Systemic metastasis of hepatocellular carcinoma responsive to multidisciplinary treatment including debulking surgery

The lung, followed by regional lymph node and bone, is the most common site for extrahepatic metastasis of hepatocellular carcinoma (HCC). Metastatic skin lesion of HCC is rare, and it is a sign of poor prognosis, indicating the strong possibility of metastases in other regions of the body. We report the case of a 52-year-old male with multiple metastases, including skin metastasis of HCC, which were treated with multidisciplinary therapy.

Prognostic Factors and Clinicopathologic Features after Resection of Small Hepatocellular Carcinoma (< or =2 cm)

PURPOSE: Hepatectomy has been regarded as the first treatment of choice for small hepatocellular carcinoma. However, hepatectomy for treatment of small hepatocellular carcinoma remains a critical issue. This study evaluates the role of treatment regarding the survival rate and clinicopathological features after resection of small hepatocellular carcinoma ((< or =2 cm) METHODS: This retrospective study was based on the medical records of 48 small hepatocellular carcinoma (< or =2 cm) patients who received surgical hepatectomy from 1990 to 2005. Patients who revealed on postoperative pathologic reports were enrolled. The survival rate was analyzed according to clinicopathologic and therapeutic factors and we analyzed the pathologic features of the recurrence group. RESULTS: The presence of liver cirrhosis, ICGR15 (Indocyanine green retension-15) was statistically significant in the univariate analysis. The vascular invasion rate and capsule formation rate was 90, 80% in the recurrence group. CONCLUSION: In the small hepatocellular carcinoma ((< or =2 cm), the presence of liver cirrhosis, ICGR15 (Indocyanine green retension-15) should be checked to predict prognosis. The small hepatocellular carcinoma ((< or =2 cm) is similar to advanced hepatocellular carcinoma so hepatectomy may play an important role in the small hepatocellular carcinoma ((< or =2 cm).

Longterm Prognostic Factors after Hepatic Resection for Hepatocellular Carcinoma

PURPOSE: Although advancement in treatment and diagnostic tools related to hepatocelluar carcinoma has been much improved, long term survival rates of hepatocellular carcinoma are still low because of delayed clinical manifestations and underlying diseases causing the cancer. Various kinds of modalities to treat hepatocellular carcinoma have developed but surgical resection is still recognized as the best method. Therefore, we studied the associated factors of long-term survival after liver resection. METHODS: We retrospectively analyzed 184 patients who were pathologically diagnosed with hepatocellular carcinoma from May 1990 to December 2002. Associated factors of long-term survival classified as preoperative, operative, pathological and recurrence factors. Univariate and multivariate analyses were done using cross tabulation analysis and logistic regression analysis. RESULTS: The cumulative 1-, 3- and 5- year survival rates were 66%, 50% and 30%, respectively. Preoperative factors, significantly associated with long-term survival, were age of 60 years and under, tumor size, HBe Ag status and preoperative tumor marker level. As pathological factors, the vascular invasion and lymphatic invasion status were significantly associated. But cirrhosis of the liver was not associated with long-term survival. And in cases of recurrence, patients who had undergone repeat resection survived significantly longer. CONCLUSION: The most significant factors of multivariate analyses were lymphatic invasion status. Tumor size, ICG-R15 and HBe Ag status followed second. We should correct the preoperative factors through screening and early diagnosis. And when recurrence occurs, if the recurring cancer has resectability, repeat hepatectomy will increase the patient's lifespan.

Clinical Results of Hepatic Resection for Metastatic Noncolorectal Nonneuroendocrine Tumor

PURPOSE: Hepatic resection has been proven to be an effective therapy for metastatic colorectal carcinoma and it is a beneficial therapy for metastatic neuroendocrine tumors. Yet the role and efficacy of hepatic resection for metastatic noncolorectal nonneuroendocrine (NCNN) carcinoma have not yet been well defined. We evaluated the outcome and the prognostic factors of patients who are undergoing hepatic resection for metastases from NCNN carcinoma. MATERIALS AND METHODS: The records of 46 patients who underwent liver resection for NCNN metastasis from Oct. 1992 to May 2006 were analyzed. Among the 46 patients, 26 patients were excluded due to direct hepatic invasion from stomach cancer. The patient demographics, tumor characteristics, the treatment and the postoperative survival rate were analyzed. RESULTS: The median patient age was 54.9 years (range: 36-69 years) and there were 13 men (85.7%) and 7 women (15.3%). The mean survival time from the date of liver resection was 48+/-7.85 months, and the 5-year survival rate was 33.7%. The primary tumor sites were identified as gastrointestinal in 60% of the patients and non-gastrointestinal in 40% of the patients. Patients with a gastrointestinal primary tumor had a median survival time that was similar to that of patients with non-gastrointestinal primary tumor (48 months versus 42 months, respectively, p=0.847). The number of liver metastases was an independent prognostic factor (p=0.030). CONCLUSIONS: In selected patients with NCNN liver metastasis, hepatic resection is an effective management and it can also prolong survival. Hepatic resection should be considered if lymphatic invasion and metastasis of the other organ are excluded.

Clinical results of hepatectomy without vascular clamping

PURPOSE: Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during a major liver resection. Here we report the results of hepatectomy without vascular clamping. METHODS: From January 2003 to December 2005, 143 hepatectomies were performed without vascular clamping. There were 102 men and 41 women, with a mean age of 56.4 years. The indications were 79 hepatocellular carcinomas, 20 intrahepatic duct stones, 13 metastases, 13 gallbladder carcinomas, 7 intrahepatic cholangiocarcinomas, 5 Klatskin's tumors, and 6 others. All procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography. RESULTS: There were 11 complications (7%) including intra-abdominal abscess (3), hyperbilirubinemia (3), postoperative bleeding (2), hepatic failure (1), ARDS (Acute respiratory distress syndrome) (1), and massive ascites (1). Sixty-one patients (42.6%) required a blood transfusion. The mean blood transfusion requirement was 1.4 pints. The liver function test results were similar to those previously reported on days 1,3,5, and 7 postoperatively, with a return to normal values after 1 week. CONCLUSIONS: Hepatectomy without vascular clamping reduces liver injuries, including ischemia of the remnant liver and splanchnic congestion. Reduction of bleeding during hepatectomy, requires accurate knowledge of the vascular anatomy, meticulous dissection of the liver parenchyma and maintenance of a low central venous pressure. Our experience with liver resections showed that hepatectomy without vascular clamping can be safely performed using intraoperative ultrasound and an ultrasonic dissector.

Application and Outcomes of Repeat Hepatectomy for Recurrent Hepatocellular Carcinom

PURPOSE: The effective treatment of an intrahepatic recurrent hepatocellular carcinoma (HCC) after a curative resection is very important in improving the prognosis after resection of HCC. The purposes of this study were to evaluate the clinicopathological characteristics and clarify the outcome of the patients after a repeat hepatectomy for a recurrent HCC. METHODS: Between March 1991 and February 2004, 16 patients underwent repeat hepatectomy for a recurrent HCC at the Yeungnam university hospital. The clinicopathological and follow-up data were retrospectively analyzed. RESULTS: There was no significant difference in the average of ICG R15 between the primary (11.2+/-1.8%) and repeat hepatectomy (18.2+/-2.8%). There were a higher proportion of minor (Couinaud's segment < or =2) resection in the repeat (93.8%) than the primary hepatectomy groups (75.0%), but the difference was not statistically significant. A significant difference was seen in the tumor size between the primary (3.6+/-0.5 cm) and repeat hepatectomy groups (2.9+/-1.9 cm). The average number of tumor in both the primary and repeat hepatectomy was equal (1.3+/-0.6). The number of cases of multicentric occurrence of HCC (12 cases) was more than that of intrahepatic metastasis of HCC (4 cases). The mean interval between the primary and repeat hepatectomy was 48.0+/-33.0 months (13~136 months). The average survival time after a primary hepatectomy was 83.6+/-36.3 months. The cumulative 1, 3, 5, and 7 year survival rates were 100, 100, 85.9, and 75.3% after a primary hepatectomy and 90, 56.5, 56.5 and 56.5% after a repeat hepatectomy, respectively. CONCLUSION: A repeat hepatectomy leads to a satisfactory outcomes in selected HCC patients.

Application of Right Hemihepatic Vascular Exclusion in Liver Resection

PURPOSE: Control of bleeding and preservation of liver function are still major keys for successful liver resection. We applied right hemihepatic vascular exclusion (RHVE) in patients with a right lobe liver tumor to verify the usefulness and safety of RHVE. METHODS: Between March 1998 and August 2002, 12 patients (Control group) underwent right liver surgeries without inflow occlusion, and 22 patients (RHVE group) underwent right liver surgeries under RHVE. Hemodynamic changes during the operation, amount of transfusion, and post- operative liver function were compared between the two groups. RESULTS: The mean duration of RHVE was 32.3+/-13.9 (15~60) minutes. The mean arterial pressure of the control group and the RHVE group after liver resection were reduced, but these changes were not statistically significant. The amount of transfusion in the RHVE group (2.66+/-1.4 unit) was significantly lower (P<0.05) than that of the control group (4.56+/-3.3 unit). AST/ALT level of the RHVE group were significantly higher on POD#1, but there were no statistically significant differences on POD#3, 5 and 7. Also, the differences in the changes of total bilirubin and IL-6 after liver resection were not significant. Cirrhotic patients in both groups were compared with the same analysis. Only the amounts of transfusion in the RHVE group were significantly lower (P<0.05) than that of the control group. CONCLUSION: RHVE is a safe and useful procedure for right liver surgery with minimal blood loss, but without significant hemodynamic alteration and functional deterioration. These characteristics are shown especially in cirrhotic liver and non-anatomical resection of metastatic cancer.

Is Laparoscopic Procedure Adequate for Colorectal Cancer Surgery?

PURPOSE: To evaluate the possibility that laparoscopic procedure could perform surgeries keeping the principle of oncologic surgery. METHODS: From July 1993 to June 1996, thrity patients undergone laparoscopic assisted colon and rectal resections (LR) for malignant disease at Yeungman university hospital. Margins of resection and lymph nodes (LNs) recovered were compared with those of thirty stage matched open resection cases (OR, n=30) retrospectively. There was no operative mortality in both group. Operative techniques used in LR vs OR were colectomy, 5:6; anterior resection, 6:5; low anterior resection, 11:12 and abdominoperineal resection, 8:7. Parameters were analgesic use, duration of postoperative ileus, operative time, hospital stay, margins of rescetion, lymph node yield (LNs), and recurrence. RESULTS: Patients who underwent LR had less pain, a shorter period of postoperative ileus and hospital stay than patients who underwent OR. But, the length of operative time was greater for patients undergoing LR. Mean lymph node yield in the laparoscopic group was 16 compared with 18.1 in the open group (P=0.560). Average margins of resection in LR vs OR were 13.9 cm vs 14.1 cm proximally (P=0.823), 3.6 cm vs 5.2 cm distally (P=0.498). In no case did the margins contain tumor. There was no statistical significance in dissected LNs and the length of both resection margins in both groups. Recurrence was similar in both groups. CONCLUSIONS: In this study, there is no evidence that laparoscopic technique is inadequate in following the cancer surgery principle.