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Surgical management of hepatic metastases in patients with stage IV breast cancer remains controversial. The purpose of this study was to examine the impact of hepatic metastasectomy on long-term outcomes.The 2004-2015 National Cancer Database was queried for all patients diagnosed with stage IV breast cancer with metastases isolated to the liver. Patient demographics, disease-, treatment- and outcome-related data were analyzed.Of 2,895 patients, only 90 (3.1%) underwent hepatic resection. Compared to patients who did not undergo metastasectomy, patients treated with metastasectomy tended to be younger (52 ± 12.7 versus 59.2 ± 14.6; P0.001) and have private insurance (74.4% versus 45.3%; P0.001). Independent predictors of metastasectomy included younger age (OR 0.98; CI 0.96-0.99; P = 0.01), lobular carcinoma (OR 2.26; CI 1.06-4.82; P = 0.03), and prior surgery of the primary site (partial mastectomy (OR 6.96; CI 3.47-13.95; P0.001) or total mastectomy (OR 5.74; CI 3.06-10.76; P0.001)). Compared to no metastasectomy, hepatic metastasectomy was independently associated with a 37% reduction in the risk of death (HR 0.63; CI 0.44-0.91; P = 0.01).Stage IV breast cancer with metastases to the liver is rare and few patients undergo hepatic resection. However, in this select patient population, hepatic metastasectomy was associated with a significant survival advantage when included in the multimodal treatment of synchronous stage IV breast cancer.

Background Data regarding clinical outcomes of patients undergoing hepatic resection for BRAF-mutated colorectal liver metastases (CRLM) are scarce. Most of the studies report an impaired median overall survival (OS) in BRAF-mutated patients, but controversial Results regarding both recurrence-free survival (RFS) and recurrence patterns. The purpose of this updated meta-analysis was to better precise the impact of BRAF mutations on clinical outcomes following liver surgery for CRLM study, especially on recurrence. Methods A systematic literature review was performed to identify articles reporting clinical outcomes including both OS and RFS, recurrence patterns, and clinicopathological details of patients who underwent complete liver resection for CRLM, stratified according to BRAF mutational status. Results Thirteen retrospective studies, including 5192 patients, met the inclusion criteria. The analysis revealed that both OS (OR = 1.981; 95% CI = [1.613–2.432]) and RFS (OR = 1.49; 95% CI [1.01–2.21]) were impaired following liver surgery for CRLM in BRAF-mutated patients. Risks of both hepatic (OR = 0.42; 95% CI [0.18–0.98]) and extrahepatic recurrences (OR = 0.53; 95% CI [0.33–0.83] were significantly higher in BRAF-mutated patients. These patients tended to have higher rates of right-sided colon primary tumors, primary positive lymph nodes, and multiple CRLM. Conclusions This meta-analysis confirms that BRAF mutations impair both OS and RFS following liver surgery. Therefore, BRAF mutational status should probably be included in further prognostic scores for the assessment of the expected clinical outcomes following surgery for CRLM.

Background To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI). Methods Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM). Results Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172). Conclusion Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

Background Mucinous adenocarcinoma represents a distinct histological subtype of colorectal cancer. To date there has been limited data available for patients with colorectal cancer liver metastases (CRCLM) derived from mucinous adenocarcinoma. This systematic review and meta-analysis aims to provide data on the clinicopathological and survival outcomes of this cohort. Methods Databases were searched for studies comparing clinicopathological and survival outcomes between patients with mucinous CRCLM and CRCLM from adenocarcinoma not otherwise specified who underwent liver resection. A random-effects model was used for analysis. Results Eight studies describing 9157 patients were included. Mucinous CRCLM were positively associated with colon tumors (OR 1⋅64, P = 0⋅01), T3/T4 tumors (OR 1⋅58, P = 0⋅02), node positive tumors (OR 1⋅55, P = 0⋅005). The review also identified a trend towards worse overall survival in patients with mucinous CRCLM. Conclusions Despite the distinct clinicopathological characteristics and impaired long term outcomes of mucinous CRCLM, resection should remain the gold standard where possible.

Background Gold standard for colorectal liver metastases (CRLM) remains hepatic resection (HR). However, patients with severe comorbidities, unresectable or deep-situated resectable CRLM are candidates for ablation. The aim of the study was to compare recurrence rate and survival benefit of the microwave ablation (MWA), radiofrequency ablation (RFA) and HR by conducting the first network meta-analysis. Data sources Systematic search of the literature was conducted in the electronic databases. Both updated traditional and network meta-analyses were conducted and the results were compared between them. Results HR cohort demonstrated significantly less local recurrence rate and better 3- and 5-year disease-free (DFS) and overall survival (OS) compared to MWA and RFA cohorts. HR cohort included significantly younger patients and with significantly lower preoperative carcinoembryonic antigen (CEA) by 10.28 ng/mL compared to RFA cohort. Subgroup analysis of local recurrence and OS of solitary and ≤ 3 cm CRLMs did not demonstrate any discrepancies when compared with the whole sample. Conclusions For resectable CRLM the treatment of choice still remains HR. MWA and RFA can be used as a single or adjunct treatment in patients with unresectable CRLM and/or prohibitive comorbidities.

Resected colorectal liver metastases (CRLM) frequently recur intrahepatically. Selection criteria for repeat hepatectomy of recurrent CRLM are ill-defined.We performed an institutional review of patients with recurrent CRLM undergoing repeat hepatectomy from 2003 to 19. Post-recurrence overall (rOS) and recurrence-free survival (RFS) were analyzed with Cox proportional hazards modeling.n = 147 experienced recurrent CRLM; 11% (n = 38) received repeat hepatectomy of which there was one Clavien-Dindo IIIa complication. Median rOS was 41 months; median RFS was 9 months. Improved rOS and RFS were independently associated with additional post-operative chemotherapy after repeat hepatectomy (HR 0.35 and 0.34, respectively); poor rOS with recurrent CRLM3 cm (HR 4.4) and12 months from first hepatectomy to recurrence (HR 4.8); poor RFS with ≥3 recurrence liver metastases (HR 2.8) (All P 0.05).Repeat hepatectomy for recurrent CRLM can be performed safely. Worse survival following repeat hepatectomy is independently associated with3 cm and ≥3 liver lesions at recurrence, and12 months to recurrence. Additional post-operative chemotherapy after repeat hepatectomy is associated with improved outcomes.

Background To evaluate the efficacy, safety and overall clinical outcome of multiprobe SRFA as a treatment for recurrent colorectal liver metastases after hepatic resection (HR). Methods A retrospective, single center study carried out between 2006 and 2018. 64 consecutive patients with recurrent or new CRLM after previous HR were treated by SRFA for 217 lesions (median size 2.7 cm, 1–7.5) in 103 ablation sessions. Endpoints consisted of i) technical efficacy ii) complication and mortality rates iii) local and distant recurrence, iv) disease free survival (DFS), and v) overall survival (OS). Results 213/217 tumors were successfully ablated at initial SRFA (97.7% primary technical efficacy rate). Four tumors required repeat ablation, resulting in a secondary technical efficacy rate of 99.5% (216/217). Local recurrence developed in 25/217 lesions (11.5%). Major complication rate was 5.8% (6/103 sessions) and mortality rate was 1.0% (1/103 ablation sessions), respectively.1-, 3-, and 5- year OS rates from date of first SRFA were 90.1%, 46.2%, and 34.8% (median 33.1 months). DFS rates were 54.2%, 17.2%, and 17.2%, at 1-, 3- and 5- years, respectively (median 13.3 months). Conclusion SRFA is a safe, feasible and effective option for CRLM after HR with low morbidity levels and favorable clinical outcome.

Background The impact of additional resection for positive proximal bile duct margins during hepatic resection of hilar cholangiocarcinoma (HCCA) on survival and disease progression remains unclear. We asked how re-resection of positive proximal bile duct margins affected outcomes. Methods Patients undergoing resection between 1993–2017 were reviewed. Both frozen section and final margin status were reviewed. Overall survival was the primary outcome. Results 153 patients underwent surgical resection for HCCA. Median survival (months) for initial margin negative (M−), margin-positive to margin-negative (M+/M−) and margin-positive to margin-positive (M+/M+) was 45, 33, and 35 months respectively. Nodal metastases increased with margin positivity: 32% with M−, 49% with M+/M− and 63% with M+/M+ (p = 0.016). Local/regional progression more frequently occurred in M+/M− (27.3%) and M+/M+ (33.3%) patients (M+/M- vs. M-: p = 0.41, M+/M+ vs. M-: p = 0.27). Patients receiving postoperative chemotherapy were 33% M−, 46% M+/M− and 63% in M+/M+. Postoperative radiation was used in 13% of M−, 31% of M+/M− and 63% of M+/M+. Most frequent initial recurrences were within the liver and hepaticojejunostomy site. Conclusion Competing risk for systemic disease based on primary characteristics of HCCA outweighs the impact of re-resection to achieve R0 status. Improved survival will likely depend on future regional and systemic therapy.

Synchronous colorectal cancer liver metastasis (CRLM) has been viewed as being more aggressive and having shorter survival than metachronous disease. Advances in CRLM management led us to examine differences in treatment characteristics of synchronous versus metachronous CRLM patients along with survival and recurrence.A retrospective review of hepatic resection for CRLM at a tertiary academic medical center was performed for two periods: a historic cohort from 1992 to 2010 (n = 121), and a modern cohort (n = 179) from 2012 to 2018. Clinical variables were compared between the patient groups, and survival outcomes were characterized.Five-year disease-specific survival for the modern synchronous group compared to the historic synchronous group was 71.7% versus 44.3% (P = 0.02). Modern metachronous versus modern synchronous 5-y disease-specific survival rates were 49.8% versus 71.7% (P = 0.31). Compared to the historic cohort, the modern one had significantly different timing of hepatic resection (P 0.01) with increased use of liver-first (30.1% versus 7.5%) and simultaneous liver-colon resections (24.1% versus 10.4%), along with greater use of neoadjuvant chemotherapy (96.4% versus 65.6%; P 0.01). Significantly more patients in the modern synchronous cohort had disease-free or alive-with-disease status at last follow-up, compared to the historic group (P 0.01), and experienced less disease recurrence (62.7% versus 77.6%; P 0.05).Modern synchronous CRLM patients who underwent hepatic resection experienced significantly improved survival compared to a historic cohort. We postulate that increased use of neoadjuvant chemotherapy and liver-first/simultaneous liver-colon resections in the modern synchronous cohort contributed to improved survival.

The role of surgery in breast cancer liver metastases (BCLM) remains elusive, and current application is limited. Our aim is to investigate whether hepatic resection (HR) of BCLM improves survival compared with non-hepatic resection (NHR) treatment.Three hundred and eighty-four patients with BCLM from 2008 to 2018 were divided into two groups. Propensity score matching (PSM) analysis was used to compare the clinical outcomes.After PSM the mean overall survival (OS) and the 1, 3, and 5-year OS rates in HR group were 61.8 months, 92.6%, 54.7% and 54.7%, respectively; while for NHR group these values were 38.6 months, 79.2%, 45.6% and 21.9%, respectively (p 0.007). Multivariate analysis indicated hormonal receptor status (p = 0.039) and hepatic resection (p = 0.032) were independent prognostic factors.Our study revealed that hepatectomy yields a survival benefit safely compared with medical treatments, especially for patients with positive hormonal receptors.

Background To evaluate the therapeutic efficacy, safety and overall clinical outcome of multiprobe stereotactic RF ablation (SRFA) as first-line treatment of HCC recurrence after hepatic resection (HR). Study design In this retrospective single-center study, 34 consecutive patients with previous HR were treated by SRFA between 2006 and 2018 for 140 HCCs in 60 ablation sessions. Results The median treated tumor size was 3.0 cm (range 0.5–10 cm). SRFA was primarily successful for 133/140 (95%) tumors. Four tumors were successfully retreated, resulting in a secondary technical efficacy rate of 97.9%. Local tumor recurrence developed in 4 of 140 tumors (2.9%). The major complication rate was 4.8% (3 of 60 ablations). No periprocedural deaths occurred. The overall survival (OS) rates at 1-, 3-, and 5- years from the date of the first SRFA were 94.0%, 70.2%, and 53.3%, respectively, with a median OS of 69.1 months (95% CI 18.8–119.3). The disease-free survival (DFS) was 52.6%, 19.7% and 15.8%, at 1-, 3- and 5- years, respectively, with a median DFS of 12.8 months (95% CI 9.0–28.9). Conclusion Stereotactic RFA is a safe, feasible and useful option in the management of recurrent HCC following HR with low morbidity paired with good clinical outcome.

Background Topical agents were designed to facilitate hemostasis during hepatic resection. The aim of this prospective randomized controlled clinical trial was to evaluate the effectiveness and safety of BioFoam® Surgical Matrix for achieving hemostasis after open hepatic resection. Methods This was a prospective, randomized controlled monocentric trial of patients undergoing elective open liver resection between December 2015 and September 2017. The primary endpoint was time-to-complete hemostasis. Results A total of 101 patients were enrolled in this trial, giving 51 patients in the BioFoam® group and 50 patients in the control group (without use of BioFoam®). Time-to-complete hemostasis was significantly reduced in the BioFoam® group (156 ± 129 versus 307 ± 264 s; P = 0.001). There were no significant differences in postoperative bile leaks (n = 6 (12%) vs. n = 5 (10%); P = 0.776), postoperative morbidity (n = 37 (73%) vs. n = 40 (80%); P = 0.482) or mortality (n = 3 (6%) vs. n = 1 (2%); P = 0.618) between groups. Conclusion BioFoam® is a safe topical agent for achieving faster hemostasis during hepatic resection, however, the true clinical relevance of this finding needs to be further evaluated. ClinicalTrials.gov ID NCT02612220 .

Background The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after hepatectomy can provide greater insight into how deaths can be prevented. The objective of this study was to determine the reasons for patient deaths post-hepatectomy in Australia. Methods ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following hepatectomy were selected for analysis. Assessors determinations of whether management could have been improved were reviewed, and then classified into groups of significant clinical events using thematic analysis with a data driven approach. Results The study included 88 deaths reported to ANZASM after hepatectomy. The assessors questioned the decision to operate in 23/88 (25%) patients with a further nine (10%) patients insufficiently investigated prior to resection. ANZASM assessors determined that there was a delay in recognising a significant complication in 16/88 (18%) patients. Conclusion Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with hepatic resection. Optimal care post-hepatectomy includes early recognition of complications and enactment of an adequate rescue plan.

Quality of life (QoL) after hepatic resection is a pertinent issue that has been poorly studied. The aim of this study was to compare changes in QoL before and after hepatic resection.A systematic review was performed using Medline, EMBASE, and the Cochrane library. Whenever possible, pooled mean differences of survey scores pre- and post-operatively were calculated.22 studies were included comprising a total of 1785 participants. Using the EORTC-QLQ 30C survey, patients with benign disease tend to have better QoL post-surgery than those with malignant disease. There were post-operative improvements in the following FACT-HEP domains: physical at 9 months (MD 3.14, 95%CI 2.70 to 3.58, P 0.001), social and family at 3 (MD 1.45, 95%CI 0.12 to 2.77, p = 0.030), 6 (MD 1.12, 95%CI 0.21 to 2.04, p = 0.020), 9 (MD 0.66, 95%CI 0.03 to 1.28, p = 0.040), and 12 (MD 0.58, 95%CI 0.12 to 1.03, p = 0.010) months, emotional at 9 (P 0.001) and 24 months (P 0.001), hepatobiliary at 24 months (p 0.001), and global health status at 9 months (p = 0.002).QoL scores tend to deteriorate post-surgery, but recover to baseline in the long-term at 9-months. Patients with malignant disease, and those who underwent major hepatectomy, have poorer QoL scores.

Background Morbidity remains a common problem following hepatic resection. The aim of this study was to investigate the association between preoperative body mass index (BMI) and morbidity in patients undergoing liver resection for hepatocellular carcinoma (HCC). Methods Patients were divided into three groups according to preoperative BMI: low-BMI (≤18.4 kg/m2), normal-BMI (18.5–24.9 kg/m2) and high-BMI (≥25.0 kg/m2). Baseline characteristics, operative variables, postoperative 30-day mortality and morbidity were compared. Univariable and multivariable analyses were performed to identify independent risk factors associated with postoperative morbidity. Results Among 1324 patients, 108 (8.2%), 733 (55.4%), and 483 (36.5%) were low-BMI, normal-BMI, and high-BMI, respectively. There were no differences in postoperative 30-day mortality among patients based on BMI (P = 0.199). Postoperative 30-day morbidity was, however, higher in low-BMI and high-BMI patients versus patients with a normal-BMI (33.3% and 32.1% vs. 22.9%, P = 0.018 and P Conclusion Compared with normal-BMI patients, low-BMI and high-BMI patients had higher postoperative morbidity, including a higher incidence of SSI after liver resection for HCC.

The benefits of adjuvant transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI) remain controversial. We compared the efficacy and safety of adjuvant TACE and hepatic resection (HR) alone for HCC patients with MVI.The PubMed, EMBASE, Cochrane Library, VIP, Wan Fang, and Sino Med databases were systematically searched to compare adjuvant TACE and HR alone for the treatment of HCC with MVI from inception to January 1, 2019. The study outcomes, including overall survival (OS) and disease-free survival (DFS), were extracted independently by two authors.12 trials involving 2190 patients were evaluated. A meta-analysis of 11 studies suggested that the 1-, 3-, and 5-year overall survival (OS) rates (OR = 0.33, P 0.001; OR = 0.49, P 0.001; and OR = 0.59, P 0.01; respectively), favored adjuvant TACE over HR alone. 11 studies were included in the meta-analysis of DFS, and adjuvant TACE showed better 1-, 3-, and 5-DFS (OR = 0.45, P 0.001; OR = 0.50, P 0.001; and OR = 0.58, P 0.001; respectively) compared to HR alone. Subgroup analysis demonstrated that adjuvant TACE could benefit HCC patients with MVI with tumor diameter5 cm or multinodular tumors.Adjuvant TACE may improve OS and DFS for HCC patients with MVI compared to HR alone and should be recommended for selected HCC patients with MVI. However, these results need to be validated through further high-quality clinical studies.The benefits of adjuvant TACE in HCC patients with microvascular invasion remain controversial. Twelve studies involving 2190 patients were include in our meta-analysis. Adjuvant TACE may improve OS and DFS for HCC patients with MVI compared to HR alone and should be recommended for selected HCC patients with MVI.

Serum ferritin (SF) may have a close relationship with the tumor. But no study has investigated the prognostic value of SF in hepatocellular carcinoma (HCC) patients receiving curative resection yet. Aim of this study is to explore the role of preoperative SF in survival outcomes of such patients.We retrospectively analyzed 427 HCC patients who received curative hepatic resection in our medical center. Significant clinical and pathological data along with the association between SF and clinicopathological parameters were compared and analyzed. The prognostic significance of SF was determined by Kaplan-Meier analysis and the Cox proportional hazards regression model.The optimal cut-off value of SF for overall survival (OS) was 267 ng/ml. Preoperative SF level could predict OS (P = 0.001, HR = 1.651, 95%CI: 1.213-2.247) and recurrence-free survival (RFS) (P 0.001, HR = 1.570, 95%CI: 1.221-2.018) independent of other prognostic factors. Patients with a low SF were more likely to have both favorable OS and RFS (both P 0.001), and vice versa. The 1-, 3-, and 5-year OS and RFS rates were 91.4%, 80.1%, 71.7%, and 78.0%, 53.0%, 47.3% in low SF group, and 91.6%, 60.2%, 45.2%, and 61.3%, 36.4%, 29.0% in high SF group, respectively.Preoperative SF was a simple, inexpensive, convenient and reliable prognostic factor that could predict survival outcomes in HCC patients who received radical hepatic resection.

Background Management of elderly patients with solitary hepatocellular carcinoma (sHCC) is challenging with perceived clinicopathologic differences driving treatment options. We sought to determine factors predictive of disease control and survival after hepatic resection of sHCC in elderly patients. Methods We identified n = 45 elderly patients (³≥65 yo) with sHCC treated with hepatic resection alone from our prospective database from 2003–16. Clinicopathologic data were analyzed and survival was assessed from the time of hepatic resection. Results The median age was 75-years-old. Less than half of patients (47%) had viral hepatitis. At resection, the median Child-Pugh score was A6, median tumor size 5 cm, and mean AFP of 1050 (ng/mL). Major hepatectomy was performed in 23 patients (51%) with R0 resection achieved in 96%. Two patients (4%) had Grade III complications with no mortalities at 30 days and one death (2%) at 90-days. After R0 resection 44% (n = 20) had intrahepatic recurrence at a median of 32 months (95% CI: 15–46) with 20% (n = 9) developing extrahepatic recurrence at a median of 78 months (95% CI: 78-.). The median survival was 72 months (95% CI: 30–108 months). For patients with at least 3 years of follow-up, the 1-, 3-, and 5-year overall survival was 74%, 59%, and 50%, respectively. Mortality was associated with higher AFP and lower Prognostic Nutritional Index (PNI). Conclusion Carefully selected elderly patients with sHCC appear to have unique disease that is amenable to hepatic resection with low morbidity and mortality with excellent overall and recurrence-free survival.

Tuberculosis (TB) affecting the liver is unusual, and isolated liver TB presenting as a liver abscess more so, even in countries where the disease is endemic. As clinical symptoms and imaging are not typical, a high index of suspicion is necessary for diagnosis. We present here a lady who was admitted with fever and chills. Ultrasound imaging showed a liver abscess. She developed bleeding into the abscess cavity, necessitating an emergency right liver resection. Final histology confirmed mycobacterial granulomatous infection of the liver. Isolated hepatic abscess of tubercular origin is a rare cause of hemorrhage but should be considered as a differential diagnosis. Suspicious features on computerized tomography (CT) scan should prompt microbiological assessment of aspirate from the abscess, establishing the diagnosis, so appropriate treatment can be started, avoiding such complications.

Backbround: Microvascular invasion (MVI) of hepatocellular carcinoma (HCC) is an independent predictor of recurrence and poor outcome following surgical hepatic resection. Prediction of MVI pre-operatively would contribute to the selection of therapy strategies. Therefore, we aimed to investigate MVI of HCC through noninvasive fusion-based radiomics modeling on dynamic contrast enhanced (DCE) computed tomography (CT). Methods: This retrospective study included 111 patients with pathologically proven hepatocellular carcinoma, which comprised 57 MVI-positive and 54 MVI-negative patients. Target volume of interest (VOI) was delineated on four DCE CT phases. The volume of tumor core (Vtc) and seven peripheral tumor regions (Vpt, with varying distances of 2, 4, 6, 8, 10, 12, and 14mm to tumor margin) were obtained. Radiomics features extracted from different combinations of phase(s) and VOI(s) were cross-validated by 150 classification models. The best phase and VOI (or combinations) were determined. The top predictive models were ranked and screened by cross-validation on the training/validation set. The model fusion, a procedure analogous to multidisciplinary consultation, was performed on the top-3 models to generate a final model, which was validated on an independent testing set. Findings: Image features extracted from Vtc + Vpt(12mm) in the portal venous phase (PVP) showed dominant predictive performances over features from other VOIs/phases combinations. Model fusion outperformed a single model in MVI prediction. The weighted fusion method achieved the best predictive performance with an AUC of 0·81, accuracy of 78·3%, sensitivity of 81·8%, and specificity of 75% on the independent testing set. Interpretation: Image features extracted from the PVP with Vtc + Vpt(12mm) are the most reliable features indicative of MVI. Fusion-based radiomics modeling is a promising tool to generate accurate and reproducible results in MVI status prediction in HCC. Funding Statement:: This work was supported by the National Natural Science Foundation of China (81971574, 81874216, 81571665); the National Key Research and Development Program of China (2017YFC0112900); the Natural Science Foundation of Guangdong Province, P.R. China (2018A030313282); the Guangzhou Science and Technology Project, P.R. China (202002030268, 201904010422), and Medical Science and Technology Research Project of Guangdong Province (A2019465). Declaration of Interests: There are no conflicts of interest between any of authors. Ethics Approval Statement: This study was approved by the Institutional Review Board of Guangzhou First People’s Hospital and the requirement for informed consent was waived based on the nature of a retrospective study.

Background: The selection criterion for hepatic resection(HR) in intermediate-stage(IM) hepatocellular carcinoma(HCC) is still controversial. We used real-world data to evaluate the overall survival (OS) treated with HR or TACE. Methods: In all, 946 patients with IM-HCC were categorized in HR and TACE group. OS was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses. The smooth curve was performed through the generalized additive model. The interaction test was performed to evaluate the HR impact on OS concerning risk factors. Also, we used multiple imputation to deal with the missing data. Findings: Totally, 23.0% (n=225) of patients received HR. At a median overall survival of 23.7 months, HR versus TACE was associated with the improved OS on multivariate analysis (hazard ratio, 0.45; 95%CI: 0.35, 0.58). The hazard ratio was 0.56(95%CI: 0.41, 0.77) after propensity score matching compared with TACE. Landmark analyses limited to long-term survivors of ≥ 6 months, ≥ 1, and ≥ 2 years demonstrated improved OS with HR in all subsets (all P 192 U/L. Moreover, TACE might be suitable for patients with LDH level ≤192 U/L. Funding Statement: The Natural Science Foundation of Fujian Province (Nos 2018J01352, 2016J01576, and 2016J01586); the Science and Technology Innovation Joint Foundation of Fujian Province(Nos 2017Y9125). Declaration of Interests: The authors have no conflicts of interest. Ethics Approval Statement: The Ethics Committee of SYSUCC approved the study protocol (2017-FXY-129). Because this was a retrospective study, the informed consent was waived.

Introduction and importance Altemeier rectosigmoidectomy has been cited in the literature as a suitable approach for incarcerated rectal prolapse when a large segment of bowel is involved. However, the literature is devoid of cases that employed the technique as an oncological procedure for rectal carcinoma. For this reason, this case report heralds a new perspective on an old technique. Case presentation We describe the case of a male in his 6th decade who presented with stage four rectal cancer. Computed tomography imaging showed a rectal mass at the rectosigmoid junction with pelvic lymphadenopathy and a solitary hepatic lesion in segment two of the liver. While admitted to the hospital a 16 cm segment of bowel containing the mass prolapsed and became incarcerated, eventually becoming necrotic. A modification of the Altemeier procedure was performed along with a diverting ileostomy and hepatic wedge resection of the solitary metastases. Histological assessment of the surgical specimens confirmed that adequate resection margins were obtained with one of twenty-one lymph nodes positive for malignancy. He is currently being followed up in the outpatient oncology clinic and has commenced adjuvant chemotherapy. Clinical discussion Synchronous excision of rectal carcinoma with hepatic metastasectomy is a feasible surgery even in the emergency setting and can offer improved patient survival. Conclusion The combination of both an abdominal and perineal approach was suitable for this patient given his improved quality of life and negative pathological margins., Highlights • Rectal prolapse can be the first presentation of rectal cancer. • Strangulated rectal procidentia should be addressed by the perineal route. • Altemeier procedure can be utilized for oncological resection of rectal cancer. • Low volume liver resection is feasible without adjustment of central venous pressure.

Liver abscesses occur in up to one-third of patients with chronic granulomatous disease (CGD). Surgery has traditionally been considered the cornerstone of management. Emerging reports in older children and adults, however, have demonstrated successful treatment of CGD-related liver abscesses with corticosteroids and antibiotics alone. We describe the safe and effective use of corticosteroids and antibiotics for CGD-related liver abscesses in an infant with X-linked CGD who had high surgical risk for hepatic resection. Medical management was started at 11 months of age and the abscesses resolved without requiring any subsequent invasive surgical procedures. This case report highlights that corticosteroids and antibiotics may be considered in the management of CGD-related liver abscesses in the infant age group, especially when surgical management is not an option. Keywords: Chronic granulomatous disease, Liver abscess, Corticosteroids

Blood transfusion has been reported to be associated with immunomodulation and poor oncologic outcomes in several malignancies. The aim of the study is to investigate the influence of the use of fresh frozen plasma (FFP) on long-term outcomes in patients with colorectal liver metastases (CRLM) after hepatic resection.The study comprised 127 patients who had undergone first hepatic resection for CRLM between April 2000 and December 2013. We retrospectively investigated the influence of the use of FFP on disease-free survival as well as overall survival and assessed the impact of such a practice on postoperative inflammation markers.In multivariate analysis, more than four lymph node metastases of the primary cancer (P = 0.001), bilobar distribution (P = 0.002), and perioperative FFP transfusion (P = 0.005) were independent risk factors for cancer recurrence, while more than four lymph node metastases of the primary cancer (P 0.001), presence of neoadjuvant chemotherapy (P = 0.002), and perioperative FFP transfusion (P = 0.004) were independent risk factors for poor overall survival. In patients who underwent FFP transfusion, tumor size (P = 0.004), anatomic resection (P 0.001), duration of operation (P = 0.039), and intraoperative blood loss (P 0.001) were significantly greater. Moreover, FFP transfusion was associated with a higher white blood cell level on postoperative day 3 (P 0.001) and day 5 (P = 0.010) and lower serum C-reactive protein level on postoperative day 1 (P 0.001) and day 3 (P = 0.017).Perioperative FFP transfusion is independently associated with poor long-term outcomes in patients with CRLM after hepatic resection. FFP may have an influence on postoperative inflammation because of its immunosuppressive effects.

Objective Modern chemotherapy and repeat hepatectomy allow to tailor the surgical strategies for the treatment of colorectal liver metastases (CRLM). This study addresses the hypothesis that parenchymal-sparing hepatectomy reduces postoperative complications while ensuring similar oncologic outcomes compared to the standardized non-parenchymal-sparing procedures. Methods Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2019 at a major hepatobiliary center in Switzerland were assessed. Patients were stratified according to the tumor burden score [TBS2 = (maximum tumor diameter in cm)2 + (number of lesions)2)] and were dichotomized in a lower and a higher tumor burden cohort according to the median TBS. Postoperative outcomes, overall survival (OS) and disease-free survival (DFS) of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing non-PSR. Results During the study period, 153 patients underwent liver resection for CRLM with curative intent. PSR was performed in 79 patients with TBS < 4.5, and in 42 patients with TBS ≥ 4.5. In patients with lower tumor burden (TBS < 4.5), PSR was associated with lower complication rate (15.2% vs. 46.2%, p = 0.009), and shorter length of hospital stay (5 vs. 9 days, p = 0.006) in comparison to non-PSR. For TBS < 4.5, PSR resulted in equivalent 5-year OS (48% vs. 39%, p = 0.479) and equivalent 5-year DFS rates (DFS, 44% vs. 29%, p = 0.184) compared to non-PSR. For TBS ≥ 4.5, PSR resulted in lower postoperative complication rate (33.3% vs. 63.2%, p = 0.031), lower length of hospital stay (6 vs. 9 days, p = 0.005), equivalent 5-year OS (29% vs. 22%, p = 0.314), and equivalent 5-year DFS rates (29% vs. 22%, p = 0.896) compared to non-PSR. Among all patients treated with PSR, patients undergoing minimal-invasive hepatectomy had equivalent 5-year OS (42% vs. 37%, p = 0.261) and equivalent 5-year DFS (34% vs. 34%, p = 0.613) rates compared to patients undergoing open hepatectomy. Conclusion PSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay, and equivalent oncologic outcomes compared to non-PSR independently from tumor burden. Our findings suggest that minimal-invasive PSR should be considered as the preferred method for the treatment of curatively resectable CRLM if allowed by tumor size and location.

Summary Background Whether hepatic resection (HR) could be performed for patients with Barcelona Clinic Liver Cancer (BCLC) B/C stage hepatocellular carcinoma (HCC) is controversial, and the safety and clinical value of HR combined with antiviral therapy for hepatitis B virus (HBV)-related HCC with BCLC-B/C stage remain to be investigated. Methods We retrospectively evaluated 126 patients with BCLC stage B/C HCC who underwent HR. These patients were divided into the antiviral group (Group A, n = 86) and the control group (Group B, n = 40). The operative indications and prognosis of 126 patients were analyzed. Results The 1-year, 3-year, and 5-year disease-free survival (DFS) rates for Group A and Group B were 55.4%, 36.1%, 33.7% and 53.8%, 28.2%, 23.1%, respectively. The corresponding overall survival (OS) rates for the two groups were 89.2%, 61.4%, 45.8% and 82.1%, 48.7%, 33.3%, respectively. The DFS and OS for Group A were better than for Group B ( p = 0.013, and p = 0.038, respectively). Antiviral therapy was an independent protective factor of late tumor recurrence [hazard ratio (HR) = 0.391, 95% confidence interval (CI): 0.190–0.806, p = 0.011] but not of early tumor recurrence. Conclusion It is safe and feasible to perform HR combined with antiviral therapy for HBV-related HCC with BCLC stage B/C.

Background The aim of this study is to investigate the association C-reactive protein to albumin (CRP/Alb) ratio, a novel inflammation based prognostic score, and long-term outcomes among patients with colorectal liver metastases (CRLM) after hepatic resection. Methods We retrospectively investigated 106 patients who underwent hepatic resection for CRLM and explored the relationship between CRP/Alb ratio and long-term outcomes. Results In multivariate analysis, more than 4 lymph node metastases ( p = 0.003), presence of neo-adjuvant chemotherapy ( p = 0.008) and CRP/Alb ratio ≥ 0.04 ( p = 0.021) were independent and significant predictors of cancer recurrence, while more than 4 lymph node metastases ( p = 0.001), presence of neo-adjuvant chemotherapy ( p p = 0.002) were independent and significant predictors of poor overall survival. Conclusions The CRP/Alb ratio seems to be a predictor of poor long-term outcomes in patients with CRLM after hepatic resection.

The obesity epidemic has significantly increased the incidence and severity of hepatic steatosis in liver surgery patients and liver donors, potentially impacting postoperative liver regeneration and function. Development of a non-invasive means to quantify hepatic steatosis would facilitate selection of candidates for liver resection and transplant donation.An IRB-approved protocol prospectively enrolled 28 patients with liver tumors requiring hepatic resection. In all patients, fast dual-echo gradient-echo MR images were acquired using 2-Point Dixon technique in 2D and 3D. The degree of steatosis was quantified by percent fat fraction (%FF) from in- and out-of-phase, and water-only and fat-only images. The technique-specific %FFs were compared to intraoperative and histopathological findings.For patients with30% steatosis by histology, the mean %FF was 22% (SD ± 5.2%) compared to a mean %FF of 5.0% (SD ± 2.1%, p = 0.0001) in patients with30% steatosis. Using scaled values for the MR-calculated %FF, all patients with30% pathologic steatosis could be identified preoperatively.Quantitative MRI identified patients with clinically-relevant steatosis with 100% accuracy. These findings could have significant impact on the management of liver resection patients and transplant donors.

Background More than half of the patients undergoing resection for colorectal cancer liver metastases develop recurrent hepatic disease. We report management and outcomes of patients undergoing repeat hepatectomy in routine practice. Methods All cases of repeat hepatectomy for colorectal cancer liver metastases from 2002 to 2009 in the Canadian Province of Ontario were identified using the population-based Ontario Cancer Registry and linked treatment records. Results Of 1,310 patients who underwent resection of CRLM, 78 (6.0%) underwent a repeat liver resection. Mean age was 56 years and the median time between resections was 19 months. Compared with the first resection, second resections were associated with fewer lesions (2.7 vs 1.5; P = .001) and fewer major resections (58% vs 31%; P = .024). The size of largest lesion, positive margin rate, length of hospital stay, and 90-day mortality were similar. Unadjusted 5-year overall survival from the time of second resection was 45% (95% confidence interval=32% to 59%) and cancer-specific survival was 47% (95% confidence interval=30% to 64%). Conclusions Repeat liver resections for metastatic CRC involve fewer lesions and less extensive surgery and a substantial proportion of patients achieve long-term survival.

Purpose The purpose of this retrospective study was to evaluate the utility of the new intraoperative bile leakage test as a preventive measure of postoperative bile leakage. Method 737 patients were retrospectively analyzed with respect to the management of intra- and post-operative bile leakage. Results Nine (8.3%) of 109 patients evaluated using conventional white light fluorescent imaging were recognized as having intra-operative bile leakage. However, performance of 5-aminolevulinic acid (5-ALA)-mediated PDD detected bile leakage intraoperatively not only in these 9 patients, but also in an additional 6 patients, such that ‘red fluorescence’ at the cut surface of the liver, was visualized in a total of 15 patients. The postoperative courses of most patients were uneventful, and postoperative bile leakages occurred in only one (0.9%) patient. Conclusion 5-ALA fluorescence imaging may be needed to prevent postoperative bile leakage in patients at high risk for this surgical complication after hepatic resection.

Symptoms of early hepatocellular carcinoma (HCC) often go unnoticed, so more than half of patients with primary HCC are diagnosed after their disease has already reached an intermediate or advanced stage, or after portal hypertension has appeared. While hepatic resection is widely recognized as a first-line therapy to treat very early or early HCC, its use in treating intermediate or advanced HCC or HCC involving portal hypertension remains controversial. Here we review PubMed-indexed literature covering the use of hepatic resection for such patients. The available evidence strongly suggests that, as a result of improvements in surgical techniques and perioperative care, hepatic resection can benefit many patients with intermediate or advanced HCC or with HCC associated with portal hypertension., Highlights • This review summarized controversies and evidence of surgery for hepatocellular carcinoma (HCC) in the present. • Hepatic resection should be actively considered for selected patients with intermediate or advanced HCC or those combining with portal hypertension, with more favorable survival benefits.