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David et al. Hepatoma Res 2018;4:2 I http://dx.doi.org/10.20517/2394-5079.2017.51 Page 5 of 8

Table 2. Pathologic findings in patients according to treatment group
OLR (n = 21) LLR (n = 28) p
Greatest tumor size (cm; mean ± SD) 5.3 ± 2.6 4.4 ± 1.7 0.048
Tumor number 2.0 ± 1.2 1.5 ± 0.7 0.074
Margin distance (cm; mean ± SD) 1.7 ± 2.4 1.4 ± 1.5 0.649
ES tumor grade (I/II/III/IV) 0:8:12:1:0 1:12:10:4:1 0.425
pT stage 0.031
T1 2 9
T2 9 15
T3 9 2
T4 1 1
Cirrhosis present 9 (42.9%) 19 (67.9%) 0.080
Microvascular invasion 10 (47.6%) 12 (42.9%) 0.740
LLR: laparoscopic liver resection; OLR: open liver resection; ES: Edmondson-Steiner. Values are expressed as mean ± standard deviation or
number (percent).

Table 3. Complications according to treatment group
OLR (n = 21) LLR (n = 28) p
Intraoperative 3 (14.3%) 5 (17.9%) 0.738
Postoperative 7 (33.3%) 4 (14.3%) 0.114
Clavien-Dindo classification 0.256
Grade I 2 0
Grade II 0 0
Grade IIIa 3 3
Grade IIIb 2 1
Grade IVa/IVb 0 0
Postoperative serious complications 5 (23.8%) 4 (14.3%) 0.237
(Clavien-Dindo Grade III or higher)
Hospital stay (days; mean ± SD: range) 20.6 ± 30.1 (7-147) 9.2 ± 4.9 (4-30) 0.023
LLR: laparoscopic liver resection; OLR: open liver resection

significant difference in terms of DFS between the groups (P = 0.947). The 1-, 3- and 5-year DFS was 59.3%,
20.2% and 16.2% for the LLR group and 51.0%, 44.6% and 37.2% for OLR groups, respectively [Figure 1].

DISCUSSION
[8]
HCC is widely endemic, with 80% of new cases worldwide expected to develop in Asia alone . The
management of HCC is complex, due to the presence of two disease processes: the primary malignancy
and the underlying liver pathology that accompanies HCC. Thus a reliable management algorithm to guide
therapeutic decisions in these patients is needed.

Currently, the BCLC classification system is one of the most widely recognized and approved staging
systems for HCC, since it considers multiple factors such as tumor stage and function, patient’s performance
[9]
status, as well as cancer-related symptoms . According to BCLC, intermediate stage (BCLC-B) patients
are asymptomatic (PS score 0), with large multi-nodular tumors but without macrovascular invasion or
[8]
extrahepatic spread . The estimated 3-year survival for patients with untreated stage B HCC ranges from 8%
to 50%; given the invasiveness of surgery, palliation with TACE is therefore recommended for these subset of
[9]
patients . However, TACE cannot induce complete tumor necrosis especially in large tumors, with reported
response rates in literature as low as 2% [8,10] .

Liver resection, based on the BCLC system, is usually reserved for patients with small, single tumors, with
[9]
absence of portal hypertension or hyperbilirubinemia . Recent data has however, supported the benefit
of surgical resection in terms of short- and long-term oncologic outcomes despite the presence of large,
[11]
[4]
multinodular nodules and macrovascular invasion . In a recent study done by Kim et al. , overall median