Therapieoptionen beim Hepatikusgabelkarzinom

Over the last decade, major progress has been made in liver resection as well as in liver transplantation for central cholangiocarcinoma. In our own experience of more than 270 patients in whom either resection or transplantation was performed during the last 19 years, a surgical concept combining an extended right hepatic resection and a principal portal vein resection has emerged as the most favorable technique. It achieves formally curative resections in 80% of the patients although a considerable share of patients suffering from Bismuth-Corlette type IV tumors is included. The 5-year survival rate in these patients is 61%. The most promising strategy in liver transplantation is based on neoadjuvant radiochemotherapy as proposed and reported by the Mayo Clinic group. The Mayo Clinic group has achieved a 5-year post-transplant survival of 83% in their patients, which is an outstanding and unprecedented figure that a few years ago would not have been considered to be a realistic goal in any type of treatment for cholangiocarcinoma.     

From minimal to maximal surgery in the treatment of hepatocarcinoma:A review

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects,from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function witha 5-year survival rate of 50%,offering good longterms results in selected patients. With the advances in laparoscopic surgery,major liver resections can be performed with minimal harm,avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection(either laparoscopic or open) who experience recurrence,re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists,liver surgeons,radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection,margin status,macrovascular tumor invasion,the place of laparoscopy,salvage liver transplantation and liver transplantation.     

Neoadjuvant chemoradiotherapy before resection of perihilar cholangiocarcinoma: A systematic review

Background: Treatment with neoadjuvant chemoradiotherapy followed by liver transplantation yields promising results in perihilar cholangiocarcinoma (PH-CCA). This study reviews the literature to assess whether there is evidence to justify modern phase Ⅱ studies of neoadjuvant chemoradiotherapy prior to resection of PH-CCA.Data sources: A systematic review of the literature for reports of patients undergoing resection of PH- CCA after neoadjuvant chemoradiotherapy was performed using MEDLINE and EMBASE databases for the period between 1990 and 2019. The keywords and MeSH headings "hilar cholangiocarcinoma", "Klatskin", "chemoradiotherapy" and "chemotherapy" were used. Data were extracted on demographic profile, dis- ease staging, chemoradiotherapy protocols, complications and outcome. Risks of bias were assessed using Cochrane methodology. Results: There were seven reports on this topic, with median recruitment period of 14 (range 4–31) years. The total number of patients in these studies was 87. Interval from completion of neoadjuvant treatment to surgery varied from 3 days to 6 months. Resection was by hepatectomy with three studies reporting an R0 rate of 100%, 24% and 63%, respectively. Three studies reported histopathological evidence of prior treatment response. There were two treatment related deaths at 90 days. Median survival was 19 (95% CI: 9.9–28) months and 5-year survival 20%. Conclusions: There are potential benefits of treatment on both R0 rate and complete response in resected specimens. Scientific equipoise exists in relation to neoadjuvant chemoradiotherapy for PH-CCA.     

“Metroticket” predictor for assessing liver transplantation to treat hepatocellular carcinoma:A single-center analysis in mainland China

AIM:To validate the"Metroticket"predictor using a large cohort of liver transplantation(LT)patients with hepatocellular carcinoma(HCC)in China.METHODS:In total,230 cases of LT for HCC treatment at our center,from July 2000 to August 2008,were included in the present study.The predicted 1-,3-and 5-year post-LT survival rates were calculated using the Metroticket model(http://89.96.76.14/metroticket/calculator/).The predicted and observed long-term survival rates were then compared and analyzed.RESULTS:The predicted survival rates for all 230cases,as calculated by the Metroticket model,were64.7%and 56.2%at 3 and 5 years,respectively,and the observed survival rates for these patients were71.3%and 57.8%,respectively.For the 23 cases with macrovascular invasion,the predicted 5-year survival rate was 43.5%,whereas the observed 5-year survival rate was only 8.7%.For the 42 cases with microvascular invasion but an absence of macrovascular invasion,the predicted 5-year survival rate was 44.9%,and the observed 5-year survival rate was 50%.For the remaining 165 patients without any vascular invasion,the predicted 5-year survival rate was 65.8%,and the observed 5-year survival rate was 66.7%.CONCLUSION:The Metroticket model can be used to accurately predict survival in HCC-related LT cases with an absence of macrovascular invasion.     

Long-Term Survival and Its Related Factors in Pediatric Liver Transplant Recipients of Shiraz Transplant Center,Shiraz, Iran in 2012

Background

Liver transplantation is considered as the standard treatment for both children and adults with end-stage liver diseases. Using this method, children who have no chance for life can live a much longer life .Shiraz Transplant Center is the major pediatric liver transplant center in Iran. Therefore, determining patients’ survival and its effective factors can help clinical programming for increasing such patients’ survival after liver transplantation.

Objectives

The present study aimed to investigate the survival of patients below-18-years-old undergoing liver transplantation and the factors affecting their survival.

Patients and Methods

The present historical cohort study was conducted on 392 patients below-18-year-sold who had undergone liver transplantation for the first time in the Namazi hospital liver transplant center, Shiraz, Iran between 2000 and 2011. In this study, 1-, 3-, 5-, and 10-year survival of the patients was assessed using Kaplan-Meier and life table methods. The effect of factors related to the recipients, donors, and the transplantation process on the patients’ survival was also investigated.

Results

According to the results, 1, 3, 5 and 10-year survival of patients was 73%, 67%, 66%, and 66%, respectively. Besides, 1 ,3, 5, and 10-year survival of the patients who survived 1 and 3 months after the transplantation was 84%, 78%, 77%, and 77% and 89%, 82%, 81%, and 81%, respectively. In the univariate analysis, age, patients’ weight at transplantation, initial diagnosis, PELD/MELD score, existence of post-transplant complications, and year of transplantation were found to be effective factors on the patients’ survival. In the multivariate analysis, only the type of graft, PELD/MELD score, and existence of post-transplant complications were the prognostic variables.

Conclusions

In this study, the patients’ survival rate was 73%, which is quite low compared to the survival rate reported in other studies. Although we only have a 12-year experience with pediatric liver transplantation, the survival rate has increased in our center through the recent years (2008-2011). However, the survival rate of the patients who had survived 3 months after the transplantation was 89% which is comparable to other studies. Overall, cholestatic diseases (biliary atresia was the most prevalent), type of transplantation (split), PELD/MELD score > 20, and existence of post-transplant complications increased the risk of death after the transplantation.     

Cholangiocarcinoma: Has there been any progress?

Cholangiocarcinoma is the second most common primary hepatic tumour after hepatocellular carcinoma. Primary sclerosing cholangitis is one of the most commonly recognized risk factors for cholangiocarcinoma; however, approximately 90% of patients have no identifiable risk factors. Extrahepatic type is its most common presentation. Cholangiocarcinoma is considered to be a devastating disease, with a poor survival rate and few therapeutic options. Although surgical resection has been considered the best treatment option for localized cholangiocarcinoma, local recurrences of this cancer are very common, and imply persistent micrometastatic disease in lymph nodes or at surgical margins, even after extended surgical resection. Consequently, the five-year survival rate after attempted curative resection is only 20% to 40%. Early studies of liver transplantation for cholangiocarcinoma did not show a survival benefit and, currently, this tumour is considered to be an absolute contraindication for liver transplantation in most transplant centres worldwide. Recently, neoadjuvant chemoradiation in combination with liver transplantation for highly selected patients with cholangiocarcinoma has shown impressive results, with five-year survival rates at approximately 76% to 82% – similar to other standard indications for liver transplantation, such as hepatocellular carcinoma or hepatitis C-induced cirrhosis. However, this success of liver transplantation applies to only a subset of patients and most of the data originated from a single centre. Wider application of this strategy, especially for patients with potentially resectable disease, will require validation by other centres.     

Treatment and prognosis of hepatic epithelioid hemangioendothelioma based on SEER data analysis from 1973 to 2014

Background: Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor of vascular origin with an unknown etiology, a low incidence, and a variable natural course. We evaluated the management and prognosis of HEH from the Surveillance, Epidemiology and End Results (SEER) program and changes in treatment modalities of HEH over 30 years. Methods: From 1973 to 2014 in the SEER database, we selected patients diagnosed with HEH. We analyzed the clinical characteristics, patterns of management, and clinical outcomes of patients with HEH. Results: We identi ed 79 patients with HEH (median age: 54.0 years;male to female ratio: 1:2.6). The initial extent of disease was local in 22 (27.8%) patients, regional metastasis in 22 (27.8%), distant metas-tasis in 31 (39.2%) and unknown in 4 (5.1%). The median size of primary tumor was 3.85 cm (interquartile range, 2.50 7.93 cm). Among 74 patients with available management data, the most common manage-ment was no treatment (29/74, 39.2%), followed by chemotherapy only (22/74, 29.7%), liver resection-based (13/74, 17.6%), and transplantation-based therapy (6/74, 8.1%). The 5-year cancer-speci c survival rate was 57.8%. Patients who underwent surgical treatment had signi cantly higher survival than those who underwent non-surgical treatment (5-year survival;88% vs. 49%, P=0.019). Multivariate analysis revealed that surgical therapy was the only independent prognostic factor for survival (hazard ratio: 0.20, P=0.040). Conclusions: Resection or liver transplantation is worth considering for treatment of patients with HEH.     

The role of liver transplantation in the treatment of hilar cholangiocarcinoma

Surgical resection or liver transplantation (LTx) are the only available treatments that offer a potential for long-term survival or cure in cases of hilar cholangiocarcinoma. Hilar resection in combination with partial hepatectomy and caudate lobectomy is regarded as the current treatment of choice. Overall 5-year survival rates range from 9% to 28%, and reach as high as 24-43% in R0 resections. Five-year survival rates in the very limited experience with LTx in hilar cholangiocarcinoma are not dramatically worse than those after resection. However, hilar cholangiocarcinoma is not at present an accepted indication for LTx given both the good results of LTx for benign diseases and the dramatic organ shortage. When compared with the prognosis of other gastrointestinal tumours, these survival rates are encouraging in the setting of an otherwise unresectable malignancy. As such, and considering the fact that it may represent the only possibility for cure, the general exclusion of patients with cholangiocarcinomas as candidates for LTx does not seem to be justified. Furthermore, recent advances in multimodal tumour therapy seem to be most promising in combination with LTx. Prospective studies are required to elucidate the influence of better patient selection and the role of multimodal treatments on the outcome of LTx in hilar cholangiocarcinoma. If the encouraging data achieved with neoadjuvant therapy prior to LTx are confirmed by further studies, we foresee that renewed interest in LTx for hilar cholangiocarcinoma could arise.     

Surgery for cholangiocarcinoma: the role of liver transplantation

Liver transplantation alone for unresectable hilar cholangiocarcinoma (CCA) is fraught with frequent recurrence and poor long-term survival. The Mayo Clinic developed a novel therapeutic protocol combining neoadjuvant chemoradiation and orthotopic liver transplantation (OLT) in 1993 to treat patients with unresectable hilar CCA or CCA arising in the setting of PSC. Aim. We recently reviewed our experience over the past 14 years with the specific aim to evaluate the long-term outcomes of CCA patients treated according to our study protocol. Methods. We analyzed data from all patients enrolled in the Mayo Clinic liver transplant protocol since 1993. Statistical data analysis of recurrence and survival rates was performed using the Kaplan-Meier method. Results. 148 patients were enrolled in the protocol. Of 90 patients who completed neoadjuvant therapy and subsequent OLT, 71 are alive and 19 have died – only 8 due to recurrent CCA. Nineteen patients are awaiting OLT and 39 were removed from the protocol owing to disease progression or death. Overall, 1-, 3-, and 5-year patient survival was 82%, 63%, and 55%, respectively; 1-, 3-, and 5-year survival after OLT was 90%, 80%, and 71%. Conclusions. Neoadjuvant chemoradiation and OLT achieves significantly lower recurrence and higher long-term survival rates than resection, OLT alone, or medical treatment in hilar CCA. Additional experience at independent transplant centers is necessary to confirm these encouraging results, address the role of neoadjuvant therapy and liver transplantation versus conventional resection, determine appropriate inclusion/exclusion criteria, and define the risk of disease progression while awaiting transplantation.     

结直肠癌肝转移的综合治疗策略

结直肠癌(colorectal cancer,CRC)是世界上常见的消化道肿瘤之一,约有50%的患者最终出现肝转移。对于发生肝转移的患者,若不经治疗,中位生存期仅为6.9个月,5年生存率为0。若肝脏转移灶行根治性手术,则中位生存期为35个月,5年生存率为30～50%,因此手术切除仍是结直肠癌肝转移治疗的首选。对于同时性肝转移的患者,若无肠道梗阻、穿孔、出血等症状,笔者倾向于同时性切除原发灶和转移灶,术中联合应用B超探查、微波、射频等新技术来提高切除率,降低复发率。而临床上只有少部分患者(10%～15%)可以行手术治疗。对于不可切除的肝转移灶,需通过多学科讨论,针对疾病某一时期,制定出详细的个体化综合性治疗方案,如术前新辅助化疗、联合靶向药物治疗、门静脉栓塞术的应用、局部治疗、放疗等,使得一些不可切除的病灶转化为可切除病灶。因此癌肿作为一项全身性疾病,单纯依靠一种治疗手段很难取得理想的效果,需要多学科的合作,通过对疾病的不同时期进行认识、讨论,以便找到针对某一时间段疾病的最佳治疗方法。同时术后需要定期复查及时发现复发和转移以及制定进一步治疗计划,从而提高患者的长期生存率及生活质量。     

Outcome after repeat resection of liver metastases from colorectal cancer

Introduction

Although advances in multimodal treatment have led to prolongation of survival in patients after resection of colorectal liver metastasis (CRC-LM), most patients develop recurrence, which is often confined to the liver. Repeat hepatic resection (RHR) may prolong survival or even provide cure in selected patients. We evaluated the perioperative and long-term outcomes after RHR for CRC-LM in a single institution series.

Patients and methods

Since 1999, 92 repeat hepatic resections (63 % wedge/segmental, 37 % hemihepatectomy or greater) for recurrent CRC-LM were performed in 80 patients. Median interval from initial liver resection to first RHR was 1.25 years. Any kind of chemotherapy (CTx) had been given in 88 % before RHR. Neoadjuvant CTx was given in 38 %.

Results

Hepatic margin-negative resection was achieved in 79 %. Mortality was 3.8 %. Overall complication rates were 53 %, including infection (17 %), operative re-intervention (12 %), and hepatic failure (5.4 %). Overall 5-year survival after first RHR was 50.3 %. Univariately, primary tumor stage, the extent of liver resection, postoperative complications, and the overall resection margin correlated with survival. By multivariate analysis, primary T stage, size of metastasis, and overall R0 resection influenced survival. Survival was not independently influenced by hepatic resection margins or (neoadjuvant) CTx.

Conclusions

Repeat hepatic resection for recurrent CRC-LM can be performed with low mortality and acceptable morbidity. Survival after repeat hepatic resection in this selected group of patients is encouraging and comparable to results after first liver resections.     

Long-term antiviral treatment for recurrent hepatitis C after liver transplantation

Background and aims

The management of patients treated for hepatitis C recurrence after liver transplantation and not achieving virological response following treatment with interferon plus ribavirin is controversial.

Methods

A retrospective analysis of the outcomes of 70 patients non-responders to antiviral treatment after liver transplantation was performed. Twenty-one patients (30.0%; Group A) were treated for ≤12 months and 49 (70.0%; Group B) for more than 12 months.

Results

The 2 groups were comparable for main demographic, clinical and pathological variables. Median duration of antiviral treatment was 8.2 months in Group A and 33.4 months in Group B. No patient achieved a complete virological response. The 5-year patient hepatitis C-related survival rate was 49.2% in Group A and 88.3% in Group B (P = 0.002), while the 5-year graft survival rate was 49.2% in Group A and 85.9% in Group B (P = 0.007). The median yearly fibrosis progression rate was 1.21 per year in Group A and 0.40 per year in Group B (P = 0.001).

Conclusions

Prolonged antiviral treatment showed an overall beneficial effect in transplanted patients with a recurrent hepatitis C infection and not responding to conventional therapy. The treatment should be continued as long as it is permitted, in order to improve clinical and histological outcomes.     

Long-term outcomes following neoadjuvant chemoradiotherapy in patients with clinical T2N0 esophageal squamous cell carcinoma

The optimal treatment for patients with local esophageal cancer (cT2N0 disease) has not yet been defined. We sought to determine whether neoadjuvant chemoradiotherapy (CRT) can improve prognosis compared with direct esophagectomy in this patient group. Between 1994 and 2005, patients with cT2N0 esophageal squamous cell carcinoma who underwent either neoadjuvant CRT or surgery as first-line treatment were retrospectively reviewed. We collected information on their demographic characteristics, staging modality, clinical and pathological stages, perioperative course, and survival. The study endpoints included tumor recurrence, disease-specific survival (DSS), and overall survival rate. Of the 71 eligible patients, 14 received an esophagectomy first, whereas the remaining 57 received neoadjuvant CRT first. Despite the high pathological complete response (pCR) rate of 37% after neoadjuvant CRT, routine neoadjuvant CRT did not translate into better survival compared to direct surgery (5-year DSS: 39% vs. 68%, P= 0.17). The dramatic survival difference between pCR and non-pCR patients (5-year DSS: 85% vs. 4%, P < 0.001) accounts for these unsatisfactory results. In our series, the administration of neoadjuvant CRT to patients with clinical stage T2N0 esophageal squamous cell carcinoma did not significantly improve outcomes compared with direct esophagectomy.     

Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience

Background/purpose

Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival.

Methods

Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma.

Results

There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years.

Conclusion

Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.     

Liver transplantation for unresectable perihilar cholangiocarcinoma

Patients with unresectable, stage I and II perihilar cholangiocarcinoma were treated with neoadjuvant external beam irradiation, brachytherapy, and 5-fluorouracil and/or oral capecitabine prior to liver transplantation. Fifty-six patients underwent treatment between 1993 and 2003. Four patients died and 4 had disease progression prior to completion of neoadjuvant therapy. Forty-eight patients underwent operative staging and 14 had findings precluding transplantation. Twenty-eight patients underwent transplantation and 6 patients are awaiting transplantation. Three patients died from perioperative complications, and 4 developed recurrent disease 22 to 63 months after transplantation. Actuarial patient survival was 54% at 5 years for all 56 patients, 64% for 48 operatively staged patients, and 84% for 34 patients with negative staging operations. Actuarial survival was 88% at 1 year and 82 % 5 years after transplantation. Neoadjuvant chemoradiotherapy with liver transplantation achieves excellent results for patients with localized, regional lymph node negative, hilar cholangiocarcinoma.     

Long-term maintenance of sustained virological response in liver transplant recipients treated for recurrent hepatitis C

BackgroundThe recurrence of hepatitis C viral infection is common after liver transplant, and achieving a sustained virological response to antiviral treatment is desirable for reducing the risk of graft loss and improving patients’ survival.AimTo investigate the long-term maintenance of sustained virological response in liver transplant recipients with hepatitis C recurrence.Methods436 Liver transplant recipients (74.1% genotype 1) who underwent combined antiviral therapy for hepatitis C recurrence were retrospectively evaluated.ResultsThe overall sustained virological response rate was 40% (173/436 patients), and the mean follow-up after liver transplantation was 11 ± 3.5 years (range, 5–24). Patients with a sustained virological response demonstrated a 5-year survival rate of 97% and a 10-year survival rate of 93%; all but 6 (3%) patients remained hepatitis C virus RNA-negative during follow-up. Genotype non-1 (p = 0.007), treatment duration >80% of the scheduled period (p = 0.027), and early virological response (p = 0.002), were associated with the maintenance of sustained virological response as indicated by univariate analysis. Early virological response was the only independent predictor of sustained virological response maintenance (p = 0.008).ConclusionsSustained virological response achieved after combined antiviral treatment is maintained in liver transplant patients with recurrent hepatitis C and is associated with an excellent 5-year survival.     

Liver resection for colorectal liver metastases in older patients

INTRODUCTION: Seventy-six percentages of patients with a newly diagnosed colorectal carcinoma are between 65 and 85 years old. A substantial proportion will develop liver metastases, for which resection is the only potential curative treatment. This study was conducted to investigate both the feasibility, and short- and long-term outcomes of liver resection for colorectal liver metastases in elderly patients. METHODS: Between August 1990 and April 2007 data were prospectively collected on patients over 70 years of age who underwent a liver resection for colorectal liver metastases in a single centre. RESULTS: One hundred and eighty-one liver resections were performed in 178 consecutive patients (median age 74 years). Thirty-four patients (18.8%) received neoadjuvant chemotherapy (all FOLFOX) prior to liver surgery and the majority (57.5%) of liver resections involved more than two Couinaud's segments. Median hospital stay was 13 days, 70 (38.5%) patients had postoperative complications, and overall in hospital mortality was 4.9% (9 patients). Overall- and disease-free survival rates at 1, 3 and 5 years were 86.1%, 43.2% and 31.5% and 65.8%, 26% and 16%, respectively. In multivariate analysis: T3 primary staging; major liver resections; more than three liver lesions; and the occurrence of postoperative complications were associated with inferior overall survival. CONCLUSIONS: Liver resection for colorectal liver metastases in elderly patients is safe and may offer long-time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.     

Clinical outcome of 214 liver resections using microwave tissue coagulation

BACKGROUND/AIMS: Liver resection is the most effective form of treatment for patients with hepatocellular carcinoma. The use of a microwave tissue coagulator has been reported to enable limited liver resections for the patients with poor hepatic reserve. Herein, we report the clinical outcome of 214 patients with HCC who underwent non-anatomical liver resection using MTC in accordance with the tumor size. METHODOLOGY: A consecutive series of 214 patients who underwent liver resections using MTC were observed over a 10-year study period. The clinical characteristics of patients were evaluated. The operative mortality and morbidity, overall patient survival and disease-free survival were calculated. RESULTS: Seventy-two percent of patients suffered from type C hepatitis and 47% of patients had pathologically proven liver cirrhosis. The overall patient survival rates were 91, 72, and 58% at 1, 3 and 5 years, respectively. Disease-free survival rates were 74, 46, and 28% at 1, 3 and 5 years, respectively. Postoperative morbidity was 36% and hospital mortality was 2.8%. Complications in most patients were well controlled. CONCLUSIONS: Non-anatomical liver resections using MTC, in accordance with tumor sizes, can be achieved safely with acceptable results and without the need to use special techniques.     

Addition of alfa fetoprotein to traditional criteria for hepatocellular carcinoma improves selection accuracy in liver transplantation

Objectives: Liver transplantation in hepatocellular cancer (HCC) is curative only for a selection of patients. Commonly used criteria are mostly based on tumor size and number. However, patients within criteria do have tumor recurrences after transplantation and patients outside criteria are excluded even though some could benefit from transplantation. The tumor marker alpha fetoprotein (AFP) is associated with poor outcome and has already been reported to improve selection. We investigated the hypothesis that AFP level combined with traditional selection criteria could ameliorate the selection accuracy for liver transplantation in HCC.

Materials and methods: A retrospective national cohort study in 336 patients who had liver transplantation for HCC in Sweden 1996–2014.

Results: AFP cut-off levels of 20, 100, 1000 and >1000?ng/mL stratified both survival and tumor recurrence, with estimated 5-year survival rates of 74, 61, 49 and 31%, respectively. A simple score, combining three risk levels according to Milan and UCSF fulfillment with three levels of AFP, increased predictive accuracy. A high score identified 35 at-risk patients with estimated post-transplant 5-year survival rate of only 29% compared to 50% for 76 patients excluded by UCSF. More patients were within the combined score cut-off compared to within UCSF, but 5-year survival was similar, 67% versus 66%.

Conclusion: AFP combined with traditional selection criteria ameliorates the selection accuracy for liver transplantation in HCC.     

Role of liver resection in the management of multinodular hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer related deaths worldwide. Various treatment modalities have been applied to HCC depending on the tumor load, functional capacity of the liver and the general condition of the patient. According to Barcelona Clinic Liver Cancer staging strategy and The American Association for the Study of Liver Disease guidelines, surgical resection is not advocated in the tretment of multinodular HCC. Despite this, many recent clinical studies show that, resection can achieve good results in patients with multinodular HCC and 5-year survival rate around 40% can be reached. If resection or transplantation is not performed, these patients are usually managed with palliative procedures such as transarterial chemoembolization, radioembolization and cytotoxic chemotherapy and 5-year survival of this group of patients will be extremely low. Although survival rates are lower and complications may be increased in this group of patients, liver resection can safely be performed in selected patients in experienced centers for the management of multinodular HCC.