Outcomes after surgery for central neurocytoma: results of a French multicentre retrospective study

Objective

Central neurocytoma (CN) is a rare intraventricular tumour. Surgery has been highly recommended for CN, although it entails a significant chance to harm the patient. We aimed to provide new data that would support surgical decision-making and optimise patient information about outcomes after surgery.

Method

Under the auspices of the French Society of Neurosurgery, we conducted a multi-institutional database search in 23 academic hospitals. In all, we reviewed the relevant clinical and radiological data of 82 patients who were operated on for CN between 1984 and 2008, and had their diagnosis confirmed by central pathological review.

Results

The median follow-up was 61 months (range, 6–96 months). Gross total resection (GTR) was achieved in 48 % of the patients, and subtotal resection (STR) in 52 %. The 5-year overall survival rate was 93.8 % (95 % CI, 93.7–93.9). The 5-year progression-free survival rate was 92.1 % (95 % CI, 91.90–92.2) in patients who underwent GTR, compared with 55.3 % (95 % CI, 55.1–55.5) in patients who had STR (p?=?0.01). The overall perioperative complication rate was 66 %. The main causes of postoperative disability were some degree of postoperative paresis and/or aphasia (39 %), memory difficulties (29 %) and temporary hydrocephalus (26 %). GTR was not associated with an increased rate of postoperative complications compared with STR. At last follow-up, Karnofsky Performance Score was at least equal to 80 for 90.6 % of the tested patients.

Conclusion

Our series emphasised that maximal surgical resection of CNs offers favourable benefit-risk ratio. These data are of importance to properly counsel patients regarding expected outcomes, and to plan relevant preoperative and postoperative investigations like language and memory function evaluation.     

Surgical Outcomes and Prognostic Factors for T2 Gallbladder Cancer Following Surgical Resection

Background

Depth of tumor invasion is an important prognostic factor for gallbladder cancer. The aim of this study was to investigate the clinicopathological prognostic factors of T2 gallbladder cancer.

Methods

We retrospectively reviewed the clinicopathological data and survival for 83 patients with T2 gallbladder cancers who underwent surgical resection between January 1995 and December 2007.

Results

The overall survival rates were 48.9% at 3 years and 29.3% at 5 years. Univariate analysis revealed that R0 resection (P?<?0.001), extended surgery (P?=?0.028), lymph node dissection (P?=?0.024), non-infiltrative tumors (P?=?0.001), well differentiation (P?=?0.001), absence of lymphatic (P?=?0.025), perineural (P?=?0.001), and vascular (P?=?0.025) invasion, absence of lymph node metastasis (P?=?0.001), negative resection margin (P?=?0.016), and stage (P?=?0.002) were significantly better predictors for survival. A significant difference in survival between Rx and R1 was not found. R0 resection, lymph node dissection, well differentiation, and absence of perineural and vascular invasion were significantly independent prognostic factors for overall survival. Recurrence occurred in 48 patients (57.8%). Age older than 65 years, R0 resection, non-infiltrative tumors, and good differentiation were significant independent predictors of disease-free survival by multivariate analysis.

Conclusions

For T2 tumors, radical surgery including lymph node dissection should be performed to achieve R0 resection. Tumors with infiltrative types and suspicious lymph node metastasis in the intraoperative findings were candidates for aggressive surgical management to improve patient survival.     

Surgery for incarcerated hernia: short-term outcome with or without mesh

Background

Incarcerated hernias represent about 5–15 % of all operated hernias. Tension-free mesh is the preferred technique for elective surgery due to low recurrence rates. There is however currently no consensus on the use of mesh for the treatment of incarcerated hernias, especially in case of bowel resection.

Aim

The aims of this study were (i) to report our current practice for the treatment of incarcerated hernias, (ii) to identify risk factors for postoperative complications, and (iii) to assess the safety of mesh placement in potentially infected surgical fields.

Methods

This retrospective study included 166 consecutive patients who underwent emergency surgery for incarcerated hernia between January 2007 and January 2012 in two university hospitals. Demographics, surgical details, and short-term outcome were collected. Univariate analysis was employed to identify risk factors for overall, infectious, and major complications.

Results

Eighty-four patients (50.6 %) presented inguinal hernias, 43 femoral (25.9 %), 37 umbilical hernias (22.3 %), and 2 mixed hernias (1.2 %), respectively. Mesh was placed in 64 patients (38.5 %), including 5 patients with concomitant bowel resection. Overall morbidity occurred in 56 patients (32.7 %), and 8 patients (4.8 %) developed surgical site infections (SSI). Univariate risk factors for overall complications were ASA grade 3/4 (P?=?0.03), diabetes (P?=?0.05), cardiopathy (P?=?0.001), aspirin use (P?=?0.023), and bowel resection (P?=?0.001) which was also the only identified risk factor for SSI (P?=?0.03). In multivariate analysis, only bowel incarceration was associated with a higher rate of major morbidity (OR?=?14.04; P?=?0.01).

Conclusion

Morbidity after surgery for incarcerated hernia remains high and depends on comorbidities and surgical presentation. The use of mesh could become current practice even in case of bowel resection.     

Postoperative Complications and Survival after Gastric Cancer Surgery in Patients Older than 80 Years of Age

Background

This study sought to identify and evaluate the risk factors of postoperative complications, prognostic factors, and appropriate surgical strategies in elderly patients undergoing surgery for gastric cancer.

Methods

The medical records of 396 radical gastrectomies conducted from January 2006 to December 2011 were retrospectively reviewed. Surgical results and survival rates were assessed for 60 elderly patients (aged?≥?80 years) and 336 non-elderly patients (aged?<?80 years). The study groups were compared with respect to clinicopathological findings, surgical outcomes, and survival.

Results

Elderly patients underwent gastrectomies with shorter operation time, showed less extensive lymphadenectomy, and had a significant difference in overall survival compared with non-elderly patients, although there was no difference in cause-specific survival among patients receiving curative resection. No significant risk factors affecting postoperative complications were identified in the elderly patients. Number of comorbidities (≥2) (HR, 5.30; 95 % CI, 1.11–25.32; P?=?0.037) and TNM stage (≥II) (HR, 12.97; 95 % CI, 1.60–105.38; P?=?0.017) were identified as independent prognostic factors in the elderly patients receiving curative resection.

Conclusions

Age is not an independent prognostic factor for patients receiving curative resection for gastric cancer. Multiple comorbidities may also influence the prognosis of elderly patients. Careful follow-up would improve overall survival for elderly patients.     

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

Aims

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

Material and Methods

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

Results

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

Conclusion

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

Nonfunctional Pancreatic Neuroendocrine Tumors <2 cm on Preoperative Imaging are Associated with a Low Incidence of Nodal Metastasis and an Excellent Overall Survival

Background

The optimal surgical management of small nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) remains controversial. We sought to identify (1) clinicopathologic factors associated with survival in NF-PNETs and (2) preoperative tumor characteristics that can be used to determine which lesions require resection and lymph node (LN) harvest.

Methods

The records of all 116 patients who underwent resection for NF-PNETs between 1989 and 2012 were reviewed retrospectively. Preoperative factors, operative data, pathology, surgical morbidity, and survival were analyzed.

Results

The overall 5- and 10-year survival rates were 83.9 and 72.8 %, respectively. Negative LNs (p?=?0.005), G1 or G2 histology (p?=?0.033), and age <60 years (p?=?0.002) correlated with better survival on multivariate analysis. The 10-year survival rate was 86.6 % for LN-negative patients (n?=?73) and 34.1 % for LN-positive patients (n?=?32). Tumor size ≥2 cm on preoperative imaging predicted nodal positivity with a sensitivity of 93.8 %. Positive LNs were found in 38.5 % of tumors ≥2 cm compared to only 7.4 % of tumors <2 cm.

Conclusions

LN status, a marker of systemic disease, was a highly significant predictor of survival in this series. Tumor size on preoperative imaging was predictive of nodal disease. Thus, it is reasonable to consider parenchyma-sparing resection or even close observation for NF-PNETs <2 cm.     

Perineural Invasion in Extrahepatic Cholangiocarcinoma: Prognostic Impact and Treatment Strategies

Background

The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and optimal treatment strategy for perineural invasion in patients with extrahepatic cholangiocarcinoma.

Methods

Medical records of 133 patients with extrahepatic cholangiocarcinoma who underwent curative resection were reviewed retrospectively. Ninety-eight patients had perineural invasion and 35 patients did not. Univariate and multivariate survival analyses were performed to clarify the prognostic impact of and optimal treatment strategy for perineural invasion.

Results

Only tumor differentiation (P?=?0.024) was independently associated with perineural invasion in the multivariate logistic regression model. Multivariate survival analysis revealed that perineural invasion (P?=?0.002), resection margin status (P?=?0.016), and International Union Against Cancer (UICC) pT factor (P?=?0.015) were independent prognostic factors of overall survival. Overall 5-year survival rates for patients with and without perineural invasion were 28 and 74 %, respectively. Among 98 patients with perineural invasion, the use of adjuvant chemotherapy (P?=?0.003), lymph node status (P?=?0.015), resection margin status (P?=?0.008), and UICC pT factor (P?=?0.016) were independently associated with overall survival by multivariate analysis. Overall 5-year survival rates for patients with perineural invasion who did and did not receive adjuvant chemotherapy were 33 and 21 %, respectively (P?=?0.023).

Conclusions

Perineural invasion is a potent prognostic factor in extrahepatic cholangiocarcinoma. Adjuvant chemotherapy may improve the overall survival of patients with perineural invasion.     

Pancreatic resection in elderly patients: should it be denied?

Background

Surgery remains the only potential curative therapy for pancreatic cancer, but compromised physiological reserve and comorbidities may deny pancreatic resection from elderly patients.

Methods

The medical records of all patients who underwent pancreatic resection at our institution (2005–2012) were retrospectively reviewed. Postoperative and long-term outcomes were compared between patients with cutoff age of 70 years.

Results

A total of 228 (66 %) and 116 (34 %) patients were <70 and ≥70 years, respectively. Elderly group had worse ASA scores (P?<?0.0001) with higher rates of invasive malignant pathologies (75 vs. 67 %, P?=?0.14), mainly pancreatic ductal adenocarcinoma (58.6 vs. 44.7 %, P?=?0.01). The most common type of resection was pancreaticoduodenectomy (PD) (59 %), followed by distal pancreatectomy (19.8 %). Mean hospital stay was comparable. Elderly patients had less grade ≥IIIb postoperative complications (12 vs. 20.1 %; P?=?0.04) and higher postoperative mortality rates (12.9 vs. 3.9 %; P?=?0.04). In multivariable Cox proportional hazards model for postoperative mortality, age ≥70 years (HR, 3.5; 95 % CI, 1.3–9.3), pancreaticoduodenectomy (HR, 12.6; 95 % CI, 1.6–96), and intraoperative blood loss were significant (P?=?0.012; P?=?0.015, and P?=?0.005, respectively). The overall 5-year survival rates for all patients, for patients aged <70 and ≥70 years were 56, 55, and 41 %, respectively (P?=?0.003).

Conclusions

Elderly patients are at higher risk of mortality after pancreatic resection than usually reported case series. Nonetheless, elderly patients can undergo pancreatic resection with acceptable 5-year survival results. Our results contribute for a better, informed decision-making for elderly patients and their family.     

Factors affecting survival after resection of intrahepatic cholangiocarcinoma

Purpose

This study aimed at assessing the prognostic factors of resection of intrahepatic cholangiocarcinoma (IHCC), which remain unclear.

Methods

Among 70 patients with IHCC, who were admitted to our hospital between 1998 and 2011, 45 (64 %) underwent resection and 25 had unresectable tumors. Univariate and multivariate analyses were conducted retrospectively to assess the factors influencing survival of the patients who underwent resection.

Results

The median survival times of the patients who underwent resection versus those who did not were 16 months versus 9 months, respectively (P < 0.001). Multivariate analysis identified residual tumor status (relative risk 4.12, P = 0.04) and pathological differentiation (relative risk 5.55, P = 0.04) as independent factors predicting survival. Patients who underwent R1 resection had a significantly higher rate of local recurrence than those who underwent R0 resection (P = 0.008). With R0 resection, there were no significant differences in patterns and rates of recurrence between patients with narrow (≤5 mm) versus wide (>5 mm) surgical margins.

Conclusions

R0/1 resection and a well-differentiated tumor were found to be independent prognostic factors for long-term survival after IHCC resection. If R0 resection was achieved, the width of the negative surgical margin did not affect the patterns and rates of recurrence.     

Surgical Resection in Hepatocellular Carcinoma Patients with Minimal Background Fibrosis: A Strategy in the Era of Organ Shortage

Background

Surgical therapies for hepatocellular carcinoma (HCC) represent the potentially curative approaches and provide patients the greatest survival advantage. We sought to examine the outcomes of patients with HCC treated with surgical resection, transplantation, and local ablation.

Methods

The Surveillance, Epidemiology, and End Results database was queried for all patients with nonmetastatic HCC from 2004 to 2007 who underwent local ablation (LA), segmental resection (SR), hemihepatectomy or extended resection (ER), or transplantation (TP).

Results

Of 16,209 patients with HCC, 3,989 (24.6 %) met criteria for inclusion and received therapies: 1,550 LA (39 %), 703 SR (18 %), 619 ER (16 %), and 1,117 TP (28 %). AFP was elevated in 69 % (2,026 of 2,921), and fibrosis grade 0–4 was noted in 32 % (368 of 1,156). The 3-year survival by procedure was 34 % (LA), 50 % (SR), 54 % (ER), and 74 % (TP), p = .001. In patients with minimal fibrosis, 1-year survival for patients undergoing resection was similar to TP (85 vs. 92 %, p = .346), but greater than LA (69 %, p = .001).

Discussion

Survival after surgical resection for HCC patients without extensive fibrosis appears to be superior to ablation and non-inferior to transplantation. In an era of organ shortage, transplantation may be better reserved for patients with cirrhosis and/or unresectable disease.     

Assessment of ISGLS Definition of Posthepatectomy Liver Failure and Its Effect on Outcome in Patients with Hepatocellular Carcinoma

Background

Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy. As there was no standardized definition, the International Study Group of Liver Surgery (ISGLS) defined PHLF as increased international normalized ratio and hyperbilirubinemia on or after postoperative day 5 in 2010. We evaluated the impact of the ISGLS definition of PHLF on hepatocellular carcinoma (HCC) patients.

Methods

We retrospectively analyzed 210 consecutive HCC patients who underwent curative hepatectomy at our facility from 2005 to 2010. The median follow-up period after hepatectomy was 35.2 months.

Results

Thirty-nine (18.6 %) patients fulfilled the ISGLS definition of PHLF. Overall survival (OS) rates at 1, 3, and 5 years in patients with/without PHLF were 69.1/93.5, 45.1/72.5, and 45.1/57.8 %, respectively (P?=?0.002). Recurrence-free survival (RFS) rates at 1, 3, and 5 years in patients with/without PHLF were 40.9/65.9, 15.7/38.3, and 15.7/20.3 %, respectively (P?=?0.003). Multivariate analysis revealed that PHLF was significantly associated with both OS (P?=?0.047) and RFS (P?=?0.019). Extent of resection (P?<?0.001), intraoperative blood loss (P?=?0.002), and fibrosis stage (P?=?0.040) were identified as independent risk factors for developing PHLF.

Conclusion

The ISGLS definition of PHLF was associated with OS and RFS in HCC patients, and long-term survival will be improved by reducing the incidence of PHLF.     

Impact of Macroscopic Morphology, Multifocality, and Mucin Secretion on Survival Outcome of Intraductal Papillary Neoplasm of the Bile Duct

Background

Intraductal papillary neoplasms of the bile duct (IPNB) are relatively rare disease with favorable prognosis. The authors investigated clinicopathologic characteristics and prognostic factors of IPNB in viewpoint of macroscopic morphology and multiplicity.

Methods

Data were collected from 84 patients who underwent surgery at Seoul National University Hospital with diagnosis of IPNB from 2000 to 2009.

Results

Median follow-up was 41.8 months and 75 (89.3 %) had invasive cancer. Tumors were confined to the bile duct in 45 patients (53.6 %) and 8 (9.5 %) had lymph node metastasis. Curative resection was achieved in 70 patients (89.3 %). Mucin secretion was identified in 23 (28.0 %) and 43 (51.2 %) had multiple tumors. Multiple IPNB had poor prognosis compared with single IPNB (5-year survival rate 50.7 vs. 85.9 %; P?=?0.011). Positive resection margin (P?=?0.046) and multiplicity (P?=?0.038) were independent prognostic factors of IPNB after multivariate analysis. Mucin secretion had no impact on survival outcome (P?=?0.595). The disease-free survival rate was significantly lower in multiple IPNB compared with single IPNB (5-year disease free survival rates 36.1 vs. 74.1 %; P?=?0.026).

Conclusion

Multiplicity is a common feature of IPNB and has a negative impact on prognosis. Current WHO classification for IPNB needs consideration for macroscopic morphology and multiplicity considering its prognostic impact of IPNB.     

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

Purpose

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

Methods

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

Results

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

Conclusion

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

The Improvement of Surgical Treatment for Patients with Gallbladder Cancer: Analysis of 208 Consecutive Cases Over the Past Decade

Objectives

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

Methods

A retrospective review of all patients with gallbladder cancer admitted during the past 11?years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n?=?77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n?=?131).

Results

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P?=?0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9?% vs. 19?%, P?=?0.040) and disease-free survival (P?=?0.017). Median survival in group 1 was 14.7?months, while in group 2 it was 22.3?months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P?=?0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P?=?0.108).

Conclusions

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.     

Surgical Resection Versus Transarterial Chemoembolization for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Propensity Score Analysis

Background

The long-term survival in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) who received surgical resection (SR) or transarterial chemoembolization (TACE) remains unclear. We compared the efficacy of SR and TACE by using a propensity score analysis.

Methods

A total of 247 and 181 HCC patients with PVTT undergoing SR and TACE, respectively, were evaluated. One hundred eight pairs of matched patients were selected from each treatment arm by using a propensity score analysis.

Results

Of all patients, the estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 85 versus 60 %, 68 versus 42 %, and 61 versus 33 %, respectively (p < 0.001). Patients selected for SR were significantly younger and had better liver functional reserve, performance status, and smaller tumor burden. In the propensity model, the survival benefit of SR remained significant. The estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 84 versus 71 %, 69 versus 50 %, and 59 versus 35 %, respectively (p = 0.004). The two groups of patients in the propensity score analysis were similar in baseline characteristics. In the Cox proportional hazards model, patients receiving TACE had a 2.044-fold increased risk of mortality compared with patients receiving SR (95 % confidence interval: 1.284–3.252, p = 0.003).

Conclusions

For either unselected patients or patients in the propensity model, SR provides significantly better long-term survival than TACE. SR should be considered as a priority treatment in this subgroup of HCC patients.     

Performance Status Enhances the Selection of Treatment for Patients with Hepatocellular Carcinoma Within the Milan Criteria

Background

Performance status (PS) is closely linked with survival in patients with hepatocellular carcinoma (HCC). We investigated its impact on treatment strategy for small HCC(s).

Methods

A total of 360 and 362 HCC patients within the Milan criteria undergoing surgical resection (SR) and radiofrequency ablation (RFA), respectively, were prospectively enrolled. Patients were classified into PS 0 (n = 558) and PS ≥1 (n = 164) groups. Propensity score analysis was performed, and 168 and 35 matched pairs were selected from patients with PS 0 and ≥1, respectively.

Results

The SR group was younger and had a higher male-to-female ratio, higher prevalence of hepatitis B, lower prevalence of hepatitis C, better PS, better liver functional reserve, and larger tumor burden than the RFA group (all p < 0.05). Among patients with PS 0, the SR group was consistently younger, less cirrhotic, and had larger tumor burden (all p < 0.05). The long-term survival was comparable between SR and RFA group in patients with PS 0. After propensity score matching, SR provided significantly better long-term survival than RFA for patients within the Milan criteria classified as PS 0 (p = 0.016); the Cox proportional hazards model showed consistent results. There was no significant difference of overall survival between the SR and RFA group in patients with PS ≥1 before or after propensity score matching (both p > 0.05).

Conclusions

For HCC patients within the Milan criteria and classified as PS 0, SR provides a better long-term survival compared with RFA. Performance status may enhance treatment selection and stratify the risk of survival in these patients.     

Prognostic Factors After Surgical Resection for Intrahepatic, Hilar, and Distal Cholangiocarcinoma

Background

The prognosis of patients with cholangiocarcinoma is unsatisfactory. Therefore, evaluation of prognostic factors and establishment of new therapeutic strategies are needed to improve their long-term survival. The aim of this study was to identify useful prognostic factors for patients with intrahepatic, hilar, and distal cholangiocarcinoma.

Materials and Methods

Records of 127 patients with cholangiocarcinoma (21 with intrahepatic cholangiocarcinoma, 50 with hilar cholangiocarcinoma, and 56 with distal cholangiocarcinoma) who underwent surgical resection were reviewed retrospectively. Relationships between survival and clinicopathological factors including patient demographics and tumor characteristics were evaluated using univariate and multivariate analysis.

Results

For all 127 patients, overall 1-, 3-, 5-year survival rates were 80, 51, and 40%, respectively. Univariate analysis revealed that adjuvant chemotherapy (P = .049), tumor differentiation (P = .014), lymph node metastasis (P < .001), surgical margin status (P < .001), UICC pT factor (P < .001), and UICC stage (P < .001) were associated significantly with survival. UICC pT factor (P = .007), adjuvant chemotherapy (P = .009), surgical margin status (P = .012), and lymph node metastasis (P = .014) remained independently associated with long-term survival by multivariate analysis. The 5-year survival rates of patients with or without positive surgical margins were 13 and 49%, respectively. The 5-year survival rates of patients treated with or without adjuvant chemotherapy were 47 and 36%, respectively.

Conclusions

R0 resection and adjuvant chemotherapy may be mandatory to achieve long-term survival for patients with cholangiocarcinoma.     

Hepatectomy for Huge Hepatocellular Carcinoma: Single Institute’s Experience

Background

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

Methods

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

Results

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

Conclusions

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

Retrospective study of 127 surgically treated patients with multiple brain metastases: indication, prognostic factors, and outcome

Background

Metastases are the most frequent tumours in the brain. At the time of diagnosis, more than 50% of patients present with multiple lesions. The goal of our retrospective investigation was to evaluate the outcome of patients who undergo surgery for multiple cerebral metastases and to determine prognostic factors.

Methods

We included 127 patients with multiple brain metastases in the study. The median number of metastases was three. All patients were operated on for at least one lesion. The indications for surgery were: large tumours ≥27 cm³, metastases of unknown primaries at the time of diagnosis, and space-occupying cerebellar lesions. If possible, adjuvant WBRT was applied.

Results

The median MST of the whole group was 6.5 months; for patients with complete resection, 10.6 months. According to the RPA classification the MST ranged between 19.4 (class I), 7.8 (class II), and 3.4 months (class III) (p < 0.001). KPS?>?70 had a significant influence on MST (9.1 months vs. 3.4 months, p?<?0.001), the number of lesions: 2–4 vs. >4 (p?=?0.046), and postoperative WBRT in multivariate analysis (p?=?0.026). Age was not a significant factor. The 2-year survival rate was 15% and the 3-year survival rate 10%.

Conclusions

Favourable factors for prolonged survival were complete resection of all lesions, no more than four metastases, RPA-class I and adjuvant WBRT. The resection of large lesions, while leaving smaller residual ones, did not result in increased survival.     

Milan Criteria, Multi-nodularity, and Microvascular Invasion Predict the Recurrence Patterns of Hepatocellular Carcinoma After Resection

Aims

This study aims to evaluate the risk factors for tumor recurrence beyond the Milan criteria (MC) for patients with hepatocellular carcinoma (HCC) after surgical resection (SR) in which salvage liver transplantation is relatively contraindicated.

Methods

A total of 447 patients who underwent SR for HCC were enrolled consecutively. Among them, 248 and 199 patients were within the Milan criteria and beyond the Milan criteria (BMC group), respectively. Overall survival, recurrence, and disease-free survival were analyzed by multivariate analysis.

Results

After a median follow-up of 34.4 months, 130 patients died. Microvascular invasion, higher Edmondson stage of tumor cell differentiation, BMC group, and no anti-viral therapy were associated with poor overall survival. Multi-nodularity, higher Edmondson stage, BMC group, and no anti-viral therapy were independent risk factors for tumor recurrence, while BMC group and no anti-viral therapy were independent risk factors for disease-free survival. The Milan criteria, multi-nodularity, and microvascular invasion were used to stratify the patients into low-, medium-, and high-risk groups for tumor recurrence outside the MC and showed statistical significance (low vs. medium, p?=?0.011; low vs. high, p?<?0.001; medium vs. high, p?=?0.009).

Conclusions

The combination of the MC, multi-nodularity, and microvascular invasion predict the post-operative recurrence of HCC and may provide a roadmap for further treatment.