Short- and Long-Term Outcomes after Hepatic Resection for Hepatocellular Carcinoma with Concomitant Esophageal Varices in Patients with Cirrhosis

Background Hepatic resection for hepatocellular carcinoma (HCC) in cirrhotic patients with esophageal varices (EV) is often avoided because of poor liver function reserve. Outcomes of resection in such cases have not been fully investigated. Methods We conducted a retrospective study of 134 cirrhotic patients (Child–Pugh class A or B) who underwent hepatic resection for HCC, comparing short- and long-term outcomes in patients with EV (n = 31) to those in patients without EV (n = 103). Results Patients with EV had higher tumor differentiation, fewer instances of portal invasion, lower liver function reserve, and more limited resections than did patients without EV. Of 31 patients with EV, four died of postoperative complication, and nine of liver failure, seven of HCC, two of ruptured EV, and two of other causes. Median survival time for patients who died of liver failure was 59 months. Mortality and morbidity rates after hepatic resection did not differ between patients with and without EV. The 5-year overall survival rate was significantly higher in patients with EV (70.1%) than in those without EV (47.5%, P = 0.045) but did not differ between patients without portal invasion with and without EV (P = 0.55). Presence of EV was not an independent predictor for survival. Conclusions Short- and long-term outcomes of hepatic resection in HCC patients with and without EV are similar. Limited hepatic resection for early-stage tumor is an option for Child–Pugh class A or B patients with EV.     

Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis.

The objective of this study was to predict postoperative liver failure and morbidity after hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis. The model for end-stage liver disease (MELD) score is currently accepted as a disease severity index of cirrhotic patients awaiting liver transplantation; however, its impact on prognosis after resection of HCC on cirrhosis has never been investigated. One hundred fifty-four cirrhotic patients resected in a tertiary care setting for HCC were retrospectively analyzed. For each patient, the MELD score was calculated and related to postoperative liver failure and complications (morbidity). Hospital stay and 1-year survival was also investigated. MELD accuracy in predicting postoperative liver failure and morbidity of cirrhotic patients was assessed using receiver operating characteristic (ROC) analysis. Eleven patients (7.1%) experienced postoperative liver failure leading to death or transplantation. ROC analysis identified cirrhotic patients with a MELD score equal to or above 11 at high risk for postoperative liver failure (area under the curve [AUC] = 0.92, 95% confidence interval [CI] = 0.87-0.96; sensitivity = 82%; specificity = 89%). Forty-six patients (29.9%) developed at least 1 postoperative complication: ROC analysis identified patients with a MELD score equal to or above 9 at major risk for postoperative complications (AUC = 0.85, 95% CI = 0.78-0.89; sensitivity = 87%; specificity = 63%). Cirrhotic patients with MELD score below 9 had no postoperative liver failure and low morbidity (8.1%). In conclusion, the MELD score can accurately predict postoperative liver failure and morbidity of cirrhotic patients referred for resection of HCC and should be used to select the best candidates for hepatectomy.     

Extent of liver resection influences the outcome in patients with cirrhosis and small hepatocellular carcinoma

BACKGROUND: The long-term outcome after resection of hepatocellular carcinoma (HCC) is influenced by parameters related to the tumor and the underlying liver disease. However, the extent of the resection, which can be limited or anatomical (including the tumor and its portal territory), is controversial. METHODS: Among 64 Child-Pugh A patients with cirrhosis who underwent curative liver resection for small HCC (< or = 4 cm) between 1990 and 1996, 34 patients underwent limited resection with a margin width of at least 1 cm, and 30 patients underwent anatomic resection of at least 1 liver segment with complete removal of the portal area containing the tumor. The 2 groups were comparable in terms of epidemiologic and pathologic parameters. The major end points were: (1) in-hospital mortality and morbidity; (2) overall and disease-free survival; and (3) rate and topography of recurrence. RESULTS: The 30-day mortality (6% vs 7%) and morbidity (52% vs 47%) rates after limited and anatomic liver resection were not statistically different. The 5- and 8-year overall survival rates after limited versus anatomic resection were, respectively, 35% versus 54% (P <.05) and 6% versus 45% (P <.05). The 5- and 8-year disease-free survival rates were, respectively, 26% versus 45% and 0% versus 21% (P <.05). Local recurrence was more frequently observed after limited resections than after anatomic resections (50% vs 10%, P <.05). CONCLUSIONS: In patients with cirrhosis and a small HCC, anatomic resection achieves better disease-free survival than limited resection without increasing the postoperative risk. Therefore, anatomical resection should be the treatment of choice and considered as the reference surgical treatment compared with other treatments.     

Appraisal of concomitant splenectomy in liver resection for hepatocellular carcinoma in cirrhotic patients with hypersplenic thrombocytopenia

BACKGROUND: Liver resection usually is not recommended for hepatocellular carcinoma (HCC) in cirrhotic patients with portal hypertension. The role of concomitant splenectomy in liver resection for HCC in cirrhotic patients with hypersplenic thrombocytopenia (HT) resulting from portal hypertension remains undefined. METHODS: Among 526 cirrhotic patients who underwent liver resection for HCC, 41 underwent a concomitant splenectomy (Sp group) because of HT (platelet count 相似文献   

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.     

Child-Pugh A Hepatitis B-Related Cirrhotic Patients with a Single Hepatocellular Carcinoma Up to 5 cm: Liver Transplantation vs. Resection

Objective

This study aims to analyze the outcomes of patients with Child-Pugh A class cirrhosis and a single hepatocellular carcinoma (HCC) up to 5 cm in diameter who underwent liver transplantation vs. resection.

Methods

During 2007 to 2012, 282 Child-Pugh A cirrhotic patients with a single HCC up to 5 cm in diameter either underwent liver resection (N?=?243) or received liver transplantation (N?=?39) at our center. Patient and tumor characteristics and outcomes were analyzed.

Results

Patients who underwent liver transplantation had a better recurrence-free survival (RFS) vs. those who underwent liver resection. However, the 5-year survival rates after these two treatments were comparable. Similar results were observed when we analyzed patients with a HCC less than 3 cm, and for patients with portal hypertension. In the multivariate analysis, tumor differentiation, difference of primary treatment, and presence of microvascular invasion were associated with postoperative recurrence. However, only differentiation negatively impacted overall survival after operation.

Conclusion

Although more recurrences were observed in Child A cirrhotic patients with a single HCC up to 5 cm after liver resection, liver resection offers a similar 5-year survival to liver transplantation, even for patients with portal hypertension.     

Impact of Tumor Characteristic on the Outcome of Liver Transplantation in Patients With Hepatocellular Carcinoma

Introduction

Orthotopic liver transplantation (OLT) is a well-established treatment for cirrhotic patients with hepatocellular carcinoma (HCC) who meet the Milan criteria. The aim of this study was to identify predictors of survival among 65 patients with HCC in cirrhotic livers who underwent liver transplantation (OLT).

Methods

From January 2001 to December 2008, we performed 655 OLT in 615 patients. HCC was diagnosed in 58 patients before OLT and in 65 by histological examination of the explanted livers; 74% of the patients met Milan criteria by histological examination.

Results

The median follow-up was 27 months (range = 1-96). We analyzed patient age and gender, etiology of liver disease, Child score at transplantation, rejection episodes, tumor number/size, vascular invasion, and differentiation grade. There was no significant difference in survival among patients grouped according to the Model for End-stage Liver Disease staging system for HCC. The 5-year survival of patients with low differentiated (G3) HCC was significantly worse than that of those with moderately differentiated (G2) or well-differentiated (G1) HCC: 50%, 81%, and 86% respectively, (P < .01). Patients with microvascular invasion displayed a worse 5-year survival than those without vascular invasion (42% vs 80%; P < .01).

Conclusions

The analysis indicated that the histological grade of the tumors and evidences of microscopic vascular invasion were the most useful predictive factors for overall survival among patients with cirrhosis after liver transplantation for HCC.     

Incidental Hepatocellular Carcinoma: Risk Factors and Long-Term Outcome After Liver Transplantation

Background

Orthotopic liver transplantation (OLT) currently represents the treatment of choice for early hepatocellular carcinoma (HCC). Preoperatively known HCC (pkHCC) is diagnosed via imaging methods before OLT or before HCC is found postoperatively in the liver explant, denoted as incidental HCC (iHCC). The aim of this study was a comprehensive analysis of the post-transplantation survival of patients with iHCC and the identification of risk factors of iHCC occurrence in cirrhotic liver.

Methods

We retrospectively reviewed 33 adult cirrhotic patients with incidentally found HCC, comparing them with 606 tumor-free adult cirrhotic patients with end-stage liver disease (group Ci) who underwent OLT in our center from January 1995 to August 2012. Within the same period, a total of 84 patients underwent transplantation for pkHCC. We compared post-transplantation survivals of iHCC, Ci, and pkHCC patients. In the group of cirrhotic patients (Ci + iHCC), we searched for risk factors of iHCC occurrence.

Results

There was no difference in sex, Model for End-Stage Liver Disease score, and time spent on the waiting list in either group. In the multivariate analysis we identified age >57 years (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.75–8.14; P < .001), hepatitis C virus or alcoholic liver disease (OR, 3.89; 95% CI, 1.42–10.7; P < .001), and alpha-fetoprotein level >6.4 μg/L (OR, 6.65; 95% CI, 2.82–15.7; P = .002) to be independent predictors of iHCC occurrence. Both the 1-, 3-, and 5-year overall survival (OS) and the 1-, 3- and 5-year recurrence-free survival (RFS) differed in iHCC patients compared with the Ci group (iHCC: OS 79%, 72%, and 68%, respectively; RFS 79%, 72%, and 63%, respectively; vs Ci: OS = RFS: 93%, 94%, and 87%, respectively; P < .001).

Conclusions

The survival of iHCC patients is worse than in tumor-free cirrhotic patients, but similar to pkHCC patients. The independent risk factors for iHCC occurrence in cirrhotic liver are age, hepatitis C virus, or alcoholic liver disease etiology of liver cirrhosis and alpha-fetoprotein level.     

Longterm favorable results of limited hepatic resections for patients with hepatocellular carcinoma: 20 years of experience

BACKGROUND: Recently, anatomic resection has been, in theory, considered preferable for eradicating portal venous tumor extension and intrahepatic metastasis in hepatocellular carcinoma (HCC). We have reported the effectiveness of limited hepatic resection for cirrhotic patients with HCC. STUDY DESIGN: A retrospective study was carried out in 321 patients who underwent curative hepatic resection (anatomic resection, n=201; limited resection, n=120) as the initial treatment for solitary HCC<5 cm in our institution in the period 1985 to 2004 (median followup period 5.1 years). RESULTS: Anatomic resection did not influence overall and recurrence-free survival rates after hepatic resection. In the liver damage A group (n=215), both 5-year overall and recurrence-free survival rates in the anatomic resection group were considerably better than those in the limited resection group (87% versus 76%, p=0.02, and 63% versus 35%, p<0.01, respectively). In the liver damage B group (n=106), both 5-year overall and recurrence-free survival rates in the anatomic resection group were substantially worse than those in the limited resection group (48% versus 72%, p<0.01, and 28% versus 43%, p=0.01, respectively). The results of multivariate analysis revealed that anatomic resection was a notably poor factor in promoting recurrence-free survival in patients with liver damage B. CONCLUSIONS: Anatomic resection should be recommended for noncirrhotic patients (liver damage A) with HCC. Longterm results of limited hepatic resection proved its validity for cirrhotic patients (liver damage B) with HCC.     

Role of Transarterial Chemoembolization Before Liver Resection for Hepatocarcinoma

The aim of this study was to clarify whether chemoembolization (TACE) before liver resection (LR) can reduce postoperative hepatocellular carcinoma (HCC) recurrence and improve disease-free and overall survival. Eighty-nine patients with tumor-stage (TNM) I-II HCC were evaluated for LR. Patients were prospectively allocated to LR alone or TACE plus LR based on their place of residence. Twenty nonlocal patients (24%) were selected for LR, while 69 (77.5%) local patients were selected for TACE plus LR. Following TACE, the tumor stage could be confirmed in only 20 patients (29%) who then underwent LR. Operative mortality was 0%, but in the TACE-LR group, 3 patients died of liver failure between 2 and 5 months after surgery. Early recurrence (<24 months) was 59% for LR versus 20% for TACE plus LR (P < .05). Late recurrence was 18% for LR versus 10% for TACE plus LR (P = not significant [NS]). The overall recurrence rate was 76% for LR versus 30% for TACE plus LR (P < .02). Death due to HCC recurrence was 70% for LR versus 15% for TACE plus LR (P < .05). The overall 1- and 5-year survival rates did not differ significantly (71% to 38% for LR v 85% to 43% for TACE + LR; P = NS), whereas the difference in 1- and 5-year disease-free survival was highly significant (64% to 21% for LR v 82% to 57% for TACE + LR; P < .02). TACE was able to improve the HCC staging process and significantly reduce the incidence of early and overall HCC recurrence and related death after LR; it improved the disease-free interval, but not the overall survival, due to an increase in liver failure in the first 5 months. (Liver Transpl 2000;6:619-626.)     

Conventional laparoscopic and robot-assisted laparoscopic liver resection for benign and malignant pathologies: a cohort study

The aim of our study was to evaluate different minimally invasive surgical approaches for liver resection in a tertiary surgical center. The study cohort comprised 104 consecutive patients who underwent total laparoscopic liver resection (n?=?17), hand-assisted laparoscopic liver resection (n?=?55), or robot-assisted laparoscopic liver resection (n?=?32) in our center between October 1998 and January 2011. Surgical complications, postoperative course, disease-free survival, and overall survival for malignancy were assessed. These 104 resections were performed on 55 men and 49 women with a mean age of 60.4?years; 43.3% of patients had liver cirrhosis. The liver pathologies comprised malignant tumors (64.4%) and benign lesions (35.6%). The most common laparoscopic liver resection was left lateral sectionectomy (53.9%), wedge resection (26.9%), segmentectomy (13.5%), right hepatectomy (3.8%), and left hepatectomy (1.9%). Conversion from laparoscopy to open approach and from laparoscopy to hand-assisted approach occurred in 1.9 and 1% of the cases, respectively. Overall mortality was 0%, and morbidity was 17.3%. The median follow-up period was 24?months. The 5-year overall survival for hepatocellular carcinoma (HCC) was 52%, and the 3-year overall survival for colorectal liver metastasis was 88%. Based on these results, we conclude that laparoscopic liver resection is feasible and safe in appropriately selected patients. In our patient cohort, it was associated with a low complications rate and favorable survival outcome.     

Short- and Long-Term Outcomes After Salvage Liver Transplantation Versus Primary Liver Transplantation for Hepatocellular Carcinoma: A Meta-analysis

Background

Salvage liver transplantation (SLT) has been performed for recurrent hepatocellular carcinoma (HCC) or deterioration of liver function after primary liver resection. However, the survival outcomes and recurrence rates of SLT versus primary liver transplantation (PLT) for HCC remain controversial. Here we sought to compare the short- and long-term outcomes after SLT and PLT, by conducting a quantitative meta-analysis.

Methods

A systematic literature research was performed to identify comparative studies on SLT and PLT. Perioperative and long-term outcomes constituted the end points. Pooled odds ratios (OR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either fixed-effects or random-effects model.

Results

A total of 1508 patients from 14 studies were included. Although SLT spent more operative time than SLT (WMD: 28.69min; 95% CI: 11.30–46.08; P = .001), the two groups had no significant differences in the postoperative morbidity, perioperative mortality and length of postoperative hospital stay. No significant difference was observed between two groups for long-term outcomes of overall survival. Although 5-year disease-free survival was inferior in SLT, 1- and 3-year disease-free survivals were similar. After stratifying the various studies by Milan criteria, no difference was seen in 1-, 3-, and 5-year survival rates between two groups who meet Milan criteria at the time of liver transplantation.

Conclusions

The current study demonstrates SLT for recurrent HCC is feasible and it can achieve the same short- and long-term outcomes as PLT. Therefore, SLT may be accepted as the treatment of choice for patients with recurrent HCC.     

原发性肝癌三种根治性方法疗效的多中心对比研究

目的 探讨肝切除、原位肝移植及射频消融三种疗法对原发性肝癌的治疗效果,以便为原发性肝癌的治疗选择恰当的方法.方法 广州市三家医院近5年来采用射频消融、肝切除及原位肝移植治疗原发性肝癌患者1198例.接受上述三种不同治疗方案的患者分别分为三组,Ⅰ组为小肝癌组,Ⅱ组为大肝癌无血管侵犯组,Ⅲ组为大肝癌并血管侵犯组.分别比较三组间1、2、3年治疗后生存率,3年肿瘤复发率;并对接受上述三种疗法各组患者肝功能Child-Pugh分级进行比较.结果 符合米兰标准的小肝癌患者行肝移植较肝切除3年生存率高(P<0.05),复发率低(P<0.05);射频消融者3年生存率及复发率均比肝切除好(P<0.05);射频消融的疗效及复发率与肝移植差异无统计学意义(P>0.05);但接受射频消融及肝切除者肝功能绝大部分为Child A级,而肝移植者大部分为B及C级(P<0.01).超出米兰标准的大肝癌进行肝移植、肝切除或射频消融效果差异无统计学意义(P>0.05),但肝移植的3年复发率偏低(P<0.05).结论 对于符合米兰标准的小肝癌患者,肝移植的中远期疗效优于肝切除;射频消融(3 cm以下肿瘤)疗效比肝切除好;射频消融的疗效及复发率与肝移植相当;但接受射频消融及肝切除者肝功能绝大部分为Child A级,而肝移植者大部分为B及C级.因而小肝癌合并肝功能不全者或衰竭者肝移植应为首选.超出米兰标准的大肝癌进行肝移植、肝切除或射频消融效果差别不大,但肝移植三年复发率偏低,在供肝短缺的情况下不主张首选肝移植.

Abstract：

Objective Partial hepatectomy, liver transplantation, and radio frequency ablation for hepatocellular carcinoma (HCC) were compared to select the most suitable method for HCC. Methods 1198 patients with HCC in 3 hospitals in Guangzhou were divided into 3 groups: group Ⅰ , small HCC; group Ⅱ > HCC without vascular invasions and group Ⅲ , HCC with vascular invasion. The patients either received partial hepatectomy, transplantation or ablation. The 1-, 2- or 3-year survival rates, the 3-year recurrent rates and Child-Pugh grades in the 3 groups were compared. Results For small HCC, there was a significant increase in the 3-year survival rate (P<0. 05) and a significant decease in the recurrent rate (P<0. 05) in patients who received transplantation, compared with those who received hepatic resection. Patients who received ablation had a higher 3-year survival rate and a lower recurrence (P<0. 05) in comparison with those who received hepatectomy. There was no significant difference(P<0. 05) between transplantation and ablation, but there were more Child A patients who received hepatectomy and ablation, and more Child B and C patients who received transplantation. For advanced HCC, there was no significant different in the 3-year survival rates for the 3 therapies, but the 3-year recurrence was lower (P<0. 05) in the transplantation group. Conclusions For small HCC, superiority of transplantation versus resection was obvious. Ablation (diameter <3 cm) was also superior to resection, whereas ablation was as effective as transplantation. There were more Child B and C patients in the transplantation group than the ablation and resection groups. Therefore, small HCC with hepatic decompensation should receive liver transplantation. Transplantation was advantageous in having less tumor recurrent but there was no difference in the 3 therapies for advanced HCC.     

Outcomes of primary liver cancer in children: an appraisal of experience

Introduction

Hepatoblastoma (HB) and hepatocellular carcinoma (HCC) are the most common primary liver cancers in children. Recent advances in management of pediatric liver cancer have improved disease-specific survival (DSS). This is a review of our experience with childhood liver malignancy over the past 3 decades.

Materials and Methods

A retrospective chart review from 1975 to 2005 identified patients who were 18 years old or younger with a histologically confirmed diagnosis of primary liver cancer. Patients were staged according to the Children's Cancer Group and Pediatric Oncology Group (CCG/POG) system. Patients were followed up prospectively through clinic visits and mail correspondence. Standard statistical methods were used for comparison, risk, and survival analyses.

Results

Fifty-two patients were confirmed to have primary liver cancers, where 24 (46%) patients had HB, 22 (42%) had HCC, 3 (6%) had sarcomas, and 3 (6%) had other histologies. Mean ages at presentation for HB and HCC were 3.2 and 13.1 years old, respectively. The most common presentations were abdominal mass (67%) and pain (40%). Most patients underwent major liver resection (n = 45, 87%), including: lobectomy (n = 25, 48%), and trisegmentectomy (n = 11, 21%). Three patients underwent liver transplantation (n = 3, 6%) for advanced local disease. Forty-five (87%) received primary or neoadjuvant and/or adjuvant chemotherapy. Patients had the following CCG/POG stages: I (n = 31, 60%), II (n = 6, 11.5%), III (n = 9, 17%), and IV (n = 6, 11.5%). Complete gross resection (stage I and II) was achieved in 37 (71%) patients. The perioperative mortality and morbidity rates were 0% and 29%, respectively. Patients with complete resection had significantly better 5-year DSS and median survival compared with incomplete gross resection: 62% vs 9% and 216 vs 18 months, P < .001. Patients treated during the period 1995-2005 had better 5-year DSS and median survival compared with those treated during 1975-1994: 68% vs 32% and 117 vs 27 months, P = .032. All 3 patients who underwent transplantation for conventionally unresectable disease are alive without disease recurrence (follow-up period, 1-15 years).

Conclusion

Complete resection of the pediatric primary liver tumors remains the cornerstone of treatment to achieve cure. Major liver resection can be performed with minimal perioperative mortality and morbidity. Patients with HB appeared to have better survival compared with patients with HCC, and there was significant improvement in the DSS of children treated in the recent decade. Liver transplantation in conjunction with chemotherapy may have an increasing role in the management of locally advanced primary liver cancers.     

Gastric cancer surgery for patients with liver cirrhosis

AIM: To elucidate the influence of liver cirrhosis (LC) on the prognosis of patients with gastric cancer (GC).METHODS: Of the 1347 GC patients who underwent curative gastrectomy for GC between January 1984 and June 2007, 25 patients (21 men and 4 women with a median age of 67 years; range 54-77 years) with LC were enrolled in this study. Using the Child-Pugh classification, 15 patients were evaluated as grade A and 10 patients as grade B. No grade C patient underwent gastrectomy in this series. Clinical outcomes, including postoperative morbidity and survival, were retrospectively analyzed based on medical records and surgical files.RESULTS: There was no significant difference in operative blood loss and perioperative blood transfusion between the two groups. The most common postoperative complication was intractable ascites, which was the single postoperative morbidity noted more frequently in grade B patients (40.0%) than in grade A patients (6.7%) with statistical significance (P = 0.041). Operative mortality due to hepatic failure was seen in one grade A patient. Three patients had hepatocellular carcinoma (HCC) at presentation and two patients developed HCC after surgery. Overall 5-year survival rate was 58.9% in patients with early GC and 33.3% in patients with advanced GC (P = 0.230). GC-specific 5-year survival rate of early GC patients was 90.0% while that of advanced GC patients was 58.3% (P = 0.010). Four patients with early GC died of uncontrolled HCC, of which two were synchronous and two metachronous.CONCLUSION: The risk of postoperative intractable ascites is high, particularly in grade B patients. Early detection and complete control of HCC is vital to improve a patient’s prognosis.     

Hepatectomy as Treatment of Choice for Hepatocellular Carcinoma in Elderly Cirrhotic Patients

In recent decades liver resection has become a safe procedure; however, the outcome of hepatectomies in aged cirrhotic patients is often uncertain. To elucidate early and long-term outcomes of hepatectomy for HCC in the elderly, we studied 241 cirrhotic patients who underwent liver resection for HCC between 1985 and 2003. According to their age at the time of surgery, patients were divided into two groups: aged > 70 years (64 patients) and aged ≤ 70 years (177 patients). Operative mortality was 3.1% in the elderly and 9.6% in the younger group (p = 0.113). Postoperative morbidity and liver failure rates were higher in the younger group (42.4% versus 23.4%, p = 0.0073; 12.9% versus l.6%, p = 0.0065). Five-year survival rates are 48.6% in the elderly group and 32.3% in the younger group (p = 0.081). Considering only radical resections in Child-Pugh A patients, survival remains similar in the two groups (p = 0.072). Disease-free survival is not different in the two groups. A survival analysis performed according to the tumor diameter shows a better survival for elderly Child-Pugh A patients with HCC larger than 5 cm radically resected (50.8% versus 16.1% 5-year survival, p = 0.034). In univariate analysis, tumor size is not a prognostic factor in the elderly, whereas younger patients with large tumors have a worse outcome. Age by itself is not a contraindication for surgery, and selected cirrhotic patients with HCC who are 70 years of age or older could benefit from resection, even in the presence of large tumors. Long-term results of liver resections for HCC in the elderly may be even better than in younger patients.     

Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?

OBJECTIVE: To evaluate the perioperative outcomes and long-term survival of extended hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis. SUMMARY BACKGROUND DATA: Hepatic resection is a well-established treatment for HCC in cirrhotic patients with preserved liver function and limited disease. However, the role of extended hepatic resection (more than four segments) for HCC in cirrhotic patients has not been elucidated. METHODS: Between 1993 and 2000, 45 consecutive patients with histologically confirmed cirrhosis underwent right or left extended hepatectomy for HCC (group A). Perioperative outcomes and long-term survival of these patients were compared with 161 patients with HCC and cirrhosis who underwent hepatic resection of a lesser extent in the same period (group B). All clinicopathologic and follow-up data were collected prospectively. RESULTS: Group A patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than group B. However, the two groups were similar in overall morbidity and hospital mortality. There were no significant differences in the incidence of liver failure or other complications. The resection margin width was similar between the two groups. Despite significantly larger tumor size in group A compared with group B, long-term survival was comparable between the two groups. CONCLUSIONS: Extended hepatic resection for HCC can be performed in selected cirrhotic patients with acceptable morbidity, mortality, and long-term survival that are comparable to those of lesser hepatic resection. Extended hepatectomy for large HCC extending from one lobe to the other or central HCC critically related to the hepatic veins is justifiable in cirrhotic patients with preserved liver function and adequate liver remnant.     

ChildA级单个直径≤5cm肝细胞肝癌行肝移植与肝切除的预后比较

目的比较ChildA级、单个、直径≤5cm肝细胞肝癌行肝移植与肝切除术的预后。方法回顾性分析笔者所在医院肝移植中心2007～2011年期间行肝切除术及肝移植术的ChildA级、单个、直径≤5cm肝细胞肝癌患者的临床资料,比较2组患者术后无瘤生存率及总体生存率。结果本研究共纳入263例患者,其中肝移植组36例,肝切除组227例。肝移植组与肝切除组患者术后1、3及5年无瘤生存率分别为91．7％、85．3％及81．0％和80．6％、59．8％及50．8％,肝移植组高于肝切除组（P=-0．003）;术后1、3及5年总体生存率分别为100％、87．5％及83．1％和96．9％、83．8％及76．1％,2组间差异无统计学意义伊=0．391）。以肿瘤直径〈3em为标准再予以分析,其肝移植组与肝切除组术后1、3及5年无瘤生存率分别为92．3％、92．3％及92．3％和80．2％、62．5％及50．5％,肝移植组高于肝切除组（P=-0．019）;术后1、3及5年总体生存率分别为100％、91．7％及91．7％和97．7％、87．5％及79．5％,2组间差异也无统计学意义（p0．470）。结论ChildA级、单个、直径≤5cm肝细胞肝癌患者肝切除术后复发率高于肝移植,但两种治疗方式的术后总体生存率相似。     

Influence of coexisting cirrhosis on outcomes after partial hepatic resection for hepatocellular carcinoma fulfilling the Milan criteria: an analysis of 293 patients

BACKGROUND: For patients with liver cirrhosis and hepatocellular carcinoma (HCC) satisfying the Milan criteria (single tumor < or =5 cm or 2 or 3 tumors < or =3 cm), orthotopic liver transplantation (OLT) is an effective treatment. Nevertheless, it remains controversial whether OLT is the best treatment strategy for patients with resectable HCC. METHODS: This study included 293 HCC patients (both with and without cirrhosis) oncologically satisfying the Milan criteria who underwent primary and curative liver resection between 1990 and 2003. RESULTS: There were 127 noncirrhotic, 129 Child-Pugh A cirrhotic, and 37 Child-Pugh B cirrhotic patients. Five-year survival rates in each population were 81%, 54%, and 28%, respectively. Coexisting cirrhosis, Child-Pugh classification, alpha-fetoprotein value, tumor burden, and vascular invasion by the tumor were identified as significant prognostic factors. Among these factors, coexisting cirrhosis was the most crucial variable by multivariate analysis. During the initial 3 postoperative years, yearly tumor recurrence rate was 22% in cirrhotic patients and 15% in noncirrhotic patients. In cirrhotic patients, the recurrence rate did not decrease even after three years of tumor-free survival post-resection, whereas in noncirrhotic patients the recurrence rate decreased to 9%. Cirrhosis was associated with a higher probability of recurrence exceeding the Milan criteria. CONCLUSIONS: Hepatic resection offers an acceptable survival result for HCC patients fulfilling the Milan criteria. Coexisting cirrhosis is associated with higher mortality and recurrence rate, possibly due to multicentric carcinogenesis which limits the efficacy of hepatic resection.     

Living donor liver transplantation for hepatocellular carcinoma

Background

Liver transplantation is a widely accepted modality in the treatment of hepatocellular carcinoma (HCC). In our center, patients with HCC limited to the liver without macrovascular invasion are accepted as candidates for living donor liver transplantation (LDLT). The aim of this study was to describe the patient characteristics and outcomes at a single institution to analyze the impact of our criteria on the survival of HCC patients.

Patients and Methods

We reviewed the medical records of all HCC (n = 105) patients who underwent liver transplantation in our institution. We excluded deaths in the early postoperative period and deceased donor liver transplantation (DDLT) patients, leaving 74 subjects (65 males and 9 female). Their median age was 53 years (range, 19-69). Univariate Kaplan-Meier and multivariate Cox proportional hazards models were used to analyze overall and disease-free survivals.

Results

Thirty-two (43%) patients were within the Milan criteria, and 42 (57%) exceeded them. One- and 2-year overall survival rates for patients within versus exceeding the Milan criteria were 72% versus 68% and 61% versus 58%, respectively. One- and 2-year disease-free survival rates for patients within versus exceeding the Milan criteria were 72% versus 68% and 60% versus 55%, respectively (P > .05). Tumor recurrence rates for patients within versus exceeding the Milan criteria were 0% versus 36%, respectively (P = .0002). Alpha-fetoprotein level was the only predictor of overall survival; alpha-fetoprotein level and tumor differentiation were predictors of disease-free survival.

Conclusion

Although higher recurrence rates have been observed among patients exceeding the Milan criteria, LDLT is the only treatment option for the patients in countries with limited sources of cadaveric organs. As a general principle, we believe that the use of cadaveric donor liver grafts is not suitable for patients who exceed these criteria.