Retrospective analysis of type of hepatic resection for hepatocellular carcinoma

Prognostic Impact of Surgical Margin in Hepatectomy on Patients With Hepatocellular Carcinoma: A Meta-Analysis of Observational Studies

Objective

This study aims to comprehensively evaluate the prognostic impact of the surgical margin in hepatectomy on patients diagnosed with hepatocellular carcinoma (HCC).

Methods

A comprehensive and systematic search for eligible articles published in English before July 2021 was conducted across PubMed, Cochrane Library, Web of Science, and Embase electronic databases. The overall survival (OS) and disease-free survival (DFS) were the primary endpoints.

Results

In total, 37 observational studies with 12,295 cases were included in this meta-analysis. The results revealed that a wide surgical margin (≥1 cm) was associated with better OS (hazard ration (HR), 0.70; 95% confidence interval (CI), 0.63–0.77) and DFS (HR, 0.66; 95% CI, 0.61–0.71) compared to a narrow surgical margin (<1 cm). Subgroup analyses were conducted based on median follow-up time, gender, country, hepatitis B surface antigen (HBsAg) status, tumor number, and liver cirrhosis. The prognostic benefit of a wide surgical margin was consistent in most subgroups, however, analysis of studies from Western countries showed that margin width was not associated with prognosis.

Conclusion

In summary, a surgical margin wider than 1 cm prolongs the long-term prognosis of HCC patients compared to a surgical margin narrower than 1 cm.

Is Doppler/Dopplex ultrasonography reliable in the assessment of percutaneous ablative therapies of hepatocellular carcinoma: a prospective cross-sectional study

INTRODUCTION

After hepatocellular carcinoma (HCC) interventional therapies, noninvasive vascular diagnostic imaging [duplex, Color/power Doppler ultrasonography, and triphasic computed tomography (CT)] determines the lesion complete/incomplete ablation. The aim was to analyze the usefulness of duplex, color/power Doppler ultrasonography in HCC ablation after percutaneous ablative therapies (PATs).

METHODS

We included 30 patients with 33 HCCs subjected to duplex/Doppler ultrasonography, ultrasound-guided fine-needle aspiration cytology (FNAC), and triphasic CT, all these before and after PATs.

RESULTS

One week after treatment ended, out of 21 lesions with pretreatment positive color-Doppler, signals disappeared in 19 (90.5%) lesions. Out of 29 lesions with pretreatment positive power-Doppler, signals disappeared in 24 (82.8%). Out of 13 lesions with pretreatment intralesional power/duplex arterial signals, signals disappeared in eight (61.5%). There was a significant correlation (P < 0.05) between power-Doppler arterial signals and FNAC. Before HCC ablation, power-Doppler demonstrated a sensitivity 40% and specificity 96% in HCC detection in relation to FNAC, it had a sensitivity 60% and specificity 85% in HCC detection compared to triphasic CT. After HCC ablation, power-Doppler had a sensitivity and specificity of 100% in viable malignancy detection in relation to FNAC. Power-Doppler had a sensitivity 89% and specificity 93% in residual malignancy detection in relation to triphasic CT.

CONCLUSION

Power-Doppler is a good positive test as intralesional arterial signals in a cirrhotic liver lesion is highly suggestive of HCC. Power-Doppler was sensitive in HCC ablation assessment in pretreatment positive cases only. Both triphasic CT and duplex/Doppler are complementary and the use of different diagnostic modalities after ablation is mandatory.

Value of contrast-enhanced ultrasound for preoperative assessment of liver reserve function in patients with liver tumors

This study aimed to investigate the value of contrast-enhanced ultrasound (CEUS) for preoperative assessment of liver reserve function in patients with liver tumors. The indocyanine green (ICG) clearance tests and CEUS examinations of 45 noncirrhotic patients with liver tumors were performed prior to liver resection. Parameters time to peak (TtoPk), arrival time (Atm) as well as perfusion parameters A, k and A x k were generated from time-intensity curve (TIC) of CEUS. The correlation analyses of the ICG clearance per unit time (ICGK) and the retention rate at 15 min (ICGR15) with TtoPk, Atm, A, k and A x k were performed, and the diagnostic ability as well as optimal cut-off values of TtoPk and Atm for differentiating patients with ICGR15>10% from ICGR15<10% were analyzed. There were significant correlations of ICGK with TtoPk and Atm, and the correlation coefficients were 0.363 (p = 0.014) and -0.482 (p = 0.001), respectively. Significant correlations of ICGR15 with TtoPk and Atm were revealed, and the correlation coefficients were -0.416 (p = 0.004) and 0.303 (p = 0.043), respectively. No correlation of ICGK or ICGR15 with A, k and A x k was found in this study. There were significant differences in TtoPk and Atm between patients with ICGR15>10% and ICGR15<10% (p = 0.028 and p = 0.026, respectively). TtoPk and Atm both had good diagnostic abilities in diagnosing patients with ICGR15>10% verusus ICGR15<10% (AUROC = 0.711 and 0.721, respectively). For ICGR15>10% vs ICGR15, the optimal cut-off values of TtoPk and Atm were 13.307 s and 11.007 s, respectively, while the sensitivity and specificity were 75.0% and 72.7%, 60.6% and 75.0%, respectively. This study revealed that CEUS has the potential to be a new method to evaluate the liver reserve function of patients. With the optimal cut-off values of TtoPk and Atm, qualitative assessment of patients with ICGR15>10% could be more easily achieved by CEUS with good diagnostic abilities.

Long-term oncologic results of anatomic vs. parenchyma-sparing resection for hepatocellular carcinoma. A propensity score-matching analysis

PURPOSE

The extent of liver resection for the optimal treatment of hepatocellular carcinoma (HCC) is debated. The purpose of this study was to compare the impact of anatomic resection (AR) vs. parenchyma-sparing resection (PSR) on disease recurrence and patient survival.

METHODS

We retrospectively analyzed patients with HCC who underwent liver resection from January 2001 to August 2015. Patients receiving AR or PSR were compared by a propensity score analysis (PSA) (caliper = 0.1). The primary outcomes were disease-free survival (DFS) and overall survival (OS) rates, and assessed by the Kaplan-Meier method.

RESULTS

455 consecutive patients were evaluated. After PSA 354 patient were studied (177 pairs for each group). The median follow-up time was 28.2 months. The median OS was 47.5 months (95% CI: 30.0-65.9) for AR and 56.5 months (95% CI 33.2-79.6) for PSR (p = 0.169). The median DFS was 29.2 months (95% CI 17.6-40.8) for AR and 24.8 months (95% CI: 15.2-34.2) for PSR (p = 0.337). The multivariate regression model showed that cirrhosis (HR 2.85, 95% CI: 1.53-5.32; p = 0.001), BCLC grade B (HR 4.15, 95% CI: 1.33-12.95; p = 0.014), microvascular invasion (HR 1.55, 95% CI: 1.03-2.31; p = 0.033), presence of satellitosis (HR 1.94, 95% CI: 1.25-3.01; p = 0.003), severe complications (HR 6.09, 95% CI: 2.26-16.40; p > 0.001) were independently associated with poor long-term oncologic outcomes.

CONCLUSIONS

The extent of resection did not significantly affect overall and disease-free survival while tumor characteristics and underlying liver function appeared significant determinants.

Comparison of survival outcomes after anatomical resection and non-anatomical resection in patients with hepatocellular carcinoma

BACKGROUNDS/AIMS

Liver resection is a curative procedure performed worldwide for hepatocellular carcinoma (HCC). Deciding on the appropriate resection range for postoperative hepatic function preservation is an important surgical consideration. This study compares survival outcomes of HCC patients who underwent anatomical or non-anatomical resection, to determine which offers the best clinical survival benefit.

METHODS

One hundred and thirty-one patients underwent liver resection with HCC, between January 2007 and February 2015, and were divided into two groups: those who underwent anatomical liver resection (n=88) and those who underwent non-anatomical liver resection (n=43). Kaplan-Meier survival analysis and Cox regressions were used to compare the disease-free survival (DFS) and overall survival (OS) rates between the groups.

RESULTS

The mean follow-up periods were 27 and 40 months in the anatomical and non-anatomical groups, respectively (p=0.229). The 3- and 5-year DFS rates were 70% and 60% in the anatomical group and 62% and 48% in the non-anatomical group, respectively. The 3 and 5-year OS rates were 94% and 78% in the anatomical group, and 86% and 80% in the non-anatomical group, respectively. The anatomical group tended to show better outcomes, but the findings were not significant. However, a relative risk of OS between the anatomical and non-anatomical group was 0.234 (95% CI, 0.061-0.896; p=0.034), which is statistically significant.

CONCLUSIONS

Although statistical significance was not detected in survival curves, anatomical resection showed better results. In this respect, anatomical resection is more likely to perform in HCC patients with preserve liver function than non-anatomical resection.

Recurrence and survivals following hepatic resection for hepatocellular carcinoma with major portal/hepatic vein tumor thrombus

AIM

To compare the recurrence and survivals between hepatocellular carcinoma (HCC) with major portal vein tumor thrombus (TT) and major hepatic vein TT after hepatic resection (HR).

METHODS

A retrospective study was carried out with the medical records of 272 patients who underwent hepatic resection and thrombectomy for HCC with major portal vein (group A) or hepatic vein (group B) TT. The clinicopathological parameters, recurrence, survivals and prognostic significance associated with major portal or hepatic vein TT were analyzed.

RESULTS

Patients in group A had a better median survival compared with their counterparts in group B (52 vs 38 weeks; P < 0.001). One-, 2- and 3-year survival rates were markedly greater in group A than in group B (50% vs 38.8%, 26% vs 15.9% and 11.4% vs 6.1%, respectively). There was no statistical difference in recurrence-free survival rate but extrahepatic recurrences were more often seen in group B. In multivariate analysis, TT location (hepatic veins vs portal veins), type of resection (anatomical vs non-anatomical) and liver cirrhosis (none/mild vs moderate/severe) were significant prognostic factors.

CONCLUSION

Patients with HCC and major hepatic vein TT had higher incidence of extrahepatic metastases and worse overall survival after hepatic resection compared with patients with major portal vein TT. With preserved liver function, patients can receive aggressive treatments and survivals could be prolonged.

Tumour size and differentiation predict survival after liver resection for hepatocellular carcinoma arising from non-cirrhotic and non-fibrotic liver: a case-controlled study

AIMS

The aims of this study were to assess the outcomes of patients who underwent potentially curative hepatic resection for hepatocellular carcinoma (HCC) in a background of non-cirrhotic/non-fibrotic livers, and to determine prognostic factors that influenced survival.

METHODS

Over a 15-year period, all patients undergoing hepatectomy for HCC were identified. Collated data included demographics, laboratory analysis, operative findings and histo-pathological data. Survival differences between these factors following liver resection were determined.

RESULTS

57 patients were included with a median age of 70 years. The majority of patients underwent a hemi-hepatectomy or more radical resection (n = 37). Overall R0 resection rate was 90.4% (n = 51). The overall morbidity and mortality rates were 26.3% and 3.5%, respectively. The median follow-up period was 28 months. The 1-, 3- and 5- year disease-free survival was 65.4%, 41.8% and 39.1%, and the overall survival was 73.5%, 49.6% and 39.5%, respectively. AFP (p = 0.039) was the only predictor of poorer disease-free survival on univariate analysis. On multi-variable analysis, poorly differentiated tumour and large tumour size were independent predictors of overall survival.

CONCLUSIONS

Liver resection is a feasible treatment option for HCC in non-cirrhotic/non-fibrotic livers with good survival outcome. Tumour size and differentiation are adverse predictors of outcome in these patients.

Anatomic considerations in the surgical resection of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and is a common cause of cancer death worldwide. Treatment of HCC usually consists of combinations of locoregional therapy, surgical resection, orthotopic liver transplantation, and in advanced cases, systemic chemotherapy. The best rates of cure are achieved with surgical resection or orthotopic liver transplantation in well-selected patients. The success of surgical resection depends on the adequacy of the extent of resection, balanced with the need to preserve functional hepatic parenchyma. Nonanatomic resection for HCC has been proposed as a surgical technique to maximize residual liver mass, but has been shown by some to yield inferior oncologic outcomes compared with formal anatomic resection. This review discusses relevant surgical anatomy of the liver, classifications of hepatic resection, and the current literature regarding outcomes of anatomic and nonanatomic resection of the liver.

Persistent increase in alpha-fetoprotein level in a patient without underlying liver disease who underwent curative resection of hepatocellular carcinoma. A case report and review of the literature

INTRODUCTION

Alpha-fetoprotein (AFP) is an oncofetal protein produced by hepatocellular carcinoma (HCC). AFP level can also be elevated in other neoplastic or non-neoplastic conditions. An elevated AFP level has high diagnostic significance for HCC; at a level of >200 ng/mL, the probability of HCC is >90%. The aim of the present paper is to report a patient who underwent curative resection of HCC, who had a persistently elevated AFP level postoperatively but did not develop recurrence during a 2-year follow-up period. A review of the literature is also presented.

CASE REPORT

An 82-year-old male was referred following a computed tomography scan showing a 160 mm diameter mass in the left lobe of the liver. This huge mass was diagnosed as HCC, arising in the absence of cirrhosis or viral hepatitis. After tumor removal, the patient's high AFP level persisted for 2 years.

CONCLUSION

As steatosis was the only pathological change in the remnant liver, this may have caused the persistently elevated AFP level in this patient.

Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

PURPOSE

The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence.

METHODS

A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model.

RESULTS

Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay.

CONCLUSIONS

AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.

Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

PURPOSE

The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence.

METHODS

A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model.

RESULTS

Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay.

CONCLUSIONS

AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.

Prognostic factors and 10-year survival in patients with hepatocellular carcinoma after curative hepatectomy

PURPOSE

There were contrary results about the effects of hepatitis B e antigen (HBeAg) positivity on the long-term survival in patients with hepatocellular carcinoma (HCC) after curative resection.

PATIENTS AND METHODS

Medical records of 170 HCC patients who underwent curative liver resections were retrospectively reviewed. The 10-year survival rate and correlations among clinical, laboratory, and pathological data, especially HBeAg, were analyzed.

RESULTS

Fifty-two patients survived more than 10 years. The 10-year actual overall survival (OS) rate was 30.6%, and the actual disease-free survival (DFS) rate was 24.1%. The median OS and DFS were 76 and 35 months, respectively. In multivariate analysis, HBeAg positivity (P = 0.032; hazard ratio [HR], 3.041), presence of a satellite nodule (P = 0.007; HR, 4.166), and elevated ICG R15 (P = 0.003; HR, 4.915) had a significant negative correlation with the 10-year DFS rate. In addition, HBeAg positivity (P = 0.044; HR, 3.725) and recurrence (recur within 1 year, P < 0.001; HR, 41.296; recur after 1 year, P = 0.03; HR, 4.848) were found as independent factors which were negatively correlated to the 10-year OS.

CONCLUSIONS

The presence of HBeAg was significantly correlated to DFS and OS after curative resection for HCC. Active treatment of B viral hepatitis before and after surgery should be provided to prolong survival in patients with 5-10-cm HCC.

Differentiating the impact of anatomic and non-anatomic liver resection on early recurrence in patients with Hepatocellular Carcinoma

Background

For Hepatocellular Carcinoma (HCC) treated with hepatectomy, the extent of the resection margin remains controversial and data available on its effect on early tumor recurrence are very few and contradictory. The purpose of this study was to compare the impact of the type of resection (anatomic versus non-anatomic) on early intra-hepatic HCC recurrence in patients with solitary HCC and preserved liver function.

Methods

Among 53 patients with similar clinico-pathologic data who underwent curative liver resection for HCC between 2000 and 2006, 28 patients underwent anatomic resection of at least one liver segment and 25 patients underwent limited resection with a margin of at least 1 cm.

Results

After a close follow-up period of 24 months, no difference was detected in recurrence rates between the anatomic (35.7%) and the non-anatomic (40%) groups in either univariate (p = 0.74) and multivariate (p = 0.65) analysis. Factors contributing to early recurrence were tumor size (p = 0.012) and tumor stage including vascular invasion (p = 0.009).

Conclusion

The choice of the type of resection for HCC should be based on the maintenance of adequate hepatic reserve. The type of resection (anatomic vs non-anatomic) was found not to be a risk factor for early tumor recurrence.

R0 liver resections for primary malignant liver tumors in the noncirrhotic liver: a diagnosis-related analysis

BACKGROUND

Primary liver cancer constitutes an increasingly malignancy in the Western world and one of the leading causes of cancer-related deaths worldwide. The purpose of this study was to evaluate and compare long-term outcomes after R0 resections in noncirrhotic livers for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC).

METHODS

Between April 1998 and May 2006 a total of 102 patients with either ICC (n = 41, group 1) or HCC (n = 61, group 2) in the absence of cirrhosis underwent curative liver resection in our department. Demographic characteristics, operative details, perioperative complications, pathologic findings, tumor recurrence and survival were analyzed.

RESULTS

Gender (P = 0.007), extent of liver resection (P = 0.036), additional surgical procedures (P < 0.001) and operative morbidity (P = 0.018) differed among the two groups. Following resection, after a median follow-up of 28 months, the calculated 5-year survival was 44% and 40% for ICC and HCC, respectively (P = 0.38). The corresponding recurrence-free survival was 25% for both ICC and HCC (P = 0.66). UICC stage was found to predict overall and recurrence-free survival in both types of tumors. Multifocality in the case of ICC, and tumor differentiation and vascular invasion in the case of HCC, were predictive factors for overall and recurrence-free survival, respectively. In multivariable analyses, vascular invasion for HCC was predictive for overall and recurrence-free survival, whereas in the case of ICC significant differences were detected in the recurrence analysis for multifocality and UICC stage.

CONCLUSIONS

R0 resections for both ICC and HCC result to similar long-term outcomes, which are characterized by good overall and acceptable recurrence-free survival rates.

Anatomic versus limited nonanatomic resection for solitary hepatocellular carcinoma

BACKGROUND

Although anatomic liver resection is preferred when treating hepatocellular carcinoma (HCC), evidence that it improves survival when compared with an adequate nonanatomic resection is lacking. The purpose of this study was to compare the survival impact of anatomic versus nonanatomic resection in patients with solitary HCC.

PATIENTS AND METHODS

Clinicopathologic data were available for 125 patients who underwent hepatectomy for a solitary HCC confined to 1 or 2 Couinaud's segments. These patients were divided into 2 groups based on the hepatectomy procedure: anatomic (n = 83) and nonanatomic (n = 42) resection.

RESULTS

No differences were detected either in the hepatic recurrence rates (P = .38) or in the overall survival rates (P = .34) between the anatomic group and the nonanatomic group. The hepatectomy procedure (anatomic vs nonanatomic resection) did not affect survival in either univariate (P = 0.34) or multivariate analysis (relative risk, 1.574; P = .22). The proportion of patients who survived after recurrence was greater in the nonanatomic (15/42) than the anatomic group (13/83; P = .049), and the median survival time after recurrence was greater in patients who underwent nonanatomic resection (991 days; range, 131-4073 days) than in patients with anatomic resection (310 days; range, 48-1887 days; P = .045).

CONCLUSIONS

No superiority was seen in survival when HCC was treated by anatomic resection. Maintaining adequate liver function regardless of whether the resection is anatomic or not may be of greater importance.

Comparison of the outcomes between an anatomical subsegmentectomy and a non-anatomical minor hepatectomy for single hepatocellular carcinomas based on a Japanese nationwide survey

BACKGROUND

Although a surgical resection is an important modality for the treatment of hepatocellular carcinoma (HCC), the impact of the operative method on both the patient survival and disease-free survival (DFS) still remains controversial.

METHODS

Using a nationwide Japanese database, 72,744 patients with HCC who underwent a curative liver resection between 1994 and 2001 were divided into two groups based on whether an anatomical subsegmentectomy (AS) or a non-anatomical minor hepatectomy (MH) was performed. A total of 5,781 patients with single HCCs were selected for the study and divided into 3 subgroups based on the size of the HCCs (less than 2 cm, 2 to 5 cm, and greater than 5 cm in diameter). An AS was performed for 2,267 patients while an MH was performed for 3,514 patients.

RESULTS

The overall DFS was significantly better after an AS (P = .0089). When the patients were stratified according to the size of the HCC, a better DFS was seen in the patients with HCC from 2 to 5 cm after an AS (P < .0005). Further stratification according to liver damage did not show any significant differences between an AS and an MH.

CONCLUSION

An AS is therefore recommended, especially when the size of HCC ranges from 2 to 5 cm.

Liver surgery in the presence of cirrhosis or steatosis: Is morbidity increased?

Background data

The prevalence of steatosis and hepatitis-related liver cirrhosis is dramatically increasing together worldwide. Cirrhosis and, more recently, steatosis are recognized as a clinically important feature that influences patient morbidity and mortality after hepatic resection when compared with patients with healthy liver.

Objective

To review present knowledge regarding how the presence of cirrhosis or steatosis can influence postoperative outcome after liver resection.

Methods

A critical review of the English literature was performed to provide data concerning postoperative outcome of patients presenting injured livers who required hepatectomy.

Results

In clinical studies, the presence of steatosis impaired postoperative outcome regardless the severity and quality of the hepatic fat. A great improvement in postoperative outcome has been achieved using modern and multidisciplinary preoperative workup in cirrhotic patients. Due to the lack of a proper classification for morbidity and a clear definition of hepatic failure in the literature, the comparison between different studies is very limited. Although, many surgical strategies have been developed to protect injured liver surgery, no one have gained worldwide acceptance.

Conclusion

Surgeons should take the presence of underlying injured livers into account when planning the extent and type of hepatic surgery. Preoperative and perioperative interventions should be considered to minimize the additional damage. Further randomized trials should focus on the evaluation of novel preoperative strategies to minimize risk in these patients. Each referral liver center should have the commitment to report all deaths related to postoperative hepatic failure and to use a common classification system for postoperative complications.

Sonographic preoperative assessment of liver volume before major liver resection

OBJECTIVE

The use of ultrasonography is widespread for both the diagnosis and treatment of liver tumors. However, the measurement of liver volume by ultrasonography is not commonly done. We report an original method of liver volumetry using ultrasonography and an investigation into the usefulness of ultrasonography in this context.

METHODS

The data for 50 patients undergoing various types of major hepatectomy were collected. We preoperatively measured liver volume using ultrasonography, dividing the liver into three main compartments according to precise anatomical landmarks, and then made comparisons with the volume of the actual specimen after hepatectomy, for all of the study participants.

RESULTS

Total volume correlation between the two groups was good (r = 0.916, P < 0.001). However, the correlation was weaker in cases of right hepatectomy compared with other types of hepatectomy.

CONCLUSION

This study demonstrates the possibility of doing liver volumetry using an ultrasound device. Further investigation to establish the reliability of this easily available and noninvasive approach is needed.

Survival and recurrence rates after resection for hepatocellular carcinoma in noncirrhotic livers

BACKGROUND

Hepatocellular carcinoma occurring in noncirrhotic livers is rare. The purpose of this article was to evaluate the outcomes and prognostic factors after hepatectomy in this setting.

STUDY DESIGN

Between June 1998 and May 2005, 83 patients underwent liver resection for hepatocellular carcinoma in noncirrhotic livers at our institution. Preoperative treatment data, intraoperative details, pathologic findings, and information on tumor recurrence, treatment of recurrence, and survival were available for 80 of these patients.

RESULTS

Postresection, the 3- and 5-year-survival rates were 48% and 30%, respectively. After R0 resection (n=66), the calculated 3- and 5-year-survivals were 54% and 39%, compared with 23% and 0%, respectively, after R1/2-resection (p<0.005). After a median followup of 25 months, tumor recurred in 40 of 63 (63%) patients after R0 resection. In univariate analysis, Union Internationale Contre le Cancer (UICC) stage, vascular invasion, and tumor grading were identified as important findings for recurrence and poor survival after R0 resection. For tumors without vascular invasion, the 3- and 5-year-survivals were 79% and 65%, respectively, which compared favorably with 21% and 7%, respectively, for tumors with vascular invasion (p<0.0001). Similarly, 3- and 5-year-survival rates (95% each) were considerably better for G1 tumors than the corresponding 36% and 22% rates in G2 and 60% and 30% in G3 tumors, respectively.

CONCLUSIONS

The 3- and 5-year survivals of 54% and 39%, respectively, after R0 resections suggest that surgery is an option in hepatocellular carcinoma arising in noncirrhotic livers. Longterm results, however, are hampered by high recurrence rates. Union Internationale Contre le Cancer stage, vascular invasion, and tumor grades are predictors of tumor recurrence and diminished survival, and may help to identify candidates for potential adjuvant therapies.

Anatomic resection independently improves long-term survival in patients with T1-T2 hepatocellular carcinoma

BACKGROUND

This study aimed to evaluate the effect of anatomic resection on long-term outcomes in patients with pathologic T1-T2 (pT1-T2) hepatocellular carcinoma.

METHODS

A retrospective analysis of 158 consecutive patients who underwent either anatomic (n = 95) or nonanatomic (n = 63) resection for pT1-T2 hepatocellular carcinoma was conducted. Anatomic resection was defined as the complete removal of at least one Couinaud segment containing the tumor; nonanatomic resection was defined as removal of the tumor plus a rim of nonneoplastic liver parenchyma. The median follow-up time was 83 months.

RESULTS

Patients who underwent anatomic resection were characterized by lower prevalence of cirrhosis (P = .015), more favorable hepatic function (P = .001), larger tumor size (P = .029), and higher prevalence of vascular invasion (P = .008) compared with patients who underwent nonanatomic resection. Anatomic resection provided better survival (median survival time, 122 months) than nonanatomic resection (median survival time, 76 months; P = .0358). Patients who underwent anatomic resection had better disease-free survival (P = .0121). Anatomic resection independently improved both survival (hazard ratio, .46; P = .003) and disease-free survival (hazard ratio, .55; P = .008). When stratified for pT classification, the effectiveness of anatomic resection remained only in patients with pT2 tumors in terms of survival (P = .0012) and disease-free survival (P = .0004).

CONCLUSIONS

Anatomic resection independently improves long-term survival in patients with T1-T2 hepatocellular carcinoma, probably because of the clearance of venous tumor thrombi within the resected domain.

Comparison of limited and anatomic hepatic resection for hepatocellular carcinoma with hepatitis C

BACKGROUND

The long-term outcome after resection of hepatocellular carcinoma is influenced by factors related to the tumor and the underlying liver disease. The prognosis of hepatocellular carcinoma is worse in hepatitis C virus antibody-positive patients than in hepatitis B surface antigen-positive patients. In patients with hepatitis C virus infection and hepatocellular carcinoma, the optimum extent of operative resection, i.e., limited versus anatomic, remains controversial.

METHODS

Among 247 patients with hepatitis C virus infection who underwent curative resection of hepatocellular carcinoma between 1992 and 2003, 213 patients received limited resection and 34 patients had anatomic resection of at least two Couinaud subsegments with complete removal of the portal territory containing the tumor. The clinical characteristics, operative results, and long-term survival of these two groups were compared.

RESULTS

Although the patients receiving limited resection had significantly worse preoperative liver function than the patients undergoing anatomic resection, the postoperative liver function of the limited resection group was significantly better. The mortality and morbidity rates were not significantly different after limited and anatomic resection. Disease-free survival and overall survival were similar after both types of resection, as were the incidence and pattern of intrahepatic tumor recurrence.

CONCLUSIONS

In patients with hepatitis C virus infection and hepatocellular carcinoma, anatomic resection does not provide any significant benefit and should not be carried out unless it is technically necessary. In patients with a limited hepatic functional reserve, removal of the tumor with preservation of the liver parenchyma may take priority over wide resection.

The actual five-year survival rate of hepatocellular carcinoma patients after curative resection

The five-year survival rate of patients after curative resection of hepatocellular carcinoma (HCC) has been reported to be 30 to 50%, however the actual survival rate may be different. We analyzed the actual 5-year survival rate and prognostic factors after curative resection of HCC. Retrospective analysis was performed on 63 HCC patients who underwent curative resection from 1998 to 1999. A total of 63 cases were reviewed, consisting of 53 men and 10 women, with a median age of 49 years. These cases included all four pathologic T stages (pT stage) and had the following representation: stage 1 (1 case), stage 2 (17 cases), stage 3 (38 cases), and stage 4 (7 cases). In our study, the actual 5-year survival rate was 57.0% and the median survival time was 60 months. In addition, the patients in our study had an actual 5-year disease-free survival rate of 50.2% and a median disease-free survival time of 46 months. Thirty-one patients had recurrences, with a majority occurring within one year (65%). These patients with early recurrences had a poor actual 5-year survival rate of 5%. A univariate analysis showed that the prognostic factors influencing survival rate were the presence of satellite nodules, increased pT stage, HCC recurrence, and the time to recurrence (within one year). Interestingly, microvascular invasion made a difference in survival rate but was not statistically significant (p = 0.08). Furthermore, factors influencing the disease free survival rate include the presence of satellite nodules, microvascular invasion, and pT stage. Multivariate analysis identified pT stage as the only statistically related factor in determining the disease-free survival rate. The most important prognostic factor of HCC is recurrence. Moreover, the major risk factor for recurrence is an advanced pT stage. Therefore, performing prospective studies of postoperative adjuvant therapy is necessary to prevent recurrences after hepatic resection. Furthermore, active preventative treatment and early diagnosis of recurrences should be of the highest priority in the care of high-risk patient groups that have an advanced pT stage.

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review

BACKGROUND

Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC.

METHODS

On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed.

RESULTS

Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate.

CONCLUSION

TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis

BACKGROUND

Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented.

METHODS

Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival.

RESULTS

Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine.

CONCLUSION

These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.

Hepatocellular carcinoma: current surgical management

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with cirrhosis, a condition that increases the risk of performing potentially curative surgical therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and perioperative care. As such, the operative mortality rate for hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial hepatectomy or total hepatectomy followed by liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without cirrhosis can tolerate extensive resections, and partial hepatectomy should be considered first. For Child class B and C patients with a small HCC, liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated cirrhosis. Living donor liver transplantation should be considered using the same criteria as that used for cadaveric transplantation.

Preoperative assessment of liver function: a comparison of 99mTc-Mebrofenin scintigraphy with indocyanine green clearance test

BACKGROUND/AIMS

The indocyanine green (ICG) clearance test is the most frequently used test for preoperative assessment of liver parenchymal function but has its limitations. The aim of this study was to investigate the correlation between ICG clearance test and the liver uptake of 99-Technetium-labelled (99mTc)-Mebrofenin (99mTc-Mebrofenin) as measured with hepatobiliary scintigraphy.

METHODS

Fifty-four patients were diagnosed as hepatocellular carcinoma (n=9), hilar tumours (n=20) and 25 patients with non-parenchymal tumours including colorectal metastasis (n=15) and miscellaneous tumours (n=10). One day prior to operation, hepatobiliary 99mTc-Mebrofenin scintigraphy was performed after intravenous injection of 85 MBq and the 15-min clearance rate of ICG (ICG-C15) was measured.

RESULTS

The mean ICG-C15 was 86.86+/-1.19% (SEM). The mean 99mTc-Mebrofenin uptake rate was 12.87+/-0.52%/min. A significant correlation was obtained between 99mTc-Mebrofenin uptake rate by scintigraphy and ICG-C15 (r=0.73, P<0.0001). The mean clearance capacity of the right liver segments (79.83+/-1.63, range 47.75-95.97%) was larger than that of the left segments (20.24+/-1.55, range 6.51-52.51%).

CONCLUSION

99mTc-Mebrofenin uptake rate as assessed by scintigraphy is an efficient method for determining liver function and correlates well with ICG clearance. At the same time, 99mTc-Mebrofenin scintigraphy provides information of segmental functional liver tissue, which is of additional use when planning liver resection.

Longterm prognosis after hepatic resection for small hepatocellular carcinoma

BACKGROUND

Treatment of small hepatocellular carcinoma (HCC) remains a critical issue. In addition, the longterm prognosis and prognostic factors of small hepatocellular carcinoma after hepatic resection are not well documented.

STUDY DESIGN

The surgical outcomes of 135 consecutive patients with one to three HCCs of diameter <or= 3 cm who underwent curative hepatic resection between 1987 and 2001 were reviewed retrospectively. Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model.

RESULTS

The overall incidence of postoperative complications was 25%, and three patients had hospital deaths (2%), including one (0.7%) operative death. The mean and median overall survival times, including hospital death after surgery, were 53 months and 43 months, respectively. The 3-, 5-, and 10-year disease-free survival percentages after hepatic resection were 49%, 30%, and 8%, respectively. The 3-, 5-, and 10-year overall survival percentages after hepatic resection were 73%, 55%, and 18%, respectively. Multivariate analysis revealed that age more than 60 years was an independent unfavorable prognostic factor affecting disease-free survival (hazard ratio 1.286, 95% confidence interval 1.107 to 1.863, p = 0.046), and the presence of liver cirrhosis was an independently significant factor of poor overall survival (hazard ratio 2.012, 95% confidence interval 1.049 to 3.861, p = 0.035). The cumulative incidence of postoperative recurrence was 82%. The 5-year overall survival in patients with tumor recurrence undergoing repeat hepatectomy (85%) was significantly greater than in patients without second resection (41%). Six patients (4%) survived longer than 10 years after hepatic resection (four with recurrence and two without recurrence). All four of these patients with postoperative recurrence underwent repeat hepatectomy.

CONCLUSIONS

The postresection survival of patients with small hepatocellular carcinoma will differ depending on the presence of liver cirrhosis. Repeat hepatectomy may contribute to the prolongation of survival in such patients with postoperative recurrence.

Hepatocellular carcinoma: surgical indications and results

Hepatocellular carcinoma (HCC) is a tumour of increasing incidence that usually arises in cirrhotic liver. Untreated, the prognosis is grim and the only curative treatment is surgical resection. The practical application of segmental surgery to the liver together with the use of ultrasound and other imaging techniques, patient selection criteria and improvements in perioperative technique and postoperative care have contributed to better results in hepatic surgery. Today, less than 10% mortality for resection of cirrhotic livers, with up to 50% 5-year survival rates are to be expected. However, the limits of resection for cure: intrahepatic recurrence makes stringent follow-up necessary. In this way the available modalities of treatment can be applied so as to improve survival. Herein, a current 'state-of-the-art' of surgical indications and results for HCC is given.

Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma

BACKGROUND

Extended hepatectomy with resection of more than four segments is a high-risk operation, especially in patients with hepatocellular carcinoma (HCC) associated with chronic liver disease. This study evaluated the risk factors for morbidity and mortality following extended hepatectomy for HCC.

METHODS

Preoperative and intraoperative variables of 155 patients who underwent extended hepatectomy for HCC were analysed to identify risk factors for postoperative morbidity and mortality.

RESULTS

The overall morbidity rate was 55.5 per cent (n = 86). Most morbidity was due to ascites or pleural effusion. Significant life-threatening complications occurred in 20.0 per cent (n = 31). The perioperative mortality rate was 8.4 per cent (n = 13). Multivariate analysis found that portal clamping (P = 0.023) and perioperative blood transfusion (P < 0.001) were risk factors for morbidity, whereas perioperative blood transfusion (P < 0.001) was the only risk factor for significant morbidity. Co-morbid illness (P = 0.019) and perioperative blood transfusion (P = 0.004) were risk factors for perioperative mortality.

CONCLUSION

Meticulous operative techniques to minimize blood loss and transfusion, while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative morbidity. Avoidance of perioperative blood transfusion and careful preoperative selection of patients in terms of overall physiological status are important measures to reduce the postoperative mortality rate.

The prognostic significance of clinical and pathological features in hepatocellular carcinoma

The prognosis of patients with HCC still remains dismal. The life expectancy of HCC patients is hard to predict because of the high possibility of postoperative recurrence. Many factors, such as patient's general conditions, macroscopic tumor morphology, as well as tumor hitopathology features, have been proven of prognostic significance. Female HCC patient often has a better prognosis than male patient, which might be due to the receptor of sex hormones. Younger patients often have tumors with higher invasiveness and metastatic potentials, and their survival and prognosis are worse than the older ones. Co-existing hepatitis status and hepatic functional reserve have been confirmed as risk factors for recurrence. Serum alpha-fetoprotein (AFP) is useful not only for diagnosis, but also as a prognostic indicator for HCC patients. AFP mRNA has been proposed as a predictive marker of HCC cells disseminated into the circulation and for metastatic recurrence. Many pathologic features, such as tumor size, number, capsule state, cell differentiation, venous invasion, intrahepatic spreading, and advanced pTNM stage, are the best-established risk factors for recurrence and important aspects affecting the prognosis of patients with HCC. Marked inflammatory cell infiltration in the tumor could predict a better prognosis. Clinical stage is still the most important factor influencing on the prognosis. Extratumor spreading and lymph nodal metastasis are independent predictors for poor outcome. Some new predictive systems have recently been proposed. Different strategies of treatment might have significant different effects on the patients' prognosis. To date, surgical resection is still the only potentially curative treatment for HCC, including localized postoperative recurrences. Extent of resection, blood transfusion, occlusion of porta hepatis, and blood loss affect the survival and prognosis of HCC patients. Regional therapies provide alternative ways to improve the prognosis of HCC patients who have no opportunity to receive surgical treatment or postoperative recurrence. The combination of these treatment modalities is hopeful to further improve the prognosis. The efficacies of neoadjuvant (preoperative) or adjuvant (postoperative) chemotherapy or chemoembolization in preventing recurrence and on the HCC prognosis still remain great controversy, and deserves further evaluation. Biotherapy, including IFN-alpha therapy, will play more important role in preventing recurrence and metastasis of HCC after operation.

Extent of liver resection influences the outcome in patients with cirrhosis and small hepatocellular carcinoma

BACKGROUND

The long-term outcome after resection of hepatocellular carcinoma (HCC) is influenced by parameters related to the tumor and the underlying liver disease. However, the extent of the resection, which can be limited or anatomical (including the tumor and its portal territory), is controversial.

METHODS

Among 64 Child-Pugh A patients with cirrhosis who underwent curative liver resection for small HCC (< or = 4 cm) between 1990 and 1996, 34 patients underwent limited resection with a margin width of at least 1 cm, and 30 patients underwent anatomic resection of at least 1 liver segment with complete removal of the portal area containing the tumor. The 2 groups were comparable in terms of epidemiologic and pathologic parameters. The major end points were: (1) in-hospital mortality and morbidity; (2) overall and disease-free survival; and (3) rate and topography of recurrence.

RESULTS

The 30-day mortality (6% vs 7%) and morbidity (52% vs 47%) rates after limited and anatomic liver resection were not statistically different. The 5- and 8-year overall survival rates after limited versus anatomic resection were, respectively, 35% versus 54% (P <.05) and 6% versus 45% (P <.05). The 5- and 8-year disease-free survival rates were, respectively, 26% versus 45% and 0% versus 21% (P <.05). Local recurrence was more frequently observed after limited resections than after anatomic resections (50% vs 10%, P <.05).

CONCLUSIONS

In patients with cirrhosis and a small HCC, anatomic resection achieves better disease-free survival than limited resection without increasing the postoperative risk. Therefore, anatomical resection should be the treatment of choice and considered as the reference surgical treatment compared with other treatments.

Improving operative safety for cirrhotic liver resection

BACKGROUND

Liver resection in a patient with cirrhosis carries increased risk. The purposes of this study were to review the results of cirrhotic liver resection in the past decade and to propose safe strategies for cirrhotic liver resection.

METHODS

Based on the date of operation, 359 cirrhotic liver resections in 329 patients were divided into two intervals: period 1, from September 1989 to December 1994, and period 2, from January 1995 to December 1999. The patient backgrounds, operative procedures and early postoperative results were compared between the two periods. The factors that influenced surgical morbidity were analysed.

RESULTS

In period 2, patient age was higher and the amounts of blood loss and blood transfused were lower. Although postoperative morbidity rates were similar, blood transfusion requirement, postoperative hospital stay and mortality rate were significantly reduced in period 2. No death occurred in 154 consecutive cirrhotic liver resections in the last 38 months of the study. Prothrombin activity and operative time were independent factors that influenced postoperative morbidity.

CONCLUSION

With improving perioperative assessment and operative techniques, most complications after cirrhotic liver resection can be treated with a low mortality rate. However, more care should be taken if prothrombin activity is low or there is a long operating time.