Hepatocellular carcinoma:Surgical perspectives beyond the barcelona clinic liver cancer recommendations

The barcelona clinic liver cancer(BCLC)staging system has been approved as guidance for hepatocellular carcinoma(HCC)treatment guidelines by the main Western clinical liver associations.According to the BCLC classification,only patients with a small single HCC nodule without signs of portal hypertension or hyperbilirubinemia should undergo liver resection.In contrast,patients with intermediate-advanced HCC should be scheduled for palliative therapies,even if the lesion is resectable.Recent studies report good short-term and long-term outcomes in patients with intermediate-advanced HCC treated by liver resection.Therefore,this classification has been criticised because it excludes many patients who could benefit from curative resection.The aim of this review was to evaluate the role of surgery beyond the BCLC recommendations.Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%.Surgery also offers good long-term result in selected patients with multiple or large HCCs with a reported 5-year survival rate of over 50%and 40%,respectively.Although macrovascular invasion is associated with a poor prognosis,liver resection provides better long-term results than palliative therapies or best supportive care.Recently,researchers have identified several genes whose altered expression influences the prognosis of patients with HCC.These genes may be useful for classifying the biological behaviour of different tumours.A revision of the BCLC classification should be introduced to provide the best treatment strategy and to ensure the best prognosis in patients with HCC.

Elevated fibrinogen plasma level is not an independent predictor of poor prognosis in a large cohort of Western patients undergoing surgery for colorectal cancer

AIM To evaluate the clinical significance of the preoperative fibrinogen plasma level as a prognostic marker after surgery for colorectal cancer.METHODS This retrospective study analysed 652 patients undergoing surgery for stage Ⅰ-Ⅳ colorectal cancer between January 2005 and December 2012, at the Division of General Surgery A, University of Verona Hospital Trust, in whom preoperative fibrinogen plasma values were assessed at baseline. Fibrinogen is involved in tumourigenesis as well as tumour progression in several malignancies. Correlations between preoperative plasma fibrinogen values and clinicopathological characteristics were investigated. Univariate and multivariate survival analyses were performed to identify factors associated with overall and tumour-related survival.RESULTS Among the 652 patients, the fibrinogen value was higher than the threshold of 400 mg/dL in 345 patients(53%). The preoperative mean ± SD of fibrinogen was 426.2 ± 23.2 mg/dL(median: 409 mg/dL; range: 143-1045 mg/d L). Preoperative fibrinogen values correlated with age(P = 0.003), completeness of tumour resection, potentially curative vs palliative(P < 0.001), presence of systemic metastasis(P < 0.001), depth of tumour invasion p T(P < 0.001), nodes involvement p N(P = 0.001) and CEA serum level(P < 0.001). The mean fibrinogen value(± SD) was 395.6 ± 120.4 mg/d L in G1 tumours, 424.1 ± 121.4 mg/dL in G2 tumours and 453.4 ± 131.6 mg/dL in G3 tumours(P = 0.045). The overall survival and tumourrelated survival were significantly higher in patients with fibrinogen values ≤ 400 mg/d L(P < 0.001). However, hyperfibrinogenemia did not retain statistical significance regarding either overall(P = 0.313) or tumour-related survival(P = 0.355) after controlling for other risk factors in a multivariate analysis.CONCLUSION Preoperative fibrinogen levels correlate with cancer severity but do not help in predicting patient prognosis after colorectal cancer surgery.