Prognosis after hepatic resection for stage IVA hepatocellular carcinoma - A need for reclassification

Objective To evaluate whether the prognosis of the four categories of patients with hepatocellular carcinoma (HCC) classified as stage IVA in the tumor-node-metastasis (TNM) classification of the International Union Against Cancer (UICC) is homogeneous. Summary Background Data Hepatic resection has been proposed as the treatment of choice for patients with TNM stage IVA HCC, which consists of four different categories. It is unknown whether the prognosis of the four categories of patients is homogeneous. Methods Clinicopathologic and follow-up data of 106 patients with resection of stage IVA HCC from 1989 to 2000 were prospectively collected. Survival results of the four categories of stage IVA patients were compared. Results Among stage IVA patients, survival was significantly worse in those with tumors involving a major branch of the portal or hepatic veins than in those with tumors invading adjacent organs, bilobar multiple tumors, or perforated visceral peritoneum. There were no significant differences in survival among the latter three groups. By Cox regression analysis, invasion of the portal or hepatic veins and presence of cirrhosis were independent adverse prognostic factors of overall survival among stage IVA patients, and invasion of the portal or hepatic veins was the only significant adverse prognostic factor of disease-free survival. Conclusions The prognosis of the four categories of patients with stage IVA HCC under the current UICC TNM staging was not homogeneous. A refined classification of stage IV HCC is needed to take into consideration the worse prognosis associated with tumor invasion of a major branch of the portal or hepatic veins.