Treatments for recurrent hepatocellular carcinoma: laparoscopic or open repeat liver resection, how to make a decision?

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Thus, we should take the first operation situation into consideration before making a decision on recurrent HCC. In this study, the number of patients who received laparoscopic liver resection (LLR) in the LRLR group was higher than that in the ORLR group at the first operation (64.0% VS 32.0%, p = 0.024). The tumor situation at first operation may be significantly different for these patients, because the tumor size or location would affect the method of hepatectomy [6,7].
Generally, another important risk factor for recurrent HCC is the time of tumor recurrence. In previous studies, the long-term outcomes of tumor recurrence within 1 year after hepatectomy were worse than those of tumor recurrence beyond 1 year after liver resection [8]. Therefore, it was necessary to compare the time of tumor recurrence when we analyzed the different treatments for recurrent HCC. On the other hand, in this study, the location of the tumor recurrence was different, which might present a different message for the tumor. The prevalent hypothesis was multicentric occurrence (MO) and intrahepatic metastasis (IM).
[8] MO indicates de-novo carcinogenesis and IM indicates primary cancer relapse. The different tumor recurrence types would result in different outcomes. IM indicated a tumor with more aggression, resulting in a high risk of recurrence, although the patient had undergone resection again. Thus, the authors should add the comparison of the pathological diagnose in first operation and second operation for these patients, respectively, to identify the tumor origins, if possible, we could perform the genetic test to clarify the tumor origins. In summary, although LRLR could obtain a better short-term outcome in this study, we could not ignore other risk factors, especially the tumor status at the first operation and the pathological diagnosis in these patients. Therefore, we should take the first operation situation into consideration when we make a decision on recurrent HCC. Jinli Zheng and Chenhao Zhang have contributed equally to this study and are co-first authors.
Author contributions JLZ and LJ contributed to study conception and design; JLZ, CHZ, and JL performed the research; JLZ and CHZ drafted the manuscript; LJ did critical revision. All the authors have read and approved the manuscript. Data availability This study is a letter for the editor, no data.

Conflict of interest
The authors have no conflicts of interest to declare.

Research involving human participants and/or animal rights and informed consent The research dosen't involve human participants.
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