Hepatocellular Carcinoma Surgery And Prognosis Of Specific Types Of Liver Cancer

Part 1.Multiple Primary Malignancies in Patients with Hepatocellular Carcinoma:A Largest Series with 26-Year Follow-UpObjectiveMultiple primary malignancies(MPM)are defined as 2 or more malignancies without subordinate relationship detected in different organs of an individual patient.Reports addressing MPM patients with hepatocellular carcinoma(HCC)are rare.We perform a 26-year follow-up study to investigate characteristics and prognosis of MPM patients associated with HCC due to the scarcity of relative researches.MethodsWe retrospectively analyzed records of 40 patients who were diagnosed with MPM including HCC at the Departments of Surgery at Peking Union Medical College Hospital during 1989 to 2010.Their clinical characteristics and postoperative survival were compared with those of 448 patients who had HCC only during the study period.ResultsAmong the 40 MPM patients,11 were diagnosed synchronously and 29 metachronously.The most common extra-hepatic malignancies were lung cancer(15%),colorectal(12.5%),and thyroid carcinoma(12.5%).MPM patients had a negative hepatitis B virus infection rate(P=0.013)and lower median alfa-fetoprotein(AFP)level(P=0.001).Post-operative 1-,3-,and 5-year overall survival(OS)rates for MPM patients were 82.5%,64.5%,and 38.6%respectively,and showed no significant difference with those of HCC-only patients(84.7%,54.2%,and 38.3%P=0.726).During follow-up,24 MPM patients died,including 17(70.8%)who died of HCC-related causes.In univariate analysis,synchronous diagnosis,higher gamma glutamyltransferase and/or AFP levels,tumor>5 cm and vascular invasion were significantly associated with shorter OS,but only tumor size was an independent OS factor in Cox modeling analysis.ConclusionHCC should be considered as a potential second primary for all cancer survivors.Most MPM patients died of HCC-related causes and showed no significant difference in OS compared with HCC-only patients.Tumor size of HCC,rather than MPMs itself,was the only independent OS predictor for the MPM patients.Part 2.Edmondson grade predicts survival of patients with primary clear cell carcinoma of liver after curative resection:A retrospective study with long-term follow-upObjectivePrimary clear cell carcinoma of liver is a specific and rare subtype of primary hepatocellular carcinoma.We performed a retrospective study with long-term follow-up to investigate predictive factors and prognosis of intrahepatic recurrences of primary clear cell carcinoma of liver after radical resection.MethodsWe retrospectively analyzed records of 38 patients with primary clear cell carcinoma of liver who were diagnosed at Peking Union Medical College Hospital between January 1989 and September 2010,with a long-term follow up to January 2015,to determine their clinical characteristics and postoperative survival.The data were compared with 400 patients received radical hepatectomy for common type hepatocellular carcinoma during the study period.ResultsPrimary clear cell carcinoma of liver tumors were smaller than those of common type hepatocellular carcinoma(P<0.001)and the incidence of vascular invasion of tumors in primary clear cell carcinoma of liver group was significantly lower than that in common type hepatocellular carcinoma(P=0.029).The 1-,3-,and 5-year overall survival for PCCCL patients were 94.6%,67.3%,and 58.5%,respectively;1-,3-,and 5-year disease-free survival were 89.2%,54.1%,and 48.6%,respectively.Both overall survival and disease-free survival were significantly better for primary clear cell carcinoma of liver patients than for common type hepatocellular carcinoma(P=0.039,P=0.044).Cox modeling showed high Edmondson grade to be the only independent predictive factor for survival of primary clear cell carcinoma of liver patients,which were different from those of common type hepatocellular carcinoma.ConclusionPrimary clear cell carcinoma of liver is a less malignant subtype of hepatocellular carcinoma than common type hepatocellular carcinoma;patients with primary clear cell carcinoma of liver likely have later intrahepatic recurrences and a better prognosis.Edmondson grade predicts survival of patients with primary clear cell carcinoma of liver after curative resection;those with higher Edmondson grades may require more careful follow-up and aggressive post-hepatectomy therapy.Part 3.Continuous Pringle maneuver does not affect outcomes of patients with hepatocellular carcinoma after curative resectionObjectiveTo investigate whether the use of continuous Pringle maneuver(PM)adversely impacts the outcome of patients with hepatocellular carcinoma(HCC).MethodsFrom January 1989 to January 2011,586 HCC patients who underwent curative resection in Peking Union Medical College Hospital were identified from the database.Continuous PM was performed in 290 patients(PM group),including 163 patients with a hepatic inflow occlusion time of<15 min(PM-1 group)and 127 with 15-30 min(PM-2 group).An additional 296 patients underwent partial hepatectomy without inflow occlusion(occlusion-free,OF group).ResultsThe PM group showed less estimated blood loss during hepatectomy than the OF group(P=0.005)and the two groups experienced similar incidence of perioperative complications.There were no significant differences in either overall survival or disease-free survival(DFS)between the PM and OF groups(P=0.117 and 0.291,respectively),and between the PM-1 and PM-2 groups(P=0.344 and 0.103,respectively).Hepatic inflow occlusion and occlusion time were not independent risk factors for OS or DFS.ConclusionContinuous PM effectively reduces intraoperative bleeding and does not adversely impact the outcomes of HCC patients.It remains a valuable tool in hepatic resection,even difficult,complicated resections requiring prolonged clamping times.Part 4.Management of Early and Late Intrahepatic Recurrence after Resection for Hepatocellular Carcinoma Exceeding the Barcelona Clinic Liver Cancer CriteriaBackgroundResection has proven to have survival benefit for patients with Barcelona Clinic Liver Cancer Stage B(BCLC-B)or C(BCLC-C)Hepatocellular Carcinoma(HCC).The prognostic factors influencing its recurrence and management after their curative resection are not clarified.This study is to evaluate the predictive factors,the therapy,and prognosis of intra-hepatic recurrences after resection of these patients.MethodsA total of 397 BCLC-B or-C HCC patients treated by curative resection from January 1989 to October 2011 were retrospectively analyzed.Intra-hepatic recurrences were classified into early(<1 year)and late(?1 year)recurrences.ResultsThe 1-,3-,and 5-year overall survival(OS)rates for HCC patients in BCLC-B or-C stage were 83.5%,50.1%and 28.2%,respectively.Early and late intra-hepatic recurrences developed in 73 patients and 104 patients,respectively.In univariate analysis,OS of non-recurrence group was significantly better than that of recurrence group(P<0.001),and OS of late recurrence group was significantly better than that of early recurrence group(P<0.001).In multivariate analysis,the total tumor size,tumor number and vascular invasion was the significant risk factor for tumor recurrence(P<0.001).The OS of patients with late recurrence who received curative treatment was comparable to those who never had tumor recur(P=0.311).ConclusionTime to recurrence and feasibility of curative treatment are the best determinants for the prognosis of HCC patients.For those with late recurrence,curative treatments may prolong their overall survival.