Early hepatocellular carcinoma (HCC) has been defined as a well-differentiated cancer containing Glisson's triad, but it remains unknown whether this lesion is curable. We prospectively studied 70 patients (enrolled from 1,172 referrals between 1982 and 1991) who had a diagnosis of a single HCC 2 cm or less in diameter (Stage T1) and who underwent curative hepatectomy and long-term follow-up (range, 0.2 to 14.3 years). Patients were eligible for surgery if they had a tumor that met the diagnostic criteria for HCC and were in Child-Pugh class A (n ؍ 59) or B (n ؍ 11) status. Among the 70 patients, there was 1 operative death. Based on our typing system, the tumors were assigned as early HCC (n ؍ 15), overt HCC (n ؍ 52), and non-HCC tumor (n ؍ 3). The rate of microscopic regional spread was lower in early HCCs than in overt HCCs (7% vs. 42%; P ؍ .01). The early HCC group had a longer time to recurrence than did the overt HCC group (3.9 vs. 1.7 years; P F .001) and had no local recurrence. After a median follow-up of 6.3 years, both overall survival and recurrence-free survival in the early HCC group were significantly better than those in the overt HCC group (P ؍ .01; P ؍ .001). In these two groups, the 5-year rates of overall survival were 93% and 54% (P ؍ .01), and those of recurrence-free survival were 47% and 16% (P ؍ .05), respectively; a significant survival benefit persisted over a decade (57% vs. 21%; P ؍ .05). The early HCC group was at a lower risk of recurrence (relative risk, 0.31; 95% CI, 0.15 to 0.65; P ؍ .002) and death (relative risk, 0.26; 95% CI, 0.09 to 0.73; P ؍ .01) than was the overt HCC group. Early HCC is a distinct clinical entity with a high rate of surgical cure, thereby justifying its definition. It can be a lesion that corresponds to ''Stage 0'' cancer in other organs. (HEPATOLOGY 1998;28:1241-1246
ObjectiveTo evaluate the long-term outcome of aggressive surgery incorporating hepatic resection and systematic nodal dissection for advanced carcinoma involving the hepatic hilus. Summary Background DataFew long-term results are available regarding radical surgery incorporating major hepatectomy and nodal dissection. MethodsA retrospective analysis was undertaken in 107 patients with carcinoma involving the hepatic hilus treated between 1980 and 1997. Resectional surgery was performed in 65 patients, 52 of whom underwent major hepatectomies. The effects of clinical and pathologic factors were assessed by univariate and multivariate analyses. ResultsSixty percent of the patients with resectional surgery had stage IVA or IVB disease, and 92.3% of them underwent major hepatectomies. No in-hospital deaths were encountered in the 35 most recent resections, whereas there were six deaths in the early period. Resectional surgery was associated with a survival benefit, especially when resection margins were free from cancerous infiltration. The estimated 5-year survival rate after resection, including all deaths, was 34.8%; this was 51.6% when the margins were clear. Nodal involvement was documented in 44.6% of the resections. However, patients with metastases limited to the regional nodes showed a survival rate similar to that in patients without nodal involvement. Significant predictive factors for survival after resection were extension to the gallbladder, nodal status, resectional margins, histologic type, and gender.
The Liver Cancer Study Group of Japan established a classification of macroscopic type and the TNM staging of intrahepatic cholangiocarcinoma (ICC). With the observation of more than 240 resected cases of ICC, three fundamental types were established. They were: (1) mass-forming (MF) type, (2) periductal-infiltrating (PI) type, and (3) intraductal growth (IG) type. The MF type forms a definite mass, located in the liver parenchyma. The PI type is defined as ICC which extends mainly longitudinally along the bile duct, often resulting in dilatation of the peripheral bile duct. The IG type proliferates toward the lumen of the bile duct papillarily or like a tumor thrombus. The TNM classification of ICC was then designed, using 136 cases of the MF type resected curatively between 1990 and 1996 at member institutes. Univariate and multivariate analyses showed: (1) tumor 2 cm or less, (2) single nodule, and (3) no vascular and serous membrane invasion as prognostic factors. T factors were defined as follows: T1 is an ICC that meets all requirements of factors (1), (2), and (3); T2 meets two of the three requirements, T3 meets one of the three requirements and T4 meets none of the three requirements. Our data did not support the idea that the hepatoduodenal lymph node is regional. The N factors were defined as N0 no lymph node metastasis; and N1, positive at any nodes. Thus, the stages of ICC were defined as stage I, T1N0M0; stage II, T2N0M0; stage III, T3N0M0; stage IVA, T4N0M0 or any TN1M0; and stage IVB, any T any NM1.
Review of 61 surgically resected small hepatocellular carcinomas (HCC) less than or equal to 3 cm in diameter yielded a simple gross classification system of five types based on tumor shape, which is highly correlated with microscopic and clinical features, including prognosis. Type 1 (single nodular type) tumors (n = 13) are expansile, roughly spheric, and often encapsulated. In Type 2 tumors (single nodular type with extranodular growth) (n = 21), replacing growth is often seen in the area of extranodular growth. Type 3 tumors (contiguous multinodular type) (n = 19) consist of small nodules growing in contiguity, often with replacing growth at the periphery. Type 4 (poorly demarcated nodular type) is a rare tumor showing infiltrating growth at its border. The authors define early HCC (n = 5) as the presence of tumor without destruction of the underlying liver structure. The lesions experienced are tiny (less than or equal to 1.2 cm) and well differentiated. Poorly differentiated histologic characteristics and elevated alpha fetoprotein are more common in Types 2 and 3 than in Type 1. Type 1 has the highest rates of positive serum hepatitis B surface antigen and liver cirrhosis; portal vein tumor thrombus (PT) and/or intrahepatic metastasis (IM) is rare (7.7%), and the effect of transcatheter arterial embolization (TAE) is remarkable. This contrasts with Type 2, which has a high rate of PT and/or IM (71.4%) and multiple local recurrences (40%), and with Type 3, which shows a poor response to TAE.
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