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Background: The Barcelona Clinic Liver Cancer (BCLC) staging system is the most widely used staging system for hepatocellular carcinoma (HCC). However, the classifications of early (BCLC-A) and intermediate (BCLC-B) stage HCC remain controversial., Aim: To refine the staging of BCLC-A and -B., Methods: A total of 986 patients with HCC undergoing liver resection from two institutions formed the training cohort, and 694 from another institution were the validation cohort. Time-dependent receiver operating characteristic (ROC) curve analysis was performed to evaluate the performance of tumour size in predicting overall survival (OS), and determined the optimised cut-off. Discriminatory performance was evaluated using Harrell's concordance index (C-index)., Results: Patients with multiple tumours exceeding Milan criteria but within up-to-seven criteria had similar OS and disease-free survival (DFS) to those with multiple tumours meeting Milan criteria, and were assigned to the modified BCLC-A stage. The area under the ROC curve of tumour size for predicting OS was 0.778, and the diameter of 7 cm was the optimal cut-off to identify patients with single tumours who had higher OS than BCLC-B stage patients. Due to the similar OS, patients with single HCCs >7 cm were assigned to the modified BCLC-B stage. The C-indexes of the modified BCLC classification for OS and DFS were higher compared to the original version. The findings were supported by the validation cohort., Conclusions: The modified staging of BCLC-A and -B, based on single tumour >7 cm and multiple tumours beyond up-to-seven criteria, could be more accurate to predict the prognosis of HCC patients. Liver resection could benefit patients with resectable multifocal HCCs beyond the Milan criteria., (© 2018 John Wiley & Sons Ltd.)

Objective: To explore the safety and feasibility of associating diaphragm resection and liver-diaphragmatic metastasis lesions resection for patients with advanced ovarian cancer. Methods: Retrospectively analysis 83 cases(98 times) of advanced ovarian cancer with liver-diaphragmatic metastasis between January 2012 and December 2016 at Department of Liver Surgery, Peking Union Medical College Hospital.The patients were aged from 19 to 75 years.Surgical procedure included metastatic lesions resection(43 times) and stripping(55 times). Operation status, post-operative complications, pathology results and follow-up of the patients were analyzed. Results: Fifteen patients received twice surgical treatment and 68 patients received one time surgical treatment. Postoperative hemorrhage in chest and between liver and diaphragm was not occurred in all cases.Dyspnea and low oxygen saturation were occurred in two cases of stripping patients and 1 case of metastatic lesions resection patients.Results of CT examination indicated that there was medium to large amount of ascites in right chests.The symptoms were relieved after placing thoracic closed drainage.Other patients were recovered smoothly.All patients were diagnosed as ovarian cancer by pathological examination. Conclusion: Associating diaphragm resection is safe and feasible for liver-diaphragmatic metastasis lesions from ovarian cancer.

The optimal treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) remains controversial. We aimed to investigate the best treatment for patients with HCC with PVTT. From January 2002 to January 2014, the data from all consecutive patients with HCC with PVTT who underwent surgical treatment (ST),TACE,TACE combined with sorafenib (TACE-Sor), or TACE combined with radiotherapy (TACE-RT) in the 4 largest tertiary hospitals in China were analyzed retrospectively. The patients were divided into 3 subtypes according to the extent of PVTT in the portal vein (type I-III). The primary endpoint was overall survival (OS). A total of 1580 patients with HCC with PVTT were included in the study. The median survival times (MST) for ST (n = 745) for type I, II, and III patients (95% CI) were 15.9 (13.3-18.5), 12.5 (10.7-14.3), and 6.0 (4.3-7.7) months, respectively. The corresponding figures for patients after TACE (n = 604) were 9.3 (5.6-12.9), 4.9 (4.1-5.7), and 4.0 (3.1-4.9), respectively; for patients after TACE-Sor (n = 113) 12.0 (6.6-17.4), 8.9 (6.7-11.1), and 7.0 (3.0-10.9), respectively; and for patients after TACE-RT (n = 118) 12.2 (0-24.7), 10.6 (6.8-14.5), and 8.9 (5.2-12.6), respectively. Comparison among the different treatments for the 3 subtypes of PVTT patients after propensity score (PS) matching showed the effectiveness of ST to be the best for type I and type II PVTT patients, and TACE-RT was most beneficial for type III patients. Treatment was an independent risk factor of OS. ST was the best treatment for type I and II PVTT patients with Child-Pugh A and selected B liver function. TACE-RT should be given to type III PVTT patients.

Background: Golgi protein 73 (GP73) is a promising biomarker of hepatocellular carcinoma (HCC). It decreases after surgical resection, and resumes upon recurrence, indicating a potential indicator for the effectiveness of the treatment. But changes of GP73 after transcatheter arterial chemoembolization (TACE) have not been reported so far. This study was to investigate the dynamic changes of GP73 in HCC patients after TACE treatment, and the possible underlying mechanisms in the cell cultures., Methods: Blood samples were collected from 72 HCC patients, before TACE, at day 1 and day 30 after TACE. GP73 levels were measured by Western blotting. The dynamic changes of GP73 were analyzed and compared with image changes and clinical data. The effects of chemotherapeutic agents (5-FU and pirarubicin) on GP73 expression were tested in three HCC cell lines (HepG2, HCCLM3 and MHCC97H)., Results: The GP73 level was significantly elevated at day 1 and day 30 after TACE in HCC patients compared with that before the procedure (P<0.05). There was no statistical difference between the two time points after TACE, nor correlation between GP73 levels and clinicopathological features, tumor metastasis, and patient survival. Pirarubicin, not 5-FU, significantly increased GP73 expression in three cell lines., Conclusions: Unlike surgical resection which decreases the GP73 level, TACE significantly increased GP73 expression in patients with HCC. No correlations were observed among GP73 levels, tumor characteristics and prognosis of patients with HCC.

Objective: To explore the clinical features, diagnosis, treatment and prognosis of primary hepatic angiosarcoma (PHA)., Methods: The clinical data of 7 PHA patients admitted to our hospital from December 2004 to December 2010 were retrospectively analyzed and the relevant literatures reviewed., Results: Seven cases (5 males and 2 females) were diagnosed as PHA among 1027 (0.68%) patients with primary hepatic malignant tumors. Their mean age was 43.3 years old (range: 33 - 74). Four cases were of solitary lesion and three of multiple lesions. No specific clinical features were observed. The PHA lesions were easily misdiagnosed as benign or hepatic metastatic tumors. Contrast enhanced ultrasound (CEUS) showed the lesions with characteristic manifestations. And the positron emission tomography (PET-CT) could confirm the hepatic lesions as malignant tumors. The survival time for two untreated cases was 3 & 5 months, for two cases with liver transplantation (LTx) 3 & 8 months and for two cases treated with surgical resection & targeted therapy was 14 & 19 months respectively. One case was lost to follow-up at 6 months after hepatic resection., Conclusion: PHA is a clinically rare and highly malignant tumor with a rapid progression and a poor prognosis. Both CEUS and PET-CT are helpful for its differential and confirmative diagnosis. LTx should be considered as a contraindication for PHA. Hepatic resection has proven to be beneficial for PHA patients with solitary lesion. Surgical resection plus targeted medicines may improve their survival.

Objective: To summarize the experience of hepatectomy in patients with hepatocellular carcinoma fulfilling the Milan criteria and analyze the clinicopathological factors for patient survival and tumor recurrence., Methods: The clinicopathological data of 104 patients with early-stage hepatocellular carcinoma fulfilling the Milan criteria and underwent hepatectomy at Peking Union Medical College Hospital between April 2003 and June 2009 were retrospectively analyzed., Results: The median follow-up was 24 months. There were 54 recurrent cases. The 1-, 3- and 5-year cumulative disease-free survival rate were 63.0%, 32.6% and 22.4% respectively. Neither univariate analysis nor multivariate analysis indicated any factor significantly correlated with recurrence (P>0.05). The cumulative overall survival rate at 1, 3 and 5 years were 88.8%, 68.1% and 68.1% respectively. Univariate analysis revealed that blood transfusion (P=0.000), involvement of hepatic capsule (P=0.000) and postoperative transarterial chemotherapy (P=0.049) were significantly correlated with survival. And multivariate analysis indicated that blood transfusion (P=0.001) and involvement of hepatic capsule (P=0.000) were independent prognostic factors for survival., Conclusion: For the patients with early-stage hepatocellular carcinoma and compensated liver function fulfilling the Milan criteria, hepatectomy serves as the preferred treatment strategy.

Aim: To investigate the impact of postoperative antiviral treatment on tumor recurrence and survival of patients with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection-related primary hepatocellular carcinoma (HCC) after curative therapy., Methods: We performed a meta-analysis of randomized and non-randomized control trials from electronic search and manual search. The fixed effect model of Mantel-Haenszel method and the random effect model of Der Simonian and Laird method were used for homogeneous and heterogeneous studies, respectively. Seven HCV-related studies, three HBV-related studies and three studies on HBV or HCV-related HCC were identified., Results: A total of 1224 patients were included in this analysis. The estimated odds ratios (OR) for the 1-, 2-, 3- and 5-year recurrence were 0.54 [15.4% vs 24.1%, 95% confidence interval (CI): 0.32-0.89, P = 0.02], 0.42 (36.9% vs 58.0%, 95% CI: 0.19-0.90, P = 0.03), 0.37 (47.9% vs 63.8%, 95% CI: 0.19-0.71, P = 0.003), and 0.32 (66.7% vs 74.3%, 95% CI: 0.15-0.66, P = 0.002), respectively; and the OR for the 1-, 2-, 3-, 5- and 7-year mortality were 0.23 (1.2% vs 9.1%, 95% CI: 0.07-0.71, P = 0.01), 0.31 (6.4% vs 22.1%, 95% CI: 0.12-0.79, P = 0.01), 0.43 (12.7% vs 20.8%, 95% CI: 0.21-0.89, P = 0.02), 0.42 (25.1% vs 42.0%, 95% CI: 0.27-0.66, P = 0.0002) and 0.28 (31.9% vs 52.2%, 95% CI: 0.13-0.59, P = 0.0008)., Conclusion: This meta-analysis indicates the postoperative antiviral therapy, interferon in particular, may serve as a favorable alternative to reduce recurrence and mortality in patients with HBV/HCV related HCCs.

Objective: To summarize the surgical experiences, risks, complications, and managements for hepatic masses in difficult sites., Methods: Totally 47 patients were divided into three groups based on the liver tumor sites: primary porta hepatis group, secondary porta hepatis group, and caudate lobe group. All patients underwent different portion of hepatectomy., Results: The surgery duration was (289.6 +/- 62.2) ml-nutes, intra-operative blood loss was (602.3 +/- 256.4) ml, and intra-operative blood transfusion was (524.0 +/- 325.9) ml. Incidence of surgical complications in each group was 61.5%, 26.9%, and 25%, respectively. Serious complications observed were biliary leakage (27.7%), bleeding (6.4%), and post-operative liver failure (2.1%). Three perioperative deaths were reported: two patients died of bleeding, and one patient died from liver failure., Conclusions: Dissection of the liver and exposure of major blood vessels and biliary ducts are of critical importance in the surgeries for hepatic masses in difficult sites, and post-operative complications may be remarkably reduced through delicate manipulations of the small intra-hepatic vessels and biliary ducts during resection. A thorough pre-operative evaluation plays a key role in predicting the feasibility and risks of the surgery. Damage to the major blood vessels adjacent to the tumor, in addition to bleeding, may result in in-flow or outflow obstruction and cause necrosis of the corresponding hepatic lobe. Compared with damage to the primary portal area, vascular damage to the secondary porta is generally associated with higher fatality.

Objective: To observe the precise time of the recurrence after resection of hepatocellular carcinoma (HCC) and to further explore the risk factors associated with postoperative recurrence., Methods: Totally 94 patients who had undergone resection of HCC were divided into three groups based on the time of recurrence, which was indicated by the digital subtraction angiography (DSA) examination: recurrence between 1 to 6 months, recurrence between 7 to 12 months, and tumor-free after 12 months. Patients with intra-hepatic recurrence were treated with transcatheter arterial chemoembolization and confirmed by CT scans after embolization, contrast-enhanced ultrasound, or magnetic resonance imaging., Results: The recurrence rates of 6 months and 1 year were 30.9% and 36.2%, respectively. No statistically significant difference between 6-month and 1-year recurrence rates was observed. Nine (26.5%) patients with recurrence and five (8.3%) patients free of tumor had previously presented as multifocal HCC, which showed a statistical significance (P = 0.032). The diagnostic accuracy of DSA was 87.2%, which was eventually confirmed by the other investigations., Conclusions: Most recurrences occure within the first six months postoperatively and multifocal carcinogenesis is one of the risk factors associated with early recurrence after liver resection for advanced HCC. DSA is an important surveillance for early detection of intra-hepatic recurrence after surgery; meanwhile, it also provides information for early management to control the disease progression and for future active therapies.

Objective: To evaluate the sensitivity and specificity of Golgi glycoprotein 73 (GP73) for the diagnosis of hepatitis B related hepatocellular carcinoma (HCC)., Methods: Western blotting was used to detect the serum GP73level in 25 patients being HBV carrier, 24 HCC patients, 12 patients with non-liver disease, and 99 healthy controls. Serum alpha-fetoprotein (AFP) was detected by electrochemiluminescence reaction. The levels of sensitivity and specificity of serum GP73 in diagnosing HCC were compared with those of AFP. The serum GP73 levels of some HCC patients during the perioperative period were compared., Results: The serum GP73 level of the HCC patients, all HBV positive, was (40.36 +/- 64.43) relative units, significantly higher than those of the HBV carriers, non-liver patients, and healthy controls [(7.82 +/- 10.72), (4.48 +/- 5.70), and (2.59 +/- 5.12) relative units respectively, all P < 0.01]. There was no difference of GP73 levels between the healthy controls and the patients of non liver diseases (P = 0.2925). The sensitivity of GP73 for the diagnosis of HCC was 76.9%, significantly higher than that of AFP (48.6%). The specificity for the diagnosis of HCC of GP73 was 92.9%. Findings in a few HCC patients showed that the GP73 level remained not remarkably lowered within a week after surgical resection; but became lower 1.5-2 years after surgery. There was no raise of GP73 in the patients with non- malignant liver lesions. The GP73 levels of 4 of the 6 intra-hepatic cholangiocarcinoma patients were between those of the HCC patients and HBV carriers., Conclusion: Serum GP73 has higher sensitivity and specificity in diagnosis of hepatitis B-related HCC than AFP, and it can become a new effective HCC tumor marker.

Objective: To explore the possibility of using melanoma antigen (MAGE)-1 and MAGE-3 gene encoding proteins as an index of potential target for immunotherapy in intrahepatic cholangiocarcinoma (IHCC) patients., Methods: The expressions of MAGE-1 and MAGE-3 genes in tumor tissues and tumor adjacent non-IHCC liver tissues were examined by RT-PCR method. The relationship between positive expression rates of MAGE-1 and MAGE-3 genes and clinical data including sex, age, tumor diameters, tumor envelope, tumor nodules number, and hepatitis B virus surface antigen were determined., Results: The positive expression rates of MAGE-1 (35%) and MAGE-3 genes (45%) were significantly higher in the tumor tissues than in tumor adjacent tissues (0) (P<0.01). The positive expression rates of MAGE-1 and MAGE-3 genes had no relationship with the clinical data (P >0.05), except the morphology of tumor (P <0.05)., Conclusion: The high expression rates of MAGE-1 and MAGE-3 genes in IHCC suggests the MAGE-1 and MAGE-3 gene may be a target for immunotherapy in IHCC patients.

Objective: To report the first case of primary epithelial-myoepithelial carcinoma (EMC) in the liver., Methods: The clinical manifestations, imaging characteristics, and histopathological changes of EMC in this case were described. The patient was a thirty-seven-year old female. A 10 cm lesion was detected in the right liver upon a routine examination. Following that, the CT scan, magnetic resonance imaging (MRI), repeated puncture biopsies, and serum alpha-fetoprotein (AFP) detection were done with no specificity and significance found., Results: Right hemi-hepatectomy was performed. The special double catheterization cannula was found in the histopathological examination, and the final diagnosis of EMC was proven by immuno-histochemical staining., Conclusions: Primary EMC is difficult to be finally diagnosed prior to the surgery. The diagnosis can be confirmed using pathological examination and immuno-histochemical staining of the specimen.