Characteristics of recurrent hepatocellular carcinoma in Japan and our surgical experience

Surgical and Oncological Outcomes of Salvage Hepatectomy for Locally Recurrent Hepatocellular Carcinoma after Locoregional Therapy: A Single-Institution Experience

Surgical and oncological outcomes of hepatectomy for recurrent hepatocellular carcinoma (HCC) after locoregional therapy, including locally recurrent HCC (LR-HCC), were examined. Among 273 consecutive patients who underwent hepatectomy for HCC, 102 with recurrent HCC were included and retrospectively reviewed. There were 35 patients with recurrent HCC after primary hepatectomy and 67 with recurrent HCC after locoregional therapies. Pathologic review revealed 30 patients with LR-HCC. Background liver function was significantly worse in patients with recurrent HCC after locoregional therapy (p = 0.002). AFP (p = 0.031) and AFP-L3 (p = 0.033) serum levels were significantly higher in patients with LR-HCC. Perioperative morbidities were significantly more frequently observed with recurrent HCC after locoregional therapies (p = 0.048). Long-term outcomes of recurrent HCC after locoregional therapies were worse than those after hepatectomy, though there was no prognostic difference according to the recurrence patterns after locoregional therapies. Multivariate analyses showed that prognostic factors for resected recurrent HCC were previous locoregional therapy (hazard ratio [HR] 2.0; p = 0.005), multiple HCCs (HR 2.8; p < 0.001), and portal venous invasion (HR 2.3; p = 0.001). LR-HCC was not a prognostic factor. In conclusion, salvage hepatectomy for LR-HCC showed worse surgical outcomes but a favorable prognosis.

Efficacy and safety of preoperative transarterial chemoembolization for hepatocellular carcinoma: a systematic review and meta-analysis

OBJECTIVE

The aim of the study was to compare preoperative transcatheter arterial chemotherapy (TACE) plus liver resection (LR) with liver resection (LR) alone for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

PubMed, Embase, Cochrane library, web of science and China National Knowledge Infrastructure (CNKI) were searched from their initiation until 24 August 2021. Eligible languages were English and Chinese. This study includes only RCT and cohort studies. The primary outcome was the prognostic factors including overall survival rate (OS), disease-free survival (DFS), recurrence-free survival (RFS), and we also research the operative time, intraoperative blood loss, and postoperative complication.

RESULTS

Twenty-nine trials (2 RCTs and 27 cohorts) were included, containing a total of 22023 patients, compared with hepatic resection, preoperative TACE plus LR shows the benefit of RFS (Hazard Ratio (HR)=0.80, 95%CI = [0.73-0.88], p < .001), and the combined therapy was associated with a higher OS for patients with HCC in Barcelona Clinic Liver Cancer (BCLC) B stage (HR = 0.76, 95%CI = [0.60-0.96], p = .024). In terms of safety, combination therapy is related to less intraoperative blood loss (Weighted Mean Difference (WMD)=-11.17, 95%CI = [-21.79 to -0.54], p = .039); and there's no statistical significance in postoperative complication (Risk Ratio (RR)=0.99, 95%CI= [0.90-1.08], p = 0.771) and operative time (WMD = 7.57, 95%CI = [-5.07 to 20.20], p = .240).

CONCLUSION

TACE prior to surgery should be recommended as a routine treatment for HCC patients, especially BCLC B stage HCC, in view of its benefits for RFS and OS. Large, multicenter, and blinded randomized trials should be performed to confirm these findings.

Application and Evaluation of a 64-Slice CT Three-Dimensional Fusion Technique in the Determination of the Effective Ablation Margin after Radiofrequency Ablation of Hepatocellular Carcinoma

Due to the low accuracy of traditional three-dimensional fusion technology in radiofrequency ablation of hepatocellular carcinoma, this paper studies the advantages of three-dimensional CT fusion technology over traditional two-dimensional imaging technology in preoperative visualization and radiofrequency ablation path selection of hepatocellular carcinoma. To study the prognostic differences of hepatocellular carcinoma patients with different ablation margins (AM) in the three groups, so as to explore the best AM value, so as to minimize the liver injury caused by radiofrequency ablation. The selected patients underwent CT plain scan and three-phase enhancement at 1, 3, 6, and 12 months after operation and were rechecked every 6 months. For recurrent patients, CT was rechecked every three months. The images were obtained by GE 64-slice spiral CT. The thickness of the reconstruction layer is 1 mm, and the interval is 1 mm. The reconstructed image is imported into 3D fusion software. The three-dimensional images of tumor focus, hepatic artery, portal vein, and hepatic vein were reconstructed by two experienced doctors by superimposing the saved tumor images, merging the vascular images into the display, and measuring the ablation boundary (AM value). The results showed that the recurrence rate in group A was higher than that in group B (P = 0.041), and there was no significant difference between group B and group C (P = 1.000). Compared with traditional two-dimensional imaging, three-dimensional CT fusion technology can display the anatomical structure and three-dimensional spatial relationship of tumors and blood vessels and select the best radiofrequency ablation path, so as to achieve accurate radiofrequency ablation.

Radiofrequency ablation in the management of primary hepatic and biliary tumors

In the United States, 80%-90% of primary hepatic tumors are hepatocellular carcinomas and 10%-15% are cholangiocarcinomas (CCA), both with high mortality rate, particularly CCA, which portends a worse prognosis. Traditional management with surgery has good outcomes in appropriately selected patients; however, novel ablative treatment options have emerged, such as radiofrequency ablation (RFA), which can improve the prognosis of both hepatic and biliary tumors. RFA is aimed to generate an area of necrosis within the targeted tissue by applying thermal therapy via an electrode, with a goal to completely eradicate the tumor while preserving surrounding healthy tissue. Role of RFA in management of hepatic and biliary tumors forms the focus of our current mini-review article.

Treatment of intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

BACKGROUND

Prognostic factors after treatment for intrahepatic recurrent hepatocellular carcinoma (RHCC) after hepatic resection (Hx) are controversial. The current study aimed to examine the impact of treatment modality on the prognosis of intrahepatic RHCC following Hx.

METHODS

For control of variables, the subjects were 56 patients who underwent treatment for intrahepatic RHCC, three or fewer tumors, each measuring ≤3 cm in diameter without macroscopic vascular invasion (MVI), between 2000 and 2011. Retreatment consisted of repeat Hx (n = 23), local ablation therapy (n = 11) and transarterial chemoembolization or transcatheter arterial infusion (TACE/TAI) (n = 22). We retrospectively investigated the relation between type of treatment for RHCC and overall survival (OS) as well as disease-free survival (DFS).

RESULTS

In multivariate (MV) analysis, the poor prognostic factors in DFS after retreatment consisted of disease-free interval (DFI) (≤1.5 y) (P = .011), type of retreatment (TACE/TAI) (P = .002), age (<65 y old) (P = .0022), perioperative RBC transfusion (P = .025), while those in OS after retreatment were DFI (≤1.5 y) (P < .0001). In evaluation of stratification for type of retreatment, DFS in the repeat Hx group was significantly better than those in the local ablation therapy group or the TACE/TAI group (P = .023 or P < .0001, respectively).

CONCLUSIONS

DFI (≤1.5 y) was an independent poor prognostic factor in both DFS and OS, and repeat Hx for intrahepatic RHCC, few in number and size without MVI, seems to achieve the most reliable local control.

Intussusception due to hematogenous metastasis of hepatocellular carcinoma to the small intestine: A case report

BACKGROUND

The commonest sites of extrahepatic metastases from hepatocellular carcinoma (HCC) are the lungs, bones, adrenal glands, and regional lymph nodes. Hematogenous metastasis to the gastrointestinal (GI) tract is a rare condition in patients with HCC, and the prognosis is usually poor. We report, herein, an extremely rare case of a patient with intussusception due to hematogenous metastasis of HCC to the ileum and his long-term survival with multidisciplinary therapy.

CASE SUMMARY

The patient was a 71-year-old man with a history of chronic hepatitis B, who had undergone three surgeries for HCC. He was treated with sorafenib for peritoneal metastases of HCC. He was admitted to our hospital with chief complaints of abdominal pain and vomiting. Abdominal contrast-enhanced computed tomography imaging revealed a small intestinal tumor, presenting with intussusception and small bowel obstruction. Conservative treatment was started, but due to repeated exacerbation of symptoms, surgery was planned on the 28^th d of hospitalization. Partial ileal resection without reducing the intussusception and end-to-end anastomosis was performed. On histological examination, tumor cells were not observed on the serosal surface, but intravascular invasion of tumor cells was seen. Immunohistochemistry was positive for immunohistochemical markers, and a diagnosis of hematogenous metastasis of HCC to the ileum was made. He remains alive 82 mo after the first surgery.

CONCLUSION

Prognosis of HCC patients with GI tract metastasis is usually poor, but in some cases, multidisciplinary therapy may prolong survival.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Efficiency of whole-body 18F-FDG PET CT in detecting the cause of rising serum AFP level in post-therapeutic follow-up for HCC patients

PURPOSE

The goal of this study was to assess the value of whole-body ¹⁸F-FDG PET/CT in detecting the cause of rising serum alpha-fetoprotein (AFP) level after the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

¹⁸F-FDG PET/CT studies were performed for 100 patients (76 men and 24 women), ranged in age from 40 to 76 years who had underwent either surgical resection or interventional therapy for HCC, but were subsequently noted to have rising AFP serum level on routine follow-up examinations. The ¹⁸F-FDG PET/CT results were correlated with histological findings or radiological and clinical follow-up.

RESULTS

According to patient-based analysis, ¹⁸F-FDG PET/CT demonstrated 74 true-positives, four false-negatives, 16 true-negative, and 6 false-positive results, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 95%, 72.7%, 92.5%, 80%, and 90%, respectively. According to Lesion-based analysis, ¹⁸F-FDG PET/CT demonstrated 202 true-positive lesions, 8 false-negatives, and 16 true-negative and 6 false-positive results, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 98%, 72.7%, 97%, 80%, and 95.6%, respectively.

CONCLUSION

¹⁸F-FDG PET/CT is a valuable imaging tool investigating patients who have a rising serum AFP level after HCC treatment. It accurately detects residual or recurrent tumor as well as extrahepatic metastasis.

HCC-derived exosomes elicit HCC progression and recurrence by epithelial-mesenchymal transition through MAPK/ERK signalling pathway

Liver cancer is the second most common cause of cancer-related death worldwide. Approximately 70-90% of primary liver cancers are hepatocellular carcinoma (HCC). Currently, HCC patient prognosis is unsatisfactory due to high metastasis and/or post-surgical recurrence rates. Therefore, new therapeutic methods for inhibiting metastasis and recurrence are urgently needed. Exosomes are small lipid-bilayer vesicles that are implicated in tumour development and metastasis. Rab27a, a small GTPase, regulates exosome secretion by mediating multivesicular endosome docking at the plasma membrane. However, whether Rab27a participates in HCC cell-derived exosome exocytosis is unclear. Epithelial-mesenchymal transition (EMT) frequently initiates metastasis. The role of HCC cell-derived exosomes in EMT remains unknown. We found that exosomes from highly metastatic MHCC97H cells could communicate with low metastatic HCC cells, increasing their migration, chemotaxis and invasion. Rab27a knockdown inhibited MHCC97H-derived exosome secretion, which consequently promoted migration, chemotaxis and invasion in parental MHCC97H cells. Mechanistic studies showed that the biological alterations in HCC cells treated with MHCC97H-derived exosomes or MHCC97H cells with reduced self-derived exosome secretion were caused by inducing EMT via MAPK/ERK signalling. Animal experiments indicated that exosome secretion blockade was associated with enhanced lung and intrahepatic metastasis of parental MHCC97H cells, while ectopic overexpression of Rab27a in MHCC97H cells could rescue this enhancement of metastasis in vivo. Injection of MHCC97H cell-derived exosomes through the tail vein promoted intrahepatic recurrence of HLE tumours in vivo. Clinically, Rab27a was positively associated with serum alpha-fetoprotein (AFP) level, vascular invasion and liver cirrhosis. Our study elucidated the role of exosomes in HCC metastasis and recurrence, suggesting that they are promising therapeutic and prognostic targets for HCC patients.

Anterior approach for right hepatectomy with hanging maneuver for hepatocellular carcinoma: a multi-institutional propensity score-matching study

BACKGROUND

This multi-institutional study aimed to assess the benefits of anterior approach for right hepatectomy with hanging maneuver (ARH-HM) for hepatocellular carcinoma (HCC) compared with conventional right hepatectomy (CRH).

METHODS

From January 2000 to December 2012, 306 patients with HCC ≥5 cm were divided into two groups: ARH-HM (n = 104) and CRH (n = 202).

RESULTS

After one-to-one propensity score-matched analysis, 72 ARH-HM and 72 CRH patients presented comparable background factors. Patients in the ARH-HM group demonstrated significantly less intraoperative blood loss (480 vs. 1,242 g, P < 0.001) and a lower frequency of red cell concentrate transfusion (21.1% vs. 50.7%, P < 0.001) compared with patients in the CRH group. The 5-year overall survival rate was significantly better in the ARH-HM group compared with the CRH group (50.2% vs. 31.4%, P = 0.021). Limited to patients with HCC ≥10 cm, recurrence-free and overall survival of the ARH-HM group was significantly greater than those of the CRH group.

CONCLUSION

In comparison with CRH, ARH-HM for large HCC can provide better overall survival rates with a decrease in intraoperative blood loss and transfusion rates. Survival impact was evident especially in patients with HCC ≥10 cm.

Salvage hepatectomy for local recurrence of hepatocellular carcinomas offers survival comparable to that of matched patients who undergo primary hepatectomies

BACKGROUND

The feasibility of salvage hepatectomy for locally recurrent hepatocellular carcinomas (HCCs) is unclear, especially for patients with viable parts of previously multinodular tumors.

METHODS

We reviewed charts of patients who underwent initial hepatectomies between 2000 and 2014 to select those with local recurrences (LR) after non-surgical treatments. Their postoperative outcomes, including morbidity, recurrence-free survival (RFS), and overall survival (OS) were compared with matched patients who underwent initial hepatectomies for primary HCCs (PR). Their local recurrence patterns were divided into recurrent solitary tumors (Subgroup A); and recurrent parts of multinodular tumors (Subgroup B).

RESULTS

Among 664 patients, hepatectomy for LR was performed in 62 patients. Matched 59 patients were selected as PR. Clinicopathologic profiles at initial surgery were comparable between the LR and PR groups. Incidence of major morbidity (LR vs. PR, 7% vs. 5%, P = 1.00), 5-year RFS (21% vs. 37%, P = 0.28), and 5-year OS (69% vs. 69%, P = 0.62) were comparable. In the LR group, Subgroup B showed worse 5-year RFS (A vs. B, 29% vs. 0%, P < 0.01) and 5-year-OS (80% vs. 53%, P = 0.01). Postoperative recurrence occurred in 46 patients, but local and extrahepatic recurrence was seen only in 2 patients and 2 patients, respectively.

CONCLUSION

Salvage hepatectomy for locally recurrent HCCs is feasible, and results in prognosis comparable with hepatectomy for primary HCCs. Although the risk of postoperative recurrence was high in Subgroup B, rare local recurrence suggests the usefulness of salvaging uncontrolled tumor by nonsurgical treatment.

Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of “de principe liver transplant” (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Impact of pathological features of primary hepatocellular carcinoma on the outcomes of intrahepatic recurrence management: single center experience from Southern Taiwan

BACKGROUND

Currently, there is no definitive management for hepatocellular carcinoma (HCC) intrahepatic recurrence (IHR) after primary resection (PR). The aim of this study was to analyze the outcomes of three modalities for patients who received curative PR and had IHR within the University of California San Francisco (UCSF) criteria.

METHODS

Between 2003 and 2010, patients with IHR after PR were treated with salvage liver transplantation (SLT), re-resection (RR) or local ablation (LA). Clinico-pathological features of primary tumor and recurrent HCC were analyzed to determine the risk factors that adversely affected overall survival (OS) and disease free survival (DFS).

RESULTS

The study included 130 patients with subgroups of SLT (n = 25), RR (n = 31) and LA (n = 74). The 5-year DFS and OS were 75%, 31% and 17% and 80%, 60% and 58% respectively for each subgroup. SLT had a significantly better DFS than other modalities (p < 0.001). There was no difference in OS. In multivariate analysis, two variables adversely affected DFS: microvascular invasion in PR and not treating patients with SLT.

CONCLUSIONS

SLT provides better DFS for patients with IHR within the UCSF criteria. However, SLT failed to show the same advantage in OS.

Kupffer Imaging by Contrast-Enhanced Sonography With Perfluorobutane Microbubbles Is Associated With Outcomes After Radiofrequency Ablation of Hepatocellular Carcinoma

OBJECTIVES

An ultrasound contrast agent consisting of perfluorobutane microbubbles (Sonazoid; Daiichi Sankyo, Tokyo, Japan) accumulates in Kupffer cells, which thus enables Kupffer imaging. This study aimed to elucidate the association of defect patterns of hepatocellular carcinoma during the Kupffer phase of Sonazoid contrast-enhanced sonography with outcomes after radiofrequency ablation (RFA).

METHODS

For this study, 226 patients with initial hypervascular hepatocellular carcinoma, who could be evaluated by contrast-enhanced sonography with Sonazoid before RFA, were analyzed. Patients were divided into 2 groups according to the tumor defect pattern during the Kupffer phase. The irregular-defect group was defined as patients with hepatocellular carcinoma that had a defect with an irregular margin, and the no-irregular-defect group was defined as patients with hepatocellular carcinoma that had either a defect with a smooth margin or no defect. Critical recurrence was defined as more than 3 intrahepatic recurrences, vascular invasion, dissemination, or metastasis.

RESULTS

The irregular-defect and no-irregular-defect groups included 86 and 140 patients, respectively, and had cumulative 5-year critical recurrence rates of 49% and 17% (P < .01). Multivariate analysis indicated that the tumor diameter, lens culinaris agglutinin- reactive α-fetoprotein level, and defect pattern were independent factors related to critical recurrence. The cumulative 5-year overall survival rates for the irregular-defect and no-irregular-defect groups were 46% and 61% (P< .01). Multivariate analysis indicated that the Child-Pugh class, tumor diameter, lens culinaris agglutinin-reactive α-fetoprotein level, and defect pattern were independent factors related to survival.

CONCLUSIONS

The defect pattern of hepatocellular carcinoma during the Kupffer phase of Sonazoid contrast-enhanced sonography is associated with critical recurrence and survival after RFA.

Implications of discordant findings between hepatic angiography and cross-sectional imaging in transplant candidates with hepatocellular carcinoma

The goal of this study was to determine whether the detection of discordant numbers of hypervascular foci at hepatic angiography versus contrast-enhanced (CE) cross-sectional imaging [computed tomography (CT) or magnetic resonance imaging (MRI)] is associated with adverse clinical outcomes in patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation. We retrospectively reviewed the records of 218 consecutive patients with HCC who were listed for a liver transplant and who underwent transarterial chemoembolization at our institution between January 1, 2006 and December 31, 2010. Patients were grouped into 3 categories: (1) the number of nodules at CT/MRI was concordant with the number of hypervascular foci detected at angiography (n=136), (2) the number of nodules at CT/MRI was greater than the number of hypervascular foci at angiography (n=45), and (3) the number of nodules at CT/MRI was fewer than the number of hypervascular foci at angiography (n=37). The study outcomes were liver transplantation and tumor recurrence after transplantation. The detection of at least 3 more hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly lower rate of transplantation [multivariate subhazard ratio (SHR), 0.39; 95% confidence interval (CI), 0.17-0.92]. The detection of fewer hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly higher rate of tumor recurrence after transplantation (multivariate SHR, 3.49; 95% CI, 1.27-9.56). In conclusion, liver transplant candidates with HCC who demonstrate discordant findings between angiography and CE CT or MRI may be at a higher risk for dropout from the transplant list and for tumor recurrence after transplantation.

DNA methylation consistency implicates the primary tumor cell origin of recurrent hepatocellular carcinoma

AIMS

To investigate if DNA methylation pattern assay could be a new approach to identifying the primary tumor cell origin of the recurrent hepatocellular carcinoma (HCC).

MATERIALS & METHODS

Methylation of 24 genes and expression of 22 cancer stem cell (CSC) biomarkers were quantitatively measured in 10 paired primary and recurrent HCC specimens. The HBV viral-host junctions were determined in six pairs of them with HBV infection.

RESULTS

Similar DNA methylation patterns were observed among nine of ten pairs of primary and recurrent tumors. In five of six paired specimens with HBV infection, exactly same HBV DNA integrations were identified in each paired tumors. The expression of seven CSC biomarkers increased significantly in either primary or recurrent tumor tissues.

CONCLUSION

Recurrent HCCs mostly originate from their primary tumors. Assay of DNA methylation patterns could provide a new approach to determining the origin of recurrent HCC.

Role of hepatectomy for recurrent or initially unresectable hepatocellular carcinoma

As a result of donor shortage and high postoperative morbidity and mortality after liver transplantation, hepatectomy is the most widely applicable and reliable option for curative treatment of hepatocellular carcinoma (HCC). Because intrahepatic tumor recurrence is frequent after loco-regional therapy, repeated treatments are advocated provided background liver function is maintained. Among treatments including local ablation and transarterial chemoembolization, hepatectomy provides the best long-term outcomes, but studies comparing hepatectomy with other nonsurgical treatments require careful review for selection bias. In patients with initially unresectable HCC, transarterial chemo-or radio-embolization, and/or systemic chemotherapy can down-stage the tumor and conversion to resectable HCC is achieved in approximately 20% of patients. However, complete response is rare, and salvage hepatectomy is essential to help prolong patients’ survival. To counter the short recurrence-free survival, excellent overall survival is obtained by combining and repeating different treatments. It is important to recognize hepatectomy as a complement, rather than a contraindication, to other nonsurgical treatments in a multidisciplinary approach for patients with HCC, including recurrent or unresectable tumors.

Early intrahepatic recurrence of hepatocellular carcinoma after hepatectomy treated with re-hepatectomy, ablation or chemoembolization: a prospective cohort study

AIMS

To observe the outcomes of various treatments for patients with early intrahepatic recurrent hepatocellular carcinoma (HCC) after partial hepatectomy.

METHODS

A total of 629 patients with intrahepatic recurrent HCC within Milan criteria following hepatectomy were prospectively collected between November 2004 and May 2010. Overall survival (OS) and recurrence to death survival (RTDS) were analyzed by the Kaplan-Meier method and log-rank test. Cox regression analysis was used for multivariate analyses.

RESULTS

The 5-year OS and RTDS rates were 64.5%, 43.0%; 37.0%, 26.7%; 27.7% and 8.3% for patients who received re-hepatectomy (n = 128), percutaneous radiofrequency ablation (PRFA, n = 162) and transarterial chemoembolization (TACE, n = 339) (re-hepatectomy vs. TACE, P < 0.001, <0.001; vs. PRFA, P = 0.005, 0.008; PRFA vs. TACE, P < 0.001, <0.001). The independent predictors of OS and RTDS were tumor number (hazard ratio: 1.54, 95% confidence interval: 1.18-2.00; 1.57, 1.21-2.04), alpha fetoprotein >20 ng/mL (1.64, 1.24-2.17; 1.66, 1.26-2.20), presence of varices (1.69, 1.28-2.22; 1.61, 1.23-2.10) and Edmondson-Steiner grade III-IV (1.66, 1.17-2.35; 1.70, 1.20-2.40) at the initial stage; and tumor number (1.34, 1.04-1.73; 1.32, 1.03-1.70), time to recurrence (TTR) (3.46, 2.58-4.65; 1.59, 1.19-2.14) and treatment for recurrence (TACE: 3.18, 2.16-4.66; 2.95, 2.02-4.31; PRFA: 1.49, 0.97-2.29; 1.44, 0.94-2.19).

CONCLUSIONS

For early intrahepatic recurrent HCC, re-hepatectomy achieved best outcome. It produced similar result as PRFA for patients with more invasive primary tumors and underlying cirrhosis/varices. TACE had worst prognosis which was only suitable for multifocal recurrence and TTR ≤1 year.

Surgical resection of a malignant liver lesion: what the surgeon wants the radiologist to know

OBJECTIVE

Hepatic malignancy is a common and lethal disease, whether due to a primary tumor or metastasis. There are numerous treatment options available depending on the stage of the disease and medical condition of the patient, including systemic chemotherapy, transcatheter embolization, thermal ablation, and surgical resection. In a subset of patients with liver malignancy, surgical resection can offer the best chance of long-term survival and potentially even cure. This article reviews the major indications and contraindications for resection, basic surgical techniques and terminology, key clinical and imaging preoperative workup, and pertinent interventional oncology procedures in the management of hepatic malignancy.

CONCLUSION

Diagnostic and interventional radiology plays an important role in the assessment and treatment of malignant hepatic lesions. Radiologists should be familiar with how surgeons select, work up, and treat candidates for liver resection to provide the most clinically valuable service.

The clinical behavior of transplantable recurrent hepatocellular carcinoma after curative resection: implications for salvage liver transplantation

BACKGROUND

This study aimed to classify transplantable recurrent hepatocellular carcinoma (HCC) after resection into subgroups according to the pattern of progression and to identify risk factors for each subgroup to select optimal candidates for salvage liver transplantation (LT).

METHODS

The patients that met the Milan criteria (MC) and were child-pugh class A at initial hepatectomy were included in the study. Of these patients, the patients with transplantable recurrence were identified and further divided into two groups according to the recurrent HCC progression pattern. Group 1 contained patients with controlled tumors within the MC. Group 2 contained patients with progressive tumors that spread beyond the MC. A controlled tumor was defined as the absence of tumor recurrence after locoregional treatment for ≥12 months or control of a recurrent tumor within the MC by active locoregional treatment.

RESULTS

After curative resection of HCC, 114 patients with transplantable recurrence were identified: 70 were classified as group 1 and 44 as group 2. Overall survival after recurrence was significantly higher in group 1 compared to group 2 (65.4 vs 35.7 %, respectively; P < 0.003). Multiple logistic regression analysis showed that risk factors in group 1 were age >50 years and an indocyanine green retention at 15 min >10 %. The presence of a satellite nodule (SN) and/or microscopic portal vein invasion (mPVI) was the only independent risk factor identified in group 2. Among the 15 patients that underwent salvage LT, 2 of 3 patients (66.7 %) with SN and/or mPVI at initial hepatectomy developed extrahepatic recurrence.

CONCLUSIONS

The patients with SN and/or mPVI at initial hepatectomy may not be candidates for salvage LT, and an extended observation time is required to determine tumor biology.

Value of radiofrequency ablation in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a malignant disease that substantially affects public health worldwide. It is especially prevalent in east Asia and sub-Saharan Africa, where the main etiology is the endemic status of chronic hepatitis B. Effective treatments with curative intent for early HCC include liver transplantation, liver resection (LR), and radiofrequency ablation (RFA). RFA has become the most widely used local thermal ablation method in recent years because of its technical ease, safety, satisfactory local tumor control, and minimally invasive nature. This technique has also emerged as an important treatment strategy for HCC in recent years. RFA, liver transplantation, and hepatectomy can be complementary to one another in the treatment of HCC, and the outcome benefits have been demonstrated by numerous clinical studies. As a pretransplantation bridge therapy, RFA extends the average waiting time without increasing the risk of dropout or death. In contrast to LR, RFA causes almost no intra-abdominal adhesion, thus producing favorable conditions for subsequent liver transplantation. Many studies have demonstrated mutual interactions between RFA and hepatectomy, effectively expanding the operative indications for patients with HCC and enhancing the efficacy of these approaches. However, treated tumor tissue remains within the body after RFA, and residual tumors or satellite nodules can limit the effectiveness of this treatment. Therefore, future research should focus on this issue.

Determination of clonal origin of recurrent hepatocellular carcinoma for personalized therapy and outcomes evaluation: a new strategy for hepatic surgery

BACKGROUND

Recurrent hepatocellular carcinoma (RHCC) after curative resection is a major challenge for hepatic surgeons. A better understanding of the clonal origin of RHCC will help clinicians design personalized therapy and assess postoperative outcomes. The current study was performed to determine the clonal origin of RHCC and its clinical significance.

STUDY DESIGN

Fifteen high-frequency of loss of heterozygosity of DNA microsatellites were determined on 100 tumor nodules in 60 matched pairs of RHCC from 40 patients who underwent liver re-resections. The relationships among the origin of clonal patterns of RHCC and the surgicopathologic features and clinical outcomes were analyzed.

RESULTS

Of 60 pairs of RHCC, there were 2 clonal patterns with 6 subclonal types. Pattern I was multicentric occurrence (MO type) in 14 pairs (23.3%) and pattern II was intrahepatic metastasis (IM type) in 46 pairs (76.7%). The clinicopathologic features, including recurrence time, tumor size, vascular invasion, histological grading, and associated chronic liver diseases in patients with the MO type of RHCC were significantly different from those with the IM type of RHCC (p < 0.05 to 0.001). Compared with patients in the IM group, patients in the MO group had significantly better overall survival (130.8 ± 8.5 months vs 80.8 ± 8.5 months; p < 0.05) and recurrence-free survival (33.8 ± 4.5 months vs 14.2 ± 2.5 months; p < 0.001).

CONCLUSIONS

The MO-type RHCC was closely associated with better postoperative outcomes when compared with the IM-type RHCC. Generally, we recommend liver re-resection for MO-type RHCC, and interventional therapy for IM-type RHCC. Microdissection-based microsatellite loss of heterozygosity protocol has advantages in assessing the clonal origin, modes of personalized treatment, and clinical outcomes of RHCC.

CD34 expression in noncancerous liver tissue predicts multicentric recurrence of hepatocellular carcinoma

BACKGROUND

Metachronous multicentric recurrence of hepatocellular carcinoma (HCC) is a common cause of morbidity and mortality following curative surgical resection. Clinical and laboratory predictors of these processes can markedly aid in managing these patients. Capillarization of hepatic sinusoids is also a well-known phenomenon in many liver diseases, especially in neoplastic liver diseases. Here, we investigated the clinical features, fibrosis scores and distribution of CD34 in noncancerous hepatic tissues of postresection patients with and without multicentric recurrence.

METHODS

Eighteen patients with multicentric recurrence of HCC diagnosed by histological examination of repeated hepatectomy specimens and 72 HCC patients with more than 5-year disease-free survival postresection participated in the study. We compared the clinicopathological features of these two groups. We examined noncancerous hepatic tissues for iron deposition by Prussian blue staining and computed the CD34-labeling index (LI) through immunohistochemistry using anti-CD34 antibody.

RESULTS

CD34-LI was significantly higher in the multicentric recurrence group (p < 0.001) and staging scores of fibrosis were also significantly higher in the recurrence group (p = 0.035). A high histological activity grade (p = 0.057) and a high alanine aminotransferase level (p = 0.060) were also associated with recurrence. There were no significant differences between the two groups in age, sex, hepatitis B virus surface antigen and anti-hepatitis C virus antibody levels, or grade of iron deposition. On multivariate analysis, high CD34-LI was the only independent risk factor (p = 0.001) for metachronous multicentric recurrence.

CONCLUSION

CD34 expression in the capillaries and sinusoids of noncancerous hepatic tissue is a risk factor for multicentric recurrence of HCC. Histologic assessment of hepatic tissue with CD34 immunohistochemistry might be useful for the prognostic evaluation of HCC patients after surgery.

18F-FDG PET or PET/CT for detecting extrahepatic metastases or recurrent hepatocellular carcinoma: a systematic review and meta-analysis

AIM

Positron emission tomography (PET) using F18-flurodeoxy-glucose (FDG) has been widely used for reflecting cellular metabolism. However, the feasibility of FDG PET in the diagnosis of hepatocellular carcinoma (HCC) is limited. The aim of the study was to assess the ability of FDG PET (PET/CT) in the detection of extrahepatic metastases or recurrent HCC.

MATERIALS AND METHODS

We conducted MEDLINE, EMBASE and COCHRANE searches (last update, April 2011). Eight eligible articles were identified evaluating F18-FDG PET (PET/CT) in extrahepatic metastases or recurrent HCC. Two authors independently evaluated the methodological quality of each study. We estimated pooled sensitivities, specificities, summary receiver-operating-characteristic (SROC) curves, and summary likelihood ratios.

RESULTS

Eight eligible studies were enrolled in this study. The pooled estimates of sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of FDG PET (PET/CT) in the detection of metastatic HCC were 76.6%, 98.0%, 14.68, and 0.28, respectively. The pooled estimates of sensitivity, specificity, LR+ and LR- of FDG PET (PET/CT) in the detection of recurrent HCC were 81.7%, 88.9%, 4.72, and 0.19, respectively.

CONCLUSION

Based on the results of this systematic review, F-18 FDG PET (PET/CT) was useful in ruling in extrahepatic metastases of HCC and valuable for ruling out the recurrent HCC.

Repeat treatment for recurrent hepatocellular carcinoma: is it validated?

PURPOSE

Hepatocellular carcinoma (HCC) usually recurs repeatedly and locoregional treatment is attempted unless liver function has deteriorated. This study was aimed to evaluate the effect of repeated treatment on patient prognosis.

METHODS

The HCC recurrence pattern and types of treatment for recurrence after hepatic resection were reviewed in 134 patients. The effects of repeated treatment on prognosis were evaluated. Univariate and multivariate analyses were performed to determine the prognostic predictors after initial recurrence.

RESULTS

Median number of treatments after recurrence was 3 (range, 0-12). Transarterial chemoembolization was the most common treatment. The number of treatments, but not the type of treatment, was associated with the prognosis. Multivariate analysis showed that a >20% indocyanine green retention rate at 15 min (hazard ratio [HR] = 2.65; 95% confidential interval [CI], 1.53-5.62), size of primary tumor >5 cm (HR = 1.81; 95% CI, 1.05-3.08), recurrence-free interval <1 year (HR = 2.17; 95% CI, 1.28-3.81), size of recurrent tumor >3 cm (HR = 2.61; 95% CI, 1.03-5.77-0.95), and extrahepatic recurrence (HR = 6.35; 95% CI, 3.49-11.39) were independent predictors of poor survival.

CONCLUSION

The prognosis after recurrence is poor in cases with large tumors or poor liver function. Repeated locoregional treatment contributes to prolong patient prognosis, especially in cases with a small tumor size, long recurrence-free interval, and no extrahepatic metastases.

Clinical features and risk factors of extrahepatic seeding after percutaneous radiofrequency ablation for hepatocellular carcinoma

AIM

  To clarify the clinical features of and risk factors for extrahepatic seeding, a major complication following radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).

METHODS

  Our prospective database of 351 nodules in 257 patients with HCC who had undergone RFA between April 2001 and April 2008 was reviewed. The following variables were assessed to identify the risk factors for extrahepatic seeding: age, sex, viral markers, Child-Pugh class, tumor size, number of tumors, RFA indication (tumor size ≤3 cm, number of tumors ≤3), tumor biopsy prior to RFA, degree of histological differentiation, tumor markers, tumor location, number of sessions, and combined transcatheter arterial chemoembolization.

RESULTS

  The median follow-up period was 36.5 months, during which the rate of seeding after was 5.1% and the 5-year cumulative seeding rate was 8.4%. The survival rate after neoplastic seeding was 21% at 5 years. Univariate analysis of the risk factors for neoplastic seeding showed significant differences in tumor size, RFA indication, subcapsular lesion, number of sessions, tumor biopsy prior to RFA, and des-gamma-carboxy prothrombin value. However, multivariate analysis showed that the only independent risk factor was RFA indication.

CONCLUSIONS

  The prognosis of patients with neoplastic seeding was poor. In particular, RFA performed for HCC not satisfying the RFA indication showed a high risk of seeding, and careful consideration should be given to the optimal treatment method and avoiding direct puncture of subcapsular tumors.

Hepatocellular carcinoma: current management and future development-improved outcomes with surgical resection

Currently, surgical resection is the treatment strategy offering the best long-term outcomes in patients with hepatocellular carcinoma (HCC). Especially for advanced HCC, surgical resection is the only strategy that is potentially curative, and the indications for surgical resection have expanded concomitantly with the technical advances in hepatectomy. A major problem is the high recurrence rate even after curative resection, especially in the remnant liver. Although repeat hepatectomy may prolong survival, the suitability may be limited due to multiple tumor recurrence or background liver cirrhosis. Multimodality approaches combining other local ablation or systemic therapy may help improve the prognosis. On the other hand, minimally invasive, or laparoscopic, hepatectomy has become popular over the last decade. Although the short-term safety and feasibility has been established, the long-term outcomes have not yet been adequately evaluated. Liver transplantation for HCC is also a possible option. Given the current situation of donor shortage, however, other local treatments should be considered as the first choice as long as liver function is maintained. Non-transplant treatment as a bridge to transplantation also helps in decreasing the risk of tumor progression or death during the waiting period. The optimal timing for transplantation after HCC recurrence remains to be investigated.

Percutaneous ablation of hepatocellular carcinoma: current status

Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.

Concurrent and subsequent radiofrequency ablation combined with hepatectomy for hepatocellular carcinomas

Partial hepatectomy has long been the standard treatment modality for patients with hepatocellular carcinoma (HCC), although the majority of patients with HCCs are not candidates for curative resection. Radiofrequency ablation (RFA) has been widely used as the preferred locoregional therapy. RFA and hepatectomy can be complementary to each other for the treatment of multifocal HCCs. Combining hepatectomy with RFA permits the removal of larger tumors while simultaneously ablating any smaller residual tumors. By using this combination treatment, more patients might become candidates for curative resection. For treating recurrent tumors involving the liver after hepatectomy, RFA has been performed recently instead of transcatheter arterial chemoembolization or ethanol ablation. Many retrospective studies on the combination of RFA and hepatectomy demonstrate favorable results of effectiveness and safety. However, further investigation of prospective design will be needed to confirm these encouraging results.

Metastasis of hepatocellular carcinoma to spleen and small intestine

Metastasis of cancer to the spleen or small intestine is rare. We encountered a case of hepatocellular carcinoma (HCC) with splenic and jejunal metastases. A 60-year-old man was referred to us in February 2005 with a diagnosis of splenic tumor. Since 2001, he had been treated repeatedly for HCC with liver cirrhosis due to hepatitis C virus infection; partial liver resection, transcatheter arterial chemo-embolization, and radiofrequency ablation therapy had been performed. In October 2004, he had undergone partial pulmonary resection due to metastasis of HCC to the lung. The splenic tumor, which was detected by computed tomography, seemed to be a metastasis of HCC. Splenectomy was performed for the splenic tumor, and a jejunal tumor was discovered and also resected. Both the splenic and jejunal tumors were diagnosed pathologically as metastases from the HCC. After repeated treatment for HCC, metastases can appear in various organs; thus, careful observation is necessary during follow-up.

Radiofrequency ablation of recurrent hepatocellular carcinoma after hepatectomy: therapeutic efficacy on early- and late-phase recurrence

OBJECTIVE

Our objective was to assess the efficacy and safety of radiofrequency ablation of recurrent hepatocellular carcinoma (HCC) after hepatectomy and to compare the effects on early- and late-phase recurrence.

SUBJECTS AND METHODS

We studied 41 patients with 76 recurrent HCC tumors (diameter range, 2.0-6.6 cm; mean, 3.8 +/- 1.3 [SD] cm) after hepatectomy who underwent sonography-guided percutaneous radiofrequency ablation in our hospital (recurrent-HCC group). The interval between surgery and recurrence ranged from 1 to 96 months (mean, 24.5 months). These patients were divided into an early-recurrence group (20 patients with 41 recurrent HCC tumors) and a late-recurrence group (21 patients with 35 recurrent HCC tumors). Early recurrence was defined as that occurring within 1 year after surgery, and late recurrence was defined as that occurring after 1 year. Another 116 patients with 172 primary HCC tumors (diameter range, 1.2-7.0 cm; mean, 3.9 +/- 1.1 cm) treated by radiofrequency ablation were regarded as a control group. No other therapies were given before radiofrequency ablation in any group. Regular follow-up with enhanced CT was performed to evaluate the treatment results. Ablation was considered successful if no contrast enhancement was detected in the treated area on 1-month CT scans. Indexes including ablation success rate, local recurrence rate, distant recurrence rate, and survival were obtained for analysis and comparison.

RESULTS

The ablation success rate, local recurrence rate, distant recurrence rate, and mean overall survival time of the recurrent-HCC group were 93.4% (71/76 tumors), 9.2% (7/76 tumors), 36.6% (15/41 patients), and 30.9 +/- 3.7 months, respectively. The incidence of distant recurrence in the early-recurrence group was significantly higher than that in the late-recurrence group (55.0% vs 19.0%, p = 0.017). The early-recurrence group had a shorter overall survival than did the late-recurrence group (mean overall survival, 16.4 +/- 2.4 vs 42.9 +/- 4.4 months, p < 0.001) or the control group (16.4 +/- 2.4 vs 45.9 +/- 2.5 months, p < 0.001). The survival time of the late-recurrence group was similar to that of the control group (42.9 +/- 4.4 vs 45.9 +/- 2.5 months, p > 0.05). Serious hemorrhage after radiofrequency ablation occurred in one patient in the late-recurrence group and was controlled with conservative treatment.

CONCLUSION

Radiofrequency ablation is generally effective and safe in treating recurrent HCC after hepatectomy and is more effective in late recurrence than in early recurrence.

Percutaneous Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma After Hepatectomy: Long-term Results and Prognostic Factors

BACKGROUND

We evaluated the long-term survival results and safety of percutaneous radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) after hepatectomy, and assessed the prognostic factors that can influence its long-term therapeutic results.

METHODS

One hundred and two patients, who had 119 recurrent HCC in their livers, underwent ultrasound-guided percutaneous RFA. All the patients had a history of hepatic resection as a first-line treatment modality for HCC. The mean diameter of the recurrent tumors was 2.0 cm (range, 0.8-5.0 cm). We evaluated the effectiveness rates, local tumor progression rates, survival rates, and complications. We also assessed the prognostic factors of the survival rates by using Cox proportional hazard models.

RESULTS

The primary effectiveness rate was 93.3% (111 of 119). The cumulative rates of local tumor progression at 1, 3, and 5 years were 6.0, 8.6, and 11.9%, respectively. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 93.9, 83.7, 65.7, 56.6, and 51.6%, respectively. Patients with a lower serum alpha-fetoprotein (AFP) level (<or=100 microg/L) before RFA or with small resected tumors (<or=5 cm) demonstrated better survival results (P < .05). There was only one major complication (liver abscess, 1.0% per treatment) during the follow-up period. There were no procedure-related deaths.

CONCLUSIONS

Percutaneous RFA is an effective and safe treatment modality for intrahepatic recurrent HCC after hepatectomy. Serum AFP level before RFA and resected tumor size were significant prognostic predictors of long-term survival.

Intrahepatic tumor recurrence after partial hepatectomy: value of percutaneous radiofrequency ablation

PURPOSE

To determine the risks and benefits of percutaneous radiofrequency (RF) ablation of recurrent hepatic tumors in patients who have undergone hepatic resection.

MATERIALS AND METHODS

Retrospective review of the institutional RF ablation database yielded 35 patients with recurrent hepatic tumor after hepatectomy. Sixty-one recurrent hepatic tumors (mean diameter +/- SD, 1.7 +/- 1.1 cm; range, 0.5-5.3 cm) were ablated percutaneously under sonographic guidance or combined guidance with sonographic and fluoroscopic computed tomography (CT). Follow-up CT, magnetic resonance imaging, or both were used for assessment of the primary and secondary therapeutic effectiveness rate and failure of RF ablation. Patients' survival status was determined by contacting the primary care physician or searching the Social Security Death Index.

RESULTS

Complete ablation was accomplished in 54 of 61 hepatic tumors (primary therapeutic effectiveness rate, 88.5%). During a mean follow-up time of 18 months (range, 1-65 months), 14.8% of the tumors (n = 9) were incompletely ablated. Three of the nine incompletely ablated tumors were treated with a second RF ablation, all three of which failed (secondary therapeutic effectiveness rate, 0%). Distant intrahepatic tumor progression appeared in 23 of 35 patients (65.7%). One major complication (2.1%, one of 48 sessions) and eight minor complications (16.7%, eight of 48 sessions) were reported. The major complication was hepatic abscess formation. The overall survival rates for all patients at 1, 2, and 3 years were 76%, 68%, and 45%, respectively. For patients with metastases from colorectal cancer (n = 14), the overall survival rates were 72%, 60%, and 60% at 1, 2, and 3 years, respectively; and for patients with hepatocellular carcinoma (n = 8), the overall survival rates were 72%, 58%, and 44% at 1, 2, and 3 years, respectively.

CONCLUSION

Percutaneous RF ablation offers a safe and effective treatment option for recurrent hepatic tumors after previous partial hepatectomy.

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.

A critical evaluation of hepatic resection in cirrhosis: optimizing patient selection and outcomes

Hepatic resection has long been the mainstay of treatment of primary liver cancers, particularly hepatocellular carcinoma (HCC). Because of the high incidence of cirrhosis in patients with HCC, the use of resection was initially limited by the ability of the cirrhotic liver to sustain the surgical insult and the mass reduction. Today, hepatectomy in cirrhosis is undergoing a remarkable evolution. Although surgical and anesthetic improvements have increased the safety of this option, the rapid development of alternative therapies has decreased the need for it. Local excision for small HCC is likely to be replaced by image-guided, percutaneous ablative techniques. Furthermore, total replacement of a cirrhotic liver may be a more effective long-term cure than resection. Unquestionably, resection remains the optimal approach for patients with large tumors and healthy underlying liver function. The role of rapidly evolving new approaches will remain the subject of intensive inquiry in the years to come. In this report, we have attempted to clarify current practice with respect to the evaluation, selection, and technique of resection in cirrhosis, and identify areas of active inquiry.

Detecting Postsurgical Recurrent Hepatocellular Carcinoma With Multiphasic Helical Computed Tomography

OBJECTIVE

The aim of this study was to assess the computed tomography (CT) patterns of postoperative recurrent hepatocellular carcinoma (HCC).

METHODS

Of 84 patients with histologically proven HCC by hepatectomies, multiphasic helical CT demonstrated 54 HCC lesions of intrahepatic recurrence in 31 (37%) patients. The initial and final appearances of HCC on hepatic arterial phase images were retrospectively determined by the serial CT scans, which were compared with appearances of primary HCC.

RESULTS

The initial appearances of 54 recurrent HCCs were identical to the appearances of primary HCC in 41 (76%) lesions. Serial changes from the initial appearance to the final appearance of recurrent HCC were observed in 10 (42%) of 24 lesions. The 13 discordant lesions and the 10 lesions with altered lesion vascularity in our series implied that at least 43% were of multicentric occurrence.

CONCLUSION

More than 40% of postoperative recurrent HCCs show intranodular hemodynamic changes. The incompatibility between CT findings of primary and recurrent HCCs implies that these tumors contain nodules of multicentric occurrence.

Decreased expression of CD28 coincides with the down-modulation of CD3zeta and augmentation of caspase-3 activity in T cells from hepatocellular carcinoma-bearing patients and hepatitis C virus-infected patients

BACKGROUND AND AIM

Hepatitis C virus (HCV) infection causes chronic inflammation and increases the risk of hepatocellular carcinoma (HCC). This immunosuppressive state may be one reason why HCV-infected patients often have multicentric cancers. Therefore, the purpose of the present study was to assess the cellular immune function in HCC-bearing and HCV-infected patients.

METHODS

The expression of cluster of differentiation (CD)3zeta, CD28 and caspase-3 activity of peripheral blood T lymphocytes (PBL) from HCC-bearing patients, HCV-infected patients and normal subjects was measured by flow cytometric methods. Furthermore, intrahepatic T lymphocytes (IHL) and tumor-infiltrating T lymphocytes (TIL) from HCC patients were used.

RESULTS

Decreased expressions of CD3zeta, CD28 and the augmentation of caspase-3 activity were recognized in PBL from HCC and HCV patients. These phenomena were more dominant in TIL and IHL than in PBL in HCC patients. Furthermore, the down-modulation of CD3zeta and increased caspase-3 activity occurred in CD28 down-modulated T cells.

CONCLUSION

These results demonstrate impairment of the cellular immune system in HCC and HCV patients from the viewpoints of the down-modulation of CD3zeta and CD28 on T cells and T-cell apoptosis. In addition, the results imply that the down-modulation of CD3zeta and T-cell apoptosis take place in activated T cells.

High pathological risk of recurrence after surgical resection for hepatocellular carcinoma: an indication for salvage liver transplantation

Surgical resection and liver transplantation offer a 5-year survival greater than 70% in patients with hepatocellular carcinoma, but the high recurrence rate impairs long-term outcome after resection. Pathological data such as vascular invasion and detection of additional nodules predict recurrence and divide patients into high and low risk profile. Based on this, we proposed salvage liver transplant to resected patients in whom pathology evidenced high recurrence risk even in the absence of proven residual disease. From January 1995 to August 2003 we have evaluated 1,638 patients. Resection was indicated in 77 patients, but only 17 (22%) (all cirrhotics, 14 hepatitis C virus+) were optimal candidates for both resection and transplantation. Of them, 8 exhibited a high risk profile at pathology and were offered transplantation. Among the 8 high risk patients, 7 presented recurrence, compared with only 2 of the 9 at low risk (P = .012). Two of the high risk patients refused transplant and developed multifocal disease during follow-up. The other 6 were enlisted and all but 1 had tumor foci in the explant. Only 1 presented extrahepatic dissemination early after transplant and died 4 months later. The others are free of disease after a median follow-up of 45 months. Two recurrences were detected in low risk patients, 1 of them being transplanted 18 months after surgery. These data in a small series of patients confirm that pathological parameters identify patients at higher risk of recurrence, which allow them to be listed for liver transplantation without proven malignant disease. In conclusion, this policy is clinically effective and could further improve the outcome of resected patients.

Multimodal image-guided tailored therapy of early and intermediate hepatocellular carcinoma: long-term survival in the experience of a single radiologic referral center

The best treatment policy for some patients with hepatocellular carcinoma (HCC) and compensated cirrhosis is still controversial. The aim of this study was to evaluate the long-term survival and related prognostic factors of patients with early and intermediate HCC (Liver Unit of Barcelona classification) treated in a radiologic referral center by a multimodal image-guided tailored therapy (MIGTT), applied over time, choosing the procedure patient by patient according to the presentation of the disease. Between May 1996 and May 2003, 374 patients (210 with early and 164 with intermediate HCC) were treated with MIGTT. Radiofrequency ablation was considered the first choice; ethanol injection was preferred for nodules at risk for radiofrequency; and selective chemoembolization was preferred for nodules not recognizable at ultrasound examination, those not retreatable after an unsuccessful ablation technique, or for satellites. The rate of perioperative mortality and major complications was 0.2% and 4.5%, respectively. The 1-, 3-, and 5-year survival rates were 90%, 69%, and 49% and 83%, 43%, and 28% for patients with early and intermediate HCC, respectively. At the univariate analysis, the indicators of a poor prognosis were Child's class B, portal hypertension, abnormal bilirubin, infiltrating tumor, and abnormal serum alpha-fetoprotein (AFP) level. In conclusion, within the limits of historical comparisons, in early HCC, MIGTT should be considered an appropriate option for unresectable patients or for resectable patients presenting with adverse prognostic factors. In intermediate HCC, the 3-year survival rate obtained with MIGTT was better than the best survival rate reported with conventional chemoembolization; however, the benefit for patients presenting with poor prognostic factors remains unclear.

Recurrent hepatocellular carcinoma: percutaneous radiofrequency ablation after hepatectomy

PURPOSE

To evaluate the therapeutic efficacy and safety of percutaneous radiofrequency (RF) ablation for recurrent hepatocellular carcinoma (HCC) in the liver after hepatectomy.

MATERIALS AND METHODS

Forty-five patients with 53 recurrent HCC tumors in the liver underwent percutaneous RF ablation with ultrasonographic guidance. All patients had a history of hepatic resection for HCC. The mean diameter of recurrent tumors was 2.1 cm (range, 0.8-4.0 cm). All patients were followed up for at least 10 months after ablation (range, 10-40 months; mean, 23 months). Therapeutic efficacy and complications were evaluated with multiphase helical computed tomography (CT) at regular follow-up visits. Overall and disease-free survival rates were calculated.

RESULTS

At follow-up CT after initial RF ablation, 11 (21%) of 53 ablated HCC tumor sites showed residual tumor or local tumor progression. After additional RF ablation, complete ablation of 46 (87%) of 53 tumors was attained. Also at initial follow-up CT, before either additional RF ablation or other treatment was performed, 21 (47%) of 45 patients were found to have 41 new HCC tumors at other liver sites. Of these, nine tumors in eight patients were treatable with a second application of RF ablation. Overall survival rates at 1, 2, and 3 years were 82%, 72%, and 54%, respectively. No deaths or complications requiring further treatment occurred as a result of RF ablation.

CONCLUSION

Percutaneous RF ablation is an effective and safe method for treating recurrent HCC in the liver after hepatectomy, with a good overall patient survival rate.

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