Background Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have emphasized the need for further refinement and subclassification of this system. Methods Patients who underwent hepatectomy with curative intent for BCLC‐0, ‐A or ‐B hepatocellular carcinoma (HCC) between 2000 and 2017 were identified using a multi‐institutional database. The tumour burden score (TBS) was calculated, and overall survival (OS) was examined in relation to TBS and BCLC stage. Results Among 1053 patients, 63 (6·0 per cent) had BCLC‐0, 826 (78·4 per cent) BCLC‐A and 164 (15·6 per cent) had BCLC‐B HCC. OS worsened incrementally with higher TBS (5‐year OS 77·9, 61 and 39 per cent for low, medium and high TBS respectively; P < 0·001). No differences in OS were noted among patients with similar TBS, irrespective of BCLC stage (61·6 versus 58·9 per cent for BCLC‐A/medium TBS versus BCLC‐B/medium TBS, P = 0·930; 45 versus 13 per cent for BCLC‐A/high TBS versus BCLC‐B/high TBS, P = 0·175). Patients with BCLC‐B HCC and a medium TBS had better OS than those with BCLC‐A disease and a high TBS (58·9 versus 45 per cent; P = 0·005). On multivariable analysis, TBS remained associated with OS among patients with BCLC‐A (medium TBS: hazard ratio (HR) 2·07, 95 per cent c.i. 1·42 to 3·02, P < 0·001; high TBS: HR 4·05, 2·40 to 6·82, P < 0·001) and BCLC‐B (high TBS: HR 3·85, 2·03 to 7·30; P < 0·001) HCC. TBS could also stratify prognosis among patients in an external validation cohort (5‐year OS 79, 51·2 and 28 per cent for low, medium and high TBS respectively; P = 0·010). Conclusion The prognosis of patients with HCC varied according to the BCLC stage but was largely dependent on the TBS.

Introduction Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Methods Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. Results The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p \ 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004-2009: 8.05 months vs. 2010-2015: 9.49 months; p \ 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of C6 lymph nodes increased over time (p \ 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24-1.79, p \ 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04-1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p \ 0.001). Conclusions The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.Lu Wu and Diamantis I. Tsilimigras contributed equally to this work.

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Background: Composite measures such as "Textbook Outcome" (TO) may be superior to individual quality metrics to assess surgical care and hospital performance. However, the incidence and factors associated with TO after resection of HCC remain poorly defined. Methods: Hospital variation in the rates of TO, factors associated with achieving a TO and the impact of TO on long-term survival following resection for HCC were examined using an international multiinstitutional database.Results: Among 605 patients who underwent curative-intent resection of HCC, the unadjusted incidence of TO ranged from 50.9% to 77.7%. While achievement of each individual quality metric was relatively high (range, 74.5-98.0%), an overall TO was achieved among only 62.3% (n = 377) of patients.At the hospital level, TO ranged from 54.3% to 72.9%. Patients with BCLC-0 HCC (referent BCLC-B/C; OR: 4.17, 95%CI: 1.62-10.7) and ALBI grade 1 (referent ALBI grade 2/3; OR: 1.49, 95%CI: 1.06-2.11) had higher odds of achieving a TO. On multivariable analysis, TO was associated with improved overall survival (HR: 0.60, 95% CI: 0.42-0.85). Conclusion:Roughly 6 in 10 patients achieved a TO following resection for HCC. When achieved, TO was associated with better long-term outcomes. TO is a simple composite measure of both short-and long-term outcomes among patients undergoing resection for HCC.

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Background Few data are available regarding the management and outcomes among patients with sarcomatoid hepatocellular carcinoma (HCC) due to its rarity. Methods Patients diagnosed with sarcomatoid HCC from 2004 through 2015 were identified in the National Cancer Data Base. Overall survival (OS) was calculated among patients with sarcomatoid versus conventional HCC using a 1:3 propensity score matching based on sex, age, and American Joint Committee on Cancer (AJCC) stage of disease. Results The final analytic cohort included 104 patients with sarcomatoid HCC and 312 patients with conventional HCC. Patients with sarcomatoid HCC more often had a larger median tumor size (8.5 cm vs 5.4 cm; P < .001) and poorly or undifferentiated tumors (52.9% vs 13.8%; P < .001) compared with patients who had conventional HCC. 5‐year OS was worse among patients with sarcomatoid versus conventional HCC (5.7% vs 30.1%; P < .001). Subgroup analysis demonstrated worse 5‐year OS among patients with sarcomatoid versus conventional HCC among patients treated with either curative‐intent or palliative therapies. Stage‐specific subgroup analysis indicated a worse OS among patients with AJCC stage I, stage II, or stage III sarcomatoid HCC. On multivariable analysis, uninsured status, advanced AJCC stage (stage III/stage IV), and histological sarcomatoid subtype were independently associated with worse outcomes (all P < .05). Conclusions Sarcomatoid HCC is a very rare variant of HCC, which was associated with larger tumor size and worse tumor grade on presentation. On propensity score matched analyses that controlled for known confounding factors, patients with sarcomatoid HCC had a worse stage‐for‐stage long‐term survival compared with patients who had conventional HCC.

Objective: The objective of the current study was to define surgical outcomes after resection of multinodular hepatocellular carcinoma (HCC) beyond the Milan criteria, and develop a prediction tool to identify which patients likely benefit the most from resection. Background: Liver resection for multinodular HCC, especially beyond the Milan criteria, remains controversial. Rigorous selection of the best candidates for resection is essential to achieve optimal outcomes after liver resection of advanced tumors. Methods: Patients who underwent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. Patients were categorized according to Milan criteria status. Pre-and postoperative overall survival (OS) prediction models that included HCC tumor burden score (TBS) among patients with multinodular HCC beyond Milan criteria were developed and validated. Results: Among 1037 patients who underwent resection for HCC, 164 (15.8%) had multinodular HCC beyond the Milan criteria. Among patients with multinodular HCC, 25 (15.2%) patients experienced a serious complication and 90-day mortality was 3.7% (n ¼ 6). Five-year OS after resection of multinodular HCC beyond Milan criteria was 52.8%. A preoperative TBSbased model (5-year OS: low-risk, 73.7% vs intermediate-risk, 45.1% vs highrisk, 13.1%), and postoperative TBS-based model (5-year OS: low-risk, 80.1% vs intermediate-risk, 37.2% vs high-risk, not reached) categorized patients into distinct prognostic groups relative to long-term prognosis (both P < 0.001). Pre-and postoperative models could accurately stratify OS in an external validation cohort (5-year OS; low vs medium vs high risk; pre: 66.3% vs 25.2% vs not reached, P ¼ 0.012; post: 61.4% vs 42.5% vs not reached, P ¼ 0.045) Predictive accuracy of the pre-and postoperative models was good in the training (c-index; pre: 0.68; post: 0.71), internal validation (n ¼ 2000 resamples) (c-index, pre: 0.70; post: 0.72) and external validation (c-index, pre: 0.67; post 0.68) datasets. TBS alone could stratify patients relative to 5year OS after resection of multinodular HCC beyond Milan criteria (c-index: 0.65; 5-year OS; low TBS: 70.2% vs medium TBS: 54.7% vs high TBS: 16.7%; P < 0.001). The vast majority of patients with low and intermediate TBS were deemed low or medium risk based on both the preoperative (98.4%) and postoperative risk scores (95.3%). Conclusion: Prognosis of patients with multinodular HCC was largely dependent on overall tumor burden. Liver resection should be considered among patients with multinodular HCC beyond the Milan criteria who have a low-or intermediate-TBS.