Diamantis I Tsilimigras1, Kota Sahara1,2, Dimitrios Moris1, J Madison Hyer1, Anghela Z Paredes1, Fabio Bagante1,3, Katiuscha Merath1, Ayesha S Farooq1, Francesca Ratti4, Hugo P Marques5, Olivier Soubrane6, Daniel Azoulay6, Vincent Lam7, George A Poultsides8, Irinel Popescu9, Sorin Alexandrescu9, Guillaume Martel10, Alfredo Guglielmi3, Tom Hugh11, Luca Aldrighetti4, Itaru Endo2, Timothy M Pawlik12. 1. Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA. 2. Yokohama City University School of Medicine, Yokohama, Japan. 3. Department of Surgery, University of Verona, Verona, Italy. 4. Department of Surgery, Ospedale San Raffaele, Milan, Italy. 5. Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal. 6. Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France. 7. Department of Surgery, Westmead Hospital, Sydney, Australia. 8. Department of Surgery, Stanford University, Stanford, CA, USA. 9. Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania. 10. Department of Surgery, University of Ottawa, Ottawa, Canada. 11. Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia. 12. Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA. tim.pawlik@osumc.edu.
Abstract
INTRODUCTION: Although a positive surgical margin is a known prognostic factor for recurrence, the optimal surgical margin width in the context of an R0 resection for early-stage hepatocellular carcinoma (HCC) is still debated. The aim of the current study was to examine the impact of wide (> 1 cm) versus narrow (< 1 cm) surgical margin status on the incidence and recurrence patterns among patients with T1 HCC undergoing an R0 hepatectomy. METHODS: Between 1998 and 2017, patients with T1 HCC who underwent R0 hepatectomy for stage T1 HCC were identified using an international multi-institutional database. Recurrence-free survival (RFS) was estimated, and recurrence patterns were examined based on whether patients had a wide versus narrow resection margins. RESULTS: Among 404 patients, median patient age was 66 years (IQR: 58-73). Most patients (n = 326, 80.7%) had surgical margin < 1 cm, while 78 (19.3%) patients had a > 1 cm margin. The majority of patients had early recurrences (< 24 months) in both margin width groups (< 1 cm: 70.3% vs > 1 cm: 85.7%, p = 0.141); recurrence site was mostly intrahepatic (< 1 cm: 77% vs > 1 cm: 61.9%, p = 0.169). The 1-, 3-, and 5-year RFS among patients with margin < 1 cm were 77%, 48.9%, and 35.3% versus 81.7%, 65.8%, and 60.7% for patients with margin > 1 cm, respectively (p = 0.02). Among patients undergoing anatomic resection, resection margin did not impact RFS (3-year RFS: < 1 cm: 49.2% vs > 1 cm: 58.9%, p = 0.169), whereas in the non-anatomic resection group, margin width > 1 cm was associated with a better 3-year RFS compared to margin < 1 cm (86.7% vs 47.3%, p = 0.017). On multivariable analysis, margin > 1 cm remained protective against recurrence (HR = 0.50, 95%CI 0.28-0.89), whereas Child-Pugh B (HR = 2.13, 95%CI 1.09-4.15), AFP > 20 ng/mL (HR = 1.71, 95%CI 1.18-2.48), and presence of microscopic lymphovascular invasion (HR = 1.48, 95%CI 1.01-2.18) were associated with a higher hazard of recurrence. CONCLUSION: Resection margins > 1 cm predicted better RFS among patients undergoing R0 hepatectomy for T1 HCC, especially small (< 5 cm) HCC. Although resection margin width did not influence outcomes after anatomic resection, wider margins were more important among patients undergoing non-anatomic liver resections.
INTRODUCTION: Although a positive surgical margin is a known prognostic factor for recurrence, the optimal surgical margin width in the context of an R0 resection for early-stage hepatocellular carcinoma (HCC) is still debated. The aim of the current study was to examine the impact of wide (> 1 cm) versus narrow (< 1 cm) surgical margin status on the incidence and recurrence patterns among patients with T1 HCC undergoing an R0 hepatectomy. METHODS: Between 1998 and 2017, patients with T1 HCC who underwent R0 hepatectomy for stage T1 HCC were identified using an international multi-institutional database. Recurrence-free survival (RFS) was estimated, and recurrence patterns were examined based on whether patients had a wide versus narrow resection margins. RESULTS: Among 404 patients, median patient age was 66 years (IQR: 58-73). Most patients (n = 326, 80.7%) had surgical margin < 1 cm, while 78 (19.3%) patients had a > 1 cm margin. The majority of patients had early recurrences (< 24 months) in both margin width groups (< 1 cm: 70.3% vs > 1 cm: 85.7%, p = 0.141); recurrence site was mostly intrahepatic (< 1 cm: 77% vs > 1 cm: 61.9%, p = 0.169). The 1-, 3-, and 5-year RFS among patients with margin < 1 cm were 77%, 48.9%, and 35.3% versus 81.7%, 65.8%, and 60.7% for patients with margin > 1 cm, respectively (p = 0.02). Among patients undergoing anatomic resection, resection margin did not impact RFS (3-year RFS: < 1 cm: 49.2% vs > 1 cm: 58.9%, p = 0.169), whereas in the non-anatomic resection group, margin width > 1 cm was associated with a better 3-year RFS compared to margin < 1 cm (86.7% vs 47.3%, p = 0.017). On multivariable analysis, margin > 1 cm remained protective against recurrence (HR = 0.50, 95%CI 0.28-0.89), whereas Child-Pugh B (HR = 2.13, 95%CI 1.09-4.15), AFP > 20 ng/mL (HR = 1.71, 95%CI 1.18-2.48), and presence of microscopic lymphovascular invasion (HR = 1.48, 95%CI 1.01-2.18) were associated with a higher hazard of recurrence. CONCLUSION: Resection margins > 1 cm predicted better RFS among patients undergoing R0 hepatectomy for T1 HCC, especially small (< 5 cm) HCC. Although resection margin width did not influence outcomes after anatomic resection, wider margins were more important among patients undergoing non-anatomic liver resections.
Authors: Diamantis I Tsilimigras; Kota Sahara; Lu Wu; Dimitrios Moris; Fabio Bagante; Alfredo Guglielmi; Luca Aldrighetti; Matthew Weiss; Todd W Bauer; Sorin Alexandrescu; George A Poultsides; Shishir K Maithel; Hugo P Marques; Guillaume Martel; Carlo Pulitano; Feng Shen; Olivier Soubrane; B Groot Koerkamp; Amika Moro; Kazunari Sasaki; Federico Aucejo; Xu-Feng Zhang; Ryusei Matsuyama; Itaru Endo; Timothy M Pawlik Journal: JAMA Surg Date: 2020-09-01 Impact factor: 14.766