Surgical treatment of recurrent hepatocellular carcinoma based on the mode of recurrence: repeat hepatic resection or ablation are good choices for patients with recurrent multicentric cancer

Clonality analysis for multicentric origin and intrahepatic metastasis in recurrent and primary hepatocellular carcinoma

AIMS

To clarify the incidence of multicentric occurrence (MO) and intrahepatic metastasis (IM) for hepatocellular carcinoma (HCC) related to hepatitis B virus in China and to identify the differences between them.

METHODS

Histopathologic and genetic features of primary and recurrent tumors in 160 cases with HCC were analyzed. The two groups, the origin of which was definitely determinable as of multicentric occurrence or as of intrahepatic metastasis, were analyzed for their disease-free survival and clinicopathological differences.

RESULTS

According to histopathological findings, 27.5% and 59.4% patients were considered to be MO and IM, respectively. By comparing the genetic information of loss of heterozygosity and microsatellite instability for 10 different markers between primary and recurrent tumor, 30.0% and 63.8% patients with recurrent HCC were considered to be MO and IM, respectively. In total, 126 cases with unanimous conclusions from the histopathological and genetic method were selected and divided into the MO group (37 cases) and the IM group (89 cases). Analysis of stepwise regression identified that recurrence time, grading, portal vein invasion, tumor number, and Child's stage were the most important discriminating factors between MO and IM (p < 0.05). As for their prognosis, Kaplan-Meier and log rank test showed that the disease-free survival in the MO group was significantly better than in the IM group (p = 0.002).

CONCLUSIONS

Combined analysis of histopathological and genetic analysis may reflect more exactly the nature of recurrent HCC. The incidence of MO in China is lower than in other countries--30% compared to up to 50% in Japan [Morimoto et al., Journal of Hepatology 39:215-221, 2003; Yamamoto et al., Hepatology 29;1446-1452, 1999]. Recurrence time, tumor grading, portal vein invasion, tumor number, and Child's stage are the most important discriminating factors between MO and IM. The prognosis (disease-free survival) of patients with MO compared to IM is significantly better.

Transarterial infusion chemotherapy with epirubicin in water-in-oil-in-water emulsion for recurrent hepatocellular carcinoma in the residual liver after hepatectomy

PURPOSE

To evaluate the midterm results of transarterial infusion (TAI) with water-in-oil-in-water (W/O/W) emulsion containing an anticancer agent for patients with recurrent hepatocellular carcinoma (HCC) after surgical resection.

MATERIALS AND METHODS

We retrospectively analyzed the results of TAI of W/O/W emulsion containing epirubicin for 18 consecutive patients with recurrent HCC after surgical resection. Fourteen patients were males and four were females; their ages ranged from 51 to 86 years (mean 69.8 years). TAI was repeated every 1-6 months based on the response of the tumor. A total of 41 TAI procedures were performed for 18 patients. Angiographically, recurrent HCC appeared a single nodule in nine patients and was multinodular in other nine patients. TAI was performed selectively in 27 procedures and non-selectively in 14 procedures. Maximum response within 3 months was rated as follows: a complete response (CR, complete disappearance of tumor and no evidence of new lesions); partial response (PR, a reduction of <50% in total volume of all tumors calculated from the two longest perpendicular diameters without a new lesion); no response (NC, a reduction of <50% in total volume or an increase of <25% without a new lesion); or progression of disease (PD, an increase of >25% in total volume or evidence of new lesions). Survival time was defined as the time from the date of first TAI to the date of death or last follow-up (median follow-up time: 17 months) and the survival curve was estimated using the Kaplan-Meier method.

RESULTS

The CR rate was 33% and the effective response rate (CR rate+PR rate) was 78%. Survival from the time of initial TAI was 94% at 1 year, 76% at 2 years, and 76% at 3 years.

CONCLUSIONS

TAI of W/O/W emulsion may be an effective treatment for patients with recurrent HCC after surgical resection.

Radiofrequency ablation of recurrent hepatocellular carcinoma after hepatectomy: therapeutic efficacy on early- and late-phase recurrence

OBJECTIVE

Our objective was to assess the efficacy and safety of radiofrequency ablation of recurrent hepatocellular carcinoma (HCC) after hepatectomy and to compare the effects on early- and late-phase recurrence.

SUBJECTS AND METHODS

We studied 41 patients with 76 recurrent HCC tumors (diameter range, 2.0-6.6 cm; mean, 3.8 +/- 1.3 [SD] cm) after hepatectomy who underwent sonography-guided percutaneous radiofrequency ablation in our hospital (recurrent-HCC group). The interval between surgery and recurrence ranged from 1 to 96 months (mean, 24.5 months). These patients were divided into an early-recurrence group (20 patients with 41 recurrent HCC tumors) and a late-recurrence group (21 patients with 35 recurrent HCC tumors). Early recurrence was defined as that occurring within 1 year after surgery, and late recurrence was defined as that occurring after 1 year. Another 116 patients with 172 primary HCC tumors (diameter range, 1.2-7.0 cm; mean, 3.9 +/- 1.1 cm) treated by radiofrequency ablation were regarded as a control group. No other therapies were given before radiofrequency ablation in any group. Regular follow-up with enhanced CT was performed to evaluate the treatment results. Ablation was considered successful if no contrast enhancement was detected in the treated area on 1-month CT scans. Indexes including ablation success rate, local recurrence rate, distant recurrence rate, and survival were obtained for analysis and comparison.

RESULTS

The ablation success rate, local recurrence rate, distant recurrence rate, and mean overall survival time of the recurrent-HCC group were 93.4% (71/76 tumors), 9.2% (7/76 tumors), 36.6% (15/41 patients), and 30.9 +/- 3.7 months, respectively. The incidence of distant recurrence in the early-recurrence group was significantly higher than that in the late-recurrence group (55.0% vs 19.0%, p = 0.017). The early-recurrence group had a shorter overall survival than did the late-recurrence group (mean overall survival, 16.4 +/- 2.4 vs 42.9 +/- 4.4 months, p < 0.001) or the control group (16.4 +/- 2.4 vs 45.9 +/- 2.5 months, p < 0.001). The survival time of the late-recurrence group was similar to that of the control group (42.9 +/- 4.4 vs 45.9 +/- 2.5 months, p > 0.05). Serious hemorrhage after radiofrequency ablation occurred in one patient in the late-recurrence group and was controlled with conservative treatment.

CONCLUSION

Radiofrequency ablation is generally effective and safe in treating recurrent HCC after hepatectomy and is more effective in late recurrence than in early recurrence.

Percutaneous Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma After Hepatectomy: Long-term Results and Prognostic Factors

BACKGROUND

We evaluated the long-term survival results and safety of percutaneous radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) after hepatectomy, and assessed the prognostic factors that can influence its long-term therapeutic results.

METHODS

One hundred and two patients, who had 119 recurrent HCC in their livers, underwent ultrasound-guided percutaneous RFA. All the patients had a history of hepatic resection as a first-line treatment modality for HCC. The mean diameter of the recurrent tumors was 2.0 cm (range, 0.8-5.0 cm). We evaluated the effectiveness rates, local tumor progression rates, survival rates, and complications. We also assessed the prognostic factors of the survival rates by using Cox proportional hazard models.

RESULTS

The primary effectiveness rate was 93.3% (111 of 119). The cumulative rates of local tumor progression at 1, 3, and 5 years were 6.0, 8.6, and 11.9%, respectively. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 93.9, 83.7, 65.7, 56.6, and 51.6%, respectively. Patients with a lower serum alpha-fetoprotein (AFP) level (<or=100 microg/L) before RFA or with small resected tumors (<or=5 cm) demonstrated better survival results (P < .05). There was only one major complication (liver abscess, 1.0% per treatment) during the follow-up period. There were no procedure-related deaths.

CONCLUSIONS

Percutaneous RFA is an effective and safe treatment modality for intrahepatic recurrent HCC after hepatectomy. Serum AFP level before RFA and resected tumor size were significant prognostic predictors of long-term survival.

Long-Term Outcome of a Hepatocellular Carcinoma 7½ Years After Surgery and Repeated Radiofrequency Ablation: Case Report and Review of the Literature

An interesting case is presented of a 78-year-old patient with cirrhosis who was managed with combined treatment (surgery and radiofrequency (RF) ablation) for hepatocellular carcinoma (HCC) and has survived for 7(1/2) years. Elevation of the alpha-FP (alpha-fetoprotein) levels was noted 2 years after surgery. CT demonstrated two lesions: one central at the remaining right liver lobe, and the other at the excision site. Biopsy of the lesions confirmed the diagnosis of HCC for both of them. RF ablation of these two lesions was performed in one session with technical success. Four and a half years after the first RF ablation a new recurrence was demonstrated at the CT follow-up control. RF ablation was again applied successfully. The imaging findings and the therapeutic percutaneous management of this patient along with the natural course of HCC and its recurrence are discussed, and the literature concerning risk factors is reviewed.

High pathological risk of recurrence after surgical resection for hepatocellular carcinoma: an indication for salvage liver transplantation

Surgical resection and liver transplantation offer a 5-year survival greater than 70% in patients with hepatocellular carcinoma, but the high recurrence rate impairs long-term outcome after resection. Pathological data such as vascular invasion and detection of additional nodules predict recurrence and divide patients into high and low risk profile. Based on this, we proposed salvage liver transplant to resected patients in whom pathology evidenced high recurrence risk even in the absence of proven residual disease. From January 1995 to August 2003 we have evaluated 1,638 patients. Resection was indicated in 77 patients, but only 17 (22%) (all cirrhotics, 14 hepatitis C virus+) were optimal candidates for both resection and transplantation. Of them, 8 exhibited a high risk profile at pathology and were offered transplantation. Among the 8 high risk patients, 7 presented recurrence, compared with only 2 of the 9 at low risk (P = .012). Two of the high risk patients refused transplant and developed multifocal disease during follow-up. The other 6 were enlisted and all but 1 had tumor foci in the explant. Only 1 presented extrahepatic dissemination early after transplant and died 4 months later. The others are free of disease after a median follow-up of 45 months. Two recurrences were detected in low risk patients, 1 of them being transplanted 18 months after surgery. These data in a small series of patients confirm that pathological parameters identify patients at higher risk of recurrence, which allow them to be listed for liver transplantation without proven malignant disease. In conclusion, this policy is clinically effective and could further improve the outcome of resected patients.

Interstitial laser thermotherapy for liver tumours

BACKGROUND

Primary hepatocellular carcinoma (HCC) and metastases from colorectal cancer are the most common malignant liver tumours. Surgical resection is the optimum treatment in suitable patients. Interstitial laser thermotherapy (ILT) is gaining acceptance for the treatment of irresectable liver tumours and as a potential alternative to surgery. An understanding of the principles of therapy and review of clinical outcomes may allow better use of this technology.

METHOD

An electronic search using the Medline database was performed for studies on the treatment of hepatic malignancy published between January 1983 and February 2003.

RESULTS

Current information on the efficacy of ILT is based on prospective studies. ILT appears to be a safe and minimally invasive technique that consistently achieves tumour destruction. The extent of destruction depends on the fibre design, delivery system, tumour size and tumour biology. Real-time magnetic resonance imaging provides the most accurate assessment of laser-induced tumour necrosis. In selected patients with HCC and colorectal cancer liver metastases, ILT achieves complete tumour necrosis, provides long-term local control, and improves survival, compared with the natural history of the disease. In addition, ILT has survival benefits for patients with other tumour types, especially those with isolated liver metastases from a breast cancer primary.

CONCLUSION

ILT improves overall survival in specific patients with liver tumours. Advances in laser technology and refinements in technique, and a better understanding of the processes involved in laser-induced tissue injury, may allow ILT to replace surgery as the procedure of choice in selected patients with liver malignancies.

Experimental study on ultrasound-guided intratumoral injection of “Star-99” in treatment of hepatocellular carcinoma of nude mice

AIM: To investigate the anti-cancer effect and the immunological mechanism of ultrasound-guided intratumoral injection of Chinese medicine “Star-99” in hepatocellular carcinoma (HCC) of nude mice.

METHODS: Twenty-eight human hepatocellular carcinoma SMMC-7721 transplanted nude mice, 14 of hypodermically implanted and 14 of orthotopic liver transplanted, were randomly divided into three groups of which 14 mice with Star-99, and 7 with ethanol and saline respectively. Ten days after the transplantation the medicines were injected into the tumors of all the nude mice once every 5 d. After 4 injections the nude mice were killed. The diameters of three dimension of the tumors were measured by high frequency ultrasound before and after the treatment and the tumor growth indexes^* (TGI) were calculated. Radioimmunoassay was used to detect the serum levels of interleukin-2 (IL-2) and tumor necrosis factor (TNF)-alpha. The tumor tissues were sent for flow cytometry (FCM) DNA analysis. Apoptotic cells were visualized by TUNEL assay. All the experiments were carried out by double blind method.

RESULTS: The TGI of Star-99 group (0.076 ± 0.024) was markedly lower than that of the saline group (4.654 ± 1.283) (P < 0.01). It also seemed to be lower than that of the ethanol group (0.082 ± 0.028), but not significantly different (P > 0.05). Serum levels of IL-2 and TNF-α were markedly higher than those of ethanol group and saline groups (P < 0.05). The mean apoptotic index (AI: percentage of TUNEL signal positive cells) in Star-99 group (48.98% ± 5.09%) was significantly higher than that of the ethanol group (11.95% ± 2.24%) and the saline group (10.48% ± 3.85%) (P < 0.01). FCM DNA analysis showed that the appearance rate of the apoptosis peak in Srar-99 group was 92.9%, markedly higher than that of the ethanol group (14.3%) and the saline group (0.0%) (P < 0.01). Correlation (r = 0.499, P < 0.05) was found between AI and serum level of TNF-α.

CONCLUSION: Star-99 has an effect on the elevation of the serum levels of IL-2 and TNF-α. It indicates that Star-99 has the function of enhancing the cellular immunity and inducing cancer cell apoptosis. The correlation between AI and serum level of TNF-α indicates that the elevation of the serum of TNF-α induced by Star-99 may be an important factor in the promotion of the hepatic cancer cell apoptosis. Star-99 has strong effects on the inhibition and destruction of cancer cells. Its curative effect is as good as ethanol. Its major mechanisms can be as follows: (1) it increases the serum levels of IL-2 and TNF-α and triggers cellular immunity. (2) It can induce cancer cells apoptosis, the effective mechanism of the Star-99 is different from that of the ethanol. The mechanisms of triggering the immunologic function of the organism and inducing cell apoptosis are, of particular significance. This study will provide a new pathway of drug administration and an experimental basis for the treatment of HCC with Chinese herbal, and the study of Star-99 in the treatment of tumor is of profound significance with good prospects.

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