Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan

Down-regulation of RhoE is associated with progression and poor prognosis in hepatocellular carcinoma

BACKGROUND

RhoE is an atypical member of Rho GTPases family, which is a crucial regulator of cytoskeletal dynamics, cell cycle progression, and cell proliferation. Previous studies have reported that RhoE was aberrantly expressed in several human cancers, but the role of RhoE in hepatocellular carcinoma (HCC) remained poor understood.

OBJECTIVES

This study investigated the expression of RhoE and its clinical significance on the outcome of patients with HCC.

METHODS

The expression of RhoE was examined in HCC patients and then the prognostic impact of the RhoE expression status was evaluated by univariate and multivariate analysis.

RESULTS

RhoE was down-regulated in HCC cell lines and tissues compared with normal hepatocyte line (HL-7702) and non-cancerous liver tissues. The expression of RhoE was significantly negatively associated with serum AFP (P = 0.013) and tumor grade (P = 0.016). Furthermore, the patients with low expression of RhoE had a shorter survival (P = 0.002) than those with high expression. Univariate and multivariate analysis showed that RhoE expression was a significant and independent prognostic predictor for HCC patients (P = 0.016).

CONCLUSIONS

RhoE, down-regulated in patients with HCC, could serve as an independent prognostic predictor for patients with HCC.

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.

Percutaneous radiofrequency ablation therapy for hepatocellular carcinoma: a proposed new grading system for the ablative margin and prediction of local tumor progression and its validation

BACKGROUND

In the present study we classified the radicality of percutaneous radiofrequency thermal ablation (RFA) therapy according to the extent of the ablated margin. We measured the local recurrence rate for each radicality grade to evaluate the significance of the grading system in assessing the therapeutic effectiveness of RFA and predicting local tumor progression.

METHODS

This retrospective study involved 269 patients with solitary hypervascular hepatocellular carcinoma who had undergone RFA. The mean ± SD observation period after RFA, number of treatment sessions, and tumor diameter were 25.7 ± 19.9 months, 1.2 ± 0.5, and 2.1 ± 0.7 cm, respectively. Patients were evaluated using dynamic computed tomography. We classified the radicality of RFA treatment into four grades (R grades: A, B, C, and D) according to the extent of the ablated tumor margin, calculated the post-RFA cumulative local recurrence rate for each R grade, and analyzed the factors (patient characteristics, biochemical data, contiguous vessels, and tumor marker) contributing to local recurrence.

RESULTS

The cumulative local recurrence rates at 3 years were 6.7, 17.6, 55.8, and 82.2% for Grades A, B, C, and D, respectively. Using univariate analysis, R grade, tumor size (> 2 cm), and des-γ-carboxy prothrombin (DCP) (> 200 mA U/mL) were shown to be significant factors contributing to local recurrence. However, using multivariate analysis, only the R grade was found to be a significant independent factor.

CONCLUSIONS

The proposed R grading method is a valid and useful method for assessing treatment efficacy, and for predicting local tumor progression after RFA.

Comparison of laparoscopic vs open liver lobectomy (segmentectomy) for hepatocellular carcinoma

AIM: To investigate the effects of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma (HCC).

METHODS: From 2006 to January 2011, laparoscopic hepatectomies were performed on 30 cases of HCC at Northern Jiangsu People’s Hospital. During this same time period, 30 patients elected to undergo conventional open hepatectomy over laparoscopic hepatectomy at the time of informed consent. The degree of invasiveness and outcomes of laparoscopic hepatectomy compared to open hepatectomy for HCC were evaluated.

RESULTS: Both groups presented with similar blood loss amounts, operating times and complications. Patients in the laparoscopic hepatectomy group started walking and eating significantly earlier than those in the open hepatectomy group, and these more rapid recoveries allowed for shorter hospitalizations. There were no significant differences between procedures in survival rate.

CONCLUSION: Laparoscopic hepatectomy is beneficial for patient quality of life if the indications are appropriately based on preoperative liver function and the location and size of the HCC.

Radiofrequency ablation versus surgical resection for small hepatocellular carcinoma: a meta-analysis

AIM: To compare the therapeutic effects of radiofrequency ablation (RFA) and surgical hepatic resection (HR) in the treatment of small hepatocellular carcinoma (HCC).

METHODS: Literature about the controlled trials evaluating the efficacy between RFA and HR for the treatment of small HCC published between 1991 and 2011 were searched electronically. The criteria recommended by the Cochrane Handbook 4.2.2 for Systematic Reviews of Interventions were used for choosing the trails and assessing the quality of included studies. RevMan5.0.25 software was used for systematic review and meta-analysis.

RESULTS: Two randomized controlled trials and nine non-randomized controlled trials were included. A total of 2 965 patients were involved: 1 459 patients were treated with radiofrequency ablation as the initial treatment and 1 506 patients with surgical resection. Compared to the RFA group, the 3, 5-year survival rates and 1, 3, 5-year recurrence-free survival rates in the HR group was significantly higher (all P < 0.05). There were no significant difference in the 1-year survival rate between the RFA group and HR group (P > 0.05). Complications were significantly fewer in the RFA group than in the HR group (P < 0.05).

CONCLUSION: Surgical resection has more major complications than radiofrequency ablation, but the overall efficacy of surgical resection is better than radiofrequency ablation in the management of small HCC.

MRI findings of recurrent hepatocellular carcinoma after liver transplantation: preliminary results

PURPOSE

To describe the patterns of recurrence and serial magnetic resonance imaging (MRI) features of hepatocellular carcinoma (HCC) after liver transplantation.

MATERIALS AND METHODS

All cases of recurrent HCC after transplantation between September 2002 and August 2009 that underwent MRI including precontrast T1, T2-weighted images, and postgadolinium dynamic images were reviewed. On MRI we evaluated the characteristics and patterns of recurrent HCC after transplantation.

RESULTS

A total 7 of 76 transplanted patients (four men, three women, age range, 45-63, mean 52.7 years) were included in this study. Four patients (57.1%) were identified to have a pattern of persistent local disease (PLD) near the transplanted liver, hepatorenal space, or suture site within 2.75 years (range, 2-4 years). Two patients showed recurrent HCC in the allograft alone within 5 years. One patient showed an intraperitoneal seeding (IPS) pattern which demonstrated diffuse peritoneal infiltration and thickening within 9 months. The diffuse metastatic disease (DMD) pattern was observed as a late manifestation of PLD and IPS. The most prominent volume of recurrent tumor burden was found in an extrahepatic (5 of 7 patients) compared to an intrahepatic (2 of 7 patients) location. The signal intensities and enhancement patterns did not exhibit change with disease progression.

CONCLUSION

We describe four patterns of recurrence of HCC following transplant. The most prominent tumor burden was located in an extrahepatic compared to an intrahepatic location.

Oxidative stress pathways in noncancerous human liver tissue to predict hepatocellular carcinoma recurrence: a prospective, multicenter study

The prediction of cancer recurrence holds the key to improvement of the postoperative prognosis of patients. In this study, the recurrence of early-stage hepatocellular carcinoma (HCC) after curative hepatectomy was analyzed by the genome-wide gene-expression profiling on cancer tissue and the noncancerous liver tissue. Using the training set of 78 cases, the cytochrome P450 1A2 (CYP1A2) gene in noncancerous liver tissue was identified as the predictive candidate for postoperative recurrence (hazard ratio [HR], 0.447; 95% confidence interval [CI], 0.249-0.808; P = 0.010). Multivariate analysis revealed the statistically significant advantage of CYP1A2 down-regulation to predict recurrence (odds ratio, 0.534; 95% CI, 0.276-0.916; P = 0.036), and the expression of CYP1A2 protein was confirmed immunohistochemically. An independently multi-institutional cohort of 211 patients, using tissue microarrays, validated that loss of expression of CYP1A2 in noncancerous liver tissue as the only predictive factor of recurrence after curative hepatectomy for early-stage HCC (HR, 0.480; 95% CI, 0.256-0.902; P = 0.038). Gene set-enrichment analysis revealed close association of CYP1A2 down-regulation with oxidative stress pathways in liver tissue (P < 0.001, false discovery rate [FDR] = 0.042; P = 0.006, FDR = 0.035). Our results indicate these pathways as the molecular targets to prevent recurrence, as well as the potential prediction of the super high-risk population of HCC using liver tissue.

Evaluation of the new AJCC staging system for resectable hepatocellular carcinoma

BACKGROUND

The aim of this study was to assess the validity of the 7th edition of the American Joint Committee on Cancer (AJCC) TNM system (TNM-7) for patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Partial hepatectomies performed for 879 patients from 1993 to 2005 were retrospectively reviewed. Clinicopathological factors, surgical outcome, overall survival (OS), and disease-free survival (DFS) were analyzed to evaluate the predictive value of the TNM-7 staging system.

RESULTS

According to the TNM-7 system, differences in five-year survival between stages I, II, and III were statistically significant. Subgroup analysis of stage III patients revealed that the difference between stages II and IIIA was not significant (OS, p = 0.246; DFS, p = 0.105). Further stratification of stages IIIA, IIIB and IIIC also did not reveal significant differences. Cox proportional hazard models of stage III analyses identified additional clinicopathological factors affecting patient survival: lack of tumor encapsulation, aspartate aminotransferase (AST) values > 68 U/L, and blood loss > 500 mL affected DFS whereas lack of tumor encapsulation, AST values > 68 U/L, blood loss > 500 mL, and serum α-fetoprotein (AFP) values > 200 ng/mL were independent factors impairing OS. Stage III factors including tumor thrombus, satellite lesions, and tumor rupture did not appear to influence survival in the stage III subgroup.

CONCLUSIONS

In terms of 5-year survival rates, the TNM-7 system is capable of stratifying post-hepatectomy HCC patients into stages I, II, and III but is unable to stratify stage III patients into stages IIIA, IIIB and IIIC. Lack of tumor encapsulation, AST values > 68 U/L, blood loss > 500 mL, and AFP values > 200 ng/mL are independent prognostic factors affecting long-term survival.

Stereotactic body radiation therapy in hepatocellular carcinoma and cirrhosis: evaluation of radiological and pathological response

BACKGROUND

Loco-regional therapies for cirrhotic patients with hepatocellular carcinoma (HCC) who are awaiting liver transplantation (OLT) attempt to prevent tumor progression. However, there is limited data regarding the efficacy of stereotactic body radiation therapy (SBRT) as loco-regional treatment.

METHODS

From 2006 to 2009, 27 HCC patients (AJCC I, II) listed for OLT underwent SBRT. Thirty-nine lesions were treated and 27 assessed radiologically. Seventeen patients had OLT, liver explants were analyzed and 22 lesions underwent pathological evaluation.

RESULTS

In a cumulative analysis of all imaging, 30% had complete response, 7% had partial response, 56% were stable, and 7% had progression of disease. Of the 22 pathologically evaluated lesions, 37% were responders: 14% with complete response, 23% with partial response, and 63% with no response. Side effects from SBRT were recorded in three patients, which included nausea in two and liver decompensation in one.

CONCLUSION

SBRT achieves total or partial radiological response in 37% of patients and total or partial pathological response in 37% of patients with early HCC in the setting of cirrhosis. SBRT may be a safe and effective alternative for local tumor control in patients with HCC and cirrhosis awaiting OLT.

Terpenoids as potential chemopreventive and therapeutic agents in liver cancer

Despite significant advances in medicine, liver cancer, predominantly hepatocellular carcinoma remains a major cause of death in the United States as well as the rest of the world. As limited treatment options are currently available to patients with liver cancer, novel preventive control and effective therapeutic approaches are considered to be reasonable and decisive measures to combat this disease. Several naturally occurring dietary and non-dietary phytochemicals have shown enormous potential in the prevention and treatment of several cancers, especially those of the gastrointestinal tract. Terpenoids, the largest group of phytochemicals, traditionally used for medicinal purposes in India and China, are currently being explored as anticancer agents in clinical trials. Terpenoids (also called "isoprenoids") are secondary metabolites occurring in most organisms, particularly plants. More than 40 000 individual terpenoids are known to exist in nature with new compounds being discovered every year. A large number of terpenoids exhibit cytotoxicity against a variety of tumor cells and cancer preventive as well as anticancer efficacy in preclinical animal models. This review critically examines the potential role of naturally occurring terpenoids, from diverse origins, in the chemoprevention and treatment of liver tumors. Both in vitro and in vivo effects of these agents and related cellular and molecular mechanisms are highlighted. Potential challenges and future directions involved in the advancement of these promising natural compounds in the chemoprevention and therapy of human liver cancer are also discussed.

Hepatocellular carcinoma and liver transplantation: clinical perspective on molecular targeted strategies

Hepatocellular carcinoma (HCC) has an aggressive clinical course with frequent recurrence and metastasis. Orthotopic liver transplantation has been the only curative tool for unresectable HCC; therefore, recent advances in molecular targeted therapy may improve the prognosis of HCC. The multiple kinase inhibitor sorafenib and the macrolide antibiotic rapamycin are currently the most promising agents for treating unresectable HCC. A large population-based clinical trial revealed that sorafenib significantly prolonged the overall survival of HCC patients. However, subsequent clinical studies showed that sorafenib rarely reduced tumor volume and inadequately prolonged survival of patients with severe liver damage. To improve its therapeutic effect, the development of a predictive biomarker and a sorafenib-based combination is awaited. Another molecular targeting agent, rapamycin, has now been considered as a putative agent for preventing tumor recurrence in post-liver transplantation HCC patients, because it not only has immunosuppressive activity but also exerts an anti-tumor effect. In the near future, a combination of molecular targeting agents, such as sorafenib and rapamycin, may become a standard protocol for treating unresectable HCC. For specifying cases with more effective and less harmful modalities, further investigation in clinical and basic research to identify unexpected effects are needed.

Suicidal gene therapy in the effective control of primary human hepatocellular carcinoma as monitored by noninvasive bioimaging

Hepatocellular carcinoma (HCC) is usually refractory to the available treatments. For cancer gene therapy purposes, real-time imaging of therapeutic gene expression is of great importance because there are multiple factors that modulate the therapeutic gene expression in a complex tumor microenvironment. As a consequence, multiple doses of therapeutic viral vectors may be required for improved efficacy. In the present study, the luciferase reporter gene and the yeast cytosine deaminase (yCD) genes were bicistronically expressed using the foot-and-mouth disease virus 2A peptide under the regulation of the cytomegalovirus (CMV) promoter. The effectiveness of the yCD/5-FC (5-fluorocytosine) killing efficacy mediated by the herpes simplex virus type 1 (HSV-1) amplicon viral vector was shown using HCC and non-HCC cell lines in vitro. In addition, in vivo experiment also showed tumor regression of a primary HCC 26-1004 tumor xenograft in tumor expressing high levels of the yCD gene (as determined by noninvasive imaging) after intratumoral injection of 1.5 × 10(6) TU HGCX-L2C HSV-1 amplicon viral vector and 5-FC administration. The HSV-1 amplicon viral vector coupled with the yCD/5-FC prodrug activated suicide gene could potentially be of use in clinical gene therapy for HCC.

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.

A phantom study comparing ultrasound-guided liver tumor puncture using new real-time 3D ultrasound and conventional 2D ultrasound

OBJECTIVE

The purpose of this study is to compare the accuracy of ultrasound-guided puncture using new real-time 3D (4D) ultrasound and conventional 2D ultrasound for focal hepatic masses using a liver phantom.

MATERIALS AND METHODS

A 4D ultrasound system equipped with a 5-MHz 4D probe displayed both axial and orthogonal images parallel to a puncture line plane. We used a liver phantom that contained four simulated spherical masses in an acrylic box (length × width × height, 300 × 299 × 150 mm) with two different sizes (15 and 30 mm in diameter) in two different positions (30 and 80 mm from the surface). Four inexperienced and four experienced physicians attempted punctures on these four simulated masses twice using 2D and 4D ultrasound guidance in a total of 128 punctures (eight operators, two techniques, and eight punctures per session). The error distance of the puncture was defined as the perpendicular distance from the center of a target mass (sphere) to the line of the puncture needle in the coronal plane of the target center, which was measured manually on the basis of the 3D volume data on off-line analysis.

RESULTS

On each tumor model, the average error distance with 4D ultrasound was significantly smaller than that with 2D ultrasound, except for one tumor model that was 15 mm in diameter and 30 mm in depth. The average error distances for the experienced group tended to be smaller than those for the inexperienced group, with both techniques and on each tumor model, and there was a statistically significant difference between the two groups on one tumor model (30 mm in diameter and 80 mm in depth) on 4D ultrasound (p < 0.05).

CONCLUSION

Four-dimensional ultrasound-guided puncture for liver tumors can markedly improve puncture accuracy for both experienced and inexperienced physicians compared with conventional 2D ultrasound guidance.

Selection criteria for hepatectomy in patients with hepatocellular carcinoma classified as Child-Pugh class B

BACKGROUND

The appropriate surgical approach for hepatocellular carcinoma (HCC) patients of Child-Pugh class B is unclear. The aim of this study was to clarify the prognostic factors after hepatectomy in Child-Pugh class B patients and to delineate the selection criteria for hepatectomy.

METHODS

One hundred fifty patients of Child-Pugh class B who underwent hepatectomy were enrolled in this retrospective study (Hx group). Univariate and multivariate analyses were performed to identify prognostic factors. The prognosis was compared with that of 23 patients of Child-Pugh class B who underwent liver transplantation (LT group).

RESULTS

The overall survival rate of the Hx group was significantly worse than that of the LT group (5-year survival: 36.0 vs. 78.3%, p = 0.001). In multivariate analyses, diabetes mellitus (p = 0.011), preoperative total bilirubin level ≥ 1.5 mg/dl (p = 0.038), and Child-Pugh score of 8 or 9 (p = 0.038) were independent prognostic factors. Although the overall 5-year survival rate of patients with none of the three adverse prognostic factors was only 50.3%, that of patients with one or more adverse prognostic factors was only 27.2% (p = 0.001).

CONCLUSIONS

Hepatectomy may be the optimal initial treatment for HCC patients classified as Child-Pugh class B and without any adverse prognostic factors.

Current status of therapy for hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide. A multi-disciplinary approach is required for its management. Screening high-risk patients allows for earlier diagnosis and the use of potentially curative therapies. Current recommendations for HCC screening for patients with cirrhosis are an abdominal ultrasound and serum alpha fetoprotein level every 6 to 12 months. Treatment choice depends on tumor stage, liver function and the patient's overall functional status. Curative therapies include surgical resection, liver transplantation (LT), transarterial chemoembolization, and radiofrequency ablation (RFA). Surgical resection, either primary resection or LT, is the treatment most likely to result in cure of HCC. Which option to pursue is based on multiple factors. LT has the potential benefit of treating both HCC and the underlying cirrhosis; however, long wait times incur the risk of tumor progression. Firm recommendations regarding the role of living donor LT for HCC are not yet possible because of conflicting data. HCC recurrence after LT is 8-11% and several adjuvant therapies have been investigated to reduce this. Bridging therapy and tumor downsizing are techniques that also may be considered to deal with long waiting periods and qualification for LT, respectively. If neither LT nor primary resection is possible, loco-regional therapies such as RFA and TACE should be considered. Systemic chemotherapies have proved disappointing for the treatment of HCC; however, newer targeted therapies such as sorafenib and cetuximab have provided new hope for the future.

Ethanol injection is highly effective for hepatocellular carcinoma smaller than 2 cm

AIM

To analyze the long-term prognosis in a cohort of western cirrhotic patients with single hepatocellular carcinoma treated with ethanol injection.

METHODS

One-hundred forty-eight patients with solitary hepatocellular carcinoma were enrolled. The tumor diameter was lower than 2 cm in 47 patients but larger in the remaining 101 patients. The impact of some pre-treatment clinical and laboratory parameters and of tumor recurrence on patients' survival was assessed.

RESULTS

Among the pre-treatment parameters, only a tumor diameter of less than 2 cm was an independent prognostic factor of survival. The occurrence of new nodules in other liver segments and the neoplastic portal invasion were linked to a poorer prognosis at univariate analysis. Patients with a single hepatocellular carcinoma smaller than 2 cm showed a better 5-year cumulative survival (73.0% vs 47.9%) (P = 0.009), 3-year local recurrence rate (29.1% vs 51.5%) (P = 0.011), and 5-year distant intrahepatic recurrence rate (52.9% vs 62.8%) (P = 0.054) compared to patients with a larger tumor.

CONCLUSION

The 5-year survival rate of patients with single hepatocellular carcinoma < 2 cm undergoing ethanol injection is excellent and comparable to that achieved using radiofrequency ablation.

Importin-α1 as a novel prognostic target for hepatocellular carcinoma

BACKGROUND

Perturbations in the nuclear microenvironment, including transport systems, play a critical role in malignant progression, but the nuclear import abnormalities remain unclear in hepatocarcinogenesis. We analyzed the role of importin in hepatocellular carcinoma (HCC).

METHODS

Gene expression profiling of the importin family was performed in HCC tissues. The significance of importin protein expression was analyzed in vitro as well as clinicopathologically.

RESULTS

According to the microarray profiles, the importin-α1 was dominantly overexpressed in HCC tissues as compared to the adjacent noncancerous tissues. By means of human HCC cell lines, a knockdown of importin-α1 by its siRNA greatly reduced cellular proliferation by 15.2-26.6% (P < 0.005). Immunohistochemical analysis on tissue samples demonstrated cancer-specific overexpression in 36.3% of HCCs. The overexpression of importin-α1 was correlated statistically with high levels of alfa-fetoprotein ( P = 0.0017), the tumor number (P = 0.0116), histological dedifferentiation (P = 0.0054), tumor morphology (P = 0.0433), portal vein invasion (P = 0.0007), hepatic vein invasion (P = 0.0081), Fc (P = 0.0367), Fc-inf (P = 0.0122), and the tumor, node, metastasis stage (P = 0.0026); this resulted in a significantly poorer prognosis in both overall survival (P = 0.0164) and recurrence-free survival (P = 0.0101). Multivariate analysis of recurrence-free survival revealed importin-α1 expression to be a statistically significant factor (P = 0.0361). In addition, early recurrence after curative resection was observed more frequently in the importin-α1-positive group as compared to the negative group (P = 0.0023). The multivariate analysis identified importin-α1 as the only independent predictor of early recurrence after HCC resection (odds ratio = 5.291, P = 0.0191).

CONCLUSIONS

Because importin-α1 might be closely associated with HCC progression, further analysis should be pursued to evaluate it as a novel prognostic target.

Significance of platelet count in the outcomes of hepatectomized patients with hepatocellular carcinoma exceeding the Milan criteria

BACKGROUND

The appropriate treatment strategy for advanced hepatocellular carcinoma (HCC) that does not meet the Milan criteria (MC) is unclear. The aim of this study was to determine the significance of surgical treatment for such patients.

STUDY DESIGN

From January 1990 to December 2007, 151 patients with HCC exceeding MC who underwent curative surgical treatment were enrolled. Survival and recurrence data and clinicopathological factors were examined. Prognostic factors were analyzed to identify those that contributed to improved surgical outcomes retrospectively.

RESULTS

After the initial hepatectomy, the overall 3-, 5-, and 10-year survival rates were 73%, 55%, and 33%, respectively, for the 151 patients in this study; the corresponding disease-free survival rates were 36%, 30%, and 17%, respectively. A platelet count under 10(5)/mm(3), multiple tumors, and liver cirrhosis of noncancerous tissue were adverse survival and disease-free survival factors by univariate analysis. Platelet count was an independent prognostic factor by multivariate analysis. The 3-, 5-, and 10-year overall survival rates of HCC exceeding MC in patients whose platelet count was 10(5)/mm(3) or greater reached 76%, 65%, and 44%, respectively, and were comparable with those that met MC (86%, 68%, and 37%, respectively).

CONCLUSIONS

Hepatectomy for patients with advanced HCC exceeding MC improves survival, especially for patients with a sufficiently high platelet count, although recurrence rates after initial hepatectomy are high.

Stereotactic body radiotherapy for primary hepatocellular carcinoma

PURPOSE

To evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) for the treatment of primary hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

From 2005 to 2009, 60 patients with liver-confined HCC were treated with SBRT at the Indiana University Simon Cancer Center: 36 Child-Turcotte-Pugh (CTP) Class A and 24 CTP Class B. The median number of fractions, dose per fraction, and total dose, was 3, 14 Gy, and 44 Gy, respectively, for those with CTP Class A cirrhosis and 5, 8 Gy, and 40 Gy, respectively, for those with CTP Class B. Treatment was delivered via 6 to 12 beams and in nearly all cases was prescribed to the 80% isodose line. The records of all patients were reviewed, and treatment response was scored according to Response Evaluation Criteria in Solid Tumors v1.1. Toxicity was graded according to the Common Terminology Criteria for Adverse Events v4.0. Local control (LC), time to progression (TTP), progression-free survival (PFS), and overall survival (OS) were calculated according to the method of Kaplan and Meier.

RESULTS

The median follow-up time was 27 months, and the median tumor diameter was 3.2 cm. The 2-year LC, PFS, and OS were 90%, 48%, and 67%, respectively, with median TTP of 47.8 months. Subsequently, 23 patients underwent transplant, with a median time to transplant of 7 months. There were no ≥Grade 3 nonhematologic toxicities. Thirteen percent of patients experienced an increase in hematologic/hepatic dysfunction greater than 1 grade, and 20% experienced progression in CTP class within 3 months of treatment.

CONCLUSIONS

SBRT is a safe, effective, noninvasive option for patients with HCC ≤6 cm. As such, SBRT should be considered when bridging to transplant or as definitive therapy for those ineligible for transplant.

Liver transplantation for hepatocellular carcinoma: an update

BACKGROUND

Hepatocellular carcinoma (HCC) is a heterogeneous malignancy with multiple etiologies, high incidence, and high mortality. The standard surgical management for patients with HCC consists of locoregional ablation, surgical resection, or liver transplantation, depending on the background state of the liver. Eighty percent of patients initially presenting with HCC are unresectable, either due to the extent of tumor or the level of underlying hepatic dysfunction. While in patients with no evidence of cirrhosis and good hepatic function resection has been the surgical treatment of choice, it is contraindicated in patients with moderate to severe cirrhosis. Liver transplantation is the optimal surgical treatment.

DATA SOURCES

PubMed search of recent articles (from January 2000 to March 2011) was performed looking for relevant articles about hepatocellular carcinoma and its treatment. Additional articles were identified by evaluating references from selected articles.

RESULTS

Here we review criteria for transplantation, the types, indications, and role of locoregional therapy in treating the cancer and in downstaging for possible later transplantation. We also summarize the contribution of immunosuppression and adjuvant chemotherapy in the management and prevention of HCC recurrence. Finally we discuss recent advances in imaging, tumor biology, and genomics as we delineate the remaining challenges for the diagnosis and treatment of this disease.

CONCLUSIONS

Much can be improved in the diagnosis and treatment of HCC. A great challenge will be to improve patient selection to criteria based on tumor biology. Another will be to incorporate systemic agents post-operatively in patients at high risk for recurrence, paying close attention to efficacy and safety. The future direction of the effort in treating HCC will be to stimulate prospective trials, develop molecular imaging of lymphovascular invasion, to improve recipient selection, and to investigate biomarkers of tumor biology.

Prognostic factors and 10-year survival in patients with hepatocellular carcinoma after curative hepatectomy

PURPOSE

There were contrary results about the effects of hepatitis B e antigen (HBeAg) positivity on the long-term survival in patients with hepatocellular carcinoma (HCC) after curative resection.

PATIENTS AND METHODS

Medical records of 170 HCC patients who underwent curative liver resections were retrospectively reviewed. The 10-year survival rate and correlations among clinical, laboratory, and pathological data, especially HBeAg, were analyzed.

RESULTS

Fifty-two patients survived more than 10 years. The 10-year actual overall survival (OS) rate was 30.6%, and the actual disease-free survival (DFS) rate was 24.1%. The median OS and DFS were 76 and 35 months, respectively. In multivariate analysis, HBeAg positivity (P = 0.032; hazard ratio [HR], 3.041), presence of a satellite nodule (P = 0.007; HR, 4.166), and elevated ICG R15 (P = 0.003; HR, 4.915) had a significant negative correlation with the 10-year DFS rate. In addition, HBeAg positivity (P = 0.044; HR, 3.725) and recurrence (recur within 1 year, P < 0.001; HR, 41.296; recur after 1 year, P = 0.03; HR, 4.848) were found as independent factors which were negatively correlated to the 10-year OS.

CONCLUSIONS

The presence of HBeAg was significantly correlated to DFS and OS after curative resection for HCC. Active treatment of B viral hepatitis before and after surgery should be provided to prolong survival in patients with 5-10-cm HCC.

Pathobiological features of small hepatocellular carcinoma: correlation between tumor size and biological behavior

PURPOSE

Increasing evidence has suggested that tumor size is one of the independent prognostic factors of patients with hepatocellular carcinoma (HCC). However, the criteria used to determine when HCC should be classified as small remain controversial. Our objective was to evaluate the relationship between the size of HCC and its clinicopathological features.

METHODS

A retrospective study on 618 patients who underwent partial hepatectomy for solitary HCC was performed. These patients were divided into Groups 1-5 according to the tumor diameter: ≤ 1, 1.1-2, 2.1-3, 3.1-5 and >5 cm, respectively. The clinicopathological variables of the patients in each group were compared statistically.

RESULTS

Except for the microHCC (≤ 1 cm) which differed significantly from the other four groups in the clinicopathological variables, almost no differences existed among HCC ranging from 1 to 3 cm, or HCCs > 3 cm. If ≤ 3 cm was used as the cut-off point for small HCC (SHCC), and >3 cm for large HCC (LHCC), significant differences (P < 0.05-0.01) were observed between SHCC and LHCC in: histological grades I-II (48.0 vs. 19.4 %), capsular invasion (15.4 vs. 36.3%), tumor thrombi (6.9 vs. 23.5%), satellite nodules (12.3 vs. 35.5%), noninvasive growth patterns (69.6 vs. 25.4%), the overall survival (OS, 119.6 ± 34.7 vs. 68.5 ± 6.6 months), and the recurrence-free survival (RFS, 67.0 ± 16.7 vs. 29.5 ± 3.2 months). Multivariate Cox regression analyses show that tumor size >3 cm was one of the independent prognostic factors for both OS and RFS.

CONCLUSIONS

The 3 cm cutoff seems to best determine the biological behavior and clinical prognosis of patients undergoing partial hepatectomy for early stage HCC. Overall, HCC smaller than 3 cm in diameter was closely related with a better prognosis which reflected the relatively benign pathobiological features at an early developmental stage. As HCC > 3 cm exhibited a tendency towards more aggressive behavior, we suggest that HCC ≤ 3 cm in diameter should be used as a critical size of SHCC at which curative treatment achieves better long-term survivals.

Hepatocellular carcinoma with extrahepatic metastasis: clinical features and prognostic factors

BACKGROUND

Despite significant advances in the treatment of intrahepatic lesions, the prognosis for patients with hepatocellular carcinoma (HCC) who have extrahepatic metastasis remains poor. The objective of this study was to further elucidate the clinical course and prognostic determinants of patients with this disease.

METHODS

In total, 342 patients who had HCC with extrahepatic metastasis were enrolled. The metastases were diagnosed at initial presentation with HCC in 28 patients and during follow-up in the remaining patients. The authors analyzed clinical features, prognoses, and treatments and established a scoring system to predict prognosis using a split-sample method with a testing set and a training set.

RESULTS

The most frequent site of extrahepatic metastasis was the lung followed by lymph nodes, bone, and adrenal glands. These metastases were related directly to death in only 23 patients (7.6%). The median survival after diagnosis of extrahepatic metastasis was 8.1 months (range, 0.03-108.7 months). In univariate analysis of the training set (n = 171), performance status, Child-Pugh classification, the number and size of intrahepatic lesions, macroscopic vascular invasion, symptomatic extrahepatic metastases, α-fetoprotein levels, and complete responses to treatment were associated significantly with prognosis. On the basis of multivariate analysis, a scoring system was developed to predict prognosis that assessed uncontrollable intrahepatic lesions, extent of vascular invasion, and performance status. This scoring system was validated in the testing set (n = 171) and produced a concordance index of 0.73.

CONCLUSIONS

The controllability of intrahepatic lesions and performance status were identified as important prognostic factors in patients with advanced HCC who had extrahepatic metastasis.

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.

Preparation of the core-shell structure adriamycin lipiodol microemulsions and their synergistic anti-tumor effects with diethyldithiocarbamate in vivo

We prepared the core-shell structure adriamycin lipiodol microemulsions (ADM-CSLMs) and evaluated their in vivo antitumor effects in combination with Diethyldithiocarbamate (DDC). Two types of ADM-CSLMs, adriamycin liposome-lipiodol microemulsion(ADM-LLM) and adriamycin microsphere lipiodol microemulsion (ADM-MLM), were prepared through the emulsification method. The drug loading and encapsulation efficiency of ADM-CSLMs were measured by the high-performance liquid chromatograph (HPLC). The size and shape of the ADM-CSLMs were determined by an atom force microscopy (AFM), a transmission electron microscopy (TEM), and a particle size analyzer, respectively. The synergistic effects of DDC and ADM-CSLMs for cancer treatment of carcinoma drug-resistance cell was evaluated by the MTT method, the activation of superoxide dismutase (SOD) was detected by chemiluminescence, and the ADM accumulation in cells was measured by flow cytometry. Walker-256 carcinoma was transplanted to the livers of the male SD rats, ADM-CSLMs were administrated to the livers of the rats by intervention hepatic artery embolization through microsurgery. The tumor growth and animal survival were evaluated. The results show that the average diameter of ADM-LLM and ADM-MLM were 4.23 ± 1.2 μm and 4.67 ± 1.4 μm, respectively, and their ADM encapsulation efficiency were 83.7% and 87.2% with respect to loading efficiency of 82 μg/ml and 91 μg/ml. The tumor growth and animal survival in two of the ADM-CSLMs combined with DDC groups were significantly higher than that of ADM only treatment, ADM liposome combined with DDC (P < 0.01), as well as the ADM microsphere combined with DDC (P < 0.01). Therefore, ADM-CSLMs are useful carriers for the treatment of carcinoma and their anti-tumor effect can be enhanced by DDC in a suitable concentration.

Molecular targeted therapy for hepatocellular carcinoma in the current and potential next strategies

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and its incidence is still increasing. While the primary curative treatment for HCC is surgical resection, a major obstacle for the treatment of HCC is the high frequency of tumor recurrence even after curative resection. Effective palliative treatment is hindered by the evidence that HCC is frequently resistant to conventional chemotherapy and radiotherapy. Targeted therapy which specifically inhibits molecular abnormalities has emerged as a novel approach for the innovative and effective medical treatment of malignancies. In order to fulfill this promise there is an urgent need to identify the optimal targets for the treatment of HCC. A multi-kinase angiogenesis inhibitor, sorafenib, has been revealed as the first agent to show favorable overall survival in patients with advanced HCC. A new era of HCC treatment has arrived, but there has been limited improvement in survival benefits with the status quo. This review summarizes molecular targeted therapy for HCC, with a focus on angiogenesis, growth signaling, and mitosis, as well as a promising concept, "cancer stemness" for the current and potential next strategies of HCC treatment.

Molecular targeted therapy for hepatocellular carcinoma in the current and potential next strategies

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and its incidence is still increasing. While the primary curative treatment for HCC is surgical resection, a major obstacle for the treatment of HCC is the high frequency of tumor recurrence even after curative resection. Effective palliative treatment is hindered by the evidence that HCC is frequently resistant to conventional chemotherapy and radiotherapy. Targeted therapy which specifically inhibits molecular abnormalities has emerged as a novel approach for the innovative and effective medical treatment of malignancies. In order to fulfill this promise there is an urgent need to identify the optimal targets for the treatment of HCC. A multi-kinase angiogenesis inhibitor, sorafenib, has been revealed as the first agent to show favorable overall survival in patients with advanced HCC. A new era of HCC treatment has arrived, but there has been limited improvement in survival benefits with the status quo. This review summarizes molecular targeted therapy for HCC, with a focus on angiogenesis, growth signaling, and mitosis, as well as a promising concept, "cancer stemness" for the current and potential next strategies of HCC treatment.

Hypofractionated stereotactic body radiotherapy for primary and metastatic liver tumors using the novalis image-guided system: preliminary results regarding efficacy and toxicity

www.tcrt.org The purpose of this study was to evaluate the efficacy and toxicity of stereotactic body radiotherapy (SBRT) for primary and metastatic liver tumors using the Novalis image-guided radiotherapy system. After preliminarily treating liver tumors using the Novalis system from July 2006, we started a protocol-based study in February 2008. Eighteen patients (6 with primary hepatocellular carcinoma and 12 with metastatic liver tumor) were treated with 55 or 50 Gy, depending upon their planned dose distribution and liver function, delivered in 10 fractions over 2 weeks. Four non-coplanar and three coplanar static beams were used. Patient age ranged from 54 to 84 years (median: 72 years). The Child-Pugh classification was Grade A in 17 patients and Grade B in 1. Tumor diameter ranged from 12 to 35 mm (median: 23 mm). Toxicities were evaluated according to the Common Terminology Criteria of Adverse Events version 4.0, and radiation-induced liver disease (RILD) was defined by Lawrence's criterion. The median follow-up period was 14.5 months. For all patients, the 1-year overall survival and local control rates were 94% and 86%, respectively. A Grade 1 liver enzyme change was observed in 5 patients, but no RILD or chronic liver dysfunction was observed. SBRT using the Novalis image-guided system is safe and effective for treating primary and metastatic liver tumors. Further investigation of SBRT for liver tumors is warranted. In view of the acceptable toxicity observed with this protocol, we have moved to a new protocol to shorten the overall treatment time and escalate the dose.

Hepatic resection versus transarterial lipiodol chemoembolization as the initial treatment for large, multiple, and resectable hepatocellular carcinomas: a prospective nonrandomized analysis

PURPOSE

To compare the survival outcomes between hepatic resection and transarterial lipiodol chemoembolization (TACE) used as the initial treatment in patients with large (≥5 cm), multiple, and resectable hepatocellular carcinomas.

MATERIALS AND METHODS

This study had local ethical committee approval; all patients gave written informed consent. Between January 2004 and December 2006, 168 consecutive patients were prospectively studied. As an initial treatment, 85 patients underwent hepatic resection and 83 underwent TACE. Of the 29 of 83 patients in whom there was a good response to TACE, 13 underwent subsequent hepatic resection. The remaining 16 patients, who refused hepatic resection, underwent TACE and local ablation. Repeated TACE was performed in patients with stable disease or progressive disease after initial TACE. The differences in survival between groups and subgroups were calculated with the Kaplan-Meier method. Univariate and multivariate analyses were performed to clarify the prognostic factors for survival.

RESULTS

The 1-, 3-, and 5-year overall survival rates for the initial hepatic resection group and the initial TACE group were 70.6%, 35.3%, 23.9% and 67.2%, 26.0%, 18.9%, respectively (P = .26). Complication rates were significantly higher in the initial hepatic resection group than in the initial TACE group (P < .01). The 1-, 3-, and 5-year overall survival rates in patients who underwent initial TACE and subsequent hepatic resection were 92.3%, 67.3%, and 50.5%, respectively, which were significantly higher than rates in patients treated with initial hepatic resection (P = .04) but were not significantly higher than in patients who responded well to TACE but refused hepatic resection (P = .07). Tumor size was the independent risk factor for survival.

CONCLUSION

TACE might be a better initial treatment in patients with large, multiple, and resectable hepatocellular carcinomas; hepatic resection should be recommended to patients who respond well to TACE.

Expression and prognostic role of pan-Ras, Raf-1, pMEK1 and pERK1/2 in patients with hepatocellular carcinoma

AIMS

Ras/Raf/mitogen-activated protein kinase (MEK)/extracellular signal-regulated kinase (ERK) signaling cascades play important roles in the transmission of signals involved in apoptosis. Importantly, components of these pathways are aberrantly expressed in human cancer. However, there is limited data linking clinical outcomes with the aberrant expression of this pathway. The present study analyzed the prognostic values of pan-Ras, Raf-1, phosphorylated MEK1 (pMEK1) and phosphorylated ERK1/2 (pERK1/2) in hepatocellular carcinoma (HCC).

METHODS

Expression of pan-Ras, Raf-1, pMEK1 and pERK1/2 in 81 HCC patients who underwent curative resection was examined by immunohistochemical staining. Long-term survival after resection of patients according to the expression of pan-Ras, Raf-1, pMEK1 and pERK1/2 was assessed using univariate analysis and multiple Cox proportional hazards model.

RESULTS

In univariate analysis, patients with Raf-1 or pMEK1 overexpression had shorter disease-free survival (DFS) (P<0.05) and poorer overall survival (OS) (P<0.05) than groups with weak-expression of Raf-1 or pMEK1, respectively. Patients with pan-Ras overexpression had poorer overall survival (OS) (P<0.05) than the group with weak-expression of pan-Ras. Importantly, Raf-1 overexpression was a promising prognostic marker for poor survival according to multivariate Cox regression analysis (DFS, Hazard Ratio 1.807, P = 0.035; OS, Hazard Ratio 1.959, P = 0.044).

CONCLUSIONS

Raf-1 overexpression could be considered as an independent prognostic biomarker in HCC and may predict early tumor recurrence and death for HCC patients. It can be used to stratify patients at higher risk for poor prognosis and help to select the appropriate therapeutic regime of HCC.

Inconsistency in the Management of Patients with Hepatocellular Carcinoma: The Need for a Strict Protocol

As more therapies become available for the treatment of hepatocellular carcinoma (HCC), the management of patients with HCC is more complex, and the indications for the various therapeutic modalities are less clear. Although all of the treatment options have shown a certain efficacy in well-selected patient groups, their everyday use, especially in nonspecialized centers, is not always appropriate. We report our experience with 81 individuals who were diagnosed and treated in our institution between 2001 and 2007. Only patients who received transplants had good long-term outcomes, and we noted significant inconsistencies in the management of patients with similar stages of disease and degrees of cirrhosis. Despite recent progress, HCC still carries an overall dismal prognosis, making the optimization of the therapeutic plan mandatory to improve outcomes. We believe that a unified protocol, as well as the early involvement of the hepatology and transplant teams, can help physicians optimize the care of these patients.

[Radiological treatment of hepatocellular carcinoma in 2010]

Several radiological techniques have been used for treating hepatocellular carcinoma. These include transcatheter arterial chemoembolization (TACE) and percutaneous therapy, such as radiofrequency (RF). The treatment efficacy of radiofrequency for hepatocellular carcinoma has been confirmed by several randomized and non randomized studies, with a benefit in terms of morbidity comparatively to surgery when cirrhosis is present. Radiofrequency ablation treatment is based on tumour size, shape and location, with a defined strategy and a proper patient selection. We will also review indications and technical aspects of transcatheter arterial chemoembolization (TACE). It is an accepted worldwide and effective treatment for patients with unresectable large or multinodular hepatocellular carcinoma. It improves significantly survival for adequate selected patients with preservation of liver function.

A comparative study of the long-term outcomes after laparoscopy-assisted and open left lateral hepatectomy for hepatocellular carcinoma

BACKGROUND

Laparoscopic hepatectomy was initially reported in 1992. However, the reported experiences are scarce, and this operation has not been a standard procedure until now. The aims of this study were to assess our results of laparoscopy-assisted left lateral hepatectomy for hepatocellular carcinoma (HCC) and to compare them with those of open conventional procedures.

METHODS

From 1984 to 2002, left lateral hepatectomy for HCC less than 5 cm in diameter was carried out in 21 patients. Ten patients received a laparoscopy-assisted procedure, and remaining 11 patients received an open procedure.

RESULTS

There were no significant differences in the operation time, blood loss, resected liver weight, and resection margin between the 2 groups. The total time that analgesics were given, body temperature on postoperative day 1, weight loss on postoperative day 7, and postoperative hospital stay in the laparoscopic group were significantly better than in the conventional group. With regard to the long-term prognosis, there were no differences in patient survival or disease-free survival rates between the 2 groups.

CONCLUSIONS

Laparoscopy-assisted left lateral hepatectomy for HCC is superior to the conventional open surgery in terms of its short-term results and does not cause the long-term survival to deteriorate. Therefore, laparoscopic hepatectomy may be an alternative choice for treatment of HCC.

HBV-related HCC, clinical issues and therapy

Every year, more than 600 thousand persons will develop hepatocellular carcinoma (HCC) worldwide. Sixty percent of all HCCs in Asia and Africa are related to chronic infection with the hepatitis B virus (HBV) compared to only 20% of HCC cases in Europe, Japan and USA. Surveillance of chronically infected patients improves treatment of HCC, since it helps detecting tumors amenable to radical therapies. In cirrhotic patients, HCC can be confidently diagnosed by contrast imaging techniques, albeit the accuracy of radiological diagnosis is largely influenced by tumor size. Hepatic resection and liver transplantation are the first therapeutic options for patients within Milan criteria. The long-term outcome of resection, however, is affected by high risk of tumor recurrence, whereas liver transplantation has a negligible risk of both HBV and HCC recurrence-related anticipated mortality. The clinical benefits of loco-regional ablative techniques are evidence based for patients with less than 3 cm tumors only, whereas the standard of care for intermediate tumors, chemoembolization, needs to be validated in view of new technical improvements. Tertiary prevention of HCC in patients with established HBV infection is doubtful, mainly due to methodological weaknesses of studies based on interferon and nucleos(t)ide analogues therapy.

Survival rates are comparable after radiofrequency ablation or surgery in patients with small hepatocellular carcinomas

BACKGROUND & AIMS

Differences in efficacy of radiofrequency ablation (RFA) and surgical resection (SR) are not clear for patients with hepatocellular carcinoma (HCC).

METHODS

From 2002 to 2007, 419 patients with HCCs ≤5 cm were enrolled consecutively in the study. Among these patients, 190 and 229 patients received RFA and SR, respectively, as their first treatment. Factors were analyzed in terms of overall survival and recurrence by multivariate analysis and propensity score matching analysis.

RESULTS

The SR group had younger age, a higher male-to-female ratio, higher prevalence of hepatitis B virus, lower prevalence of hepatitis C virus, better liver function reserve, and larger tumor size than the RFA group. The cumulative 5-year overall survival rates were 79.3% in the SR group and 67.4% in the RFA group. During the follow-up period, tumors recurred in 244 patients in a median time of 14.5 ± 15.7 months. Before propensity-score matching, the RFA group had shorter overall survival time (P = .009) and higher tumor recurrence rate (P < .001) than the SR group. After matching, RFA was comparable to SR in overall survival time (P = .519), but the RFA group still had a greater incidence of tumor recurrence (P < .001). In patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 HCC, RFA was as effective as SR for overall survival time and recurrence.

CONCLUSIONS

Patients with small HCCs have a higher rate of tumor recurrence following RFA than surgery, but overall survival rates are comparable between therapies. RFA is as effective as surgery in patients with BCLC stage 0 HCC.

Meta-analysis of the therapeutic effect of hepatectomy versus radiofrequency ablation for the treatment of hepatocellular carcinoma

Surgical resection has been considered to be the best treatment for hepatocellular carcinoma (HCC). However, in recent years, there has been growing interest in the therapy of radiofrequency ablation (RFA). This meta-analysis is to evaluate the therapeutic effect of those 2 therapeutic methods. Outcomes evaluated were death rate, complications, survival rates, recurrence-free survival rates, and recurrence. Primary authors were contacted to retrieve further information if necessary. There is no significant difference in death rates of the treatment of HCC in the groups of hepatectomy and RFA, although the recurrence of HCC may be lower in the hepatectomy group. In the group of RFA, the recurrence rate in the previous site was higher but was lower in the new area, whereas it seems equal in the extrahepatic area. RFA may have comparable results with surgical resection in patients in the therapeutic effect of ablation for the treatment of HCC, if recurrence of HCC after RFA could be timely detected and effectively treated.

Transcatheter arterial chemoembolization for liver cancer: is it time to distinguish conventional from drug-eluting chemoembolization?

Conventional transcatheter arterial chemoembolization and chemoembolization with drug-eluting beads are increasingly being performed interchangeably in many institutions throughout the world. As both therapies continue to being tested in many phase II and III studies and in combination with other therapies, especially targeted agents, for treatment of primary and metastatic liver cancer, it is imperative to review their current status and evaluate their impact on patient survival. This review critically assesses patient selection, indications, contraindications, techniques, materials, safety, and clinical outcomes of patients treated with conventional chemoembolization and chemoembolization with drug-eluting beads.

Does Surgical Resection Have a Role in the Treatment of Large or Multinodular Hepatocellular Carcinoma?

Several effective treatments are available for patients with small solitary hepatocellular carcinomas (HCCs). Conversely, the management of patients with large or multinodular HCCs is controversial, and the role of surgical resection is not well defined. Between 2000 and 2006, 51 patients with large or multinodular HCC underwent liver resection. Clinicopathologic and follow-up data were prospectively collected and retrospectively reviewed. The perioperative and long-term outcomes were analyzed. Univariate and multivariate analysis of prognostic factors were conducted. Although 20 patients had multinodular HCCs, 31 had large solitary tumors. Perioperative mortality occurred in eight patients and complications in 15. In patients with large solitary tumors, 5-year disease-free and overall survival were 41.3 per cent and 56.1 per cent, respectively. Those with multinodular HCCs demonstrated 5-year disease-free and overall survival rates of 0 per cent and 33.6 per cent, respectively. Liver resection can result in long-term survival in select patients with large or multinodular HCCs, even in select patients with impaired liver function. Large solitary HCCs seem to have better prognoses than multinodular tumors, with lower recurrence and higher survival rates after surgery. Randomized controlled trials comparing resection to other treatment modalities are indicated to determine optimal patient management.

Report of the 18th follow-up survey of primary liver cancer in Japan

In the 18th Nationwide Follow-Up Survey of Primary Liver Cancer in Japan, 20 753 people were newly registered as patients with primary liver cancer at 544 medical institutions over a period of 2 years (from 1 January 2004 to 31 December 2005). Of these patients, 94.0% had hepatocellular carcinoma (HCC) and 4.4% had intrahepatic cholangiocarcinoma (ICC). In addition, 30 677 follow-up patients were registered in the survey. Epidemiological and clinicopathological factors, diagnosis and treatment were investigated in the newly registered patients. Compared with the 17th follow-up survey, this follow-up survey in HCC indicated an increase in elder patients and women, a decrease in patients positive for hepatitis B surface antigen and hepatitis C virus antibody, and a decrease in tumor size at the clinical diagnosis. In the local ablation therapy, ratio of radio frequency ablation therapy was increasing. The cumulative survival rates of newly-registered patients between 1994 and 2005 were calculated for each histological type (HCC, ICC, and combined HCC and ICC) and stratified by background factors and treatment. The cumulative survival rates of newly-registered patients between 1978 and 2005 divided into three groups (1978-1985, 1986-1995 and 1996-2005) were also calculated. The data obtained in this follow-up survey should contribute to future research and medical practice for primary liver cancer.

Postoperative adjuvant transarterial chemoembolization for participants with hepatocellular carcinoma: A meta-analysis

AIM

  The efficacy of transarterial chemoembolization (TACE) for inoperable hepatocellular carcinoma (HCC) is positive, but for postoperative HCC, many studies have reported controversial results. The present study aimed to evaluate the efficacy of postoperative adjuvant TACE for participants with HCC.

METHODS

  Electronic and manual searches were conducted to identify randomized controlled trials (RCT) evaluating postoperative adjuvant TACE for participants with HCC.

RESULTS

  Six RCT totaling 659 participants, of whom almost all were of stage IIIA HCC, were included. For the 1-year tumor recurrence rate, hepatectomy plus TACE showed statistically significant less incidence of recurrence, with a pooled risk ratio (RR) of 0.68 (95% confidence interval [CI] = 0.55-0.84, P = 0.0003). For 1-year mortality, the trials were favorable for TACE with a pooled risk ratio of 0.48 (95% CI = 0.35-0.65, P < 0.00001). For 3-year mortality, the trials also revealed statistically significant less incidence, with a pooled risk ratio of 0.76 (95% CI = 0.64-0.90, P = 0.002). However, for 5-year mortality, TACE did not demonstrate statistically significant less incidence (RR = 0.94, 95% CI = 0.81-1.08, P = 0.36). Transient fever and nausea/vomiting were reported as side-effects of TACE but were well tolerated by most participants.

CONCLUSION

  Postoperative adjuvant TACE seems promising for participants with HCC with risk factors (multiple nodules of >5 cm or vascular invasion) but requires further trial.

Perioperative management of hepatic resection toward zero mortality and morbidity: analysis of 793 consecutive cases in a single institution

BACKGROUND

The mortality rates associated with hepatectomy are still not zero. Our aim was to define the risk factors for complications and to evaluate our perioperative management.

STUDY DESIGN

Between 2001 and 2008, 793 consecutive patients (547 men and 246 women; mean age ± SD, 56.1 ± 14.9 years) underwent hepatectomy without gastrointestinal resection and choledocojejunostomy at our center. Of these patients, 354 (44.6%) were positive for the hepatitis B virus surface antigen and/or the hepatitis C virus antibody. We categorized 783 (98.7%) patients as Child-Pugh class A. Major resection (sectionectomy, hemihepatectomy, and extended hemihepatectomy), was performed in 535 patients (67.5%) and re-resection in 81 patients (10.2%).

RESULTS

The median operative time was 345.5 minutes and median blood loss was 360 mL. The rate of red blood cell transfusion was 6.8%. The morbidity rate was 15.6%. Reoperations were performed in 19 patients (2.4%). The mean postoperative hospital stay was 18.4 ± 10.4 days. The in-hospital mortality rate was 0.1% (1 of 793 patients; caused by hepatic failure). The independent relative risk for morbidity was influenced by an operative time of more than 360 minutes, blood loss of more than 400 mL, and serum albumin levels of less than 3.5 g/dL, as determined using multivariate logistic regression analysis.

CONCLUSIONS

Shorter operative times and reduced blood loss were obtained by improving the surgical technique and using new surgical devices and intraoperative management, including anesthesia. Additionally, decision making using our algorithm and perioperative management according to CDC guidelines reduced the morbidity and mortality associated with hepatectomy.

Proton beam therapy for hepatocellular carcinoma: a comparison of three treatment protocols

BACKGROUND

Our previous results for treatment of hepatocellular carcinoma (HCC) with proton beam therapy revealed excellent local control with low toxicity. Three protocols were used to avoid late complications such as gastrointestinal ulceration and bile duct stenosis. In this study, we examined the efficacy of these protocols.

METHODS AND MATERIALS

The subjects were 266 patients (273 HCCs) treated by proton beam therapy at the University of Tsukuba between January 2001 and December 2007. Three treatment protocols (A, 66 GyE in 10 fractions; B, 72.6 GyE in 22 fractions; and C, 77 GyE in 35 fractions) were used, depending on the tumor location.

RESULTS

Of the 266 patients, 104, 95, and 60 patients were treated with protocols A, B, and C, respectively. Seven patients with double lesions underwent two different protocols. The overall survival rates after 1, 3 and 5 years were 87%, 61%, and 48%, respectively (median survival, 4.2 years). Multivariate analysis showed that better liver function, small clinical target volume, and no prior treatment (outside the irradiated field) were associated with good survival. The local control rates after 1, 3, and 5 years were 98%, 87%, and 81%, respectively. Multivariate analysis did not identify any factors associated with good local control.

CONCLUSIONS

This study showed that proton beam therapy achieved good local control for HCC using each of three treatment protocols. This suggests that selection of treatment schedules based on tumor location may be used to reduce the risk of late toxicity and maintain good treatment efficacy.