Predictors of survival after resection of early hepatocellular carcinoma

A Simple-to-Use Nomogram for Predicting the Survival of Early Hepatocellular Carcinoma Patients

Objective: This study aimed to develop and validate a simple-to-use nomogram for early hepatocellular carcinoma (HCC) patients undergoing a preoperative consultation and doctors conducting a postoperative evaluation.

Methods: A total of 2,225 HCC patients confirmed with stage I or II were selected from the Surveillance, Epidemiology, and End Results database between January 2010 and December 2015. The patients were randomly divided into two groups: a training group (n = 1,557) and a validation group (n = 668). Univariate and multivariate hazards regression analyses were used to identify independent prognostic factors. The Akaike information criterion (AIC) was used to select variables for the nomogram. The performance of the nomogram was validated concerning its ability of discrimination and calibration and its clinical utility.

Results: Age, alpha-fetoprotein (AFP), race, the degree of differentiation, and therapy method were significantly associated with the prognosis of early HCC patients. Based on the AIC results, five variables (age, race, AFP, degree of differentiation, and therapy method) were incorporated into the nomogram. The concordance indexes of the simple nomogram in the training and validation groups were 0.707 (95% CI: 0.683–0.731) and 0.733 (95% CI: 0.699–0.767), respectively. The areas under the receiver operating characteristic (ROC) curve of the nomogram in the training and validation groups were 0.744 and 0.764, respectively, for predicting 3-year survival, and 0.786 and 0.794, respectively, for predicting 5-year survival. Calibration plots showed good consistency between the predictions of the nomogram and the actual observations in both the training and validation groups. Decision curve analysis (DCA) showed that the simple nomogram was clinically useful, and the overall survival significantly differed between low- and high-risk groups divided by the median score of the nomogram in the training group (P < 0.001).

Conclusion: A simple-to-use nomogram based on a large population-based study is developed and validated, which is a conventional tool for doctors to facilitate the individual consultation of preoperative patients and the postoperative personalized evaluation.

Hepatocellular carcinoma grading and recurrence prediction using T1 mapping on gadolinium-ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging

The aim of the present study was to explore the value of T₁ mapping on gadolinium-ethoxybenzyl diethylenetriamine pentaacetic (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) for grading hepatocellular carcinoma (HCC) and predicting its recurrence rate. A retrospective study was performed that included 75 patients (66 men and 9 women; mean age, 52.89 years; age range, 23-79 years) with HCC who had undergone Gd-EOB-DTPA-enhanced MRI with T₁ mapping before surgery. The T₁ relaxation time of the 81 lesions and non-tumorous liver parenchyma in 75 patients with HCC were measured before Gd-EOB-DTPA was injected and then at 5, 10 and 20 min after administration, respectively. T_{1[lesion (L)-hepatic parenchyma (H)]/H} (%) was calculated as the increment rate of the T₁ value in the lesions relative to the non-tumorous liver parenchyma. One-way analysis of variance and Spearman's correlation analysis was used to compare the differences and relationship of T₁ mapping values among the three grades of HCC. A total of 81 lesions were divided into well-differentiated HCC (grades I; n=21), moderately differentiated HCC (grades II; n=40) and poorly differentiated HCC (grades III; n=20) according to the histopathology. The T_1(L-H)/H (%) value among grades I, II and III HCC on pre-contrast results and on post-contrast results at the 5-, 10- and 20-min hepatobiliary phase (HBP) were significantly different (P<0.05), and T_1(L-H)/H (%) was correlated with the histological grade of HCC at each time point (r=0.637, r=0.554, r=0.499 and r=0.560, respectively, P<0.001). A total of 41 recurrence cases [grade I (n=5), grade II (n=23) and grade III (n=13)] were verified by imaging (CT, MRI or ultrasound) or reoperation. Patients with grade III and grade II HCC had higher recurrence rates compared with that in patients with grade I HCC (P<0.05; median recurrence times were 258 days, 605 days and undefined, respectively). According to the optimal cut-off point for the T_1(L-H)/H (%) of the three grades of HCC, patients with HCC in the low T_1(L-H)/H (%) value group (≤155.15%) had lower cumulative recurrence rates compared with that in the medium (T_1(L-H)/H (%) >155.15% and T1_(L-H)/H (%) ≤241.20%) and high (T_1(L-H)/H (%) >241.20%) value groups at the 20-min HBP (P<0.05; median recurrence times were undefined, 530 days and 447 days, respectively). These results indicate that the parameters of T₁ mapping would be beneficial for predicting the grading and recurrence of HCC.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

High preoperative serum globulin in hepatocellular carcinoma is a risk factor for poor survival

Background: Serum globulin (GLB), albumin (ALB) and albumin/globulin ratio (AGR) have been reported as prognosis related factors for certain malignancies; however, the prognostic value of globulin (GLB) in hepatocellular carcinoma (HCC) has rarely been studied. This study was performed to evaluate whether GLB analysis could be applied for the prediction of the prognosis of patients received liver resection. Methods: A training cohort study involving 210 HCC patients undergoing curative liver resection between January 2007 and December 2012, and a validation cohort involving 100 HCC patients contemporaneously undergoing curative liver resection in another set were recruited. The survival curves were graphed and log-rank test was performed to analyze the differences between the curves. The cutoff value was selected by X-title program. Results: Univariate and multivariate analysis indicated that high serum GLB level is a risk factor for poor cancer-specific survival (CSS) (P < 0.05). Conversely, high ALB level is a prediction for favor CSS (P = 0.010). Conclusions: We identified the preoperative high GLB level as a prognostic risk factor for patients after treatment of liver cancer resection. This easily obtained variable may act as an available clinical biomarker to predict the prognosis of such patients.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Differences in the prognostic value of tumor size on hepatocellular cancer-specific survival stratified by gender in a SEER population-based study

Background and objective

Tumor size is an important prognostic factor in cancers. This study aims at investigating the interaction between gender status and tumor size to evaluate cancer-specific survival (CSS) in hepatocellular carcinoma (HCC).

Methods

In this study, we searched Surveillance, Epidemiology, and End Results (SEER) population-based data and identified 38,368 patients diagnosed with HCC between 1988 and 2012. Patients diagnosed between 1998 and 2007 were distributed into a training set (n = 19279), and the rest were assigned as a SEER validation set (n = 19089). Definition of cut-off value of tumor size stratified by gender was determined by the "X-Tile" program. The five-year CSS data were found. Long-term survival outcomes and risk factors were analyzed by the Kaplan-Meier methods and the multivariable Cox regression models.

Results

There were significant differences among these different tumor size subgroups with regards to five-year CSS (p < 0.001). When applying cutoff points of 38 mm and 75 mm tumor size in men, and 38 mm and 55 mm in women, the most significant difference was observed by the X-Tile program, respectively (p < 0.001). The five-year CSS was 27.5% for women and 25.7% for men in the training set, and 33.9% for women and 31.1% for men in the validating set (p < 0.001). Further analysis showed that this significant difference existed in localized, regional, and distant-stage patients.

Conclusions

These results demonstrated that women with HCC appeared to exhibit better survival rates than men. The sex-related discrepancies should be emphasized, particularly for HCC patients with 39 to 75 mm tumors.

Development and external validation of prognostic nomograms in hepatocellular carcinoma patients: a population based study

Background: We attempted to construct and validate novel nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in patients with hepatocellular carcinoma (HCC).

Methods: Models were established using a discovery set (n=10,262) obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Based on univariate and multivariate Cox regression analyses, we identified independent risk factors for OS and CSS. Concordance indexes (c-indexes) and calibration plots were used to evaluate model discrimination. The predictive accuracy and clinical values of the nomograms were measured by decision curve analysis (DCA).

Results: Our OS nomogram with a c-index of 0.753 (95% confidence interval (CI), 0.745–0.761) was based on age, sex, race, marital status, histological grade, TNM stage, tumor size, and surgery performed, and it performed better than TNM stage. Our CSS nomogram had a c-index of 0.748 (95% CI, 0.740–0.756). The calibration curves fit well. DCA showed that the two nomograms provided substantial clinical value. Internal validation produced c-indexes of 0.758 and 0.752 for OS and CSS, respectively, while external validation in the Sun Yat-sen Memorial Hospital (SYMH) cohort produced a c-indexes of 0.702 and 0.686 for OS and CSS, respectively.

Conclusions: We have developed nomograms that enable more accurate individualized predictions of OS and CSS to help doctors better formulate individual treatment and follow-up management strategies.

Positive Immuno-Modulation Following Radiofrequency Assisted Liver Resection in Hepatocellular Carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) often develops on a background of chronic inflammation and a complex immunosuppressive network with increased regulatory T cells, impaired CD8⁺ T cells and the secretion of immunosuppressive cytokines. Previous clinical studies have reported a superior disease-free survival (DFS) following a radiofrequency-based ablation or resection in HCC tumours compared to conventional liver resection techniques. The aim of this study was to investigate whether there is any correlation with the use of a radiofrequency-assisted liver resection and clinical outcome.

MATERIAL AND METHODS

Patients' peripheral blood was collected prior and 7 days following surgery from patients undergoing a liver resection for HCC. There were 5 liver resections performed using CUSA and 6 liver resections with the RF-based device, HabibTM 4X. The primary endpoint of the study was to assess the immunological parameters of circulating immune cell populations as well as serum cytokines. The Student's t-test, chi-square or Fisher's Exact test were applied for statistical comparisons, as appropriate.

RESULTS

Patients undergoing an RF-assisted liver resection with HabibTM 4X had a significant decrease in the inhibitory Treg cells (p = 0.002) and a significant increase in CD8⁺ T lymphocytes (p = 0.050) and CD4⁺CD45RO⁺/CD4⁺ memory T cells (p = 0.002) compared to those patients undergoing a liver resection with CUSA. It was also noted that the RF-assisted liver resection group had a significant decrease in circulating TGF-ß (p = 0.000), IL10 (p = 0.000) and a significant increase in IFN-gamma (p = 0. 027) and IL-17 compared to the CUSA group.

CONCLUSION

A liver resection with RF-based device HabibTM 4X was associated with positive immunomodulatory changes in circulating immune cells and circulating cytokines which could explain the significant improvement in DFS.

Genetic variants and Expression of Cytochrome p450 Oxidoreductase Predict Postoperative Survival in Patients with Hepatitis B Virus-Related Hepatocellular Carcinoma

Our current study investigates the prognostic values of genetic variants and mRNA expression of cytochrome p450 oxidoreductase (POR) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). A total of 19 candidate single nucleotide polymorphisms (SNPs) located in the exons of POR were genotyped using Sanger sequencing from 476 HBV-related HCC patients who underwent hepatectomy between 2003 and 2013. The mRNA expression of POR in 212 patients with HBV-related HCC was obtained from GSE14520 dataset. Survival analysis was performed to investigate the association of POR variants and mRNA expression with overall survival (OS) and recurrence-free survival (RFS). Nomograms were used to predict the prognosis of HBV-related HCC patients. Gene set enrichment analysis (GSEA) was used to investigate the mechanism of POR in HBV-related HCC prognosis. The polymorphism POR-rs1057868 was significantly associated with HBV-related HCC OS (CT/TT vs. CC, hazard ratio [HR] = 0.69, 95% confidence interval [CI] = [0.54, 0.88], P = 0.003), but not significantly associated with RFS (CT/TT vs. CC, P = 0.378). POR mRNA expression was also significantly associated with HBV-related HCC OS (high vs. low, HR = 0.61, 95% CI = [0.38, 0.97], P = 0.036), but not significantly associated with the RFS (high vs. low, P = 0.201). Two nomograms were developed to predict the HBV-related HCC OS. Furthermore, GSEA suggests that multiple gene sets were significantly enriched in liver cancer survival and recurrence, as well as POR-related target therapy in the liver. In conclusion, our study suggests that POR-rs1057868 and mRNA expression may serve as a potential postoperative prognosis biomarker in HBV-related HCC.

A wide-margin liver resection improves long-term outcomes for patients with HBV-related hepatocellular carcinoma with microvascular invasion

BACKGROUND

The impact of the resection margin on survival outcomes in patients with hepatocellular carcinoma remains to be determined. This study aimed to examine the association between the width of resection margin and the presence of microvascular invasion in hepatitis B virus-related hepatocellular carcinoma.

METHODS

We reviewed data on 2,508 consecutive patients who underwent liver resection for a solitary, hepatitis B virus-related hepatocellular carcinoma for operative morbidity, tumor recurrence, and overall survival.

RESULTS

Microvascular invasion was identified histologically in 929 patients (37.0%). A wide margin of resection (≥1 cm, n = 384) resulted in better 5-year recurrence and overall survival versus a narrow margin of resection (<1 cm, n = 545) among patients with microvascular invasion (71.1% versus 85.9%; 44.9% versus 25.0%; both P < .001), but not in patients without microvascular invasion (P = .131, .182). Similar results were identified after propensity-score matching. A wide margin resection also had a lesser incidence of early recurrence developed within the first postoperative 24 months (58.1% versus 72.7%; P < .001). Compared with a wide resection margin, a narrow margin was associated with worse recurrence and overall survival in patients with microvascular invasion (hazard ratio: 1.50 and 1.75). In addition, a wide or a narrow resection margin had differences in the rate of grade I-III, but not grade IV complications (31.0% versus 21.7%; P = .017; 3.5% versus 1.6%; P = .147) among cirrhotic patients with microvascular invasion.

CONCLUSION

The presence of microvascular invasion was associated with a worse prognosis after resection. A wide resection margin resulted in better long-term prognoses versus a narrow resection margin among patients with hepatitis B virus-related hepatocellular carcinoma with microvascular invasion.

Microvascular invasion and positive HB e antigen are associated with poorer survival after hepatectomy of early hepatocellular carcinoma: A retrospective cohort study

BACKGROUND

We aimed to identify the independent predictive factors of microvascular invasion (MVI) for curative resection of HCC and to investigate the impacts of MVI and HBeAg on long-term recurrence and survival after resection.

METHODS

The clinicopathological parameters of 237 patients with HCC with MVI who underwent hepatic resection from April 2005 to November 2010 were investigated. Clinical features and factors associated with the clinical outcomes of 386 patients with HCC without MVI were used for comparison.

RESULTS

Multivariate stepwise logistic regression analysis revealed that alpha-fetoprotein level>100μg/L, positive HBeAg, and tumour size were independent prognostic factors in patients with HCC with MVI. The overall survival (OS) of patients in the HCC with MVI group was significantly poorer compared with the HCC without MVI group (P<0.001). However, patients with HCC without MVI group exhibited a significantly better recurrence-free survival rate (RFS) (P<0.001). While the HCC with positive HBeAg group exhibited significantly lower OS compared with the HCC with negative HBeAg group (P=0.007).

CONCLUSIONS

AFP level>100μg/L, positive HBeAg, and tumour size>2cm are independent indicators of poorer prognosis for HCC with MVI. The present study confirmed that microvascular invasion itself had a negative impact on patient survival; moreover, HBeAg was an independent risk factor influencing OS, while not RFS of patients with HCC underwent hepatectomy. It is important to predict the presence of MVI before hepatic resection to determine treatment strategies.

Signal Transducer and Activator of Transcription 3 for the Differentiation of Hepatocellular Carcinoma from Cirrhosis

Background:

Overexpression and constitutive activation of signal transducer and activator of transcription (STAT) 3 have been suggested in the tumorigenesis of many human cancers, including multiple carcinomas, melanoma, and lymphoma. The diagnosis of hepatocellular carcinoma (HCC) in lobectomy specimens is usually straightforward, but distinguishing cirrhosis from well-differentiated HCC can be challenging in core biopsies. Our aims were to investigate the expression level of STAT3 and phosphorylated STAT3 (pSTAT3) in HCC and cirrhosis, and the application of STAT3 in the differential diagnosis of HCC and cirrhosis.

Methods:

Sixty cases were divided into three groups: patients with HCC only (Group 1), HCC and cirrhosis (Group 2), and cirrhosis only (Group 3). Formalin-fixed and paraffin-embedded tissue sections were stained immunohistochemically for STAT3, pSTAT3, and CD163. The values obtained from the tissue sections of each group were compared in statistical analysis.

Results:

STAT3 showed a high level in HCC and was a significant marker for differentiating HCC from cirrhosis (P < 0.0001). The odds ratio between HCC and cirrhosis increased 34.4 times when the intensity of STAT3 increased by 1 level. Spearman's correlation and Chi-square tests also demonstrated that expression level of STAT3 did not correlate with age, gender, or the presence of a cirrhotic background.

Conclusions:

STAT3 staining differs significantly in HCC and cirrhosis. The findings reinforce the role of STAT3 in the tumorigenesis of HCC and provide a useful marker to differentiate HCC from cirrhosis in challenging liver biopsies.

Hepatobiliary MRI as novel selection criteria in liver transplantation for hepatocellular carcinoma

BACKGROUND & AIMS

Hepatobiliary magnetic resonance imaging (MRI) provides additional information beyond the size and number of tumours, and may have prognostic implications. We examined whether pretransplant radiological features on MRI could be used to stratify the risk of tumour recurrence after liver transplantation (LT) for hepatocellular carcinoma (HCC).

METHODS

A total of 100 patients who had received a liver transplant and who had undergone preoperative gadoxetic acid-enhanced MRI, including the hepatobiliary phase (HBP), were reviewed for tumour size, number, and morphological type (e.g. nodular, nodular with perinodular extension, or confluent multinodular), satellite nodules, non-smooth tumour margins, peritumoural enhancement in arterial phase, peritumoural hypointensity on HBP, and apparent diffusion coefficients. The primary endpoint was time to recurrence.

RESULTS

In a multivariable adjusted model, the presence of satellite nodules [hazard ratio (HR) 3.07; 95% confidence interval (CI) 1.14-8.24] and peritumoural hypointensity on HBP (HR 4.53; 95% CI 1.52-13.4) were identified as independent factors associated with tumour recurrence. Having either of these radiological findings was associated with a higher tumour recurrence rate (72.5% vs. 15.4% at three years, p <0.001). When patients were stratified according to the Milan criteria, the presence of these two high-risk radiological findings was associated with a higher tumour recurrence rate in both patients transplanted within the Milan criteria (66.7% vs. 11.6% at three years, p <0.001, n = 68) and those who were transplanted outside the Milan criteria (75.5% vs. 28.6% at three years, p <0.001, n = 32).

CONCLUSIONS

Radiological features on preoperative hepatobiliary MRI can stratify the risk of tumour recurrence in patients who were transplanted either within or outside the Milan criteria. Therefore, hepatobiliary MRI can be a useful way to select potential candidates for LT.

LAY SUMMARY

High-risk radiological findings on preoperative hepatobiliary magnetic resonance imaging (either one of the following features: satellite nodule and peritumoural hypointensity on hepatobiliary phase) were associated with a higher tumour recurrence rate in patients transplanted either within or outside the Milan criteria.

Hepatocellular Carcinoma: Retrospective Evaluation of the Correlation Between Gadobenate Dimeglumine-Enhanced Magnetic Resonance Imaging and Pathologic Grade

OBJECTIVE

The aim of this study was to evaluate the usefulness of gadobenate dimeglumine-enhanced magnetic resonance imaging in characterizing the grade of hepatocellular carcinoma (HCC) using the signal intensity (SI) of the erector spinae as internal reference.

MATERIALS AND METHODS

Clinical data of 40 patients (a total of 44 lesions) confirmed by pathology for HCC were retrospectively reviewed. Gadobenate dimeglumine-enhanced magnetic resonance imaging was performed in all patients, and SI of lesions (SIles), liver parenchyma around the lesions (SIhep), erector spinae (SImus) and standard deviation of SI of the surrounding noise (SDnoi) on nonenhanced T2WI, nonenhanced T1WI, and contrast-enhanced T1WI (in both arterial and hepatobiliary phase [AP and HBP]) were measured, respectively. Contrast-to-noise ratio (CNR) were separately defined as CNR1 ([SIles - SIhep]/SDnoi) and CNR2 ([SIles - SImus]/SDnoi). Statistical analyses were performed using one-way analysis of variance, least significant difference test, logistic regression analysis, Spearman rank correlation, and receiver operating characteristic curves analysis.

RESULTS

Forty-four HCCs, including 3 well-differentiated HCCs, 26 moderately differentiated HCCs, and 15 poorly differentiated (PD) HCCs, were confirmed. On logistic regression analysis, only CNR2 in the HBP was predictor of PD HCCs (P = 0.015, odds ratio = 1.040). The size of lesions, CNR1 in the AP, CNR2 in the AP, and CNR2 in the HBP, showed significant correlations with the degree of differentiation (correlation coefficients = -0.371, 0.435, 0.503, and 0.512, respectively; P = 0.013, 0.003, 0.001, and 0.000, respectively). Contrast-to-noise ratio 2 in the HBP with the cutoff of less than 4.56 could distinguish moderately differentiated HCCs from PD HCC with the sensitivity and specificity of 84.6% and 60.0%, respectively.

CONCLUSIONS

Relatively low arterial enhancement and low CNR2 value in the HBP are predictive for poor histological grade of HCCs.

Multiple Antigen Stimulating Cellular Therapy (MASCT) For Hepatocellular Carcinoma After Curative Treatment: A Retrospective Study

Background & Aims: The prognosis of hepatocellular carcinoma (HCC) remains poor and available treatment options are limited. This retrospective study evaluated the efficacy of Multiple Antigen Stimulating Cell Therapy (MASCT) as an adjuvant therapy for the treatment of HCC after curative treatment.

Methods: Patients who underwent HCC curative treatments were classified into two groups: the MASCT group, in which patients received MASCT treatment after curative treatment (n = 47), and the control group, in which patients did not receive any treatment after curative treatment (n = 99). Patients who received ≥ 5 courses of MASCT treatment before recurrence or death (n = 26) were further stratified into a subgroup (multiple-course MASCT group) for analysis. The primary endpoint was overall survival (OS). The secondary endpoints were disease-free survival (DFS) and safety.

Results: Kaplan-Meier analysis showed no statistically significant difference in OS between the MASCT group and the control group (P = 0.132), nor in DFS (P = 0.310) (median: 36.17 vs. 24.27 months). However, when comparing the multiple-course MASCT treated group to the control group, Kaplan-Meier analysis showed a significant difference in OS (P = 0.011), but not in DFS (P = 0.104) (median: 47.10 vs. 24.27 months). The overall incidences of treatment-related adverse events in the MASCT group and control group were 14.89% (7/47) and 19.19% (19/99), respectively. No MASCT treatment-related serious adverse events were reported.

Conclusions: Although the MASCT group was not associated with significantly longer OS or DFS, the multiple-course MASCT group showed significantly improved overall survival after curative treatment, and the treatment procedures were well-tolerated. Multiple-course MASCT may therefore provide another choice for patients with HCC after curative treatment.

Microarray analysis on the lncRNA expression profile in male hepatocelluar carcinoma patients with chronic hepatitis B virus infection

Long non-coding RNAs are involved with development and progression of cancer, and the advance of microarray technology allows the researchers to investigate the complete expression profile of lncRNA in various kinds of sample. We enrolled 5 male primary HCC cases with chronic HBV infection and the HCC and normal tissues have been obtained during the resection surgery. After total RNA extraction, the lncRNA microarray analysis was conducted to determine the lncRNA and mRNA expression signals. 612 lncRNAs and 1,064 mRNAs were significantly up-regulated in HCC tissue while 656 lncRNAs and 1,532 mRNAs were down-regulated in HCC tissues. Compared with normal tissues, XLOC_007433 (fold change: 12.80) and AC144449.1 (fold change: 27.20) were the most over- and under-expressed lncRNAs in HCC tissues. As for the mRNA, THBS4 (fold change:41.13) and CXCL14 (fold change: 58.03) were the most over- and under-expressed mRNAs in HCC tissues when comparing with their normal counterparts. In total, 4,552 pairs of lncRNA-mRNA were identified and the co-expression network was constructed. Moreover, the gene ontology enrichment analysis showed that the significantly different transcript between HCC and normal tissues were mainly associated with response to wounding, inflammatory response, protein hetrodimerization activity, response to stress which involved with biological process and molecular function. The pathway analysis suggested that the most significant pathways consisted of alcoholism, regulatory RNA pathways and RNA polymerase transcription. Several novel differentially expressed lncRNAs and mRNAs were identified in the present study.

Prognostic significance of combining high mobility group Box-1 and OV-6 expression in hepatocellular carcinoma

The inflammatory environment and existence of cancer stem cells are critical for progression and intrahepatic recurrence of hepatocellular carcinoma (HCC) after curative resections. Here, we investigated the prognostic significance of combining high mobility group box 1 (HMGB1) expression and hepatic progenitor marker OV6 in hepatocellular carcinoma. Expression of HMGB1 and OV6 was evaluated using immunohistochemistry profiling in tissue microarrays containing samples from 208 HCC patients. Invasive clinical or pathological factors were found in patients with high expression of HMGB1 or OV6. Higher HMGB1 was associated with poorer clinical outcomes, and independently related to elevated 5-year recurrence incidence (85.5% vs. 62.4%, P<0.001). We also found that more OV6 positive staining was correlated with poor prognosis of HCC patients (P<0.001). Notably, expression of HMGB1 was positively correlated with OV6 in density (R²=0.032, P<0.001) and reversely related to HCC outcomes. Abnormal expression of HMGB1 in combination with positive staining of OV6 displayed poorer prognostic performance than single biomarker alone (area under curve (AUC) survival=0.696). Therefore, HMGB1 and OV6 positive staining are promising prognostic parameters for HCC, and we propose that HMGB1 and OV6 may cooperate with each other and predict poor prognosis of HCC.

Prognostic values of long non-coding RNA MIR22HG for patients with hepatocellular carcinoma after hepatectomy

Hepatocellular carcinoma (HCC) is the fifth most frequently diagnosed cancer worldwide and the second most frequent cause of cancer death. The aim of this study is to identify the association between the expression of long non-coding RNA (lncRNA) MIR22HG and the clinical and tumor characteristics of patients with HCC, and to explore the prognostic significance of lncRNA MIR22HG on patients with HCC. We retrospectively reviewed 127 patients with HCC(42 female, 85 male) who were managed in our hospital between May 1^st 2010 and June 30^th 2016. The expressions of lncRNA MIR22HG were detected by real-time PCR. Prognostic factors were evaluated using Kaplan-Meier curves and Cox proportional hazards models. For the entire cohort of 127 patients, the normalized real-time PCR showed that the expression of lncRNA MIR22HG was lower in HCC tissues compared with corresponding nontumorous tissues. MTT assay showed that si-MIR22HG remarkably inhibited the proliferation tumor cells in three HCC cell lines including SMMC-7721, Huh-7 and Hep3B. Moreover, under-expression of MIR22HG was closely related to tumor encapsulation, microvascular invasion (MVI), and TNM stage. Cox proportional hazards analysis demonstrated that lncRNA MIR22HG under-expression was an independent risk factor associated with the prognosis of patients with HCC. In conclusion, we found that lncRNA MIR22HG expressed significantly lower in HCC tissues compared with non-tumorous tissues. Under-expression of lncRNAMIR22HG was an independent risk factor associated with the prognosis of patients with HCC.

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.

Nomograms for prediction of long-term survival in elderly patients after partial hepatectomy for hepatocellular carcinoma

BACKGROUND

Partial hepatectomy is an important treatment for elderly patients with hepatocellular carcinoma. However, prediction of long-term outcomes of an individual elderly patient after partial hepatectomy still is lacking. This study aimed to develop 2 nomograms to pre- or postoperatively predict overall survival for these patients.

METHODS

Of the 528 elderly patients (aged ≥65 years) who underwent partial hepatectomy for hepatocellular carcinoma at the Eastern Hepatobiliary Surgery Hospital between 2008 and 2011, 425 patients served as a training cohort to develop pre- and postoperative nomograms, and the remaining 103 patients comprised a validation cohort. The Cox proportional hazards model was used for univariate and multivariable analyses of tumor recurrence and overall survival. Discrimination and calibration of the models were measured using the concordance index, calibration plots, and Kaplan-Meier curves.

RESULTS

Based on preoperative data, the independent risk factors of overall survival were age ≥75 years, Charlson score, α-fetoprotein ≥20 μg/L, hepatitis B virus-deoxyribonucleic acid ≥10⁴ IU/mL, and tumor diameter. Based on postoperative data, nonanatomic hepatectomy, absence of tumor encapsulation, and presence of microvascular invasion were additional independent risk factors. These independent predictors were incorporated into the pre- and postoperative nomograms, respectively. The concordance indexes of the 2 nomograms for overall survival prediction were 0.70 (95% confidence interval, 0.67-0.74) and 0.72 (0.69-0.78), respectively. Both nomograms accurately predicted 1-, 3-, and 5-year overall survival probability, and their predictive performances were optimally validated.

CONCLUSION

The proposed 2 nomograms showed good individualized predictive performance in elderly patients with hepatocellular carcinoma before and after partial hepatectomy.

Characterization of small (≤3 cm) hepatic lesions with atypical enhancement feature and hypointensity in hepatobiliary phase of gadoxetic acid-enhanced MRI in cirrhosis: A STARD-compliant article

It is difficult to characterize the nodular lesions in cirrhotic liver if typical enhancement pattern is not present on dynamic contrast-enhanced imagings. Although the signal intensity of the hepatobiliary phase in gadoxetic acid-enhanced magnetic resonance imaging (MRI) is helpful for characterization of the lesions, some dysplastic nodules may also exhibit low signal intensity in the hepatobiliary phase. We aimed to assess the usefulness of gadoxetic acid (Gd-EOB-DTPA)-enhanced MRI including diffusion-weighted imaging (DWI) for differentiation between atypical small hepatocellular carcinomas (HCCs) and dysplastic nodules showing low signal intensity (SI) in the hepatobiliary phase, and to evaluate the MRI findings in determining the histological grade of atypical HCCs in patients with cirrhosis.A total of 43 cirrhotic patients with a small (≤3 cm) liver nodule (n = 25, HCC; n = 18, dysplastic nodule) who underwent Gd-EOB-DTPA-enhanced MRI and pathologic confirmation were retrospectively reviewed. Atypical HCC was defined as not showing arterial hyperenhancement and delayed washout on dynamic MRI.High SI on both T2WI and DWI (sensitivity 80.0%, specificity 100%, positive predictive value 100%, negative predictive value 78.3%) was the most specific feature to differentiate atypical HCCs from dysplastic nodules. High SI on both T2WI and DWI (100% vs 61.5%, P = .039) or low SI on pre-enhanced T1WI (83.3% vs 30.8%, P = .021) was more frequent observed in Edmonson grade II-III HCCs compared with those in grade I HCCs.The combination of DWI and T2WI is most useful for the differentiation of atypical small HCCs from dysplastic nodules showing low SI in the hepatobiliary phase. Combination of DWI and T2WI or pre-enhanced T1WI seems to be useful for predicting the histological grade of atypical HCCs.

Long non-coding RNA NEAT1 overexpression is associated with unfavorable prognosis in patients with hepatocellular carcinoma after hepatectomy: A Chinese population-based study

AIM

To identify the association between the expression of lncRNA NEAT1 and clinicopathological characteristics of patients with HCC, and to explore the prognostic significance of lncRNA NEAT1 in predicting prognosis of HCC.

METHODS

We retrospectively reviewed 86 patients with HCC (35 female, 51 male) managed in our institution between 2009 and 2014. The expression level of lncRNA NEAT1 was detected by real-time PCR. Prognostic factors were evaluated using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

For the entire cohort of 86 patients, we showed that the expression level of NEAT1 was significantly higher in HCC tissues compared with non-tumorous tissues and NEAT1 was increased obviously in the HCC cell lines including SMMC-7721, Huh-7 and Hep3B (P < 0.001). MTT assay showed that si-NEAT1 remarkably inhibited the cell proliferation in three HCC cell lines. Moreover, over-expression of lncRNA NEAT1 was closely related to liver cirrhosis (P = 0.026), microvascular invasion (MVI) (P = 0.023), and TNM stage (P = 0.017). After adjusting for competing risk factors, we identified that expression level of lncRNA NEAT1 was an independently risk factor associated with the prognosis of patients with HCC (P = 0.031).

CONCLUSIONS

In this study, we found NEAT1 expressed significantly higher in HCC tissues compared with non-tumorous tissues. Overexpression of lncRNA NEAT1 was an independently risk factor associated with the prognosis of patients with HCC.

Prognostic value and preoperative predictors of microvascular invasion in solitary hepatocellular carcinoma ≤ 5 cm without macrovascular invasion

Objectives

The aim of this study was to investigate the prognostic value and preoperative predictors of microvascular invasion (MVI) in solitary hepatocellular carcinoma (HCC) ≤ 5 cm without macrovascular invasion.

Methods

A total of 233 consecutive HCC patients underwent curative hepatectomy were included in our study. Independent risk factors influencing the prognosis were identified, and preoperative predictors for MVI were determined.

Results

Multivariate regression analysis identified ICG-R15, BCLC staging and MVI as independent risk factors for the overall survival rate. Type of resection and MVI were independent risk factors for the recurrence-free survival rate. Kaplan-Meier analysis showed the overall survival and recurrence-free survival rates in patients with MVI were significantly poorer than those in patients without MVI (P = 0.002 and P = 0.001). Anatomical resection obviously improved the overall survival and recurrence-free survival rates in patients with MVI compared with non-anatomical resection (P = 0.017 and P = 0.009). A prediction scoring system for MVI was built up according to the three independent predictors (tumor size > 3.5 cm, AFP > 200 ng/mL and GGT > 53 U/L). The prevalence of MVI in HCC patients with predictive score ≥ 2 was 58.3%, which was obviously higher than patients with predictive score < 2 (20.8%).

Conclusions

MVI is associated with a poor prognosis in solitary HCC ≤ 5 cm after hepatectomy. Anatomical resection could improve the prognosis of HCC patients with MVI. The preoperative prediction scoring model has practical value for the prediction of MVI.

A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma

OBJECTIVE

To review the current management, outline recent advances and address controversies in the management of hepatocellular carcinoma (HCC).

SUMMARY OF BACKGROUND DATA

The treatment of HCC is multidisciplinary involving hepatologists, surgeons, medical oncologists, radiation oncologists, radiologists, interventional radiologists, and other disciplines. Each of these disciplines brings its unique perspective and differing opinions that add to controversies in the management of HCC.

METHODS

A focused literature review was performed to identify recent studies on the management of HCC and thereby summarize relevant information on the various therapeutic modalities and controversies involved in the treatment of HCC.

RESULTS

The main treatment algorithms continue to rely on hepatic resection or transplantation with controversies involving patients harboring early stage disease and borderline hepatic function. The other treatment strategies include locoregional therapies, radiation, and systemic therapy used alone or in combination with other treatment modalities. Recent advances in locoregional therapies, radiation, and systemic therapies have provided better therapeutic options with curative intent potential for some locoregional therapies. Further refinements in combination therapies such as algorithms consisting of locoregional therapies and systemic or radiation therapies are likely to add additional options and improve survival.

CONCLUSIONS

The management of HCC has witnessed significant strides with advances in existing options and introduction of several new treatment modalities of various combinations. Further refinements in these treatment options combined with enrollment in clinical trials are essential to improve the management and outcomes of patients with HCC.

Contrast-enhanced computed tomography plus gadolinium-ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging for gross classification of hepatocellular carcinoma

Accurate gross classification through imaging is critical for determination of hepatocellular carcinoma (HCC) patient prognoses and treatment strategies. The present retrospective study evaluated the utility of contrast-enhanced computed tomography (CE-CT) combined with gadolinium-ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) for diagnosis and classification of HCCs prior to surgery. Ninety-four surgically resected HCC nodules were classified as simple nodular (SN), SN with extranodular growth (SN-EG), confluent multinodular (CMN), or infiltrative (IF) types. SN-EG, CMN and IF samples were grouped as non-SN. The abilities of the two imaging modalities to differentiate non-SN from SN HCCs were assessed using the EOB-MRI hepatobiliary phase and CE-CT arterial, portal, and equilibrium phases. Areas under the ROC curves for non-SN diagnoses were 0.765 (95% confidence interval [CI]: 0.666-0.846) for CE-CT, 0.877 (95% CI: 0.793-0.936) for EOB-MRI, and 0.908 (95% CI: 0.830-0.958) for CE-CT plus EOB-MRI. Sensitivities, specificities, and accuracies with respect to identification of non-SN tumors of all sizes were 71.4%, 81.6%, and 75.5% for CE-CT; 96.4%, 78.9%, and 89.3% for EOB-MRI; and 98.2%, 84.2%, and 92.5% for CE-CT plus EOB-MRI. These results show that CE-CT combined with EOB-MRI offers a more accurate imaging evaluation for HCC gross classification than either modality alone.

Early stage hepatocellular carcinoma in the elderly: A SEER database analysis

BACKGROUND

Scarce evidence exists regarding the management of elderly patients (≥70years) with hepatocellular carcinoma (HCC). This study assessed the presentation and outcomes of elderly patients with early stage HCC.

METHODS

Patient with early stage HCC (T1/T2N0M0), ≥70years, diagnosed between 2004 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity score matching (for receipt of localized treatment) was performed considering baseline characteristics (age, gender, race, tumor (T) stage, tumor size, fibrosis score, alpha fetoprotein level and histological subtype).

RESULTS

A total of 6693 patients were identified. The median age group was 75-80years, and 2457 patients received local treatment (either surgical or non-surgical treatment). Both before and after propensity score matching, cancer-specific and overall survival (P<0.0001 for all) were better in the local treatment group. When stratifying the overall survival according to age group (70-80years vs. >80years) in the post matching cohort, patients treated with local treatment have better overall survival than those not treated regardless of the age group (P<0.0001 for both groups). In multivariate analysis of the matched population: local treatment, normal AFP and age (70-80years) were associated with better overall survival (P<0.0001, P<0.0001, P=0.047; respectively).

CONCLUSION

Within the known limitations of the current SEER analysis, it may be cautiously suggested that elderly patients with early HCC should be properly selected for potentially curative local therapies. Prospective confirmation of these results should be conducted.

Role of liver-directed local tumor therapy in the management of hepatocellular carcinoma with extrahepatic metastases: a SEER database analysis

BACKGROUND

This study assessed the prognostic impact of the liver-directed local tumor therapy in the management of hepatocellular carcinoma (HCC) with extrahepatic metastases.

METHODS

Metastatic HCC patients diagnosed between 2004 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity-matched analysis was performed considering baseline characteristics (age, gender, race, histology, TNM stage, site of metastases, fibrosis score and alpha fetoprotein).

RESULTS

A total of 2529 patients were identified. The median age was 65 years, and 151 patients received liver-directed local treatment (either surgical treatment or local destructive treatment). Both before and after propensity score matching, cancer-specific and overall survival (p < 0.0001 for all) were better in the liver-directed local therapy group. When the overall survival was stratified by the type of local treatment (surgical resection versus destructive treatment), both types of treatment improved overall survival (p < 0.0001 for both). In multivariate analysis of the matched population, the only factor correlated with better survival receiving is local therapy (p < 0.0001).

CONCLUSION

This analysis suggests that liver-directed local treatment may play a role -in addition to systemic treatment- in the management of selected patients with metastatic HCC. Further prospective randomized controlled trials are needed to confirm or deny this hypothesis.

Association between age and overall survival of patients with hepatocellular carcinoma after hepatic resection

AIM

The suitability of hepatic resection for older patients remains controversial. This study aimed to investigate whether age influences overall survival of patients with hepatocellular carcinoma (HCC) after resection.

METHODS

Records of 1,132 patients with HCC after hepatic resection were retrospectively reviewed. Overall survival (OS) was compared between younger and older patients based on five cut-off ages (30, 40, 50, 60, and 70 years).

RESULTS

Across all patients, OS was 89.7% at 1 year, 67.7% at 3 years, and 47.7% at 5 years. OS was similar between younger and older patients at all cut-off ages (all P > 0.1), but OS was marginally lower among patients >70 years old than those ≤70 (P = 0.090). Multivariate analyses identified several risk factors for lower OS: preoperative serum albumin <35 g/L, alanine aminotransferase >80 U/L, α-fetoprotein ≥400 ng/ml, presence of esophagogastric varices or macrovascular invasion, incomplete/absent tumor capsule, tumor size >10 cm, tumor number ≥3, and major hepatectomy.

CONCLUSION

Age does not influence the prognosis of patients with HCC after hepatic resection. Older patients should be considered for curative resection if remnant liver volume and liver function are adequate. J. Surg. Oncol. 2016;114:966-970. © 2016 Wiley Periodicals, Inc.

Comparison of Contrast-Enhanced Ultrasound and Gadolinium-Ethoxybenzyl-Diethylenetriamine Pentaacetic Acid-Enhanced MRI for the Diagnosis of Macroscopic Type of Hepatocellular Carcinoma

OBJECTIVE

We compared the efficacy of contrast-enhanced ultrasound sonography (CEUS) with sonazoid and gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI for the assessment of macroscopic classification of nodular hepatocellular carcinoma (HCC).

METHODS

Seventy-seven consecutive patients with 79 surgically resected HCCs who underwent both preoperative CEUS and Gd-EOB-DTPA-enhanced MRI were enrolled in this retrospective study. Based on the macroscopic diagnosis of resected specimens, nodules were categorized into the simple nodular (SN) and non-SN type HCC. Two hepatologists independently assessed image datasets of the post-vascular phase of CEUS and hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI to compare their diagnostic performance.

RESULTS

Gd-EOB-DTPA-enhanced MRI enabled the evaluation of macroscopic classification in a significantly larger number of nodules than CEUS (78/79 (98.7%) vs. 70/79 (88.6%), p < 0.05). Of 70 nodules that could be evaluated by both modalities, 41 and 29 nodules were pathologically categorized as SN and non-SN, respectively. The areas under the receiver operating characteristic curve (AUC) for non-SN did not differ between CEUS and Gd-EOB-DTPA-enhanced MRI (reader 1: 0.748 for CEUS, 0.808 for MRI; reader 2: 0.759 for CEUS, 0.787 for MRI). The AUC of combined CEUS and Gd-EOB-DTPA-enhanced MRI for SN HCC was 0.855 (reader 1) and 0.824 (reader 2), indicating higher AUC values for the combined modalities.

CONCLUSIONS

The diagnostic performance for macroscopic classification of nodular HCC of CEUS was comparable with that of Gd-EOB-DTPA-enhanced MRI, although some HCCs could not be evaluated by CEUS owing to lower detectability. The combination of the 2 modalities had a more accurate diagnostic performance.

The role of quantitation of real-time 3-dimensional contrast-enhanced ultrasound in detecting microvascular invasion: an in vivo study

PURPOSE

This study was to evaluate the role of quantitative perfusion analysis of 3-dimensional (3D) contrast-enhanced ultrasound (CEUS) in detecting microvascular invasion (MVI) of liver tumor in vivo.

METHODS

VX2 tumors were implanted in the livers of sixteen New Zealand rabbits. On day 10, real-time 3D CEUS was performed, and the real-time dynamic images were analyzed using online quantification software. The animals were sacrificed and sent for pathology examinations. According to the gold standard of pathology, the animals were divided into an MVI group and a group without MVI (non-MVI group). Time-intensity curves (TICs) were obtained for the VX2 tumors and the surrounding liver parenchyma, and the parameters peak intensity (PI), mean transit time (MTT), and time to peak (TTP) were compared within and between the MVI and non-MVI groups.

RESULTS

The TTP and MTT of the VX2 tumors were significantly faster than those of the surrounding liver parenchyma in both MVI and non-MVI groups. The PI of the VX2 tumors was significantly lower than that of the surrounding liver parenchyma in the non-MVI group but not the MVI group. The TTP and MTT of the VX2 tumors and surrounding liver parenchyma were not significantly different in the MVI group compared with the non-MVI group, whereas the ΔPI (the PI ratio between the VX2 liver tumors and the reference liver parenchyma) of the VX2 tumors in the MVI group was larger than that in the non-MVI group. VX2 tumors with MVI present different hemodynamic parameters, with a larger ΔPI than tumors without MVI.

CONCLUSIONS

Our data suggest that quantitative perfusion analysis of 3D CEUS might be a promising method for predicting MVI in liver tumors.

Prognostic factors for survival after hepatic resection of early hepatocellular carcinoma in HBV-related cirrhotic patients

OBJECTIVE

The study aimed to identify clinico-pathologic factors that predict survival in early hepatocellular carcinoma (HCC) patients with hepatitis B virus (HBV)-related cirrhosis undergoing liver resection.

METHODS

A population-based cohort was investigated to identify cirrhotic patients with confirmed early HCC (tumor size≤5cm and absence of nodal involvement, metastases, or major vascular invasion) after hepatic resection at the Eastern Hepatobiliary Surgery Hospital (Shanghai, China) from April 2005 and November 2010 using the Surveillance, Epidemiology, and End Results (SEER) database. These patients were studied retrospectively in terms of their clinical characteristics and prognostic factors. Predictors for survival were evaluated using Kaplan-Meier methods and Cox proportional hazards models. Besides, a simple prognostic scoring system was proposed to stratify these patients.

RESULTS

Of 537 (2.6% of all HCC patients in this period) cirrhotic patients with early HCC identified who had underwent liver resection, 87% were male. Median tumor size was 2.9cm, and 67% of patients had tumors>2cm. Following hepatic resection, overall median and 5-year survival were 75 months and 58%, respectively. Tumor size>2cm (hazard ratio [HR]=1.56), multifocality (HR=1.34), non-anatomic resection (HR=1.44) and vascular invasion (HR=2.03) were associated with worse prognosis (P<0.05). Moreover, these patients could be further stratified into 4 distinct prognostic groups based on the prognostic scoring system developed.

CONCLUSION

Tumor size>2cm, multifocality, non-anatomic resection and vascular invasion may be used to stratify HBV-related cirrhotic patients with early HCC after resection. Besides, these data also indicate that pathologic staging is important even in small HCC.

Prognostic factors affecting postoperative survival of patients with solitary small hepatocellular carcinoma

Background

Small hepatocellular carcinoma (sHCC) is a unique variant of HCC that is characterized by small tumor size (maximum tumor diameter ≤3 cm) and favorable long-term outcomes. The present study aimed to define clinicopathologic factors that predict survival in patients with sHCC.

Methods

The study population consisted of 335 patients who underwent hepatectomy for solitary sHCC between December 1998 and 2010. Prognostic factors were evaluated using Kaplan–Meier curves and Cox proportional hazard models.

Results

The 5-year overall survival (OS) and recurrence-free survival (RFS) rates were 77.7% and 59.9%, respectively. Kaplan–Meier curves showed that tumor size and vascular invasion had prognostic significance within this relatively selected cohort (P < 0.05). Multivariate analysis confirmed that increased tumor size and vascular invasion were independent prognostic factors for short OS (hazard ratio [HR] = 2.367, 95% confidence interval [CI] 1.406–3.985; HR = 2.954, 95% CI 1.781–4.900) and RFS (HR = 1.779, 95% CI 1.259–2.514; HR = 1.699, 95% CI 1.165–2.477) in sHCC patients (P < 0.05). Importantly, a proposed prognostic scoring model was derived according to the two variables; tumor size and extent of vascular invasion were significantly associated with OS and RFS in patients with sHCC (P < 0.001).

Conclusions

Tumor size and vascular invasion are feasible and useful prognostic factors for sHCC. The proposed prognostic model, based on tumor size and vascular invasion, is informative in predicting survival in sHCC patients undergoing hepatectomy.

Upregulation of FAM83D affects the proliferation and invasion of hepatocellular carcinoma

The identification of potential oncogenes plays an important role in finding novel therapeutic targets for many cancers, including hepatocellular carcinoma (HCC), which is one of the most common cancers worldwide. In our previous research, using microarray technology, we found that FAM83D was overexpressed in HCCs. However, whether the overexpression of FAM83D contributes to hepatocarcinogenesis remains unclear. In this study, we found that FAM83D was significantly upregulated in 76.6% (167 of 218) of the HCC specimens at the mRNA level and in 69.44% (50 of 72) of the HCC specimens at the protein level compared with adjacent non-cancerous liver specimens, as indicated by RT-PCR and immunohistochemical staining, respectively. The FAM83DmRNA expression level was positively correlated with the level of alpha-fetoprotein (AFP) (≥100 ng/ml), the clinical TNM stage, the presence of a portal vein tumor thrombus (PVTT), disease-free survival (DFS) and the overall survival (OS) time of the HCC patients (P < 0.05). Knocking down FAM83D significantly promoted the growth of Huh7 and HepG2 cells, as demonstrated in an RNA interference assay. Moreover, the DNA methylation status of the FAM83D promoter was significantly reduced in the HCC specimens with overexpression of FAM83D gene. Our data suggest that the upregulation of FAM83D, a potential oncotarget gene, may be triggered by epigenetic events and can contribute to hepatocarcinogenesis.

Applying of pretreatment extent of disease system in patients with hepatocellular carcinoma after curative partial hepatectomy

The Pretreatment Extent of Disease System (PRETEXT) was designed for childhood liver tumors. The aim of this study was to confirm the prognostic value of the PRETEXT staging system compared with the currently and commonly used staging systems of hepatocellular carcinoma (HCC) after applying PRETEXT system in patients with HCC who underwent curative partial hepatectomy.Clinical data of consecutive patients who underwent curative partial hepatectomy were collected between February 1st, 2005 to December 30th, 2012 as the primary and internal validation cohort. Similar patients from a western hospital formed an external validation cohort. The predictive accuracy of the PRETEXT system compared with the currently used staging systems was measured by the area under the curve (AUC) on receiver operating characteristic (ROC) curve analysis. Of the 507 patients in the primary cohort, the overall median survival was 52.3 months, and the 1-year, 3-year, and 5-year overall survival rates were 83.0%, 56.8%, and 40.2%, respectively. The multivariate analysis of Cox proportional hazard regression identified INR (p=0.001), microvascular invasion (p=0.042), maximum tumor size (p=0.002) and PRETEXT staging system were independently predictors of overall survival. In the primary cohort, the AUC of the PRETEXT system was 0.702 (95% CI, 0.656 to 0.747), which was higher than the other conventional staging systems for predicting OS of HCC (P<0.01). These findings were confirmed with the internal and external validation cohorts.This study showed that the PRETEXT was a good prognostic staging system for HCC. It performed better than the conventional and commonly used staging systems in predicting survival of patients with HCC after curative partial hepatectomy.

Increased Expression of SETD7 Promotes Cell Proliferation by Regulating Cell Cycle and Indicates Poor Prognosis in Hepatocellular Carcinoma

Purpose

To investigate the role of SET domain containing 7 (SETD7) in hepatocellular carcinoma (HCC) and determine whether SETD7 can be used as a predictor of overall survival in HCC patients.

Methods

mRNAs and proteins of SETD7 and related genes in HCC tumor samples and paired adjacent non-tumorous liver tissues (ANLTs) (n = 20) or culture cells were determined by quantitative real-time PCR and Western blot. Cell proliferation and apoptosis with SETD7 knockdown SMMC-7721 cells or SETD7 overexpressed HepG2 cells were analyzed by CCK8 assay or flow cytometry. Gene expression alterations in SETD7 knockdown of SMMC-7721 cells were determined by digital gene expression (DGE) profiling. Defined data on patients (n = 225) with HCC were retrieved for the further study. Tissue microarrays (TMAs) were performed using paraffin tissues with tumor and ANLTs. SETD7 and related proteins were determined by TMAs immunohistochemistry. Statistical analyses were conducted to associate SETD7 expression with tumor features and patient outcomes, as well as related proteins expression.

Results

SETD7 expression was significantly higher in HCC tumor tissues than in ANLTs. SETD7 overexpression in vitro can promote HepG2 cell proliferation, whereas SETD7 knockdown can inhibit SMMC-7721 cell proliferation by regulating the cell cycle. SETD7 expression was significantly correlated with five genes expression. Increased SETD7 is associated with metastasis, recurrence, large tumor size, and poor tumor differentiation, and indicates poor prognosis in HCC patients.

Conclusions

SETD7 plays a critical role in HCC, and its immunohistochemistry signature provides potential clinical significance for personalized prediction of HCC prognosis.

A novel scoring system predicts adjuvant chemolipiodolization benefit for hepatocellular carcinoma patients after hepatectomy

Our aim in this study was to develop a prognostic scoring system with which to identify patients most likely to benefit from adjuvant chemolipiodolization (ACL) after liver resection for hepatocellular carcinoma (HCC). Data from 1150 HCC patients who underwent liver resection between 2002 and 2008 at the Eastern Hepatobiliary Surgery Hospital were used to develop the scoring system. Patients were stratified into prognostic subgroups using the new scoring system, and the outcomes of patients who received ACL and those who did not were compared in each subgroup. Using data from 379 patients operated on between 2008 and 2010 for validation, the scoring system had a concordance index (C-index) of 0.75 for predicting post-resectional overall survival (OS). It optimally stratified patients into three prognostic subgroups with scores of 0-5, 6-9 and ≥ 10, having better, medium and worse survival outcomes, respectively. A difference in OS between ACL and non-ACL patients was only detected in the subgroup with scores ≥ 10 (1-, 3-, and 5-year OS rates: 63.9%, 22.6%, and 9.0% vs. 33.8%, 5.6%, and 2.8%, p = 0.001). Our proposed scoring system provides an effective tool for selecting the patients most likely to benefit from ACL.

Determination of Resectability

The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.

A concise review of updated guidelines regarding the management of hepatocellular carcinoma around the world: 2010-2016

Many guidelines for hepatocellular carcinoma (HCC) have been published and updated globally. In contrast to other cancers, there is a range of treatment options for HCC involving several multidisciplinary care of the patient. Consequently, enormous heterogeneity in management trends has been observed. To support standard care for HCC, we systematically appraised 8 current guidelines for HCC around the world, including 3 guidelines from Asia, 2 from Europe, and 3 from the United States according to the selection criteria of credibility influence and multi-faceted. After a systematic appraisal, we found that these guidelines have both similarities and dissimilarities in terms of surveillance and treatment allocation recommendations due to regional differences in disease and other variables (diagnosis, staging systems) secondary to the lack of a solid, high level of evidence. In contrast to other tumors, the geographic differences in tumor biology (i.e., areas of increased hepatitis B prevalence) and available resources (organ availability for transplantation, medical technology, accessibility to treatment, health systems, and health resources) make it impractical to have an internationally universal guideline for all patients with HCC. Although Barcelona-Clinic Liver Cancer (BCLC) has long been dominant system for treatment-guiding staging of HCC, many Asia-pacific experts do not fully agree with its principle. The concepts of BCLC, for surgical resection or other locoregional therapy, are considered too conservative. Asian guidelines represent consensus about surgical resection and TACE indication for more advanced tumor.

When Should We Propose Liver Transplant After Resection of Hepatocellular Carcinoma? A Comparison of Salvage and De Principe Strategies

INTRODUCTION

The aim of this study was to compare survival outcomes in patients enlisted for liver transplantation following liver resection for hepatocellular carcinoma before or at recurrence.

METHODS

All patients enlisted for liver transplantation following liver resection for hepatocellular carcinoma from 1996 to 2013 were included and compared according to their status at the time of enlistment: before (de principe) or at (salvage) recurrence. Primary end-point was survival since resection.

RESULTS

One hundred and twenty-one patients were enlisted for liver transplantation following liver resection for hepatocellular carcinoma. Ten patients enlisted for cirrhosis decompensation were excluded from the analysis. Sixty-three patients were enlisted de principe, and 48 for a salvage transplantation. Eleven patients dropped-out. According to per-protocol analysis, the mean diameter of the largest tumor was the only different pathological characteristic of initial resection between groups (31.6 mm in the de principe group versus 48.3 in the salvage, p = 0.017). The 5-year overall survival rate was significantly increased in the de principe group compared to salvage (84.6 versus 74.8%, p = 0.017). In a multivariate analysis, the salvage strategy was the only independent prognostic factor for death (p = 0.040; OR = 2.5 [1.1-5.8]).

CONCLUSION

De principe enlistment for liver transplantation following liver resection for hepatocellular carcinoma is associated with greater survival.

Assessment of non-surgical versus surgical therapy for localized hepatocellular carcinoma

BACKGROUND

Localized hepatocellular carcinoma (HCC) in patients with adequate liver function is typically treated with resection. Non-surgical modalities including trans-arterial embolization have emerged as options for intermediate/advanced HCC. Hypothesizing that non-surgical techniques have expanded to localized disease, we examined treatment patterns, factors associated with surgical therapy, and the impact of modality on survival.

METHODS

Non-cirrhotic, localized HCC patients were identified from the National Cancer Data Base (2003-2011). Trends were examined using average annual percent change (AAPC). Regression models were developed to determine factors associated with treatment and assess the association of modality with survival.

RESULTS

Of 10,187 patients (median tumor size: 3.7 cm), 6,387 (62.7%) underwent surgery and 3,800 (37.3%) non-surgical therapy. Surgery declined from 61.6% to 44.5% (AAPC, -3.7%; 95%CI, -4.9% to -2.6%, P < 0.001). Non-surgical therapies increased from 17.2% to 39.2% (AAPC 11.4%; 95%CI, 8.8-14.1%, P < 0.001). White race, higher income, and treatment in an academic center (OR = 1.37, 95%CI 1.13-1.66) were associated with surgery. Patients selected for non-surgical therapy had worse adjusted 5-year survival (HR=2.05, 95%CI 1.85-2.26).

CONCLUSIONS

Non-surgical therapy has become as common as surgery in the treatment of non-cirrhotic, localized HCC. Randomized studies are needed to compare the effectiveness of treatments for this disease.

Intensity-Based Assessment of Microbubble-Enhanced Ultrasonography: Phase-Related Diagnostic Ability for Cellular Differentiation of Hepatocellular Carcinoma

This prospective study aimed to elucidate the effect of phase-related quantitative parameters of contrast-enhanced ultrasound (CEUS) with perflubutane microbubble agent to assess the cellular differentiation of hepatocellular carcinoma (HCC). Intensity was analyzed in 94 lesions (19.4 ± 4.9 mm, 86 patients), 47 well-differentiated HCCs (wHCCs) and 47 moderately-differentiated HCCs (mHCCs): I(e) (early phase) = I(te) (tumor) - I(le) (liver), I(p) (post-vascular phase) = I(tp) (tumor) - I(lp) (liver), I(ep) = I(e) - I(p). The area under the receiver operating characteristic curve with the best cutoff value (I(e), 13.2, I(p), -4.5, I(ep), 21.3) for discriminating between wHCC and mHCC was 0.6922 for Ie, 0.7680 for Ip and 0.7925 for Iep, which indicated a significantly greater ability to differentiate between wHCC and mHCC compared with visual/qualitative assessment (early phase, 0.6170, p = 0.04; post-vascular phase, 0.6702, p = 0.01; both phases, 0.7021, p = 0.04). In conclusion, I(ep) was found to have the highest diagnostic ability, suggesting it is a promising parameter for the cellular differentiation of HCCs with CEUS.

Reappraisal of evidence of microscopic portal vein involvement by hepatocellular carcinoma cells with stratification of tumor size

BACKGROUND

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death internationally, it is necessary to reappraise evidences of HCC cells involving the portal vein, especially considering tumor size.

MATERIALS AND METHODS

Histopathological evidence and dynamic evidences of radiology and cytology from publication were collected and analyzed.

RESULTS

Frequencies of microscopic portal vein involvement (MPVI) and microscopic intrahepatic metastasis (MIM) in resected specimens with single nodule HCC were lower than that of multi nodule HCC, although not significantly. Early HCC (≤1.5 cm) was with extremely low to 0 frequencies of MPVI and MIM. HCC >5 cm showed a tendency of flowing HCC cells into portal vein, which was coincident with significantly high frequency (64.1 %) of MPVI for HCC >5 cm. There were no significant difference of frequencies of MPVI and MIM between groups of tumor ≤2, ≤3, and ≤5 cm.

CONCLUSIONS

Single nodule HCC >5 cm needs anatomic resection and the root of portal vein should be firstly ligated because of tendency of flowing HCC cells into portal vein. For single nodule HCC ≤2 cm, there was a risk of about 16.2 % of MPVI, and a risk of about 16.2-26.4 % of MPVI for those single nodule HCC ≤5 cm, however, there was a risk of extremely low to 0 of MPVI for early HCC (≤1.5 cm). Surgeons have to balance liver reserve and risk of MPVI for HCC ≤5 cm before deciding anatomic or nonanatomic resection.

Impact of multiple liver resections prior to salvage liver transplantation on survival in patients with recurrent HCC

OBJECTIVES

Salvage liver transplantation (SLT) is a controversial technique that has been reported to be acceptable for the management of patients with recurrent hepatocellular carcinoma (HCC) after primary hepatic resection (HR). However, whether the number of times liver resection is performed has an impact on survival after SLT has not yet been reported.

DESIGN

Retrospective study.

SETTING

The level of care is primary and the study was carried out at only 1 centre.

PARTICIPANTS

The study included 59 patients who underwent SLT for HCC from September 2001 to December 2012. 51 patients underwent HR only once before SLT, while the remaining 8 patients underwent HR more than once before SLT (HR=2 [7], HR=3, [1]).

PRIMARY AND SECONDARY OUTCOME MEASURES

In this study, the 1-year, 3-year and 5-year overall and tumour-free survival outcomes between the 2 groups were compared.

RESULTS

There were no significant differences between patients who underwent HR once and those who underwent HR more than once with respect to overall or tumour-free survival after receiving SLT. The 1-year, 3-year and 5-year overall survival rates for patients who underwent HR once were 72.9%, 35.3% and 35.5% vs 50%, 50% and 50%, respectively (p=0.986), while the 1-year, 3-year and 5-year tumour-free survival rates for those who underwent HR more than once were 66.3%, 55.3% and 44.4% vs 40%, 40% and 40%, respectively (p=0.790).

CONCLUSIONS

There was no significant difference in the survival rate of patients who underwent HR once before SLT and those who underwent HR more than once. This suggests that SLT is a reasonable choice for patients who suffer from recurrent HCC after HR.

TRIAL REGISTRATION NUMBER

This is a retrospective study and no registry or number is required.

Disparities in care for patients with curable hepatocellular carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues to be underutilized. This retrospective review investigates treatment decisions and survival for early stage HCC.

METHODS

The National Cancer Database (NCDB) was queried for all patients with curable HCC (Stage I/II) from 1998 to 2011 (n = 43 859). Patient and tumour characteristics were analysed to determine predictors of having surgery and of long-term survival.

RESULTS

Only 39.7% of patients received surgery for early stage HCC. Surgical therapies included resection (34.6%), transplant (28.7%), radiofrequency ablation (27.1%) and other therapies. Surgery correlated with improved median survival (48.3 versus 8.4 months), but was only performed on 42% of stage I patients and 50% of tumours smaller than 2 cm. Patients were more likely to receive surgery if they were Asian or white race, had private insurance, higher income, better education, or treatment at an academic centre (P < 0.05). However, private insurance and treatment at an academic centre were the only variables associated with improved survival (P < 0.05).

CONCLUSION

Fewer than half of patients with curable HCC receive surgery, possibly as a result of multiple socioeconomic variables. Past these barriers to care, survival is related to adequate and reliable treatment. Further efforts should address these disparities in treatment decisions.

Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series

BACKGROUND

The aim of this paper is to assess the current state of quality and outcomes measures being reported for hepatic resections in the recent literature.

METHODS

Medline and PubMed databases were searched for English language articles published between 1 January 2002 and 30 April 2013. Two examiners reviewed each article and relevant citations for appropriateness of inclusion, which excluded papers of liver donor hepatic resections, repeat hepatectomies or meta-analyses. Data were extracted and summarized by two examiners for analysis.

RESULTS

Fifty-five studies were identified with suitable reporting to assess peri-operative mortality in hepatic resections. In only 35% (19/55) of the studies was the follow-up time explicitly stated, and in 47% (26/55) of studies peri-operative mortality was limited to in-hospital or 30 days. The time period in which complications were captured was not explicitly stated in 19 out of 28 studies. The remaining studies only captured complications within 30 days of the index operation (8/28). There was a paucity of quality literature addressing truly patient-centred outcomes.

CONCLUSION

Quality outcomes after a hepatic resection are inconsistently reported in the literature. Quality outcome studies for a hepatectomy should report mortality and morbidity at a minimum of 90 days after surgery.

Effect of Tumor Size on Cancer-Specific Survival in Small Hepatocellular Carcinoma

OBJECTIVE

To further clarify the prognosis of small hepatocellular carcinoma (HCC) in different subgroups and to assess the connection between the tumor cutoff point and its impact on prognostic significance.

PATIENTS AND METHODS

In this study, Surveillance, Epidemiology, and End Results Program-registered patients with small HCC and patients from the Liver Transplantation Center of Nanjing Medical University (LTCNJMU) were combined and analyzed. The optimal cutoff point of the tumor size was determined by using the "X-tile" program. The 60-month, cancer-specific survival data were obtained. Kaplan-Meier methods and multivariable Cox regression models were used to analyze long-term hepatocellular carcinoma-specific survival (HCSS) outcomes and risk factors.

RESULTS

There were significant differences among these different tumor size subgroups with regard to 60-month HCSS rates (P<.001). The X-tile program indicated that the difference in survival was most significant (maximum of χ(2) log-rank values) (P<.001) for the tumor size 35 mm. A stratified analysis of the effect of tumor size on 60-month HCSS rate found that only localized and regional stages could be validated as independent predictors, but not advanced stages.

CONCLUSION

These results confirmed that patients with small HCC are essentially a heterogeneous group. Tumor size is still an independent prognostic factor for resected small HCC, and patients with tumors of 0- to 35-mm diameter have a better 60-month HCSS rate than do those with larger tumors (36-50 mm).

The Feasibility of Third or More Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma

OBJECTIVES

To investigate the feasibility and prognostic benefits of third or more hepatectomy (third or more Hx) for recurrent hepatocellular carcinoma.

BACKGROUND

Second hepatectomy (second Hx) has been accepted as an effective treatment of recurrent hepatocellular carcinoma after first hepatectomy (first Hx). However, the feasibility and efficacy of third or more Hx have not been adequately assessed.

METHODS

Data were reviewed from 1340 patients with hepatocellular carcinoma who underwent curative hepatectomy. Among them, 941, 289, and 110 underwent first Hx, second Hx, and third or more Hx, respectively. Surgical outcomes and long-term survival were compared among the groups.

RESULTS

Surgical duration was significantly longer in third or more Hx (median, 6.4 hours) than in second Hx (median, 5.9 hours). Postoperative bile leakage and wound infection were more frequently observed in third or more Hx versus second Hx (12.5% vs 6.2%, [P = 0.04] and 2.9% vs 0.4% [P = 0.03], respectively). Three and 5-year disease-free survival rates were 36.8% and 27.1% in first Hx, 24.4% and 17.9 % in second Hx, and 26.1% and 12.8% in third or more Hx, respectively (P < 0.01 [first Hx vs third Hx], P = 0.95 [second Hx vs third or more Hx]). The 5-year overall survival rates from each resection were similar among the groups (65.3%, 60.5%, 68.2%, respectively). The 5- and 10-year overall survival rates from initial hepatectomy in patients who received third or more Hx were 91.4% and 75.5%, respectively.

CONCLUSIONS

Third or more Hx is technically demanding in terms of surgical duration and morbidity compared with second Hx. However, aggressive repeat resection offers a survival similar to second Hx, leading to cumulative long-term survival from initial resection.