Primary Liver Resection Research Articles

<p>Salvage living donor liver transplantation for posthepatectomy recurrence: a higher incidence of recurrence but promising strategy for long-term survival</p>

BackgroundThe scarcity of deceased donor organ donation has led to increasing utilization of living donor liver transplantation (LDLT), which is an optimal treatment for cirrhosis associated with hepatocellular carcinoma (HCC). The study thus aims to analyze prognostic factors and beneficial effects of LDLT for patients with HCC.MethodsAll patients who underwent LDLT for HCC were included in this study. A multivariate analysis of patients’ clinicopathologic parameters was performed to determine prognostic factors. Subsequently, the type of LDLT was further analyzed and compared based on the result of multivariate analysis.ResultsOverall, 36 (11.9%) of 303 patients were identified as having HCC recurrence after LDLT. Salvage LDLT (sLDLT) defined by liver transplantation for those patients with recurrent HCC after primary liver resection (LR) was identified as the major prognostic factor of HCC recurrence following the transplantation (HR=2.49 [1.12–5.54], p=0.025). The HCC recurrence incidence and recurrence-free survival after LDLT were significantly inferior in the salvage group than the other group. The pre-transplantation factors were further evaluated and resulted in only maximum tumour size ≥5 cm at primary LR(HR=10.79 [2.10–55.43], p=0.004) affecting post-transplantation HCC recurrence in those patients who had been performed sLDLT. However, patients receiving salvage LDLT had 5- and 10-year overall survival of 86.7% and 52.9%, respectively, measured from the time of initial HCC diagnosis.ConclusionOverall, LDLT achieves a satisfactory result with low incidence of HCC recurrence based on certain transplantation criteria. Despite the higher incidence of HCC recurrence after sLDLT, it remains a promising strategy to improve long-term outcomes.

Survival after primary liver resection in metastatic colorectal cancer: A comparative analysis of the LICC trial with historical controls (FFCD ACHBTH AURC 9002 trial and EORTC Intergroup trial 40983).

e15019 Background: Metastatic colorectal cancer (mCRC) patients (pts) with liver-limited disease (LLD) have a chance of long-term survival and cure after hepatic metastasectomy. The optimal treatment after primary liver resection remains controversial. Here we compare results from the LICC trial with historical controls, the FFCD ACHBTH AURC 9002 trial (FFCD; Portier et al., 2006) and the EORTC Intergroup trial 40983 (EORTC; Nordlinger et al., 2008, 2013). The three trials investigated pts with mCRC LLD who underwent primary hepatic resection. Methods: LICC, FFCD and EORTC were compared regarding pts characteristics, treatment, surveillance and efficacy outcomes. LICC pts received the adjuvant antigen-specific cancer vaccine tecemotide (L-BLP25) or placebo after primary LLD resection for up to 2 years. The FFCD trial compared postoperative 5-FU/leucovorin and the EORTC trial perioperative FOLFOX versus surgery alone. Results: Primary resected pts in LICC (n = 80; R0 n = 76), FFCD (R0 n = 171; postoperative chemotherapy n = 86) and EORTC (n = 364) showed different pt characteristics concerning median age (60, 63 and 63 years) and rate of synchronous metastases (46.8%, 27.9% and 34.0%). In LICC, > 5 liver metastases were resected in 11.6% of pts, in FFCD and EORTC all eligible pts had < 5 liver metastases resected. In contrast to EORTC, LICC and FFCD had a close surveillance until recurrence or a maximum of 2 years. Median OS (mOS) in LICC was not yet estimable in primary resected pts (tecemotide arm: 62.8 months; placebo arm: not yet estimable). In the FFCD and the EORTC trial, mOS was 62.1 and 61.3 months, respectively. Further details will be presented. Conclusions: Despite unfavorable disease characteristic in LICC compared with the earlier EORTC and FFCD studies, primary liver resection without adjuvant chemotherapy led to surprisingly good survival outcomes. Improvements in imaging-based pt selection and liver resection techniques might in part explain our finding. Surgery alone appears to be an option for selected pts with resectable LLD. Better systemic chemo(immune-)therapy may have also contributed to the OS benefit. Clinical trial information: LICC: NCT01462513; EORTC: NCT00006479; FFCD: not registered.

The clinical impact of the treatment modality of recurrent intrahepatic single and small sized hepatocellular carcinoma after primary liver resection

The clinical impact of the treatment modality of recurrent intrahepatic single and small sized hepatocellular carcinoma after primary liver resection

Transplantable HCC in resectable cirrhosis – to resect or to transplant?

Background: The role of liver transplantation (LT) versus liver resection (LT) in patients with „transplantable“ and „resectable“ hepatocellular carcinoma (HCC) is a matter of ongoing controversy. The aim of this study was to analyze the outcome in these patients in our single center experience. Methods: Between 1998 and 2016, a total of 286 primary LT and 402 primary LR in patients with HCC were performed at our center and prospectively collected in an SPSS database. Selecting patients with HCC inside the Milan Criteria arising in Child A cirrhosis and excluding those with a contraindication to either LT or LR (age, ASA IV/V, vascular invasion, extrahepatic tumor) we identified 61 patients after primary LT (group A) and 49 after primary LR (group B). Secondary „salvage“ LT was attempted for recurrent HCC after primary LR. Results: The perioperative 90-day mortality was 1.6% in group A and 6.1% in group B, respectively. The 1-, 5- and 10-year OS (RFS) was 90 (86)%, 72 (62)%, and 49 (46)% in group A and 88 (61)%, 59 (20)%, and 29 (11)% in group B. „Salvage“ transplant was feasible in 13 (42%) out of 31 patients with recurrent HCC in group B. In this subgroup, the 1-, 5-, and 10-year OS calculated since LR was 100%, 100%, and 83%. Conclusion: For patients with “transplantable” and “resectable” HCC in this retrospective analysis, primary LT offered better overall and recurrence-free survival compared to primary liver resection. Intention-to-treat RCTs are needed.

Simultaneous laparoscopic liver resection: a single-center experience

Background: About 15 to 25% of colorectal cancer patients have synchronous liver metastasis at diagnosis. In the recent years, the strategy of simultaneous removal of colorectal cancer and liver metastases has been preferred. Development of minimally invasive technologies in abdominal and hepatopancreatobiliary surgery allows for active advance to fully laparoscopic approach to these types of interventions.Aim: Comparative analysis of simultaneous and isolated laparoscopic liver resections performed in the Department of Surgery, Russian Research Center of Roentgenoradiology (Moscow).Materials and methods: We have analyzed intra- and postoperative results of 29 laparoscopic procedures for metastatic liver disease. Group 1 included 14 patients who had undergone simultaneous laparoscopic primary tumor resection and laparoscopic liver resection for metastatic disease. Group 2 included 15 patients who had undergone isolated laparoscopic liver resection for metastatic lesions.Results: Mean (± SD) blood loss in the simultaneous and isolated procedures groups was 469 ± 176 and 408 ± 124 mL, respectively (p = 0.2), whereas the duration of surgeries was 296 ± 107 and 204 ± 82 min, respectively (p = 0.01). Conversion rate in the isolated resection group was higher (26% vs. 14%). This difference is to be explained by the learning curve in laparoscopic liver surgery. All liver resections in both groups were carried out in R0 mode. No deaths and significant complications were seen in any of the groups.Conclusion: The study demonstrated feasibility and safety of simultaneous, fully laparoscopic liver resections, including those for difficult localization of primary tumors and metastatic lesions.

Salvage hepatectomy for HCC recurrence after failed RFA, TACE or PEI: an unlock gateway to think of

Introduction: Outcomes of salvage hepatectomy for local recurrent hepatocellular carcinoma (HCC) after loco-regional or percutaneous treatments are still unclear. Methods: We conducted a retrospective analysis of 92 consecutive patients with HCC who underwent either primary liver resection (group 1, 65/92) or salvage hepatectomy for recurrent HCC after failed percutaneous or loco-regional treatments (group 2, 27/92). The two cohorts were compared in terms of perioperative mortality and morbidity and long-term disease-free and overall survival rates were analized. Results: Group 2 patients were previously submitted to a different range of treatments such as: RFA (17 cases), RFA + PEI (4 cases), TACE (4 cases), RFA + TACE (2 cases). HCC average size was comparable between group 1 and 2 (27.6 mm vs. 27.5 mm, respectively). In 6/60 (group 1) and 11/27 (group 2) liver resections were performed laparoscopically. Perioperative mortality rate was nihil in both groups and morbidity rate was comparable. The median progression-free survival was 16 months [CI 95% 12.3-19.6] for group 1 and 43 months [CI 95% 22.5-63.4] for group 2 (p=0.013). The median overall survival was 68 months [CI 95% 32.4-103.5] for group 1 and 81 months [56-106.9] for group 2 (p=0.015). Conclusions: Salvage hepatectomy for HCC recurrence in patients not resected upfront, whose HCC relapsed after failure of loco-regional or percutaneous procedures, appears to be safe and effective. In our limited series, it provided optimal outcomes in terms of disease-free and overall long term survival, being a reasonable option in such patients.

To determine if there is a difference in outcomes for patients undergoing synchronous primary colorectal cancer and liver resection with or without preoperative treatment

To determine if there is a difference in outcomes for patients undergoing synchronous primary colorectal cancer and liver resection with or without preoperative treatment

Characterization of early recurrences following liver resection by ALPPS and two stage hepatectomy (TSH) in patients with colorectal liver-metastases and small future liver remnants (FLR)

Background: Surgical resection is the only curative treatment option for patients with CRLM. Novel therapeutic strategies therefore aim at offering surgery to patients outside traditional resection criteria. In patients with small FLR, ALPPS is described as an alternative to TSH but initial reports suggested higher rates of early recurrences. This study aims at identifying clinical and biological factors associated with early recurrences following liver resection by ALPPS and TSH in patients with colorectal liver-metastases (CRLM). Materials and methods: All patients included at one site participating in the LIGRO study* were included (n = 43). Twenty-three patients were randomized to PVE and 20 to ALPPS. Cross-over to rescue surgery by ALPPS was allowed (n = 4). Three patients were excluded for inoperability. Thus, 16 liver resections were completed by TSH and 24 by ALPPS. Tumor samples were analyzed for KRAS, BRAF, NRAS, PIK3CA and TP53 gene mutations. Results: A similar fraction (25%) in each group developed recurrent liver metastases within one year after resection. Rapid recurrences were not associated with primary tumor location or liver resection margin. The mutation status of RAS/RAF/PIK3CA genes were comparable in patients with and without recurrences. All coding sequences of TP53 were investigated for 6 samples with recurrence; the 4 with mutation were all found in the ALPPS group. Conclusion: ALPPS was not associated with a higher rate of early recurrences than TSH in this randomized setting. Early recurrences were not conclusively associated with specific mutational patterns. Long term survival analysis for the entire cohort is ongoing.

Laparoscopic repeat liver resection after open liver resection is safe and feasible compared with laparoscopic primary liver resection: a comparative study from a single center

Background: Technological innovations and accumulating experience have made it possible to use laparoscopic liver resection cases with re-existing adhesions or cicatricial changes. This study aimed to clarify the outcomes of laparoscopic repeat liver resection (LRLR) among cases of recurrent liver cancer after open liver resection. Methods: There were 157 patients who underwent laparoscopic liver resection for liver tumors at our institution during September 2012-September 2016. Sixty-two patients were included in analysis and were retrospectively divided into an LRLR group (n = 13) and a laparoscopic primary liver resection group (LPLR; n = 49), and the groups were compared in term of patient demographics, surgical procedures, and short-term surgical outcomes. Recurrence-free survival and overall survival were compared for patients with hepatocellular carcinoma and with colorectal liver metastases. Results: There was a significant inter-group difference in the hepatitis virus background (p= 0.036), but other patient demographics were comparable between the two groups. The two groups had similar values for extent of resection, operative time, estimated blood loss, transfusion requirement, conversion to laparotomy, postoperative complications, surgical margins, time to oral intake, and hospital stay. Furthermore, there were no inter-group differences in recurrence-free or overall survival in the LRLR and LPLR groups when we compared patients with hepatocellular carcinoma and patients with colorectal liver metastases. Conclusion: The LRLR and LPLR groups had equivalent short-term outcomes. Furthermore, LRLR does not compromise oncological outcomes compared to LPLR.

Advantage of Early Liver Transplantation whenever Hepatocellular Carcinoma Recurrence after Primary Liver Resection

Background Liver transplantation (LT) following primary liver resection (LR) for Hepatocellular carcinoma (HCC) patients, also termed as salvage LT, has been consider as a promising strategy for improving patient’s outcome. The study aimed to identify predictors of such patients from the primary LR to LT for HCC, and to provide additional information for decision-making in therapeutic strategy for patient with HCC. Methods This is a retrospectively review of patients who had been undergone LR for HCC followed by LT for liver cirrhosis with or without recurrent HCC between May 2005 and February 2017. The clinicopathological features of the patients regarding LR and LT were analyzed to determine prognostic factors of patients after LT. Results A total of 59 patients were enrolled in this study. During the follow up, three cases (5%) encountered hospital morality, and 15 patients (26.8%) developed HCC recurrence after LT. The recurrence-free survival at 1-, 3-, and 5-year were 84.8%, 68.2%, and 68.2%, and disease specific overall survival rates were 95.7%, 74.4%, and 66.7% at 1-, 3-, 5-year after LT, respectively. Three independent prognostic factors including UCSF transplantation criteria (p = 0.018, hazard ratio (HR) = 12.70), tumor size > 5cm at LR (p = 0.012, HR = 7.90) and period between HCC recurrence following LR and LT > 1 year (p = 0.030, HR = 7.57) were identified for HCC recurrence after LT. Conclusions Tumor features of HCC at both LR and LT would play potential roles affecting HCC recurrence after LT. Importantly, LT should be considered as soon as possible whenever recurrent HCC of LR meet transplantation criteria and indicate for LT.

Liver Resection for Hepatocellular Carcinoma in Patients with Renal Dysfunction.

BackgroundThe aim of this study was to evaluate the feasibility of liver resection in hepatocellular carcinoma (HCC) patients with preoperative renal dysfunction (RD).MethodsData from 735 patients undergoing primary liver resection for HCC between 2002 and 2014 were analyzed. Short- and long-term outcomes were compared between the RD group, defined by a preoperative estimated glomerular filtration rate of <45 mL/min/1.73 m2, and the non-RD group.ResultsSixty-two patients had RD. The incidence of postoperative pleural effusion (24 vs. 11%; P = 0.007) and major complications (Clavien–Dindo III–V; 31 vs. 15%; P = 0.003) were significantly higher in RD patients. In RD patients with Child-Pugh A, 90-day mortality rate (1.9%) and median survival time (6.11 years) were comparable to that of non-RD patients. In contrast, RD patients with Child-Pugh B had a very high 90-day mortality rate (22.2%), and a significant shorter median survival time compared to non-RD patients (1.19 vs. 4.84 years; P = 0.001).ConclusionsLiver resection for Child-Pugh A patients with RD is safe and has comparable oncological outcomes compared to non-RD patients. However, selection of liver resection candidates from Child-Pugh B patients with RD should be stricter.Electronic supplementary materialThe online version of this article (10.1007/s00268-018-4698-3) contains supplementary material, which is available to authorized users.

USE OF DIODE LASER FOR LIVER RESECTION (EXPERIMENTAL STUDY)

Aim. To define oppertunities of diode laser with wave length 0.97 μm in liver surgery to prevent postoperative complications. Material and Methods. 90 rabbits were divided into 3 groups according to type of left liver lobe resection: intermitted laser (group 1), continuous laser (group 2) and bipolar coagulation (group 3). Following parameters of surgical procedure were studied: total duration of surgery, parenchyma dissection time, resected lobe volume, primary liver resection margin size, liver resection margin size by the end of experiment, blood loss, liver parenchyma hemostatic suturing after its dissection, liver parenchyma compression during its dissection, postoperative adhesive process, wound and intraabdominal infectious complications. Results. Intermitted laser in liver resection decreased blood loss (Ме (25%; 75%) = 3 ml (3; 4,5)) ( р &lt; 0.05), need for hemostatic suturing after parenchyma dissection ( р &lt; 0.05), incidence of wound and intraabdominal infectious complications, severity of adhesive process. Minimum duration of surgery was observed in group 3 (Ме (25%; 75%) = 17 min (16; 19)) ( р &lt; 0.05). Liver resection margin evolution was faster and favorable in group 1. Conclusion. Intermitted diode laser with wave length 0.97 μm is suitable method in order to perform liver parenchyma dissection in different clinical situations.

Impact of Visceral Adiposity as Well as Sarcopenic Factors on Outcomes in Patients Undergoing Liver Resection for Colorectal Liver Metastases.

We have reported preoperative low skeletal muscularity as an independent risk factor for poor outcomes after liver transplantation, resection of hepatocellular carcinoma, pancreatic cancer and extrahepatic biliary malignancies. However, the impacts of visceral adiposity and muscularity on outcomes after liver resection for colorectal liver metastases (CLM) have not been fully investigated. We retrospectively analyzed 124 patients undergoing primary liver resection for CLM between 2005 and 2014. Using preoperative computed tomography at the third lumbar vertebra level, skeletal muscle and abdominal adipose tissue were evaluated by skeletal muscle index (SMI), intramuscular adipose tissue content (IMAC) and visceral-to-subcutaneous adipose tissue area ratio (VSR), respectively. Impacts of preoperative SMI, IMAC and VSR on outcomes after liver resection for CLM were investigated. Low SMI and high VSR were not significantly associated with poor overall or recurrence-free survivals (P=0.324 and P=0.106, P=0.964 and P=0.738, respectively). Overall survival rate tended to be lower in patients with high IMAC than in patients with normal IMAC (P=0.054). Recurrence-free survival rate did not differ significantly between high and normal IMAC (P=0.721). Multivariate analysis showed that low SMI, high IMAC and high VSR were not significant risk factors for death or recurrence after liver resection for CLM. Neither preoperative visceral adiposity nor low muscularity were poor prognostic factors in patients undergoing liver resection for CLM.

Identification of the resection severity index as a significant independent prognostic factor for early mortality and observed survival >5 and >10 years after liver resection for hepatocellular carcinoma

Background and objectivesThis study evaluates predictive factors for observed long-term survival of more than 5 and 10 years for patients after liver resection for hepatocellular carcinoma and compares their life expectancy to the normal national population matched for sex, year of birth and age at resection. Methods230 patients after primary liver resection for HCC (01.01.1995–31.12.2004) were analyzed. Multivariable logistic regression models were determined based on Cox regression results and their prognostic capability evaluated with areas under the receiver operating characteristic curve (AUROCs). ResultsLife years after surgery in deceased patients compared to the normal national population matched for sex, year of birth and age at resection was reduced by median 21.7 years. Independent predictive factors for 10-year survival were age at resection (p < 0.001; OR = 0.898; 95%-CI: 0.846–0.954), UICC 7 tumor staging (p = 0.003; OR = 0.344; 95%-CI: 0.126–0.941) and ASAT (GOT) in U/l divided by Quick in percent multiplied by the extent of liver resection graded in points labelled as the resection severity index (p < 0.001; OR = 0.136; 95%-CI: 0.022–0.843) enabling prediction of 10-year survival with an AUROC of 0.884. The same factors plus revision surgery (yes/no) predict 5-year survival (AUROC 0.736). ConclusionsLiver resection enables predictable long-term survival >5 and > 10 years. The proposed resection severity index quantifies the prognostic relevance of liver cellular damage, synthesis and loss of parenchyma for long-term survival.

Survival outcomes of hepatocellular carcinoma resection with postoperative complications – a propensity-score-matched analysis

Curative resection remains the only hope of cure for hepatocellular carcinoma (HCC), but postoperative complications can have a significant impact on long-term survival. However, only scarce data on such impact can be found in the literature.This retrospective study reviewed the prospectively collected data of patients who underwent primary liver resection for HCC at our hospital during the period from December 1989 to December 2014. Patients with and without postoperative complications were compared. A 1:1 propensity score matching was adopted by matching age, comorbidity, Model of End-stage Liver Disease score, tumor stage, and extent of resection.Totally 1710 patients were eligible for the study. Four hundred and sixty-one (27.0%) of them developed postoperative complications while 1249 (73.0%) did not. After propensity score matching, 922 patients were compared in a 1:1 ratio (461 with postoperative complications and 461 without). Patients who developed postoperative complications were demographically similar to patients who did not, but had more intraoperative blood loss and transfusion (both P < 0.001), longer hospital stay (17 vs 9 days; P < 0.001), worse hospital mortality (12.1% vs 0%; P < 0.001), and shorter overall survival (P < 0.001). On multivariate analysis, factors that might have affected overall survival were cancer stage (HR 1.22, P < 0.001), tumor size (HR 1.02, P = 0.005), tumor number (HR 1.08, P < 0.001), venous invasion (HR 1.38, P = 0.003), extent of resection (HR 1.19, P = 0.045), intraoperative blood loss (HR 1.11, P < 0.001), postoperative complication (HR 1.37, P < 0.001), and era effect (HR 1.27, P = 0.01).Patients should be monitored closely after HCC resection. Prompt treatment of postoperative complications may be salvational.

Adjuvant stereotactic body radiotherapy (SBRT) for resected primary and metastatic liver cancers.

487 Background: Stereotactic body radiotherapy (SBRT) has been shown to be a safe and effective treatment for hepatobiliary cancers. However, little is known about the efficacy of adjuvant SBRT for resected liver tumors with positive margins. We examined the characteristics and outcomes of patients who received adjuvant SBRT for both primary and metastatic cancers of the liver. Methods: We retrospectively reviewed the charts of patients who had received liver SBRT from 2009-2015 at our institution. During that time frame, 11 patients were identified as having received adjuvant SBRT post resection. Patient data such as age, gender, portal vein thrombosis, cirrhosis, ECOG performance status, prior liver directed therapies, and SBRT dose were collected. Descriptive statistics were used for analysis given the small number of patients in this series. Results: Median age at the time of treatment was 63 years (range 51-79), and the majority of patients (72.7%) were male. Seven tumors (63.6%) were hepatocellular carcinomas, and 4 (36.4%) were adenocarcinomas. Of the tumors with adenocarcinoma histology, 3 were cholangiocarcinomas and one was metastatic colorectal cancer. Ten patients (90.9%) were treated for positive margins, and one was treated for inferior vena cava (IVC) invasion. Seven patients (63.6%) had no other liver-directed treatment prior to adjuvant SBRT. Two patients received systemic therapy prior to SBRT. Median EQD2 was 83.3 Gy (range 60-126), and 81.8% of patients received 5 fractions. There were no grade 3 or above late toxicities from treatment. Median follow-up was 14.1 months (range 5.4-38.1). None of the treated tumors progressed locally. Six patients (54.5%) progressed elsewhere in the liver, and one patient experienced distant metastatic progression. One patient experienced both intrahepatic progression and distant metastatic progression. Conclusions: Adjuvant SBRT appears to be a safe and feasible adjuvant treatment in patients with primary liver resection for either primary liver cancer or metastatic disease who are at high risk of recurrence.

Impact of non-neoplastic vs intratumoural hepatitis B viral DNA and replication on hepatocellular carcinoma recurrence

Background:This study aims to determine the impact of intracellular hepatitis B virus (HBV) DNA, covalently closed circular DNA (cccDNA) and viral replicative activity in both tumour and non-neoplastic liver on prognosis and to determine the relationship of viral replicative activity and Ishak fibrosis in predicting outcome following resection.Methods:A total of 99 prospectively enrolled patients treated with primary liver resection for HBV-HCC are included. Intracellular HBV DNA and cccDNA were quantitated by real-time PCR. The RNA-sequencing (RNA-seq) was performed in a subset of 21 patients who had either minimal liver fibrosis (Ishak stages 0–2) or end-stage fibrosis (Ishak stage 6).Results:Tumour tissue contained a lower cccDNA copy number compared with paired non-neoplastic liver, and larger tumours (>3 cm) had less cccDNA compared with small tumours (⩽3 cm). High viral replicative activity in non-neoplastic liver was associated with higher HCC recurrence rate independent of Ishak fibrosis stage. Genes correlated with viral replicative activity in non-neoplastic liver (620 genes) were distinct from those associated with end-stage fibrosis (1226 genes). Genes associated with viral replicative activity were preferentially distributed in regions on chr3, chr16 and chr19.Conclusions:Viral replicative activity in non-neoplastic liver is associated with HCC recurrence through mechanisms that are distinct from and independent of Ishak fibrosis stage.

Primary liver resection for patients with cirrhosis and hepatocellular carcinoma: the role of surgery in BCLC early (A) and intermediate stages (B).

This study aims to report the outcomes following primary liver resection (PLR) in patients with cirrhosis including stratification according to the Barcelona Clinic Liver Cancer (BCLC) classification. Patients with cirrhosis and hepatocellular carcinoma (HCC) who had PLR between 2000 and 2013 were examined. Overall survival (OS), disease-free survival (DFS) and recurrence rate (RR) were analysed. Management after recurrence was reviewed as well as comparison to a series of 116 patients listed directly for liver transplant. Seventy-one patients underwent PLR. Median follow-up was 40months. The 1-, 3- and 5-year OS and DFS for the series were 77, 69 and 61% and 69, 39 and 28% respectively. Overall recurrence was 59% (44/71) and only 36% (15/44) of those patients had a further potentially curative procedure. The 1-3-5-year OS and DFS in the BCLC-A (44 patients) were 86, 78 and 68% and 78, 48 and 44% respectively. The RR in BCLC-A was 45% (20 patients) with half (11 patients) suitable for further treatment with curative intent. The 1-3-5-year OS and DFS in the BCLC-B (17 patients) were 81, 74 and 60% and 58, 29 and 7% respectively. The overall RR in BCLC-B was 76% (13 patients). Recurrence following PLR for HCC in patients with cirrhosis is high with only a third of patients suitable for further potentially curative procedures. For patients with BCLC-A (or within Milan criteria), PLR provided a 68% 5-year OS with 44% of them free of disease. Surgery can offer satisfactory OS in carefully selected patients in the BCLC-B stage.

Extrahepatic metastasectomy for hepatocellular carcinoma: Predictors of long-term survival.

We report our institutional experience with extrahepatic metastasectomy (EM) in a cohort of hepatocellular carcinoma (HCC) patients with focus on predictors of survival. All patients diagnosed with metastatic HCC from 2001 to 2014 were retrospectively reviewed to identify those who underwent EM with therapeutic intent. Associations among multiple clinicopathological variables and survival after EM were analyzed by univariate and multivariate analyses. Out of 440 metastatic HCC cases, we identified 85 patients (mean age 58.8 ± 11.7 years, 81.2% males) who underwent lung (n = 36), peritoneal (n = 22), lymph node (n = 19), musculoskeletal (n = 18), and adrenal (n = 9) metastasectomy. Most patients (84.7%) underwent metachronous EM following primary liver resection or transplantation. The median follow-up period was 20.9 months, during which 55 patients (64.7%) died. The 1-/2-/5-year overall survival rates after EM were 77.4, 53.1, and 25.1%, respectively. On multivariate analysis, number of metastases resected >2 correlated independently with poor survival (HR = 2.058, P = 0.0099). EM patients had superior median survival compared to all (n = 194) metastatic HCC patients treated with sorafenib without EM during the study period (27.2 vs. 7.4 months, P < 0.001). Long-term survival may be achieved in highly selected HCC patients following EM. The presence of greater than two extrahepatic lesions correlates independently with poor survival. J. Surg. Oncol. 2016;114:469-474. © 2016 Wiley Periodicals, Inc.

The fate of recurred hepatocellular carcinoma after curative primary liver resection; are still patholgic aggressiveness and milan criteria important?

The fate of recurred hepatocellular carcinoma after curative primary liver resection; are still patholgic aggressiveness and milan criteria important?