Importance of surgical margin in the outcomes of hepatocholangiocarcinoma

AIM To evaluate the significance of resection margin width in the management of hepatocholangiocarcinoma(HCC-CC).METHODS Data of consecutive patients who underwent hepatectomy for hepatic malignancies in the period from1995 to 2014 were reviewed.Patients with pathologically confirmed HCC-CC were included for analysis.Demographic,biochemical,operative and pathological data were analyzed against survival outcomes. RESULTSForty-two patients were included for analysis.The median age was 53.5 years.There were 29 males.Hepatitis B virus was identified in 73.8%of the patients.Most patients had preserved liver function.The median preoperative indocyanine green retention rate at 15 min was 10.2%.The median tumor size was 6.5 cm.Major hepatectomy was required in over 70%of the patients.Hepaticojejunostomy was performed in 6 patients.No hospital death occurred.The median hospital stay was 13 d.The median follow-up period was 32 mo.The 5-year disease-free survival and overall survival were 23.6%and 35.4%respectively.Multifocality was the only independent factor associated with diseasefree survival[P<0.001,odds ratio 4,95%confidence interval(CI):1.9-8.0].In patients with multifocal tumor(n=20),resection margin of≥1 cm was associated with improved 1-year disease-free survival(40%vs 0%;log-rank,P=0.012).CONCLUSIONHCC-CC is a rare disease with poor prognosis.Resection margin of 1 cm or above was associated with improved survival outcome in patients with multifocal HCC-CC.

Surgical cystogastrostomy: Is it still worthwhile?

The article by Ker et al explores the treatment of peripancreatic fluid collection(PFC).The use of percutaneous drainage,endoscopy,and surgery for managing PFC are discussed.Percutaneous drainage is noted for its low risk profile,while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent.Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention,especially for cases with extensive collections and significant necrosis.The choice of treatment modality should be tailored to individual patient characteristics and disease factors,considering the expertise available.

Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm

A large number of liver transplants have been performed for hepatocellular carcinoma(HCC), and recurrence is increasingly encountered. The recurrence of HCC after liver transplantation is notoriously difficult to manage. We hereby propose multi-disciplinary management with a systematic approach. The patient is jointly managed by the transplant surgeon, physician, oncologist and radiologist. Immunosuppressants should be tapered to the lowest effective dose to protect against rejection. The combination of a mammalian target of rapamycin inhibitor with a reduced calcineurin inhibitor could be considered with close monitoring of graft function and toxicity. Comprehensive staging can be performed by dual-tracer positron emission tomography-computed tomography or the combination of contrast computed tomography and a bone scan. In patients with disseminated recurrence, sorafenib confers survival benefits but is associated with significant drug toxicity. Oligo-recurrence encompasses recurrent disease that is limited in number and location so that loco-regional treatments convey disease control and survival benefits. Intra-hepatic recurrence can be managed with graft resection, but significant operative morbidity is expected. Radiofrequency ablation and stereotactic body radiation therapy(SBRT) are effective alternative strategies. In patients with more advanced hepatic disease, regional treatment with trans-arterial chemoembolization or intra-arterial Yttrium-90 can be considered. For patients with extra-hepatic oligorecurrence, loco-regional treatment can be considered if practical. Patients with more than one site of recurrence are not always contraindicated for curative treatments. Surgical resection is effective for patients with pulmonary oligo-recurrence, but adequate lung function is a prerequisite. SBRT is a non-invasive and effective modality that conveys local control to pulmonary and skeletal oligo-recurrences.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reducedwound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a minilaparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Sarcopenia in pancreatic cancer–effects on surgical outcomes and chemotherapy

Sarcopenia is found in up to 65% of pancreatic cancer patients. The definition and diagnostic methods for sarcopenia have changed over the years, and the measurement of skeletal muscle mass with cross-sectional imaging has become the most popular way of assessment, although the parameters measured vary among different studies. It is still debatable that there is an association between sarcopenia and postoperative pancreatic fistula, but most studies showed a higher risk in patients with sarcopenic obesity. Long-term survival is worse in sarcopenic patients, as shown by meta-analysis. Sarcopenia is also associated with decreased survival and higher toxicity in patients receiving chemotherapy, and chemotherapy also tends to potentiate sarcopenia. Treatment for sarcopenia still remains an area for research, although oral supplements, nutritional modifications and exercise training have been shown to improve sarcopenia.

Survival outcomes of liver transplantation for hepatocellular carcinoma in patients with normal, high and very high preoperative alpha-fetoprotein levels

AIM To investigate the impact of alpha-fetoprotein(AFP) on long-term recurrence rate and overall survival and we also aimed to define the level of AFP leading to a higher risk of disease recurrence and affecting patient survival.METHODS Data of adult patients who received liver transplant(LT) for hepatocellular carcinoma(HCC) at our hospital from January 2000 to December 2013 were reviewed. Reviewed data included demographic characteristics, preoperative AFP level, operative details, follow-up details, and survival outcomes. Patients were mostly listed for LT based on Milan or UCSF criteria. For the purpose of this study, normal AFP level was defined as AFP value < 10 ng/m L, high AFP level was defined as AFP value ≥ 10 to < 400 ng/m L, and very highAFP level was defined as AFP ≥ 400 ng/m L. The patients were divided into these 3 groups accordingly. Survival rates were plotted as Kaplan-Meier curves and compared by log-rank analysis. Continuous variables were expressed as median(interquartile range). Categorical variables were compared by Spearman's test. Discriminative analysis was used to define the lowest value of AFP that could affect the overall survival in study population. Statistical significance was defined by a P value of < 0.05.RESULTS Totally 250 adult patients underwent LT for HCC in the study period. Eight-four of them received deceaseddonor LT and 166 had living-donor LT. The patients were divided into 3 groups: Group A, AFP < 10 ng/m L(n = 83); Group B, AFP ≥ 10 to < 400 ng/m L(n = 131); Group C, AFP ≥ 400 ng/m L(n = 36). The commonest etiology was hepatitis-B-related cirrhosis. The Model for End-stage Liver Disease scores in these groups were similar(median, 13 vs 13 vs 12; P = 0.745). The time to operation in Group A was longer(median, 94 vs 31 vs 35 d; P = 0.001). The groups were similar in hospital mortality(P = 0.626) and postoperative complication(P = 0.702). Pathology of explants showed that the 3 groups had similar numbers of tumor nodules, but the tumors in Group C were larger(A: 2.5 cm, B: 3.0 cm, C: 4.0 cm; P = 0.003). Group C had a bigger proportion of patients who were beyond Milan criteria(P = 0.010). Poor differentiation and vascular permeation were also more common in this group(P = 0.017 and P = 0.003 respectively). It also had poorer 5-year survival(A: 85.5%, B: 82.4%, C: 66%; P = 0.029). The 5-year disease-free survival was 84.3% in Group A, 80.1% in Group B, and 61.1% in Group C. Receiver operating characteristic area under the curve for AFP in predicting tumor recurrence was 0.685. The selected cut-off value was 54 ng/m L for AFP(C-index 0.685; 95%CI: 0.592-0.779; sensitivity 0.595; specificity 0.687). On discriminative analysis, AFP value of 105 ng/m L was shown to affect the overall survival of the patients.CONCLUSION HCC patients with a high preoperative AFP level had inferior survival after LT. AFP level of 54 ng/m L was associated with disease recurrence, and AFP level of 105 ng/m L was found to be the cut-off value for overall survival difference.

Initial experience with stereotactic body radiotherapy for intrahepatic hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND Graft hepatocellular carcinoma(HCC)recurrence after liver transplant is more frequently encountered.Graft hepatectomy is technically challenging and is associated with high morbidity.Stereotactic body radiation therapy(SBRT)has been shown to be safe and effective for the treatment of primary HCC.However,its role in HCC recurrence in a liver graft remains unclear.AIM To evaluate the safety and efficacy of SBRT for the treatment of graft HCC recurrence after liver transplantation.METHODS A retrospective study was conducted.From 2012 to 2018,6 patients with intrahepatic HCC recurrence after liver transplant were treated with SBRT at Queen Mary Hospital,the University of Hong Kong.The primary outcome was time to overall disease progression and secondary outcomes were time to local progression and best local response,as assessed with the Modified response Evaluation Criteria for Solid Tumours criteria.Patients were monitored for treatment related toxicities and graft dysfunction.RESULTS A total of 9 treatment courses were given for 13 tumours.The median tumour size was 2.3 cm(range 0.7-3.6 cm).Two(22%)patients had inferior vena cava tumour thrombus.The best local treatment response was:5(55%)complete response,1(11%)partial response and 3(33%)stable disease.After a median follow up duration of 15.5 mo,no local progression or mortality was yet observed.The median time to overall disease progression was 6.5 mo.There were 6 regional progression in the liver graft(67%)and 2 distant progression in the lung(22%).There was no grade 3 or above toxicity and there was no graft dysfunction after SBRT.CONCLUSION SBRT appears to be safe in this context.Regional progression is the mode of failure.

Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis

BACKGROUND Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking. AIM To evaluate the impact of small-for-size liver grafts on medium-term and longterm graft survival in adult to adult LDLT. METHODS A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted. RESULTS This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies. CONCLUSION SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.

Immunotherapy after liver transplantation:Where are we now?

BACKGROUND There is limited evidence on the safety of immunotherapy use after liver transplantation and its efficacy in treating post-liver transplant hepatocellular carcinoma(HCC)recurrence.AIM To assess the safety of immunotherapy after liver transplant and its efficacy in treating post-liver transplant HCC recurrence.METHODS A literature review was performed to identify patients with prior liver transplantation and subsequent immunotherapy.We reviewed the rejection rate and risk factors of rejection.In patients treated for HCC,the oncological outcomes were evaluated including objective response rate,progression-free survival(PFS),and overall survival(OS).RESULTS We identified 25 patients from 16 publications and 3 patients from our institutional database(total n=28).The rejection rate was 32%(n=9).Early mortality occurred in 21%(n=6)and was mostly related to acute rejection(18%,n=5).Patients who developed acute rejection were given immunotherapy earlier after transplantation(median 2.9 years vs 5.3 years,P=0.02)and their graft biopsies might be more frequently programmed death ligand-1-positive(100%vs 33%,P=0.053).Their PFS(1.0±0.1 mo vs 3.5±1.1 mo,P=0.02)and OS(1.0±0.1 mo vs 19.2±5.5 mo,P=0.001)compared inferiorly to patients without rejection.Among the 19 patients treated for HCC,the rejection rate was 32%(n=6)and the overall objective response rate was 11%.The median PFS and OS were 2.5±1.0 mo and 7.3±2.7 mo after immunotherapy.CONCLUSION Rejection risk is the major obstacle to immunotherapy use in liver transplant recipients.Further studies on the potential risk factors of rejection are warranted.

Validated model for prediction of recurrent hepatocellular carcinoma after liver transplantation in Asian population

BACKGROUND Liver transplantation(LT) is regarded as the best treatment for both primary and recurrent hepatocellular carcinoma(HCC). Post-transplant HCC recurrence rate is relatively low but significant, ranging from 10%-30% according to different series. When recurrence happens, it is usually extrahepatic and associated with poor prognosis. A predictive model that allows patient stratification according to recurrence risk can help to individualize post-transplant surveillance protocol and guidance of the use of anti-tumor immunosuppressive agents.AIM To develop a scoring system to predict HCC recurrence after LT in an Asian population.METHODS Consecutive patients having LT for HCC from 1995 to 2016 at our hospital were recruited. They were randomized into the training set and the validation set in a60:40 ratio. Multivariable Cox regression model was used to identity factors associated with HCC recurrence. A risk score was assigned to each factor according to the odds ratio. Accuracy of the score was assessed by the area under the receiver operating characteristic curve.RESULTS In total, 330 patients were eligible for analysis(183 in training and 147 invalidation). Recurrent HCC developed in 14.2% of them. The median follow-up duration was 65.6 mo. The 5-year disease-free and overall survival rates were78% and 80%, respectively. On multivariate analysis, alpha-fetoprotein > 400 ng/mL [P = 0.012, hazard ratio(HR) 2.92], sum of maximum tumor size and number(P = 0.013, HR 1.15), and salvage LT(P = 0.033, HR 2.08) were found to be independent factors for disease-free survival. A risk score was calculated for each patient with good discriminatory power(c-stat 0.748 and 0.85, respectively,in the training and validation sets). With the derived scores, patients were classified into low-(0–9), moderate-(> 9–14), and high-risk groups(> 14), and the risk of HCC recurrence in the training and validation sets was 10%, 20%, 54%(cstat 0.67) and 4%, 22%, 62%(c-stat 0.811), accordingly. The risk stratification model was validated with chi-squared goodness-of-fit test(P = 0.425).CONCLUSION A validated predictive model featuring alpha-fetoprotein, salvage LT, and the sum of largest tumor diameter and total number of tumor nodule provides simple and reliable guidance for individualizing postoperative surveillance strategy.

Mammalian target of rapamycin inhibitors after post-transplant hepatocellular carcinoma recurrence:Is it too late?

BACKGROUND Mammalian target of rapamycin(mTOR)inhibitors have been shown to reduce the risk of tumour recurrence after liver transplantation for hepatocellular carcinoma(HCC).However,their role in established post-transplant HCC recurrence is uncertain.AIM To investigate whether mTOR inhibitor offers a survival benefit in posttransplant HCC recurrence.METHODS A retrospective study of 143 patients who developed HCC recurrence after liver transplantation was performed.They were divided into 2 groups based on whether they had received mTOR inhibitor-based immunosuppression.The primary endpoint was post-recurrence survival.RESULTS Seventy-nine(55%)patients received an mTOR inhibitor-based immunosuppressive regime,while 64(45%)patients did not.The mTOR inhibitor group had a lower number of recurrent tumours(2 vs 5,P=0.02)and received more active treatments including radiotherapy(39 vs 22%,P=0.03)and targeted therapy(59 vs 23%,P<0.001).The median post-recurrence survival was 21.0±4.1 mo in the mTOR inhibitor group and 11.2±2.5 mo in the control group.Multivariate Cox regression analysis confirmed that mTOR inhibitor therapy was independently associated with improved post-recurrence survival(P=0.04,OR=0.482,95%CI:0.241-0.966).The number of recurrent tumours and use of other treatment modalities did not affect survival.No survival difference was observed between mTOR inhibitor monotherapy and combination therapy with calcineurin inhibitor.CONCLUSION mTOR inhibitors prolonged survival after post-transplant HCC recurrence.

Partial portal vein arterialization using right gastroepiploic artery:A novel solution for portal hypoperfusion

To the Editor:Establishing dual arterial and portal inflow is essential for liver transplantation[1].Inadequate portal inflow compromises graft function and graft survival[2].Portal hypoperfusion is usually a consequence of spontaneous portosystemic shunt,ligation of which

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma(HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such,further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Liver Transplantation for Hepatitis B Virus-related Hepatocellular Carcinoma in Hong Kong

Hepatocellular carcinoma(HCC)is the fifth most common cancer and the third most common cause of cancer-related deaths worldwide.Curative resection is frequently limited in Hong Kong by hepatitis B virus-related cirrhosis,and liver transplantation is the treatment of choice.Liver transplanta-tion has been shown to produce superior oncological benefits,when compared to hepatectomy for HCC.New developments in the context of patient selection criteria,modification of organ allocation,bridging therapy,salvage liver transplanta-tion and pharmaceutical breakthrough have improved the survival of HCC patients.In this article,we will share our experience in transplanting hepatitis B virus-related HCC patients in Hong Kong and discuss the recent progress in several areas of liver transplantation.

The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions

Background:The finding of pancreatic cystic lesions(PCL)on incidental imaging is becoming increasingly common.International studies report a prevalence of 2.2-44.7%depending on the population,imaging modality and indication for imaging,and the prevalence increases with age.Patients with PCL are at risk of developing pancreatic cancer,a disease with a poor prognosis.This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency(PEI)from a group of local specialists.Methods:Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022.The expert panel included gastroenterologists,hepatobiliary surgeons,oncologists,radiologists,and endocrinologists.Results:Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions.They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient.Where indicated,patients should undergo pancreatectomy to excise PCL.Following pancreatectomy,patients are at risk of PEI,leading to gastrointestinal dysfunction and malnutrition.Therefore,such patients should be monitored for symptoms of PEI,and promptly treated with pancreatic enzyme replacement therapy(PERT).Patients with poor response to PERT may require increases in dose,addition of a proton pump inhibitor,and/or further investigation,including tests for pancreatic function.Patients are also at risk of new-onset diabetes mellitus after pancreatectomy;they should be screened and treated with insulin if indicated.Conclusions:These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.

Experience of living donor liver transplantation for hepatocellular carcinoma in the University of Hong Kong Hospital

Aim:To describe the current practise of living donor liver transplantation(LDLT)for hepatocellular carcinoma(HCC),including the patient selection criteria,surgical techniques,management of small-for-size syndrome,postoperative complications,and the results of our units,in the Liver Transplant Centre of Queen Mary Hospital,Hong Kong,one of the high-volume centres for LDLT in Asia.Methods:Our centre practises careful selection for HCC patients using the University of California,San Francisco(UCSF)criteria,supplemented by alpha-fetoprotein level and the model for end-stage liver disease score.Slight flexibility is offered to enthusiastic donors and recipients in LDLT while balancing the risks and benefits.We pioneered in using the extended right lobe graft and the novel hepatic venoplasty technique,which lessen the risk of hyperperfusion and small-for-size syndrome with improved overall recipient survival.Data were collected prospectively and presented as the mean values and ranges,or the number of patients in proportion of total patient population.Results:Of our patients,74.9% met the UCSF criteria,and 64.5% met the Milan criteria.A 5-year overall and disease-free survival rate of 78.9% and 76.3% were achieved.Conclusion:LDLT is an ideal treatment for HCC in Hong Kong with regard to the critical organ shortage and high demand for transplantation.The current surgical techniques and post-transplant surveillance contribute to the positive outcome.

Combined sarcomatoid hepatocellular and cholangiocarcinoma:a case report and literature review

Hepatic sarcomatoid carcinomas are very rare.The majority of cases contain sarcomatoid features with either hepatocellular carcinoma(HCC)or cholangiocarcinoma(CC)elements alone.These are aggressive tumors and carry an unfavorable prognosis.We describe an extremely rare tumor sub-type of combined sarcomatoid HCC and CC in a hepatitis B virus carrier presenting with abdominal pain.Pre-operative imaging suggested a segment VI hepatocellular cancer with no metastatic spread.En bloc surgical resection with the right adrenal gland,Gerota’s fascia and right hemidiaphragm was performed.The patient suffered early peritoneal tumor recurrence and lymph node metastasis.Pre-operative diagnosis of such sarcomatoid tumors is diffi cult.Current evidence for adjuvant treatment is also limited.Prognosis of these patients remains extremely poor,and surgery appears to be the only curative option in cases of early disease.It is essential that clinicians carry a high index of suspicion and awareness of this rare pathological entity to improve patient outcome.

Liver transplantation:would it be the best and last chance of cure for hepatocellular carcinoma with major venous invasion?

Background:Hepatocellular carcinoma(HCC)with portal vein tumour thrombus(PVTT)signifies advanced disease,whether LT confers any survival superiority over resection remains uncertain.Methods:A propensity score matched(PSM)analysis of liver transplantation(LT)and liver resection(LR)for HCC with PVTT was performed.Results:A consecutive series of 88 patients who received either LT(10 DDLTs and 3 LDLTs)or LR(n=75)respectively were recruited.Before PSM,the LT group has a higher MELD score(17.3 vs.7.8,P<0.001),lower serum AFP levels(96 vs.2,164 ng/mL,P=0.017)and smaller tumour size(4 vs.10 cm,P<0.001).The 5-year overall survival for LT and LR were 55.4%and 15.9%respectively(P=0.007).After matching for serum AFP levels and tumour size,1-,3-and 5-year overall survival for LT were 81 ng/mL,3.9 cm,80%,70%and 70%and the corresponding rates for LR were 1,417 ng/mL,5.3 cm,51.8%,19,6%and 9.8%(P value=0.12,0.27 and 0.009 respectively).Conclusions:LT is associated with significantly better oncological outcomes in HCC patients with PVTT involving the lobar or segmental level.A modest expansion of selection criteria to include small HCC with segmental PVTT should be considered.

Erratum:Defining the role of laparoscopic liver resection in elderly HCC patients:a propensity score matched analysis

This is an Erratum of the publsihed paper:Defining the role of laparoscopic liver resection in elderly HCC patients:a propensity score matched analysis.The ethical approval and consent to participation information were missing in the DECLARATIONS section due to the production issue.The original article has been updated.

Resection of hepatocellular carcinoma after combined treatment with transarterial chemoembolization and sorafenib:a case report and literature review

Hepatocellular carcinoma(HCC)with inferior vena cava(IVC)invasion and metastatic lymph node metastases has a poor prognosis,and surgical resection is seldom indicated.We report how an initially unresectable HCC in a 36-year-old Chinese male with distant lymph node metastases and tumor thrombosis in the IVC was successfully downstaged and ultimately resected together with the IVC.After the disease had been downstaged,curative resection of the tumor and IVC was conducted with immediate reconstruction of the IVC.The patient has survived for more than 2 years after the surgery.In conclusion,tumor and IVC resection can cure metastatic HCC after downstaging treatment combining sorafenib and transarterial chemoembolization.