Portal Invasion Research Articles

Benefits of Local Treatment Including External Radiotherapy for Hepatocellular Carcinoma with Portal Invasion.

Simple SummaryThe benefit of local treatment for hepatocellular carcinoma (HCC) with portal invasion is unclear. Radiotherapy can technically palliate vessel-invasive HCC; however, the survival benefit has not been confirmed. Local treatment including radiotherapy showed a survival benefit in large propensity score-matched cohorts (median survival: 8 vs. 2 months, p < 0.001). The benefit persisted among patients with Child-Pugh class A and B liver function. Our results represent community-level data from all Korean administrative districts.We aimed to identify the oncologic benefits of local treatment including radiotherapy (LRT) in hepatocellular carcinoma (HCC) invading the portal vein. We used clinical data of patients with HCC invading the portal vein from 2008 to 2014 provided by 50 hospitals nationwide. A total of 1163 patients were included in the analysis. The LRT group was younger than the best supportive care (BSC) group (p < 0.001). The mean Child-Pugh score of the LRT group (6.1) was significantly lower than that of the BSC group (7.7) (p < 0.001). Propensity score-matched analysis generated 222 pairs. The median survival of all patients, LRT, and BSC groups were 5.0, 8.0, and 2.0 months, respectively. The overall survival (OS) rates in the LRT and BSC groups were 34.2% and 16.2% at one year, and 12.6% and 6.8% at two years, respectively (p < 0.001). Multivariate analysis showed that LRT (HR 0.41, 95% CI 0.32–0.52), age >60 years, extrahepatic metastases, tumor size ≥10 cm, and Child-Pugh class (CPC) B or C were independent predictors of higher mortality (all p < 0.05). Statistical differences in survival were maintained in all CPC-albumin-bilirubin classes (all p < 0.05). LRT was significant in patients with HCC with portal invasion, valid for patients with CPC A and B.

Portal Vein Tumor Thrombus: No Longer a Death Sentence.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and a leading cause of cancer mortality worldwide. HCC commonly results from longstanding liver cirrhosis, which presents a host of complications and a severely diminished quality of life. Despite advancements in diagnosis, molecular pathogenesis, and management of the complications associated with irreversible liver diseases, HCC remains an aggressive malignancy with high mortality. HCC is often invasive to adjacent vasculature, including the inferior vena cava (IVC) and portal veins, which present with rapid morbidity and patient decline. This article describes a patient with cirrhosis and HCC previously treated with cryoablation now presenting with multiple new foci and invasion of the left medial portal vein. These lesions were synchronously cryoablated. Cryoablation is typically reserved for solid tumor masses within the soft tissue or specific organs. This report illustrates a technique of directly cryoablating tumors within vessels. We achieved adequate cryoablation of the intravascular HCC portal vein tumor thrombus in the left medial portal vein. A one-month follow-up CT scan demonstrated significant portal vein macrovascular invasion (MVI) regression from 22.8 mm to 7.7 mm. Portal vein invasion by HCC presents unique challenges and traditionally precludes percutaneous or surgical therapy. Our technique shows successful cryoablation of MVI as a viable adjunct to treatment in select patients.

Prognostic analysis of pancreatic carcinoma with portal system invasion following curative resection.

To analyze the related factors affecting the prognosis of pancreatic carcinoma with portal system invasion. We retrospectively analyzed the clinical data of 118 patients with portal venous system invasion in Beijing Chaoyang Hospital between January 2011 and December 2018. Only patients with borderline resectable pancreatic cancer were included in this study. Borderline pancreatic cancer was defined according to NCCN (The National Comprehensive Cancer Network) guidelines. All patients underwent surgical treatment combined with vascular resection and reconstruction. The prognosis was evaluated according to the follow-up results, and the related risk factors for prognosis were analyzed. The survival curve was drawn by Kaplan-Meier method, and the survival rate was compared by log-rank test. Multivariate Cox regression was used to analyze the prognostic factors. In our research, all of 126 patients were successfully completed the operations. Complications occurred in 29.7% of patients and perioperative death in 4.0%. A total of 118 patients were followed up and the followed-up rate was 97.5% (118/121). The overall 1-year, 2-year and 3-year survival rates were 49.2%, 27.1% and 19.8%, And the median survival time was 20 months. Multivariate analysis showed that preoperative CA19-9 (RR 1.449, 95% CI: 1.053-1.994), N status (RR 2.533, 95% CI: 1.337-4.798), degree of tumor differentiation (RR 1.592, 95% CI: 1.064-2.381) and venous invasion depth (RR 2.03, 95% CI: 1.504-2.758) were independent risk factors for the prognosis. The long-term prognosis of pancreatic carcinoma patients with portal system invasion is poor. The venous invasion depth is an independent risk factor for the prognosis of pancreatic carcinoma with portal system invasion, the deeper of venous invasion, the worse the prognosis, and poorly differentiated tumors have the worst prognosis. Other independent risk factors included N status and the preoperative CA19-9. Those may help with patients' selection for different treatment protocols.

Nomograms predicting extra- and early intrahepatic recurrence after hepatic resection of hepatocellular carcinoma

BackgroundExtrahepatic recurrence and early intrahepatic recurrence of hepatocellular carcinoma after hepatic resection are indicative of poor prognoses. We aimed to develop nomograms to predict extrahepatic recurrence and early intrahepatic recurrence after hepatic resection. MethodsThe participants of this study were 1,206 patients who underwent initial and curative hepatic resection for hepatocellular carcinoma. Multivariate logistic regression analyses using the Akaike information criterion were used to construct nomograms to predict extrahepatic recurrence and early intrahepatic recurrence (within 1 year of surgery) at the first recurrence sites after hepatic resection. Performance of each nomogram was evaluated by calibration plots with bootstrapping. ResultsExtrahepatic recurrence was identified in 95 patients (7.9%) and early intrahepatic recurrence in 296 patients (24.5%). Three predictive factors, α-fetoprotein >200 ng/mL, tumor size (3–5 cm or >5 cm vs ≤3 cm), and image-diagnosed venous invasion by computed tomography, were adopted in the final model of the extrahepatic recurrence nomogram with a concordance index of 0.75. Tumor size and 2 additional predictors (ie, multiple tumors and image-diagnosed portal invasion) were adopted in the final model of the early intrahepatic recurrence nomogram with a concordance index of 0.67. The calibration plots showed good agreement between the nomogram predictions of extrahepatic recurrence and early intrahepatic recurrence and the actual observations of extrahepatic recurrence and early intrahepatic recurrence, respectively. ConclusionWe have developed reliable nomograms to predict extrahepatic recurrence and early intrahepatic recurrence of hepatocellular carcinoma after hepatic resection. These are useful for the diagnostic prediction of extrahepatic recurrence and early intrahepatic recurrence and could guide the surgeon’s selection of treatment strategies for hepatocellular carcinoma patients.

Prognostic impact of lymph node parameters in distal cholangiocarcinoma after pancreaticoduodenectomy

BackgroundPancreaticoduodenectomy is the only definitively curative therapy for the long-term survival of distal cholangiocarcinoma patients. Lymph node metastasis is widely accepted as an important prognostic factor for distal cholangiocarcinoma. The latest American Joint Committee on Cancer (AJCC) TNM classification system for distal cholangiocarcinoma has divided the lymph node metastasis patients into N1 and N2 by lymph node metastasis number. However, some studies suggested that the lymph node metastasis ratio may be better than the lymph node metastasis number. Therefore, we develop a program to analyze the correlation between lymph node parameters (lymph node dissection number, lymph node metastasis number, and lymph node metastasis rate) and long-term prognosis.MethodsWe retrospectively reviewed 123 distal cholangiocarcinoma patients after pancreatoduodenectomy from January 2011 to December 2019. The patients were grouped according to lymph node metastases and tumor-free and overall survival rates which were investigated with the Kaplan-Meier analysis. The logistic regression models were used for multivariate analysis to determine the risk factors for lymph node metastases. And the X-tile program was used to calculate the cutoff values for the lymph node parameters that discriminated survival.ResultsThe 1-year, 3-year, and 5-year overall survival rates of patients with distal cholangiocarcinoma after pancreatoduodenectomy were 75.2%, 37.1%, and 31.5%, respectively. And the 1-year, 3-year, and 5-year overall survival rates of patients without and with lymph node metastasis were 83.0%, 50.7%, and 42.5% and 63.5%, 19.0%, and 19.0% (p = 0.000), respectively. Logistic regression showed CA19-9 and portal vein system invasion as independent risk factors for lymph node metastases. The receiver operating characteristic curve showed the optimal cutoff value of CA19-9 to predict the lymph node metastases was 75.5 U/mL. Determined by the X-tile software, the optimal cutoff values of the lymph node dissection number were 24 (p = 0.021), the lymph node metastasis number were 1 and 7 (p = 0.504), and the lymph node metastasis rate were 0.13 (p = 0.002).ConclusionLymph node metastasis is an important factor affecting the long-term survival of distal cholangiocarcinoma patients.CA19-9 and portal vein system invasion are independent risk factors for lymph node metastasis. Besides, the lymph node dissection number and lymph node metastasis rate can predict the long-term survival better than lymph node metastasis number.

Microvascular Venous Invasion in Hepatocellular Carcinoma: Why Do Recurrences Occur?

Hepatocellular carcinoma is the most common primary cancer of the liver. It is almost always associated with cirrhosis and it is usually diagnosed in later stages of the disease. Furthermore, recurrence rate following liver transplantation ranges between 15 and 30%. The most important factor determining the recurrence is vascular invasion. In this review, the issue of microvascular invasion causing hepatocellular carcinomarecurrence is reviewed.Macroscopic vascular invasion is almost easy to diagnose on radiologic evaluation. However, microscopic vascular invasion is almost always diagnosed with pathologic evaluation. On the other hand, microscopic vascular invasion is associated with early recurrences and reduced disease-free survival. The type of vessel that is invaded determines the nature of the spread of the tumor cells. Invasion of the hepatic venous tributaries leads to systemic metastasis whereas portal venous invasions lead to intrahepatic spread of the tumor. Microscopic vascular invasion should be diagnosed before liver transplantation or liver resection in order to deliver the appropriate therapy to the patients. Yet, there is no ideal marker to suggest microscopic vascular invasion before any intervention. Markers such as alpha-fetoprotein, des carboxy prothrombin, or gamma-glutamyl transferase have been found to be correlated with microscopic vascular invasion. These parameters are not very efficient to be used in routine clinical practice. Therefore, further research is needed to define ideal marker associated with microscopic vascular invasion.

Hepatocellular carcinoma with a non-smooth tumor margin on hepatobiliary-phase gadoxetic acid disodium-enhanced magnetic resonance imaging. Is sectionectomy the suitable treatment?

Anatomical sectionectomy or larger resection is known to be effective in patients with hepatocellular carcinoma (HCC) with microvascular invasion. A non-smooth tumor margin on hepatobiliary-phase gadoxetic acid disodium-enhanced magnetic resonance imaging (EOB-MRI) can predict microvascular invasion of HCC. We evaluated the usefulness of EOB-MRI for operative planning. We evaluated 224 patients with single HCC who underwent hepatectomy between 2010 and 2013. The tumor margin was determined preoperatively. The hepatic resection was determined based on tumor location, liver function, 3D CT simulation and functional liver reserve. To control for confounding variable distributions, propensity score match was applied to compare the outcomes. Multivariate analysis was conducted to identify independent predictors of 5-year recurrence-free survival (RFS) and overall survival (OS). Of 113 patients with a non-smooth tumor margin, 40 patients (35%) showed microscopic portal invasion. The 5-year RFS and OS rates were significantly higher after sectionectomy or larger hepatectomy (hemihepatectomy) than after segmentectomy or smaller hepatectomy (non-anatomical resection). Of 111 patients with a smooth tumor margin, eight patients (7%) showed microscopic portal invasion. The 5-year RFS and OS rates did not differ significantly between patients who underwent sectionectomy and those who underwent segmentectomy. Our preliminary results appear to recommend that HCC with a non-smooth margin on HB-phase images is treated with anatomical sectionectomy or larger hepatectomy.

Prognostic effect of preoperative neutrophil-lymphocyte ratio is related with tumor necrosis and tumor-infiltrating lymphocytesin hepatocellular carcinoma.

Blood neutrophil-to-lymphocyte ratio (NLR) is one index representing systemic inflammation, and high preoperative NLR has been suggested as an independent prognostic factor in HCC. However, the NLR cutoff value with the highest prognostic significance is not consistent, and the mechanism of this phenomenon remains unclear. Preoperative NLR was calculated from complete blood counts obtained before 14days from operation day in 234 patients who underwent curative resection for primary HCC. The presence of tumor necrosis and degree of tumor-infiltrating lymphocytes (TILs) was determined histologically. High preoperative NLR (≥ 2.5) was observed in 28 (12.0%) of 234 HCCs and was significantly associated with younger age, larger tumor size, high Edmonson grade, microvascular invasion, major portal invasion, advanced AJCC T or BCLC stage, and low albumin level. Patients with high preoperative NLR showed shorter disease-specific survival (DSS) (p = 0.002) and a tendency for shorter recurrence-free survival (RFS) (p = 0.096). High preoperative NLR was associated with presence of tumor necrosis and low TIL. On multivariable analysis, preoperative NLR was an independent prognostic factor for DSS (hazard ratio: 2.050 (95% confidence interval 1.139-3.691), p = 0.017). However, the independent prognostic effect of NLR for DSS disappeared when tumor necrosis and TILs were added as co-variables. High NLR is an independent prognostic factor in patients with HCC who undergo curative resection. The prognostic effect of high NLR might originate from the prognostic effect of tumor necrosis or TILs.

Correlation of serum PIVKA-II and AFP level with portal vein tumor thrombus and BCLC stage in newly diagnosed hepatocellular carcinoma patients.

e16608 Background: Protein Induced by Vitamin K Absence-II (PIVKA-II) is a tumor marker specific for hepatocellular carcinoma (HCC). PIVKA-II levels correspond with HCC oncogenesis and disease progression. Portal vein tumor thrombus (PVTT) in patients with HCC is a significant factor that affect treatment and prognosis. In this study we assessed the predictive value of PIVKA-II and AFP for vascular invasion and BCLC stage in newly diagnosed HCC patients. Methods: We retrospectively reviewed records of newly diagnosed HCC patients at a tertiary hospital in India between January 2019 to December 2019. Clinical details, BCLC stage, radiological imaging records, serum levels of PIVKA-II and AFP at the time of diagnosis were obtained from medical records. Diagnostic accuracy and cut-off value of PIVKA-II in patients with portal invasion were calculated using receiver operator curve (ROC) analysis. Multiple pairwise comparisions between BCLC stage with PIVKA-II and AFP levels were analysed using Kruskal-Wallis test. Results: Out of 162 newly diagnosed HCC patients 42(25.9%) were detected with PVTT on imaging such as contrast-enhanced computed tomography or magnetic resonance imaging at the time of diagnosis.120(74.1%) patients without PVTT were taken as controls for the analysis. Serum level of PIVKA-II in HCC patients with PVTT was significantly higher than in HCC patients without PVTT (1152.57 mAU/ml vs 146.39 mAU/ml; p = 0.001). AUROC of PIVKA-II was 0.796 (95%CI 0.70-0.892, p = 0.000).The optimal cut-off value of PIVKA-II was 271.81 mAU/ml with a sensitivity of 78.6% and specificity of 52.4%, and the diagnostic accuracy was 59.98%. AUROC of AFP was 0.619 (95%CI 0.59-0.72, p = 0.001). Median PIVKA-II value increased from BCLC stage A to D. Kruskal-Wallis test showed a significant difference of PIVKA-II levels between all stages except stage A and B (p values for stage A-B (0.297), A-C (0.000), A-D(0.000),whereas for AFP results were significant only between stages A and C (p values for stage A-B (0.348), A-C (0.003), A-D(0.206). Conclusions: Serum PIVKA-II level appears as a good predictive marker for PVTT and BCLC stage when compared to AFP which may guide therapeutic strategy and assessment of prognosis in newly diagnosed HCC patients.

P883 Hepatocellular carcinoma presenting as a tumor thrombus extending from the inferior vena cava to the right atrium in echocardiography

Abstract Case A 74 year-old white male with COPD, type 2 Diabetes, Atrial Fibrillation and a Pacemaker presented to our hospital for a routine echocardiography follow-up for mild to moderate Aortic Stenosis. His past social history was positive for moderate alcohol consumption but negative for tattoos, recent travel, illicit drug use, blood transfusion or chemical exposure. During evaluation in the echocardiography lab the patient had symptoms of dyspnea, fatigue and abdominal distension. He was hemodynamically stable and physical examination was positive for signs os ascites and inferior limb oedema, but disclosed no scleral icterus, asterixis, spider angiomata or overt hepatomegaly. There was a recent weight gain of 10kg. Cardiac and pulmonary auscultation was unrevealing. The echocardiogram revealed moderate left ventricle dysfunction (EF ∼40%), moderate aortic stenosis and a dilated inferior vena cava (31mm) with an image of a mobile mass in the confluence of the central hepatic vein with the inferior vena cava with extension to the right atrium. Initial blood chemistry and blood count revealed macrocytic anaemia; slight increased y-GT, C-reactive protein and NT-proBNP (6210pg/mL). The patient was admitted and anticoagulation with subcutaneous enoxaparin was initiated with echocardiographic follow-up. An abdominal ultrasound was performed which a hyperecogenic mass (71x47mm) adjacent to the right and left supra-hepatic veins, highly suggestive of hepatocelullar carcinoma. A triple-phase abdominal CT confirmed a nodular lesion 70x50mm on segment VIII, compatible with hepatocellular carcinoma (Fig.1). A cardiac magnetic resonance was performed documenting the tumor extension to the inferior vena cava and right atrium, suggestive of tumor thrombus (Fig.2). Multidisciplinary meeting enrolled the patient in palliative care. The right heart failure picture was refractory to medical treatment and the patient progressed to multi organ failure and a consumptive state. He died approximately 20 days after diagnosis. Discussion Intravascular tumor extension, also known as Tumor thrombus (TT) is a rare complication of some forms of cancer. In the late stages of Hepatocellular carcinoma (HCC) a TT can form in the portal or hepatic vein. These are usually detected during tumor workup or during evaluation of cardiorespiratory symptoms in a patient with a known abdominal carcinoma. Tumor invasion to the portal system is quite common while invasion to the inferior vena cava (IVC) and/or heart without invasion of the portal system is rare. Tumor extension to the RA or IVC, most patients were either symptomatic, had cirrhosis, or both. Our patient presented mainly with signs of right heart failure refractory to medical treatment and had no signs of portal invasion or hypertension in the various image modalities. The prognosis for a HCC with extension to the IVC or RA is grim, with a 1 to 4 months of mean survival regardless of treatment choice. Abstract P883 Figure.

A lack of postoperative complications after pancreatectomy contributes to the long-term survival of patients with pancreatic cancer

Background/Objectives: The objectives of this study were to identify the factors affecting patients’ survival and the characteristics of five-year survivors of pancreatic ductal adenocarcinoma (PDAC) after pancreatectomy as well as to clarify the correlation between the development of postoperative complications and a five-year survival. MethodsA total of 104 patients underwent pancreatectomy for PDAC between April 2005 and March 2013 with curative intent. Patients who survived for more than five years after pancreatectomy were classified as long-term survivors. Sixteen demographic and clinical variables and 10 pathological variables were comprehensively assessed for their associations with the patients’ survival time and long-term survival. ResultsThe presence of preoperative comorbidity (OR: 1.65, 95% CI 1.02–2.67, p = 0.042), postoperative overall complications (OR: 1.78, 95% CI 1.03–3.10, p = 0.041), a lymph node positivity ratio of ≥0.2 (OR: 3.04, 95% CI 1.51–6.11, p = 0.002), and portal invasion (OR: 2.58, 95% CI 1.48–4.49, p = 0.001) were identified as independent factors affecting the patients’ survival. The absence of postoperative overall complications was identified as an independent factor related to long-term survival in the multivariate analysis (OR: 0.08, 95% CI 0.01–0.82, p = 0.034). ConclusionsThe presence of preoperative comorbidity, postoperative overall complications, LNR ≥0.2, and portal invasion were prognostic factors affecting the patients’ survival, and avoiding postoperative complications after pancreatectomy might contribute to the long-term survival of PDAC patients after pancreatectomy. The further improvement of surgical procedures and perioperative care in order to reduce the rate of postoperative complications should be attempted.

Long-term outcome and prognostic factors of intrahepatic cholangiocarcinoma involving the hepatic hilus versus hilar cholangiocarcinoma after curative-intent resection: Should they be recognized as perihilar cholangiocarcinoma or differentiated?

BackgroundPerihilar cholangiocarcinoma is defined as tumors arising predominantly at or near the biliary confluence, potentially consisting of two types: hilar cholangiocarcinoma (HC) and intrahepatic cholangiocarcinoma involving the hepatic hilum (hICC). However, whether hICC and HC should be strictly distinguished or combined remains highly controversial. We aimed to compare the clinicopathological characteristics, prognostic factors and long-term outcome of hICC versus HC after curative-intent resection. MethodsBetween January 1998 and June 2015, a total of 325 patients with hICC (n = 146) and HC (n = 179) who underwent curative-intent resection were enrolled. The medical records of these patients were retrospectively reviewed. ResultsPortal vein invasion, larger tumors, and later T stage were significantly more common in hICC group. A total of 110 (75.3%) hICC patients and 119 (66.5%) HC patients experienced tumor recurrences, respectively. The median recurrence-free survival (RFS) and overall survival (OS) of hICC patients were significantly worse than those of HC patients (median RFS, 14.3 versus 22.7 months, P = 0.014; median OS, 21.7 versus 30.6 months, P = 0.032). Multivariate analysis revealed tumor size, satellite nodules, surgical margin, and histological grade as independent factors for OS in hICC patients. On the other hand, the presence of liver parenchyma invasion, portal invasion, lymphovascular invasion, later N stage, and positive surgical margin were associated with shorter OS in HC patients. ConclusionshICC showed distinct clinicopathological features, more aggressive biological behaviors, different prognostic factors, and worse prognosis in comparison with HC. Therefore, making a strict distinction between hICC and HC is necessary.

Surgery in chronic pancreatitis – A single center experience from Oslo

/Objectives: The objectives of this study were to identify the factors affecting patients’ survival and the characteristics of five-year survivors of pancreatic ductal adenocarcinoma (PDAC) after pancreatectomy as well as to clarify the correlation between the development of postoperative complications and a five-year survival.A total of 104 patients underwent pancreatectomy for PDAC between April 2005 and March 2013 with curative intent. Patients who survived for more than five years after pancreatectomy were classified as long-term survivors. Sixteen demographic and clinical variables and 10 pathological variables were comprehensively assessed for their associations with the patients’ survival time and long-term survival.The presence of preoperative comorbidity (OR: 1.65, 95% CI 1.02–2.67, p = 0.042), postoperative overall complications (OR: 1.78, 95% CI 1.03–3.10, p = 0.041), a lymph node positivity ratio of ≥0.2 (OR: 3.04, 95% CI 1.51–6.11, p = 0.002), and portal invasion (OR: 2.58, 95% CI 1.48–4.49, p = 0.001) were identified as independent factors affecting the patients’ survival. The absence of postoperative overall complications was identified as an independent factor related to long-term survival in the multivariate analysis (OR: 0.08, 95% CI 0.01–0.82, p = 0.034).The presence of preoperative comorbidity, postoperative overall complications, LNR ≥0.2, and portal invasion were prognostic factors affecting the patients’ survival, and avoiding postoperative complications after pancreatectomy might contribute to the long-term survival of PDAC patients after pancreatectomy. The further improvement of surgical procedures and perioperative care in order to reduce the rate of postoperative complications should be attempted.

Number of positive lymph nodes and lymphatic invasion are significant prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma.

Background: Early recurrence of distal cholangiocarcinoma (DCC) may result in a poorer prognosis. This study aimed to evaluate the clinicopathological factors that predict survival and recurrence in patients with DCC.Methods: Fifty-five patients with DCC who underwent pancreaticoduodenectomy between 2005 and 2015 were studied retrospectively. The following clinicopathological parameters were analyzed as predictors of disease-free survival (DFS) and overall survival (OS): sex, age, body mass index, presence of biliary tract decompression, macroscopic type, histological type, tumor size, TNM classification, lymph node metastasis ratio, number of positive lymph nodes (PLNs), lymphatic invasion, venous invasion, perineural invasion, proximal bile duct margin, dissected margin, portal system invasion, arterial system invasion, stage, and residual tumor.Results: Univariate analysis showed that contiguous extension of the primary tumor, PLN, lymphatic invasion, venous invasion, perineural invasion, and stage were significant prognostic factors for DFS and OS. Multivariate analysis revealed that PLN and lymphatic invasion were prognostic for DFS and OS (P<0.001). Significant differences in OS and DFS were found in analyses stratified by PLN (0, 1, 2 vs ≥3) and lymphatic invasion (0 vs 1, 2, 3).Conclusion: Among the clinicopathological parameters analyzed, PLN and lymphatic invasion were confirmed as prognostic factors for DCC.

Liver Allocation Policies in the USA: Past, Present, and the Future.

Identifying the optimal allocation policy with regard to hepatocellular carcinoma has been a persistent and evolving challenge. The current criteria for LT for HCC endorsed by the United Network of Organ Sharing (UNOS) are based on the Milan Criteria: a solitary tumor <5cm, or maximum of three tumors ≤3cm each, without vascular invasion or evidence of extrahepatic spread. Contraindications to HCC exception points include: stage 1 HCC, ruptured HCC, extrahepatic HCC, and main portal or hepatic vein HCC invasion. Based upon projected waitlist dropout rates due to tumor growth, patients with HCC are assigned MELD standardized exception points. In addition to tumor size and number, AFP levels are an important predictor of recurrence of HCC following liver transplantation. Standardized exception points for HCC patients are not awarded to patients with AFP levels >1000ng/mL that do not decrease to < 500 ng/mL with treatment. Appeals for MELD exception points for patients with HCC vary widely between UNOS regions, with success of nonstandardized exception point appeals varying from 3.1 to 21% between regions. In an effort to make prioritization for HCC more consistent, a national liver review board (NLRB)is being convened that will focus on developing a national guidance for assessing common requests and addressing exception points, including for HCC.

Biological and conditional factors should be included when defining criteria for resectability for patients with pancreatic cancer

BackgroundThis study aimed to evaluate novel resectability criteria for pancreatic ductal adenocarcinoma (PDAC) proposed by the International Association of Pancreatology (IAP) by comparing them with the National Comprehensive Cancer Network (NCCN) guidelines. Methods369 patients who underwent upfront surgery for PDAC were retrospectively analyzed. Overall survival (OS) of each group as defined by either of the guidelines were compared and preoperative prognostic factors for OS were identified. ResultsBased on the IAP-criteria, 157 patients were classified as resectable (R), 192 as borderline resectable (BR) and 20 as unresectable (UR), with the median survival time (MST) of 40 months, 17 and 11, respectively. In contrast to the NCCN-criteria, BR demonstrated significantly better OS than UR (P = 0.023) under the IAP-criteria. Performance status ≥2 (hazard ratio [HR]: 2.47, P = 0.014) and lymph node metastasis suspected by imaging (HR: 1.55, P = 0.003) were identified as independent prognostic factors by the multivariate analysis along with portal or arterial invasion, while carbohydrate antigen 19-9 ≥ 500 U/ml was not (HR: 1.23, P = 0.190). ConclusionThe IAP-criteria, which includes biological and conditional factors, resulted in superior separation of survival curves stratified by the resectablity when compared with the NCCN-criteria.

The pretreatment platelet count is an independent predictor of tumor progression in patients undergoing transcatheter arterial chemoembolization with hepatitis B virus-related hepatocellular carcinoma.

To explore the prognostic value of the pretreatment platelet (PLT) count in patients undergoing transcatheter arterial chemoembolization (TACE) with hepatocellular carcinoma (HCC). We prospectively analyzed 317 hepatitis B virus-related HCC patients undergoing TACE. Time to progression (TTP) was selected to evaluate the clinical significance of PLT level in HCC patients. PLT was the only parameter showing statistical significance of all the clinical characteristics between two distinct tumor response groups. After ruling out cirrhosis as a potential major confounding factor, the conclusion was further established. Higher pretreatment PLT level, portal vessel invasion and higher stratification of α-fetoprotein level were independently associated with longer TTP. The prognostic score model combining the three risk factors revealed that higher risk scores might mean shorter TTP. The pretreatment PLT level is a potentially useful biomarker to predict the prognostic outcomes in HCC patients undergoing TACE and deserves to be further explored in subsequent works.

Combined radiotherapy and transarterial chemoembolization as a first-line treatment for hepatocellular carcinoma with macroscopic vascular invasion.

452 Background: To evaluate the long-term clinical outcome of respiratory-gatedconformal radiotherapy in combination withtransarterial chemoembolization (TACE)asafirst-line treatment foradvanced hepatocellular carcinoma (HCC) with macroscopic vascular invasion (MVI). Methods: This was a retrospective analysis of patientswho were diagnosed with HCC showing MVI who received TACE plus radiotherapy as their initial treatment between 2010 and 2015. Inclusion criteria were Child-Pugh A or B hepatic function and Eastern Cooperative Oncology Group performance score 0–2. None of the patients had a previous history of radiotherapy to the liver or extrahepatic metastasis. Results: A total of 467 patients were included in the study. Patients were between 34 and 87 years of age, and 89.3% were male. The median maximum tumor diameter was 9.8 cm and 297 patients (63.6%) had Child-Pugh A hepatic function. Two hundred and eighty (60%) patients had multiple tumors; 45% of tumors showed bilobar involvement. Unilateral portal vein invasion was observed in 206 (44.1%) patients and main/bilateral portal veinor multiple vascular invasion were observed in 261 (55.9%) patients. The median overall survival was 12.5 months, with one- and two-year survival rates of 52% and 28%, respectively. Larger tumor size, multiple tumors, infiltrative tumor type, Child-Pugh class B, and alpha-fetoprotein ≥ 200 ng/ml were independent predictors of overall survival. Grade ≥ 3 hepatic and gastrointestinal toxicities were observed in 3 (0.6%) and 5 (1.1%) patients, respectively. Conclusions: Radiotherapy combined with TACE as an initial treatment was a safe and effective modality for advanced HCC patients with MVIand could be considered as first-line therapy in patients with liver-confined HCC showing MVI.

Role of local treatment including radiotherapy in Barcelona Clinic of Liver Cancer stage C patients: a nationwide cohort analysis in South Korea.

PurposeSorafenib is recommended as the standard treatment for hepatocellular carcinoma (HCC) of Barcelona Clinic of Liver Cancer stage C (BCLC C). However, local treatment including radiation therapy (LRT) is also widely administered in practice. The aim of our study was to define the role of LRT among BCLC C patients.Patients and methodsOf the patients with HCC enrolled the Korean Central Cancer Registry from 2008 to 2014, the Korean Liver Cancer Study Group randomly extracted 10,580 patient data from ~50 hospitals nationwide. Among them, 3,401 patients were categorized to have BCLC C HCC. Among them, patients with information on initial treatments, defined as the first and secondary treatment within 60 days after the first treatment, were selected and classified into three initial treatment groups: LRT, sorafenib, and no treatment.ResultsAmong 3,401 BCLC C HCC patients, 1,486 were included in the study and the remaining patients were excluded as they did not meet the criteria (eg, underwent local treatments without radiotherapy [RT] or received chemotherapy other than sorafenib). Of these, 266 were assigned to LRT (17.9%), 316 to sorafenib (21.3%), and 904 to no treatment group (60.8%). Median survival time of the sorafenib group was shorter than that of the LRT group (3.8 vs 7.6 months, P<0.001). In multivariable analysis, sorafenib group showed significantly higher risk related to mortality compared to LRT group, not only among all patients (HR: 1.50, 95% CI: 1.23–1.84) but also between subgroup cohorts with portal invasions (1.55, 1.23–1.84), with lymph node metastases (2.42, 1.53–3.83), without distant metastases (1.43, 1.10–1.87), and with distant metastases (1.57, 1.13–2.19). Additionally, no treatment group showed the worst survival among the three treatment groups not only in all patients, but also in all subgroups of patients (P<0.001 in all).ConclusionLRT as an initial treatment showed survival benefit as compared to sorafenib in HCC patients of BCLC C.

Number of positive lymph nodes and lymphatic invasion are significant prognostic factors for distal cholangiocarcinoma

Introduction: Early recurrence of distal cholangiocarcinoma (DCC) may Result in a poorer prognosis. This study aimed to evaluate the clinicopathological factors that predict survival and recurrence in patients with DCC. Method: Fifty-five patients with DCC who underwent pancreaticoduodenectomy between 2005 and 2015 were studied retrospectively. The following clinicopathological parameters were analyzed as predictors of disease-free survival (DFS) and overall survival (OS): sex, age, body mass index, presence of biliary tract decompression, macroscopic type, histological type, tumor size, TNM classification, lymph node metastasis ratio, number of positive lymph nodes (PLN), lymphatic invasion, venous invasion, perineural invasion, proximal bile duct margin, dissected margin, portal system invasion, arterial system invasion, stage, and residual tumor. Result: Univariate analysis showed that contiguous extension of the primary tumor, PLN, lymphatic invasion, venous invasion, perineural invasion, and stage were significant prognostic factors for DFS and OS. Multivariate analysis revealed that PLN and lymphatic invasion were prognostic for DFS and OS (p<0.001). Significant differences in OS and DFS were found in analyses stratified by PLN (0, 1, 2 vs. ≥3) and lymphatic invasion (0 vs. 1, 2, 3). Conclusion: Among the clinicopathological parameters analyzed, PLN, and lymphatic invasion were confirmed as prognostic factors for DCC.