Search

Objective: We evaluated the morbidity and mortality after anatomical hepatectomy with the Glissonean pedicle approach, and long-term outcomes in relation to the morbidity in patients with hepatocellular carcinoma (HCC)., Summary Background Data: The mortality, morbidity, and long-term outcomes were evaluated retrospectively., Methods: A total of 1953 patients with HCC underwent various anatomical hepatectomies with the Glissonean pedicle approach between 1985 and 2014. The mortality (30-day and 90-day) and morbidity (Clavien-Dindo class Ilia or higher) were evaluated among six 5-year eras (1985-1989, 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014)., Results: A total of 460 patients (24%) showed morbidity, and the overall 30-day and 90-day mortality rates were 1.8% and 3.3%, respectively. The 30-day (3.9%, 3.0%, 1.8%, 1.3%, 0.3%, 0.5%: P = 0.0074) and 90-day mortality (6.0%, 4.3%, 3.8%, 2.8%, 2.2%, 1.4%: P = 0.0445) significantly improved over the eras. Blood loss >2 L (odds ratio: 11.808, P = 0.0244) was an independent risk factor for 30-day mortality, and blood loss >2 L (odds ratio: 4.046, P = 0.0271) and bile leakage (odds ratio: 2.122, P = 0.0078) were independent risk factors for 90-day mortality on multivariate analysis. Morbidity was significant independent prognostic factors for overall survival (relative risk: 2.129, P < 0.0001) and recurrence-free survival (relative risk: 1.299, P < 0.0001) in patients with HCC., Conclusions: Anatomical hepatectomy with the Glissonean pedicle approach was achieved safely in patients with HCC. For more safety and longer survival, blood loss, bile leakage, and morbidity should be reduced. Longterm outcomes after anatomical hepatectomy with the Glissonean pedicle approach in patients with HCC have been improved over 30 years with gradually less mortality and morbidity due to decreases in blood loss >2 L and bile leakage., Competing Interests: The authors report no conflicts of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background/purpose: Anatomical sectionectomy or larger resection is known to be effective in patients with hepatocellular carcinoma (HCC) with microvascular invasion. A non-smooth tumor margin on hepatobiliary-phase gadoxetic acid disodium-enhanced magnetic resonance imaging (EOB-MRI) can predict microvascular invasion of HCC. We evaluated the usefulness of EOB-MRI for operative planning., Methods: We evaluated 224 patients with single HCC who underwent hepatectomy between 2010 and 2013. The tumor margin was determined preoperatively. The hepatic resection was determined based on tumor location, liver function, 3D CT simulation and functional liver reserve. To control for confounding variable distributions, propensity score match was applied to compare the outcomes. Multivariate analysis was conducted to identify independent predictors of 5-year recurrence-free survival (RFS) and overall survival (OS)., Results: Of 113 patients with a non-smooth tumor margin, 40 patients (35%) showed microscopic portal invasion. The 5-year RFS and OS rates were significantly higher after sectionectomy or larger hepatectomy (hemihepatectomy) than after segmentectomy or smaller hepatectomy (non-anatomical resection). Of 111 patients with a smooth tumor margin, eight patients (7%) showed microscopic portal invasion. The 5-year RFS and OS rates did not differ significantly between patients who underwent sectionectomy and those who underwent segmentectomy., Conclusions: Our preliminary results appear to recommend that HCC with a non-smooth margin on HB-phase images is treated with anatomical sectionectomy or larger hepatectomy., (© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Purpose: We previously reported that hepatocellular carcinoma (HCC) changes to a phenotype producing des-γ-carboxy prothrombin (DCP) during epithelial mesenchymal transition (EMT) in vitro. To confirm this change in vivo, we evaluated the association between DCP production and HCC hemodynamics in patients undergoing resection as EMT and hemodynamic changes are closely associated with each other., Methods: We evaluated HCC hemodynamics by employing Sonazoid-enhanced ultrasound (SEUS) before surgical resection, and sought associations with histological grade and immunohistochemical staining of DCP in 19 areas from 11 patients., Results: In 10 HCC areas showing early washout (3 min ≥) using SEUS, three areas corresponded to poorly differentiated HCC and the remaining seven areas corresponded to moderately differentiated HCC, and positive DCP staining was observed in only two of the seven moderately differentiated HCC areas, whereas no staining was observed in poorly differentiated HCC areas. Six HCC areas showing intermediate washout (3-10 min) using SEUS were moderately differentiated, of which five demonstrated positive DCP staining (83.3%, 5/6). However, all HCC areas without enhancement in the arterial phase were well-differentiated and did not show DCP staining., Conclusion: Our preliminary findings suggest that HCC hemodynamics evaluated by SEUS are associated with histological grade and/or DCP production.

Couinaud described three fundamental approaches at the hepatic hilus in liver surgery. The Glissonean pedicle approach at the hepatic hilus is one of these procedures and provides anatomical hepatectomy for hepatocellular carcinoma (HCC). The Glissonean pedicle approach was introduced by Couinaud and Takasaki in the early 1980s. The key of the Glissonean pedicle approach is clamping the pedicle first, secondly confirming the territory, which includes the HCC, and finally dissecting the liver parenchyma. This procedure prevents intrahepatic metastasis of HCC, which spreads along the portal vein and improves the overall survival after surgery. Another key feature is that we do not have to consider any variations of the vascular elements in the hepatoduodenal ligament under the hilar plate. This procedure allows an approach to the tertiary branches, which feed a smaller anatomical area than Couinaud's segment. We refer to this area as a cone unit of the liver. The procedure is also available in laparoscopic hepatectomy and provides new knowledge of the surgical anatomy, especially for small anatomical liver resection in the cirrhotic liver., (© 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

In recent years, various treatment options have become available for patients with hepatocellular carcinoma (HCC) according to the degree of background liver damage, tumor diameter and other factors associated with disease progression. Therapy has also shifted toward evidence-based treatment. Policies for the management of HCC with portal vein tumor thrombus, which has been considered an intractable condition, have not been established. Surgical resection was previously positioned as the treatment of choice, but the outcomes after resection alone were found to be disappointing. At present, multiple interdisciplinary treatments, combining resection with intra-arterial chemotherapy, radiotherapy, systemic chemotherapy and/or immunotherapy, are used on a trial-and-error basis since no standard regimens have been developed. Clinical trials of surgery combined with transarterial chemoembolization, hepatic arterial infusion of chemotherapy and radiation have obtained improved 5-year survival rates of 21.5-56 %. The safety of surgical resection in HCC with major portal vein tumor thrombus has improved, but the optimal type(s) and timing of auxiliary therapy to use in combination with resection remain to be defined.

The recurrence rate after surgery in patients with hepatocellular carcinoma (HCC) is very high, while prognosis is quite poor. However, there is no standard treatment to prevent recurrence of HCC after a curative operation. In this study, we investigated the clinical utilization of an autologous tumor lysate-pulsed dendritic cell vaccine plus ex vivo activated T cell transfer (ATVAC) in an adjuvant setting for postoperative HCC as a non-randomized controlled trial. Ninety-four patients with invasive HCC received informed consent information regarding the study, and 42 opted to have the ATVAC after surgery. Their recurrence-free survival (RFS) and overall survival (OS) were measured after 5 years and compared with those of 52 patients who selected to have the curative operation alone. The median RFS and OS were 24.5 months and 97.7 months in the patients receiving adjuvant ATVAC and 12.6 months and 41.0 months in the group receiving surgery alone (P = 0.011 and 0.029). In the treated group, patients with positive delayed-type hypersensitivity (DTH) had a better prognosis (RFS P = 0.019, OS P = 0.025). No adverse events of grade 3 or more were observed. A postoperative dendritic cell vaccine plus activated T cell transfer would be a feasible and effective treatment for preventing recurrence in HCC patients and achieving long-term survival especially in DTH positive patients.

Background: To evaluate the surgical outcome of patients with huge solitary hepatocellular carcinoma (HCC, ≥10 cm in diameter) without major vascular invasion., Methods: We retrospectively studied 177 patients with huge HCC (≥10 cm in diameter) who underwent hepatectomy from 1990 to 2008. Surgical outcomes and clinicopathological characteristics were compared among 54 patients with solitary HCC without a major portal vein tumor thrombus (MPVT), 53 patients with multiple HCCs without MPVT, and 70 patients who have HCC with MPVT., Results: The mean tumor size and indocyanine green retention rate at 15 min showed no significant difference among patients groups. The overall 5-year survival rate was significantly higher in patients with solitary HCC (79%) than in patients with multiple HCCs (31%, P < 0.0001) and MPVT (17%, P < 0.0001). In patients who underwent curative surgery, the 5-year disease-free survival rate was significantly higher in patients with solitary HCC (48%) than in patients with multiple HCCs (12%, P = 0.0008) and MPVT (12%, P = 0.0003). Multivariate analysis showed solitary HCC to be a significant independent prognostic factor for overall survival and disease-free survival., Conclusions: Patients with solitary HCC without MPVT show a favorable surgical outcome even for tumor size ≥10 cm in diameter., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: Radiofrequency ablation(RFA) is minimally invasive and is easy to perform. In the RFA procedure, puncture and passing of the electrical current are painful. Therefore, some facilities use general anesthesia for RFA. In order to evaluate the use of general anesthesia for RFA of hepatocellular carcinoma, a questionnaire survey was conducted., Methods: With the cooperation of Tokyo liver-tomo-no-kai(Tokyo Liver Association), a questionnaire survey was conducted for patients who underwent RFA. In the survey, data on the following were obtained "type of anesthesia used", "number of RFA treatment points", "duration of treatment", "length of impact of pain", and "if you need to receive RFA treatment again, how would you feel about this.", Results: The ratio of local anesthesia (LA) to general anesthesia (GA) was 113:24. The ratios of the numbers of patients who felt pain to those who felt no pain were 64:49 (LA) and 0:24 (GA). The ratios of the patients who wished to not receive RFA again to the patients who were comfortable with receiving RFA were 65:45 (LA) and 4:20 (GA)., Conclusion: GA achieves better pain control compared to LA, and the patients who receive GA have greater tolerance of RFA.

Right hepatectomy for hepatocellular carcinoma is the most common major operation in liver surgery; therefore, liver surgeons should know the fundamental surgical concept and techniques of the Glissonean pedicle approach. A J-shaped or reversed T laparotomy is performed in the right subcostal area. The Glissonean pedicle approach is performed at the hepatic hilus. In this approach, the right anterior and posterior Glissonean pedicles are encircled and ligated without liver dissection. The right hepatic artery, right portal vein and right hepatic duct in the hepatoduodenal ligament should be divided if the Glissonean pedicles cannot be approached easily. After confirming the border between the right and left liver, the liver parenchyma is dissected from the anterior surface of the liver to the anterior surface of the inferior vena cava (IVC). The V5 and V8 middle hepatic veins are divided and liver dissection is performed along the main middle hepatic vein. Finally, the anterior surface of the IVC and the trunk of the right hepatic vein are identified in the liver. This approach is widely known as the anterior approach described by Lai and Fan (World J Surg 20:314-8, 1996). However, this procedure had already been reported by Takasaki et al. (Shoukakigeka 7:1545-51, 1984) but since they did not report this procedure in English, their pioneering work on the anterior approach has not been recognized. The liver hanging maneuver described by Belghiti et al. (J Am Coll Surg 193:109-111, 2001) is also useful in right hepatectomy. Among the techniques used in right hepatectomy, the Glissonean pedicle approach, the anterior approach and the liver hanging maneuver are considered to be the most important.

Background: The value of the hepatobiliary phase of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in patients with hepatocellular carcinoma (HCC) has not been evaluated in detail., Methods: Between 2008 and 2009, 61 patients with HCC within the Milan criteria underwent Gd-EOB-DTPA-enhanced MRI and hepatectomy. The tumor margin was determined preoperatively based on hepatobiliary phase images. Microscopic portal vein invasion (MPVI), intrahepatic metastasis (IM), and recurrence of HCC within 1 year after hepatectomy were evaluated in 24 patients with non-smooth margins at the periphery of the tumor and 37 patients with smooth margins., Results: The number of patients with MPVI and IM of HCC was significantly higher among those with non-smooth margins (42 and 38%, respectively) than among those with smooth margins (3%; p = 0.0002 and 5%; p = 0.0042, respectively). A non-smooth margin was identified as a significant predictor of MPVI (odds ratio 18.814, p = 0.024) and IM (odds ratio 6.498, p = 0.036) of HCC on multivariate analysis. Furthermore, a non-smooth margin was identified as a significant predictor of recurrence within 1 year after hepatectomy (odds ratio 4.306, p = 0.04) on multivariate analysis., Conclusions: A non-smooth tumor margin in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is useful to predict MPVI, IM, and early recurrence of HCC after hepatectomy.

Background: Surgical outcome of patients with hepatocellular carcinoma (HCC) in relation to the serum hepatitis B envelope (HBe) has not been clarified in detail., Methods: We retrospectively studied 732 patients with HCC within the Milan criteria who underwent hepatectomy from 1991 through 2005. Serum hepatitis B surface antigen (HBs-Ag) and hepatitis C virus (HCV) antibody were routinely performed preoperatively, and 92 patients were only positive for HBs-Ag. Serum HBe antibody (HBe-Ab) was further examined, and surgical outcomes after hepatectomy were compared with those of 70 patients who were positive for HBe-Ab and 15 patients who were negative for HBe-Ab., Results: The 5- and 10-year survival rates were significantly greater in patients who were positive for HBe-Ab (90% and 80%, respectively) than in patients who were negative for HBe-Ab (61% and 37%: P = 0.0004, respectively). The 5-year recurrence-free survival rate was significantly greater in patients who were positive for HBe-Ab (53%) than in patients who were negative for HBe-Ab (21%: P = 0.0054). Multivariate analysis showed that positive HBe-Ab was an independent prognostic factor for survival (P = 0.0045) and recurrence-free survival (P = 0.004)., Conclusions: Favorable long-term surgical outcomes were achieved in patients with HCC within the Milan criteria who were positive for HBe-Ab., ((c) 2010 Wiley-Liss, Inc.)

Fibrolamellar hepatocellular carcinoma (FL-HCC) is an uncommon clinicopathological variant of hepatocellular carcinoma (HCC). The etiology of FL-HCC is unknown, but FL-HCC is not associated with hepatic viruses or alcohol. Hepatocellular carcinoma usually occurs in cases of chronic hepatitis or cirrhosis, whereas FL-HCC predominantly occurs in a normal liver and in younger adults. Fibrolamellar HCC shows relatively slow growth, and late recurrence is common. Repeated resections for recurrences should be considered not only because there is a lack of other effective treatment options but also because FL-HCC shows a relatively better prognosis after a resection in comparison to common HCC. This report presents a case of a rare mediastinal metastasis from FL-HCC in a patient who had undergone a previous resection for retroperitoneal metastasis after the initial hepatic operation. This is the second report of the same case. This patient also had a mediastinal neurogenic tumor, and these mediastinal tumors were concurrently resected.

Background: The value of anatomical liver sectionectomy for patients with a solitary hepatocellular carcinoma (HCC) from 2 to 5 cm in greatest diameter has not been clarified., Methods: We retrospectively studied 454 patients with a solitary HCC from 2 to 5 cm in greatest diameter who underwent initial curative hepatectomy from 1991 to 2006. We separated the liver into three segments according to the Glissonean pedicle ramification (Takasaki's liver segments). Takasaki's segment is recognized as a section in the International Hepato-Pancreato-Biliary Association Brisbane 2000 terminology. Outcomes after sectionectomy (n = 143) and partial sectionectomy (n = 311) for patients with a solitary HCC from 2 to 5 cm in greatest diameter were examined., Results: The 5-year recurrence-free survival rate and survival rate after sectionectomy (42% and 81%, respectively) were significantly better than those after partial sectionectomy (27%: P = 0.0023, and 66%: P = 0.0006, respectively). Multivariate analysis showed sectionectomy to be a significant independent prognostic factor for recurrence-free survival and overall survival in patients with a solitary HCC from 2 to 5 cm in greatest diameter (P = 0.0217, and P = 0.0085, respectively)., Conclusions: Anatomical liver sectionectomy prevents intrahepatic recurrence of HCC and prolongs survival in patients with a solitary HCC from 2 to 5 cm.

Background/aims: In order to improve the therapeutic efficacy of transcatheter arterial embolization (TAE) in hepatocellular carcinoma (HCC), the relationship between CT findings and antitumor efficacy was studied., Methodology: The therapeutic effect on CT 1 year after TAE was respectively studied for 100 nodules of HCC where TAE was performed. The pre-treatment abdominal CT findings were classified, and the therapeutic effect was compared with regard to these attributes., Results: Tumors determined to have no recurrence at the treated site (defined as "complete necrosis") accounted for 58% overall. The percentage of "complete necrosis" in pre-TAE CT findings by type showed that 1) in terms of tumor shape, 73.4% were smooth type, 34.5% irregular type, and 0% invasive type (p = 0.0003), 2) in terms of the presence of corona nodules, nodules where "complete necrosis" was achieved were corona-positive in 67.7% and coronanegative in 37.1% (p = 0.003), 3) in terms of tumor size, 68.3% of tumors were smaller than 3.0cm and 28.6% were larger than 3.1cm, 4) in terms of location, 64.6% of tumors were in a peripheral location and 28.6% in a central location (p = 0.006)., Conclusions: The therapeutic effect of TAE is improved by adequate diagnosis of the tumor characteristics found on pre-treatment CT.

This study was to retrospectively compare the effectiveness of transarterial embolization (TAE) using a lipidol emulsion for large lesion of hepatocellular carcinoma (HCC). average survival time was retrospectively compared in patients with HCC larger then 3 cm in diameter. Twenty patients were treated with conventional transarterial embolization (TAE)(group A), 27 with transarterial embolization using a lipidol emulsion (TAE-L) (group B). Rates of effectiveness at 3 months and 6 months following treatment were 10.0% and 5.0% in group A and 37.0 and 33.3% in group B respectively (P=0.046, 0.029). The median survival times were 12.0 months in Group A and 23.0 months in Group B (P=0.049).

After implanting a reservoir in the hepatic artery, we performed intra-arterial chemotherapy with a smaller particle size lipiodol emulsion and examined its therapeutic effect. Subjects were 21 patients with advanced/recurrent hepatocellular carcinoma (HCC). Arterial infusion was performed once every 2 weeks on an outpatient basis using 2 mL lipiodol emulsion with lecithin added as a surface active agent and 10 mg doxorubicin hydrochloride. As of 6 months after the start of treatment, the response rate was 38.1%. Median survival was 17.0 months. Serious adverse events were not noted in any of the subjects;during the course of treatment, catheter occlusion was observed in 2 patients. This therapy allows fewer visits and provides a relatively substantial therapeutic effect while maintaining QOL, so it may serve as an effective treatment for highly advanced/multiple HCC not suited to other treatments.

Background/aims: The effectiveness of systematized hepatectomy in the modified International Union Against Cancer (UICC) staging classification for hepatocellular carcinoma (HCC) has not been clarified in detail., Methods: We retrospectively studied 406 patients with UICC T1 HCC and 124 patients with T2 HCC who underwent initial curative hepatectomy from 1994 through 2003. Outcomes after sectionectomy or larger resection and segmentectomy or smaller resection for patients with T1 HCC and T2 HCC were examined., Results: The overall recurrence-free survival rate and survival rate of sectionectomy or larger resection at 5 years (45 and 79%, respectively) did not significantly differ from those of segmentectomy or smaller resection (38 and 81%, respectively) in patients with T1 HCC. However, in patients with T2 HCC, the 5-year recurrence-free survival rate and survival rate after sectionectomy or larger resection (37 and 71%, respectively) were significantly different from those after segmentectomy or smaller resection (6%: p < 0.0001, and 35%: p = 0.0027, respectively). Multivariate analysis showed sectionectomy or larger resection to be a significant independent prognostic factor for recurrence-free survival and survival in patients with T2 HCC., Conclusions: Sectionectomy or larger resection prevents intrahepatic recurrence of HCC and prolongs survival in patients with T2 HCC.

Background/purpose: The effectiveness of systematized hepatectomy with transection of Glisson's pedicle at the hepatic hilus has not been clarified in detail in relation to previous staging systems. Outcomes after systematized hepatectomy in patients with hepatocellular carcinoma (HCC) were examined in relation to our new staging system., Methods: We retrospectively studied 955 patients with HCC who underwent hepatectomy from 1989 through 2002. We classified patients with HCC into four groups according to the pathological findings (pathological step [p-step]): p-step 1, HCC with absence of vascular invasion and absence of intrahepatic metastasis; p-step 2, HCC with vascular invasion and/or intrahepatic metastasis; p-step 3, HCC with major vascular invasion and/or intrahepatic metastasis to both lobes of the liver; and p-step 4, HCC with distant metastasis, including lymph node metastasis or ruptured HCC). We separated the liver into three segments (Takasaki's liver segments). Systematized hepatectomy was classified as systematized segmentectomy or larger resection, and partial segmentectomy. Segmentectomy refers to resection of one of Takasaki's segments., Results: Systematized segmentectomy did not affect recurrence-free survival, by univariate analysis, in patients with p-step 1, p-step 3, or p-step 4. However, systematized segmentectomy or larger resection was significantly associated with patient recurrence-free survival, by univariate analysis, in patients with p-step 2. Multivariate analysis also showed systematized segmentectomy or larger resection as a significant independent prognostic factor in patients with p-step 2., Conclusions: Systematized segmentectomy is suitable for patients with p-step 2 HCC according to this step classification.

Background: Some cases of mass-forming intrahepatic cholangiocarcinoma (ICC) are diagnosed as hepatocellular carcinoma (HCC) based on preoperative imaging and clinical findings. We investigated the backgrounds of such cases., Methods: Sixty-seven patients with mass-forming ICC underwent surgery from 1980 to 2002. Twenty-four of these patients received a diagnosis of HCC preoperatively. We compared the group diagnosed as HCC and that diagnosed as ICC. ICC was diagnosed histopathologically in all 67 patients., Results: The specific clinical findings included high rates of associated hepatitis C virus infection, high levels of serum alpha fetoprotein, lower levels of serum CA19-9, small dimension of the tumor, hypervascular staining on angiography or computed tomography, lower rates of lymph node metastasis, and high rates of HCC occurrence in the group diagnosed as HCC. None of the patients underwent extrahepatic bile duct resection and most patients did not undergo lymph node dissection in the group diagnosed as HCC. The rates of mucus secretion and the ductal expression of mucin core protein-1 (MUC1) were significantly different between the subgroups. The cumulative survival rates were significantly better in the group diagnosed as HCC than in the group diagnosed as ICC., Conclusion: Patients with ICC given a preoperative diagnosis of HCC had distinct clinical features and could be treated with the same operation as HCC patients., (Copyright 2004 Wiley-Liss, Inc.)

We encountered a patient with hepatocellular carcinoma (HCC), with adrenal gland metastasis, in whom splenic metastasis was diagnosed histopathologically. A 59-year-old man visited our hospital in May 2001 with chief complaints of abdominal distension and pretibial pitting edema. Multiple HCCs associated with HCV-positive liver cirrhosis were detected. Transarterial embolization (TAE) was performed a total of 4 times for HCCs. A left adrenal gland metastatic lesion was detected and it was found to increase in diameter from 3 cm to 6 cm over a four-month period; left adrenalectomy was performed in June 2002. Because of marked splenomegaly and findings of hypersplenism, the spleen was also resected. Although no metastatic lesions were evident on macroscopic examination of the spleen, a small metastatic lesion from moderately differentiated HCC, approximately 0.5 mm in diameter, was detected histopathologically. Splenic metastasis from HCC is rare, usually occurring with metastases involving other organs. Our patient also had adrenal gland metastasis. Therefore, hematogenous metastasis to the congested spleen via the systemic circulation was suspected.

Background/aims: Clinicopathological features and outcome after surgery in patients with synchronous multicentric hepatocellular carcinoma were examined in relation to the histopathological grade of differentiation of the main nodule., Methodology: Two hundred and sixty-five patients with synchronous multicentric hepatocellular carcinoma (total, 683 nodules) who had undergone curative hepatectomy from 1988 through 1999 were studied retrospectively. In multicentric occurrences of hepatocellular carcinoma, the tumor with the largest dimension was defined as the main nodule, and the others as accessory nodules., Results: The histopathological grade of differentiation of the main nodule was assessed to be well differentiated in 72 patients (27.2%), moderately differentiated in 160 patients (60.4%), and poorly differentiated in 33 patients (12.4%). Tumor size of the main nodule was significantly smaller in patients with well differentiated hepatocellular carcinoma than in patients with moderately or poorly differentiated hepatocellular carcinoma. Alpha-fetoprotein levels were significantly lower in cases in which the main nodule was diagnosed to be well differentiated hepatocellular carcinoma than in other cases. The 5-year survival rate and recurrence-free survival rate were significantly greater in cases in which the main nodule showed well differentiated hepatocellular carcinoma (78.1% and 33.8%, respectively) than in other cases [moderately differentiated 49.0% (p<0.0001), 11.6% (P=0.0002); poorly differentiated 37.4% (p<0.0001), 8.3% (P=0.0002), respectively]. Multivariate analysis identified the histopathological grade of the main nodule as significant independent prognostic factors., Conclusions: There were differences in surgical outcome in relation to the histopathological grade of differentiation of the main nodule in patients with synchronous multicentric hepatocellular carcinoma.

Background: Early hepatocellular carcinoma (HCC) is defined as well-differentiated HCC with an obscure tumor margin in the classification of the Liver Cancer Study Group of Japan. However, the surgical outcomes in patients with early HCC have not yet been clarified., Methods: From 1985 to 1994, 186 patients with HCC 2 cm or less in greatest dimension underwent curative hepatectomy. Of the 186 cases, 37 were early HCC and 149 were small advanced HCC. The relationship between clinicopathological findings and surgical outcomes was examined., Results: The rate of hepatitis C antibody or number of tumors was significantly higher in patients with early HCC than in patients with small advanced HCC. Liver function test showed no differences between patients with early HCC and patients with small advanced HCC. The 5-and 10-year survival rates were 85% and 61%, respectively, in patients with early HCC, which was significantly better than in patients with small advanced HCC (P = 0.0137). Univariate and multivariate analysis showed Child-Pugh class, intrahepatic metastasis, and early HCC to be significant prognostic factors., Conclusions: Patients with early HCC had a different clinical background and good surgical outcomes; therefore, it should be recognized that early HCC is a distinct clinicopathological entity.

The patient, a 61-year-old man, had sustained injuries in a traffic accident at the age of 26, for which he received a blood transfusion. Since 1988 (age, 49 years), abnormal hepatic function had been detected, and, because of the presence of hepatitis C virus antibodies, he was diagnosed as having type C chronic hepatitis. Based on a liver biopsy that was conducted in July 1992 (age, 53), a histological diagnosis of chronic active hepatitis (F(1)/A(2)) was made. Over a period of 6 months, starting in 1992, the patient was treated with interferon (IFNalpha-2a; total dosage, 720 MU). At the end of this regimen, the alanine aminotransferase level was normalized and serum hepatitis C virus-ribonucleic acid was negative. This condition was maintained until August 1996 (age, 57), after which the patient stopped reporting to our hospital. In June 2000 (age, 61) when he was hospitalized for an adhesive ileus, a small hepatocellular carcinoma (a solitary lesion measuring 18 mm in diameter) at S(8) was found, and it was extirpated by a segmental excision in July. The case is introduced to call attention to the need for longterm follow-up observation, even after effective IFN therapy.

Background: The effectiveness of systematized hepatectomy with transection of Glisson's pedicle at the hepatic hilus in patients with small nodular hepatocellular carcinoma (HCC) has not been confirmed., Methods: Surgical outcomes were reviewed in 204 patients with single nodular HCCs less than 5 cm in greatest diameter, including 68 patients with tumors that showed extranodular growth and 136 patients with tumors that did not, who had undergone curative hepatectomy (partial hepatic resection, n = 114; systematized hepatectomy, n = 90) from 1990 through 1994., Results: The rates of microscopic vascular invasion and intrahepatic metastasis were significantly higher in patients who had single nodular HCCs with extranodular growth (34% and 49%) than in patients who had single nodular HCCs without extranodular growth (13%, P =.001, and 4%, P <.001). The 5-year survival rate in patients who had single nodular HCCs with extranodular growth was significantly greater after systematized hepatectomy (67%) than after partial hepatic resection (21%, P =.0002). Multivariate analysis showed that the type of operation was an independent prognostic factor in patients with single nodular HCCs with extranodular growth (P =.0008)., Conclusions: Systematized hepatectomy with Glisson's pedicle transection at the hepatic hilus should be performed in patients who have single small nodular HCCs with extranodular growth because these tumors often invade within the liver sector containing the tumor.

We present a rare case of eight multicentric hepatocellular carcinomas (HCCs) occurring in the same segment of the liver. In a 66-year-old Japanese man, multiple liver tumors were detected during follow-up of chronic hepatitis C infection, and he was admitted to our hospital in 1995. Ultrasonography (US) showed eight tumors, each measuring between 10 and 15 mm in diameter, in the right lobe, and a 10-mm tumor in the left lobe. Angio-ultrasonography (US) showed no enhancement of the tumors, and multicentric occurrence was suspected. Portal angio-US showed eight tumors in the right lobe located in the anterior segment. Accordingly, anterior segmentectomy and partial resection of the S3 subsegment were performed, in December, 1995. On histological examination, all eight tumors in the anterior segment and the tumor in the S3 subsegment were well differentiated HCC. The liver parenchyma showed cirrhosis. The grade and stage of hepatitis did not differ between the anterior segment and the S3 subsegment, but irregular regeneration of hepatocytes was more prominent in the anterior segment. The multicentric occurrence of HCCs in the anterior segment may be related to the more severe damage caused by chronic hepatitis in the anterior segment than in the left lobe of the liver.

Hepatocellular carcinoma (HCC) shares only a small proportion of hyperechoic liver tumors detected in MHTS and mimics hemangioma on ultrasonography (US). The precise diagnosis of HCC is hence difficult in MHTS, but presence or absence of underlying chronic liver disease and serum alfa-fetoprotein (AFP) titer might provide useful informations.