Tumour size and differentiation predict survival after liver resection for hepatocellular carcinoma arising from non-cirrhotic and non-fibrotic liver: a case-controlled study

A meta-analysis: laparoscopic versus open liver resection for large hepatocellular carcinoma

BACKGROUND

The indication of laparoscopic liver resection (LLR) for treating large hepatocellular carcinoma (HCC) is controversial. In this study, we compared the short-term and long-term outcomes of LLR and open liver resection (OLR) for large HCC.

MATERIAL AND METHODS

We searched eligible articles about LLR versus OLR for large HCC in PubMed, Cochrane Library, and EMBASE and performed a meta-analysis.

RESULTS

Eight publications involving 1,338 patients were included. Among them, 495 underwent LLR and 843 underwent OLR. The operation time was longer in the LLR group (MD: 22.23, 95% CI: 4.14-40.33, p = 0.02). but the postoperative hospital stay time was significantly shorter (MD : -4.88, CI: -5.55 to -4.23, p < 0.00001), and the incidence of total postoperative complications and major complications were significantly fewer (OR: 0.49, 95% CI:0.37-0.66, p < 0.00001; OR: 0.54, 95% CI:0.36 - 0.82, p = 0.003, respectively). Patients in the laparoscopic group had no significant difference in intraoperative blood loss, intraoperative transfusion rate, resection margin size, R0 resection rate, three-year overall survival (OS) and three-year disease-free survival (DFS).

CONCLUSION

LLR for large HCC is safe and feasible. This surgical strategy will not affect the long-term outcomes of patients.

Cancer cell genetics shaping of the tumor microenvironment reveals myeloid cell-centric exploitable vulnerabilities in hepatocellular carcinoma

Myeloid cells are abundant and plastic immune cell subsets in the liver, to which pro-tumorigenic, inflammatory and immunosuppressive roles have been assigned in the course of tumorigenesis. Yet several aspects underlying their dynamic alterations in hepatocellular carcinoma (HCC) progression remain elusive, including the impact of distinct genetic mutations in shaping a cancer-permissive tumor microenvironment (TME). Here, in newly generated, clinically-relevant somatic female HCC mouse models, we identify cancer genetics' specific and stage-dependent alterations of the liver TME associated with distinct histopathological and malignant HCC features. Mitogen-activated protein kinase (MAPK)-activated, NrasG12D-driven tumors exhibit a mixed phenotype of prominent inflammation and immunosuppression in a T cell-excluded TME. Mechanistically, we report a NrasG12D cancer cell-driven, MEK-ERK1/2-SP1-dependent GM-CSF secretion enabling the accumulation of immunosuppressive and proinflammatory monocyte-derived Ly6Clow cells. GM-CSF blockade curbs the accumulation of these cells, reduces inflammation, induces cancer cell death and prolongs animal survival. Furthermore, GM-CSF neutralization synergizes with a vascular endothelial growth factor (VEGF) inhibitor to restrain HCC outgrowth. These findings underscore the profound alterations of the myeloid TME consequential to MAPK pathway activation intensity and the potential of GM-CSF inhibition as a myeloid-centric therapy tailored to subsets of HCC patients.

Hepatocellular Carcinoma in Non-Fibrotic Liver: A Narrative Review

Hepatocellular carcinoma (HCC) in a non-fibrotic liver (F0) is considered to be rare, and there is a marked paucity of studies in the literature on this HCC type. A review of the literature shows some important clinical and tumor characteristics: (a) it occurs mainly in young female and elder male patients; (b) clinically, under normal hepatic function, alpha-fetoprotein level is often normal, and there are no risk factors; (c) associated with metabolic disease; (d) macroscopically, single large lesions are noted; and (e) microscopically, the lesions are well-differentiated and encapsulated. Radiological imaging results are straightforward, showing arterial hyperenhancement and later wash-out. The combined use of B-mode and contrast-enhanced (CE) ultrasound (US) is the most reliable and cost-effective diagnostic method. Few peri-and post-operative complications are noted and 5-year survival is not inferior to patients with HCC on fibrosis liver despite the lesion's large size. Most clinicians believe that HCC is unlikely to occur if patients have no symptoms and normal hepatic function. Although detailed clinical data are very limited, we expect that this review will help to improve the clinical management of HCC in non-fibrotic livers.

SEER-based risk stratification system for patients with primary non-cirrhotic liver cancer

BACKGROUND

Little research has been done on the factors affecting the survival of patients with non-cirrhotic hepatocellular carcinoma (HCC-NCL). Our aim was to develop and validate a nomogram and a new risk stratification system that can evaluate overall survival (OS) in HCC-NCL patients.

METHODS

We retrospectively analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019 to study HCC-NCL patients. The patients were randomly split into training and validation groups at a 7:3 ratio and subjected to single-factor and multi-factor COX regression analysis. We then developed a nomogram and evaluated its accuracy and clinical validity using time-dependent ROC, DCA, and calibration curves. We compared the nomogram with the AJCC staging system by calculating C-index, NRI, and IDI. Finally, we used Kaplan-Meier curves to compare the nomogram and AJCC staging. These analyses were performed without altering the original intended meaning.

RESULTS

AFP levels, surgical intervention, T-stage, tumor size, and M-stage were independent prognostic indicators for overall survival among the HCC-NCL population studied. We developed a nomogram based on these factors, and time-dependent ROC, calibration curves, DCA analyses, and C-index proved its accuracy. Compared to the AJCC staging system, the nomogram showed better prognostic accuracy through time-dependent ROC, DCA analyses, C-index, NRI, IDI, and Kaplan-Meier curves.

CONCLUSION

We have developed and validated a survival nomogram applicable to HCC-NCL patients, with risk stratification. Our nomogram offers personalized treatment and management options superior to those provided by the AJCC staging system.

Prognostic nomograms for HBV-related BCLC 0-a stage hepatocellular carcinoma incorporating aspartate aminotransferase to albumin ratio

BACKGROUND

Curative hepatectomy is currently the first-line treatment for hepatocellular carcinoma (HCC), but the prognosis is still not optimistic. The prediction model for prognosis of hepatitis B virus (HBV)-related BCLC 0-A stage HCC has not been well established. Therefore, we aimed to develop new nomograms to predict recurrence and survival in these patients.

METHODS

A total of 982 patients with HBV-related BCLC 0-A stage HCC who underwent curative hepatectomy at West China Hospital from February 2007 to February 2016 were retrospectively collected and randomly allocated to a training set and a validation set in a ratio of 4:1. Prognostic nomograms using data from the training set were developed using a Cox regression model and validated on the validation set.

RESULTS

We constructed nomograms based on independent factors for recurrence-free survival (RFS) (tumor size, satellite, microvascular invasion, capsular invasion, differentiation and aspartate aminotransferase to albumin ratio (ASAR)) and overall survival (OS) (gender, tumor size, satellite, microvascular invasion, differentiation, lymphocyte count, and ASAR). Compared with conventional HCC staging systems and other nomograms reported by previous literature, our ASAR integrated nomograms predicted RFS and OS with the highest C-indexes (0.682 (95%CI: 0.646-0.709), 0.729 (95%CI: 0.691-0.766), respectively) and had well-fitted calibration curves in the training set. Concurrently, the nomograms also obtained consistent results in the validation set. DCA revealed that our nomograms provided the largest clinical net benefits.

CONCLUSION

We first constructed ASAR integrated nomograms to predict the prognosis of HBV-related BCLC 0-A stage HCC patients after curative hepatectomy with good performance.

Hepatocellular Carcinoma: Does the Background Liver With or Without Cirrhosis Matter?

OBJECTIVES

The pathologic differences between hepatocellular carcinoma (HCC) arising in noncirrhotic and cirrhotic livers have not been well studied.

METHODS

We performed a retrospective analysis of 378 HCC cases (95 in noncirrhotic, 283 in cirrhotic livers) from pathology archives (2010-2017).

RESULTS

Patients without cirrhosis were more likely to have hepatitis B (13.68% vs 2.83%, P < .001) or no known liver disease (30.53% vs 4.24%, P < .001), while hepatitis C was more common in patients with cirrhosis (65.72% vs 30.53%, P < .001). HCCs in noncirrhotic livers were larger in size (P < .001); were more likely to have a macrotrabecular histologic pattern (13.68% vs 4.95%, P < .01); were more likely to have fibrolamellar (3.16% vs 0%, P = .02), macrotrabecular-massive (13.68% vs 6.01%, P = .03), and clear cell (16.84% vs 6.71%, P < .01) subtypes; have a higher histologic grade (P < .01); be anaplastic tumor cells (P < .001); have a higher rate of vascular invasion (P < .01); and have a higher tumor stage (P = .04).

CONCLUSIONS

The findings indicate that HCCs in noncirrhotic livers demonstrate a larger tumor size; have a more macrotrabecular histologic pattern; have fibrolamellar, macrotrabecular-massive, and clear cell subtypes; have a higher tumor grade and stage; have a higher rate of vascular invasion; and have more anaplastic tumor cells compared with cirrhotic livers. Further studies to explore different pathways that promote oncogenesis in noncirrhotic livers are needed to better understand the pathogenesis of HCC.

Predicting HCC Response to Multikinase Inhibitors With In Vivo Cirrhotic Mouse Model for Personalized Therapy

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) arises in a cirrhotic, pro-angiogenic microenvironment. Inhibiting angiogenesis is a key mode of action of multikinase inhibitors and current non-cirrhotic models are unable to predict treatment response. We present a novel mouse cirrhotic model of xenotransplant that predicts the natural biology of HCC and allows personalized therapy.

METHODS

Cirrhosis was induced in NOD Scid gamma mice with 4 months of thioacetamide administration. Patient derived xenografts (PDXs) were created by transplant of human HCC subcutaneously into non-cirrhotic mice and intra-hepatically into both cirrhotic and non-cirrhotic mice. The applicability of cirrhotic PDXs for drug testing was tested with 16 days of either sorafenib or lenvatinib. Treatment response was evaluated by MRI.

RESULTS

8 out of 19 (42%) human HCC engrafted in the cirrhotic model compared with only 3 out of 19 (16%) that engrafted in the subcutaneous non-cirrhotic model. Tumor vasculature was preserved in the cirrhotic model but was diminished in the non-cirrhotic models. Metastasis developed in 3 cirrhotic PDX lines and was associated with early HCC recurrence in all 3 corresponding patients (100%), compared with only 5 out of 16 (31%) of the other PDX lines, P = .027. The cirrhotic model was able to predict response and non-response to lenvatinib and sorafenib respectively in the corresponding patients. Response to lenvatinib in the cirrhotic PDX was associated with reduction in CD34, VEGFR2 and CLEC4G immunofluorescence area and intensity (all P ≤ .03).

CONCLUSIONS

A clinically relevant cirrhotic PDX model preserves tumor angiogenesis and allows prediction of response to multikinase inhibitors for personalized therapy.

Is left-sided involvement of hepatocellular carcinoma an important preoperative predictive factor of poor outcome?

Background

The tumor location is the most simple clinical factor and important in liver surgery to make surgical procedure. However, no previous study has investigated the prognostic differences and clinical features of hepatocellular carcinoma showing specific laterality. This study is the first report to focus on the laterality and aimed to lead to more simple and useful predictive factor rather than recent complicated predictive models.

Methods

Patients who underwent liver resection for the first time for single tumors located within each lobe between 2000 and 2018 were enrolled. We divided them into two groups based on tumor location: a right-sided group and a left-sided group. Univariable and multivariable analyses were performed to assess survival differences in relation to several other factors.

Results

There were 595 eligible patients; the 5-year survival rates and disease-free survival rates were 49.5% and 19.1% in the left-sided group and 55.6% and 24.5% in the right-sided group, respectively (p = 0.026). Statistical analyses revealed that the following preoperative prognostic factors were independently significant (p < 0.05) in the left-sided group: indocyanine green retention rate at 15 min, alpha fetoprotein, protein induced by vitamin K absence or antagonists-II level, and larger tumor size.

Conclusion

The left-sided group had a poorer prognosis than the right-sided group. A left-sided tumor location is a significant preoperative factor predictive of poor outcome in patients with hepatocellular carcinoma.

Prognostic factors of gadoxetic acid-enhanced MRI for postsurgical outcomes in multicentric hepatocellular carcinoma

OBJECTIVES

The primary aim of this study was to determine the clinical and histopathological prognostic factors for patients who underwent surgical resection of multiple hepatocellular carcinomas (HCCs) of multicentric occurrence. The secondary aim of this study was to evaluate whether specific imaging-related factors, including arterial phase hyperenhancement (APHE) and the LI-RADS category of each lesion on gadoxetic acid-enhanced MRI, would provide additional prognostic information about multicentric HCCs.

METHODS

In this retrospective study, 54 patients with 120 multicentric HCCs were diagnosed by surgical resection at a single tertiary hospital between 2009 and 2014. Two independent readers evaluated patients' preoperative gadoxetic acid-enhanced MR images and recorded APHE and LI-RADS category for each HCC, with discrepancies resolved through consensus sessions if necessary. Potential clinicopathologic and imaging parameters for predicting disease-free survival (DFS) and overall survival (OS) were analyzed using Cox regression analysis.

RESULTS

Presence of microvascular invasion (MVI) (p = 0.003) and of three or more HCCs (p = 0.013) were both independent predictors of a shorter DFS. Patients with concurrent MVI and three or more HCCs had the shortest DFS. MVI was the only statistically significant parameter (p = 0.023) predicting OS. The number of HCCs with APHE or LR-5/M category was not associated with survival.

CONCLUSIONS

Presence of MVI and of three or more HCCs were associated with poorer outcomes after surgical resection of multicentric HCCs. Imaging parameters on gadoxetic acid-enhanced MRI such as APHE or LI-RADS category were not associated with postsurgical outcomes.

KEY POINTS

• Patients with three or more hepatocellular carcinomas showed worse disease-free survival than those with two hepatocellular carcinomas after surgical resection. • Microvascular invasion was the only significant factor to affect both the disease-free and overall survivals of patients after surgical resection of multicentric hepatocellular carcinomas. • Preoperative MRI findings related to multicentric hepatocellular carcinomas such as arterial phase hyperenhancement and LI-RADS category of lesions did not provide significant prognostic information.

Outcomes Following Resection of Hepatocellular Carcinoma in the Absence of Cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) occasionally occurs in non-cirrhotic patients; however, outcomes for these patients are not extensively documented.

METHODS

We performed an institutional review of patients without cirrhosis who underwent resection for HCC. Clinical data were evaluated to identify factors impacting recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Forty-two patients underwent hepatectomy for HCC in the absence of cirrhosis over a 10-year period. Median follow-up was 22 months. For the entire cohort, 1-, 3-, and 5-year RFS was 62%, 42%, and 38% and 1-, 3-, and 5-year OS was 78%, 60%, and 49%, respectively. On univariate analysis, RFS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.027), vascular invasion (p = 0.030), elevated alkaline phosphatase (p = 0.004), and tumor size > 10 cm (p = 0.016). OS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.044), obesity (p = 0.036), and elevated alkaline phosphatase (p = 0.007) with a trend towards decreased OS for tumor size > 10 cm (p = 0.07).

CONCLUSIONS

Patients undergoing resection for HCC in the absence of cirrhosis have fairly high recurrence and modest survival rates. Pre-operative alkaline phosphatase, tumor size, tumor encapsulation, and vascular invasion are important prognostic factors.

A Real-World Study of Prognosis of N0M0 Hepatocellular Carcinoma with Hepatic Resection Based on SEER Database

AIM

To develop and validate a simple-to-use nomogram for prediction of 3-/5-year survival in patients with N0M0 hepatocellular carcinoma after curative liver resection. Patients and Methods. Patients diagnosed HCC with hepatic resection in the Surveillance, Epidemiology, and End Results (SEER) database were included to identify prognostic factors of overall survival. Multivariate Cox regression were used to create a nomogram.

RESULTS

We identified 4856 HCC with hepatic resection from the SEER database. A nomogram to predict long-term survival with a C-index 0.667 (95% CI, 0.653 to 0.681) is more efficient than TNM staging with a lower C-index 0.613 (95% CI, 0.597 to 0.629). The C-index was confirmed to be 0.663 (95% CI, 0.640 to 0.686) through validation, suggesting a good discrimination and a good prediction capability.

CONCLUSIONS

The nomogram is a simple and effective screening tool for assessing the prognosis of HCC with hepatic resection and assists with the planning of individual postoperative surveillance protocols.

Development and validation of a risk score to predict the overall survival following surgical resection of hepatocellular carcinoma in non-cirrhotic liver

BACKGROUND

The aim of this study was to develop and validate a risk score to predict overall survival (OS) in patients undergoing surgical resection for hepatocellular carcinoma in non-cirrhotic liver (NC-HCC).

METHODS

Patients who underwent resection for NC-HCC between 2004 and 2013 were identified from the SEER database. A derivation set of 75% of this cohort was used to develop a risk score. This was then internally validated on the remaining patients, and externally validated using a cohort of patients from The HPB Unit, Birmingham, UK.

RESULTS

A total of 3897 patients were included from the SEER database, with a median post-diagnosis survival of 59 months. In the derivation set, multivariable analyses identified male sex, increasing tumour size, the presence of multiple tumours, bilobar tumours and major vascular invasion as adverse prognostic factors. A risk score generated from these factors was significantly predictive of OS, and was used to classify patients into low, medium and high-risk groups. These groups had a five-year OS of 69%, 51% and 19% in the internal, and 73%, 50% and 45% in the external validation sets.

CONCLUSION

The proposed risk score is useful in the selection, pre-operative consenting and counselling of patients for surgery and to allow patients to make an informed decision regarding treatment.

Minimally Invasive Liver Resection for Early-Stage Hepatocellular Carcinoma: Inconsistent Outcomes from Matched or Weighted Cohorts

BACKGROUND

The aim of the current study was to re-evaluate the role of minimally invasive liver resection (MILR) among patients with early-stage (stage I or II) hepatocellular carcinoma (HCC) undergoing partial hepatectomy.

METHODS

A retrospective analysis of the National Cancer Database (NCDB) was conducted to identify patients with early-stage HCC who underwent partial hepatectomy in the USA from 2010 to 2013. Overall survival (OS) was compared in three cohorts: crude; stabilized inverse probability of treatment propensity score weighting (IPTW); and propensity score matching (PSM).

RESULTS

Among 4027 patients included in the study, only 11.7%, (n = 473) underwent MILR. In the stabilized IPTW cohort, patients who underwent MILR versus open resection were more likely to have tumors greater than 3 cm (63.9%, n = 285 vs. 51.4%, n = 228, p < 0.001) and poorly/undifferentiated tumors (21.5%, n = 96 vs. 12.9%, n = 57, p < 0.001). Within the crude cohort, a 5-year OS was superior among patients in the open surgical group (67.8%) compared with patients who underwent MILR (56.6%) (p < 0.001). After classic PSM analysis, the 5-year OS of patients undergoing MILR and open surgery were noted to be comparable (57.3% vs 63.8%, p = 0.17; HR 1.16, 95% CI 0.92-1.45). In contrast, after applying IPTW, the 5-year OS of patients who underwent MILR (55.5%) was worse compared with patients who had an open resection (67.5%) (HR 1.46, 95% CI 1.15-1.84; p < 0.001).

CONCLUSIONS

Long-term outcomes of patients undergoing MILR were comparable with patients who had open surgery when assessed by standard PSM. The use of IPTW resulted in more unbalanced groups leading to residual confounding and bias.

Non-Cirrhotic Liver is Associated with Poor Prognosis of Hepatocellular Carcinoma: A Literature Review

Primary hepatocellular carcinoma (HCC) is the fifth most frequently reported malignancy, and it is also the second most common cause of cancer-related deaths worldwide. Although most HCC cases have been reported to develop from cirrhosis, accumulating data suggest that HCC is also closely related to non-cirrhotic chronic liver disease. Traditionally, HCC was thought to develop mostly from cirrhosis; however, an increasing number of reports have found that HCC can develop directly from inflammation without cirrhosis. The incidence of HCC in non-cirrhotic liver (HCC-NCL) is high, especially in developed countries. Studies have found that the most common cause of HCC-NCL is neglected fatty liver disease. This type of HCC has unique clinical characteristics and is closely related to metabolic disorders. Unfortunately, the prevention of HCC-NCL has not received enough attention worldwide, and there is also a lack of specific screening methods and clinical guidelines. This article mainly reviews the etiology, incidence, clinical characteristics, and screening markers of HCC-NCL to improve the understanding and prevention of this disease.

Treatment strategies for locally advanced hepatocellular carcinoma

Liver cancer ranks fifth in incidence and fourth in overall cancer-related mortality, with approximately 854,000 new cases and 810,000 deaths per year worldwide. Hepatocellular carcinoma (HCC) accounts for 90% of these cases, and, over time, both the incidence and mortality of this cancer have been rising in many regions. Several staging systems are used to assess the extent of primary tumor, presence of metastasis, and underlying liver disease, and thereby aid in the definition of treatment strategies and prognosis for these patients. The consequence of this heterogeneity in HCC staging is that no consensual definition of advanced disease exists, and there is still ongoing debate on the optimal treatment for these patients. Patients with advanced tumors can be candidates for multiple therapies, ranging from potentially curative options such as transplantation and resection-to locoregional and systemic treatments; these should be evaluated on an individual basis by a multidisciplinary team. This paper provides an overview of treatment options for advanced stage HCC, based on a review of the latest relevant literature and the personal experience of the authors.

Changing role of histopathology in the diagnosis and management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common and fatal cancer in the world. HCC frequently presents with advanced disease, has a high recurrence rate and limited treatment options, which leads to very poor prognosis. This warrants urgent improvement in the diagnosis and treatment. Liver biopsy plays very important role in the diagnosis and prognosis of HCC, but with technical advancements and progression in the field of imaging, clinical guidelines have restricted the role of biopsy to very limited situations. Biopsy also has its own problems of needle tract seeding of tumor, small risk of complications, technical and sampling errors along with interpretative errors. Despite this, tissue analysis is often required because imaging is not always specific, limited expertise and lack of advanced imaging in many centers and limitations of imaging in the diagnosis of small, mixed and other variant forms of HCC. In addition, biopsy confirmation is often required for clinical trials of new drugs and targeted therapies. Tissue biomarkers along with certain morphological features, phenotypes and immune-phenotypes that serve as important prognostic and outcome predictors and as decisive factors for therapy decisions, add to the continuing role of histopathology. Advancements in cancer biology and development of molecular classification of HCC with clinic pathological correlation, lead to discovery of HCC phenotypic surrogates of prognostic and therapeutically significant molecular signatures. Thus tissue characteristics and morphology based correlates of molecular subtypes provide invaluable information for management and prognosis. This review thus focuses on the importance of histopathology and resurgence of role of biopsy in the diagnosis, management and prognostication of HCC.

Serum Iron Levels Decreased in Patients with HBV-Related Hepatocellular Carcinoma, as a Risk Factor for the Prognosis of HBV-Related HCC

Background: Hepatocellular carcinoma (HCC) is common and the second leading causes of cancer-related deaths. HCC usually occurs on the basis of chronic liver diseases. At present, the study of iron metabolism in chronic liver diseases was limited to chronic HCV infection, nonalcoholic fatty liver disease, and alcoholic liver disease. This study aimed to investigate the effect of serum iron levels on the progression of chronic HBV infection and the relationship with the prognosis of HBV-related HCC. Methods: A respective study involving 277 healthy individuals as controls (HC), 295 patients with chronic hepatitis B (CHB), 224 patients with HBV-related liver cirrhosis (HBV-related LC), and 586 patients with HBV- related HCC were enrolled in this study. Hematological parameters, HBVDNA and liver biochemistry were analyzed. Child-Pugh grade and BCLC stage of the HBV-related HCC patients were calculated. Results: The serum iron levels were lowest in the HBV- related HCC group as compared with HC, CHB, and HBV-related LC groups (35.07 ± 6.97, 27.37 ± 10.26, 24.53 ± 10.36 vs. 17.90 ± 0.14, P < 0.001). Strikingly, serum iron levels were lowest in HBV- related HCC patients with tumor size more than 10 cm as compared with HBV- related HCC patients with tumor size smaller than 3, 3-5, and 5-10 cm by subgroup analysis (22.12 ± 0.94, 21.44 ± 1.41, 15.65 ± 0.98 vs. 13.36 ± 1.15, P < 0.001). Serum iron levels significantly decreased with worsening Child-Pugh grades and BCLC stages in HBV-related HCC group. In addition, serum iron levels was positively correlated with Retinol-Binding Protein, total bile acid, hemoglobin, and lymphocyte and negatively correlated with white blood cell (WBC) and platelet in HBV- related HCC group. ROC curve analysis showed serum iron levels at 15.1 μmol/L as the optimal cut-off point for determining the survival of HBV-related HCC. By the Cox regression model analysis, serum iron levels <15.1 μmol/l together with higher AFP levels, worse BCLC stages, and larger tumor size showed higher mortality of HBV-related HCC patients (hazard ratio = 2.280, 95% confidence interval, 1.815-2.865; P < 0.001). Conclusions: Serum iron levels affected the progression of chronic HBV infection. The prognosis of HBV- related HCC patients with serum iron levels <15.1 μmol/l together with higher AFP levels, worse BCLC stages, and larger tumor lesion were poor.

Laparoscopic liver resections for hepatocellular carcinoma. Can we extend the surgical indication in cirrhotic patients?

BACKGROUND

Evidence on the value of laparoscopic liver resections (LLR) for hepatocellular carcinoma (HCC) and severe cirrhosis is still lacking. The aim of this study is to assess surgical and oncological outcomes of LLR in cirrhotic HCC patients.

METHODS

The analysis included 403 LLR for HCC from seven European centres. 333 cirrhotic and 70 non-cirrhotic patients were compared. A matched comparison was performed between 100 Child-Pugh A and 25 Child-Pugh B patients.

RESULTS

There was no difference in blood loss (250 vs. 250 mL, p 0.465) and morbidity (28.6 vs. 26.4%, p 0.473) between cirrhotics and non-cirrhotics, and liver-specific complications were similar (12.8 vs. 12%, p 0.924). The sub-analysis revealed similar perioperative outcomes in either Child-Pugh A or B patients. Noteworthy, ascitis (11 vs. 12%, p 0.562) and liver failure (3 vs. 4%, p 0.595) were not different. ASA score (OR 1.76, p 0.034) and conversion (OR 2.99, p 0.019) were risk factors for major morbidity. Despite lower recurrence-free survival in cirrhotics (43 vs. 55 months, p 0.034), overall survival was similar to non-cirrhotic patients (84 vs. 76.5, p 0.598).

CONCLUSION

LLR for HCC appear equally safe in cirrhotic and non-cirrhotic patients, and the advantages can be witnessed in those with advanced cirrhosis. Severe comorbidities and conversion should be considered risk factors for complications-rather than the severity of cirrhosis and portal hypertension-when liver resection is performed laparoscopically. Such results may be of great interest to liver surgeons and hepatologists when deciding on the management of HCC within cirrhosis.

Edmondson-Steiner grade: A crucial predictor of recurrence and survival in hepatocellular carcinoma without microvascular invasio

BACKGROUND

Microvascular invasion (MVI), an important pathologic parameter, has been proven to be a powerful predictor of long-term prognosis in hepatocellular carcinoma (HCC). However, prognostic factors in HCC without MVI remain unknown. The present study aimed to identify the risk factors of recurrence and poor post-resectional survival in this type of HCC.

METHODS AND METHODS

A total of 109 patients with MVI-absent HCC underwent radical hepatectomy were enrolled. The influence of clinicopathologic variables on recurrence and patient survival was assessed using univariate and multivariate analyses.

RESULTS

Chi-square test found that Edmondson-Steiner grade and satellite nodule were significantly associated with recurrence, while the former was the single marker for early recurrence. Stepwise logistic regression analysis demonstrated the independent predictive role of Edmondson-Steiner grade for recurrence. On the other hand, Edmondson-Steiner grade, serum AFP level and satellite nodule were significant for overall and disease-free survival in univariate analysis, whereas tumor size was linked to disease-free survival. Of the variables, Edmondson-Steiner grade, serum AFP level and satellite nodule were independent indicators.

CONCLUSIONS

Edmondson-Steiner grade, a histological classification, carries robust prognostic implications for all the endpoints for prognosis, thus being potential to be a crucial prognosticator in HCC without MVI.

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

BACKGROUND

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

METHODS

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

RESULTS

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p = 0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p = 0.115).

CONCLUSION

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

Combined measurements of tumor number and size helps estimate the outcome of resection of Barcelona clinic liver cancer stage B hepatocellular carcinoma

Background

Although the Barcelona Clinic Liver Cancer (BCLC) staging system suggests that patients with stage B hepatocellular carcinoma (HCC) should be treated with transcatheter arterial chemoembolization instead of surgical treatment, recent studies indicated that the prognosis of surgical resection for patients with BCLC stage B HCC was better than that of TACE. However, the portion of patients with stage B that will achieve better outcomes from surgical treatment remains unclear. In this study, we identified risk factors that influence the prognosis of BCLC stage B HCC after R0 surgical resection to determine whether some patients with stage B HCC may benefit more from R0 resection than other patients and to provide a guideline to estimate the tendency.

Methods

The clinical data of 78 patients with BCLC stage B HCC after R0 surgical treatment within 11 years were analyzed retrospectively, using relapse or death as the endpoint. Kaplan-Meier survival and Cox regression analyses were used to study prognosis (disease-free survival, DFS and overall survival, OS) and independent risk factors.

Results

For all stage B patients, 1-, 2-, and 5-year DFS rates were 62.5, 36.4, and 16.6 %, respectively. Cumulative tumor size >5.0 cm and tumor number ≥4 were independent prognostic risk factors for DFS. The 1-, 2-, and 5- year DFS rates and OS rates of patients with at least one of these two factors were 49.0, 17.2, and 7.4 % (for DFS), and 78.6, 54.8, and 13.4 % (for OS), respectively, which were significantly lower than patients without these two factors (77.8, 58.3, and 27.2 % for DFS, and 94.4, 83.3,and 51.8 % for OS, respectively, P < 0.01).

Conclusions

The analyses indicated that the outcomes of R0 resection were much better for patients with BCLC stage B HCC with two or three tumors and cumulative tumor sizes of ≤5.0 but >3.0 cm than other patients with stage B.

Evaluation of total hepatocellular cancer lifespan, including both clinically evident and preclinical development, using combined network phenotyping strategy and fisher information analysis

We previously showed that for hepatocellular cancer (HCC) prognostication, disease parameters need to be considered within a total personal clinical context. This requires preserving the coherence of data values, observed simultaneously for each patient during baseline diagnostic evaluation. Application of the Network Phenotyping Strategy (NPS) provided quantitative descriptors of these patient coherences. Combination of these descriptors with Fisher information about the patient tumor mass and the histogram of the tumor masses in the whole cohort permitted estimation of the time from disease onset until clinical diagnosis (t(baseline)). We found faster growth of smaller tumors having total masses<70 (80% of cohort) which involved about three times more interacting cellular processes than were observed for slower growing larger tumors (20% of cohort) with total masses>70. Combining the clinical survival and t(baseline) normalized all HCC patients to a common 1,045 days of mean total disease duration (t(baseline) plus post diagnosis survival). We also found a simple relationship between the baseline clinical status, t(baseline), and survival. Every difference between individual patient baseline clinical profiles and special coherent clinical status (HL1) reduced the above common overall survival (OVS) by 65 days. In summary, we showed that HCC patients with any given tumor can best have their tumor biology understood, when account is taken of the total clinical and liver contexts, and with knowing the point in the tumor history when an HCC diagnosis is made. This ability to compute the t(baseline) from standard clinical data brings us closer to calculating survival from diagnosis of individual HCC patients.

Child-Pugh A hepatitis B-related cirrhotic patients with a single hepatocellular carcinoma up to 5 cm: liver transplantation vs. resection

OBJECTIVE

This study aims to analyze the outcomes of patients with Child-Pugh A class cirrhosis and a single hepatocellular carcinoma (HCC) up to 5 cm in diameter who underwent liver transplantation vs. resection.

METHODS

During 2007 to 2012, 282 Child-Pugh A cirrhotic patients with a single HCC up to 5 cm in diameter either underwent liver resection (N = 243) or received liver transplantation (N = 39) at our center. Patient and tumor characteristics and outcomes were analyzed.

RESULTS

Patients who underwent liver transplantation had a better recurrence-free survival (RFS) vs. those who underwent liver resection. However, the 5-year survival rates after these two treatments were comparable. Similar results were observed when we analyzed patients with a HCC less than 3 cm, and for patients with portal hypertension. In the multivariate analysis, tumor differentiation, difference of primary treatment, and presence of microvascular invasion were associated with postoperative recurrence. However, only differentiation negatively impacted overall survival after operation.

CONCLUSION

Although more recurrences were observed in Child A cirrhotic patients with a single HCC up to 5 cm after liver resection, liver resection offers a similar 5-year survival to liver transplantation, even for patients with portal hypertension.

Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome

The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.