Background hepatocarcinogenesis is considered a major cause of postoperative recurrence of de novo hepatocellular carcinoma (HCC) in patients with liver cirrhosis (LC). The degree of underlying liver ...injury has reportedly correlated with surgical outcomes of HCC. However, the pattern and annual rate of recurrence of postoperative de novo HCC are still unclear.
To clarify the pattern and rate of recurrence of de novo HCC in patients with LC.
Data from 799 patients who underwent curative hepatectomy for HCC at Toranomon Hospital and The Johns Hopkins Hospital between January 1, 1995, and December 31, 2014, were retrospectively collected and analyzed. Of the patients who underwent curative hepatectomy for HCC, 424 met inclusion criteria: 73 with normal liver (NL) and 351 with LC. Sixty-four patients who had histologically proven NL parenchyma were matched with an equal number of patients who had established LC, and postoperative outcomes were compared.
Hepatectomy in patients with HCC.
Patterns of recurrence of HCC and chronological changes in recurrence rates.
Among 128 matched patients in the study (mean SD age, 64.0 12.7 years; 93 men and 35 women) 1-, 3-, and 5-year cumulative recurrence was 17.2%, 23.0%, and 37.5%, respectively, in the NL group vs 25.0%, 55.5%, and 72.1%, respectively, in the LC group (P = .001). The 3- and 5-year disease-specific survival was 85.7% and 75.4%, respectively, in the NL group vs 74.9% and 59.1%, respectively, in the LC group (P = .04). The median annual incidence of postoperative recurrence of HCC within 5 years after surgery was lower in the NL group (5.9%) compared with the LC group (12.7%) (P = .003). Assessment of recurrence patterns revealed that multiple recurrences near the resection margin or at extrahepatic sites were more frequent in the NL group (9 50.0% vs 6 15.4%; P = .01), whereas solitary recurrence at a distant site was more common in the LC group (21 53.8% vs 1 5.6%; P < .001).
Comparison of the patterns and annual incidence of recurrence of HCC demonstrated that the poorer prognosis in the LC group was likely owing to a higher hepatocarcinogenic potential among patients with cirrhosis. Annual recurrence rates in the 2 groups indicate that de novo recurrence may continuously occur from the early postoperative period until the late period after resection of HCC.
Background
The optimal tumor-free margin width remains controversial and may be inappropriate to investigate without considering differences in the underlying tumor biology.
Methods
R1 resection was ...defined as margin clearance less than 1 mm. R0 resection was further divided into 3 groups: 1–4, 5–9, and ≥10 mm. The impact of margin width on overall survival (OS) relative to
KRAS
status wild type (wt
KRAS
) vs. mutated (mut
KRAS
) was assessed.
Results
A total of 411 patients met inclusion criteria. Median patient age was 58 years (interquartile range, 49.7–66.7); most patients were male (
n
= 250; 60.8 %). With a median follow-up of 28.3 months, median and 5-year OS were 69.8 months and 55.1 %. Among patients with wt
KRAS
tumors, although margin clearance of 1–4 mm or more was associated with improved OS compared to R1 (all
P
< 0.05), no difference in OS was observed when comparing margin clearance of 1–4 mm to the 5–9 mm and the ≥10 mm groups (all
P
> 0.05). In contrast, among patients with mut
KRAS
tumors, all three groups of margin clearance (1–4, 5–9, and ≥10 mm) fared no better in terms of 5-year survival compared to R1 resection (all
P
> 0.05).
Conclusions
While a 1–4 mm margin clearance in patients with wt
KRAS
tumors was associated with improved survival, wider resection width did not confer an additional survival benefit. In contrast, margin status—including a 1 cm margin—did not improve survival among patients with mut
KRAS
tumors.
Introduction
Post-operative bile leak (BL) and post hepatectomy liver failure (PHLF) are the major potential sources of morbidity among patients undergoing liver resection. We sought to define the ...incidence of BL and PHLF among a large cohort of patients, as well as examine the prognostic impact of model for end-stage liver disease (MELD) and albumin-bilirubin (ALBI) scores to predict these short-term outcomes.
Materials and Methods
Patients who underwent a hepatectomy between January 1, 2014 and December 31, 2014 were identified using the National Surgical Quality Improvement Program (NSQIP) liver-targeted database. Risk factors for BL and PHLF were identified using multivariable logistic regression.
Results
Among the 3064 patients identified, median age was 60 years (IQR 50–68). Most patients underwent surgery (78.9 %) for malignant lesions. Post-operatively, 250 (8.5 %) patients experienced a BL while PHLF occurred in 149 cases (4.9 %). Both MELD (MELD <10 4.9 %; MELD ≥10, 10 %;
P
= 0.001) and ALBI (grade 1, 4.0 %; grade 2, 7.2 %; grade 3, 10.0 %;
P
= 0.001) were associated with PHLF occurrence, while only ALBI predicted PHLF severity (
P
= 0.008). Moreover, ALBI was associated with BL (grade 1, 7.1 %; grade 2, 11.5 %; grade 3, 14.0 %;
P
< 0.001), whereas MELD was not (MELD <10, 8.4 %; MELD ≥10, 11.2 %;
P
= 0.13). On multivariable analysis, ALBI grade 2/3 was associated with PHLF (OR 1.57, 95 % CI 1.08–2.27;
P
= 0.02), PHLF severity (OR 3.06, 95 % CI 1.50–6.23;
P
= 0.003), and the development of a BL (OR 1.35, 95 % CI 1.02–1.80;
P
= 0.04).
Conclusion
The ALBI score was associated with short-term post-operative outcomes following hepatic resection and represents a useful pre-operative risk-assessment tool to identify patients at risk for adverse post-operative outcomes.
Abstract Background Combined hepatic resection and radiofrequency ablation (resection-RFA) is a widely accepted multidisciplinary treatment for unresectable colorectal cancer liver metastases. Worse ...prognosis after resection-RFA is correlated to tumor morphology, although unfavorable morphology is inherent to this patient cohort. This study aimed to select patients who may or may not benefit from resection-RFA with the aid of tumor biology. Method Data from 485 patients who underwent curative hepatectomy with or without concurrent RFA were retrospectively collected and analyzed. Clinicopathologic characteristics, predictors of overall survival (OS), and OS of patients stratified by tumor biology in resection-RFA were analyzed. Results Combined resection-RFA was performed in 86 patients (17.7%) and a standalone resection in 399 patients. Baseline patients' characteristics of the resection-RFA group were significantly different in terms of median tumor number (5 versus 2) and bilobar distribution (84.9% versus 29.1%) from those of the resection-only group. Multivariate analysis identified four independent predictors of decreased OS in the resection-RFA group. Three were related to tumor biology: primary tumor nodal metastases (hazard ratio HR, 2.32; 95% confidence interval (95% CI), 1.16-4.64, Kirsten rat sarcoma viral oncogene homolog mutation (HR, 2.64; 95% CI, 1.36-5.14), and preoperative high carcinoembryonic antigen (HR, 2.33; 95% CI, 1.13-4.81), and one to tumor morphology–ablated lesions ≥3 (HR, 2.05; 95% CI, 1.41-3.80; P = 0.023). To examine the prognostic influence of tumor biology, the resection-RFA group was stratified into two groups by number of predictors related to tumor biology (low risk: 0-1 risk factors; n = 56 and high risk: 2-3 risk factors; n = 30). Median OS of the low risk, high risk, and resection-alone groups were 61.8, 20.7, and 75.3 mo, respectively. The 5-y OS rate was similar between the low risk and resection-alone group (52.7% versus 58.7%, respectively; P = 0.323). Conclusions Patients with low-risk tumors undergoing a combined resection-RFA approach had roughly comparable OS to those who only underwent resection, irrespective of advanced tumor morphology. Combined resection-RFA procedures might be of value to these patients.
ABSTRACT
Background
Right-sided and left-sided colorectal cancer (CRC) is known to differ in their molecular carcinogenic pathways. We sought to investigate the variable prognostic implication of
...KRAS
mutation after hepatectomy for colorectal liver metastases (CRLM) according to the site of primary CRC.
Methods
A total of 426 patients who underwent a curative-intent hepatic resection and whose
KRAS
status was available were identified. Clinicopathologic characteristics and long-term outcomes were stratified by
KRAS
status (wild type vs. mutant type) and primary tumor location (right-sided vs. left-sided). Cecum, right and transverse colon were defined as right-sided, whereas left colon and rectum were defined as left-sided.
Results
Among patients with a right-sided CRC, 5-year recurrence-free survival (RFS) and overall survival (OS) were not correlated with
KRAS
status (wild type: 30.8 and 47.2 % vs. mutant type: 38.5 and 49.1 %, respectively) (both
P
> 0.05). Specifically, mutant-type
KRAS
was not associated with either RFS or OS on multivariable analysis (hazard ratio HR 1.51, 95 % confidence interval CI 0.73–3.14,
P
= 0.23 and HR 1.03, 95 % CI 0.51–2.08,
P
= 0.95, respectively). In contrast, among patients who underwent resection of CRLM from a left-sided primary CRC, 5-year RFS and OS were worse among patients with mutant-type
KRAS
(wild type: 23.7 and 57.2 % vs. mutant type: 19.6 and 38.2 %, respectively) (both
P
< 0.05). On multivariable analysis, mutant-type
KRAS
remained independently associated with worse RFS and OS among patients with a left-sided primary CRC (HR 1.57, 95 % CI 1.01–2.44,
P
= 0.04 and HR 1.81, 95 % CI 1.11–2.96,
P
= 0.02, respectively).
Conclusions
KRAS
status has a variable prognostic impact after hepatic resection for CRLM depending on the site of the primary CRC. Future studies examining the impact of
KRAS
status on prognosis after hepatectomy should take into account the primary CRC tumor site.
Background No study has specifically investigated patient attitudes on decisional regret concerning major operative procedures. The objective of the present study was to define the prevalence of ...regret among patients who had undergone a major abdominal or thoracic operative procedure and to identify factors associated with postoperative regret. Methods Decisional regret was assessed using the validated Decision Regret Scale, which consisted of 5 items with Likert-scale responses. Data on preoperative decision-making preferences and postoperative regret, quality of life, and symptoms of anxiety and depression were collected and analyzed. Results Overall, 157 (68.9%) patients agreed to participate and completed the survey, while 12 (5.3%) patients declined citing lack of time or interest. The types of operative procedures varied, with 65 (41.7%) patients undergoing a thoracic operation, 59 (37.8%) resection of the pancreas, liver or bile duct, and 32 (20.5%) patients having a colorectal/enteric operation. Although most patients ( n = 98, 62.4%) expressed no degree of regret, a subset of patients did; specifically, 59 (37.6%) patients conveyed a varied degree of postoperative regret, with 20 (12.7%) patients expressing a moderate degree of regret, and 13 patients (8.3%) experiencing substantial regret. Postoperative regret was associated with a history of postoperative complications (odds ratio 4.7, 95% confidence interval 1.2–17.7, P < .01) and with discordance between a patient's preferred and actual perceived decision-making role (odds ratio 5.3, 95% confidence interval 1.6–17.4, P < .01). Patients experiencing regret were 5 times more likely than patients not experiencing regret to demonstrate borderline or abnormal depression scores (odds ratio 5.4, 95% confidence interval 1.6–18.0, P < .01); anxiety scores directly correlated with regret (rho 0.254, P < .01). Conclusion Patient-reported decisional regret after major abdominal and thoracic operations was present in 37% of patients, with roughly 1 in 12 patients reporting substantial regret and distress over the decision to have undergone operation. Discordance between patients' preferred and actual involvement in operative decision-making was associated with postoperative regret, as was poor quality of life, anxiety, and depression.
Accurate prediction of prognosis for patients with intrahepatic cholangiocarcinoma (ICC) remains a challenge. We sought to define a preoperative risk tool to predict long-term survival after ...resection of ICC.
Patients who underwent hepatectomy for ICC at 1 of 16 major hepatobiliary centers between 1990 and 2015 were identified. Clinicopathologic data were analyzed and a prognostic model was developed based on the regression β-coefficients on data in training set. The model was subsequently assessed using a validation set.
Among 538 patients, most patients had a solitary tumor (median tumor number 1; interquartile range 1 to 2) and median tumor size was 5.7 cm (interquartile range 4.0 to 8.0 cm). Median and 5-year overall survival was 39.0 months and 39.0%, respectively. On multivariable analyses, preoperative factors associated with long-term survival included tumor size (hazard ratio HR 1.12; 95% CI 1.06 to 1.18), natural logarithm carbohydrate antigen 19-9 level (HR 1.33; 95% CI 1.22 to 1.45), albumin level (HR 0.76; 95% CI 0.55 to 0.99), and neutrophil to lymphocyte ratio (HR 1.05; 95% CI 1.02 to 1.09). A weighted composite prognostic score was constructed based on these factors: 9 + (1.12 × tumor size) + (2.81 × natural logarithm carbohydrate antigen 19-9) + (0.50 × neutrophil to lymphocyte ratio) + (−2.79 × albumin). The model demonstrated good performance in the testing (area under the curve 0.696) and validation (0.691) datasets. The model performed better than both the T categories (area under the curve 0.532) and the cumulative stage classifications in the American Joint Committee on Cancer staging manual, 8th edition (area under the curve 0.559). When assessing risk of death within 1 year of operation, a risk score ≥25 had a positive predictive value of 59.8% compared with a positive predictive value of 35.3% for American Joint Committee on Cancer staging manual, 8th edition T4 disease and 31.8% for stage IIIB disease.
Postsurgical long-term outcomes could be predicted using a composite weighted scoring system based on preoperative clinical parameters. The preoperative risk model can be used to inform patient to provider conversations and expectations before operation.
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