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It is well known that intermediate stage hepatocellular carcinoma (HCC) encompasses the widest class of patients with this disease. The main characteristic of this special sub-group of patients is that it is extensively heterogenous. This substantial heterogeneity is due to the wide range of liver functions of such patients and variable tumor numbers and sizes. Real world clinical data show huge support for transarterial chemo-embolization (TACE) as a therapeutic modality for intermediate stage HCC, applied in 50%–60% of those class of patients. There are special considerations in various international guidelines regarding treatment allocation in intermediate stage HCC. There is an epidemiological difference in HCC in eastern and western cohorts, and various guidelines have been proposed. In patients with HCC, it has frequently been reported that there is poor correlation between the clinical benefit and real gain in patient condition and the conventional way of tumor response assessment after locoregional treatments. This is due to the evaluation criteria in addition to the scoring systems used for treatment allocation in those patients. It became clear that intermediate stage HCC patients receiving TACE need a proper prognostic score that offers valid clinical prediction and supports proper decision-making. Also, it is the proper time to study more treatment options beyond TACE, such as multimodal regimens for this class of patients. In this review, we tried to provide a summary of the challenges and future directions in managing patients with intermediate stage HCC.

The aim of this work is to study the different factors that affect the outcome of living donor liver transplantation for patients with hepatocellular carcinoma (HCC). Between April 2003 to November 2014, 62 patients with liver cirrhosis and HCC underwent living donor liver transplantation (LDLT) in the National Liver Institute, Menoufia University, Egypt. The preoperative, operative, and postoperative data were analyzed. After studying the pathology of explanted liver; 44 (71 %) patients were within the Milan criteria, and 18 (29 %) patients were beyond Milan; 13 (21.7 %) of patients beyond the Milan criteria were also beyond the University of California San Francisco criteria (UCSF) criteria. Preoperative ablative therapy for HCC was done in 22 patients (35.5 %), four patients had complete ablation with no residual tumor tissues. Microvascular invasion was present in ten patients (16 %) in histopathological study. Seven (11.3 %) patients had recurrent HCC post transplantation. The 1, 3, 5 years total survival was 88.7, 77.9, 67.2 %, respectively, while the tumor-free survival was 87.3, 82.5, 77.6 %, respectively. Expansion of selection criteria beyond Milan and UCSF had no increased risk effect on recurrence of HCC but had less survival rate than patients within the Milan criteria. Microvascular invasion was an independent risk factor for tumor recurrence.

Background: Pancreatic ductal adenocarcinoma (PDAC) had a poor prognosis and surgical resection remains the only potentially curative treatment. The aim of the study was to identify the outcome and risk factors affecting survival after pancreaticoduodenectomy (PD) for PDAC.Methods: The patients who underwent PD for PDAC from 2007 to 2015 were retrospectively studied. Cox regression test for multivariate analysis was used for evaluation of prognostic factors for survival.Results: Ninety-four patients underwent PD for PDAC, 20 patients (21.3%) had major postoperative complications. The perioperative mortality was 4.3%. The 1-, 3-, and 5-years survival rates were 74.5%, 38.7%, 23.4, respectively. In univariate analysis the risk factors for survival were; presence of co-morbidity (P=0.03), high preoperative carbohydrate antigen (CA)19-9 > 400U/ml (P=0.02), advanced tumor stage (P=0.03), large tumor diameter >3cm (P=0.01), poorly differentiated tumor (P= 0.02), involved resection margin (P=0.04), and positive lymph nodes in pathology after surgery (P=0.03). In multivariate analysis the independent risk factors for survival were; high preoperative CA 19-9 (P=0.042), tumor size >3cm (P=0.038), poorly differentiated tumor in histopathology (P=0.045).Conclusions: High tumor marker CA19-9, tumor size, and grade are significant risk factors for poor survival after resection of PDAC and should be taken into account in the selection of patients for surgery to improve the outcome.

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Background: Hepatocellular carcinoma (HCC) has an increasing incidence worldwide, and is considered the second cause of cancer-related death. Aim: The aim of the study is to assess the usefulness of real-time shear-wave elastography in differentiating HCC from other hepatic focal lesions. Patients and methods: The current study was conducted on 110 patients in addition to 10 healthy subjects, divided into four groups as follows: liver cirrhosis, HCC, hepatic focal lesions other than HCC, and control. Demographic, laboratory and imaging data were collected and then elastographic assessment of the hepatic focal lesions and the surrounding liver parenchyma using elastograph point quantification (ElastPQ) (iU22x MATRIX, Philips) was done. Results: ElastPQ (iU22x MATRIX, Philips) has shown its ability to differentiate between HCC and cystic focal lesions, HCC and cholangiocarcinoma, and HCC and focal nodular hyperplasia (FNH). Cystic lesions demonstrated lower stiffness in comparison to HCC; however, cholangiocarcinoma and FNH demonstrated higher stiffness in comparison to HCC. ElastPQ was unable to differentiate between stiffness in both ‘HCC and hemangioma’ and ‘HCC and metastatic focal lesions’. ElastPQ showed that HCC, cystic focal lesions, and cholangiocarcinoma had lower stiffness in comparison to their surrounding liver parenchyma, whereas FNH had higher stiffness in comparison to the surrounding liver parenchyma. ElastPQ showed that the surrounding liver parenchyma of the HCC group has the highest stiffness amongst all studied hepatic focal lesions surrounding liver parenchyma. Conclusion: ‘Point’ shear-waves elastography (ElastPQ; Philips iU22x MATRIX, Philips) is a noninvasive, quantitative and nonradiating method for evaluation of tissue elasticity, and is helpful in differentiating HCC from other hepatic focal lesions.