Underwent Liver Resection For Hepatocellular Carcinoma Research Articles

Tumor burden score as a prognostic factor in patients with intermediate and locally advanced hepatocellular carcinoma undergoing liver resection: an attempt to extend resectability criteria

BackgroundSurgery is currently recommended as a curative treatment option for hepatocellular carcinomas (HCC) belonging to Barcelona Clinic Liver Cancer (BCLC) stage A only. This study aims to classify various BCLC groups as per Tumor Burden Score (TBS) in an attempt to identify patients who could benefit from resection. Materials and methodsA retrospective analysis of a prospectively maintained database of all patients operated for HCC between January 2010 and July 2022 was performed. TBS was defined as, TBS2 = (maximum tumor diameter)2 + (number of tumors)2. ResultsTwo hundred and ninety-one patients who underwent resection were staged as per the latest BCLC (A = 219, B = 45, C = 27) staging. Patients were segregated into low (<7.3) and high (>7.3) TBS. With a median follow-up of 36.2 months, the median OS for stages, A and B in the low TBS group was 107.4 and 42.7 months respectively. Median OS was not reached for patients in the BCLC C stage. In patients with high TBS, the median OS for BCLC A, B and C was 42.3, 25.72, and 16.9 months respectively. ConclusionTBS is a significant factor influencing survival in patients of HCC. TBS can be used to stratify patients in BCLC B and C stages and help select patients who would benefit from surgical resection to achieve good long-term survival with acceptable morbidity.

A Grading System of Microvascular Invasion for Patients with Hepatocellular Carcinoma Undergoing Liver Resection with Curative Intent: A Multicenter Study.

Microvascular invasion (MVI) is closely correlated with poor clinical outcomes in patients with hepatocellular carcinoma (HCC). A grading system of MVI is needed to assist in the management of HCC patient. Multicenter data of HCC patients who underwent liver resection with curative intent was analyzed. This grading system was established by detected number and distance from tumor boundary of MVI. Survival outcomes were compared among patients in each group. This system was verified by time-receiver operating characteristic curve, time-area under the curve, calibration curve, and decision curve analyses. Cox regression analysis was performed to study the associated factors of prognosis. Logistic analysis was used to study the predictive factors of MVI. All patients were classified into 4 groups: M0: no MVI; M1: 1~5 proximal MVIs (≤1 cm from tumor boundary); M2a: >5 proximal MVIs (≤1 cm from tumor boundary); M2b: ≥1 distal MVIs (>1 cm from tumor boundary). The recurrence-free survival (RFS), overall survival (OS), and early RFS rates among all the individual groups were significantly different. Based on the number of proximal MVI (0~5 vs >5), patients in the M2b group were further divided into two subgroups which also showed different prognosis. Multiple methods showed this grading system to be significantly better than the MVI two-tiered system in prognostic evaluation. Four multivariate models for RFS, OS, early RFS, late RFS, and a predictive model of MVI were then established and were shown to satisfactorily evaluate prognosis and have a great discriminatory power, respectively. This MVI grading system could precisely evaluate prognosis of HCC patients after liver resection with curative intent and it could be employed in routine pathological reports. The severity of MVI from both adjacent and distant from tumor boundary should be stated. A hypothesis about two occurrence modes of distal MVI was proposed.

Tumor burden in patients with early and intermediate-stage hepatocellular carcinoma undergoing liver resection: a retrospective multicenter study on clinical and oncological outcomes

BackgroundAccording to the Barcelona Clinic Liver Cancer (BCLC) staging system, liver resection (LR) is recommended for early-stage (BCLC-A) hepatocellular carcinoma (HCC) but not for intermediate-stage (BCLC-B). This study aimed to assess the outcomes of LR in these patients using a subclassification tumour burden score (TBS). MethodsAll consecutive patients that underwent LR for BCLC-A and BCLC-B HCC between 01/2010 and 12/2020 in 4 tertiary referral centers were included. Clinical outcomes and overall survival (OS) were assessed in relation to TBS and BCLC stages. ResultsAmong 612 patients included, 562 were classified as BCLC-A and 50 as BCLC-B. The incidence of overall postoperative complications (56.0 vs 41.5%, p = 0.053) and mortality (0 vs 1.6%, p = 1.000) were similar between BCLC-A and BCLC-B patients. OS was significantly higher for BCLC A/low TBS than BCLC B/low TBS (p = 0.009), while patients with medium and high TBS had similar OS, irrespective of BCLC stage (respectively p = 0.103 and p = 0.343). ConclusionsPatients with medium and high TBS had comparable OS and DFS, irrespective of BCLC A or B stage, and postoperative morbidity was comparable. These results highlight the need for refinement of the BCLC staging system, and LR could be considered for selected intermediate stage (BCLC-B) according to the tumour burden.

Comparisons of Viral Etiology and Outcomes of Hepatocellular Carcinoma Undergoing Liver Resection between Taiwan and Vietnam.

Epidemiologic data have suggested that etiologic variations of hepatocellular carcinoma (HCC) exist in different geographic areas, and might be associated with different outcomes. We compared the viral etiology, clinicopathological characteristics and surgical outcomes between 706 Taiwanese and 1704 Vietnamese patients with HCC undergoing liver resection. Vietnamese patients had a significantly higher ratio of hepatitis B virus (HBV) (p &lt; 0.001) and a lower ratio of hepatitis C virus (HCV) (p &lt; 0.001) and non-B non-C than Taiwanese patients. Among patients with HBV or non-B non-C, the mean age was younger in Vietnam than in Taiwan (p &lt; 0.001, p = 0.001, respectively). The HCC patients in Vietnam had significantly higher serum alpha-fetoprotein (AFP) levels (p &lt; 0.001), larger tumors (p &lt; 0.001), and a higher ratio of macrovascular invasion (p &lt; 0.001) and extrahepatic metastasis (p &lt; 0.001), compared to those in Taiwan. Patients treated in Vietnam had a higher tumor recurrent rate (p &lt; 0.001), but no difference in overall survival was found between both groups. In subgroup analysis, the recurrent rate of HCC was the highest in patients with dual HBV/HCV, followed by HCV or HBV, and non-B non-C (p &lt; 0.001). In conclusion, although the viral etiology and clinicopathological characteristics of HCC differed, postoperative overall survival was comparable between patients in Taiwan and Vietnam.

A new model based inflammatory index and tumor burden score (TBS) to predict the recurrence of hepatocellular carcinoma (HCC) after liver resection

To establish a model based on inflammation index and tumor burden score (TBS) to predict recurrence of hepatocellular carcinoma (HCC) after liver resection. A retrospective study was performed on 217 patients who diagnosed HCC underwent liver resection at Xiangya Hospital Central South University from June 1, 2017 to June 1, 2019. According to the receiver operating characteristic (ROC) curve, the optimal cut-off value of inflammatory index and the TBS was determined by the Youden index. Prediction performance was compared by the area under the receiver operating characteristic curve (AUC). Cox regression analysis was used to determine the risk factors for the recurrence of HCC after liver resection. According to the independent risk factors of the patients, a prediction model for HCC was established based on inflammation index and tumor burden score (TBS).The prediction performance of the model was compared with single index (TBS group and NLR group) and traditional HCC stage models (TNM stage and BCLC stage). MLR = 0.39, NLR = 2.63, PLR = 134, SII = 428 and TBS = 8.06 are the optimal cut-off values. AUC of SII, PLR, NLR, MLR and TBS were 0.643, 0.642, 0.642, 0.618 and 0.724respectively. MVI (P = 0.005), satellite nodule (P = 0.017), BCLC B-C stage (P = 0.013), NLR > 2.63 (P = 0.013), TBS > 8.06 (P = 0.017) are independent risk factors for the recurrence of HCC after liver resection. According to this study, the optimal inflammatory index NLR combined with TBS was obtained. The AUC of NLR–TBS model was 0.762, not only better than NLR group (AUC = 0.630) and TBS group (AUC = 0.671), also better than traditional BCLC (AUC = 0.620) and TNM (AUC = 0.587) stage models. Interestingly, we found that NLR and TBS should be good prognostic factor for recurrence of HCC after liver resection. The NLR–TBS model based the best inflammatory index (NLR) and TBS have a better prediction performance and the prediction performance of NLR–TBS model not only better than NLR group and TBS group, but better than BCLC and TNM stage models.

Platelet-albumin (PAL) score as a predictor of perioperative outcomes and survival in patients with hepatocellular carcinoma undergoing liver resection in a Western center

Background and objectivesPreoperative selection of patients with hepatocellular carcinoma (HCC) who will benefit from resection is highly advisable. The Platelet-Albumin (PAL) score was developed as a predictor of survival and morbidity following HCC resection. However, this has never been tested in western populations. MethodsThe impact of PAL score on perioperative outcomes and survival was evaluated and compared to Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) scores in patients who underwent HCC resection. ResultsA total of 182 patients were included. Postoperative morbidity was higher in patients with PAL grade II-III (P = 0.039), ALBI grade II-III (P = 0.028), and MELD >10 (P = 0.042). Post-hepatectomy liver failure (PHLF) occurred in 36 patients (19.8%) and was significantly higher in the PAL II-III and ALBI score II-III subgroup (P = 0.001). The PAL II-III group was the only one associated with higher perioperative mortality (OR 3.3, P = 0.036). The PAL score was an independent prognostic factor for overall survival in multivariate analysis (P = 0.018) and was the only one with the areas under the curve in ROC analysis significantly different for morbidity, PHLF, and mortality. ConclusionsThe PAL score predicts postoperative complications, mortality, PHLF, and survival following liver resection for HCC in western patients.

Significance of cytoplasmic expression of telomerase reverse transcriptase in patients with hepatocellular carcinoma undergoing liver resection

Telomerase reverse transcriptase (TERT) is reportedly expressed in various types of cancer. However, to the best of our knowledge, the significance of subcellular expression of TERT in hepatocellular carcinoma (HCC) has not been evaluated in detail. The present study evaluated TERT expression in resected HCC tumor tissues using immunohistochemistry. TERT expression was assessed in both the cytoplasm and the nucleus of HCC cells. The associations between TERT expression and clinical characteristics, including expression levels of DNA-dependent protein kinase catalytic unit (DNA-PKcs) and 8-hydroxyganosine (8-OHdG), were investigated. Among the 135 HCCs, TERT expression was positive only in the cytoplasm in 86 tumors (63.7%), was positive only in the nucleus in 3 tumors (2.2%), was positive in both the cytoplasm and the nucleus in 5 tumors (3.7%) and was negative in 41 tumors (30.4%). Similar results were confirmed using another antibody for TERT. Cytoplasmic TERT expression was markedly associated with hepatitis B surface antigen, poor tumor differentiation, and expression levels of DNA-PKcs and 8-OHdG. However, TERT expression in the cytoplasm or in the nucleus was not significantly associated with the overall or recurrence-free survival periods. In conclusion, TERT was mainly expressed in the cytoplasm of HCC tissues. Cytoplasmic TERT expression was closely associated with hepatitis B virus-related HCC and DNA-PKcs expression, as well as oxidative stress.

Laparoscopic Liver Resection Can Be a Standard Treatment for Hepatocellular Carcinoma of Low and Intermediate Difficulty

Introduction: To investigate the feasibility of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) with various difficulty, we compared LLR and open liver resection (OLR) in serial patient groups with matched difficulty level. Methods: We retrospectively reviewed 607 patients with HCC undergoing liver resection (81 of LLR, 526 of OLR) in our hospital from 2012 to 2019. Propensity score-matched (PSM) analysis was used to balance LLR and OLR with characteristics and difficulty levels by IWATE criteria. We compared the matched patients, and further analyzed the results in patient groups stratified by difficulty score (DS). Results: After 1:1 PSM process, 146 patients were selected. Compared to OLR, LLR had shorter hospital stay (9.4 vs. 11.5 days, p=0.071), less surgical complications (16.4% vs. 30.1%, p=0.049), lower inflow control rate (42.5% vs. 65.8%, p=0.005), while comparable disease-free and overall survival. Among the 73 matched patients of each group, 13, 41, 13 and 6 patients were classified as low, intermediate, advanced and expert DS group, respectively. Accordingly, LLR was associated with shorter hospital stay and less surgical complications in low and intermediate DS groups. The disease-free survival of LLR in intermediate DS group was superior to OLR (p=0.020). In advanced and expert DS groups, the peri-operative and oncologic outcomes between LLR and OLR were comparable. Conclusions: With careful patient selection, LLR for HCC had promising outcome in comparison to OLR. Our data suggest that LLR should be considered a standard procedure in HCC case of low and intermediate difficulty according to IWATE criteria.Tabled 1Comparison of clinical and oncologic outcomes between LLR and OLR after propensity score matching analysisMatched-LLR (n=73(100%))Matched-OLR (n=73(100%))P valueHepatic inflow control (Yes (n(%))31 (42.5)48 (65.8)0.005Grade ≧II complication (n(%))12 (16.4)22 (30.1)0.049Grade ≧III complication (n(%))2 (2.7)7 (9.6)0.166In-hospital mortality (n(%))0 (0.0)2 (2.7)0.497Surgical time (min) (mean±SD)288.6±102.1276.0±106.70.501Blood loss (ml) (mean±SD)342.5±394.4400.7±531.90.456Post-OP length of hospital stay (day) (mean±SD)9.4±5.311.5±9.80.071Positive resection margin (n(%))1 (1.4)4 (5.5)0.172Follow up period (month) (mean±SD)38.4±26.946.2±24.20.083 Open table in a new tab

Combination of three-dimensional reconstruction technique and blood parameters for the evaluation of tumor burden and prognosis in patients with hepatocellular carcinoma undergoing liver resection

Introduction: Hepatic resection is the mainstay of treatment for Hepatocellular carcinoma (HCC). Three- dimensional technique helps to create an image of the liver using pre-operative computed tomography (CT) scans which can be used for planning of surgery and counselling of the patient. Various lab parameters have also been shown to affect the prognosis of HCC. This study was designed to analyse whether three dimensional technique and blood parameters are correlated with the prognosis among HCC patients following hepatic resection and also to find a relation between these variables.&#x0D; Methods: Data were collected retrospectively to recruit HCC patients treated between January 2010 and December 2016. Seventy-three HCC patients without extrahepatic metastasis, who underwent hepatic resection and had pre-operative CT scan done in our centre were enrolled for this study. IQQA® was used to create a three-dimensional imaging, and various related laboratory parameters were also collected. Outcomes of these patients were calculated to establish a relationship between IQQA, laboratory results and the prognosis of the patients.&#x0D; Results: The one, three and five year overall survival (OS) rates were 94.4%, 53.3% and 19.4% respectively, and disease-free survival (DFS) rates were 75%, 31.3% and 12.8% respectively. IQQA percentage of tumor was statistically significant for both OS and DFS. In the multivariate analysis, patients having lymph node metastasis, vascular invasion and high pre-op CA 19-9 had lower DFS rate, while it increased in those with high pre-op albumin. Other significant variables for OS were lymph node metastasis, Child Pugh score, high pre-op alpha fetoprotein (AFP) value and high CA 19-9. Resected segments, lymph node metastasis, liver cirrhosis, blood loss and hospital stay were significant between the two IQQA subgroups (IQQA?30% and IQQA&gt;30%). Additionally in these IQQA subgroups, significant difference was found between DFS and OS.&#x0D; Conclusion: IQQA software is helpful to create a 3D image of the liver, and can be combined with lab parameters to predict prognosis for patients with liver cancer. Therefore, this three-dimensional imaging technique can be used as a routine technique for patients undergoing liver resection.

Preoperative Controlling Nutritional Status plus Tumor Burden Score for the Assessment of Prognosis after Curative Liver Resection for Hepatocellular Carcinoma

Objective: There are no previous studies analyzing the prognostic predictive value of adding the tumor factor (i.e., Tumor Burden (TB) score) to the Controlling Nutritional Status (CONUT) score for patients with hepatocellular carcinoma (HCC). This study aimed to investigate the value of the CONUT plus TB (CONUT-TB) score as a prognostic predictor in patients with HCC undergoing liver resection. Methods: Between 2015 and 2018, 96 consecutive patients with HCC underwent liver resection at our institution. Patients undergoing repeated liver resection and combined resection of a metastatic lesion were excluded. Patients were divided into 2 groups according to their CONUT-TB scores according to a cutoff value. Clinicopathologic prognostic factors for survival were analyzed using a database containing the medical records. Results: The optimal cutoff value of the CONUT-TB score determined by using a minimum p value approach was 13 points. Among the 81 patients included in the analytic cohort, 71 patients had low (<13) and 10 patients had high (>13) CONUT-TB scores. The overall 3-year survival rate of patients following liver resection for HCC in the high-CONUT-TB group was significantly worse than that of patients in the low-CONUT-TB group (62.5 vs. 89.3%, p = 0.003). Multivariate analysis indicated that a high CONUT-TB score was independently associated with overall survival after liver resection (p = 0.010). Conclusion: The CONUT-TB score is a valuable predictor of survival in patients with HCC after liver resection.

Resection of hepatocellular carcinoma in patients with portal hypertension: long-term results based on direct intraoperative measurement of portal venous pressure

Introduction: The existence of differences in long-term prognosis of hepatocellular carcinoma (HCC) patients with or without portal hypertension (PH) undergoing hepatic resection remains controversial. Our aim was to clarify the long-term prognosis of HCC patients with PH undergoing hepatectomy. PH diagnosis was based on intraoperative portal venous pressure (PVP) measurement. Materials and Methods: Between May 2001 and April 2005, 68 patients with HCC underwent liver resection. PVP was directly measured at the beginning of surgery. Patients were divided into a high (&gt;11 mm Hg) (n=33) or a low (≤11 mm Hg) (n=35) PVP group. Clinicopathologic factors and postoperative outcomes were compared between the 2 groups, with tumor staging stratification according to Milan criteria (selection criteria for patients receiving transplantation). Median follow-up time was 101 months. Results: Postoperative mortality was 0. Median PVP was 10.7 mm Hg (range; 2.9–23.5 mm Hg). Compared with patients with low PVP, patients with high PVP had lower platelet counts, lower serum albumin levels, higher ALT concentration, higher international normalized ratio, higher Model for End-Stage Liver Disease (MELD score), and increased blood loss and blood transfusion. Multivariate logistic regression analysis revealed factors related to high PVP: serum albumin level &lt;3.6 g/dL (odd ratio: 5.532, 95% confidence interval: 1.286-23.79, P=0.022), and MELD score &gt;6 (odd ratio: 5.585; 95% confidence interval: 1.638-19.040, P=0.006). Postoperative morbidity was comparable between the 2 groups. Overall survival and disease-free survival rates in the high PVP group were significantly lower than in the low PVP group (P&lt;0.05). Subgroup analysis showed that, for patients within Milan criteria, those in the high PVP group had lower overall survival (P=0.032) and disease-free survival (P=0.016) than in those in the low PVP group. For patients outside the Milan criteria, no differences in survival were observed. Conclusions: In patients with early stage HCC undergoing resection, high PVP is associated with impaired long-term prognosis. For these patients, close follow-up and early salvage liver transplants for recurrent disease may be necessary to improve long-term prognosis after surgery.

Elderly Hepatocellular Carcinoma Patients: Open or Laparoscopic Approach?

It remains unclear whether the short-term benefits and long-term outcomes of laparoscopic liver resection (LLR) accrue to elderly patients with medical comorbidities. The aim of the present study was to compare the outcomes between LLR and open liver resection (OLR) in elderly patients (≥65 years) with solitary, treatment-naïve solitary hepatocellular carcinoma (HCC). From January 2013 to August 2017, 256 elderly patients with solitary treatment-naive HCC underwent liver resection. All patients were Child–Pugh class A and older than 65 years. The OLR and LLR groups contained 160 and 96 patients, respectively. The median tumor size in the OLR group was significantly larger than that in the LLR group (3.9 vs. 2.6 cm), but the tumor size did not differ between the two groups after matching. The median operation time, blood loss, transfusion rate, and postoperative complications in the OLR group did not differ from those in the LLR group, but the operation time in the LLR group was longer than that in the OLR group after matching. The median hospitalization in the LLR group was significantly shorter than that in the OLR group. Disease-free survival (DFS) in the LLR group was better than that in the OLR group before and after matching, but the difference was not significant. Patient survival (PS) in the LLR group was similar to that in the OLR group. LLR is feasible and safe for elderly patients with solitary, treatment-naïve HCC. The short- and long-term benefits of LLR are evident in geriatric oncological liver surgery patients.

Serum metabolites may be useful markers to assess vascular invasion and identify normal alpha-fetoprotein in hepatocellular carcinoma undergoing liver resection: a pilot study

PurposeHepatocellular carcinoma (HCC) is the most common primary malignancy of the liver with a dismal prognosis. Vascular invasion, among others, is the most robust indicator of postoperative recurrence and overall survival after liver resection for HCC. Few studies to date have attempted to search for effective markers to predict vascular invasion before the operation. The current study would examine the plasma metabolic profiling via 1H-NMR of HCC patients undergoing liver resection and aim to search for potential biomarkers in the early detection of HCC with normal alpha-fetoprotein (AFP) and the diagnosis of vascular invasion preoperatively.Materials and methodsHCC patients scheduled to receive liver resections for their HCC were recruited and divided into two separate groups, investigation cohort and validation cohort. Their preoperative blood samples were collected and subjected to a comprehensive metabolomic profiling using 1H-nuclear magnetic resonance spectroscopy (NMR).ResultsThere were 35 HCC patients in the investigation group and 22 patients in the validation group. Chronic hepatitis B remained the most common etiology of HCC, followed by chronic HCV infection. The two study cohorts were essentially comparable in terms of major clinicopathological variables. After 1H-nuclear NMR analysis, we found in the investigation cohort that HCC with normal alpha-fetoprotein (AFP < 15 ng/mL) had significantly higher serum level of O-acetylcarnitine than those with higher AFP (AFP ≥ 15 ng/mL, P = 0.025). In addition, HCC with microscopic vascular invasion (VI) had significantly higher preoperative serum level of formate than HCC without microscopic VI (P = 0.023). These findings were similar in the validation cohort.ConclusionA comprehensive metabolomic profiling of HCC demonstrated that serum metabolites may be utilized to assist the early diagnosis of AFP-negative HCC patients and recognition of microvascular invasion in order to facilitate preoperative surgical planning and postoperative follow-up. Further, larger scale prospective studies are warranted to consolidate our findings.

Effect of Remote Ischemic Preconditioning in Patients Undergoing Hepatectomy With Portal Triad Clamping: A Randomized Controlled Trial.

Remote ischemic preconditioning (RIPC) is reported to reduce liver injury in patients undergoing hepatectomy for colorectal liver metastasis, but its role is unclear in hepatocellular carcinoma patients with portal triad clamping during hepatectomy. In this prospective, randomized trial, 140 patients with hepatocellular carcinoma undergoing liver resection requiring portal triad clamping were randomized to a RIPC group or a control group. Patients in the RIPC group received RIPC (3 cycles of 5-minute ischemia and 5-minute reperfusion in right upper limb with cuff pressure at 30 kPa [225 mm Hg]) approximately 10 minutes after induction of anesthesia. In the control group, patients received sham RIPC (the cuff was not inflated). The primary outcome was the postoperative peak level of total bilirubin (TBIL) and was analyzed with the independent t test. Secondary outcomes were liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay. Data from 136 patients (69 in the RIPC group and 67 in the control group) were analyzed. The RIPC group had on average a 5.9 μmol lower peak level of TBIL than the control group; the mean difference is -5.9, and the 95% confidence interval (CI) reverses to -17.9 to 6.1. There were no significant differences between the 2 groups in liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay. We found no evidence that RIPC can reduce postoperative liver injury after hepatectomy.

Preoperative aspartate aminotransferase-to-platelet-ratio index as a predictor of posthepatectomy liver failure for resectable hepatocellular carcinoma.

PurposeThis study aimed to investigate the efficacy of preoperative aspartate aminotransferase-to-platelet-ratio index (APRI) score to predict the risk of posthepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) after liver resection, and to compare the discriminatory performance of the APRI with the Child–Pugh score, model for end-stage liver disease (MELD) score, and albumin–bilirubin (ALBI) score.Patients and methodsA total of 1,044 consecutive patients with HCC who underwent liver resection were enrolled and studied. Univariate and multivariate analyses were performed to investigate risk factors associated with PHLF. Predictive discrimination of Child–Pugh, MELD, ALBI, and APRI scores for predicting PHLF were assessed according to area under the ROC curve. The cutoff value of the APRI score for predicting PHLF was determined by ROC analysis. APRI scores were stratified by dichotomy to analyze correlations with incidence and grade of PHLF.ResultsPHLF occurred in 213 (20.4%) patients. Univariate and multivariate analyses revealed that Child–Pugh, MELD, ALBI, and APRI scores were significantly associated with PHLF. Area under the ROC analysis revealed that the APRI score for predicting PHLF was significantly more accurate than Child–Pugh, MELD, or ALBI scores. With an optimal cutoff value of 0.55, the sensitivity and specificity of the APRI score for predicting PHLF were 72.2% and 68.0%, respectively, and the incidence and grade of PHLF in patients with high risk (APRI score >0.55) was significantly higher than in the low-risk cohort (APRI score <0.55).ConclusionThe APRI score predicted PHLF in patients with HCC undergoing liver resection more accurately than Child–Pugh, MELD, or ALBI scores.

Impact of conversion on the perioperative and long-term outcomes during laparoscopic hepatectomy for patient with hepatocellular carcinoma

Introduction: Conversion is not unusual in laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC). Whether unplanned conversion would impair the perioperative and long-term outcomes of HCC remains controversial. Method: From January 2012 to June 2018, patients with HCC undergoing liver resection were retrospectively reviewed. Using a propensity score matching method, patients who experienced conversion were matched with those who completed LH and those performed open hepatectomy. Then, the perioperative outcomes and long-term survival were compared between each group. Result: During the study period, 708 and 1506 patients underwent laparoscopic and open hepatectomy, respectively. Of these, 60 patients (8.5%) experienced conversion to an open procedure during LH. Multivariate regression analysis showed that a history of upper abdominal surgery, posterolateral tumor location, and major hepatectomy were independent risk factors of conversion. After a 1:3 matching, 52 patient and 156 patients were enrolled in the final analysis. Conversion would deteriorate the intraoperative outcomes and increase postoperative complications. However, lethal complication is rare in both groups. The 1-, 3-, and 5-year disease-free survival rates were 77.0%, 63.6%, and 46.4%, respectively, in the laparoscopic group and 82.7%, 58.4%, and 58.4%, respectively, in the conversion group (P=0.698); while the overall survival rates were 92.1%, 77.5%, and 65.3%, respectively, in the laparoscopic group and 95.0%, 79.3%, and 63.4%, respectively, in the conversion group (P=0.822). There was no significant difference in survival outcomes. After a 1:8 matching with 1506 patients in the open group to eliminate the influence of confounding factors, the survival outcomes were also similar between the two groups. Conclusion: A history of upper abdominal surgery, central tumor location, and major hepatectomy are independent risk factors for conversion. Conversion would deteriorate the intraoperative outcomes and increase the total complications but not lethal complications. Timely conversion should be performed to avoid weakening the long-term survival of patients with HCC.

Liver resection is justified for multinodular hepatocellular carcinoma in selected patients with cirrhosis: A multicenter analysis of 1,066 patients

BackgroundThe role of liver resection for multinodular (≥3 nodules) hepatocellular carcinoma (HCC) remains unclear, especially among patients with severe underlying liver disease. We sought to evaluate surgical outcomes among patients with cirrhosis and multinodular HCC undergoing liver resection. MethodsUsing a multicenter database, outcomes among cirrhotic patients who underwent curative-intent resection of HCC were examined stratified according to the presence or absence of multinodular disease. Perioperative mortality and morbidity, as well as overall survival (OS) and recurrence-free survival (RFS) were compared between the two groups. ResultsAmong 1066 cirrhotic patients, 906 (85.0%) had single- or double-nodular HCC (the non-multinodular group), while 160 (15.0%) had multinodular HCC (the multinodular group). There were no differences in postoperative 30-day mortality and morbidity among non-multinodular versus multinodular patients (1.8% vs. 1.9%, P = 0.923, and 36.0% vs. 39.4%, P = 0.411, respectively). In contrast, 5-year OS and RFS of multinodular patients were worse compared with non-multinodular patients (34.6% vs. 58.2%, and 24.7% vs. 44.5%, both P < 0.001). On multivariable analyses, tumor numbers ≥5, total tumor diameter ≥8 cm and microvascular invasion were independent risk factors for decreased OS and RFS after resection of multinodular HCC in cirrhotic patients. ConclusionsLiver resection can be safely performed for multinodular HCC in the setting of cirrhosis with an overall 5-year survival of 34.6%. Tumor number ≥5, total tumor diameter ≥8 cm and microvascular invasion were independently associated with decreased OS and RFS after resection in cirrhotic patients with multinodular HCC.

A modified staging of early and intermediate hepatocellular carcinoma based on single tumour >7cm and multiple tumours beyond up-to-seven criteria.

The Barcelona Clinic Liver Cancer (BCLC) staging system is the most widely used staging system for hepatocellular carcinoma (HCC). However, the classifications of early (BCLC-A) and intermediate (BCLC-B) stage HCC remain controversial. To refine the staging of BCLC-A and -B. A total of 986 patients with HCC undergoing liver resection from two institutions formed the training cohort, and 694 from another institution were the validation cohort. Time-dependent receiver operating characteristic (ROC) curve analysis was performed to evaluate the performance of tumour size in predicting overall survival (OS), and determined the optimised cut-off. Discriminatory performance was evaluated using Harrell's concordance index (C-index). Patients with multiple tumours exceeding Milan criteria but within up-to-seven criteria had similar OS and disease-free survival (DFS) to those with multiple tumours meeting Milan criteria, and were assigned to the modified BCLC-A stage. The area under the ROC curve of tumour size for predicting OS was 0.778, and the diameter of 7cm was the optimal cut-off to identify patients with single tumours who had higher OS than BCLC-B stage patients. Due to the similar OS, patients with single HCCs >7cm were assigned to the modified BCLC-B stage. The C-indexes of the modified BCLC classification for OS and DFS were higher compared to the original version. The findings were supported by the validation cohort. The modified staging of BCLC-A and -B, based on single tumour >7cm and multiple tumours beyond up-to-seven criteria, could be more accurate to predict the prognosis of HCC patients. Liver resection could benefit patients with resectable multifocal HCCs beyond the Milan criteria.

Microwave-Assisted Ablation Improves the Prognosis of Patients With Hepatocellular Carcinoma Undergoing Liver Resection.

Objective:We evaluated microwave-assisted liver resection for hepatocellular carcinoma.Patients and Methods:We enrolled 79 patients in this study, and microwave ablation was used for liver resection. Patients were randomized to group A (50.6%; n = 40), liver resection without microwave ablation, or group B (49.4%; n = 39), liver resection performed using microwave ablation. Data were analyzed for statistical significance.Results:Of the participants enrolled, 60 were male, and the participant’s average age was 59.32 ± 10.34 years. The mean overall tumor diameter was 4.39 (2.00) cm, and this did not differ between groups. Intraoperative blood loss in group B was significantly less than that in group A (P < .001). No differences were reported between the 2 groups regarding surgical time (P = .914), postoperative morbidity (P = .718), and late postoperative complications (P = .409). Postoperative drainage volume for group B was less than that of group A on the first (P = .005) and third (P = .019) day after surgery. The time of postoperative hospitalization in group B was significantly shorter than that in group A (P < .001). Local recurrence was noted in 18.99% of cases (n = 15) in group B, which is less than that of group A (P = 0.047), while in group B distant metastasis is less but not statistically significant (P = 0.061). The 1-year and 3-year cumulative survival rates were 57% and 93.7%, respectively.Conclusions:The curative effects of liver resection combined with microwave ablation during operation are superior to only liver resection in the treatment of primary liver cancer.

Impact of statin use on the prognosis of patients with hepatocellular carcinoma undergoing liver resection: a subgroup analysis of patients without chronic hepatitis viral infection

BackgroundStatins have been reported to reduce the risk of hepatocellular carcinoma (HCC). The effect of perioperative statin use on the prognosis of HCC patients undergoing liver resection remains unclear. MethodsWe retrospectively analyzed 643 patients who underwent curative liver resection for HCC. Patients negative for hepatitis B surface antigen and hepatitis C antibody were classified as the non-B non-C HCC subgroup (n = 204). Perioperative statin users were defined as patients preoperatively receiving statin medications and maintaining > 28 cumulative defined daily doses after liver resection. The recurrence-free survival (RFS) and overall survival (OS) according to statin use were analyzed in the overall HCC cohort or in the non-B non-C HCC subgroup. ResultsAmong a total of 643 (HCC) patients, 43 patients (6.7%) received perioperative statin medications. In statin users, the proportion of non-B non-C HCC patients was significantly higher than in nonstatin users. Statin users had a high prevalence of obesity and diabetes, as well as dyslipidemia. The liver function of statin users was better than that of nonstatin users. The multivariate survival analysis revealed that use of statins was significantly associated with improvement of RFS (hazard ratio [HR], .42; 95% confidence interval [CI], 0.25–0.71; P = .001), but not with OS (HR, 0.62; 95% CI, 0.30–1.27; P = .19). In the subgroup analysis of the non-B non-C HCC cohort, statin use was significantly associated with improvement of RFS (HR, 0.47; 95% CI, 0.22–0.99; P = .04). ConclusionPerioperative statin use was associated with an improvement of RFS in HCC patients undergoing curative liver resection.