Achievement of Complete Response and Drug-Free Status by Atezolizumab plus Bevacizumab Combined with or without Curative Conversion in Patients with Transarterial Chemoembolization-Unsuitable, Intermediate-Stage Hepatocellular Carcinoma: A Multicenter Proof-Of-Concept Study.

Introduction: Atezolizumab plus bevacizumab therapy is extremely effective in the treatment of intermediate-stage hepatocellular carcinoma (HCC), with a response rate of 44%, as reported in the IMbrave150 trial. When tumor shrinkage is obtained, achieving complete response (CR) is possible in many cases using curative conversion with resection, ablation, or superselective transarterial chemoembolization (TACE) with curative intent. This concept, i.e., curative conversion by combining systemic therapy and locoregional therapy, has not been reported before. This multicenter proof-of-concept study was conducted to show the value of curative conversion in immunotherapy-treated intermediate-stage HCC meeting TACE-unsuitable criteria. Methods: This study included 110 consecutive Child-Pugh A patients who received atezolizumab plus bevacizumab as first-line treatment for unresectable and TACE-unsuitable intermediate-stage HCC at seven centers in Japan. CR rate, drug-free rate, time to CR, change in liver function, efficacy in positron emission tomography (PET)-positive HCC, progression-free survival (PFS), and overall survival (OS) were assessed in patients who achieved CR using resection, ablation, superselective TACE with curative intent following atezolizumab plus bevacizumab or atezolizumab plus bevacizumab alone. Results: Clinical or pathological CR was achieved in 38 patients (35%) (median observation period: 21.2 months). The modalities of curative conversion in 35 patients were as follows: resection, 7; ablation, 13; and superselective TACE, 15. Three patients achieved clinical CR with atezolizumab plus bevacizumab therapy alone. Among the 38 CR patients, 25 achieved drug-free status. PFS was not reached, and 3 patients experienced recurrence after reaching CR. Regarding OS, there were no deaths in any of the CR patients. The albumin-bilirubin score did not deteriorate after locoregional therapy or resection. Of seven PET-positive patients who achieved CR with atezolizumab plus bevacizumab followed by curative conversion, five achieved drug-free status. Conclusion: The achievement of CR rate by curative conversion in patients treated with atezolizumab plus bevacizumab as the preceding therapy for unresectable and TACE-unsuitable intermediate-stage HCC was 35%. Overall, 23% of patients achieved drug-free status and no recurrence was observed from this patient subgroup with CR and drug-free status. Thus, achieving CR and/or drug-free status should be a therapeutic goal for patients with intermediate-stage HCC without vascular invasion or extrahepatic spread.

Longitudinal Pancreaticojejunostomy for Pancreaticodigestive Tract Anastomotic Stricture After Pancreaticoduodenectomy.

Aim: Pancreaticodigestive tract anastomotic stricture is a long-term complication of pancreticoduodenectomy (PD). However, optimal treatment has not yet been defined. We conducted longitudinal pancreaticojejunostomy (LPJ) in symptomatic patients with anastomotic stricture after PD. This study aimed to evaluate the efficacy of this procedure. Methods: Pancreticoduodenectomy was performed in 605 patients at our institution between January 2005 and April 2020. Of these, 15 patients (2.5%) developed symptomatic pancreaticodigestive tract anastomotic stricture after PD. Three patients were referred to our institution owing to recurrent pancreatitis with anastomotic stricture after PD. LPJ was indicated for these 18 patients, and they were enrolled in this study. Results: The median time from the initial operation to LPJ was 2.0 y. Preoperative clinical presentations included obstructive pancreatitis in 10 patients, a rapid deterioration of glucose tolerance in nine, and severe steatorrhea in two. Surgical morbidity ≥grade III defined by the Clavien-Dindo classification was not observed. After LPJ, preoperative symptoms improved in 16 patients (89%) during a median follow-up of 39 mo. Nine of the 10 patients with obstructive pancreatitis achieved complete pain relief. All nine patients with a rapid deterioration of glucose tolerance showed improved endocrine function. Daily insulin requirement was significantly decreased after LPJ (11.6 ± 3.3 vs 3.4 ± 4.3 units, P = .0239). Four of the seven patients who required insulin injections were free of insulin after LPJ. Conclusion: LPJ is a safe and effective surgical procedure for symptomatic patients with stricture of the pancreaticodigestive tract anastomosis after PD.

Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy.

PURPOSE: Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP. METHODS: This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas. RESULTS: Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min. CONCLUSION: The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.

Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients.

PURPOSE: The purpose of this study was to determine the factors influencing conversion from laparoscopic distal pancreatectomy (LDP) to open surgery, and the effect of such conversion on the outcome. METHODS: This retrospective single-center study included 70 consecutive patients undergoing LDP. The primary endpoint was the rate of conversion to open surgery during LDP. The secondary endpoints were determining the reasons for conversion to open surgery, with detailed analyses of these cases and a comparison of the surgical outcome with and without conversion. RESULTS: Seven patients (10%) required conversion to open surgery during LDP. Pancreatic ductal adenocarcinoma (PDAC) was identified as a risk factor for conversion (p = 0.010). The reasons for conversion included technical difficulty (two bleeding, one severe adhesion) and pancreatic stump-related issues (two margin-positive, two stapling failures). Although the overall morbidity rate (29 vs. 11%, p = 0.48) and the rate of clinically relevant postoperative pancreatic fistula (14 vs. 5%, p = 0.82) were no different for the patients with or without open conversion, the postoperative hospital stay was significantly longer in the former (median 15 vs. 10 days, p = 0.03). CONCLUSIONS: Careful preoperative assessment is required when planning LDP for PDAC. Although conversion to open surgery does not result in failure of LDP, efforts to reduce the duration of postoperative hospital stay and the occurrence of complications are desirable to improve the outcome of LDP.

Pancreatic neuroendocrine tumor with stenosis of the main pancreatic duct leading to pancreatic pleural effusion: a case report.

BACKGROUND: Pancreatic pleural effusion and ascites are defined as fluid accumulation in the thoracic and abdominal cavity, respectively, due to direct leakage of the pancreatic juice. They usually occur in patients with acute or chronic pancreatitis but are rarely associated with pancreatic neoplasm. We present here an extremely rare case of pancreatic neuroendocrine tumor with stenosis of the main pancreatic duct, leading to pancreatic pleural effusion. CASE PRESENTATION: A 51-year-old man complained of dyspnea. Left-sided pleural effusion was detected on the chest X-ray. Pleural puncture was performed, and the pleural fluid indicated a high amylase content (36,854 IU/L). Hence, the patient was diagnosed with pancreatic pleural effusion. Although no tumor was detected, the computed tomography (CT) scan showed a pseudocyst and dilation of the main pancreatic duct in the pancreatic tail. Magnetic resonance cholangiopancreatography showed a fistula from the pseudocyst into the left thoracic cavity. Endoscopic retrograde pancreatic drainage was attempted; however, it failed due to stenosis in the main pancreatic duct in the pancreatic body. Endoscopic ultrasound revealed a hypoechoic mass measuring 15 × 15 mm in the pancreatic body that was not enhanced in the late phase of contrast perfusion and was thus suspected to be an invasive ductal carcinoma. The patient underwent distal pancreatectomy with splenectomy and the postoperative course was uneventful. Histopathological examination confirmed a neuroendocrine tumor of the pancreas (NET G2). The main pancreatic duct was compressed by the tumor. Increased pressure on the distal pancreatic duct by the tumor might have caused formation of the pseudocyst and pleural effusion. To the best of our knowledge, this is the first case report of pancreatic pleural effusion associated with a neuroendocrine tumor. CONCLUSIONS: Differential diagnosis of a pancreatic neoplasm should be considered, especially when a patient without a history of pancreatitis presents with pleural effusion.

Surgical treatment for chronic pancreatitis: A single-center retrospective study in Japan.

BACKGROUND/PURPOSE: To determine the short- and long-term results of surgical treatments for chronic pancreatitis (CP) at a high-volume center in Japan. METHODS: The records of 151 consecutive patients undergoing surgery for CP were retrospectively reviewed. Selection of surgical procedures used had been according to the Japanese Clinical Practice Guidelines for CP 2015. Long-term (≥1 year) follow-up was performed in 100 patients (median of 37 months). RESULTS: Surgical drainage procedures were performed in 107 patients (Frey operation in 81, longitudinal pancreaticojejunostomy in 26), pancreatic resection in 37 (subtotal stomach-preserving pancreaticoduodenectomy in 11, distal pancreatectomy in 26), and other procedures in six. The rates of postoperative mortality and morbidity were 1% and 26%, respectively. The rates of complete and partial pain relief were 62% and 37%. The frequency of occurrence of severe morbidity was significantly higher after pancreatic resection than in patients receiving drainage procedures (13% vs 2%, P = .019). The rate of new-onset diabetes was also significantly higher after resection than drainage (60% vs 25%, P = .017). CONCLUSIONS: Surgical treatment for painful chronic pancreatitis can be safe and effective. An optimal procedure should guarantee pain relief and preserve a maximum of pancreatic function.

[A Case of Emergency Pancreaticoduodenectomy for Tumor Bleeding in Duodenal Cancer with Multiple Liver Metastases].

A 62 year-old female presenting with shortness of breath and severe anemia(Hb level 4.4 g/dL)was diagnosed with tumor bleeding and duodenal cancer by gastrointestinal endoscopy.Computed tomography scan revealed multiple liver metastases.After admission, the Hb level dropped from 9.1 g/dL to 5.1 g/dL in one night, and emergency pancreaticoduodenectomy( PD)was performed to control the bleeding.The postoperative course was uneventful, and the patient was discharged on postoperative day(POD)16.Systemic chemotherapy was initiated 1 month after surgery, but the patient died from the disease 13 months after surgery.Emergency PD could be a treatment option in patients with uncontrolled tumor bleeding and fatal conditions.

Transpancreatic mattress suture with Vicryl mesh around the stump decreases postoperative pancreatic fistula after distal pancreatectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains the most common surgical complication. We have developed a novel stump closure technique after DP using transpancreatic mattress suture with Vicryl mesh (TMV) and reported our initial findings. The purpose of this study is to evaluate the efficacy of TMV compared to the conventional handsewn stump closure technique (CHS). METHODS: This retrospective single-center study included 165 consecutive patients who underwent open DP from January 2010 to May 2018. Of these, 71 patients underwent DP using TMV after September 2014 and 94 patients underwent DP with CHS. The surgical outcomes were compared between the two groups. RESULTS: Clinically relevant POPF rate in the TMV group was significantly lower than that in the CHS group (5.6% vs. 17.2%, P = 0.027). Morbidity rate was higher in the CHS group than that in the TMV group (16.9% vs. 27.7%, P = 0.104). In the multivariate analysis, absence of additional organ resection (OR 3.57; 95% CI 1.18-10.43; P = 0.025) and TMV (OR 0.24; 95% CI 0.07-0.73; P = 0.010) were identified as independent preventing factors for clinically relevant POPF. CONCLUSION: TMV can be an effective stump closure technique for preventing POPF after DP.

Identification of aberrant subvesical bile duct by using intraoperative fluorescent cholangiography: A case report.

INTRODUCTION: Aberrant subvesical bile ducts are rare structural anomaly located in the peri-hepatic gallbladder fossa. This duct poses the risk for intraoperative bile duct injury resulting in clinically relevant bile leakage. PRESENTATION OF CASE: Aberrant subvesical bile duct was detected by preoperative magnetic resonance cholangiopancreatography in a 52-year old woman with gallbladder polypoid tumor harboring the risk to be gallbladder cancer. During open cholecystectomy with full thickness dissection, the aberrant duct was identified by intraoperative fluorescent cholangiography (IFC), and dissected safely. DISCUSSION: Aberrant subvesical bile ducts are mostly found unexpectedly as intra and/or postoperative bile leakage, and remain an important cause of bile duct injuries after laparoscopic cholecystectomy. IFC, which offers real-time imaging of biliary anatomy, has a potential to overcome these problems. CONCLUSION: We performed cholecystectomy by using IFC to identify the aberrant subvesical bile duct. To the best of our knowledge, this is the first report showing the fluorescence image of an aberrant subvesical bile duct in a state of nature.

Laparoscopic versus open distal pancreatectomy for benign and low-grade malignant lesions of the pancreas: a single-center comparative study.

PURPOSE: The purpose of the study was to compare the outcomes of laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and low-grade malignant lesions to determine the safety and efficacy of LDP. METHODS: This retrospective comparative study included 67 consecutive patients who underwent LDP (n = 32) and ODP (n = 35) for benign or low-grade malignant lesions of the pancreas from January 2012 to March 2017. Thirty-five patients who were eligible for LDP in the ODP group were carefully selected. The clinical outcomes were compared in an intention-to-treat analysis. RESULTS: LDP was associated with significantly less operative blood loss (182 ± 232 vs. 505 ± 376 ml, P < 0.001) but a longer operation time (327 ± 89 vs. 173 ± 48 min, P < 0.001), than ODP. There were no significant differences between the 2 groups in the overall morbidity rates defined by Clavien-Dindo classification ≥ grade II (13% vs. 11%), clinically relevant postoperative pancreatic fistula rates (6% vs. 9%), and lengths of postoperative hospital stay (11 vs. 11 days). CONCLUSION: The study showed that LDP was safe and feasible. LDP should be considered as the first-line treatment for benign and low-grade malignant lesions in the left side of the pancreas.

Novel Extracorporeal Hemoperfusion System for Hepatic Arterial Infusion of Cisplatin.

BACKGROUND/AIM: Hepatic venous isolation and extracorporeal charcoal hemoperfusion (HVI-CHP) can reduce systemic exposure to hepatic arterial infusion (HAI) chemotherapy. The pre-existing HVI-CHP system has limited effectiveness against high-dose cisplatin; therefore, we designed a new system and evaluated its efficacy in a canine model. MATERIALS AND METHODS: Cisplatin was administered via HAI under HVI-CHP. HVI-CHP was performed using one charcoal column in group I and two charcoal columns in group II; it was not performed in group III. The plasma cisplatin levels in the systemic circulation and at the column inlet and outlet, and the column extraction rate of were analyzed. RESULTS: The column extraction rates of free and total cisplatin in group II were significantly higher than those in group I. The systemic concentration of free cisplatin was significantly lower in group II than in groups I and III after HAI. No significant differences were observed in cisplatin concentrations in the liver tissue among all groups. CONCLUSION: A novel HVI-CHP system for HAI of cisplatin was successfully developed.

[A Case of Recurrent Colorectal Cancer with Bilateral Ovarian Metastases That Were Reduced with Regorafenib Therapy].

A 63-year-old woman had recurrences of metastatic rectal cancer in the lung, peritoneum, and ovary. Regorafenib was administered at 160mg/day as third-line chemotherapy. The patient developed Grade(Gr)3 hand-foot syndrome(HFS) and Gr 2 rash, but the abdominal distension and pain were relieved by the 1st course. Analgesics could be reduced and regorafenib was administrated at reduced dosage. The patient received keishi-bukuryo-gan(EK-25)and sai-rei-tou(TJ-114) for HFS. At the beginning of therapy, ovarian metastases were not reduced and showed poor contrast enhancement on CT. Serum levels of lactate dehydrogenase(LDH)and tumor markers were increased. During the 4th course of therapy, ovarian metastases tended to shrink and serum levels of LDH and tumor markers were decreased. Ovarian metastases showed a partial response(PR)after the 6th course. Lung metastases showed a progressive disease during the 2nd course, but a PR after the 3rd course, and were not apparent after the 6th course. Reduction of metastases was maintained at 16 months after the start of therapy, and HFS was assessed at Gr 2 or lower. Physical, laboratory, and imaging findings should be carefully evaluated prior to long-term administration of regorafenib.

New macroscopic classification and back-flow thrombectomy for advanced hepatocellular carcinoma with portal vein tumor thrombus invading the contralateral second portal branch.

PURPOSE: Patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) invading the portal trunk (Vp4) are poor surgical candidates because of the technical difficulties involved. To overcome the limitations, we developed a technique of back-flow thrombectomy (BFT) based on the inherent portal hemodynamics and the macroscopic form of PVTT. METHODS: Forty-six patients with multiple HCC and Vp4 PVTT underwent hepatectomy with tumor thrombectomy. We used the BFT to treat 24 patients, 18 of whom had PVTT in the contralateral second portal branch. The form of PVTT was classified macroscopically into the floating and expansive types. RESULTS: The rate of complete removal by BFT of PVTT in the contralateral second portal branch was 89%. The patency rates at the thrombectomy site in all 46 patients and in the 24 BFT patients, 3 months after hepatectomy were 93 and 90%, respectively. The median OS of all 46 patients was 15 months, with 1- and 3-year OS rates of 58.5 and 17.1%, respectively. The median OS of the 24 patients treated with BFT vs. the 22 not treated with BFT was 14 and 15 months, respectively. CONCLUSIONS: BFT can expand the therapeutic time window for patients with HCC and deep-seated PVTT and may improve their survival.

[Surgical Dissection for an Abdominal Para-Aortic Lymph Node Recurrence after Curative Resection for Early Gastric Cancer - Report of a Case].

A 72-year-old man underwent endoscopic submucosal dissection for early gastric cancer at antrum in July 2015. The histopathological examination revealed an adenocarcinoma invading the deep submucosal layer(SM2)with lymphatic invasion, consistent with the diagnosis of non-curative resection. Additional surgery was recommended, and he underwent laparoscopic distal gastrectomy in August 2015. The histopathological examination of resected specimen revealed there were no lymph node metastases, and postoperative diagnosis was Stage I A. However, 8 months after the surgery, abdominal enhanced computed tomography(CT)revealed an enlargement of para-aortic lymph node. Positron emission tomography-CT showed high accumulation at the enlarged lymph node. A para-aortic lymph node metastasis was suspected, and laparoscopic lymph node dissection was performed in July 2016. The histopathological examination revealed lymph node metastasis of gastric cancer. He was given systematic chemotherapy using S-1 plus cisplatin after the surgery, and has been followed-up without recurrences for 21 months after the first operation. Although recurrence of the para-aortic lymph nodes was assumed as part of a systemic metastasis, some population certainly benefit from multidisciplinary treatment including surgical approach.

A Case Report of Drug-Induced Thrombocytopenia after Living Donor Liver Transplantation.

There are few descriptions of severe thrombocytopenia during the early postoperative period after liver transplantation, and these have not been fully documented in the literature. Here, we report a case of drug-induced thrombocytopenia requiring transfusion of blood products after living donor liver transplantation. We determined that this was not caused by the interferon-free anti-viral therapy but by tacrolimus A 61-year-old woman with hepatitis C-related cirrhosis and hepatorenal syndrome underwent living donor liver transplantation using a left lobe graft from her son. After transplantation, immunosuppression consisted of tacrolimus and steroid. Seven weeks after transplantation, interferon-free therapy with daclatasvir and asunaprevir was started. Thirteen days thereafter, hepatitis C virus tested negative. However, the platelet count had begun to gradually decrease just before starting anti-viral therapy. Daclatasvir and asunaprevir were stopped because this was suspected to be a side-effect of these drugs, but the patient nonetheless went on to develop severe thrombocytopenia (platelet count 17,000/µL), which needed transfusions. Now suspecting tacrolimus as the inducer of this side effect, we changed to cyclosporin, after which the platelet count gradually recovered. Viral markers were still not detectable up to 2 months after discontinuation of the antiviral drugs. We conclude that when severe thrombocytopenia occurs, possible drug-induced thrombocytopenia as well as other disorders must be investigated.

Analysis of Portal Vein Reconstruction Technique with High-Grade Portal Vein Thrombus in Living Donor Liver Transplantation.

BACKGROUND Portal vein thrombus (PVT) has been an absolute contraindication for liver transplantation because of technical difficulties and inadequate vessel graft supply. With recent surgical innovations many difficulties have been overcome and PVT is no longer a contraindication to liver transplantation. MATERIAL AND METHODS From June 2000 to December 2014, 72 patients underwent living donor liver transplantation at Kobe University Hospital, with a focus on the high-grade PVT cases and analysis of modified PV reconstruction technique and clinical course. RESULTS Four recipients (5.6%) developed Yerdel classification grade III PVT and 2 recipients (2.8%) developed grade IV PVT. There were no statistically significant differences between the severity of PVT grades by sex (p=0.77), recipient age (p=0.49), model for end-stage liver disease (MELD) score (p=0.68), graft-recipient weight ratio (GWRW) (p=0.15), graft type of right or left lobe (p=0.55), original liver disease (p=0.09), or intra-operative bleeding (p=0.21). Four grade III recipients were anastomosed with SMV, and 2 grade IV recipients were anastomosed with coronary vein, both of which were interpositioned with vein grafts. Only 1 recipient had died of hepatocellular carcinoma recurrence by 1.5 years after liver transplantation, and all 5 remaining severe PVT recipients survived. Overall 1- and 5-year survival rates for grade 0, I, and II recipients were 78.8% and 62.4%, respectively; 75.0% and 75.0%, respectively, for grade III recipients; and 100% and 100%, respectively, for grade IV recipients (p=0.54). CONCLUSIONS High-grade PVT had comparable survival without the recurrence of PVT after living donor liver transplantation.

[Successful Multimodal Treatment for Aggressive Extrahepatic Metastatic Hepatocellular Carcinoma - A Case Report].

A 38-year-old man underwent right hepatectomy for a huge hepatocellular carcinoma(HCC)in the right hepatic lobe. Four months later, recurrent and metastatic disease were observed in the remnant liver and right lung, respectively. We performed a hepatectomy for the recurrent lesion because transcatheter arterial chemoembolization (TACE) was not effective. After surgery, we initiated sorafenib treatment for the lung metastases. One year later, the lung metastases worsened and metastases were observed in the mediastinal lymph nodes, and both metastatic lesions were resected. Seven months later, para-aortic lymph nodal metastasis was observed and dissected. Three months later, metastasis to the supraclavicular lymph node was observed. We performed particle radiation therapy and a complete response was achieved. One year later, metastases in both lungs were observed and resected. Despite continued sorafenib administration throughout the clinical course, a metastasis to the left adrenal gland was observed. This lesion was extirpated because no other recurrent lesions were detected. At 4 years and 6 months after the first operation, no other recurrences have occurred. Currently, sorafenib is the initial drug of choice for HCC with extrahepatic metastases. It is possible to improve the prognosis of patients with HCC and extrahepatic metastases by applying surgical treatment during the course of sorafenib administration.

The Predictive Power of Serum α-Fetoprotein and Des-γ-Carboxy Prothrombin for Survival Varies by Tumor Size in Hepatocellular Carcinoma.

Alpha-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP) are frequently used as tumor markers in hepatocellular carcinoma (HCC). The authors hypothesized different patient populations with varying tumor sizes would influence the predictive power of tumor markers for survival in HCC patients. The authors investigated the influence of tumor size on predictive powers of AFP and DCP. 181 patients underwent hepatectomy for HCC from 2003 to 2008 at Kobe University Hospital. Tumor markers were measured before and at 1 month post-hepatectomy. The Cox proportional-hazards model revealed that preoperative serum AFP was associated with survival; its effects depended on tumor size. Hazard ratios (HRs) for preoperative AFP were maximum for medium-sized HCC, and for DCP, HRs were maximum in small-sized tumors. Post-hepatectomy, both tumor markers were associated with survival, revealing significant interactions with tumor size. HRs for postoperative AFP were greater than 1 for relatively wide range tumors (3-11 cm). HRs for postoperative DCP increased with tumor size, with a strong prognostic predictive power for tumors >5 cm. The predictive power of serum tumor markers varied by tumor size in HCC patients. By selecting the appropriate tumor marker, its predictive power can be improved.