Hepatectomy For Recurrent Hepatocellular Carcinoma Research Articles

Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation: A Retrospective Cohort Study with Propensity Score-Matched Analysis.

Although radiofrequency ablation (RFA) is a well-established locoregional treatment modality for hepatocellular carcinoma (HCC), the optimal strategy to handle local recurrence after ablation is still debated. This study aims to investigate the role of salvage hepatectomy (SH) as a rescue therapy for recurrent HCC after RFA. Between January 2004 and December 2020, 1161 patients were subject to surgical resection for HCC. Among them, 47 patients who underwent SH for local recurrence after ablation were retrospectively analyzed and compared to a propensity score-matched group of controls (n = 47) who received primary hepatectomy (PH). Short-term and long-term outcomes were analyzed between the two groups. After matching, operation time, intraoperative blood loss, postoperative hospital stay, and postoperative morbidity rates showed no statistically significant difference. Tumors in the SH group were associated with poor differentiation (SH 9 (19.1%) vs. PH 1 (2.1%), p < 0.001). The 5-year disease-free survival rates (31.6% vs. 73.4%, p < 0.001) and overall survival rates (80.3% vs. 94.2%, p = 0.047) were significantly lower in the SH group. In multivariable analysis, less extensive resection compared to the initial plan (hazard ratio (HR) 4.68, p = 0.024), higher grade (HR 5.38, P < 0.001), negative but close (<0.1 cm) resection margin (HR 22.14, p = 0.007), and R1 resection (HR 3.13, p = 0.006) were significant predictors for recurrence. SH for recurrent tumors after ablation showed safety and effectiveness equivalent to primary resection. As recurrent tumors show a higher grade and more aggressive behavior, more extensive resections with wide surgical margins are necessary to prevent recurrence.

A commentary on "Laparoscopic versus open repeat hepatectomy for recurrent hepatocellular carcinoma: a systematic review and meta-analysis of propensity score-matched cohort studies".

aDepartment of General Surgery of Huidong, Zigong Fourth People’s Hospital, Zigong, 643000, Sichuan Province, China bDepartment of Ultrasound, Zigong Hospital of Woman and Children Healthcare, Zigong, 643000, Sichuan Province, China Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Published online ■ ■ *Corresponding author. Address: Department of General Surgery of Huidong, Zigong Fourth People’s Hospital, No. 282, Dangui Street, Ziliujing District, Zigong, 643000, Sichuan Province, China. Tel: +86 15884169385. E-mail address: [email protected] (H. Yang). This is an open access article distributed under the Creative Commons Attribution-ShareAlike License 4.0, which allows others to remix, tweak, and build upon the work, even for commercial purposes, as long as the author is credited and the new creations are licensed under the identical terms. http://creativecommons.org/licenses/by-sa/4.0/

Comparison of Open versus Laparoscopic Approaches in Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation.

Background and Objectives: Although radiofrequency ablation (RFA) is widely used as an effective local treatment for hepatocellular carcinoma (HCC), evidence on salvage hepatectomy for local recurrence after RFA is limited. This study aims to compare open and laparoscopic approaches in salvage hepatectomy for recurrent HCC after RFA. Materials and Methods: Among patients who underwent hepatectomy between January 2004 and August 2022 at a single tertiary referral center, 55 patients who underwent salvage hepatectomy for marginal recurrence after RFA were selected. An open approach was used in 23 (41.8%) patients, while 32 (58.2%) patients underwent laparoscopic surgery. Short-term and long-term outcomes were compared between the two groups. Results: Major hepatectomy was more often performed in the open group (9 [39.1%] vs. 4 [12.5%], p = 0.022). Intraoperative blood loss was also greater in the open group (450 (325-750) vs. 300 (200-600), p = 0.034). Operation time (p = 0.144) and postoperative morbidity rates (p = 0.639) were similar, and there was no postoperative mortality in either group. Postoperative hospital stay was significantly longer in the open group compared to the laparoscopy group (8 (6-11) days vs. 5 (4-7) days, p = 0.028). The 1-, 3-, and 5-year disease-free survival rates showed no difference between the two groups (44.6% vs. 62.5%, 16.5% vs. 13.5%, and 8.3% vs. 13.5%, respectively; p = 0.154). The 1-, 3-, and 5-year overall survival rates between the two groups were also similar (85.7% vs. 96.8%, 79.6% vs. 86.0%, and 79.6% vs. 79.4%, respectively; p = 0.480). Conclusions: Laparoscopic salvage hepatectomy shows oncologic outcomes comparable to the open approach with faster postoperative recovery rates. Considering that recurrence rates are high after RFA, the laparoscopic approach should be considered as a first-line option in selected patients.

Salvage hepatectomy for recurrent hepatocellular carcinoma after radiofrequency ablation

Yeshong PARK, Jai Young CHO*, Ho-Seong HAN, Yoo-Seok YOON, Hae Won LEE, Jun Suh LEE, Boram LEE, Yeongsoo JO, MeeYoung KANG, Eunhye LEE. Ann Hepatobiliary Pancreat Surg 2023;27:S174. https://doi.org/10.14701/ahbps.2023S1.LV-PP-2-2

THU-130 - Salvage hepatectomy for recurrent hepatocellular carcinoma after radiofrequency ablation

THU-130 - Salvage hepatectomy for recurrent hepatocellular carcinoma after radiofrequency ablation

Surgical and Oncological Outcomes of Salvage Hepatectomy for Locally Recurrent Hepatocellular Carcinoma after Locoregional Therapy: A Single-Institution Experience

Surgical and oncological outcomes of hepatectomy for recurrent hepatocellular carcinoma (HCC) after locoregional therapy, including locally recurrent HCC (LR-HCC), were examined. Among 273 consecutive patients who underwent hepatectomy for HCC, 102 with recurrent HCC were included and retrospectively reviewed. There were 35 patients with recurrent HCC after primary hepatectomy and 67 with recurrent HCC after locoregional therapies. Pathologic review revealed 30 patients with LR-HCC. Background liver function was significantly worse in patients with recurrent HCC after locoregional therapy (p = 0.002). AFP (p = 0.031) and AFP-L3 (p = 0.033) serum levels were significantly higher in patients with LR-HCC. Perioperative morbidities were significantly more frequently observed with recurrent HCC after locoregional therapies (p = 0.048). Long-term outcomes of recurrent HCC after locoregional therapies were worse than those after hepatectomy, though there was no prognostic difference according to the recurrence patterns after locoregional therapies. Multivariate analyses showed that prognostic factors for resected recurrent HCC were previous locoregional therapy (hazard ratio [HR] 2.0; p = 0.005), multiple HCCs (HR 2.8; p &lt; 0.001), and portal venous invasion (HR 2.3; p = 0.001). LR-HCC was not a prognostic factor. In conclusion, salvage hepatectomy for LR-HCC showed worse surgical outcomes but a favorable prognosis.

Laparoscopic versus open repeat hepatectomy for recurrent hepatocellular carcinoma: a systematic review and meta-analysis of propensity score-matched cohort studies.

The effectiveness of laparoscopic repeat hepatectomy (LRH) versus open repeat hepatectomy (ORH) on recurrent hepatocellular carcinoma (RHCC) is unclear. We compared the surgical and oncological outcomes of LRH and ORH in patients with RHCC with a meta-analysis of studies based on propensity score-matched cohorts. A literature search was conducted on PubMed, Embase, and Cochrane Library with Medical Subject Headings terms and keywords until 30 September 2022. The quality of eligible studies was evaluated with the Newcastle-Ottawa Scale. Mean difference (MD) with a 95% CI was used for the analysis of continuous variables; odds ratio (OR) with 95% CI was used for binary variables; and hazard ratio with 95% CI was used for survival analysis. A random-effects model was used for meta-analysis. Five high-quality retrospective studies with 818 patients were included; 409 patients (50%) were treated with LRH and 409 (50%) with ORH. In most surgical outcomes, LRH was superior to ORH: less estimated blood loss, shorter operation time, lower major complication rate, and shorter length of hospital stay (MD=-225.9, 95% CI=[-360.8 to -91.06], P =0.001; MD=66.2, 95% CI=[5.28-127.1], P =0.03; OR=0.18, 95% CI=[0.05-0.57], P =0.004; MD=-6.22, 95% CI=[-9.78 to -2.67], P =0.0006). There were no significant differences in the remaining surgical outcomes: blood transfusion rate and overall complication rate. In oncological outcomes, LRH and ORH were not significantly different in 1-year, 3-year, and 5-year overall survival and disease-free survival. For patients with RHCC, most surgical outcomes with LRH were superior to those of ORH, but oncological outcomes with the two operations were similar. LRH may be a preferable option for the treatment of RHCC.

The largest western experience on salvage hepatectomy for recurrent hepatocellular carcinoma: propensity score-matched analysis on behalf of He.RC.O.Le.Study Group.

We aimed to evaluate, in a large Western cohort, perioperative and long-term oncological outcomes of salvage hepatectomy (SH) for recurrent hepatocellular carcinoma (rHCC) after primary hepatectomy (PH) or locoregional treatments. Data were collected from the Hepatocarcinoma Recurrence on the Liver Study Group (He.RC.O.Le.S.) Italian Registry. After 1:1 propensity score-matched analysis (PSM), two groups were compared: the PH group (patients submitted to resection for a first HCC) and the SH group (patients resected for intrahepatic rHCC after previous HCC-related treatments). 2689 patients were enrolled. PH included 2339 patients, SH 350. After PSM, 263 patients were selected in each group with major resected nodule median size, intraoperative blood loss and minimally invasive approach significantly lower in the SH group. Long-term outcomes were compared, with no difference in OS and DFS. Univariate and multivariate analyses revealed only microvascular invasion as an independent prognostic factor for OS. SH proved to be equivalent to PH in terms of safety, feasibility and long-term outcomes, consistent with data gathered from East Asia. In the awaiting of reliable treatment-allocating algorithms for rHCC, SH appears to be a suitable alternative in patients fit for surgery, regardless of the previous therapeutic modality implemented.

Indocyanine Green Labeling of Tumors in the Liver Recurring After Radiofrequency Ablation Enables Complete Resection by Fluorescence-guided Surgery.

Radiofrequency ablation (RFA) is used to treat primary and metastatic tumors in the liver. However, local recurrence after RFA is frequent and subsequent salvage hepatectomy is often ineffective due to difficulty in visualization of tumor margins. In the present retrospective clinical trial, seven patients from the Department of General and Gastro-enterological Surgery, Showa University School of Medicine underwent salvage hepatectomy for recurrent hepatocellular carcinoma (HCC) (n=2), colorectal liver metastasis (n=4) and lung-carcinoid liver metastasis (n=1), after RFA, between 2011 and 2020. Tumors were labeled with indocyanine green (ICG) and resected under fluorescence guidance. Resected specimens were evaluated under fluorescence microscopy as well as by standard histopathological techniques. Pathological findings revealed negative tumor margins in all patients after fluorescence-guided surgery. Six of seven resected tumors had a fluorescent rim, including both HCC and liver metastasis. Fluorescence microscopy demonstrated that viable cancer tumor cells were located only on the inside of the fluorescent rim, and no malignant cells were detected within the fluorescent rim surrounding the tumor. Fluorescence microscopy showed that the tumor margin was secured if the fluorescence signal was completely resected. The present results demonstrate that ICG labeling of liver tumors recurring after RFA enabled complete resection under fluorescence guidance. The present study is the first clinical study to demonstrate that tumor types that generally cannot be completely resected with bright light are fully resectable under fluorescence guidance.

Transarterial Chemoembolization Combined With Radiofrequency Ablation Versus Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma After Curative Resection: A 10-Year Single-Center Comparative Study.

BackgroundThe purpose of this study was to compare the efficacy and safety of transarterial chemoembolization (TACE) in combination with radiofrequency ablation (RFA) (TACE-RFA) and repeat hepatectomy in the treatment of recurrent hepatocellular carcinoma (HCC) after curative resection.MethodsThis retrospective study evaluated consecutive medical records of patients who received either TACE-RFA or repeat hepatectomy between January 2010 and May 2021. Overall survival (OS), progression-free survival (PFS), and complications were compared.ResultsOf the 2672 patients who received either TACE-RFA or repeat hepatectomy, 111 eligible patients were included in our study, 63 in the TACE-RFA group and 48 in the repeat hepatectomy group. The median OS was 38 months in the TACE-RFA group and 42 months in the repeat hepatectomy group, with no statistically difference between the two groups (P=0.45). Meanwhile, there was also no statistically significant difference in PFS between the two groups (P=0.634). Although both groups achieved similar outcomes, the rate of major complications was significantly higher in the repeat hepatectomy group (P=0.003).ConclusionsPatients with recurrent HCC in the TACE-RFA group and the repeat hepatectomy group had similar OS and PFS regardless of the patient’s tumor diameter, but the TACE-RFA group was safer and more minimally invasive.

Laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma from segment 1 to 8: Is it a feasible treatment strategy?

Laparoscopic liver resection for hepatocellular carcinoma (HCC) is becoming the primary option for expert surgeons and high volume centers. However, repeat liver resection for recurrent HCC is still not yet established. This study aims to determine the surgical outcomes with laparoscopic repeat liver resection (LRLR) vs. open repeat liver resection (ORLR) for recurrent HCC. Fifty cases of repeat liver resection was done in our center since January 2009 to November 2020. The repeat surgery was performed under LRLR group for 23 patients and ORLR group for 27 patients. The surgical outcomes were studied retrospectively. We had 2 (8.6%) open conversion secondary to bleeding and severe adhesion from previous surgery. Most of the LRLR, 17 (73.9%) patients had primary laparoscopic liver resection. The LRLR had shorter operative time (mean 159.74 vs. 250.19 minutes; p ≤ 0.001), lesser intraoperative blood loss (mean 185.65 vs. 385.56 mL; p = 0.037), lower morbidity (8.6% vs. 62.9%; p ≤ 0.001) and shorter hospital stay (mean 5.83 vs. 9.26 days; p ≤ 0.001) compared with ORLR. There was no significant difference in the R0 resection and surgical margin between the two groups. LRLR is feasible and safe for highly selective patients. With the expert surgeons and in high volume centers, LRLR offers betters perioperative outcomes without compromising oncologic benefits compared with ORLR.

Repeat hepatectomy for patients with early and late recurrence of hepatocellular carcinoma: A multicenter propensity score matching analysis

BackgroundRepeat hepatectomy is a feasible treatment modality for intrahepatic recurrence after hepatectomy of hepatocellular carcinoma, yet the survival benefit remains ill-defined. The objective of the current study was to define long-term, oncologic outcomes after repeat hepatectomy among patients with early and late recurrence. MethodsPatients undergoing curative-intent repeat hepatectomy for recurrent hepatocellular carcinoma were identified using a multi-intuitional database. Early and late recurrence was defined by setting 1 year after initial hepatectomy as the cutoff value. Patient clinical characteristics, overall survival, and disease-free survival were compared among patients with early and late recurrence before and after propensity score matching. ResultsAmong all the patients, 81 had early recurrence and 129 had late recurrence from which 74 matched pairs were included in the propensity score matching analytic cohort. Before propensity score matching, 5-year overall survival and disease-free survival after resection of an early recurrence were 41.7% and 17.9%, respectively, which were worse compared with patients who had resection of a late recurrence (57.0% and 39.4%, both P < .01). After propensity score matching, 5-year overall survival and disease-free survival among patients with early recurrence were worse compared with patients with late recurrence (41.0% and 19.2% vs 64.3% and 43.2%, both P < .01). After adjustment for other confounding factors on multivariable Cox-regression analysis, early recurrence remained independently associated with decreased overall survival and disease-free survival (hazard ratio 2.22, 95% confidence interval 1.35–3.34, P = .001; hazard ratio 1.86, 95% confidence 1.26–2.74, P = .002). ConclusionRepeat hepatectomy for early recurrence was associated with worse overall survival and disease-free survival compared with late recurrence. These data may help inform patients and selection of patients being considered for repeat hepatectomy of recurrent hepatocellular carcinoma.

A case of laparoscopic hepatectomy for recurrent hepatocellular carcinoma after two previous open hepatectomies.

Introduction: Laparoscopic hepatectomy after open hepatectomy may be relatively easy depending on the positions of the tumor and the previous hepatectomy site. When adhesions are evident, however, laparotomy may be inevitable. We performed laparoscopic liver S5 partial resection for a patient with recurrent hepatocellular carcinoma(HCC) in S5 after having undergone open hepatectomy twice before and transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) multiple times during the previous 12 years. The video shows the procedure. Method: Patient: A man in his 70s. HPI: Liver S7 segmentectomy had been performed for HCC in 2006. HCC recurred in S1, and liver S1 partial resection was performed in 2009. Thereafter, TACE and RFA were performed four times each until 2018. The posterior branch of the portal vein was narrowed because of RFA. Hepatoma recurred at the inferior border of S5 of the liver in 2018. Laboratory data: HCV antibody positive, PLT 78,000/μl, ICGR15’ 18.0%. Result: Operative procedure: Left semi-lateral position. First, three ports were placed in the lower abdomen for adhesiolysis. After adhesiotomy of the greater omentum and the ascending colon was performed toward the liver, detachment of the descending part of the duodenum proceeded in a caudocranial direction. When the inferior surface of the liver was reached, the target liver tumor was confirmed with intraoperative ultrasonography. Several ports were added, and partial resection of S5 of the liver was performed. Conclusion: Even after two previous open hepatectomies, laparoscopic resection is possible, providing that preoperative image simulation and thorough adhesiotomy of the adjacent organs are performed, and laparoscopic resection should be attempted.

Laparoscopic redo hepatectomy for recurrent hepatocellular carcinoma: feasibility, safety and results

Laparoscopic redo hepatectomy for recurrent hepatocellular carcinoma: feasibility, safety and results

Detection of needle tract implantation and peritoneal seeding after radiofrequency ablation using intraoperative near-infrared fluorescence system for recurrent hepatocellular carcinoma: a case report

BackgroundRadiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is already fully established worldwide. Needle tract implantation and peritoneal seeding occasionally occur by RFA, and the prognosis of these cases is thought to be poor. In this study, intraoperative real-time near-infrared fluorescence (NIRF) system by indocyanine green (ICG) incidentally detected both needle tract implantation and peritoneal seeding. As the utility of this system for identification of implanted and disseminated lesions after RFA for HCC has not been widely reported, we report a case of successful detection by real-time ICG-NIRF imaging and subsequent resection.Case presentationA 76-year-old man originally underwent medial sectionectomy for HCC in 2009. When repeated intrahepatic recurrence occurred, he underwent RFA and transcatheter arterial chemoembolization (TACE) for recurrent HCC twice at segment III and once at segment IV. In 2013, the second hepatectomy for recurrent HCC at segment VIII was performed. In 2016, he had recurrent HCC at segment III around a previous RFA and TACE scar; therefore, left lateral sectionectomy was planned. ICG-NIRF system was used to observe a main intrahepatic metastasis at segment III and to search for other tumors in the remnant liver. Although there was no signal on the surface of the remnant liver, tiny signals were observed in the abdominal wall and greater omentum. These tumors were on the needle tract of the previous RFA; both lesions, therefore, were resected. These tumors were pathologically proven to be HCC metastases. The patient has had no recurrence 14 months after the last hepatectomy.ConclusionsICG-NIRF system might be helpful in the detection of not only intrahepatic lesions but also needle tract implantations or peritoneal seeding. RFA should be avoided in patients with high risk of needle tract implantation and peritoneal seeding.

Tu1485 - Combined Transcatheter Arterial Chemoembolization and Radiofrequency Ablation versus Hepatectomy for Recurrent Hepatocellular Carcinoma after Hepatectomy: A Propensity Score Matching Study

Tu1485 - Combined Transcatheter Arterial Chemoembolization and Radiofrequency Ablation versus Hepatectomy for Recurrent Hepatocellular Carcinoma after Hepatectomy: A Propensity Score Matching Study

Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation and/or Transcatheter Arterial Chemoembolization: A Propensity Score-Matched Analysis

Aim: We aimed to evaluate the short- and long-term surgical outcomes of salvage hepatectomy for recurrent hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) and/or transcatheter arterial chemoembolization (TACE). Methods: We reviewed the surgical outcomes of 90 recurrent HCC patients after RFA and/or TACE (salvage group) and 490 HCC patients without preoperative treatment (primary group). We performed 1:1 propensity score matching (PSM) between the 2 groups and matched 87 patients in each group. Results: Before PSM, the salvage group was pathologically more advanced than the primary group. After PSM, there were no significant differences in the clinicopathological features between the groups. The outcomes of propensity score-matched groups were compared and there was no statistically significant difference between the 2 groups regarding perioperative outcomes and survival. Univariate and multivariate analyses of propensity score-matched HCC patients revealed that stage, tumor size, differentiation, and portal vein invasion were independent prognostic factors for survival. Preoperative RFA and/or TACE was not a prognostic factor in a propensity score-matched cohort. Conclusions: The short- and long-term surgical outcomes of the primary and salvage groups were similar under the matched clinicopathological background. Salvage hepatectomy might be an acceptable treatment for recurrent HCC patients after RFA and/or TACE.

Second hepatectomy for recurrent hepatocellular carcinoma achieved sustained virological response to interferon therapy for hepatitis C.

Interferon (IFN) improves the prognosis of HCV-related hepatocellular carcinoma (HCC) in patients. However, the effects of IFN therapy for second hepatectomy (Hx) for recurrent HCC have not been established. Subjects included 96 patients who underwent a second Hx for recurrence of HCV-related HCC. Forty-four patients received IFN therapy past or postoperatively of the first Hx. Twenty of those patients attained a sustained viral response (SVR). The other 24 were non-responders (NR) and 52 patients who had not received IFN therapy (non-IFN) were classified as the NR/non-IFN group. Overall survival (SVR group vs. NR/non-IFN group: 5-yr, 91.7 vs. 51.0%; p = 0.012) and disease-free survival (SVR group vs. NR/non-IFN group: 3-yr, 64.7 vs. 25.9%; p = 0.006) rates were significantly different in both groups. By multivariate analysis, NR/non-IFN therapy, was the independent risk factor for overall survival (p = 0.025) and disease-free survival (p = 0.006) after second Hx. SVR achieved past or postoperatively of the first Hx of HCV-related HCC significantly inhibits recurrence and consequently improves patient survival after second Hx for recurrent HCC. Patients with SVR to IFN therapy would be good candidates for second Hx for recurrent HCC.

Nomograms for Pre-operative and Post-operative Prediction of Long-Term Survival of Patients Who Underwent Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma.

Repeat hepatectomy (re-hepatectomy) is an effective treatment for patients with intrahepatic recurrence following liver resection for hepatocellular carcinoma (HCC). This study aimed to develop nomograms for predicting prognosis after re-hepatectomy. The data of 635 patients who underwent re-hepatectomy for recurrent HCC at the Eastern Hepatobiliary Surgery Hospital between 2004 and 2010 were prospectively collected. Multivariable Cox regression analyses based on data obtained before and after re-hepatectomy were performed to select independent predictors of recurrence to death survival (RTDS) which were incorporated into the pre- or post-re-hepatectomy nomograms. Discrimination and calibration of the nomograms were measured using the concordance index (C-index), Kaplan-Meier curves, and calibration plots. The 1-, 3- and 5-year overall survival rates were 96.9, 74.8, and 47.8%, respectively, and the corresponding RTDS rates were 75.8, 45.7, and 37.6%, respectively. Tumor size and number at the initial and recurrent stages, time to recurrence from the initial hepatectomy, hepatitis B virus deoxyribonucleic acid level and microvascular invasion were selected into the two nomograms. The C-indexes for predicting RTDS were 0.72 [95% confidence interval (CI) 0.70-0.74] and 0.77 (95% CI 0.74-0.80) for the pre- or post-re-hepatectomy nomograms, respectively. The calibration curves for the probability of 5-year RTDS after re-hepatectomy showed optimal agreement between the prediction shown in the nomograms and the actual observations. Both nomograms were able to accurately stratify patients into four distinct incremental prognostic subgroups. The proposed nomograms have shown accurate RTDS prediction for patients with intrahepatic recurrent HCC.

The Feasibility of Third or More Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma.

To investigate the feasibility and prognostic benefits of third or more hepatectomy (third or more Hx) for recurrent hepatocellular carcinoma. Second hepatectomy (second Hx) has been accepted as an effective treatment of recurrent hepatocellular carcinoma after first hepatectomy (first Hx). However, the feasibility and efficacy of third or more Hx have not been adequately assessed. Data were reviewed from 1340 patients with hepatocellular carcinoma who underwent curative hepatectomy. Among them, 941, 289, and 110 underwent first Hx, second Hx, and third or more Hx, respectively. Surgical outcomes and long-term survival were compared among the groups. Surgical duration was significantly longer in third or more Hx (median, 6.4 hours) than in second Hx (median, 5.9 hours). Postoperative bile leakage and wound infection were more frequently observed in third or more Hx versus second Hx (12.5% vs 6.2%, [P = 0.04] and 2.9% vs 0.4% [P = 0.03], respectively). Three and 5-year disease-free survival rates were 36.8% and 27.1% in first Hx, 24.4% and 17.9 % in second Hx, and 26.1% and 12.8% in third or more Hx, respectively (P < 0.01 [first Hx vs third Hx], P = 0.95 [second Hx vs third or more Hx]). The 5-year overall survival rates from each resection were similar among the groups (65.3%, 60.5%, 68.2%, respectively). The 5- and 10-year overall survival rates from initial hepatectomy in patients who received third or more Hx were 91.4% and 75.5%, respectively. Third or more Hx is technically demanding in terms of surgical duration and morbidity compared with second Hx. However, aggressive repeat resection offers a survival similar to second Hx, leading to cumulative long-term survival from initial resection.