Risk factors for intrahepatic recurrence in human small hepatocellular carcinoma

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of hepatitis B viral load on recurrence after complete necrosis in patients with hepatocellular carcinoma who receive transarterial chemolipiodolization: implications for viral suppression to reduce the risk of cancer recurrence

BACKGROUND

Hepatocellular carcinoma (HCC) has a high tendency for recurrence after radical treatment. Apart from tumor and liver function parameters, little is known about the role of hepatitis B virus (HBV) factors in the recurrence of HCC. The objective of this study was to identify the potential relation between viral load and HCC recurrence in patients undergoing transarterial chemolipiodolization.

METHODS

This was a cohort study of 62 consecutive patients who had HBV-related HCC and achieved complete necrosis with transarterial chemolipiodolization. Risk factors, including viral load for posttreatment recurrence, were analyzed.

RESULTS

Overall, 32 of 62 patients (51.6%) developed a recurrence during the study period (7.2-37.5 months). Multivariate analysis established Child-Pugh Class B (P = .014), multiple tumors (P = .013), and high viral load (HBV DNA levels >10(5) copies/mL) at complete necrosis (P = .001) as independent risk factors for recurrence. On both univariate and multivariate analyses, high viral load at the time of complete necrosis was identified as the strongest factor for recurrence; moreover, its statistically significant effects still were observed even when conducting the analyses separately for both local recurrence (P = .018) and distant recurrence (P = .009).

CONCLUSIONS

Among individuals who underwent transarterial chemolipiodolization, high HBV viral load at complete necrosis was among the most important risk factors for posttreatment recurrence, irrespective of the locational pattern of recurrence. The current findings underscored the need for future work that tests the applicability of antiviral therapy to reduce the risk of HCC recurrence in this setting.

Longterm favorable results of limited hepatic resections for patients with hepatocellular carcinoma: 20 years of experience

BACKGROUND

Recently, anatomic resection has been, in theory, considered preferable for eradicating portal venous tumor extension and intrahepatic metastasis in hepatocellular carcinoma (HCC). We have reported the effectiveness of limited hepatic resection for cirrhotic patients with HCC.

STUDY DESIGN

A retrospective study was carried out in 321 patients who underwent curative hepatic resection (anatomic resection, n=201; limited resection, n=120) as the initial treatment for solitary HCC<5 cm in our institution in the period 1985 to 2004 (median followup period 5.1 years).

RESULTS

Anatomic resection did not influence overall and recurrence-free survival rates after hepatic resection. In the liver damage A group (n=215), both 5-year overall and recurrence-free survival rates in the anatomic resection group were considerably better than those in the limited resection group (87% versus 76%, p=0.02, and 63% versus 35%, p<0.01, respectively). In the liver damage B group (n=106), both 5-year overall and recurrence-free survival rates in the anatomic resection group were substantially worse than those in the limited resection group (48% versus 72%, p<0.01, and 28% versus 43%, p=0.01, respectively). The results of multivariate analysis revealed that anatomic resection was a notably poor factor in promoting recurrence-free survival in patients with liver damage B.

CONCLUSIONS

Anatomic resection should be recommended for noncirrhotic patients (liver damage A) with HCC. Longterm results of limited hepatic resection proved its validity for cirrhotic patients (liver damage B) with HCC.

Impact of diabetes on recurrence of hepatocellular carcinoma after surgical treatment in patients with viral hepatitis

OBJECTIVES

Consensus has been reached that diabetes is a risk factor for development of HCC, but the impact on postoperative recurrence is still controversial. To clarify this point, we analyzed the relationship of postoperative recurrence rate of HCC and coexistence of diabetes in the patients with viral hepatitis.

METHODS

A total of 90 patients who had undergone curative resection for HCC were analyzed. They were divided into two groups with and without diabetes, and the recurrence-free survival rates after surgical treatment and the factors contributing to recurrence were examined.

RESULTS

Kaplan-Meier survival analysis showed the recurrence-free survival rates in the diabetic group were significantly lower than those in the nondiabetic group (P= 0.005) and overall survival rates in the diabetic group were significantly lower than those in the nondiabetic group (P= 0.005). These results were emphasized in the analysis of patients infected with hepatitis C virus. Univariate and multivariate analyses showed diabetes was a significant factor contributing to HCC recurrence after treatment. Furthermore, multivariate analysis in HCC patients with diabetes showed Child-Pugh classification B (P= 0.001) and insulin therapy (P= 0.049) were significant factors contributing to HCC recurrence after treatment.

CONCLUSIONS

The results of the present study suggest that diabetes is a risk factor for the recurrence of HCV-related HCC and decreases the overall survival rates after surgical treatment. HCV-related HCC patients with diabetes should be closely followed for postoperative recurrence.

Risk factors for intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

BACKGROUND

Long-term survival after hepatectomy for hepatocellular carcinoma is still poor because of tumor recurrence especially in the liver remnant. The risk factors for intrahepatic recurrence after liver resection are studied in our cohort of patients.

METHODS

A retrospective analysis from a prospective database was performed on 76 consecutive successful hepatectomies for hepatocellular carcinoma.

RESULTS

Twenty-two patients had intrahepatic recurrence. The following were not found to be risk factors for recurrence: age, sex, race, number of segments resected, and mean operating time. By using multivariate analysis, serum aspartate transaminase level, more than 1 hepatocellular carcinoma nodule, and presence of tumor thrombi were found to be significant risk factors.

CONCLUSION

Patients who with these risk factors should undergo close follow-up to detect recurrence early; treatment with reresection, chemoembolization, or radiofrequency ablation can be considered.

Predictive power of biomarkers of oxidative stress and inflammation in patients with hepatitis C virus-associated hepatocellular carcinoma

BACKGROUND

This study evaluated the relationship between inflammation, intra-hepatic oxidative stress, oxidative DNA damage and the progression of liver carcinogenesis in hepatitis C virus (HCV)-infected humans.

METHODS

Non-cancerous liver tissues were collected from 30 patients with an HCV-associated solitary hepatocellular carcinoma (HCC) who received curative tumor removal. After surgery, the patients were followed at monthly intervals at the outpatient clinic. Distribution of the inflammatory cells (CD68+), the number of 8-hydroxydeoxyguanosine (8-OHdG) DNA adducts and 4-hydroxynonenal (HNE) protein adducts and the expression of apurinic/apyrimidinic endonuclease (APE) were determined by immunohistochemical analysis in serial liver sections from tumor-free parenchyma at the surgical margin around the tumor.

RESULTS

Significant positive correlations were observed between the number of CD68+ cells, the amount of HNE protein adducts, and the number of 8-OHdG adducts in liver tissue of patients with HCC and HCV. The cumulative disease-free survival was significantly shorter in patients with the highest percentage of 8-OHdG-positive hepatocytes. Using a Cox proportional hazard model, 8-OHdG, HNE and CD68 were determined to be good biomarkers for predicting disease-free survival in patients with HCC and HCV.

CONCLUSIONS

These results support the hypothesis that HCV-induced inflammation causes oxidative DNA damage and promotes hepatocarcinogenesis which directly affects the clinical outcome. Since patients with greater intra-hepatic oxidative stress had a higher incidence of HCC recurrence, we suggest that oxidative stress biomarkers could potentially be used as a useful clinical diagnostic tool to predict the duration of disease-free survival in patients with HCV-associated HCC.

The predictors of microvascular invasion in candidates for liver transplantation with hepatocellular carcinoma-with special reference to the serum levels of des-gamma-carboxy prothrombin

The microvascular invasion of cancer cells (mvi) is a good prognostic factor after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). The aim of this study is to predict mvi in patients with HCC who were candidates for OLT. We studied 218 patients with HCC resections who had HCC without any extrahepatic metastases and vascular invasion detected during preoperative evaluation. We analyzed the clinico-pathological data of these patients to predict the mvi presence. The mvi prediction scoring system was made and the accuracy of this system was examined using independent clinico-pathologic factors. The size and histological grade of the tumor were significantly correlated with the mvi. The des-gamma-carboxy prothrombin (DCP) is a mvi predictor. The sensitivity of our mvi prediction system was 75% and the specificity was 85% in 32 patients who underwent living-donor liver transplantations for HCC. Our study shows that besides the tumor size and histological grade, a measurement of the serum DCP levels could be a good predictor for mvi. A tumor biopsy and a preoperative measurement of DCP could improve the selection of patients with HCC for OLT. Our scoring system for mvi provides us a precise prediction of the presence of mvi.

Growth rate of locally recurrent hepatocellular carcinoma after transcatheter arterial chemoembolization: comparing the growth rate of locally recurrent tumor with that of primary hepatocellular carcinoma

We compared the growth rate of locally recurrent hepatocellular carcinoma (HCC) with that of primary HCC. After the first treatment by transcatheter arterial chemoembolization (TACE), 60 locally recurrent HCC nodules were reviewed. The tumor volume doubling time (DT) of locally recurrent HCC was significantly shorter than that of primary HCC. The 95% lower threshold value was 17.7 days. The 6-, 12-, and 36-month recurrence-free rates of the tumors having DTs more than 70 days after the second TACE (77.7%, 53.8%, and 40.4%) were significantly higher than those of the tumors having DTs less than 70 days (26.7%, 26.7%, and 17.8%). Locally recurrent HCCs cannot double in diameter in less than 53 days. In the case that an equivocal lesion smaller than the section collimation depicted during a contrast-enhanced computed tomography (CECT) screening cannot be ruled out as local recurrence, the next CECT screening should be performed 2 months later.

Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial

OBJECTIVE

To compare the efficacy and safety of partial hepatectomy aiming grossly at a narrow (1 cm) and a wide (2 cm) resection margin in patients with macroscopically solitary hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

For HCC treated with partial hepatectomy, the extent of the margin of liver resection remains controversial despite extensive studies.

METHODS

We conducted a prospective randomized trial in patients with solitary HCC. From January 1999 to February 2003, 169 patients with solitary HCC were stratified according to tumor size and randomized to undergo partial hepatectomy aiming grossly at either a narrow (1 cm) (n = 84) or a wide resection margin (2 cm) (n = 85). Analyses were done on an intention-to-treat basis.

RESULTS

The demographic and pathologic data were similar in the 2 groups. The mean +/- SD for the final resection margin of the narrow and the wide margin groups were 0.7 +/- 0.4 cm and 1.9 +/- 0.6 cm, respectively. There was no significant difference in the morbidity and in-hospital mortality between the 2 groups of patients. The 1-, 2-, 3-, and 5-year overall survival rates for the narrow and the wide margin groups were 92.9%, 83.3%, 70.9%, and 49.1% and 96.5%, 91.8%, 86.9%, and 74.9%, respectively. The difference was significant (stratified log-rank test, P = 0.008). Multivariate analysis identified the presence of micrometastases and the treatment allocation were independent risk factors for tumor-related death. At the time of censor, 75 (44.4%) patients had developed tumor recurrence. All recurrences at the margins of liver resection were observed in the narrow margin group. Multiple tumor recurrence was also significantly higher in the narrow margin group (chi test, P = 0.018). Survival after tumor recurrence was significantly better in the wide margin group than the narrow margin group (log-rank test, P = 0.017).

CONCLUSION

For macroscopically solitary HCC, a resection margin aiming grossly at 2 cm efficaciously and safely decreased postoperative recurrence rate and improved survival outcomes when compared with a gross resection margin aiming at 1 cm, especially for HCC < or =2 cm.

Partial hepatectomy with wide versus narrow resection margin for solitary hepatocellular carcinoma: a prospective randomized trial

OBJECTIVE

To compare the efficacy and safety of partial hepatectomy aiming grossly at a narrow (1 cm) and a wide (2 cm) resection margin in patients with macroscopically solitary hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

For HCC treated with partial hepatectomy, the extent of the margin of liver resection remains controversial despite extensive studies.

METHODS

We conducted a prospective randomized trial in patients with solitary HCC. From January 1999 to February 2003, 169 patients with solitary HCC were stratified according to tumor size and randomized to undergo partial hepatectomy aiming grossly at either a narrow (1 cm) (n = 84) or a wide resection margin (2 cm) (n = 85). Analyses were done on an intention-to-treat basis.

RESULTS

The demographic and pathologic data were similar in the 2 groups. The mean +/- SD for the final resection margin of the narrow and the wide margin groups were 0.7 +/- 0.4 cm and 1.9 +/- 0.6 cm, respectively. There was no significant difference in the morbidity and in-hospital mortality between the 2 groups of patients. The 1-, 2-, 3-, and 5-year overall survival rates for the narrow and the wide margin groups were 92.9%, 83.3%, 70.9%, and 49.1% and 96.5%, 91.8%, 86.9%, and 74.9%, respectively. The difference was significant (stratified log-rank test, P = 0.008). Multivariate analysis identified the presence of micrometastases and the treatment allocation were independent risk factors for tumor-related death. At the time of censor, 75 (44.4%) patients had developed tumor recurrence. All recurrences at the margins of liver resection were observed in the narrow margin group. Multiple tumor recurrence was also significantly higher in the narrow margin group (chi test, P = 0.018). Survival after tumor recurrence was significantly better in the wide margin group than the narrow margin group (log-rank test, P = 0.017).

CONCLUSION

For macroscopically solitary HCC, a resection margin aiming grossly at 2 cm efficaciously and safely decreased postoperative recurrence rate and improved survival outcomes when compared with a gross resection margin aiming at 1 cm, especially for HCC < or =2 cm.

Combined therapy of transcatheter hepatic arterial embolization with intratumoral dendritic cell infusion for hepatocellular carcinoma: clinical safety

The curative treatments for hepatocellular carcinoma (HCC), including surgical resection and radiofrequency ablation (RFA), do not prevent tumour recurrence effectively. Dendritic cell (DC)-based immunotherapies are believed to contribute to the eradication of the residual and recurrent tumour cells. The current study was designed to assess the safety and bioactivity of DC infusion into tumour tissues following transcatheter hepatic arterial embolization (TAE) for patients with cirrhosis and HCC. Peripheral blood mononuclear cells (PBMCs) were differentiated into phenotypically confirmed DCs. Ten patients were administered autologous DCs through an arterial catheter during TAE treatment. Shortly thereafter, some HCC nodules were treated additionally to achieve the curative local therapeutic effects. There was no clinical or serological evidence of adverse events, including hepatic failure or autoimmune responses in any patients, in addition to those due to TAE. Following the infusion of (111)Indium-labelled DCs, DCs were detectable inside and around the HCC nodules for up to 17 days, and were associated with lymphocyte and monocyte infiltration. Interestingly, T lymphocyte responses were induced against peptides derived from the tumour antigens, Her-2/neu, MRP3, hTERT and AFP, 4 weeks after the infusion in some patients. The cumulative survival rates were not significantly changed by this strategy. These results demonstrate that transcatheter arterial DC infusion into tumour tissues following TAE treatment is feasible and safe for patients with cirrhosis and HCC. Furthermore, the antigen-non-specific, immature DC infusion may induce immune responses to unprimed tumour antigens, providing a plausible strategy to enhance tumour immunity.

Single hepatocellular carcinoma ranging from 3 to 5 cm: radiofrequency ablation or resection?

BACKGROUND

The optimal therapy for hepatocellular carcinoma (HCC) is transplantation. For all those patients not eligible for transplantation (or on the waiting list) among the treatments of choice used more frequently in recent years are resection (RES) and radiofrequency ablation (RFA). RFA is less efficacious for HCC ranging over 3 cm. The aim of this study was to compare RFA to RES in a restricted cohort of patients with a single naive HCC ranging from 3 to 5 cm in size and without end-stage liver disease. PATIENTS AND METHODS. A total of 102 patients who had never been treated before were enrolled. Those patients whose HCC position would have required too much parenchymal loss at RES (central or close to main vascular structures) were treated with RFA (n=60), and the others underwent RES (n=42). The two groups were similar for HCC size and liver disease status. The outcome was considered in terms of overall survival (OS) and disease-free survival (DFS) calculated by the Kaplan-Meier method. Differences among groups were validated by log-rank test.

RESULTS

The RES group seemed to present a better long-term OS (91%, 57%, and 43% vs 96%, 53%, and 32% at 1, 3, and 5 years, respectively) and DFS (74%, 35%, and 14% vs 68%, 18%, and 0%, respectively) but there was no statistical significance. Age, gender, virus etiology, HCC size and alpha-fetoprotein levels did not correlate with survival. Patients with recurrence within the first 12 months after treatment showed a worse long-term survival (p=0.011). Patients in Child-Pugh class B had poor prognoses compared with those in class A (p=0.047).

CONCLUSION

Even if RES seemed to promise better long-term results, in the medium term this difference had no statistical significance. Survival in this series was more closely related to the stage of the underlying liver disease than to treatment (RES/RFA).

Treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third cause of cancer-related death. Despite therapeutic advances, the overall survival of patients with HCC has not significantly improved in the last two decades. In the majority of the cases there is underlying cirrhosis, so the prognosis of HCC depends on not only tumor stage but also liver function. There is not a widely accepted HCC staging system. In our group we have developed a new staging classification that stratifies HCC patients into four major categories and simultaneously links staging with treatment. Patients at an early stage are those who present with an asymptomatic single HCC with a maximum diameter of 5cm or up to three nodules each less than 3cm. They will benefit from curative therapies, including resection, liver transplantation (LT), and percutaneous ablation. Patients exceeding these limits, but who are free of cancer-related symptoms and vascular invasion or extrahepatic spread fit into the intermediate stage and may benefit from palliation with chemoembolization. The patients with mild cancer-related symptoms and/or vascular invasion or extrahepatic spread are included in the advanced stage. In this stage there is not effective therapy, and these patients may profit from new therapies in the setting of randomized controlled trials (RCTs). Finally, the patients with severe cancer-related symptoms or great tumor burden belong to the terminal stage and only benefit from symptomatic treatment.

Analysis of risk factors associated with early multinodular recurrences after hepatic resection for hepatocellular carcinoma

BACKGROUND

Sometimes patients experience an unexpected fulminant recurrence after partial hepatic resection for the treatment of hepatocellular carcinoma, and this carries a dismal prognosis. We conducted this retrospective study to investigate the risk factors of early multinodular (ie, 10 nodules within 6 months of surgery) recurrence in hepatocellular carcinoma.

METHODS

The study population consisted of 409 patients who underwent curative hepatic resection between January 2000 and April 2003. Patients were divided into 3 groups: nodular (<10 nodules) recurrence, multinodular (> or =10 nodules) recurrence, and no recurrence within the 6-month postoperative period. Twenty-six clinicopathologic and surgical variables were subject to univariate and multivariate analysis.

RESULTS

According to univariate analysis, the risk factors for early multinodular recurrence in HCC were microvascular tumor emboli, portal vein tumor thrombi, intrahepatic metastases, high Edmonson-Steiner classification, lack of tumor capsule formation, increased alpha-fetoprotein concentration, and tumor size. Of these factors, intrahepatic metastases and portal vein thrombi proved to be significant predictive factors of multinodular recurrence by multivariate analysis.

COMMENTS

Postoperative early multinodular recurrence was found to be related to portal vein tumor thrombi and intrahepatic metastases. Accordingly, an effective adjuvant therapeutic modality should be made available for patients with these risk factors.

Association between recurrence of hepatocellular carcinoma and alpha-fetoprotein messenger RNA levels in peripheral blood

PURPOSE

Intra- and extrahepatic recurrence is common, even after curative resection for hepatocellular carcinoma (HCC), suggesting preoperative or intraoperative tumor cell dissemination. Reverse transcription - polymerase chain reaction (RT-PCR) for alpha-fetoprotein (AFP) is used to detect circulating liver cancer cells. We previously developed a quantitative method that allows estimation of the AFP mRNA level by real-time PCR. In the present study, we used this method to measure the AFP mRNA level before and after resection of HCC, then correlated the findings with various clinicopathological characteristics and prognosis.

METHODS

We prospectively examined peripheral blood samples from 38 patients with HCC, and bone marrow aspirate from 25 of these patients. As a control, we examined bone marrow from 20 patients with benign diseases. The follow-up period ranged from 32 to 66 months. Real-time RT-PCR was used to detect AFP mRNA levels in the samples.

RESULTS

AFP was expressed in 9 (23.7%) of the 38 peripheral blood samples. The detection of AFP mRNA was significantly correlated with extrahepatic metastasis after primary surgery, and a shorter disease-free survival time (P = 0.0245 each). Bone marrow samples were defined as positive if they expressed AFP mRNA at levels higher than the maximum expressed level in the controls, because only 1 (5%) of the 20 control bone marrow samples had low AFP mRNA expression. Using this cutoff level, 12 (48%) of the 25 patients with HCC had positivity for AFP mRNA. The results of bone marrow RT-PCR did not correlate with the clinocopathological characteristics of prognosis.

CONCLUSIONS

Using real-time PCR to measure the AFP mRNA level in blood, but not bone marrow, could be useful for predicting postoperative tumor recurrence.

Postoperative changes in protein-induced vitamin K absence or antagonist II levels after hepatectomy in patients with hepatocellular carcinoma: relationship to prognosis

BACKGROUND

alpha-Fetoprotein (AFP) has been used as a marker for hepatocellular carcinoma (HCC). However, AFP levels are often high in patients with chronic hepatitis or cirrhosis. Protein-induced vitamin K absence or antagonist II (PIVKA-II) is more sensitive for the diagnosis of HCC and prediction of patient survival. Changes in these markers after treatment may reflect treatment curability and patient outcome.

METHODS

We conducted a retrospective analysis of prognosis of 63 HCC patients with high preoperative levels of AFP and PIVKA-II who underwent hepatectomy and examined the relationship between postoperative changes in both markers at 1 month and patient survival. Subjects were divided into three groups according to changes in these tumour markers after hepatectomy: normalization (N) group, decreased but still above the normal level (D) group and unchanged (U) group.

RESULTS

There were no significant differences in the numbers of patients who developed tumour recurrence between changes in AFP and PIVKA-II. Survival analysis showed no significant differences in tumour-free and overall survivals between groups with respect to AFP level. The PIVKA-II-N group showed significantly better tumour-free and overall survival compared with the D and U groups (p<0.01). Multivariate analysis that included other prognostic factors identified changes in PIVKA-II level as a significant and independent prognostic factor associated with overall survival.

DISCUSSION

Although changes in AFP did not correlate with patient prognosis, normalization of PIVKA-II was significantly associated with good patient survival after hepatectomy. Normalization of PIVKA-II after hepatectomy reflected the efficacy of treatment and is a suitable predictor of prognosis in HCC patients.

Comparative study of survival of patients with hepatocellular carcinoma predicted by different staging systems using multivariate analysis

AIMS

In a previous pilot study, we reported the usefulness of the modified the Cancer of the Liver Italian Program (CLIP) score for patients with hepatocellular carcinoma (HCC). To determine the best staging system for predicting the survival of HCC patients, we conducted a comparative analysis of prognosis using multivariate analysis in 210 Japanese HCC patients who underwent hepatic resection.

METHODS

We compared the survival as predicted by various staging systems, including tumour node metastasis (TNM) stage of the American Joint Commission on Cancer (AJCC) and the Liver Cancer Study Group of Japan, the Japan Integrated Staging (JIS) score (Japanese TNM and Child-Pugh classification), CLIP score and our modified CLIP score using protein induced by vitamin K absence or antagonist II (PIVKA-II).

RESULTS

Univariate analysis showed that discrimination of disease-free survival in the early and advanced stages by the JIS score and modified CLIP score was clearer than by the Japanese or AJCC TNM or the original CLIP score. Discrimination between stages of overall survival by all staging systems was significant. Multivariate analysis showed that the JIS, CLIP and modified CLIP scores were better staging systems for predicting survival than the Japanese and AJCC TNM. The modified CLIP score showed the lowest Akaike information criteria statistical value for disease-free and overall survival, which means the best discrimination ability for patient survival compared with the JIS score and CLIP score.

CONCLUSIONS

A staging system that combines tumour factors, sensitive tumour marker(s) and hepatic function is the best predictor of prognosis of HCC patients.

The combined effect of radiofrequency and ethanol ablation in the management of large hepatocellular carcinoma

Only a small percentage of patients with large hepatocellular carcinoma (HCC) may benefit out of surgical resection. Thus, most of these patients are in need of a form of local control, such as ethanol ablation, transarterial chemoembolization (TACE), radiofrequency thermal ablation (RF), or laser induced thermotherapy (LITT). The purpose of this study was to assess the short-term effect of sequential RF and ethanol ablation in the management of large HCC (>5 cm). Our series included 40 patients with large HCC tumors (>5 cm in diameter). We adopted a protocol of overlapping RF applications, followed by repeated ethanol ablation sessions. Our results showed that the volume of tumor coagulative necrosis initially induced by RF has significantly risen after adjuvant ethanol ablation sessions (P < 0.001). Patients who achieved complete tumor necrosis after RF ablation were 52.5% of the series. This percent has jumped to 80% of the series at the end of the protocol. This indicates that such combined protocol is more effective than RF alone. Besides, it is valuable in reducing the number of RF sessions.

Prognostic value of thymidine phosphorylase activity in liver tissue adjacent to hepatocellular carcinoma

BACKGROUND

Measurement of thymidine phosphorylase (TP) activity in normal liver tissue adjacent to hepatocellular carcinoma (HCC) may predict multicentric recurrence a long time after an operation. The authors investigated this activity in 92 patients with HCC who had a single HCC equal to or less than 5 cm.

METHODS

Fresh samples (tumors with adjacent normal tissues) were collected from 92 patients with HCC who underwent curative hepatic resection. The levels of TP activity in nonfixed, fresh, and frozen HCC specimens with adjacent noncancerous liver tissue were biochemically measured by using an enzyme-linked immunosorbent assay method.

RESULTS

Patients who had a high TP level in normal liver tissue had significantly earlier recurrence (median disease-free survival, 819 days; 95% confidence interval [95% CI], 478-1044 days) compared with patients who had a low TP level (median disease-free survival, 1376 days; lower limit of 95% CI, 921 days; P = 0.0171). Multivariate analysis showed that patients who had a low TP level in adjacent liver tissue had a 0.387-fold higher risk of postoperative recurrence compared with patients who had a high TP level (P = 0.0067).

CONCLUSION

TP activity in normal liver tissue adjacent to HCC is related to tumor occurrence and may predict postoperative tumor recurrence.

Relationship between Lens culinaris agglutinin-reactive alpha-fetoprotein and pathologic features of hepatocellular carcinoma

AIM

We investigated pathological features of Lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3)-positive hepatocellular carcinoma (HCC) in order to seek a pathological basis of poor prognosis of HCC patients with elevated AFP-L3.

METHODS

A total of 111 patients with HCC < or =5 cm in diameter who underwent hepatic resection were studied. Serum AFP-L3 concentration was measured within a month prior to surgery by lectin-affinity electrophoresis coupled with antibody-affinity blotting, and expressed as AFP-L3 percentage of total AFP. AFP-L3 of 10% or higher was judged to be positive. Pathologic features of resected HCC specimens were evaluated and classified concerning growth pattern (expansive or infiltrative growth), capsule formation, capsule infiltration, septal formation, portal vein invasion, hepatic vein invasion, bile duct invasion, and intrahepatic metastasis. These macroscopic and microscopic findings were compared between AFP-L3-positive and negative HCC specimens.

RESULTS

Thirty-three (29.7%) were positive for AFP-L3. The prevalence of HCC with infiltrative growth, with capsule infiltration, with septum formation, with portal vein invasion, and with hepatic vein invasion was significantly higher in AFP-L3-positive group (P=0.0121, 0.0290, 0.0442, 0.0314, and 0.0433, respectively). These pathologic features reportedly indicate the progression of the tumor.

CONCLUSIONS

AFP-L3-positive HCC had several pathologic features of progressed state of HCC, which accounted for the AFP-L3 as an indicator of poor prognosis of HCC.

Comparison of recurrence after hepatic resection in patients with hepatitis B vs. hepatitis C-related small hepatocellular carcinoma in hepatitis B virus endemic area

PURPOSE

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are two important factors in the development of hepatocellular carcinoma (HCC). The carcinogenic mechanism of HBV and HCV is considered to be different. It is interesting to compare the recurrence after hepatic resection in patients with small HCC who were infected with HBV or HCV.

METHODS

From 1991 to 1995, 145 patients who were positive for hepatitis B surface antigen (HBsAg) or antibody to HCV (anti-HCV) and diagnosed as small HCC (< or =3 cm) in three medical centers in Taiwan were evaluated in this study. All patients underwent hepatic resection. Among them, 83 (57.2%) were infected by HBV, 51 (35.2%) were infected by HCV, and 11 (7.6%) had dual HBV and HCV infection.

RESULTS

Anti-HCV+ HCCs were associated with older age, lower serum albumin, higher alanine transaminase (ALT) level and multi-nodular tumors during diagnosis. During the follow-up, 92 (63.4%) patients developed tumor recurrence. Anti-HCV + HCC had a higher cumulated recurrence rate than HBsAg+ HCC (72.4% vs 53.6 % at 5 year, P = 0.032). In multivariate analysis, the presence of vascular invasion and lower serum albumin levels (<3.9 g/dl) were the determinants for tumor recurrence.

CONCLUSIONS

HCV infection, as compared with HBV infection, had a higher cumulated recurrence after hepatic resection in patients with small HCC. Low serum albumin level was significantly associated with recurrence among these patients.

Prognostic factors for survival in patients with hepatocellular carcinoma after percutaneous microwave ablation

PURPOSE

To determine the long-term survival and prognostic factors in patients with hepatocellular carcinoma treated with percutaneous microwave ablation.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. A database of cases of hepatocellular carcinoma in 288 patients (259 men, 29 women; mean age, 54.8 years +/- 11.4 [standard deviation]; age range, 25-82 years) with 477 histologically proved lesions who underwent percutaneous microwave coagulation therapy between May 1994 and October 2002 was retrospectively analyzed. Prognostic factors for survival were evaluated by means of univariate and multivariate analyses.

RESULTS

The mean follow-up period after microwave ablation was 31.41 months +/- 20.43 (range, 5-106 months). The 1-, 2-, 3-, 4-, and 5-year cumulative survival rates among all 288 patients were 93%, 82%, 72%, 63%, and 51%, respectively. Ninety-three patients (32%) died. Local recurrence or new tumors occurred in 100 patients (35%). Age (P = .836), sex (P = .073), preablation serum alpha-fetoprotein level (P = .136), and preablation treatment (P = .256) were not related to prognosis, while tumor number (P = .004), tumor size (P < .001), Child-Pugh classification (P = .003), tumor differentiation (P = .026), and local recurrence or presence of new tumors (P = .004) significantly affected survival at univariate analysis. At multivariate analysis, only tumor size (P < .001), number of nodules (P = .005), and Child-Pugh classification (P = .01) each had a significant effect on survival.

CONCLUSION

With use of microwave ablation, there is a high probability of long-term survival of patients with a single lesion of 4.0 cm or less in maximum diameter and Child-Pugh class A cirrhosis.

N/A

N/A

A Strategy for Early Detection of Recurrent Hepatocellular Carcinoma following Initial Remission by Transcatheter Arterial Chemoembolization

OBJECTIVES

To find a better surveillance method in detecting recurrent HCCs, patterns of recurrences following initial remission by transcatheter arterial chemoembolization (TACE) were evaluated.

METHODS

Of 235 consecutive HCC patients who underwent TACE, 69 with initial remission were followed for >12 months. We compared the recurrence rates according to the characteristics of original HCCs and analyzed the locations of recurrent HCCs. We also evaluated the diagnostic efficacies of CT scan with serum AFP, angiography and Lipiodol CT scan in detecting recurrent HCCs.

RESULTS

In 37 of 69, recurrent HCCs were detected after a median period of 17 months. Multinodular HCCs recurred more frequently than single-nodular HCCs. All of 5 patients with portal vein thrombosis recurred. Although 46% of recurrences were adjacent to original tumors, 62% were separated from them (8% at both). HCC with heterogeneous lipiodol uptake frequently recurred adjacent to original tumors. Only 18 of 37 recurrent HCCs were initially detected by serum AFP and CT scans; 17 by angiography, 2 only by lipiodol CT scan.

CONCLUSIONS

Regular angiography may be valuable in detecting recurrent HCCs, especially in multinodular HCC. HCC with heterogeneous lipiodol uptake should be treated in combination with local ablation therapy.

Hepatitis serology predicts tumor and liver-disease characteristics but not prognosis after resection of hepatocellular carcinoma

The impact of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on survival rates after resection of hepatocellular carcinoma (HCC) is controversial. The objective of this study was to determine whether serologic evidence of HBV or HCV infection ("hepatitis serology") can predict underlying liver disease, tumor factors, and survival rates in patients with HCC. Using a multicenter international database, we identified 446 patients with complete HBV and HCV serology. One hundred twenty-six patients were negative for HBV and HCV, 163 patients had HBV infection only, 79 patients had HCV infection only, and 78 patients had coinfection with HBV and HCV. Patients with hepatitis were more likely to have tumors smaller than 5 cm and bilateral HCC involvement. Hepatitis status (negative vs. HBV vs. HCV vs. coinfection with HBV and HCV) did not predict tumor grade or the presence of multiple tumor nodules. Patients with HCV or coinfection with HBV and HCV exhibited a lower incidence of vascular invasion, but worse fibrosis than patients with negative serology or HBV. The median survival rate was 47.9 months. The presence of hepatitis did not significantly affect the survival rate, but hepatic fibrosis and vascular invasion predicted a decreased survival rate. The prognosis after resection of HCC is influenced by tumor factors and liver disease, but not by HBV or HCV infection. The treatment for HCC should be dictated by the extent of underlying liver disease rather than by hepatitis serology.

Overexpression of extracellular signal-regulated protein kinase and its correlation with proliferation in human hepatocellular carcinoma

BACKGROUND

Dysregulation of cell proliferation is one of the most important features of human cancers including hepatocellular carcinoma (HCC). However, the molecular basis underlying the proliferation of HCC has not been fully clarified. Because a previous study reported that overexpression of extracellular signal-regulated protein kinase (ERK), which transduces extracellular growth stimuli to the nuclei, was frequently observed in several human cancers, this study was performed to analyze the expression of ERK in human HCC and its correlation with HCC proliferation.

METHODS

Twenty-four paired samples of primary HCCs and corresponding noncancerous liver tissues, and six samples of histologically normal liver tissue were obtained from surgically resected materials. The expression of ERK was examined by immunoblotting and immunohistochemical analysis. Proliferative activity of each HCC was examined by immunohistochemical demonstration of proliferative cell nuclear antigen (PCNA).

RESULTS

The ERK1 and ERK2 expression in HCCs was significantly higher than that in noncancerous liver tissues, and the ERK1 expression in noncancerous liver tissues from patients with HCC was higher than that in tissue from normal liver. Immunohistochemical examination revealed enhanced accumulation of ERK1 in the nuclei of HCC cells. Regression analysis revealed a significant correlation between ERK expression and PCNA labeling index in HCC.

CONCLUSIONS

Our findings suggest that ERK overexpression contributes to the proliferation of HCC.

The Japanese integrated staging score using liver damage grade for hepatocellular carcinoma in patients after hepatectomy

AIMS

The new Japanese staging system for hepatocellular carcinoma (HCC), the Japan integrated staging (JIS) score, accounts for both Child-Pugh classification and Japan tumour node metastasis (TNM) staging. However, in HCC patients who undergo hepatectomy, liver function is relatively good and a better prognostic classification of hepatic function is necessary.

METHODS

The present study was designed to analyse the modified JIS score using liver damage grade by the Liver Cancer Study Group of Japan instead of the Child-Pugh classification (using the category indocyanine green retention rate at 15 min [ICG(R15)] instead of encephalopathy), and to compare the Japan TNM stage in 101 patients who underwent resection of HCC.

RESULTS

The liver damage grade showed significantly better discrimination of disease-free and overall survival than did the Child-Pugh classification. The modified JIS score system showed significant differences of disease-free and overall survivals in each score and this system was superior for discriminating survivals compared with the TNM staging.

CONCLUSIONS

The combined staging system of hepatic function, particularly ICG(R15), and tumour stage provides a better prediction of prognosis. The JIS score using the liver damage grade was a useful predictor of prognosis of HCC patients who underwent hepatic resection.

Role of expression of focal adhesion kinase in progression of hepatocellular carcinoma

PURPOSE

Although hepatocellular carcinoma (HCC) is the most common cancer of the human liver, the mechanisms that regulate HCC development and progression remain unclear. The aim of this study was to investigate whether focal adhesion kinase (FAK) is involved in the progression of human HCC.

EXPERIMENTAL DESIGN

Western blot analysis for FAK was performed on three HCC cell lines. We reviewed 64 consecutive patients who had undergone initial liver resection for HCC without preoperative treatment. Immunohistochemistry analysis for FAK was performed on paraffin-embedded tissues. FAK expression was confirmed by Western blot analysis in several clinical samples. We investigated the correlation between FAK expression and clinical outcome.

RESULTS

FAK proteins were detected in all HCC cell lines. Hepatocytes in the normal liver and chronic hepatitis with or without cirrhosis were negative for immunohistochemical staining for FAK expression. Cytoplasmic FAK expression was observed in 18 of 64 patients (28.1%), and this positive staining was correlated with gender (P < 0.05), a lower level of serum albumin (P < 0.05), and portal venous invasion (P < 0.01). Positive staining for FAK was associated with significantly poorer survival (P < 0.05). In multivariate analysis, FAK overexpression was an independent factor in determining the prognosis of patients.

CONCLUSIONS

These data suggest that FAK plays an important role in promoting tumor progression, especially vascular invasion, in HCC. FAK could play an important role in HCC progression and would be a novel target for HCC therapeutics as well as a prognostic marker.

Modified CLIP using PIVKA-II for evaluating prognosis after hepatectomy for hepatocellular carcinoma

AIMS

The new staging system proposed by the Cancer of the Liver Italian Program (CLIP) for hepatocellular carcinoma (HCC) accounts for both liver dysfunction and tumour characteristics. The present study was designed to analyze UICC TNM stage, CLIP and modified CLIP in 91 patients who underwent hepatic resection for HCC.

METHODS

In the modified CLIP, scoring of AFP was replaced by that of protein induced by vitamin K absence or antagonist II (PIVKA-II; predictive value, > or = 400 mAU/ml).

RESULTS

After hepatic resection, 54 patients developed recurrent tumours. High PIVKA-II was a significant determinant of recurrence (p<0.05). However, a high score of the modified CLIP as well as those other staging systems did not correlate with tumour-recurrence rate. Univariate analysis showed that high TNM score, CLIP score and our modified CLIP score were significant predictors of poor prognosis. Multivariate Cox's analysis revealed that high PIVKA-II and high modified CLIP score were associated with higher risk for disease-free and overall survival as well as high TNM stage.

CONCLUSIONS

Compared with the original CLIP, our modified CLIP was a better predictor of prognosis of HCC patients who underwent hepatic resection.

Liver resection for hepatocellular carcinoma on cirrhosis: univariate and multivariate analysis of risk factors for intrahepatic recurrence

OBJECTIVE

To evaluate prognostic factors that could affect disease-free survival and recurrence after liver resection for hepatocellular carcinoma (HCC) on cirrhosis.

SUMMARY BACKGROUND DATA

Tumor recurrence is the main cause of poor survival after liver resection for HCC on cirrhosis.

METHODS

Two hundred twenty-four liver resections for HCC on cirrhosis were retrospectively reviewed. Univariate and multivariate analyses were performed on several clinicopathologic variables to analyze factors affecting long-term outcome and intrahepatic recurrence. The relation between preoperative aminotransferase level and recurrence rate was evaluated in the overall group, and separately in HCV-positive and in HBsAg-positive patients. Median follow-up was 35.6 months.

RESULTS

The 1-, 3-, and 5-year overall survival rates were 83%, 62.8%, and 42.5%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 70.3%, 43%, and 27.4%, respectively. The 1-, 3-, and 5-year recurrence rates were 20.8%, 38.6%, and 54.4% respectively. Tumor recurrence appeared in 93 patients (41.5%) and was the main cause of death in 51 patients (56%). Number of nodules, tumor capsule, microvascular portal vein thrombosis, and preoperative serum aspartate aminotransferase (AST) level significantly affected disease-free survival and recurrence rates. On multivariate analysis, single nodules and preoperative AST level less than twice normal (2N) were related to a better 5-year disease-free survival and lower tumor recurrence. In particular, among HCV-positive patients the recurrence rate was strongly affected by the preoperative AST level.

CONCLUSIONS

Child A patients with single nodules are the best candidates for liver resection. Tumor recurrence is strictly linked to the status of the underlying liver disease, and a preoperative AST level equal to 2N seems to be a sensitive cutoff among patients with different risks of recurrence. HCV-positive patients with AST levels above 2N have the highest risk for intrahepatic recurrence and should be monitored carefully or offered alternative treatments.

Analysis of chromosomal instability in pulmonary or liver metastases and matched primary hepatocellular carcinoma after orthotopic liver transplantation

To investigate the genetic mechanism of metastatic spread in hepatocellular carcinoma (HCC), we analyzed genomic changes in lung or liver metastases and the corresponding primary tumors (83 tumor samples) in 18 patients who underwent orthotopic liver transplantation. We studied the incidence of microsatellite instability (MSI) and loss of heterozygosity (LOH) involving 8 highly polymorphic microsatellite markers and the polyA tract, Bat26. We also sought alterations of p53 and beta-catenin gene mutations. High MSI (>30-40% of the loci analyzed) was found only in primary tumors (11%), whereas LOH was observed in 50% of primary and in 39% of recurrent tumors. p53 mutations were found in 2 cases of primary HCC but not in the corresponding metastases. P53 was overexpressed in 4 primary HCC (22%) and 7 metastases (39%). The percentage of beta-catenin gene mutations was low (6%). Lung metastases retained the D16S402 microsatellite abnormalities observed in the primary tumors, whereas recurrent liver tumor did not (p = 0.02). In conclusion, LOH and P53 protein overexpression, rather than mutations in the p53 or beta-catenin genes or MSI, seem to be involved in the spreading of HCC, suggesting the presence of metastasis suppressor genes in the vicinity of the chromosomal loci in question.

Small hepatocellular carcinoma in Child A cirrhotic patients: hepatic resection versus transplantation

Hepatic resection (HR) is the treatment of choice for small hepatocellular carcinoma (HCC) in a noncirrhotic liver, whereas liver transplantation (LT) offers better results in patients with impaired hepatic function (Child B and C). However, it is still debated whether HR or LT is the best strategy for patients with Child A cirrhosis. We conducted a retrospective study on 37 consecutive patients with Child A cirrhosis and small HCC, treated between 1991 and 1999. Seventeen of these patients, who underwent LT, were compared with 20 patients who underwent HR, and prognostic factors for survival and tumor recurrence were analyzed. The primary endpoints were the intention-to-treat, 3- and 5-year survival, and 3- and 5-year recurrence-free survival. Three- and 5-year patient survival rate both were significantly (P =.04) higher in the LT group (87% and 71%, respectively) than in the HR group (67 and 36% respectively). Similarly, the 3- and 5- year recurrence-free survival rates were 87% and 80% for the LT group, and 52% and 40% for the HR group (P =.03). Absence of microscopic vascular invasion was the only other prognostic factor correlated with significantly better recurrence-free survival (P =.02). Therefore, we concluded that in patients with Child A cirrhosis and small HCC, liver transplantation resulted in better overall and disease-free survival than HR.

Liver resection for hepatocellular carcinoma on cirrhosis: univariate and multivariate analysis of risk factors for intrahepatic recurrence

OBJECTIVE

To evaluate prognostic factors that could affect disease-free survival and recurrence after liver resection for hepatocellular carcinoma (HCC) on cirrhosis.

SUMMARY BACKGROUND DATA

Tumor recurrence is the main cause of poor survival after liver resection for HCC on cirrhosis.

METHODS

Two hundred twenty-four liver resections for HCC on cirrhosis were retrospectively reviewed. Univariate and multivariate analyses were performed on several clinicopathologic variables to analyze factors affecting long-term outcome and intrahepatic recurrence. The relation between preoperative aminotransferase level and recurrence rate was evaluated in the overall group, and separately in HCV-positive and in HBsAg-positive patients. Median follow-up was 35.6 months.

RESULTS

The 1-, 3-, and 5-year overall survival rates were 83%, 62.8%, and 42.5%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 70.3%, 43%, and 27.4%, respectively. The 1-, 3-, and 5-year recurrence rates were 20.8%, 38.6%, and 54.4% respectively. Tumor recurrence appeared in 93 patients (41.5%) and was the main cause of death in 51 patients (56%). Number of nodules, tumor capsule, microvascular portal vein thrombosis, and preoperative serum aspartate aminotransferase (AST) level significantly affected disease-free survival and recurrence rates. On multivariate analysis, single nodules and preoperative AST level less than twice normal (2N) were related to a better 5-year disease-free survival and lower tumor recurrence. In particular, among HCV-positive patients the recurrence rate was strongly affected by the preoperative AST level.

CONCLUSIONS

Child A patients with single nodules are the best candidates for liver resection. Tumor recurrence is strictly linked to the status of the underlying liver disease, and a preoperative AST level equal to 2N seems to be a sensitive cutoff among patients with different risks of recurrence. HCV-positive patients with AST levels above 2N have the highest risk for intrahepatic recurrence and should be monitored carefully or offered alternative treatments.

Elevated expression of valosin-containing protein (p97) in hepatocellular carcinoma is correlated with increased incidence of tumor recurrence

PURPOSE

Valosin-containing protein (VCP; also known as p97) has been shown to be associated with antiapoptotic function and metastasis via activation of the nuclear factor-kappaB signaling pathway. In this study, association of VCP expression with recurrence of hepatocellular carcinoma (HCC) and patient survival was examined.

PATIENTS AND METHODS

VCP expression in 170 patients (139 male and 31 female) with ages ranging from 31 to 81 years (median, 61 years) was analyzed by quantitative reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry, in which staining intensity in tumor cells was categorized as weaker (level 1) or equal to or stronger (level 2) than that in endothelial cells.

RESULTS

Immunohistochemically, 57 patients (35.2%) showed level 1, and 105 patients (64.8%) showed level 2, VCP expression. Quantitative RT-PCR analysis revealed higher VCP mRNA expression in level 2 patients (n = 7) than level 1 (n = 4) (P <.05). Patients with VCP-level 2 HCC showed higher rate of portal vein invasion in the tumor (P <.01) and poorer disease-free and overall survival (P <.0001 and P <.05, respectively) compared with level 1 patients. Multivariate analysis revealed VCP expression level, tumor multiplicity, and degree of fibrosis in the noncancerous liver tissue to be independent prognosticators for disease-free and overall survival. VCP level was an indicator for disease-free survival in each early- (I and II) and advanced- (III and IV) stage group of pathologic tumor-node-metastasis classification (P <.001 and P <.01, respectively).

CONCLUSION

VCP expression level has prognostic significance for disease-free and overall survival of patients with HCC.

Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy

BACKGROUND/AIMS

We conducted a retrospective cohort study to investigate factors to early and late phase recurrence of hepatocellular carcinoma (HCC).

METHODS

The study population consisted of 249 patients including 157 with cirrhosis who underwent hepatectomy for HCC. The endpoint was time-to-recurrence. Using a Cox regression model, factors to early and late phase recurrences were investigated censoring recurrence-free patients at the 2-year time point and in patients without recurrence at 2 years.

RESULTS

Actuarial probability of overall recurrence at 1, 3, and 5 years were 0.301, 0.623, and 0.790, respectively, with a median follow-up of 624 days. Early recurrence was observed in 123 out of 249 patients; while late recurrence was found in 61 out of 113 patients. Factors to early recurrence were as follows: non-anatomical resection, presence of microscopic vascular invasion, and serum alpha-fetoprotein level >or=32 ng/ml. Those contributing to late phase recurrence were higher grade of hepatitis activity, multiple tumors, and gross tumor classification.

CONCLUSIONS

Variables associated with metastatic recurrence were factors to early phase recurrence; whereas those related with elevated carcinogenesis contributed to late phase recurrence, thus providing an epidemiological evidence that different mechanisms, i.e. metastasis and de novo, are involved in intrahepatic recurrence after hepatectomy for HCC.

Pathologic spectrum and prognostic significance of underlying liver disease in hepatocellular carcinoma

Although controversy persists about the influence of cirrhosis on the incidence of portal vein invasion and other prognostic indicators of recurrence and survival (e.g., histologic grade, mitotic activity, multiplicity), it is clear that the degree of cirrhosis is important for the long-term survival of patients with HCC. Multicentricity is especially important because it reflects the field carcinogenesis associated with viral hepatitis and particularly chronic HCV infection [59]. A better understanding of the different mechanisms linked to tumor recurrence will help select the best candidates for curative surgery and help tailor adjuvant therapy, such as interferon therapy, to each patient [60]. Finally, the importance of vascular invasion, number of tumors, and tumor size of HCCs in addition to the effect of fibrosis has led Vauthey et al [20] to propose a simplified staging of HCC with better prognostication of survival.

Prognostic assessment and evaluation of the benefits of treatment

Prognosis estimation in patients with hepatocellular carcinoma (HCC) can provide information at diagnosis and can indicate therapy. Because cirrhosis underlies HCC in most individuals, their outcome is related to both entities, which determine the applicability and efficacy of therapy. Accordingly, prognostic modelling should consider tumor stage, liver function impairment, the patient's general condition, and treatment efficacy. We have developed a system that stratifies patients into four categories, simultaneously setting prognosis and guiding the therapy. Patients with HCC (single HCC < or =5 cm or three or fewer nodules < or =3 cm) benefit from curative/effective therapies (resection, transplantation, and percutaneous ablation), expert application of which provides a 50% to 75% 5-year survival. Those with more advanced disease present a heterogenous outcome. Patients who do not present with cancer-related symptoms and whose tumor has not invaded vascular vessels or disseminated outside the liver may reach 50% survival at 3 years, and they benefit from chemoembolization. Those who present with symptoms (pain, deterioration of physical condition) and/or an aggressive tumor pattern do not reach a 10% survival at 3 years, and there is no effective therapy for them. Finally, those with severe liver function or health status impairment constitute the end-stage category and cannot be expected to survive more than 1 year.

Indications and results of resection for hepatocellular carcinoma

AIM

In this retrospective series we evaluate our experience in surgical treatment of HCC and examine early and long-term results of 46 hepatic resections.

METHODS

Eighty-eight patients with HCC have been observed at our Department. Fifty patients (57%) have been operated, but only 46 (92%) could be resected; 43 patients (93.5%) carried liver cirrhosis. We performed 28 non-anatomical resections (60.8%) and 18 anatomical resections (39.2%). Tumour clearance at resection margin of at least 1cm was considered for a curative resections.

RESULTS

Overall mortality and morbidity were 8.7 and 30.4% respectively. These rates significantly decreased in the last years: from 1995 to 2000 no hospital mortality has been recorded. Hospital mortality among non-anatomical and anatomical resection subgroups was 3.5 and 16.6% respectively (P<0.02). After a median f.u. of 41 months, 19 patients (45.2%) had recurrences: it was intrahepatic in 16 (84.4%). We observed a 3-, 5- and 10-years actuarial survival rate 62, 51.1 and 22.5% respectively. Long term survival significantly differed between non-anatomical and anatomical resections, with 5-year and 10-year values of 61.1 and 34.3% vs 37.7 and 18.8% respectively (P=0.0224).

CONCLUSIONS

Early results after hepatic resection for HCC can be improved by using a limited surgical approach. Long-term results are still unsatisfactory, because of the high recurrence rate that is not influenced by different surgical approaches.

Hepatocellular carcinoma in elderly patients: beneficial therapeutic efficacy using percutaneous ethanol injection therapy

BACKGROUND

The age of patients with hepatocellular carcinoma (HCC) has been increasing worldwide. The objective of this study was to assess the efficacy and safety of percutaneous ethanol injection therapy (PEIT) in elderly patients with HCC.

METHODS

The authors retrospectively analyzed 653 patients who were treated with PEIT between 1985 and 1997. One hundred thirty-seven patients were age > or = 70 years, 90 of 137 patients (66%) were male, and 106 of 137 patients (77%) were positive for hepatitis C virus antibodies. Both survival rates and standardized mortality ratios (SMRs) related to the causes of death were compared between patients age > or = 70 years and patients age < 70 years.

RESULTS

With the exception of greater maximum tumor size in elderly patients age > or = 70 years, the clinical features of tumors and underlying liver disease were similar to those of patients age < 70 years The survival rates after PEIT in patients age > or = 70 years were 83%, 52%, and 27% at 1 year, 3 years, and 5 years, respectively. These results were comparable to the rates for patients age < 70 years (1 year, 90%; 3 years, 65%; and 5 years, 40%). In addition, there was no difference in mortality from extrahepatic disease between the two groups (9.8% for patients age > or = 70 years vs. 9.4% for patients age < 70 years; P > 0.999). The SMR of patients age > or = 70 years who died of causes related to extrahepatic disease (SMR, 0.56; 95% confidence interval [95%CI], 0.18-1.30) was lower compared with the SMR of patients age < 70 years (SMR, 1.75; 95%CI, 1.07-2.71). The SMR of patients age > or = 70 years who died of causes related to liver disease (SMR, 115; 95%CI, 84.1-153.0) was similar to that of patients age < 70 years (SMR, 120; 95%CI, 103.0-138.0).

CONCLUSIONS

These results provide support for the treatment of patients with HCC age > or = 70 years by tumor ablation using PEIT.

Hepatocellular carcinoma: current approaches to diagnosis and management

Hepatocellular carcinoma, frequently associated with chronic viral hepatitis, is the fourth most common cancer worldwide. The incidence in Western countries is rising rapidly. Recent developments in diagnostic imaging allow for identification of small lesions amenable to curative therapy. Effective therapy of advanced hepatocellular carcinoma remains a major clinical problem.

alpha-Fetoprotein mRNA in the circulation as a predictor of postsurgical recurrence of hepatocellular carcinoma: a prospective study

alpha-fetoprotein (AFP) messenger RNA (mRNA) has been proposed as a marker of hepatocellular carcinoma (HCC) cells disseminated into the circulation, but its clinical significance remains controversial. We prospectively assessed the prognostic value of AFP mRNA in patients undergoing curative hepatic resection for HCC. Peripheral blood samples were taken from 87 patients before and after surgery to determine the presence of AFP mRNA by use of a reverse-transcription polymerase chain reaction. A primary endpoint was recurrence-free interval. AFP mRNA was detectable preoperatively in 31 patients (36%) and postoperatively in 30 patients (34%). With a median follow-up period of 28 months (range, 3-41 months), HCC recurred in 46 patients (53%). Among 4 groups separated according to preoperative and postoperative AFP mRNA status, patients with consistent positivity of AFP mRNA showed the highest recurrence rate (85%) and trend to distant or multiple recurrence. The recurrence-free interval was significantly shorter in patients with postoperative positivity of AFP mRNA than in those without (53% [95% CI, 36-71] vs. 88% [95% CI, 79-96] at 1 year, 37% [95% CI, 17-57] vs. 60% [95% CI, 46-75] at 2 years; P =.014), whereas the preoperative positivity of AFP mRNA provided no significance (P =.100). Cox's proportional-hazards model identified the postoperative positivity of AFP mRNA as an independent prognostic factor for HCC recurrence (relative risk, 2.33; 95% CI, 1.26-4.34; P =.007). In conclusion, postsurgical recurrence of HCC can be predicted by detecting AFP mRNA-expressing cells in peripheral blood.

Clinicopathologic and prognostic significance of the histologic activity of noncancerous liver tissue in hepatitis B virus-associated hepatocellular carcinoma

We prospectively studied 66 patients infected with the hepatitis B virus who underwent liver resection for hepatocellular carcinoma (HCC) to evaluate the influence of the histologic activity of noncancerous liver tissue on clinicopathologic features and prognosis. Based on the histologic activity index (HAI) score of nontumorous liver tissue, patients were classified into 3 groups: mild, moderate, or severe hepatitis. Overall, higher HAI scores were more frequent in patients with poorer liver function: lower serum albumin levels and higher indocyanine green retention at 15 minutes. Moreover, patients with moderate hepatitis had more frequent venous invasion, and the tumor size decreased with increasing HAI scores. Similar results were observed when the fibrosis category was excluded in the calculation of HAI scores. The overall or disease-free survival rates did not differ significantly among the 3 groups of patients. However, higher fibrosis scores were associated significantly with shorter disease-free survival rates. HAI scores correlated significantly with certain clinicopathologic features. In patients with hepatitis B-related HCC, a higher fibrosis score in the nontumorous liver tissue, but not histologic hepatitic activity, seems to be a significant factor predisposing to shorter survival.

Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation

OBJECTIVE

To evaluate the survival results and pattern of recurrence after resection of potentially transplantable small hepatocellular carcinomas (HCC) in patients with preserved liver function, with special reference to the implications for a strategy of salvage transplantation.

SUMMARY BACKGROUND DATA

Primary resection followed by transplantation for recurrence or deterioration of liver function has been recently suggested as a rational strategy for patients with HCC 5 cm or smaller and preserved liver function. However, there are no published data on transplantability after HCC recurrence or long-term deterioration of liver function after resection of small HCC in Child-Pugh class A patients. Such data are critical in determining the feasibility of salvage transplantation.

METHODS

From a prospective database of 473 patients with resection of HCC between 1989 and 1999, 135 patients age 65 years or younger had Child-Pugh class A chronic liver disease (chronic hepatitis or cirrhosis) and transplantable small HCC (solitary < or =5 cm or two or three tumors < or = 3 cm). Survival results were analyzed and the pattern of recurrence was examined for eligibility for salvage transplantation based on the same criteria as those of primary transplantation for HCC.

RESULTS

Overall survival rates at 1, 3, 5, and 10 years were 90%, 76%, 70%, and 35%, respectively, and the corresponding disease-free survival rates were 74%, 50%, 36%, and 22%. Cirrhosis and oligonodular tumors were predictive of worse disease-free survival. Patients with concomitant oligonodular tumors and cirrhosis had a 5-year overall survival rate of 48% and a disease-free survival rate of 0%, which were significantly worse compared with other subgroups. At a median follow-up of 48 months, 67 patients had recurrence and 53 (79%) of them were considered eligible for salvage transplantation. Decompensation from Child-Pugh class A to B or C without recurrence occurred in only six patients.

CONCLUSIONS

For Child-Pugh class A patients with small HCC, hepatic resection is a reasonable first-line treatment associated with a favorable 5-year overall survival rate. A considerable proportion of patients may survive without recurrence for 5 or even 10 years; among those with recurrence, the majority may be eligible for salvage transplantation. These data suggest that primary resection and salvage transplantation may be a feasible and rational strategy for patients with small HCC and preserved liver function. Primary transplantation may be a preferable option for the subset of patients with oligonodular tumors in cirrhotic liver in view of the poor survival results after resection.

Clinicopathologic risk factors for recurrence after a curative hepatic resection for hepatocellular carcinoma

BACKGROUND

The long-term prognosis after resection for patients with hepatocellular carcinoma is still unsatisfactory because of the high recurrence rate. The survival of patients with multiple intrahepatic or extrahepatic recurrence is especially poor.

METHODS

Among the patients who underwent hepatic resection for hepatocellular carcinoma between 1981 and 2000, 216 patients with 3 or less than 3 intrahepatic recurrences (group B); 156 patients with more than 3 intrahepatic recurrences, extrahepatic recurrences, or both (group C); and 51 patients who survived more than 5 years without recurrence (group A) were clinicopathologically studied.

RESULTS

The period to recurrence of group C was significantly earlier than that of group B and also showed a significantly poor prognosis after recurrence. Tumor factors, including size, portal venous invasion, intrahepatic metastasis, histologic grade, or the number of tumors at resection in group C was significantly worse than in groups A and B. Although no differences are recognized in the tumor factors between groups A and B, except for the alpha-fetoprotein level, liver function in group B was significantly worse than that in group A. In addition, the frequency of hepatitis B surface antigen in group B and that of hepatitis C virus in group B was significantly less and higher than that in group A, respectively.

CONCLUSION

Similar to extrahepatic metastasis, multinodular recurrences are also mainly caused by metastatic recurrence from the main tumor by means of the portal system, and recurrences with up to 3 intrahepatic nodules are mainly caused by metachronous multicentric hepatocarcinogenesis. Because the mechanisms of recurrence differed, determining the patterns of recurrence on the basis of the clinicopathologic findings is important for selecting the optimal postoperative therapy for each individual patient.

A 16-year experience in performing hepatic resection in 303 patients with hepatocellular carcinoma: 1985-2000

BACKGROUND

Hepatic resection is an accepted therapeutic modality for hepatocellular carcinoma (HCC). Over the past 2 decades, liver surgery has evolved to a refined and deliberate operation. In the present study surgical results are analyzed with an aim toward further improving the treatment of HCC.

METHODS

We studied 303 patients with HCC who underwent a hepatic resection at 2 university hospitals from 1985 through 2000. Living-related liver transplantation was a procedure of choice in 1 patient with early staged HCC. Fifty-five percent of the patients had associated cirrhosis. Before the operation, the liver function was mainly evaluated with the indocyanine green retention test.

RESULTS

The mortality rate within 30 days after the operation was 1.6%. One-, 3-, 5-, 10-, and 15-year cumulative survival rates were 84%, 67%, 51%, 20%, and 11%, respectively. The tumor stage I and II groups showed superior survival rates to those of the tumor stage III and IV groups, respectively, and the difference was statistically significant. The disease-free survival curves, however, showed the rate to be 27% at 5 years and 11% at 10 years.

CONCLUSIONS

Although the surgical results have greatly improved in the treatment of HCC, the recurrence rate is still high. In carefully screened patients with poor liver function and small HCC, liver transplantation enhances the possibility of cure.

Recurrences of hepatocellular carcinoma following initial remission by transcatheter arterial chemoembolization

BACKGROUND AND AIMS

The aim of this study was: (i) to define the characteristics of hepatocellular carcinoma (HCC) associated with recurrences following initial remission by transcatheter arterial chemoembolization (TACE); (ii) to evaluate the patterns of recurrences; and (iii) find a better surveillance method of detecting recurrent HCC.

METHODS

Out of 230 consecutive HCC patients who underwent TACE, 77 with initial remission were followed prospectively for at least 12 months. We compared the recurrence rates according to the characteristics of the tumors and analyzed the locations of the recurrent HCC. The diagnostic efficacies of CT scans with serum AFP, angiography and Lipiodol CT scan in detecting recurrent HCC were also evaluated.

RESULTS

Recurrent HCC was detected in 40 patients during a median period of 27 months. The recurrence rate of multinodular HCC was higher than the single nodular type. All six patients with portal vein thrombosis recurred. Even though 45% of recurrences were adjacent to original tumors, 63% were separated from them (8% at both). Hepatocellular carcinoma with heterogeneous Lipiodol uptake tended to recur at the site adjacent to the original tumors more frequently than HCC with homogeneous Lipiodol uptake. Only 18 of 40 recurrent HCC were initially detected by serum alpha-fetoprotein (AFP) and CT scans: 19 by angiography and three only by Lipiodol CT scan.

CONCLUSION

Our data indicated that HCC of the multinodular type and with portal vein thrombosis recur more frequently following initial remission by TACE. It is also suggested that regular angiography in addition to serum AFP and CT scan may be valuable in detecting recurrent HCC. Other treatment modalities may need to be combined to ablate tumors completely and to therefore reduce recurrences, especially in HCC with heterogeneous Lipiodol uptake.

Chemoprevention of hepatocellular carcinoma: concept, progress and perspectives

Hepatocellular carcinoma (HCC) often develops in patients with chronic liver diseases associated with hepatitis B (HBV) and hepatitis C (HCV) virus infections with high incidences. Particularly, post-therapeutic recurrence encountered after the curative treatment of the preceding HCC may limit the prognosis. Thus, prevention of HCC is of great significance. In the present review, immunopreventions with alpha-interferon and glycyrrhizin, as well as chemoprevention with acyclic retinoid, are discussed. alpha-Interferon prevents the development of HCC not only in patients with a long-term elimination of HCV (sustained virological responders), but in ones with normalized serum aminotransferases (sustained biochemical responders). Glycyrrhizin also suppresses serum aminotransferases and thereby prevents the tumor development, even though the compound does not have antiviral activity for HBV or HCV by itself. Therefore, suppression of hepatic necroinflammation by these drugs may serve to prevent hepatocarcinogenesis. In contrast, acyclic retinoid suppresses the post-therapeutic recurrence in cirrhotic patients who underwent curative treatment of preceding tumors. The retinoid induces the disappearance of serum lectin-reactive alpha-fetoprotein (AFP-L3), a tumor marker indicating the presence of unrecognizable tumors in the remnant liver, suggesting a deletion of such minute (pre)malignant clones (clonal deletion). As a molecular mechanism of the clonal deletion, a novel mechanism of apoptosis induction by the retinoid via tissue transglutaminase is implicated. In future, a combination of immunopreventive and chemopreventive therapies may give a clue to the further advances of cancer prevention, and thereby to the improvement of the prognosis of cirrhotic patients.