Microvascular Invasion Is a Better Predictor of Tumor Recurrence and Overall Survival Following Surgical Resection for Hepatocellular Carcinoma Compared to the Milan Criteria

Strategic overview on the best treatment option for intrahepaitc hepatocellular carcinoma recurrence

INTRODUCTION

The long-term survival after hepatectomy for HCC remains unsatisfactory because of the high incidence of recurrence. The cumulative 5-year recurrence rate ranged from 60-100% in previous studies and majority of them remains intrahepatic recurrence. The therapeutic modalities commonly used for primary tumors, including surgical resection, liver transplantation, TACE, local ablative therapy and radiotherapy have been used to treat recurrent tumors in the liver remnant and the outcomes with the heterogeneous therapeutic options are reviewed. It is important to note that the level of evidence for most therapeutic options is limited to cohort investigations with few RCTs and most were limited due to enrollment of various tumor stages and did not compare treatment modalities for specific tumor stages.

AREAS COVERED

A literature search for recurrent HCC was performed using Medline and PubMed up to May 2016. Expert commentary: The long term survival results after re-resection for recurrent HCC were favourable and aggressive management of postoperative intrahepatic recurrence remains the most important strategy in prolonging the survival of patients after resection of HCC.

A simple prognostic score system predicts the prognosis of solitary large hepatocellular carcinoma following hepatectomy

Solitary large hepatocellular carcinomas (SLHCC) form a heterogeneous group of patients with different survival probabilities. The aim of our study was to develop a simple prognostic index for identifying prognostic subgroups of SLHCC patients.A retrospective analysis of clinical data from 268 patients with operable SLHCC was conducted to investigate prognostic factors and to construct a score system based on risk factors. A Cox proportional hazard regression analysis was used to evaluate the variables associated with prognosis. Survival analyses were performed using Kaplan-Meier survival curves.Three variables remained in the final multivariate model: platelet to lymphocyte ratio (PLR), microvascular invasion (MVI), and tumor size with hazard ratios equal to 1.004 (95% confidence interval: 1.001-1.006), 1.092 (1.044-1.142), and 2.233 (1.125-2.233), respectively. A score of 1 was assigned to each risk factor. Patient scores were determined based on these risk factors; thus, the scores ranged between 0 and 3. Ultimately, three categories (0, 1-2, 3) were defined. Patients with scores of 3 had a 5-year survival rate of 25.4%, whereas patients with a score of 0 had a 5-year survival rate of 52.1%. The prognosis significantly worsened as the score increased. Similar results were found among cirrhotic and noncirrhotic patients.Our simple prognostic index successfully predicts SLHCC survival.

Impact of Visceral Obesity on Microvascular Invasion in Hepatocellular Carcinoma

BACKGROUND

Our objective was to determine whether visceral obesity is associated with increased microvascular invasion (MVI) in patients surgically treated for hepatocellular carcinoma (HCC).

METHODS

Data were collected retrospectively in a series of 79 patients treated by surgical resection for HCC, using CT-scan for evaluation of visceral obesity.

RESULTS

There was no significant association between visceral obesity and MVI (OR = 1.20 (0.38-3.75), p = 0.75). Independent predictive factors of MVI were moderate/poor differentiation, tumor size above 50 mm and underlying cirrhosis.

CONCLUSION

This study did not support the hypothesis that visceral obesity might promote MVI in patients with HCC.

Significance of neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio and prognostic nutrition index as preoperative predictors of early mortality after liver resection for huge (≥10 cm) hepatocellular carcinoma

Background

This study aimed to determine preoperative predictors of early (<1 year) mortality from disease recurrence after liver resection (LR) for huge (≥10 cm) HCC, with special emphasis on the importance of neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and prognostic nutrition index (PNI).

Methods

Between 2000 to 2013, 166 patients underwent LR for huge HCC. Optimal cut‐offs for alpha fetoprotein (AFP), NLR, PLR, and PNI were determined by plotting the receiver operator curves (ROC) in predicting early mortality and utilizing the Youden index.

Results

The 30‐day/in‐hospital postoperative mortality rate was 4.2%. The 5‐year overall survival (OS) and the 5‐year recurrence‐free survival (RFS) was 43% and 24%, respectively. Early mortality from disease recurrence occurred in 35 of 159 (22%) patients. Multivariate analyses demonstrated that tumor rupture and high AFP (>1,085 ng/ml) were independent preoperative predictors of early mortality after LR for HCC, and both a low PNI (<41) and high AFP were independent predictors of early mortality for non‐ruptured HCC. In 51 patients who had none of these three factors, only four (7.8%) patients experienced early mortality from disease recurrence.

Conclusions

Spontaneous rupture, high AFP, and low PNI were predictors of early mortality from disease recurrence after LR for huge HCC.J. Surg. Oncol. 2016;113:621–627. © 2016 Wiley Periodicals, Inc.

A Preoperative Measurement of Serum MicroRNA-125b May Predict the Presence of Microvascular Invasion in Hepatocellular Carcinomas Patients

The high recurrence rate remains a major problem that strongly influenced the prognosis of hepatocellular carcinoma (HCC) patients who received hepatectomy. The presence of microvascular invasion (MVI) is regarded as the most important risk factor that contributes to the postoperative recurrence. Our previous study has hinted that serum microRNA-125b (miR-125b) was associated with MVI. The aim of the present study was to identify whether serum miR-125b can serve as a biomarker to reliably predict microvascular invasion (MVI) preoperatively. MiR-125b was quantified in 108 HCC patients’ serum before they received surgery by quantitative real-time PCR (qRT-PCR). Our results revealed that MVI was associated with relapse free survival (RFS) of postoperative HCC patients; surgical margin width was associated with postoperative RFS in MVI present patients, but not in the patients without MVI. Multivariate analysis revealed that miR-125b, tumor size and AFP were the independent predictive factors associated with MVI in this cohort (P = .001, .001, .003, respectively). The probability of the predictive accuracy of miR-125b was 76.95% (51.32% specificity and 87.50% sensitivity), which was almost equal to the classifier established by combination of AFP and tumor size (78.82% probability, 65.63% specificity and 84.21% sensitivity). Furthermore, the combination of tumor size, AFP and miR-125b yielded a ROC curve area of 86.68% (72.37% specificity and 84.38% sensitivity). Our study indicated that serum miR-125b can be used to predict MVI of HCC patients before they received hepatic resection. Therefore, miR-125b can potentially guide individualized treatment, which helps HCC patients, with or without MVI, to benefit from different surgical approach.

National Cancer Centre Singapore Consensus Guidelines for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world, but the second most common cause of cancer death. There is no universally accepted consensus practice guidelines for HCC owing to rapid developments in new treatment modalities, the heterogeneous epidemiology and clinical presentation of HCC worldwide. However, a number of regional and national guidelines currently exist which reflect practice relevant to the epidemiology and collective experience of the consensus group. In 2014, clinicians at the multidisciplinary Comprehensive Liver Cancer Clinic (CLCC) at the National Cancer Centre Singapore (NCCS) reviewed the latest published scientific data and existing international and regional practice guidelines, such as those of the National Comprehensive Cancer Network, American Association for the Study of Liver Diseases and the Asian Pacific Association for the Study of the Liver, and modified them to reflect local practice. These would serve as a template by which treatment outcomes can be collated and benchmarked against international data. The NCCS Consensus Guidelines for HCC have been successfully implemented in the CLCC since their publication online on 26(th) September 2014, and the guidelines allow outcomes of treatment to be compared to international data. These guidelines will be reviewed periodically to incorporate new data.

Nomograms for Pre-operative and Post-operative Prediction of Long-Term Survival of Patients Who Underwent Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma

BACKGROUND

Repeat hepatectomy (re-hepatectomy) is an effective treatment for patients with intrahepatic recurrence following liver resection for hepatocellular carcinoma (HCC).

OBJECTIVE

This study aimed to develop nomograms for predicting prognosis after re-hepatectomy.

METHODS

The data of 635 patients who underwent re-hepatectomy for recurrent HCC at the Eastern Hepatobiliary Surgery Hospital between 2004 and 2010 were prospectively collected. Multivariable Cox regression analyses based on data obtained before and after re-hepatectomy were performed to select independent predictors of recurrence to death survival (RTDS) which were incorporated into the pre- or post-re-hepatectomy nomograms. Discrimination and calibration of the nomograms were measured using the concordance index (C-index), Kaplan-Meier curves, and calibration plots.

RESULTS

The 1-, 3- and 5-year overall survival rates were 96.9, 74.8, and 47.8 %, respectively, and the corresponding RTDS rates were 75.8, 45.7, and 37.6 %, respectively. Tumor size and number at the initial and recurrent stages, time to recurrence from the initial hepatectomy, hepatitis B virus deoxyribonucleic acid level and microvascular invasion were selected into the two nomograms. The C-indexes for predicting RTDS were 0.72 [95 % confidence interval (CI) 0.70-0.74] and 0.77 (95 % CI 0.74-0.80) for the pre- or post-re-hepatectomy nomograms, respectively. The calibration curves for the probability of 5-year RTDS after re-hepatectomy showed optimal agreement between the prediction shown in the nomograms and the actual observations. Both nomograms were able to accurately stratify patients into four distinct incremental prognostic subgroups.

CONCLUSION

The proposed nomograms have shown accurate RTDS prediction for patients with intrahepatic recurrent HCC.

Importance of tumor size as a prognostic factor after partial liver resection for solitary hepatocellular carcinoma: Implications on the current AJCC staging system

Background

Presently, the impact of tumors size as a prognostic factor after curative liver resection (LR) for solitary hepatocellular carcinoma (HCC) remains controversial. This study was performed to determine the prognostic factors of patients undergoing LR for solitary HCC with special emphasis on the importance of tumor size.

Methods

Between 2000 and 2013, 560 patients underwent curative LR for solitary primary HCC which met the study criteria.

Results

One‐hundred and seventy‐eight patients underwent major hepatectomies and the overall in‐hospital mortality was 2.0%. There were 282 patients (50.4%) with liver cirrhosis. The 5‐year overall survival (OS) was 64% and recurrence free survival (RFS) was 50%, respectively. Multivariate analyses demonstrated that cirrhosis, microvascular invasion and size were independent predictors of RFS and cirrhosis, microvascular invasion and age were independent prognostic factors of OS. Subset analysis demonstrated that tumor size was a prognostic factor for solitary HCC with microvascular invasion (AJCC T2) but not solitary HCC without microvascular invasion (AJCC T1).

Conclusions

Size, microvascular invasion, and cirrhosis are independent prognostic factors of RFS for solitary HCC after LR. Tumor size is an important prognostic factor in T2 but not T1 solitary tumors. These findings suggest that the current AJCC TNM staging system may need to be revised. J. Surg. Oncol. 2016;113:89–93. © 2015 Wiley Periodicals, Inc.

Postoperative Adjuvant Transcatheter Arterial Chemoembolization After R0 Hepatectomy Improves Outcomes of Patients Who have Hepatocellular Carcinoma with Microvascular Invasion

BACKGROUND

Microvascular invasion (MiVI) is a major risk factor of survival outcomes after curative resection for patients with hepatocellular carcinoma (HCC). This study aimed to investigate the impact of postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE) on HCC patients with MiVI.

METHODS

From January 2004 to June 2013, HCC patients with histologically confirmed MiVI and well-tolerated liver function who underwent PA-TACE after R0 hepatectomy (RH) or RH alone were studied retrospectively. In the PA-TACE group, PA-TACE was given 4 weeks after RH. Uni- and multivariate analyses were used to identify the prognostic significance of PA-TACE.

RESULTS

Of the 322 HCC patients with MiVI included in the analysis, 185 entered into the RH group and 137 entered into the PA-TACE group. The baseline characteristics of the two groups were similar except for alanine aminotransferase (ALT) level (p = 0.037). The 1-, 2-, 3-, and 5-year recurrence-free survival (RFS) rates were respectively 69.3, 55.5, 46.7, and 35.0 % for the PA-TACE group and 47.0, 36.2, 34.1, and 30.3 % for the RH group (log-rank, χ(2) = 6.309; p = 0.012). The 1-, 2-, 3-, and 5-year overall survival (OS) rates were respectively 94.2, 78.8, 71.5, and 54.0 % for the PA-TACE group and 78.9, 62.2, 54.1, and 43.2 % for the RH group (log-rank, χ(2) = 7.537; p = 0.006). Multivariate Cox proportional hazards regression analysis showed PA-TACE to be an independent risk factor of postoperative RFS and OS.

CONCLUSIONS

This study showed that PA-TACE may be beneficial for HCC patients with MiVI.

Can Current Preoperative Imaging Be Used to Detect Microvascular Invasion of Hepatocellular Carcinoma?

PURPOSE

To determine the accuracy of imaging features, such as tumor dimension, multinodularity, nonsmooth tumor margins, peritumoral enhancement, and radiogenomic algorithm based on the association between imaging features (internal arteries and hypoattenuating halos) and gene expression that the authors called two-trait predictor of venous invasion (TTPVI), in the prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This single-center retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. One hundred twenty-five patients (median age, 63 years; interquartile range, 53-71 years) with a diagnosis of HCC and indications for hepatic resection were included. Two observers independently reviewed radiologic images to evaluate the following features for MVI: maximum diameter, number of lesions, tumor margins, TTPVI, and peritumoral enhancement. Interobserver agreement was checked, and diagnostic accuracy of radiologic features was investigated.

RESULTS

The total number of HCC nodules was 140. Large tumor size, nonsmooth tumor margins, TTPVI, and peritumoral enhancement were significantly related to the presence of MVI (P < .05 in all cases and for both observers). Multinodularity was not significantly related (P = .158). Moreover, the diagnostic accuracy of the three "worrisome" radiologic features (nonsmooth tumor margins, peritumoral enhancement, and TTPVI) was associated with tumor size: The negative predictive value of the absence of worrisome features decreased from 0.84 for observer 1 and 0.91 for observer 2 for tumors smaller than 2 cm to 0.56 and 0.71, respectively, for tumors larger than 5 cm, whereas the presence of all three worrisome features returned to a positive predictive value of 0.95 for observer 1 and 0.96 for observer 2 independent of tumor size, with no significant interobserver differences (P > .10).

CONCLUSION

"Worrisome" imaging features, such as tumor dimension, nonsmooth tumor margins, peritumoral enhancement, and TTPVI, have high accuracy in the prediction of MVI in HCC.

Excessive intraoperative blood loss independently predicts recurrence of hepatocellular carcinoma after liver transplantation

Background

Several studies have investigated the effect of intraoperative blood loss (IBL) on recurrence of tumors. However, the independent effect of IBL on oncological outcome after liver transplantation (LT) for hepatocellular carcinoma (HCC) is unclear.

Methods

A total of 479 patients who underwent LT for HCC from January 2001 to December 2012 at our institution were enrolled in this retrospective study. Kaplan–Meier and Cox regression methods were used to assess the recurrence rate, as well as its risk factors. Stratified analysis was performed to further examine the effect of IBL on HCC recurrence according to different characteristics of tumors. We also investigated the independent risk factors for excessive IBL using logistic regression analysis.

Results

The median follow-up was 28 months (range, 1–131 months). Kaplan–Meier analysis with the log-rank test according to IBL at per liter intervals showed that IBL > 4 L was significantly associated with a higher recurrence rate (P < 0.001). Multivariate analysis identified that IBL > 4 L (P < 0.001; hazard ratio [HR] = 2.32, 95 % confidence interval [CI] = 1.60–3.36) was an independent risk factor for post-LT HCC recurrence, as well as age < 60 years, exceeding Milan criteria, α-fetoprotein levels > 400 ng/mL, and micro- and macrovascular invasion. IBL > 4 L (P < 0.001; HR = 2.45, 95 % CI = 1.64–3.66) was also independently associated with early (within 1 year) recurrence after LT. Furthermore, a significant correlation between IBL > 4 L and vascular invasion (P = 0.019) was found. IBL > 4 L was independently associated with HCC recurrence for patients with vascular invasion, but not for patients without vascular invasion. Finally, we found that the presence of ascites, model for end-stage liver disease score, and operation time were independent risk factors for IBL > 4 L.

Conclusions

Excessive IBL is an independent predictor of HCC recurrence after LT, especially in patients with vascular invasion.

A computed tomography radiogenomic biomarker predicts microvascular invasion and clinical outcomes in hepatocellular carcinoma

Microvascular invasion (MVI) in hepatocellular carcinoma (HCC) is an independent predictor of poor outcomes subsequent to surgical resection or liver transplantation (LT); however, MVI currently cannot be adequately determined preoperatively. Radiogenomic venous invasion (RVI) is a contrast-enhanced computed tomography (CECT) biomarker of MVI derived from a 91-gene HCC "venous invasion" gene expression signature. Preoperative CECTs of 157 HCC patients who underwent surgical resection (N = 72) or LT (N = 85) between 2000 and 2009 at three institutions were evaluated for the presence or absence of RVI. RVI was assessed for its ability to predict MVI and outcomes. Interobserver agreement for scoring RVI was substantial among five radiologists (κ = 0.705; P < 0.001). The diagnostic accuracy, sensitivity, and specificity of RVI in predicting MVI was 89%, 76%, and 94%, respectively. Positive RVI score was associated with lower overall survival (OS) than negative RVI score in the overall cohort (P < 0.001; 48 vs. >147 months), American Joint Committee on Cancer tumor-node-metastasis stage II (P < 0.001; 34 vs. >147 months), and in LT patients within Milan criteria (P < 0.001; 69 vs. >147 months). Positive RVI score also portended lower recurrence-free survival at 3 years versus negative RVI score (P = 0.001; 27% vs. 62%).

CONCLUSION

RVI is a noninvasive radiogenomic biomarker that accurately predicts histological MVI in HCC surgical candidates. Its presence on preoperative CECT is associated with early disease recurrence and poor OS and may be useful for identifying patients less likely to derive a durable benefit from surgical treatment.

New Pathologic Stratification of Microvascular Invasion in Hepatocellular Carcinoma: Predicting Prognosis After Living-donor Liver Transplantation

BACKGROUND

Vascular invasion of hepatocellular carcinoma (HCC) has a high incidence of recurrence after liver transplantation. Patients with microvascular invasion (MVI) show a high tumor grade; however, some show a good prognosis. This retrospective study aimed to investigate whether the degree of MVI affects prognosis after living-donor liver transplantation.

METHODS

A total of 142 patients with HCC who had undergone living-donor liver transplantation were histologically evaluated about the number of invaded vessels and the maximum number of invading carcinoma cells. Patients with MVI were classified into two subgroups: high MVI group (n = 38), which showed more than 50 carcinoma cells in the vessels, with multiple invaded vessels; and low MVI group (n = 17), which showed MVI, but not high MVI.

RESULTS

Analysis of recurrence-free survival showed that high MVI group had significantly poorer outcomes than the other groups (P < 0.001). High MVI group had significantly higher α-fetoprotein levels, des-γ-carboxy prothrombin levels, number of tumors, a larger tumor size, and a higher percentage of poorly differentiated HCC than non-MVI group. High MVI was an independent prognostic factor for recurrence-free survival (P = 0.030). Among patients exceeding the Milan criteria (n = 61), high MVI group had significantly poorer outcomes than the other groups for recurrence-free survival (P = 0.003). Patients in high MVI group had significantly higher des-γ-carboxy prothrombin levels and a larger tumor size than non-MVI group. High MVI was an independent prognostic factor for recurrence-free survival (P = 0.014).

CONCLUSION

In living-donor liver transplantation for HCC, high MVI is a novel pathologic marker for predicting prognosis.

Prognostic Nomograms for Pre- and Postoperative Predictions of Long-Term Survival for Patients Who Underwent Liver Resection for Huge Hepatocellular Carcinoma

BACKGROUND

Liver resection is an effective treatment in select patients with huge hepatocellular carcinoma (HCC, diameter ≥10 cm). This study aimed to develop nomograms for pre- and postoperative predictions of overall survival (OS) for these patients.

STUDY DESIGN

There were 464 consecutive patients who underwent liver resection for huge HCC at the Eastern Hepatobiliary Surgery Hospital (EHBH) between January 2008 and December 2009. They were collected and divided into a training cohort (n = 310) and an internal validation cohort (n = 154). Another 90 patients who were operated on at the Fujian Medical University (FMU) between January 2008 and April 2010 served as an external validation cohort. The surgical morbidity, mortality, time to recurrence, and OS were observed. Two prognostic nomograms were developed based separately on the data obtained before and after surgery. Discrimination and predictive accuracy of the models were measured using concordance index (C-index), calibration curves, and validation study.

RESULTS

The postoperative 4-year tumor recurrence and OS rates were, respectively, 79.0% and 41.2% in the patients from the EHBH and 78.8% and 37.6% in those from the FMU. Independent predictors of OS on multivariable analysis using pre- and postoperative data were respectively incorporated into the 2 nomograms. In the training cohort, calibration curves for the probability of 4-year postoperative survival fitted well. The C-indexes of the pre- and postoperative nomograms in predicting OS were 0.75 (95% CI 0.72 to 0.78) and 0.78 (95% CI 0.75 to 0.81), respectively. The internal and external validation studies optimally supported these results.

CONCLUSIONS

The 2 nomograms achieved accurate pre- or postoperative predictions of long-term survival for patients with huge HCC after liver resection.

Establishment and Validation of SSCLIP Scoring System to Estimate Survival in Hepatocellular Carcinoma Patients Who Received Curative Liver Resection

BACKGROUND AND AIMS

There is no prognostic model that is reliable and practical for patients who have received curative liver resection (CLR) for hepatocellular carcinoma (HCC). This study aimed to establish and validate a Surgery-Specific Cancer of the Liver Italian Program (SSCLIP) scoring system for those patients.

METHODS

668 eligible patients who underwent CLR for HCC from five separate tertiary hospitals were selected. The SSCLIP was constructed from a training cohort by adding independent predictors that were identified by Cox proportional hazards regression analyses to the original Cancer of the Liver Italian Program (CLIP). The prognostic performance of the SSCLIP at 12 and 36-months was compared with data from existing models. The patient survival distributions at different risk levels of the SSCLIP were also assessed.

RESULTS

Four independent predictors were added to construct the SSCLIP, including age (HR = 1.075, 95%CI: 1.019-1.135, P = 0.009), albumin (HR = 0.804, 95%CI: 0.681-0.950, P = 0.011), prothrombin time activity (HR = 0.856, 95%CI: 0.751-0.975, P = 0.020) and microvascular invasion (HR = 19.852, 95%CI: 2.203-178.917, P = 0.008). In both training and validation cohorts, 12-month and 36-month prognostic performance of the SSCLIP were significantly better than those of the original CLIP, model of end-stage liver disease-based CLIP, Okuda and Child-Turcotte-Pugh score (all P < 0.05). The stratification of risk levels of the SSCLIP showed an enhanced ability to differentiate patients with different outcomes.

CONCLUSIONS

A novel SSCLIP to predict survival of HCC patients who received CLR based on objective parameters may provide a refined, useful prognosis algorithm.

Significance of platelet count and platelet-based models for hepatocellular carcinoma recurrence

AIM

To explore the effects of platelet count (PLT) and 11 platelet-based indices on postoperative recurrence of hepatocellular carcinoma (HCC).

METHODS

We retrospectively analyzed 172 HCC patients who were treated by partial hepatectomy. Preoperative data, including laboratory biochemical results, were used to calculate the 11 indices included in the analysis. We performed receiver operating characteristic curve analysis to determine the optimal cut-off values for predicting recurrence. Cumulative rates of HCC recurrence were calculated using Kaplan-Meier survival curves and differences were analyzed by log-rank tests. Multivariate analyses were performed to identify independent predictors of recurrence, early recurrence (within one year after surgery), and late recurrence in HCC. To obtain better prognostic models, PLT-based indices were analyzed separately after being expressed as binary and continuous variables. Two platelet-unrelated, validated HCC prognostic models were included in the analyses as reference indices. Additional analyses were performed after patients were stratified based on hepatitis B virus infection status, cirrhosis, and tumor size to investigate the significance of platelets in different subgroups.

RESULTS

In the study cohort, 44.2% (76/172) of patients experienced HCC recurrence, and 50.6% (87/172) died during a median follow-up time of 46 mo. PLT and five of the 11 platelet-related models were significant predisposing factors for recurrence (P < 0.05). Multivariate analysis indicated that, among the clinical parameters, presence of ascites, PLT ≥ 148 × 10(9)/L, alkaline phosphatase ≥ 116 U/L, and tumor size ≥ 5 cm were independently associated with a higher risk of HCC recurrence (P < 0.05). Independent and significant models included the aspartate aminotransferase/PLT index, fibrosis index based on the four factors, fibro-quotient, aspartate aminotransferase/PLT/γ-glutamyl transpeptidase/alpha-fetoprotein index, and the PLT/age/alkaline phosphatase/alpha-fetoprotein/aspartate aminotransferase index. There were different risk factors between early and late recurrences, and PLT and these indices were more inclined to influence late recurrence. PLT was only predictive of recurrence in non-cirrhotic HCC patients, and was not influenced by tumor size, which was a critical confounder in our study.

CONCLUSION

PLT and PLT-based noninvasive models are effective tools for predicting postoperative recurrence, especially late recurrence. Larger cohorts are needed to validate our findings.

Risk factors and management for early and late intrahepatic recurrence of solitary hepatocellular carcinoma after curative resection

BACKGROUND

Intrahepatic recurrence is a significant problem for patients who have undergone a hepatic resection for hepatocellular carcinoma (HCC). The objective of the present study was to identify risk factors and evaluate the management of early and late recurrence of solitary HCC after curative resection.

METHODS

Included in this study were 816 patients with solitary HCC who underwent a curative partial hepatectomy. Intrahepatic recurrence in these patients was followed up retrospectively. Prognosis and therapy for the recurrence were investigated and analysed.

RESULTS

Early and late intrahepatic recurrence occurred in 423 patients and 199 patients, respectively. Multivariate analysis showed that a tumour diameter >5 cm, the absence of a tumour capsule and the presence of microvascular invasion were correlated with early recurrence, whereas cirrhosis and alpha-fetal protein >400 μg/l were independent risk factors contributing to late recurrence. The 5-year survival of HCC patients with early recurrence was significantly lower than that of patients with late recurrence. Further curative treatment for intrahepatic recurrence offered a 5-year overall survival of 56.0%, which was better than alternative management.

CONCLUSION

Early and late recurrences of solitary HCC after curative resection are associated with different predictive factors. The time to recurrence and further curative treatment after recurrence were the best predictors of survival post recurrence.

High Levels of Gamma-Glutamyl Transferase and Indocyanine Green Retention Rate at 15 min as Preoperative Predictors of Tumor Recurrence in Patients With Hepatocellular Carcinoma

This study investigated the preoperative independent risk factors associated with survival and recurrence for patients with hepatocellular carcinoma (HCC) who underwent hepatic resection. In total, 384 consecutive patients who underwent curative hepatic resection for single primary HCC were studied. Predictive factors associated with 1-, 3-, and 5-year survival and recurrence-free survival (RFS) were assessed using a univariate log-rank test and multivariate Cox proportional hazards regression model. Gamma-glutamyl transferase (GGT) > 100 U/L was identified as a preoperative independent risk factor affecting 1-, 3-, and 5-year survival whereas GGT > 50 U/L and indocyanine green retention 15 min (ICG-R15) > 10% were identified as preoperative independent risk factors affecting 1-, 3-, and 5-year RFS. The 384 patients studied had a 1-, 3-, and 5-year RFS rate of 72.8%, 43.3%, and 27%, respectively. Patients with GGT > 50 U/L had a 1-, 3-, and 5-year RFS rate of 64.5%, 36.0%, and 21.7%. These patients had lower survival rates than did patients with GGT ≤ 50 U/L (P < 0.05). Patients with GGT > 50 U/L and ICG-R15 > 10% had a 1-, 3-, and 5-year RFS rate of 62.4%, 29.5%, and 14.1%, respectively. These patients had lower survival rates than did patients in the other 2 groups with different levels of GGT and ICG (P < 0.05, respectively). The same was also true for patients with a tumor < 5 cm in size. Combined information in the form of high levels of GGT and ICG-R15 is a preoperative predictor that warrants full attention when evaluating tumor recurrence postoperatively.

Early and resectable HCC: Definition and validation of a subgroup of patients who could avoid liver transplantation

BACKGROUND

Liver transplantation (LT) remains the best curative option for early hepatocellular carcinoma (HCC) but is limited by the ongoing graft shortage. The present study aimed at defining the population in which primary liver resection (LR) could represent the best alternative to LT.

METHODS

An exploration set of 357 HCC patients (LR n = 221 and LT n = 136) operated between 2000-2012 was used in order to identify factors associated with survival following LR and define a good prognosis (GP) group for which LR may challenge the results of upfront LT. These factors were validated in an external validation set of 565 HCC patients operated at another center (LR n = 287 LR and LT n = 278).

RESULTS

In the exploration set, factors associated with survival on multivariate analysis were a solitary lesion, a diameter <50 mm, a well-moderately differentiated lesion, the absence of microvascular invasion, and preoperative AST level <2N. Thirty-nine patients (18%) displayed all these criteria and constituted the GP patients. Overall survivals at 1, 3, and 5 years did not significantly differ between GP resected patients, and the in Milan transplanted patients (93, 80.4, and 80.4% vs. 86.9, 82, and 78.8%, P = 0.79). In the validation cohort, patients with GP factors of survival still displayed better overall survivals than those without (P = 0.036) but also displayed better survivals than in Milan HCC transplanted patients (P = 0.005).

CONCLUSION

In a group of early HCC patients gathering all factors of GP, primary LR achieves at least similar survival as upfront LT and should be the approach of choice.

Vascular invasion in hepatitis B virus-related hepatocellular carcinoma with underlying cirrhosis: possible associations with ascites and hepatitis B viral factors?

Vascular invasion is one of the most important prognostic factors for patients with hepatocellular carcinoma (HCC). The objective of the current, retrospective study was to determine the associations of ascites and hepatitis B viral factors (HBeAg and anti-HBe status and HBV DNA levels), as well as tumor-related factors (size, tumor number, grade, and location) with micro- or macroscopic vascular invasion in patients with HCC that developed as a result of hepatitis B virus (HBV)-related cirrhosis. A total of 336 consecutive patients were included. Potential factors associated with micro- or macroscopic vascular invasion were analyzed by logistic regression. Ascites were more commonly detected in patients with micro- or macroscopic vascular invasion, and the presence of ascites was independently associated with vascular invasion. Among patients with mild-to-moderate or severe ascites, the odds ratio for macroscopic vascular invasion was 4.83 (95 % confidence interval [CI] 2.29-10.16) and 11.87 (95 % CI 4.53-31.07), respectively. Similarly, the presence of ascites was associated with microscopic vascular invasion (OR 5.00; 95 % CI 1.23-20.31). In contrast, hepatitis B viral factors were not significantly associated with vascular invasion. The presence of ascites was associated with vascular invasion in patients with HBV-related cirrhotic HCC. Thus, patients with ascites, vascular invasion should be considered and more frequent surveillance should be performed after curative treatment.

Circulating tumor cells in hepatocellular carcinoma: a pilot study of detection, enumeration, and next-generation sequencing in cases and controls

Background

Circulating biomarkers are urgently needed in hepatocellular carcinoma (HCC). The aims of this study were to determine the feasibility of detecting and isolating circulating tumor cells (CTCs) in HCC patients using enrichment for epithelial cell adhesion molecule (EpCAM) expression, to examine their prognostic value, and to explore CTC-based DNA sequencing in metastatic HCC patients compared to a control cohort with non-malignant liver diseases (NMLD).

Methods

Whole blood was obtained from patients with metastatic HCC or NMLD. CTCs were enumerated by CellSearch then purified by immunomagnetic EpCAM enrichment and fluorescence-activated cell sorting. Targeted ion semiconductor sequencing was performed on whole genome-amplified DNA from CTCs, tumor specimens, and peripheral blood mononuclear cells (PBMC) when available.

Results

Twenty HCC and 10 NMLD patients enrolled. CTCs ≥ 2/7.5 mL were detected in 7/20 (35%, 95% confidence interval: 12%, 60%) HCC and 0/9 eligible NMLD (p = 0.04). CTCs ≥ 1/7.5 mL was associated with alpha-fetoprotein ≥ 400 ng/mL (p = 0.008) and vascular invasion (p = 0.009). Sequencing of CTC DNA identified characteristic HCC mutations. The proportion with ≥ 100x coverage depth was lower in CTCs (43%) than tumor or PBMC (87%) (p < 0.025). Low frequency variants were higher in CTCs (p < 0.001).

Conclusions

CTCs are detectable by EpCAM enrichment in metastatic HCC, without confounding false positive background from NMLD. CTC detection was associated with poor prognostic factors. Sequencing of CTC DNA identified known HCC mutations but more low-frequency variants and lower coverage depth than FFPE or PBMC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1195-z) contains supplementary material, which is available to authorized users.

Ischemia time impacts recurrence of hepatocellular carcinoma after liver transplantation

Although experimental evidence has indicated that ischemia-reperfusion (I/R) injury of the liver stimulates growth of micrometastases and adhesion of tumor cells, the clinical impact of I/R injury on recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) has not been fully investigated. To study this issue, we conducted a retrospective review of the medical records of 391 patients from two transplant centers who underwent LT for HCC. Ischemia times along with other tumor/recipient variables were analyzed as risk factors for recurrence of HCC. Subgroup analysis focused on patients with HCC who had pathologically proven vascular invasion (VI) because of the associated increased risk of micrometastasis. Recurrence occurred in 60 patients (15.3%) with median time to recurrence of 0.9 years (range, 40 days-4.6 years). Cumulative recurrence curves according to cold ischemia time (CIT) at 2-hour intervals and warm ischemia time (WIT) at 10-minute intervals showed that CIT>10 hours and WIT>50 minutes were associated with significantly increased recurrence (P=0.015 and 0.036, respectively). Multivariate Cox's regression analysis identified prolonged cold (>10 hours; P=0.03; hazard ratio [HR]=1.9) and warm (>50 minutes; P=0.003; HR=2.84) ischemia times as independent risk factors for HCC recurrence, along with tumor factors, including poor differentiation, micro- and macrovacular invasion, exceeding Milan criteria, and alpha-fetoprotein>200 ng/mL. Prolonged CIT (P=0.04; HR=2.24) and WIT (P=0.001; HR=5.1) were also significantly associated with early (within 1 year) recurrence. In the subgroup analysis, prolonged CIT (P=0.01; HR=2.6) and WIT (P=0.01; HR=3.23) were independent risk factors for recurrence in patients with VI, whereas there was no association between ischemia times and HCC recurrence in patients with no VI.

CONCLUSION

Reducing ischemia time may be a useful strategy to decrease HCC recurrence after LT, especially in those with other risk factors.

Combined AFP-CRUT with microvascular invasion accurately predicts mortality risk in patients with hepatocellular carcinoma following curative liver resection

AIMS

To establish and validate an equation of α-fetoprotein (AFP) change rate over unit time (AFP-CRUT) as a potential predictor of survival after resection in patients with hepatocellular carcinoma (HCC).

METHODS

The AFP-CRUT was constructed based on dynamic variation in AFP over time and then categorized into quintiles. The area under the receiver operating characteristic (ROC) curve showed the performance for survival prediction.

RESULTS

As independent risk factors associated with mortality, microvascular invasion (MVI) (p = 0.003) and AFP-CRUT quintiles (p = 0.048) were combined to enhance the predictive effect. The highest 5-year overall survival rate following curative liver resection (93%) was observed in patients with MVI absent and AFP-CRUT in quintile 1 (49.64 to 209.61). In contrast, the lowest 5-year overall survival (7%) was obtained in quintile 5 (-469.29 to 6.45) with MVI present. In validation cohorts at both 12 and 24 months, AFP-CRUT performed well as a potential prognostic biomarker.

CONCLUSIONS

Combining AFP-CRUT quintiles with MVI may predict significantly improved outcomes and enhance the predictive power for patient responses to therapeutic intervention.

Clinical implication of the preoperative GSA index in ⁹⁹mTc-GSA scintigraphy in hepatitis C virus-related hepatocellular carcinoma

We aimed to examine the relationship between the preoperative GSA index [uptake ratio of the liver to the liver plus heart at 15 min (LHL15) to uptake ratio of the heart at 15 min to that at 3 min (HH15) ratio] calculated from 99mTc‑labeled diethylene triamine pentaacetate-galactosyl human serum albumin (99mTc-GSA) scintigraphy and background liver fibrosis and to investigate whether the GSA index can be a useful predictor in hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) patients treated with surgical resection (SR). A total of 213 HCV-related HCC patients were analyzed. Receiver operating characteristic (ROC) curve analysis was performed for calculating the area under the ROC (AUROC) for nine noninvasive parameters including GSA index, indocyanine green retention at 15 min, aspartate aminotransferase (AST) to platelet ratio index, FIB-4 index, AST to alanine aminotransferase ratio, serum albumin, total bilirubin, platelet count and prothrombin time for cirrhosis. We also examined predictive factors associated with overall survival (OS) and recurrence-free survival (RFS) after SR in univariate and multivariate analyses. There were 153 males and 60 females with the mean age of 69.9 years. The median observation periods were 2.8 years. The mean maximum tumor size was 4.1 cm. HH15 ranged from 0.452 to 0.897. LHL15 ranged from 0.669 to 0.982. The mean value of the GSA index was 1.41. Among the nine parameters, the GSA index yielded the highest AUROC for cirrhosis with a level of 0.786 at an optimal cut-off value of 1.37 (sensitivity, 65.9%; specificity, 79.0%). In multivariate analyses, the GSA index was an independent predictor (P<0.001) linked to RFS and it had a marginal significance in terms of OS (P=0.074). In conclusion, the preoperative GSA index can be a useful predictor in HCV-related HCC patients treated with SR.

Does the preoperative alpha-fetoprotein predict the recurrence and mortality after hepatectomy for hepatocellular carcinoma without macrovascular invasion in patients with normal liver function?

AIM

It has been highly controversial whether elevated serum α-fetoprotein (AFP) level before hepatectomy predicts recurrence and mortality of patients with hepatocellular carcinoma (HCC) or not. This study is to identify whether the index predicts recurrence and mortality after hepatectomy in HCC.

METHODS

Of 568 consecutive patients, 342 with normal liver function (Child-Pugh score, 5) and no macrovascular invasion were enrolled between April 2000 and March 2013. Multivariate analysis was performed to identify risk factors for disease-free survival (DFS) and overall survival (OS).

RESULTS

In multivariate analysis, the elevated serum AFP level was an independent risk factor for DFS (hazard ratio [HR], 1.9; P < 0.0001) and OS (HR, 2.0; P < 0.0001). Histological hepatic venous tumor thrombus was also an independent risk factor for DFS (HR, 2.6; P < 0.0001) and OS (HR, 2.5; P = 0.001). Anatomical resection decreases the risk factor for recurrence after hepatectomy (HR, 0.6; P = 0.003), though it did not decrease the risk for OS (P = 0.3). At 5 years, DFS rates were 42% and 21% (P < 0.0001) and OS rates were 75% and 46% among patients with low and high AFP levels, respectively (P < 0.0001). The area under the receiver-operator curves (AUROC) of serum AFP and des-γ-carboxy prothrombin were 0.65 and 0.58 for DFS and 0.65 and 0.57 for OS, respectively. Tumor size was the best predictor of microvascular invasion (AUROC, 0.70, P < 0.0001).

CONCLUSION

Serum AFP was a highly reliable index for DFS and OS.

A comparison of clinical manifestations and prognoses between patients with hepatocellular carcinoma and Child-Pugh scores of 5 or 6

The objective of this work is to compare the outcomes between the Child-Pugh score 5 (A5 group) and Child-Pugh score 6 (A6 group) in patients with hepatocellular carcinoma (HCC). Whether HCC patients with A5 and A6 groups have different prognoses is still obscure. We enrolled 2462 consecutive treatment-naive HCC patients from 2007 to 2012. Among them, 1486 patients had Child-Pugh grade A, including 1016 in the A5 group and 470 in the A6 group. Factors in the prognoses were analyzed by multivariate analysis. Compared with those in the A6 group, patients in the A5 group were younger, had higher proportions of tumors within the Milan criteria, and more of them underwent curative therapies. The cumulative survival rates at 5 years were 51.3% and 37.1% for patients in the A5 and A6 groups, respectively (P < 0.001). Multivariate analysis showed that the independent risk factors associated with poor overall survival were nonhepatitis C virus carrier, serum albumin ≤ 4 g/dL, aspartate aminotransferase > 45 U/L, α-fetoprotein > 20 ng/mL, multinodularity, tumor size > 3 cm, vascular invasion, and noncurative therapies, but not the Child-Pugh numeric score. The Child-Pugh numeric score had a significant prognostic effect only in patients who had tumors beyond the Milan criteria and received noncurative therapies. HCC patients with A5 group had a better overall survival rate than those with A6 group due to the early tumor stage and higher rate of receiving curative treatments. Tumor factors and treatment modalities were more important than the Child-Pugh numeric score.

Predicting recurrence patterns after resection of hepatocellular cancer

BACKGROUND

The reliable prediction of hepatocellular carcinoma (HCC) recurrence patterns potentially allows for the prioritization of patients for liver resection (LR) or transplantation.

OBJECTIVES

The aim of this study was to analyse clinicopathological factors and preoperative Milan criteria (MC) status in predicting patterns of HCC recurrence.

METHODS

During 1992-2012, 320 patients undergoing LR for HCC were categorized preoperatively as being within or beyond the MC, as were recurrences.

RESULTS

After a median follow-up of 47 months, 183 patients developed recurrence, giving a 5-year cumulative incidence of recurrence of 62.5%. Patients with preoperative disease within the MC had better survival outcomes than those with preoperative disease beyond the MC (median survival: 102 months versus 45 months; P < 0.001). Overall, 31% of patients had preoperative disease within the MC and 69% had preoperative disease beyond the MC. Estimated rates of recurrence-free survival at 5 years were 61.8% for all patients and 53.8% for patients with initial beyond-MC status. Independent factors for recurrence beyond-MC status included preoperative disease beyond the MC, the presence of microsatellite or multiple tumours and lymphovascular invasion (all: P < 0.001). A clinical risk score was used to predict survival and the likelihood of recurrence beyond the MC; patients with scores of 0, 1, 2 and 3 had 5- year incidence of recurring beyond-MC of 9.0%, 29.5%, 48.8% and 75.4%, respectively (P < 0.0001).

CONCLUSIONS

Regardless of initial MC status, at 5 years the majority of patients remained disease-free or experienced recurrence within the MC after LR, and thus were potentially eligible for salvage transplantation (ST). Incorporating clinicopathological parameters into the MC allows for better risk stratification, which improves the selection of patients for ST and identifies patients in need of closer surveillance.

Histological subclassification of cirrhosis can predict recurrence after curative resection of hepatocellular carcinoma

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) after curative resection continues to be a major cause of death. This prospective study is designed to investigate whether histological subclassification of cirrhosis using the Laennec system could predict recurrence in patients with hepatitis B virus (HBV)-related HCC after curative resection.

METHODS

Patients with HBV-related HCC who underwent curative resection and showed Laennec stage 3 to 4 were enrolled and the cases with stage 4 were subclassified histologically into three groups (stages 4A, 4B and 4C) according to the Laennec system. Between February 2006 and August 2009, 92 patients were recruited.

RESULTS

Stage 3, 4A, 4B and 4C were identified in 24 (26.1%), 15 (16.3%), 43 (46.7%) and 10 (10.9%) patients respectively. The cumulative incidence rates of recurrence at 1, 2 and 3 years were 24.2%, 40.5% and 55.1% respectively. On multivariate analysis, serum albumin [hazard ratio (HR), 0.528; 95% confidence interval (CI), 0.312-0.891; P=0.017] and Edmondson-Steiner grade III-IV (HR, 3.456; 95% CI, 1.123-10.517; P=0.031) were significantly correlated with early recurrence (<1 year), whereas stage 4C (HR, 5.426; 95% CI, 1.030-28.598; P=0.046) was the only independent risk factor for late recurrence (≥1 year).

CONCLUSIONS

Histological subclassification of cirrhosis using the Laennec system is a significant predictor of late recurrence in patients with HBV-related HCC after curative resection.

Number of nodules, Child-Pugh status, margin positivity, and microvascular invasion, but not tumor size, are prognostic factors of survival after liver resection for multifocal hepatocellular carcinoma

BACKGROUND

Presently, the role of liver resection (LR) for multifocal hepatocellular carcinoma (HCC) remains controversial. However, in many regions worldwide, LR remains the only treatment modality available to such patients which offers the possibility of long-term cure. The aim of this study is to determine the outcomes and prognostic factors of patients with multifocal HCC after LR.

METHODS

This is a retrospective analysis of 110 patients who underwent potentially curative LR for pathologically proven multifocal HCC between 2000 and 2011.

RESULTS

The median age was 64 (range, 18-84) years, and there were 88 males (80.0 %). Sixty-one patients underwent a major hepatectomy, and the overall postoperative mortality was 1.8 %. Sixty-eight patients had liver cirrhosis, of which, 58 were child's A and 10 were child's B. The 1- and 5-year overall survival (OS) was 82 and 44 %, respectively. The corresponding 1- and 5-year recurrence-free survival (RFS) was 57 and 19 %, respectively. Multivariate analysis demonstrated that the number of nodules (>3) and presence of microvascular invasion were associated with RFS. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion were independent prognostic factors of OS.

CONCLUSIONS

LR followed by treatment of recurrences may result in reasonable long-term survival and should be considered in a selected group of patients with multifocal HCC. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion, but not tumor size, were independent negative predictors of OS. These findings have potential implications on the AJCC staging for multifocal HCC.

Mammalian target of rapamycin inhibitors are associated with lower rates of hepatocellular carcinoma recurrence after liver transplantation: a systematic review

Calcineurin inhibitors (CNIs) have been associated in a dose-dependent fashion with an increased risk of post-transplant hepatocellular carcinoma (HCC) recurrence. The mammalian target of rapamycin inhibitors (mTORi) (sirolimus/everolimus) might represent an alternative immunosuppressive regimen with antineoplastic effect. In the present systematic review, the association between mTORi and HCC recurrence after liver transplantation (LT) was evaluated and compared against that of CNIs-treated patients. In total, 3666 HCC liver transplant recipients from 42 studies met the inclusion criteria. Patients under CNIs developed HCC recurrence significantly more frequently, compared with patients under mTORi (448/3227 or 13.8% vs. 35/439 or 8%, P < 0.001), although patients treated with CNIs had a higher proportion of HCC within Milan criteria (74% vs. 69%) and lower rates of microvascular invasion, compared with mTORi-treated patients (22% vs. 44%) (P < 0.05). Patients on everolimus had significantly lower recurrence rates of HCC, compared with those on sirolimus or CNIs (4.1% vs. 10.5% vs. 13.8%, respectively, P < 0.05), but everolimus-treated recipients had shorter follow-up period (13 vs. 30 vs. 43.2 months, respectively) and more frequently been transplanted for HCC within Milan criteria (84% vs. 60.5% vs. 74%, respectively, P < 0.05). Our findings favor the use of mTORi instead of CNIs to control HCC recurrence after LT, but comparative studies with longer follow-up are needed for final conclusions.

Global PROTOMAP profiling to search for biomarkers of early-recurrent hepatocellular carcinoma

This study used global protein expression profiling to search for biomarkers to predict early recurrent hepatocellular carcinoma (HCC). HCC tissues surgically resected from patients with or without recurrence within 2 years (early recurrent) after surgery were compared with adjacent nontumor tissue and with normal liver tissue. We used the PROTOMAP strategy for comparative profiling, which integrates denaturing polyacrylamide gel electrophoresis migratory rates and high-resolution, semiquantitative mass-spectrometry-based identification of in-gel-digested tryptic peptides. PROTOMAP allows examination of global changes in the size, topography, and abundance of proteins in complex tissue samples. This approach identified 8438 unique proteins from 45 708 nonredundant peptides and generated a proteome-wide map of changes in expression and proteolytic events potentially induced by intrinsic apoptotic/necrotic pathways. In the early recurrent HCC tissue, 87 proteins were differentially expressed (≥20-fold) relative to the other tissues, 46 of which were up-regulated or specifically proteolyzed and 41 of which were down-regulated. This data set consisted of proteins that fell into various functional categories, including signal transduction and cell organization and, notably, the major catalytic pathways responsible for liver function, such as the urea cycle and detoxification metabolism. We found that aberrant proteolysis appeared to occur frequently during recurrence of HCC in several key signal transducers, including STAT1 and δ-catenin. Further investigation of these proteins will facilitate the development of novel clinical applications.

Microvascular infiltration has limited clinical value for treatment and prognosis in hepatocellular carcinoma

BACKGROUND

Microvascular infiltration (MVI) is considered a necessary step in the metastatic evolution of hepatocellular carcinoma (HCC), but its prognostic value after liver resection (LR) is uncertain. We studied the clinical value of MVI compared to the Milan criteria in a consecutive series of patients submitted to radical LR.

METHODS

A total of 441 patients were retrospectively evaluated. MVI and the Milan criteria were analyzed and compared as prognostic factors for overall and disease-free survival (DFS).

RESULTS

MVI was present in 189 patients (42.8 %). Grading, satellitosis, size of cancer, and alfa fetoprotein value were significantly related to MVI, which was present in 34.3 and 53.2 % of Milan+ and Milan- patients, respectively (p = 0.00001). Both MVI and the Milan criteria were associated with a lower overall and DFS, but only the Milan criteria were associated with the rate of early recurrence and the feasibility of a curative treatment of the recurrence. The application of MVI parameters to patients classified by the Milan criteria further selects the outcome in Milan+ patients (5-year survival rate of 54.1 and 67.9 %, respectively, in the presence or absence of MVI) but not in Milan- patients.

CONCLUSIONS

MVI is related to survival after LR for HCC, but the clinical value of this information is limited. In Milan+ patients, the absence of MVI selects the cases with better prognosis. In the presence of a liver recurrence, the Milan criteria related to the primary HCC show a better prognostic accuracy and have clinical relevance in the decision-making process.

High STAT4 expression is a better prognostic indicator in patients with hepatocellular carcinoma after hepatectomy

BACKGROUND

Signal transducer and activator of transcription 4 (STAT4) mediates the intracellular effects of interleukin-12, leading to the production of interferon gamma (IFN-γ) and natural killer cells cytotoxicity. However, the clinical significance of STAT4 expression in patients with hepatocellular carcinoma (HCC) remains virtually unknown.

METHODS

A total of 66 HCC patients who underwent hepatectomy were enrolled in this study. Quantitative real-time polymerase chain reaction was performed to determine STAT4 and IFNG mRNA expression levels. Tissue microarray-based immunohistochemistry was performed to examine CD8(+) T cells, STAT4, and INF-γ proteins.

RESULTS

STAT4 was differentially expressed in tumor and nontumor tissues (P = 0.001) and positively correlated with IFNG expression (R (2) = 0.506, P < 0.05) and CD8(+) T cell infiltration (R (2) = 0.53, P < 0.001). Significant correlations were observed between STAT4 expression and tumor TNM stage (P = 0.043), hepatic venous invasion (P = 0.003), des-gamma-carboxy prothrombin (P = 0.011), tumor size (P = 0.036), and tumor differentiation (P = 0.034). Patients with high STAT4 expression had significantly better recurrence-free survival (P = 0.009). Low STAT4 expression (P = 0.030) and presence of portal venous invasion or hepatic venous invasion (P = 0.006) were independent risk factors for HCC recurrence.

CONCLUSIONS

Downregulation of STAT4 in HCC indicated aggressive tumor behavior and predicted a worse clinical outcome. STAT4 might be a useful biomarker to identify patients at high risk of recurrence after hepatectomy.

Efficacy of sorafenib as adjuvant therapy to prevent early recurrence of hepatocellular carcinoma after curative surgery: A pilot study

AIM

Until now, no effective adjuvant therapy to prevent early recurrence of hepatocellular carcinoma (HCC) after curative treatment has been reported. The aim of this study is to evaluate the clinical benefit of sorafenib as adjuvant treatment in subjects with HCC after hepatic resection.

METHODS

The pilot study was undertaken involving HCC patients who had undergone curative liver surgery with high recurrence risk factors. Time to recurrence and disease recurrence rate were assessed. Sorafenib 400 mg q.d. was administrated continuously for 4 months after hepatic resection.

RESULTS

A total of 31 patients were enrolled and eligible for final data analysis. The median follow-up time was 19 months (range, 9.5-30.2). Time to recurrence in the sorafenib arm was 21.45 ± 1.98 months (mean ± standard deviation), compared to 13.44 ± 2.66 months in the control arm (P = 0.006). The median recurrence-free survival in the sorafenib arm did not reach the data cut-off date compared to 8 months in the control arm (P = 0.006). The recurrence rate between the two groups was significantly different (29.4% vs 70.7%, P = 0.032). Cox regression analysis showed that taking study medicine was the only prognostic variable associated with HCC recurrence (hazard ratio = 0.24, 95% confidence interval = 0.08-0.75, P = 0.014).

CONCLUSION

This study showed that setting sorafenib as adjuvant therapy for HCC to prevent early recurrence after hepatic resection could be a potential indication. The cumulative recurrence-free survival rate also demonstrated the preventive effectiveness of sorafenib.

Transarterial chemoembolization versus surgery/radiofrequency ablation for recurrent hepatocellular carcinoma with or without microvascular invasion

BACKGROUND/AIMS

Microvascular invasion (MVI) is a well-known prognostic factor of postoperative recurrence and of overall survival (OS) in patients with hepatocellular carcinoma (HCC). We compared the treatment outcomes of transarterial chemoembolization (TACE) and surgery/radiofrequency ablation (RFA) according to the presence of MVI in patients with early or late recurrent HCC that presented as Barcelona Clinical Liver Cancer (BCLC) stage 0 or A after curative resection for HCC.

METHODS

A consecutive 68 patients with recurrent HCC of BCLC stage 0 or A at our institution between 1998 and 2012 were retrospectively enrolled. We compared the outcomes of patients treated by TACE or surgery/RFA. Tumor recurrence after curative resection was classified as early (≤ 12 months) or late (> 12 months) recurrence.

RESULTS

Median tumor size was 1.5 cm (range, 1-10 cm), and 67 (98.5%) had HCCs within the Milan criteria. Median post-retreatment follow-up duration was 27 months (range, 1-109 months). Of the 68 patients, 19 (27.9%) underwent surgery/RFA, 47 (69.1%) TACE, and 2 (2.9%) were lost to follow-up. After retreatment, TACE showed significantly higher OS and recurrence-free survival rates than surgery/RFA in MVI-positive patients (P = 0.03 and P = 0.05, respectively), but not in MVI-negative patients (P = 0.95 and P = 0.98, respectively). In particular, in early recurred MVI-positive patients, TACE had a significantly higher OS rate than surgery/RFA (P = 0.01).

CONCLUSIONS

TACE may be the more effective treatment option for recurrent HCC of BCLC stage 0 or A than surgery/RFA in MVI-positive patients, especially in those that recur early after curative resection.

Predictors of microvascular invasion in patients with solitary small hepatitis B related hepatocellular carcinoma

OBJECTIVE

To identify the risk factors for the presence of microvascular invasion (MVI) in patients with solitary small hepatitis B related hepatocellular carcinoma (HCC).

METHODS

The data of 215 patients who underwent liver resection between 2008 and 2011 at our hospital were reviewed. MVI was confirmed on pathological examination in 41 patients. Preoperative risk factors for MVI were analyzed using uni- and multi-variate analyses.

RESULTS

In the multivariate analysis, alpha-fetoprotein (AFP) greater than 400 ng/mL, tumor size and hypersplenism were independently associated with MVI. Receiver operating curve (ROC) analysis suggested the best cut-off value for tumor size was greater than 3.1 cm. The ROC curve analysis further identified patients with more than one above-mentioned risk factor may suffer from MVI with 75.6% sensitivity and 75.3% specificity. The recurrence-free and long-term survival rates of patients with MVI were significantly lower than patients without MVI.

CONCLUSIONS

Patients with MVI may suffer from poor outcomes. AFP greater than 400 ng/mL, tumor size and hypersplenism were preoperative predictors of MVI in patients with solitary small hepatitis B related HCC.

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM

To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.

METHODS

Between January 2002 and December 2010, 268 consecutive HCC patients, including 110 and 158 patients that underwent AR and NAR, respectively, were retrospectively enrolled in this study. Forty-four patients from each group were selected and matched using logistic multivariate analysis followed by propensity score analysis.

RESULTS

In the whole analysis set, the histological background of the liver, liver function, and tumor marker levels differed significantly among the groups. Although the overall survival (OS) and recurrence-free survival rates of the two groups did not differ significantly in the whole analysis set, the OS of the AR group was significantly longer than that of the NAR group after propensity matching (76.2 ± 6.3 mo vs 58.9 ± 6.3 mo; P = 0.0039). Although AR (HR = 0.456, P = 0.039) was found to be a prognostic factor in the univariate analysis, only vascular invasion (HR = 0.228, P = 0.002) and the hepatocyte growth factor level (HR = 52.366, P = 0.035) were subsequently found to be independent prognostic factors.

CONCLUSION

AR conveys a survival advantage over NAR in specific subpopulations of HCC patients with tumors of less than 5 cm in diameter, single tumor, and good liver function.

Microvascular invasion in small hepatocellular carcinoma: is it predictable with preoperative diffusion-weighted imaging?

BACKGROUND AND AIM

The presence of microvascular invasion (MVI) is an independent risk factor affecting recurrence-free survival following surgical treatment for small hepatocellular carcinoma (HCC). Our aim in this study was to investigate whether diffusion-weighted imaging (DWI) could be useful in predicting MVI for small HCC.

METHODS

Breath-hold DWI (b-value 0, 500 s/mm(2) ) and gadopentate dimeglumine-enhanced dynamic imaging of preoperative magnetic resonance imaging of 109 surgically proven small HCCs from 92 patients were retrospectively analyzed. The signal intensity ratio on DWI and apparent diffusion coefficients (ADCs) for lesions were quantitatively measured. Signal intensity ratio and ADC of DWI, tumor size, tumor shape, tumor capsule, peritumoral enhancement on arterial phase images, and dynamic enhancement pattern were analyzed as radiological parameters reflecting MVI and were compared with histopathological references. The chi-square test, Fisher's exact test, Mann-Whitney U test, and the independent t-test were used for univariate analysis. To identify the independent predictors of MVI among these radiological parameters and to evaluate their diagnostic performance, multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed, respectively.

RESULTS

A univariate analysis showed that a lower ADC value (P = 0.005) and irregular circumferential enhancement (P = 0.020) showed statistically significant associations with MVI. A multiple logistic regression analysis showed that the ADC value and irregular circumferential enhancement were independent predictors of MVI. With a cut-off of 1.227 × 10(-3)  mm(2) /s, the ADC value provided a sensitivity of 66.7% and a specificity of 78.6% in the prediction of MVI with an odds ratio of 7.63 (P < 0.01).

CONCLUSIONS

Lower ADC values (< 1.227 × 10(-3)  mm(2) /s) on DWI with b-value of 0.500 s/mm(2) can be a useful preoperative predictor of MVI for small HCCs.

The significance of classifying microvascular invasion in patients with hepatocellular carcinoma

BACKGROUND

Microvascular invasion (MVI) has been recognized as a risk factor for outcome following curative resection in hepatocellular carcinoma (HCC). Because MVI can range from few to many invaded vessels, we evaluated the significance of MVI classification in this study.

METHODS

Between January 1995 and December 2010, 207 consecutive patients who underwent curative resection for HCC within Milan criteria were included in this retrospective study. Patients were classified into mild and severe MVI groups based on the number of vessels invaded. This study evaluated whether MVI classification can help to predict recurrence and survival after curative resection.

RESULTS

Of the total 207 patients, 103 (50 %) patients had no detectable MVI, whereas 59 (28 %) had mild MVI, and 45 (22 %) had severe MVI. Recurrence-free survival rates at 2 years for patients without MVI, with mild MVI, and severe MVI were 75.9, 47.2, and 32.7 %, respectively. Patients with severe MVI experienced a high frequency of fatal recurrence, such as multiple tumors, macroscopic vascular invasion, and extrahepatic metastasis after curative resection. Multivariate analysis revealed age, number of tumors, mild MVI, and severe MVI as independent predictors of recurrence-free survival. Disease-specific survival rates at 5 years for patients without MVI, with mild MVI, and severe MVI were 91.5, 70.4, and 51.4, respectively. Multivariate analysis also revealed cirrhosis, tumor size, mild MVI, and severe MVI as independent predictors of disease-specific survival.

CONCLUSIONS

We demonstrated that MVI classification can stratify HCC patients by different patterns of recurrence and risk of survival after curative resection.

Comparison of clinical characteristics and survival after surgery in patients with non-B and non-C hepatocellular carcinoma and hepatitis virus-related hepatocellular carcinoma

BACKGROUND AND AIMS

We compared clinicopathologic data and long-term clinical outcomes among patients with non-B and non-C hepatocellular carcinoma (NBNC-HCC) who underwent curative resection (group A, n=129), those with hepatitis B virus-related HCC (group B, n=62) and those with hepatitis C virus-related HCC (group C, n=284).

METHODS

Clinicopathologic characteristics and cumulative overall survival (OS) and recurrence-free survival (RFS) after curative resection were compared among the three groups.

RESULTS

The proportion of patients with non-liver cirrhosis (LC) or diabetes mellitus in group A was significantly higher than that in group B or group C. The mean maximum tumor size in group A was significantly larger than that of group B or group C. Cumulative 3-year OS rates after resection were 76% in group A, 79% in group B and 72% in group C (A vs. B, P=0.638; A vs. C, P=0.090; B vs. C, P=0.091; overall significance, P=0.088). The corresponding RFS rates after resection were 38% in group A, 36% in group B and 36% in group C (A vs. B, P=0.528; A vs. C, P=0.281; B vs. C, P=0.944; overall significance, P=0.557). In subgroup analyses in patients with LC, in those without LC and in those who satisfied the Milan criteria, similar results were obtained, i.e., the difference among the three groups did not reach significance in terms of OS and RFS.

CONCLUSION

Long-term clinical outcomes in patients NBNC-HCC after curative resection were comparable to those in patients with hepatitis virus-related HCC after curative resection.

Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience

BACKGROUND/AIMS

Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection.

METHODS

This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS.

RESULTS

Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative α-fetoprotein (> 400 ng/mL), tumor size (≥ 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS.

CONCLUSIONS

The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.

Preoperative predictors of microvascular invasion in multinodular hepatocellular carcinoma

BACKGROUND

The preoperative predictors of microvascular invasion (MVI) in multinodular hepatocellular carcinoma (HCC) are currently unclear.

METHODS

We retrospectively analyzed 266 patients who underwent potentially curative resection of multinodular HCC. MVI was diagnosed on pathological examination in 64 patients. Preoperative risk factors for MVI were identified and survival curves were analyzed.

RESULTS

Patients with MVI had significantly lower overall and recurrence-free survival rates than those without MVI (overall survival, 1 year: 86% vs. 71%, 3 years: 58% vs. 16%; recurrence-free survival, 1 year: 69% vs. 12%; 3 years: 48% vs. 12%; both P < 0.001). Multivariate analysis showed that serum alpha-fetoprotein (AFP) level >400 μg/L (odds ratio [OR] = 3.732, P = 0.016), serum gamma-glutamyltransferase (GGT) level >130 U/L (OR = 19.779, P < 0.001), total tumor diameter >8 cm (OR = 5.545, P = 0.010), and tumor number >3 (OR = 11.566, P = 0.007) were independent predictors of MVI. A scoring system was constructed, and the MVI rate was significantly higher in patients with a score of ≥3 than those with a score of <3 (64.1% vs. 10.9%, P < 0.001). Overall and recurrence-free survival rates were significantly lower in patients with a score of ≥3 (both P < 0.001).

CONCLUSIONS

Serum AFP level >400 μg/L, serum GGT level >130 U/L, total tumor diameter >8 cm, and tumor number >3 were preoperative predictors of MVI in patients with multinodular HCC. In patients with a high risk of MVI and well-preserved liver function, anatomic resection may be worth considering.

Half-life of serum alpha-fetoprotein: an early prognostic index of recurrence and survival after hepatic resection for hepatocellular carcinoma

OBJECTIVE

To explore the prognostic value of the postsurgical half-life (HL) of serum alpha-fetoprotein (AFP).

BACKGROUND

There is still a paucity of early surrogate indicators of clinical endpoints after liver resection of hepatocellular carcinoma (HCC).

METHODS

The analysis was based on cohorts of 225 (exploration set) and 117 (validation set) treatment-naïve HCC patients undergoing curative liver resection. We defined 3 categories of AFP HL: early complete resolution of AFP, normal HL, and prolonged HL if the HL exceeded 7 days. Overall, probabilities of recurrence and survival were estimated and compared across the AFP HL categories.

RESULTS

In the exploration cohort, 48 patients (21.3%) achieved early AFP complete resolution, 116 (51.6%) had normal HL, and 61 (27.1%) had prolonged HL. Long AFP HL was significantly associated with early postoperative recurrence (P < 0.001), as was microvascular invasion. Early recurrence within 2 years of resection was observed in 59% of the patients with prolonged AFP HL compared with only 29.3% of those with normal AFP HL (P < 0.001). A log-rank test followed by multivariate Cox analysis identified an independent function of prolonged AFP HL in predicting shorter recurrence-free survival and overall survival time after HCC resection (hazard ratios, 2.81 and 3.58; P < 0.001). When AFP HL analysis was applied to the validation cohort, the association between prolonged AFP HL and survival endpoints (hazard ratio, 11.63 and 16.39; P < 0.001) was confirmed.

Lack of correlation between the antibody to hepatitis B core antigen and survival after surgical resection for hepatitis C virus-related hepatocellular carcinoma

The impact of antibodies to hepatitis B core antigen (anti-HBc) on survival after curative surgical resection (SR) for hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) remains unclear. The aim of the present study was to examine the relationship between anti-HBc positivity and survival of HCV-related HCC patients who underwent curative SR. A total of 222 patients with HCV-related, hepatitis B surface antigen (HBsAg)-negative HCC who underwent curative SR were analyzed. They included 119 anti-HBc-positive patients (53.6%) and 103 anti-HBc-negative patients (46.4%). Overall survival (OS) and recurrence-free survival (RFS) rates were compared between the two groups. The median follow-up periods in the anti-HBc-positive and anti-HBc-negative groups were 3.4 years (range, 0.3-10.9 years) and 3.2 years (range, 0.5-10.9 years), respectively. The 1-, 3- and 5-year cumulative OS rates were 88.8, 70.2 and 50.0%, respectively, in the anti-HBc-positive group and 95.8, 77.1 and 61.7% in the anti-HBc-negative group (P=0.300). The corresponding RFS rates were 68.7, 33.0 and 20.0%, respectively, in the anti-HBc-positive group and 74.4, 38.5 and 16.5% in the anti-HBc-negative group (P=0.482). Multivariate analyses identified serum albumin ≥3.8 g/dl (P=0.005) and the presence of microvascular invasion (P<0.001) as independent factors linked to OS, and interferon therapy after surgery (P=0.011), α-fetoprotein ≥40 ng/ml (P=0.030) and the presence of microvascular invasion (P<0.001) were significant predictors linked to RFS. In subgroup analyses according to maximum tumor size and background liver disease in terms of OS and RFS, no significant difference between the anti-HBc-positive and anti-HBc-negative groups was observed except in patients with non-cirrhotic liver in terms of RFS. In conclusion, anti-HBc-positivity is not a useful predictor for survival of patients with HCV-related HCC after curative SR.

The Relation between Obesity and Survival after Surgical Resection of Hepatitis C Virus-Related Hepatocellular Carcinoma

Background and Aims. We aimed to investigate the relationship between obesity and survival in hepatitis C virus-(HCV-) related hepatocellular carcinoma (HCC) patients who underwent curative surgical resection (SR). Methods. A total of 233 patients with HCV-related HCC who underwent curative SR were included. They included 60 patients (25.8%) with a body mass index (BMI) of > 25 kg/m(2) (obesity group) and 173 patients with a BMI of < 25 kg/m(2) (control group). Overall survival (OS) and recurrence-free survival (RFS) rates were compared. Results. The median follow-up periods were 3.6 years in the obesity group and 3.1 years in the control group. The 1-, 3-, and 5-year cumulative OS rates were 98.3%, 81.0%, and 63.9% in the obesity group and 90.0%, 70.5%, and 50.3% in the control group (P = 0.818). The corresponding RFS rates were 70.1%, 27.0%, and 12.0% in the obesity group and 70.1%, 39.0%, and 21.7% in the control group (P = 0.124). There were no significant differences between the obesity group and the control group in terms of blood loss during surgery (P = 0.899) and surgery-related serious adverse events (P = 0.813). Conclusions. Obesity itself did not affect survival in patients with HCV-related HCC after curative SR.

Pretransplantation α-fetoprotein slope and milan criteria: strong predictors of hepatocellular carcinoma recurrence after transplantation

BACKGROUND

Hepatocellular carcinoma (HCC) is a major cause of orthotropic liver transplantations (OLT). However, tumor recurrence remains a concern. Our group has shown that a rising natural α-fetoprotein (AFP) slope (NAS) correlates with tumor characteristics. We want to assess if a rising NAS predicts tumor recurrence.

METHODS

We reviewed first OLT for HCC (n=144) at our center from 1992 to 2010. Patients with less than two AFP values before treatment were excluded (n=52). A rising NAS (>0.1 μg/L/day) was found in 28 patients whereas 64 presented a stable or dropping NAS. Demographics, pre-OLT therapy, and tumor characteristics were collected. Statistical analysis was performed using ANOVA, chi-square or Fisher's test, and logistic regression for recurrence after OLT.

RESULTS

Demographics were similar among the recurrence (n=12) and nonrecurrence (n=80) groups. Patients who recurred received more treatment (P=0.017), had a higher number of lesions (P=0.025), a greater total tumor size (P=0.001), and a higher incidence of microvascular invasion (P=0.013). More patients exceeded the Milan criteria (75.0% vs. 31.3%, odds ratio [OR] 6.60, 95% confidence interval [CI] 1.45-4.05, P=0.008) and had a rising NAS (58.3% vs. 26.3%, OR 3.20, 95% CI 1.11-9.22, P=0.024) among the recurrence group. NAS was also a strong predictor of microvascular invasion (P=0.040). After correcting for age and sex, both a rising NAS (OR 3.98, 95% CI 1.01-15.81, P=0.039) and nonadherence to Milan criteria (OR 5.69, 95% CI 1.14-28.38, P=0.034) were strong predictors of recurrence after OLT.

CONCLUSION

The NAS is a predictor of microvascular invasion, a finding exclusive to pathology and in itself a predictor of HCC recurrence after OLT. The NAS and Milan criteria are good predictors of recurrence. These results encourage a frequent monitoring of AFP variations before OLT.

Milan criteria, multi-nodularity, and microvascular invasion predict the recurrence patterns of hepatocellular carcinoma after resection

AIMS

This study aims to evaluate the risk factors for tumor recurrence beyond the Milan criteria (MC) for patients with hepatocellular carcinoma (HCC) after surgical resection (SR) in which salvage liver transplantation is relatively contraindicated.

METHODS

A total of 447 patients who underwent SR for HCC were enrolled consecutively. Among them, 248 and 199 patients were within the Milan criteria and beyond the Milan criteria (BMC group), respectively. Overall survival, recurrence, and disease-free survival were analyzed by multivariate analysis.

RESULTS

After a median follow-up of 34.4 months, 130 patients died. Microvascular invasion, higher Edmondson stage of tumor cell differentiation, BMC group, and no anti-viral therapy were associated with poor overall survival. Multi-nodularity, higher Edmondson stage, BMC group, and no anti-viral therapy were independent risk factors for tumor recurrence, while BMC group and no anti-viral therapy were independent risk factors for disease-free survival. The Milan criteria, multi-nodularity, and microvascular invasion were used to stratify the patients into low-, medium-, and high-risk groups for tumor recurrence outside the MC and showed statistical significance (low vs. medium, p = 0.011; low vs. high, p < 0.001; medium vs. high, p = 0.009).

CONCLUSIONS

The combination of the MC, multi-nodularity, and microvascular invasion predict the post-operative recurrence of HCC and may provide a roadmap for further treatment.