Predictors of survival after resection of early hepatocellular carcinoma

Preoperative prediction of the microvascular invasion of hepatocellular carcinoma with diffusion-weighted imaging

The aim of this study was to investigate whether diffusion-weighted imaging (DWI) could be useful in predicting the microvascular invasion (MVI) of hepatocellular carcinoma (HCC). Sixty-seven surgically proven HCCs from 65 patients (54 men and 11 women with an age range of 35-75 years and a mean age of 56.0 years) were retrospectively analyzed. The signal intensities (SIs) of the lesions on preoperative diffusion-weighted (DW) images were visually categorized as isointense or hyperintense in comparison with the adjacent liver. We also quantitatively measured SIs and apparent diffusion coefficients (ADCs) by drawing regions of interest in HCCs and livers on DW images with b values of 50, 400, and 800 second/mm(2) and on ADC map images. Logistic regression analyses were performed so that we could identify independent predictors of MVI among laboratory and DWI findings. A univariate analysis showed that a histological grade of 3, a larger tumor size, a higher SI ratio on DW images, and a lower ADC value were significantly associated with MVI. A multiple logistic regression analysis showed that a histological grade of 3 and the ADC value were independent predictors of MVI. With a cutoff of 1.11 × 10(-3) mm(2)/second, the ADC value provided a sensitivity of 93.5% and a specificity of 72.2% for the prediction of MVI with an odds ratio of 24.5 (95% confidence interval = 4.14-144.8, P < 0.001). In conclusion, lower ADC values (1.11 × 10(-3) mm(2)/second or less) can be a useful predictor of MVI during the preoperative evaluation of HCC.

Small hepatocellular carcinomas and thrombocytopenia

BACKGROUND

Clinical phenotypes of small and large hepatocellular carcinomas (HCCs) are not well characterized.

AIM

To evaluate the characteristics of small HCCs diagnosed by screening.

METHOD

A cohort of 430 small HCCs that were diagnosed through screening, were dichotomized according to a size of ≤ 3 cm or >3 cm maximum tumor diameter and compared for radiological and blood-test parameters.

RESULTS

There were 330 males and 100 females. A higher percent of females had smaller tumors. The majority of patients had single tumors, but 15% of those with larger tumors had portal vein thrombosis (PVT) compared to 5% of those with smaller tumors. Significant differences between the tumor-size groups included alpha-fetoprotein (AFP) values and platelet counts, with thrombocytopenia and elevated bilirubin levels being associated with smaller tumors. In comparing PVT-positive and PVT-negative patients, AFP levels and platelet counts were also significantly different between the 2 groups. A mean multinomial multiple logistic regression model was developed for maximum tumor diameter plus PVT.

CONCLUSIONS

The finding of larger tumors being associated with normal platelets and bilirubin levels in comparison to smaller tumors having thrombocytopenia reveals 2 different patterns of HCC presentation.

Hyperintense HCC on hepatobiliary phase images of gadoxetic acid-enhanced MRI: correlation with clinical and pathological features

PURPOSE

To retrospectively determine whether the hyperintense hepatocellular carcinomas (HCCs) seen on the hepatobiliary phase of gadoxetic acid-enhanced MR imaging (EOB-MRI) might have different histologic characteristics from usual hypointense HCCs.

MATERIALS AND METHODS

Two hundred three surgically proven HCCs from 192 patients who underwent preoperative EOB-MRI were analyzed. The demographic and histologic characteristics of hyperintense HCCs were compared with usual hypointense HCCs by using the t-test or Fisher's exact test.

RESULTS

By visual assessment, 18 (8.8%) tumors were classified as hyperintense HCCs. Patients with hyperintense HCC were significantly (p<0.05) older (60.1 vs. 55.2 years) than those with hypointense HCCs. Hyperintense HCCs showed significantly lower rate of microvascular invasion (27.8% vs. 53.5%) and significantly higher rate of peliosis (61.1% vs. 30.8%). Hyperintense HCCs were more frequently expanding type, and none showed infiltrative type or scirrhous histologic pattern.

CONCLUSIONS

Hyperintense HCCs seem to have clinical and histologic features that might be related with more favorable outcomes.

The management of hepatocellular carcinoma around the world: a comparison of guidelines from 2001 to 2011

In the past 10 years, many guidelines for hepatocellular carcinoma (HCC) have been published worldwide. To promote standard care for HCC, we systematically evaluated 17 current guidelines for HCC around the world, including 5 guidelines from the USA, 7 from Asia and 5 from Europe, according to the selection criteria of credibility influence and multi-faceted. After a systematic evaluation, we found that these guidelines have both similarities and differences in terms of what organizations or bodies drafted the guidelines and the approach, applicability, content and recent updates of the guidelines as well as in terms of diagnostic and treatment algorithms. The differences could be attributed to various aetiological factors, high-risk patients, health systems, health resources, medical technology, treatment choices and income levels in different countries. Besides, although the full implementation of guidelines could benefit clinicians, patients and authorities, there is still a gap between projected goals and implementation. The factors potentially influencing implementation are what organizations or bodies are drafting guidelines, content and emphasis, modification and consistency of guidelines. Comparative analysis suggested that countries pay close attention to targeted audiences, a basis in evidence, a basis in available resources, applicable patients and systematic evaluation when establishing and implementing domestic guidelines for HCC.

Hepatic resection can provide long-term survival of patients with non-early-stage hepatocellular carcinoma: extending the indication for resection?

BACKGROUND

Indications for resection of non-early-stage hepatocellular carcinoma (HCC) remain controversial. This study aimed to identify factors that affect outcome of patients with Barcelona Clinical Liver Cancer Classification (BCLC) stage B or stage C HCC after hepatic resection.

METHODS

From 1991 to 2006, 478 patients with HCC (BCLC stage B, n = 318 and BCLC stage C, n = 160) who underwent resection were enrolled. Factors in terms of overall survival and recurrence were analyzed.

RESULTS

After a median follow-up of 29.5 months, 304 patients had died. The cumulative overall survival rate at 5 years was 46.5% in BCLC stage B patients and 29.1% in stage C patients (P < .001). Multivariate analysis disclosed that serum albumin levels ≤4 g/dL, indocyanine green retention rate at 15 minutes >10%, serum creatinine >1.2 mg/dL, multinodularity, Edmondson stage III or IV in tumor cell differentiation, and the presence of macroscopic vascular invasion were independent risk factors of poor overall survival. There were 331 patients with tumor recurrence after resection. Recurrence rate was less in BCLC stage B than that in BCLC stage C (P = .001). Multivariate analysis showed that serum albumin level ≤4 g/dL, multinodularity, cut margin ≤1 cm, and Edmondson stage III or IV were associated with the recurrence of HCC.

CONCLUSION

Hepatic resection can provide long-term survival benefit in selected BCLC stage B or C patients with compensated liver function, especially in those presenting with a single neoplasm without vascular invasion.

Liver resection for hepatocellular carcinoma ≤3 cm: results of an Italian multicenter study on 588 patients

BACKGROUND

The best treatment for patients with small hepatocellular carcinoma (S-HCC) is still controversial. The aim of this study was to evaluate operative and long-term results after liver resection (LR) for S-HCC, defined as tumor ≤3 cm.

STUDY DESIGN

Retrospective multicenter study of 588 LRs for S-HCC from 8 Italian hepatobiliary surgery units (years 1992 to 2008). Primary outcomes included operative risk. Logistic regression analysis was used to evaluate risk factors for postoperative mortality. Secondary outcomes were overall survival (OS) and disease-free survival (DFS), estimated by the Kaplan-Meier method.

RESULTS

Postoperative mortality was 1.9%, morbidity was 35.7% (major morbidity 7.3%), and blood transfusion rate was 13.8%. Child-Pugh class B and blood transfusions were associated with higher postoperative mortality. Rates of microvascular invasion and microsatellite nodules were 37.0% and 23.1%. After a median follow-up of 38.4 months, 5- and 10-year OS rates were 52.8% and 20.3%, with DFS of 32.4% and 21.7%. Local recurrence rate was 1.4%. Between the years 2000 and 2008, 5-year OS was significantly higher than that between the years 1992 and 1999 (61.9% vs 42.6%; p < 0.001). In multivariable analysis, Child-Pugh class B, portal hypertension, and microsatellite lesions were independently associated with poor OS. Microsatellite lesion was the only variable independently associated with poor DFS.

CONCLUSIONS

Liver resection for S-HCC has improved over the years, with decreased operative risk. Long-term survival after LR has increased. Despite small tumor size, rates of microsatellite nodules and microvascular invasion are not negligible. Presence of microsatellite lesions was the only variable identified as being associated with poor both OS and DFS.

Histological differentiation grade and microvascular invasion of hepatocellular carcinoma predicted by dynamic contrast-enhanced MRI

PURPOSE

To explore the potential use of magnetic resonance imaging (MRI) in predicting the outcome for patients with hepatocellular carcinoma (HCC), imaging characteristics were correlated with pathological findings and clinical outcome.

MATERIALS AND METHODS

With permission from the Ethical Board, clinical data and tissues of resected HCC patients were collected, including the preoperative MRI. The role of MRI characteristics on recurrence and survival were evaluated with univariate and multivariate analyses.

RESULTS

Between January 2000 and December 2008, 87 patients with 104 HCCs were operated on. Microvascular invasion was present in 55 lesions (53%). HCC was characterized as well differentiated in 15 lesions (14%), as moderate in 50 lesions (48%), and as poorly differentiated in 34 lesions (33%). Due to preoperative treatment in five lesions (5%) no vital tumor was left. In 85 lesions (88%) washout of contrast was noted. Of the 87 patients, 28 (32%) with 37 lesions developed HCC recurrence; these patients had microvascular invasion significantly more often and a moderate or poorly differentiated tumor (P < 0.001 and P = 0.025, respectively). MRI more often showed washout when HCC was moderately or poorly differentiated (P < 0.001) or microvascular invasion was present (P = 0.032).

CONCLUSION

Differentiation grade and microvascular invasion are significantly associated with the presence of washout demonstrated on dynamic contrast-enhanced MRI.

Multidisciplinary management of hepatocellular carcinoma

Hepatocellular carcinoma is a leading cause of death in patients with cirrhosis. Management algorithms continually are increasing in sophistication and involve application of single and multimodality treatments, including liver transplantation, hepatic resection, ablation, transarterial chemoembolization, radioembolization, and systemic chemotherapy. These treatments have been shown to increase survival times. As many as 75% of patients with limited-stage disease who are given curative therapies survive 5 years, whereas less than 20% of untreated patients survive 1 year. Treatment can be optimized based on the patient's tumor stage, hepatic reserve, and functional status. However, because of the heterogeneity in presentation among patients, a multidisciplinary approach is required to treat hepatocellular carcinoma, involving hepatologists, surgeons, interventional radiologists, and oncologists. We present each specialist's viewpoint on controversies and advances in the management of hepatocellular carcinoma.

Pretreatment serum C-reactive protein level predicts poor prognosis in patients with hepatocellular carcinoma

C-reactive protein (CRP) is known to be associated with poor prognosis in patients with various malignancies. We investigated the relationship between the pretreatment serum CRP level and survival in patients with hepatocellular carcinoma (HCC) in various stages of the disease. A cohort of 133 patients with newly diagnosed HCC was prospectively evaluated. The patients were divided into two groups: high-CRP group (n=27) with the pretreatment serum CRP level≧1.0 mg/dl and low-CRP group (n=106) with the CRP level<1.0 mg/dl. They were followed 22 months in average (1-69 months) and clinicopathological variables, and overall survivals between the two groups were compared at the end of the follow-up period. There was a significant difference between the two groups in aspartate aminotransferase, alanine aminotransferase, total serum bilirubin, albumin, α-fetoprotein level, maximal tumor diameter, frequency of vascular invasion and extrahepatic metastases. Patients in the high-CRP group had higher Child-Pugh scores, higher Cancer of the Liver Italian Program scores and higher Japan Integrated Staging scores than patients in the low-CRP group. The overall survival rates in the high-CRP group were significantly lower than those in the low-CRP group. Survival rates were similar in tumor stage and liver function-matched patients. On multivariate analysis, pretreatment serum CRP level was independently associated with overall survival. Our results demonstrate that the pretreatment serum CRP level is associated with tumor progression and reduced liver function and is an independent poor prognostic marker in patients with HCC.

Benefit of initial resection of hepatocellular carcinoma followed by transplantation in case of recurrence: an intention-to-treat analysis

Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by "salvage transplantation" (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) with recurrence beyond MC. Predictive factors for nontransplantability due to recurrence beyond MC included microscopic vascular invasion (hazard ratio [HR] 2.38 [range, 1.10-7.29]), satellite nodules (HR 2.46 [range, 1.01-6.68]), tumor size > 3 cm (HR 1.34 [range, 1.03-3.12]), poorly differentiated tumor (HR 3.18 [range, 1.31-7.70]), and liver cirrhosis (HR 1.90 [range, 1.04-3.12]).

CONCLUSION

The high risk of failure of ST after initial LR for HCC within MC suggests the use of tissue analysis as a selection criterion. The salvage LT strategy should be restricted to patients with favorable oncological factors.

Younger hepatocellular carcinoma patients have better prognosis after percutaneous radiofrequency ablation therapy

GOALS

To evaluate the impact of age on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing percutaneous radiofrequency ablation (RFA).

BACKGROUND

Whether age plays an important role in the outcomes of HCC after RFA remains controversial.

STUDY

Two hundred fifty-eight consecutive treatment naive HCC patients who underwent RFA were enrolled. Patients aged ≤ 65 years (n = 100) were defined as the younger group and those aged > 65 years (n = 158) were the elderly group. Their clinicopathologic features and prognosis were compared.

RESULTS

Younger patients had a higher male-to-female ratio, higher prevalence of hepatitis B virus, and smaller tumor size than elder patients. After median follow-up of 28.5 ± 18.7 months, 45 patients died. The cumulative 5-year survival rates were 81.3% and 65.4% in younger and elder HCC patients, respectively (P = 0.008). Multivariate analysis disclosed that age > 65 years, serum albumin level ≤ 3.7 g/dL, prothrombin time international normalized ratio > 1.1, α-fetoprotein (AFP) > 20 ng/mL, and no antiviral therapy after RFA were independent risk factors associated with poor overall survival. Besides, there were 163 patients with tumor recurrence after RFA. Multivariate analysis showed that age > 65 years, platelet count ≤ 10/mm, AFP > 20 ng/mL, multinodularity, and tumor size > 2 cm were the independent risk factors predicting recurrence.

CONCLUSIONS

Both liver functional reserve (serum albumin level, prothrombin time international normalized ratio, platelet count, and antiviral therapy) and tumor factors (tumor size, number, and AFP level) were crucial in determining post-RFA prognosis in HCC patients. Moreover, younger HCC patients have better overall survival and lower recurrence rate after RFA compared with elder patients.

Long-term outcome after liver resection and clinicopathological features in patients with small hepatocellular carcinoma

Backgrounds/Aims

Surveillance programs and imaging modality developments have increased the detection rate of small hepatocellular carcinoma (HCC). In particular, liver transplantation produces good results and is now regarded an alternative to liver resection. However, optimal treatment for small HCC is still debated, and thus, the authors designed this study to document clinicopathological characteristics, to identify the prognostic factors of small HCC, and to determine the effectiveness of surgery.

Methods

A total of 507 patients underwent curative liver resection for HCC between January 1996 and August 2006 in our institution. One hundred and thirty four of these patients with a single HCC of less than 3 cm and no gross vascular invasion were enrolled.

Results

Major resection was performed in 32 (23.9%) patients; there was no postoperative mortality. Fifty-eight (43.3%) patients experienced recurrence, 53 developed intrahepatic recurrence alone, and 50 (94.3%) of 53 had tumors within the Milan criteria. Five-year disease-free and overall survival rates were 51.0% and 77.3%, respectively. Microscopic vascular invasion, positivity for hepatitis B surface antigen or antibody to hepatitis C, and an indocyanine green retention test at 15 minutes of more than 10% were found to be significantly correlated with disease-free overall survival. A platelet count of less than 100,000/mm³ was the only independent prognostic factors of overall survival identified.

Conclusions

This study showed favorable outcome comparable to the survival after liver transplantation, thus that liver resection appears to be the primary treatment option for small HCC, even in cases with poor prognostic factors.

Prognosis in the early stages of hepatocellular carcinoma: Predicting outcomes and properly selecting patients for curative options

Selection of patients for curative treatment options for HCC depends on tumour bulk (size, number or volume) and liver function (as measured by Child-Pugh score, bilirubin and albumin levels, and portal hypertension). MVI is an important predictor of recurrence in early stage HCC but, unfortunately, is often only available on review of the surgical pathology after the therapy has already been performed. Patients can be transplanted beyond the Milan criteria with good outcomes, although biopsy and/or AFP should be used to exclude patients at the highest risk of recurrence.

Factors affecting prognosis of small hepatocellular carcinoma in Taiwanese patients following hepatic resection

BACKGROUND

Small hepatocellular carcinoma (HCC) affects millions of individuals worldwide. Surveillance of high-risk patients increases the early detection of small HCC.

OBJECTIVE

To identify prognostic factors affecting the overall survival (OS) and recurrence-free survival (RFS) of patients with small HCC.

METHODS

The present prospective study enrolled 140 Taiwanese patients with stage I or stage II small HCC. Clinical parameters of interest included operation type, tumour size, tumour histology, Child- Pugh class, presence of hepatitis B surface antigen and liver cirrhosis, hepatitis C status, alpha-fetoprotein, total bilirubin and serum albumin levels, and administration of antiviral and salvage therapies.

RESULTS

Tumour size correlated significantly with poorer OS in patients with stage I small HCC (P=0.014); however, patients with stage II small HCC experienced a significantly poorer RFS (P=0.033). OS rates did not differ significantly between patients with stage I and stage II small HCC. Tumour margins, tumour histology and cirrhosis did not significantly affect OS or RFS (P>0.05).

DISCUSSION

Increasing tumour size has generally been associated with poorer prognoses in cases of HCC. The present study verified the relationship between small HCC tumour size and OS; however, a reduction in OS with increasing tumour size was demonstrated for patients with stage I - but not for stage II - small HCC.

CONCLUSION

Patients with stage II small HCC may benefit from aggressive surveillance for tumour recurrence and appropriate salvage treatment. Further studies are needed for additional stratification of stage I patients to identify those at increased risk of death.

Imaging features of small hepatocellular carcinomas with microvascular invasion on gadoxetic acid-enhanced MR imaging

OBJECTIVES

Detection of hepatocellular carcinomas (HCCs) before microvascular invasion (MVI) occurs is important due to the poor outcomes associated with MVI. We retrospectively investigated the imaging features of small HCCs with MVI on gadoxetic acid-enhanced MR imaging.

METHODS

Fifty patients (40 men and 10 women; mean age, 54 years) with 58 surgically proven small (2 cm or less) HCCs were evaluated by gadoxetic acid-enhanced MRI. Signal intensities on imaging sequences and the presence of the typical dynamic enhancement pattern (arterial enhancement and washout) were assessed. Fisher's exact tests were performed to evaluate the relationships between the presence of MVI, tumor size, and imaging findings.

RESULTS

None of the 12 small HCCs with diameters of 1cm or less had MVI, while 15 (33%) of the 46 small HCCs with diameters of 1.1-2.0 cm had MVI (p=0.025, Fisher's exact test). Among the small HCCs with diameters of 1.1-2.0 cm, all HCCs with MVI showed the typical dynamic pattern and hyperintensity on T2- and diffusion-weighted images. Most HCCs (54 lesions, 93%) were hypointense on hepatobiliary phase images regardless of the presence of MVI.

CONCLUSIONS

All small HCCs with MVI showed typical dynamic pattern and hyperintensity on T2-weighted and diffusion-weighted images, while atypical dynamic pattern and size of less than 1cm in diameter may suggest absence of MVI.

Does the hepatocellular phase of gadobenate dimeglumine help to differentiate hepatocellular carcinoma in cirrhotic patients according to histological grade?

AIM

To assess the role of the hepatocellular phase on magnetic resonance imaging (MRI) following gadobenate in characterizing the grade of hepatocellular carcinoma (HCC) in cirrhotic patients.

MATERIALS AND METHODS

A retrospective review of the MRI database from October 2004 to February 2009, performed for this Institutional Review Board-approved and Health Insurance Portability and Accountability Act (HIPAA)-complaint study, revealed 237 cirrhotic patients with focal liver lesions. Patients who had both a hepatocellular phase after gadobenate and pathological confirmation of HCC were included. Forty-six patients with 73 HCC were analysed independently by two reviewers for signal characteristics. Absolute contrast-to-noise ratio (CNR) and enhancement ratio (ER) were calculated. Univariate analysis, stepwise logistic regression analysis, and receiver operating characteristic curves (ROC) were performed.

RESULTS

The mean age was 61.3 years (range 45 to 78 years). There were 11 females and 35 males, who had 22 well-differentiated (WD HCC), 35 moderately-differentiated (MD HCC), and 16 poorly-differentiated (PD HCC) hepatocellular carcinomas. On visual analysis of the hepatocellular phase, a hyperintense or isointense lesion had a sensitivity and specificity of 45% and 76%, respectively, for WD HCC. On quantitative analysis, the only significant predictor of the grade of HCC was the ER on the hepatocellular phase (p=0.019 and 0.001 for the two reviewers in logistic regression model). On ROC analysis, an ER of >13% was 47% sensitive and 89% specific in predicting WD HCC histology.

CONCLUSION

Although the hepatocellular phase of gadobenate may help to differentiate some cases of WD HCC from the more aggressive grades, there is overlap between the different grades on qualitative and quantitative analysis.

Factors predicting occurrence and prognosis of hepatitis-B-virus-related hepatocellular carcinoma

Primary liver cancer is an important cause of cancer death, and hepatocellular carcinoma (HCC) accounts for 70%-85% of total liver cancer worldwide. Chronic hepatitis B virus (HBV) infection contributes to > 75% of HCC cases. High serum viral load is the most reliable indicator of viral replication in predicting development of HCC. HBV genotype C is closely associated with HCC in cirrhotic patients aged > 50 years, whereas genotype B is associated with development of HCC in non-cirrhotic young patients and postoperative relapse of HCC. Different HBV subgenotypes have distinct patterns of mutations, which are clearly associated with increased risk of HCC. Mutations accumulate during chronic HBV infection and predict occurrence of HCC. Chronic inflammation leads to increased frequency of viral mutation via cellular cytidine deaminase induction. Mutations are negatively selected by host immunity, whereas some immuno-escaped HBV mutants are active in hepatocarcinogenesis. Inflammatory pathways contribute to the inflammation-necrosis-regeneration process, ultimately HCC. Their hallmark molecules can predict malignancy in HBV-infected subjects. Continuing inflammation is involved in hepatocarcinogenesis and closely related to recurrence and metastasis. HBV load, genotype C, viral mutations and expression of inflammatory molecules in HBV-related HCC tissues are significantly associated with poor prognosis. Imbalance between intratumoral CD8⁺ T cells and regulatory T cells or Th1 and Th2 cytokines in peritumoral tissues can predict prognosis of HBV-related HCC. These factors are important for developing active prevention and surveillance of HBV-infected subjects who are more likely to develop HCC, or for tailoring suitable treatment to improve survival or postpone postoperative recurrence of HCC.

Gadoxetic acid-enhanced MRI findings of early hepatocellular carcinoma as defined by new histologic criteria

PURPOSE

To describe the imaging features of early hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced MRI (Gd-EOB-MRI) in comparison with multidetector computed tomography (MDCT) examinations.

MATERIALS AND METHODS

We analyzed imaging findings of 19 pathologically proven early HCC lesions in 15 patients who underwent both MDCT and Gd-EOB-MRI at 3.0 Tesla (T) units before surgery. MRI included in-phase and out-of-phase T1-weighted dual-echo gradient-recalled-echo sequences, dynamic T1-weighted images before and after bolus injection of gadoxetic acid disodium, fat-saturated T2-weighted fast spin-echo sequences, and T1-weighted hepatobiliary phase images 20 min after contrast injection. Two radiologists retrospectively evaluated the signal intensities and enhancement features on MRI and MDCT.

RESULTS

None of the lesions displayed arterial enhancement and washout on MDCT. On Gd-EOB-MRI, six (32%) lesions showed T2-hyperintensity, five (26%) lesions showed signal drop on opposed-phase. Three lesions (16%) showed arterial enhancement and washout. Twelve (63%), 13 (68%), and 15 (79%) lesions were hypointense on hepatic venous, equilibrium, and hepatobiliary phase, respectively.

CONCLUSION

Most early HCCs did not show arterial enhancement and washout pattern on both MDCT and Gd-EOB-MRI. Gd-EOB-MRI may provide several ancillary findings for diagnosis of early HCC such as decreased hepatobiliary uptake, T2 hyperintensity and signal drop in opposed phase.

The impact of CD4+ CD25+ T cells in the tumor microenvironment of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common liver cancer. Therapeutic results are usually unsatisfactory because liver tumors recur often. Immunologic factors may be related to the recurrence of HCC; however, this possibility is mentioned only rarely.

METHODS

Thirty HCC patients undergoing hepatectomies were divided into 3 groups according to the diameters of their HCCs: group A (n = 8), diameter ≤3 cm; group B (n = 8), diameter >3 cm and ≤5 cm; and group C (n = 14), diameter >5 cm. T-lymphocytes from peripheral blood, nontumor liver tissue, and the HCC were analyzed.

RESULTS

The percentage of CD25+ in the CD4+ T cells did not differ between the peripheral blood and the nontumor liver tissue among the 3 groups. CD25+ cells were increased in the tumor tissue in group C patients (range, 6-41%; median, 22.9%; P = .003), compared to group A patients. The percentage of CD25+ in the CD4+ T cells in tumor tissue was positively correlated with tumor sizes (r = 0.556). These CD4+ CD25+ lymphocytes produced transforming growth factor-β and interferon-γ but not interleukin-10, and were anergic to plate-coated monoclonal antibodies (anti-CD3/anti-CD28). The characteristics of these antibodies were comparable to those of regulatory T cells. When the infiltration lymphocytes including CD4+ CD25+ T cells were added to the mixed lymphocyte reaction activated by autologous tumor lysate-pulsed dendritic cells, the proliferation of lymphocytes was inhibited.

CONCLUSION

The increase of CD4+ CD25+ T cells in the tumor microenvironment correlates with tumor sizes. These CD4+ CD25+ regulatory T cells appeared to suppress the immune response activated by dendritic cells.

Identification of MACC1 as a novel prognostic marker in hepatocellular carcinoma

Background

Metastasis-associated in colon cancer-1 (MACC1) is a newly identified gene that plays a role in colon cancer metastasis through upregulation of c-MET proto-oncogene (c-MET). However, the value of MACC1 as a potential biomarker for hepatocellular carcinoma (HCC) remains unknown.

Methods

MACC1 mRNA expression in 128 HCC tissues was examined by quantitative polymerase chain reaction. To show the potential correlation of MACC1 and c-MET, c-MET was also analysed.

Results

MACC1 was more highly expressed in HCC than in non-HCC tissues (P = 0.009). High MACC1 expression was significantly increased in cases with high alpha fetoprotein (AFP) (P = 0.025). A positive correlation was found between MACC1 and c-MET mRNAs (r = 0.235, P = 0.009). Both univariate and multivariate analyses revealed that MACC1 expression was associated with overall survival (OS) and disease-free survival (DFS). Moreover, stratified analysis showed that tumour-node-metastasis (TNM) stage I patients with high MACC1 levels had shorter OS and DFS than those with low MACC1.

Conclusions

MACC1 may identify low- and high-risk individuals with HCC and be a valuable indicator for stratifying the prognosis of TNM stage I patients. MACC1 may serve as a novel biomarker for HCC.

Hepatocarcinogenesis: imaging-pathologic correlation

Rapid advances in liver surgery, including liver transplantation, radiology, and pathology, have created a need for clinically relevant nomenclature for premalignant and early lesions of hepatocellular carcinoma (HCC). Precancerous lesions include dysplastic foci and dysplastic nodules (DNs) characterized by cytologic or structural atypia. Although imaging diagnosis is playing a crucial role in the evaluation of hepatocarcinogenesis and early diagnosis of HCC, it is still challenging to accurately characterize borderline nodules such as small arterially enhancing lesions or hypovascular nodules. This article discusses pathological and radiological features of these small nodular lesions and offers insights into the multistep process of hepatocarcinogenesis by describing the progression of pathologic change linking DNs to HCC.

Pre-operative predictors of post-hepatectomy recurrence of hepatocellular carcinoma: can we predict earlier?

BACKGROUNDS AND PURPOSE

To determine the predictors for recurrence in patients receiving curative hepatectomy for hepatocellular carcinoma (HCC).

METHODS

From January 2001 to July 2007, all patients having hepatectomy for first occurrence HCC with curative intent were identified from a prospectively collected database. Prognostic factors for recurrence and survival after resection were analyzed.

RESULTS

A total of 235 patients were included. With a median follow-up of 50.2 (0.07-125.1) months, the recurrence rate was 57.0%. The 1-, 3-, and 5-year overall survival rates were 83.9%, 66.0%, and 58.1% respectively. Multivariate analysis demonstrated that multi-focal lesions (HR: 2.93, P < 0.001), alpha-fetoprotein (AFP) level greater than 100 ng/ml (HR: 1.74, P = 0.002) and history of tumor rupture (HR: 2.84, P = 0.003) were independent risk factors for recurrence of HCC after hepatectomy.

CONCLUSIONS

Predictors for HCC recurrence can be identified before operation. These important parameters should be considered before and after contemplating curative resection for HCC patients and for risk stratification in future clinical trials for neoadjuvant or post-resection adjuvant therapy. The possible use of neoadjuvant or adjuvant treatment to improve survival should be addressed by further trials.

Hepatocellular carcinoma: locoregional and targeted therapies

HCC is a leading cause of morbidity and mortality worldwide. Advances in cancer screening and surveillance have allowed for earlier detection of tumors, affording greater treatment potential. The advent of locoregional therapies has generated greater treatment options for patients with HCC. Either alone or in combination as an adjuvant or neoadjuvant therapy, these novel approaches continue to hold promise for improving morbidity and/or mortality of patients with HCC. The emergence of systemic molecular targeted therapies increases the role of translational science. Whereas surgical resection and transplantation conventionally form the cornerstone of curative approaches, the advancement of locoregional therapies holds great promise in adding to the curative armamentarium.

Hepatic resection for "BCLC stage A" hepatocellular carcinoma. The prognostic role of alpha-fetoprotein

BACKGROUND

Our aim was to assess the capability of Barcelona Clinic Liver Cancer (BCLC) staging system in allocating stage A patients to hepatic resection (HR) and the effect on survival.

METHODS

We enrolled 132 patients with hepatocellular carcinoma (HCC) amenable to HR. All patients underwent ultrasound (US)-guided anatomical resection (≤2 segments) and then postoperative results were evaluated.

RESULTS

Results showed 95% of patients were Child A, 49% in BCLC A1, 21% in A2, 6% in A3, and 24% in A4. No 30-day mortality occurred. Overall survival got worse from A1 to A4 (P = 0.0271), while no differences were found in Childs A patients with or without portal hypertension (P = 0.1674). Multivariate analysis (Cox model) shows that only AFP (<20 ng/ml) was an independent predictor of survival: If the AFP is incorporated in BCLC staging system (all A1 and A2 patients with abnormal AFP levels were included in A3 subgroup), 5-year survival rate including normal AFP for A1 was 57% and for A2 was 65%, whereas the survival rates impaired in the worst candidates (5-year survival rate including AFP abnormal for A3 and A4 was 36%; P = 0.002). So, introducing AFP in BCLC classification it is possible to simplify the algorithm in only 2 classes, well-separated in survival curves (class 1 [AFP-]: 60%; class 2 [AFP+]: 37%; P = 0.0001).

CONCLUSION

Our experience stressed the high value of BCLC system in staging of patients with HCC, but underlined that in selected patients (normal AFP) even A2 group may benefit from HR with a good survival.

Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion

OBJECTIVES

Defining perioperative mortality as death that occurs within 30 days of surgery may underestimate 'true' mortality among patients undergoing hepatic resection. To better define perioperative mortality, trends in the risk for death during the first 90 days after hepatectomy were assessed.

METHODS

Surveillance, Epidemiology and End Results (SEER) Medicare data were used to identify 2597 patients who underwent hepatic resection during 1991-2006. Data on their clinicopathological characteristics, surgical management and perioperative mortality were collected and survival was assessed at 30, 60 and 90 days post-surgery.

RESULTS

Overall, 5.7% of patients died within the first 30 days. Postoperative mortality at 60 and 90 days were 8.3% and 10.1%. In-hospital mortality after hepatic resection was greater among patients with hepatocellular carcinoma (HCC) than among those with colorectal liver metastases (CRLM) (8.9% and 3.8%, respectively; P < 0.001). In CRLM patients, mortality increased from 4.3% at 30 days to 8.4% at 90 days, whereas mortality in HCC patients increased from 9.7% at 30 days to 15.0% at 90 days (both P < 0.05). Patients with HCC were twice as likely as CRLM patients to die within 30 days [odds ratio (OR) 2.03], 60 days (OR = 1.74) and 90 days (OR = 1.71) (all P < 0.001). Differences in 30- and 90-day mortality were greatest among HCC patients undergoing major hepatic resection (P < 0.05).

CONCLUSIONS

Reporting deaths that occur within a maximum of 30 days of surgery underestimates the mortality associated with hepatic resection. Traditional 30-day definitions of mortality are misleading and surgeons should report all perioperative outcomes that occur within 90 days of hepatic resection.

Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis

BACKGROUND

Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection.

STUDY DESIGN

Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as <150 × 10(3)/μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality.

RESULTS

A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p = 0.031), PLI (30% versus 6%, p = 0.001), and 60-day mortality (22% versus 6%, p = 0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p = 0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p = 0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p = 0.009).

CONCLUSIONS

LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.

Comparison of staging systems of hepatocellular carcinoma

Many staging systems of hepatocellular carcinoma (HCC) were established; however, there is no consensus on which is proper in predicting prognosis. This study aims to evaluate various commonly used staging systems of HCC. Patients who underwent surgery during 2001-2007 were included. All patient data were retrospectively staged using six staging systems, that are American Joint Committee on Cancer (AJCC) Tumour-Node-Metastasis (TNM), Okuda staging, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Chinese University Prognostic Index (CUPI), and Japan Integrated Staging (JIS). Child-Pugh classification was also evaluated. The staging systems were compared by mean of overall and disease-free survival. Total of 99 patient data were enrolled in the analyses. All staging systems except Okuda were significant in determining overall survival in univariate analyses. In multivariate analyses, TNM and Child-Pugh demonstrated better predictive power for overall survival. In terms of disease-free survival, univariate analyses revealed that TNM, CLIP, BCLC, CUPI, and JIS were significant, and TNM was the best predictive staging system in multivariate analyses. In our study, TNM and Child-Pugh are the representative systems in predicting survival of HCC patients who undergo surgical resection. Moreover, they are practical and easily assessable in clinical practice.

Clinical outcome of hepatectomy for hepatocellular carcinomas≤2 cm

BACKGROUND

The treatment strategy for hepatocellular carcinomas (HCCs)≤2 cm (HCC2-) is still controversial. In this study, we retrospectively analyzed clinicopathological data for HCC2- and HCCs>2 cm (HCC2+) to establish the treatment strategy for HCC2-.

METHODS

Between April 2000 and December 2008, 206 patients with single HCC, who underwent hepatectomy for the first time, and whose outcomes could be tracked, were included in the study. There were 46 HCC2- and 160 HCC2+ patients. Survival and disease-free survival rates were compared between the two groups, in relation to various clinicopathological data.

RESULTS

The 1-, 3-, and 5-year overall survival rates were 100%, 92.6%, and 72.8% for HCC2- and 93.3%, 72.4%, and 57% for HCC2+, respectively (P=0.0098). The 1, 3, and 5-year disease-free survival rates were 86%, 42.6%, and 31% for HCC2-, and 64.7%, 35.9%, and 12.5% for HCC2+, respectively (P=0.0642). Survival rates were better for HCC2- than for HCC2+ in terms of abnormal serum des-gamma-carboxy prothrombin, Child-Pugh Class A, single infection with HBV or HCV, and operative method used for anatomical resection, irrespective of ICG R15. Disease-free survival rates were better for HCC2- than for HCC2+ in terms of Child-Pugh Class A, and operative method used for anatomical resection.

CONCLUSIONS

HCC2- has a better clinical outcome than HCC2+ after hepatic resection. Especially, HCC2- with an abnormal DCP value, Child-Pugh Class A, single infection with HBV or HCV, and anatomical resection, yields better outcomes. Even for HCC2- in patients with good liver function, anatomical resection is recommended.

Tumor size as a prognostic factor in resected small hepatocellular carcinoma: a controversy revisited

BACKGROUND AND AIM

The widespread use of screening programs has resulted in an increase in detection of small hepatocellular carcinoma (HCC). Surgical resection generally leads to favorable outcomes in this group of patients; however, the prognostic significance of tumor size and the optimal cutoff point in resected specimens of small HCC have not been well defined. The aim of current study is to evaluate the prognostic significance of tumor size in small resected HCC.

METHODS

Patients who underwent surgical resection for small HCC at the Changhua Christian Hospital during January 2001 to June 2007 were enrolled. Small HCC was defined as a single HCC nodule with maximum diameter ≤ 5 cm. Cox regression hazard ratios for cancer-specific death were calculated to survey the prognostic significance of tumor size. We then determined the optimal cut-point for tumor size that could be used to stratify patients into 5-year disease-free survival (DFS) and cancer-specific survival (CSS) groups.

RESULTS

A total of 140 patients who underwent resection of small HCC were enrolled. The mean tumor size was 2.9 cm (range 0.9-5.0) and the mean follow-up period was 43.4 months. The 5-year DFS and CSS rates were 46.6% and 81.6%, respectively. Cox regression analysis revealed that tumor size (hazard ratio = 2.973, 95% confidence interval: 1.073-8.239, P = 0.036) was an independent prognostic factor. Our analysis showed that a tumor size of 3 cm was the cut-point that could dichotomize patients into statistically different 5-year DFS and CSS risk groups.

CONCLUSIONS

Tumor size is an independent prognostic factor in resected small HCC and the prognostic significance of tumor size may vary according to different cut-off points.

Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis

BACKGROUND

Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection.

STUDY DESIGN

Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as <150 × 10(3)/μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality.

RESULTS

A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p = 0.031), PLI (30% versus 6%, p = 0.001), and 60-day mortality (22% versus 6%, p = 0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p = 0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p = 0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p = 0.009).

CONCLUSIONS

LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.

Surgical treatment for hepatocellular carcinoma

Surgery is the most important therapeutic approach for patients with hepatocellular carcinoma. We have reviewed patients' survival after resection for hepatocellular carcinoma in 17 series since 2000, each including more than 100 patients. Median survival rates were 80% (range 63-97%) at 1 year, 70% (34-78%) at 3 years and 50% (17-69%) at 5 years. Such wide ranges of survival rates are attributed mainly to differences in the hepatocellular carcinoma stage among studies, but the survival rate is obviously much better for early hepatocellular carcinomas. Today, liver resection is an established treatment for hepatocellular carcinoma owing to minimal surgical mortality and improved survival. Liver transplantation is one of the best treatments for hepatocellular carcinoma in patients who meet the selection criteria. Further studies are needed to establish suitable criteria for transplantation in patients with hepatocellular carcinoma. For patients who are not candidates for liver resection or transplantation, percutaneous ablation is the best treatment option. However, no randomized controlled clinical trial has compared the results of ablation with those of surgical therapy for hepatocellular carcinoma, and none of the ablation techniques have been shown to offer a definitive survival advantage. A treatment algorithm based on published evidence is now available, which helps us to select the most suitable therapeutic option for individual patients, depending on tumor characteristics and liver functional reserve. This review paper summarizes the current status of the surgical management of hepatocellular carcinoma.

National trends in discharge disposition after hepatic resection for malignancy

BACKGROUND

There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy.

AIM

To analyse the national trends in discharge disposition after hepatic resection for malignancy.

METHODS

The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility).

RESULTS

A weighted total of 74,520 patients underwent hepatic resection of whom, 53,770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45,583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study.

CONCLUSIONS

The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.

Prognostic factors and outcome of 438 Chinese patients with hepatocellular carcinoma underwent partial hepatectomy in a single center

OBJECTIVE

This study was designed to evaluate the prognostic factors and outcome of 438 Chinese patients with hepatocellular carcinoma who underwent partial hepatectomy in a single center.

METHODS

Clinicopathological data of 438 patients with hepatocellular carcinoma who underwent partial hepatectomy at the author's hospital between 1991 and 2004 were reviewed retrospectively. The Kaplan-Meier method was adopted for evaluating survival. Prognostic factors were assessed by Cox proportional hazard model and logistic regression model.

RESULTS

The perioperative (30 days) mortality and morbidity were 7.5% (33/438) and 21.7% (95/438), respectively. The operative mortality decreased significantly from 10.6% (23/218) in 1991-2001 to 4.5% (10/220) in 2002-2004 (P = 0.019). Postoperative overall survival rates at 1 year, 3 years, and 5 years were 72.2%, 53.5%, and 43.3%, respectively. Cox multivariate analysis indicated that Child-Pugh score, tumor size, capsular invasion, tumor stage, vascular invasion, and resection margin were independent prognostic factors for overall survival (P < 0.05). Also, 254 cases had tumor recurrence after operation and 87 cases of them were reoperated. Logistic multivariate analysis showed that tumor size, capsular invasion, vascular invasion, lymph node metastasis, extrahepatic metastasis, and resection margin were independent risk factors of tumor recurrence (P < 0.05).

CONCLUSIONS

Tumor size, capsular invasion, vascular invasion, and resection margin were the main factors that may impact the overall survival and tumor recurrence. Because resection margin was the only factor that relates to the surgery, enough resection margin (>2 cm) should be obtained whenever possible.

Understanding surgical decision making in early hepatocellular carcinoma

PURPOSE

The choice between liver transplantation (LT), liver resection (LR), and radiofrequency ablation (RFA) as initial therapy for early hepatocellular carcinoma (HCC) is controversial, yet little is known about how surgeons choose therapy for individual patients. We sought to quantify the impact of both clinical factors and surgeon specialty on surgical decision making in early HCC by using conjoint analysis.

METHODS

Surgeons with an interest in liver surgery were invited to complete a Web-based survey including 10 case scenarios. Choice of therapy was then analyzed by using regression models that included both clinical factors and surgeon specialty (non-LT v LT).

RESULTS

When assessing early HCC occurrences, non-LT surgeons (50% LR; 41% LT; 9% RFA) made significantly different recommendations compared with LT surgeons (63% LT; 31% LR; 6% RFA; P < .001). Clinical factors, including tumor number and size, type of resection required, and platelet count, had significant effects on the choice between LR, LT, and RFA. After adjusting for clinical factors, non-LT surgeons remained more likely than LT surgeons to choose LR compared with LT (relative risk ratio [RRR], 2.67). When the weight of each clinical factor was allowed to vary by surgeon specialty, the residual independent effect of surgeon specialty on the decision between LR and LT was negligible (RRR, 0.93).

CONCLUSION

The impact of surgeon specialty on choice of therapy for early HCC is stronger than that of some clinical factors. However, the influence of surgeon specialty does not merely reflect an across-the-board preference for one therapy over another. Rather, certain clinical factors are weighed differently by surgeons in different specialties.

Clinical study of transarterial chemoembolization combined with 3-dimensional conformal radiotherapy for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Monotherapy is not very effective for intermediate or advanced stage HCC. Efficacy of combined therapy using transarterial chemoembolization (TACE) with three-dimensional conformal radiotherapy (3-DCRT) for advanced HCC should be evaluated.

METHODS

HCC patients were selected from our patient database. The sequence of treatments that patients underwent was several courses of TACE followed in 2-4 weeks by 3-DCRT. The median tumor irradiation dose was 44Gy. Toxicity, tumor response, and overall survival rate were analyzed.

RESULTS

140 HCC patients were followed up by the last follow-up time. Among these patients, hepatic toxicities due to treatment were notable in 15 cases. Gastrointestinal bleeding after the overall treatment occurred in 3 cases. Leukopenia of grade III was detected in 1 case. Radiation-induced liver disease (RILD) was observed in 3 patients. Among 140 patients, 27, 97, and 16 cases achieved partial response, stable disease, and progressive disease, respectively. The overall survival rates of 1-year, 3-years, and 5-years were 66%, 29%, and 13%, respectively, with a median survival time of 18 months. Both Child-Pugh grade and radiation dose were determined to be independent predictors for overall survival from multivariate analysis.

CONCLUSION

The combined modality of TACE and 3-DCRT is a promising treatment for unresectable HCC. A large-scale, prospective randomized trial should be performed to confirm the utility of this combined therapy.

Hemostasis after liver resection improves after single application of albumin and argon beam coagulation

BACKGROUND

Bleeding from the liver surface is common after hepatic resection. Animal studies have demonstrated superiority of argon beam coagulation (ABC) and 38% human serum albumin when applied together after partial liver resection when compared to ABC alone. There are no data addressing the combination of albumin and argon beam coagulation (ABCA) applied to the bleeding liver after resection in humans. The aim of this study was to evaluate the safety and efficacy of ABCA on hemostasis when applied to the surface of the liver remnant post-hepatic resection.

METHODS

Ten patients underwent liver resection and were treated with ABCA immediately after the liver was divided. The liver surface was coated with albumin and ABC applied simultaneously, the liver was covered with gauze for 3 min, and ABCA was repeated if necessary. Number of rebleeding episodes requiring re-application of ABCA, time of ABCA application, overall blood loss, and liver functions were monitored. Patients were followed for at least 6 months.

RESULTS

Nine of 10 patients required a single application of ABCA, and one patient required two treatments. Average time of ABC use was 5 ± 3 min. Median blood loss was 230 ml. Liver functions returned to near normal within 4 days of resection.

CONCLUSIONS

ABCA performed well with respect to hemostatic properties, much like previous observations in animal studies. Further clinical trials are justified using this technique.

Clinicopathological determinants of survival after hepatic resection of hepatocellular carcinoma in 97 patients--experience from an Australian hepatobiliary unit

BACKGROUND

Identification of clinicopathological determinants that predict for risk of recurrence and overall survival after undergoing potentially curative hepatic resection for hepatocellular carcinoma is a strategy towards personalizing therapy to improve outcome. Through evaluation of a center's experience with treatment of a disease, determinants unique to the treated patient cohort may be identified.

METHODS

Ninety-seven patients with hepatocellular carcinoma underwent liver resection. Clinical, treatment, and histopathological variables were collected and evaluated using univariate and multivariate analyses with disease-free survival (DFS) and overall survival (OS) as the endpoints.

RESULTS

The median follow-up period of 19 (range, 1 to 188) months from the time of hepatic resection. The median DFS and OS after resection of HCC were 17 and 41 months, respectively. Five-year overall survival rate was 45%. Eight independent factors associated with disease-free and overall survival were identified through a multivariate analysis. Three factors: Child-Pugh score (DFS p = 0.045, OS p = 0.001), histopathological grade (DFS p < 0.001, OS p < 0.001), and histological diagnosis of cirrhosis (DFS p < 0.001, OS p < 0.001) predicted for both disease-free and overall survival.

CONCLUSION

Integrating the knowledge of identified prognostic factors into clinical decision making may provide a clinicopathological signature that could identify patients at greatest risk of treatment failure such that novel interventions may be applied to improve the survival outcome.

Strategy of treatment for hepatocellular carcinomas with vascular infiltration in patients undergoing hepatectomy

BACKGROUND AND OBJECTIVES

Vascular infiltration (VI) is an important prognostic factor for hepatocellular carcinoma (HCC) and predictive parameters are necessary to preoperatively decide treatment strategies in patients with HCC.

METHODS

Relationships between presence and degree of VI in the portal and hepatic veins and bile duct, and post-hepatectomy survival were examined in 271 HCC patients who underwent hepatectomy.

RESULTS

VI was observed in 81 patients (30%). Disease-free and overall survival rates was significantly lower in patients with VI than in patients without VI, and became poorer according to the degree of infiltration (P < 0.01). Multiple, increased size, non-meeting of Milan criteria, irregular macroscopic findings and increased PIVKA-II levels were associated with degree of VI in portal vein (P < 0.01). Increased size and increased PIVKA-II level were associated with degree of VI in hepatic vein (P < 0.05). Non-meeting of Milan criteria was associated with degree of infiltration in bile duct (P = 0.034). Survival was significantly better following anatomical resection than with non-anatomical resection and, furthermore, survival was better with surgical margins >5 mm than with shorter margins in patients who underwent non-anatomical resection.

CONCLUSION

Adequate extent of operative procedures, but not limited resection with short margins, is useful when predictive parameters associated with VI are observed.

Pretreatment assessment of hepatocellular carcinoma: expert consensus statement

Staging of hepatocellular carcinoma (HCC) is complex and relies on multiple factors including tumor extent and hepatic function. No single staging system is applicable to all patients with HCC. The staging of the American Joint Committee on Cancer / International Union for Cancer Control should be used to predict outcome following resection or liver transplantation. The Barcelona Clinic Liver Cancer scheme is appropriate in patients with advanced HCC not candidate for surgery. Dual phase computed tomography or magnetic resonance imaging can be used for pretreatment assessment of tumor extent but the accuracy of these methods remains poor to characterize < 1 cm lesions. Assessment of tumor response should not rely only on tumor size and new imaging methods are available to evaluate response to therapy in HCC patients. Liver volumetry is part of the preoperative assessment of patients with HCC candidate for resection as it reflects liver function. Preoperative portal vein embolization is indicated in patients with small future liver remnant (≤ 20% in normal liver; ≤ 40% in fibrotic or cirrhotic liver). Tumor size is not a contraindication to liver resection. Liver resection can be proposed in selected patients with multifocal HCC. Besides tumor extent, surgical resection of HCC may be performed in selected patients with chronic liver disease.

Recent advances in the treatment of hepatocellular carcinoma

PURPOSE OF REVIEW

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide and continues to have a poor prognosis. Despite surveillance efforts, most tumors are diagnosed at late stages. Surgical resection, liver transplantation, and local ablative therapies such as radio frequency ablation offer the chance of a cure for tumors detected at an early stage in well selected patients.

RECENT FINDINGS

The role of adjuvant or neoadjuvant therapy is being investigated, but there is no clear evidence supporting its routine use at this time. Some have proposed expanding size criteria for transplantation or downstaging tumors detected beyond an early stage, although any benefits must be weighed against the harms to others on the waiting list. For intermediate-stage HCC, transarterial chemoembolization is the mainstay of treatment but is only possible in a minority of patients. The role of radiation therapy for these patients continues to be refined with recent advances in technology minimizing its toxicity to surrounding nonmalignant liver. For patients with advanced HCC, sorafenib is the first systemic therapy to significantly prolong survival and is now considered standard of care for patients with Child A cirrhosis and good performance status.

SUMMARY

Ongoing trials are evaluating the role of other targeted therapies in patients with advanced HCC.

Management of small hepatocellular carcinoma: a review of transplantation, resection, and ablation

PURPOSE AND DESIGN

The management of patients with early hepatocellular carcinoma has become increasingly complex. The most appropriate therapy largely depends on the functional status of the underlying liver. Here we review the modalities of transplantation, resection, and ablation in this patient population.

RESULTS AND CONCLUSION

In patients with cirrhosis and/or portal hypertension, and disease extent within the Milan criteria, liver transplantation is clearly the best option. This modality not only provides therapy for the cancer but also treats the underlying hepatic parenchymal disease. In patients with well-preserved hepatic function, on the other hand, liver resection remains the most appropriate and effective treatment. Hepatic resection is not constrained by the same variables of tumor extent and location that limit the applicability of transplantation and ablative therapies. In addition, patients whose disease recurs after resection are often still eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial embolization/chemoembolization, have been used primarily to treat patients with low-volume unresectable tumors. The question has increasingly been raised regarding whether ablation of small tumors (<3 cm) provides long-term disease control that is comparable to resection. Ablative therapies has also been used as a means of controlling disease in patients who are on transplantation waiting lists, although improved posttransplantation outcome using these techniques has yet to be proven prospectively. The major problem with assessing the efficacy of various treatment modalities in these patients is the heterogeneity of disease presentation, which often precludes the use of certain therapies and therefore makes the conduct of randomized control trial difficult.

Management of small hepatocellular carcinoma: a review of transplantation, resection, and ablation

PURPOSE AND DESIGN

The management of patients with early hepatocellular carcinoma has become increasingly complex. The most appropriate therapy largely depends on the functional status of the underlying liver. Here we review the modalities of transplantation, resection, and ablation in this patient population.

RESULTS AND CONCLUSION

In patients with cirrhosis and/or portal hypertension, and disease extent within the Milan criteria, liver transplantation is clearly the best option. This modality not only provides therapy for the cancer but also treats the underlying hepatic parenchymal disease. In patients with well-preserved hepatic function, on the other hand, liver resection remains the most appropriate and effective treatment. Hepatic resection is not constrained by the same variables of tumor extent and location that limit the applicability of transplantation and ablative therapies. In addition, patients whose disease recurs after resection are often still eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial embolization/chemoembolization, have been used primarily to treat patients with low-volume unresectable tumors. The question has increasingly been raised regarding whether ablation of small tumors (<3 cm) provides long-term disease control that is comparable to resection. Ablative therapies has also been used as a means of controlling disease in patients who are on transplantation waiting lists, although improved posttransplantation outcome using these techniques has yet to be proven prospectively. The major problem with assessing the efficacy of various treatment modalities in these patients is the heterogeneity of disease presentation, which often precludes the use of certain therapies and therefore makes the conduct of randomized control trial difficult.