Introduction: The increased survival rates of children with brain tumors is the result of decades of advancement in diagnostic and therapeutic approaches, but brought the adverse long-term effects of the treatments and tumors on these children into focus. Survivors of childhood brain tumors (SCBT) are at an increased risk of cardiometabolic disorders and premature mortality. Obesity and excess adiposity are well-established risk factor for cardiometabolic risk in the general population, but its contribution to these outcomes in survivors is unknown. More recently, adiposity has emerged as a more robust predictor of cardiometabolic risk than body mass index, the most clinically used measure of obesity. The current thesis pursued four objectives: 1) to determine the prevalence of obesity and excess adiposity in SCBT 2) to explore adiposity and its determinants in SCBT 3) to investigate the determinants of obesity in SCBT and 4) to identify potentially effective interventions to manage obesity in SCBT. Methods: Systematic reviews and meta-analyses were used to evaluate the prevalence and interventions for overweight and obesity in SCBT while the determinants of adiposity and obesity were explored using primary data and regression analyses. General health information and brain tumors information were collected with standardized questionnaires and review of medical records. The overweight or obesity status of subjects was determined by body mass index (BMI), and adiposity profile was evaluated using percent body fat (%FM), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR). Results: The results show no difference between the overweight and obesity rates in SCBT and non-cancer controls. However, SCBT have higher total and central adiposity. Birth weight is found to be a predictor of future BMI in SCBT, while a higher total adiposity in SCBT is predicted by having supratentorial tumors and receiving radiotherapy. Lastly, not enough evidence is available to conclude the effectiveness of lifestyle interventions, pharmacotherapy, and bariatric surgery on managing obesity in SCBT. Conclusions: Obesity, determined by BMI, is not enough to determine cardiometabolic risks in SCBT. Total and central adiposity should be measured as well to identify high-risk group. Special attention should be paid to SCBT with high birth weight, supratentorial tumors, and having received radiotherapy. Lastly, more randomized controlled trials are needed to provide high-quality evidence to determine the effectiveness of interventions to manage obesity and improve outcomes in SCBT. / Thesis / Master of Science (MSc) / Brain tumors are the most common solid tumors in children. The survival rates among children with brain tumors have increased significantly over the past four decades due to advances in early detection and treatment. However, these children are at increased risk of heart disease and type 2 diabetes, and early death. Evidence has suggested obesity and excess body fat as main reasons for cardiometabolic disorders in the general population, but it is not known if obesity and excess body fat contribute to diabetes and heart disease in survivors. Therefore, the current thesis aims to explore obesity and adiposity, their predictors and any existing treatments available to survivors of childhood brain tumors (SCBT) to see if outcomes can be improved. The results show that while survivors of childhood brain tumors have similar overweight and obesity rates to the general population when measured by the most common clinical measure, called body mass index (BMI), they in fact have higher fat mass. Furthermore, we identified birth weight as a predictor of obesity while the location of the tumors and receiving radiation therapy as predictors of the fat mass in SCBT. The results also show the lack of current effective interventions to manage obesity in SCBT. This data is critical to consider in the design and implementation of strategies to reduce heat disease and diabetes in survivors to improve their quality of life and lifespan.

Introdução: O carcinoma hepatocelular (CHC) é o câncer primário de fígado mais comum. A cirrose hepática é o principal fator de risco para esse tumor. O rastreamento para o CHC em pacientes com cirrose tem sido recomendado há anos. Acredita-se que a detecção e o tratamento precoce do CHC melhorem a sobrevida dos pacientes. O objetivo deste estudo foi analisar a sobrevida dos pacientes cirróticos com CHC pequeno e identificar fatores preditivos de sobrevida no Brasil. Casuística e Métodos: Entre janeiro de 1998 e dezembro de 2003, 74 pacientes cirróticos com CHC foram avaliados. Eles preenchiam os seguintes critérios: CHC com até três nódulos e no máximo 30 mm de diâmetro cada. Os fatores preditores de sobrevida foram identificados através do método de Kaplan-Meier e o modelo de Cox. Resultados: A média de idade foi de 58 anos (32-77); 71% dos pacientes eram do sexo masculino; 64% tinham hepatite C; 60% eram Child-Pugh A, o valor mediano da pontuação de MELD foi de 11; 79% tinham hipertensão portal. No momento do diagnóstico, 71% tinham uma única lesão; o tamanho do principal tumor era menor que 20 mm em 47%; o valor médio de AFP foi de 131 ng/ml. Três pacientes tinham trombose de veia porta, sugestiva de invasão vascular. Cinqüenta pacientes (67,5%) foram incluídos na lista de transplante hepático, que foi realizado só em quatro pacientes. A ressecção cirúrgica do tumor foi possível em quatro pacientes. Quarenta e oito (64,8%) pacientes receberam tratamento ablativo percutâneo (ablação por radiofreqüência ou injeção percutânea de etanol). Nove pacientes não receberam nenhum tratamento específico para o tumor. A taxa de sobrevida geral foi de 80%; 62%; 41% e 17% em 12, 24, 36 e sessenta meses, respectivamente. O tempo médio de seguimento após o diagnóstico do CHC foi de 23 meses (mediana de 22 meses, variando de um a 86 meses) para todo o grupo. Durante o seguimento, ocorreram 39 óbitos ocorreram relacionados com insuficiência hepática ou progressão do CHC. A análise univariada dos 74 pacientes mostrou que escore MELD maior que 11 (p = 0,016), classificação de Child-Pugh B e C (p = 0,007), AFP > 100 ng/ml (p = 0,006), mais de uma lesão (p = 0,041), diâmetro do tumor > 20 mm (p = 0,009) e presença de invasão vascular (p < 0,0001) foram preditores independentes de sobrevida. A análise de regressão de Cox identificou invasão vascular (RR = 14,60 - IC 95% = 3,3 - 64,56 - p < 0,001) e tamanho do tumor > 20mm (RR = 2,14 - IC 95% = 1,07 - 4,2 - p = 0,030) como preditores independentes de pior sobrevida. O tratamento do CHC esteve relacionado com melhor sobrevida. Conclusão: A identificação de CHC pequeno com até 20 mm de diâmetro está relacionada com melhores taxas de sobrevida. Por outro lado, a presença de invasão vascular, apesar do tamanho pequeno das lesões, é um fator associado a péssimo prognóstico. / Introduction: Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Liver cirrhosis is the major risk factor for this tumor. Screening for HCC in patients with cirrhosis has been recommended, in the belief that detection and treatment of early HCC improves patient survival. The aims of this study were to analyze the overall survival of small HCC in cirrhotic patients and identify independent predictors of survival, in Brazil. Methods: Between January 1998 and December 2003, seventy-four cirrhotic patients with hepatocellular carcinoma were evaluated satisfying the following criteria: HCC of 30 mm or smaller and a maximum of three lesions. Predictors of survival were identified using the Kaplan-Meier and the Cox model. Results: Mean age was 58 years-old (32-77), 71% of patients was male, 64% had hepatitis C, 60% were Child-Pugh A, mean MELD score was 11 and 79% had portal hypertension. At the time of diagnosis, 71% had one tumor, the size of the main tumor was smaller than 20 mm in 47%, mean AFP level was 131 ng/ml. Three patients had portal vein thrombosis, suggesting vascular invasion. Fifty patients (67.5%) were included in the liver transplant list, but it was performed in only four patients. Tumor resection was possible in four patients. Forty-eight (64.8%) patients received percutaneous treatment (radiofrequency ablation or percutaneous ethanol injection). Nine patients did not receive any cancer treatment. The overall survival rates were 80%, 62%, 41% and 17% at 12, 24, 36 and 60 months, respectively. The mean length of follow-up after HCC diagnosis was 23 months (median 22 months, range 1-86 months) for the entire group. During follow-up a total of 39 deaths related to liver failure or HCC progression occurred. Univariate analysis of the 74 patients showed that MELD score greater than 11 (p = 0.016), Child-Pugh classification (p = 0.007), AFP > 100 ng/ml (p = 0.006), more than one lesion (p = 0.041), tumor diameter > 20 mm (p = 0.009) and presence of vascular invasion (p < 0.0001) were significant predictors of survival. Cox regression analysis identified vascular invasion (RR = 14.60 - IC 95% = 3.3 - 64.56 - p < 0.001) and tumor size > 20mm (RR = 2.14 - IC 95% = 1.07 - 4.2 - p = 0.030) as independent predictors of decreased survival. Treatment of HCC was related to increased overall survival. Conclusion: Identification of small tumors of up to 20 mm diameter is related to increase survival. Nevertheless, vascular invasion, in spite of the small diameter of the lesions, is a factor associated with dismal prognosis.

This research explores womens experiences of arm morbidity after breast cancer. Biomedical knowledge about arm morbidity is limited and often unclear, and there has been even less focus on the health issue from a sociological perspective. While studies do exist about the experiences of arm morbidity, more investigation is required to realize its influence on the daily lives of breast cancer survivors. The purpose of my research is to convey constructed meanings of arm morbidity experiences to indicate the impact it has on womens everyday lives.<p> Qualitative data were collected via twelve in-depth, semi-structured interviews, as six participants were each interviewed twice. The interviews were focused on a broad range of themes in order to create a comprehensive understanding of the womens experiences of arm morbidity in their daily lives. Phenomenological and feminist approaches were both used to guide the research process and analyze the data, and a range of sociological ideas also informed the analysis, such as chronic illness, disability, gender roles, and embodiment.<p> The illness narratives produced two broad areas relevant to the womens experiences. The first major topic involves the meanings directly related to experiences of arm morbidity as a health issue, and is divided into four themes: 1) experiencing bodies with arm morbidity, 2) treatment, 3) information and knowledge, and 4) support. The second major topic involves understandings of arm morbidity as it affects the womens lives, in which three themes emerge: 1) changing abilities and adjusting roles, 2) identity and health, and 3) the influence of illness on approaches to life.<p> As existing research is sparse, the womens narratives present a new level of depth to understandings of arm morbidity experiences that does not exist in current literature. It is evident that more study about arm morbidity is necessary to construct important knowledge and benefit both biological and sociological understandings of this survivorship issue.

Background: Rural Saskatchewan cancer survivors have reported a lack of support once their cancer treatments have been completed. This problem is more acute the further away one lives from Saskatoon and Regina. A chronic disease self-management program titled LiveWell with Chronic Conditions (LWCC) is available to all people with any chronic condition in rural areas across Saskatchewan. This program addresses key areas of concern to survivors; however, participation is low for cancer survivors. Purpose: To determine how LWCC can reach and respond to the needs of rural cancer survivors in Saskatchewan. Objectives: 1. To gain an understanding of how the program responds to the needs of rural cancer survivors from the perspective of program leaders and cancer survivors. 2. To explore how the existing LWCC program could be enhanced in terms of content, format, delivery and marketing strategy. 3. Based on results, develop recommendations in coordination with agencies and institutions that provide services to cancer survivors. Methods: A mixed-methods case study approach was adopted. Needs questionnaires were completed by cancer survivors who participated in the LWCC program offered in rural health regions across the province (n=4). Consenting survivors who attended the program and several program facilitators, some of whom were cancer survivors themselves, were interviewed in order to provide their opinion regarding content, format, and other relevant feedback that would improve the fit of the program with the needs of rural cancer survivors (n=10). Results: Results indicate the material covered in the program is appropriate for cancer survivors who have finished acute treatment and are making the transition to life after cancer. Program benefits include improved self-efficacy and being able to manage emotional and physical issues from cancer including fatigue and pain. Rural survivors would like access to additional information to address issues specific to cancer survivorship including dealing with the fear of cancer recurrence, lymphedema and sexuality. A cancer specific rural health program would not be very feasible due to small populations. Cancer survivors felt comfortable in a group among people with other chronic conditions although support of another person with cancer participating in the LWCC group would be preferred. Knowledge Translation: A think tank was held with key stakeholders who provide services to cancer survivors to review these findings and form recommendations for improving rural cancer survivor care. These recommendations are: 1) to promote LWCC to rural cancer survivors who have finished acute cancer treatment, 2) to broaden the awareness of the program among cancer care providers, and 3) to refer cancer survivors to an existing cancer survivorship single day workshop after participation in LWCC. This workshop is available in up to 10 communities outside of Regina and Saskatoon. Conclusion: The Live Well with Chronic Conditions program is appropriate and beneficial for cancer survivors who have completed acute cancer treatments. As more cancer care providers make referrals to this program and an online version of the program becomes available, uptake will likely improve among rural cancer survivors in Saskatchewan.

This research explores womens experiences of arm morbidity after breast cancer. Biomedical knowledge about arm morbidity is limited and often unclear, and there has been even less focus on the health issue from a sociological perspective. While studies do exist about the experiences of arm morbidity, more investigation is required to realize its influence on the daily lives of breast cancer survivors. The purpose of my research is to convey constructed meanings of arm morbidity experiences to indicate the impact it has on womens everyday lives.<p> Qualitative data were collected via twelve in-depth, semi-structured interviews, as six participants were each interviewed twice. The interviews were focused on a broad range of themes in order to create a comprehensive understanding of the womens experiences of arm morbidity in their daily lives. Phenomenological and feminist approaches were both used to guide the research process and analyze the data, and a range of sociological ideas also informed the analysis, such as chronic illness, disability, gender roles, and embodiment.<p> The illness narratives produced two broad areas relevant to the womens experiences. The first major topic involves the meanings directly related to experiences of arm morbidity as a health issue, and is divided into four themes: 1) experiencing bodies with arm morbidity, 2) treatment, 3) information and knowledge, and 4) support. The second major topic involves understandings of arm morbidity as it affects the womens lives, in which three themes emerge: 1) changing abilities and adjusting roles, 2) identity and health, and 3) the influence of illness on approaches to life.<p> As existing research is sparse, the womens narratives present a new level of depth to understandings of arm morbidity experiences that does not exist in current literature. It is evident that more study about arm morbidity is necessary to construct important knowledge and benefit both biological and sociological understandings of this survivorship issue.

The recruitment, growth rate and survival of every juvenile corals on artificial substrates, deployed every 2 months since September 1998, for a total of 6 times, were investigated every 2 months, from November 1998 to September 2000, at Nanwan, southern Taiwan. The influence of season and habitat (e.g., new vs. old substrate and different positions etc.) on the above life history characteristics were the foci of this study. Coral recruitment during the 2-year period was low, averaging 1.3 recruits per 15x15 cm PVC plate; it was dominated by Pocilloporidae (50.7%) and Poritidae (31.9%), with Stylocoeniella guentheri (6.2%), Anthelia flava (5.1%) and Acropora sp. (2.4%) and others as minor constituents. Seasonal variations of new recruit densities were significant on new substrates of 2-months old, but not on old substrates of 14-month old. Pocilloporidae, for example, had the highest new recruit densities in May 1999; although the survival rate in this period, cumulative survivorship and growth rate were lower than those settled in other times. New recruit densities on new substrates were significantly higher than that on old substrates, but the survival rates of new recruits in the first 2 months were not significantly different between new and old substrates. The cumulative suvivorship and the initial juvenile growth rate of Pocilloporidae were higher on new than on old substrates. New recruit density of Pocilloporidae was higher in 1999 than in 2000, with an opposite pattern found in Poritidae. Juveniles prefer to settle on new substrates higher than old substrates and recruit densities decrease as plate age in Pocilloporidae, but an opposite pattern was found in Poritidae. The Pocilloporidae had relatively higher recruit densities but lower cumulative survivorship than Acropora sp. and Stylocoeniella. guentheri. A margin effect on the PVC plates was found, with higher new recruit densities and growth rates in the margin than in the intermediate and the inner region. The survival rate and the cumulative survivorship of recruits, however, were similar among the 3 regions on the plates. Thus the pattern of margin effect on the plate is unlikely a result of active larva preference. Among the scleractinian recruits, Acropora sp. had the highest growth rate, averaging 1.8 mm/month in maximum diameter. Within Pocilloporidae, the maximum diameters of juvenile Seriatopora hystrix was significant smaller than Pocillopora damicornis from 2-12 month. Some recruits of Seriatopora hystrix did not grow for more than a year. The overall cumulative survivorship of coral recruits was low at Nanwan, with 29.2% surviving the first year, and 0.7% surviving 2 years. Within dead juveniles, 65.7% was caused by disappearance and 34.3% was caused by algae, sediment and others organism etc. The relationship between size and mortality on juvenile Pocilloporidae is significant, implying that larger colony corals have higher survivor chance than smaller colony corals.

Abstract Introduction: Breast cancer is the most common female cancer worldwide and it is also the principal cause of death from cancer among women globally. Breast cancer has the highest prevalence among Panamanian women and its incidence is also growing every year. Women living with and beyond breast cancer have special needs that have to be considered by society and the health care systems. After diagnosis, the quality of life (QOL) of women is highly affected, due to the emergence of physical, psychological and social effects which lead to changes in attitudes and expectations towards life. Purpose: To evaluate the QOL, among Panamanian women who suffer from breast cancer, factors that could influence QOL and the main life areas where these women are more affected when they receive this diagnosis. Methodology: A cross-sectional study was developed to measure the QOL of Panamanian breast cancer survivors in four domains (physical, social, psychological and environmental). A total of 240 survivor women completed 80% of the self-assessment QOL-BREF survey at the National Cancer Institute of Panama during March, 2013. Non-parametric statistical tests were used to define QOL based on the survey results, including sociodemographic and medical characteristics. A logistic regression model was performed to evaluate variables than can influence the quality of life among this population. Results: Higher socioeconomic indicators as well as having greater levels of spiritual belief, younger age and less than 5 years of cancer diagnosis appear to produce positive and statistically significant differences in QOL among breast cancer survivors. Conclusions: Breast cancer survivors in Panama have a good quality of life perception and are satisfied with their health. Support principally from family and friends plays a very important role in all aspects of QOL. Elderly women have different physical needs that could explain the lowest score reported in this study.

Although young adult (YA) survivors of child cancer comprise a unique group from a developmental standpoint, in most treatment and research settings either child or general adult measures of quality of life (QL) are used to measure adjustment and functioning. Studies have relied heavily on survey methods, and though many hint at a variety of specific problems that a subset of YAs may experience, most identify YA survivors as relatively well adjusted. Interview studies with survivors and care-providers and interactions in survivor support venues paint a more complex and problematic picture of adjustment. To better understand the QL concerns unique to YAs this study employed grounded theory methodology to build a model of survivorship from participant perceptions. Four focus groups were conducted (N=15) with survivors between the ages of 18 and 30 years recruited from in-person and online support group settings. Themes emerged describing a larger extent of struggles than prior studies have identified. The grounded theory model detailed that having cancer can fundamentally change an individual, and these changes and resulting struggles do not end with remission. Survivors described constantly pursuing normalcy in the context of being fundamentally different, while balancing the dual roles of young adult and survivor. Survivors revealed difficulties in essentially every area of their lives (school, work, friendships, family, romance, self-esteem, outlook and attitudes, etc.), and though many could identify strategies for addressing these problems, maladaptive coping techniques dominated and survivors were left feeling overwhelmed, under-supported, and misunderstood. Results suggest that YAs could benefit from QL measures developed specifically with their unique concerns in mind. While progress has been made in developing YA-specific measures, such measures have not become widespread practice in clinical and research settings. Furthermore, this study suggests that collecting such information in a conversational, semi-structured interview format may elicit a fuller scope of survivors’ concerns than pencil and paper methods, though further research is recommended in this area.

Purpose: Many lives are affected by cancer. The number of people in England who have had a diagnosis of cancer exceeds one million. Previous research shows that one third of patients have unmet needs post-discharge from cancer treatment, including psychological issues such as negative impacts on self-identity and a lack of meaning in life. Studies have identified identity as an important factor in meaning making, but evidence regarding cancer’s impact on identity is limited to specific cancer sites and specific identity roles. Little is known about cancer’s general impact on global identity or how threats to identity relate to meaning making. The aim of this study was to understand patients’ experiences of cancer’s impact on their identity and what sense they made of these experiences. Methods: Twelve participants in the post-treatment phase of cancer shared their experiences in individual semi-structured interviews. Key themes regarding identity and meaning making in the post-treatment phase were identified using interpretative phenomenological analysis (IPA). Results and Conclusions: Four key themes in the participants’ experiences were identified. These were 1) disrupted identity roles, 2) highlights what is important, 3) focused on priorities, and 4) reducing awareness of loss and uncertainty. Relevant literature and implications for future research and clinical practice are discussed.

Introdução: O carcinoma hepatocelular (CHC) é o câncer primário de fígado mais comum. A cirrose hepática é o principal fator de risco para esse tumor. O rastreamento para o CHC em pacientes com cirrose tem sido recomendado há anos. Acredita-se que a detecção e o tratamento precoce do CHC melhorem a sobrevida dos pacientes. O objetivo deste estudo foi analisar a sobrevida dos pacientes cirróticos com CHC pequeno e identificar fatores preditivos de sobrevida no Brasil. Casuística e Métodos: Entre janeiro de 1998 e dezembro de 2003, 74 pacientes cirróticos com CHC foram avaliados. Eles preenchiam os seguintes critérios: CHC com até três nódulos e no máximo 30 mm de diâmetro cada. Os fatores preditores de sobrevida foram identificados através do método de Kaplan-Meier e o modelo de Cox. Resultados: A média de idade foi de 58 anos (32-77); 71% dos pacientes eram do sexo masculino; 64% tinham hepatite C; 60% eram Child-Pugh A, o valor mediano da pontuação de MELD foi de 11; 79% tinham hipertensão portal. No momento do diagnóstico, 71% tinham uma única lesão; o tamanho do principal tumor era menor que 20 mm em 47%; o valor médio de AFP foi de 131 ng/ml. Três pacientes tinham trombose de veia porta, sugestiva de invasão vascular. Cinqüenta pacientes (67,5%) foram incluídos na lista de transplante hepático, que foi realizado só em quatro pacientes. A ressecção cirúrgica do tumor foi possível em quatro pacientes. Quarenta e oito (64,8%) pacientes receberam tratamento ablativo percutâneo (ablação por radiofreqüência ou injeção percutânea de etanol). Nove pacientes não receberam nenhum tratamento específico para o tumor. A taxa de sobrevida geral foi de 80%; 62%; 41% e 17% em 12, 24, 36 e sessenta meses, respectivamente. O tempo médio de seguimento após o diagnóstico do CHC foi de 23 meses (mediana de 22 meses, variando de um a 86 meses) para todo o grupo. Durante o seguimento, ocorreram 39 óbitos ocorreram relacionados com insuficiência hepática ou progressão do CHC. A análise univariada dos 74 pacientes mostrou que escore MELD maior que 11 (p = 0,016), classificação de Child-Pugh B e C (p = 0,007), AFP > 100 ng/ml (p = 0,006), mais de uma lesão (p = 0,041), diâmetro do tumor > 20 mm (p = 0,009) e presença de invasão vascular (p < 0,0001) foram preditores independentes de sobrevida. A análise de regressão de Cox identificou invasão vascular (RR = 14,60 - IC 95% = 3,3 - 64,56 - p < 0,001) e tamanho do tumor > 20mm (RR = 2,14 - IC 95% = 1,07 - 4,2 - p = 0,030) como preditores independentes de pior sobrevida. O tratamento do CHC esteve relacionado com melhor sobrevida. Conclusão: A identificação de CHC pequeno com até 20 mm de diâmetro está relacionada com melhores taxas de sobrevida. Por outro lado, a presença de invasão vascular, apesar do tamanho pequeno das lesões, é um fator associado a péssimo prognóstico. / Introduction: Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Liver cirrhosis is the major risk factor for this tumor. Screening for HCC in patients with cirrhosis has been recommended, in the belief that detection and treatment of early HCC improves patient survival. The aims of this study were to analyze the overall survival of small HCC in cirrhotic patients and identify independent predictors of survival, in Brazil. Methods: Between January 1998 and December 2003, seventy-four cirrhotic patients with hepatocellular carcinoma were evaluated satisfying the following criteria: HCC of 30 mm or smaller and a maximum of three lesions. Predictors of survival were identified using the Kaplan-Meier and the Cox model. Results: Mean age was 58 years-old (32-77), 71% of patients was male, 64% had hepatitis C, 60% were Child-Pugh A, mean MELD score was 11 and 79% had portal hypertension. At the time of diagnosis, 71% had one tumor, the size of the main tumor was smaller than 20 mm in 47%, mean AFP level was 131 ng/ml. Three patients had portal vein thrombosis, suggesting vascular invasion. Fifty patients (67.5%) were included in the liver transplant list, but it was performed in only four patients. Tumor resection was possible in four patients. Forty-eight (64.8%) patients received percutaneous treatment (radiofrequency ablation or percutaneous ethanol injection). Nine patients did not receive any cancer treatment. The overall survival rates were 80%, 62%, 41% and 17% at 12, 24, 36 and 60 months, respectively. The mean length of follow-up after HCC diagnosis was 23 months (median 22 months, range 1-86 months) for the entire group. During follow-up a total of 39 deaths related to liver failure or HCC progression occurred. Univariate analysis of the 74 patients showed that MELD score greater than 11 (p = 0.016), Child-Pugh classification (p = 0.007), AFP > 100 ng/ml (p = 0.006), more than one lesion (p = 0.041), tumor diameter > 20 mm (p = 0.009) and presence of vascular invasion (p < 0.0001) were significant predictors of survival. Cox regression analysis identified vascular invasion (RR = 14.60 - IC 95% = 3.3 - 64.56 - p < 0.001) and tumor size > 20mm (RR = 2.14 - IC 95% = 1.07 - 4.2 - p = 0.030) as independent predictors of decreased survival. Treatment of HCC was related to increased overall survival. Conclusion: Identification of small tumors of up to 20 mm diameter is related to increase survival. Nevertheless, vascular invasion, in spite of the small diameter of the lesions, is a factor associated with dismal prognosis.