Role of hepatectomy for recurrent or initially unresectable hepatocellular carcinoma

As a result of donor shortage and high postoperative morbidity and mortality after liver transplantation,hepatectomy is the most widely applicable and reliable option for curative treatment of hepatocellular carcinoma(HCC).Because intrahepatic tumor recurrence is frequent after loco-regional therapy,repeated treatments are advocated provided background liver function is maintained.Among treatments including local ablation and transarterial chemoembolization,hepatectomy provides the best long-term outcomes,but studies comparing hepatectomy with other nonsurgical treatments require careful review for selection bias.In patients with initially unresectable HCC,transarterial chemo-or radio-embolization,and/or systemic chemotherapy can down-stage the tumor and conversion to resectable HCC is achieved in approximately 20%of patients.However,complete response is rare,and salvage hepatectomy is essential to help prolong patients’survival.To counter the short recurrence-free survival,excellent overall survival is obtained by combining and repeating different treatments.It is important to recognize hepatectomy as a complement,rather than a contraindication,to other nonsurgical treatments in a mul-tidisciplinary approach for patients with HCC,including recurrent or unresectable tumors.     

Risk factors of intrahepatic recurrence after curative resection of hepatocellular carcinoma

BACKGROUND/AIMS: Although the risk factors for the development of intrahepatic recurrence after hepatectomy for hepatocellular carcinoma (HCC) have been widely studied, little attention has been given to the prognostic factors affecting such patients. METHODOLOGY: Intrahepatic recurrence occurred in 105 (56%) of 188 patients who underwent curative hepatic resection of HCC and were discharged from the hospital. Among them, 17 (16%) also had simultaneous extrahepatic recurrence. Independent prognostic factors were evaluated by multivariate analysis using Cox's proportional hazards model. RESULTS: Multivariate analysis revealed that presence of extrahepatic recurrence, hepatitis B, and non-surgical treatments for recurrence were independent predictors of poor overall survival after initial hepatic resection or after recurrence. Risk factors of extrahepatic recurrence were young age, solitary and large HCC, high hepatitis activity, and large amount of intraoperative blood loss and blood transfusion. CONCLUSIONS: Survival of patients with intrahepatic recurrent HCC after resection should be stratified by the type of recurrence, type of hepatitis, and type of treatment for recurrence.     

Outcomes following resection of intrahepatic cholangiocarcinoma

ObjectivesThe aim of this analysis was to examine prognostic features and outcomes in patients undergoing resection for intrahepatic cholangiocarcinoma (ICC).MethodsA retrospective chart review was performed in all patients who underwent R0 or R1 resection for primary ICC between 1995 and 2011. Clinical data were abstracted and statistical analyses were conducted in the standard fashion.ResultsA total of 82 patients underwent curative hepatectomy for primary ICC; 51 patients in this cohort developed recurrence. The median follow-up of survivors was 27 months (range: 1–116 months). Recurrences were intrahepatic (65%), associated with multiple tumours (54%) and occurred during the first 2 years after hepatectomy (86%). The main factor associated with recurrence after resection was the presence of satellite lesions. Overall 5-year disease-free survival after primary resection was 16%. Factors associated with poor survival were transfusion and perineural invasion. Treatment of recurrence was undertaken in 89% of patients and repeat surgical resection was performed in 15 patients. The 3-year survival rate after recurrence was 25%. Prolonged survival after recurrence was associated with a solitary tumour recurrence.ConclusionsDespite curative resection of ICC, recurrence can be expected to occur in 79% of patients at 5 years. Predictors of survival and recurrence after resection vary in the literature. In patients with recurrence, selection of the optimal treatment remains challenging.     

Repeat hepatectomy for recurrent colorectal liver metastases is associated with a high survival rate

BackgroundThe outcome after a repeat hepatectomy for recurrent colorectal liver metastases (CLM) is not well defined. The present study examined the morbidity, mortality and long-term survivals after a repeat hepatectomy for recurrent CLM.MethodsData on patients who underwent surgery for recurrent CLM between 1993 and 2009 were retrospectively evaluated. Patients who underwent radiofrequency ablation at the time of first treatment or at recurrence of CLM were excluded.ResultsForty-three patients underwent a repeat hepatectomy for recurrent CLM. At the time of recurrence, patients had a median of 1 (1–3) lesions and the median tumour size was 2 (0.5–8.7) cm. The post-operative morbidity and mortality rates were 12% and 0%, respectively. After a median follow-up of 33 months from a repeat hepatectomy, 5-year overall and progression-free survival rates were 73% and 22%, respectively. Using multivariate analysis, the largest initial CLM ≥5 cm and positive surgical margins at initial resection were independently associated with a worse survival after surgery for recurrent CLM. Positive surgical margins at repeat hepatectomy were a predictive factor for an increased risk of further recurrence.DiscussionA repeat hepatectomy for recurrent CLM was associated with excellent survival, low morbidity and no mortality. Surgeon-controlled variables, including margin-negative resection at first and repeat hepatectomy, contribute to good oncological outcome.     

Surgical treatment of recurrent hepatocellular carcinoma based on the mode of recurrence: repeat hepatic resection or ablation are good choices for patients with recurrent multicentric cancer

Hepatocellular carcinomas (HCC) often recur after curvative resection. Recurrence in the remnant liver originates from intrahepatic metastasis (IM) from the primary resected tumor, and/or from multicentric (MC) occurrence. In order to achieve better survival after intrahepatic recurrence in HCC patients, we have surgically treated patients according to the recurrence pattern. In this study, we investigated the advantage of repeat surgery for MC recurrent HCC. The subjects were 176 patients who had undergone primary macroscopically complete tumor removal for HCC at our department from 1984 to 1999. Differential diagnosis of IM and MC recurrence was done by pathological analysis. Twenty‐nine of the 149 patients with recurrence (19.5%) underwent a total of 31 second and third operations. Of the 29 patients, 18 had MC (14 received repeat hepatectomy and 4, microwave tissue coagulation [MTC]), 7 had IM (4 had repeat hepatectomy and 3, MTC), and, in 4 patients, pathological investigation failed to determine the mode of recurrence. The 1‐, 3‐, and 5‐year survival rates for MC patients after the repeat operations were 100%, 69.7%, and 58.1%, respectively, and the 1‐, 3‐, and 5‐year survival rates for the IM patients were 57.1%, 14.3%, and 14.3%, respectively. Survival after the repeat operation was significantly better in the MC group than in the IM group (P = 0.0016). Moreover, there was no significant difference between survival in the MC group after a repeat operation and survival in control patients after an initial hepatectomy (P = 0.9282). These results indicated that patients with resectable or ablative recurrent MC HCC have almost the same survival benefit after repeat operations as patients who undergo initial curative resection of HCC.     

Strategy for improving survival and reducing recurrence of HCV-related hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the sixth most common cancer and the third leading cause of cancerrelated death in the world.With advances in imaging diagnostics,accompanied by better understanding of high-risk patients,HCC is now frequently detected at an early stage;however,the prognosis remains poor.The recurrence rate after treatment of HCC is higher than that associated with cancers of other organs.This may be because of the high incidence of intrahepatic distant recurrence and multicentric recurrence,especially with hepatitis C virus(HCV)-related hepatocellular carcinoma.The Barcelona Clinic Liver Cancer(BCLC)classification has recently emerged as the standard classification system for the clinical management of patients with HCC.According to the BCLC staging system,curative therapies(resection,transplantation,transcatheter arterial chemoembolization,percutaneous ethanol injection therapy,percutaneous microwave coagulation therapy and percutaneous radiofrequency ablation)can improve survival in HCC patients diagnosed at an early stage and offer a potential long-term cure.However,treatment strategies for recurrent disease are not mentioned in the BCLC classsification.The strategy for recurrence may differ according to the recurrence pattern,i.e.,intrahepatic distant recurrence vs multicentricrecurrence.In this article,we review recurrent HCC and the therapeutic strategies for reducing recurrent HCC,especially HCV-related HCC.     

Repeat hepatectomy is the most useful treatment for recurrent hepatocellular carcinoma

Hepatic resection has been regarded as a curative treatment for primary hepatocellular carcinoma (HCC), but a high incidence of postoperative recurrence is general. Thus it is important to predict the patterns of recurrence and select the appropriate treatment for recurrence for a better long‐term prognosis of patients with HCC. Clinicopathological studies on 80 patients with intrahepatic recurrence after curative hepatectomy suggested that nodular‐type recurrence with up to three nodules is mainly due to metachronous multicentric hepatocarcinogenesis rather than intrahepatic metastases. We reviewed 300 patients with recurrent HCC, and repeat hepatectomy was done in 78 cases (26.0%). The 3‐ and 5‐year survival rates after repeat hepatectomy were 82.8% and 47.5%, respectively, showing better prognosis than those for other treatments. Repeat hepatectomy is the preferred treatment offering a hope of long‐term survival for patients with recurrent HCC as long as liver function is sufficient; thus early detection of recurrence should be ensured.     

Patterns,treatments, and prognosis of tumor recurrence after resection for hepatocellular carcinoma with microvascular invasion: a multicenter study from China

BackgroundMicrovascular invasion (MVI) is a risk factor of post-hepatectomy tumor recurrence for hepatocellular carcinoma (HCC). The patterns, treatments, and prognosis have not been documented in HCC patients with MVI.MethodsA multicenter database of patients with HCC and MVI following resection was analyzed. The clinicopathological and initial operative data, timing and first sites of recurrence, recurrence management, and long-term survival outcomes were analyzed.ResultsOf 1517 patients included, the median follow-up was 39.7 months. Tumor recurrence occurred in 928 patients, with 49% within 6 months of hepatectomy and 60% only in the liver. The incidence of intrahepatic only recurrence gradually increased with time after 6 months. Patients who developed recurrence within 6 months of hepatectomy had worse survival outcomes than those who developed recurrence later. Patients who developed intrahepatic only recurrence had better prognosis than those with either extrahepatic only recurrence or those with intra- and extrahepatic recurrence. Repeat resection of recurrence with curative intent resulted in better outcomes than other treatment modalities.ConclusionPost-hepatectomy tumor recurrence in patients with HCC and MVI had unique characteristics and recurrence patterns. Early detection of tumor recurrence and repeat liver resection with curative intent resulted in improved long-term survival outcomes.     

Prediction of recurrence of hepatocellular carcinoma after curative hepatectomy using preoperative Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein

Aim: Lens culinaris agglutinin A‐reactive fraction of α‐fetoprotein (AFP‐L3) status has been reported to be an independent prognostic factor in patients with hepatocellular carcinoma (HCC). In this study, we evaluated the clinical usefulness of measuring preoperative AFP‐L3 to predict the recurrence and prognosis of HCC after curative hepatectomy. Methods: One hundred and forty‐two HCC patients who underwent curative hepatectomy were examined for the correlation between preoperative tumor marker, including AFP, des‐γ‐carboxy prothrombin (DCP) and AFP‐L3, and clinicopathological variables. The prognostic factors of disease‐free survival rates and overall survival rates were also determined using clinicopathological variables including these three tumor markers. Results: There were similar tendencies in the relationship between these three markers and malignant behaviors including lower grade tumor differentiation or vascular invasion. In multivariate analysis, increased AFP‐L3 value (P = 0.019) was found to be an independent prognostic factor of disease‐free survival after curative hepatectomy. In addition, elevated DCP (P = 0.013) and AFP‐L3 values (P = 0.012) were found to be independent prognostic factors. Furthermore, the preoperative AFP‐L3 value in the patients with early recurrence (within 1 year after hepatectomy) was significantly higher than that in those without early recurrence (26.9 ± 19.5 % vs 14.2 ± 19.8 %, P = 0.047). Conclusion: Preoperative AFP‐L3 value was strongly correlated to disease‐free and overall survival rate and the timing of recurrence, so it appears that it would be useful to predict the recurrence and prognosis of HCC after curative hepatectomy.     

Metadherin Is a Prognostic Predictor of Hepatocellular Carcinoma after Curative Hepatectomy

Background/AimsThe prognosis after surgical resection of hepatocellular carcinoma (HCC) remains poor because of a high rate of recurrence. Thus, it is crucial to identify patients with a high risk of recurrence after curative hepatectomy and to develop more effective and targeted treatment strategies to improve disease outcomes. In this study, we investigated the roles of metadherin (MTDH) in the prognosis of HCC.MethodsWe investigated MTDH expression using immunohistochemistry in tumor tissue microarrays of 288 primary HCC patients who underwent curative surgical resection.ResultsHigh MTDH expression was observed in 138 of the 288 HCC cases (47.9%). High MTDH expression was associated with a younger age (p<0.001), higher Edmondson grade (p<0.001), microvascular invasion (p<0.001), higher American Joint Committee on Cancer T stage (p=0.001), and higher α-fetoprotein level (p=0.003). Multivariate analyses revealed that high MTDH expression (p=0.014), higher Barcelona-Clinic Liver Cancer (BCLC) stage (p<0.001), and Edmondson grade III (p=0.042) were independent predictors of shorter disease-free survival (DFS). Higher BCLC stage (p<0.001) and Edmondson grade III (p=0.047) were also independent predictors of shorter disease-specific survival.ConclusionsHigh MTDH expression may be a prognostic predictor of shorter DFS in HCC patients after curative hepatectomy.     

Is intraoperative adjuvant therapy effective for satellite lesions in patients undergoing reduction surgery for advanced hepatocellular carcinoma?

BACKGROUND/AIMS: The effectiveness of intraoperative adjuvant therapy for satellite lesions of nonresectable hepatocellular carcinoma (HCC) was investigated. METHODOLOGY: We randomly assigned 30 eligible patients with advanced-stage HCC with multiple intrahepatic lesions who underwent reduction hepatectomy in conjunction with either intraoperative adjuvant therapy (hepatectomy plus microwave coagulonecrotic therapy or radiofrequency ablation) or postoperative adjuvant therapy (transcatheter arterial embolization). The cumulative survival rates were obtained for both groups using the Kaplan-Meier method and compared using the log-rank test. To evaluate whether the intraoperative adjuvant therapy significantly influenced the prognosis, we reviewed changes in clinical factors by multiple regression analysis using the Cox's proportional hazard model. Ap value of less than 0.05 was considered statistically significant. RESULTS: The 3- and 5-year cumulative survival rates in patients who underwent intraoperative adjuvant therapy were 35.7% and 7.7%, while those in patients who underwent postoperative adjuvant therapy were 35.0% and 0%, respectively. The difference was not statistically significant. The level of a-fetoprotein, maximum tumor size, number of tumors, and clinical stage were found to be independent factors affecting survival after diagnosis. Intraoperative adjuvant therapy was not an independent prognostic factor. CONCLUSIONS: The survival rates did not differ between the patients who underwent intraoperative adjuvant therapy and postoperative adjuvant therapy for satellite lesions of non-resectable HCC.     

Risk factors and management for early and late intrahepatic recurrence of solitary hepatocellular carcinoma after curative resection

Background

Intrahepatic recurrence is a significant problem for patients who have undergone a hepatic resection for hepatocellular carcinoma (HCC). The objective of the present study was to identify risk factors and evaluate the management of early and late recurrence of solitary HCC after curative resection.

Methods

Included in this study were 816 patients with solitary HCC who underwent a curative partial hepatectomy. Intrahepatic recurrence in these patients was followed up retrospectively. Prognosis and therapy for the recurrence were investigated and analysed.

Results

Early and late intrahepatic recurrence occurred in 423 patients and 199 patients, respectively. Multivariate analysis showed that a tumour diameter >5 cm, the absence of a tumour capsule and the presence of microvascular invasion were correlated with early recurrence, whereas cirrhosis and alpha-fetal protein >400 μg/l were independent risk factors contributing to late recurrence. The 5-year survival of HCC patients with early recurrence was significantly lower than that of patients with late recurrence. Further curative treatment for intrahepatic recurrence offered a 5-year overall survival of 56.0%, which was better than alternative management.

Conclusion

Early and late recurrences of solitary HCC after curative resection are associated with different predictive factors. The time to recurrence and further curative treatment after recurrence were the best predictors of survival post recurrence.     

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma ≤ 4 cm

AIM: To determine which treatment modality--hepatectomy or percutaneous ablation--is more beneficial for patients with small hepatocellular carcinoma (HCC) (< or =4 cm) in terms of long-term outcomes. METHODS: A retrospective analysis of 149 patients with HCC < or =4 cm was conducted. Eighty-five patients underwent partial hepatectomy (anatomic in 47 and non-anatomic in 38) and 64 underwent percutaneous ablation (percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6). The median follow-up period was 69 mo. RESULTS: Hepatectomy was associated with larger tumor size (P<0.001), whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy (P<0.0001). Survival was better following hepatectomy (median survival time: 122 mo) than following percutaneous ablation (median survival time: 66 mo; P=0.0123). When tumor size was divided into < or =2 cm vs >2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors>2 cm (P=0.0001). The Cox proportional hazards regression model revealed that hepatectomy (P=0.006) and tumors < or =2 cm (P=0.017) were independently associated with better survival. CONCLUSION: Hepatectomy provides both better local control and better long-term survival for patients with HCC < or =4 cm compared with percutaneous ablation. Of the patients with HCC < or =4 cm, those with tumors >2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.     

Parenchyma-sparing hepatectomy improves salvageability and survival for solitary small intrahepatic cholangiocarcinoma

BackgroundThis study aimed to investigate the prognostic impact of parenchyma-sparing hepatectomy (PSH) on solitary small intrahepatic cholangiocarcinoma (ICC).MethodsA total of 184 patients with solitary small ICC (≤ 5 cm) from 2009 to 2017 were included. Short- and long-term outcomes were compared between PSH and Non-PSH approach.Results95 (51.6%) patients underwent PSH and 89 (48.4%) patients underwent Non-PSH for solitary small ICC. PSH was associated with less intraoperative blood loss (212.9 mL versus 363.5 mL, P=0.038), lower transfusion rate (7.4% versus 16.9%, P=0.048), without increasing the frequency of tumor recurrence (60.0% versus 58.4%). No significant differences were observed in overall survival (OS), recurrence-free survival (RFS) and liver RFS (P = 0.627, 0.769 and 0.538, respectively). 109 (59.2%) patients experienced recurrence, of these, 67 (36.4%) were intrahepatic recurrence. Subgroup analysis of patients with liver-only recurrence demonstrated an increased likelihood of repeat hepatectomy for PSH compared to Non-PSH (21.2% versus 2.9%, P = 0.031), thus resulting in improved liver OS (P = 0.016).ConclusionPSH was associated with improved perioperative outcomes but it did not increase liver recurrence rates. PSH offered an increased rate of salvage hepatectomy for recurrent tumor, thus improving long-term survival in cases in which liver recurrence occurred.     

Lens culinaris agglutinin-reactive fraction of AFP is a useful prognostic biomarker for survival after repeat hepatic resection for HCC

Background and Aim: Repeat hepatic resection for recurrent hepatocellular carcinoma (HCC) is effective in improving long‐term outcome in selected patients. In the present study, we attempted to identify the prognostic factors influencing overall and recurrence‐free survival after the second hepatic resection. Methods: From 1 September 1997 to 30 September 2009, 329 consecutive patients with HCC underwent surgical exploration at Yamanashi University Hospital, Japan. Of these, 35 patients underwent curative, second hepatic resection. The survival results in the 35 patients were analyzed retrospectively, and prognostic factors were determined. Results: The univariate analysis revealed that Child–Pugh B, a Lens culinaris agglutinin‐reactive fraction of α‐fetoprotein (AFP‐L3) value more than 15%, and multiple tumors, were associated with significantly worse overall survival (P = 0.010, P = 0.0003, and P = 0.037, respectively) and only AFP‐L3 >15% was associated with significantly worse recurrence‐free survival after the second hepatic resection (P = 0.008). By multivariate analysis, only AFP‐L3 >15% was an independent predictor of adverse overall survival. The 1‐, 3‐, and 5‐year survival rates after the second hepatic resection of 27 HCC patients with low AFP‐L3 (≤15%) were 100%, 100%, and 91.7%, respectively, whereas the corresponding survival rates of eight HCC patients with high AFP‐L3 (>15%) were 100%, 47.6%, and 23.8%, respectively. Conclusions: The preoperative AFP‐L3 level was a useful prognostic biomarker for survival after repeat hepatic resection.     

Treatment for extrahepatic metastasis of hepatocellular carcinoma following successful hepatic resection

BACKGROUND/AIMS: Recent advances in both the diagnosis and treatment of hepatocellular carcinoma (HCC) have improved its prognosis. Intrahepatic recurrence after hepatectomy can be treated with repeated hepatectomy, transhepatic arterial embolization (TAE), percutaneous ethanol injection therapy (PEIT), or microwave coagulo-necrotic therapy. However, treatment for extrahepatic recurrence is also important in prolonging survival in some patients. METHODOLOGY: After radical hepatectomy in 155 patients, extrahepatic recurrences were found in 15 patients that underwent subsequent treatment. The interval between completing treatment for the primary tumor and the discovery of metastasis, the location and mode of treatment of the metastasis, and the outcomes were analyzed. RESULTS: Distant metastasis was detected at a mean of 7 months after radical resection of the primary tumor. Location of the metastasis included lung, bone, and adrenal gland. Four patients had no intrahepatic recurrence and 11 patients had simultaneous intrahepatic recurrence. Six patients with intrahepatic and extrahepatic recurrence that underwent systemic chemotherapy had poor prognoses, and all died within 12 months as a result of progression of the intrahepatic tumor. Five patients with intra- and extrahepatic recurrence that underwent systemic chemotherapy combined with hepatic arterial infusion chemotherapy had relatively good outcomes; all survived for more than 12 months. CONCLUSIONS: These results suggest that to obtain a good prognosis for extrahepatic metastasis coexisting with intrahepatic recurrence, intrahepatic recurrence should be controlled by locoregional therapy, and extrahepatic metastasis should be controlled by systemic chemotherapy and/or irradiation therapy.     

Ablative strategies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is the most common primary liver cancer and is the fifth leading cause of cancer death worldwide and the third leading cause of all diseases worldwide. Liver transplantation, surgical resection and ablation are the three main curative treatments for HCC. Liver transplantation is the optimal treatment option for HCC, but its usage is limited by the shortage of liver sources.Surgical resection is considered the first choice for early-stage HCC, but it does not apply t...     

Relationship between survivin expression and recurrence, and prognosis in hepatocellular carcinoma

AIM： To study the expression of the inhibitor of apoptosis protein survivin in hepatocellular carcinoma （HCC）, and its correlation with clinicopathological factors, cell proliferation, recurrence and prognosis after hepatectomy. METHODS： Immunohistochemical staining of survivin and Ki-67 was performed by the standard streptavidin- peroxidase technique on paraffin sections of 55 cases of HCC. RESULTS： The positive rate of survivin in HCC was 52.7% （29/55）. Significant correlation was found between survivin expression with portal vein thrombi and intrahepatic matastasistic nodes （P 〈 0.05）. The recurrent rate in survivin-positive HCC was significantly higher than that in survivin-negative HCC after hepatectomy, the 1- and 3-year survival rate in patients with survivin-positive tumors was significantly lower than that in patients with survivin-negative tumors （58.62 and 10.34% vs 76.92 and 30.77%, P 〈 0.05, log-rank test）. The proliferation index （Ki-67） in survivin-positive HCC （33.83% ± 18.90%） was significantly higher than that in survivin-negative HCC （19.60% ± 19.35%） （P 〈 0.05）. CONCLUSION： Survivin may play an important role in progression of HCC by promoting cell proliferation, and may be positively correlated with high risk of disease recurrence and poor prognosis in HCC. Its expression may serve as a prognostic factor for patients with HCC after hepatectomy.     

The preoperative positivity for serum hepatitis B e antigen did not affect overall survival after curative resection of hepatitis B virus-related hepatocellular carcinoma

Background and Aim:  Previous studies have reported different risk factors for early and late intrahepatic recurrence after resection of hepatocellular carcinoma (HCC). However, the prognostic significance of the risk factors for early and late recurrence has not been clarified.
Methods:  A total of 190 Hepatitis B surface antigen-positive patients who received curative resection for HCC were reviewed. We investigated prognostic factors for disease-free and overall survival after resection, and further analyzed the relationship between significant prognostic factors and risk factors for early (≤14 months) and late (>14 months) intrahepatic recurrence.
Results:  The 5-year disease-free and overall survival rates were 43.9% and 71.5%, respectively. In multivariate analysis, adverse prognostic factors for disease-free survival were presence of serum HBeAg, perioperative transfusion, and the presence of portal vein invasion (PVI) and/or intrahepatic metastasis (IM). Multivariate analysis revealed that overall survival was associated with ICG R15, serum albumin, Edmondson–Steiner grade, and the presence of PVI and/or IM. Independent risk factors for early intrahepatic recurrence were perioperative transfusion and PVI and/or IM, whereas positivity for HBeAg was the only risk factor for late recurrence. In addition, post-recurrence survival in patients with late intrahepatic recurrence was completely comparable to that of patients who never experienced recurrence.
Conclusions:  The presence of serum HBeAg, the risk factor for late intrahepatic recurrence did not affect overall survival after resection because late recurrence was relatively well controlled by current available treatments. To further improve long-term surgical outcomes, effective treatment and preventive methods for early intrahepatic recurrence should be investigated.     

Repeat hepatic resection in patients with colorectal liver metastases

AIM:To investigate the survival outcomes of secondaryhepatectomy for recurrent colorectal liver metastases(CRLM).METHODS:From October 1994 to December 2009,patients with CRLM who underwent surgical treatment with curative intent were investigated.Patients were divided into two groups:patients who underwent primary hepatectomy(Group 1)and those who underwent secondary hepatectomy for recurrent CRLM(Group 2).RESULTS:Survival and prognostic factors were analyzed.A total of 461 patients were included:406patients in Group 1 and 55 patients in Group 2.After a median 39-mo(range,3-195 mo)follow-up,there was a significant difference between Groups 1 and 2in terms of disease-free survival(P=0.029)although there was no significant difference in overall survival(P=0.206).Secondary hepatectomy was less effective in patients with multiple recurrent CRLM than primary hepatectomy for initial CRLM(P=0.008).Multiple CRLM and radiofrequency ablation therapy were poor prognostic factors of secondary hepatectomy in multivariate Cox regression analysis(P=0.006,P=0.004,respectively).CONCLUSION:Secondary hepatectomy for single recurrent CRLM is as effective as primary surgical treatment for single recurrent CRLM.However,secondary hepatectomy for multiple recurrent CRLM is less effective than that for single recurrent CRLM.