Risk factors for intrahepatic recurrence in human small hepatocellular carcinoma

Treatment of hepatocellular carcinoma

Treatment options have largely been selected according to empirical criteria, such as the presence or absence of cirrhosis, number and size of tumors, and degree of hepatic deterioration and taking into account the local technological and economic resources. There are virtually no controlled studies comparing the efficacy of the available treatments, and the substantial heterogeneity of survival between control groups does not allow us to obtain therapeutic evaluation by comparing results of separate trials. The reassessment of treatment outcomes on the basis of intention-to-treat analysis yielded less encouraging figures. Hepatic resection is the primary option for the few patients with a hepatocellular carcinoma arising in a normal liver with well-preserved hepatic function and for patients with a single tumor, compensated cirrhosis and low portal hypertension who are not candidable to liver transplantation. The latter is the best treatment modality for patients with a solitary tumor <5 cm in diameter or patients with less than three tumors <3 cm, resulting in a 5-year survival of 75%. Locoregional ablative treatments are curative options for patients with a "resectable" tumor who cannot be offered transplantation or hepatic resection. The 5-year survival is approximately 50% but it copes with a high risk of tumor recurrence. Patients with advanced tumor disease cannot be offered curative treatments but only symptomatic treatments.

Combination therapy with transcatheter arterial chemoembolization and percutaneous ethanol injection compared with percutaneous ethanol injection alone for patients with small hepatocellular carcinoma: a randomized control study

BACKGROUND

To assess whether the effectiveness of a combination of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) is superior to PEI alone in the treatment of patients with small hepatocellular carcinoma (HCC), a randomized controlled study was performed.

METHODS

Fifty-two patients with one to three HCC tumors measuring < than 3 cm in greatest dimension were enrolled and underwent the combination TACE-PEI therapy (26 patients with 31 nodules) or PEI alone (26 patients with 34 nodules). There were no significant differences in background between the two groups. The mean follow-up was 30.1 months +/- 17.5 months.

RESULTS

The cumulative detection rates of local residual disease in the TACE-PEI group (3.7% at 1 year and 19.3% at 3 years) were significantly lower compared with the detection rates in the PEI alone group (34.2% and 39.3%, respectively; P = 0.013). The cumulative new nodular recurrence rates in the TACE-PEI group (8.7% at 1 year and 19.3% at 3 years) tended to be lower compared with the recurrence rates in the PEI alone group (26.9% and 80.1%, respectively; P = 0.057). The cumulative survival rates were not significantly different between the two groups (TACE-PEI group: 100%, 80.8%, and 40.4% at 1 year, 3 years, and 5 years, respectively; PEI alone group: 91.3%, 65.9%, and 37.7%, respectively; P = 0.458). However, among the patients from each group with HCC tumors measuring < 2 cm, the survival rates in the TACE-PEI group were improved compared with the survival rates in the PEI alone group (P < 0.01) in addition to the detection rates of local residual disease and the new nodular recurrence rates (P < 0.01 and P = 0.047, respectively). The frequency of short-term and long-term adverse effects was not significantly different between the groups. However, only two major complications (biloma and ascites with pleural effusion) were observed, both of which occurred in patients in the TACE-PEI group.

CONCLUSIONS

Combination therapy with TACE-PEI was superior to PEI alone in the treatment of patients with small HCC tumors, especially for patients with HCC tumors measuring < 2 cm in greatest dimension.

Guidelines for treatment of liver cancer

In the treatment of hepatocellular carcinoma, the range of indications for percutaneous ablation techniques is becoming wider than surgery and intra-arterial therapies. Indeed, whereas for some years only patients with up to three small lesions were treated, with the introduction of the single-session technique under general anesthesia, even patients with more advanced disease are now being treated. Although it is understood that partial resection assures the highest local control, the survival rates after surgery are roughly comparable with percutaneous ethanol injection (PEI). The explanation is due to a balance among advantages and disadvantages of the two therapies. PEI survival curves are better than curves of resected patients who present adverse prognostic factors, and this means that surgery needs a better selection of the patients. Indications for both therapies are reported. Single-session radiofrequency (RF) ablation seems to offer better results in terms of local control and safety than transarterial chemoembolisation (TACE) in multifocal tumours. An open question remains the choice between PEI and other new ablation procedures. In our department, we use RF, PEI and segmental TACE, according to the features of the disease. In the treatment of colorectal liver metastases, the initial survival curves of thermal ablation techniques are promising. However, they are size and site dependent, so partial resection remains the gold standard. An interesting indication seems to be the treatment of breast liver metastases in selected patients.

Postoperative detection of alpha-fetoprotein mRNA in blood as a predictor for metastatic recurrence of hepatocellular carcinoma

BACKGROUND

We tested for the presence of alpha-fetoprotein (AFP) mRNA by using nested RT-PCR in the peripheral blood of hepatocellular carcinoma (HCC) patients who had undergone curative surgery, and investigated the occurrence of intrahepatic and/or extrahepatic metastasis thereafter, to reveal the optimal timing of blood sampling for the prediction of metastatic recurrence.

METHODS

Twenty-nine patients with HCC, who had been operated on were analyzed with RT-PCR at several points during the clinical course, and examined for metastatic recurrence for 3-28 months (mean = 18.7 months) after surgery.

RESULTS

The presence of AFP mRNA before surgery was significantly correlated with the tumor size (P = 0.017). Metastatic recurrence was associated with the postoperative detection of AFP mRNA (P < 0.001), but not with the preoperative and/or perioperative detection. Furthermore, AFP mRNA was detected in some cases that showed low serum AFP levels at recurrence. The recurrence-free period after the detection of AFP mRNA varied from 1 to 12 months.

CONCLUSIONS

The postoperative detection of AFP mRNA is useful for the prediction of metastatic recurrence, and long-term follow up with this method should be conducted.

Prediction of recurrence and extratumor spread of hepatocellular carcinoma following resection

BACKGROUND AND OBJECTIVES

The prognosis of patients with hepatocellular carcinoma (HCC) undergoing hepatectomy depends mostly on tumor recurrence. Portal vein invasion (Vp) and intrahepatic metastasis (IM) might strongly reflect the invasiveness of HCC, but the number of patients in the present series in whom either of these factors were detected was small. In this study, we defined Vp and IM as the extratumor spread, and we focused on the relationship between recurrence in patients after hepatectomy and the extratumor spread and the mitotic activities of cancer cells, in the hope that careful monitoring of recurrence might be possible by simply analyzing histology of the resected specimens.

METHODS

Univariate and multivariate analyses were used to determine the factors potentially related to recurrence in 50 patients who underwent hepatectomy for HCC.

RESULTS

The cumulative recurrence rate at 5 years was 81.0%. In univariate analysis, absence of the extratumor spread, mitotic index of four or less, and curative resection were significantly correlated with low incidence of recurrence. In multivariate analysis, the extratumor spread was the only significant variable influencing recurrence. The mitotic index in HCCs with the extratumor spread was significantly higher than the mitotic index in HCCs without the extratumor spread.

CONCLUSIONS

As a predictive factor for recurrence after resection of HCC, the extratumor spread that reflects the malignant potential of cancer cells was found to be more accurate than is any single invasiveness parameter such as Vp or IM.

Risk factors for recurring hepatocellular carcinoma differ according to infected hepatitis virus-an analysis of 236 consecutive patients with a single lesion

Patients with hepatocellular carcinoma (HCC) frequently experience intrahepatic HCC recurrence even after complete ablation of primary lesions. Because the oncogenic process may be different for hepatitis B viral (B-viral) and hepatitis C viral (C-viral) HCC, the present study was conducted to elucidate the factors contributing to HCC recurrence with respect to the infected hepatitis virus. Two hundred thirty-six patients with a single HCC lesion who underwent complete ablation of the tumor by PEIT and/or PMCT or surgical resection at Tokyo University and its affiliated hospitals from 1993 to 1997 were enrolled. The patients were classified into 3 groups: the B-viral group, C-viral group, and NBNC group. After complete removal of tumors, the patients were followed for a mean period of 39 months. The factors contributing to HCC recurrence were analyzed by univariate and multivariate analysis using the Cox proportional hazard model. The rate of intrahepatic recurrence in enrolled patients at 1, 3, and 5 years was 19%, 50%, and 64%, respectively. The intrahepatic recurrence rate in C-viral and B-viral HCC was higher than that in the NBNC-related HCC. Fibrosis staging, pathological grading of HCC, and serum AFP levels were significantly linked to intrahepatic recurrence by univariate analysis, and fibrosis staging was strongest in the multivariate analysis for C-viral HCC (P = .004). In contrast, fibrosis staging did not affect the recurrence in B-viral (P = .51) and NBNC-related (P = .77) HCC. Risk factors for HCC recurrence differed according to the infected viral state.

The role of des-gamma-carboxy prothrombin levels in hepatocellular carcinoma and liver tissues

We aimed to clarify the clinical significance of des-gamma-carboxy prothrombin (DCP) levels in both hepatocellular carcinoma (HCC) and liver tissues with a special reference to the relationship between DCP level in non-cancerous parts of the liver and the multicentric occurrence of HCC. Twenty-eight patients with HCC, who underwent hepatectomy, were studied. Surgical specimens were obtained from both HCC and non-cancerous liver of each patient. After the preparation of the liver tissues, including tissues with HCC, the DCP levels both in HCC and non-cancerous liver tissue were measured using an electro-chemiluminescence immunoassay. The correlation was investigated between DCP levels and other clinicopathological factors. The DCP level of HCC ranged from 55 to 77735 U/0.1 g tissue weight, with a median of 2801, while the DCP level of non-cancerous parts of the liver ranged from 24 to 721 U/0.1 g tissue weight, with a median of 86. The DCP level in the liver tissue in patients having a multicentric occurrence of HCC was significantly higher than that in patients without multicentric occurrence of HCC. The logarithm of the plasma DCP level correlated with that of the DCP level in HCC (correlation coefficient =0.46; P<0.05). No significant correlation was found between the DCP level in HCC and other clinicopathological parameters. The DCP level in non-cancerous parts of the liver with simultaneous multicentric occurrence of HCC was significantly higher than that in the liver without multicentric HCC. Furthermore, the DCP level in non-cancerous parts of the liver was one of the most important predictable factors of the multicentric occurrence of HCCs among various clinicopathological factors. Therefore, the DCP level may have an important role in hepatocarcinogenesis.

Transplantation for liver and biliary cancer

The early survival of patients transplanted for liver and biliary cancer is excellent, but the overall mid- to long-term survival is poor. In an era of severe donor organ shortage, it is not justified to allocate donor liver to patients with a suboptimal outcome. Patients with non-resectable hepatocellular carcinoma in a non-cirrhotic liver should not be assigned to liver transplantation. Although patients with the fibrolamellar variant have a somewhat better outlook, they are still likely to recur, and the young age of many of these patients is likely to overwhelm any rational approach. The results of transplantation for early-stage hepatocellular carcinoma in a cirrhotic liver are similar to those achieved with benign disease. The inclusion of such cases as a group is justified, but attempts should be made to resect tumors whenever possible and to not assign the entire group to transplantation as the first and only option. The value of pre- and postoperative adjuvant therapy for this group is still under debate, but the present waiting period is so long that some form of therapy to slow growth and prevent dissemination of tumor cells is probably required. The results following transplantation for cholangiocarcinoma can only be regarded as dismal, and the diagnosis of cholangiocarcinoma is a contraindication for the procedure. Liver transplantation has a definite place in the treatment of epithelioid hemangioendothelioma and unresectable chemo-responsive hepatoblastoma when confined to the liver, and in a limited number of metastatic neuroendocrine tumors.

Carriage of HFE mutations and outcome of surgical resection for hepatocellular carcinoma in cirrhotic patients

BACKGROUND

Aggressive hepatocellular carcinoma (HCC) complicates frequently hereditary hemochromatosis, a disease for which a strong candidate gene, named HFE, has recently been identified. Patients with HCC who are heterozygotes for mutations in the HFE gene might have distinct features and a distinct disease course.

METHODS

The presence of the 2 mutations associated with hereditary hemochromatosis (C282Y and H63D) was sought by restriction fragment length polymorphism in 61 cirrhotic patients (46 males and 15 females) who underwent resection for HCC at a single institution.

RESULTS

There were 4 heterozygotes for the C282Y mutation and 6 homozygotes + 20 heterozygotes for the H63D mutation, with no compound heterozygotes. Carriage of >/= 1 HFE mutated allele was significantly more frequent in HCC patients than in 149 control subjects (44% vs. 29%, P = 0.005). Among C282Y heterozygotes, 3 of 4 were female, compared with 12 of 57 wild-type carriers (P = 0.015); no gender distribution existed among patients carrying H63D alleles (6 of 26 vs. 9 of 35, P = 0.813). Survival was longer for patients with wild-type HFE than for those with mutated HFE (67% vs. 22% at 3 years; hazard ratio = 0.42, 95% confidence interval = 0.21-0.80) (P < 0.01). The negative effect on survival that resulted from possessing >/= 1 HFE mutated allele was maintained even after adjustment for gender, age, presence of tumor capsule, presence of comorbid factors, Okuda stage, Edmonson grading, and number of lesions (P = 0.01).

CONCLUSIONS

Testing for HFE mutations may help identify HCC patients with dismal prognoses for whom surgical resection may not represent the best treatment option.

Risk factors, prevention, and management of postoperative recurrence after resection of hepatocellular carcinoma

OBJECTIVE

To evaluate the current knowledge on the risk factors for recurrence, efficacy of adjuvant therapy in preventing recurrence, and the optimal management of recurrence after resection of hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

The long-term prognosis after resection of HCC remains unsatisfactory as a result of a high incidence of recurrence. Prevention and effective management of recurrence are the most important strategies to improve the long-term survival results.

METHODS

A review of relevant English articles was undertaken based on a Medline search from January 1980 to July 1999.

RESULTS

Pathologic factors indicative of tumor invasiveness such as venous invasion, presence of satellite nodules, large tumor size, and advanced pTNM stage, are the best-established risk factors for recurrence. Active hepatitis activity in the nontumorous liver and perioperative transfusion also appear to enhance recurrence. Recent molecular research has identified tumor biologic factors such as the proliferative and angiogenic activities of the tumor as new risk factors for recurrence. There is a lack of convincing evidence for the efficacy of neoadjuvant or adjuvant therapy in preventing recurrence. Retrospective studies suggested that postoperative hepatic arterial chemotherapy might improve disease-free survival, but results were conflicting. For the management of postoperative recurrence, studies have consistently indicated that surgical resection should be the treatment of choice for localized recurrence, be it in the liver remnant or extrahepatic organs. Transarterial chemoembolization and percutaneous ethanol injection are widely used to prolong survival in patients with unresectable intrahepatic recurrence, and combined therapy with these two modalities may offer additional benefit.

CONCLUSIONS

Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to prevention. Minimal surgical manipulation of tumors to prevent tumor cell dissemination, avoidance of perioperative blood transfusion, and suppression of chronic hepatitis activity in the liver remnant are strategies that may be useful in preventing recurrence. The efficacy of postoperative adjuvant regional chemotherapy deserves further evaluation. New concepts on the influence of tumor biologic factors such as angiogenic activity on recurrence of HCC suggest a potential role of novel approaches such as antiangiogenesis for adjuvant therapy in the future. Currently, the most realistic approach in prolonging survival after resection of HCC is early detection and aggressive management of recurrence. Randomized trials are needed to define the roles of various treatment modalities for recurrence and the benefit of multimodality therapy.

Clinical significance of microscopic tumor venous invasion in patients with resectable hepatocellular carcinoma

BACKGROUND

Tumor venous invasion in patients with resectable hepatocellular carcinoma (HCC) is frequent and can be macroscopic and microscopic or microscopic alone. Although macroscopic invasion is a well-established prognostic indicator, the clinical significance of microscopic invasion remains unclear.

METHODS

There were 322 patients enrolled who had undergone curative resection for HCC. The clinicopathologic factors and prognostic significance associated with macroscopic and microscopic venous invasion were analyzed.

RESULTS

Macroscopic invasion was observed in 50 patients (15.5%) and microscopic invasion in 190 (59.0%). The larger the tumor, the more the incidence of venous invasion. There were 140 patients with microscopic invasion only (Group 1). Patients with macroscopic invasion (Group 2, n = 50) also had microscopic invasion. Compared with patients without venous invasion (Group 3, n = 132), Group 1 had a higher alpha-fetoprotein level, a larger tumor size, and more tumors without encapsulation. For group 1, the 1-, 3-, and 5-year disease-free survival rates were 65.6%, 41.6%, and 30.8%, respectively. The 1-, 3-, and 5-year overall survival rates were 87. 8%, 60.0%, and 52.7%, respectively. The survival rates of group 1 were lower than those of group 3 and higher than those of group 2 (P <.05). Multivariate analysis indicated that microscopic and macroscopic venous invasion, surgical margin, indocyanine-green retention, and tumor size and number were significant predictors of postresectional survival.

CONCLUSIONS

In HCC patients, microscopic venous invasion is frequent and related independently to postresectional outcome.

Significance of resection margin in hepatectomy for hepatocellular carcinoma: A critical reappraisal

OBJECTIVE

To evaluate the influence of the width and histologic involvement of the resection margin on postoperative recurrence after resection of hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

The significance of the resection margin in hepatectomy for HCC remains controversial. A precise evaluation of the effects of the width and histologic involvement of the resection margin on postoperative recurrence is required to clarify the issue.

METHODS

Two hundred eighty-eight patients with macroscopically complete resection of HCC were divided into groups with narrow (<1 cm) or wide (>/=1 cm) resection margins. The two groups were compared for postoperative recurrence rate and pattern of recurrence. A further analysis was performed to investigate the effects of histologic involvement of the resection margin on postoperative recurrence.

RESULTS

Recurrence rates were similar between 150 patients with a narrow margin and 138 patients with a wide margin; the groups were comparable in other clinicopathologic variables. Most recurrent tumors occurred in the liver remnant at a segment distant from the resection margin or at multiple segments. Thirty-four patients had margin involved histologically by microscopic invasion from the main tumor (n = 13), venous tumor thrombi (n = 13), or microsatellites separate from the main tumor (n = 8). These patients had significantly higher recurrence rates than those with a histologically clear margin. However, a positive histologic margin was not a significant risk factor for recurrence by multivariate analysis. Tumor stage and perioperative transfusion were the only independent risk factors.

CONCLUSIONS

The width of the resection margin did not influence the postoperative recurrence rates after hepatectomy for HCC. A positive histologic margin was associated with a higher incidence of postoperative recurrence, but in most patients this was related to the underlying venous invasion or microsatellites. Most intrahepatic recurrences were considered to arise from intrahepatic metastasis by means of venous dissemination, which a wide resection margin could not prevent.

Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: an outcome-oriented decision analysis

Two treatments are accepted for patients with solitary hepatocellular carcinoma </=5 cm in size and with preserved hepatic function: (1) liver resection, which can be performed without delay but has a high recurrence rate, and (2) liver transplantation, which has a better long-term survival, but is not easily available because grafts are scarce. A third possibility is to offer liver resection first and liver transplantation for tumor recurrence or deteriorating liver function ("salvage" transplantation). We investigated the implications of such a strategy with a Markov-based decision analytic model. In a scenario assuming intermediate values for 4 main variables (12-month waiting list; tumor progression outside transplantation criteria: 4% per month; recurrence after resection: 20% per year; recurrences eligible for transplantation: 60%), the life expectancy was 8.8 years for primary transplantation versus 7.8 years for primary resection and salvage transplantation, with a calculated use of grafts at 5 years of 52% for primary transplantation versus 23% for salvage transplantation. This study estimates of the survival and graft-saving of a strategy of primary resection and salvage transplantation according to variables that are to some extent predictable. This strategy may be a rational way to cope with lengthening waiting lists, especially for patients with tumors close to the limit for transplantation criteria, if the results of liver resection are good, if patients with the lowest risks of recurrence can be selected, and if a strict follow-up can detect recurrences when the patients are still transplantable.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with cirrhosis: evaluation of damage to nontumorous liver tissue-long-term prospective study

PURPOSE

To evaluate damage to cirrhotic liver tissue after transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

TACE was performed in 111 patients with HCC that involved less than 30% of the liver. Baseline liver function was evaluated with Child-Pugh scores and other indicators. Eighty-two patients had Child-Pugh class A disease, 27 had class B disease, and two had class C disease. All patients underwent chemotherapy followed by gelatin sponge particle embolization in the proper ("complete" embolization; n = 69) or right or left main ("partial" embolization; n = 42) hepatic artery. Liver function was assessed 4 months later, and 95 patients underwent a second TACE (complete embolization in 57, partial in 38). Liver function was again assessed 4 months later in 60 patients.

RESULTS

No patient died. Child-Pugh scores increased in all patients from a mean 5.96 to 6.28 (not significant) and 6.51 (P =. 05) after first and second TACEs, respectively. In patients with class A disease, scores increased from a mean 5.37 to 5.73 (P =.01) and 5.89 (P =.001) after first and second TACEs, respectively; in patients with class B disease, scores changed from a mean of 7.48 to 7.67 and 7.30 after first and second TACEs, respectively (not significant).

CONCLUSION

TACE does not induce significant long-term worsening of liver function in patients with class A or B cirrhosis.

The role of telomerase activity in hepatocellular carcinoma

OBJECTIVE

The aim of this study was to clarify the role of telomerase activity in hepatocellular carcinoma (HCC).

METHODS

Specimens from both HCC and noncancerous liver were obtained from 39 patients with HCC using a 14-gauge biopsy needle immediately after laparotomy. Telomerase activity was determined using a telomeric repeat amplification protocol assay. The 3+ of telomerase activity in HCC was defined as a high telomerase group, and 2+ or less of HCC telomerase activity was defined as a low telomerase group. In noncancerous liver, 2+ or more of telomerase activity was defined as an increased telomerase group, and 1+ or less of telomerase activity was defined as a nonincreased telomerase group. The correlation between telomerase activity in HCC or noncancerous liver and clinicopathological factors, including prognosis, was investigated.

RESULTS

Telomerase activities in HCCs were 0 in one patient, 1+ in two, 2+ in seven, and 3+ in 29 patients. The disease-free survival rate in the high telomerase group was significantly worse than that in the low telomerase group. The des-gamma-carboxy prothrombin level in a high telomerase group (median, 330 mAU/ml) was significantly higher than that in the low telomerase group (median, 150 mAU/ml). A multivariate analysis revealed that higher TNM stage, high telomerase activity in HCC, female gender, and high alpha-fetoprotein value were independent significant factors related to be early recurrence. The incidence of multicentric HCC occurrence in the increased telomerase group (53.3%) tended to be higher than that in the nonincreased telomerase group (27.3%).

CONCLUSION

A high telomerase activity in HCC correlated with the potential of HCC to be more malignant, which was expressed as both a high level of des-gamma-carboxy prothrombin and an earlier recurrence after hepatectomy than that of HCC with a low telomerase activity.

Predictive factors for intrahepatic recurrence after percutaneous ethanol injection therapy for small hepatocellular carcinoma

BACKGROUND

Percutaneous ethanol injection therapy has been used widely for small hepatocellular carcinoma. This study was undertaken to determine factors predictive of local recurrence or new nodular recurrence in patients with small hepatocellular carcinoma treated with percutaneous ethanol injection.

METHODS

The authors studied 73 nodules treated with percutaneous ethanol injection in 49 patients with small hepatocellular carcinoma. The usefulness of predictive factors for recurrence was assessed with the Kaplan-Meier method. The clinicopathologic variables examined included age, gender, Child-Pugh classification, number of tumors (single vs. multiple), tumor size, degree of tumor differentiation, ultrasonographic findings such as peripheral hypoechoic band (so-called 'halo'), intratumoral echo pattern, tumor staining on enhanced computed tomography, combination therapy with transcatheter arterial embolization, and serum alpha-fetoprotein level.

RESULTS

The local recurrence rates were 19%, 27%, 33%, 33%, and 33%, respectively, and the new nodular recurrence rates were 19%, 51%, 74%, 83%, and 83%, respectively, at 1, 2, 3, 4, and 5 years after percutaneous ethanol injection therapy. The frequency of local recurrence was associated with the histologic differentiation of more than moderately differentiated (P < 0.001), presence of a sonographic halo (P < 0. 005), an intratumoral heterogeneous echo pattern (P < 0.001), and positive tumor staining on enhanced computed tomography (P < 0.01). Multivariate analysis showed that the presence of a halo and an intratumoral heterogeneous echo pattern were the most important variables for predicting local recurrence. The frequency of new nodular recurrences was related to the presence of multiple tumors (P < 0.01) and a high serum alpha-fetoprotein level (P < 0.001). Multivariate analysis showed that a high serum alpha-fetoprotein level was a reliable predictor of new nodular recurrence.

CONCLUSIONS

This study showed that the presence of a halo and an intratumoral echo pattern on ultrasonography were useful predictors for local recurrence after percutaneous ethanol injection therapy for small hepatocellular carcinoma, and that a high serum alpha-fetoprotein level was associated with a higher frequency of new nodular recurrences.

The significance of thymidine phosphorylase activity in hepatocellular carcinoma and chronic diseased livers: a special reference to liver fibrosis and multicentric tumor occurrence

The role of thymidine phosphorylase (TP), an angiogenic factor, in hepatocellular carcinoma (HCC) remains unclear. The aim of this study was to clarify the significance of TP in HCC. Thirty-seven patients with HCC, who underwent hepatectomy, were included. The TP activity in both cancerous and non-cancerous parts of livers were measured by an enzyme-linked immunosorbent assay. Another 11 patients without HCC were used to evaluate the TP activity in the non-cancerous parts of livers. Both the cancerous and non-cancerous TP activities were clinico-pathologically investigated with special reference to the multicentric occurrence of HCCs and the degree of liver fibrosis; consisting of normal, fibrosis and cirrhosis. The TP activity in the cancerous part was 94.6 +/- 70.2 U/mg protein, while that in non-cancerous parts of the liver was 80.9 +/- 48.8 U/mg protein. No significant difference was observed. The TP activity in the cancerous part did not correlate with any clinicopathological variables, such as tumor differentiation, portal vein invasion, intrahepatic metastases and prognosis. However, the TP activity in the non-cancerous parts of the liver correlated with the degree of fibrosis (normal/fibrosis/cirrhosis = 34:74:90 U/ mg protein, respectively). Furthermore, regarding the correlation between TP activity in the non-cancerous parts and the simultaneously multicentric occurrence of HCC, the TP activity in the multicentric group (n = 8; 121 U/mg protein) was significantly higher than that in the non-multicentric group (n = 29; 70 U/mg protein). The TP activity in the non-cancerous parts increased in proportion to the degree of liver fibrosis. Furthermore, it is suggested that the higher TP activity in the non-cancerous part is related to the multicentric occurrence of HCCs.

Prospective analysis of risk factors for early intrahepatic recurrence of hepatocellular carcinoma following ethanol injection

BACKGROUND/AIM

Time-dependent intrahepatic recurrence of hepatocellular carcinoma is frequent after different treatment modalities, including percutaneous ethanol injection. We attempted to prospectively analyze the possible risk factors for early intrahepatic recurrence of hepatocellular carcinoma after percutaneous ethanol injection.

METHODS

Sixty-five patients with 65 solitary hepatocellular carcinoma nodules < or =6 cm in diameter underwent initial treatment with percutaneous ethanol injection and were examined to ascertain the factors related to recurrence, local and distant, within the liver. A number of clinical and tumor parameters were analyzed.

RESULTS

Cumulative overall recurrence rates 12 and 24 months after percutaneous ethanol injection were 15.6% and 45.1%, respectively, irrespective of clinical and tumor parameters. Overall recurrence rates 12 and 24 months after percutaneous ethanol injection were 40% and 67.5%, for tumor > or =3 cm and 7.5% and 37.5%, for tumor <3 cm. Cumulative local recurrence rates at 12 and 24 months were 26.3% and 43.5%, respectively, for tumor > or =3 cm and 11.7% and 18.2%, respectively, for tumor <3 cm. The log-rank test indicated that a tumor size of > or =3 cm and the presence of capsule for a tumor of <3 cm in diameter were significant risk factors for intrahepatic recurrence. A pretreatment serum PIVKA-II level of > or =0.02 AU/ml was the only clinical parameter associated with overall recurrence (p=0.0041) and distant intrahepatic recurrence (p=0.0307). Distant intrahepatic recurrence rates 12 and 24 months after percutaneous ethanol injection were 22.5% and 31.4%, respectively, for PIVKA-II levels of > or =0.02 AU/ml and 8% and 17.8%, for PIVKA-II of <0.02 AU/ml. Cox's proportional hazard model identified that tumor size, tumor capsule and baseline serum PIVKA-II levels were independently related to intrahepatic recurrence.

CONCLUSIONS

These data demonstrate that tumor size and peritumoral capsule were associated with overall and local recurrence of hepatocellular carcinoma. Moreover, pretreatment serum levels of PIVKA-II can indicate the risk of early intrahepatic recurrence and may assist in patient selection and appropriate therapy.

Correlation of clinicopathologic features of resected hepatocellular carcinoma with hepatitis C virus genotype

Clinicopathologic findings in patients with hepatocellular carcinoma complicating hepatitis C virus and outcomes after liver resection were compared between different viral genotypes. One hundred and forty-seven patients with both anti-hepatitis C virus antibody and hepatitis C virus RNA in their sera underwent curative resection for hepatocellular carcinoma in our department between 1991 and 1997. Of these patients, 115 were infected with hepatitis C virus genotype 1b (group 1), and 32 were infected with 2a or 2b (group 2). Clinicopathologic findings and outcomes after operation were compared between the two groups. Alanine aminotransferase activity was significantly higher in group 2 than in group 1. Genotypes did not differ concomitantly with histopathologic features of the carcinoma or adjacent hepatic tissue. Although the tumor-free survival rate did not differ significantly between the two groups, recurrence was not detected during the period beyond 3 years following operation in group 2, while recurrences arose during that period in 16 group 1 patients, most of whom continued to manifest active hepatitis. In 7 of these 16 patients, the recurrent tumors were histologically multicentric in origin. The cumulative survival rate was significantly lower in group 1 than 2. Multivariate analysis indicated that genotype 1b was an independent risk factor for short survival. Patients infected with genotype 1b may have a relatively high risk of ongoing hepatocarcinogenesis and more aggressive progression of associated liver dysfunction, resulting in a poorer outcome than with other genotypes.

Usefulness of measurement of Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein as a marker of prognosis and recurrence of small hepatocellular carcinoma

OBJECTIVE

Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3%) is a recently described marker of hepatocellular carcinoma (HCC), and its usefulness has been demonstrated in many studies. We evaluated the usefulness of serial measurement of AFP-L3% as a marker of prognosis and recurrence after treatment of small HCC.

METHODS

AFP-L3% was measured before and after initial treatment in 60 patients with small HCC (maximum diameter < or = 2 cm). AFP-L3% was taken as the ratio of AFP-L3 to total AFP and multiplied by 100%, and levels > or = 10% were considered positive. Outcomes and recurrence were compared between patients AFP-L3%-negative after initial treatment (Group A, n = 43) and patients who were AFP-L3%-positive after initial treatment (Group B, n = 17).

RESULTS

Before treatment, AFP-L3% was positive in 14 (23.3%) of the 60 patients. The cumulative survival rate of Group A was significantly longer (p = 0.0091) than that of Group B. The recurrence rate was significantly higher in Group B (p = 0.0104) than in Group A. When recurrence was limited to intrahepatic metastasis, the recurrence rate was significantly higher in Group B (p = 0.0064). However, the recurrence rate of multicentric occurrence did not differ significantly between Groups A and B.

CONCLUSIONS

Measurement of AFP-L3% after treatment may be useful for understanding prognosis and recurrence of HCC.

Parenchymal echo patterns of cirrhotic liver analysed with a neural network for risk of hepatocellular carcinoma

BACKGROUND

To objectively evaluate the parenchymal echo patterns of the liver in cirrhosis, an image analysing system in which a neural network is used has been found capable of numerically calculating coarse score (CS). Using this system, we analysed whether or not CS can serve as a predictive factor for the development of hepatocellular carcinoma (HCC).

METHODS

The risk factors for HCC were evaluated in 95 patients with liver cirrhosis with an average follow-up period of 2041 +/- 823 days. We used a three-layer feed-forward neural network and a back-propagation algorithm to calculate CS.

RESULTS

There were strong correlations between CS, alanine aminotransferase (ALT) and alpha-fetoprotein (AFP) and the average cumulative incidence rate of HCC evaluated by the Cox's proportional hazards model. The adjusted rate ratios were estimated to be 3.00, 2.80 and 2.01, respectively. The cumulative risks of HCC were significantly higher with an initial CS > or = 1.5 than with an initial CS < 1.5, with ALT > or = 80 IU/L than with initial ALT < 80 IU/L and with AFP > or = 20 ng/mL than with initial AFP < 20 ng/mL, all analysed by the log-rank test.

CONCLUSIONS

Coarse score is a useful predictor for development of HCC.

Resection of hepatocellular carcinoma in cirrhotic patients: longterm results of a prospective study

BACKGROUND

Surgical resection of hepatocellular carcinoma in cirrhotic patients remains controversial because of a high reported recurrence rate. To assess the longterm results of resection, 37 patients included in a prospective study were followed for more than 5 years, with special interest in early detection of recurrence.

STUDY DESIGN

Resection was performed from 1986 to 1991 with the goal of sparing the functional liver parenchyma. The mean tumor diameter was 5.3 +/- 2.6 cm (range 2 to 11 cm). Nineteen patients had tumors smaller than 5 cm. No additional perioperative therapy was performed.

RESULTS

Evidence of intrahepatic recurrence was demonstrated in 26 of the 33 patients surviving the operation. Eight recurrences (31%) were diagnosed from the third to the fifth postoperative years. The recurrence-free survival rates at 1, 2, 3, 4, and 5 years were 68%, 40%, 26%, 13%, and 9%, respectively. Only 2 patients (7%) were alive and free of recurrence at 5 years. Some long survivals were observed after treatment of recurrence. The overall survival rates at 3 and 5 years were 35% and 24%, respectively. Tumor cell differentiation was the only significant prognostic factor for both recurrence and survival. Multifocal tumors were associated with a higher recurrence rate. Patients with good liver function had longer survivals that reached 38% in those with small solitary tumors. Study of the other dinicopathologic factors failed to demonstrate any prognostic value.

CONCLUSIONS

Only a few patients are alive and free of recurrence 5 years after resection. Some long survival can be observed after treatment. Assessment of prognostic factors remains difficult, but the best results of resection are obtained in patients with small solitary hepatocellular carcinoma function.

Association between high serum alanine aminotransferase levels and more rapid development and higher rate of incidence of hepatocellular carcinoma in patients with hepatitis C virus-associated cirrhosis

BACKGROUND

Many studies have demonstrated in animal experiments that persistent inflammation may accelerate the development of carcinoma. In this article, the question of whether the persistent elevation of serum alanine aminotransferase (ALT) levels (which represents the inflammatory necrosis of hepatocytes) correlates with the development of hepatocellular carcinoma (HCC) was studied in patients with early stage hepatitis C virus (HCV)-associated cirrhosis.

METHODS

Sixty-nine consecutive patients with biopsy proven HCV-associated cirrhosis (mostly Child's Stage A) who had been followed for >5 years for the development of HCC were studied. They were subdivided into 3 groups according to their serum ALT levels: Group A was comprised of 28 patients whose annual average serum ALT level was persistently high (>/= 80 IU) (high ALT group), Group B was comprised of 28 patients whose annual average serum ALT level was persistently low (< 80 IU) (low ALT group), and Group C was comprised of 13 unclassified patients. The patients had been studied prospectively with frequent ultrasonography and magnetic resonance imaging or computed tomography for > 5 years.

RESULTS

In the high ALT group HCC developed in 71.4% of patients compared with 25.0% in the low ALT group over the observation period (P < 0.005). The 5-year rate of incidence of HCC in the high ALT group was as high as 53.6% compared with only 7.1% in the low ALT group (P < 0.001). The expected interval between the diagnosis of cirrhosis and the development of HCC was 6.0 +/- 0.7 years (mean +/- standard error) in the high ALT group and 12.7 +/- 1.2 years in the low ALT group (P < 0.001).

CONCLUSIONS

The results of the current study demonstrated that the development of HCC was more rapid in the high ALT group with HCV-associated cirrhosis.

Hyperplastic foci reflect the risk of multicentric development of human hepatocellular carcinoma

BACKGROUND/AIMS

Identification of the risk factors of multicentric hepatocarcinogenesis is important for the clinical management of hepatocellular carcinoma. We investigated hyperplastic foci in non-cancerous liver parenchyma, and clarified their pathological features and clinical significance.

METHODS

Hyperplastic foci were defined as hypercellular areas, which architecturally and cytologically resembled early hepatocellular carcinoma or adenomatous hyperplasia but did not form macroscopically detectable nodules. Surgically resected livers from 155 patients with hepatocellular carcinoma were examined histopathologically and immunohistochemically.

RESULTS

Hyperplastic foci were found in 26 of 155 patients (16.8%). All the patients with hyperplastic foci had chronic liver diseases, and the incidence did not differ between those with chronic hepatitis and those with liver cirrhosis. Six of 92 (6.5%) patients with single primary hepatocellular carcinoma nodules, 8 of 42 (19.0%) with two nodules, and 12 of 21 (57.0%) with more than three nodules had hyperplastic foci. The incidence of hyperplastic foci showed a significant positive correlation with the multiplicity of hepatocellular carcinoma nodules. Immunohistochemically, hyperplastic foci were masses of proliferative hepatocytes similar to adenomatous hyperplasia and early hepatocellular carcinoma.

CONCLUSIONS

Hyperplastic foci reflect the risk of multicentric hepatocarcinogenesis. Our results suggest strongly that hyperplastic foci are precursors of adenomatous hyperplasia or hepatocellular carcinoma.

Loss of butyrate-induced apoptosis in human hepatoma cell lines HCC-M and HCC-T having substantial Bcl-2 expression

We have demonstrated that sodium butyrate induces differentiation in human hepatoma cells; however, recent studies have shown that this agent causes apoptosis in some types of cancer cells. In this study, we examined whether sodium butyrate causes apoptosis in the human hepatoma cell lines, HCC-M and HCC-T. The growth of human hepatoma cells was dose-dependently reduced by sodium butyrate. Flow cytometric analysis showed cell-cycle arrest at the G1 phase in the sodium butyrate-treated cells. Apoptotic change was never found in treated cells at concentration levels of less than 5 mmol/L. Sodium butyrate decreased p53 expression and increased p21WAF-1 expression in HCC-T and HCC-M cells having the wild-type p53 gene. Western blot analysis showed that Bcl-2 was expressed in the HCC-T and HCC-M cells, and its expression was increased after exposure to sodium butyrate. Antisense oligodeoxynucleotide against bcl-2 easily caused apoptosis. These results indicate that sodium butyrate hardly induces apoptotic change in the human hepatoma cell lines, HCC-T and HCC-M, with the increase of Bcl-2 expression. Cell-cycle arrest in the G1 phase caused by sodium butyrate was suggested to be induced by the increase in p21WAF-1 expression, but this change did not link with the p53 increase.

Prognostic factors affecting long term outcome after liver resection for hepatocellular carcinoma: results in a series of 100 Italian patients

BACKGROUND

Long term results after liver resection for hepatocellular carcinoma (HCC) are disappointing because the disease tends to recur. In this study, the authors assessed prognostic factors affecting long term outcome, in the hope that these factors might be used in selecting HCC patients for surgery.

METHODS

During the period 1977-1995, 100 consecutive patients underwent curative liver resection; 78 of 100 had HCC arising on preexisting cirrhosis (53 Child's Class A and 25 Child's Class B). Thirty-five prognostic factors were evaluated for their association with overall survival (OS) and disease free survival (DFS) in univariate and multivariate analysis (Cox proportional hazards model).

RESULTS

There were four postoperative deaths. Seven patients died in hospital of hepatorenal failure: six had Child's Class B cirrhosis and had undergone preoperative chemoembolization. Of the remaining 89 patients, 50 developed recurrence. All surviving Child's Class B patients had recurrence. Five-year OS, postoperative deaths included, was 38% (median, 36 months). Five-year DFS, postoperative deaths excluded, was 26% (median, 21 months). Independent prognostic factors for DFS were Child's class, glutamic-oxaloacetic transaminase, gamma-glutamyltransferase, alpha-fetoprotein, number of tumor nodules, width of resection margins, preoperative chemoembolization, and experience of the team that performed the surgery. Factors with an independent effect on OS were Child's class and width of resection margins.

CONCLUSIONS

Liver resection can provide long term DFS in HCC patients with normal liver function. In patients with liver function impairment or an inadequate resection margin, recurrences are almost certain to occur. Preoperative chemoembolization significantly prolongs DFS but may increase the risk of postoperative liver failure in patients with liver function impairment.

Prognostic influence of clinicopathologic features, DNA-ploidy, CD44H and p53 expression in a large series of resected hepatocellular carcinoma in France

Factors affecting outcome after resection of hepatocellular carcinoma (HCC) in patients from Western countries are not clearly defined. Different clinicopathological factors, including DNA ploidy and expression of p53 and CD44H proteins were evaluated retrospectively in 113 patients undergoing curative resection; 11 clinical and 12 pathological factors were studied. Survival curves were calculated by the Kaplan-Meier method and multivariate analysis of outcome predictors for 103 HCC was assessed by Cox regression. By univariate analysis, survival was significantly better in patients with a high serum albumin level >4.0 g/dl, a normal serum alpha-fetoprotein level and an absence of microscopic vascular invasion by the tumor. In multivariate analysis, only high serum albumin level and absence of vascular invasion were found to be independent favorable predictive factors. CD44H expression was significantly correlated with vascular involvement. However, CD44H and p53 expression did not affect survival. The DNA ploidy pattern showed a bimodal distribution, but did not influence the survival rate. This study suggests that pre-operative level of albumin and microscopic vascular invasion can predict long-term survival in patients who have undergone curative resection for HCC. By contrast, the DNA-ploidy pattern and the immunohistochemical detection of p53 and CD44H expression are not predictors of outcome of patients with HCC.

Predictive factors of survival and intrahepatic recurrence of hepatocellular carcinoma in cirrhosis after percutaneous ethanol injection: analysis of 71 patients

BACKGROUND/AIMS

This study was undertaken to determine the factors predicting survival and intrahepatic recurrence in hepatocellular carcinoma patients treated with percutaneous ethanol injection.

METHODS

Seventy-one patients with cirrhosis and hepatocellular carcinoma underwent percutaneous ethanol injection (54 males/17 females; median age 66 years; Child A 54/B 17). Fifty-two patients had a single nodule < or = 5 cm and 19 had multiple nodules, up to three, each one < or = 4 cm. Follow-up ranged from 2-63 months (median 26).

RESULTS

Overall survival rates were 89%, 54% and 24% and new lesions recurrence rates 32%, 73% and 81% at 1, 3 and 5 years, respectively. At univariate analysis, monofocal tumor (p<0.05), absence of ascites (p<0.05), complete tumor necrosis at CT-scan or MRI (p<0.01), post-treatment alpha-fetoprotein < or = 10 ng/ml (p<0.05) and Child A class in patients with a single nodule (p<0.05) were associated with higher survival. Presence of tumor capsule at imaging (p<0.05), complete tumor necrosis at CT-scan or MRI (p<0.01) and post-treatment alpha-fetoprotein < or = 10 ng/ml (p<0.01) were associated with lower recurrence rates. At multivariate analysis, basal alpha-fetoprotein (p=0.040) and tumor number (p=0.032) significantly affected survival; stepwise analysis revealed basal alpha-fetoprotein, tumor number and serum albumin (p=0.0012) as the best combination predicting survival. No variable reliably predicted recurrence by multivariate analysis.

CONCLUSIONS

In patients with cirrhosis and hepatocellular carcinoma, treated with percutaneous ethanol injection, survival depends on: the severity of the underlying liver disease, uni/multifocality of the tumor and basal alpha-fetoprotein. Presence of a tumor capsule is associated with lower recurrence rates. At post-treatment evaluation, both survival and recurrence rates are positively affected by complete tumor necrosis and alpha-fetoprotein < or = 10 ng/ml.

Partial hepatic resection for hepatocellular carcinoma

This review summarizes the efficacy of the most common therapeutic option for hepatocellular carcinoma (HCC), partial hepatic resection, taking into account not only its antitumoural effect, but also its consequences on survival. Partial hepatic resection results in 5 year survival rates as high as 45% in more favourable subgroups having: small tumours, well-differentiated tumours, unifocal tumours, a lack of vascular invasions, an absence of cirrhosis, and the fibrolamellar variant. Resection has been limited primarily by low resectability rates and recurrent disease. However, surgical resection in the form of partial hepatectomy is the preferred treatment for HCC. The early detection of tumours by screening high-risk populations is crucial. During the 12 year period between 1983 and 1994, hepatic resections were carried out in 382 patients with HCC. One hundred and fifty-three (40%) had HCC smaller than 5 cm in diameter. There were 294 male and 88 female patients, with an average age of 52.3 years. Among them, 45% had liver cirrhosis and 73% were positive for hepatitis B surface antigen. Two hundred and eighteen (57%) were positive for hepatitis C virus circulating antibodies (since 1991). Operative mortality was 3.9%. The overall survival rates at 1, 3 and 5 years were 71, 52 and 46%, respectively. Sex, cirrhosis, Child's staging, surgical procedure, blood loss, pathological pattern, presence of capsule, surgical margin and DNA ploidy appeared to be factors not related to prognosis. However, alpha-fetoprotein level, size (whether less than or greater than 5 cm), and vascular invasion were factors which significantly affect survival.

Risk factors for intrahepatic recurrence of hepatocellular carcinoma in cirrhotic patients treated by percutaneous ethanol injection

BACKGROUND

Hepatocellular carcinoma (HCC) complicating cirrhosis has a high intrahepatic recurrence rate after treatment by surgical resection or percutaneous ethanol injection (PEI). In this study, certain clinical, biochemical, and pathologic parameters were evaluated as risk factors for intrahepatic tumor recurrence in liver segments different from that of the first neoplasm in a group of 57 cirrhotic patients with single HCC < 5 cm treated by PEI.

METHODS

After PEI treatment of HCC, the patients were followed for a mean period of 33 +/- 16 months. The following pretreatment parameters were evaluated as predictors of tumor recurrence: age, gender, Child-Pugh score, hepatitis B virus surface antigen, hepatitis C virus antibodies, alanine aminotransferase, aspartate aminotransferase, alpha-fetoprotein (AFP) level before PEI, alcohol abuse, HCC size, HCC ultrasound pattern, HCC histologic grade, HCC capsule, and time from cirrhosis diagnosis. Furthermore, the posttreatment parameters of the AFP level 1 month after PEI and recurrence of HCC in the same liver segment were also evaluated.

RESULTS

The cumulative 4-year intrahepatic recurrence rate of HCC was 62%. The log rank test indicated that, among pretreatment parameters, time from cirrhosis diagnosis > 6 years (P = 0.05) and AFP level before PEI of > 25 ng/mL (P = 0.00005) were significantly linked to tumor recurrence. Cox's proportional hazards model showed that only AFP level before PEI was independently associated with recurrence (P < 0.002). With regard to posttreatment parameters, an AFP level 1 month after PEI of > 13 ng/mL was shown to be significantly related to tumor recurrence by the log rank test (P < 0.0001).

CONCLUSIONS

Cirrhotic patients with single HCC treated by PEI who have slightly increased serum levels of AFP before and/or after PEI treatment are at increased risk of intrahepatic tumor recurrence and should undergo a close follow-up program.

Correlation of hepatitis virus serologic status with clinicopathologic features in patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND

This study investigated the relationship between clinicopathologic features and various viral serologies in patients who underwent hepatectomy in the treatment of hepatocellular carcinoma (HCC).

METHODS

Two hundred two patients were allocated to four groups, according to their positivity or negativity for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (HCVAb): Group I (HBsAg[-], HCVAb[+], n = 151), Group II (HBsAg[+], HCVAb[-], n = 27), Group III (HBsAg[-], HCVAb[-], n = 20), or Group IV (HBsAg[+], HCVAb[-], n = 4). The mean age of the HBsAg positive patients (Groups II and IV) was 10 years younger than that of the HBsAg negative patients (Groups I and III).

RESULTS

The male-to-female ratio was higher in HCVAb negative groups (II and III). The HCVAb positive groups (I and IV) had a significantly poorer hepatic reserve and smaller resections than the HCVAb negative groups. Because the tumors were more advanced (as determined by TNM staging) in Group II, the 3-year crude and disease free survival rates were lower in Group II than in Group I. However, HCVAb negative groups (II and III), when compared at 5 years with the limited subsets of patients who had tumors at earlier stages or a curative resection, had significantly better crude and disease free 5-year survival rates than the HCVAb positive group (I).

CONCLUSIONS

Clinicopathologic features differ from one another in accordance with the viral seromarkers in HCC patients. Significantly better crude and disease free survival after complete resection were promising results for patients with non-HCV-related HCC. By comparison, for patients with HCV-related HCC, the risk of intrahepatic recurrences never subsided even in later years after complete resection. Therefore, posthepatectomy follow-up management should be individualized depending on the viral serologic status of HCC patients.

Treatment of hepatocellular carcinoma

Treatment of patients with hepatocellular carcinoma (HCC) is largely influenced by local resources and the clinical stage of the disease. Hepatic resection is the treatment of choice for patients with HCC and normal liver. Tumour size and number, and liver status are common guidelines for choosing treatment in patients with cirrhosis. Hepatic resection and liver transplantation offered the best chances of cure in patients with a single small tumour. The 3-year survival of these patients was definitively better than that of historical controls. In the setting of patients with well-preserved liver function, a controlled study comparing the cost-efficacy of resection and transplantation is deemed necessary by many, but it is hardly feasible for both ethical and practical considerations. One major drawback of surgery in patients with a small tumour is early tumour spread to regional lymph-nodes, which favours early tumour recurrence after operation. Patients with more advanced tumour disease were rarely eligible for surgery and had dismal prognoses. For those with small tumours who were not eligible for surgery, percutaneous ethanol injection appeared to be a cost-saving and effective treatment modality. Arterial embolization is the only recommendable palliative treatment of patients with large tumours and poor hepatic function.

Prevention of second primary tumors by an acyclic retinoid, polyprenoic acid, in patients with hepatocellular carcinoma. Hepatoma Prevention Study Group

BACKGROUND

In patients with hepatocellular carcinoma (hepatoma), the rate of recurrent and second primary hepatomas is high despite surgical resection and percutaneous ethanol-injection therapy. We developed an acyclic retinoid, polyprenoic acid, that inhibits hepatocarcinogenesis in the laboratory and induces differentiation and apoptosis in cell lines derived from human hepatoma. In a randomized, controlled study, we tested whether the compound reduced the incidence of recurrent and second primary hepatomas after curative treatment.

METHODS

We prospectively studied 89 patients who were free of disease after surgical resection of a primary hepatoma or the percutaneous injection of ethanol. We randomly assigned the patients to receive either polyprenoic acid (600 mg daily) or placebo for 12 months. We studied the remnant liver by ultrasonography every three months after randomization. The primary end point of the study was the appearance of a histologically confirmed recurrent or new hepatoma.

RESULTS

Treatment with polyprenoic acid significantly reduced the incidence of recurrent or new hepatomas. After a median follow-up of 38 months, 12 patients in the polyprenoic acid group (27 percent) had recurrent or new hepatomas as compared with 22 patients in the placebo group (49 percent, P = 0.04). The most striking difference was in the groups that had second primary hepatomas--7 in the group receiving polyprenoic acid as compared with 20 in the placebo group (P = 0.04 by the log-rank test). Cox proportional-hazards analysis demonstrated that as an independent factor, polyprenoic acid reduced the occurrence of second primary hepatomas (adjusted relative risk, 0.31; 95 percent confidence interval, 0.12 to 0.78).

CONCLUSIONS

Oral polyprenoic acid prevents second primary hepatomas after surgical resection of the original tumor or the percutaneous injection of ethanol.

Factors correlated with portal venous invasion by hepatocellular carcinoma: univariate and multivariate analyses of 232 resected cases without preoperative treatments

BACKGROUND

The postoperative intrahepatic recurrence of hepatocellular carcinoma (HCC) is high. It is difficult to distinguish whether the recurrence is metastatic or new primary lesion. To determine the malignant potential of HCC itself, we analyzed the risk factors associated with portal venous invasion since this is direct evidence of tumor invasiveness.

METHODS

Two hundred and thirty-two patients who underwent curative hepatectomy for HCC without preoperative treatments were included in this study, because preoperative treatment caused the tumor to undergo a variety of histologic change. We analyzed the risk factors linked to portal venous invasion by both univariate and multivariate analyses.

RESULTS

In an univariate analysis, tumors larger than 3 cm, high histologic grade (III or IV), the presence of fibrous capsule, necrosis, mitotic rate of more than 4/10 high power fields, peliotic change, presence of tumor giant cells, high platelet count, low level of indocyanine green retention rate at 15 minutes, and the absence of cirrhosis were significantly correlated with portal venous invasion. In multiple stepwise logistic regression analysis, tumors larger than 3 cm, high histologic grades, and the presence of fibrous capsule were strong predictors of portal venous invasion by HCC.

CONCLUSIONS

Because the blood vessels of the fibrous capsule were frequently invaded by cancer cells, it may have been possible to prevent postoperative metastatic recurrence if HCC were resected before becoming large enough to have a fibrous capsule.

DNA flow cytometry in patients undergoing liver transplantation for hepatocellular carcinoma

The purpose of the study was to analyse patterns of DNA content in hepatocellular carcinomas (HCC) submitted to orthotopic liver transplantation (OLT). Paraffin-embedded archival material from 15 patients (ten men, five women, mean age 51 +/- 1.78 years) transplanted in St-Roch Hospital between 1988 and 1991 was available for laboratory evaluation by flow cytometry. Five out of 15 were incidental HCC. The analysis was performed by a FACSscan flow cytometer coupled to a Hewlett-Packard computer. The cellular DNA content was defined as diploid or aneuploid in the presence of a single (DNA index of 1) or two distinct (DNA index different from 1) Gzero/G1 peaks, respectively. All incidental HCC (five patients) were diploid, the tumour size was 1.2 +/- 0.2 cm, the number of nodules was 1.4 +/- 0.24 and the mortality rate was 40%. No death in the incidental HCC group was related to neoplastic recurrence. In the remaining ten patients transplanted for HCC, we observed 50% diploid tumours, the tumour size was 5.2 +/- 1.55 cm and the number of nodules was 2.7 +/- 0.56. In this group six patients died of neoplastic recurrence (two were diploid and four aneuploid). The diameter of the neoplasm in diploid patients who died of neoplastic recurrence was over 5 cm and the number of nodules was over three. Moreover, in aneuploid patients who died of neoplastic recurrence, the diameter of the neoplasm was less than 5 cm in three cases and the number of nodules was less than three in two patients. This study indicates that incidental HCC may be a less aggressive malignancy and may have a better prognosis. In this group, no patient recurred after OLT and all tumours were diploid. Aneuploidy, tumour size (> 5 cm) and number of lesions (> 3) are prognostic indicators for neoplastic recurrence in patients transplanted for hepatocellular carcinoma.

Non-neoplastic nodular lesions in the liver

The classical nomenclature and categorization of neoplastic and non-neoplastic nodular lesions of the liver are being revised due to the tremendous volume of information recently published on this issue. The diagnostic histopathology of non-neoplastic nodular (tumor-like) lesions of the liver that are recognizable in biopsied, surgically resected and autopsied livers is reviewed using current terminology. Generally, such nodules are infrequent and even rare in routine liver specimens. Non-neoplastic nodules include focal nodular hyperplasia, nodular regenerative hyperplasia, compensatory hyperplasia of the liver, pseudonodule of the liver demonstrable by angiography, partial nodular transformation, focal fatty change, nodular hepatic area shown by modified angiography, cirrhotic large regenerative nodule with variable atypia, anoxic pseudolobular necrosis, intrahepatic bile duct adenoma, biliary and mesenchymal hamartoma, and mesenchymal nodular lesions such as inflammatory pseudotumor and pseudolymphoma, pseudolipoma, peliosis hepatis, solitary necrotic nodule, and so on. Some of these develop preferentially in non-cirrhotic or cirrhotic livers, while others occur with similar prevalence in cirrhotic and non-cirrhotic livers. Some occur multiply or diffusely and others singly. As to the pathogenesis of these nodules, it is speculated that hyperplasia due to disturbed intrahepatic circulation or hormonal imbalance, preneoplastic characteristics, abnormal metabolic disturbance, hamartoma or focal necrobiotic processes, and infection have a role. Knowledge and awareness of these non-neoplastic nodular lesions are necessary for precise diagnosis and differentiation of these nodular lesions from neoplastic hepatic nodules.