Hepatic Resection In Hepatocellular Carcinoma Patients Research Articles

Protocol of notable-HCC: a phase Ib study of neoadjuvant tislelizumab with stereotactic body radiotherapy in patients with resectable hepatocellular carcinoma

IntroductionLiver resection is the mainstay of curative-intent treatment for hepatocellular carcinoma (HCC), but the postoperative 5-year recurrence rate reaches 70%, and there are no adjuvant or neoadjuvant therapies recommended by...

Hepatic Resection Versus Stereotactic Body Radiation Therapy Plus Transhepatic Arterial Chemoembolization for Large Hepatocellular Carcinoma: A Propensity Score Analysis

Background and AimsThere are no comparative studies on the efficacy of hepatic resection (HR) and CyberKnife stereotactic body radiation therapy (CK-SBRT) plus transhepatic arterial chemotherapy embolization (TACE) in the treatment of large hepatocellular carcinoma (HCC). Therefore, this study aimed to compare the efficacy of HR and CK-SBRT+TACE in large HCC.MethodsA total of one hundred and sixteen patients were selected from November 2011 to December 2016. Among them, 50 were allocated to the CK-SBRT+TACE group and 66 were allocated to the HR group. The Kaplan-Meier method was applied to calculate overall survival (OS) and progression-free survival (PFS) rates. Propensity score matching was performed to control for baseline differences between the groups.ResultsThirty-six paired patients were selected from the CK-SBRT+TACE and HR groups. After propensity score matching, the 1-, 2- and 3-year OS rates were 83.3%, 77.8% and 66.7% in the HR group and 80.6%, 72.2% and 52.8% in the CK-SBRT+TACE group, respectively. The 1-, 2- and 3-year PFS rates were 71.6%, 57.3% and 42.3% in the HR group and 66.1%, 45.8% and 39.3% in the CK-SBRT+TACE group, respectively (OS: p=0.143; PFS: p=0.445). Both a high platelet count and low alpha-fetoprotein value were revealed as influencing factors in improving OS and PFS.ConclusionsCK-SBRT+TACE brought local effects that were similar to those of HR in HCC patients with a large and single lesion. Moreover, the liver injury occurrence rate was acceptable in both groups.

Surgical resection of early stage hepatocellular carcinoma: balancing tumor biology with the host liver.

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. In early stage HCC, current practice guidelines recommend surgical resection with 5-year overall survival (OS) rates approaching 60%. Due to heterogeneity of the patient population and underutilization of HCC screening, in the past only 10-37% of patients were eligible for surgical resection at the time of initial HCC diagnosis. With recent implementation of HCC screening programs resulting in earlier diagnosis, the number of patients that might be candidates for curative surgical resection has increased. Factors determining outcome following HCC diagnosis are complex and heterogenous in nature and treatment decisions should be based on both tumor- and patient-related factors. Tumor characteristics including tumor size, macrovascular invasion (MVI), and multifocality must be balanced against measures of liver dysfunction including portal hypertension, liver function, and future liver remnant (FLR) to assess the applicability of hepatic resection in patients newly diagnosed with HCC. The aim of this article is to review the indications for curative HCC surgical resection as it pertains to underlying tumor- and patient-related factors. We also discuss adjunctive therapies that may allow for an increased role for hepatic resection in HCC patients with early stage disease who are ineligible for upfront resection due to small liver remnant size.

Effects of branched-chain amino acids on postoperative tumor recurrence in patients undergoing curative resection for hepatocellular carcinoma: A randomized clinical trial.

No effective postoperative adjuvant therapies have been established for patients with hepatocellular carcinoma (HCC). The aim of this study was to investigate the effect of oral administration of branched-chain amino acids (BCAA) on the recurrence-free survival (RFS) after hepatic resection in HCC patients. In this randomized clinical trial, HCC patients undergoing curative resections were randomly assigned in a 1:1 ratio to the BCAA group or surgery-alone group. The BCAA group received BCAA (Livact® ) for up to 4years. The primary endpoint was RFS. The secondary endpoint was overall survival (OS). Multivariate analysis was performed to detect the clinical characteristics significantly associated with RFS. Between January 2010 and October 2014, 156 patients (75 in BCAA group and 81 in surgery-alone group) were enrolled in the study. Of these, two patients were excluded from the efficacy analysis. Comparison of the survival curves by the log rank test demonstrated no significant difference in the RFS (P=.579) or OS (P=.268) between the BCAA and the control group. Multivariate analysis revealed that the RFS was significantly associated with age and number of tumors. A beneficial effect of BCAA on the RFS was found in patients younger than 72years old with a HbA1c level of<6.4%. Oral BCAA supplementation could not reduce the risk of recurrence after hepatic resection in HCC patients; however, the results suggested that BCAA supplementation may be beneficial for selected patients who were younger and had mildly impaired glucose tolerance.

Conditional survival analysis of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide with an approximate 5-year survival of greater than 50% in patients after surgical resection. Survival estimates have limited utility for patients who have survived several years after initial treatment. We analyzed how conditional survival (CS) after curative-intent surgery for HCC predicts survival estimates over time. NCDB (2004-2014) was queried for patients undergoing definitive surgical resection for HCC. Cumulative overall survival (OS) was calculated using the Kaplan-Meier method, and CS at x years after diagnosis was calculated as CS1 = OS (X+5) /OS(X) . The final analysis encompassed 11 357 patients. Age, negative margin status, grade severity and radiation before surgery were statistically significant predictors of cumulative overall conditional survival (P ≤ .0001). Overall unconditional 5-year survival was 65.7%, but CS estimates were higher. A patient who has already survived 3 years has an additional 2-year, or 5-year CS, estimate of 86.96%. Survival estimates following hepatic resection in HCC patients change according to survival time accrued since surgery. CS estimates are improved relative to unconditional OS. The impact of different variables influencing OS is likewise nonlinear over the course of time after surgery.

Effect of Age (over 75 Years) on Postoperative Complications and Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma

BackgroundThanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged <75 years (younger). MethodOne hundred sixty-eight patients who underwent HR for HCC from 1998 to 2015 in our Center were analyzed using a prospective database. Complications, disease-free survival rates, and cumulative survival rates were compared between the two groups. ResultsDuring the immediate postoperative period, no differences were found about liver-related complications, hospital stay and 90-day mortality. However, older patients had more complications in class II or higher (Clavien classification) (p = 0.017). Although disease-free survival in both groups was similar (p = 0.099), overall survival was worse in the elderly group (p = 0.024). On multivariate analysis, only age ≥75 years was significantly related to overall survival. ConclusionIf elderly patients with liver cirrhosis and HCC are appropriately selected and evaluated, they might have favorable prognoses after HR.

Indication for surgical resection in patients with hepatocellular carcinoma with major vascular invasion.

Major portal vein invasion (MVI) by hepatocellular carcinoma (HCC) carries an extremely poor prognosis. Our aim was to clarify the indications of hepatic resection in the presence of MVI by HCC. Between 2001 and 2015, 1,306 patients undergoing primary treatment for HCC were analyzed (866 hepatic resections and 440 transarterial therapies). Significant prognostic factors were identified by retrospectively analyzing tumor status, liver function and treatment. Overall survival was compared in terms of the degree of vascular invasion and treatment. The 5-year survival rates according to the degree of vascular invasion (Vp) were Vp0: 51.9%, Vp1: 33.0%, Vp2: 16.7%, Vp3: 21.8%, and Vp4: 0%, respectively. Overall survival (OS) did not differ significantly between patients with Vp3 and Vp4 MVI (p = 0.153). Median survival following hepatic resection of Vp3 cases was significantly better than that for Vp4 cases (1,913 vs. 258 days, p = 0.014), while OS following transarterial therapy was not significantly different (164 vs. 254 days in Vp3 vs. Vp4, p = 0.137). Multivariate analysis revealed hepatic resection (Odds: 2.335 [95%CI: 1.236-4.718], p = 0.008) and multiple tumors (1.698 [1.029-2.826], p = 0.038) as independent predictors of survival. Hepatic resection in HCC patients with MVI should be indicate in patients with Vp3 invasion.

Preoperative Ratio of Neutrophils to Lymphocytes Predicts Postresection Survival in Selected Patients With Early or Intermediate Stage Hepatocellular Carcinoma.

This study aims to clarify the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) for patients with hepatocellular carcinoma (HCC) after potentially curative hepatic resection (HR). The prognostic value of the NLR for HCC patients has not been definitely reviewed by large studies, especially for those with different Barcelona Clinic Liver Cancer (BCLC) stages.A consecutive sample of 963 HCC patients who underwent potentially curative HR was classified as having low or high NLR using a cut-off value of 2.81. Overall survival (OS) and tumor recurrence were compared for patients with low or high NLR across the total population, as well as in subgroups of patients in BCLC stages 0/A, B, or C. Clinicopathological parameters, including NLR, were evaluated to identify risk factors of OS and tumor recurrence after potentially curative hepatic resection. Multivariate analyses were performed using the Cox proportional hazards model or subdistribution hazard regression model.Multivariate analyses showed that NLR (>2.81), tumor number (>3), incomplete capsule, serum albumin (≤35 g/L), alanine transaminase activity (>40 U/L), and macrovascular invasion were risk factors for low OS, whereas NLR (>2.81), tumor size (>5 cm), alpha fetal protein concentration (>400 ng/L), and macrovascular invasion were risk factors for low tumor recurrence. NLR > 2.81 was significantly associated with poor OS and tumor recurrence in the total patient population (both P < 0.001), as well as in the subgroups of patients in BCLC stages 0/A or B (all P < 0.05). Moreover, those with high NLR were associated with low OS (P = 0.027), and also with slightly higher tumor recurrence than those with low NLR for the subgroups in BCLC stage B (P = 0.058). Neither association, however, was observed among patients with BCLC stage C disease.NLR may be an independent predictor of low OS and tumor recurrence after potentially curative HR in HCC patients in BCLC stages 0/A or B.

Multiple Tumors Located in the Same Section Are Associated with Better Outcomes After Hepatic Resection for HCC Patients Meeting the Milan Criteria

The impact of the tumor location on the outcome after hepatic resection (HR) in multifocal hepatocellular carcinoma (HCC) is still poorly understood. The aim of this study was to compare the short- and long-term outcomes of HR patients with multifocal tumors meeting the Milan criteria and tumors located in the same or different sections. A total of 219 consecutive HR patients with multifocal tumors meeting the Milan criteria were divided into group SS (n = 97; same section) and group DS (n = 122; different sections) according to their anatomical location (Couinaud’s segmentation). The prognostic predictors were evaluated, and a subgroup analysis was performed. The 1-, 3-, and 5-year overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in group SS than group DS. The subgroup analysis showed that patients with two tumors in the same section and patients undergoing en bloc resection had better OS and RFS. A multivariate analysis revealed that tumors located in different sections and macrovascular invasion were independent predictors of poor prognosis. In HCC patients with multifocal tumors meeting the Milan criteria, tumors located in the same hepatic section may lead to better long-term survival and lower HCC recurrence rates than tumors in different sections after HR.

Risk factors for incisional hernia after hepatic resection for hepatocellular carcinoma in patients with liver cirrhosis

The risk factors for incisional hernia (IH) and the association between liver fibrosis and IH after hepatic resection in patients with hepatocellular carcinoma (HCC) with liver cirrhosis (LC) are still unclear. We aimed to evaluate the rate of IH and to assess the effect of perioperative factors, including serum markers for liver fibrosis, on the risk of IH. A total of 192 patients with HCC with LC who received hepatectomy were retrospectively analyzed. The primary end point was the incidence rate of IH and the secondary end points were associations between IH and 22 clinical factors. IH was diagnosed in 60 (31.3%) patients. The estimated incidence rates were 19.8% at 12 months, 32.5% at 36 months, and 38.8% at 60 months. In multivariable analysis, the presence of postoperative intractable ascites (odds ratio 24.83, P = .0003), abdominal wall closure by a single-layer mass closure with a continuous running suture (odds ratio 4.59, P = .0143), preoperative body mass index ≥ 25 kg/m(2) (odds ratio 3.36, P = .0025), and preoperative serum N-terminal pro-peptide of type IV collagen 7S domain (P4NP 7S) levels ≥ 5 ng/mL (odds ratio 3.13, P = .0234) were independent risk factors. There are several risk factors for IH after hepatic resection in HCC patients with LC. Preoperative serum P4NP 7S levels ≥ 5 ng/mL are a useful predictive marker, and abdominal wall closure with a continuous running suture by a single-layer mass closure should be avoided.

The role of clinically significant portal hypertension in hepatic resection for hepatocellular carcinoma patients: a propensity score matching analysis

BackgroundWhether portal hypertension (PHT) is an appropriate contraindication for hepatic resection (HR) in hepatocellular carcinoma (HCC) patient is still under debate.Aims: Our aim was to assess the impact of clinically significant PHT on postoperative complication and prognosis in HCC patients who undergo HR.MethodsTwo hundred and nine HCC patients who underwent HR as the initial treatment were divided into two groups according to the presence (n = 102) or absence (n = 107) of clinically significant PHT. Propensity score matching (PSM) analysis was used to compare postoperative outcomes and survival.ResultsBefore PSM, PHT patients had higher rates of postoperative complication (43.1% vs. 23.4%; P = 0.002) and liver decompensation (37.3% vs. 17.8%; P = 0.002) with similar rates of recurrence-free survival (RFS; P = 0.369) and overall survival (OS; P = 0.205) compared with that of non-PHT patients. However, repeat analysis following PSM revealed similar rates of postoperative complication (32.2% vs. 39.0%; P = 0.442), liver decompensation (25.4% vs. 32.2%; P = 0.416), RFS (P = 0.481) and OS (P = 0.417; 59 patients in each group). Presence of PHT was not associated with complication by logistic regression analysis, or with overall survival by Cox regression analysis.ConclusionsThe presence of clinically significant PHT had no impact on postoperative complication and prognosis, and should not be regarded as a contraindication for HR in HCC patients.

Portal hypertension should not be a contraindication of hepatic resection to treat hepatocellular carcinoma with compensated cirrhosis

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. To the Editor: We read with great interest the article by Berzigotti et al.1 recently published in Hepatology. They observed that the presence of clinically significant portal hypertension (PH) negatively affects outcomes after hepatic resection (HR) to treat hepatocellular carcinoma (HCC) with compensated cirrhosis. Nevertheless, we believe that limitations in the study by Berzigotti et al.1 and results from our own medical center and elsewhere argue that PH should not be considered a contradiction of HR in such cases. Berzigotti et al.1 reported the outcomes of postoperative mortality and clinical decompensation, but they did not report the highly relevant outcomes of overall or disease‐free survival. Given that extending life expectancy is the goal of HR, the outcomes of long‐term overall and disease‐free survival are as clinically relevant, if not more so, than perioperative morbidity and mortality. In addition, Berzigotti et al.1 did not examine whether their results depended on Barcelona Clinic Liver Cancer (BCLC) stage or extent of hepatectomy (major or minor). This substantially limits their conclusions, given that numerous studies suggest that prognosis after HR depends strongly on BCLC stage. Although the results reported by Berzigotti et al.1 may lead clinicians to consider PH a contraindication for HR in HCC patients with compensated cirrhosis, we believe the weight of available evidence argues the opposite. A systematic literature search as well as retrospective study of more than 1,700 patients treated at our medical center between 2007 and 2010 revealed that median perioperative mortality during HR in HCC patients with PH is 6.7%.2 A previous retrospective study of more than 1,200 patients treated at our medical center between 2000 and 2007 found a median perioperative mortality of 10.3%,4 suggesting that improvements in surgical technique and perioperative care are lowering the mortality associated with HR. Our retrospective analysis further showed that long‐term survival of HCC patients with PH was higher after HR than after transarterial chemoembolization.4 In fact, such patients showed higher median overall and disease‐free survival at 1, 3, and 5 years after HR than did those with multinodular HCC or HCC involving macrovascular invasion.2 Retrospective subgroup analysis of our patients showed that short‐ and long‐term overall survival was similar in the presence or absence of PHT if the patients had early‐stage HCC or had undergone only minor hepatectomy, or if propensity score matching was used to eliminate baseline differences.3 Recurrence rates after HR were also similar in patients with or without PH.3 We suggest that despite being a negative prognostic factor, PH should not be regarded as an absolute contraindication to HR in HCC patients with compensated cirrhosis. Indeed, Berzigotti et al.1 seem to acknowledge this in their Conclusion section. We recommend that HR be considered a first‐line therapy for HCC patients with compensated cirrhosis, as well as for patients with early‐stage HCC and HCC patients scheduled to undergo minor hepatectomy, especially when liver transplantation and radiofrequency ablation are not indicated. In any event, PH should be measured directly whenever possible, given that not all patients diagnosed with PH using indirect methods actually fulfill the Barcelona group cutoff of ≥10 mmHg.5

Hepatic resection for hepatocellular carcinoma in patients with portal hypertension: a long-term benefit compared with transarterial chemoembolization and thermal ablation.

The optimal treatment for hepatocellular carcinoma (HCC) in cirrhotic patients with portal hypertension (PHT) is still controversial. The objective of this study is to compare HCC patients with PHT treated with hepatic resection to those treated with transarterial chemoembolization (TACE) or thermal ablation.A series of 167 cirrhotic patients with HCC undergoing hepatic resection or TACE/ablation from 2001 to 2008 were retrospectively analyzed. Cirrhotic patients with HCC were divided into 3 groups: hepatic resection in HCC patients with PHT (PHT-R group, n = 58), without PHT (NPHT-R group, n = 67), and TACE or thermal ablation in HCC patients with PHT (PHT-O group, n = 42). The short-term and long-term outcomes of liver function, operative mortality and morbidity, and survival rate were compared.Baseline characteristics were similar among the 3 groups, except for patients in the PHT-R group had larger spleen (16.0 vs 11.4 cm, P = 0.001) and smaller tumor size (4.8 vs 7.1 cm, P = 0.001) in comparison with those in the NPHT-R group. The PHT-R group had better liver function compared with those in the PHT-O group (patients had Child–Turcotte–Pugh class B liver function: 5.2% vs 31%, P = 0.001). There was no significant difference of operative mortality and morbidity in all groups. The 1-, 3-, 5-year survival rates were 80.4%, 55.6%, and 28.1% in the PHT-R group; 79.1%, 64.2%, and 39.8% in the NPHT-R group (vs PHT-R, P = 0.313); and 60.7%, 24.4%, and 7.3% in the PHT-O group (vs PHT-R, P < 0.001).Hepatic resection shows better long-term results for cirrhotic HCC patients with PHT than TACE and thermal ablation.

Expression of angiopoietin-2 and prognosis in hepatocellular carcinoma

Objective To study the relationship between the expression of angiopoietins-2 (Ang-2) and prognosis in hepatocellular carcinoma (HCC) after hepatic resection.Methods Sixty patients with primary liver cancer were retrospectively analyzed and the expression of Ang-2 in carcinoma tissues were assayed by immunohistochemical staining.The interrelationships among the expression of Ang-2,clinicopathological factors and the grade of differentiation of HCC cells were studied.The relationship between the expressions of Ang-2 and survival time was analysed.Results The expression rate of Ang-2 was 70％.Ang-2 staining had no correlation with clinicopathological factors (P ＜ 0.05),but it had a significant correlation with the grade of differentiation of HCC cells (x2 =5.424,P =0.025).Ang-2 of moderately and poorly differentiated HCC were higher (66.7％) than those of well-differentiated HCC.The disease-free survival rates of patients with high Ang-2 expression and low Ang-2 expression were 50％ (1-year),33.3％ (3-year),16.7％ (5-year) and 89.6％ (1-year),50.0％ (3-year),27.1％ (5-year),respectively.The disease-free survival of patients with high Ang-2 expression were significantly less than those of patients with low Ang-2 expression (x2 =6.477,P =0.021).Conclusion The expressions of Ang-2 are correlated with the grade of differentiation of HCC cells,but are not correlate with clinicopathological factors.The survivals of patients with Ang-2 high expression are lower than those of low expression.Ang-2 is a significant predictive factor for recurrence after hepatic resection in HCC patients. Key words: Angiopoietin-2 ; Carcinoma, hepatocellular; Immunohistochemistry

Assessment of safety in hepatic resection for hepatocellular carcinoma focusing on indirect hyperbilirubinemia

The indications for hepatic resection for hepatocellular carcinoma (HCC) patients with total bilirubin (T-Bil) equal to or higher than 1.2 mg/dl remain controversial. The aim of this study was to investigate the safety of hepatic resection for HCC patients who showed high T-Bil (≥1.2 mg/dl) with low direct bilirubin (D-Bil ≤ 0.5 mg/dl). Thirty-four HCC patients showing high T-Bil with low D-Bil were treated with mono- to tri-segmentectomy between January 2000 and December 2010. The perioperative clinical parameters and prognosis of the high T-Bil/low D-Bil patients were compared with those of 253 HCC patients showing normal T-Bil. In addition, complication rates of the patients with high T-Bil/high D-Bil (n = 4) were analyzed. The prothrombin time activity, indocyanine green clearance test, asialo-scintigraphy, and platelet count were similar in the two groups. The mean serum albumin in high T-Bil/low D-Bil patients was significantly higher than that of normal T-Bil patients (4.2 ± 0.5 vs. 4.0 ± 0.4 g/dl, P = 0.004). There were no significant differences in operation time, intraoperative bleeding, red cell concentrate transfusion rate, postoperative complication rate, and disease-free and overall survivals between the two groups. Postoperative hyperbilirubinemia (T-Bil >5 mg/dl) with ascites was observed in one of four high T-Bil/high D-Bil patients (25 %). Mono- to tri-segmentectomy can be performed in patients with low D-Bil (≤0.5 mg/dl) similarly to patients with low T-Bil (<1.2 mg/dl), even in HCC patients showing high T-Bil (≥1.2 mg/dl).

Oral supplementation of branched-chain amino acids reduces early recurrence after hepatic resection in patients with hepatocellular carcinoma: a prospective study

The long-term outcomes of branched-chain amino acids (BCAA) administration after hepatic resection in patients with hepatocellular carcinoma (HCC) remain unclear. This study assessed the effect of oral supplementation with BCAA on the development of liver tumorigenesis after hepatic resection in HCC patients. Fifty-six patients were randomly assigned to receive either BCAA supplementation (Livact group, n = 26) or a conventional diet (Control group, n = 30). Twenty-six patients in the BCAA group were treated orally for 2 weeks before and 6 months after hepatic resection. Postoperative tumor recurrence was continuously evaluated in all patients by measuring various clinical parameters. There was no significant difference in the overall survival rate between the two patient groups; however, the recurrence rate at 30 months after surgery was significantly better in the Livact group in comparison to the Control group. Interestingly, the tumor markers, such as AFP and PIVKA-II, significantly decreased at 36 months after liver resection in the Livact group in comparison to the Control group. Oral supplementation of BCAA reduces early recurrence after hepatic resection in patients with HCC. This treatment regimen offers potential benefits for clinical use in such patients, even in cases with a well-preserved preoperative liver function.

The effect of overweight status on the short-term and 20-y outcomes after hepatic resection in patients with hepatocellular carcinoma

BackgroundWe aimed to evaluate the impact of body mass index (BMI) on the short- and long-term outcomes of hepatic resection in patients with hepatocellular carcinoma (HCC). MethodsWe performed 371 hepatic resections in HCC patients whom we categorized into two groups based on BMI: BMI ≥25 (n = 77) and BMI <25 (n = 294). We compared surgical outcomes between groups. ResultsThe incidence of postoperative complications in the BMI ≥25 group was comparable to those in the BMI <25 group. However, patients in the BMI <25 group showed a significantly worse long-term prognosis than those in the BMI ≥25 group (P < 0.01). The results of multivariate analyses showed that BMI <25 was an independent and prognostic indicator of long-term outcome after hepatic resection in HCC patients. ConclusionsA BMI ≥25 is not a risk factor for mortality or postoperative complications, and is considered to provide a better long-term prognosis (>20 y) than a BMI <25 in patients with HCC after hepatic resection. Further studies are needed to determine whether these results apply to other patient populations outside Japan where BMI ≥30 is more prevalent.

Risk Factors Influencing Postoperative Outcomes of Major Hepatic Resection of Hepatocellular Carcinoma for Patients with Underlying Liver Diseases

Major hepatic resection of more than three segments in patients with hepatocellular carcinoma (HCC) is a high-risk operation, especially in patients with co-existing underlying liver diseases. The present study evaluated risk factors for postoperative morbidity and mortality after major hepatic resection in HCC patients with underlying liver diseases. Perioperative data of 305 HCC patients with underlying liver diseases who underwent major hepatic resection were evaluated by univariate and multivariate analyses to identify risk factors for postoperative morbidity and mortality. The overall morbidity rate was 37.0% (n = 113), caused by pleural effusion (n = 56), ascites (n = 43), subphrenic effusion/infection (n = 23), hepatic dysfunction (n = 22), bile leakage (n = 10), respiratory infection (n = 7), incision infection (n = 7), intra-abdominal hemorrhage (n = 5), and others. The hospital mortality rate was 2.6% (n = 8), primarily caused by liver failure (4/8). Multivariate logistic regression analysis showed that preoperative platelet count <100 × 10(9)/l (P = 0.006), and increased intraoperative blood loss (≥ 800 ml) (P = 0.008) were independent risk factors of postoperative morbidity, and that preoperative prothrombin time >14 s (P = 0.015) and preoperative platelet count <100 × 10(9)/l (P = 0.007) were independent risk factors for significant hospital mortality. Careful preoperative selection of patients in terms of the Child-Pugh classification and decrease of intraoperative blood loss are important measures to reduce postoperative morbidity after major hepatic resection in HCC patients with underlying liver diseases. Moreover, we should be aware that preoperative platelet count is independently associated with postoperative morbidity and mortality for those patients following major hepatic resection.

Chronic Schistosomiasis Japonica is an Independent Adverse Prognostic Factor for Survival in Hepatocellular Carcinoma Patients Who Have Undergone Hepatic Resection: Clinicopathological and Prognostic Analysis of 198 Consecutive Patients

The present study was carried out to clarify the clinicopathological features of hepatocellular carcinoma (HCC) patients with chronic schistosomiasis japonica (SJ) who underwent hepatic resection. Furthermore, we also analyzed the impact of chronic SJ on survival after hepatic resection. During the last 10 years in our department, 198 patients have undergone hepatic resection for HCC. Forty-four patients were diagnosed as having chronic SJ by histological examination. Clinicopathological features and survival were retrospectively analyzed. Age in the SJ group was significantly higher than in the non-SJ group. In the SJ group, positivity to HBsAg (hepatitis B surface antigen) was significantly lower than in the non-SJ group, and patients more often developed intrahepatic cholangiocellular carcinoma (or cholangiolocellular carcinoma) than in the non-SJ group. Greatest tumor dimension in the SJ group was significantly larger than in the non-SJ group. Univariate analysis revealed that chronic SJ, prothrombin time 80% or less and Child-Pugh B, des-gamma-carboxyprothrombin (DCP) level >40 milli-arbitrary units (mAU)/ml, tumor diameter of more than 5.0 cm, multiple tumors, vascular invasion, intrahepatic metastasis, advanced T stage (T2-4), and non-curative resection were associated with significantly worse overall survival. By multivariate analysis, chronic SJ, Child-Pugh B, advanced T stage, and non-curative resection were independent predictors of the adverse overall survival of HCC patients after hepatic resection. Patients with chronic SJ were older, had larger HCC, and were more often complicated by cholangiocellular carcinoma (or cholangiolocellular carcinoma) than non-SJ patients. Chronic SJ was an independent adverse prognostic factor for survival after hepatic resection in HCC patients.

Adjuvant Therapy for Patients with Hepatocellular Carcinoma Undergoing Hepatic Resection

The postresectional tumor recurrence rate is high in patients with hepatocellular carcinoma (HCC). To improve the long-term outcome for HCC patients after potentially curative resection, effective measures in reducing the recurrence risk are mandatory. The aim of adjuvant therapy is to decrease the incidence, or delay tumor recurrence, or to prevent new tumor formation in the liver remnant after hepatic resection. Various therapeutic modalities, including transarterial chemoembolization, systemic and loco-regional chemotherapy, I-131-lipiodol transarterial infusion, immunotherapy and treatment with anti-angiogenesis agents have been evaluated in the adjuvant setting. A review of the current evidence of adjuvant therapy in HCC patients indicates that the role of adjuvant therapy after hepatic resection for HCC patients has not been well established. Further randomized controlled studies are needed to confirm efficacy of the adjuvant protocols.