This may explain why the optimal hepatectomy for HCC has not yet been agreed upon, despite numerous studies based on postoperative survival. BECAUSE HCC SPREADS through the blood flowing away from the

tumor, it is reasonable to determine the safety margin of locoregional therapy (e.g. hepatectomy or ablation therapy) by directly demonstrating the TBF. In 2000, we first reported the case of a HCC patient who underwent hepatectomy, the safety margin of which was based on TBF.[43] Because the blood flow from the tumor can be examined selleck by preoperative computed tomography (CT) under hepatic angiography (CTHA), the TBF drainage area (i.e. high-risk area for IM) is preoperatively demonstrated as the safety margin, namely, the distance between the edge of the tumor ABT-263 mw and the peripheral margin of the TBF drainage area (Fig. 1a,b). Hepatic dissection is performed, securing the safety margin, the adequacy of which is repeatedly

confirmed by intraoperative ultrasonography.[43] Using these procedures, the high-risk area of IM can be completely resected with a minimal but essential hepatectomy (Fig. 1c). However, patients with venous tumor invasion demonstrated preoperatively are not indicated for TBF-based hepatectomy because TBF is not correctly examined due to the interference by tumor thrombus. By comparing the CTHA images and the corresponding cut surface of the resected liver specimen, we could confirm that the safety margin was achieved (Fig. 1d). ACCORDING TO THE CTHA results, the TBF drainage area differs from tumor to tumor. Its shape is generally irregular and its width varies by site.[39] The TBF pattern is classified into three types: marginal, portal vein and hypovascular (Fig. 2). In the marginal type, the

TBF drainage area is limited to the peritumoral MCE region, which corresponds to the description of “corona enhancement” reported by Ueda et al.[44] Partial hepatic resection was commonly performed in these patients.[39] Major hepatic resection was performed only in selected patients with large tumors. In contrast, the portal vein type represents the TBF drainage through the major portal branches, and the anatomical hepatectomy, including lobectomy or segmentectomy, was performed to dissect the whole TBF drainage area. Tumors of hypovascular type have poor TBF, which is difficult to detect by CTHA. The safety margin cannot be determined in this type of HCC; therefore, only limited, partial hepatectomy with a minimal surgical margin was performed in these patients. TUMOR RECURRENCE AFTER surgery is caused either by IM or by MC. Theoretically, IM can be divided into the following two types according to the mechanism of hematogenous spread of tumor. Tumor blood first flows in the TBF drainage area, by which IM may develop. This type of IM is localized in this area, and tentatively designated as “local IM” because it can be treated by local therapy.