title: Tumor-stroma ratio is a prognostic factor for survival in hepatocellular carcinoma patients after liver resection or transplantation.
abstract: BACKGROUND
  The stromal compartment in several organs seems to play an important role in the initiation, growth, and progression of certain neoplasms. The tumor-stroma ratio (TSR) has been found to be an independent factor for prognosis of several types of carcinomas, but the effect of the TSR on hepatocellular carcinoma (HCC) has not been explored yet. The objective of the study is to evaluate the prognostic importance of TSR in HCC patients after liver resection or transplantation.
  
  
  METHODS
  A total of 300 patients with HCC who underwent liver resection or transplantation were included in this study. TSR was assessed on hematoxylin and eosin-stained sections by 2 independent investigators. Patients were divided into 2 groups: a stroma-rich group (stroma ≥ 50%) and a stroma-poor group (stroma < 50%). Chi-square test, Kaplan-Meier method, and Cox univariable and multivariable regression were used in to analyze the data.
  
  
  RESULTS
  Among the post liver resection patients, the TSR was associated with overall survival (OS) in univariate and multivariate analyses (hazard ratio [HR], 4.35 [95% CI, 2.54-7.47] and HR, 2.55 [95% CI, 1.44-4.52], respectively). Among the post liver transplant patients, the TSR was also associated with OS in univariate and multivariate analyses (HR, 2.92 [95% CI, 1.63-5.23] and HR, 2.76 [95% CI, 1.47-4.85], respectively), and TSR with recurrence-free survival (RFS) in univariate and multivariate analyses (HR, 2.63 [95% CI, 1.42-4.86] and HR, 1.93 [95% CI, 1.03-3.62], respectively). Patients with stroma-poor tumor and who were within the Milan criteria or the UCSF criteria had a better in OS and RFS.
  
  
  CONCLUSIONS
  We show for the first time that TSR is an independent prognostic factor for HCC patients after liver resection or transplantation. TSR may enable better identification of patients at risk for recurrence in HCC patients after curative treatment and may aid in patient management and development of individualized medicine for treatment of HCC.
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Zhen
authors.initials: Z
authors.lastname: Lv
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China.
authors.forename: Xianlei
authors.initials: X
authors.lastname: Cai
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Xiaoyu
authors.initials: X
authors.lastname: Weng
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Heng
authors.initials: H
authors.lastname: Xiao
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Chengli
authors.initials: C
authors.lastname: Du
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Cheng
authors.affiliation: Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
authors.forename: Lin
authors.initials: L
authors.lastname: Zhou
authors.affiliation: Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China.
authors.forename: Haiyang
authors.initials: H
authors.lastname: Xie
authors.affiliation: Department of Pathology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
authors.forename: Ke
authors.initials: K
authors.lastname: Sun
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China. Electronic address: drwujian@hotmail.com.
authors.forename: Jian
authors.initials: J
authors.lastname: Wu
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center of Diagnosis and Treatment of Infectious Diseases, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public, Hangzhou, China. Electronic address: shusenzheng@zju.edu.cn.
authors.forename: Shusen
authors.initials: S
authors.lastname: Zheng
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D002477:Cells / Q000473:pathology; D005110:Extracellular Space; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008099:Liver / Q000473:pathology* / Q000601:surgery; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis