Journal of Liver Cancer

Original Articles

Heavy Smoking Increases Early Mortality Risk in Patients with Hepatocellular Carcinoma after Curative Treatment: Jaejun Lee, Jong Young Choi, Soon Kyu Lee; Received April 24, 2024 Accepted June 2, 2024 Published online June 7, 2024; DOI: https://doi.org/10.17998/jlc.2024.06.02 [Accepted]

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Abstract PDF: Background
Although cigarette smoking has been associated with an increased risk of hepatocellular carcinoma (HCC), its association with HCC mortality remains underexplored. We aimed to evaluate the effect of smoking on early mortality in HCC patients following curative treatment.
Methods
Data from the Korean Primary Liver Cancer Registry were examined for HCC patients who underwent liver resection or radiofrequency ablation between 2015 and 2018. Smoking cumulative dose was assessed in pack-years. The primary outcome was the 3-year overall survival (OS).
Results
Among 1924 patients, 161 were classified as heavy smokers (≥ 40 pack-years). Heavy smokers exhibited a lower 3-year survival rate (77.1 %) than nonsmokers (83.3%), with a significant difference observed in the 3-year OS (p = 0.016). The assessment of smoking packyears in relation to 3-year OS revealed a dose-dependent pattern, with the hazard ratio exceeding 1.0 at 20 pack-years and continuing to rise until 40 pack-years, reaching peak at 1.21 (95% confidence interval: 1.01, 1.45). Multivariate Cox-regression analysis revealed heavy smoking, age ≥ 60 y, underlying cirrhosis, tumor size > 3 cm, vascular invasion, and Child-Pugh class B/C as risk factors for 3-year OS. Subgroup analyses of patients with a tumor size < 3 cm, absence of vascular invasion, and meeting the Milan criteria also showed inferior outcomes for heavy smokers in all three subgroups.
Conclusion
Heavy smoking, defined as a history of > 40 pack-years, was linked to poorer 3-year survival outcomes in HCC patients undergoing curative treatments, underscoring the importance of smoking cessation in this population.

Outcomes of Liver Resection and Transarterial Chemoembolization in Patients with Multinodular BCLC-A Hepatocellular Carcinoma: Jiwon Yang, Won-Mook Choi, Danbi Lee, Ju Hyun Shim, Kang Mo Kim, Young-Suk Lim, Han Chu Lee, Deok-Bog Moon, Dong-Hwan Jung, Jonggi Choi; Received March 3, 2024 Accepted March 25, 2024 Published online April 3, 2024; DOI: https://doi.org/10.17998/jlc.2024.03.25 [Accepted]

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Abstract PDF: Background
This study aimed to compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) in patients with multinodular hepatocellular carcinoma (HCC) within the Milan criteria who were not eligible for liver transplantation.
Methods
We retrospectively analyzed 483 patients with multinodular HCC within the Milan criteria, who underwent either LR or TACE as an initial therapy between 2013 and 2022. The overall survival (OS) in the entire population and recurrence-free survival (RFS) in patients who underwent LR and TACE and achieved a complete response were analyzed. Propensity score (PS) matching analysis was also used for a fair comparison of outcomes between the two groups.
Results
Among the 483 patients, 107 (22.2%) and 376 (77.8%) underwent LR and TACE, respectively. The median size of the largest tumor was 2.0 cm, and 72.3% of the patients had two HCC lesions. The median OS and RFS were significantly longer in the LR group than in the TACE group (p <0.01 for both). In the multivariate analysis, TACE (adjusted hazard ratio [aHR], 1.81 and aHR, 2.41) and large tumor size (aHR, 1.43 and aHR, 1.44) were significantly associated with worse OS and RFS, respectively. The PS-matched analysis also demonstrated that the LR group had significantly longer OS and RFS than the TACE group (PS <0.05).
Conclusion
In this study, LR showed better OS and RFS than TACE in patients with multinodular Barcelona Clinic Liver Cancer stage A HCC. Therefore, LR can be considered an effective treatment option for these patients.

Indications for open hepatectomy in the era of laparoscopic liver resection: a high volume single institutional study: Sung Jun Jo, Jinsoo Rhu, Jong Man Kim, Gyu-Seong Choi, Jae-Won Joh; J Liver Cancer. 2022;22(2):146-157. Published online September 14, 2022; DOI: https://doi.org/10.17998/jlc.2022.08.22

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Abstract PDF Supplementary Material

Background/Aim
Since the introduction of laparoscopy for liver resection in the 1990s, the performance of laparoscopic liver resection (LLR) has been steadily increasing. However, there is currently no data on the extent to which laparoscopy is used for liver resection. Herein, we investigated the extent to which laparoscopy is performed in liver resection and sought to determine whether surgeons prefer laparoscopy or laparotomy in the posterosuperior (PS) segment.
Methods
For this retrospective observational study, we enrolled patients who had undergone liver resection at the Samsung Medical Center between January 2020 and December 2021. The proportion of LLR in liver resection was calculated, and the incidence and causes of open conversion were investigated.
Results
A total of 1,095 patients were included in this study. LLR accounted for 79% of the total liver resections. The percentage of previous hepatectomy (16.2% vs. 5.9%, P<0.001) and maximum tumor size (median 4.8 vs. 2.8, P<0.001) were higher in the open liver resection (OLR) group. Subgroup analysis revealed that tumor size (median 6.3 vs. 2.9, P<0.001) and surgical extent (P<0.001) in the OLR group were larger than those in the LLR group. The most common cause of open conversion (OC) was adhesion (57%), and all OC patients had tumors in the PS.
Conclusions
We investigated the recent preference of practical surgeons in liver resection, and found that surgeons preferred OLR to LLR when treating a large tumor located in the PS.

Citations

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Radiofrequency Ablation versus Surgical Resection in Elderly Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis
Jeong-Ju Yoo, Sujin Koo, Gi Hong Choi, Min Woo Lee, Seungeun Ryoo, Jungeun Park, Dong Ah Park
Current Oncology.2024; 31(1): 324. CrossRef
Efficacy and Safety of Surgical Resection in Elderly Patients with Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis
Jin-Soo Lee, Dong Ah Park, Seungeun Ryoo, Jungeun Park, Gi Hong Choi, Jeong-Ju Yoo
Gut and Liver.2024; 18(4): 695. CrossRef
A systematic review and meta-analysis of blood transfusion rates during liver resection by country
Seonju Kim, Yun Kyung Jung, Kyeong Geun Lee, Kyeong Sik Kim, Hanjun Kim, Dongho Choi, Sumi Lee, Boyoung Park
Annals of Surgical Treatment and Research.2023; 105(6): 404. CrossRef

Prediction of Post-resection Prognosis Using the ADV Score for Huge Hepatocellular Carcinomas ≥13 cm: Shin Hwang, Ki-Hun Kim, Deok-Bog Moon, Chul-Soo Ahn, Tae-Yong Ha, Gi-Won Song, Dong-Hwan Jung, Gil-Chun Park; J Liver Cancer. 2021;21(1):45-57. Published online March 31, 2021; DOI: https://doi.org/10.17998/jlc.21.1.45

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Abstract PDF

Background/Aims
Multiplication of α-fetoprotein, des-γ-carboxy prothrombin, and tumor volume (ADV score) is a surrogate marker for post-resection prognosis of hepatocellular carcinoma (HCC). This study aimed to validate the predictive power of the ADV score-based prognostic prediction model for patients with solitary huge HCC.
Methods
Of 3,018 patients, 100 patients who underwent hepatic resection for solitary HCC ≥13 cm between 2008 and 2012 were selected.
Results
The median tumor diameter and tumor volume were 15.0 cm and 886 mL, respectively. Tumor recurrence and overall survival (OS) rates were 70.7% and 66.0% at one year and 84.9% and 34.0% at five years, respectively. Microvascular invasion (MVI) was the only independent risk factor for disease-free survival (DFS) and OS. DFS and OS, stratified by ADV score with 1-log intervals, showed significant prognostic contrasts (P=0.007 and P=0.017, respectively). DFS and OS, stratified by ADV score with a cut-off of 8-log, showed significant prognostic contrasts (P=0.014 and P=0.042, respectively). The combination of MVI and ADV score with a cut-off of 8-log also showed significant prognostic contrasts in DFS (P<0.001) and OS (P=0.001) considering the number of risk factors. Prognostic contrast was enhanced after combining the MVI and ADV score.
Conclusions
The prognostic prediction model with the ADV score could reliably predict the risk of tumor recurrence and long-term patient survival outcomes in patients with solitary huge HCCs ≥13 cm. The results of this study suggest that our prognostic prediction models can be used to guide surgical treatment and post-resection follow-up for patients with huge HCCs.

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ADV score is a reliable surrogate biomarker of hepatocellular carcinoma in liver resection and transplantation
Shin Hwang, Dong-Hwan Jung, Gi-Won Song
Annals of Liver Transplantation.2023; 3(2): 86. CrossRef

Postoperative Chemoradiotherapy for R1 Resected Intrahepatic Cholangiocarcinoma: Kim, Kyung Su , Kim, Hwi Young , Kim, Kyubo , Yi, Nam Joon , Suh, Kyung Suk , Chie, Eui Kyu; J Liver Cancer. 2018;18(2):115-120. Published online September 30, 2018; DOI: https://doi.org/10.17998/jlc.18.2.115

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Abstract PDF

Background/Aims
To investigative the potential role of postoperative chemoradiotherapy (CCRT) after R1 resection of intrahepatic cholangiocarcinoma (IHCC).
Methods
Between January 2000 and December 2012, medical records of 18 patients who underwent curative surgery with R1 resection for IHCC were retrospectively reviewed.
Results
Median age was 68 years and 12 patients (66.7%) were male. Median tumor size was 5.0 cm (range, 2.2-11.0) and 12 patients (66.7%) had T3 or higher disease. Lymph nodes were involved in four patients (22.2%). Vascular invasion and perineural invasion were present in 10 (55.6%) and 12 patients (66.7%), respectively. Postoperative CCRT given with 5-fluorouracil or gemcitabine were delivered to 7 patients (38.9%). Median radiation dose was 50.4 Gy (range, 45-54). Univariate analysis showed that median loco-regional recurrence-free survival (LRRFS), progression-free survival (PFS) and overall survival (OS) were prolonged for patients treated with CCRT (median LRRFS; 5.6 months vs. not reached, P<0.001, median PFS; 5.6 vs. 8.3 months, P=0.047, median OS; 15.0 vs. 26.6 months, P=0.064).
Conclusions
Postoperative CCRT improved the loco-regional control and PFS in IHCC patients with R1 resection. Further study is warranted to validate the role of postoperative CCRT for these patients.

Citations

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Precision therapy for intrahepatic cholangiocarcinoma: A case report on adjuvant treatment in a recurrent patient after surgery and literature review
Bao Ying, Tao Tang, Li-Xing Zhang, Jian-Wei Xiong, Kai-Feng Zhao, Jia-Wei Li, Guo Wu
Oncology Letters.2023;[Epub] CrossRef
Stereotactic radiotherapy for intrahepatic cholangiocarcinoma
Aditya Borakati, Farid Froghi, Ricky H Bhogal, Vasileios K Mavroeidis
World Journal of Gastrointestinal Oncology.2022; 14(8): 1478. CrossRef

Outcomes of Surgical Resection for Ruptured Hepatocellular Carcinoma: Hae Won Lee, Chang-Sup Lim, Hyo-Sin Kim; J Liver Cancer. 2017;17(1):54-59. Published online March 31, 2017; DOI: https://doi.org/10.17998/jlc.17.1.54

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Abstract PDF

Background/Aims
Many recent studies have shown excellent outcomes of surgical resection for ruptured hepatocellular carcinoma (HCC). In addition, there are several reports suggesting that a ruptured HCC did not increase the risk for peritoneal dissemination of a tumor after surgical resection. However, the impact of HCC rupture on recurrence and patient survival has not yet been clarified.
Methods
The medical data of patients who underwent surgical resection for ruptured HCC in our center between January 2011 and December 2015 were retrospectively reviewed. The outcomes of the patients were investigated.
Results
Among 128 patients who underwent surgical resection for HCC, 5 patients (3.9%) had a ruptured HCC. All patients underwent elective operation in a stable condition. Transarterial chemoembolization (TACE) was performed for achieving hemostasis in four patients except one who achieved spontaneous hemostasis. Two patients had tumor recurrence and one patient died due to HCC recurrence during the median follow-up duration of 28.3 months (range, 24.3–62.3 months). One patient who developed late intrahepatic recurrence at 40.0 months after resection was managed well by means of radiofrequency ablation and TACE and is now alive for 5 years without any evidence of viable tumor. However, the other patient who showed early peritoneal seeding at 1.9 months after resection finally died despite aggressive treatments.
Conclusions
Rupture of HCC might result in peritoneal seeding of the tumor in the early postoperative stage, which could lead to a poor result. Nonetheless, surgical resection may be the best treatment option yielding good survival, even for a ruptured HCC.

Citations

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Ruptured Massive Hepatocellular Carcinoma Cured by Transarterial Chemoembolization
Ji Eun Lee, Joong-Won Park, In Joon Lee, Bo Hyun Kim, Seoung Hoon Kim, Hyun Beom Kim
Journal of Liver Cancer.2020; 20(2): 154. CrossRef

Case Reports

A Case of Rapidly Recurred Hepatocellular Carcinoma with Distant Metastasis after Surgical Resection: Mi Yeon Kim, Hye Won Lee, Kyu Sik Jung, Beom Kyung Kim, Seung Up Kim, Jun Yong Park, Sang Hoon Ahn, Kwang-Hyub Han, Do Young Kim; J Liver Cancer. 2015;15(2):136-139. Published online September 30, 2015; DOI: https://doi.org/10.17998/jlc.15.2.139

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Abstract PDF: Hepatocellular carcinoma (HCC) is one of the cancers with poor prognosis. However, surgical resection is the treatment of choice as curative aim for early HCC with preserved liver function. A 5 year survival rate after curative resection is over 50%. We experienced a case of rapidly recurred HCC with bone metastasis after surgical resection. In our case, microscopically microvessel invasion was present after resection. Microvascular invasion (MVI) is an important factor to influence survival and/or HCC recurrence. So we suggested the patients with MVI need to follow up intensively and adjuvant therapy may be considered.

A Case of Management for Early Recurrence after Hepatic Resection for the Treatment of Small Hepatocellular Carcinoma: Kyung Woo Park, Young Seok Kim, Sang Gyune Kim, Soung Won Jeong, Jae Young Jang, Hong Soo Kim, Sae Hwan Lee, Boo Sung Kim, Jun Cheol Jeong, Min Hee Lee, Jae Myeong Lee, Hee Kyung Kim; J Liver Cancer. 2015;15(2):122-125. Published online September 30, 2015; DOI: https://doi.org/10.17998/jlc.15.2.122

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Abstract PDF: For a small hepatocellular carcinoma (HCC), liver resection shows most favorable outcome in
case
which liver transplantation is not available, although it has also substantial recurrence rate. Here, we report a case of recurred HCC with multiple intrahepatic metastasis at 5 months after surgical resection for small HCC was done. A 55-year-old man with chronic HBV infection received subsegmentectomy for HCC less than 2 cm. A follow-up computed tomography (CT) at 5 months from operation revealed that there were multiple enhancing nodules in entire remnant liver. Intra-arterial injections of adriamycin mixed lipiodol and gelfoam particles were instituted through hepatic artery. We assume that poorly differentiated cellular feature would be attributable to this kind of very early and aggressive recurrence of HCC. (J Liver Cancer 2015;15:122-125)

A Case of Early Multiply Recurred Hepatocellular Carcinoma after Surgical Resection in Patient Who Unprecedented Chronic Liver Disease: Wang Yong Choi, Byoung Kuk Jang, Woo Jin Chung, Jae Seok Hwang; J Liver Cancer. 2015;15(2):112-117. Published online September 30, 2015; DOI: https://doi.org/10.17998/jlc.15.2.112

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Abstract PDF: Hepatocellular carcinoma (HCC) have relatively well known causative factors such as chronic hepatitis B, chronic hepatitis C, alcoholic liver disease, Non-alcoholic fatty liver disease (NAFLD), liver cirrhosis and so on. Recently, interesting reports that HCC in the absence of cirrhosis or other chronic liver disease and HCC associated with NAFLD and metabolic syndrome are increasing in USA. So far, there is no report about these issues in Korea. We present a 65 yearold obesity male who had no preceding chronic liver disease history. He was diagnosed as primary HCC and the mass was removed completely. However, HCC recurred shortly after operation. Multiple recurred HCC were treated with transcatheter arterial chemoembolization. (J Liver Cancer 2015;15:112-117)

Review Article

Beyond BCLC in the management of patients with HCC 수술적 치료의 적응증: Dong-Sik Kim; J Liver Cancer. 2015;15(1):1-3. Published online March 31, 2015; DOI: https://doi.org/10.17998/jlc.15.1.1

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Abstract PDF: Although surgical resection can provide best treatment outcome with curative intent, patients with relatively early stage of hepatocellular carcinoma (HCC) can get benefit of this treatment. Barcelona Clinic Liver Cancer (BCLC) staging system limits surgical resection to patients with single HCC with well-preserved liver function, which is often challenged in real practice, especially from Asian countries. During last two decades, surgical outcomes have made remarkable progress approaching zero mortality in many reports. In this review, areas that surgical indications can be expanded beyond BCLC staging system will be discussed, especially in Asian population. (Journal of Liver Cancer 2015;15:1-3)

Case Report

A Case of Unresectable Hepatocellular Carcinoma Treated by Repeated Transcatheter Arterial Chemoembolization Using DC beads® Followed with Resection: Jeong-Yeop Song, Young Seok Kim, Jae Myeong Lee, Soo Ji Jin, Kyu Sung Choi, Yun Nah Lee, Sang Hyune Kim, Sung Won Jeong, Jae Young Jang, Sae Hwan Lee, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):65-69. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.65

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Abstract PDF: In patients with unresectable hepatocellular carcinoma (HCC) and no anti-cancer treatment, the prognosis is quite poor. But in some cases, repeated sessions of transcatheter arterial chemoembolization (TACE) reduce the tumor size even to resectable, and post-TACE resection may prolong the survival time. We present a case of 50-year-old HBV carrier woman with abdominal distension. The diagnosis was huge HCC with intrahepatic metastasis. Repeated intra-arterial injections of adriamycin mixed lipiodol or DC beads® (100-300/300-500/500-700 μm, ©BIOCOMPATIBLES UK LTD) were instituted through ten sessions for 13 months. The tumor size became reduced with a partial response after 10th TACE and post-TACE resection was performed. No visible HCCs and decreased tumor markers were noted on the examinations 3 months after the resection.

Review Articles

Strategies for the Curative Therapy of Early Stage HCC: Resection, Is It Real First Choice?: Wan-Bae Kim; Journal of the Korean Liver Cancer Study Group. 2012;12(2):97-101. Published online September 30, 2012

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Abstract PDF: Early stage HCC has generally been defined as the “Milan criteria”: a solitary tumor ≤ 5 cm in size, or ≤ 3 tumors each ≤ 3 cm in size and no evidence of gross vascular invasion. HCC is now increasingly detected at earlier stages. In addition, both liver transplantation and percutaneous ablative therapies have emerged as effective alternatives to hepatic resection. As a result, the ideal treatment strategy for patients with early stage HCC, particularly in the setting of well-preserved hepatic function, has become increasingly controversial. In the recent studies, the survival rates for transplantation in early stage HCC patients are excellent. However, when intention-to-treat analysis is used, dropouts from the waiting list due to death or disease progression clearly diminish long-term survival results and therefore patients are unlikely to benefit from liver transplantation. In addition, salvage transplantation after HCC resection may be performed without excessive morbidity and may result in equivalent survival rates compared with primary liver transplantation. In some studies, salvage transplantation may be feasible in up to 75-80% of patients with recurrence following hepatic resection. Similarly, locoregional therapies serve to sustain patients with HCC on the waiting list until a transplantation become available. While RFA and TACE are commonly used to prevent dropout, pretransplant therapy has not been associated with improved overall survival or disease-free survival due to persistenceof viable tumor. It is important to note that, while resection is a more invasive procedure, the benefit that it holds over nonresectional therapies is the complete removal of the tumor allowing for subsequent detailed pathologic examination of both the tumor and surrounding liver parenchyma. In conclusion, in patients with well-preserved hepatic function, liver resection remains the most appropriate and effective treatment.

Strategies for the Curative Therapy of Early Stage HCC: First or SalvageTransplantation?: Nam-Joon Yi; Journal of the Korean Liver Cancer Study Group. 2012;12(2):102-108. Published online September 30, 2012

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Abstract PDF: Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide, especially in Asian countriesas well as Korea, and liver transplantation (LT) has potentials to improve survival for patients with HCC. However, major hamper to LT for HCC has been graft shortage. To solve this problem, liver resection (LR) has to be rejuvenated in the general algorithm of HCC treatment in the light of salvage transplantation (ST) strategies. The LR followed by ST in case of HCC recurrence is an attractive concept in early stage HCC and cirrhosis with acceptable liver function. These challenges in technique, indications, pre-LT observation and treatments for recurred HCC, and prioritization policies of patients on the waiting list have to be precise through prospective investigations that have to include individualization of prognosis, biological variables and pathology surrogates as stratification criteria. Accepting this challenges have been part of the history of LT and will endure for the future. This article will focus on the ST after LR in terms of intention-to-analysis

Case Reports

A Case of Emergent Treatment for Hemodynamic Unstable Patient with Ruptured Hepatocellular Carcinoma: Jae Keun Kim, Joon Seong Park, Ja Kyung Kim, Hyo Jun Lee, Kwang Hoon Lee, Kwan Sik Lee, Dong Sup Yoon; Journal of the Korean Liver Cancer Study Group. 2012;12(2):160-163. Published online September 30, 2012

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Abstract PDF: A ruptured Hepatocellular carcinoma (HCC) is one of life threatening complication and considered as poor prognosis. Hemodynamic stability is a key to the early period survival. Hemostasis can be achieved with transarterial embolization and explo‐laparotomy or surgical resection. Prognosis is related to hemodynamic stability and liver function and tumor size. Surgical resection of ruptured HCC is recommended when it is possible. Further studies are needed for the treatment of recurred and progressive patients with ruptured HCC.

A Case of Advanced Hepatocellular Carcinoma which was Supervening with Renal Cell Cancer Cured by Repeated Transarterial Chemoembolization and Sorafenib after Resection: Bun Kim, Jae Hoon Min, Seung Up Kim, Jun Yong Park, Kwang Hoon Lee, Do Youn Lee, Jin Sub Choi, Young Deuk Choi, Nam Hoon Cho, Young Nyun Park, Sang Hoon Ahn, Kwang Hyub Han, Chae Yoon Chon, Do Young Kim; Journal of the Korean Liver Cancer Study Group. 2012;12(1):51-57. Published online February 28, 2012

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Abstract PDF: Advanced hepatocellular carcinoma (HCC) is difficult to treat and the survival is poor. Here, we present a patient diagnosed as advanced HCC (stage IIIa) which was supervening with early renal cell cancer (stage I). The patient was treated with pre-operational transarterial chemoembolization (TACE) and surgical resection (right hepatectomy, right nephrectomy, and cholecystectomy). Sorafenib were taken continually after surgery. Multiple recurred HCC nodules in remnant liver were detected 2 months later after surgery. Combined treatment modalities including 4 sessions of TACE, and 12 cycles of 5-flurouracil (FU)/carboplatin based hepatic arterial infusional chemotherapy (HAIC) induced complete response. After the diagnosis of advanced HCC, the patient survived 36 months and experienced disease-free status for 19 months.

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