DA XU *, XIAOFENG LIU *, LIJUN WANG and BAOCAI XING

ONCOLOGY LETTERS Heptectomy plus djuvnt trnsctheter rteril chemoemboliztion improves the survivl rte of ptients with multicentric occurrence of heptocellulr crcinom DA XU *, XIAOFENG LIU *, LIJUN WANG nd BAOCAI XING Key Lbortory of Crcinogenesis nd Trnsltionl Reserch (Ministry of Eduction/Beijing), Heptopncretobiliry Surgery Deprtment I, Peking University Cncer Hospitl nd Institute, Beijing 100142, P.R. Chin Received September 5, 2017; Accepted June 29, 2018 DOI: 10.3892/ol.2018.9333 Abstrct. The im of the present study ws to evlute the role of heptectomy plus djuvnt trnsctheter rteril chemoemboliztion (TACE) in ptients with multicentric occurrence (MO) or intrheptic metstses (IM) of heptocellulr crcinom (HCC). Ptients with multifocl HCC who underwent heptic resection only (HR) or HR plus djuvnt TACE (HRT) between Jnury 2005 nd December 2015 were divided into MO or IM groups. The ptient chrcteristics nd outcomes were retrospectively nlyzed. A totl of 103 ptients (59 nd 44 in the MO nd IM groups, respectively) were included in the nlysis. The 1, 3 nd 5 yer overll survivl (OS) rtes were 92.7, 76.8 nd 56.8% for the MO group, nd 93.1, 41.6 nd 18.5% for the IM group, respectively (OS, P=0.001), nd the 1, 3 nd 5 yer disese free survivl (DFS) rtes were 84.1, 44.6 nd 40.5% for the MO group nd 51.7, 22.5 nd 15.0% for the IM group, respectively (DFS, P<0.001). In the subgroup nlysis, the overll survivl were significntly better in the MO HRT group compred with those in the MO HR group (P=0.019), which ws lso observed between the IM HRT nd IM HR groups (P=0.132). Furthermore, the 1, 3 nd 5 yer OS demonstrted non significnt differences between ptients with <3 nd 3 tumors in the MO HR group (P=0.300), but significntly reduced OS for ptients with 3 tumors in the IM HR group compred with tht for ptients with <3 tumors (P=0.132). In conclusion, surgicl resection combined with Correspondence to: Professor Boci Xing, Key Lbortory of Crcinogenesis nd Trnsltionl Reserch (Ministry of Eduction/Beijing), Heptopncretobiliry Surgery Deprtment I, Peking University Cncer Hospitl nd Institute, 52 Fucheng Rod, Beijing 100142, P.R. Chin E mil: xingboci88@sin.com * Contributed eqully Key words: heptocellulr crcinom, multicentric occurrence, intrheptic metstses, heptic resection, trnsctheter rteril chemoemboliztion, survivl djuvnt TACE my result in significntly incresed survivl rtes of ptients with MO HCC. Tumor number should not be n bsolute contrdiction to heptectomy in ptients with MO HCC. Introduction Heptocellulr crcinom (HCC) is common mlignncy globlly nd the third most common cuse of cncer ssocited mortlity (1,2). Surgery hs become the primry tretment for HCC, with 5 yer overll survivl (OS) rte of 40 50% (3,4). Furthermore, >50% of ptients with HCC re initilly dignosed with multiple tumors (5), reducing the probbility of receiving successful tretment for cses tht exceed the Brcelon Clinic Liver Cncer (BCLC) stging system for rdicl heptectomy, due to its high recurrence rte following surgery (6,7); however, previous study determined tht not ll ptients with multinodulr HCC of n intermedite stge would experience poor long term survivl following surgicl resection (8). Multiple HCC lesions my originte differently from multicentric occurrence (MO) or intrheptic metstses (IM), which hve dissimilr outcomes (9). The origin of MO HCC is different from the primry lesion, while IM HCC is derived from the primry tumor. A number of methods nd fetures re used to differentite MO HCC from IM HCC, including tumor loction, stellite tumors, growth from portl tumor emboli or histologicl grding (10,11). In previous studies, ptients with MO HCC were reported to hve n improved outcome compred with ptients with IM HCC following heptectomy (12,13); thus, determining the origin of multifocl HCC my benefit the selection of ptients for rdicl surgery. Additionlly, number of studies lso determined tht djuvnt trnsctheter rteril chemoemboliztion (TACE) my be beneficil in prolonging the survivl of ptients with high risk HCC, including those with lrger size, multinodulr tumors nd microvsculr invsion (14 16); however, the current literture does not indicte the type of multifocl HCC tht my benefit from djuvnt TACE. The present study ws conducted to investigte the survivl benefits for ptients with MO HCC or IM HCC who underwent liver resection nd subsequent djuvnt TACE.

2 XU et l: SURGERY PLUS TACE FOR MULTIFOCAL HEPATOCELLULAR CARCINOMA Mterils nd methods Selection of ptients. A totl of 871 ptients with pthologiclly confirmed HCC underwent heptectomy between Jnury 2005 nd December 2015 in Heptopncretobiliry Surgery Deprtment I t the Peking University Cncer Hospitl nd Institute (Beijing, Chin). The study design ws pproved by the Ethicl Review Bord Committee of the Beijing Cncer Hospitl nd Institute (Beijing, Chin). A totl of 107 ptients (12.3%) were pthologiclly dignosed with multinodulr HCC. A totl of 4 ptients were excluded. Finlly, 103 ptients were included in the present study, including 89 men nd 14 women, with medin ge of 57 yers (rnge, 25 78 yers). According to the forementioned clinicopthologicl determintion criteri, 59 cses were included in the MO group nd 44 cses were included in the IM group. In the MO HCC subgroup, 22 ptients received heptic resection (HR) only (MO HR), nd 37 ptients received HR plus djuvnt TACE (HRT) (MO HRT). The pthologicl stge of ech nodulr ws reviewed nd recorded in the resected specimens by two senior pthologists in blinded mnner using the Edmondson Steiner stging method (6). The demogrphic, surgicl, pthologicl nd survivl dt of ll ptients were collected nd nlyzed. The inclusion criterion included the multinodulr lesions being pthologiclly confirmed s HCC. The exclusion criteri included the following: i) Mixed HCC or cholngiocellulr crcinom; ii) emergence of extrheptic metstsis; iii) no R0 resection; nd iv) existence of nother type of primry tumor. Differentition criteri for MO nd IM of multinodulr HCC. A number of studies hve exmined the differences between IM nd MO (10 12,17). The differentition criteri described in the present study re bsed on the Liver Cncer Study Group criteri (Jpnese Society of HCC criteri) (18). IM HCC is defined bsed on the following: i) Tumor cses tht pper to hve developed from or on the bsis of portl tumor emboli; ii) lrge primry tumor with multiple stellite nodules; nd iii) ll tumors re histologiclly similr. MO HCC is defined bsed on the following: i) Ech tumor occurs seprtely in different heptic segment; nd ii) the multiple tumors hve different histologicl grding of well differentited nd modertely or poorly differentited HCC (pthologicl heterogeneity) (10,11,19). Surgery. Tumor cses were confirmed using contrst enhnced computed tomogrphy (CT) or mgnetic resonnce imging with vsculr contrst gents. A number of ptients were lso ssessed using contrst enhnced ultrsonogrphy. Liver function tests were performed prior to the surgery, including tests for lbumin, bilirubin, blood cogultion function nd 15 min indocynine green clernce. Only ptients with well preserved liver function (Child Pugh grde A) nd good performnce sttus, with n estimted residul liver volume >40%, underwent HR. Ptients with heptitis B infection were treted with ntivirl drugs t lest 1 week prior to surgery. Liver trnsections were primrily performed using the clmp method with Peng multifunctionl opertive dissector [Hngzhou Shuyou Medicl Instrument Co., Ltd., Hngzhou, Chin; FDA ctlog no. 510(K), K040780]. An intermittent Pringle mneuver ws used during liver trnsection. Vsculr invsion ws dignosed if vsculr involvement or tumor invsion ws confirmed by imging or pthologicl studies. Heptic resection ws performed using ntomicl liver resection or prtil liver resection. Resection ws considered s mjor when 3 liver segments were removed nd s minor when <3 liver segments or prtil liver prenchym were removed. Postsurgicl outcomes nd follow up. Postsurgicl mortlity ws defined s mortlity within 30 dys of surgery. Grde III or higher dverse events were considered mjor complictions, while Grde I II dverse events were defined s minor complictions. Postsurgicl heptic insufficiency ws defined ccording to the Interntionl Study Group of Liver Surgery consensus (20). Contrst enhnced CT or mgnetic resonnce imging, chest rdiogrphy, liver function tests nd mesurements of serum α fetoprotein levels were performed 4 weeks fter surgery, nd every 3 months therefter. Tumor recurrences were treted with liver resection, rdiofrequency bltion or TACE. Only 13 ptients did not receive the tretment following recurrence due to fst recurrence of the tumor (within 3 months) or severe liver cirrhosis nd liver filure. Adjuvnt TACE. Adjuvnt TACE (2 cycles) ws suggested to ll ptients with multinodulr HCC by the ttending physicin ~4 weeks fter surgery, when the liver function hd recovered. Whether ptients followed the recommendtions of the physicin primrily depended on their socioeconomic sttus or wishes; therefore, djuvnt TACE ws not performed in ll ptients, with those who refused receiving heptic resection only. The Seldinger technique ws performed to plce heptic rteril ctheter into the proper heptic rtery vi the femorl rtery, with the ptient under locl nesthesi. Heptic ngiogrphy or CT ngiogrphy ws performed to detect ny notble tumor stins in the remnnt liver. Oxlipltin (150 mg) nd leucovorin (150 mg) were infused, nd fluorourcil (1,500 mg/m 2 ) ws continuously pumped (for 24 h) through the ctheter. The dosge ws determined by the body surfce re nd underlying liver function. At the 1 month follow up, CT scn ws obtined to determine the effects of TACE. Study endpoints. The primry endpoint of the study ws to evlute 1, 3 nd 5 yer OS nd disese free survivl (DFS) rtes in the IM nd MO groups. The secondry endpoint ws to evlute the OS benefits nd sfety of heptectomy plus postsurgicl djuvnt TACE. The tertiry endpoint ws to identify whether tumor number ws prognostic fctor ffecting the stging nd long term outcomes of multinodulr HCC. Sttisticl nlysis. Continuous vribles re presented s the men ± stndrd devitions or medins with interqurtile rnges, nd discreet vribles re presented s numbers with percentges. Ctegoricl vribles were compred using the χ 2 test, nd continuous vribles were compred using Student's t test or non prmetric Mnn Whitney U test. Survivl rtes were obtined by the Kpln Meier method nd were compred using the log rnk test. OS nd DFS were clculted from the dte of heptectomy to the time of

ONCOLOGY LETTERS 3 Figure 1. Study flowchrt. HCC, heptocellulr crcinom; TACE, trnsctheter rteril chemoemboliztion; MO, multicentric occurrence; IM, intrheptic metstses; HR, heptic resection; HRT, HR plus djuvnt TACE. mortlity/recurrence or the lst time of follow up. Vribles tht were sttisticlly significnt in the univrite nlysis (P<0.05) were included in the multivrite nlysis using Cox proportionl hzrds model. All ptients were followed up until mortlity or until June 1, 2016. P<0.05 ws considered to indicte sttisticlly significnt difference. The nlysis ws performed using SPSS version 21.0 sttisticl softwre (IBM Corp., Armonk, NY, USA). Results Grouping bsed on clinicopthologicl fetures. The flowchrt for the present study is depicted in Fig. 1. In totl, 107 ptients with multinodulr tumors who underwent liver resection with or without djuvnt TACE were evluted. A totl of 4 ptients were excluded, including 3 ptients with mixed HCC nd 1 ptient who received rdiofrequency therpy prior to tumor resection; subsequently, the tumor ws pthologiclly demonstrted to hve undergone complete necrosis. None of the ptients were lost to follow up, thus 103 ptients were included in the present study, including 89 men nd 14 women, with medin ge of 57 yers (rnge, 25 78 yers). According to the forementioned clinicopthologicl determintion criteri, 59 cses were included in the MO group nd 44 cses were included in the IM group for further nlysis. Clinicopthologicl nd surgicl fetures of the ptients. For further nlysis, the clinicopthologicl vribles of the two groups were investigted (Tble I). Tumor size (the lrgest tumor in one ptient) (P=0.008), portl tumor emboli (P=0.031), pthologicl heterogeneity (P=0.002), loction of segment nd stellite tumors (P<0.001) differed significntly between the two groups. The surgicl outcomes nd postsurgicl tretments re presented in Tble II. There were no significnt differences in surgicl time, surgicl blood loss or type of surgery between the two groups. Surgicl morbidities, including heptic insufficiency, scites nd biliry fistul, nd the proportion of ptients receiving djuvnt therpy were lso similr between the two groups. Survivl nlysis. The medin durtion of follow up ws 34 months (rnge, 5 123 months) for the MO group nd 25 months (rnge, 3 49 months) for the IM group. The Kpln Meier survivl curves for the two groups re depicted in Fig. 2. The 1, 3 nd 5 yer OS rtes were 92.7, 76.8 nd 56.8%, respectively, for the MO group, nd 93.1, 41.6 nd 18.5%, respectively, for the IM group (P=0.001; Fig. 2A). The 1, 3 nd 5 yer DFS rtes were 84.1, 44.6 nd 40.5%, respectively, for the MO group, nd 51.7, 22.5 nd 15.0%, respectively, for the IM group (P<0.001; Fig. 2B). There ws significnt difference between the two groups in terms of DFS nd OS. Multivrite Cox proportionl hzrds regression nlyses identified >2 tumors, no djuvnt TACE nd IM HCC s independent prognostic fctors for OS in ptients with multifocl HCC (Tble III). Subgroup nlysis by tretment method. Ptients with multifocl HCC were further clssified ccording to whether

4 XU et l: SURGERY PLUS TACE FOR MULTIFOCAL HEPATOCELLULAR CARCINOMA Tble I. Ptient demogrphic nd clinicopthologicl chrcteristics. Chrcteristics MO HCC (n=59) IM HCC (n=44) P vlue Age, yers 0.245 Men ± SD 57.05±8.39 54.84±10.81 Sex, n (%) 0.773 Mle 50 (84.7) 39 (88.6) Femle 9 (15.3) 5 (11.4) Albumin, g/l 0.529 Men ± SD 44.31±3.74 43.80±4.44 Totl bilirubin, µmol/l 0.991 Medin (IQR) 14.80 (8.30) 14.80 (7.95) Pltelet count, x10 9 /l 0.736 Medin (IQR) 126 (60) 130 (67.75) Prothrombin time, s 0.472 Medin (IQR) 11.90 (1.30) 11.65 (1.15) Liver cirrhosis, n (%) 1.000 Yes 57 (96.6) 42 (95.5) No 2 (3.4) 2 (4.5) Underlying heptitis, n (%) 0.223 HBV 50 (84.7) 40 (90.9) HCV 5 (8.5) 0 (0.0) Both 3 (5.1) 2 (4.5) None 1 (1.7) 2 (4.5) Tumor number, n (%) <0.001 2 52 (88.1) 21 (47.7) >2 7 (11.9) 23 (52.3) Tumor size (lrgest tumor), mm 0.008 Medin (IQR) 38.0 (38.0) 56.5 (43.0) Tumor size (second lrgest tumor), mm 0.328 Medin (IQR) 15.0 (20.0) 12.0 (15.0) AFP, ng/ml 0.622 Medin (IQR) 21.83 (306.95) 35.35 (686.17) Microvsculr invsion, n (%) 0.051 Yes 13 (22.0) 18 (40.9) No 46 (78.0) 26 (59.1) Portl tumor emboli, n (%) 0.031 Yes 0 (0.0) 4 (9.1) No 59 (100.0) 40 (90.9) Edmonson grde, n 0.866 I 6 4 II 37 30 III 16 10 Pthologicl heterogeneity, n (%) 0.002 Yes 40 (81.6) 41 (93.2) No 19 (18.4) 3 (6.8) Loction of segment, n (%) <0.001 Sme 10 (16.9) 32 (72.7) Different 49 (83.1) 12 (27.2) Stellite tumors, n (%) <0.001 Yes 58 (98.3) 22 (50.0) No 1 (1.7) 22 (50.0) P<0.05. MO, multicentric occurrence heptocellulr crcinom; IM, intrheptic metstses heptocellulr crcinom; AFP, α fetoprotein; SD, stndrd devition; IQR, interqurtile rnge; HBV, heptitis B virus; HCV, heptitis C virus.

ONCOLOGY LETTERS 5 Tble II. Surgicl nd postsurgicl tretment. MO IM Vribles (n=59) (n=44) P vlue Surgicl time, min 0.393 Men ± SD 167.1±50.1 176.1±8.5 Surgicl blood loss, ml 0.332 Medin (IQR) 200 (300) 200 (287.5) Type of surgery, n (%) 0.064 Minor 42 (71.2) 23 (52.3) Mjor 17 (28.8) 21 (47.7) Surgicl morbidities, n (%) 8 (13.55) 8 (18.2) 0.827 Heptic insufficiency 5 (8.5) 7 (15.9) 0.353 Biliry fistul 3 (5.1) 1 (2.3) 0.634 Adjuvnt TACE, n (%) 0.684 Yes 37 (62.7) 25 (56.8) No 22 (37.3) 19 (43.2) All ptients experienced Clvien Dindo grde I II compliction; no Grde III or higher complictions or postsurgicl mortlity occurred. MO, multicentric occurrence heptocellulr crcinom; IM, intrheptic metstses heptocellulr crcinom; TACE, trnsctheter rteril chemoemboliztion; SD, stndrd devition; IQR, interqurtile rnge. they underwent HR only or HRT. In the MO HCC subgroup, 22 ptients received HR only (MO HR), nd 37 ptients received HRT (MO HRT). The Kpln Meier survivl curves for the ptients re depicted in Fig. 3. The 1, 3 nd 5 yer OS rtes were 97.1, 86.8 nd 73.2%, respectively, for the MO HRT group, nd 85.2, 60.1 nd 28.0%, respectively, for the MO HR group (P=0.019; Fig. 3A), nd there ws significnt difference between the two groups. Multivrite Cox proportionl hzrds regression nlyses identified no djuvnt TACE s n independent prognostic fctor for OS in ptients with MO HCC (Tble IV). In the IM HCC subgroup, 19 ptients received HR only (IM HR), nd 25 ptients received HRT (IM HRT). The 1, 3 nd 5 yer OS rtes were 100.0, 46.6 nd 25.9%, respectively, for the IM HRT group, nd 84.2, 38.3 nd 25.5%, respectively, for the IM HR group (P=0.132; Fig. 3B), with no significnt difference between the two groups. Subgroup nlysis by tumor number. In order to verify whether tumor number is prognostic fctor ffecting the stging nd tretment of multinodulr HCC, the ptients were clssified ccording to whether they hd <3 or 3 tumors (Tble V). The Kpln Meier survivl curves for the ptients re depicted in Fig. 4. In the MO HCC subgroup, 52 ptients hd <3 tumors nd 7 ptients hd 3 tumors. The 1, 3 nd 5 yer OS rtes were 100.0, 60.0 nd 30.0%, respectively, for the MO HCC subgroup with <3 tumors, nd 91.8, 78.7 nd 59.8%, respectively, for the MO HCC subgroup with 3 tumors (P=0.300; Fig. 4A). There ws no significnt difference between the two groups. Additionlly, 21 ptients with IM HCC hd <3 tumors nd 23 ptients with IM HCC hd 3 tumors. The 1, 3 nd 5 yer OS rtes were 95.2, 88.4 nd 25.8%, respectively, for the IM HCC subgroup with <3 tumors, nd 86.5, 52.1 nd 24.3%, respectively, for ptients with 3 tumors (P=0.022; Fig. 4B). There ws significnt difference between the two groups. Discussion Multifocl tumors re common in HCC (21,22). A previous survey demonstrted tht pproximtely hlf of ll ptients with HCC re dignosed with multiple lesions (23). Despite dvnces in resection nd bltion techniques, the recurrence rte following initil tretment remins high, nd the prognosis of ptients with multifocl HCC following surgicl resection is generlly unfvorble (24,25). According to BCLC stging, pllitive tretment, including TACE, in the only pproprite tretment option for the mjority of ptients with multifocl HCC, with medin survivl time of <20 months nd 5 yer survivl rte of 6 20% (26). Currently, it is ccepted tht multifocl HCC my be clssified into two types: IM nd MO (27,28). IM HCC is primrily considered s metsttic lesion from the centrl tumor; therefore, tumor cses re frequently t n dvnced stge, nd the prognosis is generlly unfvorble. By contrst, MO HCC tumors re derived independently from ech other, resulting in n improved prognosis compred with tht of metsttic disese. Therefore, it is importnt to distinguish between these two tumor types. As erly s the 1990s, surgeons distinguished IM HCC from MO HCC primrily using clinicopthologicl fetures (13,17,29). In the present study, ptients were clssified with multifocl HCC ccording to the Jpnese Society of HCC criteri, nd it ws determined tht 57% were ptients with MO HCC, which is similr to the results of previous study (13). Portl tumor emboli, pthologicl heterogeneity, loction of segments nd stellite tumors differed significntly between the two groups, which is consistent with the differentition criteri for IM nd MO. Previously, number of other pproches hve been developed to differentite between these two HCC types, including profiling of integrted heptitis B virus (HBV) DNA by polymerse chin rection nd southern blotting, loss of heterozygosity nlysis of specific microstellite loci nd next genertion sequencing (28,30,31). In previous study, seven cndidte genes with notble differentil expression in 2 ptients were selected nd vlidtion studies were performed using pired tumor/non tumor tissues from 174 ptients with HBV HCC. Subsequently, the expression of threonine nd tyrosine kinse ws identified s novel dverse prognostic fctor of HBV HCC (28). Furthermore, clinicopthologicl fetures re the most convenient method to distinguish between the two types of multifocl HCC. Using this criteri, it ws determined tht ptients with MO HCC hve n improved benefit (5 yer OS rte of 56.8% nd DFS rte of 40.5%) from liver resection compred with tht of ptients with IM HCC (5 yer OS rte of 18.5% nd DFS rte of 15.0%). Multivrite nlyses identified IM HCC s n independent prognostic fctor for OS in ptients with multifocl HCC. Additionlly, surgery for IM nd MO ws not ssocited with incresed surgicl time or blood loss. All surgicl morbidities were Clvien Dindo grde I nd II, indicting tht surgicl resection for multinodulr HCC is sfe tretment option. This result is consistent with tht of previous study (32).

6 XU et l: SURGERY PLUS TACE FOR MULTIFOCAL HEPATOCELLULAR CARCINOMA Tble III. Univrite nd multivrite Cox proportionl hzrds regression nlyses of fctors ssocited with overll survivl of ptients (n=103) with multinodulr heptocellulr crcinom. Univrite Multivrite nlysis Fctor P vlue HR (95% CI) P vlue Tumor number (2/>2) <0.001 2.985 (1.425 6.251) 0.004 Tumor size (<50/ 50 mm) 0.215 AFP (<100/ 100 ng/ml) 0.144 Microvsculr invsion (no/yes) 0.102 Portl tumor emboli (no/yes) 0.639 Liver cirrhosis (no/yes) 0.652 MO/IM <0.001 2.311 (1.087 4.914) 0.031 Adjuvnt TACE (no/yes) <0.001 0.331 (0.163 0.676) 0.002 P<0.05. TACE, trnsctheter rteril chemoemboliztion; AFP, α fetoprotein; MO, multicentric occurrence heptocellulr crcinom; IM, intrheptic metstses heptocellulr crcinom; HR, hzrd rtio; CI, confidence intervl. Figure 2. (A) OS nd (B) DFS of ptients with MO or IM. (A) P=0.001 nd (B) P<0.001 (log rnk test). OS, overll survivl; DFS, disese free survivl; MO, multicentric occurrence; IM, intrheptic metstses. Figure 3. OS of (A) ptients with MO nd (B) ptients with IM following tretment with HR or HRT. (A) P=0.019 nd (B) P=0.132 (log rnk test). TACE, trnsctheter rterilv chemoemboliztion; MO, multicentric occurrence; IM, intrheptic metstses; HR, heptic resection; HRT, HR plus djuvnt TACE; OS, overll survivl.

ONCOLOGY LETTERS 7 Tble IV. Univrite nd multivrite Cox proportionl hzrds regression nlyses of fctors ssocited with overll survivl of ptients (n=59) with multicentric occurrence heptocellulr crcinom. Univrite Multivrite nlysis Fctor P vlue HR (95% CI) P vlue Tumor number (2/>2) 0.264 Tumor size (<50/ 50 mm) 0.307 AFP (<100/ 100 ng/ml) 0.371 Microvsculr invsion (no/yes) 0.200 Liver cirrhosis (no/yes) 0.698 Adjuvnt TACE (no/yes) 0.026 0.300 (0.108 0.833) 0.021 P<0.05. AFP, α fetoprotein; TACE, trnsctheter rteril chemoemboliztion; HR, hzrd rtio; CI, confidence intervl. Tble V. Subgroup nlysis clssified by tumor number. Tumor number MO (n=59) IM (n=44) P vlue 2 lesions 52 21 <0.001 >2 lesions 7 23 3 lesions 5 8 4 lesions 1 6 5 lesions 1 8 6 lesions 0 1 P<0.05. MO, multicentric occurrence heptocellulr crcinom; IM, intrheptic metstses heptocellulr crcinom. Figure 4. (A) OS of ptients with MO with <3 or 3 tumors following tretment with HRT. (B) DFS of ptients with IM with <3 or 3 tumors following tretment with HRT. (A) P=0.300 nd (B) P=0.022 (log rnk test). HRT, heptic resection plus djuvnt trnsctheter rteril chemoemboliztion; OS, overll survivl; DFS, disese free survivl; MO, multicentric occurrence; IM, intrheptic metstses. Of the ptients with HCC, ~70% experience recurrence within 5 yers; therefore, reducing the rte of postsurgicl recurrence is key fctor in prolonging long term survivl in ptients with HCC (33,34). Currently, the ccepted method for reducing the recurrence rte of cncer following surgery is djuvnt therpy; however, djuvnt TACE therpy is not recommended for HCC following rdicl surgery ccording to the previous guidelines (6,7), s not ll ptients benefit from it. Previously, number of studies indicted tht djuvnt postsurgicl TACE cn reduce the postsurgicl recurrence rte in high risk ptients with HCC (35 38). Although rndomized controlled tril indicted tht postsurgicl djuvnt therpy hd miniml effect on outcomes, it ws probble tht ptients with erly stge HCC were included in the study (39). In the

8 XU et l: SURGERY PLUS TACE FOR MULTIFOCAL HEPATOCELLULAR CARCINOMA present study, it ws determined tht djuvnt TACE ws n independent prognostic fctor for OS in ptients with multifocl HCC; however, it remins unknown if the MO nd IM groups cn benefit from djuvnt TACE therpy following surgery. A further subgroup nlysis demonstrted tht postsurgicl djuvnt TACE significntly prolonged long term survivl in ptients with MO HCC; however, OS ws not significntly prolonged in ptients with IM HCC who underwent djuvnt TACE. Bsed on these results, ptients with MO HCC should be ctively treted with djuvnt TACE to mximize the benefit of surgery. By contrst, since the prognosis of ptients with IM HCC ws significntly worse following heptectomy, postsurgicl djuvnt TACE did not result in the sme survivl benefit for ptients with IM HCC s it did for ptients with MO HCC. Thus, djuvnt TACE my be more beneficil for ptients with MO HCC. Until now, the BCLC stging system nd Americn Assocition for the Study of Liver Disese/Europen Assocition for the Study of the Liver guidelines clssified ptients with >3 tumors s stge B (6,7). TACE is recommended for these ptients s the first line tretment; however, in the present study, it ws determined tht the prognosis of ptients with MO HCC with 3 tumors ws not worse compred with tht of ptients with <3 tumors following heptectomy. For the ptients with IM HCC, n incresed tumor number indicted worse prognosis. A previous study demonstrted tht the long term survivl rte of ptients with MO HCC following surgicl resection ws similr to tht of ptients with single lesions (10). Furthermore, nother study indicted tht resection my be the tretment of choice for HCC even if ptients hve >4 tumors (40). It is probble tht single lesions in MO HCC originte independently from ech other with erly stge grding; therefore, even if >3 tumors re present, surgicl resection is suitble for these ptients. However, the lesions re metstses from one lesion in IM HCC, which re similr to distnt metstsis; therefore, n incresed number of tumors is indictive of lter stge. Although the study smple ws smll, the present results indicted tht HCC stging should not rely on tumor sttus lone, nd tht IM nd MO crcinogenesis should lso be tken into ccount. Furthermore, tumor number should not be the primry fctor considered when selecting the MO HCC tretment. There re number of limittions to the present study. Firstly, since multinodulr HCC with >3 tumors or with 2 tumors, 1 of which is >3 cm, re clssified s BCLC stge B, it ws controversil to perform surgery. Thus, limited number of these ptients were included in the study, lthough no less thn the number included in previous studies (12,13). Lrger cohort studies my be necessry to confirm the results. Secondly, the ptients included in the present study were ptients with HCC in Chin, nd 92.2% of ptients hd HBV ssocited HCC. In western countries, the most common cuses of HCC re heptitis C nd lcohol (6). The different etiologies my cuse HCC origin differences, nd thus ffect the rtio of IM nd MO. To confirm the conclusions of the present study, further multicenter perspective studies should be performed with lrger cohort. In conclusion, the present dt demonstrted tht ptients with MO HCC benefit from HRT, while the sme tretment hs miniml effect on the survivl of ptients with IM HCC. Accordingly, liver resection plus TACE is recommended for MO HCC, nd TACE, trgeted drugs or other pllitive tretment should be considered for IM HCC. Prospective multicenter studies with lrger smple re required in the future to further confirm the present results. Acknowledgements Not pplicble. Funding This study ws funded by grnts from the Chinese Stte Key Project for Bsic Reserch (973) (no. 2014CBA02001). Avilbility of dt nd mterils The dtsets used or nlyzed during the current study re vilble from the corresponding uthor on resonble request. Authors' contributions DX, XL nd BX prticipted in the design of the study. DX nd LW collected the dt. DX nd XL nlyzed nd interpreted the dt. DX, XL nd BX prepred the mnuscript. All uthors red nd pproved the finl mnuscript. Ethics pprovl nd consent to prticipte The study ws pproved by the Ethics Committee of Beijing Cncer Hospitl. Ptient consent for publiction Informed consent sttement: Ptients were not required to give informed consent to the study, s the nlysis used nonymous clinicl dt tht were obtined fter ech ptient greed to tretment by verbl consent. Individuls cnnot be identified ccording to the dt presented. Competing interests The uthors declre tht they hve no competing interests. References 1. Mluccio M nd Covey A: Recent progress in understnding, dignosing, nd treting heptocellulr crcinom. CA Cncer J Clin 62: 394 399, 2012. 2. 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