Effect of surgical margin width on patterns of recurrence among patients undergoing R0 hepatectomy for T1 hepatocellular carcinoma: an international multi-institutional analysis

Diamantis I. Tsilimigras, Kota Sahara, Dimitrios Moris, J. Madison Hyer, Anghela Z. Paredes, Fabio Bagante, Katiuscha Merath, Ayesha S. Farooq, Francesca Ratti, Hugo P. Marques, Olivier Soubrane, Daniel Azoulay, Vincent Lam, George A. Poultsides, Irinel Popescu, Sorin Alexandrescu, Guillaume Martel, Alfredo Guglielmi, Tom Hugh, Luca AldrighettiItaru Endo, Timothy M. Pawlik*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

20 Citations (Scopus)


Introduction: Although a positive surgical margin is a known prognostic factor for recurrence, the optimal surgical margin width in the context of an R0 resection for early-stage hepatocellular carcinoma (HCC) is still debated. The aim of the current study was to examine the impact of wide (≥ 1 cm) versus narrow (< 1 cm) surgical margin status on the incidence and recurrence patterns among patients with T1 HCC undergoing an R0 hepatectomy. Methods: Between 1998 and 2017, patients with T1 HCC who underwent R0 hepatectomy for stage T1 HCC were identified using an international multi-institutional database. Recurrence-free survival (RFS) was estimated, and recurrence patterns were examined based on whether patients had a wide versus narrow resection margins. Results: Among 404 patients, median patient age was 66 years (IQR: 58–73). Most patients (n = 326, 80.7%) had surgical margin < 1 cm, while 78 (19.3%) patients had a ≥ 1 cm margin. The majority of patients had early recurrences (< 24 months) in both margin width groups (< 1 cm: 70.3% vs ≥ 1 cm: 85.7%, p = 0.141); recurrence site was mostly intrahepatic (< 1 cm: 77% vs ≥ 1 cm: 61.9%, p = 0.169). The 1-, 3-, and 5-year RFS among patients with margin < 1 cm were 77%, 48.9%, and 35.3% versus 81.7%, 65.8%, and 60.7% for patients with margin ≥ 1 cm, respectively (p = 0.02). Among patients undergoing anatomic resection, resection margin did not impact RFS (3-year RFS: < 1 cm: 49.2% vs ≥ 1 cm: 58.9%, p = 0.169), whereas in the non-anatomic resection group, margin width ≥ 1 cm was associated with a better 3-year RFS compared to margin < 1 cm (86.7% vs 47.3%, p = 0.017). On multivariable analysis, margin ≥ 1 cm remained protective against recurrence (HR = 0.50, 95%CI 0.28–0.89), whereas Child-Pugh B (HR = 2.13, 95%CI 1.09–4.15), AFP ≥ 20 ng/mL (HR = 1.71, 95%CI 1.18–2.48), and presence of microscopic lymphovascular invasion (HR = 1.48, 95%CI 1.01–2.18) were associated with a higher hazard of recurrence. Conclusion: Resection margins ≥ 1 cm predicted better RFS among patients undergoing R0 hepatectomy for T1 HCC, especially small (< 5 cm) HCC. Although resection margin width did not influence outcomes after anatomic resection, wider margins were more important among patients undergoing non-anatomic liver resections.

Original languageEnglish
Pages (from-to)1552-1560
Number of pages9
JournalJournal of Gastrointestinal Surgery
Issue number7
Early online date26 Jun 2019
Publication statusPublished - Jul 2020
Externally publishedYes


  • Margin
  • Patterns
  • R0 hepatectomy
  • Recurrence


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