Overall, 47 (36%) of patients had either vascular invasion or satellite tumors and did not meet the pathological criteria for very early HCC defined as T1 by the Japanese Society of Hepatology or as BCLC stage 0. The overall recurrence rate of 68% at 5 years and the 1-year recurrence rate of 17% seemed, at first, surprisingly high to us for such small cancers. A recurrence rate of 61% at 5 years for small tumors without vascular invasion or satellites was

particularly unexpected. However, a Japanese study of 70 patients with HCC ≤2 cm undergoing resection found an overall recurrence rate of 88% for the entire Cobimetinib research buy cohort.24 The same study demonstrated 1- and 5-year recurrence rates of 8% and 53%, respectively, for patients found to have T1 tumors.24 These numbers are very similar to what we have reported (12% at 1 year and 61% at 5 years) for our patients with pathologically proven very early tumors. Again, the recurrence rates for the entire cohort from our study (17% at

1 year and 68% at 5 years) compare favorably with the 1- and 5-year recurrence rates of 34% and 80%, respectively, reported for RFA of similarly sized HCC.10 The vast majority of the recurrences occurred within the first 3 years after surgery after which there were very few events. The pattern selleck screening library of the instantaneous risk of recurrence for these small tumors was also very different from that published for more advanced tumors.25, 26 Instead of the two peaks generally seen for larger tumors—one at approximately 12 months representing early metastatic recurrence and another at approximately 36 months representing late de novo recurrence—we see only a single and delayed

peak at 30 months. This pattern may reflect a reduction in early metastatic recurrences given the early stage of the tumors but deserves further investigation. The presence of satellites, underlying cirrhosis, and nonanatomic resection were associated with time to recurrence. The presence of satellites has been found to be a significant predictor of outcome about after resection of HCC in many other studies.27 Likewise, the nature of the nontumoral liver around the HCC has also been shown to be a strong predictor of recurrence of HCC after resection.28 Generally, neither variable is known preoperatively to help guide patient selection or the selection of the most appropriate therapy. The success of sorafenib in the treatment of advanced HCC has opened the door for the testing of targeted molecules in the adjuvant setting.29 The degree of fibrosis and the presence of satellites can help select or stratify patients who are most at risk for recurrence and who may benefit most from sorafenib after resection if the drug is eventually found to be an effective agent in the adjuvant setting. Alternatively, patients with satellites who are at risk for early metastatic recurrence can be referred for salvage liver transplantation, as has been proposed by the Barcelona group.