Correlation of hepatitis virus serologic status with clinicopathologic features in patients undergoing hepatectomy for hepatocellular carcinoma

Comparison of clinicopathologic characteristics among patients with HBV-positive, HCV-positive and Non-B Non-C hepatocellular carcinoma after hepatectomy: a systematic review and meta-analysis

BACKGROUND

The incidence of HBV-negative and HCV-negative hepatocellular carcinoma (NBNC-HCC) is significantly increasing. However, their clinicopathologic features and prognosis remain elucidated. Our study aimed to compare the clinicopathologic characteristics and survival outcomes of NBNC-HCC with hepatitis virus-related HCC.

METHOD

A literature review was performed in several databases, including PubMed, Embase, Cochrane Library and Web of Science, to identify the studies comparing NBNC-HCC with HBV-positive HCV-negative HCC (B-HCC), HBV-negative HCV-positive (C-HCC) and/or HBV-positive HCV-positive HCC (BC-HCC). The clinicopathologic characteristics and survival outcomes were extracted and pooled to access the difference.

RESULTS

Thirty-two studies with 26,297 patients were included: 5390 patients in NBNC-HCC group, 9873 patients in B-HCC group, 10,848 patients in C-HCC group and 186 patients in BC-HCC group. Patients in NBNC-HCC group were more liable to be diagnosed at higher ages, but with better liver functions and lighter liver cirrhosis. Comparing to B-HCC and C-HCC groups, although NBNC-HCC group was prone to have larger tumor sizes, it did not have more advanced tumors. Meanwhile, there were no significant differences in both 5-year and 10-year disease-free survival and overall survival between NBNC-HCC group and B-HCC or C-HCC group.

CONCLUSIONS

Our meta-analysis revealed patients with NBNC-HCC had as worse prognosis as those with hepatitis virus-related HCC. More attention should be paid on patients with non-alcoholic steatohepatitis or metabolic syndromes to prevent the incidence of NBNC-HCC.

Validade dos marcadores tumorais

Considerando-se o número crescente dos chamados marcadores tumorais e a sua incorporação sistemática à prática médica, procedeu-se a um levantamento, por meio de Medline® 1995, na Biblioteca Central do Instituto Nacional de Câncer - INCA, e revisão de 95 resumos de trabalhos publicados de 1995 a abril de 1997. Verificou-se que a validade dos marcadores é maior para o diagnóstico patológico de alguns tipos tumorais e determinação de alguns fatores prognósticos; que poucos são os de real utilidade clínica, seja para prevenção, diagnóstico ou prognóstico, vez que a maioria deles só alcança significância quando a doença já provoca algum sinal ou sintoma; que a maioria das referências correspondem, a rigor, a trabalhos repetidos, que avaliam os mesmos marcadores, embora em diferentes tumores; e que há trabalhos que se referem a poucos casos, quando não pouquíssimos, e cujos resultados tomam-se, por isso, inconsistentes. Neste artigo, os marcadores tumorais são classificados por tipos (genes, expressões genéticas, substâncias circulantes, substâncias celulares, receptores da membrana celular e índices de proliferação tumoral) e por finalidades (prevenção, detecção, diagnóstico, estadiamento, monitoração terapêutica, seguimento pós-tratamento e prognóstico) e são correlacionados com o(s) tumor(es) em que foram pesquisados. Apresentam-se três grupos de critérios de validação (estatísticos, biomédicos e por finalidades) e resume-se, a partir também de mais 16 outras referências bibliográficas, a utilidade de marcadores dos cânceres de mama [ADN, fração de Fase S, índice de ADN, C-erbB-2 (HER-2/neu), P53, CAT-D, CA15.3 e CEA - sem validade; marcadores tumorais hormonais - úteis para a indicação de hormonioterapia adjuvante ou paliativa]; colorretal [LASA, CA 19.9, índice de ADN, fração de Fase S, p53 e ras - sem validade; CEA-com validade para estadiamento e planejamento cirúrgico, e para seguimento pós-operatório (dosagem seriada a cada 2-3 meses por 2 anos, se houve suspeita de metástase hepática em estádios cirúrgicos II e III)] e de próstata (PSA com utilidade para a detecção, mas associado ao toque retal, em homens acima de 40-50 anos, como indicativos da necessidade de exames mais acurados, e para o seguimento dos casos tratados). E inquestionável a utilidade da dosagem de alfa-feto-proteína (aFP) e da gonadotrofina coriônica (hCG), para o estadiamento, tratamento, avaliação da resposta terapêutica e seguimento dos casos tratados de tumores testiculares (aFP e hCG) e de neoplasia trofoblástica gestacional (hCG). Também inquestionável é o papel da identificação dos marcadores de diferenciação celular no diagnóstico patológico de leucemias e linfomas. Os dilemas evidenciados a partir deste estudo referem-se a cinco binômios: 1) ausência de sinal ou sintoma versus positividade de marcador tumoral; 2) detecção de recidiva assintomática versus a qualidade e a quantidade da sobrevida do indivíduo; 3) natureza da causa versus aumento do marcador; 4) exame falso-positivo versus tratamento; e 5) baixo risco de evolução de neoplasia detectada versus tratamento. Conclui-se que, exceto pelos marcadores de validade estabelecida para o diagnóstico, o seguimento do tratamento ou o prognóstico dos casos de alguns cânceres, o médico precisa, além de conhecer os marcadores tumorais e suas siglas, saber os limites das suas indicações e ter opinião, crítica e método na sua utilização.

Comparison of Postoperative Prognosis Among HBV-Related, HCV-Related, and Non-HBV Non-HCV Hepatocellular Carcinomas: A Systematic Review and Meta-analysis

Context: Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer, and different hepatitis viruses might affect the prognosis of patients with HCC. Objectives: This study aimed to reveal the differences in the postoperative prognosis of patients with hepatitis B virus-related HCC (HBV-HCC), hepatitis C virus-related HCC (HCV-HCC), and non-HBV non-HCV hepatocellular carcinoma (NBNC-HCC). Methods: The databases PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for articles published until April 2022. Stata software version 12 and Review Manager version 5.4 were used to conduct the meta-analysis, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adopted in this study. Results: In the present study, 26 papers on a total of 20381 participants who met the inclusion criteria were analyzed. The 5-year overall survival in the HBV-HCC and HCV-HCC groups was lower than in the NBNC-HCC group (HBV-HCC vs. NBNC-HCC, P = 0.005; HCV-HCC vs. NBNC-HCC, P = 0.001). Patients with HBV-HCC and HCV-HCC had worse 5-year recurrence-free survival than patients with NBNC-HCC (HBV-HCC vs. NBNC-HCC, P = 0; HCV-HCC vs. NBNC-HCC, P = 0). In addition, the 5-year recurrence-free rate in the HCV-HCC group was lower than in the HBV-HCC group (P = 0). The observed association between serum alpha-fetoprotein levels and the postoperative prognosis was inconsistent in different subgroups. Conclusions: Patients with NBNC-HCC had a significantly better postoperative prognosis than those with virus-related HCC. The alpha-fetoprotein levels significantly correlated with the postoperative prognosis of patients with HCC.

Treatment strategies for early stage hepatocellular carcinoma: a systematic review and network meta-analysis of randomised clinical trials

BACKGROUND

Several treatment strategies for early stage hepatocellular cancers (HCC) have been evaluated in randomised controlled trials (RCTs). This network meta-analysis (NMA) aimed to explore the relative effectiveness of these different approaches on their impact on overall (OS) and recurrence-free survival (RFS).

METHODS

A systematic review was conducted to identify RCT's reported up to 23rd January 2020. Indirect comparisons of all regimens were simultaneously compared using random-effects NMA.

RESULTS

Twenty-eight RCT's, involving 3,618 patients, reporting 13 different treatment strategies for early stage HCC were identified. Median follow-up, reported in 22 studies, ranged from 12-93 months. In this NMA, RFA in combination with iodine-125 was ranked first for both RFS (HR: 0.50, 95% CI: 0.19-1.31) and OS (HR: 0.41, 95% CI: 0.19-0.94). In subgroup with solitary HCC, lack of studies reporting RFS precluded reliable analysis. However, RFA in combination with iodine-125 was associated with markedly better OS (HR: 0.21, 95% CI: 0.05-0.93).

CONCLUSION

This NMA identified RFA in combination with iodine-125 as a treatment delivering better RFS and OS, in patients with early stage HCC, especially for those with solitary HCC. This technique warrants further evaluation in both Asia and Western regions.

Single-center experience on actual mid-term (≥5 years) and long-term (≥10 years) survival outcome in patients with hepatocellular carcinoma after curative hepatectomy: A bimodal distribution

Analysis for actual mid-term (≥5 years) and long-term (≥10 years) survivors with hepatocellular carcinoma (HCC) following curative hepatectomy are rarely reported in the literature.This retrospective study aims to study the mid- and long-term survival outcome and associated prognostic factors following curative hepatectomy for HCC in a tertiary referral center.The clinical data of 325 patients who underwent curative hepatectomy for HCC were reviewed. They were stratified into 3 groups for comparison (Group 1, overall survival <5 years; Group 2, overall survival ≥5, and <10 years; Group 3, overall survival ≥10 years). Favorable independent prognostic factors for mid- and long-term survival were analyzed.A bimodal distribution of actual survival outcome was observed, with short-term (<5 years) survival of 52.7% (n = 171), mid-term survival of 18.1% (n = 59), and long-term survival of 29.2% (n = 95). Absence of microvascular invasion (OR 3.690, 95% CI: 1.562-8.695) was independent good prognostic factor for mid-term survival. Regarding long-term overall survival, young age (OR 1.050, 95% CI: 0.920-0.986), ASA grade ≤2 (OR 3.746, 95% CI: 1.325-10.587), high albumin level (OR 1.008, 95% CI: 0.920-0.986), solitary tumor (OR 3.289, 95% CI: 1.149-7.625) and absence of microvascular invasion (OR 4.926, 95% CI: 2.192-11.111) were independent good prognostic factors.Curative hepatectomy results in bimodal actual survival outcome with favorable long-term survival rate of 29.2%. Favorable independent prognostic factors (age, ASA grade, albumin level, tumor number, and microvascular invasion) are identified for overall survival.

Volumetric parameters on FDG PET can predict early intrahepatic recurrence-free survival in patients with hepatocellular carcinoma after curative surgical resection

PURPOSE

This study assessed the prognostic values of volumetric parameters on ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in predicting early intrahepatic recurrence-free survival (RFS) after curative resection in patients with hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was performed on 242 patients with HCC who underwent staging FDG PET and subsequent curative surgical resection. The tumor-to-non-tumorous liver uptake ratio, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the HCC lesions on PET were measured. The prognostic values of clinical factors and PET parameters for predicting overall RFS, overall survival (OS), extrahepatic RFS, and early and late intrahepatic RFS were assessed.

RESULTS

The median follow-up period was 54.7 months, during which 110 patients (45.5%) experienced HCC recurrence and 62 (25.6%) died. Patients with extrahepatic and early intrahepatic recurrence showed worse OS than did those with no recurrence or late intrahepatic recurrence (p < 0.001). Serum bilirubin level, MTV, and TLG were independent prognostic factors for overall RFS and OS (p < 0.05). Only MTV and TLG were prognostic for extrahepatic RFS (p < 0.05). Serum alpha-fetoprotein and bilirubin levels, MTV, and TLG were prognostic for early intrahepatic RFS (p < 0.05) and hepatitis C virus (HCV) positivity and serum albumin level were independently prognostic for late intrahepatic RFS (p < 0.05).

CONCLUSION

Intrahepatic recurrence showed different prognoses according to the time interval of recurrence in which early recurrence had as poor survival as extrahepatic recurrence. MTV and TLG on initial staging PET were significant independent factors for predicting early intrahepatic and extrahepatic RFS in patients with HCC after curative resection. Only HCV positivity and serum albumin level were significant for late intrahepatic RFS, which is mainly attributable to the de novo formation of new primary HCC.

Clinicopathological characteristics of hepatitis B surface antigen-negative and hepatitis C antibody-negative hepatocellular carcinoma

The present study investigated the clinicopathological characteristics of resected hepatitis B virus surface antigen (HBs-Ag)-negative, hepatitis C virus antibody (HCV-Ab)-negative hepatocellular carcinoma (NBNC HCC). The clinicopathological characteristics of 164 patients with NBNC HCC, 144 patients with HBs-Ag-positive HCC (HBV group) and 550 patients with HCV-Ab-positive HCC (HCV group) were compared. In the NBCN HCC group, 61 patients succumbed after 2 years. Subsequently, NBCN HCC patients were compared according to survival time (<2 years, 39 patients vs. ≥2 years, 64 patients) to identify prognostic factors. Finally, the clinicopathological characteristics of NBNC HCC were compared according to history of alcohol abuse/pathological results: Non-alcoholic steatohepatitis HCC (NASH group, 40 patients), alcohol abuse HCC (AL group, 80 patients) and other HCCs (non-NASH/non-AL group, 44 patients). Age, diabetes prevalence and body mass index were significantly higher for NBNC HCC compared with virus-related HCC. Among stage II cases, the prognosis was significantly better for the NBNC compared with that for the HCV group. A high α-fetoprotein level, poorly differentiated HCC and advanced liver fibrosis were independent risk factors for the prognosis of NBNC HCC. The proportion of female patients was significantly higher among NASH compared with AL HCC patients. The cumulative survival rates following surgery were similar in the NASH, AL and non-NASH/non-AL groups. NBNC HCC is considered to be a lifestyle disease, with better prognosis for stage II patients. The prognostic factors for NBNC HCC patients undergoing hepatectomy were similar to those with virus-related HCC and did not differ according to alcohol abuse history or pathological results.

Glycosylation and liver cancer

Liver cancer is the fifth most common cancer, but the second leading cause of cancer death, in the world, with more than 700,000 fatalities annually. The major etiology of liver cancer is infection with an hepatotropic virus such as hepatitis B virus or hepatitis C virus infection. While chronic viral infection remains the main cause of liver disease and risk of hepatocellular carcinoma (HCC), rates of nonviral-associated HCC are occurring at an alarmingly increasing rate. Like many cancers, survival rates are closely associated with time of detection. If HCC is caught early, survival rates can be as high as 50%. Regrettably, most cases of HCC are caught late where survival rates can be as low as 2-7%. Thus, there has been great interest in discovering serum biomarkers that could be used to identify those with HCC. To this end, many groups have examined the N-linked glycans to identify changes that occur with HCC. As the liver secretes the vast majority of proteins into the serum, this has often been a starting point for study. In serum, alterations in core fucosylation, outer-arm fucosylation, increased sialylation, and glycan branching have been observed in patients with HCC. Similar findings have been found directly in HCC tissue suggesting that these glycan changes may play a role in tumor formation and development.

Differences in surgical outcomes between hepatitis B- and hepatitis C-related hepatocellular carcinoma: a retrospective analysis of a single North American center

OBJECTIVE

Compare surgical outcomes for hepatitis B virus (HBV)-hepatocellular carcinoma (HCC) versus hepatitis C virus (HCV)-hepatocellular carcinoma (HCC).

BACKGROUND

HCC is the second leading cause of death from cancer worldwide and is associated with hepatitis virus infection in 80% of cases.

METHODS

Between 1997 and 2011, 1008 patients with hepatitis B (HBV, n = 431) or hepatitis C (HCV, n = 577) underwent resection (n = 567) or transplantation (n = 441). Resection was indicated for Child's A patients with single HCC; transplantation was indicated for patients within Milan criteria. Univariate and multivariate analyses were performed as well as survival and recurrence analysis using log-rank test.

RESULTS

Based on uniform application of these criteria, resection: transplantation ratio was 3.6 for patients with HBV and 0.67 for patients with HCV. Resection: Patients with HBV had larger tumors and higher α-fetoprotein but less satellites and macrovascular invasion; 68% of HBV versus 89% of HCV were cirrhotic. Survival was better (P < 0.001) and recurrence was lower (P = 0.009) for HBV. Independent predictors of death included HCV (P = 0.024), transfusion (P = 0.013), and HCC of greater than 5 cm (P = 0.013). Limiting analysis to patients with cirrhosis, survival with HBV remained superior (P = 0.020) but recurrence did not. Transplantation: Tumors were similar in HBV and HCV. Survival was better (P = 0.002) for HBV; recurrence was similar. Independent predictors of death were HCV (P < 0.001), poor differentiation (P = 0.049), vascular invasion (P = 0.002), and outside Milan (P = 0.032). Limiting analysis to patients within Milan, HBV survival remained better for both resection (P = 0.030) and transplantation (P = 0.002).

CONCLUSIONS

Survival after both resection and transplantation for HCC was better in HBV- than in HCV-related HCC whereas recurrence was also lower for HBV-HCC in the resection group, these differences are influenced by both liver and tumor factors.

Actual 10-year survival following hepatectomy for hepatocellular carcinoma

OBJECTIVES

This study was conducted to compare 10-year survivors with patients who survived <10 years in a large Western series of patients submitted to hepatectomy for hepatocellular carcinoma (HCC).

METHODS

A retrospective review of a series of hepatic resections conducted in a referral centre for HCC between January 1987 and October 2002 was conducted.

RESULTS

A total of 176 patients were analysed. Twenty-eight patients survived ≥ 10 years (Group A) and were compared with the 148 patients who did not (Group B). Group A had smaller tumours (5.7 cm versus 8.2 cm; P = 0.001) and a lower incidence of microvascular invasion (18.5% versus 37.1%; P = 0.004). Recurrence did not differ significantly (Group A 18/28, 64.3% versus Group B 94/148, 63.5%). Median time to recurrence was longer in Group A (70 months versus 15 months; P < 0.0001), and more patients in Group A were able to undergo curative treatment for recurrence (88.8% versus 40.4%; P < 0.0001). Multivariate analysis showed that lack of vascular invasion (P = 0.020), absence of perioperative transfusion (P = 0.014), and recurrence at >2 years after primary resection (P = 0.045) were significantly associated with 10-year survival.

CONCLUSIONS

Ten-year survival after liver resection for HCC can be expected in approximately 15% of patients. Recurrence does not preclude longterm survival. Recurrence at >2 years after resection, absence of vascular invasion, and absence of perioperative transfusion are independently associated with 10-year survival.

Postoperative recurrence pattern and prognosis of patients with hepatocellular carcinoma, with particular reference to the hepatitis viral infection status

BACKGROUND & AIMS

Various modalities have been employed effectively according to the tumour recurrence status in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Therefore, their overall prognosis depends largely on the pattern of recurrence/treatment. We investigated the patterns of recurrence and prognosis in HCC patients, especially in relation to the hepatitis virus infection status.

METHODS

The study population comprised 244 patients with HCC undergoing hepatectomy. Curative treatments, including repeated hepatectomies, were performed for recurrences, whenever possible. Detailed information on recurrences was collected until the recurrences exceeded Milan criteria.

RESULTS

The 5-year disease-free survival, survival within the Milan criteria and overall survival were 38.4%, 56.3% and 74.5% respectively. In the comparison between patients with hepatitis C and B virus-related HCC (HC-HCC: n = 122; and HB-HCC: n = 45 respectively), the former showed lower disease-free (30.2% vs. 40.7% at 5 years, P = 0.061) and overall (65.7% vs. 89.7% at 5 years, P = 0.011) survivals; they also showed a higher incidence of multinodular (≥4) intrahepatic recurrences (19.4% vs. 5.3% at 3 years, P = 0.010). However, the incidences of recurrences exceeding the Milan criteria because of other components were comparable. Patients with HC-HCC showed a higher incidence of intrahepatic recurrences characterized by multiple lesions and the difference became increasingly more pronounced with time.

CONCLUSIONS

Patients with HC-HCC were associated with a higher carcinogenesis in the background liver than those with HB-HCC, and this difference was aggravated with time after hepatic resection.

Hepatitis C viral load predicts tumor recurrence after curative resection of hepatocellular carcinoma regardless of the genotype of hepatitis C virus

PURPOSE

To clarify the prognostic impact of the hepatitis C virus (HCV) genotype after curative resection for hepatocellular carcinoma (HCC).

METHODS

A total of 199 patients who underwent a curative hepatic resection for HCV-related HCC were reviewed. The clinical outcomes were compared between patients infected with HCV genotype 1b (n = 160) and those infected with other genotypes (n = 39).

RESULTS

With a comparable median HCV viral load (6.0 vs. 5.8 log10 IU/mL, p = 0.17), the 3-year recurrence-free survival (RFS) rates (25 vs. 20 %, p = 0.65) and the 5-year overall survival (OS) rates (72 vs. 65 %, p = 0.73) were similar between the two groups. A multivariate analysis confirmed that HCV viral load of +1.0 log10 IU/mL [hazard ratio (HR), 1.48], major vascular invasion (HR, 3.20), recurrent tumor (HR, 1.77), and preoperative des-gamma carboxyprothrombin level >40 mAu/mL (HR, 1.64) were independent predictors of tumor recurrence, while the HCV genotype was not a significant risk factor. When the population was stratified according to the HCV viral load, a significant difference was observed in the RFS rate for both genotype 1b (p = 0.003) and the other genotypes (p = 0.037) at HCV viral load of 5.3 log10 IU/mL.

CONCLUSIONS

The HCV genotype does not affect the surgical outcomes of patients with HCC. A lower HCV viral load is advantageous regardless of the HCV genotype.

Hepatocellular carcinoma in patients with chronic hepatitis C virus infection in the Asia-Pacific region

Hepatocellular carcinoma (HCC) is the third-leading cause of cancer-related mortality worldwide. Although hepatitis B still remains the most common risk factor worldwide, chronic hepatitis C virus (HCV) infection is the driving force for the increased incidence of HCC especially in Western countries and Japan. In hepatitis B virus (HBV)-endemic areas, after successful vaccination programs against HBV, chronic HCV infection is now emerging as an important cause of chronic liver diseases. Unlike patients with chronic hepatitis B, those with chronic hepatitis C (CHC) develop HCC in the presence of established cirrhosis in most cases. However, a significant minority of CHC develops HCC in the absence of cirrhosis. Although HCV is a RNA virus with little potential for integrating its genetic material into host genome, various HCV proteins, including core, envelope, and nonstructural proteins, have oncogenic properties by inducing oxidative stress, disturbing cellular regulatory pathways associated with proliferation and apoptosis, and suppressing host immune responses. Overall, a combination of virus-specific, host genetic, environmental, and immune-related factors are likely to determine progression to HCC. Strategies aimed at eliminating the virus may provide opportunities for effective prevention of the development of HCC. Pegylated interferon plus ribavirin therapy appears to be effective at reducing the risk of HCC in patients who achieve sustained virologic responses. In summary, with the emerging importance of CHC, mechanisms of HCV-associated hepatocellular carcinogenesis should be clarified to provide insight into advanced therapeutic and preventive approaches, which eventually decrease the incidence and mortality of HCC.

Low hepatitis C viral load predicts better long-term outcomes in patients undergoing resection of hepatocellular carcinoma irrespective of serologic eradication of hepatitis C virus

PURPOSE

Hepatitis C virus (HCV) infection has been recognized as a potent risk factor for the postoperative recurrence of hepatocellular carcinoma (HCC). However, little is known about the impact of HCV viral load on surgical outcomes. The study objective was to investigate clinical significance of HCV viral load on long-term outcomes of HCC.

PATIENTS AND METHODS

Three hundred seventy patients who were classified as Child-Pugh class A and underwent curative liver resections for HCV-related HCC were divided into low and high viral load groups (≤ or > 5.3 log(10)IU/mL) based on the results of a minimum P value approach to predict moderate to severe activity of hepatitis; the clinical outcomes were then compared.

RESULTS

The 5-year recurrence-free survival rate was 36.1% in the low viral load group and 12.4% in the high viral load group (P < .001). The 5-year overall survival rate was 76.6% in the low viral load group and 57.7% in the high viral load group (P < .001). Multivariate analysis confirmed significant correlation between high viral load and tumor recurrence with a hazard ratio of 1.87 (95% CI, 1.41 to 2.48; P < .001). Subanalysis revealed that the favorable results in the low viral load group were not attributed to whether or not serologic eradication of HCV was obtained both in primary and recurrent lesions.

CONCLUSION

Low HCV viral load predicts better long-term surgical outcomes in patients with HCC regardless of the serologic eradication of HCV.

Clinicopathologic characteristics of patients with non-B non-C hepatitis virus hepatocellular carcinoma after hepatectomy

BACKGROUND

A substantial population of hepatocellular carcinoma (HCC) patients is negative for markers of hepatitis B virus and hepatitis C virus (HCV) infection (non-B non-C hepatitis virus [NBC]).

METHODS

Clinicopathologic data and outcomes were compared retrospectively for HCC patients with hepatitis B virus, HCV, and NBC who had undergone hepatectomy.

RESULTS

The TNM stage was significantly higher, and the prevalence of cirrhosis was significantly lower, in the NBC group compared with the HCV group. Among patients with a maximum tumor diameter of 5 cm or less, the survival rates were significantly higher in the NBC group than in the HCV group. Multivariate analysis revealed that preoperative serum des-gamma-carboxy prothrombin (DCP) level was a prognostic factor for survival in NBC-HCC patients. The DCP/tumor size ratio was significantly higher in NBC-HCC patients with normal liver histology than in patients with hepatitis or cirrhosis.

CONCLUSIONS

NBC-HCC patients had more advanced tumors compared with HCV-HCC patients, but significantly higher survival rates. Measurement of DCP potentially is significant for early diagnosis of NBC HCC, which may increase the chance of curative therapy without recurrence.

Large-scale long-term follow-up study of Japanese patients with non-alcoholic Fatty liver disease for the onset of hepatocellular carcinoma

OBJECTIVES

The aim of this study was to determine the incidence and risk factors of hepatocellular carcinoma (HCC), and to elucidate the utility of two non-invasive predictive procedures for liver fibrosis: the aspartate aminotransferase (AST) to platelet ratio index (APRI) and the BARD score (which includes the following three variables: body mass index, AST/alanine aminotransferase ratio, and diabetes) in the prediction of HCC in a large population of Japanese patients with non-alcoholic fatty liver disease (NAFLD).

METHODS

This was a retrospective cohort study conducted at a public hospital. Study subjects included 6,508 patients with NAFLD diagnosed by ultrasonography. The median follow-up period was 5.6 years. The primary end point was the onset of HCC. Evaluation was performed using Kaplan-Meier methodology and Cox's proportional hazards analysis.

RESULTS

In all, 16 (0.25%) new cases with HCC were diagnosed during the study. The cumulative rates of NAFLD-related HCC were 0.02% at year 4, 0.19% at year 8, and 0.51% at year 12. The annual rate of new HCC was 0.043%. Multivariate analysis identified serum AST level ≥40 IU/L (hazard ratio (HR): 8.20; 95% confidence interval (95% CI): 2.56-26.26; P<0.001), platelet count <150 × 10(3)/μl (HR: 7.19; 95% CI: 2.26-23.26; P=0.001), age ≥60 years (HR: 4.27; 95% CI: 1.30-14.01; P=0.017), and diabetes (HR: 3.21; 95% CI: 1.09-9.50; P=0.035) as independent risk factors for HCC. With regard to the APRI, 184 patients (2.83%) were considered to have significant fibrosis (equivalent to non-alcoholic steatohepatitis (NASH) stage 3-4). The cumulative rate of HCC was significantly higher in this group (HR: 25.03; 95% CI: 9.02-69.52; P<0.001). In contrast, regarding the BARD score, 3,841 (59%) patients were considered to have advanced fibrosis (NASH stage 3-4). However, no significant associations between the BARD score and the incidence of HCC were observed (HR: 1.16; 95% CI: 0.40-3.37; P=0.780).

CONCLUSIONS

This retrospective study indicates that the annual incidence rate of HCC among Japanese NAFLD patients is low. Elderly NAFLD patients with diabetes, elevated serum AST, and especially thrombocytopenia (suggested to be associated with advanced liver fibrosis) should be monitored carefully during follow-up that includes using the APRI to ensure early diagnosis and treatment of HCC.

Influence of viral hepatitis status on prognosis in patients undergoing hepatic resection for hepatocellular carcinoma: a meta-analysis of observational studies

Background

The influence of viral hepatitis status on prognosis in patients undergoing hepatic resection for hepatocellular carcinoma (HCC) remains a matter of debate. This study is a meta-analysis of the available evidence.

Methods

A literature search was performed to identify comparative studies reporting postoperative survival of HCC in different types of viral hepatitis. Pooled odds ratios (OR) and weighted mean differences (WMD with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.

Results

Twenty studies matched the selection criteria and reported on 4744 subjects, of whom 2008 in the HBV-positive (B-HCC) group, 2222 in the HCV-positive (C-HCC) group, and 514 in the hepatitis B- and C-negative (NBNC-HCC). Meta-analysis showed that patients with HBV or HCV infection had a worse 5-year disease-free survival when compared to patients with NBNC-HCC (respectively: OR: 0.39, 95% CI: 0.28 to 0.53, P < 0.001; WMD: 0.37, 95% CI: 0.22 to 0.64, P < 0.001). There was a tendency toward higher 5-year overall survival rates in the NBNC-HCC group compared to those in the other two groups, although these differences were not statistically significant. Both the 5-year overall survival and disease-free survival were not different among the B-HCC and C-HCC groups.

Conclusions

Patients with positive serology for hepatitis B or C undergoing resection for HCC had a poor prognosis compared to patients with negative serology.

Surgical outcomes for hepatocellular carcinoma in nonalcoholic fatty liver disease

BACKGROUND

The present study investigated outcomes following surgical resection of hepatocellular carcinoma (HCC) in nonalcoholic fatty liver disease (NAFLD).

METHODS

Patients (n = 225) undergoing resection for HCC were divided into three groups: hepatitis C viral group (n = 147), hepatitis B viral group (n = 61), and NAFLD group (n = 17). Clinicopathological characteristics and surgical outcomes were analyzed retrospectively.

RESULTS

Patients in the NAFLD group were older (P < 0.001), with a higher body mass index (P < 0.001) and larger tumors (P = 0.002) than patients who were positive for hepatitis viral markers. Eight patients in the NAFLD group were found to have nonalcoholic steatohepatitis (NASH) histologically. Postoperative morbidity and 30-day mortality rates were significantly higher in the NAFLD group (59% and 12%, respectively) than in the hepatitis C viral (31% and 0.7%, respectively) and hepatitis B viral (28% and 3.3%; P = 0.043 and P = 0.016, respectively) groups. All deaths in the NAFLD group were in patients with NASH-related cirrhosis who had undergone right hemihepatectomy. Survival after resection was comparable among the three groups (P = 0.391), but patients with NAFLD showed better disease-free survival on univariate (P = 0.048) and multivariate (P = 0.020) analyses.

CONCLUSIONS

Surgical resection may provide a survival benefit for patients with NAFLD-related HCC. Patients with NASH-related cirrhosis undergoing major hepatic resection should be treated carefully.

Management of an incidental liver mass

The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.

Trends in the utilization and impact of radiofrequency ablation for hepatocellular carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is rising and radiofrequency ablation (RFA) appears to be increasingly used. The nationwide use and impact of RFA have not been well characterized.

STUDY DESIGN

We performed an historical cohort study of US patients 18 years old and older, with a diagnosis of HCC (n = 22,103) using the national Surveillance, Epidemiology, and End Results (SEER) limited-use database (1998 to 2005). Main outcomes measures were receipt of different therapeutic interventions (ablation, RFA, resection, or transplantation) and adjusted 1- and 2-year survivals.

RESULTS

A total of 4,924 (22%) patients underwent any intervention, with a 93% increase over the 8-year study period (trend test, p < 0.001). RFA accounted for 43% of this increase. Despite increased use of therapeutic interventions, 1- and 2-year survival rates did not improve over time for patients in the study cohort (48% and 34%, 52% and 37%, 50% and 36%; in 1998, 2002, and 2004, respectively; p = 0.31). Among patients with solitary lesions, adjusted 1- and 2-year survivals remained stable over time after transplantation (97% and 94%, 95% and 89%, 94% and 86% in 1998, 2002, and 2004, respectively; p = 0.99) and RFA (86% and 64%, 76% and 54%, in 2002 and 2004, respectively; p = 0.97), but improved after resection (83% and 71%, 91% and 84%, 97% and 94% in 1998, 2002, and 2004, respectively; p = 0.03).

CONCLUSIONS

Use of interventions for the treatment of HCC, and specifically RFA, have markedly increased over time. Because increased use of RFA among patients with potentially resectable disease is likely to occur, and because of a lack of high-level evidence supporting expanded indications, continued evaluation of the indications for RFA and subsequent outcomes among US patients is warranted.

Diabetes mellitus worsens the recurrence rate after potentially curative therapy in patients with hepatocellular carcinoma associated with nonviral hepatitis

BACKGROUND AND AIM

The aim of this retrospective study was to examine the relationship between diabetes mellitus and recurrence of hepatocellular carcinoma after potentially curative therapy for hepatocellular carcinoma with nonviral hepatitis.

METHODS

We studied 40 consecutive hepatocellular carcinoma patients who were diagnosed between 1980 and 2006 with hepatocellular carcinoma associated with non-B, non-C hepatitis, and later underwent surgical resection or radiofrequency ablation.

RESULTS

Twenty-two out of the 40 patients developed hepatocellular carcinoma recurrence within a median of 3.7 years. In the 18 patients with diabetes mellitus, the cumulative rates of hepatocellular carcinoma recurrence were 22.2% at the first year, 55.6% at the second year, 61.1% at the third year, 61.1% at the fourth year, and 80.6% at the fifth year. The cumulative rates of hepatocellular carcinoma recurrence in 22 nondiabetic patients were 24.6% at the first year, 24.6% at the second year, 31.5% at the third year, 31.5% at the fourth year, and 31.5% at the fifth year. The hepatocellular carcinoma recurrence rate was significantly higher in diabetic patients than in nondiabetics (P = 0.026). The multivariate Cox proportional model identified old age and diabetes as the only significant predictors for recurrence. The hazard ratio of hepatocellular carcinoma recurrence in diabetic patients was 4.61 (P = 0.007). There was no significant difference in overall survival rate between diabetic and nondiabetic patients (P = 0.392).

CONCLUSION

Diabetes is a significant predictor of tumor recurrence after potentially curative therapy for hepatocellular carcinoma in patients with nonviral hepatitis.

Influence of coexisting cirrhosis on outcomes after partial hepatic resection for hepatocellular carcinoma fulfilling the Milan criteria: an analysis of 293 patients

BACKGROUND

For patients with liver cirrhosis and hepatocellular carcinoma (HCC) satisfying the Milan criteria (single tumor < or =5 cm or 2 or 3 tumors < or =3 cm), orthotopic liver transplantation (OLT) is an effective treatment. Nevertheless, it remains controversial whether OLT is the best treatment strategy for patients with resectable HCC.

METHODS

This study included 293 HCC patients (both with and without cirrhosis) oncologically satisfying the Milan criteria who underwent primary and curative liver resection between 1990 and 2003.

RESULTS

There were 127 noncirrhotic, 129 Child-Pugh A cirrhotic, and 37 Child-Pugh B cirrhotic patients. Five-year survival rates in each population were 81%, 54%, and 28%, respectively. Coexisting cirrhosis, Child-Pugh classification, alpha-fetoprotein value, tumor burden, and vascular invasion by the tumor were identified as significant prognostic factors. Among these factors, coexisting cirrhosis was the most crucial variable by multivariate analysis. During the initial 3 postoperative years, yearly tumor recurrence rate was 22% in cirrhotic patients and 15% in noncirrhotic patients. In cirrhotic patients, the recurrence rate did not decrease even after three years of tumor-free survival post-resection, whereas in noncirrhotic patients the recurrence rate decreased to 9%. Cirrhosis was associated with a higher probability of recurrence exceeding the Milan criteria.

CONCLUSIONS

Hepatic resection offers an acceptable survival result for HCC patients fulfilling the Milan criteria. Coexisting cirrhosis is associated with higher mortality and recurrence rate, possibly due to multicentric carcinogenesis which limits the efficacy of hepatic resection.

Comparison of surgical outcomes for small hepatocellular carcinoma in patients with hepatitis B versus hepatitis C: a Chinese experience

BACKGROUND

Although both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are well recognized risk factors for hepatocellular carcinoma (HCC), little is known with respect to how HBV and HCV infection affect HCC recurrence in postoperative HCC Chinese patients. The objective of this study was to determine if differences exist in preoperative characteristics and postoperative HCC recurrence in patients with different HBV and HCV infection status.

METHODS

The study population consisted of 413 patients undergoing a curative resection at Tianjin Cancer Hospital for small HCC (< or =3 cm) from January 1997 to December 2003. The patients were divided into four groups: HCV only (n = 75), HBV only (n = 251), HBV and HCV (n = 33), and neither HBV nor HCV (NBNC, n = 54). The preoperative status and postoperative HCC recurrence were recorded. Survival analyses were used to assess the impact of HBV/HCV status on HCC recurrence.

RESULTS

Patients with HCV had a significant association with older age, lower mean preoperative platelet counts and albumin levels, higher mean prothrombin time, alanine aminotransferase and total bilirubin levels and multinodular tumors during diagnosis. Patients with HCV also had significantly less differentiated tumors and a higher incidence of vascular invasion and cirrhosis when compared to the other groups. During the follow-up, the HCV group showed a higher incidence of intrahepatic recurrence and multiple recurrent lesions than the other patients.

CONCLUSIONS

Patients with HCV infection tended to be older, and were characterized by more severe cirrhosis and higher incidence of tumor multicentricity. The statistically significant determinants for reoccurrence in patients with small HCC were HCV infection, presence of vascular invasion and multiple tumors.

Risk factors for intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

BACKGROUND

Long-term survival after hepatectomy for hepatocellular carcinoma is still poor because of tumor recurrence especially in the liver remnant. The risk factors for intrahepatic recurrence after liver resection are studied in our cohort of patients.

METHODS

A retrospective analysis from a prospective database was performed on 76 consecutive successful hepatectomies for hepatocellular carcinoma.

RESULTS

Twenty-two patients had intrahepatic recurrence. The following were not found to be risk factors for recurrence: age, sex, race, number of segments resected, and mean operating time. By using multivariate analysis, serum aspartate transaminase level, more than 1 hepatocellular carcinoma nodule, and presence of tumor thrombi were found to be significant risk factors.

CONCLUSION

Patients who with these risk factors should undergo close follow-up to detect recurrence early; treatment with reresection, chemoembolization, or radiofrequency ablation can be considered.

Analysis of prognostic factors affecting survival after initial recurrence and treatment efficacy for recurrence in patients undergoing potentially curative hepatectomy for hepatocellular carcinoma

BACKGROUND

Survival analysis in patients with initial recurrence after curative hepatectomy for hepatocellular carcinoma (HCC) has not been well evaluated. In addition, selections of the most effective treatments for patients with recurrent HCC still remain controversial.

METHODS

Three hundred and nineteen patients who underwent potentially curative hepatectomies were followed for initial recurrence, and factors predictive of recurrence were determined. The factors affecting survival including pattern of recurrence and treatment modalities from the time of initial recurrence in 211 patients were retrospectively analyzed.

RESULTS

The overall 5-year disease-free survival rate of 319 patients was 31.1%. The 5-year survival rate of 211 patients from the time of initial recurrence was 31.9%. In a multivariate analysis, a low indocyanine green retention rate, lack of liver cirrhosis, a long interval before recurrence, the absence of portal vein invasion, and intrahepatic recurrence (<or=3 nodules) were shown to be significantly favorable prognostic factors after the initial recurrence. The 5-year survival rate of patients with intrahepatic recurrence (<or=3 nodules) was 42.3%, and no survival differences were observed among different treatment modalities.

CONCLUSION

When the initial recurrence occurred after a longer interval, and/or with three or fewer intrahepatic recurrent nodules, a favorable prognosis could be expected in those patients with better liver function and no portal vein invasion at the time of the primary hepatectomy. It is important to conduct a randomized controlled trial to clarify a method for selecting optimal treatment in patients with a smaller number of initial intrahepatic recurrences.

Risk factors for microvascular tumour thrombi in hepatocellular carcinoma: a univariate and multivariate analysis

BACKGROUND

Microvascular tumour thrombi in hepatocellular carcinoma (HCC) predict poor outcome and are a risk factor for intrahepatic and extrahepatic metastases. Survival after liver transplantation is also affected. Our aim was to predict the risk factors for the presence of microvascular tumour thrombi.

METHODS

Seventy-six patients who had undergone hepatectomy for HCC in our hospital were included in a retrospective analysis from a prospective database.

RESULTS

Thirty-one patients (40.8%; mean age 50.7 +/- 12.2 years, P < 0.021) had microvascular tumour thrombi (group T) and 54 patients (group NT; mean age 58.6 +/- 15.4 years) did not. Using logistic regression analysis, we found that more than one HCC nodule, a large tumour, chronic hepatitis C infection and high serum aspartate aminotransferaselevels were significant risk factors for microvascular tumour thrombi. Age, preoperative serum bilirubin level and sex were not significant risk factors.

CONCLUSION

Patients with chronic hepatitis C infection having multiple HCC nodules, large tumour size and high preoperative aspartate aminotransferase levels are at high risk for microvascular tumour thrombi.

Clinical characteristics and surgical outcome in hepatocellular carcinoma without hepatitis B virus surface antigen or hepatitis C virus antibody

OBJECTIVE

We investigated clinical characteristics and surgical outcome of hepatocellular carcinoma in association with hepatitis viral status. No consensus exists concerning differences in surgical outcome in patients with hepatocellular carcinoma according to viral hepatitis status, especially those negative for hepatitis B virus surface antigen and antibody to hepatitis C virus.

METHODS

Clinicopathologic data were available for 39 hepatectomy patients with hepatocellular carcinoma who were negative for hepatitis B virus surface antigen and hepatitis C virus antibody. Clinical characteristics and surgical outcome were analyzed retrospectively and compared to those patients with positive hepatitis viral markers.

RESULTS

Patients negative for viral hepatitis markers were more likely to have large, advanced-stages tumors with relatively well-preserved liver function and had a lower incidence of intrahepatic recurrences (P = 0.009). The intrahepatic recurrence rate reached a plateau at approximately 3 years after resection in patients with negative viral markers, while it continued to increase steadily in patients positive for viral hepatitis markers. By multivariable analysis, the absence of viral hepatitis markers predicted a decreased rate of intrahepatic recurrence (relative risk, 0.222; P = 0.001).

CONCLUSIONS

Adequate surgical resection in hepatocellular carcinoma patients negative for viral markers offers a good survival benefit, regardless of the etiology of the hepatocellular carcinoma.

Fibrosis in non-cancerous tissue is the unique prognostic factor for primary hepatocellular carcinoma without hepatitis B or C viral infection

BACKGROUND

The relationship between the state of non-cancerous tissues in patients with hepatocellular carcinoma (HCC) who are negative for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), and hepatitis C antibody (HCVAb) (NBNC-HCC) and the prognosis has not yet been resolved.

METHODS

We examined the clinicopathological features of these patients and performed statistical analysis for the prognosis of recurrence following curative hepatic resection.

RESULTS

Disease-free survival (DFS) revealed that only the degree of fibrosis was a significant prognostic factor (P = 0.0374). On the basis of the degree of fibrosis (New Inuyama Classification), patients with NBNC-HCC were divided into a non-fibrotic liver group (NF group; F0, n = 10) and a fibrotic liver group (FL group; F1-4, n = 34). The DFS rate in the NF group was significantly better than that in the FL group (P = 0.0408). In the NF group, only one patient recurred, while in the FL group, 21 patients had recurrences. In the FL group, intra-hepatic recurrence was frequently seen in both lobes within 2 years after the initial hepatic resection, while recurrences more than 2 years after the initial operation were mainly seen in the contralateral lobe.

CONCLUSION

Histological assessment of the degree of fibrosis in the non-cancerous regions of NBNC-HCC may be useful not only for the selection of the appropriate treatment but also for the prediction of postoperative prognosis.

Risk of recurrence in a long-term follow-up after surgery in 417 patients with hepatitis B- or hepatitis C-related hepatocellular carcinoma

OBJECTIVE

The aim of this study is to clarify the difference of risk of recurrence after hepatic resection between patients with hepatitis B- and hepatitis C-related hepatocellular carcinoma (HCC).

SUMMARY AND BACKGROUND DATA

HCC is a highly recurrent carcinoma. However, consensus has not yet been reached about the relationship between hepatitis virus types and risk of recurrence in a long-term follow-up for HCC patients who underwent hepatic resection.

PATIENTS AND METHODS

From the beginning of January 1990 to the end of December 1999, of 469 HCC patients who underwent curative hepatic resection, 66 (14%) patients with positive hepatitis B virus surface antigen (HBs-Ag) and negative hepatitis C virus antibody (HCV-Ab) were regarded to have B-type hepatitis (HB)-related HCC (HB-HCC) and 351 (75%) with negative HBs-Ag and positive HCV-Ab were regarded to have C-type hepatitis (HC)-related HCC (HC-HCC). A clinical follow-up was performed to assess the existence of recurrence with the median follow-up periods of 11.0 and 10.1 years for HB- and HC-HCC patients, respectively.

RESULTS

The 3-, 5-, and 10-year disease-free survival (DFS) rates of HC-HCC (40%, 24%, and 12%, respectively) were significantly shorter than those of HB-HCC (57%, 54%, and 28%, respectively) (P = 0.0001). In multivariate Cox proportional hazard analysis, viral type, TNM stage, surgical margin, and Edmondson's grade were significantly associated with risk of recurrence. The risk of recurrence from the initial HCC increased to 1.93 times (95% confidence interval, 1.27-2.93) greater in HC-HCC patients than in HB-HCC patients.

CONCLUSION

Hepatitis viral type is an independent factor for recurrence of HCC in a long-term clinical follow-up. This finding suggests that we may need a different strategy to control postoperative recurrence by the viral types in HCC patients.

Significance of HBV DNA in the hepatic parenchyma from patients with non-B, non-C hepatocellular carcinoma

INTRODUCTION

The etiologic and prognostic factors for non-B, non-C hepatocellular carcinoma (HCC), which is defined by its seronegativity for both hepatitis B surface antigen and hepatitis C virus (HCV) antibody, remain unclear.

METHODS

Nonneoplastic liver tissue from 46 patients with non-B, non-C HCC were examined for hepatitis B virus (HBV) DNA and HCV RNA using in situ hybridization. Recurrence-free survival rates were compared between patients showing high or low HBV DNA expression. Other potential prognostic factors were examined as well.

RESULTS

HBV DNA was detected in nonneoplastic liver specimens from 35 patents (76.1%), whereas HCV RNA was not detected in any case. In patents with high HBV DNA group expression, recurrence-free survival rates at 1 and 5 years after onset were 68.8% and 13.8%, respectively; those with low expression had higher rates of 89.2% and 59.2%, respectively. Multivariate analysis identified high tumor stage (P=0.042) and high HBV DNA expression (p=0.014) as independent negative prognostic factors.

CONCLUSIONS

In many patients with non-B, non-C HCC, HBV DNA in the liver appears to be involved in the carcinogenesis, with intense HBV DNA expression predicting poor outcome for patients with these cancers.

Identification of complement C3a as a candidate biomarker in human chronic hepatitis C and HCV-related hepatocellular carcinoma using a proteomics approach

Although the significant risk factors for hepatocellular carcinoma (HCC) are well known from epidemiological studies, diagnosis of this disease at an early stage is difficult, and HCC remains one of the leading causes of cancer death worldwide. Thus, to identify any useful HCC-related biomarkers is still a need. We performed SELDI-TOF MS to identify differentially expressed proteins in HCC serum using weak cation exchange protein chips. Protein characterization was performed by 2-DE separation and nano flow LC-MS/MS. A total of 55 sera were collected from HCC patients and compared with those from 48 patients with chronic hepatitis and 9 healthy individuals. A candidate marker of about 8900 Da was detected as differentially expressed in patients with chronic hepatitis C and hepatitis C virus (HCV)-related HCC. We identified this differentially expressed protein as complement C3a. The expression of C3a in HCC sera was further validated by PS20 chip immunoassay and Western blotting. Complement C3a was found to be elevated in patients with chronic hepatitis C and HCV-related HCC. The combination of SELDI-TOF MS and 2-DE provides a solution to identify disease-associated serum biomarkers.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic hepatectomy for small hepatocellular carcinoma in Korea

BACKGROUND/PURPOSE

Systematic hepatectomy for small hepatocellular carcinoma (HCC) is a widely preferred modality, but evidence concerning its benefits is lacking. The aim of this study was to document hepatic resection for small HCC in Korea, and to determine whether patient survival or the pattern of tumor recurrence was influenced by the methods used.

METHODS

Ten major hospitals that perform hepatectomy for HCC in Korea were surveyed for surgeons' opinions concerning systematic hepatectomy and current trends in hepatic resection for small HCC. An analysis was also performed of 119 patients who underwent curative hepatectomy for small HCC (size < 5 cm) between January 2000 and December 2002 at Seoul National University Hospital. Seventy-four of these 119 patients underwent anatomical resection (AR) and 45 had a non-anatomical resection (NAR). Recurrence-free survival, recurrence pattern, overall survival rates, and the risk factors for recurrence were analyzed.

RESULTS

In the survey, eight of ten surgeons preferred systematic hepatectomy and considered it to aid prognosis. No significant difference was found between the AR and NAR groups in terms of the clinicopathologic findings, except that the presence of underlying hepatic cirrhosis was more prevalent in the NAR group. The postoperative morbidity rate was higher in the NAR group (33.3% vs 27.0%), but this difference was not statistically significant. The respective 1- and 3-year recurrence-free survival rates were 78.1% and 49.7% in the AR group, and 68.9% and 46.5% in the NAR group (P > 0.05). The corresponding 1- and 3-year overall survival rates were 88.8% and 80.8% in the AR group and 91.0% and 71.4% in the NAR group (P > 0.05).

CONCLUSIONS

Although systematic hepatectomy seems to be superior to non-anatomical hepatectomy from the oncological and anatomical aspects, this superiority is not reflected by the recurrence patterns or the survival and recurrence rates of the two procedures. Postoperative recurrence appears, rather, to be related to the underlying liver condition.

Prognostic effects of causative virus in hepatocellular carcinoma according to the Japan integrated staging (JIS) score

BACKGROUND

The Japan integrated staging (JIS) score is recognized to be useful in managing hepatocellular carcinoma (HCC). We evaluated the effects of the causative virus in patients stratified by this system.

METHODS

We compared clinicopathologic features, cumulative and tumor-free survival rates, and causes of death between 301 hepatitis C virus-positive patients (HCV group) and 60 hepatitis B virus-positive patients (HBV group).

RESULTS

Among patients with low JIS scores (0 or 1), the proportions of patients with high aspartate and alanine aminotranferase activities, moderate-to-severe active hepatitis, and with cirrhosis were significantly higher in the HCV than in the HBV group. Among patients with high JIS scores (2 to 4), the proportion with moderate-to-severe active hepatitis was also significantly higher in the HCV group. In patients with low JIS scores, those in the HCV group had significantly lower tumor-free and cumulative survival rates than those in the HBV group. Although no patient in the HBV group died of causes other than liver disease (HCC or hepatic failure), some patients in the HCV group died of causes other than liver disease. The proportion of patients who died because of HCC recurrence tended to be higher among patients with high JIS scores than among patients with a low JIS score.

CONCLUSIONS

The effects of viral status on survival outcomes are greatest in patients with JIS scores of 0 or 1.

Prognostic value of thymidine phosphorylase activity in liver tissue adjacent to hepatocellular carcinoma

BACKGROUND

Measurement of thymidine phosphorylase (TP) activity in normal liver tissue adjacent to hepatocellular carcinoma (HCC) may predict multicentric recurrence a long time after an operation. The authors investigated this activity in 92 patients with HCC who had a single HCC equal to or less than 5 cm.

METHODS

Fresh samples (tumors with adjacent normal tissues) were collected from 92 patients with HCC who underwent curative hepatic resection. The levels of TP activity in nonfixed, fresh, and frozen HCC specimens with adjacent noncancerous liver tissue were biochemically measured by using an enzyme-linked immunosorbent assay method.

RESULTS

Patients who had a high TP level in normal liver tissue had significantly earlier recurrence (median disease-free survival, 819 days; 95% confidence interval [95% CI], 478-1044 days) compared with patients who had a low TP level (median disease-free survival, 1376 days; lower limit of 95% CI, 921 days; P = 0.0171). Multivariate analysis showed that patients who had a low TP level in adjacent liver tissue had a 0.387-fold higher risk of postoperative recurrence compared with patients who had a high TP level (P = 0.0067).

CONCLUSION

TP activity in normal liver tissue adjacent to HCC is related to tumor occurrence and may predict postoperative tumor recurrence.

Tumor doubling time predicts recurrence after surgery and describes the histological pattern of hepatocellular carcinoma on cirrhosis

BACKGROUND/AIMS

Recurrence of hepatocellular carcinoma (HCC) following surgical resection is influenced by parameters detectable on the resection specimen or through a biopsy. The prognostic significance of HCC doubling time (DT) after surgery has never been investigated.

METHODS

We evaluated 62 patients who underwent curative resection of a single HCC on cirrhosis; tumors were assessed before surgery on two subsequent occasions with the same imaging technique allowing the calculation of DT. The influence of tumor DT, clinical and pathological parameters on recurrence-rate and patients survival was assessed with uni- and multivariate analysis. Relationship between DT and pathological features was also analyzed.

RESULTS

Three-year recurrence rate was 32.3% (20 patients): this was significantly higher in the presence of DT shorter than 100 days (58 versus 18% when equal to or longer; P=0.008), microvascular invasion (59 versus 17% when absent; P=0.008) or tumor undifferentiation (54 versus 25% when well/moderately differentiated; P=0.015). DT was the only independent predictor of recurrence (P=0.005). Patients survival was affected by Child-Pugh class only. DT was significantly shorter in tumors with microvascular invasion (P=0.007), undifferentiation (P=0.003) and high alpha-fetoprotein levels (P=0.011).

CONCLUSIONS

DT is easy to estimate and indicates the prognosis of single HCCs prior to liver resection.

Comparison of recurrence after hepatic resection in patients with hepatitis B vs. hepatitis C-related small hepatocellular carcinoma in hepatitis B virus endemic area

PURPOSE

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are two important factors in the development of hepatocellular carcinoma (HCC). The carcinogenic mechanism of HBV and HCV is considered to be different. It is interesting to compare the recurrence after hepatic resection in patients with small HCC who were infected with HBV or HCV.

METHODS

From 1991 to 1995, 145 patients who were positive for hepatitis B surface antigen (HBsAg) or antibody to HCV (anti-HCV) and diagnosed as small HCC (< or =3 cm) in three medical centers in Taiwan were evaluated in this study. All patients underwent hepatic resection. Among them, 83 (57.2%) were infected by HBV, 51 (35.2%) were infected by HCV, and 11 (7.6%) had dual HBV and HCV infection.

RESULTS

Anti-HCV+ HCCs were associated with older age, lower serum albumin, higher alanine transaminase (ALT) level and multi-nodular tumors during diagnosis. During the follow-up, 92 (63.4%) patients developed tumor recurrence. Anti-HCV + HCC had a higher cumulated recurrence rate than HBsAg+ HCC (72.4% vs 53.6 % at 5 year, P = 0.032). In multivariate analysis, the presence of vascular invasion and lower serum albumin levels (<3.9 g/dl) were the determinants for tumor recurrence.

CONCLUSIONS

HCV infection, as compared with HBV infection, had a higher cumulated recurrence after hepatic resection in patients with small HCC. Low serum albumin level was significantly associated with recurrence among these patients.

Prognostic Evaluation of the New American Joint Committee on Cancer/International Union Against Cancer Staging System for Hepatocellular Carcinoma: Analysis of 112 Cirrhotic Patients Resected for Hepatocellular Carcinoma

BACKGROUND

In 2002, the American Joint Committee on Cancer and the International Union Against Cancer redefined the T-classification for hepatocellular carcinoma, shifting the cutoff value for tumor size from 2 to 5 cm and giving more emphasis to vascular invasion.

METHODS

A retrospective cohort study was conducted on 223 consecutive patients with hepatocellular carcinoma observed between 1990 and 2002. One hundred twelve were resected and considered for retrospective analysis. Univariate and multivariate analyses were performed on several clinicopathologic variables. After classification according to each staging system, the long-term survival of different stages was compared. The prognostic value of each staging system was further evaluated by entering each stage, in turn, into the Cox regression model with other clinicopathologic variables. The median follow-up was 19 months.

RESULTS

On multivariate analysis, the viral etiology of cirrhosis and the presence of multiple nodules were independent prognostic factors. When the new staging system was entered into the multivariate analysis, it was the only independent factor (P = .02). When stratified according to the old tumor-node-metastasis system, there were no significant differences in the survival between stage I and II (P = .14) or between stage IIIA and IVA (P = .33); only the survival of stage II and IIIA was different (P < .01). When stratified according to the new tumor-node-metastasis system, there were significant differences between stage I and II (71.7% vs. 54.7%; P = .02).

CONCLUSIONS

The new staging system is a more reliable and objective method for T classification. It is easy to use in clinical practice and is better at stratifying curatively resected patients with respect to prognosis.

Hepatitis serology predicts tumor and liver-disease characteristics but not prognosis after resection of hepatocellular carcinoma

The impact of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on survival rates after resection of hepatocellular carcinoma (HCC) is controversial. The objective of this study was to determine whether serologic evidence of HBV or HCV infection ("hepatitis serology") can predict underlying liver disease, tumor factors, and survival rates in patients with HCC. Using a multicenter international database, we identified 446 patients with complete HBV and HCV serology. One hundred twenty-six patients were negative for HBV and HCV, 163 patients had HBV infection only, 79 patients had HCV infection only, and 78 patients had coinfection with HBV and HCV. Patients with hepatitis were more likely to have tumors smaller than 5 cm and bilateral HCC involvement. Hepatitis status (negative vs. HBV vs. HCV vs. coinfection with HBV and HCV) did not predict tumor grade or the presence of multiple tumor nodules. Patients with HCV or coinfection with HBV and HCV exhibited a lower incidence of vascular invasion, but worse fibrosis than patients with negative serology or HBV. The median survival rate was 47.9 months. The presence of hepatitis did not significantly affect the survival rate, but hepatic fibrosis and vascular invasion predicted a decreased survival rate. The prognosis after resection of HCC is influenced by tumor factors and liver disease, but not by HBV or HCV infection. The treatment for HCC should be dictated by the extent of underlying liver disease rather than by hepatitis serology.

Microvessel density and clinicopathological characteristics in hepatitis C virus and hepatitis B virus related hepatocellular carcinoma

AIMS

To compare intratumorous microvessel density (MVD) and clinicopathological features in two different groups of hepatocellular carcinoma (HCC), namely: hepatitis B virus (HBV) related HCC (B-HCC) and HCV related HCC (C-HCC).

METHODS

Fifty consecutive cases each of B-HCC and of C-HCC were studied. Microvessel numbers were assessed by staining for the antigen CD34; in each case, three areas with the highest numbers of microvessels were counted in both the intratumorous and the surrounding non-tumorous tissue; the mean value represented the final MVD.

RESULTS

Patients with B-HCC were significantly younger than those with C-HCC (mean age, 60.1 (SD, 4.1) v 66.4 (4.3) years); no significant differences were seen for sex or Child's class distribution. The tumour diameter was larger in B-HCCs than in C-HCCs (mean, 5.6 (SD, 1.8) v 3.8 (1.8) cm). Tumour microsatellite formation was significantly higher in C-HCCs (12 v 4 cases). No differences were found for histological subtype, degree of differentiation, tumour encapsulation, and vascular invasion. The mean MVD value was significantly higher in tumorous (mean, 54 (SD, 13.8) v 38 (8.9)) and in the surrounding non-tumorous liver tissue (mean, 15 (SD, 4.3) v 7 (3.1)) of C-HCCs.

CONCLUSIONS

C-HCCs present as smaller tumours in older patients, with a higher incidence of tumour microsatellite formation and higher MVD values both in the tumorous and the non-tumorous areas, suggesting a link between HCV infection, angiogenesis, and hepatocarcinogenesis.

Reevaluation of prognostic factors for survival after liver resection in patients with hepatocellular carcinoma in a Japanese nationwide survey

BACKGROUND

Advances in the diagnosis and surgical treatment of hepatocellular carcinoma (HCC) have improved the prognosis for patients with HCC who undergo liver resection. The objective of this study was to evaluate prognostic predictors for patients with HCC who underwent liver resection in a Japanese nationwide data base.

METHODS

In this study, the authors analyzed 12,118 patients with HCC in a Japanese nationwide data base who underwent liver resection between 1990 and 1999 and compared them with a previous analysis of patients between 1982 and 1989. All patients were evaluated for prognostic factors.

RESULTS

During the last decade, the increases in patients who were without hepatitis B virus surface antigen, who had small tumors, and who had portal vein invasion were noted. The 5-year overall survival rates for patients with HCC improved to 50.5%, compared with < 40% in the previous analysis. A multivariate analysis using a stratified Cox proportional hazards model according to associated liver disease indicated that age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were independent prognostic predictors for patients with HCC. Operative mortality decreased from 2.3% in 1990-1991 to 0.6% in 1998-1999.

CONCLUSIONS

Outcomes and operative mortality rates in patients with HCC improved during the last decade. Age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were prognostic factors for patients with HCC who underwent liver resection.

Comparison of the clinical characteristics among hepatocellular carcinoma of hepatitis B, hepatitis C and non-B non-C patients

BACKGROUND/AIMS

The present study was undertaken to compare the clinical characteristics, availability of initial treatment options and prognostic features of patients with hepatocellular carcinoma in relation to hepatitis B or C viral infection.

METHODOLOGY

Six hundred and ninety-two patients with hepatocellular carcinoma treated during the 12-year-period from Jan 1989 to Dec 2000 were categorized into three groups as follows: 1) 59 were classified as the HBV group: positive for hepatitis B surface antigen (HBsAg) and negative for antibody to hepatitis C (HCVAb), 2) 594 were placed in the HCV group: negative for HBsAg and positive for HCVAb, and 3) 39 were put into the Non-B, Non-C (NBNC) group: negative for both HBsAg and HCVAb. The age distribution, gender ratio, serum alpha-fetoprotein level, the presence of underlying cirrhosis, tumor size, the number of hepatocellular carcinoma tumors at the initial detection, the types of follow-up until the initial detection of hepatocellular carcinoma, the initial treatments chosen, and the survival were analyzed and compared among the three groups.

RESULTS

Regarding age, the HBV group showed a younger age (56.3 +/- 12.2 years old) than the other two groups (the HCV group: 66.3 +/- 8.3, the NBNC group: 67.9 +/- 8.5 years old), however, no difference was observed in the male-to-female ratio of the three groups. The serum alpha-fetoprotein level, the prevalence of hepatocellular carcinoma measuring more than 3 cm in diameter, non-solitary hepatocellular carcinoma and portal thrombosis were strongly demonstrated at the initial detection in the HBV group, which was most likely due to the poor follow-up until detection. Consequently, the 1-, 3-, 5- and 7-year survivals of the patients in the HBV group were 40.4, 25.1, 18.8 and 5.2%, and were significantly shorter than both the HCV group which were 72.6, 44.9, 25.0 and 10.0%, and the NBNC group which were 71.2, 41.4, 31.1 and 31.1%, respectively. As for the NBNC group, in spite of the lack of a careful follow-up a longer survival was observed probably because they had a better preserved liver condition.

CONCLUSIONS

Regarding the hepatocellular carcinoma patients, those infected with HBV presented at the advanced stage due to the lack of a careful follow-up, thus resulting in a shorter survival. As a result, hepatocellular carcinoma patients infected with HBV need to be strictly followed up.

Low-Dose Thalidomide Treatment for Advanced Hepatocellular Carcinoma

OBJECTIVE

To analyze the efficacy of oral thalidomide in the treatment of advanced hepatocellular carcinoma (HCC).

METHODS

Sixty-eight patients with unresectable and nonembolizable HCC were consecutively enrolled in a compassionate treatment program of oral thalidomide. Tumor response and treatment-related toxicity were prospectively followed. Thalidomide was given at a starting dose of 200 mg per day. The dose was gradually escalated in 100-mg steps up to 600 mg per day if no limiting toxicities developed.

RESULTS

Sixty-three patients were evaluable for response. One complete and 3 partial responses, defined by World Health Organization criteria, were seen, with a response rate of 6.3% (95% CI 0-12.5). The duration of response was 50+, 24.6, 11.6+ and 8.7+ weeks, respectively. All 4 responders had a dramatic decrease in alpha-fetoprotein (alpha-FP) levels. Another 6 of the 42 patients with elevated alpha-FP levels before treatment had a more than 50% decrease in their alpha-FP levels after thalidomide treatment. Totally 10 patients had an objective response to thalidomide. The median overall survival for all of the 68 patients was 18.7 weeks (95% CI 11.8- 25.6) with a 1-year survival rate of 27.6%. The median overall survival of the 10 patients with an objective response to thalidomide was 62.4 weeks (95% CI 31.2-93.6 weeks). All responders responded at a dose equal to or less than 300 mg per day. Toxicities of thalidomide were generally manageable, and only 16, 6, and 0 patients developed grade 2, 3, and 4 toxicities, respectively.

CONCLUSION

Low-dose thalidomide is safe and induces unequivocal tumor response in a minority of patients with advanced HCC.

Comparison of clinicopathologic characteristics and outcomes after resection in patients with hepatocellular carcinoma treated in the United States, France, and Japan

OBJECTIVE

To compare the clinicopathologic characteristics and outcomes after resection of patients with hepatocellular carcinoma (HCC) treated in the United States, France, and Japan.

SUMMARY BACKGROUND DATA

Some epidemiologic data suggests that HCC in different regions of the world may represent different forms of the disease.

METHODS

We compared the patient and tumor characteristics, underlying liver damage, and surgical outcomes of 586 patients who underwent resection of HCC from a multi-institutional database.

RESULTS

A total of 169 patients were treated in the United States, 187 in France, and 230 in Japan. The median tumor size for patients treated in the United States was 8 cm, compared with 6 cm and 3.5 cm in France and Japan, respectively (P < 0.001); 20%, 38%, and 74% of patients in the United States, France, and Japan, respectively, had positive hepatitis C serology (P < 0.001). In addition, 65% of patients in Japan had severe fibrosis/cirrhosis in the adjacent liver compared with 52% and 23% of patients in France and the United States, respectively (P < 0.001). There was no association between site of treatment and 30-day (P = 0.4) or 1-year mortality (P = 0.3). The 5-year survival of patients treated in United States, France, and Japan was not statistically different (31% vs. 31% vs. 41%, respectively; P = 0.3).

CONCLUSIONS

Although the etiology of HCC and clinicopathologic characteristics of patients treated at western and eastern centers vary widely, postresection 5-year survival is similar when controlling for these factors. Future studies should account for histopathologic differences using uniform criteria to allow better comparison of results.

A 6-month versus a 12-month surveillance for hepatocellular carcinoma in 559 hemophiliacs infected with the hepatitis C virus

Hepatocellular carcinoma (HCC) is an increasingly frequent cause of mortality in hemophiliacs with chronic viral hepatitis. Early diagnosis of the tumor at an initial stage is known to improve the outcome of HCC treatment. Because all HCC cases detected in a previous study based upon annual ultrasound (US) surveillance of hemophiliacs with elevated alanine aminotransferase levels were multinodular, this study was designed to evaluate if a more intense surveillance with US and alphafetoprotein (AFP) serum levels of all the patients infected with the hepatitis C virus (HCV) improved the identification of single nodule tumors. A multicenter cohort of 559 HCV-infected hemophiliacs was divided into 2 arms, one followed up at 6-month intervals and one at 12-month intervals depending on the choice and available facilities of each treatment center. During a 6-year surveillance period, HCC was diagnosed in 5 (2.4%) of 210 patients in the 6-month group and in 3 (0.9%) of 349 patients in the 12-month group. The overall incidence rate of HCC was 239 per 100 000 per year (397 per 100 000 per year in the 6-month group and 143 per 100 000 per year in the 12-month group; differences not statistically significant). By multivariate analysis, HCC risk was increased 12.9-fold with alcohol intake more than 80 g/d and 15.2-fold with AFP levels higher than 11 ng/mL. Liver-related death occurred in 8 cases (1.4%), including 3 with HCC. Still alive and tumor free after 24 to 34 months from diagnosis are 3 patients with multinodular tumors treated with repeat chemoembolization followed by orthotopic liver transplantation. In conclusion, 6-month surveillance with US did not increase the chances of detection of single nodule tumors, but it is reasonable to assume that successful treatment of multinodular tumors based upon debulking with chemoembolization and liver transplantation was facilitated by this approach.