Hepatic resection is the treatment of choice for colorectal liver metastases. RFA alone or in combination with resection for unresectable patients does not provide survival comparable to resection, and provides survival only slightly superior to nonsurgical treatment.

Objective:To evaluate the influence of surgical margin status on survival and site of recurrence in patients treated with hepatic resection for colorectal metastases. Methods: Using a multicenter database, 557 patients who underwent hepatic resection for colorectal metastases were identified. Demographics, operative data, pathologic margin status, site of recurrence (margin, other intrahepatic site, extrahepatic), and longterm survival data were collected and analyzed. Results: On final pathologic analysis, margin status was positive in 45 patients, and negative by 1 to 4 mm in 129, 5 to 9 mm in 85, and Ն1 cm in 298. At a median follow-up of 29 months, the 1-, 3-, and 5-year actuarial survival rates were 97%, 74%, and 58%; median survival was 74 months. Tumor size Ն5 cm, Ͼ3 tumor nodules, and carcinoembryonic antigen level Ͼ200 ng/mL predicted poor survival (all P Ͻ 0.05). Median survival was 49 months in patients with positive margins and not yet reached in patients with negative margins (P ϭ 0.01). After hepatic resection, 225 (40.4%) patients had recurrence: 21 at the surgical margin, 56 at another intrahepatic site, 82 at an extrahepatic site, and 66 at both intrahepatic and extrahepatic sites. Patients with negative margins of 1 to 4 mm, 5 to 9 mm, and Ն1 cm had similar overall recurrence rates (P Ͼ 0.05). Patients with positive margins were more likely to have surgical margin recurrence (P ϭ 0.003). Adverse preoperative biologic factors including tumor number greater than 3 (P ϭ 0.01) and a preoperative CEA level greater than 200 ng/mL (P ϭ 0.04) were associated with an increased risk of positive surgical margin. Conclusions:A positive margin after resection of hepatic colorectal metastases is associated with adverse biologic factors and increased risk of surgical-margin recurrence. The width of a negative surgical margin does not affect survival, recurrence risk, or site of recurrence. A predicted margin of Ͻ1 cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection. L iver resection currently represents the only potentially curative therapeutic option for hepatic colorectal metastasis (CRM), and 5-year survival rates of 25% to 58% have been reported. [1][2][3][4][5][6] Traditionally, primary tumor stage, preoperative carcinoembryonic antigen (CEA) level, hepatic tumor size, number of hepatic metastases, time from primary tumor treatment to diagnosis of hepatic metastases, and presence of extrahepatic disease have been reported to be independent predictors of survival after resection. 7,8 Surgical margin status is an additional factor that has been evaluated for its influence on long-term survival after resection of CRM, but its significance remains controversial. Several series concerning liver resection for colorectal liver metastasis have reported that surgical margins of less than 1 cm are an absolute 9,10 or relative contraindication to surgery.11 Cady et al 10 have reported that a surgical margin less than 1 cm was associated on univariate analys...

This is the first large report of borderline resectable PA and includes objective definitions for this stage of disease. Our neoadjuvant approach allowed for identification of the marked subset of patients that was most likely to benefit from surgery, as evidenced by the favorable median survival in this group.

H epatic resection and liver transplantation are aggressive, extirpative approaches to the treatment of selected patients for hepatocellular carcinoma (HCC) and are the only known potentially curative treatment options for this disease. Resection and transplantation are largely complimentary, not competing, treatments-resection for patients with preserved liver function and transplantation for patients with compromised liver function. Within each group, selection of patients for surgical therapy is currently based on morphologic criteria such as size, number of tumors, and degree of underlying liver disease.After resection, long-term survival can be expected in patients with solitary tumors regardless of size, especially when underlying fibrosis is minimal. 1 In fact, size has no significant impact on survival when microscopic vascular invasion is absent, as survival after resection of T1 tumors larger than 10 cm in diameter is similar to survival following resection of T1 tumors less than 5 cm. 1 Similarly, long-term survival can be expected when multiple tumors without vascular invasion are completely resected. 1 The establishment of strict morphologic criteria has significantly impacted the outcome after liver transplantation for HCC. Before the adoption of these criteria for transplantation, results with liver transplantation were poor. Recurrence rates ranged from 60% to 70%, 2,3 and the 5-year survival rate was less than 30%. 4,5 Since the implementation of more stringent selection criteria, survival rates after liver transplantation have been similar to those after resection for Abbreviations: HCC, hepatocellular carcinoma; AFP, alpha-fetoprotein; HR, hazard ratio; FNA, fine-needle aspiration.

The current AJCC staging system for HCC is unnecessarily complex. We propose a simplified model of stratification that is based on vascular invasion, tumor number, and tumor size and incorporates the effect of fibrosis on survival.

Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Hypothesis: A subset of patients with hepatocellular carcinoma (HCC) with a diameter of 10 cm or larger may benefit from hepatic resection.Design: Retrospective study of a multi-institutional database.Setting: Five major hepatobiliary centers.Patients: We identified 300 patients who underwent hepatic resection for HCC 10 cm or larger.Main Outcome Measures: Clinical and pathologic data were collected, and prognostic factors were evaluated by univariate and multivariate analyses. Patient survival was stratified according to a clinical scoring system and pathologic T classification. Results:The perioperative mortality rate was 5%. At a median follow-up of 32 months, the median survival was 20.3 months, and the 5-year actuarial survival rate was 27%. Four clinical factors-␣-fetoprotein of 1000 ng/mL or higher, multiple tumor nodules, the presence of major vascular in-Author Affiliations are listed at the end of this article. Group Information: The authors of this article comprise the International Cooperative Study Group on Hepatocellular Carcinoma.

Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.