Li et al. BMC Cancer 2010, 10:535 http://www.biomedcentral.com/1471-2407/10/535 Page 6 of 9 Table 3 Univariate and multivariate Cox regression analyses for overall survival and cumulative recurrence rate Variable Major vascular invasion* ALB level † Cirrhosis status ‡ Univariate analysis OS CRR HR 3.500 0.601 1.319 P <0.001 0.004 0.028 HR 2.436 0.541 1.223 P <0.001 0.002 0.190 HR 3.291 0.693 1.400 Multivariate analysis OS CRR P <0.001 0.094 0.044 HR 2.242 0.689 - P <0.001 0.066 - OS, overall survival; CRR, cumulative recurrence rate; HR, hazard ratio. * Major vascular invasion vs. No major vascular invasion. † ALB > 35 g/L vs. <35 g/L. ‡ Cirrhosis vs. No cirrhosis. Furthermore, applying the criteria used in the 2002 TNM classification, patients with HCC with major vas- cular invasion (pT3) in our study had worse survival and more recurrence than HCC with invasion of adja- cent organs or perforation of visceral peritoneum (pT4) or multiple tumors more than 5 cm (pT3). Moreover, for patients who had major vascular invasion combined with any of the other three locally advanced pathologic features, the prognosis was similar to patients with HCC with major vascular invasion only. Our results indicated that once major vascular invasion occurred, prognosis became so poor that it was regardless of the presence or absence of any other tumor characteristics. Our data showed there is a need to redefine the T classification and to put more emphasize on major vascular invasion because of its overwhelmingly adverse prognostic influence. It has also been widely accepted that major vascular invasion indicates advanced HCC with a high risk of recurrence, which is the main cause of death for HCC patients after surgical resection [14,16,17]. In the present study, tumor recurrence was observed in all patients with HCC with major vascular invasion. The incidences of early and/or multiple recurrence for HCC with major vascular invasion was the highest in the four categories of locally advanced HCC, while there were no significant differences in the recurrence types among the remaining three groups of patients. Similar results have also been reported by Portolani et al [16]. In their series, major vascular invasion correlated well with early and diffuse recurrence which was rarely treatable, and thus an unsa- tisfactory long-term survival. As multiple tumors can be due to multicentric occurrence, they are likely to be associated with a better prognosis [18,19]. The study by Figure 1 Kaplan-Meier curves of overall survival and cumulative recurrence rates of four categories of locally advanced HCC patients . Gp1, major vascular invasion (n = 21); Gp2, multiple tumors more than 5 cm (n = 108); Gp3, invasion of adjacent organs (n = 32); Gp4, perforation of visceral peritoneum (n = 57). (A) Overall survival; Gp1 vs. Gp2, P < 0.001; Gp1 vs.Gp3, P = 0.001; Gp1 vs. Gp4, P < 0.001; Gp2 vs. Gp3, P = 0.892; Gp2 vs. Gp4, P = 0.693; Gp3 vs. Gp4, P = 0.615. (B) Cumulative recurrence rate; Gp1 vs. Gp2, P = 0.006; Gp1 vs.Gp3, P = 0.001; Gp1 vs. Gp4, P < 0.001; Gp2 vs. Gp3, P = 0.991; Gp2 vs. Gp4, P = 0.299; Gp3 vs. Gp4, P = 0.169.