Liver cirrhosis is the most common risk factor for the development of hepatocellular carcinoma (HCC). However, 10 to 15% of all HCC arise in a non-cirrhotic liver. Few reliable data exist on outcome after liver resection in a non-cirrhotic liver. The aim of this single-centre study was to evaluate the outcome of resection for HCC in non-cirrhotic liver (NC-HCC) and to determine prognostic factors for overall (OS) and intrahepatic recurrence-free (RFS) survival. From 2008 to 2020, a total of 249 patients were enrolled in this retrospective study. Primary outcome was OS and RFS. Radiological and pathological findings, such as tumour size, number of nodules, Tumour-, Nodes-, Metastases- (TNM) classification and vascular invasion as well as extent of surgical resection and laboratory liver function were collected. Here, 249 patients underwent liver resection for NC-HCC. In this case, 50% of patients underwent major liver resection, perioperative mortality was 6.4%. Median OS was 35.4 months (range 1–151 months), median RFS was 10.5 months (range 1–128 moths). Tumour diameter greater than three centimetres, multifocal tumour disease, vascular invasion, preoperative low albumin and increased alpha-fetoprotein (AFP) values were associated with significantly worse OS. Our study shows that resection for NC-HCC is an acceptable treatment approach with comparatively good outcome even in extensive tumours.
Background: Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy, followed by intrahepatic cholangiocarcinoma (ICC). In addition, there is a mixed form for which only limited data are available. The aim of this study was to compare recurrence and survival of the mixed form within the cohorts of patients with HCC and ICC from a single center. Methods: Between January 2008 and December 2020, all patients who underwent surgical exploration for ICC, HCC, or mixed hepatocellular cholangiocarcinoma (mHC-CC) were included in this retrospective analysis. The data were analyzed, focusing on preoperative and operative details, histological outcome, and tumor recurrence, as well as overall and recurrence-free survival. Results: A total of 673 surgical explorations were performed, resulting in 202 resections for ICC, 344 for HCC (225 non-cirrhotic HCC, ncHCC; 119 cirrhotic HCC, cHCC), and 14 for mHC-CC. In addition, six patients underwent orthotopic liver transplant (OLT) in the belief of dealing with HCC. In 107 patients, tumors were irresectable (resection rate of 84%). Except for the cHCC group, major or even extended liver resections were required. Vascular or visceral extensions were performed regularly. Overall survival (OS) was highly variable, with a median OS of 17.6 months for ICC, 26 months for mHC-CC, 31.8 months for cHCC, and 37.2 months for ncHCC. Tumor recurrence was common, with a rate of 45% for mHC-CC, 48.9% for ncHCC, 60.4% for ICC, and 67.2% for cHCC. The median recurrence-free survival was 7.3 months for ICC, 14.4 months for cHCC, 16 months for mHC-CC, and 17 months for ncHCC. The patients who underwent OLT for mHC-CC showed a median OS of 57.5 and RFS of 56.5 months. Conclusions: mHC-CC has a comparable course and outcome to ICC. The cholangiocarcinoma component seems to be the dominant one and, therefore, may be responsible for the prognosis. ‘Accidental’ liver transplant for mHC-CC within the Milan criteria offers a good long-term outcome. This might be an option in countries with no or minor organ shortage.
Background: Factors predicting overall recurrence are well-known in hepatocarcinoma (HCC), but which of them are associated with local relapse (LR) on the surgical hedge rather than to an intrahepatic distant recurrence (DR) are still not explored. While local recurrence may be a surgical failure, distant may be the expression of a more advanced disease, which may be not preventable by surgery. The aim of the study was to assess the risk factors for both type of recurrence. Material & Methods: This is an international multicentric retrospective study. From 2010 to 2017, all consecutive patients with a first diagnosis of HCC without macrovascular invasion has been evaluated. Patients were analysed for local and distant recurrence. Uni and multivariate Cox analysis were employed for risk factors evaluation.Results: 376 patients were enrolled. 152 patients had recurrence, of whom 62 had LR while 90 DR. Patients with LR were less likely to be HCV positive (p:0.012), with an increased rate of satellitosis (p:0.015) and positive resection margin (p<0.001) when compared to all the others; however the extension of surgery (anatomic vs not) was not different. DR had an increased rate of major resections (p:0.020), satellitosis (p<0.001) and microvascular invasion (p:0.002). Nevertheless, local and distant recurrent patients were comparable between each other. Positive surgical margin (HR 2.1; 95%CI:1.5-5.1; p:0.012) -but not non-anatomical resection-was the only independent risk factor for LR. MVI (HR 2.2; 95%CI:1.1-4.3; p:0.023) was the only predictive factor for DR. Conclusion: Microvascular invasion predicted intra-hepatic distant recurrence and not local relapse after surgery, configuring a probable hallmark of advanced disease, and questioning the possibility to control the disease only by local curative therapies. LR seemed to be mostly the expression of a surgical failure.
Zusammenfassung Hintergrund Das hepatozelluläre Karzinom (HCC) ist der häufigste maligne Lebertumor in einer Leberzirrhose. Neben der Lebertransplantation stellt die Leberresektion in kompensierter Zirrhose eine kurative Therapieoption dar, die jedoch mit einer höheren postoperativen Morbidität und Mortalität einhergeht. Patienten Es wurden 108 Patienten identifiziert, die mit einer Leberzirrhose im Zeitraum von Januar 2008 bis Dezember 2019 an der Universitätsmedizin Mainz eine Leberresektion erhalten haben. Im gleichen Zeitraum wurden 185 Resektionen wegen eines HCC in nicht zirrhotischer Leber durchgeführt. Als weitere Kontrollgruppe dienten 167 Resektionen wegen kolorektaler Lebermetastasen (CRLM), die dem Ausmaß der Resektionen in Leberzirrhose entsprachen. Neben den generellen Patientencharakteristika wurde bei allen Patienten präoperativ der Charlson Comorbidity Index (CCI) erhoben und der MELD-/Child-Score bestimmt. Die perioperative Morbidität wurde nach der Clavien-Dindo-Klassifikation erfasst. Resektionen eines HCC in Zirrhose und kolorektaler Lebermetastasen wurden zudem in einer Match-Pair-Analyse verglichen. Ergebnisse Die 3 Gruppen waren hinsichtlich des Alters zum Operationszeitpunkt vergleichbar. Die präoperative Leberfunktion war bei Patienten mit CRLM signifikant besser (p < 0,001). Patienten mit einem HCC in einer nicht zirrhotischen Leber hatten ausgedehntere Resektionen (p < 0,001) als Patienten mit HCC in zirrhotischer Leber. Die Gesamtmorbidität (Clavien/Dindo Grad III – IV) war bei Patienten mit einem HCC in Zirrhose höher als bei Patienten mit kolorektalen Lebermetastasen (p = 0,026). Dies bestätigte sich auch in der Match-Pair-Analyse. Die Mortalität war im gesamten Kollektiv vergleichbar niedrig (2,2%). Weder MELD- noch Child-Score ließen eine Aussage über die postoperative Morbidität und Mortalität zu (Area under the Curve: AUC jeweils < 0,6). Der CCI erreichte mit einer AUC von 0,78 eine hinreichende Vorhersage auf die postoperative Mortalität. Schlussfolgerung Resektionen in einer Leberzirrhose sind bei einer Begrenzung des Resektionsausmaßes und entsprechender Patientenselektion mit einem vertretbaren Risiko möglich. Komorbiditäten erhöhen zusätzlich zu einer Einschränkung der Leberfunktion die postoperative Mortalität, weshalb diese unbedingt in die Patientenselektion integriert werden sollten.
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