Comment on "Comparison of repeat hepatectomy with radiofrequency ablation for the survival of hepatocellular carcinoma with solitary intrahepatic recurrence after hepatectomy".

Comparison of repeat hepatectomy with radiofrequency ablation for the survival of hepatocellular carcinoma with solitary intrahepatic recurrence after hepatectomy.

Prognosis of patients with intrahepatic recurrence after hepatic resection for hepatocellular carcinoma: A retrospective study

In order to elucidate prognostic factors affecting long-term survival and intrahepatic tumor recurrence, 56 patients with HCC who underwent hepatic resection in the past 10 years were studied. The actual survival rate of the patients excluding 9 hospital deaths was 65% at 3 years, and 43% at 5 years. Prothrombin time and size of tumor were the decisive factors that affected long-term prognosis. Nineteen patients had intrahepatic recurrence of HCC among 47 patients who were discharged from the hospital. Of the 19 patients with recurrence, 14 had multiple lesions, and 16 of the recurrences were detected within 3 years of surgery. Patients having multiple recurrent HCCs had larger sized tumors at the time of resection than those with a solitary recurrence. The survival rates after recurrence were significantly better in patients with a solitary recurrence, and those treated with transcatheter arterial embolization therapy (TAE). Hepatic resection for patients with functionally well-preserved livers, bearing small tumors correlates with long-term survival. Early detection as well as TAE for recurrent HCCs is necessary to improve long-term survival.

To investigate the prognostic factors and treatment choice for intrahepatic recurrence after hepatectomy in patients with hepatocellular carcinoma (HCC). Clinicopathological data of 184 HCC patients with intrahepatic recurrence after hepatectomy were collected. The influences of twenty one clinicopathological factors and treatment modalities on the survival after recurrence were retrospectively analyzed. Univariate analysis showed that preoperative serum alpha-fetoprotein (AFP) >100 ng/ml, microscopic venous invasion, patients classified as Child-Pugh class B or C at diagnosis of recurrence, multiple recurrence foci and early recurrence (< or =12 months) were poor prognostic factors. Cox multivariate analysis showed that Child-Pugh class at diagnosis of recurrence, number of recurrent foci and time to recurrence were independent risk factors for survival in patients with recurrence. Median survival after recurrence was 34 months, 23 months, 15 months and 9 months, respectively, in patients treated by repeated hepatectomy, local ablation therapy, transcatheter arterial chemoembolization (TACE) or non-treatment in 69 patients with solitary recurrence. There were statistically significant differences among these four groups (P < 0.05). classification of Child-Pugh class A at the first time of diagnosis, solitary recurrence, late recurrence (> 12 months), and intrahepatic recurrence occurred after repeated hepatectomy or local ablation therapy are better prognostic factors in patients with HCC recurrence.

IntroductionThe adrenal gland is a rare site for hepatocellular carcinoma (HCC) recurrence after living-donor liver transplantation (LDLT). Solitary adrenal recurrence can be managed by surgical excision, with expected better survival outcomes.We describe a rare case of successful left adrenalectomy of solitary recurrent HCC in the left adrenal gland 5 years after LDLT. Presentation59 years male patient with HCC complicating chronic HCV infection received a right hemi-liver graft from his son. The actual graft weight was 1208 g and GRWR was 1.5. The patient started oral direct acting antiviral drugs for recurrent HCV 2 years after LDLT.A left adrenal mass was detected on follow up radiology. No other metastatic lesions were detected on metastatic workup. Left adrenalectomy was done by an anterior approach.The postoperative course was uneventful and was discharged a week after operation. Postoperative pathological and immune-histochemical examinations confirmed the metastatic HCC nature of the mass. The patient is under regular follow up with no recurrences 6 month after resection. DiscussionThere is no consensus regarding the management of HCC recurrence after LDLT. Most patients had multi-organ recurrences and usually offered palliative or supportive care. Solitary HCC recurrence offers a better chance for more aggressive therapy, offering better prognosis. ConclusionSolitary adrenal recurrence of HCC after LDLT is extremely rare. Strict follow up protocol is necessary to allow early detection of tumor recurrence. Curative surgical resection is a safe option associated with low morbidity and expected to have a good long-term survival.

By comparing cohorts in 2 exclusive time frames, the factors that affected the surgical outcomes of patients with hepatocellular carcinoma (HCC) are presented. Reportedly, survival results of patients with HCC who underwent hepatectomy have improved in recent years. However, the major factors contributing to these favorable outcomes have not been fully explained. Between January 1985 and December 2000, 610 patients with HCC underwent liver resections as a primary and curative resection. They were categorized into 2 groups according to the year in which the surgeries were performed: before 1990 (n = 212; early group); and after 1991 (n = 398; late group). Clinicopathologic data, survival data, type of recurrence, and treatment of intrahepatic recurrence were compared between the 2 groups. Clinicopathologic data were almost identical between the groups except for age, blood loss, and duration of surgery. The overall survival rate was significantly better in the late group compared with the early group (58.0% vs. 39.1% at 5 years, P < 0.0001). By contrast, disease-free survival remained unchanged (27.8% vs. 26.2% at 5 years, P = 0.2887). The most common type of recurrence was intrahepatic relapse, and there was no difference in the rate and the type of recurrence between the 2 groups. The 5-year survival rate after recurrence was increased in the late group (21.8% vs. 11.6%, P = 0.0002). Stratified analysis by the type of initial recurrence revealed that better survival in the late group was achieved only in solitary intrahepatic recurrences, not in multiple intrahepatic or extrahepatic recurrences. Changes in modality of treatment of recurrence were observed only in the management of solitary intrahepatic recurrences, where percutaneous ablation therapies were more frequently applied with new ablation techniques. Patients that had undergone ablation therapies in the late group had better postrecurrent survival than those in the early group. Multivariate analysis showed that presence of local ablation therapies was an independent favorable prognostic factor only in the late group. Significant improvements in outcomes were achieved in patients with HCC who underwent curative liver resections. Percutaneous ablation therapy for intrahepatic recurrence was considered to be a major contributory factor for improving survival after recurrence, as well as for overall survival.

Management of solitary recurrent HCC: Is re-resection justified for those with adverse prognostic factors?

Aggressive management of patients with extrahepatic and intrahepatic recurrences of hepatocellular carcinoma by combined resection and locoregional therapy.

How should patients with hepatocellular carcinoma recurrence after liver transplantation be treated?

Hepatocellular carcinoma (HCC) is the second leading cause of cancer related death in Taiwan. However, HCC recurrence after living donor liver transplantation (LDLT) is an undesirable outcome, and the treatment is controversial due to different recurrent patterns. The aim of this study is to evaluate the efficacy of transarterial embolization (TAE) for HCC recurrence after LDLT.From March 2003 to February 20 11, 217 patients received LDLT for HCC under Milan/UCSF criteria in Kaohsiung Chang Gung Memorial Hospital. The clinical profiles, imaging features, histopathologic diagnosis, treatment methods and outcomes of HCC recurrence after LDLT were retrospectively analyzed. TAE was performed with a microcatheter system to protect hepatic artery anastomosis. The endpoint of this study was survival from time of recurrence.Recurrences were found in 15 patients (6.9%) with LDLT for HCC, and were divided into three groups by treatment. Group 1 (n=2) was surgical resection for localized extrahepatic recurrence. Group 2 (n=4) was TAE for intrahepatic recurrence. Group 3 (n=9) was systemic chemotherapy, radiation therapy or conservative treatment for multiple intrahepatic or extrahepatic recurrence. Kaplan-Meier survival estimates showed that the 6- and 12-monlhs survival after recurrence in group 1, 2, 3 was 100%, 75%, 55.5% and 100%, 37.5%, 0%.Surgery had significant benefit on survival after recurrence for solitary or localized resectable recurrence. TAE may have an effect in the loco-regional control of intrahepatic recurrence to prolong survival, even where limited extrahepatic metastasis could be controlled by other treatment. Multiple metastasis was usually unresponsive to chemotherapy and/or radiation therapy with shorter survival after recurrence.

Antiviral therapy after curative treatment of hepatocellular carcinoma in patients with chronic hepatitis B infection: Is tenofovir or entecavir preferred?

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Radiofrequency ablation (RFA) can be utilized in elderly patients and those with cirrhosis with reduced functional liver reserve as it is less invasive. The arfa RFA system is the first system to offer a linear mode. However, the differences in performance between the linear and existing (nonlinear) modes remain unknown. This retrospective observational study compared the performance of the linear (linear group) and nonlinear RFA modes (nonlinear group) in HCC. Data of 425 patients with one to three HCC tumors measuring ≤ 3 cm who underwent RFA were analyzed. Recurrence (local and distant), survival, and complication rates between the linear and nonlinear groups were determined. The intrahepatic distant recurrence rate was lower in the linear group than in the nonlinear group (p < 0.05). Multivariate analysis showed that the high platelet count, low AFP-L3 levels, initial case, and linear mode were independent factors associated with a low intrahepatic distant recurrence rate following RFA. Liver disease-related survival, HCC survival, overall survival of the initial HCC, local recurrence, and complication rates were comparable between the linear and nonlinear groups. The linear mode of the RFA protocol results in a lower intrahepatic distant recurrence rate compared with the nonlinear protocol.

Background: Non-hypervascular hypointense hepatic nodules during the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI have been reported to be associated with intrahepatic distant recurrence (IDR) after hepatectomy or radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). IDR is categorized into hypervascular transformation of non-hypervascular hypointense hepatic nodules and new intrahepatic recurrence. The aim of this study was to evaluate the relationship between non-hypervascular hypointense hepatic nodules on Gd-EOB-DTPA-enhanced MRI and IDR after RFA, focusing on new intrahepatic recurrence. Methods: Ninety-one consecutive patients with 115 HCCs undergoing pretreatment Gd-EOB-DTPA-enhanced MRI and RFA for treatment of HCC were enrolled. Results: Of the 91 patients who underwent RFA for HCC, 24 had non-hypervascular hypointense hepatic nodules on pretreatment Gd-EOB-DTPA-enhanced MRI. Recurrences were observed in 15 and 19 patients with and without non-hypervascular hypointense hepatic nodules, respectively. Of the 15 recurrences in patients with non-hypervascular hypointense hepatic nodules, 10 patients had new intrahepatic recurrences. The cumulative incidence of new intrahepatic recurrence was significantly higher in patients with non-hypervascular hypointense hepatic nodules than in those without non-hypervascular hypointense hepatic nodules (p < 0.0001). Multivariate analysis revealed that the presence of non-hypervascular hypointense hepatic nodules and Child-Pugh score were independent risk factors for new intrahepatic recurrence. Conclusions: Non-hypervascular hypointense hepatic nodules during the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI were a useful predictive factor for IDR, particularly for new intrahepatic recurrence, after RFA.

Recurrence of hepatocellular carcinoma in the liver remnant after hepatic resection

Increased survival in hepatocellular carcinoma with iodine-125 implantation plus radiofrequency ablation: A prospective randomized controlled trial