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

Percutaneous MR-Guided Thermal Ablation for Recurrent Subcentimeter Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

To evaluate the technical efficacy and therapeutic outcomes of percutaneous MR-guided thermal ablation, including microwave ablation (MWA) and radiofrequency ablation (RFA) for recurrent subcentimeter hepatocellular carcinomas (HCCs). MATERIALS AND METHODS: From January 2015 to May 2024, we recruited 101 patients with 119 recurrent subcentimeter HCCs (mean diameter: 8.0±1.3 mm, range: 5.6-9.9mm), who were treated with MR-guided thermal ablation. Technical success, technical efficacy, complications, and local tumor progression (LTP) rate were evaluated after ablation. Cumulative LTP rate, recurrence-free survival (RFS), and overall survival (OS) rates were estimated using the Kaplan-Meier method.

RESULTS

A retrospective analysis showed that MR-guided thermal ablation (MWA, n=84; RFA, n=17) was successfully executed in all cases. Technical success and efficacy were achieved in all lesions in single sessions without major complications. The mean follow-up duration was 41.1±27.1 months (median:38.0 months; range:3-105 months). The cumulative LTP rate at 1 year was 1.2%, and 5.8% at 3, 5, 7, and 9 years. The cumulative RFS rates at 1, 3, 5, 7, and 9 years were 82.2%, 44.6%, 29.0%, 23.2%, and 23.2%, respectively. The cumulative OS rates at 1, 3, 5, 7, and 9 years were 99.0%, 91.8%, 84.4%, 69.7%, and 62.0%, respectively.

CONCLUSION

Percutaneous MR-guided thermal ablation for recurrent subcentimeter HCCs demonstrated ready visualization of lesions and ablation margins as well as high technical efficacy rate, and minimal LTP after a single treatment session.

Seizing tumor factors for mortality and survival outcomes following liver resection in Indonesia's hepatocellular carcinoma patients

Backgrounds/Aims

The 3-year mortality rate for hepatocellular carcinoma (HCC) in Indonesia was 94.4%. This underscores a significant health issue in Southeast Asia, particularly in Indonesia due to its large population. This study aimed to characterize the outcomes of liver resection for HCC at a National Referral Center in Indonesia.

Methods

Between 2010 and 2020, all patients with HCC undergoing liver resection were included as subjects. Variables collected included sex, age, hepatitis status, and tumor's characteristics. Mortality and survival were the primary outcomes of the study.

Results

Among seventy patients, the mortality rate was 71.4%, with a median overall survival of 19.0 months (95% confidence interval [95%CI]: 6.831.2). Thirty-one patients (44.3%) had extra-large HCC tumors (> 10 cm). Those with extra-large tumors had a lower median survival of 8.0 months. Child-Pugh B and Edmonson-Steiner grade 4 were associated with an increased mortality risk, with unadjusted hazard ratios (HRs) of 2.2 (95%CI: 1.14.3, p = 0.026) and 3.2 (95%CI: 1.37.7, p = 0.011), respectively. Multivariate analysis indicated that Child-Pugh class B significantly increased the risk of mortality, with an adjusted HR of 2.3 (95%CI: 1.05.2, p = 0.046).

Conclusions

While surgical resection is feasible for tumors of any size, most clinical features are not statistically significantly associated with survival outcomes. The prevalence of extra-large tumors among Indonesian HCC patients highlights the importance of early diagnosis and intervention. Surgical intervention at an earlier stage and with better grade tumors could potentially enhance survival outcomes.

Deep Learning-Based Approach for Identifying and Measuring Focal Liver Lesions on Contrast-Enhanced MRI

BACKGROUND

The number of focal liver lesions (FLLs) detected by imaging has increased worldwide, highlighting the need to develop a robust, objective system for automatically detecting FLLs.

PURPOSE

To assess the performance of the deep learning-based artificial intelligence (AI) software in identifying and measuring lesions on contrast-enhanced magnetic resonance imaging (MRI) images in patients with FLLs.

STUDY TYPE

Retrospective.

SUBJECTS

395 patients with 1149 FLLs.

FIELD STRENGTH/SEQUENCE

The 1.5 T and 3 T scanners, including T1-, T2-, diffusion-weighted imaging, in/out-phase imaging, and dynamic contrast-enhanced imaging.

ASSESSMENT

The diagnostic performance of AI, radiologist, and their combination was compared. Using 20 mm as the cut-off value, the lesions were divided into two groups, and then divided into four subgroups: <10, 10-20, 20-40, and ≥40 mm, to evaluate the sensitivity of radiologists and AI in the detection of lesions of different sizes. We compared the pathologic sizes of 122 surgically resected lesions with measurements obtained using AI and those made by radiologists.

STATISTICAL TESTS

McNemar test, Bland-Altman analyses, Friedman test, Pearson's chi-squared test, Fisher's exact test, Dice coefficient, and intraclass correlation coefficients. A P-value <0.05 was considered statistically significant.

RESULTS

The average Dice coefficient of AI in segmentation of liver lesions was 0.62. The combination of AI and radiologist outperformed the radiologist alone, with a significantly higher detection rate (0.894 vs. 0.825) and sensitivity (0.883 vs. 0.806). The AI showed significantly sensitivity than radiologists in detecting all lesions <20 mm (0.848 vs. 0.788). Both AI and radiologists achieved excellent detection performance for lesions ≥20 mm (0.867 vs. 0.881, P = 0.671). A remarkable agreement existed in the average tumor sizes among the three measurements (P = 0.174).

DATA CONCLUSION

AI software based on deep learning exhibited practical value in automatically identifying and measuring liver lesions.

LEVEL OF EVIDENCE: 4

TECHNICAL EFFICACY

Stage 2.

Development and validation of nomograms for predicting prognosis in patients with solitary HCC: A TRIPOD-Compliant study

OBJECTIVE

To develop and validate nomograms for predicting the OS and CSS of patients with Solitary Hepatocellular Carcinoma (HCC).

METHODS

Using the TRIPOD guidelines, this study identified 5206 patients in the Surveillance, Epidemiology, and End Results (SEER) 17 registry database. All patients were randomly divided in a ratio of 7:3 into a training cohort (n = 3646) and a validation cohort (n = 1560), and the Chinese independent cohort (n = 307) constituted the external validation group. The prognosis-related risk factors were selected using univariate Cox regression analysis, and the independent prognostic factors of OS and CSS were identified using the Lasso-Cox regression model. The nomograms for predicting the OS and CSS of the patients were constructed based on the identified prognostic factors. Their prediction ability was evaluated using the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve in both the training and validation cohorts.

RESULTS

We identified factors that predict OS and CSS and constructed two nomograms based on the data. The ROC analysis, C-index analysis, and calibration analysis indicated that the two nomograms performed well over the 1, 3, and 5-year OS and CSS periods in both the training and validation cohorts. Additionally, these results were confirmed in the external validation group. Decision curve analysis (DCA) demonstrated that the two nomograms were clinically valuable and superior to the TNM stage system.

CONCLUSION

We established and validated nomograms to predict 1,3, and 5-year OS and CSS in solitary HCC patients, and our results may also be helpful for clinical decision-making.

Which factors predict tumor recurrence and survival after curative hepatectomy in hepatocellular carcinoma? Results from a European institution

BACKGROUND

High tumor recurrence and dismal survival rates after curative intended resection for hepatocellular carcinoma (HCC) are still concerning. The primary goal was to assess predictive factors associated with disease-free (DFS) and overall survival (OS) in a subset of patients with HCC undergoing hepatic resection (HR).

METHODS

Between 08/2004-7/2021, HR for HCC was performed in 188 patients at our institution. Data allocation was conducted from a prospectively maintained database. The prognostic impact of clinico-pathological factors on DFS and OS was assessed by using uni- and multivariate Cox regression analyses. Survival curves were generated with the Kaplan Meier method.

RESULTS

The postoperative 1-, 3- and 5- year overall DFS and OS rates were 77.9%, 49.7%, 41% and 72.7%, 54.7%, 38.8%, respectively. Tumor diameter ≥ 45 mm [HR 1.725; (95% CI 1.091-2.727); p = 0.020], intra-abdominal abscess [HR 3.812; (95% CI 1.859-7.815); p < 0.0001], and preoperative chronic alcohol abuse [HR 1.831; (95% CI 1.102-3.042); p = 0.020] were independently predictive for DFS while diabetes mellitus [HR 1.714; (95% CI 1.147-2.561); p = 0.009), M-Stage [HR 2.656; (95% CI 1.034-6.826); p = 0.042], V-Stage [HR 1.946; (95% CI 1.299-2.915); p = 0.001, Sepsis [HR 10.999; (95% CI 5.167-23.412); p < 0.0001], and ISGLS B/C [HR 2.008; (95% CI 1.273-3.168); p = 0.003] were significant determinants of OS.

CONCLUSIONS

Despite high postoperative recurrence rates, an acceptable long-term survival in patients after curative HR could be achieved. The Identification of parameters related to OS and DFS improves patient-centered treatment and surveillance strategies.

Efficacy of microwave ablation with parallel acupuncture guided by ultrasound in treating single hepatocellular carcinoma in high-risk areas: A retrospective analysis of 155 patients

OBJECTIVE

To investigate the safety and short- and long-term efficacy of ultrasound-guided microwave ablation (MWA) with parallel acupuncture for treating single hepatocellular carcinoma (HCC) in high-risk areas.

METHODS

Retrospective analysis was performed on 155 patients with single hepatocellular carcinoma who underwent microwave ablation in our hospital between December 2015 and September 2016. Patients with a tumor distance of ≤5 mm from the risk area were included in the observation group. Patients with a tumor distance of >5 mm from the risk area were placed in the control group. The patients' preoperative general health status, tumor site, tumor size, follow-up data, disease-free survival rate, overall survival rates, local tumor progression, and intrahepatic distant recurrence rate were collected and analyzed.

RESULTS

The 1-, 3-, and 5-year overall survival rates for the observation group were 91.8%, 75.5%, and 59.2%, respectively. The 1-, 3-, and 5-year overall survival rates for the control group were 97.2%, 84.0%, and 66.0%, respectively. There were no significant differences between the two groups (P = 0.522). A tumor size of ≤20 mm (HR = 0.488, 95% CI = 0.254-0.940, P = 0.032) was an independent risk factor affecting the overall survival of patients with solitary HCC treated with MWA. The 1-, 3-, and 5-year recurrence-free survival rates for the observation group were 59.2%, 28.6%, and 18.4%, respectively, and those for the control group were 79.2%, 43.4%, and 31.1%, respectively. There was a statistical difference between the two groups (P = 0.007). Tumor size ≤20 mm (HR = 0.468, 95% CI = 0.303-0.723, P = 0.001), tumor location in a risk area (HR = 1.662, 95% CI = 1.121-2.465, P = 0.011), and an α-fetoprotein (AFP) level of <200 ug/L (HR = 0.612, 95% CI = 0.386-0.970, P = 0.036) are independent factors affecting the recurrence-free survival of MWA treatment for HCC.

CONCLUSION

Microwave ablation with parallel acupuncture guided by ultrasound is a safe and effective treatment for single hepatocellular carcinoma in high-risk areas.

Predicting cancer-specific mortality in T1/2 hepatocellular carcinoma after radiofrequency ablation by competing risk nomogram: A population-based analysis

BACKGROUND

Radiofrequency ablation (RFA) is one of the primary treatment methods for T1/2 hepatocellular carcinoma (HCC), but the risk factors after RFA remain controversial. This study aims to identify the key factors associated with cancer-specific mortality (CSM) in patients with T1/2 HCC after RFA using competing risk analysis and to establish a prognostic nomogram for improved clinical management.

METHODS

A total of 2,135 T1/2 HCC patients treated with RFA were obtained from the Surveillance, Epidemiology, and End Results (SEER) database and randomly categorized into training and validation sets. Univariate and multivariable competing risk analyses were performed to identify risk factors associated with CSM and construct a competing risk nomogram. Receiver operating characteristic (ROC) curves, concordance indices (C-indexes), calibration plots, and decision curve analysis (DCA) were conducted to evaluate the predictive efficiency and clinical applicability of the nomogram in the training and validation sets. Patients were stratified according to their nomogram score, and the different risk groups were compared using cumulative incidence function (CIF) curves and Gray's validation .

RESULTS

The 5-year CSM rate for HCC patients treated with RFA was 30.1 %. Grade, tumor size, tumor number, cirrhosis, and AFP level were identified as independent risk factors for CSM. A prognostic nomogram was developed based on these risk factors. The time-dependent C-indexes (0.65) were greater than those of the AJCC stage model (0.55) during the 12 to 60 months of follow-up. The calibration plots of the competing risk nomograms demonstrated excellent consistency between actual survival and nomogram predictions. ROC analyses showed that the 1-, 3-, and 5-year AUC values in both the training and validation cohorts were all greater than 0.63 and exceeded those of the AJCC stage model. DCA demonstrated the clinical usefulness of the nomogram. Patients were classified into low-, moderate-, and high-risk groups based on the nomogram scores, with the high-risk group showing significantly higher CSM rates after RFA compared to the other two groups.

CONCLUSIONS

We identified Grade, AFP, cirrhosis, tumor size, and tumor number as independent risk factors associated with CSM. The competing risk nomogram exhibited high performance in predicting the probability of CSM for HCC patients undergoing RFA.

Comparative analysis of radiomics and deep-learning algorithms for survival prediction in hepatocellular carcinoma

To examine the comparative robustness of computed tomography (CT)-based conventional radiomics and deep-learning convolutional neural networks (CNN) to predict overall survival (OS) in HCC patients. Retrospectively, 114 HCC patients with pretherapeutic CT of the liver were randomized into a development (n = 85) and a validation (n = 29) cohort, including patients of all tumor stages and several applied therapies. In addition to clinical parameters, image annotations of the liver parenchyma and of tumor findings on CT were available. Cox-regression based on radiomics features and CNN models were established and combined with clinical parameters to predict OS. Model performance was assessed using the concordance index (C-index). Log-rank tests were used to test model-based patient stratification into high/low-risk groups. The clinical Cox-regression model achieved the best validation performance for OS (C-index [95% confidence interval (CI)] 0.74 [0.57-0.86]) with a significant difference between the risk groups (p = 0.03). In image analysis, the CNN models (lowest C-index [CI] 0.63 [0.39-0.83]; highest C-index [CI] 0.71 [0.49-0.88]) were superior to the corresponding radiomics models (lowest C-index [CI] 0.51 [0.30-0.73]; highest C-index [CI] 0.66 [0.48-0.79]). A significant risk stratification was not possible (p > 0.05). Under clinical conditions, CNN-algorithms demonstrate superior prognostic potential to predict OS in HCC patients compared to conventional radiomics approaches and could therefore provide important information in the clinical setting, especially when clinical data is limited.

Subcentimeter hepatocellular carcinoma (HCC) on gadoxetic-acid-enhanced MRI: less frequent typical imaging features compared to 1-2 cm HCC but better prognosis after surgical resection

PURPOSE

To compare the imaging features, pathologic characteristics, and survival outcomes between subcentimeter and 1-2 cm hepatocellular carcinoma (HCC).

METHODS

This retrospective observational study evaluated the imaging features and medical records of patients with HCC smaller than 2 cm who underwent surgical resection with preoperative gadoxetic-acid-enhanced MRI (EOB-MRI) from January 2013 to December 2021. The incidence of EOB-MRI features and pathological characteristics between the subcentimeter and 1-2 cm HCC were compared. The recurrence-free survival (RFS), including early and overall tumor recurrence, and overall survival (OS) were assessed.

RESULTS

A total of 223 patients (82 with subcentimeter HCC and 141 with 1-2 cm HCC, 179 men) were enrolled. Compared with 1-2 cm HCC, subcentimeter HCC showed fewer restricted diffusion (87.8 vs. 95.7%, P = 0.027), portal-phase washout (58.5% vs. 73.8%, P = 0.013), typical enhancement pattern (50.0% vs. 66.7%, P =0.014), and microvascular invasion (4.9% vs. 14.9%, P = 0.022). Patients with subcentimeter HCC had higher RFS (P = 0.027) and better OS (P = 0.029). The estimated RFS rates at 5 years was 83.3% for subcentimeter HCC and 67.3% for 1-2 cm HCC, respectively. The estimated OS rates at 5 years was 97.3% for subcentimeter HCC and 89.5% for 1-2 cm HCC, respectively.

CONCLUSION

Subcentimeter HCC showed less frequent EOB-MRI features seen typically in 1-2 cm HCC but better survival outcomes. Therefore, tailored early diagnostic criteria and immediate treatment for subcentimeter HCC may be warranted.

Consensus on the tertiary prevention of primary liver cancer

To effectively prevent recurrence, improve the prognosis and increase the survival rate of primary liver cancer (PLC) patients with radical cure, the Chinese Society of Hepatology, Chinese Medical Association, invited clinical experts and methodologists to develop the Consensus on the Tertiary Prevention of Primary Liver Cancer, which was based on the clinical and scientific advances on the risk factors, histopathology, imaging finding, clinical manifestation, and prevention of recurrence of PLC. The purpose is to provide a current basis for the prevention, surveillance, early detection and diagnosis, and the effective measures of PLC recurrence.

Neoadjuvant intensity modulated radiotherapy for a single and small (≤5 cm) hepatitis B virus-related hepatocellular carcinoma predicted to have high risks of microvascular invasion: a randomized clinical trial

BACKGROUND

The presence of microvascular invasion (MVI) significantly impairs postoperative long-term survival of patients with hepatocellular carcinoma (HCC). The role of neoadjuvant radiotherapy (RT) in treating patients with an early-stage HCC predicted to have high risks of MVI remains to be explored.

MATERIALS AND METHODS

Consecutive patients with a resectable single and small (≤5 cm) hepatitis B virus-related HCC predicted to have high risks of MVI were randomized 1:1 to receive either neoadjuvant intensity modulated radiation therapy (18 Gy with fractionated doses of 3 Gy) followed by surgery 4 weeks later or upfront surgery. The primary endpoint was disease-free survival (DFS). The secondary outcomes included overall survival (OS), objective response rate, RT-related toxicity and surgical complications.

RESULTS

There were 30 patients randomized to each of the two groups. In the neoadjuvant RT group, three patients violated the study protocol, with two having upfront hepatectomy and one radiofrequency ablation after RT. The objective response rate after RT was 25.0% (7/28), but 2 patients suffered from grade 3 liver toxicity. The median follow-up was 68 months (interquartile range, 58-70 months) in the neoadjuvant RT group, and 68 months (interquartile range, 62-75 months) in the upfront surgery group. On intention-to-treat analysis, the median DFS and median OS were not reached in both the 2 arms. The 1-year, 2-year, 3-year and 5-year DFS rates for the neoadjuvant RT group were 86.7%, 76.7%, 60.0% and 56.3%, versus 90.0%, 66.7%, 52.8% and 45.7% in the upfront surgery group ( P =0.448), respectively. The corresponding OS rates were 96.7%, 86.7%, 83.3% and 72.7%, versus 100.0%, 93.3%, 79.6% and 60.7% ( P = 0.399).

CONCLUSION AND RELEVANCE

For patients with a resectable single and small hepatitis B virus-related HCC predicted to have high risks of MVI, neoadjuvant RT gave a promising response rate with a mild toxicity. Nevertheless, the neoadjuvant RT yielded similar long-term DFS and OS rates compared with patients who underwent upfront surgery.

An improved diagnostic algorithm for subcentimeter hepatocellular carcinoma on gadoxetic acid-enhanced MRI

OBJECTIVES

Accurate diagnosis of subcentimeter hepatocellular carcinoma (HCC) is a challenge also with gadoxetic acid-enhanced MRI (EOB-MRI). This study aimed to assess the diagnostic accuracy of the Liver Imaging Reporting and Data System (LI-RADS) for subcentimeter HCC and to determine whether new diagnostic criteria (washout either on portal venous phase (PVP) or transitional phase (TP)) would improve the diagnostic performance.

METHODS

We evaluated 240 subcentimeter observations in 225 consecutive treatment-naïve patients at risk of HCC. Final diagnoses were 132 HCCs (all by pathology) and 108 non-HCC (41 by pathology and 67 by follow-up). Two radiologists assessed MR imaging features and assigned LI-RADS categories. A variety of diagnostic criteria were developed by combining significant MRI features based on washout on PVP or TP. Diagnostic performance was compared.

RESULTS

Non-rim arterial phase hyperenhancement (non-rim APHE), washout on PVP or TP, and hepatobiliary-phase hypointensity were significant predictors for subcentimeter HCC diagnosis according to multivariable analysis. One criterion (non-rim APHE and washout on PVP or TP) yielded higher sensitivity (68.2% vs. 56.8%, p = 0.011) with comparable specificity (91.7% vs. 92.6%, p > 0.999) compared to the LR-4 category. This criterion had improved sensitivity (68.2% vs. 49.2%, p < 0.001) and slightly decreased specificity (91.7% vs. 94.4%, p = 0.250) compared to non-rim APHE with washout on PVP.

CONCLUSIONS

LI-RADS exhibits modest diagnostic performance for subcentimeter HCC. Our new criterion (non-rim APHE and non-peripheral washout on PVP or TP) may increase the diagnostic sensitivity without compromised specificity compared to the LR-4 category.

KEY POINTS

• The LR-4 category shows modest diagnostic performance for the diagnosis of subcentimeter HCC on EOB-MRI with a sensitivity and specificity of 56.8% and 92.6%, respectively. • Non-rim APHE, non-peripheral washout on PVP or TP, and HBP hypointensity were independent predictors for the diagnosis of subcentimeter HCC. • The combination of non-rim APHE and non-peripheral washout on PVP or TP improves the sensitivity from 56.8 to 68.2% (p = 0.011) with comparable specificity (91.7 vs. 92.6%, p > 0.999).

Subcentimeter Nodules with Diagnostic Hallmarks of Hepatocellular Carcinoma: Comparison of Pathological Features and Survival Outcomes with Nodules Measuring 1-2 cm

Objective

To compare the pathologic diagnosis and survival of patients with subcentimeter and 1-2 cm nodules that present with diagnostic hallmarks of hepatocellular carcinoma (HCC).

Methods

Diagnostic hallmarks of HCC were defined as hyperintensity on T2 weighted imaging, restricted diffusion, arterial phase hyperenhancement, washout on portal venous phase, and hypointensity on hepatobiliary phase. We retrospectively included 139 patients undergoing curative resection with single nodules ≤2 cm that present imaging features described above on gadoxetic acid-enhanced MRI. The final diagnosis was confirmed by histopathological assessment. Recurrence-free survival (RFS) was compared using Kaplan-Meier analysis with the Log-rank test. Factors associated with overall and early recurrence were identified using Cox regression analysis.

Results

Among 139 nodules (49 nodules <1 cm), there was no significant difference in the percentage of HCC between subcentimeter and 1-2 cm nodules (94.0% vs 94.4%, P > 0.999). Microvascular invasion (MVI) was less common in subcentimeter HCC (4.3% vs 17.6%, P = 0.032). There were 27 recurrences during a median follow-up time of 46.7 months. Patients with subcentimeter HCC achieved less recurrence, with a 5-year RFS rate of 87.3%. The MVI-positive patients had more early and overall recurrence. A tumor size <1 cm was associated with lower overall recurrence (HR, 0.336; P = 0.047). No factors were independently associated with early recurrence.

Conclusion

Subcentimeter nodules with diagnostic hallmarks of HCC are highly associated with HCC diagnosis and achieve less tumor recurrence after resection. Early diagnosis and treatment of subcentimeter HCC may be more appropriate.

Prognosis of Primary Liver Cancer Based on LI-RADS Classification with Extracellular Agent-Enhanced MRI

Objective

The prognostic value of the Liver Imaging Reporting and Data System (LI-RADS) 2018 in differentiating hepatocellular carcinoma (HCC) from other primary liver cancers (PLC) with cirrhosis is unclear. We aim to evaluate the value of LI-RADS 2018 with agent-enhanced MRI in the postoperative prognosis of PLC patients with cirrhosis.

Methods

Between 2016 and 2021, 432 patients with cirrhosis and surgically proven single primary liver cancer were retrospectively evaluated. Two radiologists evaluated the preoperative MRI features independently and assigned each lesion a LI-RADS category. Overall survival (OS), recurrence-free survival (RFS), and their associated factors were evaluated by using the Kaplan-Meier method, Log rank test, and Cox proportional hazards model.

Results

The mean age of 432 patients (239 HCCs, 93 ICCs, and 100 cHCC-CCAs) was 57.27±10.92 years. The LR-M category showed poorer OS and RFS than the LR-4 or LR-5 category did for all primary liver cancers (P <0.001 for both), and so did HCCs with tumor size less than 30mm (P =0.003 and P =0.04, respectively). In the multivariable analysis, the LI-RADS category and tumor size > 30 mm had independent correlations with OS and RFS (all P < 0.05). Multivariable Cox analysis identified rim arterial phase hyperenhancement (APHE) as independent determinants of poor OS and RFS in primary liver cancers (all P < 0.05).

Conclusion

The LI-RADS categories can predict the postsurgical prognosis of primary liver cancers independently.

A nomogram model integrating LI-RADS features and radiomics based on contrast-enhanced magnetic resonance imaging for predicting microvascular invasion in hepatocellular carcinoma falling the Milan criteria

PURPOSE

To establish and validate a nomogram model incorporating both liver imaging reporting and data system (LI-RADS) features and contrast enhanced magnetic resonance imaging (CEMRI)-based radiomics for predicting microvascular invasion (MVI) in hepatocellular carcinoma (HCC) falling the Milan criteria.

METHODS

In total, 161 patients with 165 HCCs diagnosed with MVI (n = 99) or without MVI (n = 66) were assigned to a training and a test group. MRI LI-RADS characteristics and radiomics features selected by the LASSO algorithm were used to establish the MRI and Rad-score models, respectively, and the independent features were integrated to develop the nomogram model. The predictive ability of the nomogram was evaluated with receiver operating characteristic (ROC) curves.

RESULTS

The risk factors associated with MVI (P<0.05) were related to larger tumor size, nonsmooth margin, mosaic architecture, corona enhancement and higher Rad-score. The areas under the ROC curve (AUCs) of the MRI feature model for predicting MVI were 0.85 (95% CI: 0.78-0.92) and 0.85 (95% CI: 0.74-0.95), and those for the Rad-score were 0.82 (95% CI: 0.73-0.90) and 0.80 (95% CI: 0.67-0.93) in the training and test groups, respectively. The nomogram presented improved AUC values of 0.87 (95% CI: 0.81-0.94) in the training group and 0.89 (95% CI: 0.81-0.98) in the test group (P<0.05) for predicting MVI. The calibration curve and decision curve analysis demonstrated that the nomogram model had high goodness-of-fit and clinical benefits.

CONCLUSIONS

The nomogram model can effectively predict MVI in patients with HCC falling within the Milan criteria and serves as a valuable imaging biomarker for facilitating individualized decision-making.

Risk factors for recurrence beyond Milan criteria after radiofrequency ablation in transplantable small hepatocellular carcinoma

This study aims to determine the risk factors of recurrence beyond Milan criteria in patients with transplantable early hepatocellular carcinoma (HCC) after the first Radiofrequency ablation (RFA). 95 patients with newly diagnosed transplantable small HCC with single ≤ 3 cm were analyzed retrospectively. During the 39-month median follow-up period, 12 (21.8%) patients with HCC < 2 cm and 22 (56.4%) patients with HCC ≥ 2 cm relapsed beyond Milan criteria (p = 0.001). The 1- and 3-year recurrence rates beyond Milan criteria were 6.3% and 14.7% in HCC < 2 cm group, compared with 24.1% and 55.6% in HCC ≥ 2 cm group(p < 0.0001).HCC ≥ 2 cm, red blood cell distribution width-to-lymphocyte ratio (RLR) ≥ 18.3, alpha-fetoprotein (AFP) > 15 ng/ml and early recurrence after RFA were independent predictors of recurrence exceeding Milan criteria. For patients with transplantable early single small HCC whose tumor diameter ≥ 2cm and have higher RLR and AFP levels before first RFA and early recurrence after RFA (recurrence within 2 years), close follow-up and early liver transplantation should be initiated to obtain the best survival benefit.

Investigation of Changes in Liver Microanatomy in the Steatosis Model Created by Permanent Canula in Rats

Objective: The knowledge of nonalcoholic fatty liver disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH) is limited to the findings from available suitable models for this disease. A number of rodent models have been described in which relevant liver pathology develops in an appropriate metabolic context. In this experimental study, it was aimed to create a new liver fat model by giving fat from the portal vein of rats and to visualize the changes in the liver with advanced microscopic techniques. Methods: 28 female rats were used in the study. Permanent intraabdominal cannulas were inserted into the portal vein of the rats. Rats were randomly divided four group. Intralipid 20% substance was injected through cannula to the experimental groups during the test period. Control group received saline at the same rate. At the end of the experiment, the animals were visualized with a laser speckle microscope and livers were divided into sections according to the stereological method. The sections were painted with Hematoxylin-Eosin, Oil red o, Masson trichoma, Bodipy, Nile red. Sections were evaluated under a microscope. Results: Ballooning, inflammation and fibrosis were observed in the 2 week intralipid group. In the 1 week intralipid group, the rate of parenchyma decreased while the sinusoid rate increased, and sinusoid rate increased significantly in the 2 week intralipid (p˂0.05). Conclusion: According to the findings, steatohepatitis was detected in the 2 week intralipid, whereas only steatosis was observed in the 1 week intralipid. Thus, it was concluded that the newly formed rat model causes steatosis.

Clinical and laboratory parameters associated with li-rads as diagnostic of liver nodule in patients with cirrhosis

Background

Hepatocellular carcinoma (HCC) is the most common primary liver cancer in the world. Clinical and laboratory evaluation of a cirrhotic patient with a liver nodule may show alterations suggesting malignancy. There is a lack of questions related to diagnosis of HCC and evaluation of liver imaging reporting and data system (LI-RADS) could be a tool for early diagnosis of HCC. This aims to confirm an association between clinical and laboratory characteristics in cirrhotic patients with hepatic nodule after LI-RADS categorization.

Methods

A cross-sectional retrospective study was performed with 62 patients grouped according to LI-RADS algorithm. Differences between groups were confirmed using association tests and the Kappa test was employed to provide further confirmation.

Results

Associations were observed after univariate analysis with higher values of aspartate aminotransferase (AST) (P=0.008), alanine aminotransferase (ALT) (P=0.019), alkaline phosphatase (ALP) (P=0.0052), gamma glutamyl transferase (GGT) (P=0.0023), alpha-fetoprotein (AFP) (P=0.0001), nodule size (P=0.0001) and age (P=0.007) in LR 5 group compared to LR 3. Univariate analysis also revealed higher levels for the LR5 group of ALP (P=0.0228), AFP (P=0.022) and age (P=0.046) in relation to LR 1+2 group. AFP also had higher serum levels in the LR 4 group compared to LR 1+2 (P=0.004). After multivariate analysis, higher levels in LR5 group of nodule size (P=0.047) and ALP (P=0.027) were observed in relation to LR3, and were therefore considered predictors of HCC diagnosis.

Conclusions

The study suggests that the combination of clinical-laboratory and radiological factors, such as heightened serum levels of ALP and hepatic nodule size, may support the screening of HCC in cirrhotic patients with hepatic nodules using the LI-RADS algorithm.

Liver resection is associated with good outcomes for hepatocellular carcinoma patients beyond the Barcelona Clinic Liver Cancer criteria: A multicenter study with the Hiroshima Surgical study group of Clinical Oncology

BACKGROUND

Liver resection for hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer criteria remains controversial. Strict candidate selection is crucial to achieve optimal results in this population. This study explored postoperative outcomes and developed a preoperative predictive formula to identify patients most likely to benefit from liver resection.

METHODS

In total, 382 patients who underwent liver resection for hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer resection criteria between 2000 and 2017 were identified from a multicenter database with the Hiroshima Surgical study group of Clinical Oncology. An overall survival prediction model was developed, and patients were classified by risk status.

RESULTS

The 5-year overall survival after curative resection was 50.0%. Overall survival multivariate analysis identified that a high a-fetoprotein level, macrovascular invasion, and high total tumor burden were independent prognostic risk factors; these factors were used to formulate risk scores. Patients were divided into low-, moderate-, and high-risk groups; the 5-year overall survival was 65.7%, 49.5%, and 17.0% (P < .001), and the 5-year recurrence-free survival was 31.3%, 26.2%, and 0%, respectively (P < .001). The model performance was good (C-index, 0.76). Both the early and extrahepatic recurrence increased with higher risk score.

CONCLUSION

The prognosis of patients with hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer resection criteria depended on a high a-fetoprotein level, macrovascular invasion, and high total tumor burden, and risk scores based on these factors stratified the prognoses. Liver resection should be considered in patients with hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer criteria with a low or moderate-risk score.

Radiomic Features of Multi-ROI and Multi-Phase MRI for the Prediction of Microvascular Invasion in Solitary Hepatocellular Carcinoma

Objectives

To develop and validate an MR radiomics-based nomogram to predict the presence of MVI in patients with solitary HCC and further evaluate the performance of predictors for MVI in subgroups (HCC ≤ 3 cm and > 3 cm).

Materials and Methods

Between May 2015 and October 2020, 201 patients with solitary HCC were analysed. Radiomic features were extracted from precontrast T₁WI, arterial phase, portal venous phase, delayed phase and hepatobiliary phase images in regions of the intratumoral, peritumoral and their combining areas. The mRMR and LASSO algorithms were used to select radiomic features related to MVI. Clinicoradiological factors were selected by using backward stepwise regression with AIC. A nomogram was developed by incorporating the clinicoradiological factors and radiomics signature. In addition, the radiomic features and clinicoradiological factors related to MVI were separately evaluated in the subgroups (HCC ≤ 3 cm and > 3 cm).

Results

Histopathological examinations confirmed MVI in 111 of the 201 patients (55.22%). The radiomics signature showed a favourable discriminatory ability for MVI in the training set (AUC, 0.896) and validation set (AUC, 0.788). The nomogram incorporating peritumoral enhancement, tumour growth type and radiomics signature showed good discrimination in the training (AUC, 0.932) and validation sets (AUC, 0.917) and achieved well-fitted calibration curves. Subgroup analysis showed that tumour growth type was a predictor for MVI in the HCC ≤ 3 cm cohort and peritumoral enhancement in the HCC > 3 cm cohort; radiomic features related to MVI varied between the HCC ≤ 3 cm and HCC > 3 cm cohort. The performance of the radiomics signature improved noticeably in both the HCC ≤ 3 cm (AUC, 0.953) and HCC > 3 cm cohorts (AUC, 0.993) compared to the original training set.

Conclusions

The preoperative nomogram integrating clinicoradiological risk factors and the MR radiomics signature showed favourable predictive efficiency for predicting MVI in patients with solitary HCC. The clinicoradiological factors and radiomic features related to MVI varied between subgroups (HCC ≤ 3 cm and > 3 cm). The performance of radiomics signature for MVI prediction was improved in both the subgroups.

β-Catenin Expression and Its Association with Prognostic Factors in Hepatocellular Carcinoma: A Study on Alpha-fetoprotein, Histologic Grade, and Microvascular Invasion

Background. Hepatocellular carcinoma (HCC), the most common primary liver cancer. In addition to its high incidence, the disease burden is high due to its poor prognosis and high recurrence rate. Some of the currently known clinicopathologic prognostic factors include alpha-fetoprotein (AFP) level, histologic grade, and microvascular invasion. At the molecular level, β-catenin is one of the most common driver mutation found in HCC. The Wnt/β-catenin pathway regulates cellular processes related to initiation, growth, survival, migration, differentiation, and apoptosis. Although the underlying pathogenesis of hepatocarcinogenesis is known, clinical application warrants a greater understanding of the molecular characteristics and tumor phenotype, especially for determining the prognosis. This study aims to analyze the expression of β-catenin and its association with AFP, histologic grade, and microvascular invasion. Materials and methods. Thirty-five samples of surgically resected HCCs at Cipto Mangunkusumo National Referral Hospital were examined. Diagnoses were made based on histopathological and immunohistochemical findings followed by β-catenin staining. β-catenin expression was analyzed to determine difference between variables. Results and conclusions. Here we show that β-catenin expression is significantly associated with low serum alpha-fetoprotein and well to moderate differentiation Implications. Strong nuclear β-catenin expression implies better prognosis in HCC.

Preoperative Prediction of Microvascular Invasion in Patients With Hepatocellular Carcinoma Based on Radiomics Nomogram Using Contrast-Enhanced Ultrasound

PURPOSE

This study aimed to develop a radiomics nomogram based on contrast-enhanced ultrasound (CEUS) for preoperatively assessing microvascular invasion (MVI) in hepatocellular carcinoma (HCC) patients.

METHODS

A retrospective dataset of 313 HCC patients who underwent CEUS between September 20, 2016 and March 20, 2020 was enrolled in our study. The study population was randomly grouped as a primary dataset of 192 patients and a validation dataset of 121 patients. Radiomics features were extracted from the B-mode (BM), artery phase (AP), portal venous phase (PVP), and delay phase (DP) images of preoperatively acquired CEUS of each patient. After feature selection, the BM, AP, PVP, and DP radiomics scores (Rad-score) were constructed from the primary dataset. The four radiomics scores and clinical factors were used for multivariate logistic regression analysis, and a radiomics nomogram was then developed. We also built a preoperative clinical prediction model for comparison. The performance of the radiomics nomogram was evaluated via calibration, discrimination, and clinical usefulness.

RESULTS

Multivariate analysis indicated that the PVP and DP Rad-score, tumor size, and AFP (alpha-fetoprotein) level were independent risk predictors associated with MVI. The radiomics nomogram incorporating these four predictors revealed a superior discrimination to the clinical model (based on tumor size and AFP level) in the primary dataset (AUC: 0.849 vs. 0.690; p < 0.001) and validation dataset (AUC: 0.788 vs. 0.661; p = 0.008), with a good calibration. Decision curve analysis also confirmed that the radiomics nomogram was clinically useful. Furthermore, the significant improvement of net reclassification index (NRI) and integrated discriminatory improvement (IDI) implied that the PVP and DP radiomics signatures may be very useful biomarkers for MVI prediction in HCC.

CONCLUSION

The CEUS-based radiomics nomogram showed a favorable predictive value for the preoperative identification of MVI in HCC patients and could guide a more appropriate surgical planning.

Upregulation of Stress-Induced Protein Kinase CK1 Delta is associated with a Poor Prognosis for patients with Hepatocellular Carcinoma

Objective: This study was designed to analyze the expression of CSNK1D in hepatocellular carcinoma (HCC) and investigate the relationship between the expression of CSNK1D and the prognosis of HCC patients. Methods: The CSNK1D and alpha-fetoprotein (AFP) expression levels in patients with HCC and their corresponding clinical data were downloaded from The Cancer Genome Atlas (TCGA) and sorted with a Perl program. CSNK1D and AFP expression differences in liver tissue and liver cancer were compared and analyzed, based on the online database human cancer metastasis database, the relationships between the expression levels of CSNK1D and AFP and the proliferation and metastases of HCC were explored. The immunohistochemical data obtained from the Human Protein Atlas Database further verified the differences in the expression levels of CSNK1D and AFP in liver tissues and liver cancer tissues. Through Kaplan-Meier survival analysis, the effects of CSNK1D and AFP expression levels on the prognosis of patients with HCC were investigated, and the influences of and patients' gender, age and grades of cancer cells, tumor size, the status of lymph node metastasis, distant metastasis, and tumor stage on the expression of CSNK1D were analyzed with R language. The influence of differential expressions of CSNK1D on survival time was compared and the prognostic factors influencing the survival of HCC patients were statistically explored by univariate analysis and multivariate analysis. The potential influencing mechanism of CSNK1D on the prognosis of HCC patients was explored by Gene Set Enrichment Analysis (GSEA) enrichment. Results: The expression level of CSNK1D and AFP in cancer foci was significantly higher than that in normal tissues, However, in the same patient, the expression levels of AFP in paracarcinoma tissues and cancer tissues showed no significant difference. The expression level of CSNK1D in HCC with distant metastases was higher than that in those without metastasis, but the expression level of AFP in metastatic HCC was lower than that in those HCC without metastases. In immunohistochemical tests, CSNK1D was moderately positive in normal liver tissues, slightly positive in normal bile duct tissues, and highly positive in HCC. AFP was slightly positive in normal liver tissues and negative in HCC, but it was not detected in normal intrahepatic bile duct tissue. Survival analysis results suggested that the higher expression level of CSNK1D corresponded to the shorter survival period, whereas the expression level of AFP showed no significant influence on survival time. The expression level of CSNK1D was not correlated with gender, age, the status of lymph node metastasis status, or distant metastasis of patients. The main factors influencing the expression level of CSNK1D included tumor size, cancer cell grade, and tumor stage. The expression levels of CSNK1D in T2 and T3 were higher than that in T1. The expression levels of CSNK1D in G3 and G4 were higher than that in G1. The expression levels of CSNK1D in Stage II and Stage III were higher than that in Stage I. Univariate analysis suggested that tumor size, cell grade, distant metastasis, clinical stage, and CSNK1D expression level were the prognostic factors influencing the survival of patients. Multivariate analysis suggested that CSNK1D expression level was an independent factor influencing the prognosis of HCC patients. GSEA enrichment analysis indicated that CSNK1D mainly affected the prognosis of HCC patients through cell cycle, WNT signaling pathway, amino acid degradation metabolism, and other pathways. Conclusion: CSNK1D is an independent influencing factor for the prognosis of HCC patients and has the potential to be developed as a potential therapeutic target for HCC, and better than AFP in predicting the prognosis of HCC.

Prognostic nomogram for hepatocellular carcinoma with radiofrequency ablation: a retrospective cohort study

Background

Radiofrequency ablation (RFA) is an effective treatment option for hepatocellular carcinoma (HCC). This study aimed to analyze the prognostic factors of HCC patients treated with RFA and to develop nomograms for outcome prediction.

Methods

A total of 3142 HCC patients treated with RFA were recruited, and their data were collected from the Surveillance, Epidemiology, and End Results database. Univariate and multifactor Cox analyses were performed to identify independent prognostic factors. These factors were integrated into a nomogram to predict 3- and 5-year cancer-specific survival (CSS) and overall survival (OS). Consistency indices and calibration plots were used to assess the accuracy of the nomograms in both the internal and external cohorts.

Results

The median follow-up periods for HCC patients treated with RFA were 27 and 29 months for OS and CSS, respectively. Marital status, age, race, histological grade of differentiation, tumor size, T stage, and serum alpha-fetoprotein levels at the time of diagnosis were identified as prognostic factors for OS and CSS. Additionally, M stage was identified as risk factors for OS. These risk factors are included in the nomogram. The calibration plots of the OS and CSS nomograms showed excellent consistency between actual survival and nomogram predictions. The bootstrap-corrected concordance indices of the OS and CSS nomograms were 0.637 (95% CI, 0.628–0.646) and 0.670 (95% 0.661–0.679), respectively. Importantly, our nomogram performed better discriminatory compared with 8th edition tumor-node-metastasis (TNM) stage system for predicting OS and CSS.

Conclusions

We identified prognostic factors for HCC patients treated with RFA and provided an accurate and personalized survival prediction scheme.

Postoperative adjuvant transcatheter arterial chemoembolization improves the prognosis of patients with huge hepatocellular carcinoma

BACKGROUND

Surgical resection of huge hepatocellular carcinoma (HCC, ≥ 10 cm) is potentially curative. More adjuvant treatments are needed to reduce relapses in these patients. We evaluated the influence of postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE) on the prognosis of huge HCC.

METHODS

Data from consecutive patients who underwent curative resection for huge HCC in our center were retrospectively collected. Recurrence-free survival (RFS) and overall survival (OS) were compared between patients who did and did not undergo PA-TACE. Propensity score matching (PSM) was used.

RESULTS

Among the 255 enrolled patients, 93 underwent PA-TACE. The clinical outcomes were significantly better in the PA-TACE group than those in the non PA-TACE group (5-year RFS rate: 33.5% vs. 18.0%; 5-year OS rate: 47.0% vs. 28.0%, all P < 0.001). After PSM, similar results were obtained (5-year RFS rate: 28.8% vs. 17.6%, P < 0.001; 5-year OS rate: 42.5% vs. 25.0%, P = 0.004). PA-TACE decreased the possibility of early recurrence (< 2 years, crude cohort: P < 0.001, PSM cohort: P < 0.001) but not late recurrence (≥ 2 years, crude cohort: P = 0.692, PSM cohort: P = 0.325). Multivariable Cox regression analysis suggested that PA-TACE was an independent protective factor prolonging early RFS, RFS and OS.

CONCLUSIONS

PA-TACE is a safe intervention for huge HCC patients after liver resection and improves outcomes.

An excellent nomogram predicts microvascular invasion that cannot independently stratify outcomes of small hepatocellular carcinoma

Background

Whether microvascular invasion is a prognosis factor for small hepatocellular carcinoma (sHCC) is controversial, and a preoperatively predictive model based on gadoxetate disodium (Gd-EOB-DTPA) MRI is clinically needed for MVI in sHCC.

Methods

Between March 2012 and September 2020, 455 consecutive patients with pathologically confirmed HCC ≤3 cm who underwent hepatectomy and preoperative Gd-EOB-DTPA MRI were retrospectively enrolled. Univariate and multivariate logistic regression combined with cox regression were conducted to find the confounding factors in the cohorts. Propensity score matching (PSM) was employed to balance the biases between MVI and non-MVI groups. Nomogram with C-index visualized the predictive model of MVI.

Results

Multivariate logistic regression identified that 5 characteristics (AFP, tumor size, tumor margin, peritumoral enhancement, radiologic capsule) were markedly associated with MVI of sHCC and incorporated into the nomogram with excellent predictive performance in the training (AUC/C-index: 0.884/0.874, n=288), validation (AUC/C-index: 0.845/0.828, n=123) and test cohorts (AUC/C-index: 0.903/0.954, n=44). Before PSM, histologic MVI independently affected tumor recurrence (hazard ratio: 1.555, 95% CI: 1.055–2.293, P=0.026). However, due to the confounder of tumor size, there was a significant bias between MVI-positive and MVI-negative groups (propensity score: 0.249±0.105 vs. 0.179±0.106, P<0.001). Meanwhile, the frequency of MVI significantly increased as tumor size growing (P<0.001). After PSM, 70 of 79 MVI cases matched with 171 non-MVI (total 332), and no biases were observed between the two groups (propensity score: 0.238±0.104 vs. 0.217±0.109, P=0.186). Although the median recurrence time in non-MVI sHCC was still longer than that in MVI group (74.3 vs. 43.0 months, P=0.063), MVI was not an independent risk factor for RFS in sHCC. Additionally, MVI was not independently vulnerable to mortality in our population.

Conclusions

A preoperative model, mainly based on the peritumoral hallmarks of Gd-EOB-DTPA MRI, showed an excellent performance to predict the occurrence of MVI. Nevertheless, MVI was a potential but not an independent risk factor for recurrence and mortality in sHCC ≤3 cm.

Preoperative MR imaging for predicting early recurrence of solitary hepatocellular carcinoma without microvascular invasion

OBJECTIVES

This study aimed to identify preoperative MR imaging features for predicting early recurrence after curative resection of solitary hepatocellular carcinoma (HCC) without microvascular invasion (MVI).

METHODS

124 patients with MVI-negative HCC who underwent preoperative dynamic contrast-enhanced 1.5-T MR imaging before surgical resection were included. Liver Imaging Reporting and Data System (LI-RADS v2018) imaging features and three non-LI-RADS MR imaging features for predicting early recurrence (intrahepatic recurrence<2 years) were identified by univariable and multivariable analyses. A nomogram was constructed for individualized risk estimation, and its predictive accuracy and discriminative ability were identified by concordance index (C-index) and calibration curve.

RESULTS

In multivariable analysis, tumor size (p = 0.045), nonsmooth tumor margin (p = 0.013), and presence of mosaic architecture (p = 0.035) were independent significant variables associated with early recurrence. These were all incorporated to establish the nomogram. The C-index of the nomogram was 0.743 (95 % CI: 0.697-0.788).

CONCLUSION

At dynamic contrast-enhanced MR imaging, tumor size, nonsmooth tumor margin, and presence of mosaic architecture may be helpful to predict early recurrence of solitary HCC without MVI after curative resection.

Predictors and patterns of recurrence after radiofrequency ablation for hepatocellular carcinoma within up-to-seven criteria: A multicenter retrospective study

PURPOSE

To determine the risk factors and patterns of recurrence after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) meeting the up-to-seven criteria and to develop a nomogram to predict the recurrence free survival (RFS).

MATERIALS AND METHODS

This retrospective study included 481 HCC patients meeting the up-to-seven criteria and who received RFA as the primary therapy at three Chinese hospitals from January 2013 to December 2016. All clinical variables were assessed by univariate and multivariate Cox regression analyses and a nomogram was constructed to predict the probability of RFS.

RESULTS

The recurrence rate was 50.7 % (244/481). Age > 60 years, male gender, and multiple tumors were independent risk factors of recurrence. The incidence of early and late recurrence was 68.03 % (n = 166) and 31.97 % (n = 78), respectively. Seven patterns of spatial recurrence were identified: local tumor progression (LTP) alone (n = 18, 7.38 %), intrahepatic distant recurrence (IDR) alone (n = 136, 55.74 %), extrahepatic recurrence (ER) alone (n = 21, 8.61 %), IDR + ER (n = 45, 18.44 %), LTP + IDR (n = 16, 6.56 %), LTP + ER (n = 4, 1.64 %) and LTP + IDR + ER (n = 4, 1.64 %). The 1-, 2-, and 3-year RFS rates were 79.63 %, 65.23 %, and 51.03 %, respectively. A well-discriminated and calibrated nomogram was constructed.

CONCLUSIONS

The factors affecting recurrence after RFA were age, gender, and the number of tumors. IDR was the most common type of recurrence after complete ablation.

Predictive value of preoperative and postoperative peripheral lymphocyte difference in hepatitis B virus-related hepatocellular cancer patients: Based on the analysis of dynamic nomogram

BACKGROUND

Inflammation plays an important role in the progression and prognosis of hepatocellular carcinoma (HCC). Our aim is to explore the prognostic value of preoperative and postoperative peripheral lymphocyte differences and to develop a dynamic prognosis nomogram in hepatitis B virus-related HCC patients.

METHODS

Important indicators related to overall survival (OS) are screened out by Cox proportional hazard models. The receiver operating characteristic curves, decision curve analysis curves, net reclassification improvement, and integrated discrimination improvement were used to evaluate the performance of the model.

RESULTS

Lymphocyte (L) difference was an independent risk factor. It was further verified that the performance of the nomogram was significantly improved after the L difference was incorporated into the nomogram. The nomogram generated had the area under curves of 0.779, 0.775, and 0.793 at 3, 5, and 7 years after surgery, respectively. Our nomogram models showed significantly better performance in predicting the HCC prognosis compared to other models. And online webserver and scoring system table was built based on the proposed nomogram for convenient clinical use.

CONCLUSIONS

It is newly found that L difference is an effective predictor of OS, and the nomogram based on this indicator can accurately predict the prognosis of HCC patients.

Reclassification of tumor size for solitary HBV-related hepatocellular carcinoma by minimum p value method: a large retrospective study

BACKGROUND AND OBJECTIVES

Tumor size is one of the most important issues for hepatocellular carcinoma (HCC) treatment and prognosis, but the classification of it is still controversial. The aim of this study was to screen appropriate cutoffs for size of solitary hepatitis B virus (HBV)-related HCC.

METHODS

A cohort of 1760 patients with solitary HBV-related HCC undergoing curative liver resection was divided into 11 groups based on tumor size in 1-cm interval. The minimum p value method was used to screen the appropriate size cutoff according to overall survival (OS). If multiple cutoffs meet the above standard, a univariate analysis will be performed by using the Cox proportional hazards regression model, and hazard ratio (HR) will be considered as a criterion to assess the difference in survival.

RESULTS

There are 8 dichotomy, 8 trichotomy, and no inquartation cutoffs that were screened when classifying tumor sizes in accordance with OS. The HR values of tumor size at these trichotomy cutoffs for OS were compared, and the highest HR value is 2.79 when size cutoff is 3/9 cm. Then, we reclassified patients into three new classifications: ≤ 3 cm (n = 422), > 3 and ≤ 9 cm (n = 1072), and > 9 cm (n = 266). The comparison of clinicopathologic characteristics among these three classifications showed that the increase of tumor size was associated with the increase of α-fetoprotein (AFP), microvascular invasion (MVI), tumor differentiation, and liver cirrhosis. And the comparison of the OS among three classifications showed statistical differences.

CONCLUSIONS

This study suggested that size criteria of 3 cm and 9 cm in solitary HBV-related HCC patients were appropriate based on biological characteristics and prognostic significance.

Characteristics and risk differences of different tumor sizes on distant metastases of hepatocellular carcinoma: A retrospective cohort study in the SEER database

INTRODUCTION

A typical feature of hepatocellular carcinoma (HCC) is growth with metastasis to distant organs, which is associated with poor survival. Whether tumor size can predict distant metastases in HCC remains unclear.

METHODS

We identified 29,170 HCC patients with or without distant metastases between 2010 and 2016 in the Surveillance, Epidemiology and End Results database. According to an optimal cutoff value of tumor size (58 mm) for predicting distant metastases using Youden's index, patients were categorized into groups of tumor size ≤30 cm, 30-58 mm, and ≥58 mm.

RESULTS

Tumor size had a significantly positive correlation with distant metastases (r = 0.245, P < 0.001). Among patients with distant metastasis, the most common metastasis site was lung (39.3%), followed by bone (30.0%), and brain (2.0%). Incidence of distant metastases in patients with tumor ≥58 mm was 5.7 times (22.8%/4.0%) that of patients with tumors ≤30 mm and 2.9 times (22.8%/7.9%) that of patients with tumors 30-58 mm. Multivariate analyses showed that compared with ≤30 mm, tumor size ≥58 mm was an independent risk predictor of overall distant metastases (OR, 5.200; 95% CI, 4.635-5.834; P<0.001), lung (OR, 6.036; 95% CI, 5.006-7.278; P<0.001); bone (OR, 3.365; 95% CI, 2.781-4.071; P<0.001); and brain metastasis (OR, 1.905; 95% CI, 1.023-3.547; P<0.05).

CONCLUSIONS

Tumor size ≥58 mm is significantly associated with HCC distant metastases. In clinical practice, patients with tumors ≥58 mm may benefit from timely identification of distant metastases.

Postoperative recurrent factors and therapeutic and preventive strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. The recurrence rate is about 50% at 3 years and over 70% at 5 years after hepatectomy for HCC. The high recurrence rate seriously affects the curative effect and long-term survival of patients with HCC, and is the primary cause of death after operation. Postoperative recurrence of HCC is a complex multi-step, multi-factorial process involving three factors: the body, microenvironment, and tumor tissue, which include body immunity, local pH value, interstitial pressure, vascular osmotic pressure, inflammatory reaction, tumor cell adhesion, extracellular matrix degradation, cell migration, cell proliferation, and tumor angiogenesis. HCC recurrence is closely related to abnormal gene expression and related molecular function changes, but the molecular mechanism has not been fully elucidated. How to treat the recurrence of HCC after operation directly affects the prognosis of patients with HCC, and treatments include reoperation, liver transplantation, local minimally invasive treatment, radiotherapy, molecular targeted drugs, immunotherapy, and traditional Chinese medicine treatment. It is difficult to cure or control tumor progression by a single therapy. Two or more therapeutic methods need to be combined organically to achieve a synergistic therapeutic effect. According to the specific situation of patients with HCC, it is key to analyze the individual characteristics of patients, to combine the clinical experience of clinicians and the best evidence, to adopt the individualized treatment plan, and to choose the appropriate treatment methods. For HCC patients with high-risk factors for recurrence, selecting the appropriate treatment is important to reduce the recurrence of HCC after operation and prolong the survival of patients.

MT1G serves as a tumor suppressor in hepatocellular carcinoma by interacting with p53

Poor prognosis of hepatocellular carcinoma (HCC) patients is frequently associated with rapid tumor growth, recurrence and drug resistance. MT1G is a low-molecular weight protein with high affinity for zinc ions. In the present study, we investigated the expression of MT1G, analyzed clinical significance of MT1G, and we observed the effects of MT1G overexpression on proliferation and apoptosis of HCC cell lines in vitro and in vivo. Our results revealed that MT1G was significantly downregulated in tumor tissues, and could inhibit the proliferation as well as enhance the apoptosis of HCC cells. The mechanism study suggested that MT1G increased the stability of p53 by inhibiting the expression of its ubiquitination factor, MDM2. Furthermore, MT1G also could enhance the transcriptional activity of p53 through direct interacting with p53 and providing appropriate zinc ions to p53. The modulation of MT1G on p53 resulted in upregulation of p21 and Bax, which leads cell cycle arrest and apoptosis, respectively. Our in vivo assay further confirmed that MT1G could suppress HCC tumor growth in nude mice. Overall, this is the first report on the interaction between MT1G and p53, and adequately uncover a new HCC suppressor which might have therapeutic values by diminishing the aggressiveness of HCC cells.

Clinical predictors of small solitary hepatitis B virus-related hepatocellular carcinoma microinvasion

BACKGROUND

Microinvasion serves as a reliable indicator of poor prognosis after hepatectomy or transplantation for hepatocellular carcinoma (HCC). However, microinvasion is difficult to detect with current imaging modalities and is usually diagnosed histopathologically. The aim of this study is to identify the preoperative clinical predictors of microinvasion of small solitary hepatitis B virus (HBV)-related HCC.

METHODS

From January 2000 to December 2009, 110 patients with HBV-related small primary solitary HCC (tumour diameter ≤3.0 cm) who underwent hepatectomy at Chinese PLA General Hospital were enrolled. The independent predictors of microinvasion, such as microvascular invasion and microscopic satellite nodules, were analysed. The prognosis of patients with microinvasion was compared with that of patients without microinvasion.

RESULTS

Of the 110 patients, 31 (28.2%) exhibited microinvasion. Among them, 16 (51.6%) had microvascular invasion with microscopic satellite nodules, five (16.1%) had microscopic satellite nodules without microvascular invasion and 10 (32.3%) had microvascular invasion without microscopic satellite nodules. Two independent predictors of microinvasion were identified: serum alpha-fetoprotein >20 ng/mL and a viral load of >10⁴ copies/mL. Patients without microinvasion exhibited a significantly better prognostic outcome compared with those with microinvasion.

CONCLUSION

Regarding HBV-related small HCC, patients presenting with alpha-fetoprotein levels >20 ng/mL and a high viral load (HBV-DNA >104 copies/mL) are at substantial risk for microinvasion.

Association between Ambient Particulate Matter 2.5 Exposure and Mortality in Patients with Hepatocellular Carcinoma

Air pollution is a severe public health problem in Taiwan. Moreover, Taiwan is an endemic area for hepatocellular carcinoma (HCC). This study examined the effect of particulate matter 2.5 (PM2.5) exposure on mortality in this population. A total of 1003 patients with HCC treated at Chang Gung Memorial Hospital between 2000 and 2009 were included in this study. At the end of the analysis, 288 (28.7%) patients had died. Patients with HCC living in environments with PM2.5 concentrations of ≥36 µg/m3 had a higher mortality rate than patients living in environments with PM2.5 concentrations of <36 µg/m3 (36.8% versus 27.5%, p = 0.034). The multivariate Cox regression analysis confirmed that PM2.5 ≥ 36 µg/m3 was a significant risk factor for mortality (1.584 (1.162-2.160), p = 0.004). A nonlinear relationship was observed between the odds ratio and PM2.5. The odds ratio was 1.137 (1.015-1.264) for each increment of 5 µg/m3 in PM2.5 or 1.292 (1.030-1.598) for each increment of 10 µg/m3 in PM2.5. Therefore, patients with HCC exposed to ambient PM2.5 concentrations of ≥36 µg/m3 had a 1.584-fold higher risk of death than those exposed to PM2.5 concentrations of <36 µg/m3. Further studies are warranted.

Prognostic value of preoperative computed tomography in HBV-related hepatocellular carcinoma patients after curative resection

Background: Preoperative treatments are considered for patients with worse outcome to improve overall survival and reduce tumor relapse. This study developed a prognostic risk estimation for patients with hepatitis B virus (HBV)-related solitary hepatocellular carcinoma after curative resection, including preoperative computed tomography (CT) signatures. Methods: Preoperative multiphasic CTs for 166 patients with operable HCC were performed in our hospital from 15 November 2013 through 15 May 2015. Follow-up information, until 5 June 2017, included: CT, pathological and clinical characteristics, and recurrence and metastases of HCC confirmed by pathological or radiological diagnosis. The parameters were analyzed by the Kaplan-Meier method and Cox proportional hazards regression analysis. Results: In multivariate analyses, overall survival was not significantly associated with any of the analyzed prognostic risk factors, but did show that the following were significant prognostic risk factors for disease-free survival: larger tumor size, positive radiogenomic venous invasion, non-smooth tumor margin, and histological microvascular invasion. These were all incorporated into the nomogram. The calibration curves for predicting the probability of disease-free survival between the nomogram and actual observation showed good conformity. Conclusion: In patients with HBV-related HCC, CT signatures were a noninvasive significant indicator of disease-free survival. Thus, consideration of CT signatures may optimize preoperative treatment strategies for the individual patient.

The tumor diameter cut-off for predicting microscopic intrahepatic metastasis of hepatocellular carcinoma patients without treatment history differs from that of hepatocellular carcinoma patients with a treatment history

BACKGROUND AND AIM

Intrahepatic metastasis (IM) of hepatocellular carcinoma (HCC) occurs via vascular invasion; the tumor diameter that affects the risk of micro intra-hepatic metastasis (MIM) should be larger than that which affects the risk of micro vessel invasion (MVI). The aim of the present study was to determine the optimum tumor diameter cut-off value for predicting the presence of MIM in HCC patients without treatment history and HCC patients with a treatment history and to compare these diameters between cases of MVI and MIM.

METHODS

This retrospective study included 621 patients without macroscopic vessel invasion or intrahepatic metastasis on preoperative imaging who underwent hepatectomy. The cut-off tumor diameter for predicting the presence of MIM was determined by a receiver operating characteristic curves analysis.

RESULTS

The optimum cut-off value for predicting the presence of MIM in HCC patients without treatment history was 43 mm. In contrast, the optimum cut-off value for predicting the presence of MIM in HCC patients with a treatment history was 20 mm. Among 46 HCC patients with MIM without treatment history, there were 20 patients with MIM without MVI who were considered to have potential multi-centric (MC) tumors rather than IM. The cumulative overall survival rates in patients with MIM without MVI (potential MC) was significantly better than that in patients with both MIM and MVI (P = 0.022).

CONCLUSIONS

The tumor diameter cut-off value for predicting MIM differed between HCC patients without treatment history and with a treatment history and slightly smaller than those for predicting MVI beyond our expectation.

Microvascular invasion predicts a poor prognosis of solitary hepatocellular carcinoma up to 2 cm based on propensity score matching analysis

AIM

Microvascular invasion (MVI) is not discussed for solitary hepatocellular carcinoma (HCC) up to 2 cm in the 8th Edition of the American Joint Committee on Cancer Staging Manual. The present study aimed to reappraise the influence of MVI on solitary HCC up to 2 cm in diameter.

METHODS

Between January 2010 and December 2012, a retrospective cohort of 496 HCC patients from the Eastern Hepatobiliary Surgery Hospital was analyzed. Propensity score matching was carried out to balance the baseline characteristics. Survival analysis was carried out using the Kaplan-Meier method. Risk factors were evaluated using the Cox proportional hazards model. Multivariate logistic regression was used to identify the risk factors associated with MVI.

RESULTS

All patients were classified into either an MVI-negative group (n = 332) or an MVI-positive group (n = 164). The MVI-positive group had poorer recurrence-free survival and overall survival before and after propensity score matching. The multivariate analysis showed that MVI; being male; increased total bilirubin levels, alanine transaminase levels and γ-glutamyl transpeptidase levels; decreased albumin levels; and HBV DNA load >10³  IU/mL were risk factors for recurrence-free survival. MVI, older age, lower albumin levels, and cirrhosis were risk factors for overall survival. Age <50 years, alpha-fetoprotein >20 ng/mL, and lack of or an incomplete capsule were significantly independent predictors for MVI.

CONCLUSIONS

MVI had a negative impact on the prognosis of solitary HCC up to 2 cm after curative hepatectomy. The 8th edition of the American Joint Committee on Cancer staging system could be improved by subdividing solitary HCC up to 2 cm according to MVI.

Stromal morphological changes and immunophenotypic features of precancerous lesions and hepatocellular carcinoma

AIMS

To evaluate stromal histopathological features and immunostaining expression for differential diagnosis of low- and high-grade dysplastic nodules (HGDN) to early and progressed hepatocellular carcinomas (eHCC, pHCC).

MATERIALS

We evaluated sinusoid capillarisation (SC), solitary artery (SA), ductular reaction (DR), stromal invasion and expression of six biomarkers (GPC3, HSP70, GS, CD34, CK19, EpCAM) in a series of 97 cases.

RESULTS

Stromal morphological changes, including SC, DR and SA, exhibited significant differences in differential diagnosis. In one indicator, SC had the best sensitivity (90.00%) and accuracy (85.42%), and SA had the best specificity at 88.89 %. In combinations, SC +and SA +were favourable and optimal. The immunoreactivity of GPC3, HSP70 and GS increased significantly in line with the stepwise progression of hepatocarcinogenesis.

CONCLUSIONS

Stromal histopathology features are useful for diagnosing HGDN, eHCC and small HCC. The immunostaining panel of GPC3, HSP70 and GS can also be supplementary.

The Predictors of Microscopic Vessel Invasion Differ Between Primary Hepatocellular Carcinoma and Hepatocellular Carcinoma with a Treatment History

BACKGROUND AND AIM

Previous studies have shown that microscopic vessel invasion (MVI) occurs in hepatocellular carcinoma (HCC) with a treatment history due to its poorer malignant behavior in comparison with primary HCC. The aim of the present study was to determine the predictors of MVI and overall survival in HCC patients with a treatment history.

METHODS

This retrospective study included 580 patients who underwent hepatectomy and whose preoperative imaging showed no evidence of macroscopic vessel invasion. The patients were classified into two groups: primary HCC (n = 425) and HCC with a treatment history (n = 155). MVI was defined as the presence of either microscopic portal vein invasion or venous invasion, which was invisible on preoperative imaging.

RESULTS

MVI was identified in 34 (21.9%) patients with a treatment history. A multivariate analysis showed that a high des-gamma-carboxy prothrombin (odds ratio [OR] 5.16, P = 0.002) and a large tumor diameter (OR 2.57, P = 0.030) were the significant predictor of MVI in HCC with a treatment history. Moreover, the presence of MVI (hazard ratio [HR] 2.27, P = 0.001) and tumor diameter >27 mm (HR 2.04, P = 0.006) remained significant predictors of the overall survival in HCC with a treatment history. The tumor diameter cutoff value for predicting MVI (27 mm) in HCC with a treatment history was smaller than in primary HCC (37 mm).

CONCLUSIONS

The presence of MVI was a significant predictor in the HCC patients with a treatment history. The tumor diameter is an important factor that can be used to predict the presence of MVI, especially in HCC with a treatment history.

Importance of tumor size at diagnosis as a prognostic factor for hepatocellular carcinoma survival: a population-based study

Objective

The effects of hepatocellular carcinoma (HCC) tumor size on clinical presentation and treatment selection and its role as a prognostic factor remain unclear. The present study is a comprehensive analysis of the clinical correlation between tumor size at diagnosis and pathological grades, clinical staging, disparities of treatment, and survival of patients with HCC.

Materials and methods

Patients with HCC were separated into groups according to tumor size as follows: 0.1–2.0, 2.1–5.0, 5.1–10.0, and 10.1–20.0 cm. Logistic regression analysis was used to determine the relationship between tumor size at diagnosis and pathological grade, Surveillance, Epidemiology, and End Results (SEER) historic stage A, and treatment selection. The survival of HCC patients stratified by tumor size was estimated by Kaplan–Meier and 5-year survival analyses using the log-rank test. Multivariable analysis of overall survival was performed using the Cox proportional hazards model. Tumor size at diagnosis was an independent risk factor of pathological grade, and SEER historic stage A was revealed by logistic regression analysis.

Results

The 5-year survival rate was 21.9% vs 14.3% vs 9.2% vs 7.7% for all HCC patients and 31.2% vs 23.6% vs 20.3% vs 15.5% for patients who underwent surgery with tumor sizes of 0.1–2.0 vs 2.1–5.0 and 5.1–10.0 vs 10.1–20.0 cm, respectively; multivariable Cox regression analysis identified tumor size at diagnosis as an independent predictor of survival risk with HR of 1.00 vs 1.66 vs 2.92 vs 3.67, respectively.

Conclusion

Tumor size at diagnosis could be used as an independent risk predictor associated with histological grade, stage, selection of surgery, and survival in HCC.

Nomograms to Predict the Individual Survival of Patients with Solitary Hepatocellular Carcinoma after Hepatectomy

Background/Aims

Solitary hepatocellular carcinoma (HCC) is a subgroup of HCCs. We aimed to establish nomograms for predicting the survival of solitary HCC patients after hepatectomy.

Methods

A total of 538 solitary HCC patients were randomly classified into training and validation sets. A Cox model was used to identify predictors of overall survival (OS) in the training set. A nomogram was generated based on these predictors and was validated using the validation set.

Results

Tumor size, microvascular invasion, and major vascular invasion were significantly associated with OS in the training set. Nomograms were developed based on these predictors in the multivariate analysis. The C-index was 0.75 for the OS nomogram and 0.72 for the recurrence-free survival nomogram. Compared to the index of conventional staging systems for predicting survival (0.71 for Barcelona Clinic Liver Cancer, 0.66 for the seventh American Joint Committee on Cancer, 0.68 for Cancer of the Liver Italian Program, and 0.70 for Hong Kong Liver Cancer), the index of the OS nomogram was significantly higher. Moreover, the calibration curve fitted well between the predicted and observed survival rate. Similarly, in the validation set, the nomogram discrimination was superior to those of the four staging systems (p<0.001).

Conclusions

The nomograms demonstrated good discrimination performance in predicting 3- and 5-year survival rates for solitary HCCs after hepatectomy.

Efficacy of postoperative adjuvant transcatheter arterial chemoembolization in hepatocellular carcinoma patients with microvascular invasion

AIM

To investigate the efficacy and safety of postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE) in preventing tumor recurrence and improving survival in Barcelona Clinic Liver Cancer (BCLC) early (A) and intermediate (B) stage hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI).

METHODS

A total of 519 BCLC A or B HCC patients treated by liver resection alone or followed by PA-TACE between January 2012 and December 2015 were studied retrospectively. Univariate and multivariate analyses were performed to investigate the risk factors for recurrence-free survival (RFS) and overall survival (OS). Multiple logistic regression was used to identify the clinicopathological characteristics associated with MVI. The rates of RFS and OS were compared among patients with or without MVI treated with liver resection alone or followed by PA-TACE.

RESULTS

Univariate and multivariate analyses demonstrated that serum AFP level > 400 ng/mL, tumor size > 5 cm, tumor capsule invasion, MVI, and major hepatectomy were risk factors for poor OS. Tumor capsule invasion, MVI, tumor size > 5 cm, HBV-DNA copies > 1 x 10⁴ IU/mL, and multinodularity were risk factors for poor RFS. Multiple logistic regression identified serum AFP level > 400 ng/mL, tumor size > 5 cm, and tumor capsule invasion as independent predictors of MVI. Both OS and DFS were significantly improved in patients with MVI who received PA-TACE as compared to those who underwent liver resection alone. Patients without MVI did not show a significant difference in OS and RFS between those treated by liver resection alone or followed by PA-TACE.

CONCLUSION

PA-TACE is a safe adjuvant intervention and can efficiently prevent tumor recurrence and improve the survival of BCLC early- and intermediate-stage HCC patients with MVI.

Validated preoperative computed tomography risk estimation for postoperative hepatocellular carcinoma recurrence

AIM

To develop and validate a risk estimation of tumor recurrence following curative resection of operable hepatocellular carcinoma (HCC).

METHODS

Data for 128 patients with operable HCC (according to Barcelona Clinic Liver Cancer imaging criteria) who underwent preoperative computed tomography (CT) evaluation at our hospital from May 1, 2013 through May 30, 2014 were included in this study. Follow-up data were obtained from hospital medical records. Follow-up data through May 30, 2016 were used to retrospectively analyze preoperative multiphasic CT findings, surgical histopathology results, and serum α-fetoprotein and thymidine kinase-1 levels. The χ² test, independent t-test, and Mann-Whitney U test were used to analyze data. A P-value of < 0.05 was considered statistically significant.

RESULTS

During the follow-up period, 38 of 128 patients (29.7%) had a postoperative HCC recurrence. Microvascular invasion (MVI) was associated with HCC recurrence (χ² = 13.253, P < 0.001). Despite postoperative antiviral therapy and chemotherapy, 22 of 44 patients with MVI experienced recurrence after surgical resection. The presence of MVI was 57.9% sensitive, 75.6% specific and 70.3% accurate in predicting postoperative recurrence. Of 84 tumors without MVI, univariate analysis confirmed that tumor margins, tumor margin grade, and tumor capsule detection on multiphasic CT were associated with HCC recurrence (P < 0.05). Univariate analyses showed no difference between groups with respect to hepatic capsular invasion, Ki-67 proliferation marker value, Edmondson-Steiner grade, largest tumor diameter, necrosis, arterial phase enhanced ratio, portovenous phase enhanced ratio, peritumoral enhancement, or serum α-fetoprotein level.

CONCLUSION

Non-smooth tumor margins, incomplete tumor capsules and missing tumor capsules correlated with postoperative HCC recurrence. HCC recurrence following curative resection may be predicted using CT.

MELD score and AST-to-platelet ratio index (APRI) predict long-term survival in patients with a small hepatocellular carcinoma following non-transplant therapies: a pilot study

AIM

Liver transplantation (LT) is the most effective treatment for long-term survival from hepatocellular carcinoma (HCC); however, insufficient donors limit therapy. We sought to identify characteristics that predicted long-term survival after non-transplant therapies in patients with small HCC.

METHODS

In a database of 1,050 HCC patients, we identified those with single HCC ≤ 3.0 cm, who underwent hepatic resection (HR, n = 16), radiofrequency ablation (RFA, n = 55), or LT (n = 23) with 5-years follow-up. Survival and odds-ratios for survival (OS) after HR/RFA were calculated for MELD score, platelet count, creatinine, albumin, AST/Platelet Ratio Index (APRI), INR, and bilirubin.

RESULTS

LT patients had 3 and 5-year OS of 82.6% and 73.9% compared to HR/RFA patients with 3 and 5-year OS of 40.8% and 33.8%. The strongest predictors of survival after HR/RFA were MELD < 10 (OR 4.43, 95% CI 1.85-10.58) and APRI ≤ 0.5 (OR 4.25, 95% CI 1.63-11.08). HR/RFA patients with both MELD < 10 and APRI ≤ 0.5 had 3- and 5-year OS of 77.3% and 72.7%.

CONCLUSION

Patients with MELD < 10 and APRI ≤ 0.5 who undergo HR/RFA have survival approaching LT. Perhaps patients who meet these criteria can safely undergo non-transplant therapy and donor livers can be allocated to patients with a greater need.

Prognostic factors of hepatocellular carcinoma survival after radiofrequency ablation: A US population-based study

OBJECTIVE

To determine the survival outcome and prognostic factors of hepatocellular carcinoma (HCC) survival in patients who underwent radiofrequency ablation (RFA).

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was queried: There were 2588 HCC patients from 2004 to 2012 who underwent RFA. The Kaplan-Meier curves and the multivariate Cox regression analysis were used to assess the prognostic factors.

RESULTS

With a median follow-up of 20 months, the 1-, 3- and 5-year overall survival (OS) rates were: 83%, 51% and 33%. Patients with a tumor size ≤5 cm in diameter had a better 5-year OS, as compared to patients with a tumor size >5 cm. The 5-year OS was significantly higher among patients with a normal level of alpha-fetoprotein (AFP), compared with those having elevated AFP. In an adjusted multivariate Cox regression analysis, those with ≥60 years of age (HR: 1.19; 95% CI 1.05-1.36), non-Asian race (HR: 1.53; 95% CI 1.30-1.81), tumor size >5 cm (HR: 1.43; 95% CI 1.24-1.65), elevated AFP (HR: 1.42; 95% CI 1.22-1.64), American Joint Committee on Cancer (AJCC) stages II-III (HR: 1.30; 95% CI 1.14-1.48) and the year of diagnosis from 2004-2007 (HR: 1.22; 95% CI 1.07-1.40) were significantly associated with a poor prognosis.

CONCLUSIONS

Age, race, tumor size, AFP level, AJCC stage and year of diagnosis were prognostic factors for OS in HCC patients who underwent RFA.

Microwave ablation for the treatment of hepatocellular carcinoma that met up-to-seven criteria: feasibility, local efficacy and long-term outcomes

OBJECTIVES

This study aimed to evaluate the feasibility, local efficacy and long-term outcomes of microwave (MW) ablation for the treatment of hepatocellular carcinoma (HCC) that met up-to-seven criteria.

METHODS

Between January 2007 and January 2012, 142 HCC patients with 294 nodules, which conformed to up-to-seven criteria, were enrolled into this retrospective study. All patients were followed up for more than 3 years after receiving MW ablation. Technical success, complications, local tumour progression (LTP) and distant recurrence (DR) were monitored. Recurrence-free survival (RFS), overall survival (OS) and prognostic factors were analysed.

RESULTS

Primary technical efficacy was achieved in 95.2% (280/294) of the carcinomatous nodules, and major complications occurred in four (2.8%) patients. Among the 294 tumours, LTP was observed in 44 (15.0%) tumours. Among the 142 patients, DR was observed in 97 (68.3%) patients. The estimated OS rates after MW ablation at 1, 3 and 5 years were 97.2%, 75.4% and 50.6%, respectively; and the corresponding RFS rates were 76.1%, 33.1% and 19.5%, respectively.

CONCLUSIONS

MW ablation is a safe and effective treatment with a high rate of primary technical efficacy for patients with HCC that met up-to-seven criteria.

KEY POINTS

• The first study expanding MW ablation to HCC category beyond Milan criteria. • The first report that used up-to-seven criteria as indications for MW ablation. • HCC of up-to-seven criteria viewed as a subgroup of BCLC stage B. • MW ablation is safe and effective for treating HCC within up-to-seven criteria. • MW ablation is preferable in treating unresectable HCC within up-to-seven criteria.

Novel microvascular invasion-based prognostic nomograms to predict survival outcomes in patients after R0 resection for hepatocellular carcinoma

PURPOSE

To propose a novel histopathological classification system for microvascular invasion (MVI) and to establish nomograms to predict postoperative survival and early tumor recurrence in patients with hepatocellular carcinoma (HCC) after R0 liver resection.

METHODS

The clinicopathological and follow-up data of 686 consecutive patients with HCC who underwent R0 liver resection in our hospital between December 2009 and April 2010 were retrospectively reviewed. A classification system was established based on histological characteristics of MVI. Nomograms were then formulated using a multivariate Cox proportional hazards model to analyze. The results were validated using bootstrap resampling and a new 225-patient validation cohort operated in May and June 2010 at the same institution.

RESULTS

A 4-stratification classification system of MVI was established, which satisfactorily determined the risk of survival and early tumor recurrence. Then, an eight-factor nomogram for survival prediction and a seven-factor nomogram for prediction of early tumor recurrence were established. The concordance indices were 0.78 for the survival-prediction nomogram and 0.72 for the recurrence-prediction nomogram. These indices were both significantly higher than the following three commonly used staging systems: tumor-node-metastasis staging system (seventh edition, 0.67/0.65), Japan Integrated Staging System (0.58/0.58) and Chinese University Prognostic Index (0.52/0.51). The calibration curves showed good agreement between predictions by the nomograms and actual survival outcomes. These results were confirmed in the validation cohort.

CONCLUSIONS

The novel classification system of MVI and the nomograms enabled more accurate predictions of risk of tumor recurrence and overall survival in patients with HCC after R0 liver resection.