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Zeindler J, Hess GF, von Heesen M, Aegerter N, Reber C, Schmitt AM, Muenst S, Bolli M, Soysal SD, Kollmar O. Anatomic versus non-anatomic liver resection for hepatocellular carcinoma-A European multicentre cohort study in cirrhotic and non-cirrhotic patients. Cancer Med 2024; 13:e6981. [PMID: 38477510 DOI: 10.1002/cam4.6981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) is increasing in the western world over the past decades. As liver resection (LR) represents one of the most efficient treatment options, advantages of anatomic (ALR) versus non-anatomic liver resection (NALR) show a lack of consistent evidence. Therefore, the aim of this study was to investigate complications and survival rates after both resection types. METHODS This is a multicentre cohort study using retrospectively and prospectively collected data. We included all patients undergoing LR for HCC between 2009 and 2020 from three specialised centres in Switzerland and Germany. Complication and survival rates after ALR versus NALR were analysed using uni- and multivariate Cox regression models. RESULTS Two hundred and ninety-eight patients were included. Median follow-up time was 52.76 months. 164/298 patients (55%) underwent ALR. Significantly more patients with cirrhosis received NALR (n = 94/134; p < 0.001). Complications according to the Clavien Dindo classification were significantly more frequent in the NALR group (p < 0.001). Liver failure occurred in 13% after ALR versus 8% after NALR (p < 0.215). Uni- and multivariate cox regression models showed no significant differences between the groups for recurrence free survival (RFS) and overall survival (OS). Furthermore, cirrhosis had no significant impact on OS and RFS. CONCLUSION No significant differences on RFS and OS rates could be observed. Post-operative complications were significantly less frequent in the ALR group while liver specific complications were comparable between both groups. Subgroup analysis showed no significant influence of cirrhosis on the post-operative outcome of these patients.
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Affiliation(s)
- Jasmin Zeindler
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Gabriel Fridolin Hess
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Maximilian von Heesen
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar, Germany
- Department of General- and Visceral Surgery, University Hospital Göttingen, Göttingen, Germany
| | - Noa Aegerter
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Cornelia Reber
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Andreas Michael Schmitt
- The Royal Marsden NHS Foundation Trust, London, UK
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Simone Muenst
- Institute of Medical Genetics and Pathology University Hospital Basel, Basel, Switzerland
| | - Martin Bolli
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Savas Deniz Soysal
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Otto Kollmar
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar, Germany
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Zhang J, Shi M, Ding W, Duan M, Dai Z, Chen Y. Effect of minimally invasive versus open surgery in hepatectomy on postoperative wound complications in patients with hepatocellular carcinoma: A meta-analysis. Int Wound J 2023; 20:4159-4165. [PMID: 37442783 PMCID: PMC10681463 DOI: 10.1111/iwj.14313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023] Open
Abstract
In a meta-analysis, we assessed the impact of different surgical approaches on the outcome of hepatectomy with hepatocellular carcinoma. Four databases, including PubMed, Embase, Cochrane Library, and the Web of Science, have been critically reviewed through the full literature through June 2023. Eleven related trials were examined once they had met the trial's classification and exclusion criteria, as well as the assessment of the quality. A random effects approach was applied to analysis of operative organ infections, and a fixed-effect model was applied to determine the 95% CI and OR. Analysis of the data was done with RevMan 5.3. Our findings indicated that patients undergoing minimally invasive liver cancer surgery had significantly lower risks of surgical organ infection (OR, 0.35; 95% CI, 0.16-0.77; p = 0.009) and wound infection (OR, 0.19; 95% CI, 0.13-0.28; p < 0.001) compared to those undergoing open surgery. There was no heterogeneity observed between the two groups (I2 = 0) in wound infection. Nevertheless, because of the limited number of randomised controlled trials in this meta-analysis, care should be taken and carefully considered in the treatment of these values. Further high-quality studies involving a large number of samples are needed to validate and reinforce the results.
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Affiliation(s)
- Junli Zhang
- Department of AnesthesiologyThe Sixth Medical Center of PLA General HospitalBeijingChina
| | - Meiping Shi
- Department of AnesthesiologyThe Sixth Medical Center of PLA General HospitalBeijingChina
| | - Wan Ding
- Department of AnesthesiologyThe Sixth Medical Center of PLA General HospitalBeijingChina
| | - Mingda Duan
- Department of AnesthesiologyHainan Branch of General Hospital of People's Liberation ArmySanyaChina
| | - Ziqing Dai
- Department of Medical RecordsThe Sixth Medical Center of PLA General HospitalBeijingChina
| | - Yu Chen
- Department of AnesthesiologyThe Sixth Medical Center of PLA General HospitalBeijingChina
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Morise Z, Aldrighetti L, Belli G, Ratti F, Cheung TT, Lo CM, Tanaka S, Kubo S, Okamura Y, Uesaka K, Monden K, Sadamori H, Hashida K, Kawamoto K, Gotohda N, Chen K, Kanazawa A, Takeda Y, Ohmura Y, Ueno M, Ogura T, Suh KS, Kato Y, Sugioka A, Belli A, Nitta H, Yasunaga M, Cherqui D, Abdul Halim N, Laurent A, Kaneko H, Otsuka Y, Kim KH, Cho HD, Lin CCW, Ome Y, Seyama Y, Troisi RI, Berardi G, Rotellar F, Wilson GC, Geller DA, Soubrane O, Yoh T, Kaizu T, Kumamoto Y, Han HS, Ekmekcigil E, Dagher I, Fuks D, Gayet B, Buell JF, Ciria R, Briceno J, O’Rourke N, Lewin J, Edwin B, Shinoda M, Abe Y, Hilal MA, Alzoubi M, Tanabe M, Wakabayashi G. An International Retrospective Observational Study of Liver Functional Deterioration after Repeat Liver Resection for Patients with Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:2598. [PMID: 35681578 PMCID: PMC9179920 DOI: 10.3390/cancers14112598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/08/2022] [Accepted: 05/11/2022] [Indexed: 02/06/2023] Open
Abstract
Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.
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Affiliation(s)
- Zenichi Morise
- Department of General Surgery, Fujita Health University School of Medicine Okazaki Medical Center, Okazaki 444-0827, Japan
| | - Luca Aldrighetti
- Hepatobiliary Division in Department of Surgery, San Raffaele Hospital, 20132 Milano, Italy; (L.A.); (F.R.)
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, 80127 Naples, Italy;
| | - Francesca Ratti
- Hepatobiliary Division in Department of Surgery, San Raffaele Hospital, 20132 Milano, Italy; (L.A.); (F.R.)
| | - Tan To Cheung
- Division of HBP and Liver Transplant, University of Hong Kong Queen Mary Hospital, Hong Kong, China; (T.T.C.); (C.M.L.)
| | - Chung Mau Lo
- Division of HBP and Liver Transplant, University of Hong Kong Queen Mary Hospital, Hong Kong, China; (T.T.C.); (C.M.L.)
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (S.T.); (S.K.)
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (S.T.); (S.K.)
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Sunto, Shizuoka 411-8777, Japan; (Y.O.); (K.U.)
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Sunto, Shizuoka 411-8777, Japan; (Y.O.); (K.U.)
| | - Kazuteru Monden
- Departments of Surgery, Fukuyama City Hospital, Fukuyama 721-8511, Japan; (K.M.); (H.S.)
| | - Hiroshi Sadamori
- Departments of Surgery, Fukuyama City Hospital, Fukuyama 721-8511, Japan; (K.M.); (H.S.)
| | - Kazuki Hashida
- Department of Surgery, Kurashiki Central Hospital, Kurashiki 710-8602, Japan; (K.H.); (K.K.)
| | - Kazuyuki Kawamoto
- Department of Surgery, Kurashiki Central Hospital, Kurashiki 710-8602, Japan; (K.H.); (K.K.)
| | - Naoto Gotohda
- Division of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa 277-8577, Japan;
| | - KuoHsin Chen
- Division of General Surgery, Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan;
- Department of Electrical Engineering, Yuan Ze University, Taoyuan City 320, Taiwan
| | - Akishige Kanazawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka 534-0021, Japan;
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki 660-8511, Japan; (Y.T.); (Y.O.)
| | - Yoshiaki Ohmura
- Department of Surgery, Kansai Rosai Hospital, Amagasaki 660-8511, Japan; (Y.T.); (Y.O.)
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, Wakayama 641-8509, Japan;
| | - Toshiro Ogura
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan; (T.O.); (M.T.)
| | - Kyung Suk Suh
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University Hospital, Seoul 03080, Korea;
| | - Yutaro Kato
- Department of Gastrointestinal Surgery, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (Y.K.); (A.S.)
| | - Atsushi Sugioka
- Department of Gastrointestinal Surgery, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (Y.K.); (A.S.)
| | - Andrea Belli
- Department of Abdominal Surgical Oncology, Fondazione G.Pascale-IRCCS, National Cancer Institute of Naples, 80131 Napoli, Italy;
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Morioka 028-3695, Japan;
| | - Masafumi Yasunaga
- Department of Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan;
| | - Daniel Cherqui
- Paul Brousse Hospital, 94800 Villejuif, France; (D.C.); (N.A.H.)
- Paris-Sud University, 91190 Gif-sur-Yvette, France;
| | | | | | - Hironori Kaneko
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University Faculty of Medicine, Tokyo 143-8540, Japan; (H.K.); (Y.O.)
| | - Yuichiro Otsuka
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University Faculty of Medicine, Tokyo 143-8540, Japan; (H.K.); (Y.O.)
| | - Ki Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Ulsan University and Asan Medical Center, Seoul 05505, Korea; (K.H.K.); (H.-D.C.)
| | - Hwui-Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Ulsan University and Asan Medical Center, Seoul 05505, Korea; (K.H.K.); (H.-D.C.)
| | - Charles Chung-Wei Lin
- Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan;
- IRCAD-AITS, Changhua 505, Taiwan
| | - Yusuke Ome
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan; (Y.O.); (Y.S.)
| | - Yasuji Seyama
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan; (Y.O.); (Y.S.)
| | - Roberto I. Troisi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80138 Napoli, Italy;
| | - Giammauro Berardi
- General Hepato-Biliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, 9000 Gent, Belgium;
| | - Fernando Rotellar
- Hepato-Bilio-Pancreatic Unit of Clinica Universitaria de Navarra, 31008 Pamplona, Spain;
| | - Gregory C. Wilson
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.W.); (D.A.G.)
| | - David A. Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.W.); (D.A.G.)
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplant, Beaujon Hospital, Clichy 92110, France; (O.S.); (T.Y.)
| | - Tomoaki Yoh
- Department of HPB Surgery and Liver Transplant, Beaujon Hospital, Clichy 92110, France; (O.S.); (T.Y.)
| | - Takashi Kaizu
- Department of Surgery, Kitasato University School of Medicine, Sagamihara 252-0374, Japan; (T.K.); (Y.K.)
| | - Yusuke Kumamoto
- Department of Surgery, Kitasato University School of Medicine, Sagamihara 252-0374, Japan; (T.K.); (Y.K.)
| | - Ho-Seong Han
- Seoul National University College of Medicine, Bundang Hospital, Seongnam-si 13620, Korea; (H.-S.H.); (E.E.)
| | - Ela Ekmekcigil
- Seoul National University College of Medicine, Bundang Hospital, Seongnam-si 13620, Korea; (H.-S.H.); (E.E.)
| | | | - David Fuks
- Department of Digestive Diseases, Institute Mutualiste Montsouris, University of Paris Descartes, 75014 Paris, France; (D.F.); (B.G.)
| | - Brice Gayet
- Department of Digestive Diseases, Institute Mutualiste Montsouris, University of Paris Descartes, 75014 Paris, France; (D.F.); (B.G.)
| | - Joseph F. Buell
- Tulane Transplant Abdominal Institute, Tulane University, New Orleans, LA 70112, USA;
| | - Ruben Ciria
- Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofia, 30003 Murcia, Spain; (R.C.); (J.B.)
| | - Javier Briceno
- Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofia, 30003 Murcia, Spain; (R.C.); (J.B.)
| | - Nicholas O’Rourke
- Department of General Surgery and HPB Surgery, Royal Brisbane Hospital, The University of Queensland, St Lucia, QLD 4072, Australia; (N.O.); (J.L.)
| | - Joel Lewin
- Department of General Surgery and HPB Surgery, Royal Brisbane Hospital, The University of Queensland, St Lucia, QLD 4072, Australia; (N.O.); (J.L.)
| | - Bjorn Edwin
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital-Rikshospitalet, 0372 Oslo, Norway;
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (Y.A.)
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (Y.A.)
| | - Mohammed Abu Hilal
- Istituto Ospedaliero—Fondazione Poliambulanza, 25124 Brescia, BS, Italy;
- University Hospital Southampton, Hampshire SO16 6YD, UK;
| | - Mohammad Alzoubi
- University Hospital Southampton, Hampshire SO16 6YD, UK;
- General Surgery Department, The University of Jordan, Amman 11972, Jordan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan; (T.O.); (M.T.)
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Ageo 362-8588, Japan;
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Morise Z. Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma. Surg Today 2019; 49:649-655. [PMID: 30649611 DOI: 10.1007/s00595-019-1765-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023]
Abstract
Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.
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Affiliation(s)
- Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukakecho, Toyoake, Aichi, Japan.
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R Ebrahim A, El-Mesery M, El-Karef A, Eissa LA. Vitamin D potentiates anti-tumor activity of 5-fluorouracil via modulating caspase-3 and TGF-β1 expression in hepatocellular carcinoma-induced in rats. Can J Physiol Pharmacol 2018; 96:1218-1225. [PMID: 30205014 DOI: 10.1139/cjpp-2018-0445] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We investigated the role of vitamin D (Vit D) alone and in combination with 5-fluorouracil (5-FU) in thioacetamide (TAA)-induced hepatocellular carcinoma (HCC) in rats. Fifty male Sprague-Dawley rats were randomized into a control group and 4 groups that received TAA (200 mg/kg, i.p.) twice per week for 16 weeks. These 4 groups were further divided as follows: HCC group; 5-FU group (75 mg/kg, i.p., once weekly for 3 weeks starting from the 12th week); Vit D group (200 IU/kg daily by oral tube for 16 weeks); and 5-FU + Vit D group (received the previously mentioned dosage regimens of 5-FU and Vit D). HCC was detected by histopathological changes in liver sections and the elevation of serum α-fetoprotein (AFP). Treatment with 5-FU + Vit D significantly decreased gene expression of nuclear factor erythroid 2-related factor 2 (NrF2) and transforming growth factor β1 (TGF-β1) at both the gene and protein level and serum AFP concentrations in comparison with their corresponding monotherapy. Moreover, 5-FU + Vit D treatment enhanced apoptosis by increasing caspase-3 gene and protein expression. Conclusively, Vit D enhances antitumor activity of 5-FU in an HCC-induced model and improves liver function of treated animals. Combination therapy in a TAA-induced HCC rat model was more effective than 5-FU or Vit D through the modulation of TGF-β1, caspase-3, and NrF2 expressions.
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Affiliation(s)
- Amal R Ebrahim
- a Biochemistry Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | - Mohamed El-Mesery
- a Biochemistry Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | - Amro El-Karef
- b Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Laila A Eissa
- a Biochemistry Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
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Garancini M, Nespoli S, Romano F, Uggeri F, Degrate L, Okolicsanyi S, Gianotti L. Surgical management of hepatocellular carcinoma within and beyond BCLC indications in a middle volume center. J Visc Surg 2018; 155:275-282. [PMID: 29606603 DOI: 10.1016/j.jviscsurg.2017.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIM OF THE STUDY 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 AND METHODS Patients were grouped according to BCLC classification. Postoperative mortality, morbidity, overall and disease-free survival, univariate analysis of prognostic factors on survival was analyzed. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- M Garancini
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy.
| | - S Nespoli
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
| | - F Romano
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
| | - F Uggeri
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
| | - L Degrate
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
| | - S Okolicsanyi
- Department of Gastroenterology, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
| | - L Gianotti
- Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, University of Milano- Bicocca, via Pergolesi 33, 20900 Monza, MI, Italy
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Garancini M, Nespoli S, Romano F, Uggeri F, Degrate L, Okolicsanyi S, Gianotti L. Traitement chirurgical du carcinome hépatocellulaire dans le cadre et en dehors des indications de Barcelone dans un centre de moyen volume. JOURNAL DE CHIRURGIE VISCÉRALE 2018; 155:278-285. [DOI: 10.1016/j.jchirv.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
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Morise Z. Laparoscopic liver resection for the patients with hepatocellular carcinoma and chronic liver disease. Transl Gastroenterol Hepatol 2018; 3:41. [PMID: 30148226 PMCID: PMC6088100 DOI: 10.21037/tgh.2018.07.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 06/29/2018] [Indexed: 12/12/2022] Open
Abstract
Liver resection (LR), liver transplantation (LT), transarterial chemoembolization, and local ablation therapy are the treatment options for hepatocellular carcinoma (HCC). Although LR, LT and local ablation therapy (only for small tumor) provide the best hope for cure, most patients with HCC have also chronic liver disease (CLD) backgrounds, including HCV-liver cirrhosis. Therefore, they are at high risk for development of postoperative complications-sometimes fatal-and metachronous multicentric recurrent tumors occurring from the preneoplastic CLD background. Appropriate treatment is selected for HCC patients, on the combined evaluations of tumor condition and liver function. However, not small number of patients cannot undergo any treatment option due to poor liver function and/or complicated tumor condition. After repeated treatments, it can happen more often. It is thought that the features of laparoscopic LR could lead to the expansion of the LR indication to those patients, in the settings of severe CLD, repeat LR and bridging to LT. In our experience, Child-Pugh (CP) score is one of the promising candidates as a selection indicator which correlates well to our indication criteria of surface small laparoscopic LR to severe CLD patients, patient's performance status, and prognosis. Portal hypertension should be also counted in the selection criteria.
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Affiliation(s)
- Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Yang J, Yang JY, Yan LN, Wen TF, Li B, Wang WT. Hepatic resection vs. transarterial chemoembolization for hepatocellular carcinoma beyond the Milan criteria with portal hypertension. Dig Liver Dis 2018; 50:713-719. [PMID: 29622387 DOI: 10.1016/j.dld.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess the value of hepatic resection by comparing it with transarterial chemoembolization for hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension. METHODS A total of 363 patients and 193 propensity score-matched patients who had hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension and underwent hepatic resection or transarterial chemoembolization were retrospectively analyzed. The short-term and long-term results were compared. RESULTS Postoperative complications and 30-day mortality were similar between the two groups. The hepatic resection provided a survival benefit over TACE at 1, 2, 3, and 5 years. Similar results were observed in the propensity score analysis. Five variables were identified as independent prognostic factors: treatment, AFP, Child-Pugh classification, tumor number and extension of disease in a multivariate analysis of the whole study population. In addition, only the tumor number was identified as an independent risk factor after propensity matching. The subgroup analysis demonstrated that the survival benefit of the hepatic resection can only be derived in a subset of patients with a single tumor. CONCLUSIONS In a properly selected group of patients with hepatocellular carcinoma beyond the Milan criteria with clinically relevant portal hypertension, hepatic resection appears to be as safe as TACE and provides a significant survival benefit.
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Affiliation(s)
- Jian Yang
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jia-Yin Yang
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Lu-Nan Yan
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Tian-Fu Wen
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Bo Li
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wen-Tao Wang
- Department of Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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10
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Otsuka Y, Kaneko H. Laparoscopic liver resection in the treatment of HCC with liver cirrhosis: would it provide superiority to conventional open hepatectomy? Hepatobiliary Surg Nutr 2017; 6:356-358. [PMID: 29152489 DOI: 10.21037/hbsn.2017.06.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Yuichiro Otsuka
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
| | - Hironori Kaneko
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
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11
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Selby LKE, Tay RXY, Woon WWL, Low JK, Bei W, Shelat VG, Pang TCY, Junnarkar SP. Validity of the Barcelona Clinic Liver Cancer and Hong Kong Liver Cancer staging systems for hepatocellular carcinoma in Singapore. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:143-152. [PMID: 28012284 DOI: 10.1002/jhbp.423] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Staging is vital in guiding therapeutic approach in patients diagnosed with hepatocellular carcinoma (HCC). Our study's goal is to compare paradigms in the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) systems, and evaluate the use of both in a local context, comparing their prognostic ability and therapeutic efficacy in the management of HCC. METHODS Seven hundred and sixty-six patients diagnosed between 2010 and 2015 were identified and staged according to BCLC and HKLC. Both system's performances were compared using Akaike information criterion (AIC), bootstrap concordance-index (c-index), and through Kaplan-Meier survival curves of patients who came under HKLC stages 1, 2, and 3 and the individual BCLC stages. Independent prognostic factors of survival were identified using univariate and multivariate analyses. RESULTS According to AIC and c-index, HKLC (AIC = 5,711, c-index = 0.74) has equivalent prognosticating value as BCLC (AIC = 5,764, c-index = 0.72). Through Kaplan-Meier curves, we determined that more aggressive treatments resulted in better outcomes. Particularly for patients under BCLC stage C, patients who followed the HKLC system's recommended treatments performed markedly better. CONCLUSIONS In our patient population, the HKLC system is comparable to the BCLC system in prognosticating patients, but is suggested to have better performance in guiding treatment.
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Affiliation(s)
- Li Kim E Selby
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rosanna X Y Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Winston W L Woon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Wang Bei
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Vishalkumar G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Tony C Y Pang
- Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Sameer P Junnarkar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
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12
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Zhang QB, Zhang XG, Jiang RD, Hu CX, Sun D, Ran L, Zhang ZL. Microwave ablation versus hepatic resection for the treatment of hepatocellular carcinoma and oesophageal variceal bleeding in cirrhotic patients. Int J Hyperthermia 2016; 33:255-262. [PMID: 27817240 DOI: 10.1080/02656736.2016.1257824] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The aim of this study was to compare the results of microwave ablation (MWA) and hepatic resection (HR) when combined with pericardial devascularisation plus splenectomy (PCDV) for the treatment of patients with cirrhosis complicated by small hepatocellular carcinoma (HCC) and oesophageal variceal bleeding (EVB). MATERIALS AND METHODS Between 2001 and 2013, 73 patients (median age 53.2 years, 67% male) with small HCC and concomitant EVB who underwent MWA or HR for HCC and PCDV for cirrhotic portal hypertension were selected retrospectively for inclusion in this study. The overall survival curves and recurrence-free survival curves were calculated using the Kaplan-Meier method and compared using log-rank tests. Multivariate analysis was performed using the Cox regression model. RESULTS The 1-, 3- and 5-year overall survival rates were 95.2%, 71.4% and 38.1% and 96.7%, 53.3% and 43.3% for the HR and MWA groups, respectively; these did not differ significantly between the two groups. However, patients in the HR group had more post-operative complications (52.3% vs. 13.7%; p = 0.002). Multivariate analysis identified albumin and bilirubin levels and tumour size to be statistically significant and independent prognostic factors for overall survival, while BCLC stage was associated with poor recurrence-free survival. Furthermore, albumin levels were shown to be an independent predictive factor for post-operative complications. CONCLUSIONS For patients with small HCC and concomitant EVB, MWA plus PCDV may reduce the incidence of post-operative complications relative to and provide similar therapeutic benefits as HR plus PCDV, especially for patients with low albumin levels.
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Affiliation(s)
- Qiang-Bo Zhang
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Xiu-Guo Zhang
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Run-de Jiang
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Chun-Xiao Hu
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Dong Sun
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Lin Ran
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
| | - Zong-Li Zhang
- a Department of General Surgery , Qilu Hospital, Shandong University , Jinan , China
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Balogh J, Victor D, Asham EH, Burroughs SG, Boktour M, Saharia A, Li X, Ghobrial RM, Monsour HP. Hepatocellular carcinoma: a review. J Hepatocell Carcinoma 2016; 3:41-53. [PMID: 27785449 PMCID: PMC5063561 DOI: 10.2147/jhc.s61146] [Citation(s) in RCA: 796] [Impact Index Per Article: 88.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and is a leading cause of cancer-related death worldwide. In the United States, HCC is the ninth leading cause of cancer deaths. Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, incidence and mortality continue to rise. Cirrhosis remains the most important risk factor for the development of HCC regardless of etiology. Hepatitis B and C are independent risk factors for the development of cirrhosis. Alcohol consumption remains an important additional risk factor in the United States as alcohol abuse is five times higher than hepatitis C. Diagnosis is confirmed without pathologic confirmation. Screening includes both radiologic tests, such as ultrasound, computerized tomography, and magnetic resonance imaging, and serological markers such as α-fetoprotein at 6-month intervals. Multiple treatment modalities exist; however, only orthotopic liver transplantation (OLT) or surgical resection is curative. OLT is available for patients who meet or are downstaged into the Milan or University of San Francisco criteria. Additional treatment modalities include transarterial chemoembolization, radiofrequency ablation, microwave ablation, percutaneous ethanol injection, cryoablation, radiation therapy, systemic chemotherapy, and molecularly targeted therapies. Selection of a treatment modality is based on tumor size, location, extrahepatic spread, and underlying liver function. HCC is an aggressive cancer that occurs in the setting of cirrhosis and commonly presents in advanced stages. HCC can be prevented if there are appropriate measures taken, including hepatitis B virus vaccination, universal screening of blood products, use of safe injection practices, treatment and education of alcoholics and intravenous drug users, and initiation of antiviral therapy. Continued improvement in both surgical and nonsurgical approaches has demonstrated significant benefits in overall survival. While OLT remains the only curative surgical procedure, the shortage of available organs precludes this therapy for many patients with HCC.
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Affiliation(s)
- Julius Balogh
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Department of Gastroenterology and Transplant Hepatology
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Emad H Asham
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Sherilyn Gordon Burroughs
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Maha Boktour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Ashish Saharia
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Xian Li
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - R Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Division of Transplantation, Department of Surgery
| | - Howard P Monsour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation
- Department of Gastroenterology and Transplant Hepatology
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
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Current Treatment Approaches to HCC with a Special Consideration to Transplantation. J Transplant 2016; 2016:7926264. [PMID: 27413539 PMCID: PMC4931061 DOI: 10.1155/2016/7926264] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. The mainstay of treatment of HCC has been both resectional and transplantation surgery. It is well known that, in selected, optimized patients, hepatectomy for HCC may be an option, even in patients with underlying cirrhosis. Resectable patients with early HCC and underlying liver disease are however increasingly being considered for transplantation because of potential for better disease-free survival and resolution of underlying liver disease, although this approach is limited by the availability of donor livers, especially in resectable patients. Outcomes following liver transplantation improved dramatically for patients with HCC following the implementation of the Milan criteria in the late 1990s. Ever since, the rather restrictive nature of the Milan criteria has been challenged with good outcomes. There has also been an increase in the donor pool with marginal donors including organs retrieved following cardiac death being used. Even so, patients still continue to die while waiting for a liver transplant. In order to reduce this attrition, bridging techniques and methods for downstaging disease have evolved. Additionally new techniques for organ preservation have increased the prospect of this potentially curative procedure being available for a greater number of patients.
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15
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Morise Z. Perspective of laparoscopic liver resection for hepatocellular carcinoma. World J Gastrointest Surg 2015; 7:102-106. [PMID: 26225191 PMCID: PMC4513431 DOI: 10.4240/wjgs.v7.i7.102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/30/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023] Open
Abstract
Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is associated with high risks of developing significant postoperative complications and multicentric metachronous lesions, which can result in the need for repeated treatments. Studies comparing laparoscopic procedures to open LR consistently report reduced blood loss and transfusions requirements, lower postoperative morbidity, and shorter hospital stays, with no differences in oncologic outcomes. In addition, laparoscopic LR is associated with reduced postoperative ascites and a lower incidence of liver failure for HCC patients with CLD, due to the reduced surgery-induced parenchymal injury to the residual liver and limited destruction of the collateral blood/lymphatic flow around the liver. Finally, this procedure facilitates subsequent repeat LR due to minimal adhesion formation and improved vision/manipulation between adhesions. These characteristics of laparoscopic LR may lead to an expansion of the indications for LR. This editorial is based on the review and meta-analysis presented at the 2nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan, in October 2014 (Chairperson of the congress is Professor Go Wakabayashi from the Department of Surgery, Iwate Medical University School of Medicine), which is published in the Journal of Hepato-Biliary-Pancreatic Sciences.
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16
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Kluger MD, Salceda JA, Laurent A, Tayar C, Duvoux C, Decaens T, Luciani A, Van Nhieu JT, Azoulay D, Cherqui D. Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis. J Hepatol 2015; 62:1131-40. [PMID: 25529622 DOI: 10.1016/j.jhep.2014.12.018] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors. METHODS Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model. RESULTS Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69). CONCLUSION By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.
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Affiliation(s)
- Michael D Kluger
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Section of Gastrointestinal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, United States
| | - Juan A Salceda
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alexis Laurent
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Claude Tayar
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Christophe Duvoux
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Thomas Decaens
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alain Luciani
- Service d'Imagerie Medicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Jeanne Tran Van Nhieu
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Azoulay
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Cherqui
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Centre Hépato Biliaire, Paul Brousse Hôpital, Université Paris Sud, Villejuif, France.
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Morise Z, Ciria R, Cherqui D, Chen KH, Belli G, Wakabayashi G. Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:342-52. [PMID: 25663288 DOI: 10.1002/jhbp.215] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/18/2014] [Indexed: 02/06/2023]
Abstract
Liver resection (LR) for patients with hepatocellular carcinoma (HCC) and chronic liver disease (CLD) poses a high risk of serious postoperative complications and multicentric metachronous lesions requiring repeated treatment. The efficacy of laparoscopic LR (LLR) for such patients has yet to be established. The objective of this study is to test the outcomes of LLR for HCC with the aim of considering potential expansion of the indications for LLR. We performed a systematic review of the pertinent English-language literature. Our search yielded four meta-analyses and 23 comparative studies of LLR for HCC. On the basis of the findings from these studies and our newly conducted meta-analysis, the possibility for expanding the indications for LLR to HCC was examined. The studies show that LLR (vs open) for HCC generally yields better short-term outcomes without compromising long-term outcomes, and that incidences of postoperative ascites and liver failure are decreased with LLR. Several studies show the benefits of LLR for patients with severe CLD and for repeat surgery. Reductions of postoperative ascites and liver failure are among the advantages of LLR. These characteristics of LLR may allow us to expand the indications of LLR to HCC with CLD.
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Affiliation(s)
- Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine, Banbuntane Houtokukai Hospital, 3-6-10 Otobashi, Nakagawa-ku, Nagoya, Aichi, 454-8509, Japan.
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Hepatocellular Carcinoma in Liver Cirrhosis: Surgical Resection versus Transarterial Chemoembolization-A Meta-Analysis. Gastroenterol Res Pract 2015; 2015:696120. [PMID: 25642245 PMCID: PMC4302354 DOI: 10.1155/2015/696120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 02/07/2023] Open
Abstract
We compare the value of TACE to liver resection for patients with BCLC stage A and B HCC. For patients with HCC in cirrhosis LT is the treatment of choice. TACE represents the current standard for unresectable BCLC stage B patients not eligible for LT. Recently liver resection for HCC and significant cirrhosis has become increasingly popular. A systematic search of the literature and meta-analysis was conducted to identify studies, reporting short- and long-term results of hepatic resection versus TACE for HCC treatment. The data were analyzed regarding the odds for 30-day mortality and hazard ratio for overall-survival. 12 studies comparing short- and long-term outcome of HR versus TACE for HCC were identified. Peri-interventional mortality and overall survival were investigated. Peri-interventional mortality was higher for surgical resection (n.s.), and overall-survival was significantly better for surgically treated patients at one year (P = 0.002) and 3 years (P ≤ 0.00001). The hazard ratio of overall-survival for all twelve studies was 0.70 (P = 0.0001) and significantly in favor of surgical treatment. Although large RCTs are missing and the available data are limited and not homogeneous a reappraisal of the current treatment guidelines should be considered based on the superior long-term outcome for surgically treated patients.
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Kawabe N, Morise Z, Tomishige H, Nagata H, Kawase J, Arakawa S, Isetani M. Laparoscopic liver resection for the treatment of hepatocellular carcinoma. World J Surg Proced 2015; 5:137. [DOI: 10.5412/wjsp.v5.i1.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
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Guerrini GP, Soliani P. Repeated hepatic resection combined with inferior vena cava replacement: Case report and review of literature. Int J Surg Case Rep 2014; 6C:114-7. [PMID: 25528040 PMCID: PMC4347956 DOI: 10.1016/j.ijscr.2014.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Advanced tumors of the liver involving the inferior vena cava (IVC) have always been considered a contraindication to surgery. PRESENTATION OF CASE We report a case of a patient, who previously underwent right hepatectomy, with recurrence of colorectal liver metastasis invading the IVC. The patient had a liver resection together with replacement of the vena cava using a ringed polytetrafluoroethylene (PTFE) graft tube. The operation was carried out in hepatic vascular exclusion (HVE) without the use of veno-venous bypass. The patient was healthy and tumor-free at 6 months post-surgery. DISCUSSION In patients with hepatic malignancy involving the IVC, extended hepatic resection and reconstruction of the IVC is often the prerequisite to obtaining a resection margin. CONCLUSION Extended hepatic resection with IVC reconstruction for hepatic malignancy may offer a chance of cure to selected patients who otherwise have poor survival rates.
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Affiliation(s)
- Gian Piero Guerrini
- Ravenna Hospital, AUSL Romagna, HBP and General Surgery Unit, Randi 5, 48121 Ravenna, Italy.
| | - Paolo Soliani
- Ravenna Hospital, AUSL Romagna, HBP and General Surgery Unit, Randi 5, 48121 Ravenna, Italy
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Child-Pugh A hepatitis B-related cirrhotic patients with a single hepatocellular carcinoma up to 5 cm: liver transplantation vs. resection. J Gastrointest Surg 2014; 18:1469-76. [PMID: 24903846 DOI: 10.1007/s11605-014-2550-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/20/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to analyze the outcomes of patients with Child-Pugh A class cirrhosis and a single hepatocellular carcinoma (HCC) up to 5 cm in diameter who underwent liver transplantation vs. resection. METHODS During 2007 to 2012, 282 Child-Pugh A cirrhotic patients with a single HCC up to 5 cm in diameter either underwent liver resection (N = 243) or received liver transplantation (N = 39) at our center. Patient and tumor characteristics and outcomes were analyzed. RESULTS Patients who underwent liver transplantation had a better recurrence-free survival (RFS) vs. those who underwent liver resection. However, the 5-year survival rates after these two treatments were comparable. Similar results were observed when we analyzed patients with a HCC less than 3 cm, and for patients with portal hypertension. In the multivariate analysis, tumor differentiation, difference of primary treatment, and presence of microvascular invasion were associated with postoperative recurrence. However, only differentiation negatively impacted overall survival after operation. CONCLUSION Although more recurrences were observed in Child A cirrhotic patients with a single HCC up to 5 cm after liver resection, liver resection offers a similar 5-year survival to liver transplantation, even for patients with portal hypertension.
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Guerrini GP, Gerunda GE, Montalti R, Ballarin R, Cautero N, De Ruvo N, Spaggiari M, Di Benedetto F. Results of salvage liver transplantation. Liver Int 2014; 34:e96-e104. [PMID: 24517642 DOI: 10.1111/liv.12497] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 02/05/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Salvage liver transplantation (SLT) is an attractive sequential strategy which combines liver resection (LR) for hepatocellular carcinoma (HCC), followed by liver transplant (LT) in the event of HCC recurrence or progressive liver deterioration. To compare the long-term results of SLT with primary liver transplant (PLT). METHODS Between 2000 and 2011, 125 patients (72 transplantable) underwent LR and 226 underwent LT in our unit. The outcome of SLT was analysed in a two-step fashion: firstly, SLT (n = 28) was compared with PLT (n = 198), secondly an intention-to-treat analysis was performed on all transplantable HCC patients who underwent LR (LRT group = 72) compared to PLT (n = 198). RESULTS The five-year overall survival (OS) was 65.4% vs. 49.2% (P = 0.63), and disease-free survival (DFS) was 89.7% vs. 80.6% (P = 0.31) for PLT and SLT respectively. Predictive factors for DFS after LT included HCC total diameter [hazard ratio (HR) 1.29 P = 0.003], alpha-foetoprotein (HR 1.002 P < 0.001) and number of HCC nodules (HR 1.317 P = 0.035), whereas viral hepatitis C positivity (HR 1.911 P = 0.03) and outside Up-to-seven criteria (HR 2.652 P < 0.001) were negative independent prediction factors of OS. Intention-to-treat analysis showed that OS at 5 years was improved in PLT vs. LRT (LRT n = 72 including SLT plus LR group) and was 69.4% vs. 42.2% (P < 0.004), with an additional increase in DFS (89.2% vs. 54.5% respectively P < 0.001). CONCLUSION Salvage liver transplantation is a safe treatment strategy, as it does not impair long-term survival. At intention-to-treat analysis, PLT showed improved survival compared with LRT.
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Affiliation(s)
- Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgery and Transplantation, University of Modena and Reggio Emilia, Modena, Italy
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Zhang H, Yuan SX, Dai SY, Zhang JM, Huang X, Lu CD, Lu JH, Wu FQ, Lau WY, Wu MC, Yang T, Shen F. Tumor size does not independently affect long-term survival after curative resection of solitary hepatocellular carcinoma without macroscopic vascular invasion. World J Surg 2014; 38:947-957. [PMID: 24258262 DOI: 10.1007/s00268-013-2365-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the prognostic value of tumor size alone on long-term survival and recurrence after curative resection for solitary hepatocellular carcinoma (HCC) without macroscopic vascular invasion. METHODS A single-center cohort of 615 patients with solitary HCC (a single tumor, without macroscopic vascular invasion or distant metastasis) undergoing curative hepatic resection from 2002 to 2010 was retrospectively studied. Using 2.0, 3.0, 4.0, 5.0, 8.0, and 10.0 cm as cut-off values of tumor size, the overall survival (OS) and recurrence-free survival (RFS) rates were compared between the groups of patients with tumor size up to a certain cut-off value and the groups of patients with tumor size above that cut-off value. Thus, multiple comparisons were done. The prognostic factors of OS and RFS were evaluated using univariate and multivariate analyses. RESULTS The median tumor size of all HCCs was 4.0 cm (range 0.9-22.0 cm). The in-hospital mortality rate was 1.0 %, and the overall morbidity rate was 22.3 %. The 1-, 3-, and 5-year OS rates were 96.0, 79.8, and 69.9 %, and the corresponding RFS rates were 83.6, 72.7, and 57.2 %, respectively. On univariate analyses, the 1-, 3-, and 5-year OS and RFS rates were significantly different between the individual two groups of patients as divided by the aforementioned different cut-off values of tumor sizes (all p < 0.05). However, when tumor size was put as a continuous variable into multivariate analysis, it was no longer an independent prognostic factor of OS or RFS after curative resection. CONCLUSIONS Tumor size did not independently affect long-term survival and recurrence after curative resection of solitary HCC without macroscopic vascular invasion. Therefore, there is no size limit that precludes hepatic resection for solitary HCC, provided the tumor is resectable.
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Affiliation(s)
- Han Zhang
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, No.225, Changhai Road, Shanghai, China
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Herman P, Perini MV, Coelho FF, Kruger JAP, Lupinacci RM, Fonseca GM, Lopes FDLM, Cecconello I. Laparoscopic resection of hepatocellular carcinoma: when, why, and how? A single-center experience. J Laparoendosc Adv Surg Tech A 2014; 24:223-228. [PMID: 24568364 DOI: 10.1089/lap.2013.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate short- and intermediate-term results of laparoscopic liver resection in selected patients with hepatocellular carcinoma (HCC). PATIENTS AND METHODS Eighty-five patients with HCC were subjected to liver resection between February 2007 and January 2013. From these, 30 (35.2%) were subjected to laparoscopic liver resection and were retrospectively analyzed. Special emphasis was given to the indication criteria and to surgical results. RESULTS There were 21 males and 9 females with a mean age of 57.4 years. Patients were subjected to 10 nonanatomic and 20 anatomic resections. Two patients were subjected to hand-assisted procedures (right posterior sectionectomies); all other patients were subjected to totally laparoscopic procedures. Conversion to open surgery was necessary in 4 patients (13.3%). Postoperative complications were observed in 12 patients (40%), and the mortality rate was 3.3%. Mean overall survival was 29.8 months, with 3-year overall and disease-free survival rates of 76% and 58%, respectively. CONCLUSIONS Laparoscopic treatment of selected patients with HCC is safe and feasible and can lead to good short- and intermediate-term results.
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Affiliation(s)
- Paulo Herman
- Liver Surgery Unit, Department of Gastroenterology, University of São Paulo Medical School , São Paulo, Brazil
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25
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Cucchetti A, Piscaglia F, Cescon M, Serra C, Colecchia A, Maroni L, Venerandi L, Ercolani G, Pinna AD. An explorative data-analysis to support the choice between hepatic resection and radiofrequency ablation in the treatment of hepatocellular carcinoma. Dig Liver Dis 2014; 46:257-63. [PMID: 24284006 DOI: 10.1016/j.dld.2013.10.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 09/16/2013] [Accepted: 10/27/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whether to prefer hepatic resection or radiofrequency ablation as first line therapy for hepatocellular carcinoma is a matter of debate. AIMS To compare outcomes of resection and ablation, in the treatment of early hepatocellular carcinoma, through a decision-making analysis. METHODS Data of 388 cirrhotic patients undergoing resection and of 207 undergoing radiofrequency ablation were reviewed. Two distinct regression models were devised and used to perform sensitivity and probabilistic analyses, to overcome biases of covariate distributions. RESULTS Actuarial survival curves showed no difference between resection and ablation (P=0.270) despite the fact that ablated patients were older, with worse liver function and smaller, unifocal tumours (P<0.05), suggesting a complex, non-linear relationship between clinical, tumoral variables and treatments. Sensitivity and probabilistic analyses suggested that the superiority of resection over ablation decreased at higher Model for-End stage Liver Disease scores, and that ablation provided better results for smaller tumours and higher Model for-End stage Liver Disease scores. In patients with 2-3 tumours up to 3 cm, the two treatments produced opposite comparative results in relation to the Model for-End stage Liver Disease score. CONCLUSIONS The superiority, or the equivalence, of resection and ablation depends on the non-linear relationship existing between treatment, tumour number, size and degree of liver dysfunction.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Carla Serra
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Lorenzo Maroni
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Laura Venerandi
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Antonio Daniele Pinna
- Department of Medical and Surgical Sciences, S.Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
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Morise Z, Kawabe N, Kawase J, Tomishige H, Nagata H, Ohshima H, Arakawa S, Yoshida R, Isetani M. Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease. World J Hepatol 2013; 5:487-495. [PMID: 24073300 PMCID: PMC3782686 DOI: 10.4254/wjh.v5.i9.487] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/06/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.
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Zhang P, Liu XK, Chu Z, Ye JC, Li KL, Zhuang WL, Yang DJ, Jiang YF. Detection of interleukin-33 in serum and carcinoma tissue from patients with hepatocellular carcinoma and its clinical implications. J Int Med Res 2013. [PMID: 23206447 DOI: 10.1177/030006051204000504] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the clinical significance of intercellular interleukin (IL)-33 in hepatocellular carcinoma (HCC). METHODS Using immunohistochemistry, this prospective study compared IL-33 protein levels in samples of HCC tissue and normal tissue adjacent to the tumour in 60 patients with HCC, and in normal liver tissue from six healthy controls. Interferon (IFN)-α, IFN-γ and IL-33 serum levels were also analysed by enzyme-linked immunosorbent assay in HCC 30 patients and 10 healthy controls. The level of IL-33 immunohistochemical staining was compared with the rate of lymph node metastasis in HCC patients. RESULTS IL-33 was strongly positive in the cytoplasm of hepatocytes. The median percentage of IL-33-positive tissue was higher in HCC than in normal liver tissue samples (adjacent to the tumour or from controls). Serum IFN-α, IFN-γ and IL-33 levels were higher in pre- and postoperative samples from HCC patients than in control samples, and in patients with metastasis compared with those without metastasis. CONCLUSIONS Increased IL-33 protein levels were observed in serum and liver tissue from HCC patients; IL-33 may be a useful biological marker for monitoring HCC growth and metastasis.
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Affiliation(s)
- P Zhang
- Central Laboratory, Norman Bethune First Hospital, Jilin University, Changchun, China
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Santambrogio R, Salceda J, Costa M, Kluger MD, Barabino M, Laurent A, Opocher E, Azoulay D, Cherqui D. External validation of a simplified BCLC staging system for early hepatocellular carcinoma. Eur J Surg Oncol 2013; 39:850-7. [PMID: 23726257 DOI: 10.1016/j.ejso.2013.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 04/07/2013] [Accepted: 05/02/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND AIMS The aim was to externally validate the capability of a simplified Barcelona Clinic Liver Cancer (s-BCLC) staging system in allocating patients to hepatic resection (HR) and the effect on survival: S-BCLC was defined by only 2 groups: AA included BCLC A1 + A2 classes with alpha-fetoprotein (AFP) ≤ 20 ng/ml and AB included A1 + A2 with AFP > 20 ng/ml plus A3 + A4 subgroups. METHODS This study compared a training group (TG) with hepatocellular carcinoma (HCC) submitted to hepatic resection (HR) in Milan with another group of patients, the validation group (VG) in Creteil. All patients underwent ultrasound-guided anatomical resection (<3 segments). RESULTS Overall survival got worse from A1 to A4 (p = 0.0271) in TG (n = 132), as well as in VG (n = 100) (p = 0.0044) with a more important overlapping of each curves. According s-BCLC classification, the survival curves of TG (p = 0.0001) and VG (p = 0.0250) showed a definitive separation in two different staging groups. The s-BCLC provided the best predictive accuracy and it also presented the highest separability index and C-statistics in both TG and VG. On the other hand, in the evaluation of discriminatory ability for death, measured by ROC curve areas, the s-BCLC system gave better results than the others. CONCLUSION This experience stressed the high value of BCLC system in staging of HCC, but the s-BCLC system seems to be more useful for therapeutic decision making.
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Affiliation(s)
- R Santambrogio
- Chirurgia 2 - Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, Italy.
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A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: is it adherent to the EASL/AASLD recommendations?: an observational study of the HCC East-West study group. Ann Surg 2013; 257:929-37. [PMID: 23426336 DOI: 10.1097/sla.0b013e31828329b8] [Citation(s) in RCA: 404] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to investigate in a retrospective setting the patients' profile and results of those undergoing surgery for hepatocellular carcinoma (HCC) in high-volume surgical centers throughout the world. BACKGROUND Whether surgery for HCC is a suitable approach and for which subset of patients is still controversial. The EASL/AASLD (European Association for the Study of Liver Disease/American Association for the Study of Liver Disease) guidelines, based on the Barcelona Clinic Liver Cancer (BCLC) classification, leave little room for hepatic resection; inversely, other reports promote its wider application. METHODS On the basis of the network "Hepatocellular Carcinoma: Eastern & Western Experiences," data for 2046 consecutive patients resected for HCC in 10 centers were collected. According to the BCLC classification, 1012 (50%) were BCLC 0-A, 737 (36%) BCLC B, and 297 (14%) BCLC C. Analysis of overall survival and disease-free survival and multivariate analysis of prognostic factors were performed. FINDINGS The 90-day mortality rate was 2.7%. Overall morbidity was 42%. After a median follow-up of 25 months (range, 1-209 months), the 1-, 3-, and 5-year overall survival rates were 95%, 80%, and 61% for BCLC 0-A; 88%, 71%, and 57% for BCLC B; and 76%, 49%, and 38% for BCLC C (P = 0.000). The 1-, 3-, and 5-year disease-free survival rates were as follows: 77%, 41%, and 21% for BCLC 0-A; 63%, 38%, and 27% for BCLC B; and 46%, 28%, and 18% for BCLC C (P = 0.000). The multivariate analysis identified bilirubin, cirrhosis, esophageal varices, tumor size, and macrovascular invasion to be statistical and independent prognostic factors for overall survival. CONCLUSIONS This large multicentric survey shows that surgery is in current practice widely applied among patients with multinodular, large, and macrovascular invasive HCC, providing acceptable short- and long-term results and justifying an update of the EASL/AASLD therapeutic guidelines in this sense.
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Yamamoto K, Fukumori D, Yamamoto F, Yamamoto M, Igimi H, Yamashita Y. First report of hepatectomy without endotracheal general anesthesia. J Am Coll Surg 2013; 216:908-14. [PMID: 23490541 DOI: 10.1016/j.jamcollsurg.2013.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/31/2012] [Accepted: 01/08/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Local anesthesia, including epidural anesthesia, has much merit over general anesthesia for the reduction of perioperative cardiac and respiratory complications. Liver operations commonly require general anesthesia. This is the first report of hepatectomy performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation. STUDY DESIGN We devised the following protocol for hepatectomy under epidural anesthesia with conscious sedation: the patient receives 10 mg diazepam orally 1 hour before surgery, followed by 10 mg diazepam and 15 mg pentazocine intravenously just before surgery. An epidural catheter is inserted via the thoracic vertebra 7 to 9 interspaces. Intraoperatively, the patient receives a bolus of 7 mL 2% mepivacaine hydrochloride every 40 minutes through the epidural catheter. We conducted 4 left hepatectomies, 1 left lateral sectorectomy, and 5 partial hepatectomies under this protocol. We assessed the efficacy and safety of hepatectomy under epidural anesthesia with conscious sedation in terms of mortality rate, surgical time, amount of bleeding, and central venous pressure during the procedure. RESULTS Every patient was managed without endotracheal intubation and laryngeal masks. There was no perioperative mortality. Median intraoperative blood loss was 453.0 mL (range 144.0 to 1292.0 mL) and median surgical time was 273.0 minutes (range 137.0 to 440.0 minutes). Median total amount of 2% mepivacaine hydrochloride used was 52.0 mL (range 23.0 to 95.0 mL). Central venous pressure values were significantly lower during the Pringle maneuver than at preclamp. CONCLUSIONS The traditional belief is that liver resection should be performed under general anesthesia. We report the world's first series of liver resections for malignant tumors performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation.
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Affiliation(s)
- Kentaroh Yamamoto
- Department of Surgery, Yamamoto Memorial Hospital, Imari City, Japan.
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Henry JC, Malhotra L, Khabiri H, Guy G, Michaels A, Hanje J, Azevedo M, Bloomston M, Schmidt CR. Best radiological response to trans-arterial chemoembolization for hepatocellular carcinoma does not imply better outcomes. HPB (Oxford) 2013; 15:196-202. [PMID: 23374360 PMCID: PMC3572280 DOI: 10.1111/j.1477-2574.2012.00529.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Regional therapy with trans-arterial chemoembolization (TACE) is a common treatment for unresectable hepatocellular carcinoma (HCC). Outcomes were examined in patients with the best radiological response (BR) after the initial TACE. METHODS This was a retrospective cohort study of patients who underwent TACE as the initial treatment for HCC between the years 2000 and 2010. BR was defined as complete disappearance of the tumour or no enhancement with contrast on the first cross-sectional imaging study after the initial TACE. RESULTS Seventy-eight out of 104 total consecutive patients were identified with the potential for a BR to TACE therapy for unresectable HCC, and 24 met the criteria for BR. Patients with BR had a median survival of 12.8 months (2.2-54.9) compared with 18.9 months(1.3-56.7) for the entire cohort (P= 0.313). The median time to progression was 10.6 months (1.2-24.3) in the BR group and 3.2 months (0.7-49.2) in the patients without a BR (P= 0.003). DISCUSSION BR to initial TACE for unresectable HCC is associated with comparable survival to those without BR in spite of a longer time to cancer progression. It may be reasonable to consider further therapy such as repeat TACE or biological/systemic therapy in patients with HCC even when the radiological response to the initial TACE is favourable.
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Affiliation(s)
- Jon C. Henry
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lavina Malhotra
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hooman Khabiri
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Gregory Guy
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Anthony Michaels
- Department of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - James Hanje
- Department of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marcela Azevedo
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark Bloomston
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Carl R. Schmidt
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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Abstract
The current treatment of HCC is truly multidisciplinary. Notwithstanding, surgical management remains the gold standard which other therapies are compared to. Operative management is divided into transplantation and resection; the latter is further subdivided among open and laparoscopic approaches. Resection has become safer, remains superior to locoregional treatments, and can be a life-prolonging bridge to transplantation. The decision to pursue laparoscopic resection for HCC is driven by safety and a view toward the long-term management of both the malignancy and the underlying liver disease. For patients with a solitary HCC <5 cm in segments 2, 3, 4b, 5, and 6, no evidence of extrahepatic tumor burden, compensated liver disease, and the absence of significant portal hypertension, laparoscopy has an important role. Under these circumstances, resection can be performed with reduced mortality and morbidity and equivalent oncologic outcomes, disease-free survival, and overall survival when compared with similarly selected cirrhotic patients undergoing open resection. Blood loss and transfusion requirements are low, and laparoscopy itself does not expose the patient to complications and does not increase the risk of cancer recurrence or dissemination. Finally, because HCC recurrence remains high in the cirrhotic liver, treatment following surgical resection mandates routine surveillance and treatment by locoregional therapy, reresection, or transplantation as required-the latter two of which are facilitated by an initial laparoscopic resection.
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Xiong JJ, Altaf K, Javed MA, Huang W, Mukherjee R, Mai G, Sutton R, Liu XB, Hu WM. Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma. World J Gastroenterol 2012; 18:6657-68. [PMID: 23236242 PMCID: PMC3516221 DOI: 10.3748/wjg.v18.i45.6657] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 09/17/2012] [Accepted: 09/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).
METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).
RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).
CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.
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Huang J, Hernandez-Alejandro R, Croome KP, Zeng Y, Wu H, Chen Z. Hepatic resection for huge (>15 cm) multinodular HCC with macrovascular invasion. J Surg Res 2012; 178:743-50. [PMID: 22656039 DOI: 10.1016/j.jss.2012.04.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 04/02/2012] [Accepted: 04/25/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Surgical resection has routinely not been recommended for patients with huge (>15 cm) multinodular lesions and macrovascular invasion (advanced-stage hepatocellular carcinoma [HCC] patients) because of high operative mortality, recurrence rate, and lack of survival benefit. METHODS A retrospective study of 1425 patients was carried out, of which 1245 patients met EASL/AASLD criteria for hepatic resection (HR-EA group), 116 were surgically treated advanced-stage HCC patients (HR-AS group), and 64 were advanced-stage HCC patients receiving nonsurgical treatments (N-AS group). CONCLUSION HR may still be suitable for the HCC patients with huge (>15 cm) multinodular lesions and macrovascular invasion in selected cases. Advanced-stage HCC patients without liver cirrhosis and with a tumor-free resection margin could enjoy longer survival and lower recurrence. Preoperative and/or postoperative TACE provides no survival benefits for advanced-stage HCC patients.
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Affiliation(s)
- Jiwei Huang
- Division of Liver Transplantation, Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Waly Raphael S, Yangde Z, YuXiang C. Hepatocellular carcinoma: focus on different aspects of management. ISRN ONCOLOGY 2012; 2012:421673. [PMID: 22655206 PMCID: PMC3359687 DOI: 10.5402/2012/421673] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 03/04/2012] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third cause of cancer-related mortality worldwide. Its incidence is clearly arising comprised by the prevalence of major risk factors mainly hepatitis B and hepatitis C. The population at risk is composed of chronic liver patients at the stage of extensive fibrosis or cirrhosis. The monitoring programs of this population have allowed early detection of disease management to promote a radical therapy. Understanding the carcinogenic process and the mastery of the staging systems remain essential keys in diagnosis and treatment of HCC. Recent advances in diagnosis and new treatments have made important impacts on the disease by increasing survival rates and improving quality of life for HCC patients. This paper outlines the different management aspects of HCC which include epidemiology, prevention, carcinogenesis, staging systems, diagnosis, surveillance, and the treatment.
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Affiliation(s)
- Sene Waly Raphael
- National Hepatobiliary and Enteric Surgery Research Center of Ministry of Health, Central South University, Changsha, Hunan 410008, China
| | - Zhang Yangde
- National Hepatobiliary and Enteric Surgery Research Center of Ministry of Health, Central South University, Changsha, Hunan 410008, China
| | - Chen YuXiang
- National Hepatobiliary and Enteric Surgery Research Center of Ministry of Health, Central South University, Changsha, Hunan 410008, China
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Ratti F, Cipriani F, Paganelli M, Ferla G, Aldrighetti LAM. Surgical approach to multifocal hepatocellular carcinoma with portal vein thrombosis and arterioportal shunt leading to portal hypertension and bleeding: a case report. World J Surg Oncol 2012; 10:34. [PMID: 22330617 PMCID: PMC3305563 DOI: 10.1186/1477-7819-10-34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 02/13/2012] [Indexed: 02/06/2023] Open
Abstract
It is reported the case of a 69 years man who presented to the Emergency Room because of pain and abdominal distension from ascites. After admission and paracentesis placement, he developed a digestive hemorrhage due to oesophageal varices from portal ipertension secondary to the formation of a portal shunt concomitant with a multifocal HepatoCellular Carcinoma (HCC) with portal vein thrombosis (PVT). The patient underwent endoscopic varices ligation, twice transarterial embolization (TAE) of arterial branches feeding the shunt and subsequent left hepatectomy. During the postoperative course he developed mild and transient signs of liver failure and was discharged in postoperative day 16. He is alive and disease free 8 months after surgery.
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Affiliation(s)
- Francesca Ratti
- Department of Surgery, Vita-Salute S Raffaele University, Milan, Italy.
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Ruzzenente A, Valdegamberi A, Campagnaro T, Conci S, Pachera S, Iacono C, Guglielmi A. Hepatocellular carcinoma in cirrhotic patients with portal hypertension: is liver resection always contraindicated? World J Gastroenterol 2011; 17:5083-5088. [PMID: 22171142 PMCID: PMC3235591 DOI: 10.3748/wjg.v17.i46.5083] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 05/26/2011] [Accepted: 06/26/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the outcome of hepatocellular carcinoma (HCC) resection in cirrhosis patients, related to presence of portal hypertension (PH) and extent of hepatectomy. METHODS A retrospective analysis of 135 patients with HCC on a background of cirrhosis was submitted to curative liver resection. RESULTS PH was present in 44 (32.5%) patients. Overall mortality and morbidity were 2.2% and 33.7%, respectively. Median survival time in patients with or without PH was 31.6 and 65.1 mo, respectively (P = 0.047); in the subgroup with Child-Pugh class A cirrhosis, median survival was 65.1 mo and 60.5 mo, respectively (P = 0.257). Survival for patients submitted to limited liver resection was not significantly different in presence or absence of PH. Conversely, median survival for patients after resection of 2 or more segments with or without PH was 64.4 mo and 163.9 mo, respectively (P = 0.035). CONCLUSION PH is not an absolute contraindication to liver resection in Child-Pugh class A cirrhotic patients, but resection of 2 or more segments should not be recommended in patients with PH.
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Kitisin K, Packiam V, Steel J, Humar A, Gamblin TC, Geller DA, Marsh JW, Tsung A. Presentation and outcomes of hepatocellular carcinoma patients at a western centre. HPB (Oxford) 2011; 13:712-22. [PMID: 21929672 PMCID: PMC3210973 DOI: 10.1111/j.1477-2574.2011.00362.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The present study examines the presentation and outcomes of hepatocellular carcinoma (HCC) at a Western centre over the last decade. METHODS Between January 2000 and September 2009, 1010 patients with HCC were evaluated at the University of Pittsburgh Medical Center (UPMC). Retrospectively, four treatment groups were classified: no treatment (NT), systemic therapy (ST), hepatic artery-based therapy (HAT) and surgical intervention (SI) including radiofrequency ablation, hepatic resection and transplantation. Kaplan-Meier analysis assessed survival between groups. Cox regression analysis identified factors predicting survival. RESULTS Patients evaluated were 75% male, 87% Caucasian, 84% cirrhotic, and predominantly diagnosed with hepatitis C. In all, 169 patients (16.5%) received NT, 25 (2.4%) received ST, 529 (51.6%) received HAT and 302 (29.5%) received SI. Median survival was 3.6, 5.6, 8.8, and 83.5 months with NT, ST, HAT and SI, respectively (P= 0.001). Transplantation increased from 9.5% to 14.2% after the model for end-stage liver disease (MELD) criteria granted HCC patients priority points. Survival was unaffected by bridging transplantation with HAT or SI (P= 0.111). On multivariate analysis, treatment modality was a robust predictor of survival after adjusting for age, gender, AFP, Child-Pugh classification and cirrhosis (P < 0.001, χ(2) = 460). DISCUSSION Most patients were not surgical candidates and received HAT alone. Surgical intervention, especially transplantation, yields the best survival.
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Affiliation(s)
- Krit Kitisin
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA,Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Vignesh Packiam
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Jennifer Steel
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA,Department of Psychiatry, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of WisconsinMilwaukee, MI, USA
| | - David A Geller
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
| | - J Wallis Marsh
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Allan Tsung
- Divisions of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical CenterPittsburgh, PA
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The modernized treatment of hepatocellular cancer: time to think twice! Updates Surg 2011; 63:229-31. [PMID: 21789680 DOI: 10.1007/s13304-011-0097-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Santambrogio R, Opocher E, Costa M, Barabino M, Zuin M, Bertolini E, De Filippi F, Bruno S. Hepatic resection for "BCLC stage A" hepatocellular carcinoma. The prognostic role of alpha-fetoprotein. Ann Surg Oncol 2011; 19:426-34. [PMID: 21732145 DOI: 10.1245/s10434-011-1845-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Our aim was to assess the capability of Barcelona Clinic Liver Cancer (BCLC) staging system in allocating stage A patients to hepatic resection (HR) and the effect on survival. METHODS We enrolled 132 patients with hepatocellular carcinoma (HCC) amenable to HR. All patients underwent ultrasound (US)-guided anatomical resection (≤2 segments) and then postoperative results were evaluated. RESULTS Results showed 95% of patients were Child A, 49% in BCLC A1, 21% in A2, 6% in A3, and 24% in A4. No 30-day mortality occurred. Overall survival got worse from A1 to A4 (P = 0.0271), while no differences were found in Childs A patients with or without portal hypertension (P = 0.1674). Multivariate analysis (Cox model) shows that only AFP (<20 ng/ml) was an independent predictor of survival: If the AFP is incorporated in BCLC staging system (all A1 and A2 patients with abnormal AFP levels were included in A3 subgroup), 5-year survival rate including normal AFP for A1 was 57% and for A2 was 65%, whereas the survival rates impaired in the worst candidates (5-year survival rate including AFP abnormal for A3 and A4 was 36%; P = 0.002). So, introducing AFP in BCLC classification it is possible to simplify the algorithm in only 2 classes, well-separated in survival curves (class 1 [AFP-]: 60%; class 2 [AFP+]: 37%; P = 0.0001). CONCLUSION Our experience stressed the high value of BCLC system in staging of patients with HCC, but underlined that in selected patients (normal AFP) even A2 group may benefit from HR with a good survival.
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Affiliation(s)
- Roberto Santambrogio
- UOC di Chirurgia 2 (Chirurgia Epato-bilio-pancreatica e Digestiva), A.O. San Paolo, Dipartimento di Medicina, Chirurgia ed Odontoiatria, Università degli Studi di Milano, Milan, Italy.
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Zhang ZM, Guo JX, Zhang ZC, Jiang N, Zhang ZY, Pan LJ. Therapeutic options for intermediate-advanced hepatocellular carcinoma. World J Gastroenterol 2011; 17:1685-1689. [PMID: 21483627 PMCID: PMC3072631 DOI: 10.3748/wjg.v17.i13.1685] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 01/18/2011] [Accepted: 01/25/2011] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies, ranking the sixth in the world, with 55% of cases occurring in China. Usually, patients with HCC did not present until the late stage of the disease, thus limiting their therapeutic options. Although surgical resection is a potentially curative modality for HCC, most patients with intermediate-advanced HCC are not suitable candidates. The current therapeutic modalities for intermediate-advanced HCC include: (1) surgical procedures, such as radical resection, palliative resection, intraoperative radiofrequency ablation or cryosurgical ablation, intraoperative hepatic artery and portal vein chemotherapeutic pump placement, two-stage hepatectomy and liver transplantation; (2) interventional treatment, such as transcatheter arterial chemoembolization, portal vein embolization and image-guided locoregional therapies; and (3) molecularly targeted therapies. So far, how to choose the therapeutic modalities remains controversial. Surgeons are faced with the challenge of providing the most appropriate treatment for patients with intermediate-advanced HCC. This review focuses on the optional therapeutic modalities for intermediate-advanced HCC.
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Affiliation(s)
- Zong-Ming Zhang
- Department of General Surgery, Digestive Medical Center, The First Affiliated Hospital, School of Medicine, Tsinghua University, Beijing 100016, China.
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Kishi Y, Hasegawa K, Sugawara Y, Kokudo N. Hepatocellular carcinoma: current management and future development-improved outcomes with surgical resection. Int J Hepatol 2011; 2011:728103. [PMID: 21994868 PMCID: PMC3170840 DOI: 10.4061/2011/728103] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 04/16/2011] [Accepted: 04/24/2011] [Indexed: 12/13/2022] Open
Abstract
Currently, surgical resection is the treatment strategy offering the best long-term outcomes in patients with hepatocellular carcinoma (HCC). Especially for advanced HCC, surgical resection is the only strategy that is potentially curative, and the indications for surgical resection have expanded concomitantly with the technical advances in hepatectomy. A major problem is the high recurrence rate even after curative resection, especially in the remnant liver. Although repeat hepatectomy may prolong survival, the suitability may be limited due to multiple tumor recurrence or background liver cirrhosis. Multimodality approaches combining other local ablation or systemic therapy may help improve the prognosis. On the other hand, minimally invasive, or laparoscopic, hepatectomy has become popular over the last decade. Although the short-term safety and feasibility has been established, the long-term outcomes have not yet been adequately evaluated. Liver transplantation for HCC is also a possible option. Given the current situation of donor shortage, however, other local treatments should be considered as the first choice as long as liver function is maintained. Non-transplant treatment as a bridge to transplantation also helps in decreasing the risk of tumor progression or death during the waiting period. The optimal timing for transplantation after HCC recurrence remains to be investigated.
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Affiliation(s)
- Yoji Kishi
- Division of Surgery, Depatments of Hepatobiliary Pancreatic Surgery and Artificial Organ and Transplantation, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kiyoshi Hasegawa
- Division of Surgery, Depatments of Hepatobiliary Pancreatic Surgery and Artificial Organ and Transplantation, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan,*Kiyoshi Hasegawa:
| | - Yasuhiko Sugawara
- Division of Surgery, Depatments of Hepatobiliary Pancreatic Surgery and Artificial Organ and Transplantation, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Norihiro Kokudo
- Division of Surgery, Depatments of Hepatobiliary Pancreatic Surgery and Artificial Organ and Transplantation, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Prognostic significance of the DNA-index in liver transplantation for hepatocellular carcinoma in cirrhosis. Ann Surg 2010; 250:1008-13. [PMID: 19953719 DOI: 10.1097/sla.0b013e3181b2b195] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study was conducted to evaluate the prognostic significance of the tumor DNA index in patients receiving liver transplantation for hepatocellular carcinoma (HCC) in cirrhosis. BACKGROUND In patients suffering from HCC in cirrhosis, the current selection for liver transplantation does not optimally achieve the goal to simultaneously maximize the number of viable transplant candidates and reject the smallest number of those who could have benefited. This is the first report on the prognostic significance of the tumor DNA index. PATIENTS AND METHODS From 1988 to 2007, liver transplantation for HCC in cirrhosis was performed in 246 consecutive patients. The DNA-index was determined by Feulgen staining and semiautomatical image analysis. Interpretation of DNA histograms followed the recommendations outlined in the European Society for Analytical Cellular Pathology consensus report on diagnostic DNA image cytometry. RESULTS A DNA-index <or=1.5 was detected in the HCC of 159 patients (65%). Five- and 10-year post-transplant survival rates in this group were 86% and 80%, respectively. The DNA-index exceeded 1.5 in 87 patients (35%). These patients had 5- and 10-year survival rates of 27% and 6%, respectively, which were significantly lower than in the DNA-index <or=1.5 group (P < 0.0001). On univariate analysis, DNA-index, vascular invasion, fulfillment of the Milan criteria, and histopathological grading were prognostic parameters. In the multivariate analysis, only DNA-index (odds ratio: 11.9; 95% confidence interval: 7.1-20.0; P < 0.0001) and vascular infiltration (odds ratio: 1.7; 95% confidence interval: 1.1-2.6; P < 0.01) were identified as prognostic variables. CONCLUSION This is the first study to describe the DNA-index as a strong prognostic indicator after liver transplantation for HCC in cirrhosis. At this time, determination of the DNA-index is likely to be the most promising diagnostic tool in the selection of transplant candidates.
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Proton beam therapy for large hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2009; 76:460-6. [PMID: 19427743 DOI: 10.1016/j.ijrobp.2009.02.030] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 02/06/2009] [Accepted: 02/07/2009] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate the safety and efficacy of proton beam therapy (PBT) in patients with large hepatocellular carcinoma (HCC). METHODS AND MATERIALS Twenty-two patients with HCC larger than 10 cm were treated with proton beam therapy at our institution between 1985 and 2006. Twenty-one of the 22 patients were not surgical candidates because of advanced HCC, intercurrent disease, or old age. Median tumor size was 11 cm (range, 10-14 cm), and median clinical target volume was 567 cm(3) (range, 335-1,398 cm(3)). Hepatocellular carcinoma was solitary in 18 patients and multifocal in 4 patients. Tumor types were nodular and diffuse in 18 and 4 patients, respectively. Portal vein tumor thrombosis was present in 11 patients. Median total dose delivered was 72.6 GyE in 22 fractions (range, 47.3-89.1 GyE in 10-35 fractions). RESULTS The median follow-up period was 13.4 months (range, 1.5-85 months). Tumor control rate at 2 years was 87%. One-year overall and progression-free survival rates were 64% and 62%, respectively. Two-year overall and progression-free survival rates were 36% and 24%, respectively. The predominant tumor progression pattern was new hepatic tumor development outside the irradiated field. No late treatment-related toxicity of Grade 3 or higher was observed. CONCLUSIONS The Bragg peak properties of PBT allow for improved conformality of the treatment field. As such, large tumor volumes can be irradiated to high doses without significant dose exposure to surrounding normal tissue. Proton beam therapy therefore represents a promising modality for the treatment of large-volume HCC. Our study shows that PBT is an effective and safe method for the treatment of patients with large HCC.
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Choi GH, Han DH, Kim DH, Choi SB, Kang CM, Kim KS, Choi JS, Park YN, Park JY, Kim DY, Han KH, Chon CY, Lee WJ. Outcome after curative resection for a huge (>or=10 cm) hepatocellular carcinoma and prognostic significance of gross tumor classification. Am J Surg 2009; 198:693-701. [PMID: 19268907 DOI: 10.1016/j.amjsurg.2008.09.019] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Revised: 09/23/2008] [Accepted: 09/23/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study was to investigate the surgical outcomes in patients with huge (>or=10 cm) hepatocellular carcinoma (HCC). METHODS Clinicopathological features and surgical outcomes of 50 patients with huge HCC who underwent curative resection (group A) were compared with 447 patients with smaller tumors (group B). In group A, we investigated prognostic factors. RESULTS Group A patients had a higher incidence of alpha-fetoprotein at more than 1,000 IU/mL, microscopic vascular invasion, and advanced stage tumors. The disease-free survival of group A was significantly worse than group B. The rates of initial extrahepatic recurrence and early recurrence were higher in group A. The 5 year-overall survival of group A was 40.2%, significantly lower than that of group B (65.9% at 5 years). In group A, multivariate analysis revealed that the presence of single nodular type tumors was the only good prognostic factor for survival. CONCLUSIONS Huge HCCs exhibit a more aggressive clinical behavior and worse survival. However, because the outcome of surgical treatment is far better than that of nonsurgical treatment, resection should be actively considered for patients with huge HCC. A single nodular type tumor is the best candidate for surgical resection.
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Affiliation(s)
- Gi Hong Choi
- Department of Surgery, Yonsei University Health System, Seoul 120-752, Korea
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