title: Predicting recurrence patterns after resection of hepatocellular cancer.
abstract: BACKGROUND
  The reliable prediction of hepatocellular carcinoma (HCC) recurrence patterns potentially allows for the prioritization of patients for liver resection (LR) or transplantation.
  
  
  OBJECTIVE
  The aim of this study was to analyse clinicopathological factors and preoperative Milan criteria (MC) status in predicting patterns of HCC recurrence.
  
  
  METHODS
  During 1992-2012, 320 patients undergoing LR for HCC were categorized preoperatively as being within or beyond the MC, as were recurrences.
  
  
  RESULTS
  After a median follow-up of 47 months, 183 patients developed recurrence, giving a 5-year cumulative incidence of recurrence of 62.5%. Patients with preoperative disease within the MC had better survival outcomes than those with preoperative disease beyond the MC (median survival: 102 months versus 45 months; P < 0.001). Overall, 31% of patients had preoperative disease within the MC and 69% had preoperative disease beyond the MC. Estimated rates of recurrence-free survival at 5 years were 61.8% for all patients and 53.8% for patients with initial beyond-MC status. Independent factors for recurrence beyond-MC status included preoperative disease beyond the MC, the presence of microsatellite or multiple tumours and lymphovascular invasion (all: P < 0.001). A clinical risk score was used to predict survival and the likelihood of recurrence beyond the MC; patients with scores of 0, 1, 2 and 3 had 5- year incidence of recurring beyond-MC of 9.0%, 29.5%, 48.8% and 75.4%, respectively (P < 0.0001).
  
  
  CONCLUSIONS
  Regardless of initial MC status, at 5 years the majority of patients remained disease-free or experienced recurrence within the MC after LR, and thus were potentially eligible for salvage transplantation (ST). Incorporating clinicopathological parameters into the MC allows for better risk stratification, which improves the selection of patients for ST and identifies patients in need of closer surveillance.
authors.affiliation: Department of Surgery, Memorial SloanKettering Cancer Center, New York, NY, USA; Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore; Department of Surgical Oncology, National Cancer Centre, Singapore, Singapore.
authors.forename: Ser Yee
authors.initials: SY
authors.lastname: Lee
authors.forename: Ioannis T
authors.initials: IT
authors.lastname: Konstantinidis
authors.forename: Anne A
authors.initials: AA
authors.lastname: Eaton
authors.forename: Mithat
authors.initials: M
authors.lastname: Gönen
authors.forename: T Peter
authors.initials: TP
authors.lastname: Kingham
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Allen
authors.forename: Yuman
authors.initials: Y
authors.lastname: Fong
authors.forename: Ronald P
authors.initials: RP
authors.lastname: DeMatteo
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult