Long-term results of elective hepatectomy for the treatment of ruptured hepatocellular carcinoma

Background/Purpose

According to the General rules for the clinical and pathological study of primary liver cancer, compiled by the Liver Cancer Study Group of Japan, ruptured hepatocellular carcinoma (HCC) is classified as stage 4, even if the tumor is small and solitary. We examined the long-term results of elective hepatectomy for the treatment of ruptured HCC.

Methods

A first hepatectomy was performed without operative death in 193 patients with HCC. Ten patients had ruptured HCC (ruptured group) and 183 patients had nonruptured HCC (nonruptured group). The extension of HCC was macroscopically classified as stage 1 in 23 patients, stage 2 in 71, stage 3 in 53, and stage 4 in 46.

Results

Cumulative survival rates in the ruptured group at 1, 5, and 10 years were 90.0%, 67.5%, and 20.3%, respectively. The cumulative survival rate was lower in patients with stage 4 disease in the nonruptured group than that in patients in the ruptured group (P < 0.05). Cumulative survival rates did not differ significantly between patients in the ruptured group and those with stage 2 or stage 3 disease.

Conclusions

Survival rates after elective hepatectomy in patients with ruptured HCC are good, even if the disease is classified as stage 4.     

Tumor-related factors do not influence the prognosis of solitary hepatocellular carcinoma after partial hepatectomy

Background/purpose

Although many factors related to the tumor or the hepatic functional reserve may affect the outcome of partial hepatectomy for hepatocellular carcinoma (HCC), these factors have not yet been intensively investigated in patients with solitary HCC. The purpose of this study is to determine the clinicopathological factors influencing the long-term outcomes of partial hepatectomy for solitary HCC.

Methods

Data on 266 consecutive patients with a solitary HCC who underwent curative hepatectomy between 1997 and 2006 were analyzed with regard to prognosis.

Results

Overall survival rates at 3, 5, and 10?years were 89.5, 79.6, and 56.1%, respectively. The significant independent predictors for overall survival included hepatitis C virus infection, liver cirrhosis, and prolonged prothrombin activity. Disease-free survival rates at 3, 5, and 10?years were 51.7, 41.1, and 20.4%, respectively. The significant independent predictors for disease-free survival included elevated levels of aspartate amino transferase, decreased platelet counts, presence of liver cirrhosis, and prolonged prothrombin activity. Tumor-related factors such as tumor size and microscopic vascular invasion were not significant predictors of overall or disease-free survival.

Conclusions

The long-term outcomes of patients with a solitary HCC who underwent partial hepatectomy mainly depended on the background liver status but not on tumor-related factors; this suggests that partial hepatectomy is a remarkably effective antitumor therapy. If the hepatic functional reserve is within the permissible range, partial hepatectomy should be considered as the treatment of choice for patients with a solitary HCC.     

Positive glypican-3 expression in early hepatocellular carcinoma predicts recurrence after hepatectomy

Background

Glypican-3 (GPC3) is a new prognostic factor after curative hepatectomy in patients with hepatocellular carcinoma (HCC), and the expression of GPC3 is known to be associated with postoperative metastasis. However, the role of GPC3 in patients with early HCC remains unknown.

Methods

We retrospectively studied 55 patients with early HCC (total 99 nodules) who underwent initial hepatectomy between 1995 and 2010. Clinicopathological features and surgical outcomes were compared in relation to GPC3 expression.

Results

The GPC3-positive expression was seen in 28 of 55 patients (50.9 %) with early HCC (44 of 99 nodules). The GPC3-positive expression was significantly associated with hepatitis C virus (HCV) infection (P = 0.0019) and with multiple early HCCs (P < 0.0001). The 5-year disease-free survival rate was significantly lower in patients with GPC3-positive early HCC (27 %) than in patients with GPC3-negative early HCC (62 %, P = 0.0036). The GPC3 expression was a significant independent prognostic factor for disease-free survival. However, it showed no significant difference in overall survival.

Conclusions

The GPC3 expression is capable to be a new prognostic factor for disease-free survival in patients with early HCC.     

Risk factors for organ/space surgical site infection after hepatectomy for hepatocellular carcinoma in 359 recent cases

Background

Surgical site infections (SSIs), particularly organ/space SSIs, remain a common cause of major morbidity after hepatectomy for hepatocellular carcinoma (HCC).

Methods

Risk factors for SSIs were analyzed in 359 patients who underwent hepatectomy for HCC between 2001 and 2010. The causative bacteria, management, outcome, and characteristics of organ/space SSIs were investigated.

Results

Anatomic hepatectomy was performed for 296 patients (82.5%), and repeat hepatectomy was carried out for 59 patients (16.4%). SSIs developed in 52 patients (14.5%; incisional, 24 cases; organ/space, 31 cases [3 patients showed both incisional and organ/space SSIs]). No in-hospital mortality related to incisional or organ/space SSIs was encountered. Independent risk factors for SSIs were repeat hepatectomy and operative time ≥280 min. Independent risk factors for organ/space SSIs were repeat hepatectomy and bile leakage. Methicillin-resistant Staphylococcus aureus was detected more frequently in organ/space SSIs after repeat hepatectomy than after initial hepatectomy.

Conclusions

Repeat hepatectomy and bile leakage represent independent risk factors for organ/space SSIs after hepatectomy for HCC. Establishing treatment strategies is important for preventing postoperative bile leakage and reducing the high rate of organ/space SSIs after repeat hepatectomy.     

Risk factors for major morbidity after hepatectomy for hepatocellular carcinoma in 293 recent cases

Background/Purpose

The purpose of this study was to identify risk factors for major morbidity after hepatectomies for hepatocellular carcinoma (HCC).

Methods

Univariate and multivariate analyses of risk factors for major morbidity were performed in 293 patients who underwent hepatectomy for HCC between 2001 and 2008.

Results

Two hundred and forty-three patients (82.9%) underwent an anatomic hepatectomy, and a repeat hepatectomy was performed in 50 patients (17.1%). The prevalences of bile leakage and intraabdominal abscess were 12.9% and 9.2%, respectively. The risk factor for bile leakage was an operative time ≥ 300 min and the risk factor for intraabdominal abscess was a repeat hepatectomy (odds ratios = 4.9 and 5.3, respectively). The main cause of bile leakage that made endoscopic therapy or percutaneous transhepatic biliary drainage necessary was a latent stricture of the biliary anatomy that had existed preoperatively, caused by previous treatments for HCC. Methicillin-resistant Staphylococcus aureus was the main causative bacteria of intraabdominal abscess after repeat hepatectomies.

Conclusions

Our recent series revealed that prolonged operative time and repeat hepatectomy were independent risk factors for bile leakage and intraabdominal abscess, respectively, after hepatectomies for HCC. Preoperative assessment of the biliary anatomy should be considered for patients who have had previous multiple treatments for HCC, including hepatectomy, to reduce bile leakage that makes invasive treatment necessary.     

Fucosylated Fraction of Alpha-Fetoprotein as a Predictor of Prognosis in Patients with Hepatocellular Carcinoma After Curative Treatment

Aim

The aim of this study was to evaluate the clinical usefulness of measuring the Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) for prognostic predictor in patients with hepatocellular carcinoma (HCC).

Methods

A total of 477 HCC patients who underwent percutaneous ablative therapy or hepatectomy were enrolled. Overall survival and recurrence-free survival were respectively evaluated retrospectively and prospectively. Multivariate analyses of clinical prognostic factors were performed by Cox’s stepwise proportional hazard model.

Results

AFP-L3 status was a statistically significant independent prognostic factor of long-term survival (P = 0.013) and recurrence-free survival (P = 0.006) in patients who underwent percutaneous ablative therapy. In contrast, AFP-L3 did not affect prognosis in patients who underwent hepatectomy.

Conclusions

AFP-L3 had different impacts on prognosis in patients with HCC who underwent percutaneous ablative therapy and hepatectomy. Our results suggest that AFP-L3 positivity (≥15%) might be a promising indicator for choosing therapeutic modalities in HCC patients.     

Step classification is useful for the determination of indications for systematized hepatectomy in hepatocellular carcinoma

Background/Purpose

The effectiveness of systematized hepatectomy with transection of Glisson's pedicle at the hepatic hilus has not been clarified in detail in relation to previous staging systems. Outcomes after systematized hepatectomy in patients with hepatocellular carcinoma (HCC) were examined in relation to our new staging system.

Methods

We retrospectively studied 955 patients with HCC who underwent hepatectomy from 1989 through 2002. We classified patients with HCC into four groups according to the pathological findings (pathological step [p-step]): p-step 1, HCC with absence of vascular invasion and absence of intrahepatic metastasis; p-step 2, HCC with vascular invasion and/or intrahepatic metastasis; p-step 3, HCC with major vascular invasion and/or intrahepatic metastasis to both lobes of the liver; and p-step 4, HCC with distant metastasis, including lymph node metastasis or ruptured HCC). We separated the liver into three segments (Takasaki's liver segments). Systematized hepatectomy was classified as systematized segmentectomy or larger resection, and partial segmentectomy. Segmentectomy refers to resection of one of Takasaki's segments.

Results

Systematized segmentectomy did not affect recurrence-free survival, by univariate analysis, in patients with p-step 1, p-step 3, or p-step 4. However, systematized segmentectomy or larger resection was significantly associated with patient recurrence-free survival, by univariate analysis, in patients with p-step 2. Multivariate analysis also showed systematized segmentectomy or larger resection as a significant independent prognostic factor in patients with p-step 2.

Conclusions

Systematized segmentectomy is suitable for patients with p-step 2 HCC according to this step classification.     

Hepatocellular carcinoma biology predicts survival outcome after liver transplantation in the USA

Purpose

The aim of this study is to evaluate the clinicopathologic prognostic factors of cancer-specific survival (CSS) in hepatocellular carcinoma (HCC) patients who underwent liver transplantation (LT) stratified by tumor size.

Methods

From the Surveillance, Epidemiology, and End Results (SEER) 18 registries (2004–2012), we retrieved data of 570 patients who underwent LT for a solitary primary HCC lesion ≤5 cm. A two multivariable Cox models were constructed to identify prognostic factors of CSS in a two different tumor sizes (2 cm cutoff).

Results

Out of 570 HCC patients (median age 57 years), 16% had microvascular invasion (MVI) and 12% had a poorly differentiated tumor. Male sex (odds ratio [OR] 2.6), tumor size >2 cm (OR 1.78), elevated AFP (OR 2.31), and poor tumor differentiation (OR 2.59) are significant predictors of MVI. With a median follow up of 41.5 months (range 1–107 months), the 5-year CSS rate was 90% in the absence of MVI compared to 75% in the presence of MVI (p<0.001). Multivariate models revealed that age ≥60 years (hazard ratio [HR] 2.08), MVI (HR 2.26), and poor tumor differentiation (HR 2.42), were significant risk factors of a dismal CSS with HCC size >2 cm, but not with HCC ≤2 cm.

Conclusions

Primary HCC tumor size ≤2 cm had an excellent prognosis after LT and was not affect by the presence of MVI or poor tumor differentiation.

     

Risk factors for postoperative infectious complications after hepatectomy

Background/purpose

This study aimed to clarify the incidence of surgical site infections (SSIs) after hepatectomy.

Methods

The database records of three hundred and eight patients who underwent elective surgical treatment for hepatolithiasis, hepatocellular carcinoma (HCC), and metastatic carcinoma were retrospectively analyzed to determine the occurrence of postoperative infectious complications. The incidences of SSIs, classified as superficial or deep incisional SSIs and organ or space SSIs, and all other infectious complications within 30?days after hepatectomy were evaluated.

Results

The incidences of SSIs after a hepatectomy for hepatolithiasis (23.8%) were higher than those after a hepatectomy for HCC (11.3%) (p?=?0.034) and after a hepatectomy for metastatic carcinoma (2.7%) (p?<?0.001), and the incidence of SSIs after a hepatectomy for HCC was higher than that after a hepatectomy for metastatic carcinoma (p?=?0.028). However, there was no significant difference in the incidence of remote site infections between the three groups. The incidence of superficial or deep incisional SSIs after a hepatectomy for hepatolithiasis (11.9%) was higher than that after a hepatectomy for metastatic carcinoma (1.4%) (p?<?0.001) and the incidence of superficial or deep incisional SSIs after a hepatectomy for HCC (7.8%) was higher than that after a hepatectomy for metastatic carcinoma (1.4%) (p?=?0.050). There was a significant difference in the incidence of space/organ SSIs between the patients with hepatolithiasis (11.9%) and HCC patients (3.6%) (p?=?0.029), and between the patients with hepatolithiasis and metastatic carcinoma patients (1.4%) (p?<?0.001). The rate of positive bile culture was 36.2% in all patients in this study, and the rates were 83.3, 7.8, and 10.0% for patients with hepatolithiasis, HCC, and metastatic carcinoma, respectively. A significantly higher (p?<?0.001) positive bile culture rate was observed in patients with hepatolithiasis as compared with HCC or metastatic carcinoma patients.

Conclusions

Our study suggests the existence of a relationship between postoperative SSIs and bile infection, thus supporting the proposed relationship between post-hepatectomy infection and such variables as liver function, blood sugar control, and nutritional status.     

A non-smooth tumor margin in the hepatobiliary phase of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging predicts microscopic portal vein invasion, intrahepatic metastasis, and early recurrence after hepatectomy in patients with hepatocellular carcinoma

Background

The value of the hepatobiliary phase of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in patients with hepatocellular carcinoma (HCC) has not been evaluated in detail.

Methods

Between 2008 and 2009, 61 patients with HCC within the Milan criteria underwent Gd-EOB-DTPA-enhanced MRI and hepatectomy. The tumor margin was determined preoperatively based on hepatobiliary phase images. Microscopic portal vein invasion (MPVI), intrahepatic metastasis (IM), and recurrence of HCC within 1 year after hepatectomy were evaluated in 24 patients with non-smooth margins at the periphery of the tumor and 37 patients with smooth margins.

Results

The number of patients with MPVI and IM of HCC was significantly higher among those with non-smooth margins (42 and 38%, respectively) than among those with smooth margins (3%; p = 0.0002 and 5%; p = 0.0042, respectively). A non-smooth margin was identified as a significant predictor of MPVI (odds ratio 18.814, p = 0.024) and IM (odds ratio 6.498, p = 0.036) of HCC on multivariate analysis. Furthermore, a non-smooth margin was identified as a significant predictor of recurrence within 1 year after hepatectomy (odds ratio 4.306, p = 0.04) on multivariate analysis.

Conclusions

A non-smooth tumor margin in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is useful to predict MPVI, IM, and early recurrence of HCC after hepatectomy.     

Perioperative change in white blood cell count predicts outcome of hepatic resection for hepatocellular carcinoma

Background

In spite of improvements in surgical management, hepatocellular carcinoma (HCC) still recurs after operation in 60–70% of patients. Therefore, we investigated the relation between perioperative change in white blood cell count (WBC) and tumor recurrence as well as survival in patients with HCC after hepatic resection.

Methods

Subjects were 53 patients who underwent elective hepatic resection for HCC. We retrospectively examined the relation between perioperative change in WBC and recurrence of HCC as well as overall survival.

Results

Advanced tumor stage and increasing of WBC on postoperative day (POD) 1 were positively associated with worse disease-free survival rate on both univariate and multivariate analysis (P < 0.05). Advanced tumor stage, increasing of WBC on POD 1, and blood transfusion were positively associated with worse overall survival rate on univariate analysis (P < 0.05), while change in WBC was the only independent factor on multivariate analysis (P < 0.05).

Conclusions

Perioperative change in WBC after elective hepatic resection for HCC is positively associated with recurrence and worse survival.     

Tolerance of radiofrequency ablation by patients of hepatocellular carcinoma

Background

Radiofrequency ablation (RFA) is currently an effective method for ablation of hepatocellular carcinoma (HCC). Early reports have indicated that RFA is safe and virtually free from major complications. Unlike partial hepatectomy for HCC on patients with cirrhosis, there are no data on the safety limit of RFA. However, information is vital for selection of appropriate patients for the procedure. In this study, we analyzed results from use of RFA on HCC patients and determined the lower limit of liver function with which HCC patients can tolerate RFA.

Method

Preoperative variables of 310 patients who underwent RFA for HCC were analyzed to identify the risk factors in RFA intolerance in terms of morbidity associated with stress-induced complications.

Results

Thirty-nine (12.6%) patients developed intolerance of RFA. Postoperative morbidity was mainly because of intractable ascites (n = 13), hyperbilirubinemia (n = 10), massive pleural effusion (n = 7), and other complications (n = 14). Multivariate analysis revealed that serum albumin level (P = 0.001), serum bilirubin level (P = 0.000), tumor number (P = 0.002), and RFA duration (P = 0.017) all played a role in this issue.

Conclusions

Simple data such as serum bilirubin, serum albumin level, and tumor number can be used to predict HCC patients’ tolerance of RFA. Avoidance of excessive RFA time and careful monitoring of patients at risk are important means of reducing the postoperative morbidity rate.     

Fibrosis and AST to platelet ratio index predict post-operative prognosis for solitary small hepatitis B-related hepatocellular carcinoma

Purpose

Although advanced liver fibrosis is crucial in the development of hepatocellular carcinoma (HCC) for patients with chronic hepatitis B, whether it is associated with the recurrence of HCC after resection remains obscure. This study was aimed to compare the outcomes for patients with minimal or advanced fibrosis in solitary small hepatitis B virus (HBV)-related HCC.

Methods

This study enrolled 76 patients with small (<5 cm) solitary HBV-related HCC who underwent resection. The outcomes of patients with minimal and advanced fibrosis in non-tumor areas were compared. Serum markers were tested to assess the stage of hepatic fibrosis and to predict prognosis.

Results

Fourteen patients with an Ishak fibrosis score of 0 or 1 were defined as having minimal fibrosis; the remaining 62 patients were defined as having advanced fibrosis. During a follow-up period of 77.0 ± 50.7 months, 41 patients died. The overall survival rate was significantly higher (P = 0.018) and recurrence rate was lower (P = 0.018) for patients in the minimal fibrosis group. Aspartate aminotransferase–platelet ratio index (APRI) exhibited the most reliable discriminative ability for predicting advanced fibrosis. The overall survival rate was significantly higher (P = 0.003) and recurrence rate was lower (P = 0.005) for patients with an APRI of 0.47 or less.

Conclusions

For patients with solitary small HBV-related HCC who underwent resection, minimal fibrosis is associated with a lower incidence of recurrence and with better survival. APRI could serve as a reliable marker for assessing hepatic fibrosis and predicting survival.     

Diffusion-weighted imaging of hepatocellular carcinoma for predicting early recurrence and survival after hepatectomy

Purpose

The effectiveness of imaging (including apparent diffusion coefficient [ADC] of diffusion-weighted magnetic resonance imaging [DWI]) and laboratory variables for predicting early tumor recurrence and overall survival after surgery in hepatocellular carcinoma (HCC) patients are analyzed.

Methods

The present study included 116 consecutive patients with HCC who underwent partial hepatectomy. Patients were classified into two groups: patients with and without early recurrence (<1 year). Preoperative imaging variables (tumor number, size, shape, capsule, ADC, and venous invasion) and laboratory variables were evaluated to predict early recurrence using univariate and multivariate analyses. Overall survival was calculated using the Kaplan–Meier method.

Results

Twenty patients (17 %) developed early recurrence after surgery. Multivariate logistic regression analysis showed that tumor ADC (p = 0.0002), aspartate aminotransferase (p = 0.0121), and serum prothrombin time activity percentage (p = 0.0082) were statistically significant for predicting early recurrence. The optimal ADC cutoff value for predicting early recurrence obtained from receiver operating characteristic analysis was ≤0.898 × 10^?3 mm²/s. In patients with ADC ≤0.898 × 10^?3 mm²/s, the 3- and 5-year survival rates (77 and 56 %, respectively) were significantly decreased compared with those in patients with ADC >0.898 × 10^?3 mm²/s (97 and 97 %, respectively; p = 0.0015).

Conclusions

Low tumor ADC value by DWI was a risk factor for early postoperative HCC recurrence and was associated with lower patient survival rates.     

Radiofrequency-Assisted Versus Clamp-Crushing Parenchyma Transection in Cirrhotic Patients with Hepatocellular Carcinoma: A Randomized Clinical Trial

Background

Surgical resection remains the optimal therapy for cirrhotic patients with hepatocellular carcinoma (HCC) that are not suitable for liver transplantation (LT). Recently, various innovative techniques for liver resection have been developed.

Aim

The aim of the study was to compare radiofrequency-assisted parenchyma transection (RF-PT) with the traditional clamp-crushing (CC) technique to explore the preferred therapy in cirrhotic patients with HCC.

Methods

From January 2009 to December 2010, 75 cirrhotic patients with HCC who underwent hepatectomy were randomized to RF-PT (group 1, n = 38) or CC-PT (group 2, n = 37) groups. The primary endpoint was intraoperative blood loss. The secondary endpoints included hepatic transection time, total operating time, postoperative morbidity, mortality, length of intensive care unit and hospital stays, and liver function.

Results

The characteristics of the two patient groups were closely matched. The Pringle maneuver was not used in RF-PT patients. The blood loss of the RF-PT group, total or during transection, was significantly lower than that of the CC-PT group (385 vs. 545 ml, p = 0.001; 105 vs. 260 ml, p = 0.000, respectively). Compared with CC-PT patients, the morbidity of the RF-PT group was lower though not statistically significant (28.9 vs. 38.8 %, p = 0.197). One death occurred in the RF-PT group 12 days postoperative due to a large area cerebral embolism.

Conclusion

RF-PT is a safe and feasible surgical resection method for patients with cirrhosis and concomitant HCC. In addition, RF-PT results in lower blood loss and lower morbidity than the CC technique during liver resection.     

Value of Highly Sensitive Fucosylated Fraction of Alpha-Fetoprotein for Prediction of Hepatocellular Carcinoma Recurrence After Curative Treatment

Background

The fucosylated fraction of alpha-fetoprotein (AFP-L3) has been used as a diagnostic marker for hepatocellular carcinoma (HCC). Recently, a highly sensitive immunoassay using an on-chip electrokinetic reaction and separation by affinity electrophoresis (micro-total analysis system; μTAS) has been developed.

Aim

The aim of this study was to investigate the relationship between changes in the serum AFP-L3 level measured by μTAS assay and recurrence of HCC after curative treatment.

Methods

A total of 414 HCC patients who met the Milan criteria and underwent hepatectomy or radiofrequency ablation were investigated prospectively for the relationship between HCC recurrence and values of tumor markers.

Results

There were significant differences in recurrence-free survival between groups with and without AFP-L3 elevation measured before and after treatment (p = 0.024 and p = 0.001 for before and after treatment, respectively). Multivariate analysis revealed that AFP-L3 status (p = 0.002) measured 1 month after treatment was a significant independent predictor of HCC recurrence after curative treatment.

Conclusions

Elevation of the serum AFP-L3 level before treatment is a predictor of HCC recurrence, and sustained elevation of the AFP-L3 level after treatment is an indicator of HCC recurrence. Repeated measurement of μTAS AFP-L3 should be performed for surveillance of HCC recurrence after curative treatment.     

A new classification for hepatocellular carcinoma with portal vein tumor thrombus

Background/purpose

We aimed to correlate the survival of patients with hepatocellular carcinoma (HCC) with macroscopic portal vein tumor thrombus (PVTT) who underwent partial hepatectomy with or without portal thrombectomy with our PVTT classification. Currently, different staging systems for HCC are widely used in clinical practice. However, they lack the refinement in giving prognosis and guiding surgical treatment once macroscopic PVTT is present.

Methods

A retrospective study was carried out, in a single tertiary center, from January 2001 to December 2004 on 441 patients who underwent partial hepatectomy with or without portal thrombectomy for HCC with macroscopic PVTT. Overall survival was examined to determine whether it was correlated with our PVTT classification, and with the TNM staging, Cancer of the Liver Italian Program (CLIP) scoring system, and the Japan Integrated Staging (JIS) scoring system.

Results

With our PVTT classification, the numbers (percentages) of patients with types I, II, III, and IV PVTT were 144 (32.7%), 189 (42.9%), 86 (19.5%), and 22 (5.0%), respectively. The corresponding 1-, 2-, and 3-year overall survival rates for types I to IV PVTT were 54.8, 33.9, and 26.7%; 36.4, 24.9, and 16.9%; 25.9, 12.9, and 3.7%; and 11.1, 0, and 0%, respectively (log-rank of the survival curves P?<?0.0001). Using the TNM system, the majority of patients were classified as stage III (n?=?379 or 85.9%). Similarly, the majority of patients (n?=?388 or 88.0%) were classified as having CLIP scores of 2 (n?=?143, or 32.4%), 3 (n?=?171, or 38.8%), and 4 (n?=?74, or 16.8%). The 1-, 2-, and 3-year overall survivals for these 3 CLIP scores were very similar. Using the JIS score, the majority of patients (n?=?372 or 84.4%) were classified with a JIS score of 2. The 1-, 2-, and 3-year overall survivals of patients with a JIS score of 2 were worse than those of the patients with a JIS score of 1 (this was expected) as well as being worse than those with a JIS score of 3 (this was unexpected). Thus, the latter 3 systems of classification were not refined enough, and they were inadequate for stratifying HCC with macroscopic PVTT treated with partial hepatectomy with or without thrombectomy.

Conclusions

In patients with HCC with macroscopic PVTT treated by partial hepatectomy with or without thrombectomy, our PVTT classification better stratified and predicted prognosis than the TNM staging, CLIP scoring system, and JIS scoring system, which were unrefined and inadequate for this group of patients.     

Novel virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy

Background

The novel technique of virtual hepatectomy is useful for evaluation of the portal territory of the liver, since this software program includes functions for liver surgery planning. We evaluated the accuracy of virtual hepatectomy for anatomical hepatectomy.

Methods

Between 2010 and 2011, 92 patients with liver tumors underwent virtual hepatectomy preoperatively. The predicted liver volume was compared with the actual liver volume among patients who underwent anatomical sectionectomy, segmentectomy, and hemihepatectomy.

Results

Ninety of 92 patients underwent anatomical hepatectomy on the basis of virtual hepatectomy. According to the surgical procedure, the predicted liver resection volume showed a strong correlation with the actual liver volume in patients who underwent sectionectomy (r = 0.985, p < 0.0001, n = 44, median error rate 9 %), segmentectomy (r = 0.949, p < 0.0001, n = 17, median error rate 12 %), and hemihepatectomy (r = 0.967, p < 0.0001, n = 29, median error rate 7 %).

Conclusions

The novel technique of virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy.     

No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction

Background/Purpose

Locoregional recurrence following resection of hilar biliary cancers could be caused by the microscopic dissemination of cancer cells during dissection of the portal vein from the involved bile duct at the hilar region. This retrospective study assessed the feasibility and safety of a new procedure consisting of right-sided hepatectomy, caudate lobectomy, and bile duct resection combined with routine resection of the portal bifurcation to enable no-touch resection of hilar malignancies.

Methods

Of 64 patients who underwent right-sided hepatectomy for hilar biliary cancer, the portal bifurcation was routinely resected by the above new procedure in 25 patients, based on preoperative imaging diagnoses. Perioperative outcomes were compared with those in patients who underwent conventional portal reconstruction (n = 18) and with those in patients who had preservation of the portal bifurcation (n = 21).

Results

Perioperative data from patients with routine portal reconstruction were similar to those in the patients with conventional portal reconstruction and the patients without portal reconstruction. There were no postoperative complications directly related to portal reconstruction.

Conclusions

No-touch resection of hilar malignancies with right hepatectomy and the routine use of portal reconstruction was feasible and safe. The oncologic impact of this technique merits further evaluation.     

Equivalent Outcomes After Anatomical and Non-anatomical Resection of Small Hepatocellular Carcinoma in Patients with Preserved Liver Function

Background

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument.

Aim

The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function.

Methods

The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups.

Results

There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival.

Conclusions

AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.