Concomitant lung metastasis in patients with advanced hepatocellular carcinoma

AIM:To investigate the clinical features and prognostic factors of advanced hepatocellular carcinoma (HCC)patients presenting with lung metastasis at initial diagnosis. METHODS:Between 2001 and 2010,we recruited 76 consecutive HCC patients initially presenting with lung metastasis,without co-existing metastasis from other sites.These patients were divided into three groups:untreated group(n=22),single treatment group(n= 19),and combined treatment group(n=35). RESULTS:Metastasis of bilateral lung lobes was common and noted in 35 patients(46.1%),and most of patients(59/76,77.6%)presented with multiple lung metastatic nodules.Nineteen patients(25.0%) received single-method treatment,including hepatectomy in 4,transcatheter arterial chemoembolization in 6,radiotherapy in 5,and oral sorafenib in 4.Thirty-five patients(46.1%)received combined treatment modalities.The overall median survival of the all patients was 8.7±0.6 mo;4.1±0.3,6.3±2.5 and 18.6±3.9 mo, respectively in the untreated group,single treatment group and combined treatment group,respectively, with a significant difference(log-rank test,P<0.001). Multivariate analysis revealed that Child-Pugh score, the absence or presence of portal vein tumor thrombus,and treatment modality were three independent prognostic factors affecting survival of patients with advanced HCC and concomitant lung metastasis. CONCLUSION:Combined treatment modalities tend to result in a better survival as compared with the conservative treatment or single treatment modality for HCC patients initially presenting with lung metastasis.

Grey zone in the Barcelona Clinic Liver Cancer Classification for hepatocellular carcinoma: Surgeons' perspective

Hepatocellular carcinoma(HCC) is the sixth most common cancer and the third most common cause of cancer-related deaths worldwide. The Barcelona Clinic Liver Cancer(BCLC) classification has been endorsed as the optimal staging system and treatment algorithm for HCC by the European Association for the Study of Liver Disease and the American Association for the Study of Liver Disease. However, in real life, the majority of patients who are not considered ideal candidates based on the BCLC guideline still were performed hepatic resection nowadays, which means many hepatic surgeons all around the world do not follow the BCLC guidelines. The accuracy and application of the BCLC classification has constantly been challenged by many clinicians. From the surgeons' perspectives, we herein put forward some comments on the BCLC classification concerning subjectivity of the assessment criteria, comprehensiveness of the staging definition and accuracy of the therapeutic recommendations. We hope to further discuss with peers and colleagues with the aim to make the BCLC classification more applicable to clinical practice in the future.

Classification of right hepatectomy for special localized malignant tumor in right liver lobe

AIM: To describe a new classification method of right hepatectomy according to the different special positions of tumors.METHODS: According to positions, 91 patients with malignant hepatic tumor in the right liver lobe were divided into six groups: tumors in the right posterior lobe and (or) the right caudate lobe compressing the right portal hilum (n = 14, 15.4%), tumors in the right liver lobe compressing the inferior vena cava and (or) hepatic veins (n = 11, 12.9%), tumors infiltrating diaphragmatic muscle (n = 7, 7.7%), tumors in the hepatorenal recess (infiltrating the right fatty renal capsule, transverse colon and right adrenal gland, n = 8, 8.8%), tumors deeply located near the vertebral body (n = 3, 3.3%), tumors at other sites in the right liver lobe (the control group, n = 48,52.75%). The values of intraoperative blood loss (IBL),tumor's maxim cross-section area (TMCSA), and time of hepatic hilum clamping (THHC) and incidence of postoperative complications were compared between five groups of tumor and control group, respectively.RESULTS: The THHC in groups 1-4 was significantly longer than that in the control group, the IBL in groups 1-4 was significantly higher than that in the control group, the TMCSA in groups 2-4 was significantly larger than that in the control group, and the ratio of IBL/TMCSA in group 1 was significantly higher than that in the control group.There was no significant difference in the indexes between group 5 and the control group.CONCLUSION: The site of tumor is the key factor that determines IBL.

Endoscopic papillary large balloon dilation alone or combined with small or complete sphincterotomy for the removal of large common bile duct stones

Background:Endoscopic papillary large balloon dilation(EPLBD)has been proposed as an alternative to manage large bile duct stones.However,EPLBD alone or combined with sphincterotomy remains controversial.Methods:Between Jan.2014 and Dec.2017,195 consecutive patients with proven large common bile duct stones(size≥10 mm)were retrospectively analyzed.We compared the baseline characteristics,procedure time,success rate of stone removal and morbidity outcomes in different groups.Results:There were no significant difference between baseline characteristics of the groups compared.A total of 89.2%,95.4%,and 93.8% of the patients in the EPLBD,EPLBD+small sphincterotomy(SES),and EPLBD+complete sphincterotomy(CES)groups had stones cleared(P=0.473),respectively.There was no difference in terms of procedure time(33.5±10.2,34.8±9.0,34.9±8.2,in the EPLBD,EPLBD+SES,and EPLBD+CES groups,respectively).However,when assigned to tvvo groups according to bile duct stones diameter(bile duct stones<13 mm,bile duct stones≥13 mm).in the bile duct stones<13 mm group,the procedure time was significantly less in the EPLBD group than the EPLBD+SES group and the EPLBD+CES group(P=0.028).In the bile duct stones≥13 mm group,the mechanical lithotripsy rate of EPLBD was significantly higher compared to EPLBD+SES or EPLBD+CES(P=0.032).The complication rates were similar among all groups.Conclusions:The diameter of bile duct stones should be taken into consideration when choosing EPLBD alone or combined with small sphincterotomy for the removal of common bile duct stones.