title: Surgical treatment of fibrolamellar hepatocellular carcinoma: an underestimated malignant tumor?
abstract: BACKGROUND
  Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare disease with an indolent behavior. Its prognosis is better than that of patients with hepatocellular carcinoma. The authors present their experience with resection of FLHCC.
  
  
  METHODS
  Twenty-one patients with FLHCC were treated at our institution between 1990 and 2012. Of these patients, 14 were subjected to resection of the tumor. Patient demographics, medical history, results of imaging studies and laboratory tests, surgical data, and pathologic findings were evaluated.
  
  
  RESULTS
  The median age of the patients at the diagnosis of the tumor was 20 years and 14 patients were female. None of the patients had tumor-associated chronic liver disease or cirrhosis. The mean tumor size was 12.8 cm (range 6-19) and 18 patients had a single liver nodule. Fourteen patients were subjected to hepatectomy and six of them had lymph node metastases resected. Pathologic evaluation revealed that 5 (35.7%) patients had major vascular invasion. Tumor recurrence was seen in 8 patients (66.7%), during a follow-up. The median survival time for patients who were subjected to resection was 36 months. The 5-year overall survival rate and disease free survival rate were 28.0% and 8.5%, respectively. Univariate analysis showed that vascular invasion was the only variable associated with the disease free survival rate.
  
  
  CONCLUSIONS
  Despite an aggressive treatment, patients with FLHCC presented unexpected low survival rates. It seems that an underestimated malignant behavior is attributed to this disease, and that the forms of adjuvant treatment should be urgently evaluated.
authors.affiliation: Digestive Surgery Division, Department of Gastroenterology, University of Sao Paulo School of Medicine, Avenida Doutor Eneas de Carvalho Aguiar, 255, Instituto Central, 9 degree andar, Sala 9074, CEP: 05403-900, Cerqueira Cesar-Sao Paulo, SP, Brazil. pherman@uol.com.br.
authors.forename: Paulo
authors.initials: P
authors.lastname: Herman
authors.forename: Aline Lopes
authors.initials: AL
authors.lastname: Chagas
authors.forename: Marcos Vinicius
authors.initials: MV
authors.lastname: Perini
authors.forename: Fabricio Ferreira
authors.initials: FF
authors.lastname: Coelho
authors.forename: Gilton Marques
authors.initials: GM
authors.lastname: Fonseca
authors.forename: Venancio Avancini Ferreira
authors.initials: VA
authors.lastname: Alves
authors.forename: Flair Jose
authors.initials: FJ
authors.lastname: Carrilho
authors.forename: Ivan
authors.initials: I
authors.lastname: Cecconello
mesh_terms: D000293:Adolescent; D000328:Adult; D001808:Blood Vessels / Q000473:pathology; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology* / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local; D015996:Survival Rate; D047368:Tumor Burden; D055815:Young Adult