Surgical resection versus radiofrequency ablation for small hepatocellular carcinomas within the Milan criteria

Background/Purpose  It has been reported that hepatic resection may be preferable to other modalities for the treatment of small hepatocellular carcinomas (HCCs), by contributing to improved overall and disease-free survival. Ablation techniques such as radiofrequency ablation (RFA) have also been used as therapy for small HCCs; however, few studies have compared the two treatments based on long-term outcomes. The effectiveness of hepatic resection and RFA for small nodular HCCs within the Milan criteria were compared. Methods  A retrospective cohort study was performed with 278 consecutive patients who underwent curative hepatic resection (n = 123) or initial RFA percutaneously (n = 110) or surgically (thoracoscopic-, laparoscopic-, and open-approaches; n = 45) for HCC. The selection criteria for treatment were based on uniform criteria. Mortality related to therapy and 3- and 5-year overall and disease-free survivals were analyzed. Results  The model for endstage liver disease (MELD) scores for all patients in the series were less than 13. There were no therapy-related mortalities in either the hepatic resection or RFA groups. The incidence of death within 1 year after therapy (1.6 and 1.9%, respectively) was similar in the hepatic resection and RFA groups. The group that underwent hepatic resection showed a trend towards better survival (P = 0.06) and showed significantly better disease-free survival (P = 0.02) compared with the RFA group, although differences in liver functional reserve existed. The advantage of hepatic resection was more evident for patients with single tumors and patients with grade A liver damage. In contrast, patients with multinodular tumors survived longer when treated with RFA, regardless of the grade of liver damage. Further analysis showed that surgical RFA could potentially have survival benefits similar to those of hepatic resection for single tumors, and that surgical RFA had the highest efficacy for treating multinodular tumors. Conclusions  In patients with small HCCs within the Milan criteria, hepatic resection should still be employed for those patients with a single tumor and well-preserved liver function. RFA should be chosen for patients with an unresectable single tumor or those with multinodular tumors, regardless of the grade of liver damage. In order to increase long-term oncological control, surgical RFA seems preferable to percutaneous RFA, if the patient’s condition allows them to tolerate surgery.     

Prognostic impact of anatomic resection for hepatocellular carcinoma

OBJECTIVES: To evaluate the prognostic impact of anatomic versus nonanatomic resection on the patients' survival after resection of a single hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA: Anatomic resection is a reasonable treatment option for HCC; however, its clinical significance remains to be confirmed. METHODS: Curative hepatic resection was performed for a single HCC in 210 patients; the patients were classified into the anatomic resection (n = 156) and nonanatomic resection (n = 54) groups. In 84 patients assigned to the anatomic resection group, segmentectomy or subsegmentectomy was performed. We evaluated the outcome of anatomic resection, including segmentectomy and subsegmentectomy, in comparison with that of nonanatomic resection, by the multivariate analysis taking into consideration 14 other clinical factors. RESULTS: Both the 5-year overall survival and disease-free survival rates in the anatomic resection group were significantly better than those in the nonanatomic resection group (66% versus 35%, P = 0.01, and 34% versus 16%, P = 0.006, respectively). In the segmentectomy and subsegmentectomy group, the 5-year overall and disease-free survival rates were 67% and 28%, respectively, both of which were also higher than the corresponding rates in the nonanatomic resection group (P = 0.007 and P = 0.001, respectively). The results of multivariate analysis revealed that anatomic resection was a significantly favorable factor for overall and disease-free survivals: the hazard ratios were 0.57 (95% confidence interval, 0.32-0.99, P= 0.04), and 0.65 (0.43-0.96, P = 0.03). CONCLUSION: Anatomic resection for a single HCC yields more favorable results rather than nonanatomic resection.     

Is Liver Resection Justified in Advanced Hepatocellular Carcinoma? Results of an Observational Study in 464 Patients

Background and Objective  The role of liver resection in advanced hepatocellular carcinoma (multinodular or with macroscopic vascular involvement) is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced hepatocellular carcinoma (HCC). Methods  Four hundred sixty four patients with HCC observed from 1991 to 2007 were included in the study. All the patients were evaluated for the treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included in the study had no evidence of distant metastases. Results  Median follow up time for surviving patients was 25 months (range 1–155). Two-hundred and eighty-three patients were in Child–Pugh class A, 161 in class B, and 20 in class C. Two-hundred and seventy-one patients had single HCC, 121 patients had two or three HCCs, and 72 more than three HCCs. One-hundred and thirty-six patients (29.3%) were submitted to liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), eight (1.7%) to liver transplantation (LT), and 88 (19%) to supportive therapy (ST). Median survival time for all patients was 36 months (95% CI 24–36). Median survival time was 57 months for LR, 30 months for LAT, and 8 months for ST, with a 5-year survival of 47%, 20%, and 2.5%, respectively (p = 0.001). Actuarial 5-year survival for patients submitted to LT was 75%. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC, with median survival times of 39, 16, and 11 months for patients with a single HCC, with two to three HCCs, and with more than three HCCs, respectively (p = 0.01). Survival for patients with single HCC was significantly longer in patients submitted to LR compared to LAT and ST with median survival times of 57, 37, and 14 months, respectively (p = 0.02). Also, in patients with multinodular HCCs (2–3 HCCs) LR showed the best results with a median survival time of 58 months compared to 22 and 8 months for LAT and ST (p = 0.01). In patients with more than three HCCs, LR did not show different results compared to LAT and ST. Seventy-three patients had evidence of macroscopic vascular involvement; median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 10 and 36 months, respectively. Survival for patients with macroscopic vascular involvement submitted to LR or LAT was significant longer compared to ST, with mean survivals of 27, 30, and 12 months, respectively (p = 0.01). Conclusions  The present study shows that the surgery can achieve good results in patients with single HCC and good liver function. Also, patients with multinodular HCCs (two to three nodules) could benefit from LR where survival is longer than after LAT or ST. In patients with more than three HCCs, LR have similar results of LAT. Macroscopic vascular invasion is a major prognostic factor, and the LR is justified in selected patients, where it can allow good long-term results compared to ST. This study was presented as Quick Shot oral presentation of the Surgical Society Alimentary Tract at Digestive Disease Week, May 20, 2008, San Diego Convention Center, San Diego, CA, USA and as oral presentation at 23rd Annual SSAT Residents & Fellows Research Conference, May 17, 2008, Omni San Diego, San Diego, CA.     

Does Anatomic Versus Nonanatomic Resection Affect Recurrence and Survival in Patients Undergoing Surgery for Colorectal Liver Metastasis?

Anatomic resection of colorectal liver metastases may offer a survival advantage because (1) it removes the hepatic functional unit as a whole and (2) nonanatomic resection has been reported to have a higher incidence of positive margins. A retrospective review was performed of patients undergoing hepatic resection for colorectal liver metastases. 183 patients met inclusion criteria of undergoing either anatomic or nonanatomic resection with the aim of removing all gross disease. Mean age was 61 years (range 31–90 years), 57% were male. 89 patients (49%) underwent nonanatomic resection, the remaining 94 (51%) had anatomic resection. Average duration of inflow occlusion was 10 min. Average length of stay was 7.4 days. There were three deaths, yielding a 1.6% 30-day mortality rate. There was no difference in the incidence of positive margins between types of resection. Recurrence was 27%, 55%, and 59% at 1, 3, and 5 years respectively. Overall survival was 89%, 67%, and 55% at 1, 3, and 5 years, respectively. Type of resection was not associated with significant differences in recurrence or survival even when adjusted for differences in preoperative risk. We conclude that hepatic resection for colorectal metastases can be performed safely and offers select patients with stage IV disease prolonged survival. Resection type should be based on the number and location of tumors, rather than on segmental anatomy. An emphasis on the preservation of hepatic parenchyma may be of increasing importance in the setting of chemotherapy-associated steatohepatitis, and the growing number of patients undergoing repeated metastasectomy.     

Surgical Treatment for Hepatocellular Carcinoma Detected After Successful Interferon Therapy

Purpose Interferon therapy suppresses the development of hepatocellular carcinoma (HCC) and tumor recurrence after a resection of HCC in patients with chronic hepatitis C. However, the value of a liver resection and which method is best for the treatment of HCC detected after successful interferon therapy remains to be clarified. The risk factors for tumor recurrence after a liver resection for HCC detected after successful interferon therapy were investigated to determine the appropriate operative method for such HCC. Methods Risk factors including the clinicopathologic findings and the operative methods for tumor recurrence were evaluated by univariate and multivariate analyses in 24 patients who underwent liver resection for HCC detected after successful interferon therapy (sustained viral response or biochemical response). Results According to a univariate analysis, large tumor (>2 cm, P = 0.0326), multiple tumors (P = 0.0372), nonanatomic resection (P = 0.0103), and positive surgical margin (<5 mm of a free surgical margin, P = 0.0245) were possible risk factors for short tumor-free survival time after surgery. A multivariate analysis showed that large tumor (P = 0.0407), nonanatomic resection (P = 0.0215), and positive surgical margin (P = 0.0253) were independent risk factors for a short tumor-free survival time after surgery. Conclusion An anatomic resection with an appropriate surgical margin (≥5 mm of a free surgical margin) is recommended for patients with HCC detected after successful interferon therapy.     

Additional Hepatocellular Carcinomas Undetectable before Surgery

The presence of small additional hepatocellular carcinomas (HCCs) undetectable before hepatic resection is a crucial topic for hepatic surgeons. We assessed the incidence of pathologically diagnosed multiple HCCs in 267 patients who underwent hepatic resection for HCC. Ninety-five additional HCC nodules were detected in 72 of the patients (27%). The survival rate of these 72 patients was significant worse than for the 195 with single nodular HCC (p= 0.0013). Twenty-one (22%) were detected before surgery, 29 (31%) during surgery, and 45 (47%) on pathologic examination after surgery. The mean nodule diameters for each group were 2.1, 1.0, and 0.9 cm, respectively (p < 0.0001). None of the 21 nodules detected before surgery was well differentiated, whereas 30 of the 74 nodules in the other two groups were well-differentiated. Although the mean nodule diameter of the well-differentiated HCC group was the smallest, there was no significant difference among the three groups assigned according to tumor differentiation (p= 0.2355). Altogether, 9 of 16 patients with additional nodules detected before surgery (56%) and 49 of 59 with additional nodules detected during or after surgery (88%) had cirrhosis of the liver. The odds ratio for detecting a new HCC nodule during or after surgery in the presence of cirrhosis was 5.444 (p= 0.0087). Improvement in the detection of small additional HCC nodules before and during surgery and meticulous follow-up after surgery are necessary for patients with cirrhosis. For patients without cirrhosis, surgical treatment may be performed according to the results of preoperative imaging studies.     

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.     

Does anatomic resection improve the postoperative outcomes of solitary hepatocellular carcinomas located on the liver surface?

Background

It is unclear whether anatomic resection achieves better outcomes than nonanatomic resection in patients with hepatocellular carcinoma. This study aimed to compare the outcomes of anatomic resection and nonanatomic resection for hepatocellular carcinoma located on the liver surface via one-to-one propensity score-matching analysis.

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.     

Liver Resection Improves the Survival of Patients with Multiple Hepatocellular Carcinomas

Background  According to current guidelines of hepatocellular carcinoma (HCC) treatment, multiple HCCs are usually not suitable for surgical resection. However, surgical resection is still possible for patients with multiple HCCs. The role of hepatic resection vs transarterial chemoembolization (TACE) for multiple HCCs should be further clarified. Methods  We retrospectively enrolled 1065 patients with multiple HCCs. Among them, 294 received surgical resection, 367 received transarterial chemoembolization (TACE), and 404 received chemotherapy or supportive care. Three staging systems (TNM, CLIP, and BCLC) were used for comparison of stage-specific survival between different treatment modalities. Results  The median survival of multiple HCC patients who received surgical resection was 37.9 months, while it was 17.3 months in TACE group, and 2.8 months in supportive group (P < .001). The 1-year, 3-year, 5-year survival rates for surgical group were 77.4%, 51.9%, and 36.6%, respectively. Kaplan-Meier survival analysis demonstrated that patients who received surgical resections had the best survival, followed by TACE and supportive care. For patients of the same stage, surgical resection yields better results than TACE. Surgery could offer better survival than TACE for patients either within or beyond Milan’s criteria. Conclusions  Our results indicate that if patients have preserved liver functions, hepatic resection is helpful, even for patients with multiple HCCs.     

Effectiveness of systematized hepatectomy with Glisson's pedicle transection at the hepatic hilus for small nodular hepatocellular carcinoma: retrospective analysis

BACKGROUND: The effectiveness of systematized hepatectomy with transection of Glisson's pedicle at the hepatic hilus in patients with small nodular hepatocellular carcinoma (HCC) has not been confirmed. METHODS: Surgical outcomes were reviewed in 204 patients with single nodular HCCs less than 5 cm in greatest diameter, including 68 patients with tumors that showed extranodular growth and 136 patients with tumors that did not, who had undergone curative hepatectomy (partial hepatic resection, n = 114; systematized hepatectomy, n = 90) from 1990 through 1994. RESULTS: The rates of microscopic vascular invasion and intrahepatic metastasis were significantly higher in patients who had single nodular HCCs with extranodular growth (34% and 49%) than in patients who had single nodular HCCs without extranodular growth (13%, P =.001, and 4%, P <.001). The 5-year survival rate in patients who had single nodular HCCs with extranodular growth was significantly greater after systematized hepatectomy (67%) than after partial hepatic resection (21%, P =.0002). Multivariate analysis showed that the type of operation was an independent prognostic factor in patients with single nodular HCCs with extranodular growth (P =.0008). CONCLUSIONS: Systematized hepatectomy with Glisson's pedicle transection at the hepatic hilus should be performed in patients who have single small nodular HCCs with extranodular growth because these tumors often invade within the liver sector containing the tumor.     

Appropriate Surgical Management of Small Hepatocellular Carcinomas in Patients Infected with Hepatitis C Virus

Abstract We investigated the incidence of recurrence after resection of small hepatocellular carcinomas (HCC) in patients infected with hepatitis C virus (HCV) to determine the appropriate surgical management of these patients. Sixty-one patients with anti-HCV antibody who underwent curative liver resection for small HCC (≦ 2.0 cm in greatest diameter) were categorized into two groups. Group 1 consisted of 27 patients with serum concentrations of type IV collagen 7S domain (7S collagen), a marker for hepatic fibrosis, < 8 ng/ml. Group 2 consisted of 34 patients with serum concentrations of 7S collagen ≧ 8 ng/ml. Serum concentration of 7S collagen correlated with the severity of active hepatitis and the degree of fibrosis in the noncancerous hepatic tissue, both of which are related to risk potential of hepatocarcinogenesis. Serum concentration of total bilirubin, aspartate aminotransferase activity, indocyanine green retention rate at 15 minutes, the proportion of patients who were Child-Pugh class B, and the proportion of patients with severe active hepatitis or cirrhosis (determined by histologic examination) were significantly higher in group 2 than in group 1. Platelet count was significantly lower in group 2. Tumor-free survival rates were not different between the groups. In group 1, nonanatomic resection was a risk factor for recurrence by univariate and multivariate analyses (odds ratio = 3.45, p = 0.040). In group 2, nonanatomic resection was not a risk factor for recurrence. In patients with small HCV-related HCC, anatomic resection is recommended when the serum concentration of 7S collagen is low (< 8 ng/ml) because the potential of hepatocarcinogenesis may be low even after the operation.     

Comparison between hepatic wedge resection and anatomic resection for colorectal liver metastases

Some investigators have suggested that wedge resection (WR) confers a higher incidence of positive margins and an inferior survival compared with anatomic resection (AR) of colorectal liver metastases (CLM). We sought to investigate the margin status, pattern of recurrence, and overall survival of patients with CLM treated with WR or AR. We identified 253 consecutive patients, in a multi-institutional database from 1991 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection of the CLM, and AR was defined as single or multiple resections of one or two contiguous Couinaud segments. Clinicopathologic factors were analyzed with regard to pattern of recurrence and survival. One hundred six WRs were performed in 72 patients and 194 ARs in 181 patients. There was no difference in the rate of positive surgical margin (8.3%), overall recurrence rates, or patterns of recurrence between patients treated with WR vs. AR. Patients who had a positive surgical resection margin were more likely to recur at the surgical margin regardless of whether they underwent WR or AR. The median survival was 76.6 months for WR and 80.8 months for AR, with 5-year actuarial survival rates of 61% and 60%, respectively. AR is not superior to WR in terms of tumor clearance, pattern of recurrence, or survival. WR should remain an integral component of the surgical treatment of CLM. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

Prognostic factors affecting oncologic outcomes in patients with locally recurrent rectal cancer: impact of patterns of pelvic recurrence on curative resection

Background  The purpose of this study is to investigate prognostic factors affecting oncologic outcomes in patients with locally recurrent rectal cancer and determine whether recurrence patterns influence curative resection of recurrent tumor. Materials and methods  We examined 62 patients with isolated local recurrence following total mesorectal excision (TME) of the primary rectal cancer. Recurrence patterns were classified as central, anterior, posterior, lateral, and perineal with respect to the intra-pelvic tumor location. Prognostic factors affecting oncologic outcomes were analyzed, and the rate of curative resection was analyzed according to recurrence patterns. Results  The mean follow-up period was 49.0 ± 29.0 months, and the mean time to recurrence after TME was 27.9 ± 23.3 months. Twenty-three patients underwent curative resection, and the remaining 39 patients received palliative treatment. Patients with a central recurrence had the highest rate of curative resection (p = 0.006). The overall 5-year survival rate was 13.9% and significantly higher in those treated with curative resection (35.1%; p = 0.0002). Multivariate analysis demonstrated that disease-free survival less than 1 year and curative resection of local recurrence were independent prognostic factors influencing 5-year survival. Conclusion  Patients with central recurrences have a high probability of curative resection. Disease-free survival less than 1 year and curative resection of local recurrence were independent prognostic factors affecting oncologic outcomes in patients with locally recurrent rectal cancer.     

Long-term outcome after multivisceral and tumor/vascular resection in patients with soft tissue sarcoma

Background/Aims  Soft tissue sarcomas (STS) are rare tumors. General treatment is difficult while multimodality treatment strategies are more and more common. In these strategies, surgical resection of the primary tumor is essential to achieve local control of the tumor. In certain cases, complex resections (CR) including multivisceral and/or vascular resection are needed to achieve resection with tumor-free margins. In this study, we evaluated retrospectively the overall prognosis, morbidity, and mortality of patients treated for STS at our university hospital. Patients/Methods  Between 1992 and 2000, 24 of 154 patients with STS received multivisceral resection and four of 154 underwent vascular resection. To determine the influence of CR on overall prognosis, we compared n = 19 patients after CR with a matched control group after simple tumor resection (SR). To determine surgical morbidity and mortality the whole study group was used (n = 154, SR n = 126, CR n = 28). Results  The median follow up for all patients was 6.89 years (mean 5.64 years SD 4.3) with no difference between the groups (CR vs SR: 5.4 SD 4.8 vs 5.9 SD 3.9 years; p = 0.711). Patients receiving CR had a similar overall prognosis (mean survival 9.9 years), morbidity (10.7%) and mortality (0%) compared to patients with SR (mean survival 8.5 years; morbidity 10.3%; mortality 3.96%). Conclusions  Multivisceral resection and/or vascular resection with tumor-free margins can be achieved with the same overall prognosis, same morbidity and mortality as SR. This has to be taken into account when evaluating the treatment strategy in patients with STS.     

Standard-radical vs. function-preserving surgery of benign nodular goiter—a sonographic and biochemical 10-year follow-up study

Background  The necessary extent of thyroid resection in benign nodular goiter is under debate. The aim of our study was to compare the long-term outcome of different thyroid resection modes with special interest in the incidence of recurrent nodules and the use of oral thyroid hormone medication. Materials and methods  We performed a follow-up examination of 109 patients (23 men and 86 women) having been operated for benign nodular goiter at our department 10 years ago. Unilateral resections and function-preserving resections of at least one thyroid lobe were classified as function-preserving (FP). Total thyroidectomy, Dunhill’s operation and bilateral subtotal thyroidectomy were rated as standard-radical (STR). On follow-up, we recorded current oral thyroid hormone medication, thyroid function tests and ultrasound of the neck. Results  Seventy-three patients had FP resection (67%), while 36 were STR-operated (33%). The subsequent medical treatment was performed by dedicated endocrinologists (n = 19), internists (n = 11) or primary-care physicians (n = 59). Twenty patients had no medical attendance. Recurrent nodules were found in 13 cases in the FP group (18.6%) vs. 3 cases in the STR group (2.5%; p < 0.001). In both groups, about 80% of patients used thyroid hormone medication 10 years after operation. Conclusion  There was no advantage in thyroid function tests nor lesser medication in the FP group. The risk for recurrent nodules was significantly higher in the FP than in the STR-operated patients. The data of this study have been presented in oral form at the Meeting of the German Endocrine surgeons (CAEK 2006 Duisburg) and at the German Surgical congress (Munich 2007).     

解剖性和非解剖性切除治疗小肝细胞癌疗效的Meta分析

目的 比较解剖性切除和非解剖性切除治疗小肝癌疗效的差异.方法 计算机检索PubMed、Medline、中国期刊全文数据库(CJFD)及万方数据库1980-2010年发表的有关解剖性切除和非解剖性切除治疗小肝癌的相关文献,采用RevMan5.0进行Meta分析.结果 按照入选标准,有6项临床试验纳入.Meta分析结果显示,与非解剖性切除相比,解剖性切除能明显增加3年总存活率[OR=1.17,95%CI(1.11,2.83),P=0.02]及5年总存活率[OR=1.61,95%CI(1.16,2.25),P=0.005],1年无瘤存活率[OR=1.65,95%CI(1.01,2.68),P=0.04]、3年无瘤存活率[OR=1.74,95%CI(1.13,2.68),P=0.01]及5年无瘤存活率[OR=2.22,95%CI(1.61,3.06),P<0.01],也能降低术后复发率[OR=0.55,95%CI(0.37,0.81),P=0.003].但术后死亡率(P=0.90)和术后并发症发生率(P=0.37)差异无统计学意义.结论 对肝储备功能良好的患者,当肿瘤适宜于行解剖性肝段切除治疗时应首选解剖性切除;对肝储备功能较差的患者,则应行非解剖性切除,避免术后发生肝功能衰竭.     

Predictive Factors of Microvascular Invasion in Patients with Hepatocellular Carcinoma Larger Than 5 cm

BACKGROUND: Patients with hepatocellular carcinoma (HCC) who undergo liver resection and transplantation are predicted to have a poor outcome if the disease is associated with vascular invasion. This study aimed to identify preoperative predictors of microvascular invasion in patients with HCCs larger than 5 cm. METHODS: From May 1992 to October 2005, 231 patients underwent curative hepatic resection for HCC. Of these, 96 patients had HCCs larger than 5 cm. Analysis was limited to patients without macroscopic vascular invasion (n = 65). RESULTS: Multivariate analysis showed that patients with tumors larger than 7 cm and type 2 (single nodular type with extranodular growth) and type 3 (contiguous multinodular type formed by a cluster of small and contiguous nodules) tumors had an increased risk of microscopic vascular invasion. The overall incidence of microscopic vascular invasion was 46.2% (n = 30), but only 12.5% (2/16) in patients with type 1 tumors (single nodular type that is approximately round with a clear demarcation) measuring less than 7 cm. CONCLUSION: Larger tumors (>7 cm) and type 2 and type 3 tumors are strong predictors of microvascular invasion in patients with HCCs larger than 5 cm.     

Surgical Resection Versus Radiofrequency Ablation in the Treatment of Small Unifocal Hepatocellular Carcinoma

Background  Hepatocellular carcinoma (HCC) has a high worldwide prevalence and mortality. While surgical resection and transplantation offers curative potential, donor availability and patient liver status and comorbidities may disallow either. Interventional radiological techniques such as radiofrequency ablation (RFA) may offer acceptable overall and disease-free survival rates. Materials and Methods  Sixty-eight cirrhotic patients matched for age, sex, tumor size, and Child–Pugh grade with small (1–5 cm) unifocal HCC were studied retrospectively to find determinants of overall and disease-free survival in those treated with surgical resection and RFA between 1991 and 2003. Results  Multivariate analysis using Cox proportional regression modeling showed that overall survival was related to tumor recurrence (p = 0.010), tumor diameter (p = 0.002), and treatment modality (p = 0.014); overall p = 0.008. Recurrence was independently related to the use of RFA over surgery (p = 0.023) on multivariate analysis; overall p = 0.034. Conclusion  Surgical resection offers longer disease-free survival and potentially longer overall survival than RFA in patients with small unifocal HCC.     

Outcomes after sublobar resection versus lobectomy in non–small cell carcinoma in situ

ObjectiveGuidelines for treatment of non–small cell lung cancer identify patients with tumors ≤2 cm and pure carcinoma in situ histology as candidates for sublobar resection. Although the merits of lobectomy, sublobar resection, and lymphoid (LN) sampling, have been investigated in early-stage non–small cell lung cancer, evaluation of these modalities in patients with IS disease can provide meaningful clinical information. This study aims to compare these operations and their relationship with regional LN sampling in this population.MethodsThe National Cancer Database was used to identify patients diagnosed with non–small cell lung cancer clinical Tis N0 M0 with a tumor size ≤2 cm from 2004 to 2017. The χ² tests were used to examine subgroup differences by type of surgery. Kaplan-Meier method and Cox proportional hazard model were used to compare overall survival.ResultsOf 707 patients, 56.7% (401 out of 707) underwent sublobar resection and 43.3% (306 out of 707) underwent lobectomy. There was no difference in 5-year overall survival in the sublobar resection group (85.1%) compared with the lobectomy group (88.9%; P = .341). Multivariable survival analyses showed no difference in overall survival (hazard ratio, 1.044; P = .885) in the treatment groups. LN sampling was performed in 50.9% of patients treated with sublobar resection. In this group, LN sampling was not associated with improved survival (84.9% vs 85.0%; P = .741).ConclusionsWe observed no difference in overall survival between sublobar resection and lobectomy in patients with cTis N0 M0 non–small cell lung cancer with tumors ≤2 cm. Sublobar resection may be an appropriate surgical option for this population. LN sampling was not associated with improved survival in patients treated with sublobar resection.