Ultrasound surveillance for early detection of hepatocellular carcinoma among patients with chronic hepatitis C

Gold nanoparticles decorated on MOF derived Cu5Zn8 hollow porous carbon nanocubes for magnetic resonance imaging guided tumor microenvironment-mediated synergistic chemodynamic and photothermal therapy

Combining chemodynamic therapy (CDT) with photothermal therapy (PTT) has developed as a promising approach for cancer treatment, as it enhances therapeutic efficiency through redox reactions and external laser induction. In this study, we designed metal organic framework (MOF) -derived Cu5Zn8/HPCNC through a carbonization process and decorated them with gold nanoparticles (Au@Cu5Zn8/HPCNC). The resulting nanoparticles were employed as a photothermal agent and Fenton catalyst. The Fenton reaction facilitated the conversation of Cu2+ to Cu+ through reaction with local H2O2, generating reactive hydroxyl radicals (·OH) with potent cytotoxic effects. To enhance the Fenton-like reaction and achieve combined therapy, laser irradiation of the Au@Cu5Zn8/HPCNC induced efficient photothermal therapy by generating localized heat. With a significantly increased absorption of Au@Cu5Zn8/HPCNC at 808 nm, the photothermal efficiency was determined to be 57.45 %. Additionally, Au@Cu5Zn8/HPCNC demonstrated potential as a contrast agent for magnetic resonance imaging (MRI) of cancers. Furthermore, the synergistic combination of PTT and CDT significantly inhibited tumor growth. This integrated approach of PTT and CDT holds great promise for cancer therapy, offering enhanced CDT and modulation of the tumor microenvironment (TME), and opening new avenues in the fight against cancer.

Combined Ultrasound and Computed Tomography Guidance in Radiofrequency Ablation for Hepatocellular Carcinoma Reduces Local Recurrence Rate

Background/Aim

In radiofrequency ablation (RFA) treatment of hepatocellular carcinoma (HCC), the therapeutic effect depends on the appropriate position of the electrode. To improve the accuracy of the electrode needle position, we currently perform RFA with combined ultrasound sonography (US) and computed tomography (CT) guidance. The purpose of this study was to evaluate the effectiveness of this US/CT-guided RFA method.

Patients and Methods

This retrospective study recruited 97 patients with single tumors treated with transcatheter arterial chemoembolization and monopolar RFA between January 2013 and December 2017. Among these, 50 patients were treated with RFA under US/CT guidance (US/CT-guided group) and 47 were treated with RFA under US guidance alone (US-guided group). We analyzed the efficacy of US/CT guidance compared with US guidance alone.

Results

The 1-, 2-, and 3-year local recurrence rates for the US/CT-guided and US-guided groups were 4.1%, 6.3%, and 8.6%, and 19.6%, 31.6%, and 41.9%, respectively. The local recurrence rate was lower in the US/CT-guided group (p=0.0030). Cox proportional hazards model for multivariate analysis demonstrated that the independent risk factors associated with local recurrence were tumor size (p=0.0028) and US/CT guidance (p=0.0037).

Conclusion

US/CT-guided RFA for HCC reduced the local recurrence rate compared with US-guided RFA alone.

Screening of liver cancer with abbreviated MRI

Current recommendations for the surveillance of HCC are based on the semiannual liver ultrasound (with or without serum alpha-fetoprotein) in patients with cirrhosis and in subgroups with chronic hepatitis B infection. However, the sensitivity of this strategy is suboptimal for the detection of early-stage tumors, especially in obese patients, due to interoperator variability and poor adherence. The detection rate of focal liver lesions is excellent with MRI, making it the best alternative candidate for surveillance. However, performing a full contrast-enhanced MRI is unrealistic because of limited availability and health economics. Abbreviated MRI (AMRI) corresponds to the acquisition of a limited number of sequences with a high detection rate. The theoretical benefits of AMRI are a reduced acquisition time (≤10 min) with improved time-effectiveness and cost-effectiveness compared with conventional MRI, and greater accuracy than ultrasound. Numerous protocols may be performed, including T1-weighted, T2-weighted, and DWI sequences, with or without contrast administration. Although published studies report promising per-patient results, they should be interpreted with caution. Indeed, most studies were simulated, retrospectively reviewing a subset of sequences in relatively small populations who underwent a full MRI. They also included groups that were not representative of screening populations. In addition, most were published by Asian groups, with at-risk populations that were different from Western populations. There are no existing longitudinal studies that directly compare the different AMRI approaches or AMRI to ultrasound. Finally, it is possible that 1 approach will not fit all patients and that strategies should be tailored to the risk of HCC, in particular in relation to the cost and availability of AMRI. Several trials are ongoing to evaluate these questions.

Comparison of a multitarget blood test to ultrasound and alpha-fetoprotein for hepatocellular carcinoma surveillance: Results of a network meta-analysis

Ultrasound-based surveillance has suboptimal sensitivity for early detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. There are several emerging alternatives, including a novel multitarget HCC blood test (Mt-HBT). We compared performance of mt-HBT against ultrasound with or without alpha-fetoprotein (AFP) for early HCC detection in patients with cirrhosis. Per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, two reviewers searched PubMed, Cochrane, Embase, and clinicaltrials.gov databases from January 1990 through December 2020 to identify studies reporting sensitivity and/or specificity of ultrasound and AFP for overall and early stage HCC detection in patients with cirrhosis. Mt-HBT diagnostic performance was derived from a clinical validation study. A network meta-analysis model was built for comparative assessment, and pooled estimates of sensitivity at a fixed specificity were estimated based on Bayesian binormal receiver operating characteristic models for each modality. Forty-one studies (comprising 62,517 patients with cirrhosis) met inclusion criteria. Ultrasound-alone sensitivity was 51.6% (95% credible interval [CrI], 43.3%-60.5%) for early stage HCC detection, which increased with the addition of AFP to 74.1% (95% CrI, 62.6%-82.4%); however, this was offset by decreased specificity (87.9% vs. 83.9%, respectively). With specificity fixed at 90%, mt-HBT sensitivity for early stage HCC detection was higher than ultrasound alone (18.2%; 95% CrI, 0.2%-37.7%) and similar to ultrasound with AFP (-3.3%; 95% CrI, -22.3%-17.4%). Pairwise posterior probabilities suggested a preference for mt-HBT over ultrasound alone in 97.4% of cases but only 36.3% of cases versus ultrasound with AFP. Conclusion: A blood-based mt-HBT has higher sensitivity than ultrasound alone for early stage HCC detection but similar sensitivity compared to ultrasound and AFP. Mt-HBT could be a comparable alternative to existing methods for HCC surveillance in patients who are at risk.

Abdominal ultrasound and alpha-foetoprotein for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma (HCC) occurs mostly in people with chronic liver disease and ranks sixth in terms of global instances of cancer, and fourth in terms of cancer deaths for men. Despite that abdominal ultrasound (US) is used as an initial test to exclude the presence of focal liver lesions and serum alpha-foetoprotein (AFP) measurement may raise suspicion of HCC occurrence, further testing to confirm diagnosis as well as staging of HCC is required. Current guidelines recommend surveillance programme using US, with or without AFP, to detect HCC in high-risk populations despite the lack of clear benefits on overall survival. Assessing the diagnostic accuracy of US and AFP may clarify whether the absence of benefit in surveillance programmes could be related to under-diagnosis. Therefore, assessment of the accuracy of these two tests for diagnosing HCC in people with chronic liver disease, not included in surveillance programmes, is needed.

OBJECTIVES

Primary: the diagnostic accuracy of US and AFP, alone or in combination, for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of abdominal US and AFP, alone or in combination, for the diagnosis of resectable HCC; to compare the diagnostic accuracy of the individual tests versus the combination of both tests; to investigate sources of heterogeneity in the results.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic-Test-Accuracy Studies Register, Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, until 5 June 2020. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of US and AFP, independently or in combination, for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional and case-control designs, using one of the acceptable reference standards, such as pathology of the explanted liver, histology of resected or biopsied focal liver lesion, or typical characteristics on computed tomography, or magnetic resonance imaging, all with a six-months follow-up.

DATA COLLECTION AND ANALYSIS

We independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest-plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 373 studies. The index-test was AFP (326 studies, 144,570 participants); US (39 studies, 18,792 participants); and a combination of AFP and US (eight studies, 5454 participants). We judged at high-risk of bias all but one study. Most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Most studies with AFP had a case-control design. We also had major concerns for the applicability due to the characteristics of the participants. As the primary studies with AFP used different cut-offs, we performed a meta-analysis using the hierarchical-summary-receiver-operating-characteristic model, then we carried out two meta-analyses including only studies reporting the most used cut-offs: around 20 ng/mL or 200 ng/mL. AFP cut-off 20 ng/mL: for HCC (147 studies) sensitivity 60% (95% CI 58% to 62%), specificity 84% (95% CI 82% to 86%); for resectable HCC (six studies) sensitivity 65% (95% CI 62% to 68%), specificity 80% (95% CI 59% to 91%). AFP cut-off 200 ng/mL: for HCC (56 studies) sensitivity 36% (95% CI 31% to 41%), specificity 99% (95% CI 98% to 99%); for resectable HCC (two studies) one with sensitivity 4% (95% CI 0% to 19%), specificity 100% (95% CI 96% to 100%), and one with sensitivity 8% (95% CI 3% to 18%), specificity 100% (95% CI 97% to 100%). US: for HCC (39 studies) sensitivity 72% (95% CI 63% to 79%), specificity 94% (95% CI 91% to 96%); for resectable HCC (seven studies) sensitivity 53% (95% CI 38% to 67%), specificity 96% (95% CI 94% to 97%). Combination of AFP (cut-off of 20 ng/mL) and US: for HCC (six studies) sensitivity 96% (95% CI 88% to 98%), specificity 85% (95% CI 73% to 93%); for resectable HCC (two studies) one with sensitivity 89% (95% CI 73% to 97%), specificity of 83% (95% CI 76% to 88%), and one with sensitivity 79% (95% CI 54% to 94%), specificity 87% (95% CI 79% to 94%). The observed heterogeneity in the results remains mostly unexplained, and only in part referable to different cut-offs or settings (surveillance programme compared to clinical series). The sensitivity analyses, excluding studies published as abstracts, or with case-control design, showed no variation in the results. We compared the accuracy obtained from studies with AFP (cut-off around 20 ng/mL) and US: a direct comparison in 11 studies (6674 participants) showed a higher sensitivity of US (81%, 95% CI 66% to 90%) versus AFP (64%, 95% CI 56% to 71%) with similar specificity: US 92% (95% CI 83% to 97%) versus AFP 89% (95% CI 79% to 94%). A direct comparison of six studies (5044 participants) showed a higher sensitivity (96%, 95% CI 88% to 98%) of the combination of AFP and US versus US (76%, 95% CI 56% to 89%) with similar specificity: AFP and US 85% (95% CI 73% to 92%) versus US 93% (95% CI 80% to 98%).

AUTHORS' CONCLUSIONS

In the clinical pathway for the diagnosis of HCC in adults, AFP and US, singularly or in combination, have the role of triage-tests. We found that using AFP, with 20 ng/mL as a cut-off, about 40% of HCC occurrences would be missed, and with US alone, more than a quarter. The combination of the two tests showed the highest sensitivity and less than 5% of HCC occurrences would be missed with about 15% of false-positive results. The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

Ultrasound or Sectional Imaging Techniques as Screening Tools for Hepatocellular Carcinoma: Fall Forward or Move Forward?

Hepatocellular carcinoma (HCC) is probably the epitome of a screening target, with a well-defined high-risk population, accessible screening methods, and multiple curative-intent treatments available for early disease. Per major societies guideline consensus, biannual ultrasound (US) surveillance of the at-risk patients is the current standard of care worldwide. Yet, despite its documented success in the past decades, this standard is far from perfect. While the whole community is working to further tighten the knots, a worrying number of cases still slip through this safety net. Consequently, these patients lose their chance to a curative solution which leads to a high disease burden with disproportionate mortality. While US will probably remain the fundamental staple in the screening strategy, key questions are seeking better answers. How can its caveats be addressed, and the technique be improved? When are further steps needed? How to increase accuracy without giving up on accessibility? This narrative review discusses the place of US surveillance in the bigger HCC picture, trying to navigate through its strengths and limits based on the most recent available evidence.

Enhancement patterns of small hepatocellular carcinoma (≤ 30 mm) on contrast-enhanced ultrasound: Correlation with clinicopathologic characteristics

PURPOSE

To analyze the correlation between enhancement patterns of small hepatic carcinomas (HCCs; ≤ 30 mm) on contrast-enhanced ultrasound (CEUS) and the clinicopathologic characteristics.

METHODS

The retrospective study included 346 inpatients (288 males and 58 females) with 372 pathologically confirmed small HCCs between January 2017 and December 2018. All patients underwent CEUS examination before pathological examination. Statistical analysis was used to determine the correlation between enhancement patterns of small HCCs on CEUS and clinicopathologic characteristics including serum alpha-feto-protein level, protein induced by vitamin K absence or antagonist-II (PIVKA-II) level, primary or recurrent HCC condition, tumor number, tumor differentiation, tumor size, liver background and microvascular invasion (MVI).

RESULTS

Three hundred forty-seven out of 372 (93.3 %) HCCs manifested arterial phase hyper-enhancement (APHE). The arterial enhancement patterns were correlated with the tumor differentiation (odds ratio = 10.336, P = 0.000). Moderately- or poorly-differentiated HCCs were more likely to display APHE than well-differentiated HCCs (96.2 % vs 58.6 %, P < 0.001). Two hundred ninety-five of 372 (79.3 %) HCCs showed washout in the portal venous/late phase. Washout was correlated with serum PIVKA-II level, tumor size, tumor differentiation, and MVI on univariate analysis (P < 0.05). Logistic regression analysis revealed that only tumor size was significantly associated with washout of small HCCs (odds ratio = 2.335, P = 0.006). Large HCCs (20-30 mm) displayed a higher proportion of washout compared with that of HCCs ≤ 20 mm.

CONCLUSIONS

Enhancement patterns of small HCCs on CEUS were significantly correlated with tumor size and tumor differentiation among all clinicopathologic characteristics.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Sensitivity of ultrasound in detecting hepatocellular carcinoma in obese patients compared to explant pathology as the gold standard

BACKGROUND/AIMS

The American Association for the Study of Liver Diseases recommends ultrasound (US) screening for hepatocellular carcinoma (HCC) among cirrhotic patients, regardless of body mass index (BMI), every 6 months. We examined US sensitivity for diagnosis of HCC in obese patients.

METHODS

Liver transplant patients data with HCC in explant was used (January 2012-December 2017). All patients underwent liver US within 3 months of diagnosis of HCC. Number/size of HCC lesions were extracted from radiologic and pathologic reports. Obesity was defined as BMI ≥30 kg/m2.

RESULTS

One hundred sixteen patients were included. 80% were male, with mean BMI of 31 kg/m2. The most common underlying liver disease was hepatitis C virus (62%). At the time of diagnosis, median number of HCC lesions was 2 (interquartile range [IQR], 1-3), and median size of the largest lesion was 2.5 cm (IQR, 1.75-3.9). Overall sensitivity of US study for detection of HCC was 33% (95% confidence interval [CI], 29-48%). Sensitivity was 77% (95% CI, 62-93%) in patients with BMI<30 and 21% (95% CI, 11-30%) in patients with BMI≥30 (P<0.001). Size of the largest HCC lesion (P=0.290) and number of lesions (P=0.505) were not different between groups. Computed tomography (CT) scan detected HCC in 98% of the obese patients with negative US.

CONCLUSION

Sensitivity of US for detection of HCC is significantly lower among obese patients compared to overweight and normal weight patients. These patients may benefit from alternating between US and a different imaging modality.

Diagnostic performance of a minimized protocol of non-contrast MRI for hepatocellular carcinoma surveillance

PURPOSE

To evaluate the per-patient diagnostic performance of a minimized non-contrast MRI protocol for hepatocellular carcinoma (HCC) surveillance in cirrhotic liver, as well as factors affecting diagnostic sensitivity.

METHODS

A total of 226 patients who underwent MRI for HCC surveillance over an 8 year period were included in this retrospective study. Set1 consisted of diffusion-weighted imaging and respiratory-triggered, fast-spin echo T2-weighted imaging with fat suppression. Set2 included T1-weighted in/opposed-phase images added to the images from Set1. Image sets were scored as positive or negative for HCC according to predetermined criteria by two readers independently. The diagnostic performance of the two sets in conjunction with α-fetoprotein (AFP) was assessed and compared using the McNemar test. Logistic regression was used to determine factors that affected sensitivity.

RESULTS

The sensitivity, specificity, and accuracy of Set1 of readers 1 and 2 were 84.4%/87.3%, 86.8%/86.8%, and 85.0%/87.2%, respectively; and those for Set2 were 87.3%/89.6%, 81.1%/79.2%, and 85.8/87.2%, respectively. The sensitivities of the sets were not significantly different (p = 0.063). Sensitivities of both sets in conjunction with AFP were higher than those of MRI alone without statistical significance (87.3%/89.6%, p = 0.063/> 0.99; 89.6%/89.6%, p = 0.125/> 0.99). In very early-stage HCC, the sensitivities of Sets1 and 2 were 73.1%/76.9% and 76.9%/82.7%, respectively. Perihepatic ascites and size less than 2 cm were associated with sensitivity (p < 0.05).

CONCLUSIONS

A minimized non-contrast MRI protocol consisting of Fat-sat T2WI and DWI is highly sensitive and may be a viable method for HCC surveillance of the cirrhotic liver. The inclusion of T1-weighted in/opposed-phase and AFP may increase this sensitivity.

Geographical Disparities of Outcomes of Hepatocellular Carcinoma in France: The Heavier Burden of Alcohol Compared to Hepatitis C

BACKGROUND

Data on alcohol-related HCC are limited.

AIMS

Our aim was to describe the incidence, management, and prognosis of alcohol compared to Hepatitis C (HCV)-related HCC at a national level.

METHODS

Incident cases of HCC were identified in French healthcare databases between 2009 and 2012 and analyzed retrospectively. Demographic data, type, location, and annual HCC-caseload of the hospitals where patients were first managed were retrieved. Survival of incident cases was computed from the time of diagnosis and adjusted for potential confounding variables.

RESULTS

The study population included 14,060 incident cases of alcohol and 2581 HCV-related HCC. Alcohol-related HCC was more frequent than HCV-related HCC (29.37 and 5.39/100,000 adults/year, respectively) with an heterogeneous distribution on the French territory. The optimal treatment was less frequently curative (20.5% vs 35.9%; p < 0.001), and survival was significantly shorter (9.5 [9.0-10.0] versus 16.8 [15.5-18.7] months p < 0.001) in alcohol compared to HCV-related HCC, with marked variations between regions for a given risk factor. In multivariable analysis in the whole study population, curative treatment was a strong predictor of survival (adjusted HR 0.28 [0.27-0.30] months p < 0.001). Being managed at least once in a teaching hospital during follow-up was independently associated with receiving a curative treatment and survival.

CONCLUSION

In France, incidence of alcohol-related HCC is high and prognosis is poor compared to HCV-related HCC, with marked variations between regions. These results should guide future health policy initiatives pertaining to HCC care. Importantly, increasing patient' referral in expert centers could increase chances to receive curative treatment and improve outcomes.

Expression of c-Met in Primary and Recurrent Hepatocellular Carcinoma

BACKGROUND

The clinical course of hepatocellular carcinoma (HCC) is complicated, because it often recurs and shows multiple lesions, some of which progress to a more malignant form, shortening the life of the patient. The hepatocyte growth factor receptor c-Met has been shown to play an important role in the pathogenesis of HCC, but the influence of c-Met expression on the clinical course of HCC remains to be fully elucidated.

METHODS

We randomly selected and included 600 tumor specimens obtained from the primary and recurrent lesions of 319 HCC cases between 1995 and 2007. The expression of c-Met was determined by immunohistochemistry using archived formalin-fixed paraffin-embedded samples. We analyzed the correlation between c-Met expression and clinical parameters, including survival. In addition, we examined c-Met expression in the malignant transition of HCC in all cases including recurrent lesions.

RESULTS

Survival analysis using the multivariate Cox proportional-regression model revealed that the prognosis was significantly better in the primary cases with high c-Met expression than in those with low c-Met expression (hazard ratio 0.159, 95% confidence interval 0.065-0.391; p < 0.001). During the course of recurrence, some cases with high c-Met expression returned to low c-Met expression. Among 40 cases with high c-Met expression, 29 survived more than 2 years after detecting the high c-Met expression.

CONCLUSION

High expression of c-Met may be a prognostic factor for a good, rather than a poor, HCC prognosis. The involvement of c-Met expression in the malignant transition of recurrent HCC is obscure.

Hepatocellular carcinoma surveillance: Eastern and Western perspectives

Eastern and Western guidelines for the management of hepatocellular carcinoma (HCC) are known to significantly differ on many points, because they reflect different diagnostic and therapeutic approaches to this cancer. Importantly, these guidelines are primarily consensus-driven when it comes to surveillance, both in term of the tests used and surveillance program design. The main difference between East and West lies in clinical practice, as several Eastern countries implement coordinated and systematic surveillance programs, while most Western countries rely on individual adherence to surveillance recommendations. This review article presents an overview of the evidence supporting surveillance programs for HCC, with a particular focus on the efficacy, cost-effectiveness, and consequences of this approach for patient survival. Western and Eastern guideline recommendations are discussed.

Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis

BACKGROUND & AIMS

Society guidelines differ in their recommendations for surveillance to detect early-stage hepatocellular carcinoma (HCC) in patients with cirrhosis. We compared the performance of surveillance imaging, with or without alpha fetoprotein (AFP), for early detection of HCC in patients with cirrhosis.

METHODS

Two reviewers searched MEDLINE and SCOPUS from January 1990 through August 2016 to identify published sensitivity and specificity of surveillance strategies for overall and early detection of HCC. Pooled estimates were calculated and compared using the DerSimonian and Laird method for a random effects model. The study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

RESULTS

Thirty-two studies (comprising 13,367 patients) characterized sensitivity of imaging with or without AFP measurement for detection of HCC in patients with cirrhosis. Ultrasound detected any stage HCC with 84% sensitivity (95% confidence interval [CI] 76%-92%), but early-stage HCC with only 47% sensitivity (95% CI 33%-61%). In studies comparing ultrasound with vs without AFP measurement, ultrasound detected any stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (relative risk [RR] 0.88; 95% CI 0.83-0.93) and early-stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (RR 0.81; 95% CI 0.71-0.93). However, ultrasound alone detected HCC with a higher level of specificity than ultrasound plus AFP measurement (RR 1.08; 95% CI 1.05-1.09). Ultrasound with vs without AFP detected early-stage HCC with 63% sensitivity (95% CI 48%-75%) and 45% sensitivity (95% CI 30%-62%), respectively (P = .002). Only 4 studies evaluated computed tomography or magnetic resonance image-based surveillance, which detected HCC with 84% sensitivity (95% CI 70%-92%).

CONCLUSIONS

We found ultrasound alone has a low sensitivity to detect early stage HCC in patients with cirrhosis. Addition of AFP to ultrasound significantly increases sensitivity of early HCC detection in clinical practice.

Hepatocellular carcinoma surveillance with ultrasound-cost-effectiveness, high-risk populations, uptake

Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer and the second cause of cancer-related deaths worldwide. In most cases, it is diagnosed in patients with identified risk factors, mainly cirrhosis from all causes. These patients are candidates for a surveillance program that, depending on guidelines, involves regular liver ultrasound alone or combined with serum markers. These programs have been shown to improve the oncological outcome by detecting earlier stage tumors and providing patients with potentially curative treatment and improved survival. Yet, the level of evidence supporting these guidelines remains limited. This review article presents an overview of the evidence supporting surveillance programs for hepatocellular carcinoma, in particular the efficacy, cost-effectiveness, and consequences of this approach for patient survival. Western and Eastern guideline recommendations are described and discussed.

Screening and Surveillance of Hepatocellular Carcinoma: An Introduction to Ultrasound Liver Imaging Reporting and Data System

Given the high prevalence, increasing incidence, and significant morbidity and mortality related to hepatocellular carcinoma (HCC), a robust and cost-effective screening and surveillance program is needed. Most societies recommend ultrasound for HCC screening, despite lack of standardization in imaging acquisition, reporting content and language, and follow-up recommendations. The American College of Radiology Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) fills this unmet need by providing standardization in the use of US in at-risk patients. It is anticipated that US LI-RADS will improve the performance of ultrasound for HCC screening and surveillance and unify management recommendations.

Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update

There is great geographical variation in the distribution of hepatocellular carcinoma (HCC), with the majority of all cases worldwide found in the Asia-Pacific region, where HCC is one of the leading public health problems. Since the "Toward Revision of the Asian Pacific Association for the Study of the Liver (APASL) HCC Guidelines" meeting held at the 25th annual conference of the APASL in Tokyo, the newest guidelines for the treatment of HCC published by the APASL has been discussed. This latest guidelines recommend evidence-based management of HCC and are considered suitable for universal use in the Asia-Pacific region, which has a diversity of medical environments.

Diagnosis of hepatocellular carcinoma: An update on international guidelines

Imaging is essential for the successful management of patients with or at risk of developing hepatocellular carcinoma (HCC). If ultrasound remains the key screening modality, computed tomography and magnetic resonance imaging (MRI) can play a major role in the characterization and noninvasive diagnosis of nodules in patients at risk of developing HCC. Each technique has succeeded in adapting to the wide histological spectrum of focal liver lesions. In this review, we discuss recent advancements in imaging techniques and evaluation - notably diffusion-weighted imaging, contrast-enhanced ultrasound, and liver-specific MRI contrast agents - as well as their addition to international guidelines and reporting systems such as the Liver imaging reporting and data system (LI-RADS).

Brazilian society of hepatology recommendations for the diagnosis and treatment of hepatocellular carcinoma

Hepatocellular carcinoma is a malignancy of global importance and is associated with a high rate of mortality. Recent advances in the diagnosis and treatment of this disease make it imperative to update the recommendations on the management of the disease. In order to draw evidence-based recommendations concering the diagnosis and management of hepatocellular carcinoma, the Brazilian Society of Hepatology has sponsored a single-topic meeting in João Pessoa (PB). All the invited pannelists were asked to make a systematic review of the literature and to present topics related to the risk factors for its development, methods of screening, radiological diagnosis, staging systems, curative and palliative treatments and hepatocellular carcinoma in noncirrhotic liver. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript containing the recommendations of the Brazilian Society of Hepatology.

Hepatocellular carcinoma detected by regular surveillance: Does timely confirmation of diagnosis matter?

BACKGROUND

Although current guidelines recommended surveillance of hepatocellular carcinoma, prognosis in patients undergoing enhanced follow-up has yet to be evaluated.

AIMS

Examine outcomes of hepatocellular carcinoma diagnosed during enhanced follow-up.

METHODS

During 2010-2012, 194 patients underwent ultrasonography surveillance were diagnosed with hepatocellular carcinoma and divided into: (A) immediate diagnosis (N=105, 54.1%) after positive ultrasonography, (B) enhanced follow-up: (N=38, 19.6%) for initial negative recall procedures, (C) late call back: (N=28, 14.4%) recall procedures were deferred after positive ultrasonography, and (D) beyond ultrasonography: (N=23, 11.9%) surveillance ultrasonography had been negative.

RESULTS

Median time from positive ultrasonography to confirmation of hepatocellular carcinoma were 9.5 months (2-67) in the Group B and 6.5 months (3-44) in the Group C. Stage distribution and 3-year survival rates were similar amongst all Groups. Surveillance intervals longer than 6 months were associated with the non-curative stage (3.7% vs. 12.5%, p=0.04). Nine (4.6%) patients underwent surveillance were diagnosed as Barcelona-Clinic Liver Cancer stage C.

CONCLUSION

Enhanced follow-up by current guidelines is appropriate that treatment can be deferred until a definite diagnosis. Despite optimal surveillance interval and recall policies, few non-curative stage diagnoses seemed inevitable under current standard of care.

The role of the diffusion sequence in magnetic resonance imaging for the differential diagnosis between hepatocellular carcinoma and benign liver lesions

Background and aim

To assess the role of diffusion weighted imaging sequence (DWI), routinely used in hepatic magnetic resonance imaging (MRI) for the differentiation of hepatocellular carcinoma (HCC) from benign liver lesions.

Methods

A number of 56 liver MRI examinations were retrospectively analyzed independently by two experienced radiologists, blinded to each other results. A total number of 70 Focal Liver Lesions (FLLs) assessed by liver MRI in 56 patients were included in the present study. All lesions were retrospectively analyzed by two experienced radiologists, independently from each other and who were not aware of the previous results given by using different imaging techniques. All included FLLs had a final histological diagnosis, or the final diagnosis was based on consensus reading by two experienced radiologists. The signal of the included FLLs was qualitatively appreciated on the b-800 sequences and on the apparent diffusion coefficient (ADC) map. The ADC value of each FLL was measured and the ADC ratio between the ADC value of the assessed FLL and that of the surrounding liver parenchyma was calculated.

Results

The mean ADC value for benign FLLs as assessed by the two independent readers was 1.75 × 10⁻³ and 1.72 × 10⁻³. The mean ADC value for HCC nodules was 0.92 × 10⁻³ for the first reader and 0.91 × 10⁻³ for the second reader respectively. The mean ADC ratio for benign FLLs was 1.81 and 1.84 for the two readers, respectively. The ADC ratio for HCC nodules was 0.91 and 0.91, respectively. The ADC value is an indicator which is less prone to interobserver variability (correlation of 0.919→1). The ADC ratio has, as the analysis of the ROC curve shows, the best predictive value for differentiation between benign FLLs and HCC nodules. Analysis of the signal intensity on the DWI b-800 image alone is of no significance in differentiating benign FLLs from HCC nodules (p>0.005).

Conclusions

The ADC value and the ADC ratio assessed on liver DWI are useful diagnostic tools in the differential diagnosis of benign FLLs vs HCC nodules. Quantitative methods such as calculating the ADC value or ADC ratio have better diagnostic value than qualitative techniques.

Impact of serum ferritin level on hepatocarcinogenesis in chronic hepatitis C patients

AIM

To elucidate the impact of the serum ferritin level, a surrogate indicator of hepatic iron accumulation, on hepatocarcinogenesis in chronic hepatitis C patients.

METHODS

Serum ferritin was measured in 487 chronic hepatitis C patients without history of hepatocellular carcinoma (HCC) after excluding patients in phlebotomy, those with overt chronic gastrointestinal bleeding and those who achieved sustained virological response before enrollment. Patients were divided into four groups (G1-G4) by quartile points of serum ferritin, with sexes separated.

RESULTS

The serum ferritin level was positively correlated with total bilirubin, aspartate aminotransferase, alanine aminotransferase (ALT), γ-glutamyltransferase, hemoglobin and AFP, and inversely correlated with prothrombin activity in both sexes. A significant difference in HCC incidence was observed only in male patients; the incidence was higher in G1 (≤80 ng/mL, n = 54) and G4 (≥323 ng/mL, n = 54) compared with that of G2 (81-160 ng/mL, n = 54) and G3 (161-322 ng/mL, n = 52). The spline curve indicating the relationship between the hazard ratio and serum ferritin level took the form of a J-shape for male patients. In multivariate analysis, G1 and G4 showed higher incidence of HCC among men with a hazard ratio of 2.19 (95% confidence interval, 1.02-4.70; P = 0.045) compared with G2 and G3, together with older age, lower serum albumin and ALT above the normal upper limit.

CONCLUSION

The serum ferritin level is an independent risk factor for HCC development in male patients with chronic hepatitis C when the level is extremely high or low.

Hepatocellular Carcinoma in Pakistan: National Trends and Global Perspective

Hepatocellular carcinoma (HCC) ranks second amongst all causes of cancer deaths globally. It is on a rise in Pakistan and might represent the most common cancer in adult males. Pakistan contributes significantly to global burden of hepatitis C, which is a known risk factor for HCC, and has one of the highest prevalence rates (>3%) in the world. In the absence of a national cancer registry and screening programs, prevalence of hepatitis and HCC only represents estimates of the real magnitude of this problem. In this review, we present various aspects of HCC in Pakistan, comparing and contrasting it with the global trends in cancer care. There is a general lack of awareness regarding risk factors of HCC in Pakistani population and prevalence of hepatitis C has increased. In addition, less common risk factors are also on a rise. Majority of patients present with advanced HCC and are not eligible for definitive treatment. We have attempted to highlight issues that have a significant bearing on HCC outcome in Pakistan. A set of strategies have been put forth that can potentially help reduce incidence and improve HCC outcome on national level.

Imaging of HCC-Current State of the Art

Early diagnosis of hepatocellular carcinoma (HCC) is crucial for optimizing treatment outcome. Ongoing advances are being made in imaging of HCC regarding detection, grading, staging, and also treatment monitoring. This review gives an overview of the current international guidelines for diagnosing HCC and their discrepancies as well as critically summarizes the role of magnetic resonance imaging (MRI) and computed tomography (CT) techniques for imaging in HCC. The diagnostic performance of MRI with nonspecific and hepatobililiary contrast agents and the role of functional imaging with diffusion-weighted imaging will be discussed. On the other hand, CT as a fast, cheap and easily accessible imaging modality plays a major role in the clinical routine work-up of HCC. Technical advances in CT, such as dual energy CT and volume perfusion CT, are currently being explored for improving detection, characterization and staging of HCC with promising results. Cone beam CT can provide a three-dimensional analysis of the liver with tumor and vessel characterization comparable to cross-sectional imaging so that this technique is gaining an increasing role in the peri-procedural imaging of HCC treated with interventional techniques.

Surveillance for hepatocellular carcinoma is associated with increased survival: Results from a large cohort in the Netherlands

BACKGROUND & AIMS

Effectiveness of surveillance for hepatocellular carcinoma is controversial. We here explore its effects in "real life" clinical practice.

METHODS

Patients with hepatocellular carcinoma diagnosed in the period 2005-2012 in five Dutch academic centers were evaluated. Surveillance was defined as ⩾2 screening tests during three preceding years and at least one radiologic imaging test within 18 months before diagnosis.

RESULTS

295 (27%) of 1074 cases underwent surveillance. Median time interval between last negative radiologic imaging and hepatocellular carcinoma diagnosis was 7.5 months. In the surveillance group, cirrhosis (97% vs. 60%, p<0.001) and viral hepatitis were more frequent, and non-alcoholic fatty liver disease or absence of risk factors less frequent. In case of surveillance, tumor size was significantly smaller (2.7 vs. 6.0 cm), with lower alpha-fetoprotein levels (16 vs. 44 μg/L), earlier tumor stage (BCLC 0 and A combined: 61% vs. 21%) and resection/transplantation (34% vs. 25%) or radiofrequency ablation (23% vs. 7%) more often applied, with significantly higher 1-, 3-, and 5-year survival rates. Survival benefit by surveillance remained significant after adjustment for lead-time bias based on assumed tumor doubling time of 90 days, but not with doubling time of ⩾120 days. In multivariate analysis, surveillance was an independent predictor for mortality (for interval ⩽9 respectively >9 months: adjusted HRs 0.51 and 0.50, 95% confidence intervals: 0.39-0.67 and 0.37-0.69).

CONCLUSIONS

Surveillance for hepatocellular carcinoma was associated with smaller tumor size, earlier tumor stage, with an impact on therapeutic strategy and was an independent predictor of survival.

Differentiation of small (≤2 cm) hepatocellular carcinomas from small benign nodules in cirrhotic liver on gadoxetic acid-enhanced and diffusion-weighted magnetic resonance images

OBJECTIVE

To identify imaging characteristics that differentiate small (≤2 cm) HCCs from small (≤2 cm) benign nodules in cirrhotic liver on gadoxetic acid-enhanced and diffusion-weighted (DW) magnetic resonance (MR) images.

MATERIALS AND METHODS

On gadoxetic acid-enhanced and DW MR images, we analysed signal intensity of 222 small HCCs and 61 benign nodules (diameter, 0.5-2 cm) at each sequence and rim enhancement during portal or equilibrium phases. Univariate and multivariate logistic regression analyses identified predictors of HCC. Combinations of significant MR findings in multivariate analysis were compared with American Association for the Study of Liver Disease (AASLD) practice guidelines.

RESULTS

In multivariate analysis, arterial enhancement (adjusted odds ratio [aOR], 8.6), T2 hyperintensity (aOR, 5.8), and hyperintensity on DW images (aOR, 3.8) were significant for differentiating small HCCs from benign nodules (p ≤ 0.004). When two or all three findings were applied as diagnostic criteria for differentiating small HCCs from benign nodules, sensitivity and accuracy were significantly higher compared with AASLD practice guidelines (91% vs. 78% and 89% vs. 81%, respectively; each p < 0.0001).

CONCLUSION

On gadoxetic acid-enhanced MR imaging, arterial enhancement and hyperintensity on T2-weighted and DW MR images are helpful for differentiating small HCCs from benign nodules in liver cirrhosis.

Serum Alpha-Fetoprotein Has High Specificity for the Early Detection of Hepatocellular Carcinoma After Hepatitis C Virus Eradication in Patients

Alpha-fetoprotein (AFP) has not played a large role in the surveillance of hepatocellular carcinoma due to inadequate sensitivity and specificity for active chronic hepatitis or cirrhosis. The aim of this study was to evaluate the diagnostic accuracy of AFP in small hepatocellular carcinomas after hepatitis C virus eradication to determine the optimal cutoff value. We conducted a case-control study of 29 cases and 58 controls, matched for age, gender, and platelet counts. The AFP cutoff was 5 ng/mL in patients after hepatitis C virus eradication and 17 ng/mL in those without hepatitis C virus eradication. The areas under the receiver operating characteristic curve were 0.86 (95% confidence interval, 0.76-0.96) in patients after hepatitis C virus eradication and 0.83 (95% confidence interval, 0.74-0.91) in those without hepatitis C virus eradication. In patients after hepatitis C virus eradication, the sensitivity and specificity of AFP levels were 24.1% and 100%, respectively, using a cutoff value of 17 ng/mL. Using a lower cutoff value of 5 ng/mL, the sensitivity increased to 75.9%, although the specificity decreased to 89.0%. AFP is a specific tumor marker for the diagnosis of hepatocellular carcinoma after hepatitis C virus eradication when using the optimal cutoff value of 5 ng/mL.

Imagiological Diagnosis of Gastrointestinal Diseases - Diagnostic Criteria of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of neoplastic morbidity and mortality worldwide, and despite recent treatment advances, the prognosis remains dismal, with a 5-year mortality rate of 85%.

The surveillance and timely diagnosis is therefore of crucial importance in order to improve survival rates and alleviate the health burden imposed by the HCC.

Previously, HCC diagnosis warranted liver biopsy, an invasive process with limited diagnostic accuracy. In the past 15 years, HCC diagnosis based solely on imaging criteria was accepted by all the major national and international guidelines, and is now widely employed across the globe.

Current European guidelines for the HCC diagnosis support the use of both dynamic contrasted computer tomography as well as magnetic resonance imaging for the non-invasive diagnosis of HCC for nodules >1 cm in a cirrhotic liver. The non-invasive diagnosis of HCC depends on radiological hallmarks, such as homogeneous contrast uptake during the arterial phase and wash-out during the venous and late phases, but while such tumoral behaviour is frequent in nodules >2 cm, high-end equipment and superior expertise is often needed for the correct diagnosis of early HCC.

Nevertheless, the accuracy of imaging techniques for the diagnosis of HCC is permanently improving, and supports the progressively reduced need for liver biopsy during liver nodule workout in a cirrhotic liver.

Tumor markers are more useful in patients undergoing surveillance for hepatocellular carcinoma with unreliable results by ultrasonography

AIM

The objectives of this study was to evaluate the utility of tumor markers in hepatocellular carcinoma (HCC) surveillance based on the reliability of ultrasonography.

METHODS

We analyzed 313 patients with HCC detected through a surveillance program using ultrasonography combined with three tumor markers from February 2000 to December 2010. The patients were categorized into two groups based on the triggering event: the US group (n = 281) in which a tumor was first detected using ultrasonography and the TM group (n = 32) in which elevated tumor markers led to the diagnosis of a tumor that was undetected using ultrasonography. The reliability of ultrasonography was scored on a 4-point scale based on three items (coarseness of liver parenchyma, patient obesity and liver atrophy). Additionally, patient survival was assessed using the Kaplan-Meier method and log-rank test.

RESULTS

The median tumor size was 20 mm (interquartile range, 15-24). The reliability of ultrasonography was evaluated as good in 208 (66.5%), satisfactory in 80 (8.0%), poor in 21 (6.7%) and unsatisfactory in four (1.2%) patients. The proportion of patients in the TM group increased significantly according to the score, from 7.2% to 25.0% (P = 0.01). The survival rates of patients at 3 and 5 years were 83.7% and 57.2% in the US group, and 79.3% and 59.4% in the TM group, respectively (P = 0.98).

CONCLUSION

Tumor markers may play a diagnostic role in patients with unreliable ultrasonography results. The survival of patients diagnosed by elevated tumor markers was not significantly different from those diagnosed by ultrasonography.

Evaluation and management of hepatocellular carcinoma

The burden of hepatocellular carcinoma is rising and anticipated to escalate and while the best chance for long term cure remains transplantation, however the shortage of available organs remains a limitation. Liver directed therapy can serve the role of bridge/downstaging to transplant or as palliative care. Despite an improved overall survival among patients with HCC, due to advancements in surgical techniques, liver directed and systemic therapy, the 5 year overall survival remains low at 18% high-lightening the need for novel therapies. Surveillance for HCC is key to detect disease at an early stage to increase the chances for a potentially curative option.

Frequency of and predictive factors for vascular invasion after radiofrequency ablation for hepatocellular carcinoma

BACKGROUND

Vascular invasion in patients with hepatocellular carcinoma (HCC) is representative of advanced disease with an extremely poor prognosis. The detailed course of its development has not been fully elucidated.

METHODS

We enrolled 1057 consecutive patients with HCC who had been treated with curative intent by radiofrequency ablation (RFA) as an initial therapy from 1999 to 2008 at our department. We analyzed the incidence rate of and predictive factors for vascular invasion. The survival rate after detection of vascular invasion was also analyzed.

RESULTS

During a mean follow-up period of 4.5 years, 6075 nodules including primary and recurrent lesions were treated by RFA. Vascular invasion was observed in 97 patients. The rate of vascular invasion associated with site of original RFA procedure was 0.66% on a nodule basis. The incidence rates of vascular invasion on a patient basis at 1, 3, and 5 years were 1.1%, 5.9%, and 10.4%, respectively. Univariate analysis revealed that tumor size, tumor number, alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), and Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein were significant risk predictors of vascular invasion. In multivariate analysis, DCP was the most significant predictor for vascular invasion (compared with a DCP of ≤100 mAu/mL, the hazard ratio was 1.95 when DCP was 101-200 mAu/mL and 3.22 when DCP was >200 mAu/mL). The median survival time after development of vascular invasion was only 6 months.

CONCLUSION

Vascular invasion occurs during the clinical course of patients initially treated with curative intent. High-risk patients may be identified using tumor markers.

Chronic hepatitis B in 2014: great therapeutic progress, large diagnostic deficit

This review analyzes progress and limitations of diagnosis, screening, and therapy of patients with chronic hepatitis B infection. A literature review was carried out by framing the study questions. Vaccination in early childhood has been introduced in most countries and reduces the infection rate. Treatment of chronic hepatitis B can control viral replication in most patients today. It reduces risks for progression and may reverse liver fibrosis. The treatment effect on development of hepatocellular carcinoma is less pronounced when cirrhosis is already present. Despite the success of vaccination and therapy chronic hepatitis B remains a problem since many infected patients do not know of their disease. Although all guidelines recommend screening in high risk groups such as migrants, these suggestions have not been implemented. In addition, the performance of hepatocellular cancer surveillance under real-life conditions is poor. The majority of people with chronic hepatitis B live in resource-constrained settings where effective drugs are not available. Despite the success of vaccination and therapy chronic hepatitis B infection remains a major problem since many patients do not know of their disease. The problems in diagnosis and screening may be overcome by raising awareness, promoting partnerships, and mobilizing resources.

Lipid-AuNPs@PDA nanohybrid for MRI/CT imaging and photothermal therapy of hepatocellular carcinoma

Multifunctional theranostic nanoparticles represent an emerging agent with the potential to offer extremely sensitive diagnosis and targeted cancer therapy. Herein, we report the synthesis and characterization of a multifunctional theranostic agent (referred to as LA-LAPNHs) for targeted magnetic resonance imaging/computed X-ray tomography (MRI/CT) dual-mode imaging and photothermal therapy of hepatocellular carcinoma. The LA-LAPNHs were characterized as having a core-shell structure with the gold nanoparticles (AuNPs)@polydopamine (PDA) as the inner core, the indocyanine green (ICG), which is electrostatically absorbed onto the surface of PDA, as the photothermal therapeutic agent, and the lipids modified with gadolinium-1,4,7,10-tetraacetic acid and lactobionic acid (LA), which is self-assembled on the outer surface as the shell. The LA-LAPNHs could be selectively internalized into the hepatocellular cell line (HepG2 cells) but not into HeLa cells due to the specific recognition ability of LA to asialoglycoprotein receptor. Additionally, the dual-mode imaging ability of the LA-LAPNH aqueous solution was confirmed by enhanced MR and CT imaging showing a shorter T1 relaxation time and a higher Hounsfield unit value, respectively. In addition, the LA-LAPNHs showed significant photothermal cytotoxicity against liver cancer cells with near-infrared irradiation due to their strong absorbance in the region between 700 and 850 nm. In summary, this study demonstrates that LA-LAPNHs may be a promising candidate for targeted MR/CT dual-mode imaging and photothermal therapy of hepatocellular carcinoma.

Surveillance for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a dreaded complication of cirrhosis as it is the commonest cause of mortality in these patients. The last few years have seen a dramatic improvement in the management of this tumor as nearly 50-70% of selected patients with early HCC survive for a median period of up to 5 years after liver transplantation, resection or local ablation. Surveillance has been found to be an effective tool to detect early tumors and expand the applicability of these curative treatment options. Semiannual ultrasonogram is recommended for surveillance by the American, European and Asia Pacific liver societies and is the standard of care in many countries. There is increasing evidence that this practice improves survival too. Since the only way to improve the outlook of HCC is its diagnosis prior to commencement of symptoms, providing surveillance becomes a major responsibility of physicians caring for patients with chronic liver disease. This review attempts to discuss the population at risk of HCC, modalities and frequency of surveillance tests, cost effectiveness and also the logistics of its delivery in the Indian context.

Hepatocellular carcinoma screening in patients with compensated hepatitis C virus (HCV)-related cirrhosis aware of their HCV status improves survival: a modeling approach

Because of the ongoing debate on the benefit of ultrasound (US) screening for hepatocellular carcinoma (HCC), we assessed the impact of screening on hepatitis C virus (HCV)-related compensated cirrhosis patients aware of their HCV status. A Markov model simulated progression from HCC diagnosis to death in 700 patients with HCV-related compensated cirrhosis aware of their HCV status to estimate life expectancy (LE) and cumulative death at 5 years. Five scenarios were compared: S1, no screening; S2, screening by currently existing practices (57% access and effectiveness leading to the diagnosis of 42% at Barcelona Clinic Liver Cancer stage [BCLC-0/A]); S3, S2 with increased access (97%); S4, S2 with an efficacy of screening close to that achieved in a randomized controlled trial leading to the diagnosis of 87% of patients at stage BCLC-0/A; S5, S3+S4. The analysis was corrected for lead-time bias. Currently existing practices of HCC screening increased LE by 11 months and reduced HCC mortality at 5 years by 6% compared to no screening (P = 0.0013). Compared to current screening practices, we found that: 1) increasing the rate of access to screening would increase LE by 7 months and reduce HCC mortality at 5 years by 5% (P = 0.045); 2) optimal screening would increase LE by 14 months and reduce HCC mortality at 5 years by 9% (P = 0.0002); 3) the combination of an increased rate of access and optimal effectiveness of HCC screening would increase LE by 31 months and decrease HCC mortality at 5 years by 20% (P < 0.0001).

CONCLUSION

The present study shows that US screening for HCC in patients with compensated HCV-related cirrhosis aware of their HCV status improves survival and emphasizes the crucial role of screening effectiveness.

Role of stereotactic body radiation therapy for hepatocellular carcinoma

The integration of new technologies has raised an interest in liver tumor radiotherapy, with literature evolving to support its efficacy. These advances, particularly stereotactic body radiation therapy (SBRT), have been critical in improving local control or potential cure in liver lesions not amenable to first-line surgical resection or radiofrequency ablation. Active investigation of SBRT, particularly for hepatocellular carcinoma (HCC), has recently started, yielding promising local control rates. In addition, data suggest a possibility that SBRT can be an alternative option for HCC unfit for other local therapies. However, information on optimal treatment indications, doses, and methods remains limited. In HCC, significant differences in patient characteristics and treatment availability exist by country. In addition, the prognosis of HCC is greatly influenced by underlying liver dysfunction and treatment itself in addition to tumor stage. Since they are closely linked to treatment approach, it is important to understand these differences in interpreting outcomes from various reports. Further studies are required to validate and maximize the efficacy of SBRT by a large, multi-institutional setting.

Natural course of hypovascular nodules detected on gadoxetic acid-enhanced MR imaging: presence of fat is a risk factor for hypervascularization

PURPOSE

Hypovascular nodules that exhibit hypointensity in hepatocyte-phase images of gadoxetic acid-enhanced magnetic resonance (MR) imaging are frequently encountered in clinical practice. We investigated risk factors for the development of these nodules into hypervascular hepatocellular carcinoma (HCC).

METHODS

We retrospectively reviewed our institutional database and identified 302 patients who underwent gadoxetic acid-enhanced MR imaging for suspected or confirmed HCC from February 1, 2008 to January 30, 2011. We excluded patients who were examined for metastasis of other malignancies or for other hepatic tumors, such as focal nodular hyperplasia. We identified hypovascular nodules that were hypointense in hepatocyte-phase images, recorded their characteristics, and calculated the cumulative hypervascularization rate for nodules that were followed up.

RESULTS

Of the 302 patients, 82 had hypovascular nodules (178 nodules; mean size, 9.3 mm). Sixty nodules were followed up for over 6 months, and eight progressed to hypervascular HCC. Hypervascularization occurred more frequently in nodules with fat than those without (P<0.01). The cumulative hypervascularization rate was 5.1% over a year.

CONCLUSION

The presence of intralesional fat was found to be a risk factor for hypervascularization of hypovascular nodules that exhibited hypointensity in the hepatocyte-phase images of gadoxetic acid-enhanced MR imaging.

Surveillance for early diagnosis of hepatocellular carcinoma: How best to do it?

Surveillance for hepatocellular carcinoma (HCC) is considered a standard of care for patients with chronic liver disease who are at risk of developing this malignancy. Several studies have shown that surveillance can improve the prognosis of patients diagnosed with HCC through an increased likelihood of application of curative or effective treatments. Repetition of liver ultrasonography (US) every 6 mo is the recommended surveillance program to detect early HCCs, and a positive US has to entrain a well-defined recall policy based on contrast-enhanced, dynamic radiological imaging or biopsy for the diagnosis of HCC. Although HCC fulfills the accepted criteria regarding cost-effective cancer screening and surveillance, the implementation of surveillance in clinical practice is defective and this has a negative impact on the cost-effectiveness of the procedure. Education of both physicians and patients is of paramount importance in order to improve the surveillance application and its benefits in patients at risk of HCC. The promotion of specific educational programs for practitioners, clinicians and patients is instrumental in order to expand the correct use of surveillance in clinical practice and eventually improve HCC prognosis.

Review article: the management of autoimmune hepatitis beyond consensus guidelines

BACKGROUND

Consensus guidelines aid in the diagnosis and management of autoimmune hepatitis, but they are frequently based on low-quality clinical evidence, conflicting experiences and divergent opinions. Recommendations may be weak, discrepant or non-existent at critical decision points.

AIMS

To identify the decision points where guidelines are weak or non-existent and review the evidence essential in the decision process.

METHODS

Full-text articles published in English using the keyword 'autoimmune hepatitis' were identified by PubMed from 1972 to 2013. Personal experience and investigations in autoimmune hepatitis also identified important contributions.

RESULTS

Seventy per cent of the guidelines developed by the American Association for the Study of Liver Diseases and 48% of those proposed by the British Society of Gastroenterology are based on low-quality evidence, conflicting experiences or divergent opinions. The key uncertainties in diagnosis relate to the timing of liver biopsy, recognising acute severe (fulminant) disease, interpreting coincidental nonclassical histological changes, accommodating atypical or deficient features in non-White patients, differentiating drug-induced from classical disease and identifying overlap syndromes. The key uncertainties in management relate to pre-treatment testing for thiopurine methyltransferase activity, treating asymptomatic mild disease, determining treatment end points, managing suboptimal responses, incorporating nonstandard medications as front-line and salvage agents, using azathioprine in pregnancy and instituting surveillance for hepatocellular carcinoma.

CONCLUSIONS

Consensus guidelines are fraught with uncertainties in the diagnosis and management of autoimmune hepatitis. Each decision point must counterbalance the current available evidence and tailor the application of this evidence to the individual patient.

Management of hepatocellular carcinoma: Enlightening the gray zones

Management of hepatocellular carcinoma (HCC) has been continuously evolving during recent years. HCC is a worldwide clinical and social issue and typically a complicates cirrhosis. The incidence of HCC is increasing, not only in the general population of patients with cirrhosis, but particularly in some subgroups of patients, like those with human immunodeficiency virus infection or thalassemia. Since a 3% annual HCC incidence has been estimated in cirrhosis, a bi-annual screening is generally suggested. The diagnostic criteria of HCC has recently had a dramatic evolution during recent years. HCC diagnosis is now made only on radiological criteria in the majority of the cases. In the context of cirrhosis, the universally accepted criteria for HCC diagnosis is contrast enhancement in arterial phase and washout in venous/late phase at imaging, the so called “typical pattern”. However, recently updated guidelines slightly differ in diagnostic criteria. Apart from liver transplantation, the only cure of both HCC and underlying liver cirrhosis, all the other treatments have to match with higher rate of HCC recurrence. The latter can be classified into curative (resection and percutaneous ablation) and palliative treatments. The aim of this paper was to review the current knowledge on management of HCC and to enlighten the areas of uncertainty.

Extending survival with the use of targeted therapy in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with an increasing incidence projected through 2020. HCC is the third-leading cause of cancer-related deaths worldwide. Management of HCC is complicated by the fact that these patients also have a cirrhotic or otherwise diseased liver that led to the tumorigenesis. To aid in treatment decisions, several staging systems have been developed. In the United States, the Barcelona Clinic Liver Cancer (BCLC) system has emerged as the predominant system, owing to its concomitant consideration of tumor stage, liver function, and physical status, as well as its ability to identify patients with early-stage disease who may benefit from curative therapies. Surveillance for HCC has gained increasing importance in light of several studies demonstrating both clinical and cost benefits. Once HCC is detected and diagnosed, it is usually managed according to its BCLC stage. Patients with early-stage disease often benefit from potentially curative therapies, such as surgical resection and liver transplantation. Often, local ablation such as radiofrequency ablation or percutaneous alcohol injection can be used not only as an effective treatment, but also as a bridge therapy to maintain the status of patients on the liver transplant list. Intermediate-stage patients are typically treated with transarterial chemoembolization, but have a high rate of disease recurrence. The multikinase inhibitor sorafenib is the only treatment option approved for patients with advanced-stage HCC. Sorafenib has demonstrated a significant survival advantage in these patients. Numerous studies have evaluated other novel targeted therapies in this setting, but none have shown superiority to sorafenib.

New serum markers of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), one of the most common cancers worldwide, usually develops in a liver already suffering from chronic damages, often cirrhosis. There has been marked progress in the treatment of HCC. However, effective treatments are limited to patients with less advanced HCC. The detection of HCC at an early stage is still a prerequisite for improved prognosis. To address this problem, a variety of screening modalities are used, including measurement of alpha-fetoprotein (AFP) and ultrasonography (US) at regular intervals in high-risk populations. Unfortunately, poor sensitivity and specificity of AFP and the operator-dependency of US limit the value of either test to diagnose early-stage lesions. Other tests, including Lens culinaris agglutinin-reactive AFP and des-gamma carboxyprothrombin (DCP), are currently being evaluated and may be superior to current tests. Recent developments in gene-expressing microarrays and proteomics promise even more potential diagnostic options. The strict application of the Early Detection Research Network methodology will aid in the assessment of their diagnostic utility, and provide an objective basis for the assessment of their clinical utility.

Clinical utility of protein induced by vitamin K absence in patients with chronic hepatitis B virus infection

Hepatitis B virus (HBV) is a leading cause of hepatocellular carcinoma (HCC). α-fetoprotein (AFP) is a common tumor marker for the diagnosis of HCC, although not for protein induced by the absence of vitamin K or antagonist-II (PIVKA-II). The present study aimed to evaluate the role of PIVKA-II in the diagnosis of HCC in HBV-infected Vietnamese patients. A total of 166 consecutive HBV-infected Vietnamese patients were enrolled, including 41 HCC, 43 liver cirrhosis (LC), 26 chronic hepatitis (CH) and 56 asymptomatic carriers (ASC). AFP was examined using ELISA, while PIVKA-II was analyzed using Eitest PIVKA-II. The cut-off level of AFP and PIVKA-II was 20 ng/ml and 40 mAU/ml, respectively. Although the markers, AFP (344±356 ng/ml) and PIVKA-II (16,200±25,386 mAU/ml), were the highest in the HCC groups, only PIVKA-II in HCC was significantly higher compared to the other groups (P<0.001). The univariate analysis demonstrated that age over 50, male, genotype C, AFP and PIVKA-II were risk factors of LC and HCC. Results of the receiver operating characteristics (ROC) analysis showed that PIVKA-II was more sensitive to HCC compared to AFP. Moreover, PIVKA-II was strongly correlated with the portal venous thrombosis in HCC, as opposed to AFP. Results of the multivariate analysis demonstrated that PIVKA-II was the strongest independent risk factor of LC and HCC. In conclusion, PIVKA-II is likely to be a better marker for the diagnosis of HCC in chronic HBV-infected Vietnamese patients.