The Utility of Anatomical Liver Resection in Hepatocellular Carcinoma: Associated with Improved Outcomes or Lack of Supportive Evidence?

Left hepatectomy for hepatocellular carcinoma in situs inversus totalis

INTRODUCTION

One of the most prevalent primary liver cancer, particularly in Eastern Asia, is hepatocellular carcinoma (HCC), which has a poor prognosis. A rare condition known as situs inversus totalis (SIT) causes the abdominal and thoracic organs to be completely inverted.

PRESENTATION OF CASE

A 51-year-old woman complained of a lump in the abdomen since 4 years ago, slowly enlarging to the suprapubic area, without pain. Laboratory findings showed an alpha-fetoprotein level was 13.24 IU/mL. A three-phase abdominal CT scan showed a left lobe hepatoma with local metastases and situs inversus totalis. The patient was diagnosed with left lobe HCC cT2N0M0, stage II, Barcelona Clinic Liver Cancer (BCLC) A, Child-Pugh A, Karnofsky 80 % and SIT. In this case, segment II, III, and IV left hepatectomy was performed with the crushing clamp technique. The main challenges during surgery were the inverted intra-abdominal organs, where the liver was located on the left and the spleen on the right, and the very large tumor size of approximately 28 cm × 20 cm.

DISCUSSION

This interesting case creates challenges in clinical practice, particularly in surgery, due to the reversal of the normal anatomy. Thus, accurate imaging is crucial for diagnosis and treatment planning. The surgeon should remain adaptable while performing the procedure for mirrored anatomy in situs inversus.

CONCLUSION

The unique anatomy may make the liver resection procedure for HCC in patients with SIT challenging. Surgery involving these patients with inverted anatomy can be assisted by the appropriate preoperative imaging and staging using BCLC.

Anatomic versus non-anatomic liver resection for hepatocellular carcinoma-A European multicentre cohort study in cirrhotic and non-cirrhotic patients

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is increasing in the western world over the past decades. As liver resection (LR) represents one of the most efficient treatment options, advantages of anatomic (ALR) versus non-anatomic liver resection (NALR) show a lack of consistent evidence. Therefore, the aim of this study was to investigate complications and survival rates after both resection types.

METHODS

This is a multicentre cohort study using retrospectively and prospectively collected data. We included all patients undergoing LR for HCC between 2009 and 2020 from three specialised centres in Switzerland and Germany. Complication and survival rates after ALR versus NALR were analysed using uni- and multivariate Cox regression models.

RESULTS

Two hundred and ninety-eight patients were included. Median follow-up time was 52.76 months. 164/298 patients (55%) underwent ALR. Significantly more patients with cirrhosis received NALR (n = 94/134; p < 0.001). Complications according to the Clavien Dindo classification were significantly more frequent in the NALR group (p < 0.001). Liver failure occurred in 13% after ALR versus 8% after NALR (p < 0.215). Uni- and multivariate cox regression models showed no significant differences between the groups for recurrence free survival (RFS) and overall survival (OS). Furthermore, cirrhosis had no significant impact on OS and RFS.

CONCLUSION

No significant differences on RFS and OS rates could be observed. Post-operative complications were significantly less frequent in the ALR group while liver specific complications were comparable between both groups. Subgroup analysis showed no significant influence of cirrhosis on the post-operative outcome of these patients.

Anatomic versus non-anatomic resection for early-stage intrahepatic cholangiocarcinoma: a propensity score matching and stabilized inverse probability of treatment weighting analysis

BACKGROUND

Radical resection is still the most cost-effectiveness curative strategy for intrahepatic cholangiocarcinoma (ICC), but it remains controversial on the survival benefit of anatomic resection (AR). In this study, we sought to compare the oncologic outcomes between AR versus non-AR (NAR) as the primary treatment for early-stage ICC patients.

METHODS

Data of ICC patients who underwent hepatectomy and staged at AJCC I were retrospectively collected from 12 hepatobiliary centers in China between Dec 2012 and Dec 2015. Propensity score matching (PSM) and stabilized inverse probability of treatment weighting (IPTW) analysis were performed to minimize the effect of potential confounders, and the perioperative and long-term outcomes between AR and NAR groups were compared.

RESULTS

Two hundred seventy-eight ICC patients staged at AJCC I were eligible for this study, including 126 patients receiving AR and 152 patients receiving NAR. Compared to the NAR group, the AR group experienced more intraoperative blood loss before and after PSM or stabilized IPTW (all P > 0.05); AR group also experienced more intraoperative transfusion after stabilized IPTW (P > 0.05). In terms of disease-free survival (DFS) and overall survival (OS), no significant differences were observed between the two groups before and after PSM or stabilized IPTW (all P > 0.05). Multivariable Cox regression analyses found that AR was not an independent prognostic factor for either DFS or OS (all P > 0.05). Further analysis also showed that the survival benefit of AR was not found in any subgroup stratified by Child-Pugh grade (A or B), cirrhosis (presence or absence), tumor diameter (≤ 5 cm or > 5 cm) and pathological type (mass-forming or non-mass-forming) with all P > 0.05.

CONCLUSION

Surgical approach does not influence the prognosis of patients with stage I primary ICC, and NAR might be acceptable and oncological safety.

Effects of Anatomical or Non-Anatomical Resection of Hepatocellular Carcinoma on Survival Outcome

Background: The relative benefit of anatomical resection (AR) versus non-anatomical resection (NAR) in hepatocellular carcinoma (HCC) remains controversial. This study compared the survival outcomes and recurrence rates of HCCs analysed according to tumour size and the extent of resection. Methods: Consecutive patients with HCC who underwent curative resection at Asan Medical Center between January 1999 and December 2009 were included in this study. We performed propensity score matching (PSM) according to tumour size to compare the survival outcomes between AR and NAR. A total of 986 patients were analysed; 812 and 174 patients underwent AR and NAR, respectively. Results: Before PSM, regardless of tumour size, the AR group demonstrated significantly better 5-year overall survival (OS) and recurrence-free survival (RFS) than the NAR group (p < 0.001). After PSM, the AR group demonstrated better OS and RFS rates than the NAR group when tumour size was less than 5 cm, but there was no significant difference in the OS and RFS rates between the two groups when tumour size was equal to or greater than 5 cm. In tumours less than 5 cm in size, AR was the most significant factor associated with OS and RFS. However, this prognostic effect of AR was not demonstrated in tumours with sizes equal to or greater than 5 cm. Conclusion: In patients with HCCs smaller than 5 cm, AR reduced the risk of tumour recurrence and improved OS. In HCCs larger than 5 cm, AR and NAR showed comparable survival outcomes.

Combined treatments in hepatocellular carcinoma: Time to put them in the guidelines?

The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma (HCC) we do have a far-reaching arsenal. Moreover, because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options. The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies, discussing their advantages and flaws in comparison to the current standard of care. One particular combination therapy seems to be in the forefront: Transarterial chemoembolization plus ablation for medium-size non-resectable HCC (3-5 cm), which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B. Not only does it improve the outcome in contrast to each individual therapy, but it also seems to have similar results to surgery. Also, the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC. Although the path of combination therapies in HCC is still filled with uncertainty and caveats, in the following years the hepatology and oncology fields could witness an HCC guideline revolution.

Long non-coding RNA LINC00630 facilitates hepatocellular carcinoma progression through recruiting transcription factor E2F1 to up-regulate cyclin-dependent kinase 2 expression

This study is aimed to investigate the role of long non-coding RNA 630 (LINC00630) in hepatocellular carcinoma (HCC). Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to examine LINC00630 expression in HCC cell lines and tissues. After LINC00630 was overexpressed or depleted in HCC cell lines, cell counting kit-8 (CCK-8) assay, BrdU assay, and flow cytometry were conducted for detecting HCC cell multiplication, apoptosis, and cell cycle progression. The catRAPID database was adopted to predict the binding relationship between LINC00630 and E2F transcription factor 1 (E2F1), and RNA pull-down and RNA immunoprecipitation (RIP) assays were carried out to verify this binding relationship. The binding of E2F1 to the cyclin-dependent kinase 2 (CDK2) promoter region was verified by dual-luciferase reporter gene assay and chromatin immunoprecipitation-quantitative polymerase chain reaction (ChIP-qPCR) assay. Western blotting was conducted to detect the protein expression of E2F1 and CDK2 in HCC cells. We report that LINC00630 expression was up-regulated in HCC and was significantly correlated with TNM stage and lymph node metastasis. LINC00630 overexpression facilitated HCC cell proliferation and cell cycle progression and inhibited the cell apoptosis, while LINC00630 knockdown had the opposite effects. LINC00630 directly bounds with E2F1. LINC00630 overexpression enhanced the binding of E2F1 to the CDK2 promoter region, thereby promoting CDK2 transcription, whereas knocking down LINC00630 inhibited CDK2 transcription. Collectively, LINC00630 promoted CDK2 transcription by recruiting E2F1 to the promoter region of CDK2, thereby promoting the malignant progression of HCC. Our data suggest that LINC00630 is a promising molecular target for HCC.

PEComa-A Rare Liver Tumor

PEComa (perivascular epithelioid cell tumor) is a rare liver tumor. Decisions regarding patient management are currently based on a few small case series. The aim of this study was to report the clinicopathological features of PEComa in order to provide guidance for management, complemented by our own experience. This retrospective observational study included all patients with PEComa who underwent surgical treatment in two departments between 2002 and 2020. A total of 20 patients were diagnosed with PEComa following histopathological examination. The age of the patients ranged from 21 to 73 years. The majority of patients were women (85%). In most patients, the tumors were incidental. In diagnostic studies, PEComas with high arterial vascularization have been described. Liver resection was the treatment of choice. There was only one postoperative complication. During histopathological evaluation, tumors were composed mostly of epithelioid cells, rarely with spindle cell components, thick-walled vessels, and adipocytes in different proportions. Melanocytic markers (HMB45, MelanA) and at least one smooth muscle marker were expressed in all tumors. Features suggestive of malignancy were found in three cases. In conclusion, PEComa is a rare liver tumor that is usually diagnosed incidentally. In radiological studies, tumors with high arterial vascularization are observed. Liver resection is the treatment of choice.

Is the Rationale of Anatomical Liver Resection for Hepatocellular Carcinoma Universally Adoptable? A Hypothesis-Driven Review

Surgical resection is the first-line curative treatment modality for resectable hepatocellular carcinoma (HCC). Anatomical resection (AR), described as systematic removal of a liver segment confined by tumor-bearing portal tributaries, may improve survival by reducing the risk of tumor recurrence compared with non-AR. In this article, we propose the rationale for AR and its universal adoption by providing supporting evidence from the advanced understanding of a tumor microenvironment and accumulating clinical experiences of locoregional tumor ablation therapeutics. AR may be advantageous because it completely removes the en-bloc by interrupting tumor vascular supply and thus extirpates the spreading of tumor microthrombi, if they ever exist, within the supplying portal vein. However, HCC is a hypervascular tumor that can promote neoangiogenesis in the local tumor microenvironment, which in itself can break through the anatomical boundary within the liver and even retrieve nourishment from extrahepatic vessels, such as inferior phrenic or omental arteries. Additionally, increasing clinical evidence for locoregional tumor ablation therapies, such as radiofrequency ablation, predominantly performed as a non-anatomical approach, suggests comparable outcomes for surgical resection, particularly in small HCC and colorectal, hepatic metastases. Moreover, liver transplantation for HCC, which can be considered as AR of the whole liver followed by implantation of a new graft, is not universally free from post-transplant tumor recurrence. Overall, AR should not be considered the gold standard among all surgical resection methods. Surgical resection is fundamentally reliant on choosing the optimal margin width to achieve en-bloc tumor niche removal while balancing between oncological radicality and the preservation of postoperative liver function. The importance of this is to liberate surgical resilience in hepatocellular carcinoma. The overall success of HCC treatment is determined by the clearance of the theoretical niche. Developing biomolecular-guided navigation device/technologies may provide surgical guidance toward the total removal of microscopic tumor niche to achieve superior oncological outcomes.

Robotic hepatic resection in postero-superior region of liver

OBJECTIVE

Laparoscopic hepatectomy in the posterosuperior hepatic region is technically challenging and demanding. However, minimally invasive procedures carried out using the Da Vinci robot provide potential advantages in complex hepatectomy. This study reported the experience of a single center on robotic hepatectomy in the posterosuperior hepatic region.

METHODS

This retrospective study evaluated the general characteristics and perioperative outcomes of consecutive patients who underwent robotic hepatectomy in the posterosuperior hepatic region at our center from March 2015 to January 2020.

RESULTS

For 100 patients who were included into this study, 53 underwent anatomical segmentectomy or subsegmentectomy and 47 non-anatomical partial hepatectomy. There was no conversion to laparotomy. The R0 resection rate was 100%. The following perioperative outcomes were compared between patients who underwent anatomical segmentectomy/subsegmentectomy versus those who underwent non-anatomical partial hepatectomy: operation times of 160 versus 126 min, intraoperative blood losses of 100 versus 50 ml, intraoperative blood transfusion rates of 7.54% versus 4.26%, postoperative lengths of hospital stay of 5 versus 4 days, Clavien-Dindo Grade I-II complications rates of 15.09% versus 19.15%, Grade III-V complications rates of 3.77% versus 0%, bile leakage rates of 4% versus 7% and pleural effusion rates of also 4% versus 7%, respectively.

CONCLUSION

The results indicated the safety and feasibility of robotic anatomical and non-anatomical liver resections in the posterosuperior hepatic region. The robotic transabdominal approach is an option for hepatectomy in the posterosuperior hepatic region.