Risk factors for intrahepatic recurrence in human small hepatocellular carcinoma

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Improvement of Image Quality Using Hybrid Iterative Reconstruction with Noise Power Spectrum Model in Computed Tomography During Hepatic Arteriography

Objectives:

In CT during hepatic arteriography (CTHA), the addition of a noise power spectrum (NPS) model to conventional hybrid iterative reconstruction (HIR) may improve spatial resolution and reduce image noise. This study aims at assessing the image quality provided by HIR with a NPS model at CTHA.

Methods:

This institutional review board-approved retrospective analysis included 26 patients with hepatocellular carcinomas (HCCs) who underwent CTHA. In all acquisitions, images were reconstructed with filtered back projection (FBP), adaptive iterative dose reduction 3D (AIDR), and AIDR enhanced (eAIDR) with the NPS model. Four radiologists analyzed the signal-to-noise ratio (SNR) of HCC nodules and its associated feeding arteries. The radiologists used a semiquantitative scale (–3 to +3) to rate the subjective image quality comparing both the FBP and eAIDR images with the AIDR images.

Results:

The feeding arteries’ attenuation was significantly higher in eAIDR compared to AIDR [514.3 ± 121.4 and 448.3 ± 107.3 Hounsfield units (HU), p < 0.05]. The image noise of eAIDR was significantly lower than that of FBP (15.2 ± 2.2 and 28.5 ± 4.8 HU, p < 0.05) and comparable to that of AIDR. The SNR of feeding arteries on eAIDR was significantly higher than on AIDR (34.1 ± 7.9 and 27.4 ± 6.3, p < 0.05). Subjective assessment scores showed that eAIDR provided better visibility of feeding arteries and overall image quality compared to AIDR (p < 0.05). The HCC nodule visibility was not significantly different among the three reconstructions.

Conclusion:

In CTHA, eAIDR improved the visibility of feeding arteries associated with HCC nodules without compromising nodule detection.

Increased Visceral Adipose Tissue and Hyperinsulinemia Raise the Risk for Recurrence of Non-B Non-C Hepatocellular Carcinoma after Curative Treatment

Simple Summary

With the increasing prevalence of obesity and diabetes in most countries, the increase in hepatocellular carcinoma (HCC) associated with these factors has recently become a serious healthcare problem. HCC can often emerge in the non-cirrhotic liver among obese patients, and it might suggest that the conventional surveillance strategies for HCC, which is mainly targeted at cirrhotic patients with hepatitis B or C virus, might be insufficient in the overnutrition era. We tried to extract factors that affect recurrence-free survival in patients with non-viral HCC, among obesity and diabetes factors, together with the established recurrence risk factors, using a decision-tree analysis.

Abstract

We investigated the factors affecting recurrence-free survival in patients with non-B non-C hepatocellular carcinoma (HCC) who received curative treatment. Decision-tree analysis was performed in 72 curative cases of non-B non-C HCC to extract the risk factors for recurrence. The reliability of the extracted risk factors was evaluated using the Kaplan–Meier method and the Cox proportional hazards model. The decision-tree analysis extracted three factors—visceral adipose tissue (VAT) index (VATI; <71 and ≥71 cm²/m²), which was the cross-sectional areas of VAT on the computed tomographic image at the umbilical level, normalized by the square of the height, fasting immunoreactive insulin (FIRI; <5.5 and ≥5.5 µU/mL), and alpha-fetoprotein (AFP; <11 and ≥11 ng/mL). The Cox proportional hazards model showed that VATI (hazard ratio (HR): 2.556, 95% confidence interval (CI): 1.191–5.486, p = 0.016), FIRI (HR: 3.149, 95% CI: 1.156–8.575, p = 0.025), and AFP (HR: 3.362, 95% CI: 1.550–7.288, p = 0.002) were all independent risk factors for HCC recurrence. Non-B non-C HCC patients with a higher VATI (≥71 cm²/m²) or higher FIRI (≥5.5 µU/mL) and AFP (≥11 ng/mL) if VATI was <71 cm²/m² are prone to recurrence after curative treatment.

Clinicopathologic Features of Patients With Primary Hepatocellular Carcinoma Surviving Without Recurrence More Than 10 Years After Primary Hepatic Resection

Objective: 

The aim of this study was to clarify the predictive factors of recurrence-free time more than 10 years after primary hepatic resection for hepatocellular carcinoma (HCC).

Summary of background data: 

Surgical resection is a curative treatment for HCC patients with hepatic functional reserve; however, the high recurrence rate must be addressed.

Methods: 

The study included 595 patients who had undergone curative resection for HCC. Multivariate analysis was performed to identify factors associated with recurrence-free survival at more than 10 years.

Results: 

Multivariate analysis revealed that tumor size ≤2 cm (P = 0.004), albumin-bilirubin (ALBI) grade 1 (P = 0.03), Fibrosis-4 (FIB-4) index ≤3.3 (P = 0.002), and histologic inflammation grade ≤1 (P = 0.03) were independent predictive factors for recurrence-free survival for more than 10 years. Predictive points were scored as follows: 2 points, tumor size ≤2 cm or FIB-4 index ≤3.3; and 1 point, ALBI grade 1 or histologic inflammation grade ≤1. Patients were divided into 3 groups according to their total points: group 1, 0 to 2 points (n = 317); group 2, 3 to 4 points (n = 239); and group 3, 5 to 6 points (n = 39). Recurrence-free survival rates among the 3 groups were significantly different (P &lt; 0.0001).

Conclusions: 

Tumor size, ALBI, FIB-4 index, and histologic inflammation grade were independent predictive factors for recurrence-free survival longer than 10 years after curative hepatic resection for HCC.

Size measurements of hepatocellular carcinoma: comparisons between contrast and two-dimensional ultrasound

Background

Ultrasound (US) imaging is known to underestimate tumor size in clinical. This study is aimed to compare the size measurements of hepatocellular carcinoma (HCC) in three US imaging modalities, i.e. two-dimensional (2D) imaging, the arterial phase (AP) and the late phase (LP) imaging of contrast-enhanced US (CEUS).

Methods

Fifty-eight clinically proved HCC patients were included. The 2D and CEUS imaging were performed with Siemens S2000, Philips iu22 and BioSound Twice. 2.5 mL of SonoVue® was injected for every CEUS performance. Two physicians measured the maximal longitudinal and the transverse diameters of the tumors in 2D, the AP and the LP of CEUS from one image section. The three measurements were compared by paired t test.

Results

The mean longitudinal diameter of HCC appeared to be maximal in the AP (4.73 ± 2.04 cm) of CEUS and minimal in the LP (3.98 ± 1.99 cm) of CEUS. The 2D diameter (4.26 ± 2.07 cm) was in the middle between two CEUS measurements. There were significant differences between any two measurements.

Conclusion

There is size difference between the three kinds of HCC measurement. It appeared to be maximal in the AP of CEUS and minimal in the LP. The 2D diameter was in the middle.

The preoperative platelet to albumin ratio predicts the prognosis of hepatocellular carcinoma patients without portal hypertension after liver resection

There is little information concerning the predictive ability of the preoperative platelet to albumin ratio (PAR) in hepatocellular carcinoma (HCC) patients after liver resection. In the current study, we aimed to assess the prognostic power of the PAR in HCC patients without portal hypertension (PH) following liver resection.Approximately 628 patients were included in this study. A receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of the PAR for both recurrence-free survival (RFS) and overall survival (OS). Univariate and multivariate analyses were used to identify the independent risk factors for both RFS and OS.During the follow-up period, 361 patients experienced recurrence, and 217 patients died. ROC curve analysis suggested that the best cut-off value of the PAR for RFS was greater than 4.8. The multivariate analysis revealed that microvascular invasion (MVI), tumor size >5 cm, high aspartate aminotransferase-to-platelet count ratio index (APRI) and high PAR were four independent risk factors for both RFS and OS. Patients with a low PAR had significantly better RFS and OS than those with a high PAR.The PAR may be a useful marker to predict the prognosis of HCC patients after liver resection. HCC patients with a high preoperative PAR had a higher recurrent risk and lower long-term survival rate than those with a low preoperative PAR.

Utility of scoring systems combining the product of tumor number and size with liver function for predicting the prognosis of patients with hepatocellular carcinoma after hepatectomy

Our previous study reported the effectiveness of the product of tumor number and size (NxS factor) as a predictor of the prognosis of patients with hepatocellular carcinoma (HCC) following hepatectomy. The aim of the present study was to validate the prognostic value of scoring systems based on the NxS factor for HCC. The records of 940 patients who underwent hepatectomy for HCC at Osaka University Graduate School of Medicine and Osaka International Cancer Institute were analyzed. The discriminatory abilities of the mathematical integrated model for tumor staging (MITS) score, which combines the NxS factor with liver function, and known prognostic systems, including the Japan Integrated Staging system, the Barcelona Clinic Liver Cancer, Cancer of the Liver Italian Program and the Tokyo system, were compared. Firstly, the present study demonstrated that a higher NxS factor was associated with decreased disease-free survival (DFS) and overall survival (OS) in patients with HCC (P<0.05). Subsequently, univariate analysis of DFS and OS curves revealed significant differences among all NxS factor and liver damage combinations (MITS-LD score; score 0 vs. score 1; score 1 vs. score 2; score 2 vs. score 3; all P<0.05) and all NxS factor and albumin-bilirubin (ALBI) score combinations (MITS-ALBI score; score 0 vs. score 1; score 1 vs. score 2; score 2 vs. score 3; all P<0.05). Furthermore, multivariate Cox proportional hazards model analysis demonstrated that there were significant differences in DFS [Hazard Ratio (HR); score 0 vs. score 1 (1.48); score 1 vs. score 2 (1.27); score 2 vs. score 3 (1.64); all P<0.05] and OS [HR; score 0 vs. score 1 (1.34); score 1 vs. score 2 (1.29); score 2 vs. score 3 (1.64); all P<0.05] among patients with different MITS-LD scores, and there were significant differences in DFS [HR; score 0 vs. score 1 (1.38); score 1 vs. score 2 (1.43); score 2 vs. score 3 (1.60); all P<0.05] among patients with different MITS-ALBI scores. The NxS factor may be a comprehensive measure of tumor burden for predicting the prognosis of patients with HCC following liver resection, and MITS scores could be an improved scoring system for predicting the prognosis of patients with HCC after hepatectomy.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

A nomogram to predict early postoperative recurrence of hepatocellular carcinoma with portal vein tumour thrombus after R0 liver resection: A large-scale, multicenter study

BACKGROUND

Portal vein tumour thrombus (PVTT) is a significant poor prognostic factor for hepatocellular carcinoma (HCC). Patients with PVTT limited to a first-order branch or above of the main portal vein (MPV) could benefit from R0 liver resection (LR). A nomogram is needed to predict early postoperative recurrence (ER) in HCC patients with PVTT and to guide selection of these patients for adjuvant therapy to reduce postoperative recurrence risks.

METHODS

HCC patients with PVTT limited to a first-order branch or above of the MPV after R0 LR as an initial therapy were included. A nomogram using data from a retrospective training cohort was developed with the Cox regression model. The model was tested in a prospective internal validation cohort and three external validation cohorts.

RESULTS

Of 979 patients, 657 developed postoperative ER (67.1%). ER occurred in 165 of 264 patients (62.5%) in the training cohort, 146 of 218 patients (70.0%) in the internal validation cohort, and 204 of 284 patients (71.8%), 77 of 113 patients (68.1%), and 65 of 100 patients (65%) in the three external validation cohorts, respectively. The nomogram included the following variables: hepatitis B surface antigen (HBsAg), PVTT, HBV DNA, satellite nodules, α-fetoprotein, and tumour diameter. The ROC were 0.836, 0.763, 0.802, 0.837, and 0.846 in predicting ER in the five respective cohorts.

CONCLUSION

A nomogram was developed and validated to predict postoperative ER in patients with HCC with PVTT after R0 LR. This nomogram could select appropriate patients with high ER risks for postoperative adjuvant therapy.

Sex difference in recurrence and survival after liver resection for hepatocellular carcinoma: A multicenter study

BACKGROUND

There is a striking sex difference in the incidence of hepatocellular carcinoma, with a strong predominance for men; however, the impact of sex on the incidence of recurrence after curative resection of hepatocellular carcinoma remains controversial. This study aimed to assess sex differences in the risks of recurrence and mortality for patients treated with curative resection of hepatocellular carcinoma.

METHODS

We retrospectively reviewed data from 1,435 hepatocellular carcinoma patients treated with curative resection (1,228 men and 207 women) between 2004 and 2014 at 5 institutions in China. Patients' baseline characteristics, operative variables, and rates of early recurrence (≤2 years after resection), late recurrence (>2 years after resection), and cancer-specific mortality were evaluated and compared. To clarify the true oncologic impact of sex, multivariable competing-risks regression analyses were performed to identify predictors associated with early and late recurrence, as well as cancer-specific mortality.

RESULTS

The early recurrence rates between men and women were similar (43.3% vs 42.0%, P = .728), but the late recurrence and rates of cancer-specific mortality in men were greater compared with women (17.2% vs 11.2%, P = .044; and 42.8% vs 34.3%, P = .022, respectively). Multivariable competing-risks regression analyses revealed no sex difference in early recurrence; however, men had greater late recurrence rate (hazard ratio, 1.752; 95% confidence interval, 1.145-2.682; P = .010) and rate of cancer-specific mortality (hazard ratio, 1.307; 95% confidence interval, 1.015-1.683; P = .038).

CONCLUSION

There was no difference in early recurrence rate (≤2 years after resection between men and women, but men had significantly greater late recurrence (>2 years) and rates of cancer-specific mortality after hepatocellular carcinoma resection than women.

Assessment of the Surveillance Interval at 1 Year after Curative Treatment in Hepatocellular Carcinoma: Risk Stratification

Background/Aims

Guidelines recommend surveillance for hepatocellular carcinoma (HCC) recurrence at 3-month intervals during the first year after curative treatment and 6-month intervals thereafter in all patients. This strategy does not reflect individual risk of recurrence. We aimed to stratify risk of recurrence to optimize surveillance intervals 1 year after treatment.

Methods

We retrospectively analyzed 1,316 HCC patients treated with resection/radiofrequency ablation at Barcelona Clinic Liver Cancer stage 0/ A. In patients without 1-year recurrence under 3-monthly surveillance, a new model for recurrence was developed using backward elimination methods: training (n=582)/ validation cohorts (n=291). Overall survival (OS) according to risk stratified by the new model was compared according to surveillance intervals: 3-monthly versus 6-monthly (n=401) after lead time bias correction and propensity-score matching analyses.

Results

Among patients without 1-year recurrence, age and international normalized ratio values were significant factors for recurrence (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.00 to 1.03; p=0.009 and HR, 5.63; 95% CI, 2.24 to 14.18; p<0.001; respectively). High-risk patients stratified by the new model showed significantly higher recurrence rates than low-risk patients in the validation cohort (HR, 1.73; 95% CI, 1.18 to 2.53; p=0.005). After propensity-score matching between the 3-monthly and 6-monthly surveillance groups, OS in high-risk patients under 3-monthly surveillance was significantly higher than that under 6-monthly surveillance (p=0.04); however, OS in low-risk patients under 3-monthly surveillance was not significantly different from that under 6-monthly surveillance (p=0.17).

Conclusions

In high-risk patients, 3-monthly surveillance can prolong survival compared to 6-monthly surveillance. However, in low-risk patients, 3-monthly surveillance might not be beneficial for survival compared to 6-monthly surveillance.

Celastrol delays hepatic steatosis and carcinogenesis in a rapid AKT/c-Met-transfected hepatocellular carcinoma model via suppressing fatty acid synthase expression and AKT/ERK phosphorylation

Although the suppressing effects of celastrol on hepatocellular carcinoma (HCC) have been demonstrated, evidence for the targeting of fatty acid synthetase (FASN) in the development of HCC by celastrol is still rare. In this study, the effect of celastrol on a rapid HCC model featuring co-activation of AKT/c-Met oncogenes in mice was studied. The effect of celastrol on the alpha-fetoprotein level in the liver and serum was also investigated. Protein expressions of PCNA, Ki67 and FASN in celastrol-treated AKT/c-Met HCC mice were observed. The molecular mechanism of celastrol on the AKT/c-Met signaling pathway was elucidated. The results revealed that celastrol significantly repressed the AKT/c-Met induced HCC development and down-regulated the mRNA expression of AFP in the liver and the AFP level in serum. Furthermore, the expression of proliferation-associated proteins in the HCC tissues was reduced by celastrol treatment. Moreover, the abundant steatosis that resulted from FASN accumulation in the liver in AKT/c-Met mice was also attenuated. Finally, the phosphorylation of AKT and ERK1/2 in HCC mice was repressed by celastrol treatment. Overall, our data demonstrate that celastrol exerts an antiproliferative and novel lipid-decreasing effect by targeting AKT/ERK and FASN in HCC development in vivo.

A new prognostic model for hepatocellular carcinoma recurrence after curative hepatectomy

We previously reported the effectiveness of the product of tumor number and size (NxS factor) for the prognosis of hepatocellular carcinoma (HCC) in patients following hepatectomy. The present study aimed to propose a new score based on the NxS factor to predict HCC recurrence following hepatectomy. A total of 406 patients who underwent hepatectomy for HCC at Osaka University Graduate School of Medicine were retrospectively analyzed to develop the new score. Among clinicopathological factors, including the NxS factor, the marker subset that achieved the best performance for prediction of early recurrence was assessed, and a prognostic model for HCC recurrence after curative hepatectomy (REACH) was developed. As the validation set, 425 patients who underwent hepatectomy for HCC at Yamaguchi University Graduate School of Medicine and Shimonoseki Medical Center were analyzed, and the prognostic ability of the REACH score was compared with that of well-known staging systems. Following analysis, the REACH score was constructed using six covariates (NxS factor, microscopic hepatic vein invasion, differentiation, serum albumin, platelet count and indocyanine green retention rate at 15 min). In the validation set, the REACH score predicted early recurrence in 73 of 81 samples, with a sensitivity of 89% and a specificity of 58%. The area under the curve (AUC) of the receiver operating characteristic curve of the REACH score was 0.78 and 0.74, respectively, for 1- and 2-year recurrence after hepatectomy; each AUC was higher than that of any of the other staging systems. Survival analysis indicated the REACH score had the best predictive value in disease-free and overall survival. The present findings demonstrated that the REACH score may be used to classify patients with HCC into high- and low-risk of recurrence, and to predict subsequent survival following hepatic resection.

Increased visceral fat volume raises the risk for recurrence of hepatocellular carcinoma after curative treatment

Obesity is a risk factor for the development of hepatocellular carcinoma (HCC). This study aimed to assess the influence of visceral fat on the recurrence of HCC after curative treatment. In 207 curative cases of HCC, the cross-sectional areas of visceral and subcutaneous fat mass on the computed tomographic image at the fourth lumbar vertebra were normalized by the square of the height to obtain the visceral fat mass index (VFMI) and the subcutaneous fat mass index (SFMI), respectively. Whether VFMI and SFMI contributed to recurrence of HCC and overall survival was analyzed using a Cox proportional hazards model. Increased VFMI was significantly associated with recurrence of HCC (P = 0.006), whereas SFMI was not (P = 0.502). When the patients were divided based on the optimal cut off value for VFMI (47.2 cm²/m²), obtained from maximally selected rank statistics to best predict the risk for recurrence, the higher VFMI group (n = 79) had more probability of recurrence than the lower VFMI group (n = 128) (log rank test, P = 0.002). There were significant differences in body mass index (P < .0001), SFMI (P < .0001), L3 skeletal muscle index (P < .0001), platelet count (P = 0.003), hemoglobin A1c (P < .0001), triglycerides (P = 0.004), serum leptin (P = 0.043), and underlying liver disease (P < .0001) between the groups. Neither VFMI (P = 0.689) nor SFMI (P = 0.117) significantly contributed to overall survival. VFMI, which is involved in obesity and its related metabolic disorders such as diabetes, hyperlipidemia, and adipokine imbalance, is an extremely promising indicator that can predict the risk of recurrence of HCC after curative treatment.

Prognostic factors after curative resection hepatocellular carcinoma and the surgeon's role

Purpose

Patient, surgical, and tumor factors affect the outcome after surgical resection for hepatocellular carcinoma (HCC). The surgical factors are only modifiable by the surgeon. We reviewed our experience with curative resection for HCC in terms of surgical factors.

Methods

After analyses of the prospectively collected clinical data of 256 consecutive patients undergoing surgical resection for HCC, prognostic factors for disease-free survival (DFS) and overall survival (OS) were identified; all patients were stratified by tumor diameters > or <5 cm and their outcomes were compared.

Results

Multivariate analyses showed that microvascular invasion, estimated blood loss, blood transfusion, and the number of tumors were independent adverse prognostic factors for DFS, whereas microvascular invasion, serum alpha fetoprotein, and tumor diameter were independent adverse prognostic factors for OS. Blood transfusion had borderline significance (P = 0.076). After stratification by tumor diameter, blood transfusion was only associated with poor DFS and OS in patients with tumor diameters > 5 cm.

Conclusion

Tumor recurrence after liver resection for HCC depends on tumor status, bleeding, and transfusions, which subsequently lead to poor patient survival. Surgeons can help improve the prognosis of patients by minimizing blood loss and transfusion, particularly in patients with larger tumors.

RIPK1 protects hepatocytes from Kupffer cells-mediated TNF-induced apoptosis in mouse models of PAMP-induced hepatitis

BACKGROUND & AIMS

The severity of liver diseases is exacerbated by the death of hepatocytes, which can be induced by the sensing of pathogen associated molecular patterns (PAMPs) derived from the gut microbiota. The molecular mechanisms regulating these cell death pathways are poorly documented. In this study, we investigated the role of the receptor interacting protein kinase 1 (RIPK1), a protein known to regulate cell fate decisions, in the death of hepatocytes using two in vivo models of PAMP-induced hepatitis.

METHODS

Hepatitis was induced in mice by independent injections of two different bacterial PAMPs: lipopolysaccharide (LPS) and unmethylated CpG oligodeoxynucleotide (CpG-DNA) motifs. The role of RIPK1 was evaluated by using mice specifically lacking RIPK1 in liver parenchymal cells (Ripk1^LPC-KO). Administration of liposome-encapsulated clodronate served to investigate the role of Kupffer cells in the establishment of the disease. Etanercept, a tumor necrosis factor (TNF)-decoy receptor, was used to study the contribution of TNF-α during LPS-mediated liver injury.

RESULTS

Whereas RIPK1 deficiency in liver parenchymal cells did not trigger basal hepatolysis, it greatly sensitized hepatocytes to apoptosis and liver damage following a single injection of LPS or CpG-DNA. Importantly, hepatocyte death was prevented by previous macrophage depletion or by TNF inhibition.

CONCLUSIONS

Our data highlight the pivotal function of RIPK1 in maintaining liver homeostasis in conditions of macrophage-induced TNF burst in response to PAMPs sensing.

LAY SUMMARY

Excessive death of hepatocytes is a characteristic of liver injury. A new programmed cell death pathway has been described involving upstream death ligands such as TNF and downstream kinases such as RIPK1. Here, we show that in the presence of LPS liver induced hepatic injury was due to secretion of TNF by liver macrophages, and that RIPK1 acts as a powerful protector of hepatocyte death. This newly identified pathway in the liver may be helpful in the management of patients to predict their risk of developing acute liver failure.

Strain elastography for assessment of liver fibrosis and prognosis in patients with chronic liver diseases

BACKGROUND

Estimation of liver stiffness is essential in the treatment of liver diseases. Various procedures alternative to liver biopsy have been developed, and transient elastography using shear wave is an established method for evaluating liver stiffness and has been shown to be a prognostic indicator. In contrast, strain elastography (SE) has been applied to evaluate liver stiffness, however the significance remains uncertain.

METHODS

We retrospectively analyzed 598 patients who underwent SE to evaluate the ability of estimating liver stiffness and the prognosis. Elasticity index (EI) was evaluated as an indicator of liver stiffness in this study.

RESULTS

EI was increased as histological fibrosis advanced. EI was significantly different between mild fibrosis (F0-2) and advanced fibrosis (F3, 4). In contrast, EI was similar among those with different activity scores. EI showed better diagnostic performance in estimating advanced fibrosis than other serological markers and good reproducibility. Furthermore, EI was shown to be an independent prognostic factor in patients with chronic liver diseases and also with hepatocellular carcinoma (HCC) with advanced stage.

CONCLUSIONS

SE could estimate advanced liver fibrosis without influence of liver inflammation unlike other serological liver fibrosis markers. SE might be a prognostic factor in chronic liver diseases and HCC.

Accelerated carcinogenesis following liver resection in chronically inflamed livers: A window of opportunity for treatment

The long-term prognosis following resection of hepatocellular carcinoma (HCC) remains unsatisfactory as a result of a high incidence of recurrence. Prevention of recurrence is the most important strategy to improve the long-term survival results. The role of hepatectomy itself, as an accelerator of carcinogenesis, has not been adequately evaluated in HCC patients. Studies in animal models have revealed a link between liver regeneration under chronic inflammation and hepatic tumorigenesis. Inhibiting different signal transduction pathways during liver regeneration without compromising the ability of the liver to regenerate appears to be a rational strategy and may decrease HCC development and recurrence. If this hypothesis is proven using animal models, this strategy could be evaluated in future clinical trials in humans.

Nomogram predicting long-term survival after the diagnosis of intrahepatic recurrence of hepatocellular carcinoma following an initial liver resection

BACKGROUND

The aim of this study was to construct and validate a nomogram for predicting survival after the intrahepatic recurrence of hepatocellular carcinoma (HCC) following an initial hepatectomy.

METHODS

A primary cohort of 268 patients who underwent curative hepatectomy for HCC at Shinshu University Hospital between 1990 and 2010 was retrospectively studied. A nomogram was constructed based on independent prognostic factors for overall survival after recurrence. The predictive performance was evaluated using the concordance index (c-index) and a calibration curve. The nomogram was then externally validated in a cohort of patients from Tokyo University Hospital (n = 296).

RESULTS

In multivariate analysis, the following 5 variables were identified as independent predictors of overall survival and incorporated into the nomogram-Japan Integrated Stage score at initial liver resection, platelet count at initial liver resection, time until intrahepatic recurrence, vascular invasion at recurrence, and type of treatment used for intrahepatic recurrence. The nomogram had a c-index of 0.75 (95% confidence interval 0.60-0.85) for the Shinshu cohort and 0.71 (0.57-0.81) for the Tokyo cohort. The predicted 3- and 5-year survival probabilities corresponded well with the actual outcomes.

CONCLUSIONS

The established nomogram might be useful for estimating survival after the intrahepatic recurrence of HCC.

Silencing PRDX3 Inhibits Growth and Promotes Invasion and Extracellular Matrix Degradation in Hepatocellular Carcinoma Cells

PRDX3 is a mitochondrial peroxide reductase that regulates cellular redox state. It has been reported that PRDX3 is overexpressed in liver cancer, but how PRDX3 is involved in hepatocellular carcinoma (HCC) tumorigenesis and progression has not been well-characterized. In the present study, we established two stable cell lines by overexpressing or knocking down PRDX3 in HepG2 cells. We found that PRDX3 silencing decreased the growth rate of HepG2 cells and increased mtDNA oxidation. Quantitative proteomics identified 475 differentially expressed proteins between the PRDX3 knockdown and the control cells. These proteins were involved in antioxidant activity, angiogenesis, cell adhesion, cell growth, ATP synthesis, nucleic acid binding, redox, and chaperones. PRDX3 knockdown led to the down-regulation of ATP synthases and the decreased cellular ATP level, contributing to the slow-down of cell growth. Furthermore, silencing PRDX3 enhanced invasive properties of HepG2 cells via TIMP-1 down-regulation and the increased ECM degradation. Taken together, our results indicate that PRDX3 promotes HCC growth and mediates cell migration and invasiveness and is a potential therapeutic target for HCC treatment.

Sorafenib treatment during partial hepatectomy reduces tumorgenesis in an inflammation-associated liver cancer model

The long-term prognosis after resection of hepatocellular carcinoma (HCC), which is one of the treatment options for early-stage HCC, remains unsatisfactory as a result of a high incidence of disease recurrence. Recent studies performed in murine models revealed a link between liver regeneration under chronic inflammation and hepatic tumorigenesis. Sorafenib is a potent drug for advanced HCC with multikinase inhibition activity. We propose that inhibition of signal transduction pathways which are activated during hepatectomy, using Sorafenib, will reduce accelerated tumorigenesis. To test this hypothesis, we studied the Mdr2-knockout (KO) mouse strain, a model of inflammation-associated cancer, which underwent partial hepatectomy (PHx) at three months of age, with or without Sorafenib.Here we show that Sorafenib treatment during PHx inhibited different signal transduction pathways at the multikinase levels, but did not result in increased morbidity or mortality. At the early stages after PHx, Sorafenib treatment had no effect on the course of proliferation, apoptosis and DNA repair in the regenerating liver, but resulted in decreased stellate cells activation and inflammatory response. Finally, we show that Sorafenib treatment during PHx at three months of age resulted in decreased fibrosis and tumor formation at 8.5 months.In conclusion our study indicates that short-term Sorafenib treatment during PHx is safe and effective in inhibiting inflammation-associated cancer, and is therefore a potential strategy for recurrence prevention in patients with early-stage HCC treated with PHx.

Parametric response mapping of dynamic CT for predicting intrahepatic recurrence of hepatocellular carcinoma after conventional transcatheter arterial chemoembolization

OBJECTIVES

The aim of our study was to determine the diagnostic value of a novel image analysis method called parametric response mapping (PRM) for prediction of intrahepatic recurrence of hepatocellular carcinoma (HCC) treated with conventional transcatheter arterial chemoembolization (TACE).

METHODS

This retrospective study was approved by the IRB. We recruited 55 HCC patients who achieved complete remission (CR) after TACE and received longitudinal multiphasic liver computed tomography (CT). The patients fell into two groups: the recurrent tumour group (n = 29) and the non-recurrent tumour group (n = 26). We applied the PRM analysis to see if this technique could distinguish between the two groups. The results of the PRM analysis were incorporated into a prediction algorithm. We retrospectively removed data from the last time point and attempted to predict the response to therapy of the removed data.

RESULTS

The PRM analysis was able to distinguish between the non-recurrent and recurrent groups successfully. The prediction algorithm detected response to therapy with an area under the curve (AUC) of 0.76, while the manual approach had AUC 0.64.

CONCLUSIONS

Adopting PRM analysis can potentially distinguish between recurrent and non-recurrent HCCs and allow for prediction of response to therapy after TACE.

KEY POINTS

Parametric response mapping (PRM) could help assess patients with recurrent HCCs after TACE. Parametric response mapping could direct patients to individualized therapy. Longitudinal CT images were analyzed with advanced image analysis method.

Significance of viral status on prognosis of hepatitis B-related hepatocellular carcinoma after curative resection in East Asia

Tumor recurrence remains one major obstacle for further improving the prognosis of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients after curative liver resection. It has been widely reported that tumor size, positive surgical margin, macroscopic vascular invasion, tumor-node-metastasis stage and Edmondson's grade were significantly related to HCC recurrence. However, the association between HCC recurrence and important viral factors, including the HBV DNA levels, status of hepatitis B surface antigen and hepatitis B e-antigen, levels of cccDNA and hepatitis B core-related antigen, viral genotypes and specific viral sequence mutations remained controversial. Meanwhile, studies on the effect of postoperative adjuvant antiviral therapy on HCC recurrence have been relatively limited and have yielded conflicting results. Identification of certain viral risk factors for HCC recurrence and stratification of patient risk are very important to perform future surveillance programs. As a HBV hyperendemic region, the majority of HBV-related HCC patients develop in East Asia. In this article, we thus systematically reviewed the risk of important viral factors involved in recurrent carcinogenesis and the role of adjuvant antiviral therapy in preventing tumor recurrence in this area.

Infection and Cancer: The Case of Hepatitis B

Infection is a well-described cause of cancer in humans. Being one of the most common infections worldwide, hepatitis B virus (HBV) is the leading cause of hepatocellular carcinoma (HCC), particularly in Asian countries. The etiological link between HBV and HCC provides an important opportunity for health care policy makers and clinicians to intervene with HBV infection to prevent cancer development and improve the outcomes of cancer. This review aims to use HBV as an example to illustrate the potential of tackling infection-related conditions to help improve cancer outcomes. This article is divided into four parts: In the first part, an overview is given on the epidemiologic data and risk factors of HCC development in patients with chronic hepatitis B. In the second part, recent progress on the anti-HBV strategies for preventing HCC is updated. In the third part, approaches to improve the outcomes of established HBV-related HCC are covered. These methods include surveillance strategies to identify asymptomatic HCC among patients with chronic HBV infection, and use of antiviral treatment to avoid HBV reactivation during treatment for HCC and reduce the recurrence of HCC after curative treatment. Finally, the status of the development of targeted drugs specifically for HBV-related HCC is discussed in the section on future development.

Hepatic resection alone versus in combination with pre- and post-operative transarterial chemoembolization for the treatment of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND AIMS

The prognosis of hepatocellular carcinoma (HCC) treated with hepatic resection may be improved by the adjunctive use of transarterial chemoembolization (TACE). This study aimed to systematically compare the outcomes between hepatic resection with and without TACE groups.

METHODS

All relevant randomized controlled trials (RCTs) and non-RCTs were searched by the PubMed, EMBASE, and Cochrane Library databases. Overall survival (OS) and disease-free survival (DFS) were two major outcomes. Meta-analyses were performed according to the timing of TACE (pre- or post-operative TACE). Subgroup analyses were also performed. Hazard ratios (HRs) with 95% confidence intervals (95%CIs) were calculated.

RESULTS

Overall, 55 papers were included (14 RCTs and 41 non-RCTs). Overall meta-analyses demonstrated that OS and DFS were statistically similar between hepatic resection with and without pre-operative TACE groups (HR = 1.01, 95%CI = 0.87-1.19, P = 0.87; HR = 0.91, 95%CI = 0.82-1.01, P = 0.07). Subgroup analyses of RCTs or non-RCTs showed that OS and DFS remained statistically similar between hepatic resection with and without pre-operative TACE groups. Subgroup analysis of incomplete or no tumor necrosis showed that OS was worse in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group. By contrast, subgroup analysis of complete tumor necrosis showed that DFS was better in hepatic resection with pre-operative TACE group than in hepatic resection without pre-operative TACE group.Overall meta-analyses demonstrated that OS and DFS were better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group (HR = 0.85, 95%CI = 0.72-1.00, P = 0.06; HR = 0.83, 95%CI = 0.73-0.94, P = 0.004). Subgroup analyses of RCTs, vascular invasion, or large HCC showed that OS and DFS remained better in hepatic resection with post-operative TACE group than in hepatic resection without post-operative TACE group. By contrast, subgroup analyses of non-RCTs, no vascular invasion, or small HCC showed that OS and DFS were statistically similar between the two groups.

CONCLUSIONS

Post-operative TACE, rather than pre-operative TACE, may be considered as an adjunctive treatment option for HCC treated with hepatic resection.

2014 KLCSG-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

Management of hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC), a common cause for cancer-related death, is increasing worldwide. Over the past decade, survival and quality of life of HCC patients have significantly improved due to better prevention strategies, early diagnosis, and improved treatment options. We performed this narrative review to synthesize current status on the HCC management.

METHODS

Literature search for publications especially over the last decade, which has changed the paradigm on the management of HCC.

RESULTS

Hepatitis B vaccination and treatment of chronic hepatitis B and C are important measures for HCC prevention. Screening and surveillance for HCC using ultrasonogram and alpha-fetoprotein estimation are directed toward cirrhotics and hepatitis B patients at high risk of HCC. If detected at an early stage, curative treatments for HCC can be used such as tumor resection, ablation and liver transplantation. HCC patients without curative options are managed by loco-regional therapies and systemic chemotherapy. Loco-regional treatments include trans-arterial chemoembolization, radioembolization and combinations of loco-regional plus systemic therapies. Currently, sorafenib is the only FDA-approved systemic therapy and newer better chemotherapeutic agents are being investigated. Palliative care for terminally ill patients with metastatic disease and/or poor functional status focusses on comfort care and symptom control.

CONCLUSIONS

In spite of significant advancement in HCC management, its incidence continues to rise. There remains an urgent need to continue refining understanding of HCC and develop strategies to increase utilization of the available preventive measures and curative treatment modalities for HCC.

2014 Korean Liver Cancer Study Group-National Cancer Center Korea practice guideline for the management of hepatocellular carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

Antiviral therapy improves postoperative survival in patients with hepatocellular carcinoma: a randomized controlled trial

OBJECTIVE

A randomized controlled trial was conducted to find out whether antiviral therapy in patients with hepatitis B-related hepatocellular carcinoma (HCC) improves long-term survival after hepatic resection.

BACKGROUND

Despite advances in surgery and in multidisciplinary treatment, there is still no effective adjuvant treatment to prevent HCC recurrence after R0 resection for HCC. Whether antiviral therapy is useful in reducing postoperative HCC recurrence is unclear.

METHODS

Between May 2007 and April 2008, patients who received R0 hepatic resection for HBV-related HCC were randomly assigned to receive no treatment (the control group, n = 100) or antiviral therapy (adefovir 10 mg/d, the antiviral group, n = 100).

RESULTS

The baseline clinical, laboratory, and tumor characteristics of the 2 groups were comparable. The 1-, 3-, and 5-year recurrence-free survival rates for the antiviral group and the control group were 85.0%, 50.3%, 46.1% and 84.0%, 37.9%, 27.1%, respectively. The corresponding overall survival rates for the 2 groups were 96.0%, 77.6%, 63.1% and 94.0%, 67.4%, 41.5%, respectively. The recurrence-free survival and overall survival for the antiviral group were significantly better than the control group (P = 0.026, P = 0.001). After adjusting for the confounding prognostic factors in a Cox model, the relative risks of recurrence and death for antiviral treatment were 0.651 [95% confidence interval (CI): 0.451-0.938; P = 0.021] and 0.420 (95% CI: 0.271-0.651; P < 0.001). Antiviral therapy was an independent protective factor of late tumor recurrence (HR = 0.348, 95% CI: 0.177-0.687; P = 0.002) but not of early tumor recurrence [hazard ratio (HR) = 0.949, 95% CI: 0.617-1.459; P = 0.810].

CONCLUSIONS

In patients with hepatitis B-related HCC, adefovir antiviral therapy reduced late HCC recurrence and significantly improved overall survival after R0 hepatic resection.

Liver cancer: Approaching a personalized care

The knowledge and understanding of all aspects of liver cancer [this including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA)] have experienced a major improvement in the last decades. New laboratory technologies have identified several molecular abnormalities that, at the very end, should provide an accurate stratification and optimal treatment of patients diagnosed with liver cancer. The seminal discovery of the TP53 hotspot mutation [1 ,2 ] was an initial landmark step for the future classification and treatment decision using conventional clinical criteria blended with molecular data. At the same time, the development of ultrasound, computed tomography (CT) and magnetic resonance (MR) has been instrumental for earlier diagnosis, accurate staging and treatment advances. Several treatment options with proven survival benefit if properly applied are now available. Major highlights include: i) acceptance of liver transplantation for HCC if within the Milan criteria [3 ], ii) recognition of ablation as a potentially curative option [4 ,5 ], iii) proof of benefit of chemoembolization (TACE), [6 ] and iv) incorporation of sorafenib as an effective systemic therapy [7 ]. These options are part of the widely endorsed BCLC staging and treatment model (Fig. 1 ) [8 ,9 ]. This is clinically useful and it will certainly keep evolving to accommodate new scientific evidence.

This review summarises the data which are the basis for the current recommendations for clinical practice, while simultaneously exposes the areas where more research is needed to fulfil the still unmet needs (Table 1 ).

Serosal invasion strongly associated with recurrence after curative hepatic resection of hepatocellular carcinoma: a retrospective study of 214 consecutive cases

The purpose of this study was to clarify the individual prognostic factors after curative and primary resection of hepatocellular carcinoma (HCC).Reliable prognostic factors and tumor staging for HCC have been required to predict an appropriate prognosis. However, in HCC, no staging system has received universal acceptance, and several tumor factors seem to relate to HCC prognosis, but they are not definitive. At present, few studies have mentioned the importance of serosal invasion as a prognostic factor.A retrospective search of our database identified 214 consecutive patients who underwent primary and curative hepatectomy for HCC at our department between January 1998 and December 2011. Risk factors for recurrence-free survival (RFS) and overall survival (OS) were analyzed with Cox proportional hazard model, Kaplan-Meier method, and log-rank tests.Multivariate analyses showed that serosal invasion (hazard ratio [HR], 2.75; P = 0.0005) and vascular invasion (HR, 1.71; P = 0.0331) were independently correlated with RFS. Serosal invasion was significantly correlated with HCC recurrence (P = 0.0230). The Kaplan-Meier method and log-rank tests revealed that the patients with serosal invasion showed significantly worse prognosis both in RFS (P < 0.0001) and OS (P = 0.0016).Serosal invasion should be regarded as a strong independent predictor for recurrence in curatively resected HCC cases.

Hepatic Re-resection Versus Transarterial Chemoembolization for the Treatment of Recurrent Hepatocellular Carcinoma after Initial Resection: a Systematic Review and Meta-analysis

BACKGROUND

A systematic review and meta-analysis were performed to compare the post-recurrence survival with hepatic re-resection versus transarterial chemoembolization (TACE) for recurrent hepatocellular carcinoma (HCC) after initial resection.

MATERIALS AND METHODS

All relevant papers were searched via PubMed, EMBASE, and Cochrane Library databases. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Subgroup analysis was performed according to country. Sensitivity analysis was performed in studies which clearly reported the recurrent regions, in moderate/high-quality studies, in studies published in full-text form, and in studies published after 2005.

RESULTS

In total, twelve papers were included in our study. Five and seven of them were of moderate- and poor-quality, respectively. The overall meta-analysis demonstrated a statistically significantly higher post-recurrence survival in the hepatic re-resection group than in those undergoing TACE (HR=0.64, 95%CI=0.52-0.79, P<0.0001). Heterogeneity was statistically significant and statistical significance remained in the subgroup analysis. Sensitivity analyses were also consistent with the overall analysis.

CONCLUSIONS

Hepatic re-resection might provide a better post-recurrence survival than TACE for recurrent HCC after initial resection. However, considering the low quality of published studies and the potential bias of treatment selection, further randomized trials should be warranted to confirm these findings.

An accurate prognostic staging system for hepatocellular carcinoma patients after curative hepatectomy

The aim of this study was to develop an accurate predictive system for prognosis of hepatocellular carcinoma (HCC) patients after hepatectomy. We pooled data of clinicopathological features of 234 HCC patients who underwent curative hepatectomy. On the basis of the pooled data, we established a simple predictive staging system (PS score) scored by the mathematical product of tumor number and size, and degree of liver function. We compared the prognostic abilities of the PS score (score 0-3) with those of six well-known clinical staging systems. Then, we found that there were significant differences (P<0.05) in both disease-free survival (DFS) and overall survival (OS) between patients with different PS scores (PS score 0 vs. 1; PS score 1 vs. 2), and there was a significant difference in DFS, but not OS, between patients with PS score 2 and those with PS score 3. Moreover, the PS score had smaller values of the Akaike information criterion for both DFS and OS than any of the six well-known clinical staging systems. These results suggest that the PS score serves as a simple, accurate predictor for the prognosis of HCC patients after hepatectomy.

Metastatic tumor antigen in hepatocellular carcinoma: golden roads toward personalized medicine

Hepatocellular carcinoma (HCC), a prototype of hypervascular tumors, is one of the most common malignancies in the world, especially hyperendemic in the Far East where chronic hepatitis B virus (HBV) infection is highly prevalent. It is characterized by the clinical feature of a poor prognosis or a high mortality due to its already far advanced stages at diagnosis. It is so multifactorial that hepatocarcinogenesis cannot be explained by a single molecular mechanism. To date, a number of pathways have been known to contribute to the development, growth, angiogenesis, and even metastasis of HCC. Among the various factors, metastatic tumor antigens (MTAs) or metastasis-associated proteins have been vigorously investigated as an intriguing target in the field of hepatocarcinogenesis. According to recent studies including ours, MTAs are not only involved in the HCC development and growth (molecular carcinogenesis), but also closely associated with the post-operative recurrence and a poor prognosis or a worse response to post-operative anti-cancer therapy (clinical significance). Herein, we review MTAs in light of their essential structure, functions, and molecular mechanism in hepatocarcinogenesis. We will also focus in detail on the interaction between hepatitis B x protein (HBx) of HBV and MTA in order to clarify the HBV-associated HCC development. Finally, we will discuss the prognostic significance and clinical application of MTA in HCC. We believe that this review will help clinicians to understand the meaning and use of the detection of MTA in order to more effectively manage their HCC patients.

Viable hepatocellular carcinoma around retained iodized oil after transarterial chemoembolization: radiofrequency ablation of viable tumor plus retained iodized oil versus viable tumor alone

OBJECTIVE

The objective of our study was to compare the effectiveness of radiofrequency ablation (RFA) for viable hepatocellular carcinoma (HCC) including areas of retained oil after transarterial chemoembolization (TACE) versus RFA treatment of viable HCC alone for ablation coverage.

MATERIALS AND METHODS

Eighty-five patients with 88 viable HCCs underwent RFA of residual viable HCCs around retained iodized oil after TACE. RFA of both viable HCC and retained iodized oil was performed on 47 viable tumors (group A), and RFA of viable HCC only was used to treat the remaining 41 viable tumors (group B).

RESULTS

After initial RFA, the endpoint of ablation was successfully achieved for 45 of 47 tumors in group A and for all 41 tumors in group B. Two residual viable tumors in group A were successfully treated by additional RFA. Major complications occurred after initial RFA treatment of one tumor each in group A (pleural effusion) and group B (collateral damage). During follow-up (mean, 37.1 months; range, 5-116.5 months), local tumor progression of treated lesions was found in 28% in group A and 59% in group B. The respective 1-, 3-, 5-, and 7-year local tumor progression rates were significantly lower in group A (15%, 32%, 32%, and 32%) than in group B (43%, 71%, 81%, and 81%) (p = 0.001).

CONCLUSION

In treatment of viable tumors after TACE in patients with HCC, RFA of both viable tumor and retained iodized oil may reduce rates of local tumor progression compared with RFA of viable tumor only.

Hepatitis B viral load affects prognosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a complex disease that is dually challenging to treat due to underlying chronic liver disease in addition to the cancer itself. The prognosis of patients with HCC is determined by intrahepatic tumor status and reserved hepatic function. Hepatitis B virus (HBV) is an established major risk factor of HCC development, and HBV viral load is being increasingly recognized as a prognostic factor in the presence of established HCC. High HBV viral load may affect the prognosis of HBV-related HCC patients in several ways. First, it is associated with more frequent recurrence of HBV-related HCC after treatment. Second, it is associated with more occurrence and severity of potentially life-threatening HBV reactivation. Last, it is associated with more worsened liver function, which limits the therapeutic options for HBV-related HCC. HBV, directly or indirectly, can induce hepatocarcinogenesis. In patients with a high HBV DNA level and subsequent active hepatitis, adhesion molecules expressed on the sinusoidal cells are up-regulated and may increase intrahepatic metastasis. HCC progression after treatment can lead to a poor prognosis by reducing number of normal functioning hepatocytes. Thus, high HBV viral load can affect the prognosis of patients with HCC by frequent recurrence after treatment for HCC and deterioration of hepatic function associated with HCC progression. Recent meta-analysis showed that antiviral treatment reduces HCC recurrence and liver-related mortality after curative therapy of HCC. Given the strong relationship between high HBV DNA load and poor survival outcome of HCC patients due to cancer progression, it is expected that long-term antiviral therapy results in the sustained HBV suppression, control of inflammation, reduction in HCC progression, and eventually in improved overall survival.

Impact of epidermal growth factor single-nucleotide polymorphism on recurrence of hepatocellular carcinoma after hepatectomy in patients with chronic hepatitis C virus infection

Epidermal growth factor (EGF) gene single-nucleotide polymorphism (SNP) is associated with an increased risk of hepatic tumors. The study aimed to elucidate the impact of EGF SNP and EGF receptor (EGFR) expression on the recurrence of hepatocellular carcinoma (HCC) after hepatectomy. To examine the impact of EGF SNP and EGFR on recurrent HCC, we retrospectively analyzed 141 HCC patients with chronic hepatitis C virus infection who underwent curative hepatectomy. The EGF *61 GG allele was present in 69 patients (48.9%), AG in 56 (39.7%) and AA in 16 (11.4%). The AA group had a significantly lower rate of intrahepatic metastasis (0% vs 16.5%, P = 0.02), lower serum EGF concentration (26.3 ± 15.9 pg/mL vs 43.4 ± 30.5 pg/mL, P = 0.02) and lower proportion of early recurrence (≤2 years; 28.6% vs 71.2%, P = 0.03) than the AG/GG group. The AA group had significantly higher recurrence-free survival than the AG/GG group (P = 0.04), but there was no significant difference in overall survival between these two groups (P = 0.97). High versus low EGFR expression analyzed by immunohistochemical staining in cancer cells was not significantly associated with overall survival (P = 0.37) or recurrence-free survival (P = 0.39). Therefore, EGF *61 AA was associated with a lower risk of recurrence after curative hepatectomy for HCC in patients with hepatitis C virus infection than other genotypes, but EGFR expression in cancer cells was not significantly associated with prognosis.

Latin American Association for the Study of the Liver (LAASL) clinical practice guidelines: management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third most common cause of cancer death, and accounts for 5.6% of all cancers. Nearly 82% of the approximately 550,000 liver cancer deaths each year occur in Asia. In some regions, cancer-related death from HCC is second only to lung cancer. The incidence and mortality of HCC are increasing in America countries as a result of an ageing cohort infected with chronic hepatitis C, and are expected to continue to rise as a consequence of the obesity epidemic. Clinical care and survival for patients with HCC has advanced considerably during the last two decades, thanks to improvements in patient stratification, an enhanced understanding of the pathophysiology of the disease, and because of developments in diagnostic procedures and the introduction of novel therapies and strategies in prevention. Nevertheless, HCC remains the third most common cause of cancer-related deaths worldwide. These LAASL recommendations on treatment of hepatocellular carcinoma are intended to assist physicians and other healthcare providers, as well as patients and other interested individuals, in the clinical decision-making process by describing the optimal management of patients with liver cancer.

Transarterial chemoembolization versus surgery/radiofrequency ablation for recurrent hepatocellular carcinoma with or without microvascular invasion

BACKGROUND/AIMS

Microvascular invasion (MVI) is a well-known prognostic factor of postoperative recurrence and of overall survival (OS) in patients with hepatocellular carcinoma (HCC). We compared the treatment outcomes of transarterial chemoembolization (TACE) and surgery/radiofrequency ablation (RFA) according to the presence of MVI in patients with early or late recurrent HCC that presented as Barcelona Clinical Liver Cancer (BCLC) stage 0 or A after curative resection for HCC.

METHODS

A consecutive 68 patients with recurrent HCC of BCLC stage 0 or A at our institution between 1998 and 2012 were retrospectively enrolled. We compared the outcomes of patients treated by TACE or surgery/RFA. Tumor recurrence after curative resection was classified as early (≤ 12 months) or late (> 12 months) recurrence.

RESULTS

Median tumor size was 1.5 cm (range, 1-10 cm), and 67 (98.5%) had HCCs within the Milan criteria. Median post-retreatment follow-up duration was 27 months (range, 1-109 months). Of the 68 patients, 19 (27.9%) underwent surgery/RFA, 47 (69.1%) TACE, and 2 (2.9%) were lost to follow-up. After retreatment, TACE showed significantly higher OS and recurrence-free survival rates than surgery/RFA in MVI-positive patients (P = 0.03 and P = 0.05, respectively), but not in MVI-negative patients (P = 0.95 and P = 0.98, respectively). In particular, in early recurred MVI-positive patients, TACE had a significantly higher OS rate than surgery/RFA (P = 0.01).

CONCLUSIONS

TACE may be the more effective treatment option for recurrent HCC of BCLC stage 0 or A than surgery/RFA in MVI-positive patients, especially in those that recur early after curative resection.

Recurrences of hepatocellular carcinoma following complete remission by transarterial chemoembolization or radiofrequency therapy: Focused on the recurrence patterns

AIM

In this study, we analyzed the rates and patterns of recurrences in hepatocellular carcinoma (HCC) patients who had achieved complete remission (CR) by transarterial chemoembolization (TACE) or radiofrequency ablation (RFA), and also examined the differences of recurrence patterns between TACE-treated and RFA-treated groups.

METHODS

We followed 309 consecutive HCC patients who achieved CR following TACE (n = 220) or RFA (n = 89) for a median of 68 months. Recurrence patterns were classified as local recurrence and secondary tumor according to location of recurrence (≤2 cm and >2 cm from primary tumor).

RESULTS

Recurred HCC had been found in 231 out of 309 patients (75%) with CR by TACE or RFA; 112 local recurrences (48%), 100 secondary tumor (43%) and 19 both (9%). The cumulative recurrence rates at 1, 3 and 5 years were 22%, 64% and 79%, respectively. The overall recurrences at 1, 3 and 5 years following CR in the TACE-treated group was not different from those in the RFA-treated group (21%, 68% and 81% vs 26%, 56% and 84%, respectively; P = NS) However, the cumulative occurrence rates of local recurrence rates at 1, 3 and 5 years were significantly higher in the TACE-treated group compared to the RFA-treated group (15%, 53% and 65% vs 15%, 27% and 34%, respectively; P = 0.001).

CONCLUSION

Recurrence of HCC is very common, even following CR by TACE or RFA. Especially, local recurrences are very frequent in cases who achieved CR by TACE, which suggests that additional ablation therapy may be beneficial to prevent recurrences following CR by TACE.

Risk factors for recurrence after curative resection of hepatitis C-related hepatocellular carcinoma in patients without postoperative interferon therapy

AIM

Hepatitis C (HC)-related hepatocellular carcinoma (HCC; HC-HCC) is highly recurrent.

METHODS

From 1995-2007, 183 curative hepatic resections for primary solitary HC-HCC without postoperative interferon therapy were included in this study. The patients were divided into three groups: (i) 2 cm or less (n = 56); (ii) more than 2 cm to less than 5 cm (n = 79); and (iii) 5 cm or more (n = 48). Independent risk factors for HC-HCC recurrence for each group were determined.

RESULTS

Independent risk factors for recurrence were aspartate aminotransferase or alanine aminotransferase (AST/ALT) of 80 IU/L or more (hazard ratio [HR], 2.1; P = 0.02) in patients with HCC of 2 cm or less, des-γ-carboxy prothrombin of 100 mAU/mL or more (HR, 2.5; P = 0.02) and AST/ALT of 80 IU/L or more (HR, 2.1; P = 0.04) in patients with HCC of more than 2 cm to less than 5 cm, and the presence of macroscopic portal vein tumor thrombus (HR, 2.8; P = 0.02) and AST/ALT of 80 IU/L or more (HR, 2.1; P = 0.04) in patients with HCC of 5 cm or more. All 13 late recurrences of 1 year or more after hepatic resection (27.1%) in patients with HCC of 5 cm or more were accompanied by AST/ALT of 80 IU/L or more.

CONCLUSION

AST/ALT of 80 IU/L or more is an independent risk factor for the recurrence of primary solitary HC-HCC after curative resection irrespective of the primary HC-HCC size.

Assessment of treatment outcomes based on tumor marker trends in patients with recurrent hepatocellular carcinoma undergoing trans-catheter arterial chemo-embolization

PURPOSE

The aim of the present study was to evaluate whether serum alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) trends might be correlated with overall survival rates in patients with recurrent hepatocellular carcinoma (HCC) undergoing trans-catheter arterial chemo-embolization (TACE).

METHODS

We performed a retrospective cohort study of 142 patients with recurrent HCC who were treated by TACE at our hospital from April 1990 to December 2011. Patients were divided into three groups, as follows, according to the trends of the two tumor markers AFP and DCP: the low group, comprising patients with tumor marker levels below the cutoff values (AFP 100 ng/mL and DCP 100 mAU/mL) both pre- and post-TACE; the decreased group, comprising patients with elevated tumor marker levels pre-TACE in whom the levels decreased post-TACE; and the elevated group, comprising patients with elevated tumor marker levels post-TACE.

RESULT

Analysis using a Cox proportional hazards model identified the DCP trend (elevated group vs. low group, hazard ratio 8.47, 95 % confidence interval 4.53-15.84, p < 0.0001), but not the AFP trend, as an independent prognostic factor for survival. While the AFP trend was correlated only with the overall response rate assessed using the modified Response Evaluation Criteria in Solid Tumors (mRECIST; p = 0.041), the DCP trend was strongly associated with both the overall response rate (p = 0.009) and the disease control rate (p = 0.004).

CONCLUSION

The DCP trend might be useful for assessing treatment outcomes after TACE in patients with recurrent HCC.

The role of liver cancer stem cells in donor liver allocation for patients with hepatocellular carcinoma

Previous criteria for liver transplantation in patients with hepatocellular carcinoma (HCC) has predominantly emphasized the size and number of existent tumors; however, criteria have not included tumor biology, which may comprise a critical factor for predicting patient prognosis. This issue has been recognized in the Hangzhou criteria, which take tumor histopathologic grade and pre-transplant α-fetoprotein (AFP) level into consideration. However, neither histopathologic grading nor AFP level are precise enough to adequately represent tumor biology in patients with HCC. Recent research has indicated that the development and progression of HCC are driven by a subpopulation of liver cells with stem cell features (cancer stem cells, [CSCs]). Liver CSCs with cluster of differentiation (CD)133 antigen positivity show a high tumorigenic capacity, and the increase in the percentage of CD133+ liver cancer cells is consistent with increased levels of serum AFP. In addition, the number of CD90+ cells increases with the tumorigenicity of HCC, and a positive correlation between the number of circulating CD90+ liver CSCs and disease progression has been observed. As liver CSCs can be detected using the CD profile and could more accurately represent tumor biology in HCC, we hypothesized that liver CSCs with specific phenotypes could be used for modifying the Hangzhou criteria, thereby providing valuable guidance for the development of more accurate prognosis prediction algorithms for patients with HCC being considered for liver transplantation. We provide reliable evidence supporting this hypothesis, and offer proposals for future applications in transplant practice.

Preoperative neutrophil-to-lymphocyte ratio is a predictor of survival after hepatectomy for hepatocellular carcinoma: a retrospective analysis

OBJECTIVE

To clarify the prognostic value of the preoperative blood neutrophil-to-lymphocyte ratio (NLR) in patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

BACKGROUND

Although a high NLR has been reported to be a predictor of poor survival in patients with various cancers, it has not been extensively examined in patients with HCC.

METHODS

This retrospective study enrolled 958 patients who underwent hepatectomy without preoperative therapy for HCC from 1996 to 2009. Clinicopathological parameters, including NLR, were evaluated to identify predictors of overall and recurrence-free survival after hepatectomy. Univariate and multivariate analyses were performed, using the Cox proportional hazards model. The best cutoff was determined with time-dependent receiver operating characteristic curve. To determine the mechanism of NLR elevation, immunohistological examination using CD163 staining was performed in 150 patients.

RESULTS

Univariate and multivariate analyses showed that NLR was an independent prognostic factor in overall and recurrence-free survival. The best cutoff of NLR was 2.81, and 238 of 958 patients (24.8%) had NLR of more than 2.81. The 5-year survival rate after hepatectomy was 72.9% in patients with NLR less than 2.81 and 51.5% in those with NLR 2.81 or more (P < 0.0001). CD163-positive cell counts were significantly higher in tumors in the group with NLR 2.81 or more than in the group with NLR less than 2.81 (P = 0.0004).

CONCLUSIONS

Our results show that NLR is an independent predictor of survival after hepatectomy in patients with HCC. Accumulation of tumor-associated macrophages in the tumor is associated with a high NLR.

Safety and efficacy of adjuvant pegylated interferon therapy for metastatic tumor antigen 1-positive hepatocellular carcinoma

BACKGROUND

Metastatic tumor antigen 1 (MTA1) overexpression is closely associated with postoperative recurrence of hepatocellular carcinoma (HCC). It has been suggested that pegylated interferon (Peg-IFN) can prevent the occurrence of HCC in patients who have chronic viral hepatitis. In this study, the authors examined whether postoperative adjuvant Peg-IFN therapy can reduce the recurrence of MTA1-positive HCC after curative surgical resection.

METHODS

In this case-control study, 93 patients with MTA1-positive HCC who underwent curative surgical resection were prospectively enrolled. The median patient age was 53 years (range, 27-78); there were 65 men and 28 women; the etiology was hepatitis B virus (HBV) in 77 patients, hepatitis C virus (HCV) in 6 patients, and non-HBV/non-HCV in 10 patients; 31 patients received Peg-IFN (Peg-INTRON) subcutaneously at a dose of 50 μg per week for 12 months (the Peg-IFN group); and the remaining 62 patients were followed only and did not receive any adjuvant therapies (control group). Patients were followed every 1 to 3 months for a median of 24 months.

RESULTS

HCC recurred postoperatively in 26 of 93 patients (28%), and 9 patients (10%) died during follow-up. The overall cumulative recurrence rates were significantly lower in the Peg-IFN group than in the control group (7% and 14% vs. 24% and 34% at 1 year and 2 years, respectively; P < .05). In addition, the 1-year and 2-year cumulative survival rates were higher in the Peg-IFN group compared with the control group (100% vs. 93% and 100% vs. 87%, respectively; P < .05). In multivariate analysis, the receipt of adjuvant Peg-IFN therapy, in addition to having a lower Cancer of the Liver Italian Program score and being a woman, was an independent, favorable factor for a lower risk of postoperative recurrence.

CONCLUSIONS

The current data indicate that adjuvant Peg-IFN therapy may reduce the recurrence of HCC in patients who have MTA1-positive HCC after curative surgical resection.

Predisposing factors of hepatocellular carcinoma recurrence following complete remission in response to transarterial chemoembolization

BACKGROUND AND AIM

The aim of our study was to determine the predictors of recurrences in hepatocellular carcinoma (HCC) patients who had achieved complete remission (CR) by transarterial chemoembolization (TACE).

METHODS

A total of 220 consecutive HCC patients who had achieved CR by TACE were followed for a median 72 months. CR was defined as complete lipiodol uptake based on the results of lipiodol-computed tomography 4 weeks after TACE and no additional tumor staining on the follow-up angiography. Recurrence patterns were classified as local recurrence and secondary tumor, respectively, in relation to the location of recurrence; early and late recurrence were classified in relation to recurrence time.

RESULTS

Recurrence of HCC was observed in 169 patients (77 %), of whom 91 (54 %) had local recurrences, 61 (36 %) had secondary tumor, and 17 (10 %) had both. There were 45 (27 %) early and 124 (73 %) late recurrences. Local recurrence developed more frequently in patients with early recurrence than in those with late recurrence (62 vs. 51 %, respectively), while secondary tumor was detected more commonly in patients with late recurrence than in those with early recurrence (39 vs. 29 %, respectively; P < 0.001). In multivariate analyses, multinodularity [hazard ratio (HR) 2.351, P = 0.023] and a persistently high serum alpha-fetoprotein level following CR (HR 3.173, P < 0.001) were significant predictors of early recurrence. Older age (≥ 60 years; HR 1.531, P = 0.043), advanced Child-Pugh class (HR 1.983, P = 0.002), and the association with cirrhosis (HR 1.756, P = 0.028) were predictors of late recurrence following CR.

CONCLUSIONS

Early recurrences following CR by TACE may be due mainly to undetectable remaining tumors, whereas late recurrences may be caused by newly appearing tumors in patients with a background of advanced cirrhotic liver.