Inferior Right Hepatic Vein-preserving Major Right Hepatectomy for Hepatocellular Carcinoma in Patients with Significant Fibrosis or Cirrhosis

Background

Liver resection represents a most effective treatment for hepatocellular carcinoma (HCC). The extent of hepatectomy for HCC involves maintaining a tricky balance between radical resection of tumors and preservation of sufficient liver parenchyma. Generally, removal of the right hepatic vein often involves resection of the whole posterior right lobe, which may prevent patients with impaired liver function from maintaining a functional reserve and could also limit the future liver remnant from curative hepatectomy. As a common anatomic variation, preservation of the inferior right hepatic vein (IRHV) may enable preservation of liver segment 6, even when the right hepatic vein has to be removed. In the present study, we report our experience with IRHV-preserving major right hepatectomy.

Methods

From February 2009 to December 2011, eight trisegmentectomies 5-7-8 and two segmentectomies 4-5-7-8 were performed with the IRHV-sparing technique on patients with HCC and significant fibrosis or cirrhosis. Data including demographic information, preoperative evaluations, postoperative outcomes, and follow-up results were collected and evaluated.

Results

All patients survived and recovered from hepatectomy. The incidence of complications was higher in cirrhotic patients. The 1-year overall survival rate was 80 %, and the 1-year disease free survival rate was 60 %.

Conclusions

IRHV-preserving major right hepatectomy increases the resectability of HCC. Intraoperative ultrasonography is recommended to facilitate protection of the IRHV. This technique is safe with careful preoperative evaluation and meticulous perioperative care. The short-term outcome of IRHV-preserving liver resections is satisfactory.     

Long-Term Outcomes of Repeat Hepatic Resection in Patients with Recurrent Hepatocellular Carcinoma and Analysis of Recurrent Types and Their Prognosis: A Single-Center Experience in China

Background

Recurrent hepatocellular carcinoma (HCC) after curative resection usually originates from intrahepatic metastasis (IM) or multicentric occurrence (MO). The long-term outcomes of repeat hepatic resection in patients with different types of recurrence have not been evaluated in a large number of patients. The surgical indications for recurrent HCC remain controversial. The purpose of this study was to investigate long-term outcomes of repeat hepatic resection and clinicopathologic factors associated with different types of recurrent HCC, and to single out principle differentiating factors between IM and MO.

Methods

82 patients who underwent repeat hepatic resection for recurrent HCC were retrospectively studied. The recurrent type was evaluated by histopathologic analysis of primary and recurrent HCC. The recurrence and survival rates as well as clinicopathologic factors associated with different types of recurrence were analyzed.

Results

45 patients (54.9%) had confirmed with IM, and 37 patients (45.1%) had with MO. The recurrence rates in the MO patients after initial or repeat resection were significantly lower than those in the IM patients (p?p?Conclusions Repeat hepatic resection resulted in much higher survival rates in the MO patients than in the IM patients. Repeat hepatic resection could be recommended for those patients in whom the recurrent HCC occurs more than 18?months after initial resection.     

Impact of Pegylated Interferon Therapy on Outcomes of Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma After Curative Hepatic Resection

Background

Several published reports investigating the effects of interferon (IFN) therapy on survival and tumor recurrence after curative resection of hepatocellular carcinoma (HCC) have been inconclusive. The aim of this study is to investigate the efficacy of pegylated-IFN (peg-IFN) therapy after curative hepatic resection for HCC in patients infected with hepatitis C virus (HCV).

Methods

Data from 175 patients who underwent curative hepatic resection for HCC associated with HCV were retrospectively collected and analyzed; 75 patients received peg-IFN therapy after surgery, whereas 100 patients did not receive IFN therapy. To overcome biases resulting from the different distribution of covariates in the two groups, a one-to-one match was created using propensity score analysis. After matching, patient outcomes were analyzed.

Results

After one-to-one matching, patients (n?=?38) who received peg-IFN therapy after surgery and patients (n?=?38) who did not receive IFN therapy had the same preoperative and operative characteristics. The 3- and 5-year overall survival rates of patients who received peg-IFN therapy after hepatic resection were significantly higher than those of patients who did not receive IFN therapy (P?=?0.00135). The 3- and 5-year overall survival rates were 100 and 91.7% and 76.6 and 50.6% in the peg-IFN group and non-IFN group, respectively. There was no significant difference in disease-free survival between the two matched groups (P?=?0.886).

Conclusion

Peg-IFN therapy may be effective as an adjuvant chemopreventive agent after hepatic resection in patients with HCV-related HCC.     

Effect of Body Composition on Outcomes after Hepatic Resection for Hepatocellular Carcinoma

Purpose

To evaluate the effect of body composition on outcomes after hepatic resection for patients with hepatocellular carcinoma (HCC).

Methods

We performed 190 hepatic resections for HCC and divided the patients into 2 groups on the basis of visceral fat area (VFA), assessed by computed tomographic measurement at the level of the umbilicus, into high VFA (H-VFA) (n = 106) and low VFA (L-VFA) (n = 84) groups. We compared the surgical outcomes between the two groups.

Results

L-VFA was significantly correlated with a lower body mass index, sarcopenia, lower serum albumin, and liver cirrhosis. There was no difference in the incidence of postoperative complications and mortality between the 2 groups. Patients in the L-VFA group had a significantly poorer prognosis than those in the H-VFA group in terms of both overall (P = 0.043) and recurrence-free (P = 0.001) survival. The results of multivariate analysis showed that sarcopenia rather than L-VFA was an independent and prognostic indicator after hepatic resection with HCC.

Conclusions

Body composition is an important factor affecting cancer outcomes after hepatic resection for HCC in Japan.     

Is There any Benefit from Expanding the Criteria for the Resection of Hepatocellular Carcinoma in Cirrhotic Liver? Experience from a Developing Country

Background

Patients with large-size (>10?cm) hepatocellular carcinoma (HCC) in Child B cirrhosis are usually excluded from curative treatment, i.e., hepatic resection, because of marginal liver function and poor outcome. This study was designed to evaluate the feasibility of the radiofrequency (RF)-assisted sequential “coagulate-cut liver resection technique” in expanding the criteria for resection of large HCC in cirrhotic livers with impaired liver function.

Methods

Forty patients with Child-Pugh A or B cirrhosis underwent liver resection from December 1, 2001 to December 31, 2008. Of these, 20 patients (13 Child-Pugh A and 7 Child-Pugh B) with advanced stage HCC (stage B and C according to Barcelona-Clinic Liver Cancer Group) underwent major liver resection. The two groups were comparable in terms of patient age, liver cirrhosis etiology, tumor number, and size.

Results

All resections were performed without the Pringle maneuver. There was no significant difference found between the two groups regarding resection time, perioperative transfusion, postoperative complications, hospital stay, and day 7 values of hemoglobin and liver enzymes. Likewise, there was no significant difference found in the overall survival between Child A and Child B patients who underwent major liver resection

Conclusions

RF-assisted sequentional “coagulate-cut liver resection technique“ may be a viable alternative for management of patients with advanced HCC in cirrhotic liver with impaired function.     

Venous Thromboembolism After Hepatic Resection: Analysis of 5,706 Patients

Objective

The routine use of venous thromboembolism (VTE) chemoprophylaxis after hepatic surgery remains controversial due to the relatively low incidence of this complication and the significant risk of perioperative bleeding. The objective of our analysis was to identify perioperative predictors of postoperative VTE in patients undergoing resection.

Methods

All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2009 who underwent hepatic resection were included for analysis. Forward stepwise multivariate logistic regression models were used to determine perioperative variables that are significantly associated with VTE after hepatic surgery.

Results

The overall incidence of VTE after hepatic resection was 2.9?%. Significant predictors of VTE after hepatic resection included preoperative mechanical ventilation, male gender, operative time?>?3?h, age????70?years, intraoperative transfusion, and extended hepatectomy. Several non-VTE postoperative complications were also associated with subsequent VTE, including prolonged mechanical ventilation, need for early reoperation, and postoperative bleeding.

Conclusions

Many perioperative factors, including extended hepatectomy as well as several postoperative non-VTE complications, are associated with an increased risk of VTE after hepatic resection. Knowledge of these factors may assist surgeons in deciding which patients merit more aggressive prophylaxis against this complication.     

Trends in the Multimodality Treatment of Resectable Colorectal Liver Metastases: an Underutilized Strategy

Objective

Advances in multimodality therapy have led to increased survival for patients with metastatic colorectal cancer, but the impact on patients undergoing resection for colorectal liver metastases is unclear. The purpose of this study was to evaluate patterns of treatment for resectable colorectal liver metastases in the USA over the last two decades.

Methods

Using the Surveillance, Epidemiology, and End Results-Medicare database, 1,926 patients who underwent hepatic resection for colorectal liver metastasis between 1991 and 2007 were included and divided into two cohorts: period 1 (1991–2000) and period 2 (2001–2007). Demographic data, treatment patterns, and outcomes of the two periods were compared by univariate methods. Multivariable regression models were constructed to predict the use of perioperative chemotherapy, postoperative complications, and 90-day mortality following liver resection.

Results

The overall use of perioperative chemotherapy was 33 % and did not differ between periods, but shifted from postoperative to preoperative over time. By multivariable analysis, older age, black race, stage III primary cancer, and metachronous disease were predictive of lesser likelihood of chemotherapy use. The use of preoperative chemotherapy was not associated with any increase in perioperative morbidity or mortality.

Conclusions

Despite increased survival and widespread recommendations for the use of multimodality therapy, the overall resection rate and use of perioperative chemotherapy for resectable colorectal liver metastases remain underutilized and have not increased over time. Efforts to investigate barriers to the widespread use of multimodality therapy for these patients are warranted.     

Impact of Simultaneous Diaphragm Resection During Hepatectomy for Treatment of Metastatic Colorectal Cancer

Introduction

For colorectal cancer patients with liver metastases involving the hepatic dome or invading the diaphragm, a concomitant diaphragm resection is often required to achieve negative surgical margins. The purpose of this study is to determine whether diaphragm resection during partial hepatectomy for metastatic colorectal cancer influences short-term perioperative outcomes and overall survival.

Methods

Demographics, treatments, and outcomes of 442 patients who underwent hepatic resection for metastatic colorectal cancer from 1996 to 2010 at a high-volume center were reviewed. Recurrence and survival were measured from the date of metastectomy. Actuarial curves were generated using the Kaplan?CMeier method and compared using log?Cranks testing. Multivariate predictors of worse survival were compared using a Cox-proportional hazards model.

Results

A total of 442 patients underwent hepatectomy for metastatic colorectal cancer. Of these, 34 required simultaneous diaphragm resection (DR) and 408 did not (LR). No significant differences existed in patient demographics or comorbidities. The DR group had longer median operative times (336 vs. 267?min, p?=?0.0008) but had comparable rates of perioperative morbidity and mortality. Median overall survival was shorter in the DR group compared to the LR group (18.8 vs. 36?months, p?=?0.0017). When controlling for potential cofounders, liver metastases size?>?5?cm (HR 1.45 95?% CI (1.08?C1.99), p?=?0.015) and diaphragm resection (HR?=?1.72 95?% CI (1.03?C2.86), p?=?0.038) predicted worse survival.

Conclusions

Simultaneous diaphragm resection during partial hepatectomy does not significantly influence perioperative morbidity or mortality despite longer operative times. However, patients who require diaphragm resection have less favorable survival rates as compared to those who do not.     

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

Background

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

Methods

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

Results

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p?=?0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p?=?0.115).

Conclusion

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

     

Perioperative Complications After Neoadjuvant Chemotherapy With and Without Bevacizumab for Colorectal Liver Metastases

Purpose

Bevacizumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Neoadjuvant bevacizumab is commonly used in patients undergoing liver resection. Our purpose was to evaluate whether bevacizumab is associated with increased rate of perioperative complications in patients undergoing hepatic resection for colorectal liver metastases (CRLM).

Methods

Retrospective analysis of patients undergoing hepatic resection for CRLM who received chemotherapy and bevacizumab (group 1, n?=?134), or chemotherapy alone (group 2, n?=?57). We compared demographics, surgical characteristics, and perioperative course.

Results

Perioperative complications developed in 35 % of patients in group 1, and 47 % in group 2 (p?=?0.11). Of those complications, 15 (11.2 %) in group 1, and 5 (8.8 %) in group 2 were considered major (p?=?0.617). Four patients, all of whom received preoperative bevacizumab, developed enteric leaks following combined liver and bowel resection. The rate of anastomotic leak in group 1 was 10 %, compared with 0 in group 2, p?=?0.56.

Conclusion

Neoadjuvant chemotherapy along with bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection. Possible association of increased morbidity with simultaneous bowel and liver resections following bevacizumab administration was found and we recommend avoiding such treatment combination.     

Oral supplementation of branched-chain amino acids reduces early recurrence after hepatic resection in patients with hepatocellular carcinoma: a prospective study

Purposes

The long-term outcomes of branched-chain amino acids (BCAA) administration after hepatic resection in patients with hepatocellular carcinoma (HCC) remain unclear. This study assessed the effect of oral supplementation with BCAA on the development of liver tumorigenesis after hepatic resection in HCC patients.

Methods

Fifty-six patients were randomly assigned to receive either BCAA supplementation (Livact group, n = 26) or a conventional diet (Control group, n = 30). Twenty-six patients in the BCAA group were treated orally for 2 weeks before and 6 months after hepatic resection. Postoperative tumor recurrence was continuously evaluated in all patients by measuring various clinical parameters.

Results

There was no significant difference in the overall survival rate between the two patient groups; however, the recurrence rate at 30 months after surgery was significantly better in the Livact group in comparison to the Control group. Interestingly, the tumor markers, such as AFP and PIVKA-II, significantly decreased at 36 months after liver resection in the Livact group in comparison to the Control group.

Conclusions

Oral supplementation of BCAA reduces early recurrence after hepatic resection in patients with HCC. This treatment regimen offers potential benefits for clinical use in such patients, even in cases with a well-preserved preoperative liver function.     

Resection of Hepatocellular Carcinoma with Macroscopic Vascular Invasion

Background

Survival for Child’s A patients with hepatocellular cancer (HCC) and macroscopic vascular invasion (MVI) has been reported as approximately 8.1 months with sorafenib. The role of surgery for these patients remains controversial.

Methods

The records of all patients undergoing resection of HCC at a single center were reviewed. Only patients with pathologically proven MVI were included. Inclusion criteria for resection required Child’s A liver disease, no clinical portal hypertension (after 2002), and no extrahepatic disease. The superior mesenteric vein and portal vein branch to the remaining lobe had to be patent.

Results

We identified 165 patients with MVI treated with hepatic resection between June 1992 and March 2010. Median follow-up was 11.9 months with 127 deaths, including 12 (7.3 %) perioperative mortalities. Median and 5-year survivals were 13.1 months and 14 %. Multivariate analysis found α-fetoprotein (AFP) >30 ng/ml (hazard ratio 2.07), tumor size >7 cm (hazard ratio 1.59), and extent of vascular invasion (hazard ratio 1.74) to be independently associated with survival. Those with invasion of hepatic veins or vena cava had a median survival of only 4.7 months.

Conclusions

The results for resection of HCC with MVI remain somewhat disappointing but are better than what is reported with medical therapy in similar patients. Tumor size, AFP, and extent of vascular invasion can help select those that will benefit most from hepatic resection. Resection of patients with hepatic vein or vena cava involvement may not be justified, given such poor results.     

Major Hepatectomy Is a Safe Modality for the Treatment of Intrahepatic Cholangiocarcinoma in Selected Patients Complicated with Cirrhosis

Objective

The objective of this paper is to evaluate the perioperative outcomes of major hepatectomy for intrahepatic cholangiocarcinoma (ICC) in patients with cirrhosis.

Methods

We retrospectively evaluated the preoperative, intraoperative, and postoperative findings in 42 consecutive patients with cirrhosis and in 102 patients with normal livers who underwent major hepatectomy for ICC.

Results

Preoperative liver function was worse in patients with cirrhosis compared to patients without cirrhosis. Cirrhotic patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than non-cirrhotic patients. However, the two groups had similar overall morbidity and hospital mortality rates and similar rates of liver failure or other complications. Their R0 resection rates, resection margin widths and disease-free survival rates were also similar.

Conclusions

Major hepatectomy for ICC can be performed in selected cirrhotic patients with acceptable morbidity and mortality rates, as compared to patients without cirrhosis.     

Comparing Hepatic Resection and Transarterial Chemoembolization for Barcelona Clinic Liver Cancer (BCLC) Stage B Hepatocellular Carcinoma: Change for Treatment of Choice?

Background

Compared to transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC), stage B in the Barcelona Clinic Liver Cancer (BCLC) classification, the role of hepatic resection remains unclear. The present study compared the long-term outcome of hepatic resection with TACE in the treatment of BCLC stage B HCC.

Methods

A total of 171 patients with BCLC stage B, Child’s classification A (Child A), HCC were included in this retrospective study. Of these, 93 patients underwent hepatic resection (group I) and 73 patients received TACE (group II). We evaluated the long-term outcome and therapy-related mortality in both groups. The risk factors of mortality were assessed. The survival curve was analyzed by the Kaplan–Meier method.

Results

The 1-, 2-, and 3-year overall survival rates for the two groups after hepatic resection and TACE were 83%, 62%, 49% and 39%, 5%, 2%, respectively (P < 0.0001). We did not observe significant differences in the therapy-related mortality between the two groups (P = 0.78). Treatment modality and serum albumin level were independent risk factors for survival by Cox regression analysis.

Conclusions

Our study demonstrated that hepatic resection for BCLC stage B, Child A HCC patients had better survival rates than TACE group. Thus, hepatic resection is indicated in selected patients with BCLC stage B.     

Safety and efficacy of early postoperative hyperbaric oxygen therapy with restriction of transfusions in patients with HCC who have undergone partial hepatectomy

Background

Recent studies have shown that intraoperative blood loss and blood transfusions promote postoperative recurrence of hepatocellular carcinoma (HCC). Hyperbaric oxygen therapy (HBOT) is a specific method of oxygen administration, which is independent of fluid therapy or blood transfusion. The aim of the present study was to assess the usefulness of acute HBOT after liver resection for patients with HCC in order to minimize the requirement for perioperative blood transfusions.

Patients and methods

Forty-one consecutive patients who showed Hb level < 9.0?mg/dl at the end of hepatic resection were randomly assigned to a control group (n = 21) or an HBOT group (n = 20). HBOT at 2.0?atm. with inhalation of 100% oxygen for a duration of 60?min was performed at 3, 24, and/or 48?h after the end of the hepatectomy. Regarding postoperative hepatic hemodynamics, liver function tests, and outcome data, prospective comparisons were completed in both groups. The two groups of patients were similar with respect to results from preoperative assessments.

Results

In six patients from the HBOT group, who experienced intraoperative major bleeding or showed fatal hepatic hypoxia (ShvO₂ < 50%), the levels of ShvO₂ and serum lactate were significantly improved after HBOT. When compared to the control group, the HBOT group showed better changes of ShvO₂, serum lactate, and bilirubin levels for the first 3 postoperative days following surgery. Additionally, the HBOT group did not experience any fatal complications and had a lower incidence of postoperative hyperbilirubinemia than the control group. We also observed that postoperative NK cell activity and cancer-free survival in the HBOT group tended to be better than in the control group, although the differences did not reach significance.

Conclusion

These results suggest that acute HBOT after hepatectomy, aimed at reducing perioperative erythrocyte transfusions, may be employed for overcoming deficiencies in systemic and hepatic oxygen supply and thus diminishing postoperative complications. As an added benefit, such therapy may affect postoperative immunological responses and long-term survival after liver resection in HCC patients. Further analyses of the use of HBOT is warranted to confirm surgical outcome data and to assess the economic impact on healthcare costs.     

Hepatectomy for Huge Hepatocellular Carcinoma: Single Institute’s Experience

Background

The surgical resection of huge hepatocellular carcinoma (HCC) is still controversial. This study was designed to introduce our experience of liver resection for huge HCC and evaluate the safety and outcomes of hepatectomy for huge HCC.

Methods

A total of 258 hepatic resections for the patients with huge HCC were analysed retrospectively from December 2002 to December 2011. The operative outcomes were compared with 293 patients with HCC >5.0 cm but <10.0 cm in diameter. Prognostic factors for long-term survival were evaluated by univariate and multivariate analyses.

Results

The 1-, 3-, 5-year overall survival rates after liver resection were 84, 62, and 33 %. Overall survival and disease-free survival in huge HCC group and HCC >5.0 cm but <10.0 cm group were similar (P = 0.751, P = 0.493). Solitary huge HCC group has significantly a more longer overall and disease-free survival time than nodular huge HCC (P = 0.026, P = 0.022). Univariate and multivariate analysis revealed that the types of tumour, vascular invasion, and UICC stage were independent prognostic factors for overall survival (P = 0.047, P = 0.037, P = 0.033).

Conclusions

Hepatic resection can be performed safely for huge HCC with a low mortality and favorable survival outcomes. Solitary huge HCC has the better surgical outcomes than nodular huge HCC.     

A Prospective Randomized Controlled Trial to Compare Pringle Manoeuvre with Hemi-hepatic Vascular Inflow Occlusion in Liver Resection for Hepatocellular Carcinoma with Cirrhosis

Background

The duration of hepatic vascular inflow occlusion and the amount of intraoperative blood loss have significant negative impacts on postoperative morbidity, mortality and long-term survival outcomes of patients who receive partial hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis.

Aim

This study aimed to compare the perioperative outcomes of partial hepatectomy for HCC superimposed on hepatitis B-related cirrhosis using two different occlusion techniques.

Methods

A randomized controlled trial was carried out to evaluate the impact of two different vascular inflow occlusion techniques. The postoperative short-term results were compared.

Results

During the study period, 252 patients received partial hepatectomy for HCC with cirrhosis. Of these patients, 120 were randomized equally into two groups: the Pringle manoeuvre group (n?=?60) and the hemi-hepatic vascular inflow occlusion group (n?=?60). The number of patients who had poor liver function on postoperative day 5 with ISLGS grade B or worse was 24 and 13, respectively (P?=?0.030). The postoperative complication rate was significantly higher in the Pringle manoeuvre group (40 versus 22 %, P?=?0.030). However, the Pringle manoeuvre group had significantly shorter operating time (116 versus 136 min, P?=?0.012) although there was no significant difference in intraoperative blood loss between the two groups [200 ml (range 10–5,000 ml) versus 300 ml (range 100–1,000 ml); P?=?0.511]. There was no perioperative mortality.

Conclusions

The results indicated that for patients with HCC with cirrhosis, hemi-hepatic vascular inflow occlusion was a better inflow occlusion method than Pringle manoeuvre.     

Laparoscopic approach for treatment of multiple hepatocellular carcinomas

Background

The aim of this study is to evaluate clinical and oncologic outcomes after laparoscopic surgery for patients with multiple hepatocellular carcinoma (HCC).

Methods

Among the 260 patients who underwent laparoscopic procedures, including laparoscopic liver resection and laparoscopic radiofrequency ablation (LRFA), between September 2003 and December 2009, 107 patients with HCC were included in this retrospective study. According to tumor multiplicity, patients were divided into multiple lesion (n?=?23) and single lesion (n?=?84) groups. We compared the operative outcomes after the laparoscopic procedures between the single and multiple tumor groups.

Results

There was no difference in the clinicopathologic characteristics between the two groups, except the multiple group had more frequent previous history of preoperative transarterial chemoembolization. LRFA was more frequently used in the multiple group as compared with the single group. There was no postoperative mortality in either group. Application of laparoscopic surgery in the multiple group did not increase the operative time, rate of intraoperative transfusion, length of postoperative hospital stay, or postoperative complications, as compared with the single group. After median follow-up of 33.7?months, there was no statistically significant difference of the survival rates between the two groups, although there was a better disease-free survival rate in the single group.

Conclusions

This study shows that laparoscopic surgery, including LH and LRFA, can be safely applied to patients with multiple HCCs, and the survival outcomes are acceptable.     

Predictors for Microinvasion of Small Hepatocellular Carcinoma ≤2?cm

Background

Hepatocellular carcinoma (HCC) ??2?cm in diameter is considered to have a low potential for malignancy.

Methods

A retrospective review was undertaken of 149 patients with primary solitary HCC ??2?cm who underwent initial hepatic resection between 1994 and 2010. The independent predictors of the microinvasion (MI) such as portal venous, hepatic vein, or bile duct infiltration and/or intrahepatic metastasis were identified by multivariate analysis. Prognosis of patients with HCC ??2?cm accompanied by MI was compared to that of patients with HCC ??2?cm without MI.

Results

Forty-three patients with HCC ??2?cm had MI in patients (28.9%). Three independent predictors of the MI were revealed: invasive gross type (simple nodular type with extranodular growth or confluent multinodular type), des-??-carboxy prothrombin (DCP) >100?mAU/ml, and poorly differentiated. Disease-free survival rates of patients with HCC ??2?cm with MI (3?year 44%) were significantly worse than those for HCC ??2?cm without MI (3?year 72%). This disadvantage of disease-free survival rate of patients with HCC ??2?cm with MI could be dissolved by hepatic resection with a wide tumor margin of ??5?mm (P?=?0.04).

Conclusions

Even in cases of HCC ??2?cm, patients who are suspected of having invasive gross type tumors in preoperative imaging diagnosis or who have a high DCP level (>100?mAU/ml) are at risk for MI. Therefore, in such patients, hepatic resection with a wide tumor margin should be recommended.     

Surgical Resection versus Open-Approach Radiofrequency Ablation for Small Hepatocellular Carcinomas within Milan Criteria after Successful Transcatheter Arterial Chemoembolization

Aims

The aim of this study was to compare the effectiveness and safety of hepatic resection versus open-approach RFA (ORFA) for small hepatocellular carcinomas (HCC) within Milan criteria after successful downstaging therapy by transcatheter arterial chemoembolization.

Material and Methods

Between February 2005 and February 2008, a total of 110 patients with advanced HCC met the Milan criteria after successful downstaging therapy; 58 patients then underwent hepatic resection and 52 received ORFA. Outcomes, including short- and long-term morbidity, 1-, 3-, and 5-year mortality and HCC-free survival, were analyzed and compared between the two groups.

Results

Patients in the hepatic resection and ORFA groups showed similar baseline characteristics and downstaging protocols. The ORFA group showed less blood loss, lower hospital costs, shorter surgical time, and fewer hospital stay days (P?<?0.05). The 1-, 3-, and 5-year overall survival rates were 94.8, 86.2, and 79.3 %, respectively, with liver resection and 96.2, 82.7, and 76.9 % with ORFA (P?=?0.772). The 1-, 3-, and 5-year recurrence-free survival rates were 93.1, 81.0, and 77.6 % with resection and 94.2, 76.9, and 73.1 % with ORFA (P?=?0.705). The ORFA patients suffered fewer postoperative complications (P?=?0.09), particularly among the cases of central HCC (P?=?0.015).

Conclusion

Resection and ORFA achieved similar survival benefits in the management of HCC within Milan criteria after successful downstaging. The decreased blood loss, hospital costs, surgical time, and hospital stay days, and lower complication rates in central cases render ORFA a preferred treatment option.