Gastroenterology

Gastroenterology

Volume 137, Issue 3, September 2009, Pages 850-855
Gastroenterology

Clinical Advances in Liver, Pancreas, and Biliary Tract
A System of Classifying Microvascular Invasion to Predict Outcome After Resection in Patients With Hepatocellular Carcinoma

https://doi.org/10.1053/j.gastro.2009.06.003Get rights and content

Background & Aims

Hepatocellular carcinoma (HCC) recurs in approximately 70% of cases after resection. Vascular invasion by tumor cells can be classified as gross or microscopic (microvascular invasion [mVI]) and is a risk factor for recurrence. We examined a large cohort of patients with HCC who were treated by resection to identify features of mVI that correlated with recurrence and survival.

Methods

We reviewed the records of all HCC resections performed at the Mount Sinai School of Medicine between January 1990 and March 2006 to identify those with mVI, established by histologic analysis. The numbers and sizes of vessels invaded, invasion of a vessel with a muscular wall, distance from the tumor, and satellite nodules were recorded.

Results

Of the 384 patients who underwent resection for HCC, 131 (34.1%) met the entry criteria. The median follow-up period was 28.9 months. There were 68 recurrences and 54 deaths. In multivariate analysis, invasion of a vessel with a muscular wall predicted recurrence (hazard ratio, 1.8; P = .02), and invasion of a vessel with a muscular wall (hazard ratio, 2.2; P = .018) and invasion of a vessel that was more than 1 cm from the tumor (hazard ratio, 2.1; P = .015) predicted survival. A risk score that assigned points for the presence of each variable correlated with recurrence (P = .028) and survival (P < .0001).

Conclusions

A novel classification system that includes invasion of a vessel with a muscular wall and invasion of a vessel that is more than 1 cm from the tumor can accurately predict risk of recurrence and survival of patients with mVI after resection of HCC.

Section snippets

Patients

We analyzed the prospectively collected data of a cohort of patients undergoing hepatic resection for HCC between January 1990 and March 2007 after obtaining approval from the Institutional Review Board. To have the outcomes affected primarily by tumor-related factors and not by the degree of underlying liver disease or portal hypertension, a homogenous study population was selected. Consequently, the inclusion criteria required patients to have Child–Pugh A liver function and platelet count

Results

During the study period, 385 patients underwent hepatic resection for treatment of HCC. Of these, 14 had either platelet count <100,000/μL or Child–Pugh B liver function, and they were excluded from analysis (Figure 2). No vascular invasion was detected in 109 (29%) of patients, whereas 151 (40%) had mVI, and 111 (30%) had gross vascular invasion on pathologic examination. The patient demographics, liver function, and tumor characteristics are provided in Table 1. Survival and recurrence were

Discussion

Hepatic resection for HCC can result in excellent long-term survival in properly selected patients. Nevertheless, resection continues to be plagued by a high rate of tumor recurrence. As our current study demonstrates, the large majority of recurrences is within the remaining liver. This is primarily because of intrahepatic dissemination of the tumor via the portal circulation. Consequently, it is not surprising that vascular invasion has been repeatedly identified as a predictor of recurrence

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Conflicts of interest The authors disclose no conflicts.

Funding Supported by grants from the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (1R01DK076986-01; to J.L.), by the Samuel Waxman Cancer Research Foundation, by the Spanish National Health Institute (SAF-2007-61898), by Institut Catala de Recerca Avançada (ICREA), and by a grant from the National Institute of Health (K24 DK 60498-01; to M.E.S.).

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