Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan

Radiofrequency ablation vs. surgical resection for resectable hepatocellular carcinoma: A systematic review and meta-analysis

The treatment of hepatocellular carcinoma (HCC) is a significant challenge. Although radiofrequency ablation (RFA) has emerged as a popular therapeutic option for patients with resectable HCC, whether it can achieve comparable survival outcomes compared with surgical resection (RES) remains unclear. The aim of the present study was to conduct a meta-analysis to assess the survival outcomes of RFA vs. RES in patients with early resectable HCC tumors. A Medline, Embase, and Cochrane Library search was performed for data published between January 2000 and February 2018. A meta-analysis of the efficacy of RFA compared with RES for HCC was subsequently performed, with particular emphasis on overall survival and disease-free survival (DFS) rates. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the random-effects model. In the present study, a total of 13,147 patients with HCC were included; of which, 6,727 were treated with RFA and 6,420 were treated with RES. The overall survival rates (OR_1-year, 0.757, 95% CI, 0.578–0.989; OR_3-year, 0.530, 95% CI, 0.401–0.700; OR_5-year, 0.566, 95% CI, 0.423–0.758) and the DRS rates (OR_1-year, 0.569, 95% CI, 0.456–0.711; OR_3-year, 0.418, 95% CI, 0.267–0.653; OR_5-year, 0.374, 95% CI, 0.231–0.606) of RES were significantly higher than those of RFA. The results indicate that RES is superior to RFA for promoting the survival of selected patients with resectable HCC. However, future randomized controlled trials are required to investigate the specific relevance of these modalities in the treatment of HCC.

Conventional Versus Small Doxorubicin-eluting Bead Transcatheter Arterial Chemoembolization for Treating Barcelona Clinic Liver Cancer Stage 0/A Hepatocellular Carcinoma

PURPOSE

Approximately, 60-70% of patients with early-stage hepatocellular carcinoma (HCC) globally are ineligible for the recommended first-line procedures. This study aimed to compare conventional transcatheter arterial chemoembolization (cTACE) with a treatment, small drug-eluting bead TACE (DEB-TACE), in patients with stage 0/A HCCs.

MATERIALS AND METHODS

We retrospectively investigated 76 patients who underwent first-time cTACE (n = 40) or DEB-TACE using 75-150 µm DC Beads^® (n = 36) for Barcelona Clinic Liver Cancer (BCLC) stage 0/A HCC < 3 cm at a single tertiary care center between July 2015 and March 2017. Outcome measurements were time to local progression (assessed per modified response evaluation criteria in solid tumors), tumor response at one month and intrahepatic distal recurrence, progression-free survival, overall survival, safety, and toxicity.

RESULTS

The study included 60 (78%) men and 16 (21%) women; participant mean age was 65.8 years. Objective response rates between the cTACE and DEB-TACE groups were similar (p > 0.05). Complete and partial 1-month tumor response rates were 60.0% and 22.5%, respectively, in the cTACE group and 69.4% and 25.0%, respectively, in the DEB-TACE group. The abdominal pain grade was significantly lower with DEB-TACE than with cTACE (p = 0.001). AST and ALT levels after tumor treatment with DEB-TACE were significantly lower than those after treatment with cTACE (p = 0.018 and 0.006). Time to local progression, intrahepatic distal recurrence, progression-free survival, and overall survival were not significantly between the DEB-TACE group and the cTACE group (p > 0.05).

CONCLUSION

Time to local progression between groups was not significantly different; however, post-embolic syndrome occurred less frequently in the DEB-TACE group. DEB-TACE appears to be a feasible treatment for small HCCs.

LEVEL OF EVIDENCE

Level 3.

Incorporation of biochemical factors for survival analysis of transarterial chemoembolization in patients with hepatocellular carcinoma: A retrospective cohort study

Introduction

Hepatocellular carcinoma (HCC) is a common gastrointestinal cancer that occurs worldwide, and conventional transarterial chemoembolization (cTACE) is one of the first treatment choices for advanced HCC. However, biochemical factors and comorbidity have seldom been reported in the long-term outcomes.

Methods

This retrospective cohort study included 444 HCC patients who underwent cTACE-based therapy in 2010 to 2012. Survival outcomes were analyzed using a Kaplan–Meier curve and Cox regression analysis.

Results

The mean age was 62.1 ± 12.5 years, and 74.3% were men. Analysis of the mean biochemical values indicated that the presence of portal vein thrombosis, α-fetoprotein (AFP) >200 ng/mL, AJCC 7th stage III, diabetes, albumin <3 g/dL, and hemoglobin were significantly and independently associated with poorer long-term outcomes.

Discussion

The presence of venous thrombus and elevation of AFP levels are the most important factors in cTACE treatment. The host factors, including metabolic status and liver damage, should be evaluated in these patients.

Timely eradication of HCV viremia by PegIFN/RBV is crucial in prevention of post RFA recurrence in CHC-HCC patients

BACKGROUND

Secondary prevention of hepatocellular carcinoma (HCC) among patients with chronic hepatitis C (CHC) who achieve sustained virologic response (SVR) with interferon-based therapy has been proved effective. However, tertiary prevention with PegIFN/RBV therapy of HCC recurrence seems limited effect in CHC-HCC patients post curative therapies. This study aims to investigate the timing and impact of PegIFN/RBV treatment on prevention of HCC recurrence in patients after RFA treatment.

METHODS

From 2013 to 2016, a total of 137 CHC-HCC patients from a 508 patient based cohort receiving complete RFA treatment in Chang Gung Memorial Hospital, Linkou Medical Center were retrospectively recruited. Pre-RFA patient demographics were analyzed by cox regression analysis for prediction on tumor recurrence. Statistics analysis was performed with SPSS V.20 (IBM, USA).

RESULTS

The mean age of the 137 patients were 69.6 year-old and 71.5% of patients were cirrhotic. After propensity score matching, one hundred and two patients were enrolled into the analysis. Fifty-one patients (50%) received PegIFN/RBV therapy and twenty-seven patients (52.9%) achieved SVR. Patients who could achieve SVR had lower tumor recurrence rate than non-SVR and untreated groups (29.6% vs. 66.7% vs. 49.0%, P = 0.030). The effect is more prominent in those achieve SVR prior to compared with after RFA despite not reach statistically significant (26.1% vs. 50.0%, P = 0.334).

CONCLUSION

Timely treatment with SVR achievement has the lowest tumor recurrence rate in CHC-HCC patients. Secondary prevention might be even more important than tertiary prevention in CHC patients, especially regarding prevention of post RFA HCC recurrence.

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

Actual 10-Year Survival After Surgical Microwave Ablation for Hepatocellular Carcinoma: A Single-Center Experience in Japan

BACKGROUND

Little evidence exists regarding long-term survival after microwave ablation for hepatocellular carcinoma (HCC). The aim of this study is to determine actual 10-year survival and clarify the clinicopathological features of patients surviving ≥ 10 years after surgical microwave ablation.

PATIENTS AND METHODS

This retrospective study identified 459 patients who underwent surgical microwave ablation for HCC with curative intent between 2001 and 2008. We compared 100 patients who survived ≥ 10 years with 321 patients who died within 10 years.

RESULTS

Median overall survival and recurrence-free survival rates were 5.5 and 2.4 years, respectively. The actual 10-year overall survival rate was 23.8%, and the actual 10-year recurrence-free survival rate was 8.1%. Multivariate analysis showed that age > 70 years [odds ratio 1.87, P = 0.029], hepatitis C virus positivity (OR 2.30, P = 0.004), Child-Pugh class B (OR 3.28, P = 0.003), and platelet count < 10 × 10⁴ /µL (OR 1.93, P = 0.033) were independent risk factors for actual 10-year survival. During 10-year follow-up, 66% of the ≥ 10-year survivors developed recurrence, and 91% of these patients underwent further curative treatment, including hepatic resection or local ablation, for HCC recurrence.

CONCLUSION

Ten-year survival after surgical microwave ablation for HCC can be expected in approximately 24% of patients, even though nearly 2/3 of our 10-year survival patients experienced recurrence. Close postoperative follow-up and further curative treatment for recurrence are important for improving long-term survival.

The Optimal Management for Sub-Centimeter Hepatocellular Carcinoma: Curative Treatments or Follow-Up?

Background

The optimal strategy for dealing with sub-centimeter hepatic nodules has not yet been established. This study aimed to assess whether there was a need to provide curative treatments for sub-centimeter hepatocellular carcinomas (HCCs) to patients at risk for high false positives.

Material/Methods

We identified patients with primary pathologically diagnosed HCC ≤2 cm from 2004 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database. They were divided according to the interventions they received: local ablation, surgical resection, or liver transplantation. In each group, overall survival and cancer-specific survival were used as endpoints to compare the prognoses between patients with sub-centimeter HCC and patients with HCC measuring 1 to 2 cm by Kaplan-Meier. Propensity score matching was performed to reduce bias. We also compared the survival of patients with a primary solitary HCC based on interventions, in the different tumor size groups. Bootstrapping was performed to validate the findings.

Results

Overall, 10.4% of patients (197 out of 1894) had HCCs <1 cm, and 89.6% of patients (1697 out of 1894) had HCCs in the 1 to 2 cm range. There was no significant difference in overall and cancer-specific survival between patients with HCCs <1 cm and those with HCCs in the 1 to 2 cm range, in all treatment groups. After adjusting confounding factors, no significant correlation was found between tumor size and survival time. In patients with HCCs measuring ≤2 cm, overall survival and cancer-specific survival were superior in liver transplantation compared with surgical resection and local ablation. Surgical resection provided better survival than local ablation.

Conclusions

Compared to patients with HCCs measuring 1 to 2 cm, the survival rates of patients with sub-centimeter HCCs was not improved through curative treatments, risking high false positives.

Validation of US Liver Imaging Reporting and Data System Version 2017 in Patients at High Risk for Hepatocellular Carcinoma

Background The 2017 version of the Liver Imaging Reporting and Data System (LI-RADS) recently included standardized interpretation, reporting, and management guidelines for US (US LI-RADS); however, this system has not yet been validated. Purpose To evaluate the diagnostic performance of US LI-RADS version 2017 for detecting hepatocellular carcinoma (HCC) in participants at high risk and to determine the clinical factors associated with a poor visualization score. Materials and Methods This study included 407 prospectively recruited participants (mean age, 56 years; age range, 28-76 years) with cirrhosis at high risk for HCC who underwent US surveillance from November 2011 to August 2012. Two radiologists retrospectively analyzed US images, assigning a LI-RADS category (US-1 = negative, US-2 = subthreshold, US-3 = positive) and a visualization score (A = no or minimal limitations, B = moderate limitations, C = severe limitations). The sensitivity and specificity for diagnosing HCC were calculated on a per-patient and per-lesion basis, using pathologic results and typical CT or MRI as reference standards. The risk factors for a poor visualization score were determined by using univariable and multivariable analyses. Results Of 429 lesions in 407 participants, there were 32 HCCs in 28 participants. In the per-lesion analysis, the specificity for US-3 was 366 of 397 (92%; 95% confidence interval [CI]: 89%, 95%) and the sensitivity was 11 of 32 (34%; 95% CI: 20%, 52%). In the per-patient analysis, the specificity for US-3 was 352 of 379 (93%; 95% CI: 90%, 95%) and the sensitivity was 11 of 28 (39%; 95% CI: 24%, 58%). Visualization score C (114 of 407 [28%] participants) had the highest false-negative rate (six of seven [86%] participants). High body weight (adjusted odds ratio [OR], 2.1 [95% CI: 1.2, 3.6]; P = .01), Child-Pugh class B disease (OR, 2.9 [95% CI: 1.7, 4.9]; P < .001), and moderate to severe fatty liver (OR, 1.7 [95% CI: 1.0, 2.8]; P = .047) were associated with a poor visualization score of C. Conclusion The US-3 category demonstrated high specificity but low sensitivity for diagnosing hepatocellular carcinoma. The visualization score C had a higher false-negative rate than scores A or B, and patients with high body weight, Child-Pugh class B disease, and moderate to severe fatty liver may present limitations for US surveillance. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Milot in this issue.

In-hospital mortality associated with transcatheter arterial embolization for treatment of hepatocellular carcinoma in patients on hemodialysis for end stage renal disease: a matched-pair cohort study using a nationwide database

Objectives:

No previous study has evaluated the risks associated with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma in patients on hemodialysis (HD) for end stage renal disease (ESRD), because invasive treatment is rarely performed for such patients. We used a nationwide database to investigate in-hospital mortality and complication rates following TACE in patients on HD for ESRD.

Methods:

Using the Japanese Diagnosis Procedure Combination database, we enrolled patients on HD for ESRD who underwent TACE for hepatocellular carcinoma. For each patient, we randomly selected up to four non-dialyzed patients using a matched-pair sampling method based on the patient’s age, sex, treatment hospital, and treatment year. In-hospital mortality and complication rates were compared between dialyzed and non-dialyzed patients following TACE.

Results:

We compared matched pairs of 1551 dialyzed and 5585 non-dialyzed patients. Although the complication rate did not differ between the dialyzed and non-dialyzed ESRD patients [5.7% vs 5.8%, respectively; odds ratio, 0.99; 95% confidence interval (0.79–1.23); p = 0.90], the in-hospital mortality rate was significantly higher in dialyzed ESRD patients than in non-dialyzed patients [2.2% vs 0.97%, respectively; odds ratio, 2.21; 95% confidence interval (1.44–3.40); p < 0.001]. Among the dialyzed patients, the mortality rate was not significantly associated with sex, age, Charlson comorbidity index, or hospital volume.

Conclusions:

The in-hospital mortality rate following TACE was 2.2 % and was significantly higher in dialyzed than in non-dialyzed ESRD patients. The indications for TACE in HD-dependent patients should be considered carefully with respect to the therapeutic benefits vs risks.

Advances in knowledge:

In hospital mortality rate following TACE in dialyzed patients was more than twice compared to non-dialyzed patients. Post-procedural complication following TAE in ESRD onHD patients was 5.7%, and did not differ from that in non dialyzed patients.

Conditional survival in patients with spontaneous tumor rupture of hepatocellular carcinoma after partial hepatectomy: a propensity score matching analysis

BACKGROUND

Spontaneous tumor rupture (STR) of hepatocellular carcinoma (HCC) is a life-threatening condition. This study investigates the influences of STR on the observed survival and conditional survival of patients received hepatectomy.

METHODS

A retrospective cohort of patients who underwent hepatectomy from 2009 to 2013 was divided into tumor rupture group and non-rupture group. Propensity score matching (PSM) was used for comparison of the observed survival and conditional survival probabilities between these two groups.

RESULTS

89 pairs of patients who had comparable background and tumor characteristics were created using PSM analysis. There was significant association between STR and increased risk of OS no matter when before or after PSM (p < 0.01). STR was significantly associated with increased risks of PFS before, while not after PSM. Multivariate Cox regression analyses demonstrated that STR was an independent risk factor associated with OS. There were significant differences in two groups for conditional probabilities of OS and PFS for an additional 6 months and 1 year before PSM, while not after PSM.

CONCLUSIONS

This study identified STR but not PFS as an independent risk factor influencing OS, in patients with HCC following hepatectomy. In selected patients with STRHCC, hepatectomy should be performed with acceptable outcomes.

Targeted and Multifunctional Technology for Identification between Hepatocellular Carcinoma and Liver Cirrhosis

Continuously updated diagnostic methods and advanced imaging methods have led to an increase in the early detection rate of small liver cancer; however, even with current diagnosis methods, it is still challenging to accurately judge a nodule with a diameter less than 2 cm whether it is hepatocellular carcinoma or liver cirrhosis. To solve this issue, a new technology is needed to distinguish above two kinds of liver nodules. There is an emerging imaging method that improves tissue resolution and sensitivity to detect micronodules with diameters less than 2 cm. To detect micronodules, photoacoustic imaging was used to provide noninvasive images at depths of several centimeters with a resolution of approximately 100 μm. To improve specificity, we developed a probe that specifically targets hepatocellular carcinoma by recognizing the biomarker GPC3 on the hepatocellular carcinoma cell membrane. The probe not only has a strong photoacoustic signal but also has a magnetic resonance signal. Furthermore, the material owns photothermal effect that absorbs longer wavelength light and releases heat that effectively and accurately kills tumor cells, thus improving patient's survival and postoperative quality of life. Herein, we present a new technology that uses photoacoustic imaging to image and target microhepatocellular carcinoma biological processes derived from liver cirrhosis with high spatial resolution.

Advanced Hepatocellular Carcinoma with Bone Metastases: Prevalence, Associated Factors, and Survival Estimation

BACKGROUND The objective of the present research was to explore the prevalence, risk, and prognostic factors associated with bone metastases (BM) in newly diagnosed hepatocellular carcinoma (HCC) patients. MATERIAL AND METHODS From 36 507 HCC patients who were registered in Surveillance, Epidemiology, and End Results (SEER) database, we enrolled 1263 with BM at the initial diagnosis of HCC from 2010 to 2014. Kaplan-Meier curves and log-rank tests were used to estimate overall survival for different subgroups. Univariate and multivariate logistic and Cox regression analyses were performed to identify risk factors and independent prognostic factors for BM. RESULTS A total of 1567 (4.29%) HCC patients were detected with BM at initial diagnosis. Male sex, unmarried status, higher T stage, lymph node involvement, intrahepatic metastases, and extrahepatic metastases (lung or brain) were positively associated with BM. The median survival of the patients was 3.00 months (95% CI: 2.77-3.24 months). Marital status and primary tumor surgery were independently associated with the better survival. CONCLUSIONS A list of factors associated with BM occurrence and the prognosis of the advanced HCC patients with BM were found. These associated factors may provide a reference for BM screening in HCC and guide prophylactic treatment in clinical settings.

A new formula to calculate the resection limit in hepatectomy based on Gd-EOB-DTPA-enhanced magnetic resonance imaging

Background and aim

Dynamic magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB-MRI) can be used not only to detect liver tumors but also to estimate liver function. The aim of this study was to establish a new EOB-MRI-based formula to determine the resection limit in patients undergoing hepatectomy.

Methods

Twenty-eight patients with a normal liver (NL group) and five with an unresectable cirrhotic liver (UL group) who underwent EOB-MRI were included. Standardized liver function (SLF) was calculated based on the signal intensity (SI), the volume of each subsegment (S1–S8), and body surface area. A formula defining the resection limit was devised based on the difference in the SLF values of patients in the NL and UL groups. The formula was validated in 50 patients who underwent EOB-MRI and hepatectomy.

Results

The average SLF value in the NL and UL groups was 2038 and 962 FV/m², respectively. The difference (1076 FV/m²) was consistent with a 70% in resection volume. Thus, the resection limit for hepatectomy was calculated as a proportion of 70%: 70×(SLF−962)/1076 (%). The one patient who underwent hepatectomy over the resection limit died due to liver failure. In other 49 patients, in whom the resection volume was less than the resection limit, procedures were safely performed.

Conclusions

Our formula for resection limit based on EOB-MRI can improve the safety of hepatectomy.

Feasibility of Hepatology-Directed Microwave Ablation in Management of Hepatocellular Carcinoma in North America: A Pilot Project

In North America, the role of Hepatologists in treatment of hepatocellular carcinoma is limited. We conducted a pilot project wherein a Hepatologist participated directly in microwave ablation of HCC at an academic center in the United States (n = 14). The pilot project shows promising outcomes, with complete remission rate of 93%.

Inhibition of SRC/FAK cue: A novel pathway for the synergistic effect of rosuvastatin on the anti-cancer effect of dasatinib in hepatocellular carcinoma

PURPOSE

Statins extended their hypocholestremic effect to show a promising anticancer activity. Hepatocellular carcinoma (HCC), the third common cause of cancer-related death, responded positively to statins. Some in-vitro studies reveal the rosuvastatin antitumor effect, but barely in-vivo studies. Hence, we evaluated the antitumor potential of rosuvastatin in a HCC model, the possible signaling cues involved, and whether it augments the dasatinib anticancer effect.

METHOD

For the in-vitro study, the IC₅₀ and the combination (CI)/dose reduction (DRI) indices were determined for HCC cell line (HepG2) treated with dasatinib and/or rosuvastatin. For the in-vivo study, mice with diethylnitrosamine-induced HCC were treated for 21 days with dasatinib and/or rosuvastatin (10 and 20 mg/kg, respectively). The p-focal adhesion kinase/p-rous sarcoma oncogene cellular homolog (p-FAK/p-Src) cascade and its downstream molecules were assessed.

RESULTS

The in-vitro study confirmed the synergistic effect of rosuvastatin with dasatinib, which entailed the in-vivo results. The two drugs decreased the p-FAK/p-Src cue along with p-Ras/c-Raf, p-STAT-3, and p-Akt levels to enhance apoptosis by an increase in caspase-3 level and a decline in survivin level. Additionally, they inhibited HGF, VEGF, and the MMP-9. Moreover, the different treatments downregulated the expression of proliferative cell nuclear antigen (PCNA) and Ki-67. The best effect was mediated by the combination regimen that surpassed the effect of either drug alone.

CONCLUSION

Our results highlighted some of the signals involved in rosuvastatin antitumor effect and nominate it as an adds-on therapy with dasatinib to yield a better effect in HCC through inhibiting the FAK/Src cascade.

Comparative efficacy and safety between ablative therapies or surgery for small hepatocellular carcinoma: a network meta-analysis

BACKGROUND

Major treatments for small hepatocellular carcinoma (SHCC) include percutaneous ethanol injection (PEI), percutaneous acetic acid injection (PAI), radiofrequency ablation (RFA), or surgical resection (SR). We aimed to compare these therapies concerning with effectiveness and safety.

METHODS

Cochrane Library, PubMed, and Embase were searched for randomized controlled studies (RCTs) from inception to 30 April 2017. Odds ratios (OR) for proportion dead (PD), local recurrence (LR) and adverse events (AEs).

RESULTS

Fourteen RCTs were identified. Compared with SR, PEI (OR 2.79, CrI 1.25, 6.45, p < 0.01) provided a significantly increased risk of PD. Similarly, PEI (OR 4.29, CrI 1.18, 18.35, p < 0.01) yielded more LR than SR. Also, SR significantly conferred more AEs than RFA (OR 0.10; CrI 0.02, 0.35, p < 0.01), PEI (OR 0.06; CrI 0.01, 0.31, p < 0.01). Besides, RFA conferred the highest efficacy for survival, time to recurrence, and new development of HCC.

CONCLUSIONS

SR was superior to PEI. Although SR achieved highest cumulative ranking probabilities in clinical efficacy, it obtained a low benefit-to-risk ratio for patients. RFA was superior to the other ablative therapies. For tumor sizes > 2 cm or ≤ 2 cm in diameter, SR conferred non-significant effects compared with other therapies for SHCC.

The prognostic analysis of different metastatic patterns in advanced liver cancer patients: A population based analysis

Background

The prognostic impact of different distant metastases pattern in liver cancer is unexplored still now. The aim of this study is to analyze the metastasis patterns and prognosis differences for patients with stage IV liver cancers.

Methods

A SEER analysis was performed. Overall survival and cancer-specific survival were calculated by the Kaplan-Meier method. Multivariable Cox regression models were used to further analyze survival outcome and other prognostic factors.

Results

A total of 37526 eligible cases were retrieved in the Surveillance, Epidemiology, and End Results database. Among these patients, stage of IV liver cancer accounted for 14.80% (5555/37526) at initial diagnosis. Patients who suffered bone, brain or lung metastasis occupied 55.61% (3089/5555). Comparing with other two single metastases, the patients with brain metastasis exhibited worst overall survival whose mean of survival was 4.758 months. Multivariate analysis with Cox hazard regression model showed that metastatic site was an independent prognostic factor of overall survival and cancer-specific survival in patients with single metastasis (P<0.05). The results of univariate analysis showed that metastatic pattern was significantly correlated with overall survival (P = 0.038) and cancer-specific survival (P = 0.035) of patients with two sites.

Conclusions

Lung was the most common site of single metastasis for liver cancers. Patients with bone metastasis had best survival outcome comparing with other two distant metastases. Patients with two metastatic sites, where one of them is the lung tends to have a slight trend to a worse outcome.

High level of serum Cripto-1 in hepatocellular carcinoma, especially with hepatitis B virus infection

BACKGROUND

Human Cripto-1 (CR-1), a member of the epidermal growth factor-Cripto-1/FRL-1/Cryptic protein family (EGF-CFC), is highly expressed in a variety of human cancers. We aimed to detect serum CR-1 level in liver diseases especially in hepatocellular carcinoma (HCC) patients.

METHODS

Serum CR-1 level was Sandwich-type enzyme-linked immuno sorbent assay (ELISA) detected in 330 patients with liver diseases including HCC, cirrhosis, and chronic hepatitis and 50 volunteers without hepatitis B virus (HBV) or hepatitis C virus (HCV) infection as control.

RESULTS

The serum CR-1 level was significantly higher in HCC patients than volunteer controls and it was also significantly higher in HBV-related HCC than HCV-related HCC. In addition, serum CR-1 level was correlated with serum alpha-feto-protein (AFP) in HBV-related HCC patients. The serum CR-1 was also higher in cirrhosis and chronic hepatitis than volunteer controls. The serum CR-1 in HBV-related cirrhosis was higher than chronic hepatitis B, but there was no significant difference between HCV-related cirrhosis and chronic hepatitis C.

CONCLUSIONS

Serum CR-1 was higher in HCC patients and might serve as a complementary biomarker to clinical diagnosis of HBV-related HCC. The high level of serum CR-1 in HBV-related liver disease might be partly attributed to HBV infection.

Dual-phase Cone-beam CT-based Navigation Imaging Significantly Enhances Tumor Detectability and Aids Superselective Transarterial Chemoembolization of Liver Cancer

RATIONALE AND OBJECTIVES

The objective of this study was to investigate the impact of a dual-phase cone-beam computed tomography (DP-CBCT)-based navigation imaging during transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) in a perspective randomized study.

MATERIALS AND METHODS

Forty-two patients with HCC (39 men, 57 ± 9 years, 13 first-time TACE) underwent TACE using three-dimensional image guidance with automatic detection of tumor-feeding vessels computed from DP-CBCT (early and delayed arterial phases). Forty-nine other patients with HCC (44 men, 55 ± 12 years, 14 first-time TACE) were treated conventionally using digital subtraction angiography (DSA). Tumor detectability in DP-CBCT was compared to DSA and preoperative CT or magnetic resonance (MR) imaging. Tumor-feeding vessel visibility was rated (good, fair, and poor) intraoperatively by the operators. The superselective embolization success rate, the number of DSA acquisitions, fluoroscopy time, and patient radiation dose were collected and compared using paired t test and the Mann-Whitney U test.

RESULTS

Tumor detection of DP-CBCT was superior to DSA (100% vs 83%, P = .001) and comparable to CT-MR (96%, P = .456). Tumor and feeder visibilities were significantly enhanced by DP-CBCT (P < .001). Compared to using DSA, more superselective embolization was achieved (60% vs 49%) with less DSA acquisitions (n = 2.6 ± 0.8 vs n = 3.4 ± 0.7, P < .001) and shorter fluoroscopy time (4.1 ± 2.6 vs 7.1 ± 4.2 minutes, P < .001) with a slight increase in patient radiation exposure, that is, air kerma (median: 0.33, first to third quartiles: 0.24-0.48 vs 0.30, 0.24-0.44 Gy; P = .519) and dose-area product (134, 92-181 vs 97, 75-140 Gy⋅cm², P = .048).

CONCLUSIONS

DP-CBCT and navigation imaging improve tumor detectability and superselective embolization in TACE.

Network meta-analysis of treatment regimens for inoperable advanced hepatocellular carcinoma with portal vein invasion

Purpose

We assessed the efficacy and safety of different modalities using the network meta-analysis for inoperable hepatocellular carcinoma (HCC) with portal vein invasion. The interested modalities included stereotactic body radiotherapy (SBRT) combined with transarterial chemoembolization (TACE), three-dimensional radiotherapy (3D-RT) combined with hepatic arterial infusion chemotherapy (HAIC) or TACE, TACE plus sorafenib, and use of SBRT, HAIC, sorafenib, and TACE alone.

Methods

PubMed and Cochrane Library electronic databases were systematically searched for eligible studies published up to June 2017. We used network meta-analysis to compare the disease control rate (DCR) and severe adverse events for the eight interested regimens included in this analysis. Study quality was assessed following the Grading of Recommendations, Assessment, Development and Evaluations method.

Results

Fifteen studies published between 2010 and 2016 involving a total of 2,359 patients were enrolled in this network meta-analysis. With indirect comparison of DCR and overall safety, the pooled results showed that RT plus HAIC was the most effective regimen in treating advanced HCC with portal vein tumor thrombosis, followed by RT plus TACE. HAIC alone and sorafenib combined with HAIC appeared least effective intervention regimens. The incidence of treatment-related adverse events of grade 3 or 4 occurred less in the patients who received SBRT alone compared with other interested regimens.

Conclusion

3D-RT combined with HAIC or TACE showed more favorable treatment responses compared with other regimens in advanced HCC patients with portal vein tumor thrombosis.

The diagnostic value of 99m-Tc GSA scintigraphy for liver function and remnant liver volume in hepatic surgery: a retrospective observational cohort study in 27 patients

Background

The aim was to analyze hepatic hypertrophy after portal vein embolization (PVE) and Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) to determine whether clinical circumstances associated with major hepatic resections correlated with remnant growth.

Methods

Data was abstracted from a retrospectively maintained database on 27 patients undergoing hepatic resection followed by PVE and the ALPPS procedure between October 1, 2007 and December 31, 2016. The increasing rate of liver volume and remnant liver LU15 was defined as the percentage-point difference between the liver volume and remnant liver LU15 before and after the intervention or surgery. And correlation between kinetic growth rate (KGR) of liver and future remnant liver volume or remnant liver LU15 was analyzed.

Results

The degree of hypertrophy (DH) of volume and LU15 was significantly greater after ALPPS (volume: 40.3% and LU15: 65.0%) than after PVE (volume: 22.7% and LU15: 48.8%) (P < 0.05). KGR of volume and LU15 was significantly greater after ALPPS (volume: 19.0 cm³/day and 2.00%/day) (LU15: 0.61 /day and 1.82%/day) than after PVE (volume: 3.89 cm³/day and 0.42%/day) (LU15: 0.19 /day and 0.63%/day) (P < 0.001). An inverse correlation between KGR and initial remnant liver volume was observed. And a positive correlation between KGR and LU15 was observed.

Conclusion

Future remnant liver volume and KGR was greater after the ALPPS procedure than after PVE. Liver hypertrophy is related to the expected remnant liver volume and total liver function. This study suggested that total liver function and initial remnant liver volume might be a new indication of hepatectomy after PVE and ALPPS in the case of insufficient remnant liver volume.

A meta-analysis of long-term survival outcomes between surgical resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤ 2 cm (BCLC very early stage)

INTRODUCTION

The optimal management choice in consideration of long-term overall survival (OS) and disease-free survival (DFS) for patients with BLCL very early stage is a matter of debate.

AIM

A systematic review and meta-analysis was conducted to evaluate the efficacy of liver resection (RES) and radiofrequency ablation (RFA) for single HCC 2 cm or less.

MATERIAL AND METHOD

The primary sources of the reviewed studies through December 2017, without restriction on the languages or regions, were Pubmed and Embase. The hazard ratio (HR) was used as a summary statistic for long-term outcomes.

RESULTS

A total of 5 studies qualified for inclusion in this quantified meta-analysis with a total of 729 HCC patients of BCLC very early stage. Only postoperative 1-year OS was comparable in both RES and RFA groups. As for long-term outcomes of 3-year and 5-year OSs, RES was significantly better than RFA, the HRs were 0.64 (95%CI: 0.41, 1.00; P = 0.05) and 0.63 (95%CI: 0.42, 0.95; P = 0.03) respectively. In terms of postoperative DFS, reduced tumor recurrence was observed in RES, and all the short- and long-terms outcomes were favored RES.

DISCUSSION

RES offers better long-term oncologic outcomes compared with RFA in current clinical evidences.

Post-operative delayed elevation of ALT correlates with early death in patients with HBV-related hepatocellular carcinoma and Post-hepatectomy Liver Failure

BACKGROUND

Post-hepatectomy Liver Failure (PHLF) remains the primary cause of perioperative death. The kinetics of transaminase levels are usually measured as markers of hepatocellular injury following partial hepatectomy, but their correlation with PHLF and post-operative mortality is unclear. The aim of study was to compare the post-operative transaminase kinetics with short term survival in those patients that developed PHLF.

METHODS

A retrospective review of patients with HBV-related HCC and who developed PHLF was performed. Logistic regression analysis was conducted to analyze risk factors for postoperative delayed elevation of ALT (PDE-ALT) PHLF and lethal PHLF.

RESULT

Of the 69 patients who developed PHLF 36 (52%) died. In those patients who died the mean ± SD ALT and AST rose from day (POD) 1-3 and continued to fluctuate with highly abnormal levels beyond day 3 with a mean ± SD peak ALT level beyond POD 3 of 1851 ± 1644 U/L (p < 0.001).

CONCLUSIONS

The kinetics of the post-operative transaminases were significantly correlated with perioperative mortality in those patients who developed PHLF. PDE-ALT indicates an increased risk of death in HBV-related HCC patients with PHLF.

Current topics in the surgical treatments for hepatocellular carcinoma

Treatment strategy for hepatocellular carcinoma (HCC) requires optimal selection of therapies based on various factors related to tumor condition and liver functional reserve. Although several evidence-based guidelines have been proposed for the treatment of HCC, the criteria and range of indications differ among these guidelines according to the circumstances of each country. In European nations and the USA, patients with the Barcelona Clinic Liver Cancer stage 0-A are subjects for surgical resection, whereas in Asian countries, even those with the intermediate stage are regarded as surgical candidates. Furthermore, since the recent introduction and rapidly widely spreading use of laparoscopic liver resection, this technique has become an important treatment option for surgical resection. In this review article, we overview the current topics of treatment of HCC with a special focus on surgical therapy.

Experimental study of the anti-tumour activity and pharmacokinetics of arctigenin and its valine ester derivative

Arctigenin (ARG) is a functional active component that has important physiological and pharmacological activities. The anti-tumour and anti-inflammatory activities of ARG show good potential for application and development, but this material has the defect of low water solubility. In this experiment, the valine derivative of ARG (ARG-V) was designed and synthesized to overcome this disadvantage. The ARG amino acid, EDCI and DMAP were raw materials in the addition reaction, with a molar ratio of 1:2:2:0.5. The yield of ARG-V was up to 80%. ARG-V has strong anti-tumour activity in vivo and in vitro. The inhibitory rate of ARG-V was 69.2%, with less damage to the immune organs and different degrees of increased serum cytotoxicity. Moreover, the pharmacokinetics of ARG following oral administration and ARG-V following oral administration in rats were also studied. The C_max and AUC values of ARG-V showed significant differences compared to ARG. The relative bioavailabilities of three doses of ARG-V compared to ARG were 664.7%, 741.5% and 812.9%. These pharmacokinetic results may be useful for further studies of the bioactive mechanism of ARG and provide a theoretical basic for clinical use.

Liver Resection for Hepatocellular Carcinoma: a Multivariate Analysis of Factors Associated with Improved Prognosis. the Role of Clinical, Pathological and Surgical Related Factors

Aims and background

Hepatocellular carcinoma (Hcc) is the third most common cause of cancer death. The aim of this study is to examine the factors associated with improved prognosis in Hcc after liver resection.

Patients and methods

From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. All patients enrolled in the study were followed-up three times during the first year after resection and twice the next years.

Results

In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, temporary liver impairment function, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Overall survival resulted to be influenced by etiology (P = 0.03), underlying liver disease, in particular Child A vs BC (P = 0.04), Endmondson-Steiner grading (P = 0.01), the absence of a capsule (P = 0.004), the presence of more than one lesion (P = 0.02), lesion's size over 5 cm (P = 0.04), Pringle maneuver length over than 20 minutes (P = 0.03), an amount of resected liver volume lesser than 50% of total liver volume (P = 0. 03), and the relapse of Hcc (P = 0.01).

Conclusions

The treatment of hepatocellular carcinoma should be both the most radical to obtain the best outcome and to reduce the recurrence's rate, and the most suitable according to the patient's condition, lesion's characteristics and underlying liver disease: because of the large number of factors affecting the outcome of Hcc, unfortunately, we are still far from an agreement upon a group of criteria useful to select the best candidates for liver resection.

Phase I dose escalation study of helical intensity-modulated radiotherapy-based stereotactic body radiotherapy for hepatocellular carcinoma

Background

Phase I trial was conducted to determine feasibility and toxicity of helical intensity-modulated radiotherapy (IMRT)-based stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC).

Results

Eighteen patients (22 lesions) were enrolled. With no DLT at 52 Gy (13 Gy/fraction), protocol was amended for further escalation to 60 Gy (15 Gy/fraction). Radiologic complete response rate was 88.9%. Two outfield intrahepatic, 2 distant, 4 concurrent local and outfield, and 1 concurrent local, outfield and distant failures (no local failure at dose levels 3–4) occurred. The worst toxicity was grade 3 hematologic in five patients, with no gastrointestinal toxicity > grade 1. At median follow-up of 28 months for living patients, 2-year local control, progression-free (PFS), and overall survival rates were 71.3%, 49.4% and 69.3%, respectively. Multi-segmental recurrences prior to SBRT was independent prognostic factor for PFS (p = 0.033).

Materials and Methods

Eligible patients had Child-Pugh's class A or B, unresectable HCC, ≤ 3 lesions, and cumulative tumor diameter ≤ 6 cm. Starting at 36 Gy in four fractions, dose was escalated with 2 Gy/fraction per dose-level. CTCAE v 3.0 ≥ grade 3 gastrointestinal toxicity and radiation induced liver disease defined dose-limiting toxicity (DLT).

Conclusions

Helical IMRT-based SBRT was tolerable and showed encouraging results. Confirmatory phase II trial is underway.

Hepatectomy for hepatocellular carcinoma with portal vein tumor thrombus

Despite surgical removal of tumors with portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) patients, early recurrence tends to occur, and overall survival (OS) periods remain extremely short. The role that hepatectomy may play in long-term survival for HCC with PVTT has not been established. The operative mortality of hepatectomy for HCC with PVTT has also not been reviewed. Hence, we reviewed recent literature to assess these parameters. The OS of patients who received hepatectomy in conjunction with multidisciplinary treatment tended to be superior to that of patients who did not. Multidisciplinary treatments included the following: preoperative radiotherapy on PVTT; preoperative transarterial chemoembolization (TACE); subcutaneous administration of interferon-alpha (IFN-α) and intra-arterial infusion of 5-fluorouracil (5-FU) with infusion chemotherapy in the affected hepatic artery; cisplatin, doxorubicin and 5-FU locally administered in the portal vein; and subcutaneous injection of IFN-α, adjuvant chemotherapy (5-FU + Adriamycin) administration via the portal vein with postoperative TACE, percutaneous isolated hepatic perfusion and hepatic artery infusion and/or portal vein chemotherapy. The highest reported rate of operative mortality was 9.3%. In conclusion, hepatectomy for patients affected by HCC with PVTT is safe, has low mortality and might prolong survival in conjunction with multidisciplinary treatment.

Predicting hepatic failure with a new diagnostic technique by preoperative liver scintigraphy and computed tomography: a pilot study in 123 patients undergoing liver resection

Background

A novel index, total liver LU15, has been identified as a surrogate marker for liver function. We evaluated the ability of preoperative remnant liver LU15 values to predict postoperative hepatic failure.

Methods

Preoperative risk factors for postoperative hepatic failure and remnant liver LU15 were evaluated in 123 patients undergoing liver resection for several diseases from September 1st, 2007 to December 1st, 2016. We calculated the remnant liver LU15 value from the total liver LU15 value and the functional remnant liver ratio. Risk factors for postoperative hepatic failure was determined by univariate and multivariate analysis.

Results

Hepatic failure grade B/C developed postoperatively in six patients of seven patients within Makuuchi criteria / without criteria for remnant liver LU15. Operative time (p = 0.0242) and criteria for remnant liver LU15 (p = 0.0001) were prognostic factors for hepatic failure according to the univariate analysis. And criteria for remnant liver LU15 (p = 0.0009) was only prognostic factor by multivariate analysis.

Conclusion

Based on the findings form this pilot study, it appears that patients with a remnant liver LU15 value of 13 or less may have a high risk of postoperative hepatic failure.

Eighth Edition of the UICC Classification of Malignant Tumours: an overview of the changes in the pathological TNM classification criteria-What has changed and why?

The TNM classification of malignant tumours is a mainstay tool in clinical practice and research for prognostic assessment of patients, treatment allocation and trial enrolment, as well as for epidemiological studies and data collection by cancer registries worldwide. Pathological TNM (pTNM) represents the pathological classification of a tumor, assigned after surgical resection or adequate sampling by biopsy, and periodical updates to the relative classification criteria are necessary to preserve its clinical relevance by integrating newly reported data. A structured approach has been put in place to fulfil this need and, based upon this process, the Eighth Edition of Union for International Cancer Control (UICC) TNM Classification of Malignant Tumours has been published, introducing many significant changes, including novel classification criteria for specific tumour types. In this review, we aim to describe the major changes introduced in the pTNM classification criteria and to summarize the evidence supporting these changes.

Combined low miRNA-29s is an independent risk factor in predicting prognosis of patients with hepatocellular carcinoma after hepatectomy: A Chinese population-based study

The prediction of prognosis of hepatocellular carcinoma (HCC) following partial hepatectomy is still an unresolved issue. The aim of this study is to identify the association between miRNA-29s family and the prognosis of patients with HCC in a large Asian cohort. We retrospectively reviewed 122 patients with HCC managed in our institution between 2008 and 2015. The expression of miRNA-29s was detected by real-time polymerase chain reaction (PCR). Prognostic factors were evaluated using Kaplan-Meier curves and Cox proportional hazards models. For the entire cohort of 122 patients, the normalized real-time PCR results showed that miRNA-29s (miR-29a, miR-29b, and miR-29c) were deregulated in tumor tissues as compared with corresponding nontumorous tissue samples. We then performed survival analysis to investigate the prognostic value of miRNA-29s. We found that low miR-29b was associated with a decreasing 5-year overall survival (OS) rate from 70.2% to 39.1% and low miR-29c was associated with a decreasing 5-year OS rate from 53.6% to 23.7%. We further conducted multivariate Cox proportional hazards analysis adding the variable of combined low miR-29b and low miR-29c. The results demonstrated that combined low miR-29b and miR-29c was an independent prognostic factor of patients with HCC. In conclusion, we found that the miRNA-29s were down-regulated in tumor tissues as compared with corresponding nontumorous tissue samples. Combined low miR-29b and miR-29c was an independent prognostic factor of patients with HCC.

Validation of the American Joint Committee on Cancer eighth edition staging system in patients undergoing hepatectomy for hepatocellular carcinoma: a US population-based study

BACKGROUND

The American Joint Committee on Cancer (AJCC) eighth edition staging system for hepatocellular carcinoma (HCC) has incorporated several significant changes. This study aims to evaluate the newly proposed staging system and assess its strengths and weaknesses.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified patients with pathologically confirmed stage I-III HCC diagnosed between 2004 and 2014.

RESULTS

After all exclusion criteria were applied, AJCC seventh and eighth edition staging was possible in 4931 patients. According to the AJCC eighth edition staging system, stages IB and II did not differ significantly in terms of overall survival (OS) and cause-specific survival (CSS) (P = 0.928 and 0.872, respectively). On the basis of the above results, we reclassified T1a, T1b, and T2 into several subgroups. According to the modified AJCC eighth edition staging system, OS and CSS among the five groups of patients differed significantly. For OS predication, the Akaike information criterion values for the AJCC seventh, eighth, and modified eighth edition staging systems were 29,288.24, 29,282.85, and 27,182.21, respectively, and the c-indices for the AJCC seventh, eighth, and modified eighth edition staging systems were 0.5716, 0.5805, and 0.6082, respectively. Regarding CSS, the Akaike information criterion values for the AJCC seventh, eighth, and modified eighth edition staging systems were 21,701.11, 21,682.12, and 20,313.26, respectively, and the c-indices for the AJCC seventh, eighth, and modified eighth edition staging systems were 0.5983, 0.6117, and 0.6436, respectively.

CONCLUSIONS

This is the first large-scale validation of the AJCC eighth edition staging system for patients undergoing hepatectomy. Our study revealed that there was a lack of discrepancy in the outcomes for stage IB and II tumors for AJCC eighth edition staging system of HCC. Our modified AJCC eighth edition staging system allows for finer stratification of patients undergoing hepatectomy according to more detailed tumor size and vascular invasion classifications.

Survival outcomes of hepatectomy for stage B Hepatocellular carcinoma in the BCLC classification

BACKGROUND

Because hepatectomy is not recommended in patients with stage B hepatocellular carcinoma (HCC) of the Barcelona Clinic Liver Cancer (BCLC) staging, we evaluated the survival outcomes of hepatectomy for stage B in the BCLC system.

METHODS

Data were collected from 297 consecutive adult stage B patients who underwent curative hepatectomy for HCC between 1996 and 2014 in Hokkaido University Hospital. Overall survival (OS), disease-free survival (DFS), and risk factors were analyzed using the Kaplan-Meier method. Independent prognostic factors were evaluated using a Cox proportional hazards regression model. AP-factor (alpha-fetoprotein [AFP] × protein induced by vitamin K absence or antagonism factor II [PIVKA-II]) was categorized according to the serum concentrations of AFP and PIVKA-II: AP1 (AFP < 200 ng/ml and PIVKA-II < 100 mAU/ml), AP2 (AFP × PIVKA-II < 105), and AP3 (AFP × PIVKA-II ≥ 105).

RESULTS

There were 130 deaths among our 297 stage B patients (43.8%). The causes of death in these cases were HCC recurrence (n = 106; 81.5%), liver failure (n = 7; 5.4%), and other causes (n = 17; 16.1%). The operative mortality rate was 0.34% (1/297). The 5-year OS and DFS rates for the stage B cases were 54.3 and 21.9%, respectively. By multivariate analysis, tumor number and AP-factor were risk factors for both survival and recurrence that were tumor related and could be evaluated preoperatively. The study patients with stage B HCC were classified into three groups by tumor number (B1, 1; B23, 2 or 3; B4over: ≥4) and into three groups stratified by AP-factor (AP1, AP2, and AP3). The 5-year OS rates of B1, B23, and B4over were 63.6, 52.3, and 29.0%. The 5-year OS rates of AP1, AP2, and AP3 were 67.6, 65.2, and 39.1%. Stratified by the 5-year OS rate, stage B HCC patients were classified into three subgroups (A-C).The 5-year OS rates of groups A (B1 or B23 and AP-1 or AP-2), B (B1 or B23 and AP-3, or B4over and AP-1 or AP-2), and C (B4over and AP-3) were 69.5, 43.7, and 21.3%.

CONCLUSION

Stage B HCC patients with a tumor number ≤ 3 and/or AP-factor < 1 × 105 show acceptable 5-year OS rates and could be treated by hepatectomy.

Association between relative liver enhancement on gadoxetic acid enhanced magnetic resonance images and histologic grade of hepatocellular carcinoma

We evaluated the association between histologic grade of hepatocellular carcinoma (HCC) and degree of HCC enhancement on Gd-EOB-DTPA (Gadoxetic acid, Primovist)-enhanced magnetic resonance images (MRI) in HCC patients.A total of 121 patients who underwent curative surgical resection for HCC at our institution between January 2012 and March 2015 were retrospectively analyzed. Gadoxetic acid enhanced MRI was performed in all patients before surgery. Signal intensities of HCC and peri-HCC areas were measured using regions of interest. Relative intensity ratios of HCC lesions versus the surrounding non-HCC areas on unenhanced images (precontrast ratio) and on hepatobiliary phase images (postcontrast ratio) were calculated. Relative liver enhancement (RLE) ratios (post-contrast ratio/pre-contrast ratio) were also calculated. The Edmondson-Steiner (E-S) grading system was used to histologically grade HCC.E-S grades I, II, III, and IV were observed in 2 (1.7%), 14 (11.6%), 54 (44.6%), and 51 (42.1%) of the patients, respectively. For E-S grades I/II (n = 16), III (n = 54), and IV (n = 51), mean RLE (%) were 85.5, 84.9, and 71.2, respectively (P = .01), and for E-S grades I-III (n = 70) and IV (n = 51), mean RLE (%) were 85.1 and 71.2, respectively (P < .01). Barcelona Clinic Liver Cancer (BCLC) stage A (vs 0) (odds ratio 4.38, P = .03) and mean RLE (odds ratio 0.05, P < .01) were found to predict E-S grade IV.E-S grade IV was associated with a low level mean RLE in the gadoxetic acid enhanced MR images of HCC patients.

Prognostic value of the albumin-bilirubin grade in patients with hepatocellular carcinoma: Validation in a Chinese cohort

AIM

The prognostic value of the newly raised objective liver function assessment tool, the albumin-bilirubin (ALBI) grade, in patients with hepatocellular carcinoma has not been fully validated. We aimed to compare the performance of ALBI grade with the specific Child-Pugh (C-P) score in predicting prognosis in this study.

METHODS

The clinical data of 491 C-P class A patients who underwent liver resection as initial therapy from January 2000 to December 2007 in Cancer Hospital, Chinese Academy of Medical Sciences (Beijing, China) were retrospectively analyzed. The prognostic performances of ALBI and C-P score in predicting the short- and long-term clinical outcomes were compared.

RESULTS

The ALBI score gained a significantly larger area under the receiver operating characteristic curve for predicting the occurrence of severe postoperative complications than that of C-P score. With a median follow-up of 57 months, the 1-year, 3-year, and 5-year overall survival rates of the patients were 92.1%, 65.8%, and 45.2%, respectively. Tumor number, tumor size, and ALBI grade were proved to be the independent prognostic factors for overall survival in the multivariate analysis. Prognostic performance was shown to be better for ALBI grade when it was compared to C-P score in terms of both the Akaike information criterion value and χ² value of likelihood ratio test.

CONCLUSIONS

The ALBI grade, which was featured by simplicity and objectivity, gained a superior prognostic value than that of C-P grade in patients with hepatocellular carcinoma who underwent liver resection. Future well-designed studies with larger sample sizes are warranted.

Role of hepatic resection in patients with intermediate-stage hepatocellular carcinoma: A multicenter study from Japan

Transarterial chemoembolization (TACE) is recommended for patients with intermediate-stage (Barcelona Clinic Liver Cancer criteria B [BCLC-B]) hepatocellular carcinoma (HCC). However, patients with BCLC-B HCC can differ in background factors related to hepatic function, as well as tumor size and number. In the present study, we clarified the role of hepatic resection in patients with BCLC-B HCC. A total of 489 BCLC-B HCC patients with Child-Pugh class A disease initially treated with hepatic resection or TACE were included. After propensity score matching (n = 264), hepatic resection (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.35-0.91) was independently associated with survival in the multivariate analysis. We then divided patients into two groups based on the results of statistical analysis. There were 170 patients treated with resection and 319 with TACE. Child-Pugh score and number of tumors (cut-off, three tumors) were independently associated with type of HCC treatment in the multivariate analysis. We then divided patients in Group A (Child-Pugh score of 5 and ≤3 tumors; n = 186) and Group B (Child-Pugh score of 6 or ≥4 tumors; n = 303). In Group A, cumulative survival was significantly higher in the hepatic resection group than in the TACE group (P = 0.014). In Cox proportional hazards models, hepatic resection (HR, 0.38; 95% CI, 0.23-0.64) was independently associated with survival in Group A patients. In Group B, treatment status was not associated with overall survival. Hepatic resection should be considered in patients with a Child-Pugh score of 5 and ≤3 tumors, despite having BCLC-B HCC.

Utility of percutaneous radiofrequency ablation alone or combined with transarterial chemoembolization for early hepatocellular carcinoma

Percutaneous radiofrequency ablation (RFA) combined with transarterial chemoembolization (TACE) is an effective, standard therapy against small hepatocellular carcinoma (HCC). However, there is debate regarding the effectiveness of RFA combined with TACE (RFA/TACE) compared with RFA alone. These two approaches were compared for the treatment of early HCC. The present study examined 83 HCC tumors in 83 patients treated with RFA between April 2007 and August 2014 at three medical institutions. All HCCs were single hypervascular tumors, with a median diameter of 16 mm (range, 6-30 mm). The overall survival (OS) rate of all patients (n=83) was 97.5% at 1 year, 82.8% at 3 years and 48.6% at 5 years, and the local recurrence rate of all patients was 14.3% at 1 year, 32.3% at 3 years and 36.5% at 5 years. The tumor-free survival (TFS) rate of all patients was 95.1% at 1 year, 56.3% at 3 years and 23.4% at 5 years. Compared with RFA alone, RFA/TACE significantly improved OS (P<0.001), intrahepatic distant recurrence (IDR; P=0.038) and TFS (P=0.010). A univariate analysis of prognostic indicators revealed that age <70 years (P=0.008), aspartate transaminase <40 IU/l (P=0.003), alanine aminotransferase <40 IU/l (P=0.006) and platelet count >10×10⁴/µl (P=0.05) were associated with a high survival rate. Multivariate analysis identified RFA/TACE [hazard ratio (HR), 0.108; P=0.001] as an independent prognostic indicator. RFA/TACE was identified as the only independent indicator of IDR (HR: 0.467; P=0.042) and TFS (HR: 0.452; P=0.012). RFA/TACE improved OS rate, IDR and TFS compared with RFA alone. The data suggested that RFA/TACE should be considered for the treatment of single hypervascular HCC.

Emerging tyrosine kinase inhibitors for the treatment of hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is the fifth most diagnosed cancer in the world and the third leading cause of death. Unfortunately, when diagnosed two thirds of patients have an advanced disease for which only palliative treatment can be proposed and most likely systemic therapy. Areas covered: As of today only one systemic therapy is validated in the treatment of advanced HCC, a tyrosine kinase inhibitor (TKI): Sorafenib. Treatment options are therefore lacking. With the advent of Sorafenib other TKIs have been studied with some disappointing results. Many explanations can be found to the failure of these tested TKIs such as the underlying cirrhosis leading to rapidly serious adverse events, or trial design imperfections. Expert opinion: Taking into account these failures, new trials with more appropriate designs have led to recent success with multi-target TKIs (Regorafenib and Lenvatinib). This multi-target approach allows to overcome the molecular heterogeneity of advanced HCC which is associated with multiple simultaneously dysregulated signaling pathways. On the contrary, another lead is to study target a specific TKI such as c-MET inhibitors or TGFβR inhibitors in HCC sub-populations with promising results in early phase trials. These results will have to be validated in the ongoing phase III trials.

HSVtk/GCV system on hepatoma carcinoma cells: Construction of the plasmid pcDNA3.1‑pAFP-TK and targeted killing effect

Previous studies demonstrated that herpes simplex virus thymidine kinase (HSVtk) could phosphorylate non-toxic gancyclovir (GCV) efficiently to produce phosphorylated products that result in cell apoptosis, to kill tumor cells. The present study aimed to construct a plasmid vector, pcDNA3.1-pAFP-TK, carrying the suicide gene driven by the alpha-fetoprotein (AFP) promoter, to investigate the cytotoxicity of HSVtk/GCV suicide gene system on hepatoma carcinoma cells. Reverse transcription-polymerase chain reaction and western blotting results demonstrated that the HSVtk gene was effectively expressed in HepG2 hepatoma carcinoma cells transfected with pcDNA3.1-pAFP-TK plasmid, whereas HSVtk gene expression was not detected in normal HL-7702 liver cells. In addition, MTT assays indicated that cell viability of HepG2 cells with the plasmid pcDNA3.1-pAFP-TK decreased in a dose-dependent manner following treatment with GCV for 48 h. Flow cytometry also revealed that the cell apoptosis rate and mitochondrial membrane potential reduction rate in the HepG2 cells treated with HSVtk/GCV suicide gene system were significantly higher than in the control group. Apoptosis rates in the control group and the pcDNA3.1-pAFP-TK group were (1.00±0.62%) and (38.70±6.03%), respectively. Mitochondrial membrane potential reduction rates in the control group and the pcDNA3.1-pAFP-TK group were (0.57±0.11%) and (22.84±5.79%), respectively. Caspase-3 staining demonstrated that activated caspase-3 increased significantly in the HepG2 cells treated with HSVtk/GCV suicide gene system, whereas in the control group activated caspase-3 increase was not observed. The results of the present study, therefore, indicated that HSVtk suicide gene was obviously expressed in the HepG2 cells and that the HSVtk/GCV system was effective at killing HepG2 hepatoma carcinoma cells.

Identification and functional analysis of differentially expressed genes in poorly differentiated hepatocellular carcinoma using RNA-seq

Poorly differentiated (PD) hepatocellular carcinoma (HCC) has a worse prognosis compared to moderately differentiated (MD) and well differentiated (WD) HCC. We aimed to identify differentially expressed genes (DEGs) to explore the mechanism of PD HCC. Transcriptome sequencing was performed on tumor and adjacent non-tumorous tissues of PD, MD and WD HCC patients (3 for each group). DEGs were thus identified and functionally analyzed. Further RT-PCR was performed to validate DEGs specific for PD HCC in 47 pairs of samples (15 for PD, 18 for MD, 14 for WD). A total of 681 PD DEGs were detected, including 368 up-regulated and 313 down-regulated genes. Less DEGs were found for MD and especially for WD HCC. Through bioinformatics analysis, PD HCC DEGs were enriched in liver tissue and liver cancer cells, and in biological process and pathway including metabolism, cell cycle, translation and blood coagulation. Potential drugs and genetic perturbations were found to reverse the cancer condition. The RT-PCR results showed consistency with RNA-seq in the validation of 4 DEGs specific for PD HCC. This study detected and validated DEGs of PD HCC, which provides useful information on molecular mechanism of PD HCC for development of new biomarkers, therapeutic targets and drugs.

Diagnosis of Hepatocellular Carcinoma with Gadoxetic Acid-Enhanced MRI: 2016 Consensus Recommendations of the Korean Society of Abdominal Radiology

Diagnosis of hepatocellular carcinoma (HCC) with gadoxetic acid-enhanced liver magnetic resonance imaging (MRI) poses certain unique challenges beyond the scope of current guidelines. The regional heterogeneity of HCC in demographic characteristics, prevalence, surveillance, and socioeconomic status necessitates different treatment approaches, leading to variations in survival outcomes. Considering the medical practices in Korea, the Korean Society of Abdominal Radiology (KSAR) study group for liver diseases has developed expert consensus recommendations for diagnosis of HCC by gadoxetic acid-enhanced MRI with updated perspectives, using a modified Delphi method. During the 39th Scientific Assembly and Annual Meeting of KSAR (2016), consensus was reached on 12 of 16 statements. These recommendations might serve to ensure a more standardized diagnosis of HCC by gadoxetic acid-enhanced MRI.

Is there a standard for surgical therapy of hepatocellular carcinoma in healthy and cirrhotic liver? A comparison of eight guidelines

Background and aims

Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis.

Methods

We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines.

Results

All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria.

Conclusions

Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.

Clinical features of hemodialysis patients treated for hepatocellular carcinoma: Comparison between resection and radiofrequency ablation

There is no consensus regarding which therapeutic option is better and/or safer for treating hemodialysis (HD) patients with hepatocellular carcinoma (HCC). The present study compared surgical resection (Hx) and radiofrequency ablation (RFA) with regard to therapeutic efficacy in HD patients with HCC. Of 108 HD patients with naïve HCC treated at 15 institutions between 1988 and 2014 enrolled in the present study, 58 fulfilled the up-to-7 criteria [7 as the sum of the size of the largest tumor (cm) and the number of tumors] and were treated with Hx (n=23) or RFA (n=35); their clinical features, complications and prognosis were assessed. The frequency of hepatitis C virus was higher in the RFA group compared with that in the Hx group (P=0.002), whereas there were no differences between the groups with regard to the average time from the first HD (P=0.953), tumor-nodes-metastasis (TNM) stage (Union for International Cancer Control 7th edition) (P=0.588), TNM stage (Liver Cancer Study Group of Japan 5th edition) (P=0.095), Child-Pugh classification (P=0.094), and Japan Integrated Scoring system (P=0.489). There were no significant differences in overall survival (OS) and disease-free survival (DFS) rates between the Hx and RFA groups [1-, 3- and 5-year OS rates: 81.7, 55.6 and 43.3% vs. 89.9, 67.1 and 56.3%, respectively (P=0.454); 1-, 3- and 5-year DFS rates: 71.1, 30.5 and 18.3% vs. 63.8, 31.6 and 21.1%, respectively (P=0.911)] Complications were observed in 4 patients (11.4%) in the RFA group (2 with subcapsular hemorrhage, 1 with intraperitoneal bleeding and 1 with tardive intrahepatic hematoma) and in 4 patients (17.4%) in the Hx group (2 with postoperative infection, 1 with liver failure and 1 with pleural effusion) (P=0.700). In conclusion, Hx and RFA have a similar therapeutic efficacy in HD patients with naïve HCC who fulfilled the up-to-7 criteria.

Characteristics of patients with liver cancer in the BioBank Japan project

Background

Liver cancer is the fifth cause of cancer-related deaths in Japan. The BioBank Japan (BBJ) project included 200,000 patients with 47 diseases and samples; their clinical information can be used for further studies.

Methods

Patients diagnosed with liver cancer (n = 1733; 1316 men, 417 women) were included. Histology, patient characteristics, clinical characteristics, and causes of death were collected. Cumulative and relative survival rates for liver cancer were calculated.

Results

Of the 1354 patients with available liver cancer histology, 91.9% had hepatocellular carcinoma (HCC). Compared with the National Health and Nutrition Examination Survey, greater proportions of the male patients in this cohort were daily alcohol consumers (26%), and a greater proportion of the men was overweight/obesity (22%). Although Japan is the only Asian country with a predominance of hepatitis C virus (HCV)-related HCC, the prevalence of HCV infection (44%) was lower than that in a previous study. The 3-, 5-, and 10-year cumulative survival rates were 57%, 47%, and 25% in men, respectively, and 49%, 41%, and 27% in women, respectively.

Conclusions

The present results provide an overview of the patients with liver cancer in the BBJ project. We are planning further analyses combined with various high-throughput ‘omics’ technologies.

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Liver cancer is the second leading cause of death worldwide.

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We aimed to provide an overview of patients with liver cancer.

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Based on liver cancer histology, 91.9% had hepatocellular carcinoma.

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The 10-year relative survival rates were 34% in men and 38% in women.

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Future studies will help develop preventive programs for liver cancer.