Hepatic resection for hepatocellular carcinoma. An audit of 343 patients

Pilot study for a new bipolar radiofrequency ablation/aspirator device in the management of primary and secondary liver cancers

BACKGROUND

In the US, the thermal ablation workload for cancer involving the liver is predicted to more than double in the next 5 years, emphasising the need to develop and improve the current technology.

STUDY DESIGN

A multicentre nonrandomised prospective clinical trial (NCT00514930) was undertaken, to assess the efficacy and safety of a new bipolar radiofrequency ablation/aspirator device, in the treatment of primary and secondary cancers of the liver.

RESULTS

A total of 34 lesions in 16 patients were ablated at laparotomy and followed up at 4 weeks. The mean diameter of lesion before ablation was 3.2+/-2.22 (range 1-10) cm, the mean volume aspirated during ablation was 9.25+/-7.3 (range 0-25) ml and the mean operative time was 145.95+/-40.7 (range 60-215) min. There was one major complication of a pleural effusion, which required drainage. The mean length of stay was 8+/-3.2 (range 3-14) days. In 11 patients, the ablated tumour was resected. On histological assessment, there was no evidence of viable cancer at the tumour edge. On follow-up computed tomography, the ablation zone fully encompassed the targeted tumour and there were no local complications related to ablation.

CONCLUSION

Initial analysis of the data from this small cohort, with only a short-term follow-up, shows this device to be safe and effective.

Laparoscopic liver resection: a systematic review

BACKGROUND

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

METHODS

Studies about LLR published before September 2008 were identified and their results summarized.

RESULTS

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

CONCLUSIONS

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.

A modified TNM-based Japan Integrated Score combined with AFP level may serve as a better staging system for early-stage predominant hepatocellular carcinoma patients

BACKGROUND

Combinations of Child-Pugh classification and Liver Cancer Study Group of Japan/Tumor-Node-Metastasis (LCSGJ/TNM) have been reported as Japan Integrated Staging (JIS). We previously modified the 6th AJCC/TNM to serve as a better staging system than the 5th and 6th AJCC/TNM.

AIMS

To develop a modified TNM-based JIS to predict the survival of hepatocellular carcinoma (HCC) patients more accurately.

METHODS

3764 HCC patients were enrolled from 1986 to 2002 (2882 patients from 1986 to 2000 and 882 patients from 2001 to 2002). We compared the performance of original JIS, modified TNM-based JIS, modified TNM-based JIS combined alpha-fetoprotein (AFP), BCLC, and CLIP. Lower Akaike information criteria (AIC) values indicated better discriminatory abilities.

RESULTS

AIC value was lowest in CLIP during all periods. However, during 2001-2002, when early-stage HCC patients were predominant, AIC value was lowest when modified TNM-based JIS combined AFP was used.

CONCLUSION

The CLIP system provided the best prognostic stratification in the present cohort of HCC patients who were mainly at late stages. However, early detection of HCCs has become more common in Taiwan in recent years, which has led to the predominance of early-stage HCC patients. Therefore, modified TNM-based JIS combined AFP may now be the most applicable system in recent years.

Heparanase inhibitor PI-88 as adjuvant therapy for hepatocellular carcinoma after curative resection: a randomized phase II trial for safety and optimal dosage

BACKGROUND/AIMS

Hepatocellular carcinoma recurrence after curative treatment adversely influences clinical outcome. It is important to explore adjuvant therapies. This phase II/stage 1 multi-center, randomized trial investigated the safety, optimal dosage and preliminary efficacy of PI-88, a novel heparanase inhibitor, in the setting of post-operative recurrence of HCC according to a Simon's 2-stage design.

METHODS

Three groups were included: one untreated arm (Group A) and two PI-88 arms (Group B: 160 mg/day; Group C: 250 mg/day). Treatment groups received PI-88 over nine 4-week treatment cycles, followed by a 12-week treatment-free period. Safety and optimal dosage were assessed.

RESULTS

Overall, 172 patients were randomized and 168 were included in the intention-to-treat (ITT) population. Treatment-related adverse effects included cytopenia, injection site hemorrhage, PT prolongation, etc. Four serious adverse events were possibly related to PI-88 treatment. One (1.8%) group B patients and six (10.5%) group C had hepatotoxicity-related withdrawals. Among the ITT population, 29 patients (50%) in Group A, 35 (63%) in Group B, and 22 (41%) in Group C remained recurrence-free at completion. Calculated T(1) value suggested 160 mg/day treatment satisfied the criteria for the next stage of the trial.

CONCLUSIONS

PI-88 at 160 mg/day is optimal and safe, and shows preliminary efficacy as an adjunct therapy for post-operative HCC.

Real-time intraoperative assessment of residual liver functional reserve using pulse dye densitometry

BACKGROUND

For a safe major hepatectomy, preoperative methods that can reliably estimate postoperative liver function are necessary. The aim of this study was to assess the utility of ICG-R15 measured by pulse dye densitometry to predict residual liver function prior to hepatectomy.

PATIENTS AND METHOD

In 29 patients who underwent various types of hepatectomies, indocyanine green (ICG)-R15 was measured by pulse dye densitometry at the time of opening the abdomen (laparotomy phase), clamping the Glisson's pedicles to cutting (clamping phase), and closing abdomen after hepatectomy (resection phase). The relationships among these measurements and postoperative liver function were examined.

RESULTS

The mean ICG-R15 was 12.3 +/- 6.0% preoperatively (+/-SD), 9.3 +/- 7.0% at laparotomy, 18.8 +/- 11.6% at clamping, and 20.1 +/- 10.9% at resection. The preoperative and laparotomy and the clamping and resection ICG-R15 values correlated significantly. Eleven (38%) patients developed postoperative hyperbilirubinemia [total bilirubin (T-Bil) >3.0 mg/dl]. The postoperative peak T-Bil correlated significantly with clamping ICG-R15 (r = 0.637, p = 0.0002), but not with preoperative ICG-R15 (r = 0.283, p = 0.137), total clamp time (r = 0.005, p = 0.975), and blood loss (r = 0.097, p = 0.615). Multivariate analysis identified ICG-R15 measured at clamping as the only determinant of postoperative peak T-Bil (r = 0.612). ICG-R15 measured at clamping correlated with the postoperative hospital stay (p = 0.046).

CONCLUSIONS

ICG-R15 can be measured in real time during surgery by pulse dye densitometry. ICG-R15 measured by this technique before hepatectomy provides a direct and reliable measure of postoperative residual liver function, thus helping in surgical decision making regarding the extent of hepatectomy.

Expression of STK15 mRNA in hepatocellular carcinoma and its prognostic significance

OBJECTIVES

To investigate whether the STK15 mRNA expression correlates with clinicopathologic features and the prognosis of HCC patients.

DESIGN AND METHODS

Three hepatoma cell lines, two normal liver epithelial cell lines, hepatoma tissues, adjacent tumor tissues and normal liver tissues were obtained from 46 HCC patients. Semi-quantitative RT-PCR assays were performed to detect the expression of STK15 mRNA in above cell lines and tissues. Moreover, the expression of STK15 protein in hepatoma tissues, adjacent tumor tissues and normal liver tissues was also examined by immunohistochemical staining. Finally, correlations between STK15 mRNA expression and the clinicopathological features and prognosis of HCC patients were evaluated.

RESULTS

STK15 mRNA showed higher levels in hepatoma cell lines than in normal liver epithelial cell lines. Moreover, the mean levels of STK15 mRNA and protein expression showed statistical difference between tumor tissues, tumor adjacent tissues and normal liver tissues (P<0.01). By immunohistochemical analysis, we found that paraffin-embedded archival HCC tissues showed higher expression of STK15 than adjacent tumors and normal liver tissues. Furthermore, HCC patients with higher STK15 mRNA expression showed poorer prognosis than those with lower STK15 mRNA expression. The high level of STK15 mRNA expression was significantly correlated with tumor stage (P=0.0081), more frequent lymph node (P=0.0380) or hematogenous metastasis (P=0.0066), and a higher incidence of cancer-related death (P=0.0083). Furthermore, the disease-free survival (DFS) and overall survival (OS) rates of HCC patients with higher STK15 mRNA expression group (47.6% and 52.7%) were significantly lower than those of patients with low STK15 mRNA expression group (56.9% and 68.8%, P=0.0018 and 0.0047).

CONCLUSIONS

STK15 mRNA might be a good marker for predicting the prognosis of HCC patients.

Sorafenib and rapamycin induce growth suppression in mouse models of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide. Vascular endothelial growth factor, platelet derived growth factor and the Raf/mitogen-activated protein kinase/extracellular signal regulated kinase (Raf/MEK/ERK) signalling pathway regulates the growth, neovascularization, invasiveness and metastatic potential of HCC. In this study, we investigated the in vivo antitumour activity and mechanisms of action of sorafenib tosylate on four patient-derived HCC xenografts. Sorafenib dosed at 50 mg/kg and 100 mg/kg inhibited tumour growth by 85% and 96%, respectively. Sorafenib-induced growth suppression and apoptosis were associated with inhibition of angiogenesis, down-regulation of phospho-platelet-derived growth factor receptor beta Tyr1021, phospho-eIF4E Ser209, phospho-c-Raf Ser259, c-Raf, Mcl-1, Bcl-2, Bcl-x and positive cell cycle regulators, up-regulation of apoptosis signalling kinase-1, p27 and p21. Expression of IGF-1Rbeta and phosphorylation of c-Raf Ser338, MEK1/2 Ser217/221 and ERK1/2 Thr202/Tyr204 were increased by sorafenib treatment. Phosphorylation of mammalian target-of-rapamycin (mTOR) targets (p70S6K, S6R and 4EBP1) was reduced by sorafenib in sorafenib-sensitive lines but activated in sorafenib-less-sensitive 10-0505 xenograft. Sorafenib-induced phosphorylation of c-met, p70S6K and 4EBP1 was significantly reduced when 10-0505 cells were co-treated with anti-human anti-HGF antibody, suggesting that treatment with sorafenib leads to increased HGF secretion and activation of c-met and mTOR targets. Treatment of 10-0505 tumours with sorafenib plus rapamycin resulted in growth inhibition, inhibition of vascular endothelial growth factor receptor-2 phosphorylation, increased apoptosis and completely blocked sorafenib-induced phosphorylation of mTOR targets and cyclin B1 expression. These data also provide a strong rationale for clinical investigation of sorafenib in combination with mTOR inhibitors in patients with HCC.

Efficacy of lamivudine on hepatitis B viral status and liver function in patients with hepatitis B virus-related hepatocellular carcinoma

BACKGROUND/AIMS

Treatment of patients with hepatocellular carcinoma (HCC) depends on the tumour extent and underlying liver function. Antiviral therapy with nucleoside/nucleotide analogues has been shown to be effective in improving the liver function of chronic hepatitis B (CHB) patients. We assessed whether lamivudine could induce biochemical and virological improvements in patients with hepatitis B virus-related HCC.

PATIENTS/METHODS

Of 148 CHB patients treated with 100 mg/day lamivudine for at least 6 months, 80 had HCC (CHB/HCC group) and 68 did not (CHB group). Biochemical and virological parameters were serially monitored.

RESULTS

Compared with the CHB group, the CHB/HCC group was older, had higher male predominance, bilirubin levels and liver cirrhosis rate, and lower albumin and hepatitis B virus (HBV) DNA levels and hepatitis B e antigen (HBeAg) positivity (P<0.05 each). The two groups showed similar cumulative rates of alanine aminotransferase normalization, HBV DNA seroconversion, HBeAg loss and viral breakthrough during 12 months of lamivudine treatment. After 12 months, the CHB/HCC group showed, relative to baseline, increased albumin levels (3.51+/-0.5 vs. 3.72+/-0.5 mg/ml) and decreased ascites scores (1.63+/-0.7 vs. 1.45+/-0.6) and Child-Pugh scores (6.92+/-1.9 vs. 6.02+/-1.38) (P<0.05 each).

CONCLUSION

Lamivudine had comparable antiviral effects both in patients with CHB and CHB/HCC, and improved underlying liver function in the latter group. Treatment of HBV may increase the chance of curative treatments in patients with HBV-related HCC.

A randomized, controlled trial of postoperative adjuvant cytokine-induced killer cells immunotherapy after radical resection of hepatocellular carcinoma

BACKGROUND

With a resistance to conventional chemotherapy and radiotherapy, hepatocellular carcinoma has a high recurrence rate after radical resection. Adjuvant immunotherapy is a promising treatment for hepatocellular carcinoma.

AIM

To evaluate the effect of adjuvant immunotherapy with cytokine-induced killer cells on the prognosis of hepatocellular carcinoma after radical resection.

PATIENTS AND METHODS

From January 2000 to January 2002, we collected 127 patients that met the selection criteria and randomly divided them into 3 groups. After radical resection of the tumor, immunotherapy with cytokine-induced killer cells was performed for 3 courses in 41 patients (CIK-I group) and 6 courses in 43 patients (CIK-II group). The other 43 patients received no postoperative adjuvant therapy (the control group). The 1-, 3-, and 5-year disease free survival rates and the overall survival were compared among the 3 groups.

RESULTS

The log-rank test showed that the disease-free survival rates were significantly higher in CIK-I group (p=0.001) and CIK-II group (p=0.004) than in the control group. No statistical significance was found between CIK-I group and CIK-II group (p=0.345). Cox regression suggested that treatment modality was a risk factor for recurrence. No statistical significance was found in the overall survival among the three groups.

CONCLUSIONS

Postoperative immunotherapy with cytokine-induced killer cells may prevent recurrence/metastasis after radical resection of hepatocellular carcinoma. However, it cannot improve the overall survival.

A simple, noninvasively determined index predicting hepatic failure following liver resection for hepatocellular carcinoma

BACKGROUND

A novel index, the serum aspartate aminotransferase activity/platelet count ratio index (APRI), has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. We evaluated the ability of preoperative APRI to predict hepatic failure following liver resection for hepatocellular carcinoma.

METHODS

Potential preoperative risk factors for postoperative hepatic failure (hepatic coma with hyperbilirubinemia, four patients; intractable pleural effusion or ascites, 30 patients; and variceal bleeding, one patient) as well as APRI were evaluated in 366 patients undergoing liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses.

RESULTS

Hepatic failure developed postoperatively in 30 patients, causing death in four. APRI correlated with histological intensity of hepatitis activity and degree of hepatic fibrosis, and was significantly higher in patients who developed postoperative hepatic failure than in others without failure. Risk of postoperative hepatic failure increased as the serum albumin concentration and platelet count decreased and as indocyanine green retention rate at 15 min, aspartate and alanine aminotransferase activities, and APRI increased. Only APRI was an independent preoperative factor on multivariate analysis. Of the four patients who died of postoperative hepatic failure, three had an APRI of at least 10.

CONCLUSIONS

Preoperative APRI independently predicted hepatic failure following liver resection for hepatocellular carcinoma. Patients with an APRI of 10 or more have a high risk of postoperative hepatic failure.

Prediction of postoperative hepatic insufficiency by liver stiffness measurement (FibroScan((R))) before curative resection of hepatocellular carcinoma: a pilot study

BACKGROUND

Liver stiffness measurement (LSM) using transient elastography (FibroScan((R))) reflects the degree of hepatic fibrosis. This prospective study investigated how well LSM predicts the development of hepatic insufficiency after curative liver resection surgery for hepatocellular carcinoma.

METHODS

The study enrolled 72 consecutive patients who underwent a preoperative LSM to assess the degree of liver fibrosis followed by curative liver resection surgery for hepatocellular carcinoma between July 2006 and December 2007. The primary end point was the development of hepatic insufficiency.

RESULTS

The mean age of the patients was 54.9 years. Twenty patients (27.7%) had chronic hepatitis and 52 (72.3%) had cirrhosis (44 and 8 patients showed Child-Pugh class A and B, respectively). The mean LSM was 17.1 kPa. Twelve patients (16.6%) had segmentectomy only, 16 patients (22.2%) had bisegmentectomy, and 44 patients (61.2%) had lobectomy. Nine patients (12.5%) had stage I tumor, 56 (77.7%) had stage II, and 7 (9.8%) had stage III. Univariate and subsequent multivariate analyses revealed that preoperative LSM was the only independent risk factor for predicting the development of postoperative hepatic insufficiency (cutoff, 25.6 kPa; P = 0.001; relative risk, 19.14; 95% confidence interval, 2.71-135.36).

CONCLUSIONS

LSM is potentially useful to predict the development of postoperative hepatic insufficiency in patients with hepatocellular carcinoma undergoing curative liver resection surgery.

Complete hepatocellular carcinoma necrosis following sequential porto-arterial embolization

Most patients with hepatocellular carcinoma (HCC) are not eligible for curative treatment, which is resection or transplantation. Two recent series have emphasized the potential benefits of preoperative arterio-portal embolization prior to surgical resection of such tumours. This preoperative strategy offers a better disease free survival rate and a higher rate of total tumor necrosis. In case of non resectable HCC it is now widely accepted that transarterial chemoembolization (TACE) leads to a better survival when compared to conservative treatment. Thus, the question remains whether combined portal vein embolization (PVE) may enhance the proven efficiency of TACE in patients with unresectable HCC. We herein report the case of a 56-year-old cirrhotic woman with a voluminous HCC unsuitable for surgical resection. Yet, complete tumour necrosis and prolonged survival could be achieved after a combined porto-arterial embolization. This case emphasizes the potential synergistic effect of a combined arterio-portal embolization and the hypothetical survival benefit of such a procedure, in selected patients, with HCC not suitable for surgery or local ablative therapy.

Brivanib alaninate, a dual inhibitor of vascular endothelial growth factor receptor and fibroblast growth factor receptor tyrosine kinases, induces growth inhibition in mouse models of human hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) is the fifth most common primary neoplasm; surgery is the only curative option but 5-year survival rates are only 25% to 50%. Vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) are known to be involved in growth and neovascularization of HCC. Therefore, agents that target these pathways may be effective in the treatment of HCC. The aim of this study was to determine the antineoplastic activity of brivanib alaninate, a dual inhibitor of VEGF receptor (VEGFR) and FGF receptor (FGFR) signaling pathways.

EXPERIMENTAL DESIGN

Six different s.c. patient-derived HCC xenografts were implanted into mice. Tumor growth was evaluated in mice treated with brivanib compared with control. The effects of brivanib on apoptosis and cell proliferation were evaluated by immunohistochemistry. The SK-HEP1 and HepG2 cells were used to investigate the effects of brivanib on the VEGFR-2 and FGFR-1 signaling pathways in vitro. Western blotting was used to determine changes in proteins in these xenografts and cell lines.

RESULTS

Brivanib significantly suppressed tumor growth in five of six xenograft lines. Furthermore, brivanib-induced growth inhibition was associated with a decrease in phosphorylated VEGFR-2 at Tyr(1054/1059), increased apoptosis, reduced microvessel density, inhibition of cell proliferation, and down-regulation of cell cycle regulators. The levels of FGFR-1 and FGFR-2 expression in these xenograft lines were positively correlated with its sensitivity to brivanib-induced growth inhibition. In VEGF-stimulated and basic FGF stimulated SK-HEP1 cells, brivanib significantly inhibited VEGFR-2, FGFR-1, extracellular signal-regulated kinase 1/2, and Akt phosphorylation.

CONCLUSION

This study provides a strong rationale for clinical investigation of brivanib in patients with HCC.

Is hepatectomy beneficial in the treatment of multinodular hepatocellular carcinoma?

BACKGROUND/PURPOSE

Hepatectomy remains the standard treatment for primary hepatocellular carcinoma (HCC). However, its role in the treatment of multinodular HCC (MNHCC) is unknown.

METHODS

The study consisted of 599 patients undergoing curative hepatic resection for HCC between October 1990 and June 2006, in which 112 patients had MNHCC (tumor number > or = 2). The type of MNHCC was classified into: A, nodules involving one or two adjoining segments; B, large tumor with satellite nodules involving three or more segments; C, three or fewer nodules that are scattered in remote segments; and D, more than three separate tumors. Univariate and multivariate analyses were used to identify the prognostic factors related to postoperative survival. During the same period of time, and from our database of 178 patients with pathologically proven MNHCC who were undergoing nonsurgical multidisciplinary therapy, 48 patients with serum albumin level > or = 3.5 g/dL, total bilirubin < 2 mg/dL, tumor number < or = 3, and tumor size < or = 5 cm were compared with 38 patients with the same condition treated with hepatectomy, in which 16 received one-block resection and 22 underwent multiple-site resection.

RESULTS

The overall 1-, 3- and 5-year survival rates for patients with single-tumor HCC and MNHCC were 88.0%, 69.2% and 58.4%, and 86.1%, 55.5% and 29.9%, respectively (p < 0.001). Alpha-fetoprotein > 400 ng/mL, total tumor size > 5 cm, largest tumor size > 5 cm, total tumor number > 3, microvascular invasion, non-A type MNHCC and multiple-site resection were poor prognostic factors for MNHCC in the hepatectomy group. Multivariate analysis revealed that only multiple-site hepatic resection was an independent adverse factor related to postoperative survival. In addition, patients who underwent one-block resection had significantly better survival compared with the nonsurgical group (p = 0.0016), but the multiple-site resection subgroup did not.

CONCLUSION

The prognosis of MNHCC is poor in comparison with that of single-nodular HCC. Hepatectomy is the treatment of choice if the tumors can be removed by one-block resection and liver function reserve is acceptable.

Prediction of postoperative hepatic insufficiency by liver stiffness measurement (FibroScan((R))) before curative resection of hepatocellular carcinoma: a pilot study

BACKGROUND

Liver stiffness measurement (LSM) using transient elastography (FibroScan((R))) reflects the degree of hepatic fibrosis. This prospective study investigated how well LSM predicts the development of hepatic insufficiency after curative liver resection surgery for hepatocellular carcinoma.

METHODS

The study enrolled 72 consecutive patients who underwent a preoperative LSM to assess the degree of liver fibrosis followed by curative liver resection surgery for hepatocellular carcinoma between July 2006 and December 2007. The primary end point was the development of hepatic insufficiency.

RESULTS

The mean age of the patients was 54.9 years. Twenty patients (27.7%) had chronic hepatitis and 52 (72.3%) had cirrhosis (44 and 8 patients showed Child-Pugh class A and B, respectively). The mean LSM was 17.1 kPa. Twelve patients (16.6%) had segmentectomy only, 16 patients (22.2%) had bisegmentectomy, and 44 patients (61.2%) had lobectomy. Nine patients (12.5%) had stage I tumor, 56 (77.7%) had stage II, and 7 (9.8%) had stage III. Univariate and subsequent multivariate analyses revealed that preoperative LSM was the only independent risk factor for predicting the development of postoperative hepatic insufficiency (cutoff, 25.6 kPa; P = 0.001; relative risk, 19.14; 95% confidence interval, 2.71-135.36).

CONCLUSIONS

LSM is potentially useful to predict the development of postoperative hepatic insufficiency in patients with hepatocellular carcinoma undergoing curative liver resection surgery.

High intensity focused ultrasound therapy resulted in a complete response in a patient with advanced gastric cancer with liver metastases: a case report

Different therapeutic strategies have been tried when liver metastasis develops after a gastrectomy for gastric cancer, but the disease still has a poor prognosis. We present a 35-year-old woman who achieved complete radiological remission of liver metastases from advanced gastric cancer after a single therapeutic high intensity focused ultrasound session. Our observations suggest that high intensity focused ultrasound combined with chemotherapy may be an additional treatment option for patients with liver metastases from advanced gastric cancer.

Hepatocellular carcinoma developed on compensated cirrhosis: resection as a selection tool for liver transplantation

The objective of this study was to evaluate the histological profile obtained from primary resection of hepatocellular carcinoma (HCC) as a selection tool for liver transplantation (LT). The natural history of HCC depends on its histological features. The clinical effectiveness of resection as a selection tool for salvage or de principe LT has been previously advocated. Between 1987 and 2006, 20 patients underwent a resection prior to LT. Long-term survival of these 20 patients was compared to that of 73 patients who underwent primary LT. Histological features of the resected specimen were compared to those of the recurrences. Feasibility, morbidity, and mortality of LT following primary resection were also analyzed. Mean follow-up was 3.8 +/- 4.4 and 2.7 +/- 4.5 years from resection and LT, respectively; 6 patients died. The mean 1-, 3-, 5-, and 10-year overall survival rates were 71%, 61%, 55%, and 45% and 74%, 66%, 66%, and 40% after primary transplantation and primary resection, respectively (not significant). At LT, 14 patients had a recurrence, but histological study of the recurrence was not possible in 2 (complete necrosis). For 9 patients (75%), histological features of both primary and recurrent tumors were exactly the same. Four patients had recurrence following LT; in each case, primary and recurrent nodules shared the same histological markers of poor prognosis. De principe transplantation was proposed to 6 patients because of poor prognosis histological features on the resected specimen. All these patients are alive without recurrence with a mean follow-up of 55 months. In conclusion, the natural history of HCC can be predicted on the basis of the histological profile of the resected specimen, which may be used as a selection tool for LT. De principe LT in patients within Milan criteria with poor prognosis histological features may be an optimal strategy.

Surgical treatment of hepatocellular carcinoma: evidence-based outcomes

Surgeons may be severely criticized from the perspective of evidence-based medicine because the majority of surgical publications appear not to be convincing. In the top nine surgical journals in 1996, half of the 175 publications refer to pilot studies lacking a control group, 18% to animal experiments, and only 5% to randomized controlled trials (RCT). There are five levels of clinical evidence: level 1 (randomized controlled trial), level 2 (prospective concurrent cohort study), level 3 (retrospective historical cohort study), level 4 (pre-post study), and level 5 (case report). Recently, a Japanese evidence-based guideline for the surgical treatment of hepatocellular carcinoma (HCC) was made by a committee (Chairman, Professor Makuuchi and five members). We searched the literature using the Medline Dialog System with four keywords: HCC, surgery, English papers, in the last 20 years. A total of 915 publications were identified systematically reviewed. At the first selection (in which surgery-dominant papers were selected), 478 papers survived. In the second selection (clearly concluded papers), 181 papers survived. In the final selection (clinically significant papers), 100 papers survived. The evidence level of the 100 surviving papers is shown here: level-1 papers (13%), level-2 papers (11%), level-3 papers (52%), and level-4 papers (24%); therefore, there were 24% prospective papers and 76% retrospective papers. Here, we present a part of the guideline on the five main surgical issues: indication to operation, operative procedure, peri-operative care, prognostic factor, and post-operative adjuvant therapy.

Anatomic versus limited nonanatomic resection for solitary hepatocellular carcinoma

BACKGROUND

Although anatomic liver resection is preferred when treating hepatocellular carcinoma (HCC), evidence that it improves survival when compared with an adequate nonanatomic resection is lacking. The purpose of this study was to compare the survival impact of anatomic versus nonanatomic resection in patients with solitary HCC.

PATIENTS AND METHODS

Clinicopathologic data were available for 125 patients who underwent hepatectomy for a solitary HCC confined to 1 or 2 Couinaud's segments. These patients were divided into 2 groups based on the hepatectomy procedure: anatomic (n = 83) and nonanatomic (n = 42) resection.

RESULTS

No differences were detected either in the hepatic recurrence rates (P = .38) or in the overall survival rates (P = .34) between the anatomic group and the nonanatomic group. The hepatectomy procedure (anatomic vs nonanatomic resection) did not affect survival in either univariate (P = 0.34) or multivariate analysis (relative risk, 1.574; P = .22). The proportion of patients who survived after recurrence was greater in the nonanatomic (15/42) than the anatomic group (13/83; P = .049), and the median survival time after recurrence was greater in patients who underwent nonanatomic resection (991 days; range, 131-4073 days) than in patients with anatomic resection (310 days; range, 48-1887 days; P = .045).

CONCLUSIONS

No superiority was seen in survival when HCC was treated by anatomic resection. Maintaining adequate liver function regardless of whether the resection is anatomic or not may be of greater importance.

Accomplishments in 2007 in the management of hepatobiliary cancers

Hepatocellular CarcinomaOverview of the Disease IncidencePrognostic or Predictive FactorsCurrent Therapy Standards SurgeryLocoablative TreatmentSystemic TreatmentAccomplishments and Lack of Accomplishments TherapyMilan Criteria to Select Patients for Liver TransplantBiologic AgentsBiomarkersBasic ScienceWhat Needs To Be DoneFuture Directions Comments on ResearchObstacles to ProgressBiliary Tract CancerOverview of the Disease IncidencePrognostic or Predictive FactorsCurrent Therapy StandardsAccomplishments and Lack of Accomplishments TherapyBiomarkersWhat Needs To Be DoneFuture Directions.

Early-stage hepatocellular carcinoma: radiofrequency ablation combined with chemoembolization versus hepatectomy

PURPOSE

To retrospectively evaluate the long-term results of radiofrequency (RF) ablation combined with chemoembolization (combination therapy) as compared with hepatectomy for the treatment of early-stage hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

The study was approved by the institutional review board, and informed consent was waived. Patients with early-stage HCC were included if they underwent either combination therapy or hepatectomy and met the following inclusion criteria: no previous treatment for HCC, three or fewer tumors with a maximum diameter of 3 cm or less each or a single tumor with a maximum diameter of 5 cm or less, Child-Pugh class A liver profile, no vascular invasion, and no extrahepatic metastases. The primary endpoint was overall survival, and the secondary endpoint was recurrence-free survival.

RESULTS

One hundred four patients (mean age, 66.5 years +/- 8.7 [standard deviation]; 79 men, 25 women) underwent combination therapy, and 62 patients (mean age, 64.5 years +/- 9.6; 51 men, 11 women) underwent hepatectomy. The 1-, 3-, and 5-year overall survival rates following combination therapy (98%, 94%, and 75%, respectively) were similar (P = .87) to those following hepatectomy (97%, 93%, and 81%, respectively). The 1-, 3-, and 5-year recurrence-free survival rates were also comparable (P = .70) for combination therapy (92%, 64%, and 27%, respectively) and hepatectomy (89%, 69%, and 26%, respectively).

CONCLUSION

RF ablation combined with chemoembolization in patients with early-stage HCC provides overall and disease-free survival rates similar to those achieved by hepatectomy.

Surgical treatment of hepatocellular carcinoma beyond Milan criteria. Results of liver resection, salvage transplantation, and primary liver transplantation

BACKGROUND

There is no clear consensus regarding the best treatment strategy for patients with advanced hepatocellular carcinoma (HCC).

METHODS

Patients with cirrhosis and HCC beyond Milan who had undergone liver resection (LR) or primary orthotopic liver transplantation (OLT) between November 1995 and December 2005 were included in this study. Pathological tumor staging was based on the American Liver Tumor Study Group modified Tumor-Node-Metastasis classification.

RESULTS

A total of 23 HCC patients were primarily treated by means of LR, 5 of whom eventually underwent salvage OLT. An additional 32 patients underwent primary OLT. The overall actuarial survival rates at 3 and 5 years were 35% after LR, and 69% and 60%, respectively, after primary OLT. Recurrence-free survival at 5 years was significantly higher after OLT (65%) than after LR (26%). Of the patients who underwent LR, 11 (48%) experienced HCC recurrence only in the liver; 6 of these 11 presented with advanced HCC recurrence, poor medical status, or short disease-free intervals and were not considered for transplantation. Salvage OLT was performed in 5 patients with early stage recurrence (45% of patients with hepatic recurrence after LR and 22% of all patients who underwent LR). At a median of 18 months after salvage OLT, all 5 patients are alive, 4 are free of disease, and 1 developed HCC recurrence 16 months after salvage OLT.

CONCLUSION

For patients with HCC beyond Milan criteria, multimodality treatment-including LR, salvage OLT, and primary OLT-results in long-term survival in half of the patients. When indicated, LR can optimize the use of scarce donor organs by leaving OLT as a reserve option for early stage HCC recurrence.

Adenovirus-delivered CIAPIN1 small interfering RNA inhibits HCC growth in vitro and in vivo

Hepatocellular carcinoma (HCC) is an aggressive cancer with a poor prognosis. The specific cellular gene alterations responsible for hepatocarcinogenesis are not well known. Cytokine-induced antiapoptotic molecule (CIAPIN1), a recently reported antiapoptotic molecule which plays an essential role in mouse definitive hematopoiesis, is considered a downstream effecter of the receptor tyrosine kinase–Ras signaling pathway. However, the exact function of this gene in tumors is not clear. In this study, we reported that CIAPIN1 is highly expressed in HCC as compared with non-tumor hepatic tissue (P < 0.05). We employed adenovirus-mediated RNA interference technique to knock down CIAPIN1 expression in HCC cells and observed its effects on HCC cell growth in vitro and in vivo. Among the four HCC and one normal human liver cell lines we analyzed, CIAPIN1 was highly expressed in HCC cells. Knock down of CIAPIN1 could inhibit HCC cell proliferation by inhibiting the cell cycle S-phase entry. Soft agar colony formation assay indicated that the colony-forming ability of SMMC-7721 cells decreased by ∼70% after adenovirus AdH1-small interfering RNA (siRNA)/CIAPIN1 infection. In vivo experiments showed that adenovirus AdH1-siRNA/CIAPIN1 inhibited the tumorigenicity of SMMC-7721 cells and significantly suppressed tumor growth when injected directly into tumors. These results suggest that knock down of CIAPIN1 by adenovirus-delivered siRNA may be a potential therapeutic strategy for treatment of HCC in which CIAPIN1 is overexpressed.

Surgical treatment of hepatocellular carcinoma: Evidence-based outcomes

Surgeons may be severely criticized from the perspective of evidence-based medicine because the majority of surgical publications appear not to be convincing. In the top nine surgical journals in 1996, half of the 175 publications refer to pilot studies lacking a control group, 18% to animal experiments, and only 5% to randomized controlled trials (RCT). There are five levels of clinical evidence: level 1 (randomized controlled trial), level 2 (prospective concurrent cohort study), level 3 (retrospective historical cohort study), level 4 (pre-post study), and level 5 (case report). Recently, a Japanese evidence-based guideline for the surgical treatment of hepatocellular carcinoma (HCC) was made by a committee (Chairman, Professor Makuuchi and five members). We searched the literature using the Medline Dialog System with four keywords: HCC, surgery, English papers, in the last 20 years. A total of 915 publications were identified systematically reviewed. At the first selection (in which surgery-dominant papers were selected), 478 papers survived. In the second selection (clearly concluded papers), 181 papers survived. In the final selection (clinically significant papers), 100 papers survived. The evidence level of the 100 surviving papers is shown here: level-1 papers (13%), level-2 papers (11%), level-3 papers (52%), and level-4 papers (24%); therefore, there were 24% prospective papers and 76% retrospective papers. Here, we present a part of the guideline on the five main surgical issues: indication to operation, operative procedure, peri-operative care, prognostic factor, and post-operative adjuvant therapy.

Preoperative surgery planning for percutaneous hepatic microwave ablation

A novel preoperative surgery planning method is proposed for percutaneous hepatic microwave ablation. An iterative framework for necrosis field simulation and 3D necrosis zone reconstruction is introduced here, and the necrosis model is further superimposed to patient anatomy structures using advanced GPU-accelerated visualization techniques. The full surgery planning is performed by the surgeon in an interactively way, until the optimal surgery plan is achieved. Experiments have been performed on realistic patient with hepatic cancer and the actual necrosis zone are measured in postoperative CT images for patient. Results show that this method is relative accurate for preoperative trajectory plan and could be used as an assistant to the clinical practice.

Microwave ablation of hepatocellular carcinoma

OBJECTIVE

This article reviews the basic principles, equipment, current therapeutic status and future trends of microwave ablation (MWA) in the treatment of hepatocellular carcinoma (HCC).

METHODS

All articles published in English on MWA or MWA as a treatment for HCC were identified with a PubMed search from the 1990s through June 2007. Papers were reviewed on the technical advances of MWA equipment and the clinical applications of MWA including indications, techniques, therapeutic outcomes, complications and combination therapies.

RESULTS

MWA has several advantages, including high thermal efficiency, higher capability of coagulating blood vessels, faster ablation time, and an improved convention profile. MWA can induce large ablation volumes and yield good local tumor control, especially for small HCC. Larger HCC can also be completely ablated by using more effective antenna or simultaneous application of multiple antennae. Long-term survival comparable to that of surgery was obtained for tumors measuring 4 cm or less. Associated complications appear to be low.

CONCLUSIONS

MWA is a promising minimally invasive technique for the treatment of HCC. Future advances are warranted to improve the therapeutic efficacy.

Phase 2 study of erlotinib in patients with unresectable hepatocellular carcinoma

BACKGROUND

Growth factor overexpression, including epidermal growth factor receptor (EGFR) expression, is common in hepatocellular cancers. Erlotinib is a receptor tyrosine kinase inhibitor with specificity for EGFR. The primary objective of this study was to determine the proportion of hepatocellular carcinoma (HCC) patients treated with erlotinib who were alive and progression-free (PFS) at 16 weeks of continuous treatment.

METHODS

Patients with unresectable HCC, no prior systemic therapy, performance status (PS) of 0, 1, or 2, and Childs-Pugh (CP) cirrhosis A or B received oral erlotinib 150 mg daily for 28-day cycles. Tumor response was assessed every 2 cycles by using Response Evaluation Criteria in Solid Tumors (RECIST; National Cancer Institute Cancer Therapy Evaluation Program, Bethesda, Md) criteria. Patients accrued to either "low" or "high" EGFR expression cohorts; each cohort had stopping rules applied when there was a lack of efficacy.

RESULTS

Forty HCC patients were enrolled. Median age was 64 years (range, 33-83 years), sex distribution was 32 males and 8 females, performance scores were 40% PS 0, 55% PS 1, Childs-Pugh distribution was 75% A and 20% B. There were no complete or partial responses; however, 17 of 40 patients achieved stable disease at 16 weeks of continuous therapy. The PFS at 16 weeks was 43%, and the median overall survival (OS) was 43 weeks (10.75 months). No patients required dose reductions of erlotinib. No correlation between EGFR expression and outcome was found.

CONCLUSIONS

Results of this study indicated that single-agent erlotinib is well tolerated and has modest disease-control benefit in HCC, manifested as modestly prolonged PFS and OS when compared with historical controls.

Main complications after major liver resections and possible waysof prevention

Results of 325 major liver resections were investigated. The common indications were malignant and benign lesions, hydatid cysts, purulent cholangitis, posttraumatic liver necrosis. The main complications after liver resections were massive intraoperative bleedings and acute postoperative liver failure. The main causes of blood loss and liver failure were discovered. The most effective means to prevent bleeding was anatomical liver resection. Lobe vascular occlusion is essential for minimal blood loss. Postoperative liver failure was strong associated with the small volume of the remnant liver and decrease in functional liver capacity. Precision selection of patients and preoperative portal vein embolisation lead to decrease the rate of liver failure (5,4%).

Assessment of systemic inflammatory response (SIR) in patients undergoing radiofrequency ablation or partial liver resection for liver tumors

INTRODUCTION

Local therapies for liver tumors are considered to be safe. However, cryoablation (CA) has been associated with an exaggerated systemic inflammatory response (SIR). Aim of this study was to assess the degree of SIR after radiofrequency ablation (RFA) in comparison with major (MR) or minor (mR) liver resection.

MATERIAL AND METHODS

Thirty-nine patients were treated with RFA (n = 11), MR (n = 10) or mR (n = 18). SIR parameters [white blood count (WBC) and C-reactive protein (CRP)], proinflammatory mediators [IL-6, TNF-alpha and sPLA2], liver damage parameters [AST/ALT] and platelet counts were determined at different time points. The volume of ablated liver was calculated on the first CT after RFA in order to correlate ablated liver volume with liver enzyme release and SIR. All data are expressed as median values with quartiles [25%, 75%].

RESULTS

RFA induced a moderate SIR, as demonstrated by a significant elevation of CRP (77 mg/L vs 3 mg/L), IL-6 (96 pg/ml vs 4 pg/ml) and sPLA2 (41 ng/ml vs 7 ng/ml, p < 0.05). Peak point values of SIR (WBC and CRP at 24 vs 48 h and 48 vs 72 h) and proinflammatory response parameters (24 vs 48 h) occurred earlier after RFA than after mR or MR. Time-to-time comparison revealed even increased levels of CRP (77 mg/L [59, 160]) 24h after RFA when compared to patients undergoing major or minor resection (50 mg/L [28, 66] and 59 mg/L [24, 91], respectively) and increased levels of IL-6 (67 pg/ml [42, 131]) 4 h after RFA when compared to patients undergoing minor resection (29 pg/ml [20, 55]). Postoperative levels of AST and LDH correlated significantly with the ablated liver volume 1h after RFA (RC = 0.860 and RC = 0.868, respectively, p < 0.05).

CONCLUSION

RFA induced a moderate SIR of the same magnitude as in patients undergoing partial liver resection. None of the patients showed signs of an exaggerated SIR, as has been reported after cryoablation.

AZD6244 and doxorubicin induce growth suppression and apoptosis in mouse models of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide, with no effective treatment for most individuals who succumb to this neoplasm. We report that treatment of primary HCC cells with the mitogen-activated protein/extracellular signal-regulated kinase (ERK) kinase 1/2 inhibitor AZD6244 (ARRY-142886) plus doxorubicin led to synergistic growth inhibition and apoptosis. In vivo administration of AZD6244, doxorubicin, or the combination of AZD6244 and doxorubicin in mice bearing 5-1318 HCC xenografts resulted in approximately 52% +/- 15%, 12% +/- 9%, and 76% +/- 7% growth inhibition, respectively. AZD6244-inhibited tumor growth was associated with increased apoptosis, inactivation of ERK1/2, inhibition of cell proliferation, and down-regulation of cell cycle regulators, including cyclin D1, cdc-2, cyclin-dependent kinases 2 and 4, cyclin B1, and c-Myc. The AZD6244-doxorubicin combined protocol not only promoted apoptosis but also induced a synergistic effect not seen in single-agent-treated tumors, including increased expression of the p130 RB tumor suppressor gene. Our study provides a strong rationale for clinical investigation of combination therapy with the mitogen-activated protein/ERK kinase 1/2 inhibitor AZD6244 and doxorubicin in patients with HCC.

Risk factors of survival after percutaneous radiofrequency ablation of hepatocellular carcinoma

AIMS

This study aimed to determine the risk factors of survival in patients with hepatocellular carcinoma (HCC) undergoing percutaneous radiofrequency ablation (PRFA).

PATIENTS AND METHODS

Between August 1999 and May 2005, 281 patients (250 males and 31 females) who were 33-80 years old (mean 65.3 years) received PRFA only or PRFA in combination with percutaneous ethanol injection (PEI) in our center. Patients were treated with PRFA or PEI by a percutaneous approach with ultrasound (US) guidance and were evaluated at regular intervals to determine disease recurrence and survival. The survival curves were constructed by the Kaplan-Meier method and compared by the log-rank test. The relative significance of the variables in the risk factors of overall survival was assessed by multivariate Cox proportional hazards regression analysis.

RESULTS

At the end of the study, 189 patients were alive, and 92 were dead. Median survival was 48.7 months. The overall 1-, 3-, and 5-year survival rates were 89%, 54%, and 43%, respectively. The overall 1-, 3-, and 5-year survival rates for small tumor (size < or = 3cm) were 97.8%, 65.7%, 58.6%, respectively, for medium tumor (size 3.1-5cm) 94.1%, 57.1%, 37.1%, respectively, and for large tumor (size >5cm) 62.8%, 40.3%, 0%, respectively. Survival of patients treated with PRFA was dependent on tumor size (p<0.001; risk ratio [RR] 9.6, 95% CI 5.2-17.8), number of tumors (p=0.003; RR 1.6, 95% CI 1.2-2.0), combination with PEI (p=0.01; RR 0.6, 95% CI 0.4-0.9), Child-Pugh class (p=0.002; RR 2.0, 95% CI 1.3-3.0) and safety margin (p=0.0026; RR 0.6, 95% CI 0.4-0.9).

CONCLUSIONS

PRFA is an effective treatment for HCC. This study showed after PRFA, tumor size, number of tumors, combination with PEI, safety margin, and Child-Pugh class were independent risk factors of survival.

Percutaneous radiofrequency ablation for the treatment of hepatocellular carcinoma in the caudate lobe

AIMS

This study aimed to evaluate the efficacy and safety of percutaneous radiofrequency ablation (PRFA) for hepatocellular carcinoma (HCC) in the caudate lobe.

PATIENTS AND METHODS

Between January 2001 and December 2006, 17 patients (twelve males and five females) who were between 33 and 68years old (mean 54.3), with caudate lobe HCC [2.0-6.5cm in diameter (mean 3.1)] were treated with either PRFA alone (n=14), or PRFA with percutaneous ethanol injection (n=3) under ultrasound guidance. The right or the anterior approach was used in 12 and 5 patients, respectively.

RESULTS

All procedures were performed successfully. There was no mortality and major morbidity due to PRFA. Fourteen tumors (82%) were completely ablated after one to two sessions of treatment. During follow-up (range 3-60, mean 29.1months), two (14%) developed local recurrence. Intrahepatic metastases developed in 9 of 17 patients (53%). No distant metastasis was found. Four patients died (24%), 3 from tumor progression and 1 from hepatic failure. The 1-, 2-, and 4-year overall survivals were 88%, 80%, and 72%, respectively, and the progress free survivals were 47%, 20%, and 10%, respectively.

CONCLUSIONS

PRFA is efficacious and safe for patients with HCC in the caudate lobe.

Hepatocellular Carcinoma Treated with Radiofrequency Ablation with or without Ethanol Injection: A Prospective Randomized Trial

PURPOSE

To prospectively evaluate whether use of combined radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) results in better survival compared with use of RFA alone in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

This study was local ethical committee approved; all patients gave written informed consent. One hundred thirty-three patients were randomly assigned to undergo RFA-PEI (n = 66; 57 men, nine women; mean age, 53.3 years; age range, 32-73 years) or RFA alone (n = 67; 58 men, nine women; mean age, 52.2 years; age range, 33-74 years). Patients with viable tumors at computed tomography (CT) 4 weeks after treatment received additional treatment. Overall survival rates were calculated and 3-year survival rates were compared with life-table and Mantel-Haenszel analyses, respectively. Survival curves were constructed and compared by using Kaplan-Meier and log-rank tests, respectively. The relative prognostic significance of variables in predicting overall survival and the time to tumor recurrence or metastasis were assessed with multivariate Cox proportional hazards regression and logistic regression analyses, respectively.

RESULTS

One-, 2-, 3-, 4-, and 5-year overall survival rates were 95.4%, 89.2%, 75.8%, 63.3%, and 49.3%, respectively, with RFA-PEI and 89.6%, 68.7%, 58.4%, 50.3%, and 35.9%, respectively, with RFA alone. The survival curve for the RFA-PEI group was significantly better than that for the RFA-only group (P = .04). The survival curve for the RFA-PEI group was better than that for the RFA-only group with 3.1-5.0-cm tumors (P = .03) but not for those with 3.0 cm or smaller (P = .44) or 5.1-7.0-cm (P = .70) tumors. Overall tumor recurrence was lower with RFA-PEI (23 patients) than with RFA alone (33 patients, nonsignificant difference). Local recurrence was significantly lower with RFA-PEI (four patients) than with RFA alone (14 patients, P = .012). Tumor diameter proved to be the only significant prognostic factor for overall recurrence and intrahepatic recurrence. Treatment type and tumor size were significant prognostic factors for local recurrence.

CONCLUSION

RFA-PEI facilitated better local tumor control and long-term survival compared with RFA alone.

Validation of clinical AJCC/UICC TNM staging system for hepatocellular carcinoma: analysis of 5,613 cases from a medical center in southern Taiwan

This study was aimed to validate the 5th and 6th editions of tumor-node-metastasis (TNM) system for patients with hepatocellular carcinoma (HCC), and attempted to improve prognostic stratification by modifying the 6th edition according to vascular invasion and tumor size. From 1986 to 2002, a total of 5,613 HCC cases from Kaohsiung Chang Gung Memorial Hospital in southern Taiwan were enrolled. The 6th edition was modified by dividing stage I into stages IA (single tumor, < or =2cm) and IB (single tumor, >2cm), and by dividing stage II into IIA (multiple tumors, none >5cm) and IIB (tumor with segmental macro vascular invasion). The Akaike information criteria (AIC), within a Cox proportional hazard regression model were used; lower AIC value indicated a better discriminatory ability for staging system. The 1-, 3-, 5-, and 7-year overall survival rates were 45.6, 25.9, 17.9, and 13.4%, respectively. Significant differences in survival curve existed in the 5th, 6th, and modified 6th edition TNM systems. For the modified 6th edition TNM, survival differed significantly between stages IA and IB, and between stage IIA and IIB. The AIC values of 5th (72,328), 6th (72,188), modified 6th (71,991) edition TNM system were decreasing. This investigation demonstrated better prognostic stratifications for the 6th edition than the 5th edition TNM staging system. Moreover, the modified 6th edition staging system demonstrated better prognostic prediction than the former two. Pretreatment staging and simple classification of current modified 6th edition TNM staging can be applied to all HCC patients and are clinically useful.

Hepatitis B viral load predicts survival of HCC patients undergoing systemic chemotherapy

HCC is a common cause of morbidity and mortality. For patients who are not candidates for curative surgery, systemic chemotherapy is one of the standard treatments. In parts of China and the Far East, over 80% of HCC patients have chronic HBV infection. In this study, we aimed to assess the relationship between pre-chemotherapy HBV viral load and the survival of HCC patients. HBV infection status was determined prior to chemotherapy in 188 patients, 170 of whom had evidence of HBV chronic infection/exposure (160 hepatitis B surface antigen [HBsAg]-positive, 10 HBsAg-negative/hepatitis B core antibody-positive). Of these, 125 had pretreatment HBV DNA levels determined via real-time PCR. Virological data were analyzed using conventional clinical variables to identify factors that influenced survival. Multivariate analysis revealed that high total bilirubin (P = 0.0016; hazard ratio = 1.040 per 1 muM increase; 95% CI 1.015-1.065), HCV infection (P = 0.0095; hazard ratio = 6.955; 95% CI 1.606-30.129), and high HBV DNA level (P = 0.0217; hazard ratio = 1.650; 95% CI 1.076-2.531) affected survival significantly. Exploratory analysis revealed that high levels of pretreatment HBV DNA had a significantly higher incidence of severe hepatitis during chemotherapy.

CONCLUSION

For HCC patients with HBV chronic infection/exposure, a high viral load prior to treatment is an adverse factor for survival and may be associated with a higher incidence of severe hepatitis during chemotherapy. Future strategies to improve the prognosis of HCC patients undergoing chemotherapy should consider supportive therapy that incorporates antiviral therapies to reduce HBV viral load.

Trends in morbidity and mortality after hepatic resection for hepatocellular carcinoma: an institute's experience with 625 patients

BACKGROUND

Despite recent developments in surgery and patient management during the perioperative period, critical complications still developed in a few patients who had hepatic resection for hepatocellular carcinoma (HCC).

STUDY DESIGN

Six hundred twenty-five consecutive patients who had hepatic resection for HCC were reviewed and operative morbidity and mortality rates assessed.

RESULTS

There were progressive decreases in the surgical blood loss and the rate of blood transfusion (p = 0.0001). Occurrence of ascites and other complications dramatically decreased in the study series (p = 0.0001). Hospital death rate and incidence of postoperative liver failure also decreased from 2.5%, 1.9% (1985 to 1990), 4.4%, 3.2% (1991 to 1996) to 1.9%, 1.4% (1997 to 2002), respectively. Using multiple logistic regression, independent risk factors associated with postoperative complications were found to be the period of operation (odds ratio [OR] = 0.408; p < 0.0001) and alanine aminotransferase > or = 70 IU/L (OR = 2.020; p = 0.0009) over the entire period of this study (1985 to 2002), or the platelet count of < 100 x 10(3)/mm(3) (OR = 4.654; p = 0.0072) and the presence of blood transfusion during operation (OR = 8.249; p = 0.0230) in 1997 to 2002.

CONCLUSIONS

In this series, there has been a decline in surgical blood loss and rate of blood transfusion and in the number of patients with major complications. These results are largely attributable to the adequate selection of surgical candidate and factors aimed at reducing surgical blood loss.

Identification of an Oligopeptide Binding to Hepatocellular Carcinoma

OBJECTIVES

We carried out identification of a small peptide binding to human hepatocellular carcinoma (HCC) cells with the aim of applying the peptide for future HCC-targeted therapy or imaging.

METHODS

The biopanning technique using phage peptide display libraries was performed on HCC cells in vitro, and a phage clone expressing the HCC-binding peptide motif was selected. The binding activity of the selected phage was evaluated by plaque infection assay and immunofluorescence on cell lines. In addition, the binding activity of the peptide-expressing phage was investigated using HCC specimens derived from patients who had undergone hepatectomy for HCC.

RESULTS

A heptapetide, Thr-Thr-Pro-Arg-Asp-Ala-Tyr (TTPRDAY), was identified as a motif binding to HCC. TTPRDAY bound specifically to HCC cells in comparison with other cancer cells, and the binding to HCC cells was also confirmed by immunofluorescence. In addition, the synthesized TTPRDAY peptide showed binding activity and a non-mitogenic effect on HCC cells in vitro. TTPRDAY-presenting phage showed more significant binding to HCC cells derived from specimens obtained from actual patients than to non-cancerous liver tissue.

CONCLUSION

The motif TTPRDAY, identified by the biopanning technique, shows significant binding to HCC cells.

Targeted inhibition of the extracellular signal-regulated kinase kinase pathway with AZD6244 (ARRY-142886) in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignancy in Asia and Africa. We previously reported that overexpression of extracellular signal-regulated kinase (ERK) kinase 1/2 (MEK1/2) and ERK1/2 was detected in HCC, and that their activation was required for liver cancer cell proliferation and survival. In the present study, we determined the efficacy of a specific MEK1/2 inhibitor AZD6244 (ARRAY-142886) in treatment of HCC. Treatment of primary HCC cells with AZD6244 led to growth inhibition, elevation of the cleavage of caspase-3 and caspase-7, and cleaved poly(ADP)ribose polymerase, but inhibition of ERK1/2 and p90RSK phosphorylation. Studying the protein expression profile of seven HCC xenografts revealed that their growth rate was positively correlated with the levels of phosphorylated MEK. AZD6244, when given p.o. to mice bearing these xenografts, resulted in a dose-dependent inhibition of tumor growth. AZD6244-induced growth suppression was associated with inactivation of ERK1/2 and p90RSK, and up-regulation of activated caspase-3 and caspase-7, and cleaved poly(ADP)ribose polymerase. Our data suggest that the MEK-ERK pathway plays an important role in the growth and survival of liver cancer cells and that the HCC xenograft models are excellent tools for screening preclinical drugs. Targeted inhibition of the MEK-ERK pathway with AZD6244 may represent an alternative approach for the treatment of this disease.

Gene expression profiling reveals potential biomarkers of human hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC), a common cancer worldwide, has a dismal outcome partly due to the poor identification of early-stage HCC. Currently, one third of HCC patients present with low serum alpha-fetoprotein (AFP) levels, the only clinically available diagnostic marker for HCC. The aim of this study was to identify new diagnostic molecular markers for HCC, especially for individuals with low serum AFP.

EXPERIMENTAL DESIGN

We used the microarray technique to determine the expression profiles of 218 HCC specimens from patients with either high or low serum AFP. From the microarray study, we selected five candidate genes (i.e., GPC3, PEG10, MDK, SERPINI1, and QP-C), which were overexpressed in HCCs. Using quantitative real-time PCR analyses, we validated the expression of these five genes in 50 AFP-normal and 8 AFP-positive HCC specimens and 36 cirrhotic noncancerous hepatic specimens, which include 52 independent specimens not used in microarray analysis.

RESULTS

A significant increase in the expression of the five candidate genes could be detected in most of the HCC samples, including those with normal serum AFP and small tumors. GPC3, MDK, and SERPINI1 encode known serum proteins. Consistently, a significant increase in serum midkine, encoded by MDK, was associated with HCC patients, including those with normal serum AFP. Using prediction analysis of microarray, we showed that a combined score of these five genes can accurately classify noncancerous hepatic tissues (100%) and HCC (71%).

CONCLUSIONS

We suggest that a diagnostic signature approach using a combined score of these five biomarkers rather than a single marker may improve the prediction accuracy of HCC patients, including those with normal serum AFP and smaller-sized tumors.

Frequent epigenetic inactivation of spleen tyrosine kinase gene in human hepatocellular carcinoma

PURPOSE

The aim of present study was to investigate the methylation and expression status of spleen tyrosine kinase (SYK) in human hepatocellular carcinoma (HCC) and to evaluate this information for its ability to predict disease prognosis. E-cadherin and TIMP-3 methylation was also analyzed here as control because both were associated with poor prognosis in some types of tumors.

EXPERIMENTAL DESIGN

We analyzed the methylation status of SYK, E-cadherin, and TIMP-3 in 124 cases of HCC and assessed the correlation of such methylations with clinicopathologic variables and prognosis after tumor resection.

RESULTS

We found that SYK, E-cadherin, and TIMP-3 genes were methylated in 27%, 27%, and 42% of HCC neoplastic tissues, respectively. The loss of SYK mRNA or Syk protein expression was highly correlated with SYK gene methylation. The patients with methylated SYK in neoplastic tissues had a significantly lower overall survival rate after hepatectomy than those with unmethylated SYK. No significant difference in overall survival rates, however, was found between groups of patients with methylated and unmethylated E-cadherin or TIMP-3. Patients with negative Syk protein expression had a significantly lower overall survival rate than those with positive Syk protein expression. Multivariate analyses indicated that factors affecting overall survival were tumor-node-metastasis stage, Child-Pugh classification, SYK methylation, or Syk protein status.

CONCLUSIONS

Our results indicate that SYK methylation and loss of Syk expression in HCC neoplastic tissues are independent biomarkers of poor patient outcome and that determination of SYK methylation or Syk expression status may offer guidance for selecting appropriate treatments.

Liver transplantation for hepatocellular carcinoma: single nodule with Child-Pugh class A sized less than 3 cm

BACKGROUNDS/AIMS

Hepatic resection (HR) has been the standard therapy for patients with small hepatocellular carcinoma (HCC) with preserved liver function in Child A cirrhosis. However, the underlying cirrhosis is responsible for high recurrence and long-term complications of portal hypertension and liver failure. Currently, liver transplantation (LT) has proven to be a good alternative to HR. We studied to determine whether LT could be an alternative initial therapy or not in HCC patients with less than 3 cm-sized, single nodule with Child A cirrhosis.

METHODS

From January 1995 to December 2005, there were 100 HR and 17 LT (living donor LT 15, deceased donor LT 2) patients. Clinicopathologic characteristics were reviewed and survival rates between LT and HR groups were compared. The applicability of salvage LT at the time of recurrence was also evaluated.

RESULTS

There was no difference in age, sex, etiology and in-hospital mortality between the two groups. LTs were not performed for the patients with preserved liver function, that is, BCLC stage A1. Most initial recurrences after HR occurred in liver (37/39), but only one recurrence after LT occurred in lung. Overall survival differences between LT and HR were not significant. However, disease-free survival after LT and HR were significantly different (p = 0.047). Potential candidates for salvage LT were 37 patients including hepatic failure (n = 10), and its applicability on recurrence was 69.2% (27/39).

CONCLUSION

HR is still a good option for the selected patients because of lower cost and no requirement of donors. However, primary LT can be a treatment of choice for single, small HCC of Child A cirrhosis in the presence of portal hypertension because of excellent disease-free survival.

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).

Positional expression profiling indicates candidate genes in deletion hotspots of hepatocellular carcinoma

Molecular characterizations of hepatocellular carcinoma have indicated frequent allelic losses on chromosomes 4q, 8p, 16q and 17p, where the minimal deleted regions have been further defined on 4q12-q23, 4q31-q35, 8p21-p22, 16q12.1-q23.1 and 17p13. Despite these regions are now well-recognized in early liver carcinogenesis, few underlying candidate genes have been identified. In an effort to define affected genes within common deleted loci of hepatocellular carcinoma, we conducted transcriptional mapping by high-resolution cDNA microarray analysis. In 20 hepatocellular carcinoma cell lines and 20 primary tumors studied, consistent downregulations of novel transcripts were highlighted throughout the entire genome and within sites of frequent losses. The array-derived candidates including fibrinogen gamma peptide (FGG, at 4q31.3), vitamin D binding protein (at 4q13.3), fibrinogen-like 1 (FGL1, at 8p22), metallothionein 1G (MT1G, at 16q12.2) and alpha-2-plasmin inhibitor (SERPINF2, at 17p13) were confirmed by quantitative reverse transcription-polymerase chain reaction, which also indicated a more profound downregulation of FGL1, MT1G and SERPINF2 relative to reported tumor-suppressor genes, such as DLC1 (8p22), E-cadherin (16q22.1) and TP53 (17p13.1). In primary hepatocellular carcinoma examined, a significant repression of MT1G by more than 100-fold was indicated in 63% of tumors compared to the adjacent nonmalignant liver (P = 0.0001). Significant downregulations of FGG, FGL1 and SERPINF2 were also suggested in 30, 23 and 33% of cases, respectively, compared to their nonmalignant counterparts (P < 0.016). In summary, transcriptional mapping by microarray indicated a number of previously undescribed downregulated genes in hepatocellular carcinoma, and highlighted potential candidates within common deleted regions.

Improved long-term survival after liver resection for hepatocellular carcinoma in the modern era: retrospective study from HCV-endemic areas

INTRODUCTION

It remains unclear whether recent progress in perioperative management and treatment for recurrent hepatocellular carcinoma (HCC) has improved patient outcomes in hepatitis C virus-endemic areas.

METHODS

The clinicopathologic and follow-up data of 218 consecutive HCC patients who underwent curative resection between 1982 and 2003 were analyzed. Patients were assigned to one of two groups: before 1992 (early group; n=82) and 1992 and later (late group; n=136). Factors influencing survival rates were investigated by multivariate analysis. The effects of the period during which the hepatic resection was done on the patients' outcome were examined with respect to tumor size.

RESULTS

The 5-year cancer-related and disease-free survival rates were 51.4% and 20.4%, respectively. The late group showed better 5-year cancer-related survival than the early group (64.1% vs. 33.8%), but disease-free survival did not differ significantly between the groups. On multivariate analysis, the period of the hepatic resection was identified as an independent prognostic factor for cancer-related survival (relative risk 0.70, P<0.01) but not disease-free survival. There were no differences in the cancer-related and disease-free survival rates between the two groups for patients with tumors<or=25 mm. In patients with HCCs>50 mm, both cancer-related and disease-free survival rates were better in patients in the late group.

CONCLUSIONS

During the past two decades, improvements in the treatment of recurrent HCC tumors have contributed to controlling large HCCs but not to controlling the multicentric development of HCCs. It may be important to control multicentric recurrence of HCC to improve patient survival in areas where the hepatitis C virus is endemic.

Preoperative regional maximal removal rate of technetium-99m-galactosyl human serum albumin (GSA-Rmax) is useful for judging the safety of hepatic resection

BACKGROUND

For hepatic resection, the preoperative estimation of hepatic functional reserve in the predicted remnant liver may be more important than that of the entire liver. We evaluated the maximal removal rate of technetium-99m-galactosyl-human serum albumin (GSA-Rmax) in the remnant.

METHODS

One hundred and seventy-eight patients were admitted for elective hepatectomy. Conventional liver function, and 15-minute retention rate of indocyanine green (ICGR15) were carried out preoperatively. The GSA-Rmax was calculated according to a radiopharmacokinetic model; then we used the single photon emission computed tomography images to calculate the regional GSA-Rmax in the predicted residual liver (GSA-RL), depending on the operative procedures. The volume of the predicted residual liver (LV-RL) was calculated on the basis of computed tomography images.

RESULTS

The preoperative LV-RL correlated well with the GSA-RL in patients with normal liver; however, there was no such correlation in those with chronic hepatitis or cirrhosis. All of 7 postoperative hyperbilirubinemia occurred in the patients with GSA-RL < 0.15. Two patients died of postoperative liver failure 1 to 2 months after the operation. These 2 patients had GSA-RL values of 0.078 and 0.090, respectively, and severe discrepancies between the GSA-Rmax in the remnant liver and ICGR15.

CONCLUSIONS

We concluded that GSA-RL may be useful for determining the procedure of hepatectomy and that the value should be maintained at greater than 0.15 to avoid postoperative hyperbilirubinemia or hepatic failure.

Implication of frequent local ablation therapy for intrahepatic recurrence in prolonged survival of patients with hepatocellular carcinoma undergoing hepatic resection: an analysis of 610 patients over 16 years old

OBJECTIVE

By comparing cohorts in 2 exclusive time frames, the factors that affected the surgical outcomes of patients with hepatocellular carcinoma (HCC) are presented.

SUMMARY BACKGROUND DATA

Reportedly, survival results of patients with HCC who underwent hepatectomy have improved in recent years. However, the major factors contributing to these favorable outcomes have not been fully explained.

METHODS

Between January 1985 and December 2000, 610 patients with HCC underwent liver resections as a primary and curative resection. They were categorized into 2 groups according to the year in which the surgeries were performed: before 1990 (n = 212; early group); and after 1991 (n = 398; late group). Clinicopathologic data, survival data, type of recurrence, and treatment of intrahepatic recurrence were compared between the 2 groups.

RESULTS

Clinicopathologic data were almost identical between the groups except for age, blood loss, and duration of surgery. The overall survival rate was significantly better in the late group compared with the early group (58.0% vs. 39.1% at 5 years, P < 0.0001). By contrast, disease-free survival remained unchanged (27.8% vs. 26.2% at 5 years, P = 0.2887). The most common type of recurrence was intrahepatic relapse, and there was no difference in the rate and the type of recurrence between the 2 groups. The 5-year survival rate after recurrence was increased in the late group (21.8% vs. 11.6%, P = 0.0002). Stratified analysis by the type of initial recurrence revealed that better survival in the late group was achieved only in solitary intrahepatic recurrences, not in multiple intrahepatic or extrahepatic recurrences. Changes in modality of treatment of recurrence were observed only in the management of solitary intrahepatic recurrences, where percutaneous ablation therapies were more frequently applied with new ablation techniques. Patients that had undergone ablation therapies in the late group had better postrecurrent survival than those in the early group. Multivariate analysis showed that presence of local ablation therapies was an independent favorable prognostic factor only in the late group.

CONCLUSIONS

Significant improvements in outcomes were achieved in patients with HCC who underwent curative liver resections. Percutaneous ablation therapy for intrahepatic recurrence was considered to be a major contributory factor for improving survival after recurrence, as well as for overall survival.

Completeness of treatment in hepatocellular carcinomas treated with image-guided tumor therapies: Evaluation of positive predictive value of contrast-enhanced CT with histopathologic correlation in the explanted liver specimen

OBJECTIVE

To evaluate the positive predictive value of contrast-enhanced multiphase computed tomography (CT) in determining the completeness of treatment, after radiofrequency (RF) ablation and/or transcatheter arterial chemoembolization, based on histopathologic correlation in the explanted liver specimen.

MATERIALS AND METHODS

During a recent 10-year period, 84 consecutive patients who had a history of RF ablation and/or transcatheter arterial chemoembolization for hepatocellular carcinoma (HCC) underwent liver transplantation in our institution. Among them, we selected the patients in whom complete treatment had been considered at periodic follow-up CT (29 tumors in 20 patients, M:F = 18:2, mean age, 47.2 years). The mean size of the tumor at the initial CT was 2.2 cm (range, 0.7-3.6 cm). We investigated the necrosis rate of HCC on the basis of microscopic examinations of the explanted liver specimen and calculated the positive predictive value of CT in determining the completeness of treatment.

RESULTS

The last CT examinations had been obtained 1-37 days before surgery. The overall necrosis rate of HCC for both RF ablation and transcatheter arterial chemoembolization on microscopic examination was 92.9% +/- 12.3%. The positive predictive value of contrast-enhanced CT in determining completeness of treatment was 69.0% (20/29). The tumor necrosis rate for the RF ablation-only group (n = 12) was 91.5% +/- 15.2% with a positive predictive value of 58.3% (7/12) and that of the transcatheter arterial chemoembolization-only group (n = 11) was 91.4% +/- 19.2% with a positive predictive value of 72.7% (8/11).

CONCLUSIONS

Our results suggest that contrast-enhanced CT is limited in accurately determining the completeness of treatment after image-guided tumor ablation for HCC.

The role of 5′ untranslated region in translational suppression of OKL38 mRNA in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide. OKL38 is a pregnancy-induced growth inhibitory gene and its expression is lost in various breast cancer cell lines and kidney tumor. To determine the role of OKL38 expression in HCC, we investigated its expression in various HCC samples and liver cancer cell lines. Western blot analysis revealed that OKL38 protein was absent or reduced in 64.2% (18 of 28) of the HCCs examined and four liver cancer cell lines. Immunohistochemistry study demonstrated that OKL38 protein was undetectable in 41.3% (38 of 92) of HCC, whereas 39.1% (36 of 92) of HCC showed low expression of the protein. Lost or reduced expression level of OKL38 protein was significantly correlated to high tumor stages in HCC (P=0.0042). Overexpression of the OKL38 caused cell death in Chang liver cells. 5' Untranslated region (5'UTR) deletion studies demonstrated that OKL38 was downregulated via translation suppression associated with the 5'UTR of its mRNA. Taken together, the 5'UTRs of OKL38 might play an important role in downregulation of its protein and the absence of OKL38 could lead to the development or progression of HCC.