BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update

Navigating the complexities: challenges and opportunities in conversion therapy for advanced hepatocellular carcinoma

Primary liver cancer ranks as the sixth most prevalent malignant tumor and stands as the second leading cause of cancer-related mortality globally, posing a significant threat to public health. Hepatocellular carcinoma (HCC) is the most common type of liver cancer worldwide. Surgical resection remains the cornerstone treatment for achieving radical cure and prolonged survival in HCC patients. Contrary to Western countries, the majority of HCC patients in China present with hepatitis B virus infection and consequent liver cirrhosis, with most cases diagnosed at an intermediate or advanced stage. This complexity results in a poor prognosis. Recent advancements in local therapeutic techniques and the introduction of systemic therapies, including targeted and immunotherapy agents, have provided new avenues for both clinical and basic conversion therapy for advanced HCC. Integrating multi-dimensional local and systemic therapies, multi-modal sequential, and comprehensive multidisciplinary approaches into the management of HCC patients has demonstrated promising conversion success rates. This holistic management strategy involves combining multiple treatment modalities vertically and coordinating various disciplines horizontally. However, significant challenges remain, including the precise selection of patients eligible for conversion therapy, the optimal choice of conversion therapy regimens, and the accurate determination of surgical timing post-conversion therapy. Addressing these challenges is crucial for hepatobiliary surgeons. High-quality, randomized controlled trials are urgently needed to generate robust evidence for clinical practice. This review aims to synthesize the latest research developments both in China and internationally and examines key issues in the realm of HCC conversion therapy.

Radiomics of Dynamic Contrast-Enhanced MRI for Predicting Radiation-Induced Hepatic Toxicity After Intensity Modulated Radiotherapy for Hepatocellular Carcinoma: A Machine Learning Predictive Model Based on the SHAP Methodology

Objective

To develop an interpretable machine learning (ML) model using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) radiomic data, dosimetric parameters, and clinical data for predicting radiation-induced hepatic toxicity (RIHT) in patients with hepatocellular carcinoma (HCC) following intensity-modulated radiation therapy (IMRT).

Methods

A retrospective analysis of 150 HCC patients was performed, with a 7:3 ratio used to divide the data into training and validation cohorts. Radiomic features from the original MRI sequences and Delta-radiomic features were extracted. Seven ML models based on radiomics were developed: logistic regression (LR), random forest (RF), support vector machine (SVM), eXtreme Gradient Boosting (XGBoost), adaptive boosting (AdaBoost), decision tree (DT), and artificial neural network (ANN). The predictive performance of the models was evaluated using receiver operating characteristic (ROC) curve analysis and calibration curves. Shapley additive explanations (SHAP) were employed to interpret the contribution of each variable and its risk threshold.

Results

Original radiomic features and Delta-radiomic features were extracted from DCE-MRI images and filtered to generate Radiomics-scores and Delta-Radiomics-scores. These were then combined with independent risk factors (Body Mass Index (BMI), V5, and pre-Child-Pugh score(pre-CP)) identified through univariate and multivariate logistic regression and Spearman correlation analysis to construct the ML models. In the training cohort, the AUC values were 0.8651 for LR, 0.7004 for RF, 0.6349 for SVM, 0.6706 for XGBoost, 0.7341 for AdaBoost, 0.6806 for Decision Tree, and 0.6786 for ANN. The corresponding accuracies were 84.4%, 65.6%, 75.0%, 65.6%, 71.9%, 68.8%, and 71.9%, respectively. The validation cohort further confirmed the superiority of the LR model, which was selected as the optimal model. SHAP analysis revealed that Delta-radiomics made a substantial positive contribution to the model.

Conclusion

The interpretable ML model based on radiomics provides a non-invasive tool for predicting RIHT in patients with HCC, demonstrating satisfactory discriminative performance.

Prognostic Impact of the Pathologic Response of Patients with Hepatocellular Carcinoma After Preoperative Treatments

BACKGROUND

Hepatocellular carcinoma (HCC) exhibits varying degrees of tumor regression after preoperative treatments. However, the relationship between a tumor residual and its impact on recurrence-free survival (RFS) remains poorly defined. This study aimed to assess the effect of pathologic response on RFS in HCC patients undergoing preoperative treatments.

METHODS

Data from 400 patients with HCC who received preoperative treatments were retrospectively analyzed. The correlation between tumor residual and RFS was assessed using the "surv_cutpoint" function in R software and further validated through Cox proportional hazards regression models, with the objective of identifying a cutoff value that was significantly associated with RFS.

RESULTS

The overall analysis showed that pathologic response significantly influenced postoperative recurrence when tumor residual of 15% or less was detected. Multivariate regression analysis found that the independent risk factors for RFS were pathologic satellite nodules (hazard ratio [HR], 1.56; 95% confidence interval [CI] 1.05-2.25; P = 0.047), microvascular invasion (HR, 1.72; 95% CI 1.16-2.55; P = 0007), and advanced tumor stage (HR, 1.60; 95% CI 1.05-2.44; P = 0.031). In contrast, an independent protective factor affecting RFS was found to be residual of 15% or less (HR 0.41; 95% CI 0.26-0.63; P < 0.001). Subgroup analyses showed that RFS was significantly associated with a tumor residual cutoff value of 15% in Barcelona Clinic Liver Cancer (BCLC) stage A, 20% in stage BCLC stage B, and 26% in stage BCLC stage C.

CONCLUSIONS

This study demonstrated that achieving tumor residual of 15% or less after liver resection significantly reduces postoperative recurrence rates for HCC patients treated with preoperative therapies. The effect of tumor regression on RFS varied according to tumor stages.

Temporal evolution of the LI-RADS radiation treatment response assessment on multiphase CT/MRI in patients undergoing selective internal radiation therapy for hepatocellular carcinoma

OBJECTIVES

To assess the temporal evolution and interobserver agreement of the early categories per the liver imaging reporting and data system (LI-RADS) radiation treatment response assessment (TRA) algorithm in patients receiving selective internal radiation therapy (SIRT) with Yttrium-90 for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This single-center retrospective study included consecutive patients with treatment-naïve HCC who underwent serial contrast-enhanced CT/MRI before and after SIRT. Three masked radiologists independently evaluated response at 3-6 months. Another senior radiologist assessed response at 9, 12, 15, 18, 21, 24, and > 24 months after comprehensive review of available clinical-radiological information.

RESULTS

65 patients (mean age, 66.7 ± 11.2 years; 48 men) were included. At 3-6 months after SIRT, 47.7% (31/65) of lesions were assigned to the nonprogressing category, and the remaining 52.3% (34/65) to the nonviable category. Among early nonprogressing lesions, 64.5% (20/31) regressed to the nonviable category, 25.8% (8/31) remained nonprogressing, and 9.7% (3/31) evolved into the viable category at ≥ 12 months. The nonprogressing category decreased in number over time, with 61.3% (19/31) conversion to the nonviable category at 9 months. Among the early nonviable lesions, 91.2% (31/34) remained nonviable at ≥ 12 months, and 8.8% (3/34) evolved into the viable category. Agreement for the 3-6 months LR-TR category assignment was moderate (kappa = 0.46) with CT but almost perfect (kappa = 0.85) with MRI.

CONCLUSIONS

SIRT induced a delayed and sustained response in the majority of HCC patients after ≥ 12 months. MRI demonstrated superior agreement over CT in assessing response at 3-6 months.

KEY POINTS

Question Tumor response to SIRT can change; there is limited evidence on the evolution of the imaging appearance of HCC following SIRT. Findings Sixty-four and five-tenths of early nonprogressing lesions regressed to nonviable, and 91.2% of early nonviable lesions remained free of viability. LR-TR category assignment agreement was moderate with CT but almost perfect with MRI. Clinical relevance SIRT induced a delayed and sustained response in HCC, underscoring the necessity of dynamic evaluation of long-term changes in treated lesions. MRI with subtraction imaging may be preferred over CT for long-term monitoring, which may help prevent premature retreatment decisions.

Liver resection versus interventional treatments for hepatocellular carcinoma patients with hypohepatia: a multicenter study

BACKGROUND

Hypohepatia limits the feasibility of therapeutic options for hepatocellular carcinoma (HCC), negatively affecting patient prognosis. Established guidelines for the treatment strategies of HCC patients with hypohepatia are lacking. This study was performed to evaluate therapeutic benefits between liver resection (LR) and interventional treatments using ablation or transarterial chemoembolization (TACE) in such population.

METHODS

Survival analyses were performed using the Kaplan-Meier method and log-rank test. The Cox proportional hazards regression models were used to analyze potential risk factors associated with prognosis. Multivariate regression and propensity score regression adjustment analyses were applied to adjust for baseline confounding variables. Restricted cubic spline curves were used to assess the association between prognostic index and risk of death or progression on a continuous scale.

RESULTS

Of the enrolled 5774 HCC patients with hypohepatia, 506 (8.8%), 2326 (40.3%) and 2942 (51.0%) underwent ablation, LR and TACE, respectively. A tentative analysis of the overall cohort demonstrated that a high degree of heterogeneity existed in this population, while LR rendered a possible tendency to survival benefit over ablation and TACE through adjustment for baseline confounding variables. After categorizing the patients according to the indication of ablation treatment, the indisputable superiority of LR over ablation and TACE in terms of OS and DFS before and after adjustments were evident and the survival advantages of LR were consistent across all pre-specified subgroups. Individualized treatment decision analyses based on restricted cubic spline curves demonstrated that LR group presented the lowest risk of death and disease progression.

CONCLUSIONS

HCC patients with hypohepatia could obtain survival benefits through surgical and non-surgical treatment approaches. LR appears to confer a significant survival benefit compared with interventional treatments using ablation or TACE, even for selected intermediate and advanced populations.

MRI Radiomics to Predict Early Treatment Response to TACE Combined with Lenvatinib Plus a PD-1 Inhibitor for Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Purpose

To develop and validate a predictor for early treatment response in hepatocellular carcinoma (HCC) patients accompanied by portal vein tumor thrombus (PVTT) undergoing transarterial chemoembolization (TACE), lenvatinib and a programmed cell death protein 1 (PD-1) inhibitor (TLP) therapy.

Patients and Methods

In this retrospective study, patients with HCC and PVTT from two institutions receiving triple TLP therapy were enrolled. Radiomics features derived from pretreatment contrast-enhanced MRI were curated using intraclass correlation coefficient (ICC), Student's t-test, least absolute shrinkage and selection operator (LASSO), and recursive feature elimination (RFE) to ensure robust selection. Various machine learning (ML) algorithms were then used to construct the models. The meaningful clinical indicators were obtained via logistic regression analysis and ultimately integrated with radiomics features to develop a combined model. In addition, we used Shapley Additive exPlanation (SHAP) to clarify the model's operational dynamics.

Results

Our study ultimately included 115 patients (7:3 randomization, 80 and 35 in the training and test cohorts, respectively) in total. No patients achieved complete remission, 47 achieved partial remission, 29 achieved stable disease, and 39 experienced disease progression. Among objective response rates (ORRs) and disease control rates (DCRs), 40.9% and 66.1% were reported. One of the four ML classifiers with optimal performance, namely random forest, was adopted as the radiomics model after testing. Regarding the performance assessment, the radiomics model's area under the curve (AUC) values reached 0.92 (95% CI: 0.86-0.97) and 0.79 (95% CI: 0.61-0.95), inferior to the combined model's AUCs of 0.95 (95% CI: 0.68-0.98) and 0.84 (95% CI: 0.91-0.99). Moreover, the SHAP plots illustrate the importance of global variables and the prediction process for individual samples.

Conclusion

The model based on machine learning and radiomics showed favorable performance, and the operating mode was visualized through SHAP.

Comparing PD-L1 and PD-1 inhibitors plus bevacizumab combined with hepatic arterial interventional therapies in unresetable hepatocellular carcinoma: A single-center, real-world study

With the rise of anti-vascular endothelial growth factor antibody and programmed cell death-ligand 1 (PD-L1) regimens, particularly bevacizumab and atezolizumab, as first-line treatments for advanced hepatocellular carcinoma (HCC), there is a need to explore PD-L1 and programmed cell death 1 inhibitors in combination therapies for unresectable HCC (uHCC). Integrating systemic therapies with locoregional approaches is also emerging as a potent strategy. This study compares the outcomes of atezolizumab (PD-L1 inhibitor) and sintilimab (programmed cell death 1 inhibitor) with bevacizumab or its biosimilar, combined with hepatic arterial interventional therapies (HAIT) in uHCC patients. From January 2020 to September 2023, a retrospective analysis was conducted on 138 uHCC patients at Sun Yat-sen University Cancer Center. The cohort included 69 patients treated with atezolizumab with bevacizumab (Bev/Ate) and 69 with bevacizumab biosimilar with sintilimab (Bio/Sin), combined with HAIT. The propensity score matching was also employed to further explore the efficacy and safety. The median progression-free survival (mPFS) was 13.8 months for the Bev/Ate group and 10.0 months for the Bio/Sin group (p = 0.188). The Bev/Ate group showed significantly longer intrahepatic mPFS (HR 0.381; 95% confidence interval 0.176-0.824; p = .018) and higher overall response rates compared with the Bio/Sin group (60.87% vs. 31.88%, p = .001; 69.57% vs. 49.28%, p = .024) based on Response Evaluation Criteria in Solid Tumors v1.1 and modified Response Evaluation Criteria in Solid Tumors criteria. Treatment-related adverse events were similar between groups (p > .050). Combining atezolizumab or sintilimab with bevacizumab or its biosimilar alongside HAIT provided similar overall PFS in uHCC patients. However, the atezolizumab-bevacizumab combination with HAIT showed superior intrahepatic PFS and control rates, warranting further validation.

Genome-Wide Methylation Sequencing to Identify DNA Methylation Markers for Early-stage Hepatocellular Carcinoma in Liver and Blood

BACKGROUND

Hepatocellular carcinoma (HCC) is associated with a poor 5-year survival mainly due to detection at late stages. Better non-invasive surveillance methods are needed to improve early detection and maximize survival. We performed a strict assessment of DNA methylation markers (DMMs) for HCC detection.

METHODS

A total of 385 samples from liver tissues and blood were analyzed. Genome-wide Methylated DNA sequencing (MeD-seq) was initially performed on 46 liver tissues, followed by the validation using quantitative methylation-specific PCR (qMSP) on 175 liver tissues. The selected DMMs with and without ASAP/GAAD score were further evaluated in 180 blood samples. Additionally, MeD-seq was performed to validate the results on blood.

RESULTS

MeD-seq revealed a substantial number of differentially methylated regions (DMRs) in HCC tissues compared to non-HCC controls. By qMSP, the top 5 DMMs demonstrated strong performance in distinguishing cirrhotic HCC from cirrhosis controls in tissue (AUC 0.842 to 0.957). However, evaluation of these DMMs in blood showed lower performance in early HCC detection compared to cirrhosis in both the training (sensitivity 26.7-43.3%, 81.3% specificity) and validation cohorts (sensitivity 16.2-43.2%, 85.7% specificity). The addition of DMMs to the ASAP/GAAD score only provided an additional 5.4% sensitivity in the validation cohort compared to the ASAP/GAAD score alone. These findings were confirmed using MeD-seq analysis in blood samples, which revealed no detectable DMRs between cirrhotic HCC and cirrhosis controls. Interestingly, DNA methylation patterns in blood of healthy individuals differed strongly from both groups (cirrhosis and cirrhotic HCC).

CONCLUSION

DNA methylation patterns in liver tissue were distinctly different between HCC and controls. In blood, DMMs contributed minimally to early-stage HCC detection compared to cirrhosis, whether used alone or in combination with the ASAP/GAAD score. It is likely that high baseline DNA methylation related to cirrhosis and possibly the low input of tumor-related DNA impacts the use of DMMs in early HCC detection in blood.

Atezolizumab Plus Bevacizumab Combined with or without Transarterial Chemoembolization in the Treatment of Advanced Hepatocellular Carcinoma: A Single-Center Retrospective Study

Purpose

This study aimed to compare the efficacy and safety of atezolizumab plus bevacizumab (T+A) in combination with transarterial chemoembolization (TACE) (T+A+TACE) and T+A for patients with advanced hepatocellular carcinoma (HCC).

Patients and Methods

From December 2020 to August 2024, 83 patients with advanced HCC who received T+A+TACE treatment or T+A treatment in our hospital were included, and these patients were categorized into TACE+T+A group (n=52) and T+A group (n=31). The clinical outcomes between the two groups were analyzed and compared, and the prognostic factors that affected the efficacy were analyzed.

Results

The median overall survival (OS) and median progression-free survival (PFS) in the T+A+TACE group were significantly longer than those of in the T+A group (OS: 22.8 vs 16.9 months, P = 0.015; PFS: 7.1 vs 4.9 months, P = 0.006). A significantly higher objective response rate (ORR) and disease control rate (DCR) that are based on the modified RECIST were achieved in the T+A+TACE group than those of in the T+A group (ORR: 51.9% vs 6.5%, P < 0.001; DCR: 88.5% vs 54.8%, P < 0.001). No significant differences in adverse events (AEs) were observed between the two groups (P > 0.05). The T+A+TACE treatment was identified as a protective factor for OS and PFS.

Conclusion

TACE further improved the efficacy of T+A treatment for patients with advanced HCC, and it did not increase the incidence of AEs. T+A+TACE treatment is a promising treatment option for patients with advanced HCC.

Usefulness of preoperative peripheral blood GPC3-positive circulating tumor cells in subclassification of Barcelona Clinic Liver Cancer stage B hepatocellular carcinoma: a retrospective cohort study

AIM

The treatment strategy for hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage B, representing the intermediate stage, remains unclear. This study aimed to evaluate the utility of glypican-3 (GPC3)-positive circulating tumor cells (CTCs) in subclassifying BCLC stage B.

METHODS

The present retrospective cohort study included patients with hepatocellular carcinoma who underwent primary liver resection at our hospital between April 2015 and March 2022. The primary endpoints were overall survival (OS) and recurrence-free survival (RFS).

RESULTS

A total of 338 patients were included in the analysis. GPC3-positive CTCs were significantly associated with a positive rate of microscopic portal vein invasion. In BCLC stages 0/A, there was no significant difference in survival rates between patients with GPC3-positive CTC counts. However, in BCLC stage B, both OS and RFS were significantly lower in the high number of GPC3-positive CTC group (p = 0.02 and p = 0.03, respectively). Further analysis using a four-group classification based on BCLC stage and GPC3-positive CTC count revealed that both OS and RFS were significantly lower in BCLC stage B with the high number of GPC3-positive CTC group (p < 0.01). Multivariate analysis identified Child-Pugh B status and beyond up-to-7 criteria as independent risk factors for poor OS (p = 0.01 and p = 0.04, respectively). For RFS, beyond up-to-7 criteria and a high number of GPC3-positive CTCs were identified as independent predictive factors (p = 0.04). Based on BCLC stage B, combining GPC3-positive CTCs with the up-to-7 criteria significantly stratified OS and RFS.

CONCLUSIONS

Glypican-3-positive CTCs are effective for subclassifying BCLC stage B HCC. When combined with the up-to-7 criteria, they may help with the development of new treatment strategies.

Effects of the COVID-19 Pandemic and Post-Pandemic Changes on the Diagnosis, Treatment, and Mortality of Hepatocellular Carcinoma in a Tertiary Center in Western Romania

BACKGROUND/OBJECTIVES

Access to healthcare services was significantly restricted during the COVID-19 pandemic, leading to changes in the management of hepatocellular carcinoma (HCC). However, limited research has examined how these changes evolved post-pandemic. This study evaluated the impact of the pandemic at a tertiary center in Romania, focusing on diagnosis rates, treatments, and survival outcomes.

METHODS

A retrospective study conducted at Timișoara County Hospital divided patients into three equal cohorts of 23 months each: the pre-pandemic period (PreP: 1 May 2018-31 March 2020), the pandemic period (PandP: 1 April 2020-28 February 2022), and the post-pandemic period (PostP: 1 March 2022-31 January 2024). Newly diagnosed HCC cases were evaluated for the tumor stage, biological markers, and treatment received during each period. A survival census was conducted nine months after the diagnosis.

RESULTS

During the PandP and PostP periods, the numbers of newly diagnosed HCC cases decreased to 58 cases (p < 0.001) and 64 cases (p < 0.005), respectively, representing reductions of 38.3% and 31.9% compared to the PreP period, which had 94 cases. The proportion of patients in the BCLC-B stage increased from 31.9% in the PreP period to 50% during the PandP period (p = 0.0401), with fewer BCLC-A-0 cases (17% vs 5.1%; p = 0.059) during PandP. The tumor characteristics, BCLC classification, and TNM staging showed no significant differences between the PreP and PostP periods. Systemic therapy was the most commonly used treatment (39.7-50%). No significant differences were observed across treatment types when comparing all three periods (p > 0.05). The median follow-up times in the PreP, PandP, and PostP periods were 157.5, 159.5, and 183.5 days, respectively, with no statistically significant differences. The survival curve showed no statistically significant differences in survival between the groups at the nine-month follow-up (p > 0.05).

CONCLUSIONS

The COVID-19 pandemic decreased HCC diagnoses, with only a partial rebound in the PostP period that did not reach PreP levels. While the PandP period showed worsening BCLC staging and an increase in tumor numbers, the tumor stage and treatment in the PostP period were similar to those in the PreP period. Similarly, the nine-month survival rates remained similar across all three periods.

Multicenter, prospective clinical trial for balloon-occluded alternative infusion of cisplatin solution and fragmented gelatin particles of transarterial chemoembolization for hepatocellular carcinoma beyond up-to-seven criteria

Transarterial chemoembolization (TACE) is considered unsuitable for hepatocellular carcinoma (HCC) that exceeds up-to-7 criteria. Balloon-occluded alternative infusion of cisplatin solution and gelatin particles of transarterial chemoembolization (BOAI-TACE) has shown promise in the treatment of HCC and preservation of liver function. This prospective, single-arm study enrolled patients with HCC beyond up-to-7 criteria from five hospitals. The primary endpoint was objective response ratio (ORR) for BOAI-TACE, according to response evaluation criteria in cancer of the Liver (RECICL), at 2 months after treatment. Eighteen patients were enrolled in this study. Fourteen patients achieved response, resulting in an ORR of 77.8% (95% confidence interval [CI] 54.3-91.5%) according to both RECICL and modified response evaluation criteria in solid tumor (mRECIST) guidelines, meeting the primary endpoint. Disease control rate was 88.9% (95% CI 66.0-98.1%). No worsening of either Child-Pugh or albumin-bilirubin (ALBI) scores was observed. No serious adverse events were recorded, indicating that BOAI-TACE retains utility even in severe HCC cases while preserving liver function.

Recent Strategies to Attenuate Hepatocellular Carcinoma Recurrence After Liver Transplantation: A Narrative Review

Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplant worldwide. While liver transplantation offers a survival advantage for early-stage HCC patients, post-transplant recurrence remains a significant concern, affecting up to 15% of recipients. We sought to conduct a comprehensive review related to HCC recurrence after liver transplant. Tumor-related factors such as poor differentiation, vascular invasion, and elevated tumor biomarkers like alpha-fetoprotein are key predictors of recurrence. Donor-related factors, including graft type and surgical procedures, can also influence outcomes, though their effects are less conclusive. Advancements in patient selection criteria and scoring systems, such as the Milan Criteria and RETREAT score, have improved risk stratification by incorporating tumor size, biomarkers, and response to pre-transplant treatment. Despite these measures, recurrent HCC after transplantation poses treatment challenges. Curative approaches such as resection are feasible for localized or oligometastatic recurrence and offer the best outcomes when applicable. Locoregional treatments, including ablation and transarterial chemoembolization, provide options for unresectable cases but have limited long-term efficacy. Systemic therapies, including targeted agents like sorafenib, regorafenib, and lenvatinib, have shown modest benefits in managing advanced recurrent HCC. Emerging immunotherapy approaches hold promise but face unique challenges due to the required immunosuppression in transplant recipients. Multidisciplinary evaluation remains essential for tailoring treatment plans. Future efforts should focus on refining predictive tools and exploring novel therapies to improve survival outcomes for patients with recurrent HCC after liver transplantation.

Conditional survival after liver resection for early-stage hepatocellular carcinoma

Conditional survival (CS) is a measure of prognosis of patients who have already survived several years since diagnosis. However, few studies have investigated the CS of patients who underwent liver resection (LR) for early-stage hepatocellular carcinoma (HCC). We enrolled 942 consecutive patients who underwent LR for HCC with pathology-defined American Joint Committee on Cancer (AJCC) 7th edition stage 1 or 2 disease. The three-year CS was calculated as CS = S(x + 3)/S(x) and represented the probability of surviving an additional three years, given that the patient had already survived x years. The one-, three-, and five-year survival rates were 97.1%, 86.7%, and 76.1%, respectively, and were lower in cases with AJCC stage 2 disease, alpha-fetoprotein level of ≥ 20 ng/ml, presence of cirrhosis, anti-hepatitis C virus positivity, age > 65 years, and Model for End-Stage Liver Disease score of > 9. However, the three-year CS indicated that these variables were associated with shortened survival only in the first two years. From the third year after LR, the probability of survival of patients was similar between subgroups. CS is useful for providing a dynamic evaluation of survival during postoperative follow-up.

Platelet-albumin-bilirubin versus albumin-bilirubin as a predictor of long-term survival for hepatitis B-Induced hepatocellular carcinoma after hepatic resection

BACKGROUND

The Child-Pugh (CP) score is widely used to evaluate the severity of liver dysfunction in patients with hepatocellular carcinoma (HCC). Recently, both the albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grade have been raised to be objective measurement indexes of liver function which can sufficiently stratify HCC patient survival. In this study, we aim to compare the ability of albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grade to predict outcomes in hepatitis B-Induced HCC after liver resection with curative intent.

METHODS

Between April 2013 and April 2023, 1005 consecutive hepatitis B-Induced HCC patients who underwent liver resection were included in this study. The performance of PALBI and ALBI score in predicting long-term survival was evaluated.

RESULTS

The area under the ROC curve (AUC) of the PALBI(AUC:0.618) for predicting long-term survival was greater than that of the ALBI(AUC:0.522). In the multivariate analysis for OS, both the ALBI (HR: 1.246 95%CI: 1.029-1.508 P = 0.024) and PALBI (HR: 1.207 95%CI: 1.049-1.388 P = 0.009) scores were identified as independent predictors of OS in HCC patients. In the univariate analysis for DFS, the PALBI grade was also significantly associated with poor DFS (P = 0.041). In contrast, the ALBI grade was not found to be significantly associated with poor DFS (P = 0.414). Subgroup analysis also showed, among patients across each BCLC stage, the group with ALBI grade 1 had DFS similar to that of the group with ALBI grade 2 (both P > 0.05). However, the PALBI grade can differentiate each BCLC stages into three prognostic groups (all P < 0.05).

CONCLUSION

Compared to ALBI grade, the PALBI grade is more clinically feasible and has better prognostic ability regardless of the grade of BCLC stage.

Can Intra-Operative Ablation-Specific Features Based on Ultrasound Fusion Imaging be Used to Predict Early Recurrence of Hepatocellular Carcinoma After Microwave Ablation: A Proof-of-Concept Study

Purpose

Intra-operative factors are crucial to early recurrence of hepatocellular carcinoma (HCC) after microwave ablation (MWA), but few models have been developed based on intra-operative data to predict HCC recurrence after MWA. To quantify the intra-operative factors associated with MWA and establish an artificial intelligence (AI) model for predicting early recurrence of HCC after ablation based on contrast-enhanced ultrasound (CEUS) fusion imaging.

Patients and Methods

79 hCC patients, who underwent MWA with one-year follow-up and intraoperative CEUS fusion imaging assessment were retrospectively included. Three classifiers (support vector machine (SVM), random forest (RF), and multilayer perceptron (MLP)) were developed to predict early HCC recurrence from CEUS fusion images. Thirteen ablation-specific features were defined and screened using minimum redundancy maximum relevance (mRMR), and leave-one-out cross-validation (LOOCV) was adopted for performance evaluation. Comparative analyses were conducted among classifiers and between a senior interventional doctor and the best classifier in terms of the area under the receiver operating characteristic curve (AUC).

Results

Of 79 eligible patients who were included, 22 were in the early-recurrence (age 60.18 ± 10.97; 20 males) and 57 were in the non-early recurrence (age 58.81 ± 10.89; 50 males). Six features were selected out by mRMR for early recurrence prediction and AUCs of three models were 0.84 (95% CI: 0.74, 0.94) 0.79 (95% CI: 0.69, 0.89) and 0.77 (95% CI: 0.67, 0.88) (p = 0.20 and 0.23 for SVM and RF, respectively), which was significantly better than that achieved by senior doctor's assessment (AUC, 0.56; 95% CI: 0.44, 0.68; p = 0.002 for MLP).

Conclusion

The prediction model based on ablation-specific features using intra-operative ultrasound fusion imaging data was feasible to predict early recurrence of HCC after MWA and showed great potential in guiding the real-time adjustment of the intra-operative ablation strategy so as to achieve precise ablation.

The clinical implications of trial endpoints in immunotherapy for hepatocellular carcinoma

INTRODUCTION

Investigative work in the treatment of hepatocellular carcinoma is rapidly growing with the advent of immunotherapy. Nonetheless, trial endpoints and, more importantly, clinically meaningful endpoints need to be accurately chosen depending on the phase of trial and the patient population studied. We provide a scoping review focusing on trial endpoints on the use of immunotherapy in hepatocellular carcinoma.

AREAS COVERED

We searched PubMed and Google Scholar for prospective phase II and III trials using immunotherapy, whether in the neoadjuvant, adjuvant, bridging, downstaging, or palliative settings, while discussing the clinical implications of trial endpoints.

EXPERT OPINION

The field of immune oncology is rapidly progressing and has become the standard of care in advanced hepatocellular carcinoma. However, the role of immunotherapy in the treatment of early and intermediate stage hepatocellular carcinoma is yet to be defined. Prospective trials for all stages of disease must strive for endpoints that are not only statistically significant but also clinically consequential. Whereas overall response rate may be a reasonable trial endpoint in phase II trials, phase III trials should rather aim for the improvement of overall survival or quality of life to have clinically meaningful impacts.

Multi-omic analysis reveals a CAF-stemness-governed classification in HCC liver transplant recipients beyond the Milan criteria

In patients with hepatocellular carcinoma (HCC) meeting the Milan criteria, liver transplantation (LT) is an effective therapy. This study aims to define the survival-related molecular biological features helping precisely identifying the patients with HCC beyond the Milan criteria who have acceptable outcomes. In the derivation cohort, integrated analyses of tumor tissues are conducted using RNA sequencing (RNA-seq), proteomic landscape, and transposase-accessible chromatin sequencing (ATAC-seq). Based on transcriptomics, three subgroups that significantly differ in overall survival were identified in the derivation cohort, and these findings are validated in an independent cohort. In-depth bioinformatics analysis using RNA-seq and proteomics reveals that the promotion of cancer stemness by cancer-associated fibroblasts (CAFs) can be responsible for the negative biological characteristics observed in high-risk HCC patients. The ATAC-seq identifies key factors regulating transcription, which may bridge CAF infiltration and stemness. Finally, we demonstrate that the CAF-derived CXCL12 sustains the stemness of HCC cells by promoting XRCC5 through CXCR4.

Optimization and evaluation of liver deformation modeling under microwave ablation based on ex vivo data

Objective. Microwave ablation (MWA) has emerged as a crucial therapeutic technique for treating hepatocellular carcinoma. Despite its effectiveness, temperature-dependent structural modifications in liver tissues can adversely affect outcomes. Numerical modeling and simulations are essential tools for predicting tissue temperature and deformation prediction. However, existing methods lack comprehensive consideration of deformation-causative factors and fail to validate accuracy throughout the ablation zone.Approach. To overcome these limitations, we analyzed the gap between theex vivoablation deformation results and numerical simulations, and combined them to optimize the physical fields of thermally induced deformation across the entire liver tissue ablation zone. Specifically, we employed a grid marker arrangement with delayed computed tomography (CT) imaging inex vivoexperiments to capture high-resolution global deformation data. The optimization of the simulation was based on updating the coefficient for protein denaturation shrinkage and incorporating vapor diffusion influence in the mechanical model. The effect of vapor diffusion was thoroughly investigated and modeled into the stress-strain equation.Main results. Evaluation results demonstrate that our method significantly improves simulation alignment with observed experimental data, enhancing prediction accuracy of tissue deformation by 30%-90%. Additionally, our model exhibits enhanced capability for expansion representation to describe localized region deformation, resulting in increases of 2.2%-10.0% in dice similarity coefficient (DICE) and 4.2%-19.0% in intersection over union (IoU) when quantifying morphological differences withex vivoexperimental results.Significance. The improved simulation modeling could benefit the planning and optimization of MWA procedures, potentially enhancing treatment efficacy.

Unsupervised machine learning-based stratification and immune deconvolution of liver hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most prevalent type of liver cancer and a leading cause of cancer-related deaths globally. The tumour microenvironment (TME) influences treatment response and prognosis, yet its heterogeneity remains unclear.

METHODS

The unsupervised machine learning methods- agglomerative hierarchical clustering, Multi-Omics Factor Analysis with K-means++, and an autoencoder with K-means++ - stratified patients using microarray data from HCC samples. Immune deconvolution algorithms estimated the proportions of infiltrating immune cells across identified clusters.

RESULTS

Thirteen genes were found to influence HCC subtyping in both primary and validation datasets, with three genes-TOP2A, DCN, and MT1E-showing significant associations with survival and recurrence. DCN, a known tumour suppressor, was significant across datasets and associated with improved survival, potentially by modulating the TME and promoting an anti-tumour immune response.

CONCLUSIONS

The discovery of the 13 conserved genes is an important step toward understanding HCC heterogeneity and the TME, potentially leading to the identification of more reliable biomarkers and therapeutic targets. We have stratified and validated the liver cancer populations. The findings suggest further research is needed to explore additional factors influencing the TME beyond gene expression, such as tumour microbiome and stromal cell interactions.

Tumoricidal dosing approach with parenchymal sparing using voxel-based dosimetry in 90Y glass microspheres treatment of hepatocellular carcinoma

OBJECTIVE

We aimed to evaluate the effect of tumor absorbed doses (TAD) on treatment response in patients with hepatocellular cancer (HCC) treated with 90Y glass microspheres. We aimed to define a cutoff value for complete response (CR).

METHODS

The voxel-based dosimetry for the treatment of 66 HCC lesions in 56 patients was analyzed retrospectively. Nineteen patients had BCLC A, 23 patients had BCLC B, and 14 patients had BCLC C disease. Treatments were grouped as selective (radiation segmentectomy and super-selective segmentectomy, n:49) and nonselective (palliative treatments for tumors occupying >2 segments, n:17). Treatment response was evaluated by mRECIST criteria, defined as CR, partial response (PR), stable lesion (SL), and progressive lesion (PL). TAD associated with CR was analyzed.

RESULTS

TAD was 525 ± 222 Gy in our cohort. Fifteen lesions had CR, 28 had PR, eight remained stable, and 15 lesions progressed. CR, PR, SL, and PL rates for selective vs. nonselective treatments were 31, 42, 12, and 14% vs. 0, 41, 11, and 47% for nonselective treatments, respectively (P:0.01). TAD was significantly associated with treatment response. Receiver operating characteristic analysis showed TAD > 475 Gy predicted CR with 100% sensitivity and 68% specificity (area under the curve = 0.83, P < 0.001). Overall survival declined as treatment response deteriorated. None of the patients had radiation-induced liver dysfunction on follow-up (6-21 months).

CONCLUSION

Higher TAD is crucial for CR. Segmentectomy with TAD > 475 Gy is associated with favorable response and better survival in HCC patients. Even for palliative treatments, as high as reasonably tolerated doses must be applied to achieve a favorable response.

PP1A Modulates the Efficacy of Lenvatinib Plus ICIs Therapy by Inhibiting Ferroptosis in Hepatocellular Carcinoma

Advanced hepatocellular carcinoma (HCC) is characterized by poor prognosis, primarily due to limited therapeutic options and resistance to treatment. Although the combination of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) has shown promising potential, the underlying mechanisms remain inadequately understood. Here, serine/threonine-specific protein phosphatase (PP1A) is upregulated in Lenvatinib-resistant HCC cells and correlates with poor prognosis. Functional experiments revealed that PP1A promotes HCC progression both in vitro and in vivo. Transcriptomic analysis and ferroptosis metabolite profiling (e.g., ROS, Fe2⁺, lipid-ROS, and GSH) demonstrated that PP1A inhibits Lenvatinib-induced ferroptosis by dephosphorylating Keap1 at site 104. This disruption of the Keap1-Nrf2 interaction enhances the transcription of ferroptosis-related markers and immune checkpoint PD-L1. Notably, single-cell sequencing and co-culture experiments revealed that PP1A knockdown alleviates T cell exhaustion and immune evasion, thereby improving antitumor immunity. In vivo experiments further demonstrated that PP1A knockdown significantly enhances the efficacy of Lenvatinib-ICIs combination therapy. Overall, our findings highlight PP1A as a critical regulator of ferroptosis and antitumor immunity, suggesting its potential as a predictive biomarker and therapeutic target for improving outcomes in advanced HCC.

Multidisciplinary intervention for adverse events associated with ATZ + BEV therapy: a case report

BACKGROUND

Atezolizumab (ATZ) plus bevacizumab (BEV) combination therapy has recently been approved for the treatment of unresectable hepatocellular carcinoma. However, immune-related adverse events (irAEs), including peripheral neuropathy, have also been reported. This case report describes a multidisciplinary intervention for a patient who developed peripheral neuropathy as an irAE following ATZ+BEV combination therapy.

CASE PRESENTATION

The patient was a 60-year-old man with a history of hypertension. ATZ + BEV combination therapy was initiated for unresectable hepatocellular carcinoma on day 0. On day 6, he experienced a grade 2 hypertensive episode with a systolic blood pressure of 160 mmHg, despite being on amlodipine (5 mg) and azilsartan (20 mg). Based on the pharmacist's recommendations, the amlodipine dose was increased to 10 mg. However, as hypertension persisted, an additional 20 mg of azilsartan was prescribed, ultimately stabilizing the patient's blood pressure to approximately 110/60 mmHg. On day 23, the patient reported numbness in his extremities, which was later diagnosed as grade 3 peripheral neuropathy. Notably, data from the IMbrave150 trial indicated that the of peripheral neuropathy as an irAE was 1.5%. This prompted a consultation with a neurologist. Prednisolone (40 mg/day) was initiated on day 26, followed by steroid pulse therapy with methylprednisolone (1000 mg/day for three days) starting on day 37. Despite these interventions, the symptoms did not improve. Rehabilitation therapy was commenced on day 42 after steroid tapering. On day 48, the patient underwent a five-day course of high-dose intravenous immunoglobulin therapy, which also failed to yield improvement. Rehabilitation efforts subsequently shifted to enhancing activities of daily living. Initially, the patient required assistance to stand and faced significant difficulty walking. With consistent strength and mobility training, the patient progressed to walking with crutches and demonstrated increased walking distance.

CONCLUSIONS

The pathophysiology of irAE-induced peripheral neuropathy associated with immune checkpoint inhibitors remains poorly understood. This case underscores the challenges of managing irAE-related neuropathy, which may exhibit limited responsiveness to conventional treatments. Early detection, timely intervention, and multidisciplinary approaches are crucial for optimizing patient outcomes and mitigating the impact of severe side effects.

The efficacy of transarterial chemoembolization combined with helical iodine-125 seed implant, lenvatinib and PD-1 inhibitors in patients with hepatocellular carcinoma complicated by main portal vein tumor thrombus: a retrospective study

Purpose

To evaluate the efficacy and safety of a multimodal therapeutic approach involving transarterial chemoembolization (TACE) in conjunction with helical iodine-125 (I-125) seed implant, lenvatinib, and programmed cell death-1(PD-1) inhibitors for hepatocellular carcinoma (HCC) complicated by main portal vein tumor thrombus (MPVTT).

Material and methods

HCC patients with MPVTT treated with TACE coupled with helical I-125 implant, lenvatinib, PD-1 inhibitors between September 2019 and August 2022 were retrospectively analyzed, and constituted as study group. Those treated with TACE, helical I-125 seed implant, and sorafenib between December 2016 and August 2020 served as the historical control group. All patients received sorafenib or lenvatinib combined with PD-1 inhibitors within 3-7 days after TACE and helical I-125 seed implantation. The longest follow-up period for all patients in both groups was 36 months from the date of helical I-125 seed implantation. Primary outcome was overall survival time (OS), and secondary outcomes were progression free survival time (PFS), objective response rate (ORR), and disease control rate (DCR). The Cox proportional hazards regression model was employed to identify independent prognostic factors influencing OS and PFS. The value P < 0.05 was deemed statistically significant.

Results

A total of 53 patients were enrolled, with 22 assigned to the study group and 31 to the control group. The study group exhibited superior overall ORR(54.5% vs. 25.8%, P = 0.033) and overall DCR (77.3% vs. 64.5%, P = 0.319). Notably, the ORR and DCR of MPVTT were higher in the study group (86.4% vs. 51.6%, P = 0.008; and 95.5% vs. 83.9%, P = 0.382, respectively). Median OS (16.1 ± 6.1 months vs. 10.2 ± 0.8 months, P = 0.008) and PFS (13.6 ± 3.0 months vs. 6.1 ± 0.6 months, P = 0.014) were prolonged in the study group. The maximal tumor size, alpha fetoprotein level, and treatment modality were independent predictors for OS, while the maximal tumor size and treatment modality were independent determinants for PFS. Study group showed frequent hypothyroidism and reactive cutaneouscapillary (P < 0.01), with comparable grade 3/4 adverse events between groups.

Conclusions

The integration of the helical I-125 seed implant with TACE, lenvatinib, and PD-1 inhibitors is the safe and efficacious approach in the management of HCC complicated by MPVTT.

Laparoscopic and Percutaneous Microwave Ablation for Hepatocellular Carcinoma-An Institutional Analysis of Complimentary Therapeutic Modalities

INTRODUCTION

Microwave ablation (MWA) is a locoregional thermoablative treatment for early HCC with equivalent outcomes to liver resection with reduced morbidity. Our study aimed to assess the oncological and perioperative outcomes of percutaneous and surgical MWA demonstrating their complementary utilization.

METHODS

All patients undergoing percutaneous (pMWA) and surgical (sMWA) MWA for HCC at St Vincent's Hospital in Melbourne, Australia between August 2011 and April 2023 were included.

RESULTS

140 microwave ablations occurred in 107 patients with a median follow-up of 37.1 months (range 2.4-105.9 months). There were 51 pMWA and 56 sMWA cases, of which 53 were undertaken laparoscopically. Surgical ablations had a higher BCLC stage, and due to more instances of multiplicity, sMWA delivered more ablations and energy per lesion. This was associated with longer procedural time (69.5 min vs. 45 min and p < 0.001) and postoperative length of stay (1 day vs. 2 days and p < 0.001). Clavien-Dindo III or more complications were no different between the groups (p = 0.404). Local recurrence was significantly higher in the percutaneous group (31.4% vs. 10.7% and p = 0.016), and multivariate analysis demonstrated that technique was a predictor of local recurrence (sMWA HR 0.22, 95% CI 0.08-0.65, and p = 0.006). The median disease-free survival was 3.0 years (95% CI 2.6-NS) for sMWA and 1.7 years (95% CI 1.5-3.7) for pMWA, but the difference was not significant (p = 0.36). There were insufficient events to calculate median overall survival for each group; however, no differences were observed with an overall 5-year survival estimate of 0.64 (95% CI 0.54-0.77 and p = 0.86).

CONCLUSION

pMWA and sMWA are effective locoregional therapies for HCC. sMWA has the ability to deliver more energy per ablation with reduced local recurrence. However, overall survival is unaffected using the approach and both modalities should be used in a complimentary manner.

Liver transplantation as a treatment for cancer: comprehensive review

BACKGROUND

Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

METHODS

A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

RESULTS

Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

CONCLUSION

Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

Impact of muscle volume changes following atezolizumab-bevacizumab therapy in patients with unresectable hepatocellular carcinoma

AIM

This study aimed to evaluate the prognostic impact of muscle volume changes during atezolizumab-bevacizumab (AB) combination therapy (AB therapy) for unresectable hepatocellular carcinoma (u-HCC). Additionally, we evaluated whether changes in muscle volume relate to prognosis based on treatment response.

METHODS

The present retrospective, multicenter study included 165 patients with u-HCC treated with AB therapy at eight institutions.

RESULTS

The median albumin-bilirubin score in the entire cohort was -2.42. The objective response rate was 31.5%, and the disease control rate was 80.6%. The median overall survival (OS) was not reached, whereas the median progression-free survival (PFS) was 6.9 months (95% confidence interval [CI]: 5.3-8.5). At the first post-treatment computed tomography scan, patients were categorized into two groups: those with a nondecreased psoas muscle area index (PI) (group A) and those with a decreased PI (group B). The median OS was not reached in either group (p = 0.059). The median PFS was 10.5 months in group A and 5.5 months in group B (p = 0.025). Multivariate analysis using the Cox proportional hazards model identified alpha-fetoprotein ≥400 ng/mL (hazard ratio [HR]: 1.68; 95% CI: 1.11-2.54; p = 0.01) and decreased PI (HR: 1.59; 95% CI: 1.07-2.36; p = 0.02) as factors associated with PFS.

CONCLUSIONS

Nondecreased muscle volume after initiating AB therapy was associated with improved treatment efficacy and prognosis in patients with u-HCC.

Survival in patients receiving reduced dose intensity of bevacizumab for unresectable hepatocellular carcinoma

IMBrave 150 established atezolizumab and bevacizumab as the new standard for advanced hepatocellular carcinoma (HCC) treatment. However, the trial reported significant adverse events leading to bevacizumab dose interruptions or discontinuations. This retrospective, real-world analysis evaluated the effect of reduced bevacizumab dose intensity on clinical outcomes in 354 patients receiving first-line combination immunotherapy for advanced HCC. To minimize immortal time bias, only those on therapy for over 3 months were included. Of 219 patients included in the landmark analysis, 52 received a reduced dose intensity of bevacizumab. The median relative dose intensity (RDTI) of bevacizumab was 75% (range 9.1-96.9%). There was no significant difference in progression-free survival (11.2 vs. 14.8 months, p = 0.5) or overall survival (20.4 vs. 26.8 months, p = 0.1) between those receiving 100% vs. reduced RDTI. Exploratory analysis showed that even doses under 75% had no survival impact. Treatment-related grade 3/4 adverse events occurred more frequently with RDTI (30.7% vs. 15.5%). Reduced bevacizumab doses do not impact survival.

The Combined Use of Lenvatinib and Locoregional Therapies for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a commonly diagnosed malignancy, with the treatment for transplant-ineligible localized disease traditionally relying on locoregional therapies, such as surgical resection, transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). Systemic therapy has historically been reserved for advanced, unresectable HCC. However, lenvatinib, an oral multikinase inhibitor, has recently gained traction as part of a multimodal approach for localized HCC in combination with locoregional treatments. An upfront TACE or TARE can induce tumor hypoxia, leading to the upregulation of hypoxia-inducible factor-1 alpha (HIF-1α) and vascular endothelial growth factor (VEGF), which promotes tumor angiogenesis and progression. The rationale for combining lenvatinib with a locoregional therapy is to enhance tumor shrinkage while preserving liver function before a definitive intervention. Clinical trials, such as TACTICS and LAUNCH, have demonstrated improved outcomes with this approach. Additionally, retrospective studies, including those incorporating immune checkpoint inhibitors, have reported further benefits. This review explores the combination of lenvatinib with various locoregional modalities, including TARE, microwave ablation (MWA), and radiofrequency ablation (RFA), highlighting their indications and clinical outcomes. Furthermore, we discuss the ongoing and upcoming clinical trials investigating the integration of systemic agents with locoregional therapies for intermediate-stage HCC, including EMERALD-1, EMERALD-3, LEAP-012, and CheckMate 74W.

Skeletal muscle index/systemic immune-inflammation index (SMI/SII) ratio predicts prognosis in patients with hepatocellular carcinoma

BACKGROUND

Systemic inflammation and skeletal muscle are associated with prognosis in hepatocellular carcinoma (HCC). The prognostic value of a combination of skeletal muscle index (SMI) and systemic immune-inflammation index (SII) remains unclear. The present study aims to investigate the prognostic value of combined SMI and SII in predicting overall survival (OS) for HCCs after liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

This multi-institutional study included three retrospective datasets and one prospective dataset. The SMI/SII was calculated for each cohort. The performance of SMI/SII in predicting recurrence after LR was evaluated in the training cohort, and the optimal cut-off value was calculated. Based on optimal cut-off value, patients were stratified into low and high SMI/SII groups. Cox regression analysis were performed to determine the independent prognostic factors for poor OS. In prospective validation-3 cohort, peripheral blood samples were analyzed for correlation between SMI/SII and distribution of immune cells.

RESULTS

A total of 1504 patients were included. The AUC of SMI/SII was 0.701. The OS was significantly better in the high SMI/SII group than that in the low SMI/SII group in the training, validation-1, validation-2 cohorts, and combined those three cohorts. Furthermore, low SMI/SII level was an independent prognostic factor for poor OS. Additionally, findings in validation-3 cohort indicated that patients with HCCs and high SMI/SII display anti-tumor attributes in their peripheral blood composition.

CONCLUSION

A decreased SMI/SII may be a distinct biomarker of unfavorable prognosis in patients with HCCs, which may be practical to develop personalized treatment strategies for HCC.

Advances in Locoregional and Systemic Treatments for Hepatocellular Carcinoma

Significant advances have occurred in the locoregional and systemic therapy landscape for hepatocellular carcinoma (HCC), with the most notable being the introduction of immune checkpoint inhibitor (ICI) combinations. ICI combinations have significantly improved the overall survival of patients with unresectable HCC, affording median survival over 2 years and long-term survival exceeding 5 years in a subset of patients. Accordingly, there has been increased interest in the earlier application of systemic therapies, including (neo)adjuvant therapy in the perioperative setting or in combination with intra-arterial therapies. However, recent data failed to demonstrate improved recurrence-free survival with use of adjuvant ICI therapy. Conversely, 2 trials showed improved progression-free survival when ICI therapies were combined with transarterial chemoembolization, although data regarding the impact on overall survival are still immature. These improved outcomes raise several new questions, including which patients with liver-localized HCC should receive systemic therapy, how should this be sequenced or combined with other available therapies, and how to manage those patients with marked responses, including consideration of liver transplantation. These questions are often determined on a case-by-case basis and best made in a multidisciplinary manner considering several factors, including tumor burden, degree of liver dysfunction, performance status, and patient's long-term goals of care.

Dose-response relationships in Y90 resin microsphere radioembolization for patients with hepatocellular carcinoma: insights from a Brazilian cohort

OBJECTIVE

To evaluate the relationship between the absorbed dose and radiological response in patients with hepatocellular carcinoma undergoing resin microsphere radioembolization to enhance treatment precision and potentially adjust protocols for better outcomes.

METHODS

This single-center retrospective study was conducted at a quaternary care center in Brazil and comprised 27 patients with 58 target lesions treated between November 2014 and April 2023. The patients' dosimetric profiles were analyzed using advanced imaging software to assess post-treatment clinical and radiological responses. This study explored the correlation between the absorbed doses and tumor objective responses using statistical analyses to confirm the findings.

RESULTS

Higher absorbed doses were significantly associated with improved objective responses in the target lesions. The analysis demonstrated that achieving higher dosimetric thresholds correlated with better clinical outcomes, suggesting that a dose-response relationship is essential to optimize treatment protocols.

CONCLUSION

These findings emphasize the importance of personalized dosimetry in managing hepatocellular carcinoma using resin microsphere radioembolization. By quantifying the absorbed dose and understanding its impact on tumor response, treatment strategies can be tailored to enhance efficacy and potentially shift palliative treatments toward curative outcomes. This study provides a crucial foundation for dosimetric adjustment and highlights the need for further research in this area, particularly in Brazil.

[Position Paper of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Roentgen Society (DRG) on Structural and Professional Requirements in Interventional Oncology]

Interventional oncology (IO) employs various techniques to enable minimally invasive, image-guided treatment of tumor diseases with both curative and palliative goals. Additionally, it significantly contributes to managing tumor-related and perioperative complications, offering diverse supportive procedures for patients at all stages of their diseases. The execution of IO procedures places unique demands on the equipment, personnel, and structural organization of radiological clinics, necessitating specific expertise from interventional radiologists.This position paper aims to comprehensively outline the multifaceted aspects of IO and discuss the requisite criteria for hospitals, radiological clinics, and interventional radiologists (IRs). Furthermore, it underscores overarching considerations of quality assurance that clinics and professional societies should prioritize.The requirements for hospitals, radiological clinics, and IRs are varied and demand not only a high level of proficiency in performing IO procedures but also in-depth knowledge of the differential therapy for various tumor diseases. This expertise is essential for effectively serving as clinical partners in the interdisciplinary treatment of oncologic patients. Additionally, a thorough understanding and safe handling of ionizing radiation technologies, along with proficiency in radiation protection methods, which are fundamental aspects of radiological specialist training, is crucial for ensuring the safety of IO procedures for both patients and staff. The Deutsche Gesellschaft für Interventionelle Radiologie und minimal-invasive Therapie (DeGIR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) have long-established dedicated quality management programs, accrediting radiology clinics and certifying IRs. These initiatives aim to uphold the highest standards of care and meet the quality expectations set by politics in healthcare system, particularly in the realm of interventional radiology. · The various procedures in the field of interventional oncology (IO) are complex medical interventions that require not only the most advanced technical equipment but also adequate human resources, particularly specialized expertise in interventional radiology, diagnostic imaging, oncology, and radiation protection.. · This expertise is an integral part of the specialized medical training in radiology and is certified by professional societies such as the German Society for Interventional Radiology (DeGIR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).. · Professional societies like DeGIR, CIRSE, and the American Society of Interventional Radiology (SIR) establish the necessary quality assurance framework for comprehensive, high-quality IO therapy through quality assurance (QA) registries, standard operating procedure (SOP) documents, and participation in guideline development.. · Currently, radiology is the only discipline that provides physicians with the theoretical and practical knowledge, skills, and competencies required to perform the demanding procedures in the field of IO through specialized training programs and tailored certification processes.. · Isfort P, Sommer CM, Bruners P et al. Position Paper of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Roentgen Society (DRG) on Structural and Professional Requirements in Interventional Oncology. Rofo 2025; 197: 546-556.

The effectiveness and safety of therapies for hepatocellular carcinoma with tumor thrombus in the hepatic vein, inferior vena cave and/or right atrium: a systematic review and single-arm meta-analysis

BACKGROUND

This review evaluates the efficacy and safety of therapies for hepatocellular carcinoma (HCC) with hepatic vein tumor thrombus (HVTT), inferior vena cava tumor thrombus (IVCTT), and/or right atrium tumor thrombus (RATT).

RESEARCH DESIGN AND METHODS

A systematic review of PubMed, EMBASE, Cochrane Library, and Wanfang databases up to 22 August 2024, was conducted, focusing on overall survival (OS), progression -free survival (PFS), and adverse reactions.

RESULTS

Seven studies involving 453 patients were analyzed. Treatment strategies included surgery alone, local ± systemic therapy, and surgery with adjuvant therapy. The pooled 1-, 3-, and 5-year OS rates for all patients were 63.3%, 21.6% , and 8.3%, respectively. Surgery with adjuvant therapy achieved the highest 1-year OS, while local ± systemic therapy led to the best 5-year OS. The pooled 1-, 3-, and 5-year PFS rates for all patients were 56.8%, 9.4%, and 1.6%, respectively. Surgery alone commonly caused ascites and pleural effusion; the local ± systemic therapy commonly caused hepatic dysfunction and platelet abnormalities; and surgery with adjuvant therapy commonly caused peritoneal abscess.

CONCLUSION

Local ± systemic therapy provided the best long-term OS and manageable complications among the therapeutic strategies for HCC with HVTT, IVCTT, and/or RATT.

REGISTRATION

PROSPERO, (CRD42024573152).

Multicenter evaluation of abbreviated MRI and ultrasound for detecting early-stage hepatocellular carcinoma

Background & aims

Abbreviated MRI (AMRI) has been proposed as an alternative to ultrasound for hepatocellular carcinoma (HCC) surveillance; however, comparative data for AMRI and ultrasound are needed. Thus, we evaluated the sensitivity and specificity of dynamic contrast-enhanced (DCE)-AMRI and ultrasound for early-stage HCC detection in patients with cirrhosis.

Methods

We conducted a multicenter retrospective case-control study among patients with cirrhosis (cases with early-stage HCC as per Milan Criteria; controls without HCC) who underwent an ultrasound and a DCE-MRI within a 6-month period between 2012 and 2019. HCC diagnosis was confirmed by imaging alone in 85% and by histopathology in 15% of patients. Dynamic AMRI examinations were simulated from the full MRI by selecting relevant sequences. Independent, blinded interpretations of ultrasounds and AMRI results were performed using Liver Imaging Reporting and Data System algorithms. Ultrasounds were considered positive if US-3 observations were detected. AMRI was considered positive if LR-4, LR-5, or LR-M were detected. Per-patient sensitivity and specificity for early-stage HCC detection were estimated, and cross-modality differences were tested.

Results

We included 216 cases and 432 controls. Patient-level sensitivity and specificity of AMRI were significantly higher compared with ultrasound: 80.1% (95% CI 76.1-83.6) vs. 71.1% (95% CI 66.6-75.2), p <0.001, and 91.9% (95% CI 89.9-93.5) vs. 72.3% (95% CI 69.3-75.2), p <0.001, respectively. AMRI sensitivity was significantly higher compared with ultrasound among patients with Child-Pugh B cirrhosis (80.8% vs. 57.4%, p <0.001) but not among those with Child-Pugh A (84.7% vs. 78.6%, p = 0.07) or Child-Pugh C cirrhosis (52.6% vs. 68.4%, p = 0.18).

Conclusions

Dynamic AMRI may be more sensitive and specific for early-stage HCC detection in patients with cirrhosis compared with ultrasound, although its relative benefit might be smaller in patients with Child-Pugh A cirrhosis. Larger direct comparative data sets are needed, particularly among patients with Child-Pugh C cirrhosis who may benefit from alternative surveillance strategies.

Impact and implications

Abbreviated MRI (AMRI) is increasingly recognized as an alternative to ultrasound for hepatocellular carcinoma (HCC) surveillance. However, existing data are limited by single-center samples, spectrum bias, and lack of comparative data for AMRI vs. ultrasound. We found that AMRI had significantly higher per-patient sensitivity and specificity compared with ultrasound for the detection of early-stage HCC, although its relative benefit might be smaller in patients with Child-Pugh A cirrhosis, and both modalities underperformed in patients with Child-Pugh C cirrhosis. If sufficiently validated, AMRI could be adopted into practice guidelines for HCC surveillance and serve as a preferred alternative in select subgroups of patients.

Outcomes and Complications of Image-Guided Percutaneous Tumour Ablation for Hepatocellular Carcinoma at the Irish National Liver Transplant Centre

Background: Image-guided tumour ablation is a minimally invasive treatment for early stage hepatocellular carcinoma (HCC). Our study reviews the complications and long term outcomes in patients treated at a tertiary referral centre. Methods: Retrospective study. All patients with HCC who underwent microwave ablation (MWA) or radiofrequency ablation (RFA) from 1st January 2014 to 31st December 2022 were identified. Treatment response of target lesion, complications, and survival were recorded. Results: One hundred seventy ablations were performed in 118 patients; 70% MWA, 30% RFA. Median radiological follow-up 21 months (range 3-107). Follow-up imaging was reported using LI-RADS and mRECIST. At first follow-up imaging, 94 patients had complete response (primary efficacy rate 80.3%) while 19.7% (n = 23) had residual disease. Fifteen of these had repeat ablation; 10 had complete response (secondary efficacy rate 85.6%). By end of study duration, 70.5% (n = 79) achieved sustained local complete response from single ablation without documented recurrence. 14.3% (n = 16) required more than one ablation of target lesion. Overall, 84.8% (n = 95) demonstrated long term local complete response to ablation. Complication occurred in 5.9% (n = 10); 40.0% Grade I, 40.0% Grade II, 10.0% Grade III, 10.0% Grade IV as per the CIRSE Classification. 1-, 3-, and 5-year overall survival (OS) rate was 97%, 68%, and 61% respectively. Mean OS was 5.3 years (median 4.7). No difference in OS (P = .7) or local progression free survival (P = .5) between patients treated with MWA versus RFA. Conclusion: This study demonstrates excellent long-term response to TA, with acceptable complication profile. No difference in survival between RFA versus MWA.

Vision transformer-based model can optimize curative-intent treatment for patients with recurrent hepatocellular carcinoma

The treatment selection for recurrent hepatocellular carcinoma (rHCC) within Milan criteria after hepatectomy remains challenging. Here, we present HEROVision, a Vision Transformer-based model designed for personalized prognosis prediction and treatment optimization between thermal ablation (TA) and surgical resection (SR). HEROVision is trained on initial HCC cohorts (8492 images; 772 patients) and independently tested on rHCC cohorts (9163 images; 833 patients) from five centers. Propensity score matching (PSM) forms two groups of rHCC patients underwent TA and SR to fairly evaluate whether optimized treatment selection by HEROVision have clinical benefits. HEROVision significantly outperforms all six guideline staging systems in the external testing cohort, both in time-dependent concordance index and area under the curve (all P < 0.002). After PSM, 35.9% (23/64) and 6.6% (6/91) high-risk rHCC patients are identified, who could achieve improved prognosis by changing their treatments. HEROVision shows promise in optimizing individualized treatment between TA and SR for early-stage rHCC, complementing current clinical guidelines.

Predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma: nomograms based on deep learning analysis of gadoxetic acid-enhanced MRI

OBJECTIVES

This study aimed to develop nomograms for predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC), using deep learning analysis of Gadoxetic acid-enhanced hepatobiliary (HBP) MRI.

METHODS

This retrospective study analyzed patients who underwent gadoxetic acid-enhanced MRI and hepatectomy for HCC between 2016 and 2020 at two referral centers. Using a deep learning algorithm, volumes and signal intensities of whole non-tumor liver, expected remnant liver, and spleen were measured on HBP images. Two multivariable logistic regression models were formulated to predict PHLF, defined and graded by the International Study Group of Liver Surgery: one based on whole non-tumor liver measurements (whole liver model) and the other on expected remnant liver measurements (remnant liver model). The models were presented as nomograms and a web-based calculator. Discrimination performance was evaluated using the area under the receiver operating curve (AUC), with internal validation through 1000-fold bootstrapping.

RESULTS

The study included 1760 patients (1395 male; mean age ± standard deviation, 60 ± 10 years), with 137 (7.8%) developing PHLF. Nomogram predictors included sex, gamma-glutamyl transpeptidase, prothrombin time international normalized ratio, platelets, extent of liver resection, and MRI variables derived from the liver volume, liver-to-spleen signal intensity ratio, and spleen volume. The whole liver and the remnant liver nomograms demonstrated strong predictive performance for PHLF (optimism-corrected AUC of 0.78 and 0.81, respectively) and symptomatic (grades B and C) PHLF (optimism-corrected AUC of 0.81 and 0.84, respectively).

CONCLUSION

Nomograms based on deep learning analysis of gadoxetic acid-enhanced HBP images accurately stratify the risk of PHLF.

KEY POINTS

Question Can PHLF be predicted by integrating clinical and MRI-derived volume and functional variables through deep learning analysis of gadoxetic acid-enhanced MRI? Findings Whole liver and remnant liver nomograms demonstrated strong predictive performance for PHLF with the optimism-corrected area under the curve of 0.78 and 0.81, respectively. Clinical relevance These nomograms can effectively stratify the risk of PHLF, providing a valuable tool for treatment decisions regarding hepatectomy for HCC.

Socioeconomic inequalities in diagnostics, care and survival outcomes for hepatocellular carcinoma in Sweden: a nationwide cohort study

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. This study evaluates how strongly socioeconomic factors associate with diagnostics, treatment, and survival among patients with HCC in Sweden.

Methods

All adult patients registered with a diagnosis of HCC in the Swedish quality register for liver cancer between 2011 and 2021 were included. Household income was classified as low (first quartile; poorest), medium (second or third quartile), or high (in fourth quartile; wealthiest) based on the overall distribution of household income across all household in Sweden. Outcomes included likelihood of diagnosis under surveillance, early-stage diagnosis (Barcelona Clinic Liver Cancer [BCLC] staging 0-A), and receipt of curative treatment (ablation, resection or liver transplantation), as well as mortality risk.

Findings

Among 5490 patients, a significant association was found between low household income and decreased likelihood of diagnosis while under surveillance (adjusted odds ratio [aOR] 0·63; 95% confidence interval [CI]: 0·50-0·80), early-stage diagnosis (aOR 0·58; 95% CI: 0·51-0·67), and curative treatment receipt (aOR 0·65; 95% CI: 0·50-0·85). After adjustments for all variables in the BCLC, other sociodemographic variables, comorbidities, and cirrhosis status, patients with low household income had an adjusted hazard ratio for mortality of 1·29 (95% CI: 1·15-1·45) compared to patients with high household income.

Interpretation

Socioeconomic disparities associate markedly with more advanced stage at HCC diagnosis, less curative treatment, and poorer survival in Sweden. Addressing these disparities through targeted public health interventions may improve HCC care and outcomes in socioeconomically disadvantaged populations.

Funding

The Swedish Cancer Society-Cancerfonden.

Bolus-Tracked Biphasic Contrast-Enhanced CT Imaging Following Microwave Liver Ablation Improves Ablation Zone Conspicuity and Semi-automatic Segmentation Quality

PURPOSE

Contrast-enhanced CT (CECT) may be performed immediately following microwave liver ablation for assessment of ablative margins. However, practices and protocols vary among institutions. Here, we compare a standardized bolus-tracked biphasic CECT protocol and compare this with a single venous phase fixed delay protocol for ablation zone (AZ) assessment.

METHODS

An institutional review board approved study performed at a specialist cancer centre. A prospective cohort of patients undergoing bolus-tracked biphasic imaging was compared with a retrospective cohort of patients who underwent fixed delay venous phase imaging. AZ conspicuity and segmentation quality were semi-quantitatively scored using Five-point Likert scales. Time between ablation and image acquisition was recorded for each AZ and was correlated to AZ conspicuity and segmentation quality.

RESULTS

Forty patients, median age 59 years (IQR 48-66 years), 24 men, underwent microwave ablation of 68 liver tumours. AZ conspicuity was higher in the bolus-tracked (n = 33) vs. fixed delay (n = 35) cohorts, 4.5 vs. 2.5, P < 0.0001. Commensurate segmentation quality was also higher, 5.0 vs. 3.0 respectively, P < 0.0001. Ordinal regression showed that image quality scores declined by 3-4% for each minute that passes after ablation, particularly for arterial phase images, where regression coefficients were - 0.04, P = 0.007, and -0.03, P = 0.012 for conspicuity and segmentation quality, respectively.

CONCLUSION

Bolus-tracked biphasic contrast-enhanced CT protocols improve both conspicuity and semi-automatic segmentation quality of microwave liver ablation zones, particularly if imaged soon after ablation.

EVIDENCE-BASED MEDICINE

Level 2b; exploratory prospective cohort study.

Prognostic Value of the ASAP Score for Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma: A Multicenter Analysis of 1,239 Patients

BACKGROUND AND AIMS

The ASAP score, which incorporates age, sex, alpha-fetoprotein (AFP), and protein induced by vitamin K absence-II, has demonstrated promise for early detection of hepatocellular carcinoma (HCC). However, its prognostic value after HCC treatment remains unknown. The current study sought to evaluate the prognostic value of the ASAP score to predict recurrence and survival following curative hepatic resection for HCC.

METHODS

This study using prospectively collected data included HCC patients who underwent curative-intent hepatic resection. The ASAP score was calculated preoperatively, and X-tile analysis was used to determine the optimal cutoff value. Univariate and multivariate analyses were performed to identify independent risk factors associated with recurrence and overall survival (OS).

RESULTS

Among 1239 patients in the analytic cohort, the optimal ASAP score cutoff was 4.8; patients were divided into low (n = 749) and high (n = 490) ASAP score subgroups. Patients with high ASAP scores had a higher incidence of 5-year recurrence (73.9% vs 51.0%, P < 0.001) and worse OS (31.7% vs 60.1%, P < 0.001) versus individuals with low scores. Multivariate analysis identified ASAP score ≥4.8 as an independent risk factor of both recurrence (hazard ratio [HR] 1.976, 95% confidence interval [CI]: 1.633-2.390, P < 0.001) and OS (HR 1.407, 95% CI 1.170-1.691, P < 0.001) after controlling for established clinicopathological factors.

CONCLUSION

Preoperative ASAP score was independently associated with recurrence and survival after HCC resection. The clinical utility of the ASAP score may be applicable to both diagnosis and prognosis, potentially improving postoperative surveillance and management strategies for HCC patients.

Looking Toward the Future: Emerging Therapies for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related deaths worldwide. Despite the decreasing prevalence of hepatitis C, the burden of HCC is expected to rise owing to the increasing prevalence of metabolic syndrome and increased global alcohol consumption. Guideline-concordant screening with ultrasound every 6 months has been associated with increased rates of early-stage detection and receipt of curative treatment. However, most patients with cirrhosis do not undergo screening, with HCC often diagnosed only at an advanced stage when curative resection or ablation is not feasible. Systemic medical therapy is indicated in patients diagnosed with infiltrative or advanced HCC, or when early-stage disease progresses or recurs after resection, transplant, or other locoregional therapy. Sorafenib was approved as first-line therapy for HCC in 2007. Since 2017, there has been an exponential rate of approval of novel agents targeting HCC, including lenvatinib, regorafenib, and cabozantinib. Checkpoint inhibitors, including pembrolizumab, nivolumab, ipilimumab, and combination therapy with atezolizumab plus bevacizumab and durvalumab plus tremelimumab, have expanded treatment options. This article describes treatment for all HCC stages, with a brief discussion of locoregional therapy for context, as some emerging treatment regimens combine locoregional and systemic therapies. The article highlights approved systemic therapies that are guideline-endorsed and emerging therapies for advanced HCC.

Assessing treatment accuracy of image-guided liver stereotactic body radiotherapy: a quantitative analysis based on 4D CT through post-therapeutic MRI-morphologic alterations

Background

Stereotactic body radiotherapy (SBRT) has become a promising alternative for patients with inoperable liver cancer. However, the accurate delivery of high doses to moving liver tumors remains challenging. Treatment accuracy can be quantified by comparing post-radiotherapeutic magnetic resonance imaging (MRI)-morphologic alterations (MMA) and corresponding isodose-structure cropped to the liver (ISL) upon planning computed tomography (CT). The study aimed to evaluate the robustness of accuracy metrics, and investigate the factors influencing treatment accuracy of liver SBRT using an internal target volume (ITV) strategy based on four-dimensional (4D) CT.

Methods

A retrospective observational study was conducted on a cohort of 31 liver cancer patients who underwent liver SBRT using an ITV strategy based on 4D CT from October 2018 to March 2024. All patients exhibited localized morphological changes on MRI. In vivo analysis (IVA) of liver SBRT was performed by comparing MMA and ISL following deformable image registration of post-radiotherapeutic MRI and planning CT. Accuracy metrics included Dice similarity coefficient (DSC), conformity index of MMA and ISL (CIMI), Hausdorff distance (HD), mean distance to agreement (MDA), and three-dimensional center-of-mass difference (3D-CoMD). Correlation analysis regarding accuracy metrics and potential factors was conducted to evaluate the robustness of accuracy metrics. Patients were stratified into two groups in ascending order. Kaplan-Meier method was used to evaluate IVA's influence on progression-free survival (PFS) of clinical target volume (CTV) in the two groups. Two-sample t-test was used to analysis the difference of motion amplitude in the two groups.

Results

Distance metrics (HD, MDA, and 3D-CoMD) were significantly (P<0.050) influenced by gross tumor volume (GTV), planning target volume (PTV), and time to post-therapeutic MRI. Patients with DSC >0.7, CIMI >0.5, HD <25 mm, MDA <5 mm, and 3D-CoMD <8 mm showed significant differences in PFS of CTV (log-rank P=0.013, log-rank P=0.013, log-rank P=0.001, log-rank P=0.009, and log-rank P=0.022, respectively). Motion amplitude did not show significant difference in the two groups defined by thresholds of DSC, CIMI, HD, MDA, and 3D-CoMD.

Conclusions

In this in vivo accuracy evaluation, conformity metrics such as the DSC and CIMI were more robust than HD, MDA, and 3D-CoMD. Therefore, DSC and CIMI could be a potential predictor for PFS within CTV. However, motion amplitude could not affect the DSC and CIMI. Therefore, a quality assurance procedure in dose delivery should be applied for the ITV strategy based on 4D CT.

[Hepatocellular carcinoma: Histological and molecular classifications]

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumour, with a poor prognosis, ranking third for cancer mortality worldwide. HCC is a morphologically and molecularly heterogeneous tumour. This update aims to address this heterogeneity by describing the different histological and molecular subtypes of HCC. Morphologically, eight subtypes have been described according to the WHO classification: steatohepatitic, macrotrabecular massive (MTM), clear cell, chromophobe, scirrhous, fibrolamellar, lymphocyte-rich and neutrophil-rich. Other HCCs are classified as non-specific (not otherwise specified or NOS). These subtypes may be associated with a different prognosis, particularly the MTM, which displays a poorer survival than the other subtypes. Genomically, most HCCs present mutations in the TERT promoter, while other mutations occured later in carcinogenesis, such as TP53 and CTNNB1. TP53 mutated HCCs are associated with a poor prognosis and the MTM subtype. From a transcriptomic standpoint, two classifications are particularly noteworthy, as they are associated with both prognosis (proliferative vs. non-proliferative classification) and clinical, morphological and genomic tumour characteristics (G1-G6 classification). In conclusion, the morphological heterogeneity of HCC, directly linked to molecular heterogeneity, is associated with prognosis. This strongly supports the specification of the different HCC subtypes in our reports.

Differences between hepatocellular carcinoma caused by alcohol and other aetiologies

Alcohol-related liver disease is the third leading cause of hepatocellular carcinoma worldwide and the leading cause in Europe. Additionally, the recent definition of metabolic dysfunction-associated steatotic liver disease with increased alcohol intake (MetALD) will enrich this population with a more nuanced phenotype, reflecting recent epidemiological trends. In these patients, the hepatocellular carcinoma diagnosis is often delayed and less frequently detected through screening programmes. Moreover, at the time of diagnosis, patients with alcohol-related hepatocellular carcinoma tend to have a poorer general condition, more severely impaired liver function, and a higher prevalence of comorbidities, leading to increased competitive mortality. However, when hepatocellular carcinoma is diagnosed during surveillance programmes in patients with alcohol-related liver disease or MetALD, the rate of allocation to first-line curative treatments is high (56%) and comparable to that of patients with virus-related hepatocellular carcinoma. As a consequence, the aetiology of the underlying cirrhosis cannot be considered an independent prognostic factor in patients with hepatocellular carcinoma. Instead, prognosis is driven by liver function, general condition, and tumour burden. This underscores the crucial role of early diagnosis through periodic surveillance in patients with alcohol- or MetALD-related cirrhosis.

Comparison of initial treatments for resectable hepatocellular carcinoma within Milan criteria: an observational study based on a nationwide survey

Purpose

Treatment options for hepatocellular carcinoma (HCC) vary according to known guidelines among liver resection (LR), liver transplantation (LT), radiofrequency ablation (RFA), and transarterial chemoembolization (TACE). This study aimed to compare the outcomes of initial treatment for patients with resectable HCC within Milan criteria (MC) via nationwide data.

Methods

Patients with resectable HCC (Child-Pugh class A; platelet count, ≥100,000/µL) within MC from the Korean Liver Cancer Association databank were analyzed, retrospectively. Outcomes according to initial treatment and subgroups according to tumor size and number were analyzed. Overall survival (OS) rates after initial treatment were compared.

Results

A total of 3,241 patients who underwent LR (n = 1,371), LT (n = 12), RFA (n = 679), or TACE (n = 1,179) were included. The 5-year OS rates differed significantly between the groups (P < 0.05), except for LT (LR, 84.9%; LT, 82.5%; RFA, 76.2%; and TACE, 59.9%). For patients with a single tumor of any size, the 5-year OS rates of the LR group were significantly higher than RFA and TACE groups. For patients with multiple tumors, the 5-year OS rates were 78.2%, 100%, 74.3%, and 53.0% for the LR, LT, RFA, and TACE groups, respectively, but without significant difference between LR and RFA (P = 0.86).

Conclusion

For resectable HCC within MC, the LR had the highest OS rate for a single tumor of any size. LR and RFA showed no significant differences in OS rate for multiple tumors. LR has a much more optimistic outlook for HCC within MC.

Percutaneous thermal ablation in hepatocellular carcinoma patients with and without TIPS

PURPOSE

Managing hepatocellular carcinoma (HCC) in patients with a transjugular intrahepatic portosystemic shunt (TIPS) is becoming increasingly common. This study aimed to evaluate the safety and efficacy of percutaneous thermal ablation for treating HCC in patients with TIPS.

METHODS

This retrospective longitudinal study was conducted at Nantes University Hospital. The main inclusion criteria were patients undergoing percutaneous thermal ablation for HCC. Patients with a pre-existing TIPS were included in the 'TIPS group'. A 1:1 control group without TIPS, the 'n-TIPS group', was created for this case-control study. The primary endpoints were overall survival and progression-free survival over 12 months. Safety was assessed by comparing complications between the groups.

RESULTS

Between 2008 and 2020, 371 patients underwent percutaneous thermal ablation for HCC. The 'TIPS group' included 34 patients (66 nodules), while 34 patients (84 nodules) were randomly assigned to the 'n-TIPS group.' Overall survival rates at 1 year were 97% and 94% respectively (p = 0.52). The progression-free survival rate was 68% and 57% respectively (p = 0.35). No deaths occurred within 30 days post-procedure. There were 3 immediate complications in the TIPS group and 4 in the n-TIPS group (p = 1), none of which were related to the TIPS, including thrombosis.

CONCLUSION

Percutaneous thermal ablation for HCC in patients with TIPS appears to be as safe and effective as in TIPS-naïve patients. These results suggest that the presence of a TIPS should not be considered a contraindication for percutaneous thermal ablation in treating HCC.