Advanced Cholangiocarcinoma With High Tumor Mutation Burden Achieving Complete Response to Immune Check Point Inhibitor.

BACKGROUND/AIM: Genomic examination of tumor tissue has been clinically accepted, and the identification of actionable mutations for molecular-targeted therapy may provide substantial survival benefit for patients with advanced malignancies. CASE REPORT: A female patient in her 60s showed a stenosis of the afferent loop of the small intestine because of circumferential metastatic tumor 14 months after curative surgery for hilar cholangiocarcinoma. Chemotherapy with gemcitabine plus cisplatin was administered for 18 months. An oncopanel examination was performed during chemotherapy, and a high tumor mutation burden was revealed. At 38 months after surgery, a new recurrent tumor, 2.7 cm in size, was observed in the abdominal wall, which was histologically proven to be metastatic adenocarcinoma. Atezolizumab was administered. After three cycles of treatment, treatment was switched to pembrolizumab because of its acceptance by healthcare insurance. The recurrent tumors in the abdominal wall and small intestine disappeared 6 months after the administration of immune checkpoint inhibitor, and the patient has continued pembrolizumab, surviving for 76 months after surgery without any clinical evidence of tumor. CONCLUSION: Immune checkpoint blockade successfully prolonged the survival of a patient with advanced hilar cholangiocarcinoma with high tumor mutation burden, although the optimal number of mutations for such a successful response needs to be clarified.

Diagnostic accuracy of preoperative adhesion mapping by ultrasonography for laparoscopic surgery in patients with past abdominal surgery with special reference to loose adhesion.

PURPOSE: Endoscopic surgery is widely accepted for both elective and emergent abdominal surgery. This study was performed to assess the accuracy of preoperative adhesion mapping by abdominal ultrasonography (US). METHODS: Intra-abdominal intestinal adhesions on the abdominal wall in 50 patients with a history of abdominal surgery were prospectively assessed by the visceral slide test with US before laparoscopic surgery from 2019 to 2022. Adhesion was assessed in six separate abdominal zones during US. Actual adhesion on the abdominal wall was confirmed during laparoscopic surgery. RESULTS: The sliding distances in upper right, upper central, upper left, lower right, lower central, and lower left zones in patients with versus without intestinal adhesion were 4.4 versus 1.4 cm (P = .004), 3.4 versus 2.5 cm, 4.3 versus 1.3 cm (P = .011), 3.1 versus 1.5 cm (P = .0014), 3.3 versus 1.1 cm (P = .013), and 3.4 versus 0.8 cm (P = .0061), respectively. Receiver operating characteristic analysis revealed the optimal value of sliding distance as 2.5 cm and the area under the curve as 0.86. The specificity of US assessment of adhesion was lower in the central zone than in lateral zones. Loose adhesion mostly seen around the scar was attributed to either filmy tissue or omental adhesion, leading to visceral sliding during US. CONCLUSION: This study revealed the reason for insufficient accuracy of preoperative US assessment of intestinal adhesion around the scar area because of loose adhesion. The upper lateral area might be optimal for first port insertion.

Combined Neutrophil-to-Lymphocyte Ratio Score Is Associated With Chemotherapeutic Response and Predicts Prognosis in Patients With Advanced Pancreatic Cancer.

BACKGROUND/AIM: Neutrophil-to-lymphocyte ratio (NLR) is a prognostic indicator for several malignancies, including pancreatic cancer. We developed a novel combined NLR score (cNLRS) based on baseline NLR and change in NLR after chemotherapy (ΔNLR), and examined its prognostic value and role in chemotherapeutic response in patients with advanced pancreatic cancer. PATIENTS AND METHODS: This study retrospectively assessed 210 advanced pancreatic cancer patients receiving chemotherapy between 2010 and 2021. The cNLRS was developed and its association with chemotherapeutic response and prognosis was investigated. RESULTS: The cNLRS consisted of baseline NLR ≥2.5 and ΔNLR ≥0, both of which were remained as independent poor predictors of prognosis adjusting for other traditional clinicopathological features. A high cNLRS served as an independent prognostic factor of reduced overall survival. Of note, the cNLRS was significantly associated with disease control rate and treatment duration not only in 1st line treatment but also in 2nd line treatment. CONCLUSION: The cNLRS established as a useful prognostic biomarker might be associated with chemotherapeutic response and could predict survival in advanced patients with pancreatic ductal adenocarcinoma treated with chemotherapy.

Microsatellite Instability-high Signet Ring Cell Carcinoma of the Colon Treated With Immunotherapy: Report of a Case.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are attracting increasing attention as a novel and potentially curative therapy for microsatellite instability-high (MSI-H) colorectal cancer (CRC). CASE REPORT: An 80-year-old female visited our hospital with complaints of lower abdominal pain due to bowel obstruction caused by descending colon cancer. After 1 month of metallic stent detention, she underwent radical surgery, although laparotomy showed broad peritoneal dissemination. Based on the genetic finding of MSI-H status, pembrolizumab therapy was administered in two cycles. Unfortunately, the therapy was ineffective, and the patient died after being discharged 5 months after surgery. CONCLUSION: The findings in this case of MSI-H CRC with a poor response to an ICI suggest the importance of confirming HLA status, including beta-2-microglobulin and HLA expression, before starting ICI therapy in cases of MSI-H CRC.

A case of accessory hepatic duct entering cystic duct successfully treated by laparoscopic cholecystectomy for cholecystolithiasis.

Although laparoscopic cholecystectomy is a well-established surgical procedure, an accessory hepatic duct (AcHD) entering the cystic duct is poorly understood. A 77-year-old woman with symptomatic cholecystlithiasis was referred to our hospital. Abdominal ultrasonography indicated several small stones in the gall bladder. Magnetic resonance cholangiopancreatography (MRCP) did not reveal an anomalous cystic duct. Dissecting the gall bladder bed at operation, AcHD entering the cystic duct was suspected. Intraoperative cholangiography revealed that B5 branch entered the cystic duct. We ligated the AcHD, and divided it. Laparoscopic cholecystectomy was completed, and the patient was discharged without any complication. A week after the operation, MRCP showed that ventral branch of B5 was dilated. The patient showed no symptom for more than a year. The present case exhibited extremely rare AcHD entering the cystic duct, which was hardly recognized before surgery. It is possible to recognize such anomalous variants with standard laparoscopic approach based on 2018 Tokyo Guidelines and with attention to the possibilities of AcHD entering the cystic duct.

Thrombospondin-1 overexpression stimulates loss of Smad4 and accelerates malignant behavior via TGF-ß signal activation in pancreatic ductal adenocarcinoma.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is characterized by abundant stroma and cancer-associated fibroblasts (CAFs) provide a favorable tumor microenvironment. Smad4 is known as tumor suppressor in several types of cancers including PDAC, and loss of Smad4 triggers accelerated cell invasiveness and metastatic potential. The thrombospondin-1 (TSP-1) can act as a major activator of latent transforming growth factor-ß (TGF-ß) in vivo. However, the roles of TSP-1 and the mediator of Smad4 loss and TGF-ß signal activation during PDAC progression have not yet been addressed. The aim is to elucidate the biological role of TSP-1 in PDAC progression. METHODS AND RESULTS: High substrate stiffness stimulated TSP-1 expression in CAFs, and TSP-1 knockdown inhibited cell proliferation with suppressed profibrogenic and activated stroma-related gene expressions in CAFs. Paracrine TSP-1 treatment for PDAC cells promoted cell proliferation and epithelial mesenchymal transition (EMT) with activated TGF-ß signals such as phosphorylated Akt and Smad2/3 expressions. Surprisingly, knockdown of DPC4 (Smad4 gene) induced TSP-1 overexpression with TGF-ß signal activation in PDAC cells. Interestingly, TSP-1 overexpression also induced downregulation of Smad4 expression and enhanced cell proliferation in vitro and in vivo. Treatment with LSKL peptide, which antagonizes TSP-1-mediated latent TGF-ß activation, attenuated cell proliferation, migration and chemoresistance with enhanced apoptosis in PDAC cells. CONCLUSIONS: TSP-1 derived from CAFs stimulates loss of Smad4 expression in cancer cells and accelerates malignant behavior by TGF-ß signal activation in PDAC. TSP-1 could be a novel therapeutic target, not only for CAFs in stiff stroma, but also for cancer cells in the PDAC microenvironment.

Perirectal abscess with dysuria.

Perirectal abscesses often occur in the dorsal portion of the perirectal tissues. We report a patient who presented with fever, pain on defecation, and dysuria. He was found to have a perirectal abscess in the anterior perineum pressing on the urethra. After emergency surgery to drain the abscess, the symptoms improved.

Enhancer of zeste homolog 2 (EZH2) regulates tumor angiogenesis and predicts recurrence and prognosis of intrahepatic cholangiocarcinoma.

BACKGROUND: Enhancer of zeste homolog 2 (EZH2) is the catalytic subunit of the polycomb repressive complex 2 (PRC2) and regulates tumor malignancy by gene silencing via histone methylation. In this study we investigate the role of EZH2 in angiogenesis of intrahepatic cholangiocarcinoma (ICC). METHODS: The influence of EZH2 on tumor angiogenesis was examined by bioinformatics analysis of a public database. We also assessed the correlation between EZH2 and vasohibin 1 (VASH1) expression in 47 patients with ICC by immunohistochemical (IHC) staining and in vitro gene silencing assays. The prognostic significance of EZH2 and VASH1 expression by IHC was also examined in the ICC cohort. RESULTS: Bioinformatics analysis showed that EZH2 was associated with several angiogenesis gene sets in the public database. EZH2 suppressed VASH1 expression in in vitro assays and IHC studies. EZH2-high/VASH1-low status was independently associated with poor disease-free survival (P = 0.019) and poor overall survival (P = 0.0055). CONCLUSION: The current study demonstrated that high EZH2 expression was associated with activation of tumor angiogenesis, and activation of the EZH2-mediated angiogenesis pathway predicted the prognosis of patients with ICC.

Thrombospondin-1 expression may be implicated in liver atrophic mechanism due to obstructed portal venous flow.

AIM: Liver is an amazing organ that can undergo regenerative and atrophic changes inversely, depending on blood flow conditions. Although the regenerative mechanism has been extensively studied, the atrophic mechanism remains to be elucidated. METHODS AND RESULTS: To assess the molecular mechanism of liver atrophy due to reduced portal blood flow, we analyzed the gene expressions between atrophic and hypertrophic livers induced by portal vein embolization in three human liver tissues using microarray analyses. Thrombospondin (TSP)-1 is an extracellular protein and a negative regulator of liver regeneration through its activation of the transforming growth factor-ß/Smad signaling pathway. TSP-1 was extracted as the most upregulated gene in atrophic liver compared to hypertrophic liver due to portal flow obstruction in human. Liver atrophic and hypertrophic changes were confirmed by HE and proliferating cell nuclear antigen staining and terminal deoxynucleotidyl transferase-mediated digoxigenin-dUTP nick-end labeling. In an in vivo model with portal ligation, TSP-1 and phosphorylated Smad2 expression were continuously induced at 6 h and thereafter in the portal ligated liver, whereas the induction was transient at 6 h in the portal non-ligated liver. Indeed, while cell proliferation represented by proliferating cell nuclear antigen expression at 48 h was induced in the portal ligated liver, the sinusoidal dilatation and hepatocyte cell death with terminal deoxynucleotidyl transferase-mediated digoxigenin-dUTP nick-end labeling was detectable at 48 h in the portal ligated liver. CONCLUSIONS: Obstructed portal flow induces persistent TSP-1 expression and transforming growth factor-ß/Smad signal activation in atrophic liver. Thrombospondin-1 may be implicated in the liver atrophic change due to obstructed portal flow as a pro-atrophic factor.

Hand-assisted laparoscopic spleen-preserving distal pancreatectomy combined with laparoscopic distal gastrectomy for the treatment of pancreatic neuroendocrine tumor with early gastric cancer: Report of a case.

INTRODUCTION: In a distal pancreatectomy combined with a distal gastrectomy, the splenic artery and vein must be conserved. However, it is not easy in pure laparoscopic surgery. We performed a hand-assisted laparoscopic spleen-preserving distal pancreatectomy (HALS-SPDP) combined with a laparoscopic distal gastrectomy (LDG) for the treatment of a pancreatic neuroendocrine tumor (NET) with early gastric cancer. PRESENTATION OF CASE: A 67-year-old male was hospitalized with no complaint. He was diagnosed with a pancreatic tail tumor (1.5cm in diameter) and early gastric cancer. He had undergone an endoscopic submucosal dissection (ESD). The pathohistology of the dissected tissue demonstrated that the histology was moderately differentiated adenocarcinoma, and the depth of the gastric cancer was pT1b2 (submucosal layer ∼1000µm). First, a pancreatectomy was performed extracorporeally under direct vision after detaching the spleen and the distal pancreas from the retroperitoneum under a hand-assisted laparoscopy. After the distal pancreatectomy, an LDG with a D1 lymphadenectomy was performed intracorporeally. The postoperative course was not eventful. Six months after surgery, an enhanced computed tomography (CT) scan revealed the patency of the splenic artery. CONCLUSION: An HALS-SPDP combined with an LDG is beneficial and safe for the patients who have a pancreatic benign or low-grade malignant tumor and gastric cancer.

Sarcopenia, but not visceral fat amount, is a risk factor of postoperative complications after major hepatectomy.

BACKGROUND: Major hepatectomy is associated with significant morbidity and mortality rates, particularly in patients aged more than 70 years. This study assessed whether physical indicators, such as sarcopenia and visceral fat amount, could predict morbidity and mortality after major hepatectomy. METHODS: The study enrolled 144 patients who underwent curative major hepatectomy. Skeletal muscle and visceral fat amount at the third lumbar vertebra (L3) in the inferior direction were quantified using enhanced computed tomography scans. The patients were divided into two subgroups, with and without sarcopenia, based on median skeletal muscle mass in men and women (43.2 cm(2)/m(2) in men; 35.3 cm(2)/m(2) in women). RESULTS: The study included 108 men and 36 women, with median skeletal muscle tissue of 43.2 and 35.3 cm(2)/m(2), respectively. The mortality rate was significantly higher in patients with than without sarcopenia [seven cases (9.7 %), one case (1.4 %), respectively; P = 0.021], whereas liver-related morbidity and mortality rates were similar. In patients aged >70 years, the morbidity, liver dysfunction-related morbidity, and mortality rates were significantly higher in patients with than without sarcopenia (P < 0.05 each). In contrast, surgical outcomes were similar in patients with high and low visceral fat amounts. CONCLUSIONS: Sarcopenia was a risk factor for postoperative complications after major hepatectomy, particularly in elderly patients.

An Imbalance in TAZ and YAP Expression in Hepatocellular Carcinoma Confers Cancer Stem Cell-like Behaviors Contributing to Disease Progression.

Transcriptional coactivator with PDZ-binding motif (TAZ) and yes-associated protein (YAP) are equivalently placed downstream effectors of the Hippo pathway with oncogenic roles in human cancers. However, the expression profiles of TAZ/YAP differ depending on the cancer cell type, suggesting that these proteins have different roles during cancer progression, yet no studies have examined the biologic significance of the balance between TAZ and YAP expression levels. Here we examined the functional roles of TAZ/YAP in hepatocellular carcinoma progression. We found that TAZ, but not YAP, was predominantly expressed in HCC. TAZ knockdown under normal conditions attenuated cell growth in HCC cells; however, TAZ knockdown combined with 5-fluorouracil treatment significantly increased chemoresistance compared with control cells. Notably, TAZ knockdown induced compensatory YAP expression and was accompanied by upregulation of CD90, a HCC-specific cancer stem cell marker. Continuous treatment with 5-fluorouracil also induced YAP expression and promoted tumor formation in vivo. Conversely, double knockdown of TAZ/YAP reduced chemoresistance and tumorigenicity. Moreover, YAP knockdown aggravated HCC cell growth to a greater degree than TAZ knockdown, and YAP overexpression was strongly associated with poor prognoses in patients with HCC. Collectively, these studies demonstrate that TAZ and YAP exhibit different functional roles in cancer progression, and a shift to predominant YAP expression upon TAZ depletion conferred cancer stem cell-like properties including chemoresistance and tumorigenicity in HCC. Therefore, targeting of both TAZ/YAP will be required for a complete antitumor response in HCC.

The Neutrophil-to-Lymphocyte Ratio Predicts Malignant Potential in Intraductal Papillary Mucinous Neoplasms.

BACKGROUND: Accurately identifying malignant components in patients with pancreatic intraductal papillary mucinous neoplasms (IPMN) remains challenging. Preoperative neutrophil-to-lymphocyte ratio (NLR) is a marker of poor prognosis in patients with several types of malignancy. This study assessed whether NLR was predictive of intraductal papillary mucinous carcinoma (IPMC) in patients with IPMN. METHOD: This study retrospectively assessed 76 patients who underwent curative resection for IPMN from 1995 to 2015. The correlation between the presence of malignant components and preoperative NLR was analyzed. RESULTS: Preoperative NLR in IPMC was significantly higher in patients with in IPMC (2.51 ± 0.84) than in patients with intraductal papillary mucinous adenoma (2.01 ± 0.71, P = 0.0079) and healthy volunteers (1.37 ± 0.33, P < 0.0001). NLR was significantly reduced after curative tumor resection. The main duct type (P = 0.0231) and NLR >2.074 (P = 0.0329) were independent predictors of IPMC in all patients. Combined criteria including international consensus guidelines, CA19-9 >37 IU/ml, and NLR >2.074 shows a high positive predictive value of 78 % and high specificity of 96 %. CONCLUSIONS: Preoperative NLR is a useful supportive marker to predict IPMC in patients with IPMN.

Scoring system based on tumor markers and Child-Pugh classification for HCC patients who underwent liver resection.

BACKGROUND: The long-term prognosis of hepatocellular carcinoma (HCC) patients after hepatic resection (HR) remains poor because of limited liver function and frequent recurrences. We created a prognostic system of HCC based on tumor markers and Child-Pugh classification. PATIENTS AND METHODS: This study investigated 427 HCC patients and three tumor markers (alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3), des-γ -carboxyprothrombin (DCP)) in relation to Child-Pugh classification by the stepwise Cox regression model for establishing a tumor marker staging (TMS). RESULTS: The TMS shows four levels (0/1/2/3) with 5-year recurrence rate of each stage of 76.7, 72.3, 80.9 and 100%, respectively, and 5-year overall survival of 77.0, 68.7, 52.1 and 28.9%, respectively. This TMS appears to be a better model to predict the recurrence and survival of HCC patients after hepatectomy than only the number of positive tumor markers. CONCLUSION: TMS is a useful staging system to evaluate biological status and background liver function.

Functional assessment versus conventional volumetric assessment in the prediction of operative outcomes after major hepatectomy.

PURPOSE: In this study we examined whether conventional future remnant liver volume (FR volume) or function (FR function) better predicted the operative outcome after major hepatectomy. METHODS: Of 510 patients who underwent hepatectomy for various indications, 133 patients with major hepatectomy were enrolled in this study. FR volume and the corresponding FR function routinely were measured with a 99mTc-GSA scintigraphy single-proton emission computed tomography fusion system. FR function was defined as the future remnant liver uptake ratio of 99mTc-GSA per whole liver by single-proton emission computed tomography. FR volume or function in cases with insufficient FR volume or function required for major hepatectomy were defined as marginal. RESULTS: Morbidity, liver dysfunction-related morbidity, and mortality after major hepatectomy occurred in 40 (30%), 10 (7.5%), and 8 (5.7%) patients, respectively. Thirty-two of the 133 patients were diagnosed as marginal using FR volume, but only 11 patients were diagnosed as marginal using FR function. These results indicated that 21 patients (16%) were switched to the safe group using functional assessment. Operative outcomes in patients with safe FR function (n = 122) were equivalent to those of patients with safe FR volume (n = 101), but patients with marginal FR function (n = 11) had substantially worse outcomes than patients with marginal FR volumes (n = 32). Logistic regression analysis identified marginal FR function, but not volume, as a risk factor for worse operative outcome after major hepatectomy. Portal vein embolization induced the substantially greater FR function compared with FR volume. Although liver volume equally corresponds to liver function under normal conditions, liver cirrhosis was greatly associated with the major discrepancy (more than 10%) in patients without portal vein embolization. CONCLUSION: Functional assessment for future remnant liver identified patients who were eligible for curative hepatectomy despite a marginal status based on conventional volumetric assessment. Thus, marginal FR function is a better predictor of operative outcome after major hepatectomy than FR volume, especially in patients with nonhealthy liver.

Intra-aortic balloon pump-assisted major hepatectomy in a case with coronary disease.

Clinically, we often encounter cancer patients who also have cardiovascular disease such as coronary artery disease. We experienced a case of severe coronary artery disease and a large hepatocellular carcinoma in a 69-year-old man. To reduce the risk of a perioperative cardiovascular event during mesohepatectomy, an elective intra-aortic balloon pump (IABP) was used. After an uneventful recovery, the patient was discharged on day 15. While IABP is frequently introduced in cardiac surgery, there have been few reports of its use during liver surgery. Here, we present IABP-assisted major hepatectomy as an option in a patient with both cancer and coronary artery disease.

EZH2 is associated with malignant behavior in pancreatic IPMN via p27Kip1 downregulation.

BACKGROUND: The epigenetic mechanism of tumorigenesis in pancreatic intraductal papillary mucinous neoplasm (IPMN) remains largely unknown. The aim of this study is to examine the role of enhancer of zeste homologue 2 (EZH2) alteration in pancreatic IPMN progression. METHODS: Fifty-four surgically resected pancreatic IPMN specimens, including a total of 181 lesions (normal duct in 48, adenoma in 50, borderline atypia in 53, carcinoma in situ (CIS) in 19, and invasive carcinoma in 11) were analyzed by immunohistochemical staining (EZH2, Ki-67, p27Kip1). Using paraffin embedded sections, total RNA was successfully extracted from 20 IPMN lesions (borderline IPMN in 9, CIS in 6, invasive carcinoma in 5) and 7 pancreatic normal ducts, and then levels of EZH2 and p27Kip1 mRNA were analyzed by real time PCR. RESULTS: In immunohistochemical analysis, cell proliferative activity revealed by Ki-67 positive nuclei was increased during IPMN progression (normal duct

Rank classification based on the combination of indocyanine green retention rate at 15 min and (99m)Tc-DTPA-galactosyl human serum albumin scintigraphy predicts the safety of hepatic resection.

OBJECTIVES: (99m)Tc-galactosyl human serum albumin (GSA) scintigraphy is helpful in estimating liver function and the extent of liver fibrosis. Estimation of the liver function necessary for evaluating hepatic resection damage may be difficult in patients with chronic liver damage because of the discrepancy between liver functional parameters. The aim of this study was to develop a classification system for liver function using indocyanine green retention rate at 15 min (ICG R15) and the ratio of uptake by the liver to that by the liver and the heart at 15 min (LHL15) in GSA scintigraphy for hepatic resection. METHODS: A total of 548 consecutive patients who underwent hepatectomy were enrolled in this study. On the basis of ICG R15 cutoff values, the corresponding LHL15 values were determined for rank classification. Postoperative outcomes were compared between patients who met the classification and those who did not. RESULTS: Ranks were classified into four categories (rank, ICG R15 range, LHL15 range, minimum percentage of future liver remnant volume) - rank 1: ≤10%, ≥0.935, >35%; rank 2: ≤20%, ≥0.90, >60%; rank 3: ≤30%, ≥0.87, >80%; and rank 4: >30%, <0.87, >90%. Patients meeting each classification showed significantly better morbidity, mortality, postoperative prothrombin time (PT) activity, and total bilirubin value on day 5 compared with those who did not. In the ICG rank 2 group (n=249), patients with LHL rank 4 had significantly worse platelet count, PT activity, and histological fibrosis than those with LHL rank 1 despite similar ICG R15 values. CONCLUSION: Rank classification can predict the safety of hepatic resection. LHL15 contributes to the classification by predicting histological liver fibrosis.

Triple positive tumor markers predict recurrence and survival in early stage hepatocellular carcinoma.

AIM: Hepatectomy is feasible for patients with hepatocellular carcinoma (HCC) with good hepatic function who meet the Milan criteria. Several studies have indicated that tumor markers of HCC, α-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP percentage and protein induced by vitamin K absence/antagonist-II were good predictors of malignant potential. It is important to identify highly malignant cases of HCC, and the aim of this study was to clarify the impact of triple positive tumor markers as the prognostic factors for early stage HCC within the Milan criteria. METHODS: This study investigated 199 patients who underwent hepatectomy for HCC within the Milan criteria between January 2001 and May 2009. Cumulative recurrence-free survival (RFS), overall survival (OS) and clinicopathological parameters were analyzed according to the number of positive tumor markers. RESULTS: In patients with triple positive tumor markers, 5-year RFS and OS was poor (17.1 and 61.4%, respectively). Multivariate analyses revealed independent risk factors for recurrence to be hepatitis C virus antibody positivity, non-initial treatment for HCC and triple positive tumor markers, and the independent risk factors for OS were high indocyanine green retention rate at 15 min value, maximum tumor size and triple positive tumor markers. Pathologically invasive growth, microvascular invasion and moderate to poor differentiation were significantly related to the number of the three tumor markers. CONCLUSION: Triple positive tumor markers for early stage HCC within the Milan criteria showed poor prognosis and malignant characteristics. These markers could be a useful predictor for the degree of malignant potential in early stage HCC.