Critical evaluation of the different staging systems for hepatocellular carcinoma

Construction of a 12-Gene Prognostic Risk Model and Tumor Immune Microenvironment Analysis Based on the Clear Cell Renal Cell Carcinoma Model

OBJECTIVES

Accurate survival predictions and early interventional therapy are crucial for people with clear cell renal cell carcinoma (ccRCC).

METHODS

In this retrospective study, we identified differentially expressed immune-related (DE-IRGs) and oncogenic (DE-OGs) genes from The Cancer Genome Atlas (TCGA) dataset to construct a prognostic risk model using univariate Cox regression and least absolute shrinkage and selection operator (LASSO) analysis. We compared the immunogenomic characterization between the high- and low-risk patients in the TCGA and the PUCH cohort, including the immune cell infiltration level, immune score, immune checkpoint, and T-effector cell- and interferon (IFN)-γ-related gene expression.

RESULTS

A prognostic risk model was constructed based on 9 DE-IRGs and 3 DE-OGs and validated in the training and testing TCGA datasets. The high-risk group exhibited significantly poor overall survival compared with the low-risk group in the training (P < 0.0001), testing (P = 0.016), and total (P < 0.0001) datasets. The prognostic risk model provided accurate predictive value for ccRCC prognosis in all datasets. Decision curve analysis revealed that the nomogram showed the best net benefit for the 1-, 3-, and 5-year risk predictions. Immunogenomic analyses of the TCGA and PUCH cohorts showed higher immune cell infiltration levels, immune scores, immune checkpoint, and T-effector cell- and IFN-γ-related cytotoxic gene expression in the high-risk group than in the low-risk group.

CONCLUSION

The 12-gene prognostic risk model can reliably predict overall survival outcomes and is strongly associated with the tumor immune microenvironment of ccRCC.

Interferon regulatory factor 1 (IRF-1) downregulates Checkpoint kinase 1 (CHK1) through miR-195 to upregulate apoptosis and PD-L1 expression in Hepatocellular carcinoma (HCC) cells

BACKGROUND

CHK1 is considered an oncogene with overexpression in numerous cancers. However, CHK1 signalling regulation in hepatocellular carcinoma (HCC) remains unclear.

METHODS

CHEK1 mRNA, protein, pri-miR-195 and miR-195 expression in HCC tissue was determined by qPCR, WB and IF staining assay. Survival analyses in HCC with high- and low-CHEK1 mRNA expression was performed using TCGA database. Relative luciferase activity was investigated in HCC cells transfected with p-CHEK1 3'UTR. Apoptosis was detected by TUNEL assay. NK and CD8+ T cells were analysed by flow cytometry.

RESULTS

CHK1 is increased in human HCC tumours compared with non-cancerous liver. High CHK1 predicts worse prognosis. IFN-γ suppresses CHK1 via IRF-1 in HCC cells. The molecular mechanism of IRF-1 suppressing CHK1 is post-transcriptional by promoting miR-195 binding to CHEK1 mRNA 3'UTR, which exerts a translational blockade. Upregulated IRF-1 inhibits CHK1, which induces apoptosis of HCC cells. Likewise, CHK1 inhibition augments cellular apoptosis in HCC tumours. This effect may be a result of increased tumour NK cell infiltration. However, IRF-1 expression or CHK1 inhibition also upregulates PD-L1 expression via increased STAT3 phosphorylation.

CONCLUSIONS

IRF-1 induces miR-195 to suppress CHK1 protein expression. Both increased IRF-1 and decreased CHK1 upregulate cellular apoptosis and PD-L1 expression in HCC.

Survival Predictability Between the American Joint Committee on Cancer 8th Edition Staging System and the Barcelona Clinic Liver Cancer Classification in Patients with Hepatocellular Carcinoma

This study compared the prognostic significance of staging between the American Joint Committee on Cancer 8th edition Tumor, Node, Metastasis (TNM) staging system and the Barcelona Clinic Liver Cancer (BCLC) classification in patients with hepatocellular carcinoma (HCC). The study population comprised patients with liver cancer registered in the Taiwan Cancer Database from 2007 to 2013 and was followed up until December 31, 2016. The study included patients with HCC, with known staging in both TNM and BCLC systems, and with follow-up >1 month. Primary endpoint was overall survival. Univariate and multivariate Cox proportional hazards model were constructed to investigate the significance of staging by two systems. Goodness-of-fit of model was evaluated via Akaike's information criterion (AIC), the lower the better. Among 73,136 patients with newly diagnosed liver cancer, a total of 37,062 patients with HCC (25.6% underwent surgery) were eligible. The mean age and overall survival of this cohort were 63.9 years and 27.2%, respectively. Overall survivals for stages I, II, III, and IV (the TNM system) were 54.5%, 34.9%, 10.3%, and 6.4%, respectively. Overall survivals for stages A, B, C, and D (the BCLC classification) were 54.5%, 29.2%, 9.8%, and 4.0%, respectively. The median follow-up time was 59.4 months. Multivariate Cox proportional hazards model revealed that both systems predicted overall survival, cancer-specific survival, disease-free survival, and local recurrence-free rate well. Values of ΔAIC of the BCLC classification and the TNM system were lower for the surgery group and nonsurgery group, respectively. The TNM system (8th edition) predicted long-term outcome better than the BCLC classification in patients with HCC. But in patients treated initially with surgery, the BCLC classification outperformed the 8th edition of the TNM system. IMPLICATIONS FOR PRACTICE: This work demonstrates that the Tumor, Node, Metastasis (TNM) system (8th edition) and the Barcelona Clinic Liver Cancer (BCLC) classification both predict long-term outcome significantly in patients with hepatocellular carcinoma but that the TNM system (8th edition) predicts long-term outcome better than the BCLC classification. For patients treated initially with surgery, BCLC classification outperforms in 8th edition TNM system in predicting long-term outcome.

NMFBFS: A NMF-Based Feature Selection Method in Identifying Pivotal Clinical Symptoms of Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy. Traditional Chinese Medicine (TCM), with the characteristics of syndrome differentiation, plays an important role in the comprehensive treatment of HCC. This study aims to develop a nonnegative matrix factorization- (NMF-) based feature selection approach (NMFBFS) to identify potential clinical symptoms for HCC patient stratification.

METHODS

The NMFBFS approach consisted of three major steps. Firstly, statistics-based preliminary feature screening was designed to detect and remove irrelevant symptoms. Secondly, NMF was employed to infer redundant symptoms. Based on NMF-derived basis matrix, we defined a novel similarity measurement of intersymptoms. Finally, we converted each group of redundant symptoms to a new single feature so that the dimension was further reduced.

RESULTS

Based on a clinical dataset consisting of 407 patient samples of HCC with 57 symptoms, NMFBFS approach detected 8 irrelevant symptoms and then identified 16 redundant symptoms within 6 groups. Finally, an optimal feature subset with 39 clinical features was generated after compressing the redundant symptoms by groups. The validation of classification performance shows that these 39 features obviously improve the prediction accuracy of HCC patients.

CONCLUSIONS

Compared with other methods, NMFBFS has obvious advantages in identifying important clinical features of HCC.

Systematic review of catheter-based intra-arterial therapies in hepatocellular carcinoma: state of the art and future directions

Intra-arterial therapies (IATs) play a pivotal role in the management of patients with primary and secondary liver malignancies. The unique advantages of these treatments are their ability to selectively deliver a high dose of anticancer treatment while preserving healthy liver tissue. The proven efficacy of these catheter-based locoregional therapies in a highly systemic chemoresistant cancer such as hepatocellular carcinoma (HCC), along with the minimally invasive nature of these treatments, quickly yielded wide acceptance in the medical community and revolutionized the field of Interventional Oncology. In this article, we describe the clinical rationale and background of catheter-based IATs. We provide an overview of clinical achievements of these treatments alone and in combination with sorafenib in patients with HCC.

Comparing staging systems for predicting prognosis and survival in patients with hepatocellular carcinoma in Egypt

Introduction

Several hepatocellular carcinoma (HCC) staging systems are available. Although the European Association for Study of Liver Diseases (EASL) and American Association for the Study of Liver Diseases (AASLD) recommended the use of Barcelona Clinic Liver Cancer (BCLC), many studies in different populations revealed heterogeneous results. The aim of this study was to compare different staging systems for predicting prognosis and survival, and for stratifying HCC patients for treatment at a national referral centre for liver disease in Egypt.

Methods

2000 Patients were included in this study. Baseline demographic, clinical, laboratory, and radiological data were determined at diagnosis. Patients were stratified using the Okuda, BCLC, Cancer of the Liver Italian Program (CLIP), and Japan Integrated Staging (JIS). Patients’ survival in different stages within each staging system and the validity of the system in predicting survival were compared.

Results

The overall survival was 15 months. The 1-, 2-, 3- and 4-year survival of the entire cohort was 56%, 34%, 25% and 15% respectively. The presence of ascites, multiple focal lesions, large tumour size >5 cm, portal vein thrombosis, extra-hepatic spread, AFP≥200 ng/ml and poor Child score were independent predictors of survival (p<0.001). All staging systems were significant in determining overall survival in univariate and multivariate analyses. BCLC was the most predictive staging system for the whole cohort (p<0.001). Among the subgroup of patients offered potentially curative therapy, BCLC was the most informative system in predicting patient survival (p<0.001). For patients with advanced HCC not amenable for specific therapy, CLIP was the best staging system for predicting prognosis (p<0.001).

Conclusion

BCLC staging system provided the best prognostic stratification for HCC patients. However, CLIP score has the highest stratification ability in patients with advanced HCC highlighting the importance of including AFP in best staging system.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Underweight patients show an increased rate of postoperative death after surgery for hepatocellular carcinoma

OBJECTIVE

To evaluate the influence of body mass index (BMI) on postoperative death in patients undergoing surgery for HCC.

METHODS

Three hundred forty-two patients were enrolled, and divided into three groups: Group A, BMI <22.5; Group B, BMI ≥22.5 to <25; Group C, BMI ≥25. Univariate and multivariate analyses of postoperative death were performed to compare BMI with clinical factors. Kaplan-Meier analysis and log rank test were used to compare such outcome in Groups A, B, and C.

RESULTS

Kaplan-Meier analysis and log rank test revealed that Group A had a higher rate of postoperative death than Group B or C (P = 0.010). Univariate and multivariate analyses selected being underweight (Group B, C/Group A) (odds ratio, 1.829; 95% C.I., 1.091-3.068; P = 0.022) as one of the factors predictive of postoperative death, together with aspartate aminotransferase level (P = 0.042) and HCC growth pattern (P = 0.032).

CONCLUSIONS

BMI is a simple but important predictor of postoperative death in patients undergoing surgery for HCC, and is able to classify such patients into three independent groups.

Comparison of staging systems of hepatocellular carcinoma

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

A unique metastasis gene signature enables prediction of tumor relapse in early-stage hepatocellular carcinoma patients

Metastasis-related recurrence often occurs in hepatocellular carcinoma (HCC) patients who receive curative therapies. At present, it is challenging to identify patients with high risk of recurrence, which would warrant additional therapies. In this study, we sought to analyze a recently developed metastasis-related gene signature for its utility in predicting HCC survival, using 2 independent cohorts consisting of a total of 386 patients who received radical resection. Cohort 1 contained 247 predominantly HBV-positive cases analyzed with an Affymetrix platform, whereas cohort 2 contained 139 cases with mixed etiology analyzed with the NCI Oligo Set microarray platform. We employed a survival risk prediction algorithm with training, test, and independent cross-validation strategies and found that the gene signature is predictive of overall and disease-free survival. Importantly, risk was significantly predicted independently of clinical characteristics and microarray platform. In addition, survival prediction was successful in patients with early disease, such as small (<5 cm in diameter) and solitary tumors, and the signature predicted particularly well for early recurrence risk (<2 years), especially when combined with serum alpha fetoprotein or tumor staging. In conclusion, we have shown in 2 independent cohorts with mixed etiologies and ethnicity that the metastasis gene signature is a useful tool to predict HCC outcome, suggesting the general utility of this classifier. We recommend the use of this classifier as a molecular diagnostic test to assess the risk that an HCC patient will develop tumor relapse within 2 years after surgical resection, particularly for those with early-stage tumors and solitary presentation.

Development and validation of a new prognostic score of death for patients with hepatocellular carcinoma in palliative setting

BACKGROUND & AIMS

Patients with hepatocellular carcinoma (HCC) in a palliative setting have a poor prognosis despite recent therapeutic progress. Several prognostic scores, such as the BCLC and the CLIP, have been shown to be useful in helping select treatment options ranging from transplantation to palliative care. However, the discriminatory ability of these scores is inadequate in palliative settings, which concern about 70% of HCC patients. In this paper, we propose and validate a new prognostic score for patients in the palliative setting.

METHODS

The prognostic score was developed on a set of 416 patients from a negative randomized clinical trial conducted by the Fédération Francophone de Cancers Digestifs. It was then subsequently validated on a second set of 271 patients from another negative trial. Backward selection was used to identify independent baseline characteristics. Measures of discrimination and predictive values were computed to assess the quality of the developed score. Comparisons with the BCLC and the CLIP - with and without the WHO performance status (PS) score - were performed.

RESULTS

Tumour morphology, portal vein obstruction, metastasis, ascites, jaundice, alpha-foetoprotein, and serum alkaline phosphatase were included in the final score. From the training dataset, three groups of increasing risk were defined, and these were associated with hazard ratios (HR) of 2.13 and HR = 5.72. Similar results were obtained on the validation dataset. This score provides a better discriminatory ability than BCLC and CLIP in this setting. Unfortunately, absolute performances for these scores remain poor.

CONCLUSIONS

The new prognostic score and CLIP + PS are recommended in palliative settings. However, new prognostic variables are necessary.

Stathmin1 overexpression associated with polyploidy, tumor-cell invasion, early recurrence, and poor prognosis in human hepatoma

Frequent intrahepatic metastasis causes early tumor recurrence and dismaying prognosis of human hepatocellular carcinoma (HCC). We recently identified overexpression of stathmin1 (STMN1) in human HCC. This study was designed to elucidate the clinical and biological significance of overexpression of STMN1 in HCC. Expression of STMN1 was conducted by quantitative reverse transcription-polymerase chain reaction and immunoblotting assays on 58 pairs of HCC and para-tumor liver tissues from patients with HCC along with normal liver tissues as the controls. Association of STMN1 overexpression with tumor recurrence and prognosis was investigated by Kaplan-Meier cumulative survival and Cox Regression analyses. Roles of STMN1 in cell cycle, cell motility, and invasion were determined by in vitro assays. STMN1 overexpression in hepatoma was strongly associated with local invasion (P = 0.031), early recurrence (P = 0.002), and poor prognosis (P = 0.005), and was an independent indicator for tumor recurrence (P = 0.0045). STMN1 overexpression further identified subgroups of HCC patients with higher tumor recurrence and worse prognosis among HCC patients with early tumor stage (T1) or intermediate histological grades (G2 and G3), both of whom represent the majority of HCC patients receiving primary curative hepatectomy. Silencing STMN1 expression via RNA interference suppressed invasion activity, while ectopic expression of STMN1 enhanced cell invasion and caused polyploidy of cells. In conclusion, STMN1 overexpression could predict early tumor recurrence and poor prognosis, particularly at early stage of hepatoma. Overexpression of STMN1 promoted polyploidy formation, tumor-cell invasion, and intrahepatic metastasis, suggesting that STMN1 can be a target for anti-cancer therapy of human hepatoma.

Pretreatment assessment of hepatocellular carcinoma: expert consensus statement

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

Perioperative risk assessment for hepatocellular carcinoma by using the MELD score

BACKGROUND/AIMS

The aim of this study was to evaluate the ability of Model for End-Stage Liver Disease (MELD) in predicting post hepatectomy outcome for hepatocellular carcinoma (HCC).

METHODS

Between 2001 and 2005, 94 cirrhotic patients with HCC underwent hepatectomy and were analyzed retrospectively. MELD score associated with postoperative mortality and morbidity, hospital stay, and 3-year survival.

RESULTS

Twenty-eight major and 66 minor resections were performed. Thirty-day mortality rate was 6.4%. MELD <or= 9 was associated with no perioperative mortality vs 15.3% when MELD > 9 (p = 0.01). Overall morbidity rate was 32%; 21% when MELD <or= 9 vs 42% when MELD > 9 (p = 0.01). Median hospital stay was 11 days (7 days, when MELD <or= 9 and 14 days when MELD > 9; p = 0.03). Three-year survival reached 48% (63% when MELD <or= 9; 30% when MELD > 9; p < 0.01). In multivariate analysis, MELD > 9 (p = 0.01), clinical tumor symptoms (p = 0.04), and American Society of Anesthesiologists score (p = 0.04) were independent predictors of perioperative mortality; MELD > 9 (p = 0.01), tumor size >5 cm (p = 0.01), presence of tumor symptoms (p = 0.02), high tumor grade (p = 0.01), and absence of tumor capsule (p = 0.01) were independent predictors of decreased long-term survival.

CONCLUSION

MELD score seems to predict outcome of cirrhotic patients with HCC after hepatectomy.

Early and very early hepatocellular carcinoma: when and how much do staging and choice of treatment really matter? A multi-center study

Background

A consensus on the most reliable staging system for hepatocellular carcinoma (HCC) is still lacking but the most used is a revised Barcelona Clinic Liver Cancer (BCLC) system, adopted by the American Association for the Study of Liver Diseases (AASLD). We investigated how many patients are diagnosed in "very early" and "early" stage, follow the AASLD guidelines for treatment and whether their survival depends on treatment.

Methods

Data were collected in 530 "very early" and "early" HCC patients recruited by a multicentric Italian collaborative group (ITA.LI.CA). The Kaplan-Meier method was used to estimate overall survival and the log rank to test the statistical significance of difference between groups. Cox's multivariate stepwise regression analysis was used to pinpoint independent prognostic factors and the adjusted relative risks (hazard ratios) were calculated as well. A statistical analysis based on the chi-square test was used to identify significant differences in clinical or pathological features between patients. A P-value < 0.05 was considered statistically significant.

Results

"Very early" HCC were 3%; Cox multivariate analysis did not identify variables independently associated with survival. The patients following AASLD recommendations (20%) did not show longer survival. In "early" HCC patients (25%), treatment significantly modulated survival (p = 0.0001); the 28% patients treated according to the AASLD criteria survived longer (p = 0,004). The Cox analysis however identified only age, gender, number of lesions and Child class as independent predictors of survival.

Conclusion

patients with very early" HCC were very few in this analysis. In most instances they were not treated with the treatment suggested as the most appropriate by the AASLD guidelines and the type of treatment had no impact on survival, even though the number of patients was relatively low and part of the patients were diagnosed before the introduction of the guidelines: this analysis, therefore, might not be considered as conclusive and should be validated. The "early" stage group involved more patients, rarely treated according to the guidelines, both overall and also in those diagnosed after their publication; the survival was in part predicted by the type of treatment, with better results in those treated according to AASLD indications.

Comparison of four current staging systems for Chinese patients with hepatocellular carcinoma undergoing curative resection: Okuda, CLIP, TNM and CUPI

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. However, there is no general consensus as to which staging system is the most reliable for predicting the survival of patients with HCC. The aims of this study were to compare commonly-used staging systems in a cohort of Chinese HCC patients undergoing curative resection.

METHODS

From January 1991 to June 2002, 234 Chinese patients undergoing curative resection for HCC from one medical center were evaluated. All patients were classified by the Okuda, Cancer of the Liver Italian Program (CLIP), tumor node metastasis (TNM) (6th edition) and the Chinese University Prognostic Index (CUPI) staging systems. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated by the area under the receiver operating characteristic (ROC) curve.

RESULTS

The overall median survival of the entire cohort was 24.9 months (95% confidence interval (CI) 18.15-31.65 months) and the estimated survival rates at 1, 3, and 5 years were 69.66% 3.01%, 41.02% 3.31%, and 29.08% 3.55%, respectively. In our patient cohort, the log-rank test demonstrated that the TNM and Okuda staging systems gave better results than the other staging systems in the prognosis stratification. The prognostic predictive powers of the TNM staging for survival, evaluated by ROC curve areas, was also superior.

CONCLUSIONS

For HCC patients undergoing curative resection, the TNM staging system (6th edition) proved the best for prognostic stratification and prognosis prediction.

Prediction of postoperative hepatic insufficiency by liver stiffness measurement (FibroScan((R))) before curative resection of hepatocellular carcinoma: a pilot study

BACKGROUND

Liver stiffness measurement (LSM) using transient elastography (FibroScan((R))) reflects the degree of hepatic fibrosis. This prospective study investigated how well LSM predicts the development of hepatic insufficiency after curative liver resection surgery for hepatocellular carcinoma.

METHODS

The study enrolled 72 consecutive patients who underwent a preoperative LSM to assess the degree of liver fibrosis followed by curative liver resection surgery for hepatocellular carcinoma between July 2006 and December 2007. The primary end point was the development of hepatic insufficiency.

RESULTS

The mean age of the patients was 54.9 years. Twenty patients (27.7%) had chronic hepatitis and 52 (72.3%) had cirrhosis (44 and 8 patients showed Child-Pugh class A and B, respectively). The mean LSM was 17.1 kPa. Twelve patients (16.6%) had segmentectomy only, 16 patients (22.2%) had bisegmentectomy, and 44 patients (61.2%) had lobectomy. Nine patients (12.5%) had stage I tumor, 56 (77.7%) had stage II, and 7 (9.8%) had stage III. Univariate and subsequent multivariate analyses revealed that preoperative LSM was the only independent risk factor for predicting the development of postoperative hepatic insufficiency (cutoff, 25.6 kPa; P = 0.001; relative risk, 19.14; 95% confidence interval, 2.71-135.36).

CONCLUSIONS

LSM is potentially useful to predict the development of postoperative hepatic insufficiency in patients with hepatocellular carcinoma undergoing curative liver resection surgery.

Prediction of postoperative hepatic insufficiency by liver stiffness measurement (FibroScan((R))) before curative resection of hepatocellular carcinoma: a pilot study

BACKGROUND

Liver stiffness measurement (LSM) using transient elastography (FibroScan((R))) reflects the degree of hepatic fibrosis. This prospective study investigated how well LSM predicts the development of hepatic insufficiency after curative liver resection surgery for hepatocellular carcinoma.

METHODS

The study enrolled 72 consecutive patients who underwent a preoperative LSM to assess the degree of liver fibrosis followed by curative liver resection surgery for hepatocellular carcinoma between July 2006 and December 2007. The primary end point was the development of hepatic insufficiency.

RESULTS

The mean age of the patients was 54.9 years. Twenty patients (27.7%) had chronic hepatitis and 52 (72.3%) had cirrhosis (44 and 8 patients showed Child-Pugh class A and B, respectively). The mean LSM was 17.1 kPa. Twelve patients (16.6%) had segmentectomy only, 16 patients (22.2%) had bisegmentectomy, and 44 patients (61.2%) had lobectomy. Nine patients (12.5%) had stage I tumor, 56 (77.7%) had stage II, and 7 (9.8%) had stage III. Univariate and subsequent multivariate analyses revealed that preoperative LSM was the only independent risk factor for predicting the development of postoperative hepatic insufficiency (cutoff, 25.6 kPa; P = 0.001; relative risk, 19.14; 95% confidence interval, 2.71-135.36).

CONCLUSIONS

LSM is potentially useful to predict the development of postoperative hepatic insufficiency in patients with hepatocellular carcinoma undergoing curative liver resection surgery.

Quality of life as a prognostic factor of overall survival in patients with advanced hepatocellular carcinoma: results from two French clinical trials

AIM

The aims of our study were to assess quality of life (QoL) as a prognostic factor of overall survival (OS) and to determine whether QoL data improved three prognostic classifications among French patients with advanced hepatocellular carcinoma (HCC).

METHODS

We pooled two randomized clinical trials conducted by the Fédération Francophone de Cancérologie Digestive in a palliative setting. In each trial QoL was assessed at baseline using the Spitzer QoL Index (0-10). Three prognostic classifications were calculated: Okuda, Cancer of the Liver Italian Program (CLIP), and Barcelona Clinic Liver Cancer group (BCLC) scores. To explore whether the scores could be improved by including QoL, univariate Cox analyses of all potential baseline predictors were performed. A final multivariate Cox model was constructed including only significant multivariate baseline variables likely to result in improvement of each scoring system. In order to retain the best prognostic variable to add for each score, we compared Akaike information criterion, likelihood ratio, and Harrell's C-index. Cox analyses were stratified for each trial.

RESULTS

Among 538 included patients, QoL at baseline was available for 489 patients (90%). Longer median OS was significantly associated with higher Spitzer scores at baseline, ranging from 2.17 months (Spitzer=3) to 8.93 months (Spitzer=10). Variables retained in the multivariate Cox model were: jaundice, hepatomegaly, hepatalgia, portal thrombosis, alphafetoprotein, bilirubin, albumin, small HCC, and Spitzer QoL Index (hazard ratio=0.84 95% CI [0.79-0.90]). According to Harrell's C-index, QoL was the best prognostic variable to add. CLIP plus the Spitzer QoL Index had the most discriminating value (C=0.71).

CONCLUSIONS

Our results suggest that QoL is an independent prognostic factor for survival in HCC patients with mainly alcoholic cirrhosis. The prognostic value of CLIP score could be improved by adding Spitzer QOL Index scores.

Analysis of 6381 hepatocellular carcinoma patients in southern Taiwan: prognostic features, treatment outcome, and survival

BACKGROUND

This hospital-based analysis was conducted to identify prognostic factors of hepatocellular carcinoma (HCC) in a hepatitis B virus endemic area.

METHODS

A total of 6381 HCC cases, diagnosed from 1986 to 2002, were enrolled, and 2890 (42.3%) of them were not treated. Survival rates were analyzed by correlation with the national mortality databank. Missing data and correlations among prognostic factors were considered in the analysis.

RESULTS

The overall 1-year, 3-year, 5-year, and 7-year survival rates were 44.3%, 24.9%, 17.1%, and 13%, respectively. Multivariate analysis revealed that the independent factors influencing survival were the initial treatment modality, degree of liver function impairment, hepatitis B surface antigen positivity, tumor status, and alpha-fetoprotein. Besides these well-known prognostic factors, high alanine aminotransferase (ALT) levels and a high aspartate aminotransferase (AST)/ALT ratio were identified as independent poor prognostic factors.

CONCLUSIONS

This study, which considered untreated cases, missing data, and correlations between variables and official survival data sets, provides a large-scale comprehensive survival analysis. According to our results, high ALT and high AST/ALT were independent poor prognostic factors. Therefore, viral activity should be controlled in HCC patients, and patients with elevated AST/ALT ratios should be carefully monitored.

Comparison of seven staging systems in cirrhotic patients with hepatocellular carcinoma in a cohort of patients who underwent radiofrequency ablation with complete response

BACKGROUND AND AIMS

Many staging systems for hepatocellular carcinoma (HCC) have been proposed but the best tool for staging of HCC remains controversial. The aim of the present study was to identify the best staging system evaluating the predictive ability for outcome for each of the seven different staging systems applied in a homogeneous group of patients who underwent percutaneous radiofrequency ablation (RFA).

METHODS

We analyzed retrospectively 112 patients with HCC and cirrhosis treated with percutaneous RFA from January, 1998 to April, 2005. Response to treatment after 30 days and for long-term follow-up was evaluated with computed tomography (CT) or magnetic resonance imaging (MRI) and serum alpha-fetoprotein level (AFP). All of the 112 patients were grouped according to each one of the seven different staging systems: Okuda, TNM, BCLC, CLIP, GRETCH, CUPI, JIS.

RESULTS

The mean follow-up time of the 112 patients submitted to RFA was 24 months (range 3-92 months) with survival rates at 1, 3, and 5 yr of 82%, 40%, and 18%, respectively. Univariate and multivariate analyses showed that factors related to survival were Child-Pugh score (P

CONCLUSIONS

The BCLC staging system shows a superior discriminatory power in our cohort of HCC patients who underwent RFA; moreover, it can give important prognostic information after complete response to treatment. Our study confirms the validity of the BCLC staging system in patients with HCC in cirrhosis.

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MESH Headings

• Aged
• Carcinoma, Hepatocellular/classification
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/mortality
• Carcinoma, Hepatocellular/surgery
• Catheter Ablation
• Female
• Humans
• Liver Cirrhosis/complications
• Liver Neoplasms/classification
• Liver Neoplasms/complications
• Liver Neoplasms/mortality
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Neoplasm Staging
• Prognosis
• Survival Rate
• Treatment Outcome

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Affiliation(s)

Alfredo Guglielmi Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy
Andrea Ruzzenente
Silvia Pachera
Alessandro Valdegamberi
Marco Sandri
Mirko D'Onofrio
Calogero Iacono

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Identification of metastasis-related microRNAs in hepatocellular carcinoma

MicroRNAs (miRNAs) have been used as cancer-related biomarkers. Hepatocellular carcinoma (HCC) is an aggressive cancer with a dismal outcome largely due to metastasis and postsurgical recurrence. We investigated whether the expression of certain miRNAs are associated with HCC metastasis. We examined the miRNA expression profiles of 482 cancerous and noncancerous specimens from radical resection of 241 patients with HCC. Using a supervised algorithm and a clinically well-defined cohort of 131 cases, we built a unique 20-miRNA metastasis signature that could significantly predict (P < 0.001) primary HCC tissues with venous metastases from metastasis-free solitary tumors with 10-fold cross-validation. However, significant miRNAs could not be identified from the corresponding noncancerous hepatic tissues. A survival risk prediction analysis revealed that a majority of the metastasis-related miRNAs were associated with survival. Furthermore, the 20-miRNA tumor signature was validated in 110 additional cases as a significant independent predictor of survival (P = 0.009) and was significantly associated with both survival and relapse in 89 cases of early stage HCC (P = 0.022 and 0.002, respectively). These 20 miRNAs may provide a simple profiling method to assist in identifying patients with HCC who are likely to develop metastases/recurrence. In addition, functional analysis of these miRNAs may enhance our biological understanding of HCC metastasis.

Outcomes of Liver Transplantation in 490 Patients with Hepatocellular Carcinoma: Validation of a Uniform Staging after Surgical Treatment

BACKGROUND

The aim of this study was to compare the ability of staging systems (American Joint Committee on Cancer/Union Internationale contre le Cancer [AJCC/UICC], Japanese TNM, Pittsburgh, United Network for Organ Sharing [UNOS], Cancer of the Liver Italian Program [CLIP], Japan Integrated Staging [JIS], and Barcelona Clinic Liver Cancer [BCLC]) to predict survival after liver transplantation for hepatocellular carcinoma.

STUDY DESIGN

Four hundred ninety consecutive patients who underwent liver transplantation for hepatocellular carcinoma at 4 centers (1985 to 2005) were identified using a registry (US, Belgium, Germany). End points were overall (OS) and recurrence-free survival (RFS). Survival by stage was compared with the log-rank test. Sequential stage-wise discrimination of each system was evaluated using Cox regression.

RESULTS

Three- and 5-year overall survival rates were 71% and 64%, respectively; recurrence-free survival rates were 67% and 61%, respectively. Median followup among 327 living and 308 recurrence-free patients was 40 months. In only three systems--AJCC/UICC, Japanese TNM, and Pittsburgh--were overall and recurrence-free survivals longer for patients with low stage versus more advanced stage. For overall and recurrence-free survivals, sequential stages were different only for AJCC/UICC. In the Japanese TNM system, stages II and I were similar; for Pittsburgh, grades 3 and 2 were similar. For the United Network for Organ Sharing system, stages II and I and stages IVA1 and III were similar. All stages were similar for the Cancer of the Liver Italian Program. For the Japan Integrated Staging, scores 2 and 1 and scores 4 and 3 were similar. In the Barcelona Clinic Liver Cancer, stage D patients had significantly better survival than patients at stage C.

CONCLUSIONS

The AJCC/UICC staging system provides the best stratification of prognosis for patients undergoing liver transplantation for hepatocellular carcinoma. This confirms previous analyses in patients treated with hepatic resection. The AJCC/UICC staging system should be considered for uniform prediction of outcomes after surgery for hepatocellular carcinoma.

Radio frequency ablation for hepatocellular carcinoma in cirrhotic patients: prognostic factors for survival

BACKGROUND

Radio frequency ablation (RFA) of hepatocellular carcinoma has proved to be useful in local control of tumor. A few data on survival after treatment are available in literature. The aim of the study was to evaluate factors related to survival and to identify different classes of risk after radio frequency ablation.

METHODS

Ninety-eight cirrhotic patients with 145 hepatocellular carcinomas were treated with radio frequency ablation from January 1998 to May 2004. In 55 patients, cirrhosis was in Child-Pugh class A, and in 43, in class B. Tumor was single in 60 and multiple in 38; mean tumor number was 1.5 (range 1-3). Tumor size ranged from 1.5 to 6.0 cm, mean 3.8 cm. Mean follow up period was 24.9 months. Radio frequency ablation was performed with expandable type needle with percutaneous approach under real-time ultrasound guidance. For statistical analysis, univariate and multivariate analysis were performed.

RESULTS

Complete ablation of the tumor was achieved in 85.5% of lesions. Survival, 1 and 3 years, was 76.7 and 36.6%, respectively. Univariate analysis showed that Cancer of the Liver Italian Program (CLIP) score, tumor growth pattern, alpha-fetoprotein level, and complete tumor necrosis, were factors significantly related to poor survival. Multivariate analysis identified that factors related to poor survival were alpha-fetoprotein level >100 ng/ml, Child-Pugh class B, and incomplete tumor necrosis with a hazard ratio of 4.0, 2.7, and 3.8, respectively. After complete ablation, median survival was 38 months in patients with Child-Pugh class A cirrhosis and alpha-fetoprotein level < or =100 ng/ml, 22 months for patient with Child-Pugh class B cirrhosis and alpha-fetoprotein < or =100 ng/ml, and 9 months for patient with Child-Pugh class A cirrhosis and alpha-fetoprotein >100 ng/ml (P < 0.01).

CONCLUSIONS

Complete necrosis and absence of residual tumor positively affect survival after RFA. In patients with Child-Pugh A cirrhosis and alpha-fetoprotein level < or =100 radio frequency, ablation have results, 55% after 3 years, that are comparable to those of surgical resection. Patients with Child-Pugh B cirrhosis and/or alpha-fetoprotein >100 ng/ml showed less satisfactory results, and in these patients, multimodality treatment or other treatments should be considered.

A modified Japan Integrated Stage score for prognostic assessment in patients with hepatocellular carcinoma

BACKGROUND

For patients with hepatocellular carcinoma (HCC), the selection of effective therapeutic options depends on a reliable prognostic assessment of both the tumor characteristics and liver impairment. This study sought to provide a modified Japan Integrated Stage (m-JIS) score to predict more accurately the survival of patients with HCC.

METHODS

We analyzed the records of 42,269 patients diagnosed with HCC that were registered between 1992 and 1999 in a nationwide Japanese database. The m-JIS score was calculated from the tumor-node-metastasis stage and the grade of liver damage as defined by the Liver Cancer Study Group of Japan. The predictive accuracy for patient survival based on the m-JIS score was compared with that determined by the modified Cancer of the Liver Italian Program (m-CLIP) score using the cross-validation method.

RESULTS

Patients were divided randomly into two groups, a training sample for construction of prediction models (n = 21,127 patients with 8,458 deaths) and a validation sample for assessment of those prediction models (n = 21,142 patients with 8,434 deaths). Both the m-JIS score and the m-CLIP score showed good discriminatory ability in the training sample. In the validation sample, the residuals of prediction based on the m-JIS score were smaller than those of the m-CLIP score (P < 0.0001).

CONCLUSIONS

The m-JIS scoring system had better predictive accuracy than the m-CLIP score system for survival of Japanese patients with HCC.

Prognostic value and clinical relevance of the 6th Edition 2002 American Joint Committee on Cancer staging system in patients with resectable hepatocellular carcinoma

BACKGROUND

A simplified American Joint Committee on Cancer (AJCC) TNM staging system for hepatocellular carcinoma (HCC) (the 6th edition) was proposed in 2002. In this study, we validated the prognostic value of the staging system in a patient cohort undergoing hepatic resection with longterm followup.

STUDY DESIGN

From a prospective database, the study cohort consisted of 440 patients who underwent curative hepatic resection for HCC between July 1991 and January 1999. Median followup time was 66 months. Multivariate analysis was performed to identify the independent prognostic factors related to postoperative survival. Patients were staged according to both the 5th edition (TNM-5) and 6th edition (TNM-6) AJCC TNM staging criteria.

RESULTS

The independent prognostic factors included major vascular invasion, microvascular invasion, surgical margin < 1 cm, indocyanine green retention rate at 15 minutes > 10%, multiple tumors, tumor rupture, male, and serum aspartate aminotransferase > 90 U/L. The breakdown by TNM-5 staging: I, 27 (6.1%); II, 108 (24.5%); III, 218 (49.5%); and IVA, 87 (19.8%) and by TNM-6 staging: I, 120 (27.3%); II, 170 (38.6%); and III, 150 (34.1%). When stratified according to the TNM-5 system, difference in survival was notable between stages II and IIIA (p < 0.001), between stages IIIA and IVA (p < 0.001), but not between stages I and II (p > 0.05). When stratified according to the TNM-6 system, difference in survival was considerable between stages I and II (p < 0.01), stages II and III (p < 0.001), and stages I and III (p < 0.001).

CONCLUSIONS

Overall, the TNM-6 staging system appears to provide a reliable prognostic classification of HCC patients and is simpler to use than the TNM-5 staging system.

Evaluation of liver function for hepatic resection

New limits have been established to decrease mortality and morbidity rates after liver resection in cirrhotic and non-cirrhotic patients. Various laboratory data and imaging techniques have been used to complement the Child-Pugh score to predict liver failure after hepatectomy and to assess functional hepatic reserve. The greatest experiences are with the aminopyrine breath test and the galactosyl elimination capacity, which are decreased among hepatic failure patients after liver resection. However, absence of these changes do not totally exclude it. The indocyanine green retention test is the most widely used clearance test. Nevertheless, it remains imperfect because it depends both on hepatic blood flow and on the functional capacity of the liver. Nuclear imaging of the asialoglicoprotein receptors with radiolabelled synthetic asialoglicoproteins provides volumetric information as well a functional assessment of the liver. In summary, while liver function is complex, a successful liver test to assess quantitative functional hepatic reserve still needs to be established. The combination of the Child-Pugh score, the presence of ascites, the serum bilirubin levels, the indocyanine green retention (ICG R15) value, and the remnant liver CT volumetry seems to avoid an index of liver failure after hepatic resection. Cases when ICG R15 is above 15% should be combined with portal vein embolization. If there is no possibility to perform an ICG clearance test, it may be replaced with other available, well known dynamic liver function tests.

Prospective validation of the Barcelona Clinic Liver Cancer staging system

BACKGROUND/AIMS

The Barcelona Clinic Liver Cancer (BCLC) classification offers a prognostic stratification of patients with hepatocellular carcinoma (HCC). We recently demonstrated the BCLC's peculiar prognostic ability in a retrospective cohort of HCC patients. The aim of this study was to evaluate the BCLC system prospectively in a subsequent separate group of HCC patients enrolled at the same surgically oriented liver unit.

METHODS

One hundred and ninety-five consecutive HCC patients were prospectively enrolled and their liver disease was staged before therapy. Unlike the BCLC treatment protocol, nodule size and number were not used as absolute exclusion criteria for radical treatment. Predictors of survival were identified using the Cox model.

RESULTS

The median survival time was 23 months overall, and 53, 16, 7 and 3 months, respectively, for BCLC categories A, B, C, and D. In our cohort, BCLC had the best independent predictive power for survival when compared with the Okuda, CLIP, UNOS-TNM, and JIS prognostic systems (linear trend chi(2)=43.01, likelihood chi(2)=57.94, AIC 885.98). Moreover, the BCLC classification showed a better prognostic ability than the AJCC-TNM 2002 system in surgical patients.

CONCLUSIONS

The discriminating power of BCLC staging was prospectively assessed in an Italian cohort of HCC patients treated mainly with radical therapies.

Hepatocellular carcinoma: overcoming challenges in disease management

Hepatocellular carcinoma is the third most frequent cause of death from cancer and the eighth most commonly occurring cancer in the world. In the United States, hepatocellular carcinoma appears to be increasing along with evolution of chronic hepatitis infection, especially in the immigrant population, a major risk group. A disease of multifactorial etiology, hepatocellular carcinoma confers many management challenges. Hepatocarcinogenesis is a multistep process involving different genetic alterations that ultimately lead to malignant transformation of the hepatocyte. Early hepatocellular carcinoma is characteristically silent and slow growing with few symptoms until late in disease. Early and accurate diagnosis of hepatic tumors relies on clinical suspicion, screening protocols, serologic testing, radiologic imaging, and tissue confirmation. Lack of clinically validated biomarkers and clinical identification of hepatocellular carcinoma at advanced disease make diagnosis and treatment difficult. Advances in computed tomography and magnetic resonance imaging have markedly increased the sensitivity and specificity of testing, yet they are still flawed with a relatively high false-positive rate. Several surgical and nonsurgical therapies have been developed and used with varying degrees of success. Options include surgical resection, liver transplantation, local ablation therapies, and pharmaceutical interventions. At 5 years after resection, in those patients who are surgical candidates, the recurrence rate ranges between 30% and 60%. In patients with nonresectable disease, the prognosis is dismal, with a median survival of less than 12 months even with chemotherapy. The medical community faces numerous challenges in hepatocellular carcinoma and must work toward better management and multidisciplinary care of this complex disease.

Controversies in staging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. As the natural history of HCC is better delineated, treatment strategies are in constant evolution. Classic staging systems based on histopathology following resection are often inadequate because the majority of patients present with advanced disease. The dissatisfaction with anatomic staging systems has resulted in the emergence of several new clinical staging systems, which attempt to integrate tumor biology and the underlying function of the nondiseased liver. Tragically, the byproduct of multiple staging strategies is confusion for physicians, patients, and clinical researchers; this undermines the principles on which staging systems are created. To address this issue, a consensus conference was organized in 2002 to identify the best staging strategy for HCC. The purpose of this article is to review the current clinical and pathologic staging strategies and to highlight the recommendations from the consensus conference.

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.

The continuing challenge of hepatic cancer in Asia

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. The number of new cases is estimated to be 564,000 per year. About 80% of all cases are found in Asia. The goal of HCC management is "cancer control"--a reduction in its incidence and mortality as well as an improvement in the quality of life of patients with HCC and their family. Overall, 80% of HCC can be attributed to chronic hepatitis B and C infection. Prevention of infection with hepatitis B and C virus is the key strategy to reduce the incidence of HCC in Asia. Liver resection and liver transplantation remain the options that give the best chance of a cure. In the past two decades, operative mortality and surgical outcome of liver resection and liver transplantation for HCC have improved. Progress also has been made in multi-modality therapy which can increase the chance of survival and improve the quality of life for patients with advanced HCC. Many challenges are still present in Asia, such as the high prevalence of chronic hepatitis, the low resection rate of HCC, the high postoperative recurrence and the severe shortage of cadaveric organ donor. This article aims to discuss the development and challenges in the prevention and management of HCC in Asia.

Comparison of the usefulness of three staging systems for hepatocellular carcinoma (CLIP, BCLC, and JIS) in Japan

OBJECTIVES

We retrospectively compared the usefulness of three different staging systems for hepatocellular carcinoma (HCC), the Cancer of the Liver Italian Program (CLIP) scoring system, the Barcelona Clinic Liver Cancer (BCLC) classification system, and the Japan Integrated Staging (JIS) system, in terms of patient distribution and survival rates.

METHODS

Subjects were 1,508 patients diagnosed as having initial HCC during the period of 1976-2003. The disease was staged in all patients by means of the three staging systems, and the distribution of patients across stages and associated survival rates were compared between systems. In addition, comparisons were made on the basis of the time of diagnosis: 1976-1990 (n = 497) and 1991-2003 (n = 1,011).

RESULTS

Patients were evenly distributed across stages within each staging system, and survival rates differed between stages except for BCLC C and D. During the period 1991-2003, when HCCs were smaller at diagnosis, JIS system is in particular yielded even distribution of patient across stages and marked differences in survival rates.

CONCLUSIONS

Overall, the CLIP and the JIS scoring systems proved to be suitable for patients in Japan with HCC. The CLIP staging systems proved to be more suitable before 1991. In contrast, the JIS system was the most suitable after 1990, when early detection and early treatment of HCC became common. The JIS system is, therefore, the appropriate system in this era of early detection and treatment of HCC.

Surgical therapy of hepatocellular carcinoma

There is no worldwide consensus of an algorithm for the radical treatment of hepatocellular carcinoma (HCC). Surgical resection, liver transplantation and, recently, local ablation therapies achieve high curative rates in selected patients. However, recurrence of HCC remains a major problem. This review provides an overview of the current surgical treatment options available for patients with HCC.

Prognosis of hepatocellular carcinoma: comparison of 7 staging systems in an American cohort

Currently there is no consensus as to which staging system is best in predicting the survival of patients with hepatocellular carcinoma (HCC). The aims of this study were to identify independent predictors of survival and to compare 7 available prognostic staging systems in patients with HCC. A total of 239 consecutive patients with cirrhosis and HCC seen between January 1, 2000, and December 31, 2003, were included. Demographic, laboratory, and tumor characteristics and performance status were determined at diagnosis and before therapy. Predictors of survival were identified using the Kaplan-Meir test and the Cox model. Sixty-two percent of patients had hepatitis C, 56% had more than 1 tumor nodule, 24% had portal vein thrombosis, and 29% did not receive any cancer treatment. At the time of censorship, 153 (63%) patients had died. The 1- and 3-year survival of the entire cohort was 58% and 29%, respectively. The independent predictors of survival were performance status (P < .0001), MELD score greater than 10 (P = .001), portal vein thrombosis (P = .0001), and tumor diameter greater than 4 cm (P = .001). Treatment of HCC was related to overall survival. The Barcelona Clinic Liver Cancer (BCLC) staging system had the best independent predictive power for survival when compared with the other 6 prognostic systems. In conclusion, performance status, tumor extent, liver function, and treatment were independent predictors of survival mostly in patients with cirrhosis and HCC. The BCLC staging system includes aspects of all of these elements and provided the best prognostic stratification for our cohort of patients with HCC.

Differential expression of antioxidant enzymes in various hepatocellular carcinoma cell lines

Recent evidence suggests that reactive oxygen species (ROS) play an important role in the pathogenesis of various illnesses, and the ROS and antioxidant enzymes are highly associated with cell differentiation and diseases. In this study, we tested the hypothesis that specific antioxidant enzymes are differentially expressed in hepatocellular carcinoma (HCC) cell lines with various degrees of differentiation. We compared the expression of several antioxidant enzymes including catalase (CAT), superoxide dismutase (SOD), glutathione reductase (GRx), and glutathione peroxidase (GPx) in five HCC cell lines with well (Hep G2 and Hep 3B) or poor (HA22T/VGH, HA55T/VGH, and SK-Hep-1) differentiation. Our results showed that both well-differentiated HCC cell lines expressed extremely higher CAT and GRx enzyme activities than all three poorly differentiated ones. Moreover, the protein and mRNA levels of CAT were much higher in two well-differentiated HCC cell lines than in all three poorly differentiated ones. Both well-differentiated HCC cell lines also showed a higher protein or mRNA expression of Cu/ZnSOD and MnSOD than three poorly differentiated ones. Our results demonstrate that specific antioxidant enzymes (especially, CAT and GRx) are differentially expressed in HCC cell lines with well or poor differentiation. These findings suggest that CAT and GRx are two potential differentiation markers for HCC.

Validation of a new prognostic staging system for hepatocellular carcinoma: the JIS score compared with the CLIP score

The Japan Integrated Staging score (JIS score), which combines the Child-Turcotte-Pugh classification and tumor-node-metastasis staging, has been proposed as a better prognostic staging system for hepatocellular carcinoma (HCC) than the Cancer of the Liver Italian Program (CLIP) scoring system. In this study, validation was performed among a larger patient population. A total of 4,525 consecutive patients with HCC who had been diagnosed at five institutions were included. Stratification ability, prognostic predictive power, and reproducibility were analyzed and compared with results from the CLIP scoring system. Only 45% (1,951 of 4,525) of all patients were categorized as early stage HCC according to JIS score (0 or 1), whereas 63% (2,878 of 4,525) of the patients were categorized as having a CLIP score of 0 or 1. Significant differences in survival curves were not observed among CLIP scores 3 to 6. In contrast, survival curves showed significant differences among all the JIS scores. The same JIS scoring subgroups showed a similar prognosis, and good internal reproducibility was observed in each of the institutions. Multivariate analysis of the prognosis in all 4,525 patients proved the JIS score to be the best prognostic factor. Furthermore, the Akaike information criteria proved that the JIS scoring system was statistically a better model for predicting outcome than the CLIP scoring system. In conclusion, the stratification ability and prognostic predictive power of the JIS score were much better than that of the CLIP score and were simple to obtain and remember.