Surgical Management Of Hepatocellular Carcinoma Research Articles

Laparoscopic versus open hepatectomy for exophytic hepatocellular carcinoma: A multicenter propensity-matched comparative study.

e16268 Background: As laparoscopic hepatectomy (LH) gains traction in the surgical management of hepatocellular carcinoma (HCC), its efficacy for exophytic HCC, a subtype with unique surgical challenges, remains under scrutiny. This study aims to compare the long-term outcomes of LH with traditional open hepatectomy (OH) in treating exophytic HCC. Methods: A multicenter retrospective analysis was conducted on patients with solitary exophytic HCC undergoing LH or OH at 10 hepatobiliary centers. Propensity score matching (PSM) and inverse probability treatment weighting (IPTW) were employed to balance the LH and OH groups for overall survival (OS) and recurrence-free survival (RFS) comparisons. Multivariable Cox-regression analysis determined the independent impact of surgical approach on OS and RFS. Results: The study included 270 patients, with 132 undergoing OH and 138 LH. Post-PSM, 97 matched pairs were analyzed. In this cohort, LH was associated with significantly lower 5-year OS (36.1% vs. 53.5%, P = 0.021) and RFS (31.7% vs. 44.9%, P = 0.013) compared to OH. Additionally, LH patients exhibited a higher rate of abdominal seeding metastases (19.6% vs. 8.2%, P = 0.023). Multivariable analysis in the PSM cohort revealed LH as an independent factor for reduced OS (HR, 1.62; 95% CI, 1.06-2.47; P = 0.025) and RFS (HR, 1.79; 95% CI, 1.22-2.64; P = 0.003), corroborated by IPTW cohort findings. Conclusions: This study indicates that LH may be less favorable than OH for exophytic HCC, potentially contraindicating its use in such cases. These findings highlight the necessity for further prospective research to refine surgical protocols for exophytic HCC.

Immunotherapy as a Complement to Surgical Management of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver tumor in adults, and the fourth leading cause of cancer-related deaths worldwide. While surgical and ablative therapies remain the standard of care in early localized disease, late presentation with advanced stages of disease, impaired hepatic function, or local recurrence following surgical resection preclude operative management as the sole treatment modality in a subgroup of patients. As such, systemic therapies, namely immunotherapy, have become an integral part of the HCC treatment algorithm over the past decade. While agents, such as atezolizumab/bevacizumab, have well-established roles as first-line systemic therapy in intermediate- and advanced-stage HCC, the role of immunotherapy in disease amenable to surgical management continues to evolve. In this review, we will discuss the current evidence and aggregate impact of immunotherapy in the context of HCC amenable to surgical management, including its application in the neoadjuvant and adjuvant settings.

Current Trends in Surgical Management of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Surgical management, including hepatic resection, liver transplantation, and ablation, offers the greatest potential for a curative approach. This review aims to discuss recent advancements in HCC surgery and identify unresolved issues in the field. Treatment selection relies on the BCLC staging system, with surgical therapies primarily recommended for early-stage disease. Recent studies have shown that patients previously considered unresectable, such as those with portal vein tumor thrombus and uncomplicated portal hypertension, may benefit from hepatic resection. Minimally invasive surgery and improved visualization techniques are also explored, alongside new techniques for optimizing future liver remnant, ex vivo resection, and advancements in hemorrhage control. Liver transplantation criteria, particularly the long-standing Milan criteria, are critically examined. Alternative criteria proposed and tested in specific regions are presented. In the context of organ shortage, bridging therapy plays a critical role in preventing tumor progression and maintaining patients eligible for transplantation. Lastly, we explore emerging ablation modalities, comparing them with the current standard, radiofrequency ablation. In conclusion, this comprehensive review provides insights into recent trends and future prospects in the surgical management of HCC, highlighting areas that require further investigation.

Non-anatomical liver resection for hepatocellular carcinoma: the SegSubTe classification to overcome the problem of heterogeneity

BackgroundThe superiority of anatomical resection (AR) vs. non-anatomical resection (NAR) in the surgical management of hepatocellular carcinoma (HCC) is debated. ARs are well-defined procedures, whereas the lack of NAR standardization results in heterogeneous outcomes. This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor. MethodsA single-center retrospective analysis of pre- and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted. The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section (segmental, subsegmental or terminal next to the tumor) of vascular pedicles feeding the HCCs; then, the population was divided in “SegSubTe-IN” or “SegSubTe-OUT” groups, and the tumor recurrence and survival were analyzed. ResultsNinety-seven patients who underwent NAR were included; 76% were SegSubTe-IN and 24% were SegSubTe-OUT. Total disease recurrence, local recurrence and cut-edge recurrence in the SegSubTe-IN vs. SegSubTe-OUT groups were 50% vs. 83% (P = 0.006), 20% vs. 52% (P = 0.003) and 16% vs. 39% (P = 0.020), respectively. SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis. One-, three-, and five-year disease-free survival rates in the SegSubTe-IN vs. SegSubTe-OUT groups were 81%, 58% and 35% vs. 46%, 21% and 11%, respectively (P < 0.001). ConclusionsThe SegSubTe classification is a useful tool to stratify and standardize NAR for HCC, aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

The segsubte classification of non-anatomical liver resections for hepatocellular carcinoma

Background: The superiority of hepatic anatomical resection (AR) vs. non-anatomical resection (NAR) in the surgical management of hepatocellular carcinoma (HCC) is debated. ARs are well defined, whereas the lack of NAR standardisation results in heterogeneous outcomes. The aim of this study is to introduce the SegSubTe classification for NAR with purpose of determining the appropriateness of the level of surgical section of the vascular pedicles feeding the tumor.

Individualized Approach in the Surgical Management of Hepatocellular Carcinoma: Results from a Greek Multicentre Study.

Background: Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the third leading cause of death worldwide. The management of HCC is complex, with surgical treatment providing long-term survival in eligible patients. This study aims to present the experience of aggressive surgical management of HCC in Greece. Methods: This is a retrospective multicentre clinical study with 242 patients. Results: Most patients were male (79%) and had a median age of 71 yrs. According to the most recent BCLC criteria, 172 patients (71.1%) were classified as BCLC 0-A stage, 33 patients (13.6%) were classified as BCLC B, and 37 (15.3%) were classified as BCLC C. A total of 54% of the patients underwent major hepatectomy. Major postoperative morbidity was 15.6%, and the 90-day postoperative mortality rate was 4.5%. The median follow-up was 33.5 months. Three- and five-year overall survival was 65% and 48%, respectively. The median overall survival was 55 months. Significantly, five-year survival was 55% for BCLC A, and 34% and 21% for BCLC B and C, respectively. In univariate analysis, cirrhosis, type of resection (R status), and BCLC stage were associated with overall survival. Multivariate analysis indicated that R1 and R2 resections compared to R0, and BCLC C compared to BCLC 0-A, were independently associated with increased mortality. Conclusions: Aggressive surgical treatment of HCC offers satisfactory long-term survival prospects. A significant percentage (29%) of HCCs that underwent liver resection were of the intermediate and advanced BCLC stage. The management of patients with HCC should be discussed in multidisciplinary tumour board meetings on a case-by-case basis to be more effective.

Challenging the Treatment Paradigm: Selecting Patients for Surgical Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus.

Portal vein tumor thrombus (PVTT) remains a common presentation in patients with hepatocellular carcinoma (HCC). Approximately 30–50% of patients newly diagnosed with HCC will present with a concomitant PVTT. Current guidelines recommend systemic therapy for treatment of HCC with PVTT. Real-world application of partial hepatectomy in HCC patients with PVTT has increased over the past two decades, as perioperative complications have declined. However, it is unclear if there is an association between the extent of PVTT and overall survival and rates of recurrence and whether the perioperative morbidity outweighs these potential benefits. Partial hepatectomy with en bloc resection of PVTT in second-order branches and distal can offer significant benefits in carefully selected patients; however, once the HCC-associated PVTT extends into first-order portal venous branches or more proximal into the superior mesenteric vein, the risks of surgical resection outweigh the benefits. The aim of this review is to determine which patients with HCC presenting with PVTT benefit from surgical resection. We will discuss the classification systems of PVTT and review both outcome and perioperative measures in patients undergoing partial hepatectomy with extirpation of HCC-related PVT.

Recent advances in the surgical management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing, despite effective antiviral treatment for hepatitis B (HBV) and C virus infection and the application of preventive measures such as vaccination at birth against HBV infection. This is mainly due to the increase in metabolic syndrome and its hepatic components, nonalcoholic fatty liver disease and steatohepatitis. Liver resection and transplantation are the main treatment options, offering long-term survival and potential cure. In this review, the recent advances in the surgical management of HCC are presented. More specifically, the role of liver resection in the intermediate and advanced stages, according to the Barcelona Clinic Liver Cancer classification, is analyzed. In addition, the roles of minimally invasive surgery and of living-related liver transplantation in the management of patients with HCC are discussed. Finally, recent data on the role of molecular markers in the early diagnosis and recurrence of HCC are presented. The management of HCC is complex, as there are several options for each stage of the disease. In order for, each patient to get the maximum benefit, an individualized approach is suggested, in specialized liver units, where cases are discussed in multidisciplinary tumor boards.

A Concise Review on Current Trends in Imaging and Surgical Management of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a primary cancer of the liver whose incidence has seen an upsurge in the United States within the last 2 decades. Despite improvements in detection and management techniques, the prognosis for patients with HCC generally remains poor. There are multiple factors that have been implicated in the etiology of HCC with cirrhosis occurring as a common final pathway. This review presents a concise summary of current trends in imaging and surgical management of HCC. An internet-based (PubMed) search using the search terms “hepatocellular carcinoma” and “imaging” and "surgical management" was performed. Our search was limited to articles related to human studies published in English during the period of 07/01/2011 to 06/30/2016. A review of all relevant articles was conducted, and findings were summarized. Modern imaging modalities employed in the diagnosis of HCC include ultrasound scan (USS), computed tomography (CT), and magnetic resonance imaging (MRI) scan. The utility of diagnostic imaging is enhanced when interpreted in conjunction with appropriate laboratory tests such as alpha-fetoprotein. The definitive treatment for HCC remains challenging; hepatic resection (HR) and liver transplantation (LT) are two approaches offering potentially curative options. For patients undergoing HR, important considerations include achieving maximum resection while maintaining optimal post-resection liver remnant volume (LRV) and functional capacity (FC), which can be assessed using 3-dimensional CT and indocyanine green clearance. Generally, an LRV of 40-50% is considered an acceptable lower limit for individuals with HCC compared to 20-30% among individuals with normal livers. With increasing knowledge of disease pathology, appropriate patient selection, coupled with advances in anesthesia and surgical technique, overall 5-year survival rates have significantly improved.Challenges associated with LT on the other hand include donor-liver shortages with resultant long wait times and continued disease progression. The scarcity of cadaveric-donor livers has led to employing living-donor livers. Ethical considerations with respect to subjecting potentially healthy donors to undue morbidity and mortality risk however remain. Additional donor-shortage circumventing strategies include employing marginal, domino, and split-organ liver transplants. For patients awaiting transplant, employing bridging therapy such as radiofrequency ablation and transhepatic artery chemoembolization might occasionally help slow disease progression and maintain transplant eligibility. Appropriate patient selection achieved through the Milan and UCSF criteria designed to guide allotment of donor livers to patients with the best chances of survival could help improve outcomes and 5-year survival rates. The main radiological options for diagnosis include USS, CT, and MRI. HR and LT are two distinct surgical options, which in practice can be used to complement one another. Appropriate patient selection is necessary to achieve maximum benefits from HCC therapies.

Surgical management of hepatocellular carcinoma—Western versus Eastern attitude

Hepatocellular carcinoma (HCC) is the most common liver tumour and represents a significant health burden. The different characteristics of the disease in the various parts of the world, as much as economic and social features, explain only partially the great diversity in the treatment options offered to patients in different countries. The most apparent contrast in term of tumour management is between the western and eastern world. Striking differences involve not only the attitude towards indications for liver transplantation or liver resection but also the surgical techniques adopted. Although remarkable signs of progress have been achieved in surgical and pharmacological fields, univocal guidelines are yet lacking, preventing effective comparisons between retrospective studies and clinical trials. This review aims to analyse and compare some of the most relevant and essential traits of the eastern and western therapeutic strategy against HCC.

Changing Paradigm in the Surgical Management of Hepatocellular Carcinoma With Salvage Transplantation

ObjectiveThe objective of this study was to compare the long-term outcomes of primary and salvage liver transplantation for patients with hepatocellular carcinoma (HCC). MethodThis was a 10-year retrospective analysis in a tertiary referral center. ResultsThere were 184 patients recruited (primary liver transplantation [pLT]:salvage liver transplantation [sLT], 143:41). The median follow-up time was 79 months. Operation time was shorter in the pLT group than the sLT group (661 ± 164 minutes vs 754 ± 206 minutes; P = .01) and the blood loss was 3749 mL and 3545 mL for pLT and sLT, respectively (P = .735). The reoperation rate was 5.6% and 4.9%, respectively (P = 1.0). The 5-year overall and disease-free survival rates from the time of transplantation for pLT and sLT were 84.1% versus 70.2% (P = .01) and 82.2% versus 65.8% (P = .01), respectively. The 5-year overall survival rate from the time of primary treatment for sLT was 80.3% (P = .1). Subgroup analysis of sLT showed that young age (50 vs 56 year old; P = .004) was the only factor associated with poor overall survival. Young age (P = .004) and microvascular permeation (P = .008) in the recurrent tumor were associated with HCC recurrence. Young age stands out to be the only independent factor associated with HCC recurrence. ConclusionsLT is the treatment of choice for patients with recurrent HCC in regions of graft shortage.

FRI-170 - Adherence to enhanced post-treatment surveillance is associated with increased detection of early stage recurrence after radiofrequency ablation but not surgical management of hepatocellular carcinoma

FRI-170 - Adherence to enhanced post-treatment surveillance is associated with increased detection of early stage recurrence after radiofrequency ablation but not surgical management of hepatocellular carcinoma

Surgical management of hepatocellular carcinoma within and beyond BCLC indications in a middle volume center

Current criteria for hepatic resection in patients with hepatocellular carcinoma (HCC) according to Barcellona Clinic Liver Cancer (BCLC) classification is debated. Actually, patients with multinodular or large HCC>5cm are excluded from surgical treatment following the algorithm, but several studies from referral centers showed that such patients may benefit from surgical resection in the clinical practice. The aim of this study was to compare short- and long-term outcomes after liver resection for HCC in stage 0/A or B in a middle volume center. Patients were grouped according to BCLC classification. Postoperative mortality, morbidity, overall and disease-free survival, univariate analysis of prognostic factors on survival was analyzed. Among 66 surgical procedures in 64 patients included in the study, 41 were BCLC stage 0/A (62.1%) and 25 BCLC stage B (37.9%). The overall 30- and the 90-days mortality rates were 1.5% and 3%. Patients in BCLC stage B had higher transfusion rate (P=0.04) but similar morbidity and mortality compared to patients in BCLC stage 0/A. After a median follow-up of 35 months (range: 14-147), the overall survival at 1, 3 and 5 years resulted 95%, 61.1%, 46.2% for stage 0-A and 83.3%, 50%, 41.2% for stage B (P=0.73). Univariate analysis identified poorly differentiated tumors (P=0.02) and positive margin (P=0.02) as negative prognostic factors on survival. Surgical treatment of HCC in BCLC stage B offers similar results than the ones in BCLC stage 0/A and consequently should not be considered contraindicated for such patients.

Current and Future Treatment of Hepatocellular Carcinoma: An Updated Comprehensive Review.

Hepatocellular carcinoma (HCC) is among the leading causes of cancer-related mortality. The principal treatment is surgical resection or liver transplantation, depending on whether the patient is a suitable transplant candidate. However, in most patients with HCC the diagnosis is often late, thereby excluding the patients from definitive surgical resection. Medical treatment includes sorafenib, which is the most commonly used systemic therapy; although, it has been shown to only minimally impact patient survival by several months. Chemotherapy and radiotherapy are generally ineffective. Due to the poor prognosis of patients with HCC, newer treatments are needed with several being in development, either in pre-clinical or clinical studies. In this review article, we provide an update on the current and future medical and surgical management of HCC.

Review of Current Trends in Imaging and Surgical Management of Hepatocellular Carcinoma

Review of Current Trends in Imaging and Surgical Management of Hepatocellular Carcinoma

Surgical Treatment of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.

Asian Perspectives and Controversies in Surgical Management of Hepatocellular Carcinoma: How Far Have We Come?

Asian Perspectives and Controversies in Surgical Management of Hepatocellular Carcinoma: How Far Have We Come?

Surgical management of hepatocellular carcinoma – The northern ireland perspective

Surgical management of hepatocellular carcinoma – The northern ireland perspective

Changing paradigm in the surgical management of hepatocellular carcinoma with salvage transplantation

Changing paradigm in the surgical management of hepatocellular carcinoma with salvage transplantation

Surgical management of hepatocellular carcinoma after Fontan procedure.

The Fontan operation has successfully prolonged the lives of patients born with single-ventricle physiology. A long-term consequence of post-Fontan elevation in systemic venous pressure and low cardiac output is chronic liver inflammation and cirrhosis, which lead to an increased risk of hepatocellular carcinoma (HCC). Surgical management of patients with post-Fontan physiology and HCC is challenging, as the requirement for adequate preload in order to sustain cardiac output conflicts with the low central venous pressure (CVP) that minimizes blood loss during hepatectomy. Consequently, liver resection is rarely performed, and most reports describe nonsurgical treatments for locoregional control of the tumors in these patients. Here, we present a multidisciplinary approach to a successful surgical resection of a HCC in a patient with Fontan physiology.