title: Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis.
abstract: OBJECTIVE
  Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors.
  
  
  METHODS
  Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model.
  
  
  RESULTS
  Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69).
  
  
  CONCLUSIONS
  By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Section of Gastrointestinal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, United States.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Kluger
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Salceda
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Alexis
authors.initials: A
authors.lastname: Laurent
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Claude
authors.initials: C
authors.lastname: Tayar
authors.affiliation: Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Duvoux
authors.affiliation: Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: Decaens
authors.affiliation: Service d'Imagerie Medicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Luciani
authors.affiliation: Service d'Anatomie et Cytologie Pathologiques, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Jeanne Tran
authors.initials: JT
authors.lastname: Van Nhieu
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France.
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.affiliation: Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Centre Hépato Biliaire, Paul Brousse Hôpital, Université Paris Sud, Villejuif, France. Electronic address: daniel.cherqui@pbr.aphp.fr.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cherqui
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000473:pathology / Q000601:surgery; D018572:Disease-Free Survival; D005260:Female; D005602:France; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology; D008103:Liver Cirrhosis / Q000473:pathology / Q000601:surgery; D008111:Liver Function Tests; D008113:Liver Neoplasms / Q000175:diagnosis / Q000473:pathology / Q000601:surgery; D016031:Liver Transplantation / Q000379:methods; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D016016:Proportional Hazards Models; D011859:Radiography; D047368:Tumor Burden
keywords: Cirrhosis; Liver disease; Pathology; Prognosis; Transplantation