Prognostic prediction and treatment strategy in hepatocellular carcinoma

Cost-effectiveness of EOB-MRI for Hepatocellular Carcinoma in Japan

PURPOSE

The objective of the study was to evaluate the cost-effectiveness of gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) in the diagnosis and treatment of hepatocellular carcinoma (HCC) in Japan compared with extracellular contrast media-enhanced MRI (ECCM-MRI) and contrast media-enhanced computed tomography (CE-CT) scanning.

METHODS

A 6-stage Markov model was developed to estimate lifetime direct costs and clinical outcomes associated with EOB-MRI. Diagnostic sensitivity and specificity, along with clinical data on HCC survival, recurrence, treatment patterns, costs, and health state utility values, were derived from predominantly Japanese publications. Parameters unavailable from publications were estimated in a Delphi panel of Japanese clinical experts who also confirmed the structure and overall approach of the model. Sensitivity analyses, including one-way, probabilistic, and scenario analyses, were conducted to account for uncertainty in the results.

FINDINGS

Over a lifetime horizon, EOB-MRI was associated with lower direct costs (¥2,174,869) and generated a greater number of quality-adjusted life years (QALYs) (9.502) than either ECCM-MRI (¥2,365,421, 9.303 QALYs) or CE-CT (¥2,482,608, 9.215 QALYs). EOB-MRI was superior to the other diagnostic strategies considered, and this finding was robust over sensitivity and scenario analyses. A majority of the direct costs associated with HCC in Japan were found to be costs of treatment. The model results revealed the superior cost-effectiveness of the EOB-MRI diagnostic strategy compared with ECCM-MRI and CE-CT.

IMPLICATIONS

EOB-MRI could be the first-choice imaging modality for medical care of HCC among patients with hepatitis or liver cirrhosis in Japan. Widespread implementation of EOB-MRI could reduce health care expenditures, particularly downstream treatment costs, associated with HCC.

N-myc downstream-regulated gene 1 inhibits the proliferation and invasion of hepatocellular carcinoma cells via the regulation of integrin β3

N-myc downstream-regulated gene 1 (NDRG1) is a multifunctional protein associated with carcinogenesis and tumor progression. The function of NDRG1 in hepatocellular carcinoma (HCC) cells remains controversial. The present study investigated the role of NDRG1 in HCC as well as its molecular mechanism using a range of techniques, including western blot analysis, cellular proliferation test, wound healing assay and Transwell assay. In HCC, the levels of NDRG1 expression were highest in the cytoplasm, followed by the membrane, and were lowest in the nucleus. NDRG1 was revealed to inhibit the proliferation and invasion of BEL7402 cells, which facilitated the hypothesis that NDRG1 expression levels may be lower in cell line with a high metastatic potential compared with those in cell lines with a low metastatic potential. However, the present study identified that NDRG1 expression was higher in detached BEL7402 cells and MHCC-97H cells compared with that in attached BEL7402 cells and MHCC-97L cells. Thus, this finding was contrary to what was expected, suggesting that NDRG1 overexpression in the HCC with a high metastatic potential may be the compensatory mechanism. The human HCC BEL7402 cell line demonstrated a significant increase in the capability of motility, invasion and cellular proliferation following NDRG1-short hairpin RNA transfection. Integrin β3 (ITGB3) protein expression was increased in NDRG1-downregulated BEL7402 cells and SMMC7721 cells compared with that in the control cells. The present study suggested that NDRG1 may be a potential anti-tumor target for the treatment of patients with HCC. A potential mechanism for these roles of NDRG1 is by regulating ITGB3 expression; however, this requires additional investigation.

Liver resection for hepatocellular carcinoma ≥5 cm

BACKGROUND

Management of hepatocellular carcinoma (HCC) larger than 5 cm is still debated. The aim of our study was to compare morbidity and mortality after the surgical resection of HCC according to the nodule size.

METHODS

Since 2001, 429 liver resections for HCC were performed in our institution. We divided the cohort into two groups, 88 patients in group 1 patients with HCC diameter from 5 to 10 cm and 39 patients in group 2 with HCC diameter ≥10 cm.

RESULTS

In 30.7% of cases in the first group and in 35.9% of cases in the second group the HCC grew into a healthy liver. A major liver resection was performed in 36.3% of cases in group 1 vs. 66.6% in group 2 (P=0.001). In two cases for the first group and in ten cases in the second group a laparoscopic approach was performed. Median operative time was higher in group 2 (P=0.001). The median post-operative hospital stay was similar in the two groups (P=0.897). The post-operative morbidity was not different between the two groups (P=0.595).

CONCLUSIONS

The tumour size does not contraindicate a surgical resection of HCC even in patient with HCC ≥10 cm.

Knockdown of SLC34A2 Inhibits Hepatocellular Carcinoma Cell Proliferation and Invasion

The gene solute carrier family 34 (sodium phosphate), member 2 (SLC34A2), is a member of the SLC34 family. Increasing evidence suggests that SLC34A2 is involved in the development of many human carcinomas. However, its role in hepatocellular carcinoma (HCC) is still unclear. Therefore, in this study we investigated the role of SLC34A2 in HCC and explored the underlying mechanism. We found that the expression of SLC34A2 is upregulated in HCC cell lines. Knockdown of SLC34A2 obviously inhibited HCC cell proliferation, migration/invasion, and the epithelial–mesenchymal transition (EMT) phenotype. Furthermore, knockdown of SLC34A2 significantly inhibited the expression of phosphorylated PI3K and AKT in HCC cells. Taken together, these results suggest that knockdown of SLC34A2 inhibits proliferation and migration by suppressing activation of the PI3K/AKT signaling pathway in HCC cells, and SLC34A2 may be a potential therapeutic target for the treatment of HCC.

Overexpression of SASH1 Inhibits the Proliferation, Invasion, and EMT in Hepatocarcinoma Cells

The SASH1 (SAM- and SH3-domain containing 1) gene, a member of the SLY (SH3 domain containing expressed in lymphocytes) family of signal adapter proteins, has been implicated in tumorigenesis of many types of cancers. However, the role and mechanism of SASH1 in the invasion and metastasis of hepatocarcinoma are largely unknown. In this study, we investigated the role and mechanism of SASH1 in the invasion and metastasis of hepatocarcinoma. Our results showed that SASH1 was lowly expressed in hepatocarcinoma cell lines. The in vitro experiments showed that overexpression of SASH1 inhibited the proliferation and migration/invasion of hepatocarcinoma cells, as well as the epithelial-mesenchymal transition (EMT) progress. Furthermore, overexpression of SASH1 suppressed the expression of Shh as well as Smo, Ptc, and Gli-1 in hepatocarcinoma cells. Taken together, these results suggest that overexpression of SASH1 inhibited the proliferation and invasion of hepatocarcinoma cells through the inactivation of Shh signaling pathway. Therefore, these findings reveal that SASH1 may be a potential therapeutic target for the treatment of hepatocarcinoma.

Hepatocellular carcinoma biology predicts survival outcome after liver transplantation in the USA

PURPOSE

The aim of this study is to evaluate the clinicopathologic prognostic factors of cancer-specific survival (CSS) in hepatocellular carcinoma (HCC) patients who underwent liver transplantation (LT) stratified by tumor size.

METHODS

From the Surveillance, Epidemiology, and End Results (SEER) 18 registries (2004-2012), we retrieved data of 570 patients who underwent LT for a solitary primary HCC lesion ≤5 cm. A two multivariable Cox models were constructed to identify prognostic factors of CSS in a two different tumor sizes (2 cm cutoff).

RESULTS

Out of 570 HCC patients (median age 57 years), 16% had microvascular invasion (MVI) and 12% had a poorly differentiated tumor. Male sex (odds ratio [OR] 2.6), tumor size >2 cm (OR 1.78), elevated AFP (OR 2.31), and poor tumor differentiation (OR 2.59) are significant predictors of MVI. With a median follow up of 41.5 months (range 1-107 months), the 5-year CSS rate was 90% in the absence of MVI compared to 75% in the presence of MVI (p<0.001). Multivariate models revealed that age ≥60 years (hazard ratio [HR] 2.08), MVI (HR 2.26), and poor tumor differentiation (HR 2.42), were significant risk factors of a dismal CSS with HCC size >2 cm, but not with HCC ≤2 cm.

CONCLUSIONS

Primary HCC tumor size ≤2 cm had an excellent prognosis after LT and was not affect by the presence of MVI or poor tumor differentiation.

Safety and efficacy of HepaSphere 50-100 μm in the treatment of hepatocellular carcinoma

AIM

To evaluate the effects of HepaSphere 50-100 μm (Merit Medical) as a doxorubicin carrier and embolization agent for the treatment of hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

A prospective analysis of 18 patients recruited from a national cancer center was conducted. This analysis evaluated the efficacy and safety of HepaSphere, as expressed by the treatment response rate (measured by the modified Response Evaluation Criteria in Solid Tumors, mRECIST) and by the prevalence of treatment-related adverse events, respectively.

RESULTS

The cohort was predominantly male, with a mean age of 69 years. The objective response rate (complete + partial response) was 53.3%. The variable most likely to be associated with objective response was Barcelona Clinic Liver Cancer (BCLC) staging. The most prevalent adverse events were nausea, vomiting and abdominal pain.

CONCLUSION

HepaSphere chemoembolization yielded a substantial objective response rate with an acceptable toxicity profile and should be considered an option for HCC treatment.

Natural History of Untreated Hepatocellular Carcinoma in a US Cohort and the Role of Cancer Surveillance

BACKGROUND & AIMS

Determining the natural history and predictors of survival in patients with untreated hepatocellular carcinoma (HCC) in the United States is useful to test existing tumor classifications, identify subgroups of patients likely to benefit from treatment, and estimate lead time related to HCC surveillance.

METHODS

We identified a national cohort of 518 veterans diagnosed with HCC from 2004 through 2011, with follow-up ending in 2014, who received no palliative or curative treatment. We examined the association between postdiagnosis survival and patient factors, tumor characteristics, and prediagnosis surveillance.

RESULTS

The mean age at HCC diagnosis was 65.7 years and most patients had hepatitis C (60.6%). Almost all patients (99%) died within the observation period; the median overall survival time was 3.6 months and survival times were 13.4, 9.5, 3.4, and 1.6 months for patients of Barcelona Clinic Liver Cancer stages 0/A, B, C, and D, respectively. In addition, model for end-stage liver disease and levels of α-fetoprotein were predictive of survival. Nearly 28% received prediagnosis HCC surveillance, which was associated with detection of disease at an earlier stage (Barcelona Clinic Liver Cancer 0/A/B; 26.4% vs 14.4%; P = .0006) and slightly longer survival than patients with no surveillance overall (5.2 months vs 3.4 months; P = .021); there was no difference in survival times of patients with 0/A stage who did versus did not receive surveillance (10.3 months vs 10.5 months).

CONCLUSIONS

Patients with HCCs, including those detected through surveillance, survived for short time periods in the absence of treatment, irrespective of their initial stage at diagnosis. Model for end-stage liver disease scores and levels of α-fetoprotein were prognostic factors, independent of Barcelona Clinic Liver Cancer stage. The lead time related to detection by surveillance was modest (<2 months) and therefore unlikely to explain the survival benefit associated with surveillance in previous studies.

Lymphocyte to monocyte ratio and neutrophil to lymphocyte ratio are superior inflammation-based predictors of recurrence in patients with hepatocellular carcinoma after hepatic resection

AIM

The purpose of this study was to investigate which inflammation-based marker more accurately predict recurrence in patients receiving hepatectomy for hepatocellular carcinoma (HCC).

METHODS

A total of 1020 patients was included. The impacts of clinical variables and inflammation-based markers on disease-free survival (DFS) were measured by Kaplan-Meier method. Selected potential prognostic factors were further analyzed in multivariate model. To reduce influences of selection bias and possible confounders, clinical characteristics of patients were balanced by propensity score matching (PSM).

RESULTS

Of the 1020 patients, 881 (86.4%) were male and 323 (31.7%) received major hepatectomy. In multivariate analysis, cirrhosis (HR: 1.49), tumor size (HR: 1.32), tumor number (HR: 1.57), portal vein tumor thrombus (HR: 1.66), microvascular invasion (HR: 1.60), histological grade (HR: 1.82), operation time (HR: 1.50), alpha foetal protein (HR: 1.29), neutrophil to lymphocyte ratio (NLR) (HR: 1.38), and lymphocyte to monocyte ratio (LMR) (HR: 1.51) were independently predictive of DFS. After PSM, 258 and 213 pairs of patients were generated for LMR and NLR, respectively. LMR and NLR were still independent predictors of recurrence for HCC patients receiving hepatectomy.

CONCLUSION

Both LMR and NLR might be preferable independent prognostic factors for DFS in HCC patients undergoing hepatectomy.

From Clinical Standards to Translating Next-Generation Sequencing Research into Patient Care Improvement for Hepatobiliary and Pancreatic Cancers

Hepatobiliary and pancreatic (HBP) cancers are associated with high cancer-related death rates. Surgery aiming for complete tumor resection (R0) remains the cornerstone of the treatment for HBP cancers. The current progress in the adjuvant treatment is quite slow, with gemcitabine chemotherapy available only for pancreatic ductal adenocarcinoma (PDA). In the advanced and metastatic setting, only two targeted drugs have been approved by the Food & Drug Administration (FDA), which are sorafenib for hepatocellular carcinoma and erlotinib for PDA. It is a pity that multiple Phase III randomized control trials testing the efficacy of targeted agents have negative results. Failure in the development of effective drugs probably reflects the poor understanding of genome-wide alterations and molecular mechanisms orchestrating therapeutic resistance and recurrence. In the post-ENCODE (Encyclopedia of DNA Elements) era, cancer is referred to as a highly heterogeneous and systemic disease of the genome. The unprecedented potential of next-generation sequencing (NGS) technologies to accurately identify genetic and genomic variations has attracted major research and clinical interest. The applications of NGS include targeted NGS with potential clinical implications, while whole-exome and whole-genome sequencing focus on the discovery of both novel cancer driver genes and therapeutic targets. These advances dictate new designs for clinical trials to validate biomarkers and drugs. This review discusses the findings of available NGS studies on HBP cancers and the limitations of genome sequencing analysis to translate genome-based biomarkers and drugs into patient care in the clinic.

Should we routinely use DEBTACE for unresectable HCC? cTACE versus DEBTACE: a single-center survival analysis

Conventional trans-arterial chemoembolization (cTACE) for intermediate stage hepatocellular carcinoma (HCC) achieves a partial response in up to 72% of patients and improves median survival. Drug-eluting-beads-TACE (DEBTACE) improves treatment efficacy and tolerance as compared to cTACE. Our aim was to retrospectively evaluate our experience in the treatment of intermediate/advanced HCC with cTACE versus DEBTACE. Overall survival (OS) was the first endpoint. We retrospectively considered our department register data between 2006 and 2012. A total of 82 non-surgical patients, who underwent cTACE or DEBTACE, with a minimum of 12 months follow-up, met the inclusion criteria. Patients received a standard chemotherapy dose (50 mg). Radiological response was evaluated by CT after 30 days and re-treatment was considered. Statistical analysis was performed with SPSS software. 54 patients received cTACE and 28 DEBTACE. In the DEBTACE group the median survival times was 22.7 months (CI 11.6-33.8), while in the cTACE group it was 21.8 months (CI 15.7-27.9). The survival analysis at log-rank (p = 0.708) and Wilcoxon (p = 0.661) tests demonstrated no differences between DEBTACE and cTACE. The probability of death in function of time was significantly associated only to the Child-Pugh score. A Child A score was shown to be protective instead of Child B (OR 0.583; IC 95% = 0.344-0.987). DEBTACE for treating HCC is comparable to cTACE in terms of effectiveness, but seems to be better tolerated. Both treatments can be performed in case of tumor recurrence without substantial increase in procedural complications and risk of liver failure. We do confirm that there are no differences between the two techniques in terms of survival and that it is mainly affected by the reserved liver function proper of each patient.

Compensating effect of minor portal hypertension on the muscle mass loss-related poor prognosis in cirrhosis

Background: To examine the influence of the severity of portal hemodynamic abnormality on the prognosis of cirrhosis with respect to the muscle mass loss (MML). Methods: The study involved a subgroup analysis in 98 cirrhosis patients (63.5 ± 11.8 years) who prospectively underwent both Doppler ultrasound and hepatic venous catheterization. The prognostic influence of MML diagnosed by computed tomography using the L3 skeletal muscle index was evaluated (median observation period, 32.7 months). Results: The cumulative survival rate showed difference between patients with MML (n = 34; 82.2%/1year, 41.2%/3years and 36.1%/5years) and those without (n = 64; 92.1%/1year, 74.9%/3years and 69.4%/5years; P = 0.005). When divided with respect to the portal velocity, the survival rate showed differences between patients with and without MML in the cohort < 12.8 cm/s (n=52, p=0.009) and ≥ 12.8 cm/s (n=44, p=0.041). The survival rate also showed differences between patients with MML (n = 24; 78.8%/1year, 40.6%/3years and 34.8%/5years) and those without (n = 45; 91.1%/1year, 71.3%/3years and 63.1%/5years; P = 0.008) in the cohort with hepatic venous pressure gradient (HVPG) > 12 mmHg. However, in the cohort with HVPG ≤ 12 mmHg, survival rate showed no difference between patients with MML (n=10; 100%/1year, 61.9%/3years and 61.9%/5years) and those without (n=19; 93.8%/1year, 71.2%/3years and 59.4%/5years; p = 0.493) Conclusion: Lower HVPG has a compensating effect on the MML-induced poor prognosis of cirrhosis. Care should be taken in the evaluation of the influence of MML in consideration of the severity of portal hypertension.

Biomarker identification of hepatocellular carcinoma using a methodical literature mining strategy

Hepatocellular carcinoma (HCC), one of the most common causes of cancer-related deaths, carries a 5-year survival rate of 18%, underscoring the need for robust biomarkers. In spite of the increased availability of HCC related literatures, many of the promising biomarkers reported have not been validated for clinical use. To narrow down the wide range of possible biomarkers for further clinical validation, bioinformaticians need to sort them out using information provided in published works. Biomedical text mining is an automated way to obtain information of interest within the massive collection of biomedical knowledge, thus enabling extraction of data for biomarkers associated with certain diseases. This method can significantly reduce both the time and effort spent on studying important maladies such as liver diseases. Herein, we report a text mining-aided curation pipeline to identify potential biomarkers for liver cancer. The curation pipeline integrates PubMed E-Utilities to collect abstracts from PubMed and recognize several types of named entities by machine learning-based and pattern-based methods. Genes/proteins from evidential sentences were classified as candidate biomarkers using a convolutional neural network. Lastly, extracted biomarkers were ranked depending on several criteria, such as the frequency of keywords and articles and the journal impact factor, and then integrated into a meaningful list for bioinformaticians. Based on the developed pipeline, we constructed MarkerHub, which contains 2128 candidate biomarkers extracted from PubMed publications from 2008 to 2017. Database URL: http://markerhub.iis.sinica.edu.tw.

Ultrasound surveillance for hepatocellular carcinoma: service evaluation of a radiology-led recall system in a tertiary-referral centre for liver diseases in the UK

AIM

To review the radiology-led ultrasound (US) surveillance programme for the detection of hepatocellular carcinoma (HCC) in cirrhotic patients in a UK tertiary-referral centre.

MATERIALS AND METHODS

The radiology information system was searched for patients who had undergone US for surveillance of cirrhosis from September 2009 to May 2013. Patient demographics and cirrhosis aetiology were documented. Data including numbers of surveillance scans, abnormal findings suspicious for HCC, subsequent radiological investigations, numbers of HCC and survival for HCC patients were recorded. Service performance data, such as rates of attendance and rebooking, were also recorded.

RESULTS

Eight hundred and four patients entered surveillance and 2,366 surveillance US examinations were performed; 368 (46%) underwent follow-up (6-monthly US). Abnormalities leading to further radiological investigations were found in 81 patients. Reasons for incomplete surveillance included non-attendance and radiology failure to re-book appointments. HCC was diagnosed in 22 patients. Fourteen had HCC diagnosed on a surveillance scan, eight had HCC diagnosed on a scan performed for other reasons. Patients diagnosed with HCC on a surveillance scan were more likely to be treated with curative intent and had longer survival.

CONCLUSION

Even with a radiology-led recall service for HCC surveillance, the proportion of patients receiving scans 6-monthly was low, due in part to the lack of organisational support that is available for other screening programmes. This study gives a realistic representation of the implementation of surveillance in a UK hospital at the current time and of the rates of HCC proceeding to treatment.

Dynamic change of the systemic immune inflammation index predicts the prognosis of patients with hepatocellular carcinoma after curative resection

BACKGROUND

The aim of the study was to determine the utility of the dynamic change and serial monitoring of the systemic immune inflammation index (SII), which was based on the numbers of patients' lymphocytes (L), platelets (P), neutrophils (N) and defined as P*N/L, for predicting prognosis of patients with hepatocellular carcinoma (HCC) after curative resection.

METHODS

We conducted a prospective study of 163 patients with HCC who underwent curative resection at Zhongshan Hospital from January 2012 to May 2013. SII was calculated using data acquired before and approximately 1 month after surgery. An optimal cutoff value stratified patients into groups with high or low SII. Patients were classified into unfavorable and favorable groups using the dynamic change of the SII. Two groups that were further divided into four categories within the entire cohort and the low-risk subgroups were serially monitored for ≥6 months. Prognostic values of the SII and other factors were determined using the Kaplan-Meier method, the Cox proportional hazards model, and the receiver operating characteristics (ROC) curve.

RESULTS

The favorable group was likely to have cirrhosis, and the unfavorable group was likely to have larger tumors and a higher recurrence rate. Multivariate analysis revealed that tumor size and dynamic change of the SII were independent risk factors for early recurrence. Moreover, the predictive value of the SII was retained in α-fetoprotein (AFP)-negative and HBeAg-negative-HBV-DNA <2000 IU/mL subgroups. Further, the serial changes of the SII for recurrence and no recurrence groups were statistically significant.

CONCLUSIONS

The dynamic change and serial monitoring of the SII represent new indicators for predicting the early recurrence of HCC determining advance optimal therapy in advance.

"Hepatocellular carcinoma: A life-threatening disease"

An estimated rise in liver cancer incidence will increase to 95374 new cases by 2020. Hepatocellular Carcinoma (HCC), the most common primary malignant tumour of the liver, is considered to be the third leading cause of all cancer-related deaths and fifth common cancer worldwide. The reported data shows that the rate of HCC incidence in male population is three to four times higher compared with the female population. In the United States, HCV-induced liver cancer is increasing very fast because of the lack of proper treatment option. There are various treatment strategies available for HCC like liver transplantation, resection, ablation, embolization and chemotherapy still the prognosis is destitute. If the patient is eligible, liver transplantation is the only therapeutic option that may give around 90% survival rate, but the scarcity of liver donor limits its broad applicability. A sudden address is necessary to develop specific drugs, personalized medicine, for HCC.

Hepatic resection versus transarterial chemoembolization for patients with Barcelona Clinic Liver Cancer intermediate stage Child-Pugh A hepatocellular carcinoma

The present study aimed to compare the overall and recurrence-free survival rates following hepatic resection (HR) and transcatheter arterial chemoembolization (TACE) in patients with Barcelona Clinic Liver Cancer (BCLC) classified intermediate-stage Child-Pugh A hepatocellular carcinoma (HCC). A total of 443 patients were examined, among whom 274 underwent HR, whereas 169 received TACE. The overall survival, recurrence-free survival between groups and subgroups, and risk factors with respect to mortality and recurrence, were analyzed. The 1-, 3- and 5-year overall and recurrence-free survival rates were 70, 46 and 37% and 73, 52, and 37%, respectively after HR, compared with 38, 15, and 12% and 44, 25 and 16%, respectively after TACE. Overall and recurrence-free survival rates were significantly increased following HR compared with TACE. Subgroup analysis in the multi-nodule group showed that the 1-, 3- and 5-year overall survival rates were 68, 38 and 30% after HR, compared with 36, 10 and 0% following TACE. In the solitary tumor group, 1-, 3- and 5-year overall survival rates were 71, 50 and 38% after HR, and 41, 22 and 15% after TACE. The overall survival rate after HR was significantly increased compared with that after TACE in the solitary tumor and multi-nodule groups. The risk factors for mortality include solitary tumor diameter >10 cm, multi-nodules, serum albumin level ≥35 g/l, prothrombin time >13 sec, alphafetoprotein levels >400 ng/ml, and patients with hepatitis B virus. Solitary tumor diameter >10 cm, multi-nodules, and hepatitis B virus (P<0.001) were found to be associated with higher recurrence of HCC. Overall and recurrence-free survival rates were improved after HR compared with those after TACE in BCLC stage B, Child-Pugh A, HCC patients.

Targeting Hepatocellular Carcinoma: What did we Discover so Far?

Hepatocellular carcinoma (HCC) is increasingly considered an issue of global importance. Its rates of incidence and mortality have been markedly increasing over the last decades. Among risk factors, some should be highlighted, namely the infections by hepatitis B and C virus, as well as clinical cases of cirrhosis. HCC is characterized as asymptomatic disease in the initial stages which most often leads to a late diagnosis. At molecular and genetic level HCC represents a highly complex tumor entity, including a wide variety of mutations, thus accounting for different mechanisms of resistance towards therapeutic approaches. In particular, mutations of the TP53 gene, as well as a deregulation between the expression of pro- and anti-apoptotic proteins of the BCL-2 family are observed. Regarding treatment modalities, surgical procedures offer the best chance of cure, however, due to a late diagnosis, most of concerned patients cannot be subjected to them. Chemotherapy and radiotherapy are also ineffective, and currently, the treatment with sorafenib is the most commonly used systemic therapy although it can only increase the patient survival for some months. In this sense, a quick and accurate investigation is of utmost importance in order to develop ways of early diagnosis as well as new therapies for HCC.

Downregulated expression of DIXDC1 in hepatocellular carcinoma and its correlation with prognosis

Dishevelled-Axin domain containing 1 (DIXDC1) is a DIX (Dishevelled-Axin) domain possessing protein that acts as a positive regulator of the Wnt pathway. Although DIXDC1 has been investigated in several cancers, it has not yet been studied in human hepatocellular carcinoma (HCC). The purpose of the current study was to investigate the expression pattern of DIXDC1 and assess the clinical significance of DIXDC1 expression in HCC patients. Data containing three independent investigations from Oncomine database demonstrated that DIXDC1 mRNA was downregulated in HCC compared with matched non-cancerous tissues. Similar results were also obtained in 25 paired HCC tissues and corresponding non-cancerous tissues by qPCR and Western blot analysis. Additionally, another independent set of 140 pairs of HCC specimens was evaluated for DIXDC1 expression by IHC and demonstrated that reduced expression of DIXDC1 in 50.7 % (71/140) of HCC tissues was significantly correlated with tumor size (p = 0.024), tumor differentiation (p < 0.001), tumor thrombi (p = 0.019), TNM stage (p = 0.019), and BCLC stage (p = 0.008). Importantly, Kaplan-Meier survival and Cox regression analyses were executed to evaluate the prognosis of HCC patients and found that DIXDC1 protein expression was one of the independent prognostic factors for overall survival of HCC patients.

Nomogram of the Barcelona Clinic Liver Cancer system for individual prognostic prediction in hepatocellular carcinoma

BACKGROUND & AIMS

The predictive accuracy of the Barcelona Clinic Liver Cancer (BCLC) staging system on a single patient is not clear. This study aimed to develop a nomogram to predict individualized survival of patients with hepatocellular carcinoma (HCC) based on the BCLC system.

METHODS

A total of 3179 patients were randomly grouped into derivation (n = 2119) and validation (n = 1060) sets. The multivariate Cox proportional hazards model was used to generate the nomogram from tumour burden, cirrhosis and performance status (PS). The performance of the nomogram was evaluated by concordance indices and calibration tests.

RESULTS

Beta coefficients from the Cox model were used to assign nomogram points to different degrees of tumour burden, Child-Turcotte-Pugh classification and PS. A nomogram with a scale of 0-26 was developed and the predicted survival rates at 3 and 5 years were calculated. The derivation set had a concordance index of 0.766 (95% confidence interval [CI]: 0.686-0.838); and the validation set showed a concordance index of 0.775 (95% CI: 0.607-0.909). The calibration plots were close to the 45-degree line for 3- and 5-year survival prediction of BCLC stages 0-C patients in both derivation and validation groups. For BCLC stage D patients, calibration plots in both groups showed deviation from the 45-degree line for 3- and 5-year prediction.

CONCLUSIONS

This study provides quantitative evidence to support the prognostic ability of BCLC system. This straightforward and easy-to-use nomogram may accurately predict the survival at 3 and 5 years for individual HCC patient except for BCLC stage D patients.

Sequential Use of Transhepatic Arterial Chemoembolization and Bipolar Radiofrequency Ablation in the Clinical Therapy of Hepatocellular Carcinoma

This retrospective study investigated the clinical application of sequential therapy with transarterial chemoembolization (TACE) and CT-guided radiofrequency ablation (RFA) using a bipolar needle in treating hepatocellular carcinoma (HCC) tumors of different sizes. The study included patients (N = 46) with HCC from Shengjing Hospital of China Medical University who had received TACE and RFA from November 2012 to November 2013. Eligible patients had an Eastern Cooperative Oncology Group (ECOG) score of 0-1, a Child-Pugh grade of A-B, and no contradictions for TACE and/or RFA. Fifty one hepatic lesions of varying sizes were treated with TACE followed by RFA. Clinical response and 1- and 2-year survival rates were assessed. The frequency of complete and incomplete ablation following therapy was significantly different across the varying RFA pin numbers and the maximum diameter of the lesion (p ≤ 0.001). A greater percentage (97.3%) of lesions that were ≤3 cm in diameter were completely ablated compared with lesions that were 3-5 cm (88.9%) and >5 cm in diameter (20%). The median survival time of patients was 16.5 months, and the 1- and 2-year survival rates were 95.7% and 69.3%, respectively. There were only a limited number of complications, all of which were minor. These included hemothorax (4.3%), abdominal hemorrhage (10.9%), and abdominal hemorrhage with minor pneumothorax (2.2%). This study found that the sequential treatment with TACE and CT-guided RFA using a bipolar needle is effective and well tolerated in patients with HCC and that the effectiveness of treatment is dependent on tumor size.

3D Quantitative tumour burden analysis in patients with hepatocellular carcinoma before TACE: comparing single-lesion vs. multi-lesion imaging biomarkers as predictors of patient survival

OBJECTIVES

To compare the ability of single- vs. multi-lesion assessment on baseline MRI using 1D- and 3D-based measurements to predict overall survival (OS) in patients with hepatocellular carcinoma (HCC) before transarterial chemoembolization (TACE).

METHODS

This retrospective analysis included 122 patients. A quantitative 3D analysis was performed on baseline MRI to calculate enhancing tumour volume (ETV [cm(3)]) and enhancing tumour burden (ETB [%]) (ratio between ETV [cm(3)] and liver volume). Furthermore, enhancing and overall tumour diameters were measured. Patients were stratified into two groups using thresholds derived from the BCLC staging system. Statistical analysis included Kaplan-Meier plots, uni- and multivariate cox proportional hazard ratios (HR) and concordances.

RESULTS

All methods achieved good separation of the survival curves (p < 0.05). Multivariate analysis showed an HR of 5.2 (95 % CI 3.1-8.8, p < 0.001) for ETV [cm(3)] and HR 6.6 (95 % CI 3.7-11.5, p < 0.001) for ETB [%] vs. HR 2.6 (95 % CI 1.2-5.6, p = 0.012) for overall diameter and HR 3.0 (95 % CI 1.5-6.3, p = 0.003) for enhancing diameter. Concordances were highest for ETB [%], with no added predictive power for multi-lesion assessment (difference between concordances not significant).

CONCLUSION

3D quantitative assessment is a stronger predictor of survival as compared to diameter-based measurements. Assessing multiple lesions provides no substantial improvement in predicting OS than evaluating the dominant lesion alone.

KEY POINTS

• 3D quantitative tumour assessment on baseline MRI predicts survival in HCC patients. • 3D quantitative tumour assessment predicts survival better than any current radiological method. • Multiple lesion assessment provides no improvement than evaluating the dominant lesion alone. • Measuring enhancing tumour volume in proportion to liver volume reflects tumour burden.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Iodine-125 implantation plus transarterial chemoembolization for the treatment of hepatocellular carcinoma of 3-5cm: A propensity score matching study

BACKGROUND

Both iodine-125 implantation and transarterial chemoembolization (TACE) are feasible options for hepatocellular carcinoma (HCC). The aim of the research is to investigate whether iodine-125 implantation combined with TACE could improve the overall survival of patients with HCC of 3-5cm.

METHODS

144 patients with HCC of 3-5cm who underwent iodine-125 implantation plus TACE and TACE alone were retrospectively enrolled in this study. To reduce the selection bias, 55 matched pairs of patients were generated by propensity score matching (PSM). Their overall survival was compared by the Kaplan-Meier method. Independent prognostic factors were identified by Cox proportional hazards regression model.

RESULTS

patients receiving iodine-125 implantation plus TACE have significantly better overall survival than patients receiving TACE alone (P<0.001). After PSM, treatment of iodine-125 plus TACE still provide better survival (1-year, 89.1% vs. 65.5%; 3-year, 51.0% vs. 7.4%; P<0.001). In multivariate analysis, BCLC stage, vascular invasion and treatment modality independently predicted the prognosis. No severe adverse events occurred in both groups.

CONCLUSION

for HCC patients of 3-5cm for whom surgical intervention is not an option, iodine-125 implantation combined with TACE might be an effective and viable alternative to provide better overall survival.

Systemic treatment of hepatocellular carcinoma: why so many failures in the development of new drugs?

INTRODUCTION

The increasing knowledge of the genomic landscape of hepatocellular carcinoma (HCC) and the development of molecular targeted therapies are a promising background for increasing the number of effective drugs for HCC patients. In recent years, many new drugs have been tested as an alternative to sorafenib or after sorafenib failure.

AREAS COVERED

In this review, our aim is to describe the randomized trials recently conducted in HCC patients, in order to understand the main reasons potentially related to the failures of many drugs. In addition, we briefly describe the main ongoing trials, that could potentially change the scenario of HCC treatment in the next years. Expert commentary: Heterogeneity of study populations, lack of understanding of critical drivers of tumor progression, risk of liver toxicity associated with experimental agents, flaws in trial design and marginal antitumoral potency can be considered the main reasons for failure of phase III clinical trials in HCC. Most ongoing trials are conducted without any molecular selection criteria, although many drugs could be probably better tested in a molecularly selected population. The knowledge of potential predictive factors for drug efficacy in patients with advanced HCC could improve the chance of obtaining positive results in clinical trials.

Impact of portal hemodynamics on Doppler ultrasonography for predicting decompensation and long-term outcomes in patients with cirrhosis

OBJECTIVE

Significance of portal hemodynamics for non-invasive marker of cirrhosis remains unclear. The aim was to determine the value of portal hemodynamics on Doppler ultrasound for predicting decompensation and prognosis in cirrhosis.

METHODS

This retrospective study comprised 236 cirrhotic patients (132 males, 104 females; age 63.7 ± 11.3 years; 110 compensated, 126 decompensated). Clinical data, including Doppler findings, were analyzed with respect to decompensation and prognosis. The median follow-up period was 33.2 months (0.1-95.4).

RESULTS

Fifty-three patients developed clinical decompensation, 13 patients received liver transplantation, and 71 died. Higher model for end-stage liver disease score (p < 0.001) at baseline was the significant factor for the presence of decompensation. Higher alanine transaminase (p = 0.020), lower albumin (p = 0.002) and lower mean velocity in the portal trunk (p = 0.038) were significant factors for developing decompensation (best cut-off value: Alanine transaminase > 31 IU/L, albumin < 3.6 g/dL, and portal trunk < 12.8 cm/s). The cumulative incidence of decompensation was higher in patients with portal trunk < 12.8 cm/s (22.5% at 1 year, 71.2% at 5 years) than those without (6.9% at 1 year, 35.4% at 5 years; p < 0.001). The significant prognostic factors were hepatocellular carcinoma (p = 0.036) and lower albumin (p = 0.008) for compensated patients, and reversed portal flow (p = 0.028), overt ascites (p < 0.001), and higher bilirubin (p < 0.001) for decompensated patients.

CONCLUSION

Portal hemodynamics offer a non-invasive marker for decompensation and prognosis of cirrhosis, suggesting a future direction for practical management.

Global profiling of alternative RNA splicing events provides insights into molecular differences between various types of hepatocellular carcinoma

Background

Dysregulations in alternative splicing (AS) patterns have been associated with many human diseases including cancer. In the present study, alterations to the global RNA splicing landscape of cellular genes were investigated in a large-scale screen from 377 liver tissue samples using high-throughput RNA sequencing data.

Results

Our study identifies modifications in the AS patterns of transcripts encoded by more than 2500 genes such as tumor suppressor genes, transcription factors, and kinases. These findings provide insights into the molecular differences between various types of hepatocellular carcinoma (HCC). Our analysis allowed the identification of 761 unique transcripts for which AS is misregulated in HBV-associated HCC, while 68 are unique to HCV-associated HCC, 54 to HBV&HCV-associated HCC, and 299 to virus-free HCC. Moreover, we demonstrate that the expression pattern of the RNA splicing factor hnRNPC in HCC tissues significantly correlates with patient survival. We also show that the expression of the HBx protein from HBV leads to modifications in the AS profiles of cellular genes. Finally, using RNA interference and a reverse transcription-PCR screening platform, we examined the implications of cellular proteins involved in the splicing of transcripts involved in apoptosis and demonstrate the potential contribution of these proteins in AS control.

Conclusions

This study provides the first comprehensive portrait of global changes in the RNA splicing signatures that occur in hepatocellular carcinoma. Moreover, these data allowed us to identify unique signatures of genes for which AS is misregulated in the different types of HCC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-016-3029-z) contains supplementary material, which is available to authorized users.

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

Background

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

Methods

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

Results

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

Conclusions

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

Characterization of Portal Vein Thrombosis (Neoplastic Versus Bland) on CT Images Using Software-Based Texture Analysis and Thrombus Density (Hounsfield Units)

OBJECTIVE

The purpose of this study was to investigate the role of CT texture analysis and thrombus density (measured in Hounsfield units) in distinguishing between neoplastic and bland portal vein thrombosis (PVT) on portal venous phase CT.

MATERIALS AND METHODS

In this retrospective study, 117 contrast-enhanced CT studies of 109 patients were included for characterization of PVT. Assessment of PVT was performed by estimation of CT textural features using CT texture analysis software and measurement of attenuation values. For CT texture analysis, filtered and unfiltered images were assessed to quantify heterogeneity using a set of predefined histogram-based texture parameters. The Mann-Whitney U test and binary logistic regression were applied for statistical significance. ROC curves were used to identify accuracy and optimal cutoff values.

RESULTS

Of the 117 CT studies, 63 neoplastic thrombi and 54 bland thrombi were identified on the images. The two most discriminative CT texture analysis parameters to differentiate neoplastic from bland thrombus were mean value of positive pixels (without filtration, p < 0.001) and entropy (with fine filtration, p < 0.001). Mean thrombus density values could also reliably distinguish neoplastic (81.39 HU) and bland (32.88 HU) thrombi (p < 0.001). The AUCs were 0.97 for mean value of positive pixels (p < 0.001), 0.93 for entropy (p < 0.001), 0.99 for the model combining mean value of positive pixels and entropy (p < 0.001), 0.91 for thrombus density (p < 0.001), and 0.61 for the radiologist's subjective evaluation (p = 0.037). The optimal cutoffs values were 56.9 for mean value of positive pixels, 4.50 for entropy, and 54.0 HU for thrombus density.

CONCLUSION

CT texture analysis and CT attenuation values allow reliable differentiation between neoplastic and bland thrombi on a single portal venous phase CT examination.

Comparison of Two Types of Liquid Biopsies in Patients With Hepatocellular Carcinoma Awaiting Orthotopic Liver Transplantation

INTRODUCTION

Orthotopic liver transplantation (OLT) is considered one of the few curative treatments available for early stages of hepatocellular carcinoma (HCC). It has been shown that more than 10% of transplanted individuals suffer relapse during the first year after surgery and most of them die because of the tumor. The circulating tumor cells (CTCs) are the main source of recurrences as they disseminate from a primary or metastatic tumor lesion through peripheral blood. We aimed to determine the concentration of CTCs in peripheral blood in these patients by 2 different approaches: the CellSearch and the IsoFlux systems to assess their applicability to this disease monitoring.

PATIENTS AND METHODS

A comparative study was conducted in 21 patients with HCC eligible for liver transplantation according to the Milan criteria, whose peripheral blood was processed by the CellSearch and the IsoFlux systems.

RESULTS

CTCs were isolated in 1 of the 21 patients (4.7%) by the CellSearch system and in 19 of the 21 patients (90.5%) by the IsoFlux method. The comparison of both methods using Bland-Altman plot shows that there is not consistency in the determination of CTCs in our patients, finding a proportional bias between them.

CONCLUSION

The results obtained by both CTCs isolation systems are not interchangeable nor transferable. The CellSearch system does not seem to be the ideal approach for studying CTCs in patients with HCC. The IsoFlux system displays greater sensitivity in the identification of CTCs and might become an important tool in patient management.

Efficacy and Safety of a Steroid-Free Immunosuppressive Regimen after Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND/AIMS

We aimed to evaluate the efficacy and safety of an immunosuppressive regimen without steroids after liver transplantation (LT) for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC).

METHODS

Sixty-six HCC patients who underwent an immunosuppressive regimen without steroids after LT were enrolled in the steroid-free group. The preoperative characteristics and postoperative outcomes of these patients were compared with those of 132 HCC recipients who were placed on an immunosuppressive regimen using steroids (steroid group). The incidence of acute rejection, HBV recurrence, infection, and new-onset diabetes mellitus and the overall and tumor-free survival rates were compared between the two groups.

RESULTS

Differences were not observed in the 1-year (83.3% vs 97.0%, p=0.067), 3-year (65.4% vs 75.8%, p=0.067) or 5-year (56.3% vs 70.7%, p=0.067) patient survival rates or in the 1-year (62.1% vs 72.7%, p=0.067), 3-year (49.8% vs 63.6%, p=0.067) or 5-year (48.6% vs 63.6%, p=0.067) tumor-free survival rates between the two groups, respectively. In the steroid-free group, the patients who fulfilled the Milan criteria had higher overall and tumor-free survival rates than those in the steroid group (p<0.001). The prevalence of HBV recurrence (3.0% vs 13.6%, p=0.02) was significantly lower in the steroid-free group compared with the steroid group.

CONCLUSIONS

After LT, an immunosuppressive regimen without steroids could be a safe and feasible treatment for HBVrelated HCC patients, thus resulting in the reduction of HBV recurrence. Based on the observed survival rates, patients who fulfill the Milan criteria may derive benefits from teroidfree immunosuppression.

Current status and future prospects of chemotherapy for advanced hepatocellular carcinoma

Sorafenib is the only drug that demonstrates a survival benefit for advanced hepatocellular carcinoma (HCC). However, the therapeutic effect of sorafenib is limited, so development of a more effective treatment method and second-line treatments is needed. Since the advent of sorafenib, clinical studies have been conducted with a variety of drugs and treatment methods, mainly with molecular targeted therapy, but almost all trials have ended in failure. The reasons for the difficulty in the development of a novel drug or treatment method include the diversity of mechanisms in the carcinogenesis and development of HCC, as well as the presence of background liver diseases such as chronic hepatitis and cirrhosis. Trials with immune-checkpoint inhibitors, which have an entirely different anti-tumor mechanism from that of molecular targeted drugs or cytotoxic drugs, have recently begun. Based on the results to date, clinical trials are now being conducted with enriched target subjects. In the future, providing more individualized treatment approaches for patients with advanced HCC will be essential.

Proposed New Sub-Grouping for Intermediate-Stage Hepatocellular Carcinoma Using Albumin-Bilirubin Grade

AIM

We retrospectively evaluated the efficacy of albumin-bilirubin (ALBI) grade, which has been proposed as a new classification for hepatic function, for evaluation of the prognosis of intermediate-stage hepatocellular carcinoma (Barcelona Clinic Liver Cancer criteria stage B, BCLC-B).

PATIENTS AND METHODS

We enrolled 754 naïve BCLC-B patients (multiple tumors) and retrospectively analyzed their clinical features [surgical resection (hepatectomy), n = 170; radiofrequency ablation (RFA), n = 110; percutaneous ethanol injection, n = 7; transcatheter arterial chemoembolization, n = 396; others, n = 25; best supportive care, n = 46]. Four sub-groups were defined for the Modified Intermediate Stage of Liver Cancer (MICAN) criteria as follows: B1 (ALBI-1/within up-to-7 criteria), B2 (ALBI-2/within up-to-7 criteria), B3 (ALBI-1 and ALBI-2/multiple and beyond up-to-7 criteria), and B4 (ALBI-3/any).

RESULTS

The median survival time of patients classified as B1 (n = 94), B2 (n = 175), B3 (n = 452), and B4 (n = 33) was 65.1, 48.1, 29.6, and 14.6 months, respectively (p < 0.01 for each). Those in B1 treated with hepatectomy and RFA comprised 67.0%, while that ratio was 51.4% in B2, 28.3% in B3, and 12.1% in B4.

CONCLUSION

The MICAN criteria based on ALBI grade are simple and useful for prediction of prognosis and therapy decision-making in the heterogeneous population of BCLC-B patients.

Preoperative γ-glutamyl transpeptidase to platelet ratio (GPR) is an independent prognostic factor for HBV-related hepatocellular carcinoma after curative hepatic resection

Liver fibrosis and cirrhosis is associated with the prognosis of patients with hepatocellular carcinoma (HCC) after treatment. The γ-glutamyl transpeptidase to platelet ratio (GPR) is reported to predict significant liver fibrosis and cirrhosis. The aim of this study was to investigate the predictive value of preoperative GPR on the recurrence and survival of patients with HCC who underwent curative hepatectomy.A retrospective review of demographics, medical records, and prognosis of patients with hepatitis B virus (HBV)-related HCC was performed. Overall survival (OS) and disease-free survival (DFS) were evaluated using Kaplan-Meier method, and the log-rank test was used to analyze differences in recurrence and survival. Univariate and multivariate analyses were used for significance of prognostic factor.A total of 357 patients with HBV-related HCC were included in this analysis. The preoperative GPR was associated with recurrence and survival rates, independent of HCC progression or tumor marker levels, in a multivariate analysis. OS was higher in patients with a GPR <0.84 versus ≥084 (5-year survival rates 58.6% vs. 38.5%; P < 0.001). DFS was also worse in patients with a GPR ≥0.84 than in those with GPR <0.84 (5-year recurrence rates 42.8% vs. 22.8%; P < 0.001).GPR score of ≥0.84 represents a major risk factor for the poor prognosis for HBV-related HCC after hepatic resection, and GPR served as an independent predictive factor for HBV-related HCC OS.

SW43-DOX ± loading onto drug-eluting bead, a potential new targeted drug delivery platform for systemic and locoregional cancer treatment - An in vitro evaluation

Treatment of unresectable primary cancer and their distant metastases, with the liver representing one of the most frequent location, is still plagued by insufficient treatment success and poor survival rates. The Sigma-2 receptor is preferentially expressed on many tumor cells making it an appealing target for therapy. Thus, we developed a potential targeted drug conjugate consisting of the Sigma-2 receptor ligand SW43 and Doxorubicin (SW43-DOX) for systemic cancer therapy and for locoregional treatment of primary and secondary liver malignancies when loaded onto drug-eluting bead (DEB) which was compared in vitro to the treatment with Doxorubicin alone. SW43-DOX binds specifically to the Sigma-2 receptor expressed on hepatocellular (Hep G2, Hep 3B), pancreatic (Panc-1) and colorectal (HT-29) carcinoma cell lines with high affinity and subsequent early specific internalization. Free SW43-DOX showed superior concentration and time depended cancer toxicity than treatment with Doxorubicin alone. Action mechanisms analysis revealed an apoptotic cell death with increased caspase 3/7 activation and reactive oxygen species (ROS) production. Only ROS scavenging with α-Tocopherol, but not the caspase inhibition (Z-VAD-FMK), partly reverted the effect. SW43-DOX could successfully be loaded onto DEB and showed prolonged eluting kinetics compared to Doxorubicin. SW43-DOX loaded DEB vs. Doxorubicin loaded DEB showed a significantly greater time dependent toxicity in all cell lines. In conclusion, the novel conjugate SW43-DOX ± loading onto DEB is a promising drug delivery platform for targeted systemic and locoregional cancer therapy.

Solitary Large Hepatocellular Carcinoma: Staging and Treatment Strategy

BACKGROUND & AIMS

Controversies exist on staging and management of solitary large (>5 cm) hepatocellular carcinoma (HCC). This study aims to evaluate the impact of tumor size on Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy.

METHODS

BCLC stage A and B patients were included and re-classified as single tumor 2-5 cm or up to 3 tumors ≤3 cm (group A; n = 657), single tumor >5 cm (group SL; n = 224), and multiple tumors >3 cm (group B; n = 351). Alternatively, 240 and 229 patients with solitary large HCC regardless of tumor stage received surgical resection (SR) and transarterial chemoembolization (TACE), respectively. The propensity score analysis identified 156 pairs of patients from each treatment arm for survival comparison.

RESULTS

The survival was significantly higher for group A but was comparable between group SL and group B patients. Of patients with solitary large HCC, the 1-, 3- and 5-year survival rates were 88% versus 74%, 76% versus 44%, and 63% versus 35% between SR and TACE group, respectively (p<0.001). When baseline demographics were adjusted in the propensity model, the respective 1-, 3- and 5-year survival rates were 87% versus 79%, 76% versus 46%, and 61% versus 36% (p<0.001). The Cox proportional hazards model identified TACE with a 2.765-fold increased risk of mortality compared with SR (95% confidence interval: 1.853-4.127, p<0.001).

CONCLUSIONS

Patients with solitary large HCC should be classified at least as intermediate stage HCC. SR provides significantly better survival than TACE for solitary large HCC regardless of tumor stage. Further amendment to the BCLC classification is mandatory.

Transcatheter intra-arterial infusion of doxorubicin loaded porous magnetic nano-clusters with iodinated oil for the treatment of liver cancer

A promising strategy for liver cancer treatment is to deliver chemotherapeutic agents with multifunctional carriers into the tumor tissue via intra-arterial (IA) transcatheter infusion. These carriers should release drugs within the target tissue for prolonged periods and permit intra-procedural multi-modal imaging of selective tumor delivery. This targeted transcatheter delivery approach is enabled via the arterial blood supply to liver tumors and utilized in current clinical practice which is called chemoembolization or radioembolization. During our study, we developed Doxorubicin (Dox) loaded porous magnetic nano-clusters (Dox-pMNCs). The porous structure and carboxylic groups on the MNCs achieved high-drug loading efficiency and sustained drug release, along with magnetic properties resulting in high MRI T2-weighted image contrast. Dox-pMNC within iodinated oil, Dox-pMNCs, and Dox within iodinated oil were infused via hepatic arteries to target liver tumors in a rabbit model. MRI and histological evaluations revealed that the long-term drug release and retention of Dox-pMNCs within iodinated oil induced significantly enhanced liver cancer cell death.

Early detection of hepatocellular carcinoma co-occurring with hepatitis C virus infection: A mathematical model

AIM: To develop a mathematical model for the early detection of hepatocellular carcinoma (HCC) with a panel of serum proteins in combination with α-fetoprotein (AFP).

METHODS: Serum levels of interleukin (IL)-8, soluble intercellular adhesion molecule-1 (sICAM-1), soluble tumor necrosis factor receptor II (sTNF-RII), proteasome, and β-catenin were measured in 479 subjects categorized into four groups: (1) HCC concurrent with hepatitis C virus (HCV) infection (n = 192); (2) HCV related liver cirrhosis (LC) (n = 96); (3) Chronic hepatitis C (CHC) (n = 96); and (4) Healthy controls (n = 95). The R package and different modules for binary and multi-class classifiers based on generalized linear models were used to model the data. Predictive power was used to evaluate the performance of the model. Receiver operating characteristic curve analysis over pairs of groups was used to identify the best cutoffs differentiating the different groups.

RESULTS: We revealed mathematical models, based on a binary classifier, made up of a unique panel of serum proteins that improved the individual performance of AFP in discriminating HCC patients from patients with chronic liver disease either with or without cirrhosis. We discriminated the HCC group from the cirrhotic liver group using a mathematical model (-11.3 + 7.38 × Prot + 0.00108 × sICAM + 0.2574 ×β-catenin + 0.01597 × AFP) with a cutoff of 0.6552, which achieved 98.8% specificity and 89.1% sensitivity. For the discrimination of the HCC group from the CHC group, we used a mathematical model [-10.40 + 1.416 × proteasome + 0.002024 × IL + 0.004096 × sICAM-1 + (4.251 × 10^-4) × sTNF + 0.02567 ×β-catenin + 0.02442 × AFP] with a cutoff 0.744 and achieved 96.8% specificity and 89.7% sensitivity. Additionally, we derived an algorithm, based on a binary classifier, for resolving the multi-class classification problem by using three successive mathematical model predictions of liver disease status.

CONCLUSION: Our proposed mathematical model may be a useful method for the early detection of different statuses of liver disease co-occurring with HCV infection.

Combined measurements of tumor number and size helps estimate the outcome of resection of Barcelona clinic liver cancer stage B hepatocellular carcinoma

Background

Although the Barcelona Clinic Liver Cancer (BCLC) staging system suggests that patients with stage B hepatocellular carcinoma (HCC) should be treated with transcatheter arterial chemoembolization instead of surgical treatment, recent studies indicated that the prognosis of surgical resection for patients with BCLC stage B HCC was better than that of TACE. However, the portion of patients with stage B that will achieve better outcomes from surgical treatment remains unclear. In this study, we identified risk factors that influence the prognosis of BCLC stage B HCC after R0 surgical resection to determine whether some patients with stage B HCC may benefit more from R0 resection than other patients and to provide a guideline to estimate the tendency.

Methods

The clinical data of 78 patients with BCLC stage B HCC after R0 surgical treatment within 11 years were analyzed retrospectively, using relapse or death as the endpoint. Kaplan-Meier survival and Cox regression analyses were used to study prognosis (disease-free survival, DFS and overall survival, OS) and independent risk factors.

Results

For all stage B patients, 1-, 2-, and 5-year DFS rates were 62.5, 36.4, and 16.6 %, respectively. Cumulative tumor size >5.0 cm and tumor number ≥4 were independent prognostic risk factors for DFS. The 1-, 2-, and 5- year DFS rates and OS rates of patients with at least one of these two factors were 49.0, 17.2, and 7.4 % (for DFS), and 78.6, 54.8, and 13.4 % (for OS), respectively, which were significantly lower than patients without these two factors (77.8, 58.3, and 27.2 % for DFS, and 94.4, 83.3,and 51.8 % for OS, respectively, P < 0.01).

Conclusions

The analyses indicated that the outcomes of R0 resection were much better for patients with BCLC stage B HCC with two or three tumors and cumulative tumor sizes of ≤5.0 but >3.0 cm than other patients with stage B.

Cancer of the Liver Italian Program score helps identify potential candidates for transarterial chemoembolization in patients with Barcelona Clinic Liver Cancer stage C

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging system for hepatocellular carcinoma (HCC) recommends transarterial chemoembolization (TACE) as the first line therapy for stage B patients and sorafenib treatment for stage C patients. However, stage C patients exhibit variations in terms of tumor burden, liver function, and extrahepatic metastasis, which could potentially affect disease outcome. Here, we assessed whether the Cancer of the Liver Italian Program (CLIP) scores can help identify stage C patients likely to benefit from TACE.

METHODS

Out of 295 BCLC stage C HCC patients enrolled between January 2009 and December 2011, those with platelet counts >30 X 10(9) cells/L, total bilirubin <51 μmoL/L, and an unobstructed main portal vein were scheduled for TACE (n=195). The remaining patients received best supportive care (BSC, n=100). All the patients were followed up for symptoms, performance status, and Child-Pugh classification scores every 4 weeks until death or December 2013. The prognosis of each group was evaluated by using the log-rank test and Cox-Mantel test.

RESULTS

The median overall survival (OS) was 6 months [95% confidence interval (CI): 4.64-7.36]. The OS was 9 months for the TACE group and 4 months for the BSC group. The TACE group had a longer OS than the BSC subgroup for CLIP scores 0-2 [13 months (95% CI: 8.55-17.45) vs 4 months (95% CI: 0.00-10.96), P=0.001]. No significant differences were found between the TACE and BSC groups for CLIP scores 3-5. The CLIP score and treatment methods were found to be independent prognostic factors.

CONCLUSIONS

BCLC stage C HCC patients exhibit definite disease heterogeneity and can be reclassified by using the CLIP scoring system. Moreover, patients with CLIP scores 0-2 are likely to benefit from TACE. However, additional studies with long-term follow-up will be required to validate these findings.

Subclassification of patients with solitary hepatocellular carcinoma based on post-hepatectomy survival: a large retrospective study

Official guidelines group together all cases of solitary hepatocellular carcinoma (HCC) without macroscopic vascular invasion, regardless of tumor size. Here, we examined whether this is justified based on overall survival (OS) after hepatic resection (HR). Patients with newly diagnosed solitary HCC treated by initial HR from January 2004 to October 2013 were classified into six groups based on tumor size (in 2-cm increments). Combining adjacent categories with similar OS led to three groups: ≤5 cm (n = 426), >5 and ≤8 cm (n = 229), and >8 cm (n = 202). Among all patients, median survival time was 62 months, and OS was 95 % at 1 year, 73 % at 3 years, and 54 % at 5 years. Patients in the ≤5 cm group showed significantly higher OS (P < 0.001) and lower tumor recurrence (P = 0.004) than those in the >5 and ≤8 cm group, who in turn showed significantly higher OS (P = 0.003) and lower tumor recurrence (P = 0.021) than those in the >8 cm group. Our results suggest that patients with solitary HCC should be subclassified based on tumor size for more accurate prognosis. We propose defining solitary HCC tumors >5 and ≤8 cm as "large" and tumors >8 cm as "huge".

Determination of Resectability

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

Radiofrequency ablation of hepatocellular carcinoma: Mono or multipolar?

BACKGROUND AND AIMS

Thermo-ablation by radiofrequency is recognized as a curative treatment for early-stage hepatocellular carcinoma. However, local recurrence may occur because of incomplete peripheral tumor destruction. Multipolar radiofrequency has been developed to increase the size of the maximal ablation zone. We aimed to compare the efficacy of monopolar and multipolar radiofrequency for the treatment of hepatocellular carcinoma and determine factors predicting failure.

METHODS

A total of 171 consecutive patients with 214 hepatocellular carcinomas were retrospectively included. One hundred fifty-eight tumors were treated with an expandable monopolar electrode and 56 with a multipolar technique using several linear bipolar electrodes. Imaging studies at 6 weeks after treatment, then every 3 months, assessed local effectiveness. Radiofrequency failure was defined as persistent residual tumor after two sessions (primary radiofrequency failure) or local tumor recurrence during follow-up. This study received institutional review board approval (number 2014/77).

RESULTS

Imaging showed complete tumor ablation in 207 of 214 lesions after the first session of radiofrequency. After a second session, only two cases of residual viable tumor were observed. During follow-up, there were 46 local tumor recurrences. Thus, radiofrequency failure occurred in 48/214 (22.4%) cases. By multivariate analysis, technique (P < 0.001) and tumor size (P = 0.023) were independent predictors of radiofrequency failure. Failure rate was lower with the multipolar technique for tumors < 25 mm (P = 0.023) and for tumors between 25 and 45 mm (P = 0.082). There was no difference for tumors ≥ 45 mm (P = 0.552).

CONCLUSIONS

Compared to monopolar radiofrequency, multipolar radiofrequency improves tumor ablation with a subsequent lower rate of local tumor recurrence.

Eradication of esophageal varices by sclerotherapy combined with argon plasma coagulation: Effect of portal hemodynamics and longitudinal clinical course

BACKGROUND AND AIM

To demonstrate the effect of endoscopic injection sclerotherapy (EIS) with argon plasma coagulation (APC) as a primary/secondary prophylaxis for esophageal varies (EV) on portal hemodynamics and long-term outcomes in cirrhosis.

METHODS

This prospective study included 48 cirrhotic patients (64.5 ± 11.4 years; 26 bleeders, 22 non-bleeders). Post-treatment outcomes (EIS and APC; median observation period, 12.8 months for recurrence and 21.1 months for prognosis) were evaluated with respect to the findings of hepatic venous catheterization, Doppler ultrasound, and endoscopic ultrasonography (EUS).

RESULTS

All patients showed EV eradication after endoscopic treatment, and a decreased frequency of a patent left gastric vein (pre: 83.3%, post: 27.1%, P < 0.001). However, hepatic venous pressure gradient (HVPG, mmHg) remained unchanged after the treatment, pre: 16.1 ± 3.6, post: 15.6 ± 3.8 (P = 0.269). Cumulative variceal recurrence/rebleeding rates were 25.5%/5.6% and 62.4%/23.1% at 1 and 3 years, respectively. Post-treatment EUS finding, area of submucosal vessels in the cardia ≥12 mm2 was the only significant factor for variceal recurrence (hazard ratio 9.769, 95% confidence interval 3.046-31.337; P < 0.001). Cumulative recurrence rate was significantly higher in patients with area of submucosal vessels in the cardia ≥12 mm2 (58.3% at 1 year and 100% at 3 years) than in those without (11.4% at 1 year and 40.9% at 3 years, P < 0.001). Cumulative overall survival rates were 95.2% and 71.9% at 1 and 3 years, respectively, showing no significant relationship with HVPG.

CONCLUSION

EIS with APC for EV is unlikely to have a significant influence on portal pressure.

High expression of HEF1 predicts a poorer prognosis of hepatocellular carcinoma: A retrospective study

Human enhancer of filamentation 1 (HEF1), a scaffold protein, is highly expressed in a variety of cancer types and is involved cancer cell growth, migration and invasion. The prognostic value of HEF1 in hepatocellular carcinoma (HCC) remains to be elucidated. The aim of the present study was to assess the association between the expression of HEF1, the clinical/pathological parameters and survival in HCC. In the present study, immunohistochemistry was performed to investigate the protein expression of HEF1 in 123 hepatocellular carcinoma tissues and their adjacent normal liver tissues. Spearman's rank correlation, Kaplan-Meier plots and Cox regression model were used to analyze the data. Overexpression of HEF1 protein was observed in HCC tissue when compared with their adjacent non-malignant liver tissue. High expression of HEF1 correlated with higher advanced tumor, node, metastasis (TNM) stage and vascular invasion (P<0.05). In univariate and multivariate analysis, the expression of HEF1 was identified as an independent prognostic factor in the 123 patients with HCC. In subgroup analysis, high expression of HEF1 correlated with a poorer prognosis in advanced (TNM III+IV) stages (P<0.05). These findings demonstrated the potential value of detecting the expression of HEF1 by immunohistochemistry as a prognostic biomarker and therapeutic target for patients with HCC.

Stratified neutrophil-to-lymphocyte ratio accurately predict mortality risk in hepatocellular carcinoma patients following curative liver resection

OBJECTIVES

Neutrophil lymphocyte ratio (NLR) has been shown to predict prognosis of cancers in several studies. This study was designed to evaluate the impact of stratified NLR in patients who have received curative liver resection (CLR) for hepatocellular carcinoma (HCC).

METHODS

A total of 1659 patients who underwent CLR for suspected HCC between 2007 and 2014 were reviewed. The preoperative NLR was categorized into quartiles based on the quantity of the study population and the distribution of NLR. Hazard ratios (HRs) and 95% confidence intervals (CIs) were significantly associated with overall survival (OS) and derived by Cox proportional hazard regression analyses. Univariate and multivariate Cox proportional hazard regression analyses were evaluated for association of all independent parameters with disease prognosis.

RESULTS

Multivariable Cox proportional hazards models showed that the level of NLR (HR = 1.031, 95%CI: 1.002-1.060, P = 0.033), number of nodules (HR = 1.679, 95%CI: 1.285-2.194, P<0.001), portal vein thrombosis (HR = 4.329, 95%CI: 1.968-9.521, P<0.001), microvascular invasion (HR = 2.527, 95%CI: 1.726-3.700, P<0.001) and CTP score (HR = 1.675, 95%CI: 1.153-2.433, P = 0.007) were significant predictors of mortality. From the Kaplan-Meier analysis of overall survival (OS), each NLR quartile showed a progressively worse OS and apparent separation (log-rank P=0.008). The highest 5-year OS rate following CLR (60%) in HCC patients was observed in quartile 1. In contrast, the lowest 5-year OS rate (27%) was obtained in quartile 4.

CONCLUSIONS

Stratified NLR may predict significantly improved outcomes and strengthen the predictive power for patient responses to therapeutic intervention.

Circulating CD147 predicts mortality in advanced hepatocellular carcinoma

BACKGROUND AND AIM

The glycoprotein CD147 has a role in tumor progression, is readily detectable in the circulation, and is abundantly expressed in hepatocellular carcinoma (HCC). Advanced HCC patients are a heterogeneous group with some individuals having dismal survival. The aim of this study was to examine circulating soluble CD147 levels as a prognostic marker in HCC patients.

METHODS

CD147 was measured in 277 patients (110 HCC, 115 chronic liver disease, and 52 non-liver disease). Clinical data included etiology, tumor progression, Barcelona Clinic Liver Cancer (BCLC) stage, and treatment response. Patients with HCC were stratified into two groups based upon the 75th percentile of CD147 levels (24 ng/mL).

RESULTS

CD147 in HCC correlated inversely with poor survival (P = 0.031). Increased CD147 predicted poor survival in BCLC stages C and D (P = 0.045), and CD147 levels >24 ng/mL predicted a significantly diminished 90-day and 180-day survival time (hazard ratio [HR] = 6.1; 95% confidence interval [CI]: 2.1-63.2; P = 0.0045 and HR = 2.8; 95% CI: 1.2-12.6; P = 0.028, respectively). In BCLC stage C, CD147 predicted prognosis; levels >24 ng/mL were associated with a median survival of 1.5 months compared with 6.5 months with CD147 levels ≤24 ng/mL (P = 0.03). CD147 also identified patients with a poor prognosis independent from treatment frequency, modality, and tumor size.

CONCLUSIONS

Circulating CD147 is an independent marker of survival in advanced HCC. CD147 requires further evaluation as a potential new prognostic measure in HCC to identify patients with advanced disease who have a poor prognosis.