Li et al. BMC Cancer 2010, 10:535 http://www.biomedcentral.com/1471-2407/10/535 Page 7 of 9 Figure 2 Kaplan-Meier curves of overall survival and cumulative recurrence rates to compare vascular invasion with or without any of the other pathologic features of locally advanced HCC patients . Gp1, major vascular invasion (n = 21); Gp5, multiple tumors more than 5 cm and major vascular invasion (n = 17); Gp6, invasion of adjacent organs and major vascular invasion (n = 10); Gp7, perforation of visceral peritoneum and major vascular invasion (n = 13). (A) Overall survival; Gp1 vs. Gp5, P = 0.392; Gp1 vs.Gp6, P = 0.121; Gp1 vs. Gp7, P = 0.901; Gp5 vs. Gp6, P = 0.854; Gp5 vs. Gp7, P = 0.287; Gp6 vs. Gp7, P = 0.250. (B) Cumulative recurrence rate; Gp1 vs. Gp5, P = 0.914; Gp1 vs.Gp6, P = 0.909; Gp1 vs. Gp7, P = 0.455; Gp5 vs. Gp6, P = 0.807; Gp5 vs. Gp7, P = 0.511; Gp6 vs. Gp7, P = 0.651. Poon et al. showed early recurrence within one year after resection of HCC was more likely to be due to metastasis than multicentric occurrence and was asso- ciated with a worse prognosis when compared with late recurrence [20]. Our results supported that patients with HCC with major vascular invasion had a signifi- cantly poorer prognosis than those with multiple tumors more than 5 cm, those with invasion of adjacent organs, or those with perforation of visceral peritoneum. The prognosis of HCC is extremely poor in patients with advanced disease [21]. For hepatic resection, the presence of distant metastasis is generally considered a contraindication [22]. In contrast, in view of the lack of other effective treatment options, surgical resection especially in eastern countries, is still advocated as the treatment of choice for patients with locally advanced HCC which is classified as pT3-4N0M0 [22-24]. Ishi- zawa et al. demonstrated that partial hepatectomy pro- vided survival benefits for patients with multiple tumors with Child-Pugh class A cirrhosis [25]. For locally advanced HCC, studies have also shown that survival following hepatic resection compared favorably with those treated non-surgically [10,11,26,27]. To improve future survival rates, innovative multidisciplinary approaches will also be needed. With recent advances in adjuvant therapy such as immunotherapy and molecular targeted therapy, whether these new modalities can improve the prognosis of locally advanced HCC treated with curative resection need to be clarified [28,29]. For patients with major vascular invasion, the prog- nosis is particularly grave. Nonsurgical treatment with systemic chemotherapy, intra-arterial chemotherapy, or radiofrequency ablation for these patients results in dis- mal 1-year survival rates, ranging from 7% to 18% [30-32]. Patients with HCC and major vascular invasion do not present technical contraindications to surgery. However, results after hepatic resection for HCC with major vascular invasion have been disappointing [22,33,34]. In the current study, the median OS was only 5.8 months after hepatic resection. Recently, the Table 4 Recurrence types in four groups of locally advanced HCC Group Variables Gp1 Gp2 Gp3 Gp4 Major vascular invasion only Multiple tumors more than 5 cm only Invasion of adjacent organs only Perforation of visceral peritoneum only * Early recurrence, recurrence ≤ 12 months; late recurrence, recurrence > 12 months. Recurrence time* No. of recurrence Cases 21 108 32 57 Early(%) 19 (90.5) 54 (58.7) 19 (65.5) 34 (64.2) Late(%) 2 (9.5) 38 (41.3) 10 (34.5) 19 (35.8) P 0.006 0.041 0.024 Single(%) 3 (14.3) 32 (34.8) 12 (41.4) 21 (39.6) Multiple(%) 18 (85.7) 60 (65.2) 17 (58.6) 32 (60.4) P 0.067 0.039 0.036