Exploratory randomized phase II trial for optimizing treatment dosage and duration of adjuvant S-1 plus oxaliplatin in patients with stage III colon cancer: YCOG1402 (SOAP trial).

Introduction: Conventionally, the recommended duration of adjuvant chemotherapy of colon cancer had been 6 months. The IDEA Collaboration suggested that shortening capecitabin and oxaliplatin (CAPOX) adjuvant chemotherapy may be possible. S-1 and oxaliplatin (SOX) treatment is standard treatment in metastatic colorectal cancer in Japan. The aim of this study was to optimize treatment dosage and duration of adjuvant SOX in stage III colon cancer. Methods: This trial was as open-label multi-center randomized phase II study. Patients with stage III colon cancer were randomly assigned to 3 months or 6 months of adjuvant SOX treatment in different doses: 130 mg/m2 (3 months) or 100 mg/m2 (6 months) of oxaliplatin. The primary endpoint was 3-year disease-free survival (DFS) and the null hypothesis for the primary endpoint was that the 3-year DFS was ≤72% in each arm and was tested with a one-sided significance level of 10%. Results: Eighty-two patients were assigned to the 6 months arm and 81 to the 3 months arm. The 3-year DFS was 75.0% (80% CI 67.95-80.72, p = 0.282) in the 6 months arm and 76.9% (80% CI 70.1-82.38, p = 0.171) in the 3 months arm. Treatment completion rate and relative dose intensity (RDI) were higher in 3 months than 6 months arm. The adverse events (AE) were similar in both arms. Conclusions: The 3-year DFS was not significantly superior to null hypothesis in both 3 months and 6 months arms for the stage III colon cancer. Primary endpoint was not achieved. The SOX regimen was not feasible in long-term outcomes.

Treatment of hepatocellular carcinoma with hepatic vein tumor thrombosis protruding into the inferior vena cava by conversion surgery following chemotherapy with regorafenib: a case report.

Regorafenib is an oral multikinase inhibitor affecting angiogenesis, oncogenesis, metastasis, and tumor immunity. As a systemic treatment, it has been shown to provide survival benefits in hepatocellular carcinoma (HCC) patients progressing on sorafenib treatment. We report herein a case of HCC with hepatic vein tumor thrombosis protruding into the inferior vena cava (IVC-HVTT) which was successfully treated by surgery following second-line chemotherapy with regorafenib. A 79-year-old man with chronic hepatitis was diagnosed with HCC. Computed tomography revealed a solitary tumor in segments 7 and 8 and an IVC-HVTT from the right hepatic vein. Since IVC-HVTT removal is a difficult procedure, the tumor was diagnosed as unresectable, and administration of sorafenib was started. Five weeks later, the lesion had increased in size by 15.3%; subsequently, regorafenib was given as second-line therapy for 12 months. After shrinkage of the IVC-HVTT, the patient was referred to our hospital for surgery. One month after the cessation of regorafenib, an extended resection of segment 8 and total removal of the IVC-HVTT was successfully performed without using total hepatic vascular exclusion. There were no serious postoperative complications. Additionally, there has been no recurrence for about 2 years since the initial therapy.

Abdominal drain straying into right atrium: a case report.

BACKGROUND: A drain exchange with the use of a guidewire may be accompanied by serious complications. CASE PRESENTATION: This case involved an 86-year-old man with overlapping cancers of intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma. A left hepatectomy, a left caudal lobectomy (with a medial hepatic vein preservation), an extrahepatic bile duct resection, and a right hepatojejunostomy were performed. The abdominal drain was placed into the hepatectomy side. Bile leakage occurred on the seventh day after the surgery, and the drain was exchanged. Since the bile leakage was still detectable via a computed tomography (CT) scan on the 15th postoperative day, the drain was exchanged again. On the next day, blood had discharged from the drain. A CT scan revealed that the tip of the drain was straying into the right atrium (RA) and the drain was removed from the inferior vena cava (IVC) under general anesthesia. One week later, a fiburin thrombus was observed from the IVC to the RA via the use of transthoracic echocardiography. A right atrial incision, a thrombus removal, and a middle hepatic vein merging section closure surgery were performed. Afterward, the patient's general condition gradually improved, and he was transferred to the hospital for rehabilitation. CONCLUSION: More careful guidewire operations are necessary at the time of the exchange of the drain to prevent the drain from being placed too close to blood vessels.

[A case of resected synchronous hepatocellular and cholangiolocellular carcinoma in the background of resolved hepatitis B virus infection].

An 85-year-old male patient was referred to our hospital for further examination of a liver tumor. Imaging examination revealed a 90-mm tumor in segment 4/8 and 30-mm tumor in segment 6 of the liver. Histopathological examination revealed that the tumor in segment 4/8 was cholangiolocellular carcinoma (CLC) and the tumor in segment 6 was hepatocellular carcinoma (HCC). This case shows that although the frequency of CLC is very low, recent studies have indicated the novel knowledge of CLC. Herein, we report a surgical case of CLC and HCC in the background of resolved hepatitis B virus infection.

Esophageal Carcinosarcoma that Was Diagnosed as a Granulocyte-colony Stimulating Factor and Interleukin-6-producing Tumor with a Tumor Fever.

A 51-year-old man visited our hospital with a main complaint of precordial pain, difficulty swallowing, and pyrexia. The patient was diagnosed with esophageal carcinosarcoma, based on the characteristic morphology noted on upper gastrointestinal endoscopy and histology tests, and he underwent surgical treatment. His preoperative blood granulocyte-colony stimulating factor (G-CSF) and interleukin-6 (IL-6) levels were high, and the surgical specimens were positive in both immunohistochemical tests; therefore, he was diagnosed with a G-CSF- and IL-6-producing tumor. When pyrexia is seen as a paraneoplastic symptom, it is important to consider and investigate the possibility of a cytokine-producing tumor.

Isolated breast metastasis from gastric cancer in a male patient.

A 72-year-old man underwent total gastrectomy for gastric cancer (por2, T3, N2, Stage IIIA). Eleven courses of postoperative chemotherapy with TS-1 (tegafur/gimeracil/oteracil) were administered. Five months after surgery, the serum carcinoembryonic antigen value was slightly elevated. However, computed tomography did not reveal any metastatic lesions in other organs. Two years after surgery, the patient felt a mass in the left mammary. A 2-cm tumor was palpable in the central portion of the breast. Ultrasonography revealed a hypoechoic tumor, which was Class 3 on aspiration biopsy cytological examination. No mass was detected on positron emission tomography-computed tomography. The mammary gland tumor increased in size to 3 cm, and a core needle biopsy procedure was performed. Histological examination findings revealed breast metastasis of gastric cancer. No other recurrence was found, and radical mastectomy was performed 2 years and 5 months after gastrectomy. Immunohistological analysis of the resected material confirmed breast metastasis of the gastric cancer. Two courses of TS-1 + cisplatin were administered, but this treatment was subsequently terminated because the patient experienced Grade 3 diarrhea and neutropenia. Three years and 1 month after the gastrectomy, the tumor recurred in the pelvic area. Chemotherapy and radiation therapy were performed, but the patient's overall condition became progressively worse, and he died 3 years and 9 months after gastrectomy.

Surgical Resection of a Ruptured Pancreaticoduodenal Artery Aneurysm.

BACKGROUND: Ruptured aneurysms of the pancreaticoduodenal artery result in fatal hemorrhage and high mortality. Therefore, prompt diagnosis and treatment are required, but there are sometimes problems differentiating this specific diagnosis from other abdominal pathologies. CASE REPORT: We encountered a rare case of a ruptured pancreaticoduodenal artery aneurysm with an atypical clinical presentation that simulated acute pancreatitis. A 71-year-old woman was admitted to the emergency department with abdominal pain in the left upper quadrant, a slightly elevated level of pancreatic amylase, and cholelithiasis on ultrasonography. With persistent pain and progressively decreasing hemoglobin level, computed tomography with contrast showed fluid collection in the subphrenic space, a retroperitoneal hematoma, and a pancreaticoduodenal artery aneurysm that appeared to originate from a branch of the SMA. Urgent angiography indicated spontaneous rupture of a pancreaticoduodenal artery aneurysm. Emergent surgery was undertaken, and a simple aneurysmectomy was successfully performed. The patient's recovery was unremarkable. The prompt diagnosis of a pancreaticoduodenal artery aneurysm was difficult because the initial symptoms were vague and misleading in our case. CONCLUSIONS: A high level of suspicion, rapid diagnostic capability, and prompt surgical or endovascular intervention, as well as effective teamwork in the emergency department, are critical to avoid the devastating consequences of a ruptured visceral artery aneurysm.

A prospective multicenter study on self-expandable metallic stents as a bridge to surgery for malignant colorectal obstruction in Japan: efficacy and safety in 312 patients.

BACKGROUND: Endoscopic stenting with a self-expandable metallic stent (SEMS) is a widely accepted procedure for malignant colonic obstruction. The Colonic Stent Safe Procedure Research Group conducted the present prospective feasibility study. METHODS: Our objectives were to estimate the safety and feasibility of SEMS placement as a bridge to surgery (BTS) for malignant colorectal obstruction. We conducted a prospective, observational, single-arm, multicenter clinical trial from March 2012 to October 2013. Each patient was treated with an uncovered WallFlex enteral colonic stent. Patients were followed up until discharge after surgery. RESULTS: A total of 518 consecutive patients were enrolled in this study. The cohort intended for BTS consisted of 312 patients (61 %), and the stent could be released in 305 patients. Technical and clinical success rates were 98 and 92 %, respectively. Elective surgery was performed in 297 patients, and emergency surgery was performed in eight patients for the treatment of complications. The overall preoperative complication rate was 7.2 %. Major complications, including perforation, occurred in 1.6 %, persistent colonic obstruction occurred in 1.0 %, and stent migration occurred in 1.3 % patients. The median time from SEMS to surgery was 16 days. Silent perforations were observed in 1.3 %. Open and laparoscopic surgery was performed in 121 and 184 patients, respectively. The tumor could be resected in 297 patients. The primary anastomosis rate was 92 %. The rate of anastomotic leakage was 4 %, and the overall stoma creation rate was 10 %. The median duration of hospitalization following surgery was 12 days. Overall postoperative morbidity and mortality rates were 16 and 0.7 %, respectively. CONCLUSIONS: This largest, multicenter, prospective study demonstrates the feasibility of SEMS placement as a BTS for malignant colorectal obstruction. SEMS serves as a safe and effective BTS with acceptable stoma creation and complication rates in patients with acute malignant colonic obstruction.

Colonic low-grade endometrial stromal sarcoma and orthotopic endometrial stromal tumor with limited infiltration sharing the JAZF1-SUZ12 gene fusion.

Endometrial stromal tumors (ESTs) are composed of cells resembling endometrial stroma, and are divided into benign and malignant types based on morphology. Endometrial stromal nodule (ESN) is a benign localized tumor, and endometrial stromal sarcoma (ESS) is an infiltrative and potentially metastatic neoplasm. A series of genetic aberrations contribute to pathological diagnosis of ESTs. At present, subsets of ESN and ESS-low grade (ESS-LG) are characterized as JAZF1-SUZ12/JJAZ1 gene fusion. The ESTs that show higher grade atypia but lack nuclear pleomorphism include YWHAE-FAM22 ESS. Here we report an unusual case of ESTs. Sudden colonic perforation occurred to the patient, and emergency surgery was performed. Pathological findings suggested metastatic ESS. Thorough medical examination of the genital organs detected a 1 cm-sized well-demarcated uterine tumor. Microscopically, the tumor lacked infiltrative features, conforming to the definition of ESN. Both lesions demonstrated identical cytology and shared JAZF1-SUZ12 gene fusion. Endometriosis was not found in any areas of the resected organs, strongly suggesting that the uterine orthotopic tumor metastasized. The current case uncovered the problems of differential diagnosis between ESN and ESS-LG. We demonstrate detailed pathological features of the two lesions, and discuss the possibility of orthotopic EST with limited infiltration to develop into ESS-LG.

Giant mesenchymal hamartoma of the liver in an adult.

We report a case of hepatic mesenchymal hamartoma in an adult; this condition is extremely rare, with only 15 cases having been reported in the English-language literature worldwide. The patient was a 36-year-old woman who was seen at her local hospital for upper abdominal distension. A giant multilocular cystic tumor, which had almost entirely replaced the normal parenchyma of the right lobe of the liver, was diagnosed. She was referred to our hospital, where, with a diagnosis of biliary cystadenoma, the tumor was successfully removed by right hemihepatectomy. After an uneventful postoperative course, the patient was discharged from our hospital. On histological examination, the tumor consisted of numerous cystic lesions without epithelial lining cells; hepatocytes, bile duct, and vascular components, without either lobular structure or atypia, were observed in the pseudocyst wall, leading to a diagnosis of hepatic mesenchymal hamartoma. There have been a few previously reported cases of multifocal hepatic mesenchymal hamartoma reappearing in the remaining liver after hepatectomy, although these cases are considered to be extremely rare. Therefore, periodic follow-up will be necessary for the patient.

Surgical anatomy of hepatic hilum with special reference of the plate system and extrahepatic duct.

BACKGROUND: When resecting hilar cholangiocarcinoma, the surgeon cannot visualize the hilar vessels through thick connective tissue known as the plate system. Little has been reported regarding the anatomical relationship between the plate system and the extrahepatic bile duct. METHODS: Twenty-five formalin-fixed cadaveric livers were dissected carefully and 7 were sectioned sagittally. The extent, composition, and distribution of the extrahepatic bile ducts within the system were investigated. The length between the confluence of the hepatic duct and the branch point of the segmental duct (level I) and the length between the branch point of the segmental duct and the segmental Glisson's pedicle (level II) were measured. RESULTS: The plate system-composed of the hilar, cystic, Arantian, and umbilical regions--was easily separated from the hepatic parenchyma. Histologically, dense connective tissue with abundant capillaries, lymphatic vessels, and neural fibers were noted. Level I of B1pcp and B4a measured 13.0 and 14.7 mm, respectively. Level II measured 8.6 and 17.3 mm, respectively. CONCLUSIONS: The bile ducts in the plate system correspond to the extrahepatic bile ducts and their lengths are variable for every segment. Knowing the lengths of the resectable extrahepatic bile ducts is useful for deciding which segment should be resected according to the cancerous invasion.

Retroportal hepaticojejunostomy for extended resection of hilar bile ducts.

High hepatic duct resection sometimes is unavoidable in achieving curative resection of hilar cholangiocarcinoma, as tumor cells can extend further than expected along the bile ducts from the macroscopically evident cancer. In patients undergoing left hemihepatectomy with caudate lobectomy whose bile duct must be severed at the subsegmental bile duct levels, the orifices of the posterior bile ducts would lie behind the right portal vein. Conventional hepaticojejunostomy would be risky in such cases because an anastomosis performed in the usual manner would be subjected to strain. Instead, between 2002 and 2004, three patients underwent retroportal hepaticojejunostomy using a jejunal limb mobilized and positioned behind the hepatoduodenal ligament. Primary tumors were classified as type IV in the Bismuth-Corlette classification. Tension-free hepaticojejunal anastomosis was performed successfully in all three patients; insufficiency of the hepaticojejunostomy did not develop. Neither early nor late complications directly related to this method occurred. Retroportal hepaticojejunostomy, thus, permits more peripheral resection of the hepatic duct while providing a sufficient operative field for safe, tension-free anastomosis. This technique is very useful for patients undergoing left hemihepatectomy requiring high hilar resection of the bile duct.

Porcelain gallbladder complicated with pancreas divisum.

We report a rare case of porcelain gallbladder associated with pancreas divisum (PD). A 60-year-old woman suffered from discomfort in the back of the right side. An abdominal radiograph revealed a calcified spherical mass in the right upper quadrant. Ultrasonography revealed a scattered echo with a posterior acoustic shadow in the gallbladder wall. A plain computed tomography (CT) scan showed flecks of intramural calcification in the wall of the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed separate openings for the Santorini and Wirsung ducts. The patient underwent cholecystectomy after porcelain gallbladder and pancreas divisum had been diagnosed. The porcelain gallbladder resulted from a stone impacted in the neck of the gallbladder. Patients with PD should be followed carefully, because gallstones often accompany PD, and porcelain gallbladder may result, as in this patient.

Disruption of the middle hepatic vein is not crucial for liver regeneration of the remnant liver after right hemihepatectomy for hepatic tumors.

BACKGROUND: To clarify the role of the middle hepatic vein (MHV) in liver regeneration of the remnant liver after right hemihepatectomy for hepatic tumors, we reviewed 29 patients to evaluate liver regeneration for up to 12 postoperative months. METHODS: Volume regeneration of the remnant liver was investigated by computed tomography at 3, 6, and 12 postoperative months. The remnant liver was divided into the following three areas: the medial section (segment IV), the lateral section (segments II and III), and segment I. The patients were divided into two groups: group A (n = 17), in which the MHV was preserved in the remnant liver, and group B (n = 12), in which the MHV was removed. RESULTS: Volume regeneration of each area continued until 6 postoperative months but did not increase thereafter. On univariate analysis, differences in the volume regeneration of each area between the groups were not significant at any measured time point. Furthermore, disruption of the MHV was determined to not be crucial to the volume regeneration of any liver area on multivariate analysis. Only the resection volume (percentage) significantly affected liver regeneration of the remnant liver. CONCLUSIONS: Disruption of the MHV does not decisively affect liver regeneration of remnant liver after right hemihepatectomy for hepatic tumors.

Applicability of the Milan criteria for determining liver transplantation as a first-line treatment for hepatocellular carcinoma.

BACKGROUND: To determine whether or not the Milan criteria (MC) should be used to determine the applicability of liver transplantation (LT) as a first-line treatment for patients with cirrhosis with hepatocellular carcinoma (HCC) who are able to endure hepatectomy. METHODS: Retrospective analysis of 82 patients with cirrhosis with HCC who were treated by hepatectomy without LT at our institution between 1990 and 2003. RESULTS: Of these 82 patients, 48 met the MC. Proportional hazard regression analyses to determine the independent prognostic factors for postoperative cumulative patient and disease-free survival showed that meeting the MC is the strongest prognostic factor for both patient and disease-free survival. The cumulative patient and disease-free survival rates were 76.7% and 28.9%, respectively, at 5 years in patients who met the MC. The cumulative disease-free survival was markedly inferior to those in previously reported series of LT for HCC who met the MC, but the cumulative patient survival was comparable to those in the previously reported series. A comparison of cumulative postoperative survival between patients who met the MC and fulfilled all five factors listed below and patients who met the MC but did not fulfill any of the five factors demonstrated that the latter patients showed statistically significantly worse postoperative patient survival than the former. The five factors included: Model for End-Stage Liver Disease score < 10, indocyanine green retention rate at 15 minutes < 20%, absence of microscopic fibrous capsular invasion and microscopic intrahepatic metastases, and earlier grade (T1 or T2) of American Joint Committee on Cancer tumor classification. CONCLUSIONS: The MC should not be used to determine the applicability of LT as a first-line treatment for patients with HCC considered able to endure hepatectomy. However, modifying MC with some clinicopathological factors could satisfy the appropriate criteria for applying LT as a first-line treatment for these patients.

Outcome using hemihepatic vascular occlusion versus the pringle maneuver in resections limited to one hepatic section or less.

Consensus is lacking concerning how to manage afferent vessels during hepatectomy, particularly as to the Pringle maneuver vs. selective hemihepatic clamping. Data for 81 hepatocellular carcinoma patients with chronic hepatitis or liver cirrhosis whose liver resection was limited to one section or less, including intraoperative data and postoperative liver function data, were analyzed retrospectively to compare two strategies. No significant differences of intraoperative data or postoperative clinical course were seen between the two groups, even in patients with chronic hepatitis or liver cirrhosis whose postoperative deterioration of liver function could be expected to be more than patients with a normal liver. The difference was evident only in serum alanine aminotransferase level on postoperative day 10 (mean +/- SEM, 64.5 +/- 5.1 IU in the Pringle group vs. 51.6 +/- 4.4 IU in the selective clamping group; P < 0.05). During liver resection limited to one section or less, even with underlying chronic hepatitis or cirrhosis, intermittent use of the Pringle maneuver preserved liver function to the same extent as selective clamping.

Prognostic significance of the number of positive lymph nodes in gallbladder cancer.

The aim of this study was to assess the prognostic impact of the number of lymph node metastases. The medical records of 33 patients with node-positive gallbladder cancer (GBC) treated at our institution from January 1985 through December 2002 were reviewed. There were 10 cases with a single node metastasis. The sites were as follows: the cystic duct node, the pericholedochal node, the retroportal node, the hilar node, the lymph node around the common hepatic artery, and the paraaortic node. According to the International Union Against Cancer (UICC) 5th edition, 5-year survival rates for the patients with pN1, pN2, and greater than pN2 were 19.2%, 10%, and 0%, respectively (not significant). Patients with a single node metastasis had a higher 5-year survival rate (33%) than patients with two or more lymph node metastases (0%; P < 0.05). There were no lymph node recurrences in patients with a single node metastasis. Number of positive nodes and liver metastasis were factors predictive of significantly worse survival. Rather than using the topographic classification, or even simply classifying whether nodal involvement is positive or negative, classification according to the number of positive nodes will contribute to establishing a more practically useful staging system.

Perioperative complications after hepatectomy with or without intra-arterial chemotherapy for bilobar colorectal cancer liver metastases.

BACKGROUND: We investigated perioperative complications of hepatic arterial infusion chemotherapy preceding major hepatectomy for multiple bilobar colorectal cancer metastases. No consensus exists concerning operative feasibility or perioperative course in patients undergoing major liver resection with neoadjuvant chemotherapy--partly because such chemotherapy is considered hepatotoxic, increasing the risk of postoperative liver failure. METHODS: Clinicopathologic data were available for 41 consecutive patients with 5 or more bilobar liver metastases from colorectal cancer who underwent major liver resection with or without prior hepatic arterial chemotherapy. Data concerning operative feasibility, postoperative liver function, complication rates, and histologic findings in the non-neoplastic liver were analyzed retrospectively. RESULTS: Prehepatectomy and postoperative day 1 platelet counts were lower (P < .01 and P < .05), alkaline phosphatase on postoperative day 3 was higher (P < .01), and prothrombin time on day 1 was more prolonged (P < .01) in the chemotherapy group. No significant difference was seen between groups in intraoperative data, morbidity, or duration of hospitalization. Histologic examination of adjacent non-neoplastic liver confirmed mild to severe fatty degeneration in 91% of the patients undergoing neoadjuvant chemotherapy, compared with 53% in those without neoadjuvant chemotherapy (P = .023). Although the number of neoplasms in chemotherapy patients was greater than that of the other group, overall and disease-free survival rates were comparable between groups. CONCLUSIONS: Despite mild postoperative liver dysfunction, pre-resection hepatic arterial chemotherapy did not increase morbidity.

Safety limit of the extent of hepatectomy for rats with moderately fatty liver: experimental study concerning living liver donor safety.

INTRODUCTION: The aim of the present study was to determine whether rats with moderately fatty liver could withstand a 90% hepatectomy, which rats with normal livers can survive. MATERIAL AND METHODS: Nine-week-old male Wistar rats were used. Normal rat chow was fed to the normal liver group, and fat-enriched rat chow was fed to the fatty liver group for 4 weeks to induce a moderately fatty liver. The authors have previously reported that this fatty liver rat model can cause fatal liver dysfunction after reduced-size-liver transplantation. A 90% and 95% hepatectomy were performed using rats of both groups to evaluate posthepatectomized liver function. RESULTS: All rats undergoing a 90% hepatectomy were still alive 30 days after the hepatectomy, but the rats that underwent a 95% hepatectomy were all dead within 4 days regardless of group. Increases in the liver remnant wet weight measured until 7 postoperative days after 90% hepatectomy were almost similar among the two groups. Alanin aminotransferase measured at 24, 48, 72, and 168 h after a 90% hepatectomy were significantly higher in the fatty liver group than in the normal liver group. Similarly, at up to 72 h postoperatively, the serum hyarulonic acids were significantly higher in the fatty liver group. CONCLUSION: A moderately fatty liver did not cause mortality in 90% hepatectomized rats. However, it caused a higher degree of hepatic parenchymal as well as sinusoidal injury.

Outcome after hepatic resection versus combined resection and microwave ablation for multiple bilobar colorectal metastases to the liver.

BACKGROUND: We investigated the efficacy of microwave ablation plus hepatectomy for multiple bilobar colorectal metastases to the liver. No consensus exists concerning local ablation plus hepatic resection for treating multiple bilobar colorectal liver metastases, partly because of a lack of long-term comparative survival data. METHODS: Clinicopathologic data were analyzed retrospectively for 53 consecutive patients with 5 or more bilobar liver metastases from colorectal cancer who underwent hepatectomy with or without microwave ablation. Outcome measures were recurrence rate, recurrence pattern, and survival. RESULTS: Combined resection/ablation was performed more frequently in patients with more liver metastases (P = .03). No significant differences were found for overall, disease-free, or hepatic recurrence-free survival between 16 patients with resection/ablation and 37 patients with resection (P = .43, .54, and .86, respectively). Multivariate analysis selected prehepatectomy carcinoembryonic antigen concentration in serum as an independent prognosticator for survival (P = .02), but not resection/ablation versus resection. In patients with combined resection/ablation, recurrence occurred near the resection or ablation line in only 2 patient (22%), whereas multiple neoplasms (>/=4) was the most common liver recurrence pattern (78%). CONCLUSIONS: Microwave ablation plus hepatic resection expanded indications for operation to treat multiple bilobar liver metastases, with survival similar to that in less-involved hepatic resection patients.