Anatomical versus Non-anatomical Resection for Hepatocellular Carcinoma with Microscope Vascular Invasion: A Propensity Score Matching Analysis

Construction of a nomogram combining CEUS and MRI imaging for preoperative diagnosis of microvascular invasion in hepatocellular carcinoma

Purpose

To use Sonazoid contrast-enhanced ultrasound (S-CEUS) and Gadolinium-Ethoxybenzyl-Diethylenetriamine Penta-Acetic Acid magnetic-resonance imaging (EOB-MRI), exploring a non-invasive preoperative diagnostic strategy for microvascular invasion (MVI) of hepatocellular carcinoma (HCC).

Methods

111 newly developed HCC cases were retrospectively collected. Both S-CEUS and EOB-MRI examinations were performed within one month of hepatectomy. The following indicators were investigated: size; vascularity in three phases of S-CEUS; margin, signal intensity, and peritumoral wedge shape in EOB-MRI; tumoral homogeneity, presence and integrity of the tumoral capsule in S-CEUS or EOB-MRI; presence of branching enhancement in S-CEUS; baseline clinical and serological data. The least absolute shrinkage and selection operator regression and multivariate logistic regression analysis were applied to optimize feature selection for the model. A nomogram for MVI was developed and verified by bootstrap resampling.

Results

Of the 16 variables we included, wedge and margin in HBP of EOB-MRI, capsule integrity in AP or HBP/PVP images of EOB-MRI/S-CEUS, and branching enhancement in AP of S-CEUS were identified as independent risk factors for MVI and incorporated into construction of the nomogram. The nomogram achieved an excellent diagnostic efficiency with an area under the curve of 0.8434 for full data training set and 0.7925 for bootstrapping validation set for 500 repetitions. In evaluating the nomogram, Hosmer-Lemeshow test for training set exhibited a good model fit with P > 0.05. Decision curve analysis of nomogram model yielded excellent clinical net benefit with a wide range (5-80 % and 85-94 %) of risk threshold.

Conclusions

The MVI Nomogram established in this study may provide a strategy for optimizing the preoperative diagnosis of MVI, which in turn may improve the treatment and prognosis of MVI-related HCC.

Preoperative Prediction of Microvascular Invasion with Gadoxetic Acid-Enhanced Magnetic Resonance Imaging in Patients with Single Hepatocellular Carcinoma: The Implication of Surgical Decision on the Extent of Liver Resection

Introduction

Microvascular invasion (MVI) is one of the most important prognostic factors for hepatocellular carcinoma (HCC) recurrence, but its application in preoperative clinical decisions is limited. This study aimed to identify preoperative predictive factors for MVI in HCC and further evaluate oncologic outcomes of different types and extents of hepatectomy according to stratified risk of MVI.

Methods

Patients with surgically resected single HCC (≤5 cm) who underwent preoperative gadoxetic acid-enhanced magnetic resonance imaging (MRI) were included in a single-center retrospective study. Two radiologists reviewed the images with no clinical, pathological, or prognostic information. Significant predictive factors for MVI were identified using logistic regression analysis against pathologic MVI and used to stratify patients. In the subgroup analysis, long-term outcomes of the stratified patients were analyzed using the Kaplan-Meier method with log-rank test and compared between anatomical and nonanatomical or major and minor resection.

Results

A total of 408 patients, 318 men and 90 women, with a mean age of 56.7 years were included. Elevated levels of tumor markers (alpha-fetoprotein [α-FP] ≥25 ng/mL and PIVKA-II ≥40 mAU/mL) and three MRI features (tumor size ≥3 cm, non-smooth tumor margin, and arterial peritumoral enhancement) were independent predictive factors for MVI. As the MVI risk increased from low (no predictive factor) and intermediate (1-2 factors) to high-risk (3-4 factors), recurrence-free and overall survival of each group significantly decreased (p = 0.001). In the high MVI risk group, 5-year cumulative recurrence rate was significantly lower in patients who underwent major compared to minor hepatectomy (26.6 vs. 59.8%, p = 0.027).

Conclusion

Tumor markers and MRI features can predict the risk of MVI and prognosis after hepatectomy. Patients with high MVI risk had the worst prognosis among the three groups, and major hepatectomy improved long-term outcomes in these high-risk patients.

Effect of anatomical liver resection on early postoperative recurrence in patients with hepatocellular carcinoma assessed based on a nomogram: a single-center study in China

Introduction

We aimed to investigate risk factors for early postoperative recurrence in patients with hepatocellular carcinoma (HCC) and determine the effect of surgical methods on early recurrence to facilitate predicting the risk of early postoperative recurrence in such patients and the selection of appropriate treatment methods.

Methods

We retrospectively analyzed clinical data concerning 428 patients with HCC who had undergone radical surgery at Mianyang Central Hospital between January 2015 and August 2022. Relevant routine preoperative auxiliary examinations and regular postoperative telephone or outpatient follow-ups were performed to identify early postoperative recurrence. Risk factors were screened, and predictive models were constructed, including patients' preoperative ancillary tests, intra- and postoperative complications, and pathology tests in relation to early recurrence. The risk of recurrence was estimated for each patient based on a prediction model, and patients were categorized into low- and high-risk recurrence groups. The effect of anatomical liver resection (AR) on early postoperative recurrence in patients with HCC in the two groups was assessed using survival analysis.

Results

In total, 353 study patients were included. Multifactorial logistic regression analysis findings suggested that tumor diameter (≥5/<5 cm, odds ratio [OR] 2.357, 95% confidence interval [CI] 1.368-4.059; P = 0.002), alpha fetoprotein (≥400/<400 ng/L, OR 2.525, 95% CI 1.334-4.780; P = 0.004), tumor number (≥2/<2, OR 2.213, 95% CI 1.147-4.270; P = 0.018), microvascular invasion (positive/negative, OR 3.230, 95% CI 1.880-5.551; P < 0.001), vascular invasion (positive/negative, OR 4.472, 95% CI 1.395-14.332; P = 0.012), and alkaline phosphatase level (>125/≤125 U/L, OR 2.202, 95% CI 1.162-4.173; P = 0.016) were risk factors for early recurrence following radical HCC surgery. Model validation and evaluation showed that the area under the curve was 0.813. Hosmer-Lemeshow test results (X 2 = 1.225, P = 0.996 > 0.05), results from bootstrap self-replicated sampling of 1,000 samples, and decision curve analysis showed that the model also discriminated well, with potentially good clinical utility. Using this model, patients were stratified into low- and high-risk recurrence groups. One-year disease-free survival was compared between the two groups with different surgical approaches. Both groups benefited from AR in terms of prevention of early postoperative recurrence, with AR benefits being more pronounced and intraoperative bleeding less likely in the high-risk recurrence group.

Discussion

With appropriate surgical techniques and with tumors being realistically amenable to R0 resection, AR is a potentially useful surgical procedure for preventing early recurrence after radical surgery in patients with HCC.

Surgical Strategies Affect the Long-Term Prognosis of Patients with Hepatocellular Carcinoma Adjacent to the Left Branch of the Portal Vein

Purpose

When hepatocellular carcinoma (HCC) is closely associated with the left branch of the portal vein, there is still controversy regarding the surgical approach.

Methods

This study enrolled 330 HCC patients with tumors adjacent to the left branch of the portal vein. Among them, 85 patients underwent left hemihepatectomy (LH), while the remaining 235 underwent liver lobectomy (LL), which included left medial segmentectomy or left lateral sectionectomy. Perioperative complications, time to recurrence and overall survival (OS) were compared using propensity score matching.

Results

LH resulted in a lower 5-year recurrence rate and higher 5-year OS rate than LL (56.5% vs 74.0%, p=0.002; 67.4% vs 53.5%, p=0.029). The LL group showed a higher tendency for early recurrence (ER) and intrahepatic recurrence (IR). The cumulative IR rates at 1- 3-, and 5-years for the LH group and the LL group were 17.0%, 36.7%, 45.1% and 33.8%, 57.1%, 63.7%, respectively, with a p-value of 0.007. There was no statistically significant difference in the cumulative ER rates between the two groups at 1-, 3-, and 5- years. Furthermore, the LH group and the LL group had similar perioperative complications, and no cases of liver failure occurred.

Conclusion

LH, compared to LL, reduced the IR rate and ER rate in HCC patients with tumor adjacent to the left branch of the portal vein. It improved the OS outcome of the patients, and there was no significant difference in perioperative complications between the two groups.

Scientific Hepatectomy for Hepatocellular Carcinoma

With advances in imaging technology and surgical instruments, hepatectomy can be perfectly performed with technical precision for hepatocellular carcinoma (HCC). However, the 5-year tumor recurrence rates remain greater than 70%. Thus, the strategy for hepatectomy needs to be reappraised based on insights of scientific advances. Scientific evidence has suggested that the main causes of recurrence after hepatectomy for HCC are mainly related to underlying cirrhosis and the vascular spread of tumor cells that basically cannot be eradicated by hepatectomy. Liver transplantation and systemic therapy could be the solution to prevent postoperative recurrence in this regard. Therefore, determining the severity of liver cirrhosis for choosing the appropriate surgical modality, such as liver transplantation or hepatectomy, for HCC and integrating newly emerging immune-related adjuvant and/or neoadjuvant therapy into the strategy of hepatectomy for HCC have become new aspects of exploration to optimize the strategy of hepatectomy. In this new area, hepatectomy for HCC has evolved from a pure technical concept emphasizing anatomic resection into a scientific concept embracing technical considerations and scientific advances in underlying liver cirrhosis, vascular invasion, and systemic therapy. By introducing the concept of scientific hepatectomy, the indications, timing, and surgical techniques of hepatectomy will be further scientifically optimized for individual patients, and recurrence rates will be decreased and long-term survival will be further prolonged.

Effect of anatomical liver resection for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Despite retrospective studies comparing anatomical liver resection (AR) and non-anatomical liver resection (NAR), the efficacy and benefits of AR for hepatocellular carcinoma remain unclear.

MATERIALS AND METHODS

The authors systemically reviewed MEDLINE, Embase, and Cochrane Library for propensity score matched cohort studies that compared AR and NAR for hepatocellular carcinoma. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Secondary outcomes were recurrence patterns and perioperative outcomes.

RESULTS

Overall, 22 propensity score matched studies (AR, n =2,496; NAR, n =2590) were included. AR including systemic segmentectomy was superior to NAR regarding the 3-year and 5-year OS. AR showed significantly better 1-year, 3-year, and 5-year RFS than NAR, with low local and multiple intrahepatic recurrence rates. In the subgroup analyses of tumour diameter less than or equal to 5 cm and tumours with microscopic spread, the RFS in the AR group was significantly better than that in the NAR group. Patients with cirrhotic liver in the AR group showed comparable 3-year and 5-year RFS with the NAR group. Postoperative overall complications were comparable between AR and NAR.

CONCLUSIONS

This meta-analysis demonstrated that AR showed better OS and RFS with a low local and multiple intra-hepatic recurrence rate than NAR, especially in patients with tumour diameter less than or equal to 5 cm and non-cirrhotic liver.

Liver resection versus liver transplantation for hepatocellular carcinoma within the Milan criteria based on estimated microvascular invasion risks

Background

Preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC) may optimize individualized treatment decision-making. This study aimed to investigate the prognostic differences between HCC patients undergoing liver resection (LR) and liver transplantation (LT) based on predicted MVI risks.

Methods

We analysed 905 patients who underwent LR, including 524 who underwent anatomical resection (AR) and 117 who underwent LT for HCC within the Milan criteria using propensity score matching. A nomogram model was used to predict preoperative MVI risk.

Results

The concordance indices of the nomogram for predicting MVI were 0.809 and 0.838 in patients undergoing LR and LT, respectively. Based on an optimal cut-off value of 200 points, the nomogram defined patients as high- or low-risk MVI groups. LT resulted in a lower 5-year recurrence rate and higher 5-year overall survival (OS) rate than LR among the high-risk patients (23.6% vs 73.2%, P < 0.001; 87.8% vs 48.1%, P < 0.001) and low-risk patients (19.0% vs 45.7%, P < 0.001; 86.5% vs 70.0%, P = 0.002). The hazard ratios (HRs) of LT vs LR for recurrence and OS were 0.18 (95% confidence interval [CI], 0.09-0.37) and 0.12 (95% CI, 0.04-0.37) among the high-risk patients and 0.37 (95% CI, 0.21-0.66) and 0.36 (95% CI, 0.17-0.78) among the low-risk patients. LT also provided a lower 5-year recurrence rate and higher 5-year OS rate than AR among the high-risk patients (24.8% vs 63.5%, P = 0.001; 86.7% vs 65.7%, P = 0.004), with HRs of LT vs AR for recurrence and OS being 0.24 (95% CI, 0.11-0.53) and 0.17 (95% CI, 0.06-0.52), respectively. The 5-year recurrence and OS rates between patients undergoing LT and AR were not significantly different in the low-risk patients (19.4% vs 28.3%, P = 0.129; 85.7% vs 77.8%, P = 0.161).

Conclusions

LT was superior to LR for patients with HCC within the Milan criteria with a predicted high or low risk of MVI. No significant differences in prognosis were found between LT and AR in patients with a low risk of MVI.

Impact of anatomic resection on long-term survival in patients with hepatocellular carcinoma with T1-T2 disease or microscopic vascular invasion

BACKGROUND

This study aimed to clarify potential candidates for anatomic resection (AR) among patients with pathological T1-T2 (pT1-T2) hepatocellular carcinoma (HCC) and to determine whether AR is effective for HCC with microscopic vascular invasion (MVI).

METHODS

We retrospectively analyzed 288 patients with pT1a (n = 50), pT1b (n = 134) or pT2 (n = 104) HCC who underwent curative-intent resection between 1990 and 2010. Surgical outcomes were compared between patients who underwent AR (n = 189) and those who underwent nonanatomic resection (NAR; n = 99) according to pT category and MVI status.

RESULTS

Patients who underwent AR were more likely to have good hepatic functional reserve and an aggressive primary tumor than those who underwent NAR. When patients were stratified according to pT category, AR had a more favorable impact on survival than NAR only in patients with pT2 HCC in univariate (5-year survival, 51.5% vs. 34.6%; p = 0.010) and multivariate analysis (hazard ratio 0.505; p = 0.014). However, AR had no impact on survival in patients with pT1a or pT1b HCC. In patients with MVI (n = 57), AR achieved better survival than NAR (5-year survival, 52.0% vs. 16.7%; p = 0.019) and was an independent prognostic factor (hazard ratio 0.335; p = 0.020). In patients without MVI (n = 231), there was no significant difference in survival between the two groups (p = 0.221).

CONCLUSION

AR was identified as an independent factor in improved survival in patients with pT2 HCC or HCC with MVI.

Hepatic Resection vs Particle Therapy as an Initial Treatment for Single Hepatocellular Carcinoma: Bi-institutional Propensity Score-Matched Analysis

BACKGROUND

Curative treatment for hepatocellular carcinoma (HCC) is limited to hepatic resection (HR), radiofrequency ablation, and liver transplantation, but the value of particle therapy (PT) as an initial treatment remains unclear. This study aimed to compare the outcomes of HR and PT for single HCC.

STUDY DESIGN

A total of 554 patients with single HCC without vascular invasion were enrolled from January 2000 to December 2015. Patients underwent either HR (n = 279) or PT (n = 275) as initial treatments. A one-to-one propensity score-matching analysis was performed to evaluate the overall survival (OS) and progression-free survival after dividing patients according to liver function as assessed by the modified albumin-bilirubin grade.

RESULTS

The median OS (130 vs 85 months, p = 0.001) and progression-free survival (47 vs 30 months HR, p = 0.004) of HR were also significantly better than that of PT in the propensity score-matching cohort with modified albumin-bilirubin grade 1/2a (n = 145 per group). Meanwhile, in a propensity score-matching cohort with modified albumin-bilirubin grade 2b/3 (n = 53 per group), there were no significant differences in median OS and progression-free survival between HR and PT.

CONCLUSIONS

HR may be preferable as an initial treatment for patients with single HCC without vascular invasion, especially those with preserved liver function. PT can be an acceptable alternative to HR for patients without surgical indication and/or impaired liver function.

A novel multimodal deep learning model for preoperative prediction of microvascular invasion and outcome in hepatocellular carcinoma

BACKGROUND

Accurate preoperative identification of the microvascular invasion (MVI) can relieve the pressure from personalized treatment adaptation and improve the poor prognosis for hepatocellular carcinoma (HCC). This study aimed to develop and validate a novel multimodal deep learning (DL) model for predicting MVI based on multi-parameter magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CT).

METHODS

A total of 397 HCC patients underwent both CT and MRI examinations before surgery. We established the radiological models (R^CT, R^MRI) by support vector machine (SVM), DL models (DL^CT_ALL, DL^MRI_ALL, DL^CT + MRI) by ResNet18. The comprehensive model (C^ALL) involving multi-modality DL features and clinical and radiological features was constructed using SVM. Model performance was quantified by the area under the receiver operating characteristic curve (AUC) and compared by net reclassification index (NRI) and integrated discrimination improvement (IDI).

RESULTS

The DL^CT + MRI model exhibited superior predicted efficiency over single-modality models, especially over the DL^CT_ALL model (AUC: 0.819 vs. 0.742, NRI > 0, IDI > 0). The DL^MRI_ALL model improved the performance over the R^MRI model (AUC: 0.794 vs. 0.766, NRI > 0, IDI < 0), but no such difference was found between the DL^CT_ALL model and R^CT model (AUC: 0.742 vs. 0.710, NRI < 0, IDI < 0). Furthermore, both the DL^CT + MRI and C^ALL models revealed the prognostic power in recurrence-free survival stratification (P < 0.001).

CONCLUSION

The proposed DL^CT + MRI model showed robust capability in predicting MVI and outcomes for HCC. Besides, the identification ability of the multi-modality DL model was better than any single modality, especially for CT.

Preoperative Microvascular Invasion Prediction to Assist in Surgical Plan for Single Hepatocellular Carcinoma: Better Together with Radiomics

BACKGROUND

Prediction models with or without radiomic analysis for microvascular invasion (MVI) in hepatocellular carcinoma (HCC) have been reported, but the potential for model-predicted MVI in surgical planning is unclear. Therefore, we aimed to explore the effect of predicted MVI on early recurrence after anatomic resection (AR) and non-anatomic resection (NAR) to assist surgical strategies.

METHODS

Patients with a single HCC of 2-5 cm receiving curative resection were enrolled from 2 centers. Their data were used to develop (n = 230) and test (n = 219) two prediction models for MVI using clinical factors and preoperative computed tomography images. The two prediction models, clinico-radiologic model and clinico-radiologic-radiomic (CRR) model (clinico-radiologic variables + radiomic signature), were compared using the Delong test. Early recurrence based on model-predicted high-risk MVI was evaluated between AR (n = 118) and NAR (n = 85) via propensity score matching using patient data from another 2 centers for external validation.

RESULTS

The CRR model showed higher area under the curve values (0.835-0.864 across development, test, and external validation) but no statistically significant improvement over the clinico-radiologic model (0.796-0.828). After propensity score matching, difference in 2-year recurrence between AR and NAR was found in the CRR model predicted high-risk MVI group (P = 0.005) but not in the clinico-radiologic model predicted high-risk MVI group (P = 0.31).

CONCLUSIONS

The prediction model incorporating radiomics provided an accurate preoperative estimation of MVI, showing the potential for choosing the more appropriate surgical procedure between AR and NAR.

Prognostic factors in hepatocellular carcinoma patients with Child-Pugh A liver function after hepatectomy: Not related to the surgical approach

INTRODUCTION AND OBJECTIVES

Improving the prognosis of patients with hepatocellular carcinoma (HCC) undergoing hepatectomy is critical. This article aims to investigate the risk factors affecting the prognosis of HCC patients with Child-Pugh A (CPA) liver function after hepatectomy and to compare the prognosis of patients with anatomical resection (AR) and nonanatomical resection (NAR).

METHODS

In total, 186 patients diagnosed with HCC between 2013 and 2019 were retrospectively enrolled. Univariate and multivariate analyses were performed using a Cox proportional hazard regression model to explore the factors related to prognosis. Overall survival (OS) and progression-free survival (PFS) were analyzed by log-rank tests and are shown by Kaplan-Meier curves. Chi-square tests and Mann-Whitney U tests were used to compare the difference in clinical characteristics between AR and NAR patients.

RESULTS

Among the 186 enrolled patients, only 73 were followed over 60 months. The 1-, 3-, and 5-year survival rates were 74.5%, 46.7% and 26.0%, respectively. Multivariate analyses demonstrated that portal vein invasion (PVI) and tumor size were independent risk factors for OS and PFS. Preoperative hepatitis B surface antigen (HBsAg) and a-fetoprotein (AFP) levels were identified as independent risk factors only for PFS. In univariate analysis, the NAR group had a better OS rate than the AR group (1-year: 80.4% vs. 63.6%, 3-year: 55.9% vs. 30.3%, 5-year: 34.8% vs. 11.1%), but this was not confirmed by multivariate analysis.

CONCLUSIONS

PVI and tumor size > 5 cm are risk factors for the prognosis of CPA HCC patients after hepatectomy, but the surgical type is not.

Radiomics Analysis of Contrast-Enhanced CT for the Preoperative Prediction of Microvascular Invasion in Mass-Forming Intrahepatic Cholangiocarcinoma

Background

Microvascular invasion (MVI) has been shown to be closely associated with postoperative recurrence and metastasis in patients with intrahepatic cholangiocarcinoma (ICC). We aimed to develop a radiomics prediction model based on contrast-enhanced CT (CECT) to distinguish MVI in patients with mass-forming ICC.

Methods

157 patients were included and randomly divided into training (n=110) and test (n=47) datasets. Radiomic signatures were built based on the recursive feature elimination support vector machine (Rfe-SVM) algorithm. Significant clinical-radiologic factors were screened, and a clinical model was built by multivariate logistic regression. A nomogram was developed by integrating radiomics signature and the significant clinical risk factors.

Results

The portal phase image radiomics signature with 6 features was constructed and provided an area under the receiver operating characteristic curve (AUC) of 0.804 in the training and 0.769 in the test datasets. Three significant predictors, including satellite nodules (odds ratio [OR]=13.73), arterial hypo-enhancement (OR=4.31), and tumor contour (OR=4.99), were identified by multivariate analysis. The clinical model using these predictors exhibited an AUC of 0.822 in the training and 0.756 in the test datasets. The nomogram combining significant clinical factors and radiomics signature achieved satisfactory prediction efficacy, showing an AUC of 0.886 in the training and 0.80 in the test datasets.

Conclusions

Both CECT radiomics analysis and radiologic factors have the potential for MVI prediction in mass-forming ICC patients. The nomogram can further improve the prediction efficacy.

Prognostic value and predication model of microvascular invasion in patients with intrahepatic cholangiocarcinoma: a multicenter study from China

BACKGROUND

At present, hepatectomy is still the most common and effective treatment method for intrahepatic cholangiocarcinoma (ICC) patients. However, the postoperative prognosis is poor. Therefore, the prognostic factors for these patients require further exploration. Whether microvascular invasion (MVI) plays a crucial role in the prognosis of ICC patients is still unclear. Moreover, few studies have focused on preoperative predictions of MVI in ICC patients.

METHODS

Clinicopathological data of 704 ICC patients after curative resection were retrospectively collected from 13 hospitals. Independent risk factors were identified by the Cox or logistic proportional hazards model. In addition, the survival curves of the MVI-positive and MVI-negative groups before and after matching were analyzed. Subsequently, 341 patients from a single center (Eastern Hepatobiliary Hospital) in the above multicenter retrospective cohort were used to construct a nomogram prediction model. Then, the model was evaluated by the index of concordance (C-Index) and the calibration curve.

RESULTS

After propensity score matching (PSM), Child-Pugh grade and MVI were independent risk factors for overall survival (OS) in ICC patients after curative resection. Major hepatectomy and MVI were independent risk factors for recurrence-free survival (RFS). The survival curves of OS and RFS before and after PSM in the MVI-positive groups were significantly different compared with those in the MVI-negative groups. Multivariate logistic regression results demonstrated that age, gamma-glutamyl transpeptidase (GGT), and preoperative image tumor number were independent risk factors for the occurrence of MVI. Furthermore, the prediction model in the form of a nomogram was constructed, which showed good prediction ability for both the training (C-index = 0.7622) and validation (C-index = 0.7591) groups, and the calibration curve showed good consistency with reality.

CONCLUSION

MVI is an independent risk factor for the prognosis of ICC patients after curative resection. Age, GGT, and preoperative image tumor number were independent risk factors for the occurrence of MVI in ICC patients. The prediction model constructed further showed good predictive ability in both the training and validation groups with good consistency with reality.

Effectiveness of Anatomical Resection for Small Hepatocellular Carcinoma: a Propensity Score-Matched Analysis of a Multi-institutional Database

BACKGROUND

The superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score-matched (PSM) analysis.

METHODS

A total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis.

RESULTS

Applying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33-0.90) for disease-free survival and 0.61 (95% CI, 0.24-1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014).

CONCLUSIONS

AR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter.

Revisiting Surgical Strategies for Hepatocellular Carcinoma With Microvascular Invasion

Although liver resection (LR) and liver transplantation (LT) are widely considered as potentially curative therapies for selected patients with hepatocellular carcinoma (HCC); however, there is still high risk of tumor recurrence in majority of HCC patients. Previous studies demonstrated that the presence of microvascular invasion (MVI), which was defined as the presence of tumor emboli within the vessels adjacent to HCC, was one of the key factors of early HCC recurrence and poor surgical outcomes after LR or LT. In this review, we evaluated the impact of current MVI status on surgical outcomes after curative therapies and aimed to explore the surgical strategies for HCC based on different MVI status with evidence from pathological examination. Surgical outcomes of HCC patients with MVI have been described as a varied range after curative therapies due to a broad spectrum of current definitions for MVI. Therefore, an international consensus on the validated definition of MVI in HCC is urgently needed to provide a more consistent evaluation and reliable prediction of surgical outcomes for HCC patients after curative treatments. We concluded that MVI should be further sub-classified into MI (microvessel invasion) and MPVI (microscopic portal vein invasion); for HCC patients with MPVI, local R0 resection with a narrow or wide surgical margin will get the same surgical results. However, for HCC patients with MI, local surgical resection with a wide and negative surgical margin will get better surgical outcomes. Nowadays, MVI status can only be reliably confirmed by histopathologic evaluation of surgical specimens, limiting its clinical application. Taken together, preoperative assessment of MVI is of utmost significance for selecting a reasonable surgical modality and greatly improving the surgical outcomes of HCC patients, especially in those with liver cirrhosis.

Long-Term Outcomes of Anatomic Versus Nonanatomic Resection in Hepatocellular Carcinoma Patients with Bile Duct Tumor Thrombus: A Propensity Score Matching Analysis

BACKGROUND

Anatomic resection (AR) of the liver is generally recommended in hepatocellular carcinoma (HCC) patients. However, the benefits of AR and nonanatomic resection (NAR) in HCC patients with bile duct tumor thrombus (BDTT) are unknown. This study aimed to compare long-term outcomes of AR and NAR in HCC patients with BDTT after curative resection.

PATIENTS AND METHODS

A total of 175 consecutive HCC patients with BDTT after curative resection between April 2009 and December 2017 were included. One-to-one propensity score matching (PSM) was performed to minimize the influence of potential confounders. Recurrence-free survival (RFS) and overall survival (OS) were compared between the cohorts.

RESULTS

After PSM, 120 patients were analyzed. The AR group had better RFS than the NAR group (P = 0.010). Even though there was no statistically significant difference in OS (P = 0.140, power = 0.33), the 3- and 5-year OS rates in the AR group (52.4% and 44.2%, respectively) were obviously higher than those in the NAR group (35.4% and 30.4%, respectively). When patients were further stratified according to tumor size, better RFS and OS were observed in patients with small (≤ 5 cm) tumors after AR (P < 0.001 and P = 0.004, respectively). Multivariate analysis identified AR (P = 0.024) as an independent favorable prognostic factor for RFS in HCC patients with BDTT.

CONCLUSIONS

AR is recommended for HCC patients with BDTT, especially in patients with small (≤ 5 cm) tumors.

Actual long-term survival in hepatocellular carcinoma patients with microvascular invasion: a multicenter study from China

BACKGROUND

Microvascular invasion (MVI) is a risk factor for postoperative survival outcomes for hepatocellular carcinoma (HCC) after liver resection (LR). This study aims to investigate the actual long-term survival and its associated prognostic factors after LR for HCC patients with MVI.

METHODS

This study was conducted on HCC patients with MVI who underwent LR from January 2009 to December 2012 at five major hospitals in China. The patients were divided into the 'long-term survivor group' and the 'short-term survivor group'. The clinicopathologic characteristics, perioperative data and survival outcomes were compared between these two groups. Univariate and multivariate regression analyses were performed to identify predictive factors associated with long-term survival outcomes.

RESULTS

The study included 1517 patients with an actual 5-year survival rate of 33.3%. Multivariate regression analysis revealed that HBV DNA > 10⁴ IU/mL, alanine aminotransferase > 44 U/L, alpha-fetoprotein > 400 ng/ml, anatomical hepatectomy, varices, intraoperative blood loss > 400 ml, tumor diameter > 5 cm, tumor number, satellite nodules, tumor encapsulation, wide resection margin and adjuvant transarterial chemoembolization (TACE) were independent prognostic factors associated with actual long-term survival.

CONCLUSIONS

One-third of HCC patients with MVI reached the long-term survival milestone of 5 years after resection. Anatomical hepatectomy, controlling intraoperative blood loss, a wide resection margin, and postoperative adjuvant TACE should be considered for patients to achieve better long-term survival outcomes.