Surgical treatment of extrahepatic recurrence of hepatocellular carcinoma. 
The purpose of this study was to clarify the clinicopathological features of extrahepatic hepatocellular carcinoma (HCC) recurrence after hepatectomy in order to schedule optimal treatment strategies for better long-term outcomes.  A cohort of 206 patients who had undergone curative hepatectomy for HCC was analysed; 133 patients had developed relapse.  Among them, 101 patients had intrahepatic recurrence only (IHR), and 32 patients had extrahepatic recurrence (EHR).  Clinicopathological and survival data were compared between the two groups.  The overall survival rate after hepatectomy was better in the IHR than in the EHR group (p<0.0001).  The recurrence-free interval after hepatectomy was significantly shorter in the EHR than in the IHR group (258 vs. 487 days, p<0.0043).  Patients in the EHR group were more likely to have a high PIVKA II, a large tumour, and microscopic portal vein invasion when compared with patients in the IHR group.  Microscopic portal vein invasion was the most important independent risk factor for EHR after hepatectomy (p=0.0295).  Patients with more than two risk factors for EHR showed poor prognosis in comparison with patients without any risk factors (p<0.001).  In the EHR group, patients who underwent repeated resection had significantly better survival than patients receiving only the best supportive care (539 vs. 133 days, p=0.0098).  Furthermore, among EHR patients with concomitant IHR, patients with controllable IHR had significantly better survival than those with uncontrollable IHR (524 vs. 147 days, p=0.0131).  EHR of HCC was associated with early recurrence, and risk factors for the occurrence of EHR included the presence of high PIVKA II, large tumours, and microscopic portal vein invasion.  Resection of recurrent tumour and local control of concomitant IHR may improve the prognosis of EHR patients.