Management of centrally located hepatocellular carcinoma:Update 2016

Centrally located hepatocellular carcinoma(HCC)is sited in the central part of the liver and adjacent to main hepatic vascular structures.This special location is associated with an increase in the difficulty of surgery,aggregation of the recurrence disease,and greater challenge in disease management.This review summarizes the evolution of our understanding for centrally located HCC and discusses the development of treatment strategies,surgical approaches and recurrence prevention methods.To improve patient survival,a multi-disciplinary modality is greatly needed throughout the whole treatment period.

Predictive factors for central lymph node metastases in papillary thyroid microcarcinoma

Papillary thyroid microcarcinoma(PTMC)measures 1 cm or less in its longest dimension.The incidence of PTMC is increasing worldwide.Surgery is the primary treatment;however,prophylactic central lymph node dissection is controversial,and discrepancies between different guidelines have been noted.Routine prophylactic central lymph node dissection may result in hypoparathyroidism and recurrent laryngeal nerve injury in some patients without lymph node metastasis,while simple thyroidectomy may leave metastatic lymph nodes in high-risk patients.To selectively perform prophylactic lymph node dissections in high-risk patients,it is important to identify predictive factors for lymph node metastases in patients with PTMC.Several studies have reported on this,but their conclusions are not entirely consistent.Several clinicopathologic characteristics have been identified as risk factors for central lymph node metastases,and the most commonly reported factors include age,gender,tumor size and location,multifocality,bilaterality,extrathyroidal extension,and abnormal lymph node found using ultrasound.Here,we provide an overview of previous studies along with a favorable opinion on or against these factors,with the aim of increasing the understanding of this topic among the medical community.In addition,current opinions about prophylactic central lymph node dissection are reviewed and discussed.

Inhibitory Effect of Pulmonary Carcinoma by Adenovirus-Mediated CD/UPRT Gene

The cell killing effects and bystander effects of double suicide gene on pulmonary carcinoma cells were explored. Lung adenocarcinoma cells （A549） were transfected with different titers of adenovirus vector and followed with different concentrations of 5-FC after a recombinant adenovirus vector carrying CD/UPRT gene （Ad-CD/UPRT） was constructed. The cell viability was measured by MTT assay 4 days later. The cell viability was dropped to 30.57 %-8.62 % after 10 MOI of Ad-CD/UPRT transfected and 5-FC （10-1000 μg/mL） administration. Furthermore, Ad-CD/UPRTinfected A549 cells showed a profound neighbor cell killing effect in the same methods. These results suggested that Ad-CD/UPRT/5-FC system can effectively suppress growth of lung adenocarcinoma cells, which may provide a novel and powerful candidate for lung cancer gene therapy strategies.

Nonintubated thoracoscopic lobectomy plus lymph node dissection following segmentectomy for central type pulmonary masses

Lung cancer is the most common cancer worldwide. In the United States, it causes more cancer-related deaths than the next four causes （breast cancer, prostate cancer, colon cancer, and pancreatic cancer） of cancer-related mortality combined （1）. About 30% of people have already progressed to stage III lung cancer and 40% to stage IV at the time they are diagnosed （2）. Although chest X-ray and sputum cytology, when applied in health check-ups, can identify some relatively small tumors, they are not able to lower the overall mortality （3）. More recently,

Three-dimensional morphometric analysis for hepatectomy of centrally located hepatocellular carcinoma:A pilot study

AIM: To describe a three-dimensional model(3DM) to accurately reconstruct anatomic relationships of centrally located hepatocellular carcinomas(HCCs).METHODS: From March 2013 to July 2014, reconstructions and visual simulations of centrally located HCCs were performed in 39 patients using a 3D subject-based computed tomography(CT) model with customdeveloped software. CT images were used for the 3D reconstruction of Couinaud's pedicles and hepatic veins, and the calculation of corresponding tumor territories and hepatic segments was performed using Yorktal DMIT software. The respective volume, surgical margin, and simulated virtual resection of tumors were also estimated by this model preoperatively. All patients were treated surgically and the results were retrospectively assessed. Clinical characteristics, imaging data, procedure variables, pathologic features, and postoperative data were recorded and compared to determine the reliability of the model.RESULTS: 3D reconstruction allowed stereoscopic identification of the spatial relationships between physiologic and pathologic structures, and offered quantifiable liver resection proposals based on individualized liver anatomy. The predicted values were consistent with the actual values for tumor mass volume(82.4 ± 109.1 m L vs 84.1 ± 108.9 m L, P = 0.910), surgical margin(10.1 ± 6.2 mm vs 9.1 ± 5.9 mm, P = 0.488), and maximum tumor diameter(4.61 ± 2.16 cm vs 4.53 ± 2.14 cm, P = 0.871). In addition,the number and extent of portal venous ramifications, as well as their relation to hepatic veins, were visualized. Preoperative planning based on simulated resection facilitated complete resection of large tumors located in the confluence of major vessels. And most of the predicted data were correlated with intraoperative findings.CONCLUSION: This 3DM provides quantitative morphometry of tumor masses and a stereo-relationship with adjacent structures, thus providing a promising technique for the management of centrally located HCCs.

Residual tumor and central lymph node metastasis after thermal ablation of papillary thyroid carcinoma: A case report and review of literature

BACKGROUND Debate exists regarding the use of thermal ablation(TA)to treat papillary thyroid carcinoma(PTC).Some studies have recommended TA as a new,ef
cient and safe technology for PTC.In this article,we report one case of a residual tumor and central lymph node metastasis(CLNM)after TA for PTC.CASE SUMMARY A 63-year-old female underwent bilateral ultrasound(US)-guided radiofrequency ablation for PTC.Three months later,she was diagnosed as thyroid cancer with suspected CLNM by US and contrast-enhanced computed tomography.The subsequent fine-needle aspiration(FNA)biopsies were negative.Due to her strong personal preference,she underwent total thyroidectomy and central lymph node dissection.Local tissue adhesion and a difficult dissection were noted during the operation.The pathology of the frozen sections during the operation was still negative.The final pathology results of paraffin-embedded sections revealed residual tumor cells at the edge of the PTC and CLNM.CONCLUSION TA may lead to a residual tumor in patients with PTC.Follow-up using US and FNA biopsy may not be adequate to evaluate the residual tumor.TA should be carefully considered in PTC treatment.

Role of prophylactic central neck lymph node dissection for papillary thyroid carcinoma in the era of de-escalation

Thyroid cancer is the most common endocrine malignancy.While there has been no appreciable increase in the observed mortality of well-differentiated thyroid cancer,there has been an overall rise in its incidence worldwide over the last few decades.Patients with papillary thyroid carcinoma(PTC)and clinical evidence of central(cN1)and/or lateral lymph node metastases require total thyroidectomy plus central and/or lateral neck dissection as the initial surgical treatment.Nodal status in PTC patients plays a crucial role in the prognostic evaluation of the recurrence risk.The 2015 guidelines of the American Thyroid Association(ATA)have more accurately determined the indications for therapeutic central and lateral lymph node dissection.However,prophylactic central neck lymph node dissection(pCND)in negative lymph node(cN0)PTC patients is controversial,as the 2009 ATA guidelines recommended that CND“should be considered”routinely in patients who underwent total thyroidectomy for PTC.Although the current guidelines show clear indications for therapeutic CND,the role of pCND in cN0 patients with PTC is still debated.In small solitary papillary carcinoma(T1,T2),pCND is not recommended unless there are high-risk prediction factors for recurrence and diffuse nodal spread(extrathyroid extension,mutation in the BRAF gene).pCND can be considered in cN0 disease with advanced primary tumors(T3 or T4)or clinical lateral neck disease(cN1b)or for staging and treatment planning purposes.The role of the preoperative evaluation is fundamental to minimizing the possible detrimental effect of overtreatment of the types of patients who are associated with low disease-related morbidity and mortality.On the other hand,it determines the choice of appropriate treatment and determines if close monitoring of patients at a higher risk is needed.Thus,pCND is currently recommended for T3 and T4 tumors but not for T1 and T2 tumors without high-risk prediction factors of recurrence.

Correlation between Central and Lateral Neck Dissection in Differentiated Thyroid Carcinoma

Objective: To determine the histopathological correlation between central and lateral neck metastasis in differentiated thyroid carcinoma, and its potential therapeutic impact. Although the central neck dissection (CND) is recommended in differentiated thyroid carcinoma, the indication for lateral neck dissection (LND) remains controversial. Design: Retrospective study. Methods and Main Outcome Measures: Pathological analysis of systematic ipsilateral central neck dissection (CND) and LND performed with total thyroidectomy in differentiated thyroid carcinoma was retrospectively reviewed according to “side” and to “patient”. Results: A total of 56 sides (46 patients) were suitable for analysis. Analysis by “side” revealed that CND and LND dissection samples were both negative in 15 cases, both positive in 32, CND was positive and LND was negative for 8 cases and CND was negative and LND was positive in 1 case. The combined presence of positive LND and positive CND was therefore observed in 32/40 “sides” and 26/46 “patients”. Analysis by “side” of the impact of the treatment decision to perform ipsilateral LND only in patients with positive CND and vice versa demonstrated a sensitivity, specificity, and accuracy of 97%, 65%, and 84%, respectively. Conclusions: In most cases, the presence of positive LND was associated with positive ipsilateral CND. The very low prevalence of positive LND in patients with negative CND may justify LND as a second step procedure only in patients with positive CND, except in the case of documented lateral neck metastasis.

The Number of Lymph Nodes and Relationship with Presence of Thyroiditis and Thymic Tissue in the Central Neck Dissection Materials for Thyroid Papillary Carcinoma: Pathologic Analysis

Background: Central lymph node dissection (CLND) for papillary thyroid carcinoma (PTC) allows correct pathologic staging of lymph nodes and planning of postoperative management. The purpose of this study was to determine the number of the lymph nodes in the CLND and the relationship to presence of chronic lymphocytic thyroiditis (CLT) and thymic tissue (TT). Methods: Total thyroidectomy and CLND materials from 153 patients with PTC were included in this study. Two histopathologic features (presence of CLT and TT) were evaluated for their value in adequacy of CLND. Results: Histopathologic examination revealed CLT and TT in CLND materials in 70 (46%) and 63 (41%) patients, respectively. Total number of lymph nodes in CLND materials was significantly higher in CLT (+) and TT (+) groups (p Conclusions: Our study demonstrates that presence of CLT in thyroid gland has been associated with higher number of central lymph nodes mainly due to increased number of benign hyperplastic lymph nodes. It may be possible to conclude that upper limit of lymph nodes for satisfactory CLND would be higher to correctly evaluate central lymph node status in existing staging systems if specimens have CLT. Results of this study also show that the presence of TT in surgical materials may represent the adequacy of CLND.

Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery,ensuring the complete removal of the primary tumor and draining lymph nodes is crucial.Lymphatic drainage in the colon follows the vascular supply,typically progressing from pericolic to paraaortic lymph nodes.While NCCN guidelines recommend the removal of 10-12 lymph nodes for ade-quate oncological resection,achieving complete oncological resection involves more than just meeting these numerical targets.Various techniques have been developed and studied over time to attain optimal oncological outcomes.A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels.Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen,while D3 lymphade-nectomy targets all draining regional lymph nodes.Although these principles emphasize different aspects,they ultimately converge to achieve the same goal of complete oncological resection.This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Treatment of superior vena cava syndrome caused by pulmonary carcinoma with percutaneous endovascular stent

Objective To evaluate value of endovascular stent in treatment of superior vena cava syndrome(SVCS) caused by pulmonary carcinoma.Methods There were ten diagnosed SVCS male patients,aged from 63 to 81.With DSA scanning,the lesion was confirmed and localized through angiography.Appropriate stent was advanced and inserted at a right place.Stents were observed for their positions by fluoroscopy or chest films and patency of blood stream by echo-Doppler during follow-up.Results Initial clinical success was achieved to 100%.Average venous pressure of distal end of SVC decreased from 31.5 cm H2O before and 14.7 cm H2O(P<0.05) after stent insertion,and related clinical symptoms and signs significantly alleviated or disappeared within 2～3 days.No symptoms or signs of stents displacement or pulmonary embolism could be detected during follow-up.Recurrent symptoms of SVCS were found in two cases,one was conduced by thrombosis at the stent three days after operation,and the others were caused by carcinoma progression 90 days after operation.Five cases survived for 11,11,12,14,20 months up to now.Conclusion Percutaneous endovascular stent insertion is a mini-invasive,effective,rapid technique and usually the first choice of treatment for palliation of SVCS.To prolong survival,appropriate treatment of pulmonary carcinoma is important.

Clinicopathological and Molecular Biological Studies of Primary Pulmonary Carcinoma with the p53 Gene Mutations

Objective To investigate the relationship between p53 aberrations and human pulmonary carcinoma prognosis and to evaluate as a genetic marker in the prognostic significance of the P53 mutations in the lung cancer. Methods DNAs from normal(n=5) and tumor(n=31) tissue specimens from non-small cell lung carcinomas(NSCLC), p53 exons 5-8 mutations were analyzed by polymerase chain reaction single-strand conformation polymorphism(PCR-SSCP) analysis. Results The detected mutation rate is 48.4%(15/31) in the pulmonary carcinoma group, which was significantly higher than that in the control group. The control group showed that there is no p53 mutations. In the pulmonary carcinoma group, detection rates of p53 exons 5-8 mutations for squamous cell carcinomas, adenocarcinomas, bronchioloalveolar carcinomas and large cell carcinomas were 56.3%, 30.0%, 33.3% and 100.0%, respectively. The incidence of p53 point mutational activation in the adenocarcinomas was lower in pulmonary carcinomas as compared to that in the squamous cell carcinomas. The level of p53 gene mutations was associated with TNM stages, the mutations of p53 gene in cancer tissues of the stages Ⅲ-Ⅳ were higher than in tumor stage Ⅰ and/or stage Ⅱ(χ~2=6.556, P=0.038). The mutations in poor differentiated tumors were obviously higher than well differentiated and moderately differentiated tumors(χ~2=4.045, P=0.044; χ~2=4.232, P=0.040, respectively). However, statistical analysis showed that there is no significant correlations between p53 mutations and other clinical parameters, such as: age, sex, tumor size, and histological subtypes. Conclusion Detection of p53 gene mutations in lung carcinomas by PCR-SSCP can be used as a follow-up intermediate biomarker for the prognostic surveillance of human pulmonary carcinoma.

Low central venous pressure reduces blood loss in hepatectomy

AIM： To investigate the effect of low central venous pressure （LCVP） on blood loss during hepatectomy for hepatocellular carcinoma （HCC）. METHODS： By the method of sealed envelope, 50 HCC patients were randomized into LCVP group （n=25） and control group （n=25）. In LCVP group, CVP was maintained at 2-4 mmHg and systolic blood pressure （SBP） above 90 mmHg by manipulation of the patient＇s posture and administration of drugs during hepatectomy, while in control group hepatectomy was performed routinely without lowering CVP. The patients＇ preoperative conditions, volume of blood loss during hepatectomy, volume of blood transfusion, length of hospital stay, changes in hepatic and renal functions were compared between the two groups. RESULTS： There were no significant differences in patients＇ preoperative conditions, maximal tumor dimension, pattern of hepatectomy, duration of vascular occlusion, operation time, weight of resected liver tissues, incidence of post-operative complications, hepatic and renal functions between the two groups. LCVP group had a markedly lower volume of total intraoperative blood loss and blood loss during hepatectomy than the control group, being 903.9 ± 180.8 mL vs 2 329.4 ±2 538.4 （W=495.5, P〈0.01） and 672.4±429.9 mL vs 1 662.6±1 932.1 （W=543.5, P〈0.01）. There were no remarkable differences in the pre-resection and post-resection blood losses between the two groups. The length of hospital stay was significantly shortened in LCVP group as compared with the control group, being 16.3±6.8 d vs 21.5 ± 8.6 d （W= 532.5, P〈0.05）.CONCLUSION： LCVP is easily achievable in technique. Maintenance of CVP ≤4 mmHg can help reduce blood loss during hepatectomy, shorten the length of hospital stay, and has no detrimental effects on hepatic or renal function.

Effect of controlled low central venous pressure on renal function in major liver resection

Objective： To investigate the effects of low central venous pressure （LVCP） on blood loss and evaluate its influence on renal function in patients undergoing hepatectomy. Methods： Forty-six patients, ASA classification Ⅰ-Ⅲ, undergoing liver resection were randomized into LCVP group （n = 23） and control group （n = 23）. In LCVP group, CVP was maintained at 2-4 mmHg and MBP above 60 mmHg during hepatectomy, while in control group hepatectomy was performed routinely without lowering CVP. Volume of blood loss during hepatectomy, volume of blood transfusion, and changes of renal functions were compared between the two groups. Results： There were no significant differences in demographics, ASA score, type of hepatectomy, duration of inflow occlusion, operation time, weight of resected liver tissues, and renal functions between the two groups. LCVP group had a significantly lower volume of total intraoperative blood loss （P 〈 0.01） and RBC transfusion （P 〈 0.05）. Conclusion： Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss and blood infusion during liver resection, and has no detrimental effects on renal functions.

Standards of liver cirrhosis care in Central Australia

BACKGROUND Liver cirrhosis and hepatocellular carcinoma(HCC)are highly prevalent in Australia’s Northern Territory.Contributing factors include high levels of alcohol consumption,viral hepatitis and metabolic syndrome.Rural Aboriginal residents form a significant proportion of the Central Australian population and present a challenge to traditional models of liver care.HCC surveillance and variceal screening are core components of liver cirrhosis management.AIM To assess participation in HCC and variceal surveillance programmes in a Central Australian liver cirrhosis patient cohort.METHODS Retrospective cohort study of patients with liver cirrhosis presenting to Alice Springs Hospital,Australia between January 1,2012 and December 31,2017.Demographic data,disease severity,attendance at hepatology clinics,participation in variceal and/or HCC surveillance programmes was recorded.Regression analyses were conducted to assess factors associated with two independent outcomes:Participation in HCC and variceal surveillance.RESULTS Of 193 patients were identified.82 patients(42.4%)were female.154 patients(80%)identified as Aboriginal.Median Model for End-stage Liver Disease Score at diagnosis was 11.Alcohol was the most common cause of cirrhosis.Aboriginal patients were younger than non-Aboriginal patients(48.4 years vs 59.9 years,P<0.001).There were similar rates of excess alcohol intake(72.6%vs 66.7%,P=0.468)and obesity(34.5%vs 38.4%,P=0.573 across non-Aboriginal and Aboriginal cohorts.20.1%of patients took part in HCC surveillance and 42.1%of patients completed variceal screening.Aboriginal patients were less likely to engage with either HCC surveillance(OR:0.38,95%CI:0.16-0.9,P=0.025)or undergo variceal screening(OR:0.31,95%CI:0.14-0.65,P=0.002).CONCLUSION HCC or variceal surveillance programmes had less uptake amongst Aboriginal patients.Greater emphasis needs to be placed on eliminating cultural obstacles to accessing hepatology services.

Left lower lobe sleeve resection for the clear cell variant of pulmonary mucoepidermoid carcinoma:A case report

BACKGROUND Pulmonary mucoepidermoid carcinoma(PMEC)is a rare malignancy that arises from minor salivary glands within the tracheobronchial tree.The clear cell variant of PMEC is exceptionally uncommon and presents notable diagnostic challenges,primarily attributable to its morphological similarity to other tumors containing clear cells.CASE SUMMARY A 22-year-old male,formerly in good health,came in with a two-month duration of persistent cough and production of sputum.Subsequent imaging and bronchoscopy examinations revealed a 2 cm tumor in the distal left main bronchus,which resulted in complete atelectasis of the left lung.Further assessment via positron emission tomography/computed tomography scans and endoscopic biopsy confirmed the primary malignant nature of the tumor,charac-terized by clear cell morphology in most of the tumor cells.The patient underwent a left lower lobe sleeve resection accompanied by systematic mediastinal lymph node dissection.Molecular pathology analysis subsequently revealed a CRTC3-MAML2 gene fusion,leading to a definitive pathological diagnosis of the clear cell variant of PMEC,staged as T2N0M0.After surgery,the patient experienced a smooth recovery and exhibited no signs of recurrence during the one-and-a-half-year follow-up period.CONCLUSION This article describes an unusual case of a clear cell variant of PMEC characterized by the presence of a CRTC3-MAML2 gene fusion in a 22-year-old male.The patient underwent successful left lower lobe sleeve resection.This case underscores the distinctive challenges associated with diagnosing and treating this uncommon malignancy,underscoring the importance of precise diagnosis and personalized treatment strategies.

Clinical Observation on Effect of Kanglaite(康莱特)in Treating Pulmonary Carcinoma Patients withLung-Qi Deficienoy and ImmunologicInadequacy sfter Pneumonectomy

Objective: To study the effect of Kanglaite (KLT) in treating pulmonary carcinoma (PC) patients with Lung-Qi Deficiency and immunologic inadequacy (LDII) after pneumonectomy. Methods: Thirtysix patients of PC-LDII were treated with KLT and the lymphocyte subset was examined before and after treatment. Results: The markedly effective rate of treatment was 50. 0 % and the total effective rate 66. 7%. Immunological examination showed that the lymphocyte subset of patients tended to get normal and the difference between pre-treatment and post-treatment was significant. Conclusion: KLT could improve the symptom ofLung-Qi Deficiency and markedly strengthen the immune function of PC patients.

Effects of herpes simplex virus thymidine kinase/acyclovir system on growth of human pulmonary adenocarcinoma A549 cell line in vitro and in vivo

Objective: To observe the effect of anciclovir (ACV) treatment on tumors induced by inoculation of TK gene-transfected human pulmonary adenocarcinoma A549 cells in nude mice. Methods: A recombinant plasmid containing TK gene was constructed and transfected into A549 cells by electroporation. The sensitivity of the transgenic cells (A549-TK) to ACV was examined by MTT assay in vitro and for in vivo observation, inoculation of A549-TK and A-549 cells into nude mice was separately performed to induce tumor growth, the response of which to ACV treatment was observed, and the tumor tissues were pathologically examined. Results: A recombinant plasmid containing TK gene was successfully constructed and transfected into A549 cells. The sensitivity of A549-TK cells to ACV was 43 times higher than that of A549 cells. The tumors induced by A549-TK cells showed no significant increase in size after ACV treatment (P>0. 05) , and light microscopy revealed local tissue necrosis, karyoklasis, and nuclei disappearance. Conclusion: A549-TK cells acquires sensitivity to ACV both in vitro and in vivo, and ACV can inhibit the growth of tumors induced by A549-TK cell inoculation in nude mice.

Pulmonary tumor thrombotic microangiopathy of hepatocellular carcinoma: A case report and review of literature

BACKGROUND Pulmonary tumor thrombotic microangiopathy(PTTM)is a rare condition in patients with hepatocellular carcinoma(HCC);to date,few cases have been reported.While hepatic dysfunction has been focused on the later stages of HCC,the management of symptoms in PTTM is important for supportive care of the cases.For the better understanding of PTTM in HCC,the information of our recent case and reported cases have been summarized.CASE SUMMARY A patient with HCC exhibited acute and severe respiratory failure.Radiography and computed tomography of the chest revealed the multiple metastatic tumors and a frosted glass–like shadow with no evidence of infectious pneumonia.We diagnosed his condition as acute respiratory distress syndrome caused by the lung metastases and involvement of the pulmonary vessels by tumor thrombus.Administration of prednisolone to alleviate the diffuse alveolar damages including edematous changes of alveolar wall caused by the tumor cell infiltration and ischemia showed mild improvement in his symptoms and imaging findings.An autopsy showed the typical pattern of PTTM in the lung with multiple metastases.CONCLUSION PTTM is caused by tumor thrombi in the arteries and thickening of the pulmonary arterial endothelium leading to the symptoms of dyspnea in terminal staged patients.Therefore,supportive management of symptoms is necessary in the cases with PTTM and hence we believe that the information presented here is of great significance for the diagnosis and management of symptoms of PTTM with HCC.

Clinical outcome after pulmonary metastasectomy from primary hepatocellular carcinoma:Analysis of prognostic factors

AIM： To review the surgical outcomes in terms of the surgical indications and relevant prognostic factors. METHODS： Sixteen patients underwent therapeutic lung surgery between March 1999 and May 2006. The observation period was terminated on May 31, 2007. The surgical outcomes and the clinicopathological factors were compared. RESULTS： There was no mortality or major morbidity encountered in this study. The mean follow-up period after metastasectomy was 26.7 ＋ 28.2 （range： 1-99 mo）, and the median survival time was 20 mo. The 1- and 5-year survival rates were 56% and 26%, respectively. At the end of the follow-up, 1 patient died from hepatic failure without recurrence, 6 died from hepatic failure with a recurrent hepatocellular carcinoma （HCC）, and 4 died from recurrent HCC with cachexia. Among several clinical factors, Kaplan Meier analysis revealed as a treatment for the that liver transplantation primary lesion, grade of cell differentiation, and negative evidence HBV infection were independent predictive factors. On Cox＇s proportional hazard model, there were no significant factors affecting survival after pulmonary metastasectomy in patients with HCC. CONCLUSION： A metastasectomy should be performed before other treatments in selected patients, Although not significant, patients with liver transplantation of a primary HCC survived longer, Liver transplantation might be the most beneficial modality that can offer patients better survival, A multi- institutional and collaborative study would be needed for identifying clinical prognostic factors predicting survival in patients with HCC and lung metastasis.