0811-y) contains supplementary material, which is available to authorized users.

BCLC stage B is a better designation for single large hepatocellular carcinoma than BCLC stage A

BACKGROUND AND AIM

Although the Barcelona Clinic Liver Cancer (BCLC) staging system is widely used for hepatocellular carcinoma (HCC) staging, the most appropriate BCLC stage designation for single large HCC (SLHCC, single nodule > 5 cm) remains controversial. This study investigated the prognosis of patients with SLHCC.

METHODS

Patients with newly diagnosed HCCs (BCLC stages A or B) were classified according to tumor burden: group 1, a single nodule > 2 and ≤ 5 cm or two or three nodules ≤ 3 cm; group 2, a single nodule > 5 cm; and group 3, two or three nodules > 3 cm or > 3 nodules. Survival analysis was performed according to tumor stage, treatment type, and Child-Pugh grade.

RESULTS

A total of 1005 patients were enrolled. Age was 59.3 ± 10.6 years, and 788 patients (78.4%) were men. Groups 1, 2, and 3 consisted of 613 (61.0%), 124 (12.3%), and 268 (26.7%) patients, respectively. HCC treatment included resection in 202 patients (20.1%), radiofrequency ablation ± transarterial chemoembolization in 311 patients (30.9%), and transarterial chemoembolization in 492 patients (49.0%). The median survival time differed significantly according to tumor stage (75.2, 44.9, and 30.3 months in groups 1, 2, and 3, respectively; P < 0.001). Multivariate analysis showed that group 2 had significantly worse survival compared with group 1 and similar survival to group 3.

CONCLUSIONS

Patients in group 2 had a worse prognosis than those in group 1 and a similar prognosis to those in group 3. Our results suggest that BCLC stage B is the best stage designation for SLHCC.

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

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

Outcomes of resection of giant hepatocellular carcinoma in a tertiary institution: does size matter?

BACKGROUND

The surgical management of giant hepatocellular carcinoma (G-HCC), or HCC of ≥10 cm in diameter, remains controversial. The aim of this study was to compare the outcomes of surgical resection of, respectively, G-HCC and small HCC (S-HCC), or HCC measuring <10 cm.

METHODS

A retrospective review of all patients (n = 86) diagnosed with HCC and submitted to resection in a tertiary hospital during the period from January 2007 to June 2012 was conducted. Overall survival (OS), recurrence rates and perioperative mortality at 30 days were compared between patients with, respectively, G-HCC and S-HCC. Prognostic factors for OS were analysed.

RESULTS

The sample included 23 patients with G-HCC (26.7%) and 63 with S-HCC (73.3%) based on histological tumour size. Patient demographics and comorbidities were comparable. Median OS was 39.0 months in patients with G-HCC and 65.0 months in patients with S-HCC (P = 0.213). Although size did not affect OS in this cohort, the presence of satellite lesions [hazard ratio (HR) 3.70, P = 0.012] and perioperative blood transfusion (HR 2.85, P = 0.015) were negative predictors for OS.

CONCLUSIONS

Surgical resection of G-HCC provides OS comparable with that after resection of S-HCC.

Sub-classification of intermediate-stage (Barcelona Clinic Liver Cancer stage-B) hepatocellular carcinomas

Hepatocellular carcinoma (HCC), the fifth most common cancer in the world, shows increasing incidence worldwide. Curative treatments such as hepatectomy, liver transplantation, and radiofrequency ablation are applied in only 30%-60% of cases. Most remaining patients receive transarterial chemoembolization (TACE). Patients with intermediate-stage HCCs are regarded as good candidates for TACE. However, the intermediate stage includes non-homogeneous patients. Some movements are underway to stratify patients using prognostic factors to identify patient groups exhibiting greater benefit from TACE than other patient groups. This review describes two substaging systems that subclassify intermediate-stage HCCs and discusses the importance of dividing intermediate-stage patients.

The Preference for Anterior Approach Major Hepatectomy: Experience Over 3 Decades and a Propensity Score-Matching Analysis in Right Hepatectomy for Hepatocellular Carcinoma

Surgical treatment for primary hepatocellular carcinoma (HCC) has progressed enormously over time. The aim of this study was to analyze the evolution of surgical techniques and outcomes of patients undergoing major right hepatectomy (RH) over the last few decades.A retrospective review of 557 consecutive patients who had undergone RH for HCC between January 1982 and December 2011 was performed. Patients were categorized into subgroups and analyzed according to period and surgical approach to hepatectomy. Based on a propensity score-matching model, the surgical approach in patients in the second period was also analyzed in terms of anterior approach (AA) and conventional approach (CA)-RH.Tumor factors remained the most important prognostic factors related to postoperative HCC recurrence throughout the 2 periods examined in this study. Comparison of patients selected by a propensity score-matching model showed that AA-RH led to significantly better outcomes including recurrence-free survival (RFS) (P = 0.011) and overall survival (OS) (P = 0.012) in patients with HCC as compared with CA-RH. The 5-year RFS and OS were 33.4% and 52.2% after AA-RH, and 21.0% and 36.5% after CA-RH.Major hepatectomy has evolved into a safe procedure that can be performed with confidence. RH by an AA has shown several advantages over CA-RH, and can thus be recommended as the standard procedure for liver resection in patients who require right hepatectomy.