Backgrounds/Aims Although cigarette smoking has been associated with an increased risk of hepatocellular carcinoma (HCC), its association with HCC mortality remains underexplored. We aimed to evaluate the effect of smoking on early mortality in HCC patients following curative treatment.
Methods Data from the Korean Primary Liver Cancer Registry were examined for HCC patients who underwent liver resection or radiofrequency ablation between 2015 and 2018. Smoking cumulative dose was assessed in pack-years. The primary outcome was the 3-year overall survival (OS).
Results Among 1,924 patients, 161 were classified as heavy smokers (≥40 pack-years). Heavy smokers exhibited a lower 3-year survival rate (77.1%) than nonsmokers (83.3%), with a significant difference observed in the 3-year OS (P=0.016). The assessment of smoking pack-years in relation to 3-year OS revealed a dose-dependent pattern, with the hazard ratio exceeding 1.0 at 20 pack-years and continuing to rise until 40 pack-years, reaching peak at 1.21 (95% confidence interval, 1.01-1.45). Multivariate Cox-regression analysis revealed heavy smoking, age ≥60 years, underlying cirrhosis, tumor size >3 cm, vascular invasion, and Child-Pugh class B/C as risk factors for 3-year OS. Subgroup analyses of patients with a tumor size <3 cm, absence of vascular invasion, and meeting the Milan criteria also showed inferior outcomes for heavy smokers in all three subgroups.
Conclusions Heavy smoking, defined as a history of >40 pack-years, was linked to poorer 3-year survival outcomes in HCC patients undergoing curative treatments, underscoring the importance of smoking cessation in this population.
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Background/Aim Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOBMRI) further enhances the identification of additional hepatic nodules compared with computed tomography (CT) alone; however, the optimal treatment for such additional nodules remains unclear. We investigated the long-term oncological effect of aggressive treatment strategies for additional lesions identified using EOB-MRI in patients with hepatocellular carcinoma (HCC).
Methods Data from 522 patients diagnosed with solitary HCC using CT between January 2008 and December 2012 were retrospectively reviewed. Propensity score-matched (PSM) analysis was used to compare the oncologic outcomes between patients with solitary HCC and those with additional nodules on EOB-MRI after aggressive treatment (resection or radiofrequency ablation [RFA]).
Results Among the 383 patients included, 59 had additional nodules identified using EOB-MRI. Compared with patients with solitary HCC, those with additional nodules on EOB-MRI had elevated total bilirubin, aspartate transaminase, and alanine transaminase; had a lower platelet count, higher MELD score, and highly associated with liver cirrhosis (P<0.05). Regarding long-term outcomes, 59 patients with solitary HCC and those with additional nodules after PSM were compared. Disease-free survival (DFS) and overall survival (OS) were comparable between the two groups (DFS, 60.4 vs. 44.3 months, P=0.071; OS, 82.8 vs. 84.8 months, P=0.986).
Conclusion The aggressive treatment approach, either resection or RFA, for patients with additional nodules identified on EOBMRI was associated with long-term survival comparable with that for solitary HCC. However, further studies are required to confirm these findings.
Background/Aim The aim of this study was to compare the therapeutic efficacy of ablation and surgery in solitary hepatocellular carcinoma (HCC) measuring ≤5 cm with a large HCC cohort database.
Methods The study included consecutive 2,067 patients with solitary HCC who were treated with either ablation (n=1,248) or surgery (n=819). Th e patients were divided into three groups based on the tumor size and compared the outcomes of the two therapies using propensity score matching.
Results No significant difference in recurrence-free survival (RFS) or overall survival (OS) was found between surgery and ablation groups for tumors measuring ≤2 cm or >2 cm but ≤3 cm. For tumors measuring >3 cm but ≤5 cm, RFS was significantly better with surgery than with ablation (3.6 and 2.0 years, respectively, P=0.0297). However, no significant difference in OS was found between surgery and ablation in this group (6.7 and 6.0 years, respectively, P=0.668).
Conclusion The study suggests that surgery and ablation can be equally used as a treatment for solitary HCC no more than 3 cm in diameter. For HCCs measuring 3-5 cm, the OS was not different between therapies; thus, ablation and less invasive therapy can be considered a treatment option; however, special caution should be taken to prevent recurrence.
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Reply to the Letter regarding “Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs. ablation: a multicenter retrospective study” Kazuhiro Nouso, Kazuya Kariyama Journal of Liver Cancer.2024; 24(1): 5. CrossRef
Radiofrequency for hepatocellular carcinoma larger than 3 cm: potential for applications in daily practice Ji Hoon Kim, Pil Soo Sung Journal of Liver Cancer.2024; 24(1): 1. CrossRef
Letter regarding “Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs. ablation: a multicenter retrospective study” Jongman Kim Journal of Liver Cancer.2024; 24(1): 3. CrossRef
Although hepatocellular carcinoma (HCC) is associated with a poor prognosis, management of early-stage HCC is often successful with highly efficacious treatment modalities such as liver transplantation, surgical resection, and radiofrequency ablation. However, unfavorable clinical outcomes have been observed under certain circumstances, even after efficient treatment. Factors that predict unsuitable results after treatment include tumor markers, inflammatory markers, imaging findings reflecting tumor biology, specific outcome indicators for each treatment modality, liver functional reserve, and the technical feasibility of the treatment modalities. Various strategies may overcome these challenges, including the application of reinforced treatment indication criteria with predictive markers reflecting tumor biology, compensation for technical issues with up-to-date technologies, modification of treatment modalities, downstaging with locoregional therapies (such as transarterial chemotherapy or radiotherapy), and recently introduced combination immunotherapies. In this review, we discuss the challenges to achieving optimal outcomes in the management of early-stage HCC and suggest strategies to overcome these obstacles.
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Heavy smoking increases early mortality risk in patients with hepatocellular carcinoma after curative treatment Jaejun Lee, Jong Young Choi, Soon Kyu Lee Journal of Liver Cancer.2024; 24(2): 253. CrossRef
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Background/Aims Although the Barcelona Clinic Liver Cancer staging system seems to underestimate the impact of curative-intent surgical resection for multifocal hepatocellular carcinoma (HCC), recent studies have indicated favorable results for the surgical resection of multiple HCC. This study aimed to assess clinical outcomes and feasibility of surgical resection for multifocal HCC with up to three nodules compared with single tumor cases.
Methods Patients who underwent surgical resection for HCC with up to three nodules between 2009 and 2020 were included, and those with the American Joint Committee on Cancer (AJCC) 8th edition, T1 and T4 stages were excluded to reduce differences in disease distribution and severity. Finally, 81 and 52 patients were included in the single and multiple treatment groups, respectively. Short- and long-term outcomes including recurrence-free survival (RFS) and overall survival (OS), were evaluated.
Results All patients were classified as Child-Pugh class A. RFS and OS were not significantly different between the two groups (P=0.176 and P=0.966, respectively). Multivariate analysis revealed that transfusion and intrahepatic metastasis were significantly associated with recurrence (P=0.046 and P=0.005, respectively). Additionally, intrahepatic metastasis was significantly associated with OS (hazard ratio, 1.989; 95% confidence interval, 1.040-3.802; P=0.038).
Conclusions Since there was no significant difference in survival between the single and multiple groups among patients with AJCC 8th stage T2 and T3, surgical resection with curative intent could be considered with acceptable long-term survival for selected patients with multiple HCC of up to three nodules.
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Heavy smoking increases early mortality risk in patients with hepatocellular carcinoma after curative treatment Jaejun Lee, Jong Young Choi, Soon Kyu Lee Journal of Liver Cancer.2024; 24(2): 253. CrossRef
Parenchymal-sparing hepatectomy (PSH), though technically challenging, is emerging as a choice of treatment for colorectal liver metastases (CRLM). PSH in Jehovah’s witness (JW) patients, for whom transfusion is not an option, involves complex surgical and medicolegal issues. A 52-year-old JW male with synchronous, multiple, bilobar liver metastases from a rectal adenocarcinoma was referred following neoadjuvant chemotherapy. At surgery, 10 metastatic deposits were observed and confirmed by intraoperative ultrasonography. Parenchymal-sparing non-anatomical resections were performed using a cavitron ultrasonic aspirator with the application of intermittent Pringle maneuvres. Histology confirmed multiple CRLMs with tumor-free resection margins. PSH is increasingly employed for CRLMs to preserve residual liver volume and minimize morbidity without compromising oncological outcomes. It is technically challenging, especially in the presence of bilobar, multi-segmental disease. This case illustrates the feasibility of performing complex hepatic surgery in special patient groups by meticulous planning and preparation involving multiple specialties and the patient.
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Jehovah’s Witnesses: Challenges in liver disease management and in liver transplantation Jordan S. Sack, Sander S. Florman, Thomas D. Schiano Liver Transplantation.2024;[Epub] CrossRef
There are various methods for treating advanced hepatocellular carcinoma with portal vein invasion, such as systemic chemotherapy, transarterial chemoembolization, transarterial radioembolization, and concurrent chemoradiotherapy. These methods have similar clinical efficacy but are designed with a palliative aim. Herein, we report a case that experienced complete remission through “associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)” after concurrent chemoradiotherapy and hepatic artery infusion chemotherapy. In this patient, concurrent chemoradiotherapy and hepatic artery infusion chemotherapy induced substantial tumor shrinkage, and hypertrophy of the nontumor liver was sufficiently induced by portal vein ligation (stage 1 surgery) followed by curative resection (stage 2 surgery). Using this approach, long-term survival with no evidence of recurrence was achieved at 16 months. Therefore, the optimal use of ALPPS requires sufficient consideration in cases of significant hepatocellular carcinoma shrinkage for curative purposes.
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Higher objective responses by hepatic arterial infusion chemotherapy following atezolizumab and bevacizumab failure than when used as initial therapy in hepatocellular carcinoma: a retrospective study Jae-Sung Yoo, Ji Hoon Kim, Hee Sun Cho, Ji Won Han, Jeong Won Jang, Jong Young Choi, Seung Kew Yoon, Suho Kim, Jung Suk Oh, Ho Jong Chun, Pil Soo Sung Abdominal Radiology.2024; 49(9): 3127. CrossRef
Is multidisciplinary treatment effective for hepatocellular carcinoma with portal vein tumor thrombus? Won Hyeok Choe Journal of Liver Cancer.2022; 22(1): 1. CrossRef
Hepatocellular carcinoma (HCC) has poor prognosis, even after curative resection. Early
recurrence after curative treatment is a major cause of the poor prognosis. Pathologic factors
such as vessel invasion, satellite nodule, size of tumor and pathologic grade are prognostic
factors predicting early recurrence and poor prognosis. We share our experience of two case s which both showed early recurrence after curative hepatic resection, but eventually
demonstrated different prognosis. Since the most common cause of death after potentially
curative treatment is tumor recurrence, suppression of tumor recurrence might be linked
to survival gain. Currently, there is no adjuvant therapy for HCC endorsed by international
guidelines. However, recent studies have shown that antiviral treatment for hepatitis B virusrelated
HCC and immunotherapy using autologous cytokine-induced killer cell reduced
HCC recurrence. Further study is needed to select patients who will benefit from adjuvant
treatments.
A case of hepatocellular carcinoma (HCC) with portal vein tumor thrombi (PVTT) which was performed hepatectomy after
down-staging by proton therapy is reviewed. Generally, the recommended therapeutic strategy for this kind of HCC is radiation
therapy, systemic or infusion anticancer chemotherapy. However, the response of HCC and its PVTT of this 56 year-old male
patient was relatively good after 22 times of proton therapy, and we performed right hemihepatectomy on the concept of clinical
trial under the informed consent of patient and his families. He is still alive without recurrence 15 months after hepatectomy. We
suggest that hemihepatectomy with removal of PVTT could be an alternative strategy in the PVTT accompanied HCC cases who
show good responses after the above generally recommended therapies.
Jaejun Shim, Byung-Ho Kim, Young Hwangbo, Sang Wook Lee, Young Ju Lee, Seung Hyung Ha, Jae Young Jang, Seok Ho Dong, Hyo Jong Kim, Young Woon Chang, Rin Chang, Sang Mok Lee
Journal of the Korean Liver Cancer Study Group. 2009;9(1):33-36. Published online June 30, 2009
Long term results of hepatic resection for hepatocellular carcinoma (HCC) are not satisfactory due to a high incidence of
postoperative recurrence. To improve the prognosis in patients who underwent hepatic resection, identification of risk factors
for recurrence and development of effective preventive strategies are required. A single nodular mass was found in the right
hepatic lobe of 53-year old male with B viral cirrhosis by surveillance ultrasonography. Dynamic abdominal CT showed a
3 cm-sized hypervascular mass in the right posteroinferior segment (S6). AFP was 359 ng/mL. Child-Pugh classification was
A, and ICG R15 was 18.8%. After preoperative transarterial chemoembolization (TACE), right hepatic wedge resection was
performed. Resection margin was free of tumor. Microinvasions in the surrounding vessels, lymphatics, bile ducts were not
found and microsatellite nodules were absent in the resected specimen. Although there were no risk factors that associated
with high postoperative recurrence, multifocal intrahepatic recurrence in the right lobe and left medial lobe occurred at 7
months after hepatic resection. He underwent two sessions of TACE.
Intrahepatic (IH) metastasis is more frequent but extrahepatic (EH) metastasis results in worse prognosis and
proper treatment on IH and EH metastasis is essential for improving the long-term survival. The purpose of this
report is to review the current experience of EH metastasectomy and also to review the results of re-hepatectomy
on IH metastasis after hepatectomy of HCC. EH metastasis can occur in lung, lymph nodes, bone, adrenal gland
and brain in frequency. Indications of EH metastatectomy of HCC are 1) cured or controlled IH lesion, 2)
acceptable operation risk, 3) complete removal of EH lesions seems possible. After lung metastasectomy, 5-year
survival rates in previous reports are 23-67% according to the indications. The poor prognosis factors after lung
metastasectomy are short disease-free interval between hepatectomy and lung resection, high alpha-fetoprotein.
In selected patients with EH metastasis of HCC, long-term survival can be achieved by proper and aggressive
surgery. The 5-year recurrence rate after hepatectomy of HCC ranges 60-100% and more than half of them is
IH recurrence. IH recurrence can be classified to IH metastasis and multicentric occurrence (MO) by mode of
recurrence, and MO is known to be related to HCV infection, long disease-free interval and better survival.
Though it is impossible to discriminate IH metastasis and MO, re-hepatectomy should be considered in patients
with single nodule recurrence and with more than 1-year of disease-free survival after hepatectomy of HCC.
Stem cells of the liver are differentiated to both hepatocytes and cholangiole. So bidirectional malignant
transformation may be occurred. Hepatocellular carcinoma with bile-duct tumor thrombi is clinically rare and
cause the obstructive jaundice. We experienced the poorly differentiated hepatocellular carcinoma showed the
bidirectional differentiation. And she had metastatic foci in right intrahepatic duct with tumor thrombi to the
common bile duct. A 72-year-old female patient was admitted to hospital by pruritus, general weakness and dark
urine for 15 days. She was diagnosed liver cirrhosis due to chronic HBV 15 years ago. She showed icteric sclerae.
The laboratory findings were followed; total bilirubin/direct bilirubin was 9.7/7.3 mg/dL, SGOT/SGPT was 59/115
IU/L, alkaline phosphatase 681 IU/L, alpha-fetoprotein was 16.9 ng/mL and CA19-9 was 76.2 U/mL. ICG-R15
was 11.8%. The hilar cholangiocarcinoma type IIIa with liver abscess was diagnosed by CT scan and MRI scan.
She underwent Rt. hepatectomy with resection of CBD, Roux-en-Y hepaticojejunostomy. After pathologic
examination, the poorly differentiated hepatacellular carcinoma with bile duct metastasis was confirmed.
Metastasis to right lower lung was detected at 1 years after 1st operation. So, she underwent wedge resection of
RLL. She remains without any problems 6 months after 2nd operation.
A 43-year-old man who had hepatic segmentectomy due to hepatocellular carcinoma was found to have a recurrent hepatocelllular carcinoma in the remnant liver along the resection margin. The patient has been performed radiofrequency ablation three times for recurrent hepatocellular carcinomas through 27 months after initial hepatectomy. We report a case of recurrent hepatocellular carcinomas after hepatectomy that were susccessfully treated radiofrequency ablation.