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It has been obscure whether or not noncurative hepatic resection (Hx) has a favorable impact on the clinical course in patients with advanced hepatocellular carcinoma (HCC). The aim of this study is to clarify the significance of noncurative Hx for advanced HCC. Among 666 consecutive patients undergoing Hx for HCC in our department, 79 patients underwent noncurative Hx. These patients were classified as Group A (presence of macrovascular invasion [MVI]; n = 29), Group B (residual tumors in the remnant liver; n = 37), Group C (residual tumors in the remnant liver with MVI; n = 7), or Group D (residual tumors in the remnant liver with distant metastasis [with or without MVI]; n = 6). The three-year survival rates were 49.6 per cent in Group A, 30.3 per cent in Group B, 14.3 per cent in Group C, and 0.0 per cent in Group D, respectively (Groups A and B vs Group D, P < 0.05). Moreover, the survival rate was significantly higher in patients with ≤3 tumors than in those with ≥4 tumors ( P < 0.05), when Group B was divided into subgroups according to the number of residual tumors in the remnant liver. In conclusion, noncurative Hx might be acceptable for advanced HCC with MVI or ≤3 residual tumors in the remnant liver.

Background: Posthepatectomy liver failure (PHLF) was recently defined with the corresponding recommendations as follows: grade A, no change in clinical management; grade B, clinical management with noninvasive treatment; and grade C, clinical management with invasive treatment. In this study, we identified the risk factors for grade B and C PHLF in patients with hepatocellular carcinoma (HCC)., Methods: Of 339 HCC patients who underwent curative hepatic resection, 218 were included for analysis. The LHL15 index (uptake ratio of the liver to that of the liver and heart at 15 min) was measured by 99m Tc-GSA (99m technetium-labelled galactosyl human serum albumin); remnant LHL15 was calculated as LHL15 × [1 - (resected liver weight - tumor volume)/whole liver volume without tumor]., Results: A total of 163 patients were classified as having no PHLF, whereas 17, 37, and 1 patient had PHLF grade A, B, and C, respectively. There were significant differences in indocyanine green R15, serum albumin, prothrombin time, Child-Pugh classification, LHL15 and remnant LHL15 between patients with grades B/C PHLF and patients with grade A or no PHLF. Only remnant LHL15 was identified as an independent risk factor for grades B/C PHLF (p = 0.023), with a cut-off value of 0.755., Conclusions: Remnant LHL15 was an independent risk factor for grades B/C PHLF. Patients with impaired remnant LHL15 value of <0.755 should be carefully monitored for PHLF., (© 2018 S. Karger AG, Basel.)

Clinically, peritoneal dissemination of hepatocellular carcinoma (HCC) rarely occurs. We herein report a case that had a good outcome following laparoscopic extirpation of peritoneal dissemination after hepatectomy for ruptured HCC. A 66-year-old man underwent central bisectionectomy 12 days after emergency transcatheter arterial embolization for a ruptured HCC. Thereafter, pulmonary resection was performed twice for lung metastasis. About 8 months after the second pulmonary resection, a mass lesion was detected at the left subphrenic space on CT and (18) F-fluorodeoxyglucose PET scans. We made a diagnosis of peritoneal dissemination of HCC, and laparoscopic extirpation was performed. The patient is now doing well without any signs of recurrence 2 years after the last operation. Laparoscopic surgical resection for peritoneal dissemination that develops after hepatectomy for HCC may have a beneficial effect as a less-invasive approach and may improve the prognosis in select patients., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

We report an extremely rare case of the development of hepatocellular carcinoma (HCC) in cardiac congestive liver fibrosis. A 62-year-old female presented to our hospital with a complaint of right upper quadrant pain. The patient had undergone cardiac surgery for pulmonary valve insufficiency, pulmonary stenosis and atrial septal defect when she was fifteen years of age. During the subsequent 47 years, she had occasionally suffered from various symptoms associated with right-sided heart failure due to pulmonary stenosis. Computed tomography revealed a liver tumor measuring 63 mm in diameter in segment 5 and other liver tumors in segments 5 (18 mm), 8 (17 mm) and 4 (12 mm), which were diagnosed as HCCs. There was no evidence of stenosis in any hepatic veins or inferior vena cava, and no infectious hepatitis or alcoholic liver damage. Anterior sectionectomy and partial resection of segment 4 was performed, and histological examination showed that these tumors were HCC accompanied by congestive liver fibrosis. Nine months later, multiple recurrent HCCs were detected in segment 6, and transcatheter arterial chemoembolization was employed thereafter. The patient died 40 months after surgery due to advanced recurrence.

Safety and efficacy of hepatic resection for large hepatocellular carcinomas (HCCs 10 cm or greater in diameter) remain controversial. Surgical results of patients with HCCs 10 cm or greater (n = 24) who underwent hepatic resection over an 11-year period were compared with those of patients with HCCs less than 10 cm (n = 291). There was no significant difference in mortality between the two groups (P > 0.99). Overall 5-year survival rate was 44.6 per cent among patients with HCCs 10 cm or greater and 70.5 per cent among those with HCCs less than 10 cm (P = 0.010); however, there was no significant difference in disease-free survival rate between the two groups (P = 0.16). Incidence of synchronous intra- and extrahepatic recurrence was higher in patients with HCCs 10 cm or greater than in those with HCCs less than 10 cm (P = 0.0012). Macrovascular invasion alone was an independent risk factor for poor prognosis (hazard ratio [HR],: 11.1) and recurrence (HR, 6.02) after hepatic resection for HCCs 10 cm or greater, which was correlated with synchronous intra- and extrahepatic recurrence. Hepatic resection for large HCCs is safe and efficacious. However, incidence of synchronous intra- and extrahepatic recurrence is high, especially in patients with macrovascular invasion.

Background/aims: Risk factors for recurrence and types of recurrence following hepatic resection for non-B non-C hepatitis hepatocellular carcinoma (NBC-HCC) have not yet been established., Methodology: The clinicopathological data of 76 patients with NBC-HCC were retrospectively reviewed. Risk factors for postoperative recurrence were analyzed using univariate and multivariate analyses. In addition, types of intrahepatic recurrence were investigated., Results: Of the 76 patients, 38 (50%) developed recurrence during the follow-up period, with disease-free survival rates at 1/3/5 years of 72%/46%/40%, respectively. Of the 38 patients with recurrence, 36 (95%) were found to have recurrence within three years after surgery. Of the 38 patients, 34 exhibited intrahe patic recurrence. In multivariate analysis, Child-Pugh B (p = 0.009) and microscopic vascular invasion (MVI) (p = 0.002) were independent risk factors for postoperative recurrence. Based on our definitions, of the 34 patients with intrahepatic recurrence, recurrence at the stump was present in one patient, multicentric recurrence in 11 patients and intrahepatic metastasis in 22 patients., Conclusions: Child-Pugh B and MVI are independent risk factors for the postoperative recurrence. Although most recurrences occurred within three years after hepatic resection, incidence of multicentric recurrence is not negligible. Preventing recurrence according to types of recurrence is therefore considered to be essential.

Background/aims: The serum aspartate aminotransferase-to-platelet ratio index (APRI) is a biomarker for hepatic fibrosis. The relationship between the APRI and postoperative hepatic failure is unclear., Methodology: The risk factors for postoperative hepatic failure and the APRI were evaluated in 457 patients who underwent liver resection for HCC., Results: Nineteen patients (4.2%) experienced postoperative hepatic failure and five (1.1%) died. An increased APRI (p = 0.039), increased total bilirubin (p = 0.044), longer operation (p = 0.035) and increased intraoperative blood loss (p = 0.028) were independent risk factors in the multivariate analysis. Incidence of postoperative hepatic failure in patients with an APRI ≥ 1.57 (13/127, 10%) was significantly higher than in patients with an APRI < 1.57 (6/330,1.8%, p = 0.0002). Moreover, incidence of hepatic failure in high APRI cases with both an operation ≥ 500 min and intraoperative blood loss ≥ 1L (6/33 (18.1%)) tended to be higher than in those with lower values (7/94 (7.4%), p = 0.051)., Conclusions: Increased APRI (≥ 1.57) may be a preoperative predictor of postoperative hepatic failure. Meticulous surgery with shorter operations and reduced blood loss may reduce the incidence of postoperative hepatic failure, even in patients with a high APRI.

Purpose: This study aimed at investigating the safety of hepatic resection for hepatocellular carcinoma (HCC) in obese patients with cirrhosis in Japan., Methods: We reviewed the clinical records of 202 patients with liver cirrhosis, who underwent hepatic resection for HCC between January, 2001 and August, 2011. The patients were divided into three groups according to their body mass index (BMI): the normal body weight (BMI < 24.9 kg/m(2)), obese class I (BMI 25.0-29.9 kg/m(2)), and obese class II (BMI ≥ 30 kg/m(2)) groups. We compared the patient backgrounds, intraoperative factors, and postoperative complications among the three groups., Results: The normal body weight, obese class I, and obese class II groups comprised 138 (68.3 %), 55 (27.2 %), and 9 (4.5 %) patients, respectively. The incidence of non-B non-C cirrhosis was higher in the obese class II group (22 %) than in the normal body weight group (14 %, p = 0.034). Intraoperative blood loss tended to be higher in the obese class II patients than in the other two groups. Postoperative complications and mortality did not differ significantly among the three groups. According to multivariate analysis, obesity was not a risk factor for postoperative complications (Clavien-Dindo classification Grade III or higher) or mortality., Conclusion: Hepatic resection for HCC can be performed safely in obese patients with cirrhosis.

A 72-old-year Japanese man was incidentally found to have out liver dysfunction on serum examination and a cystic tumor in the liver. Dynamic computed tomography revealed a solitary cystic tumor 14 cm in diameter with multiple septa. The cyst wall was occasionally irregular with hyperarterial inflow. After admission, he suffered from fever and right upper abdominal pain. We suspected cystadenocarcinoma with intraluminal infection. Percutaneous transhepatic drainage was performed. However, neither cytologic examination nor culture test was positive. The cystic tumor had been decreasing in size, and hepatic resection performed. Macroscopically, the tumor was a gray-yellow solid tumor with a fine boundary between tumor and liver parenchyma, and the cystic lesion collapsed. Microscopically, the tumor consisted of hepatic infarction, degenerated Glisson's sheath, and chronic inflammation, and chronic liver abscess was diagnosed. Most cases of bacterial liver abscess can be diagnosed because progression is accompanied by typical signs. However, it is difficult to diagnose liver abscess in the chronic phase because chronic liver abscesses exhibit various features on imaging series without typical signs or symptoms. When atypical liver cyst is found, the possibility of liver abscess in chronic phase should be considered.

Background: A novel index, the serum aspartate aminotransferase activity/platelet count ratio index (APRI), has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. We evaluated the ability of preoperative APRI to predict hepatic failure following liver resection for hepatocellular carcinoma., Methods: Potential preoperative risk factors for postoperative hepatic failure (hepatic coma with hyperbilirubinemia, four patients; intractable pleural effusion or ascites, 30 patients; and variceal bleeding, one patient) as well as APRI were evaluated in 366 patients undergoing liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses., Results: Hepatic failure developed postoperatively in 30 patients, causing death in four. APRI correlated with histological intensity of hepatitis activity and degree of hepatic fibrosis, and was significantly higher in patients who developed postoperative hepatic failure than in others without failure. Risk of postoperative hepatic failure increased as the serum albumin concentration and platelet count decreased and as indocyanine green retention rate at 15 min, aspartate and alanine aminotransferase activities, and APRI increased. Only APRI was an independent preoperative factor on multivariate analysis. Of the four patients who died of postoperative hepatic failure, three had an APRI of at least 10., Conclusions: Preoperative APRI independently predicted hepatic failure following liver resection for hepatocellular carcinoma. Patients with an APRI of 10 or more have a high risk of postoperative hepatic failure.

A 62-year-old man had been followed up for chronic hepatitis B (HB) since 1973. Hepatocellular carcinoma (HCC) was detected in 1985, at the age of 42 years. Serum HB surface antigen and anti-HB envelope antibody were positive at that time. A right hepatic lobectomy was performed. In 1995, serum HB surface antigen had cleared spontaneously and liver function had normalized. In March 2005, at the age of 62 years, a 1.5-cm diameter hepatic mass was detected in the left lateral segment. At that time, he was seropositive only for anti-HB core antibody. A diagnosis of recurrent HCC was made, and partial hepatectomy was performed. Covalently closed circular HBV DNA was detected in both cancerous and noncancerous tissues by nested polymerase chain reaction (PCR). Cassette-ligation-mediated PCR showed that HBV DNA was integrated into the telomerase reverse transcriptase gene located on chromosome 5p15.

Background: Although a second hepatic resection (SHR) for recurrent hepatocellular carcinoma (HCC) is widely accepted, the indications for SHR have not been established. The risk factors for HCC recurrence after SHR were evaluated to investigate the indications for SHR., Methods: Subjects included 51 patients who underwent a second hepatic resection for recurrence of HCV-related HCC. Sixteen patients received interferon therapy before or after the first operation. Six patients attained a sustained viral response (SVR) that was defined as return of the alanine aminotransferase (ALT) activity to within the reference range and no detectable serum HCV RNA for at least 1 year after interferon therapy. A biochemical response (BR), defined as a normalized ALT activity for at least 1 year after interferon therapy with or without the transient disappearance of serum HCV RNA, was attained in three patients. The other seven patients were defined as the nonresponse (NR) group., Results: By univariate analysis, NR and lack of interferon therapy, high indocyanine green retention rate at 15 min (ICGR15), high aspartate aminotransferase activity, high ALT activity, large tumor, and multiple tumors were risk factors for HCC recurrence after SHR. By multivariate analysis, NR and lack of interferon therapy, high ICGR15, large tumor, and multiple tumors were independent risk factors., Conclusions: Patients in whom active hepatitis has been controlled by interferon therapy are the best candidates for SHR. Interferon therapy should be recommended in patients undergoing resection of an HCV-related HCC because SHR can prolong life in SVR and BR patients.

Background/aims: Liver resection for hepatocellular carcinoma in patients with cirrhosis carries risk of major hemorrhage and sometimes requires blood transfusion. We investigated risk factors for massive blood loss during liver resection and indications for storing blood for autologous intraoperative transfusion., Methodology: We analyzed clinical records of 100 patients with cirrhosis who underwent liver resection for hepatocellular carcinoma. Autologous blood was stored preoperatively for 19 patients., Results: Intraoperative blood loss ranged from 5 to 3000 mL (mean, 640). Liver resection was performed without transfusion in 67 patients and with autologous blood storage in 17 patients not receiving homologous blood. In the other 16 patients, homologous blood was transfused. Univariate analysis identified youth, large tumors (> 4cm), major hepatectomy, portal tumor involvement, hepatic vein involvement, and prolonged operation time as risk factors for massive blood loss; multivariate analysis identified portal involvement and hepatic vein involvement as independent risk factors. Blood loss exceeded 1000 mL in the 4 transfused group B patients and 3 of the 4 patients had hepatic vein involvement., Conclusions: Portal involvement and hepatic vein involvement were risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis. Autologous blood storage is indicated in patients with such risk factors.

Background/aims: Combined hepatocellular and cholangiocarcinoma of the liver is relatively infrequent, and its pathogenesis remains obscure. The aim of this study is to investigate its clinical and pathological features and proliferative activity., Methodology: In this study, we investigated the histopathological features, Ki-67 labeling index, and p53 immunohistochemistry of 18 surgically resected cases of combined hepatocellular and cholangiocarcinoma among 1102 consecutive cases of surgically resected primary liver cancers. All tumors were compatible with the WHO definition of this tumor. Microscopically, we classified the cases into the following three categories according to the arrangement of the hepatocellular carcinoma and cholangiocarcinoma components; (1) Type I in which hepatocellular carcinoma and cholangiocarcinoma formed nodules that could easily be distinguished from each other, (2) Type II in which the both components were finely mixed, so that the two components were almost indistinguishable, and (3) Type III in which the tumors had lobular structures with hepatocellular carcinomas existing centrally and cholangiocarcinomas existing peripherally., Results: Microscopically, the tumors were classified into type I 7 tumors, type II 5 tumors, and type III 6 tumors. In one case of type I, well differentiated hepatocellular carcinoma demonstrated cholangiocarcinoma in "nodules-in-nodules" fashion. The average of Ki-67 labeling index of hepatocellular carcinoma component of combined hepatocellular and cholangiocarcinoma was 4.4 +/- 3.4% and the index of cholangiocarcinoma component was 11.0 +/- 8.5%, which is significantly higher than that of the hepatocellular carcinoma component. On p53 immunohistochemistry, 5 of 18 cases (29.4%) were positive. In one case, the cholangiocarcinoma component was positive for p53, but the hepatocellular carcinoma component was negative. In the other 4 cases, both the hepatocellular carcinoma and cholangiocarcinoma components were positive., Conclusions: Microscopically, type III seems to be a feature of metaplasia or proliferation of bipotential progenitor cells. Metaplasia of hepatocellular carcinoma to intrahepatic cholangiocarcinoma is assumed to be one of the pathogenic pathways of combined hepatocellular and cholangiocarcinoma.

Purpose: Interferon therapy suppresses the development of hepatocellular carcinoma (HCC) and tumor recurrence after a resection of HCC in patients with chronic hepatitis C. However, the value of a liver resection and which method is best for the treatment of HCC detected after successful interferon therapy remains to be clarified. The risk factors for tumor recurrence after a liver resection for HCC detected after successful interferon therapy were investigated to determine the appropriate operative method for such HCC., Methods: Risk factors including the clinicopathologic findings and the operative methods for tumor recurrence were evaluated by univariate and multivariate analyses in 24 patients who underwent liver resection for HCC detected after successful interferon therapy (sustained viral response or biochemical response)., Results: According to a univariate analysis, large tumor (> 2 cm, P = 0.0326), multiple tumors (P = 0.0372), nonanatomic resection (P = 0.0103), and positive surgical margin (< 5 mm of a free surgical margin, P = 0.0245) were possible risk factors for short tumor-free survival time after surgery. A multivariate analysis showed that large tumor (P = 0.0407), nonanatomic resection (P = 0.0215), and positive surgical margin (P = 0.0253) were independent risk factors for a short tumor-free survival time after surgery., Conclusion: An anatomic resection with an appropriate surgical margin (> or = 5 mm of a free surgical margin) is recommended for patients with HCC detected after successful interferon therapy.

Background/purpose: CYFRA 21-1, a soluble fragment of cytokeratin 19, is increased in serum in some patients with hepatocellular carcinoma, but the clinical significance of this increase is still unknown., Methods: Serum concentrations of CYFRA 21-1 were measured in 240 patients with hepatocellular carcinoma prior to hepatic resection. The relationships between serum CYFRA 21-1 concentrations and clinicopathologic features were analyzed., Results: The sensitivity of CYFRA 21-1 as a test for hepatocellular carcinoma was 18.8%. Serum CYFRA 21-1 was significantly higher in patients with portal vein tumor thrombus, and serum CYFRA 21-1 increased with the progression of portal vein tumor thrombus. Tumor size was related to serum CYFRA 21-1, but there were no significant correlations between serum CYFRA 21-1 concentrations and tumor differentiation or number of tumors. Although patients with stage IV tumor had significantly higher CYFRA 21-1 concentrations than those with stages I, II, and III, CYFRA 21-1 was not associated with postoperative prognosis., Conclusions: Although high concentrations of CYFRA 21-1 were often detected in patients with a tumor diameter greater than 5 cm or tumor thrombus in the major portal vein, CYFRA 21-1 is not a useful diagnostic tool for hepatocellular carcinoma because of its low sensitivity.

Background: The Japan integrated staging (JIS) score is recognized to be useful in managing hepatocellular carcinoma (HCC). We evaluated the effects of the causative virus in patients stratified by this system., Methods: We compared clinicopathologic features, cumulative and tumor-free survival rates, and causes of death between 301 hepatitis C virus-positive patients (HCV group) and 60 hepatitis B virus-positive patients (HBV group)., Results: Among patients with low JIS scores (0 or 1), the proportions of patients with high aspartate and alanine aminotranferase activities, moderate-to-severe active hepatitis, and with cirrhosis were significantly higher in the HCV than in the HBV group. Among patients with high JIS scores (2 to 4), the proportion with moderate-to-severe active hepatitis was also significantly higher in the HCV group. In patients with low JIS scores, those in the HCV group had significantly lower tumor-free and cumulative survival rates than those in the HBV group. Although no patient in the HBV group died of causes other than liver disease (HCC or hepatic failure), some patients in the HCV group died of causes other than liver disease. The proportion of patients who died because of HCC recurrence tended to be higher among patients with high JIS scores than among patients with a low JIS score., Conclusions: The effects of viral status on survival outcomes are greatest in patients with JIS scores of 0 or 1.

Clinicopathologic variables favoring recurrence after hepatic resection for intrahepatic cholangiocarcinoma showing intraductal growth remain unclear. We investigated various clinicopathologic features in three patients who underwent resection for this type of intrahepatic cholangiocarcinoma. All underwent extended left hepatectomy plus resection of the caudate lobe and lymph node dissection. Lymph nodes showed no pathologic involvement. Although no cancer cells were seen in the mucosal layer by intraoperative pathologic examination at the bile duct stump in any patient, pathologic examination of resected specimens showed cancer cells invading beyond the mucosal layer in connective tissues surrounding the bile duct stump (interstitial invasion) of the Glisson's sheath in 2 patients. One of them died of cancer recurrence near the bile duct stump, while the third patient, without interstitial invasion, has survived for 10.6 years. In the intraductal growth type of intrahepatic cholangiocarcinoma, absence of cancer cells should be confirmed by intraoperative pathologic examination of not only the mucosal layer of the bile duct but also the connective tissue surrounding the bile duct, since interstitial invasion may be a risk factor for cancer recurrence.

Aim: To clarify whether hepatocellular carcinoma (HCC) originates from hepatic progenitor cells and whether there is any correlation with the clinicopathologic factors of HCC, we reviewed 217 resected HCC specimens., Methods: Immunohistochemical examination of cytokeratin (CK) 7, CK19, CD34, and CD117 (c-KIT) was performed. Overexpression of CK7 and CK19 indicates differentiation from cholangiocellular and hepatic progenitor cells, while overexpression of CD34 and CD117 indicates hepatic stem cells. Fresh specimens were obtained from 20 HCC patients for mutation of the c-KIT gene., Results: CK7, CK19, and CD117 were positive in 41, 9.7, and 0.9% of the HCC specimens, respectively, and CD34 was never positive. None of the fresh HCC specimens demonstrated a c-KIT mutation. CK19 positivity was significantly correlated with a positive hepatitis B core antibody, and with poor survival outcome, and tended to correlate with poor histologic differentiation., Conclusion: These results suggest that: (i) about 10% of HCCs with typical histologic features originate from an intermediate hepatic progenitor cell, such as the canal of Hering and oval cells in the rat, or acquire the characteristics of cholangiocellular epithelium by metaplasia; (ii) HCC with typical histologic features rarely originates from hepatic stem cells, and (iii) patients with CK19-positive HCC have a poor prognosis., (Copyright (c) 2005 S. Karger AG, Basel.)

Although hepatitis C virus (HCV)-related cirrhosis has been suggested as a risk factor for intrahepatic cholangiocarcinoma (ICC), few sizeable studies have tested this hypothesis. We investigated ICC risk factors, with special reference to HCV infection. We conducted a hospital-based case-control study including 50 ICC patients and 205 other surgical patients without primary liver cancer. HCV seropositivity was detected in 36% of ICC patients and 3% of controls. By univariate analysis, the odds ratio (OR) for association of anti-HCV antibodies with development was 16.87 (95% confidence interval (CI), 5.69 to 50.00). History of blood transfusion or diabetes mellitus, elevated serum total bilirubin, elevated aspartate aminotransferase and alanine aminotransferase, decreased serum albumin and decreased platelet count were identified as other possible ICC risk factors. By multivariate analysis, anti-HCV antibodies (adjusted OR, 6.02; 95% CI, 1.51 to 24.1), elevated alanine aminotransferase, decreased serum albumin, and decreased platelet count were found to be independent risk factors for ICC development. As liver status worsened, the adjusted OR for ICC tended to increase. HCV infection is a likely etiology of ICC in Japan.

Background: The prognosis of hepatocellular carcinoma originating in or mainly involving the caudate lobe (caudate HCC) is generally poor. We reviewed the clinicopathologic findings of patients who underwent liver resection of caudate HCC and correlated the outcome with the surgical strategy., Methods: Records of 402 patients who underwent liver resection for HCC were reviewed. The patients were divided into 2 groups. One group consisted of 15 patients who underwent liver resection for caudate HCC. The other group included 387 patients with HCC in a site other than the caudate lobe., Results: Anatomic resection of Couinaud segment I or IX (a partial caudate lobectomy), conforming to portal anatomy, was performed in 13 patients with caudate HCC, and segmentectomies of segments I and IX (a total caudate lobectomy) were performed in 2 patients with caudate HCC. The incidence of postoperative complications was similar in the caudate HCC group and HCC in other sites group, with no operative deaths in the caudate HCC group. Tumor-free survival and cumulative survival were similar in the 2 groups. However, among patients with caudate HCC, tumor-free and cumulative survival were lower in patients with than without microscopic portal venous involvement (P<.01)., Conclusions: Partial caudate lobectomy (anatomic resection of segment I or IX) along the portal system is an appropriate procedure for caudate HCC, especially in patients with impaired liver function or a small HCC. Patients with caudate HCC who have microscopic portal venous involvement may require adjuvant therapy as early recurrence is likely.

A 40-year-old Japanese woman, who previously had undergone choledocho-jejunostomy in childhood for a congenital choledocal cyst, presented with right-sided chest pain. Computed tomography and ultrasonography demonstrated a right pleural effusion and a 10-cm unilocular hepatic cystic lesion with no solid component. These findings suggested a non-neoplastic cyst or cystadenoma. However, intracystic fluid aspirated had high concentrations of carbohydrate antigen 19-9 and carcinoembryonic antigen. Cytology of the pleural effusion demonstrated malignant cells. During exploratory laparo- and thoracotomy, a hepatic cystadenocarcinoma with invasion of the diaphragm and pleural dissemination was discovered. This case demonstrates that malignancy should be ruled out when a patient with an intrahepatic unilocular cystic lesion presents with atypical symptoms and findings, such as chest pain, pleural effusion, and high serum concentration of tumor markers. We believe that intrahepatic cystic lesions should be approached aggressively, including the use of exploratory laparotomy/laparoscopy to be certain that cancer is not present.

The prognosis of hepatocellular carcinoma originating from the caudate lobe (caudate HCC) is generally poor, and surgical treatment for caudate HCC is difficult to perform due to the location. We postulate that a combination of surgical resection and transcatheter arterial embolization improves the prognosis, and that operative procedure is straightforward. We examined three cases of large solitary caudate HCC. Three patients (a 68-year-old woman, 65-year-old man, and 71-year-old man) with caudate HCC and viral chronic hepatitis were treated with preoperative transcatheter arterial embolization and partial resection of the caudate lobe. After transcatheter arterial embolization, the solitary hepatocellular carcinomas decreased in size (9 to 6, 10 to 8, and 7 to 5 cm in diameter, respectively) which simplified surgical resection (1120, 3010, and 2110 cc blood loss; 4.5, 7, and 7 hours of operative time, respectively). All the hepatocellular carcinomas were poorly differentiated, and had infiltrated microscopically into the portal vein. The outcome was satisfactory (18, 16, and 10 months after the operation, two cases were alive, and one dead, respectively). The combination of preoperative transcatheter arterial embolization and partial resection for caudate HCC, especially large solitary caudate HCC, works well as a multimodal therapy.

Background: The clinicopathologic features of cystic neoplasms of the liver, such as cystadenoma and cystadenocarcinoma, are poorly defined because these lesions are extremely rare., Methods: Clinicopathologic findings in six patients who underwent surgery for a cystic hepatic neoplasm were reviewed retrospectively to determine the best surgical strategy to treat this condition., Results: Five patients had a multilocular cyst or elevated lesions detected on preoperative imaging studies. The remaining patient had elevated serum concentrations of carcinoembryonic antigen and carbohydrate antigen 19-9, even though preoperative imaging studies of the hepatic cystic lesion revealed no imaging features of cystadenocarcinoma. Cytology failed to detect malignant cells in the cyst contents of any patient. One patient underwent palliative resection because pleural dissemination was present, and five patients underwent curative resection. Three patients had cystadenoma diagnosed in the surgical specimen. One patient with cystadenocarcinoma has survived for more than 8 years after a curative resection that was limited to the cyst wall, and another patient died of recurrence 13 months after surgery., Conclusions: When a cystic neoplasm is suspected of being cystadenocarcinoma, hepatic resection should be considered, because reliable criteria for distinguishing cystadenoma from cystadenocarcinoma clinically do not exist.

A 65-year-old Japanese man underwent radiofrequency ablation (RFA) therapy of a hepatocellular carcinoma. Hemobilia from the intrahepatic bile ducts adjacent to the tumor developed on the fifth day after the RFA therapy. Ultrasonograms and computed tomograms showed swelling of the gallbladder, which was filled with a clot, suggesting the diagnosis of hemocholecyst. The hemobilia resolved with conservative therapy, but a cholecystectomy was performed to manage postprandial abdominal pain. The resected gallbladder was filled with a clot, but injury or ulceration of the gallbladder was absent, suggesting that the hemocholecyst developed secondary to the hemobilia. Secondary hemocholecyst is a rare complication of RFA therapy. The number of cases of secondary hemocholecyst is likely to increase as hepatocentestic therapy becomes more common. Cholecystectomy is indicated for hemocholecyst because spontaneous liquefication and drainage of a clot in the gallbladder usually does not occur.