Results of repeated hepatectomy for recurrent hepatocellular carcinoma

BACKGROUND/AIMS: The long-term outcome of patients undergoing repeated hepatectomy for secondary hepatocellular carcinoma (HCC) were investigated to assess the selection criteria for, and efficacy of, repeated hepatectomy. METHODOLOGY: 21 patients with secondary HCC who had undergone repeated hepatectomy (R group) were analyzed. Clinical characteristics, histopathologic findings and postoperative clinical course were compared for patients with primary and secondary HCCs in the R group. The risk factors for post repeated hepatectomy survival and disease-free survival were estimated for the R group. RESULTS: There were no significant differences in patient characteristics or histologic features of primary and secondary HCCs in the R group. A significant difference in cumulative postoperative disease-free survival was not seen for primary and secondary HCCs, average duration was 39.4 and 21.3 months. Liver cirrhosis and narrow hepatectomy (subsegmentectomy, limited resection and enucleation) were found to be significant risk factors of survival after secondary hepatectomy. The 5-year post-recurrence survival rate of nine patients in the R group who had two risk factors was 14.8%. CONCLUSIONS: In cirrhotic patients with secondary HCC, inadequate narrow repeated hepatic resection should not receive repeated hepatectomy.     

Comparison of the outcomes between anatomical resection and limited resection for single hepatocellular carcinomas no larger than 5 cm in diameter: a single-center study

Background/Purpose

Liver resection is a widely preferred treatment modality for hepatocellular carcinomas (HCCs). This study aimed to compare the survival impact of anatomical resection with that of limited resection, in patients with single HCCs no larger than 5 cm in diameter.

Methods

A cohort study was carried out on 209 consecutive patients who underwent hepatic resection for a single HCC no larger than 5 cm in diameter between January 1994 and March 2007 at Osaka City General Hospital.

Results

The cumulative 5-year overall survival and disease-free survival rates in the anatomical resection group (n = 111) were 71 and 40%, respectively, both of which were significantly better than the 48 and 25% seen in the limited resection group (n = 98) (P = 0.0043 and P = 0.0232, respectively). Better effects of the anatomical resection on both overall and disease-free survival were seen in patients having HCC larger than 2 cm in diameter and in patients with moderately or poorly differentiated HCC. But no significant difference in either overall or disease-free survival was seen between the groups in patients with a HCC 2 cm or less in diameter or in the patients with well-differentiated HCC. Using Cox’s regression model, anatomical resection was confirmed to be an independent favorable factor for both overall and disease-free survival.

Conclusions

Anatomical resection is therefore recommended for histologically advanced single HCCs ranging from 2 to 5 cm in diameter.     

Surgical management of recurrence after resection of colorectal liver metastases

The optimal treatment for recurrent lesions after hepatectomy for colorectal liver metastases is controversial. We report the outcome of aggressive surgery for recurrent disease after the initial hepatectomy and the influence on quality of life of such treatment. Forty-five (70%) of the 64 surviving patients developed recurrence after the initial hepatectomy for liver metastases. The determinants of hepatic recurrence were the distribution and the number of liver metastases. Twenty-eight (62%) of patients with recurrence underwent resection. A second hepatectomy was performed in 20 patients, and a third hepatectomy was done in 5 patients. Ten patients with pulmonary metastasis underwent partial lung resection on 14 occasions, while resection of brain metastases was performed in 3 patients on 5 occasions. There were no operative deaths after resection of recurrent disease. The morbidity rate was 28% after repeat hepatectomy, 21% after pulmonary resection, and 0% after resection of brain metastasis. The Karnofsky performance status (PS) after the last surgery was not significantly different from that after the initial hepatectomy. The 3- and 5-year survival rates after the second hepatectomy were 54% and 14%, respectively. The 3-and 5-year survival rates of the patients undergoing resection of extrahepatic recurrence were both 17%. The survival rate after resection of recurrent disease (n=28) was significantly better than that of patients (n=17) with unresectable recurrence (P < 0.05). For the 66 patients with colorectal liver metastases, the 5-year survival rate after initial hepatectomy was 50%. The distribution and the number of liver metastases and the presence of extrahepatic disease, as single factors, significantly affected prognosis after the initial hepatectomy. Multivariate analysis revealed that only the presence of extrahepatic metastasis and a disease-free interval of less than 6 months were independent predictors of survival after the initial and second hepatectomy, respectively. It is concluded that aggressive surgery is an effective strategy for selected patients with recurrence after initial hepatectomy. Careful selection of candidates for repeat surgery will yield increased clinical benefit, including long-term survival.     

Resection margin in laparoscopic hepatectomy: a comparative study between wedge resection and anatomic left lateral sectionectomy

Background

Experience from open hepatectomy shows that anatomic liver resection achieves a better resection margin than wedge resection. In recent years, laparoscopic hepatectomy has increasingly been performed in patients with liver pathology including malignant lesions. Wedge resection (WR) and left lateral sectionectomy (LLS), which also represent non-anatomic and anatomic resection respectively, are the two most common types of laparoscopic hepatectomy performed. The aim of the present study was to compare the two types of laparoscopic hepatectomy with emphasis on resection margin.

Methods

Between November 2003 and July 2009, 44 consecutive patients who underwent laparoscopic hepatectomy were identified and retrospectively reviewed. The WR and LLS group of patients were compared in terms of operative outcomes, pathological findings, recurrence patterns and survival.

Results

Out of the 44 patients, 21 underwent LLS and 23 a WR. The two groups of patients were comparable in demographics. The two groups did not differ in conversion rate, blood loss, blood transfusion, mortality, morbidity and post-operative length of stay. The LLS group patients had significantly larger liver lesions, wider resection margin and less sub-centimetre margins. In patients with malignant liver lesions, there was no difference between the two groups in incidence of intra-hepatic recurrence and 3-year overall and disease-free survival.

Conclusion

Operative outcomes are similar between laparoscopic WR and LLS. However, WR is less reliable than LLS in achieving a resection margin of more than 1 cm. Larger studies involving more patients with longer follow-up are warranted to determine the impact of the resection margin on intra-hepatic recurrence and survival.     

Efficacy of anatomic resection vs nonanatomic resection for small nodular hepatocellular carcinoma based on gross classification

Background/Purpose

It has been reported that anatomic resection may be preferable to nonanatomic resection for small hepatocellular carcinomas (HCCs), by reducing socalled “micrometastases” (portal venous tumor extension and intrahepatic metastases). Nonanatomic resection or ablation has also been used as therapy for small HCCs. We studied the effectiveness of anatomic resection for small nodular HCCs, especially from the viewpoints of tumor size and gross classification.

Methods

A retrospective cohort study was performed in 116 consecutive patients who underwent curative hepatic resection for HCCs 3 cm or smaller and with three or fewer nodules. The outcome of anatomic resection (including segmentectomy, sectoriectomy, and hemihepatectomy) was compared to that of nonanatomic partial hepatectomy.

Results

The group that underwent anatomic resection (n = 52) had relatively better overall survival and significantly better recurrence-free survival than those with nonanatomic resection (n = 64). On Cox multivariate analysis, however, liver function was more closely associated with survival. The effect of anatomic resection was more prominent in the subgroup with the nonboundary type nodules (single nodular type with extranodular growth, confluent multinodular type, and invasive type) than in the subgroup with the boundary type (vaguely nodular and single nodular type). Micrometastases in the nonboundary type were found further from the main tumor (9.5 ± 6.2 mm) than those in the boundary type (within 3.1 +-1.4 mm).

Conclusions

In patients with HCC nodules equal to or less than 3 cm and with the nonboundary type, anatomic resection should be employed to the extent that liver function allows, because this procedure would be more favorable than nonanatomic resection in eradicating micrometastases that have extended away from the tumor’s margin.     

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism:A casecontrol study

AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.     

Liver resection for large-size hepatocellular carcinomas in 47 non-cirrhotic patients--no mortality and long-term survival

BACKGROUND/AIMS: Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocellular carcinoma (HCC) on non-cirrhotic liver. METHODOLOGY: From January 1985 to December 2002, 277 patients underwent liver resection for HCC; in only 47 the liver was normal or showed mild chronic hepatitis at histology. RESULTS: A major hepatectomy (MHR) was accomplished in 37 cases (78.7%) including an extended hepatic resection in 18 (38.3%). In-hospital mortality was nil. The rate of complications was 40.4%. Overall and disease-free survival rates at 5 years were 30.9% and 33.9%. Fifteen patients are actually alive with a median survival of 33.3 months. By multivariate analysis, tumor size > 10cm and presence of satellite nodules were independent predictive factors of 5-year survival; median survival of thirteen patients with HCCs < or = 10cm and without daughter nodules was 60 months. Twenty-six patients had a margin less than 1cm and without cancer involvement; overall and recurrence-free survival rates were comparable to those of the patients with a > 1cm margin. CONCLUSIONS: In the treatment of HCC without cirrhosis, major hepatic resections are often needed. Tumors less than 10cm in size and without satellite nodes are the best candidates for operation. The width of the resection margin is unimportant provided that there is no microscopic infiltration.     

Role of surgical resection for multiple hepatocellular carcinomas

AIM:To clarify the role of surgical resection for multiple hepatocellular carcinomas(HCCs)compared to transarterial chemoembolization(TACE)and liver transplantation(LT). METHODS:Among the HCC patients who were managed at Yonsei University Health System between January 2003 and December 2008,160 patients who met the following criteria were retrospectively enrolled:(1) two or three radiologically diagnosed HCCs;(2)no radiologic vascular invasion;(3)Child-Pugh class A;(4) main tumor smaller than 5 cm in diameter;and(5) platelet count greater than 50 000/mm3.Long-term outcomes were compared among the following three treatment modalities:surgical resection or combined radiofrequency ablation(RFA)(n=36),TACE(n=107), and LT(n=17).The survival curves were computed using the Kaplan-Meier method and compared with a log-rank test.To identify the patients who gained a survival benefit from surgical resection,we also investigated prognostic factors for survival following surgical resection.Multivariate analyses of the prognostic factors for survival were performed using the Cox proportional hazard model. RESULTS:The overall survival(OS)rate was significantly higher in the surgical resection group than in the TACE group(48.1%vs 28.9%at 5 years,P<0.005). LT had the best OS rate,which was better than that of the surgical resection group,although the difference was not statistically significant(80.2%vs 48.1%at 5 years,P=0.447).The disease-free survival rates were also significantly higher in the LT group than in the surgical resection group(88.2%vs 11.2%at 5 years, P<0.001).Liver cirrhosis was the only significant prognostic factor for poor OS after surgical resection. Clinical liver cirrhosis rates were 55.6%(20/36)in the resection group and 93.5%(100/107)in the TACE group.There were 19 major and 17 minor resections. En bloc resection was performed in 23 patients,multisite resection was performed in 5 patients,and combined resection with RFA was performed in 8 patients. In the TACE group,only 34 patients(31.8%)were record     

Prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection: univariate and multivariate analysis

BACKGROUND/AIMS: Intrahepatic cholangiocarcinoma is clinicopathologically distinct from hepatocellular carcinoma and hilar cholangiocarcinoma, and the prognostic factors after hepatic resection of these rare tumors are not well documented. The aim of this study was to evaluate prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection. METHODOLOGY: We retrospectively studied 20 consecutive patients with intrahepatic cholangiocarcinoma who underwent hepatectomy over a 15-year period from 1984 to 1998. Fifteen prognostic factors were evaluated for their association with overall and disease-free survivals in univariate and multivariate analysis (Cox's proportional hazards model). RESULTS: Eighty percent of the resected patients had major hepatectomy. Operative morbidity and mortality rates were 30% and 0%, respectively. Four patients (20%) survived more than 5 years without recurrence after hepatic resection. The 1-year, 3-year, and 5-year overall or disease-free survival rate after hepatic resection were 56.0% or 49.5%, 43.8% or 43.3%, and 43.8% or 37.3%, respectively. Univariate analysis showed young age and periductal invasion tumor or the presence of vascular invasion, lymphatic invasion, and lymph node metastasis as significant poor prognostic predictors contributing overall and disease-free survivals. Multivariate analysis revealed only lymph node metastasis as an independent prognostic factor affecting disease-free survival. During the same time, 17 unresectable patients were treated by intrahepatic arterial infusion chemotherapy (12), systemic chemotherapy (4), or radiation (1). Median overall survival time in resected patients (16 months) was significantly better than in unresectable patients (5 months) (P = 0.005). CONCLUSIONS: Hepatic resection remains to be the best current therapeutic option. The prognosis after hepatic resection for intrahepatic cholangiocarcinoma was determined by lymph node metastasis. New adjuvant chemotherapy after surgery is imperative for such patients.     

手术切除与射频消融治疗符合米兰标准的不同肝段多发肝癌的效果分析

目的探讨手术切除与射频消融治疗多发位于不同肝段符合米兰标准肝癌的效果。方法回顾性分析2009年2月-2013年2月在华西医院肝脏外科及肝移植中心行手术切除及射频消融术的多发位于不同肝段的符合米兰标准的158例肝癌患者的临床资料,手术切除110例,射频消融48例。比较两种治疗方法的效果差异。计数资料2组间比较采用χ2检验或Fisher确切检验;计量资料满足正态分布的2组间比较采用t检验,不满足正态分布的2组间比较采用Mann-Whitney U检验;采用Kaplan-Meier分析总体生存率及无瘤生存率,生存率比较采用log-rank检验。采用受试者工作特征曲线(ROC曲线)分析肿瘤分化程度与微脉管侵犯的关系。结果射频消融组患者血红蛋白、Alb较手术切除组低(P值均<0.05),术后住院时间较手术切除组短(P<0.05)。手术切除组与射频消融组患者预后差异无统计学意义(1、3、5年总体生存率分别为94.5%、55.2%、28.8%和83.3%、50.0%、26.5%,χ2=1.161,P=0.281;1、3、5年的无瘤生存率分别为86.4%、42.5%、21.9%和79.2%、37.5%、11.0%,χ2=1.771,P=0.183)。无微脉管侵犯者与有微脉管侵犯的患者预后差异有统计学意义(1、3、5年总体生存率分别为94.6%、59.1%、31.8%和94.1%、33.1%、10.1%,χ2=4.250,P=0.039;1、3、5年无瘤生存率分别为87.1%、48.1%、25.0%和82.4%、17.6%、6.1%,χ2=8.120,P=0.004)。低分化肝癌与非低分化肝癌患者预后差异有统计学意义(1、3、5年总体生存率分别为91.2%、33.7%、4.1%和96.1%、64.5%、39.0%,χ2=19.092,P<0.001;1、3、5年无瘤生存率分别为79.4%、10.3%、3.2%和89.5%、56.6%、31.4%,χ2=25.973,P<0.001)。整块肝肿瘤切除与分开局部切除的1、3、5年总体生存率分别为93.7%、57.7%、29.8%和93.3%、38.9%、23.3%(χ2=1.282,P=0.257),1、3、5年无瘤生存率分别为85.3%、46.0%、23.7%和86.7%、26.7、10.0%(χ2=1.706,P=0.191),二者差异均无统计学意义。手术切除组与射频消融组患者术后并发症无明显差异(χ2=3.088,P=0.079),2组患者在术后30 d内均无死亡。结论对于多发的位于不同肝段的符合米兰标准的肝癌患者,手术切除效果与射频消融效果没有明显差异。在手术切除组,整块切除与分开局部切除的效果无明显差异。肿瘤的微脉管侵犯情况、肿瘤的分化程度对患者的预后存在影响。     

Resection of hepatic metastases of colorectal carcinoma: 20 years' experience

We analyzed the results and the prognostic factors influencing survival in 79 patients with metastases of colorectal carcinoma who underwent hepatectomy at our hospital in the 20-year period 1978—1998. The 5- and 10-year survival rates were 49% and 33%, respectively. Repeat hepatectomy was done 29 times in 24 patients with relapse of liver tumors. The 3- and 5-year survival rates after repeat hepatectomy were 58% and 14%, respectively. The distribution of and number of tumors in the liver, the disease-free interval from initial to second hepatectomy, and the presence of extrahepatic disease were significantly associated with survival (P < 0.01). Seven of 43 patients who underwent hilar node dissection had metastasis and 2 of them survived for more than 5 years. Repeat hepatectomy and hilar lymphadenectomy may be effective in prolonging the sur-vival of selected patients with hepatic metastasis. We also discuss prognostic factors after extensive surgery for hepatic metastases of colorectal carcinoma.     

Risk factors of post-operative recurrence and adequate surgical approach to improve long-term outcomes of hepatocellular carcinoma

Introduction

A high recurrence rate of hepatocellular carcinoma (HCC) remains a significant concern. The risk factors for recurrence were analysed and the optimal surgical approaches were investigated.

Methods

The subjects comprised 280 consecutive patients with primary solitary HCC measuring ≤5 cm in diameter, who underwent curative resections. Multivariate analysis was conducted to identify the risk factors for post-operative recurrence, and the clinical significance of an anatomic resection was evaluated.

Results

Multivariate analysis identified HCV infection, a des-gamma-carboxyprothrombin level >100 mAU/ml, underlying cirrhosis, the presence of microvascular invasion, the presence of micrometastases and non-anatomic resection as being significant risk factors for post-operative recurrence. The 5-year recurrence rate was 56.7% in the anatomic resection (AR) group and 74.7% in the non-AR group. The 5-year survival rate was 82.2% in the AR group and 71.9% in the non-AR group. Local recurrence within the same segment was observed in 25% of the patients of the non-AR group. The prognostic superiority of AR was confirmed only in patients with histopathological evidence of microvascular invasion and/or micrometastases, and in patients having a solitary HCC measuring 2 to 5 cm in diameter.

Conclusions

Anatomic resection may decrease local recurrence and improve the surgical outcomes in solitary HCC measuring 2 to 5 cm in diameter.     

Determinants of long-term survival following hepatectomy for hepatocellular carcinoma,with special reference to patients surviving more than 10 years

To elucidate the determinants of survival and the clinicopathologic features of long-term survivors of resections for HCC, we reviewed 539 patients who had had hepatectomy alone or hepatectomy together with hepatic arterial ligation or ethanol injection for the treatment of hepatocellular carcinoma (HCC) at our department between 1973 and December 1992. Of these patients, 30% (79/264) survived for more than 5 years and 11% (10/87) for more than 10 years. All the long-term survivors had received curative resections. The 5- and 10-year survivors accounted for 58% (79/136) and 29% (10/35) of those with curative resections, respectively. Crucial determinants for long-term survival were the absence of portal invasion and satellite nodules, a diploid pattern of DNA content, and a curative resection. A curative resection for diploid HCCs led to much better survival rates (73%) at 5 years than such a resection for aneuploid HCCs (35%), and than for non-curative resections for aneuploid HCCs (0%). The history and tumor background of the ten patients who survived for more than 10 years were characterized by good reserve liver function, warranting a wider resection, predominance of female sex, single nodular growth, and the absence of poorly differentiated cells, in addition to the favorable conditions described above. Three of the ten patients developed a new lesion; these were successfully treated by re-resection or repeated arterial embolization, since they were confined to the remnant liver and showed single nodular growth without extranodular spread. This analysis indicates that hepatectomy is the option of first choice for HCC patients with the potential for cure and good reserve liver function.     

Radiofrequency Ablation Versus Surgical Resection for Small Unifocal Hepatocellular Carcinomas

We aimed to compare the effectiveness and safety of hepatic resection and radiofrequency ablation (RFA) for small hepatocellular carcinomas (HCCs) less than 5 cm in diameter.A total of 289 patients were diagnosed with a small HCC (a single tumor no larger than 5 cm). Among these patients, 133 underwent hepatic resection, and 156 received RFA. Demographic data, intraoperative data, post-operative recovery data, and the baseline characteristics of the 2 groups of patients were compared. The incidence of post-operative complications; 1-, 3-, and 5-year survival rates; and tumor recurrence were determined.No statistically significant differences in the baseline characteristics were noted between the 2 groups. By contrast, operation time (P = 0.003), intraoperative blood loss (P = 0.000), and the length of post-operative hospital stay (P = 0.000) were significantly lower in the RFA group compared with the surgical resection group. The 2 groups displayed similar post-operative complication rates (12% or 16/133 in the liver resection group vs. 8.3% or 13/156 in the RFA group, P = 0.395). The 1-, 3-, and 5-year overall survival rates of the patients in the liver resection group were 88.7%, 78.2%, and 66.2%, respectively, whereas the rates in the RFA group were 90.4%, 76.3%, and 66.0%, respectively (P = 0.722). The 1-, 3-, and 5-year tumor-free survival rates of patients in the resection group were 87.2%, 69.9%, and 58.6%, respectively, whereas the rates in the RFA group were 85.9%, 66.0%, and 54.5%, respectively (P = 0.327). In addition, among HCC patients receiving RFA, patients with tumors no greater than 3 cm in diameter exhibited no significant differences regarding overall survival and tumor-free survival rates compared with patients with tumors 3 to 5 cm in diameter (all P > 0.05).RFA is an effective and safe treatment option for small HCCs and may be a preferred choice for HCC patients with small lesions.     

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.     

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience

BACKGROUND: Hepatopancreatoduodenectomy is a com-plicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This ret-rospective study was to examine the safety and survival out-comes of hepatopancreatoduodenectomy in our center. METHODS: Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. RESULTS: Curative resection was achieved in 11 (91.7%) pa-tients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leak-age. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. CONCLUSIONS: Morbidity and mortality after hepatopan-creatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.     

Adjuvant hepatic arterial infusion chemotherapy after radical hepatectomy for hepatocellular carcinoma--results of long-term follow-up.

BACKGROUND/AIMS: This clinical study aimed to clarify the effectiveness and indication of adjuvant hepatic arterial infusion chemotherapy (HAIC) that is performed to prevent recurrence after radical hepatectomy for hepatocellular carcinoma (HCC). METHODOLOGY: From January 1986 to December 1992, 135 HCC patients, who tolerated curative hepatic resection in which all of the macroscopic HCC was removed, were included in this study. They were divided into two groups. One group was comprised of 68 patients who received HAIC after radical hepatectomy (HAIC (+) group), and the other group was comprised of 67 patients who received radical hepatectomy alone (HAIC (-) group). In the HAIC (+) group, an emulsion of doxorubicin (30-50 mg) and lipiodol (3-5 ml) was injected from a reservoir every 2 or 3 months for 1 year. RESULTS: The cumulative survival rates in the HAIC (+) group (79.1%, 54.5% and 39.9% at 3, 5, and 7 years after hepatectomy, respectively) were better than those in the HAIC (-) group (69.2%, 38.1% and 26.8%, respectively) (p = 0.086). The disease-free survival rates in the HAIC (+) group (50.8%, 31.7% and 25.6% at 3, 5, and 7 years after hepatectomy, respectively) were significantly better than those in the HAIC (-) group (25.7%, 20.6% and 6.4%, respectively) (p = 0.006). This improvement was evident for 3 years after hepatectomy. The adjuvant HAIC was effective especially in patients with good liver function, whose tumor size ranged between 2.1 cm and 5 cm in diameter, and who received a minor hepatic resection. CONCLUSIONS: Adjuvant HAIC was effective in preventing recurrence after radical hepatectomy for HCC. This treatment is especially indicated for patients with good liver function, whose tumor size ranges between 2.1 cm and 5 cm in diameter, and who have received a minor hepatic resection.     

Prognostic factors for hepatocellular carcinoma < or = 3 cm in diameter

BACKGROUND/AIMS: As surgical morbidity and mortality for hepatocellular carcinoma resection decline, we would like to analyze the possible prognostic factors for small hepatocellular carcinoma after curative resection. METHODOLOGY: A total of 170 patients receiving primary hepatectomies for small hepatocellular carcinoma (< or = 3 cm in diameter) at the National Taiwan University Hospital from December 1987 to February 1997 were enrolled as Group 1. The other 281 patients receiving hepatectomies for hepatocellular carcinoma larger than 3 cm were enrolled as the control group (Group 2). The overall patient and disease-free survival rates were calculated and the possible prognostic factors analyzed. RESULTS: The 1-, 3-, 5-, and 10-year patient survival rates in Group 1 were 89.6, 73.1, 55.7 and 34.0%, respectively. A safety margin > or = 1 cm (p = 0.0283), single tumor (p = 0.0324), and multiple hepatic resection (p = 0.0239) were factors favorable to patient survival by multivariate risk factor analysis. The disease-free survivals for Group 1 were 75.6, 41.4, 25.9 and 19.2% at 1, 3, 5, and 10 years, respectively. Significant factor for better disease-free survival included only euploid DNA content (p = 0.0026). The patient survival and disease-free survival rates of Group 1 were significantly better than those of Group 2. CONCLUSIONS: We conclude that patients with small hepatocellular carcinoma have better prognosis than those patients with larger tumors. Early detection of hepatocellular carcinoma and its recurrence are crucial for both patient and disease-free survival. The only prognostic factors that can be manipulated are the keeping of adequate safety margin and repeated resection for recurrent hepatocellular carcinoma.     

Systematic hepatectomy for small hepatocellular carcinoma in Korea

Background/Purpose

Systematic hepatectomy for small hepatocellular carcinoma (HCC) is a widely preferred modality, but evidence concerning its benefits is lacking. The aim of this study was to document hepatic resection for small HCC in Korea, and to determine whether patient survival or the pattern of tumor recurrence was influenced by the methods used.

Methods

Ten major hospitals that perform hepatectomy for HCC in Korea were surveyed for surgeons' opinions concerning systematic hepatectomy and current trends in hepatic resection for small HCC. An analysis was also performed of 119 patients who underwent curative hepatectomy for small HCC (size < 5?cm) between January 2000 and December 2002 at Seoul National University Hospital. Seventy-four of these 119 patients underwent anatomical resection (AR) and 45 had a nonanatomical resection (NAR). Recurrence-free survival, recurrence pattern, overall survival rates, and the risk factors for recurrence were analyzed.

Results

In the survey, eight of ten surgeons preferred systematic hepatectomy and considered it to aid prognosis. No significant difference was found between the AR and NAR groups in terms of the clinicopathologic findings, except that the presence of underlying hepatic cirrhosis was more prevalent in the NAR group. The postoperative morbidity rate was higher in the NAR group (33.3% vs 27.0%), but this difference was not statistically significant. The respective 1- and 3-year recurrence-free survival rates were 78.1% and 49.7% in the AR group, and 68.9% and 46.5% in the NAR group (P > 0.05). The corresponding 1- and 3-year overall survival rates were 88.8% and 80.8% in the AR group and 91.0% and 71.4% in the NAR group (P > 0.05).

Conclusions

Although systematic hepatectomy seems to be superior to nonanatomical hepatectomy from the oncological and anatomical aspects, this superiority is not reflected by the recurrence patterns or the survival and recurrence rates of the two procedures. Postoperative recurrence appears, rather, to be related to the underlying liver condition.     

Resection of liver metastasis from gastric adenocarcinoma

BACKGROUND/AIMS: To determine the factors influencing the prognosis of patients undergoing resection of liver metastases from gastric adenocarcinoma. METHODOLOGY: Over a 10-year period, at Kiryu Kousei General Hospital, 12 patients underwent potentially curative hepatectomy for metastatic adenocarcinoma of gastric origin. Two patients were excluded from this study, one because of postoperative death and one due to insufficient follow-up. We retrospectively examined the following factors: including TNM classification of the primary tumor, disease-free interval between gastric and hepatic resection, number and maximum diameter of the metastases, histological differentiation of the metastases, and the presence of lymphocyte aggregation enclosing the metastatic lesions. Survival rates were estimated by the Kaplan-Meier method and the weighting of each factor was compared by the log-rank test. RESULTS: The overall 5-year survival rate of the 10 patients was 10%. The median survival time after hepatectomy was 16.3 months, ranging from 3.1 to 245.7 months. Eight patients died of recurrent cancer and 1 died of unrelated septic shock with no evidence of cancer recurrence. Only one patient was alive without recurrence at the time of maximum follow-up. A significant survival advantage was noted in patients with disease-free interval > or = 1 year, and those with metastatic tumors < 5 cm in maximum diameter and/or enclosed by the aggregated lymphocytes, when compared with patients with disease-free interval < 1 year and those with metastatic tumors > or = 5 cm and/or directly infiltrated hepatic parenchyma. CONCLUSIONS: It was suggested that hepatectomy should be attempted in patients where the disease-free interval was > or = 1 year and with metastatic nodules < 5 cm. Lymphocyte aggregation around the metastatic tumor is a good prognostic sign for long-term survival.