Xiao-Yun Zhang

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism: A case-control study.

AIM To investigate whether the use of synchronous hepatectomy and splenectomy (HS) is more effective than hepatectomy alone (HA) for patients with hepatocellular carcinoma (HCC) and hypersplenism. METHODS From January 2007 to March 2013, 84 consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone. The short-term and long-term outcomes of the two groups were analyzed and compared. RESULTS The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group, and these values were significantly different (P=0.001). The 1-, 3-, 5-, and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%, 70.9%, 52.7%, and 45.9% and 88.1%, 59.4%, 43.3%, and 39.5%, respectively (P=0.008). Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day, one week, one month and one year postoperatively (P<0.001). Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival. Gender, tumor number, and recurrence were independent prognostic factors for overall survival. CONCLUSION Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.

Appropriate treatment strategies for intrahepatic recurrence after curative resection of hepatocellular carcinoma initially within the Milan criteria: according to the recurrence pattern.

Objective The aim of this study was to investigate appropriate treatment strategies for recurrent intrahepatic hepatocellular carcinoma (HCC) in patients who fulfilled the Milan criteria at primary hepatectomy. Patients and methods A total of 124 patients who underwent curative-intent resection of HCC at our center between January 2007 and March 2014 were retrospectively enrolled; patients had initially fulfilled the Milan criteria, but developed intrahepatic recurrence. Seventy-four patients underwent transarterial chemoembolization (TACE) and another 50 patients underwent repeat resection (RR) or radiofrequency ablation (RFA). The recurrent HCCs were classified into intrahepatic metastasis and multicentric occurrence by pathologic analysis. Demographic and clinical data and overall survival rates were compared between the RR/RFA and the TACE groups. Subgroup analysis on the basis of the recurrence pattern (early recurrence or late recurrence) was carried out, and prognostic factors for survival were investigated. Results The 1-, 3-, and 5-year overall survival rates for the 124 patients after retreatment were 88.3, 55.4, and 44.3%, respectively. The 1-, 3-, and 5-year overall survival rates after retreatment were not significantly different between the RR/RFA and the TACE groups (P=0.140). Subgroup analysis showed that for late recurrence, survival in the RR/RFA group was better than those of patients in the TACE group (P=0.045). Conclusion TACE may be as effective as RR or RFA for early intrahepatic recurrence, whereas RR/RFA is the preferred option for patients with late recurrence after curative resection of HCC who initially fulfilled the Milan criteria. Prognosis was determined by the number of recurrent tumors and the Child–Pugh class at the time of recurrence.

Synchronous splenectomy and hepatectomy for patients with small hepatocellular carcinoma and pathological spleen: neutrophil to lymphocyte ratio changes can predict the prognosis

Background Treatments about small hepatocellular carcinoma (HCC) and hypersplenism associated with good hepatic reserve are not well established. The aim of this study was to investigate the outcome of synchronous hepatectomy and splenectomy for those patients. Study Design Splenomegaly and hypersplenism were defined as a pathological spleen. Seven hundred fifty-six patients with small HCC (381 with a pathological spleen, 375 without a pathological spleen) were divided into three groups. One hundred ten of 381 patients underwent synchronous hepatectomy and splenectomy (group A), 271 of 381 patients underwent hepatectomy alone (Group B) and 375 patients without pathological spleen underwent hepatectomy alone (Group C). The influence of pathological spleen, outcome of different treatments and systemic inflammatory response indexes were analyzed. Results Both overall survival (OS, P=0.023) and disease-free survival (DFS, P=0.020) were significantly increased in group C compared to group B. A pathological spleen was a significant independent prognostic factor for OS and DFS among those two groups. In addition, OS (P=0.025) and DFS (P=0.004) were increased in the group A compared to group B. Splenectomy and neutrophil to lymphocyte ratio changes (ΔNLR) were significant independent prognostic factors of the prognosis for patients in groups A and B. Conclusions A Pathological spleen influences the outcome of HCC patients. Synchronous hepatectomy and splenectomy should be performed among patients with small HCC and a pathological spleen. ΔNLR can predict the prognosis of these patients.

IQGAP1 expression in hepatocellular carcinoma predicts poor prognosis by inducing epithelial-mesenchymal transition

Background: The prognostic value of expression of the IQ motif containing GTPase activating protein 1 (IQGAP1) in hepatocellular carcinoma (HCC) following liver resection and its potential mechanism were unclear. In this study, we attempted to clarify them. Methods: The expression of IQGAP1 in HCC and adjacent samples was assessed by immunohistochemistry staining, and its correlations with postoperative recurrence and mortality were also analyzed. Epithelial and mesenchymal markers and the invasive and migration ability of HCC cells were examined in HCC cell lines by overexpression or silencing expression of IQGAP1 using IQGAP1 plasmids or SiRNA. Results: IQGAP1 expression was significantly increased in HCC tissues in comparison with adjacent tissues (57.78% versus 8.15%; P Conclusions: The positive expression of IQGAP1 in HCC was related to poor prognosis following liver resection, which may occur through induction of the epithelial-mesenchymal transition (EMT).

FibroScan predicts ascites after liver resection for hepatitis B virus-related hepatocellular carcinoma: A prospective cohort study

OBJECTIVE To assess the correlation of preoperative FibroScan value and postoperative ascites in patients undergoing liver resection for hepatitis B virus-related hepatocellular carcinoma (HBV-related HCC). METHODS A prospective study group of consecutive HBV-related HCC patients considered eligible for liver resection was conducted from 2012 to 2014 (N = 77). Liver stiffness measured by FibroScan was administrated to all patients. Patients pre- and intra-operative variables were prospectively collected. RESULTS FibroScan was successfully performed in 75 patients. Postoperative ascites was observed in 13 patients. Univariate analyses suggested tumor size, high preoperative hepatitis B viral load, intraoperative blood loss, major hepatectomy and FibroScan value were potential risk factors for postoperative ascites. However, in multivariate analysis, only FibroScan value (OR = 1.506, 95%CI = 1.21-1.87) showed prognostic power. The best cut-off value of FibroScan value to predict postoperative ascites was 15.6 kpa with a sensitivity of 76.9% and a specificity of 98.4%. The corresponding area under the receiver operating curve was 0.902. CONCLUSIONS FibroScan value was a reliable surrogate marker for predicting postoperative ascites should be routinely performed in patients with HBV-related HCC undergoing liver resection.

Impact of tumor size and cirrhotic background for differentiating HCC and ICC with CEUS: does it matter for patients undergoing hepatectomy?

Objectives The aim of this study was to investigate the role of contrast-enhanced ultrasound (CEUS) in differentiating hepatocellular carcinoma (HCC) vs. intrahepatic cholangiocarcinoma (ICC) and primary liver cancer vs. benign liver lesions for surgical decision making. Methods Data from 328 patients (296 primary liver cancer patients: 232 HCC and 64 ICC patients and 32 benign hepatic lesion patients) who underwent hepatectomy at our center were retrospectively collected from 2010 to 2015. Conventional ultrasound (US) and CEUS were performed for all patients before hepatectomy. Enhancement patterns in CEUS were classified and compared for HCC vs. ICC and for primary liver cancer vs. benign lesions. Results Primary liver cancer and hepatic benign lesions could be distinguished by CEUS in different phases. The most obvious differences were in the portal and delayed phases, in which benign lesions could still show hyperenhancement (46.9% vs. 0.0% and p < 0.001 in the portal phase; 43.7% vs. 0.0% and p < 0.001 in the delayed phase). For differentiating HCC and ICC, our results revealed that HCC and ICC displayed different enhancement patterns in the arterial phase (p < 0.001) and the portal phase (p < 0.001). In the subgroup analyses, both HCC and ICC showed a high rate of homogeneous hyperenhancement during the arterial phase when tumors were ≤5 cm (87.2% vs. 64.0% and p = 0.008) or the Ishak score was ≥5 (75.8% vs. 42.9% and p = 0.023), although there was statistical difference. However, during the portal phase, ICC > 5 cm showed significantly more frequent hypoenhancement (92.3% vs. 54.5% and p < 0.001) and less isoenhancement (7.7% vs. 45.5% and p < 0.001) than HCC; additionally, during the portal phase, there was no statistical difference in the enhancement patterns of ICC with different hepatic backgrounds. Conclusions Tumor size and hepatic background should be taken into consideration when distinguishing HCC and ICC before surgery. However, CEUS is a helpful tool for differentiating malignant and benign hepatic lesions. For patients who require surgical treatment, CEUS may help with surgical decision making.

Changes of alpha-fetoprotein levels could predict recurrent hepatocellular carcinoma survival after trans-arterial chemoembolization

Background There is paucity of information concerning whether AFP change is a predictor of prognosis for recurrent hepatocellular carcinoma (RHCC) patients after trans-arterial chemoembolization (TACE). Methods A total of 177 RHCC patients who received TACE as first-line therapy were retrospectively analyzed. The patients were classified into three groups according to their pre-TACE and post-TACE AFP levels (group A: AFP decreased, group B: AFP consistent normal, and group C: AFP increased). The recurrence to death survival (RTDS) and overall survival (OS) were estimated by the Kaplan-Meier method, and compared by the log-rank test. Multivariate analyses were performed to identify prognostic factors for OS and RTDS. Results There was no significant difference among the three groups concerning the baseline characteristics. The median overall survival (OS) was 74.5 months in group A (95% confidence interval (CI): 63.5, 85.6), 64.0 months in group B (95% CI: 52.3, 75.7) and 29.0 months in group C (95% CI: 24.1, 33.9; P<0.001). The median recurrence to death survival (RTDS) was 66.5 months (95% CI: 53.4, 79.6) in group A, 50.4 months (95% CI: 39.5, 61.4) in group B and 17.7 months (95% CI: 13.4, 22.1; P<0.001) in group C. Multivariate analysis revealed that tumor size at resection stage, tumor number at recurrent stage, cycles of TACE, mRECIST response and AFP change after TACE were significant independent risk factors for RTDS and OS. Conclusions AFP change could predict the prognoses of patients with RHCC who received trans-arterial chemoembolization, which may help clinicians make subsequent treatment decision.

Distinct Recurrence Risk Factors for Intrahepatic Metastasis and Multicenter Occurrence After Surgery in Patients with Hepatocellular Carcinoma: What Is More Is About Different Therapeutic Strategies

To the Editor: We read with great interest the report by Hao et al. which was recently published in the Journal of Gastrointestinal Surgery. In this study, the authors demonstrated that intrahepatic metastasis (IM) and multicenter occurrence (MO) of intrahepatic recurrent hepatocellular carcinoma (HCC) were associated with distinct risk factors: tumorrelated factors mainly affect the IM type of recurrence, and patient-related factors are mainly involved in the MO type of recurrence. We quite agree with this view. And this result may be conducive to surgical decision-making. The authors found that large-size tumor (> 5 cm), multiple tumors (two or more), and vascular invasion were significantly associated with IM recurrence, and liver cirrhosis and Ishak hepatic inflammatory activity were highly associated with MO recurrence. In addition, blood transfusion and a high hepatitis B virus (HBV)-DNA load (> 2000 IU/ml) were independent risk factors common to both IM and MO recurrences. This could help for differentiating these two recurrent patterns of intrahepatic recurrence. As is well known to us, IM presents as an early recurrence, while MO is associated with late recurrence. Different originations and biological features between IM and MO signify different prognoses of patients with intrahepatic recurrent HCC. ,3 And long-term outcomes of treatments for these two types of relapse were significant difference as well. Thus, the clinical implication of the present study is more important than it seems. A number of investigations proposed that repeat hepatic resection or ablation was a good choice for patients with MO compared to patients with IM. –4 We also conducted a study and suggested that transarterial chemoembolization (TACE) may be as effective as re-resection or ablation for early intrahepatic recurrence, whereas re-resection/ablation is the preferred option for patients with late recurrence after curative resection of HCC who initially fulfilled the Milan criteria. However, few studies compare the outcome between salvage liver transplantation (SLT) and re-resection/ablation according to recurrent pattern. Further effort is needed for this aspect. Salvage liver transplantation may be the ideal treatment for both recurrent intrahepatic HCC and deteriorating liver function after primary resection. Long-term survival outcomes of this strategy are comparable to that of primary liver transplantation. Although most of liver transplantation centers performed SLT after HCC recurrence, Barcelona Clinic Liver Cancer (BCLC) group proposed to enlist HCC patients in whom these major predictors of recurrence were detected in the surgical specimen before recurrence development. ,8 As early (< 6 months) recurrence reflects an aggressive tumor behavior leading to tumor extent exceeding transplant criteria, they propose to wait at least 6 months before enlistment. This policy could avoid transplanting those patients with aggressive tumors associated with a high risk of post-LT recurrence and impaired survival. Interestingly, Hao et al. also demonstrated that the overall survival of SLT for late recurrence (the time interval to recurrence > 1 year) were significantly better than that for early recurrence (the time interval to recurrence < 1 year, P = 0.005). Following this reasoning, caution should be taken when SLT was recommended for patients with early recurrent HCC (i.e., IM). Therefore, the therapeutic strategies for intrahepatic recurrence of HCC can be optimized based on recurrent tumor * Tianfu Wen cdwentianfu@sohu.com