混合型肝癌的临床病理特点及预后分析

目的 探讨混合型肝癌的临床病理特点、诊断和手术方案选择.方法 回顾性分析北京协和医院1990年1月至2010年10月收治的经病理学确诊的12例混合型肝癌临床资料,总结其临床病理特点、诊断及手术方案选择,根据随访结果应用SPSS 13.0软件Kaplan-Meier法绘制生存曲线.结果 12例患者术前均误诊为原发性肝细胞癌,术后经病理学证实为混合型肝癌.其中男性10例(83.3％),女性2例(16.7％),年龄40～59岁,平均(51士6.3)岁.11例(91.7％)患者有乙型肝炎病史,10例(83.3％)存在不同程度的肝硬化.16.7％ (2/12)的患者术前甲胎蛋白(AFP)阳性C＞25 ng/ml),33.3％(3/10)的患者CA19-9阳性(＞37 U/ml).在获得随访患者中,术后1、3、5年生存率分别为63.6％、27.2％和9.1％.结论 混合型肝癌罕见,临床表现缺乏特异性,明确诊断依靠术后病理学检查.根治性手术切除是改善患者预后的惟一有效手段,但由于肿瘤恶性程度高,总体预后较差.     

混合型肝癌临床特点及近期预后分析

目的 探讨混合型肝癌(mixed hepatocellular carcinoma and cholangiocarcinoma,mHCCCC)的临床特点及近期预后.方法 回顾分析2009年4月至2010年2月在浙江大学医学院附属第一医院病理确诊为mHCC-CC的17例患者的临床资料,总结其临床特点并统计术后生存时间. 结果 患者平均发病年龄27～76岁;其中男性11例(64.7％);无临床症状10例(58.8％);乙肝表面抗原阳性12例(70.6％);甲胎蛋白阳性( ＞25 ng/ml) 12例(75.1％);糖类抗原199阳性(≥37 U/ml)4例(25.0％).17例患者中肿瘤均完整切除,即包括转移灶在内的肿瘤切除,切缘离肿瘤边缘1.5 cm以上,同时清扫肉眼可见或影像学提示的肿大淋巴结.术后6、12和18个月累积生存率分别为93.8％、86.5％、57.7％;术后100、200 d的无瘤生存率分别为65.3％、43.5％;中位无瘤生存期为161 d.结论 mHCC-CC术前诊断困难,确诊依靠病理诊断;手术切除是主要治疗手段,但总体预后较差.     

46例混合型肝癌临床特点分析

目的探讨混合型肝癌的临床病理特点,并分析影响其预后的危险因素。方法回顾性分析我院2007年1月~2014年1月经病理学检查证实的46例混合型肝癌病人的临床病理资料。利用SPSS13.0软件应用Kaplan-Meier法绘制生存曲线,Cox回归模型分析影响其预后的因素。结果 46例患者术前均误诊为原发性肝细胞癌或胆管细胞癌。术前血清AFP及CA19-9阳性率分别为48.8%和58.1%。在获得随访患者中,术后1、3、5年总体生存率和无瘤生存率分别为58.8%,32.6%,17.1%和41.9%,23.5%,5.9%。中位生存时间和中位复发时间分别为14个月和10个月。多因素分析结果提示脉管癌栓,淋巴结转移,卫星灶是影响预后的独立危险因素。结论混合型肝癌术前缺乏特异性诊断指标。总体预后较差,脉管癌栓,淋巴结转移,卫星灶是影响预后的独立危险因素。     

混合型肝癌的诊治与影响预后因素研究

<正>混合型肝癌(combined hepatocellular-cholangiocarcinoma, cHCC-CCA)是临床较为少见的一种原发性肝癌类型,单一肿瘤组织中既有肝细胞癌(hepatocellular carcinoma, HCC)又有胆管细胞癌(chlangiocarcinoma, CC)结构,兼具HCC和CC特征,作为一种具有独特生物学行为的肿瘤,其流行病学、放射学和组织学特征,     

混合型肝癌预后评价及相关影响因素分析

目的 评价混合型肝癌（cHCC-CC）病人的预后并分析与预后相关的影响因素。方法 回顾性分析2015年9月至2019年9月海军军医大学东方肝胆外科医院收治的54例cHCC-CC病人的临床资料。随访观察3年,采用Kaplan-Meier法进行生存分析,并分析cHCC-CC病人预后的影响因素。结果 54例cHCC-CC病人术后1、2、3年总体生存率为84.7%、61.1%、47.0%,无病生存率为50.8%、46.9%、26.4%,中位生存期（OS）、无病生存期（DFS）分别为29.1、17.7个月。单因素分析显示,肿瘤最大径≥5 cm、微血管侵犯、淋巴结转移为OS和DFS的影响因素。Cox多因素分析显示,肿瘤最大径≥5 cm（P=0.035）、微血管侵犯（P=0.023）、淋巴结转移（P=0.041）为OS的独立危险因素;微血管侵犯（P=0.007）、淋巴结转移（P=0.024）是DFS的独立危险因素。结论 cHCC-CC预后较差,兼有肝细胞癌及胆管细胞癌的特点,肿瘤直径≥5 cm、微血管侵犯及淋巴结转移影响病人预后生存,建议据此选择个体化治疗方案。     

107例肝细胞肝癌切除术后预后因素分析

目的 探讨影响肝细胞肝癌切除术后的预后因素。方法 回顾性分析广西医科大学肿瘤医院2002年6月~2004年5月间107例肝细胞肝癌手术切除患者的临床资料,选择38项临床病理因素分析其对生存率的影响。Kaplain-Meier法计算生存率,单因素分析采用Log-rank检验,多因素分析采用Cox模型筛选出对肝细胞肝癌切除预后有影响的临床病理因素。结果 全组1、3、5年生存率为85.0%,53.3%,43.9%。单因素分析：术前GGT,术前肝功能Child-Pugh分级,术后ALB,术后TBIL,术后ALP,术后GGT,肿瘤最大直径,门静脉癌栓,术中失血情况,围手术期输血,术后是否复发以及手术是否根治切除等。多因素分析：术后ALB,术后ALP,门静脉癌栓,术后是否复发,手术是否根治切除与预后相关。结论 术后ALB,术后ALP,门静脉癌栓,术后复发,根治性切除是影响肝细胞肝癌术后生存期的独立预后因素。     

影响肝细胞肝癌手术切除预后因素的COX模型分析

目的 对影响肝细胞肝癌手术切除预后的因素进行多因素分析。方法 1986－1996年经手术切除的145例肝癌患者,随访至1999年底。单因素分析采用Kaplain-Meier Log-rank时序检验,多因素采用COX比例风险模型。结果 手术后1、3、5、7、10、12年生存期分别为75．0％、44．4％、29．5％、23．5％、21．2％、16．9％;单因素分析影响预后因素为发现方式、肝癌体积、有否门静脉癌栓、卫星结节及肝癌结节数、UICC分期、手术切缘、有否复发及复发后治疗方式、是否根治性切除;多因素分析得出和预后有关的因素为发现方式、UICC分期、手术切缘、有否复发及复发后治疗方式,是否根治性切除。结论 肝癌的预后取决于早期诊断及治疗方式;UICC分期与预后相关,且与卫星结节、结节数、门静脉癌栓相关。1cm以上的手术切缘,可明显提高切除疗效。     

105例小肝癌手术治疗经验及预后分析

目的探讨影响小肝癌手术后生存率的临床病理因素。方法回顾性分析1986.1-2006.6月手术切除并获得随访的105例小肝癌（≤3 cm）的临床病理资料,中位随访时间33个月。对有无结节性肝硬化、肝功能Ch ild分级、术前血清AFP水平、肿瘤大小、有无肿瘤包膜、肿瘤分化程度（Edmondson分级）、有无门脉癌栓、是否多灶性（包括卫星灶）及手术方式等与术后生存率的关系进行分析。结果截止2006年12月,随访105例,失访5例,手术后1、3、5年生存率分别为86.5%、70.3%、55.2%,无瘤生存率分别为78%、58.9%、45.6%。再次手术死亡1例。随访期内36例肝内复发,34例死亡。分析提示术前肝功能Ch ild分级、肿瘤大小、门静脉癌栓及多灶性是影响手术后生存率的预后因素。结论距肿瘤1 cm以上切缘的局部肝脏切除是治疗小肝癌的合理手术方式,手术后的肝内复发和转移是导致小肝癌病人术后死亡的主要原因。     

影响原发性肝癌肝移植治疗的预后因素分析

目的分析影响肝癌肝移植术后生存率和无瘤生存率的危险因素，探讨国内肝移植治疗肝癌的选择标准。方法对67例接受同种异位原位肝移植治疗的原发性肝癌病人的基本资料和肿瘤相关资料包括术前病情分级、血清AFP水平、术前辅助治疗以及肝癌大小、数目、pTNM分期、肿瘤恶性程度分级等因素进行单因素和多因素分析。结果术后1年、2年累积生存率为77％、67％，6个月和12个月无瘤生存率为66％和58％。单因素分析显示对肝癌肝移植术后累积生存率影响有统计学意义的因素为CHILD分级（MELD积分）和肝外大血管侵犯；多因素分析影响肝癌肝移植术后无瘤生存率有统计学义的因素是肿瘤大小、大血管侵犯和肿瘤分化程度。结论影响肝癌肝移植术后生存率的因素仍是术前患者肝功能状态。对存在大血管侵犯的肝癌患者需严格控制肝移植术适应证，而无血管侵犯的患者在选择肝移植治疗时肿瘤大小指标可较米兰标准适当放宽。     

肝切除治疗巨大原发性肝癌的预后因素分析

目的研究影响巨大原发性肝癌手术切除治疗的预后因素,探讨提高巨大肝癌疗效的途径。方法回顾性分析2001年6月至2008年6月在我院手术治疗的69例巨大原发性肝癌患者的临床资料,用Cox回归分析选择16个对预后可能产生影响的因素进行统计学分析。结果随访到的58例外科手术治疗患者1、3、5年生存率分别为58.2%,31.4%,12.3%;单因素分析结果表明预后影响因素为是否肝内转移、血管侵犯、肝硬化程度和是否根治性切除;多因素分析得出影响巨大肝癌切除术后远期疗效的独立预后因素为肝硬化程度、是否肝内转移和是否根治性切除。结论积极手术切除是治疗巨大肝癌的主要措施,其疗效取决于是否肝内转移、肝硬化程度和是否根治性切除,对术后肝内复发和转移的积极预防和治疗是提高HPLC生存率的主要策略。     

Comparison of Combined Hepatocellular and Cholangiocarcinoma with Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

Purpose Combined hepatocellular and cholangiocarcinoma (HCC-CC) is a rare primary hepatic neoplasm (PHN) with features of both hepatocellular and biliary differentiation. We compared the outcome of hepatic resection in patients with HCC-CC, those with hepatocelluar carcinoma (HCC), and those with cholangiocarcinoma (ICC). Methods Between November 1994 and December 2003, 952 patients underwent hepatic resection for a PHN. Results The incidence of HCC-CC was 3.5%. Hepatitis B surface antigen was positive in 51.2% of these patients and the HCV antibody was positive in 12.2%. Positive hepatitis serology was more common in the HCC group (66.7%). The prevalence of underlying liver cirrhosis was significantly lower in the ICC group (7.8%) than in the HCC (49%) and HCC-CC (41.5%) groups (P < 0.0001). The median overall survival periods after hepatic resection of HCC-CC, HCC, and ICC were 47.3, 71.7, and 21.5 months, respectively (P < 0.0001). The median disease-free survival (DFS) periods after hepatic resection for HCC-CC, HCC, and ICC were 23.4, 68.2, and 15.5 months, respectively (P < 0.0001). Conclusion Patients with transitional type HCC-CC had significantly poorer survival rates than those with HCC, after hepatic resection. Therefore, a more aggressive treatment modality should be explored to improve the survival rate of these patients.     

Long-term Outcomes and Prognostic Factors of Elderly Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

Objective  The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Material and Methods  From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, ≥70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively. Results  The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked α-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor–node–metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC. Conclusion  HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.     

男性肝细胞癌患者的临床病理特点及影响因素

目的探讨男性肝细胞癌患者的临床病理特征、术后生存及预后影响因素。方法回顾性分析1995年1月至2002年12月期间我科行肝切除术之155例男性肝细胞癌患者的临床及随访资料,单、多因素分析确定预后影响因素。结果与同期24例女性患者比较,男性肝细胞癌患者年长5.7岁,并有较高的HBsAg阳性率(80.6%vs54.2%)和肝硬变比率(87.1%vs37.5%),P<0.05,其他临床病理指标差异无统计学意义(P>0.05)。多因素分析提示,Edmondson-Steiner分级和门静脉癌栓为男性患者术后总体生存和无瘤生存的独立影响因素,卫星灶和肿瘤大小仅影响总体生存。结论男性肝细胞癌患者主要的临床病理特征及术后生存情况与女性患者相似。肿瘤分化程度和生物学行为是影响男性肝细胞癌患者术后生存的主要因素。     

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.     

Surgical Treatments and Prognoses of Patients with Combined Hepatocellular Carcinoma and Cholangiocarcinoma

Background  Combined hepatocellular carcinoma and cholangiocarcinoma is a very rare form of primary liver cancer containing components of both tumor types. We evaluated the effectiveness of surgical treatment and factors related to survival and recurrence. Patients and Methods  Of the 2427 patients who underwent hepatectomy or liver transplantation because of a primary hepatic malignancy from January 1989 to July 2006 at the Asan Medical Center, Seoul, Korea, 29 had hepatocellular carcinoma and cholangiocarcinoma as a single mixed or transitional tumor. Their medical records were retrospectively reviewed. Results  Disease-free survival rates at 6 months, 1 year, and 3 years were 51.1%, 38.3%, and 25.6%, respectively. Univariate analysis showed that CA 19–9 above 37 U/ml was predictive of low overall survival (P = .03) and that TNM stage was significantly associated with disease-free survival (P = .04). Conclusions  Patients with combined hepatocellular carcinoma and cholangiocarcinoma had poor postoperative survival rates. High CA 19–9 level was associated with poorer survival, suggesting that the cholangiocarcinoma portion may be a major determining factor for patient prognosis. Aggressive surgical treatment, including lymph node dissection, may improve survival in patients suspected of or diagnosed with these tumors.     

Clinicopathological Features and Prognosis in Resectable Synchronous and Metachronous Colorectal Liver Metastasis

Introduction Hepatic resection may offer long-term survival for patients with colorectal metastases. However, controversies exist regarding the prognostic factors. Herein, the impact of synchronicity of liver metastasis on patient clinicopathological features and prognosis was evaluated. Methods One hundred and fifty-five patients who underwent hepatectomy for colon cancer metastasis, from 1995 to 2004, were enrolled in this study. Patients were divided into two groups: synchronous and metachronous colorectal liver metastasis. Patient demographics, the nature of the primary and metastatic tumors, surgery-related complications, and long-term outcome were analyzed. Results Patients included in the synchronous group tended to be younger than those in the metachronous group. Compared to the metachronous group, patients in the synchronous group showed more metastases (P = 0.008) and bilobarly distributed metastases (P = 0.016). Bile leakage was the most common surgical complication. The estimated 5-year disease-free and overall survival rates were 16.8 and 41.1%, respectively. Univariate analysis indicated that synchronous metastases, advanced stage of the primary tumor, bilobar distribution of the metastases, more than three metastases, and colonic versus rectal location of the primary tumor were prognostic factors of shorter disease-free survival, but not overall survival. Multivariate analysis revealed that synchronous metastases and the advanced stage of the primary tumor were indicators for a worse disease-free survival. Conclusion The synchronous presence of primary colon cancer and liver metastasis may indicate a more disseminated disease status and is associated with a shorter disease-free survival than metachronous metastasis. These patients may need more careful monitoring and aggressive chemotherapy following curative resection.     

Referrals for Surgical Therapy in Patients with Hepatocellular Carcinoma: A Community Experience

The treatment of hepatocellular carcinoma (HCC) is notoriously difficult. Either because of oncogenic behavior or the frequent association of cirrhosis, successful therapy is elusive, particularly in cirrhotic patients. Surgical removal has been the only modality that has produced long-term, disease-free survival. In a large series of patients from specialty institutions, median survival in those who underwent resection of HCC lesions has ranged from 30 to 70 months. Similarly, liver transplantation has been shown to be an effective treatment when HCC is favorable (limited in size and number), producing long-term survival in greater than 70% of patients. However, less information is known about community-based treatment of HCC. Reports from referral centers may not accurately reflect the community experience. We have retrospectively reviewed patients with HCC seen in surgical referral from three teaching hospitals in a medium-size urban community from 1995 to 2004 who were not felt to be candidates for liver transplantation and who were not sent to referral centers. We sought to examine their suitability for operation and resection. The study group comprised 61 patients, whose ages ranged from 35 to 83 years old. There were 44 patients (72%) with cirrhosis (Childs A, B, and C in 27, 15, and 2 patients, respectively), 21 from hepatitic C virus (HCV) infection. Three recognized staging systems were used that incorporated the estimation of hepatic reserve and tumor burden. Seven patients (11%) were deemed nonoperable (five advanced disease by imaging, two comorbidities). Of the 54 patients who underwent surgical procedures, 32 underwent resection (28 patients) or cryoablation (4 patients). The reasons for unresectability were unrecognized multifocality (ten patients), poor risk for major hepatectomy (five patients), portal vein/hepatic vein involvement (three patients), metastatic disease (two patients), and excessive blood loss prior to hepatectomy (two patients). Eleven of 17 (65%) noncirrhotic patients and 21 of 44 (48%) cirrhotic patients were resectable or ablatable. There were ten postoperative deaths: six following resection, two following cryoablation, and two following exploratory celiotomy. All deaths were in cirrhotic patients (Childs A in four patients, B in five patients, and C in one patient), 10 of 44 patients (23%); 3 of 11 (27%) patients died following segmentectomy and 3 of 9 (33%) following major hepatectomy. Seven deaths that occurred were in patients with HCV; (P = NS). From this series, the difficulty in surgically treating cirrhotic patients in an urban practice is evident. From 39 to 73% of patients had advanced local disease. Less than half were resectable and, for cirrhotic patients, the postoperative mortality was high, even after “minor” hepatectomies. Noncirrhotic patients fared somewhat better. While HCC in community practice can be treated surgically in the majority of noncirrhotic patients, cirrhotic patients are less likely candidates, and surgical treatment is associated with significant postoperative mortality. This frequently reflected advanced disease and HCV but may be associated with access to preventative and surveillance measures. Only those with optimum hepatic reserve and small tumor burden should be considered for surgical resection. Presented at the 2006 Spring Meeting of the American Hepato-Pancreato-Biliary Association, Miami Beach, FL, March 9–12, 2006 (poster of distinction).     

Clinicopathological Prognostic Factors After Hepatectomy for Patients with Mass-Forming Type Intrahepatic Cholangiocarcinoma: Relevance of the Lymphatic Invasion Index

Background  

The present study was conducted to clarify the pathological factors in patients who underwent surgery for mass-forming type intrahepatic cholangiocarcinoma (IHC).     

Identification of Risk and Prognostic Factors for Patients with Clonorchiasis-Associated Intrahepatic Cholangiocarcinoma

Background

Intrahepatic cholangiocarcinoma caused by clonorchiasis (CICC) has a poor prognosis, and there have been insufficient studies regarding risk and prognostic factors. We aimed to identify CICC-associated factors.

Methods

A retrospective analysis of 127 eligible patients with CICC was performed with 254 clonorchiasis cases used as matched controls to identify risk factors for CICC. The main outcomes analyzed included overall survival (OS) and disease-free survival (DFS).

Results

Out of 127 surgeries, R0 resection was performed in 61 patients, R1 in 32 patients, and R2 in 22 patients; nonresection surgery was performed in 12 patients. Median OS for the entire cohort was 29.5 months. Median OS and DFS for 61 patients with R0 resection were 52.4 months and 41.5 months, respectively. We found independent risk factors for CICC were duration of raw fish consumption of ≥28 years (p < 0.001) and hepatitis B virus infection (p = 0.040). R0 resection (p < 0.001), well or moderately differentiated tumor (p = 0.019), and stage I to II tumor (p < 0.001) predicted improved OS for CICC. Serum carcinoembryonic antigen level of ≤5 ng/ml (p = 0.029) and stage I to II tumor (p < 0.001) predicted improved DFS.

Conclusions

Duration of raw fish consumption ≥28 years and hepatitis B virus infection were significant risk factors for CICC in patients with clonorchiasis. For patients with CICC, curative resection is an effective treatment. Higher tumor differentiation and earlier American Joint Committee on Cancer stage predicted good prognosis. Serum carcinoembryonic antigen level was found to predict the possibility of recurrence after curative resection.     

Incomplete Ablation After Radiofrequency Ablation of Hepatocellular Carcinoma: Analysis of Risk Factors and Prognostic Factors

Background Complete ablation rates after a single session of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) vary from 48% to 97%. Limited data are available regarding risk factors and prognostic significance of incomplete ablation. Methods Between April 2001 and March 2006, 298 patients underwent RFA of 393 HCC nodules with an intent of complete ablation after a single session. Risk factors for incomplete ablation and its effect on overall survival were analyzed. Results Two hundred seventy-three (91.6%) underwent complete tumor ablation, whereas the other 25 (8.4%) underwent incomplete tumor ablation after a single session of RFA. By multivariate analysis, tumor size >3 cm (P = .049) was found to be the only independent risk factor for incomplete ablation. There was no statistically significant difference in overall survival between patients with complete and incomplete ablation. By univariate analysis, no previous transarterial chemoembolization (TACE), preoperative serum alfa-fetoprotein ≤100 μg/mL, and complete response after further treatment of incomplete ablation were associated with better overall survival in patients with incomplete ablation. Conclusions This study demonstrated that incomplete ablation after RFA of HCC was associated with tumor size >3 cm. Our data also suggest that aggressive further treatment of tumors with incomplete ablation aiming at complete tumor response improves overall survival.