Non-anatomical liver resection for hepatocellular carcinoma:the SegSubTe classification to overcome the problem of heterogeneity

Background:The superiority of anatomical resection(AR)vs.non-anatomical resection(NAR)in the surgical management of hepatocellular carcinoma(HCC)is debated.ARs are well-defined procedures,whereas the lack of NAR standardization results in heterogeneous outcomes.This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor.Methods:A single-center retrospective analysis of pre-and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted.The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section(segmental,subsegmental or terminal next to the tumor)of vascular pedicles feeding the HCCs;then,the population was divided in“SegSubTe-IN”or“SegSubTe-OUT”groups,and the tumor recurrence and survival were analyzed.Results:Ninety-seven patients who underwent NAR were included;76%were SegSubTe-IN and 24%were SegSubTe-OUT.Total disease recurrence,local recurrence and cut-edge recurrence in the SegSubTe-IN vs.SegSubTe-OUT groups were 50%vs.83%(P=0.006),20%vs.52%(P=0.003)and 16%vs.39%(P=0.020),respectively.SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis.One-,three-,and five-year disease-free survival rates in the SegSubTe-IN vs.SegSubTe-OUT groups were 81%,58%and 35%vs.46%,21%and 11%,respectively(P<0.001).Conclusions:The SegSubTe classification is a useful tool to stratify and standardize NAR for HCC,aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

Hepatic resection beyond barcelona clinic liver cancer indication:When and how

Hepatocellular carcinoma(HCC)is the main common primary tumour of the liver and it is usually associated with cirrhosis.The barcelona clinic liver cancer(BCLC)classification has been approved as guidance for HCC treatment algorithms by the European Association for the Study of Liver and the American Association for the Study of Liver Disease.According to this algorithm,hepatic resection should be performed only in patients with small single tumours of 2-3 cm without signs of portal hypertension(PHT)or hyperbilirubinemia.BCLC classification has been criticised and many studies have shown that multiple tumors and large tumors,as wide as those with macrovascular infiltration and PHT,could benefit from liver resection.Consequently,treatment guidelines should be revised and patients with intermediate/advanced stage HCC,when technically resectable,should receive the opportunity to be treated with radical surgical treatment.Nevertheless,the surgical treatment of HCC on cirrhosis is complex:The goal to be oncologically radical has always to be balanced with the necessity to minimize organ damage.The aim of this review was to analyze when and how liver resection could be indicated beyond BCLC indication.In particular,the role of multidisciplinary approach to assure a proper indication,of the intraoperative ultrasound for intraoperative restaging and resection guidance and of laparoscopy to minimize surgical trauma have been enhanced.

Rethinking the Barcelona clinic liver cancer guidelines:Intermediate stage and Child-Pugh B patients are suitable for surgery?

According to Barcelona Clinic Liver Cancer recommendations,intermediate stage hepatocellular carcinomas(stage B)are excluded from liver resection and are referred to palliative treatment.Moreover,Child-Pugh B patients are not usually candidates for liver resection.However,many hepatobiliary centers in the world manage patients with intermediate stage hepatocellular carcinoma or Child-Pugh B cirrhosis with liver resection,maintaining that hepatic resection is not contraindicated in selected patients with non–early-stage hepatocellular carcinoma and without normal liver function.Several studies demonstrate that resection provides the best survival benefit for selected patients in very early/early and even in intermediate stages of Barcelona Clinic Liver Cancer classification,and this treatment gives good results in the setting of multinodular,large tumors in patients with portal hypertension and/or Child-Pugh B cirrhosis.In this review we explore this controversial topic,and we show through the literature analysis how liver resection may improve the short-and long-term survival rate of carefully selected Barcelona Clinic Liver Cancer B and Child-Pugh B hepatocellular carcinoma patients.However,other large clinical studies are needed to clarify which patients with intermediate stage hepatocellular carcinoma are most likely to benefit from liver resection.

Is there a role for treatment-oriented surgery in liver metastases from gastric cancer?

BACKGROUND Distant metastases are found in approximately 35%of patients with gastric cancer at their first clinical observation,and of these,4%-14%involves the liver.Unfortunately,only 0.4%-2.3%of patients with metastatic gastric cancer are eligible for radical surgery.Although surgical resection for gastric cancer metastases is still debated,there have been changes in recent years,although several clinical issues remain to be defined and that must be taken into account before surgery is proposed.AIM To analyze the clinicopathological factors related to primary gastric tumor and metastases that impact the survival of patients with liver metastatic gastric cancer.METHODS We performed a systematic review of the literature from 2000 to 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.The study protocol was based on identifying studies with clearly defined purpose,eligibility criteria,methodological analysis,and patient outcome.RESULTS We selected 47 studies pertaining to the purpose of the review,which involved a total of 2304 patients.Median survival was 7-52.3 mo,median disease-free survival was 4.7-18 mo.The 1-,2-,3-,and 5-year overall survival(OS)was 33%-90.1%,10%-60%,6%-70.4%,and 0%-40.1%,respectively.Only five papers reported the 10-year OS,which was 5.5%–31.5%.The general recurrence rate was between 55.5%and 96%,and that for hepatic recurrence was between 15%and 94%.CONCLUSION Serous infiltration and lymph node involvement of the primary cancer indicate an unfavorable prognosis,while the presence of single metastasis or≤3 metastases associated with a size of<5 cm may be considered data that do not contraindicate liver resection.

Branching patterns of the left portal vein and consequent implications in liver surgery:The left anterior sector

To the Editor: There are still some open issues about the systematization of the knowledge of the branching of the left portal vein(LPV) and the division in anatomo-functional units within the left liver. The first controversial topic concerns the division of S4 in subsegments. The Brisbane 20 0 0 system of Nomenclature of Hepatic Anatomy and Resections(B20 0 0) [1] does not mention such subdivision, but in literature this is still a matter of discussion.

Gastric Cancer Immunotherapy: An Overview

Gastric adenocarcinoma is the third most common cancer and the second most common cause of death due to cancer worldwide. Surgery is still the major prognostic factor for gastric cancer. Patients who could not be resected have a poor prognosis with survival ranging from 3 to 11 months. There is evidence that surgical operations can cause a variety of immunological disturbances in man both in vivo and in vitro. The postoperative changes in the systemic immune response are proportional to the degree of surgical trauma leading to a generalized state of immunosuppression, which is implicated in the development of septic complications and provided a “fertile soil” for tumor cell metastasis. Immunotherapy may be a potentially promising alternative strategy for gastric cancer. In early clinical trials, systemic immunotherapy included both active vaccination directed against defined tumor-associated antigens expressed in gastric carcinoma cells and passive administration of IL-2 with some evidence of regression of metastatic gastric cancer. Other studies have applied immunotherapy in the adjuvant setting with equally promising results. For example, OK-432, a streptococcal preparation, demonstrated marginal improvement in survival for patients with stage III gastric cancer and a meta-analysis of centrally randomized controlled clinical trials indicated a significant survival benefit with combination OK-432 and chemotherapy compared to chemotherapy alone (p 0.05). Additional data suggesting a biological and clinical benefit of subcutaneous, preoperative administration of low-dose IL-2 in colon cancer encouraged us to evaluate low-dose IL-2 therapy in the neoadjuvant setting for patients with gastric adenocarcinoma who undergo surgery and to evaluate its effects on systemic and tumor infiltrating lymphocyte numbers. We also sought to determine if neoadjuvant low-dose IL-2 could influence the clinical outcome for patients undergoing gastric resection for cancer. We report the biological, histological and clinical results with the full accrual of patients and a median follow-up of 51 months.