EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Mechanically assisted non-invasive ventilation for liver SABR: Improve CBCT, treat more accurately

Background and purpose

Cone-beam computed tomography (CBCT) for image-guided radiotherapy (IGRT) during liver stereotactic ablative radiotherapy (SABR) is degraded by respiratory motion artefacts, potentially jeopardising treatment accuracy. Mechanically assisted non-invasive ventilation-induced breath-hold (MANIV-BH) can reduce these artefacts. This study compares MANIV-BH and free-breathing CBCTs regarding image quality, IGRT variability, automatic registration accuracy, and deep-learning auto-segmentation performance.

Materials and methods

Liver SABR CBCTs were presented blindly to 14 operators: 25 patients with FB and 25 with MANIV-BH. They rated CBCT quality and IGRT ease (rigid registration with planning CT). Interoperator IGRT variability was compared between FB and MANIV-BH. Automatic gross tumour volume (GTV) mapping accuracy was compared using automatic rigid registration and image-guided deformable registration. Deep-learning organ-at-risk (OAR) auto-segmentation was rated by an operator, who recorded the time dedicated for manual correction of these volumes.

Results

MANIV-BH significantly improved CBCT image quality ("Excellent"/"Good": 83.4 % versus 25.4 % with FB, p < 0.001), facilitated IGRT ("Very easy"/"Easy": 68.0 % versus 38.9 % with FB, p < 0.001), and reduced IGRT variability, particularly for trained operators (overall variability of 3.2 mm versus 4.6 mm with FB, p = 0.010). MANIV-BH improved deep-learning auto-segmentation performance (80.0 % rated "Excellent"/"Good" versus 4.0 % with FB, p < 0.001), and reduced median manual correction time by 54.2 % compared to FB (p < 0.001). However, automatic GTV mapping accuracy was not significantly different between MANIV-BH and FB.

Conclusion

In liver SABR, MANIV-BH significantly improves CBCT quality, reduces interoperator IGRT variability, and enhances OAR auto-segmentation. Beyond being safe and effective for respiratory motion mitigation, MANIV increases accuracy during treatment delivery, although its implementation requires resources.

Hepatocellular carcinoma in patients without cirrhosis

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, the sixth most common cancer worldwide, and the third leading cause of cancer-related death. Cirrhosis is the predominant risk factor for HCC, driven by major etiologies including hepatitis B and C, excessive alcohol consumption, and metabolic dysfunction-associated steatotic liver disease (MASLD). While approximately 80% of HCC cases occur in patients with cirrhosis, its incidence among individuals without cirrhosis has significantly increased, particularly in developed countries, driven by the rising prevalence of MASLD. The prevalence of patients with non-cirrhotic HCC varies geographically, yet data on this subgroup remain limited. Consequently, screening and clinical management guidelines for patients with non-cirrhotic HCC are underdeveloped. Current surveillance is typically not recommended for non-cirrhotic populations, except for individuals with hepatitis B, and diagnostic criteria like Liver Imaging Reporting and Data System are designed explicitly for cirrhotic or hepatitis B-associated HCC. Furthermore, treatment strategies for non-cirrhotic HCC are often extrapolated from studies focused on patients with cirrhosis, leading to gaps in knowledge regarding treatment efficacy, survival outcomes, and etiological variability in non-cirrhotic cohorts. Thus, emerging evidence must be reviewed to guide the development of enhanced diagnostic and therapeutic strategies for patients with non-cirrhotic HCC. To address these gaps, we comprehensively reviewed the epidemiology, clinical and genetic characteristics, diagnostic modalities, and therapeutic approaches for patients with non-cirrhotic HCC.

Conversion study of hepatocellular carcinoma using HAIC combined with lenvatinib and PD-1/L1 immunotherapy under the guidance of BCLC staging

Objective

This study aimed to assess the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) combined with lenvatinib and immunotherapy and explore its potential as a conversion treatment for unresectable hepatocellular carcinoma (uHCC).

Methods

A retrospective analysis was performed on clinical data from patients with uHCC who underwent HAIC, lenvatinib, and PD-1/PD-L1 immunotherapy. Data were collected from our hospital between November 2018 and December 2022. Efficacy was assessed based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST). The primary endpoints were overall survival (OS), progression-free survival (PFS), and conversion therapy rate. Additionally, survival status curves were plotted using the Kaplan-Meier method. Lastly, prognostic risk factors affecting conversion therapy and survival outcomes were evaluated using Logistic and Cox regression models.

Results

As of December 2022, 318 patients were included, comprising 40 patients (12.6%) in BCLC stage A, 123 patients (38.7%) in BCLC stage B, and 155 patients (48.7%) in BCLC stage C. The overall objective response rate (ORR) was 47.1%, whilst the disease control rate (DCR) was 85.5%. Meanwhile, the median overall survival (mOS) for the entire cohort was 21.7 months (95% CI: 19.7-24.3), with a median progression-free survival (mPFS) of 11.4 months (95% CI: 9.4-13.4). A total of 110 patients (34.6%) underwent conversion surgery. Multivariate logistic regression analysis identified BCLC stage as the sole independent risk factor affecting eligibility for conversion therapy. Subgroup analysis revealed that BCLC-B stage patients who achieved successful conversion therapy demonstrated significantly superior outcomes compared to those who did not undergo successful conversion therapy (median OS: 29.3 months [95% CI: 24.3-NA] vs. 19.7 months [95% CI: 17.2-24.6], P = 0.0013). Multivariate regression analysis identified the BCLC stage, the presence of distant metastasis, and receipt of conversion therapy as independent prognostic factors influencing OS. Among the cohort, 169 (53.1%) experienced grade 3-4 adverse events (AEs), with the most commonly reported AEs being fatigue, fever, and pain.

Conclusion

The combination of HAIC with lenvatinib and immunotherapy yielded a high ORR, improved the conversion therapy rate, and prolonged both OS and PFS in patients with uHCC while maintaining a favorable safety profile. BCLC stage was identified as an independent prognostic factor influencing the success of conversion therapy, with patients in stage B deriving significant survival benefits post-conversion.

Anticancer effects of vitamin K combined with transarterial chemoembolization in hepatocellular carcinoma, a randomized controlled trial

BACKGROUND

We have previously reported that vitamin K dosing augments the anticancer effects of sorafenib by suppressing levels of des-γ-carboxy prothrombin, a known tumor growth and angiogenesis factor produced in HCC under sorafenib-induced ischemia. Herein, we aimed to establish whether vitamin K dosing could afford a similar anticancer effect when combined with transarterial chemoembolization (TACE).

METHODS

We performed a randomized controlled trial, assigning patients with unresectable HCC (1:1) to TACE + vitamin K or TACE alone groups. Co-primary endpoints were objective response rate and PFS; the secondary endpoint was safety.

RESULTS

The TACE + vitamin K group (n = 50) exhibited a significantly higher objective response rate than the TACE alone group (n = 51) (96.0% vs. 82.4%, p = 0.028). The PFS was significantly longer in the TACE + vitamin K group than that in the TACE alone group (median time: 262 days [95% confidence interval (CI), 35.8-488.2 days] vs. 146 days [95% CI, 111.6-180.4 days]; p = 0.013, hazard ratio: 0.55 [95% CI, 0.34-0.89]). There were no significant differences in the incidence of adverse events between groups.

CONCLUSIONS

Compared with TACE alone, vitamin K dosing combined with TACE improved anticancer outcomes.

CLINICAL TRIAL NUMBER

UMIN000026404.

A Retrospective Study on Biliary Cooling During Thermal Ablation of Central Liver Tumors in Taiwan

Background: Thermal ablation of centrally located liver tumors carries an increased risk of bile duct injury due to their proximity to the biliary tree. We aim to evaluate whether biliary cooling using a nasobiliary tube can effectively mitigate bile duct injury during the ablation process. Methods: We retrospectively analyzed the data of 322 patients who underwent thermal ablation at Dalin Tzu Chi Hospital from July 2020 to June 2023 and identified those who received prophylactic biliary cooling during thermal ablation for central liver tumors. Data including demographics, tumor characteristics, procedural details, and clinical outcomes were analyzed. Results: Among the 322 patients who underwent thermal ablation, 9 with central liver tumors received prophylactic biliary cooling. The median distance between the tumor and the central bile duct was 1 mm (range: 0-4 mm), the temperature of the cold normal saline was 4 °C, and the mean volume of normal saline infused was 150 mL (range: 100-200 mL). Complete ablation was achieved in all patients in a single session without any biliary injury. One patient developed acute cholangitis after ENBD placement, which resolved with antibiotic therapy. Conclusions: Biliary cooling with 4 °C cold saline through a nasobiliary tube can improve the safety and effectiveness of thermal ablation for central liver tumors.

Optimizing TACE for Hepatocellular Carcinoma: The Impact of Intra-Arterial Contrast Enhanced Ultrasound

Transarterial chemoembolization (TACE) is a well-established treatment for intermediate-stage hepatocellular carcinoma (HCC), shown through randomized trials to improve survival compared to supportive care in patients with large, unresectable tumors who are not candidates for liver transplantation or local ablation. As the most commonly used transarterial intervention, TACE is also employed to downstage advanced HCC, allowing certain patients to become eligible for orthotopic liver transplantation under the Milan criteria. Despite its widespread use, variability in therapeutic outcomes highlights the need for improved procedural guidance. Recent advancements in intra-arterial contrast-enhanced ultrasound (IA CEUS) offer new opportunities to enhance TACE precision with real-time imaging that provides superior visualization of tumor vasculature and chemoembolic agent distribution. This review explores the role of IA CEUS in refining TACE for HCC, emphasizing its potential to increase intraprocedural accuracy and reduce the risk of incomplete tumor embolization. The enhanced spatial resolution of IA CEUS enables real-time tracking of embolic agent dispersion within tumor vessels, which could improve therapeutic efficacy by ensuring complete tumor targeting and minimizing non-target embolization. Additionally, IA CEUS may decrease procedural complications by allowing dynamic adjustment of embolic delivery based on real-time imaging feedback. By reviewing existing evidence on IA CEUS applications in TACE, this article highlights the modality's potential to transform treatment protocols, improve outcomes, and expand the patient population eligible for TACE.

Contrast-Enhanced Ultrasound for Hepatocellular Carcinoma Diagnosis-AJR Expert Panel Narrative Review

Despite growing clinical use of contrast-enhanced ultrasound (CEUS), inconsistency remains in the modality's role in clinical pathways for hepatocellular carcinoma (HCC) diagnosis and management. This AJR Expert Panel Narrative Review provides practical insights on the use of CEUS for the diagnosis of HCC across populations, including individuals at high risk for HCC, individuals with metabolic dysfunction-associated steatotic liver disease, and remaining individuals not at high risk for HCC. Considerations addressed with respect to high-risk patients include CEUS diagnostic criteria for HCC, use of CEUS for differentiating HCC from non-HCC malignancy, use of CEUS for small (≤2 cm) lesions, use of CEUS for characterizing occult lesions on B-mode ultrasound, and use of CEUS for indeterminate lesions on CT or MRI. Representative literature addressing the use of CEUS for HCC diagnosis as well as gaps in knowledge requiring further investigation are highlighted. Throughout these discussions, the article distinguishes two broad types of ultrasound contrast agents used for liver imaging: pure blood-pool agents and a combined blood-pool and Kupffer-cell agent. Additional topics include the use of CEUS for treatment response assessment after nonradiation therapies and implications of artificial intelligence technologies. The article concludes with a series of consensus statements from the author panel.

Comparison of Surgical Resection and Radiofrequency Ablation for Early-Stage HCC Patients With Child-Pugh Class B

AIM

The aim of this study is to compare the clinical outcomes of surgical resection (SR) and radiofrequency ablation (RFA) in patients with early-stage hepatocellular carcinoma (HCC) and Child-Pugh Class B liver function.

METHODS

Among 7210 treatment-naïve HCC patients in our group between 2000 and 2021, this retrospective study included 41 and 456 patients who underwent SR and RFA, respectively. All included patients had Child-Pugh Class B liver function, an Eastern Cooperative Oncology Group (ECOG) performance status of ≤ 2, and early-stage HCC (≤ 3 nodules, ≤ 3 cm in diameter). To adjust for baseline imbalances between the two groups, we applied inverse probability of treatment weighting (IPTW) analysis. Recurrence-free survival (RFS) and overall survival (OS) were assessed using Kaplan-Meier survival analysis and Cox regression models.

RESULTS

Before IPTW analysis, significant differences were observed between the SR and RFA groups in Child-Pugh scores (p = 0.003), total bilirubin levels (p = 0.04), prothrombin time (p = 0.003), and the presence of ascites (p = 0.01), all of which were more favorable in the SR group. The SR group also had fewer tumors (p = 0.03) and larger tumor diameters (p = 0.002) compared to the RFA group. In the entire cohort, there were no significant differences in RFS between the two groups (p = 0.6). After IPTW analysis, the differences remained statistically nonsignificant (p = 0.4). Regarding OS, the difference was not observed between the two groups in the entire cohort (p = 0.5) and in the IPTW cohort (p = 0.9).

CONCLUSION

RFA appears to be as effective as SR in patients with early-stage HCC with the liver function of Child-Pugh Class B.

Long-term effects of peginterferon-based therapy versus nucleos(t)ide analogue monotherapy in non-cirrhotic HBeAg-positive chronic hepatitis B patients

BACKGROUND & AIMS

The long-term clinical benefits of interferon (IFN)-based therapy compared to nucleos(t)ide analogue (NA) monotherapy in HBeAg-positive chronic hepatitis B (CHB) have not been well defined. This study aimed to evaluate the cumulative incidence of new-onset cirrhosis, serological responses, and hepatocellular carcinoma (HCC) development between these treatment strategies.

METHODS

Two independent cohorts of non-cirrhotic, HBeAg-positive CHB patients were analyzed: a treatment-naïve cohort (n = 686) and an NA-experienced cohort (n = 531). Patients received either IFN-based therapy or NA monotherapy. Propensity score matching (PSM) was employed to minimize intergroup heterogeneity. The primary endpoint was the cumulative incidence of new-onset cirrhosis.

RESULTS

After PSM, the 10-year cumulative incidence of new-onset cirrhosis was significantly lower in the IFN-based therapy group compared to the NA monotherapy group in both the treatment-naïve (3.3 % vs 20.0 %, p = 0.005) and NA-experienced (4.9 % vs 20.9 %, p = 0.034) cohorts. IFN-based therapy also resulted in significantly higher serological response rates across both cohorts, including HBeAg loss (treatment-naïve: 84.7 % vs 55.6 %; NA-experienced: 60.4 % vs 43.6 %, both p < 0.001) and HBsAg loss (treatment-naïve: 14.3 % vs 5.7 %, p = 0.006; NA-experienced: 10.2 % vs 1.3 %, p < 0.001). Subgroup analysis showed that patients receiving IFN-based therapy who achieved HBeAg loss within 96 weeks had the greatest long-term benefits, with lower cirrhosis incidence and higher HBsAg loss rates. Although the incidence of HCC was lower in the IFN-based group, the difference did not reach statistical significance (both p > 0.05).

CONCLUSIONS

IFN-based therapy provides superior long-term benefits over NA monotherapy in reducing cirrhosis risk and enhancing serological responses in HBeAg-positive CHB patients.

Liver transplantation for hepatocellular carcinoma following immunotherapy

PURPOSE OF REVIEW

To explore the emerging use of immune checkpoint inhibitors (ICIs) in hepatocellular carcinoma (HCC) patients eligible for liver transplantation (LT), particularly as bridging and downstaging therapies. This review also addresses the clinical challenges of integrating ICIs into transplant protocols, including graft rejection, immune-related toxicities, and gaps in evidence.

RECENT FINDINGS

ICIs have shown potential as bridging and downstaging therapies before LT, with multicentric studies reporting 75.6% successful downstaging, 85% 3-year post-LT survival, and 7.2% rejection-related mortality. A washout interval >94 days and older age have been identified as protective factors against allograft rejection. Combining locoregional therapies with ICIs has proven effective in the EMERALD-1 and LEAP-012 trials, which demonstrated improved progression-free survival (15.0 and 14.6 months, respectively) with ICI-TACE combinations. Similarly, the STAR-FIT phase II trial, combining TACE, SBRT, and avelumab, showed a 42% complete response rate and 12% conversion to curative therapy. Toxicity and rejection risk remain major challenges.

SUMMARY

ICIs represent a promising tool for expanding transplant eligibility in HCC, but their integration into LT pathways remains complex. Safety concerns, particularly regarding timing and immune modulation, require careful evaluation. Prospective studies and biomarker development are needed to guide clinical decision-making. Novel therapies such as CAR-T cells may offer more targeted approaches in the future.

Clinical trajectories in liver cirrhosis: An evidence-based reappraisal for the internist

Over the last few years, the approach to clinical recognition and risk stratification of advanced liver disease has changed substantially, and liver cirrhosis has been increasingly conceptualized as a clinical rather than a histopathologic condition. In this Clinical Insight, we summarize the latest developments on recognition and management of 'clinically' advanced chronic liver disease.

Socioeconomic inequalities in diagnostics, care and survival outcomes for hepatocellular carcinoma in Sweden: a nationwide cohort study

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. This study evaluates how strongly socioeconomic factors associate with diagnostics, treatment, and survival among patients with HCC in Sweden.

Methods

All adult patients registered with a diagnosis of HCC in the Swedish quality register for liver cancer between 2011 and 2021 were included. Household income was classified as low (first quartile; poorest), medium (second or third quartile), or high (in fourth quartile; wealthiest) based on the overall distribution of household income across all household in Sweden. Outcomes included likelihood of diagnosis under surveillance, early-stage diagnosis (Barcelona Clinic Liver Cancer [BCLC] staging 0-A), and receipt of curative treatment (ablation, resection or liver transplantation), as well as mortality risk.

Findings

Among 5490 patients, a significant association was found between low household income and decreased likelihood of diagnosis while under surveillance (adjusted odds ratio [aOR] 0·63; 95% confidence interval [CI]: 0·50-0·80), early-stage diagnosis (aOR 0·58; 95% CI: 0·51-0·67), and curative treatment receipt (aOR 0·65; 95% CI: 0·50-0·85). After adjustments for all variables in the BCLC, other sociodemographic variables, comorbidities, and cirrhosis status, patients with low household income had an adjusted hazard ratio for mortality of 1·29 (95% CI: 1·15-1·45) compared to patients with high household income.

Interpretation

Socioeconomic disparities associate markedly with more advanced stage at HCC diagnosis, less curative treatment, and poorer survival in Sweden. Addressing these disparities through targeted public health interventions may improve HCC care and outcomes in socioeconomically disadvantaged populations.

Funding

The Swedish Cancer Society-Cancerfonden.

A nationwide investigation on imaging follow-up after Locoregional therapy for hepatocellular carcinoma in China: Current practices and challenges

PURPOSE

To investigate the perspectives of interventional radiologists in China on imaging follow-up protocols and adherence to treatment response criteria for hepatocellular carcinoma (HCC) following locoregional therapies (LRT), with a particular focus on identifying gaps and proposing strategies to bridge the discrepancy between clinical guidelines and real-world practice.

MATERIALS AND METHODS

The web-based survey was conducted among members of Chinese Society of Radiology and Zhongda Radiology Alliance between 1st October 2024 to 30th November 2024, via WPS Office survey tool. The frequencies and percentages of responses were summarized as n (%), and a chi-squared test was employed to compare the responses among diagnostic radiologists, interventional radiologists, and interventional physicians.

RESULTS

A total of 604 respondents from 325 hospitals in 31 provinces were analyzed. Of the respondents, 72.7 % (439/604) believed that the same imaging modality should be used for follow-up after conventional transarterial chemoembolization (cTACE) and other LRT for HCC. Among these respondents, contrast-enhanced computed tomography (CE-CT) (57.2 %, 251/439) was the most preferred imaging modality for initial follow-up, and hepatobiliary contrast-enhanced MRI (63.1 %, 277/439) for subsequent follow-up examinations. For respondents (27.3 %, 165/604) who believed that follow-up strategies should be tailored to the type of LRT, CE-CT was most commonly recommended for post-cTACE HCC, both for initial (64.2 %, 106/165) and subsequent (60.6 %, 100/165) follow-up. For HCC treated with other LRT, the majority of respondents preferred extracellular contrast-enhanced MRI for initial follow-up (55.8 %, 92/165) and hepatobiliary contrast-enhanced MRI for subsequent follow-up (61.2 %, 101/165). The most recommended time frame for initial follow-up was "within 1-2 months" among all respondents. However, significant differences in the recommended time frame were observed among diagnostic radiologists, interventional radiologists, and interventional physicians (P < 0.001). Notably, more than 95 % of the respondents who selected 'unclear' were diagnostic radiologists. The most recommended monitoring frequency was every 3-4 months (46.0 %, 278/604) for viable lesions and every 5-6 months (32.9 %, 199/604) for nonviable lesions. Regarding adherence to treatment response criteria, mRECIST (32.0 %, 193/604) and LR-TRA (v2017/v2024) (24.2 %, 146/604) were commonly adopted in clinical practice. Nevertheless, a significant proportion of respondents (25.2 %, 152/604) indicated that none of these criteria were applied in their clinical practice.

CONCLUSION

CE-CT performed within 1-2 months was the most preferred modality and time frame for initial follow-up. Significant variability remains in follow-up frequency and treatment response criteria for post-LRT HCC, highlighting the need for further standardization of imaging follow-up protocols and structured treatment response assessment to optimize post-LRT management in clinical practice.

Systemic therapy plus HAIC versus systemic therapy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) exhibits synergistic anticancer effects with systemic therapy in treating hepatocellular carcinoma (HCC). The approach combining systemic therapy and HAIC is likely to establish a new survival benchmark for advanced HCC. However, related evidence is still lacking.

METHOD

PubMed, Embase, Cochrane Library, and Web of Science were searched from January 1990 to July 2024. The extracted data were pooled using fixed- or random-effects models and expressed as hazard ratios (HRs) or risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Meta-regression, subgroup analysis, prognostic factor analysis, correlation analysis, as well as trial sequential analysis were further conducted.

RESULT

Seventeen trials involving 3070 participants were included. Patients receiving HAIC combined systemic therapy displayed superior overall survival (OS) (HR, 0.52; 95% CI, 0.48-0.58), progression-free survival (PFS) (HR, 0.54; 95% CI, 0.46-0.63), objective response rate (ORR) (RR, 2.20; 95% CI, 1.77-2.72) and disease control rate (RR, 1.21; 95% CI, 1.14-1.29) over systemic therapy. Combining HAIC resulted in higher incidences of grade ≥3 manageable adverse events. Subgroup analyses showed that HAIC could bring significant survival improvement for almost all specific populations; however, patients without portal vein tumor thrombosis might not benefit from it (HR, 0.74; 95% CI, 0.53-1.03). Prognostic factor analyses found extra HAIC was a protective factor for both OS (HR, 0.42; 95% CI, 0.34-0.51) and PFS (HR, 0.44; 95% CI, 0.36-0.53). Correlation analyses demonstrated a robust association between ORR and OS when applying systemic therapy with HAIC ( P -value = 0.031). In addition, trial sequential analyses visually showed the present data were compelling to draw reliable conclusions.

CONCLUSION

With manageable toxicity, integrating HAIC with systemic therapy could bring favorable survival benefits for HCC patients. Further evidence is necessary to standardize the integration of HAIC with first-line systemic therapy.

Hepatobiliary phase MRI-guided radiofrequency ablation of small hepatocellular carcinomas invisible on precontrast MRI

PURPOSE

In cirrhotic livers reliable visualization and exact localization of small hepatocellular carcinoma (HCC) can be challenging without adequate contrast enhancement. To investigate the feasibility, technical success rate, and safety of hepatobiliary phase MRI-guided percutaneous radiofrequency ablation (RFA) of small HCCs invisible on precontrast MRI.

METHODS

53 patients (17f, 63.6 ± 16.7 years), with small HCC that were not visible in non-contrast MRI underwent MRI guided RFA. Feasibility was assessed by analyzing proper identification of the target tumor, tumor delineation during MRI-guided needle positioning and number of needle adjustments required for accurate placement. Technical success was defined as complete ablation with a safety margin of 5 mm. Safety was assessed from reports of procedure-related complications.

RESULTS

In all 53 cases, target tumors were not visible in non-contrast MRI but in the hepatobiliary phase. In 5 cases, planning imaging showed new tumors, which were either treated in the same session (n = 4) or altered the therapeutic approach (n = 1). Mean tumor diameter was 9.7 ± 1.9 mm and the number of needle adjustments was 5 ± 3. Post-ablation imaging showed a technical success rate of 98 % (51 cases, 55 tumors). No major complications occurred. Follow-up imaging (26.2 ± 22.4 month) showed no local tumor progression or recurrence.

CONCLUSIONS

Use of the hepatobiliary phase for MRI-guided ablation of otherwise MR-occult tumors is a feasible approach for an effective and safe treatment of small HCC nodules.

Hepatocellular carcinoma in people living with HIV

People living with HIV (PLWH) carry a higher risk of developing chronic liver disease and hepatocellular carcinoma (HCC). This relates to shared transmission pathways of HIV and viral hepatitis and a plethora of direct and indirect effects of HIV in the progression of chronic liver disease and HCC. In absence of active cancer treatment, the prognosis of PLWH affected by HCC is worse compared to matched controls without HIV. Evolving evidence suggests that PLWH may receive curative therapies including liver transplantation, loco-regional and systemic anti-cancer therapy for HCC with comparable benefit than people without HIV, underscoring that well controlled HIV infection should not be a barrier to the delivery of cancer care. Nevertheless, PLWH have historically been excluded from interventional clinical trials, and most of the evidence supporting clinical decision making in this population comes from small retrospective studies, adding further challenges to the management of PLWH affected by HCC. Furthermore, whether the biology of the tumour and its microenvironment is influenced by HIV and affects response to treatment is incompletely understood. In this review we summarise the current understanding of pathophysiology, screening and management of HCC in PLWH and discuss the persisting challenges and disparities in care which may contribute to clinical outcome in PLWH.

Systemic treatment in patients with hepatocellular carcinoma and advanced liver dysfunction

Systemic therapy represents the standard of care treatment for patients with advanced hepatocellular carcinoma (HCC). Given the increased risk of death from cirrhosis-related complications in patients with advanced liver dysfunction, pivotal phase III trials traditionally limited inclusion to patients with Child-Pugh class A, where death is more likely to be attributed to HCC progression. Therefore, Western guidelines recommend the use of systemic therapies primarily in patients with preserved liver function. However, patients with HCC and Child-Pugh class B are commonly encountered in clinical practice, but due to limited prospective evidence, there is no clear guidance on their optimal management.In this recent advances article, we discuss how the clinical course of cirrhosis can affect eligibility to treatment in the modern era of systemic therapy for HCC, elaborate on strategies to improve liver function in HCC patients by targeting cirrhosis-related and tumour-related factors and summarise the current literature on systemic therapy in HCC patients with Child-Pugh class B. Based on this information, we finally propose a clinical algorithm on how to systematically approach patients with HCC and advanced liver dysfunction in clinical practice.

Diagnostic performance of [18F]FAPI-04 PET/CT in suspected recurrent hepatocellular carcinoma: prospective comparison with contrast-enhanced CT/MRI

PURPOSE

To evaluate the diagnostic performance of [18F]FAPI-04 PET/CT in differentiating hepatocellular carcinoma (HCC) recurrence from treatment-induced lesions (TILs) after therapy and compare it with contrast-enhanced CT/MRI (Ce-CT/MRI).

METHODS

Patients with suspected HCC recurrence after resection or local-regional therapy, who underwent Ce-CT/MRI and [18F]FAPI-04 PET/CT, were prospectively enrolled. For each patient or lesion, a three-point-scale (positive, negative, or equivocal) was assigned to Ce-CT/MRI and [18F]FAPI-04 PET/CT. The diagnostic performances of Ce-CT/MRI, [18F]FAPI-04 PET/CT, and their combination were compared by McNemar's test, with histopathology or radiographic follow-up as a reference standard. The maximum standardized uptake value (SUVmax) and lesion-to-background ratio (LBR) of lesions derived from [18F]FAPI-04 PET/CT were analyzed, and the cut-off points for distinguishing between HCC recurrence and TILs were calculated.

RESULTS

A total of 44 patients with 129 lesions were analyzed, of which 31 patients (91 lesions) were proved to be recurrent HCC and 38 lesions were TILs. On lesion-based analysis, the combination of [18F]FAPI-04 PET/CT with Ce-CT/MRI demonstrated superior sensitivity (86.8% vs. 70.3% vs. 72.5%), specificity (89.5% vs. 42.1% vs. 52.6%), and accuracy (87.6% vs. 62.0% vs. 66.7%) compared to Ce-CT/MRI and [18F]FAPI-04 PET/CT alone (all P < 0.001). The combination altered therapy management in 22.7% of patients. On semiquantitative analysis, the SUVmax and LBR of [18F]FAPI-04 PET in HCC recurrence (n = 91) were significantly higher than those in TILs (n = 38) (SUVmax: 8.1 vs. 3.65, P < 0.001; LBR: 5.4 vs. 1.9, P < 0.001). Using cutoff points of 5.1 for SUVmax and 2.3 for LBR, [18F]FAPI-04 PET/CT exhibited high sensitivity and specificity in differentiating recurrent HCC from TILs, with 83.5%, 78.9% and 96.2%, 63.2%, respectively.

CONCLUSIONS

The combination of [18F]FAPI-04 PET/CT with Ce-CT/MRI significantly improved diagnostic sensitivity, specificity, and accuracy in differentiating recurrent HCC from TILs. [18F]FAPI-04 PET may be a promising imaging modality in detecting recurrent HCC.

TRIAL REGISTRATION

clinicaltrials.gov: NCT05485792.

Neurogastroenterology: The Cinderella among the ecological niches of gastroenterology?

Neurogastroenterology (NGE) refers to a specific sub-specialty of gastroenterology that investigates the pathophysiology, diagnostics and therapeutic approaches to the "disorders of gut-brain interaction" (DGBIs), frequently encountered in clinical practice and often associated with poor quality of life and high healthcare costs. Two recent national surveys, focused on common DGBIs, highlighted two main issues. Despite the high incidence of DGBIs there is a lack of awareness and appropriate training to effectively treat these conditions and a lack of specific referral centers in each region. Indeed, specific training and a multidisciplinary approach are required to properly manage these patients, but these are not always available. As a result, NGE lacks attractiveness for many young gastroenterologists. We believe that NGE has great potential to emerge among the various sub-branches of gastroenterology. However, its growth is limited by lack of specific training, knowledge, accessibility, diagnostic capabilities, multidisciplinary integration, and financial investments in research. To bridge this gap, it would be helpful to overcome these limits through an increase in specific training concerning DGBIs among students, residents, physicians and general practitioners. This, coupled with improved access to advanced diagnostic tests, innovative therapies, and a better multidisciplinary approach, could help expand the knowledge in this still niche area and achieve better treatment outcomes for patients.

Cachexia is an independent predictor of mortality in patients with hepatocellular carcinoma on systemic targeted therapy

BACKGROUND & AIM

This study aimed to investigate the prevalence and prognostic impact of cachexia in patients with unresectable hepatocellular carcinoma (HCC) receiving systemic targeted therapy.

METHODS

This single-center retrospective study included patients with HCC who underwent systemic targeted therapy. Cachexia was defined using novel criteria proposed in 2023. The prognostic impact of cachexia was evaluated using the Cox proportional hazards model.

RESULTS

Of the 200 patients (160 males [80%]; median age, 73 years), cachexia was identified in 70 patients and associated with higher des-gamma-carboxy prothrombin levels, and extrahepatic spread. Patients with cachexia had significantly shorter overall survival (OS) (median 14.1 vs. 20.9 months, p = 0.002) and post-progression survival (PPS) (4.8 vs. 11.1 months, p = 0.001) compared to patients without cachexia. Multivariable analyses revealed cachexia as an independent adverse factor for OS (hazard ratio 1.54; 95% confidence interval 1.03-2.30, p = 0.035) and PPS (hazard ratio 1.64; 95% confidence interval 1.08-2.47, p = 0.018). No significant differences were observed in Progression-free survival between the two groups. Treatment discontinuation due to general appearance deterioration was more common in cachectic patients.

CONCLUSIONS

Cachexia was prevalent among patients with HCC receiving systemic targeted therapy and was identified as an independent predictor of poorer OS and PPS. Given the prognostic impact, the evaluation of cachexia is crucial in managing patients with HCC undergoing systemic targeted therapy.

What can real-world data teach us about treating patients with unresectable hepatocellular carcinoma?

INTRODUCTION

Hepatocellular carcinoma (HCC) remains a major global health concern, as it is the most common primary liver cancer and the fourth leading cause of cancer-related mortality.

AREAS COVERED

Immune checkpoint inhibitors (ICIs) have significantly shifted the treatment paradigm, offering promising survival outcomes. However, the controlled conditions of randomized clinical trials (RCTs) often fail to reflect real-world complexities, emphasizing the necessity for strong real-world evidence (RWE). RWE, in most cases derived from observational studies, provides critical insights into the effectiveness, safety, and tolerability of systemic therapies across diverse populations and settings. The authors searched MEDLINE, Ovid Embase, and Scopus for full-text published articles in any language from the inception to 30 June 2024.This review evaluates RWE on systemic therapies for advanced HCC, including tyrosine kinase inhibitors (TKIs) like sorafenib and lenvatinib, ICIs such as nivolumab and pembrolizumab, and combination therapies like atezolizumab/bevacizumab and durvalumab/tremelimumab.

EXPERT OPINION

Studies reveal discrepancies in treatment efficacy and adverse event profiles between RCTs and routine clinical practice, underscoring the need for individualized treatment strategies. RWE highlights the influence of liver disease etiology, liver function, and tumor burden on treatment outcomes, guiding therapy selection.

Molecular Landscape and Treatment Paradigms of Hepatocellular and Cholangiocarcinoma: A Multinational Review

Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) represent the most prevalent primary liver cancers and pose significant challenges in oncology. While their etiology and incidence vary globally, the molecular landscape of these tumors is increasingly understood, offering new opportunities for precision medicine. In this joint multinational review, we present a comprehensive analysis of the key molecular pathways involved in the pathogenesis of HCC and CCA, highlighting actionable targets for emerging therapies. Recent advances in molecular diagnostics have significantly influenced treatment paradigms for both cancers. In HCC, while genetic alterations have not yet led to established diagnostic or therapeutic applications, targeting vascular endothelial growth factor (VEGF), immune checkpoints, and tyrosine kinase pathways has demonstrated considerable therapeutic potential. In CCA, genetic profiling has uncovered actionable alterations, such as FGFR2 fusions and IDH1 mutations, driving the development of targeted therapies. The growing complexity of precision oncology underscores the need for standardized molecular testing and streamlined diagnostic workflows to ensure timely and effective treatment. This review also emphasizes the importance of collaborative efforts between clinicians, pathologists, and oncologists to optimize outcomes. By synthesizing the latest molecular insights and treatment trends, this review provides a valuable resource to guide the personalized management of HCC and CCA.

GINS1 is a prognostic biomarker and correlated with methylation and immune escape in liver hepatocellular carcinoma

GINS1 is correlated with a poor prognosis in numerous cancers including liver hepatocellular carcinoma (LIHC). Here, efforts have been made to explore the function and underlying mechanism in LIHC through bioinformatics analysis. The mRNA and protein expression data of GINS1 were downloaded from The Cancer Genome Atlas (TCGA) database, the Clinical Proteomic Tumor Analysis Consortium (CPTAC), the University of Alabama at Birmingham CANcer Data Analysis Portal (UALCAN), and the Human Protein Atlas (HPA) database. Moreover, the protein expression of GINS1 was further substantiated by immunohistochemistry staining from 116 clinical samples. Subsequently, the diagnostic and prognostic role of GINS1 in LIHC patients were determined using receiver operating characteristic (ROC) analysis and the Kaplan-Meier plotter (KM-plotter) database. GeneMANIA and STRING databases were respectively used to construct gene and protein-protein interaction (PPI) networks of GINS1. Enrichment analyses were conducted to investigate the functions of GINS1. To assess the genetic alterations, methylation, and prognostic value, cBioPortal, and MethSurv databases were utilized. Additionally, Tumor Immune Estimation Resource (TIMER), Tumor-Immune System Interaction Database (TISIDB), and Gene Expression Profiling Interactive Analysis (GEPIA) were used to explore the correlation with tumor immune. Differential expression analyses validated the upregulation of GINS1 in LIHC. Furthermore, the prognostic and diagnostic values of GINS1 were substantiated by the ROC curve, Kaplan-Meier plotters, and forest plots. Further enrichment, methylation, and tumor immune microenvironment analyses showed an intimate connection with GINS1. In conclusion, GINS1 which is correlated with methylation and immune escape may predict the prognosis of LIHC.

Determining safe washout period for immune checkpoint inhibitors prior to liver transplantation: An international retrospective cohort study

BACKGROUND AND AIMS

Immune checkpoint inhibitors (ICIs) are increasingly used in patients with advanced HCC patients awaiting liver transplantation (LT). However, concerns about the risk of posttransplant rejection persist.

APPROACH AND RESULTS

We conducted an international retrospective cohort study including 119 HCC patients who received ICIs prior to LT. We analyzed the incidence of allograft rejection, graft loss, and posttransplant recurrence with a particular focus on the washout period between the last ICI dose and LT. In this study, 24 of the 119 (20.2%) patients experienced allograft rejection with a median time to rejection of 9 days (IQR 6-10) post-LT. A linear relationship was observed between shorter washout periods and higher rejection risk. Washout periods <30 days (OR: 21.3, 95% CI: 5.93-103, p< 0.001) and between 30 and 50 days (OR: 9.48, 95% CI 2.47-46.8, p =0.002) were significantly associated with higher rejection rates in the univariate analysis compared to the washout period above 50 days. Graft loss as a result of rejection occurred in 6 patients (25%) with rejection. No factors related to grafts were associated with rejection. A longer washout period was not associated with a lower recurrence-free survival posttransplantation at 36 months (71% vs. 67%, p =0.71).

CONCLUSIONS

Our findings suggest that a washout period longer than 50 days for ICIs before LT appears to be safe with respect to rejection risk. While these results may help guide clinical decision-making, future prospective studies are essential to establish definitive guidelines.

Recent advances and issues in imaging modalities for hepatocellular carcinoma surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Early detection via surveillance plays a crucial role in enabling curative treatment and improving survival rates. Since the initial randomized controlled trial, biannual ultrasound (US) has been established as the standard surveillance method because of its accessibility, safety, and low cost. However, US has some limitations, including operator dependency, suboptimal sensitivity for early-stage HCC, and challenges such as a limited sonic window that may result in inadequate examination. Alternative imaging modalities, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), have demonstrated higher sensitivity for detecting very early-stage HCC. Recent advancements, such as low-dose CT with deep learning-based reconstruction, have enhanced the safety and feasibility of CT-based surveillance by reducing radiation exposure and amount of contrast media. MRI, particularly with gadoxetic acid or abbreviated protocols, offers superior tissue contrast and sensitivity, although its accessibility and cost remain challenges. Tailored surveillance strategies based on individual risk profiles and integration of advanced imaging technologies have the potential to enhance the detection performance and cost-effectiveness. This review highlights the recent developments in imaging technologies for HCC surveillance, focusing on their respective strengths and limitations.

Management of hepatocellular carcinoma in elderly and adolescent/young adult populations

Hepatocellular carcinoma (HCC) presents unique challenges in both the elderly and adolescent/young adult (AYA) populations, requiring distinct management approaches. Recent epidemiological data show an increasing incidence of HCC in both age groups, with elderly cases rising significantly and AYA cases showing trends in specific regions. The clinical characteristics and treatment considerations vary substantially among these populations. Elderly patients with HCC typically present with hepatitis C virus infection, metabolic dysfunction-associated steatotic liver disease, well-differentiated tumors, and multiple comorbidities. In contrast, AYA patients with HCC often present with more aggressive tumor characteristics and predominantly with hepatitis B virus-related diseases. Treatment decisions for elderly patients with HCC require careful consideration of physiological reserves, comprehensive geriatric assessments, and potential complications. Recent studies have demonstrated that elderly patients can achieve outcomes comparable to younger patients across various treatment modalities when properly selected. While surgical outcomes are comparable to those of younger patients with proper selection, less-invasive options such as radiofrequency ablation or transarterial therapies may be more appropriate for some elderly patients. The treatment approach for AYA HCC emphasizes curative intent while considering long-term effects. AYA patients require specialized attention to their psychosocial needs, fertility preservation, and long-term health maintenance. Although data on AYA patients remain limited, they are known to have relatively favorable prognoses despite exhibiting more aggressive tumor characteristics. Management of HCC in both the elderly and AYA populations requires individualized approaches that consider age-specific factors. Both groups benefit from multidisciplinary team involvement and careful consideration of quality of life.

Exploring the Role of Metabolic Hyperferritinaemia (MHF) in Steatotic Liver Disease (SLD) and Hepatocellular Carcinoma (HCC)

The increasing prevalence of the spectrum of Steatotic Liver Disease (SLD), including Metabolic-Associated Steatotic Liver Disease (MASLD), Metabolic-Associated Steatohepatitis (MASH), and progression to Cirrhosis and Hepatocellular Carcinoma (HCC) has led to intense research in disease pathophysiology, with many studies focusing on the role of iron. Iron overload, which is often observed in patients with SLD as a part of metabolic hyperferritinaemia (MHF), particularly in the reticuloendothelial system (RES), can exacerbate steatosis. This imbalance in iron distribution, coupled with a high-fat diet, can further promote the progression of SLD by means of oxidative stress triggering inflammation and activating hepatic stellate cells (HSCs), therefore leading to fibrosis and progression of simple steatosis to the more severe MASH. The influence of iron overload in disease progression has also been shown by the complex role of ferroptosis, a type of cell death driven by iron-dependent lipid peroxidation. Ferroptosis depletes the liver's antioxidant capacity, further contributing to the development of MASH, while its role in MASH-related HCC is potentially linked to alternations in the tumour microenvironment, as well as ferroptosis resistance. The iron-rich steatotic hepatic environment becomes prone to hepatocarcinogenesis by activation of several pro-carcinogenic mechanisms including epithelial-to-mesenchymal transition and deactivation of DNA damage repair. Biochemical markers of iron overload and deranged metabolism have been linked to all stages of SLD and its associated HCC in multiple patient cohorts of diverse genetic backgrounds, enhancing our daily clinical understanding of this interaction. Further understanding could lead to enhanced therapies for SLD management and prevention.

Evolving Indications for Liver Transplantation for Hepatocellular Carcinoma Following the Milan Criteria

Background/Objectives: Since their introduction in the 1990s, the Milan criteria have been the gold standard of indication for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Nevertheless, several institutions have reported wider indication criteria for LT with comparable survival outcomes. Methods: This paper summarizes the recent indications for LT for HCC through a literature review. Results: There are several criteria expanding the Milan criteria, which can be subdivided into the "based on tumor number and size only", "based on tumor number and size plus tumor markers", and "based on tumor differentiation" groups, with the outcomes being comparable to those of patients included within the Milan criteria. Besides the tumor size and number, which are included in the Milan criteria, recent criteria included biomarkers and tumor differentiation. Several retrospective studies have reported microvascular invasion (MVI) as a significant risk factor for postoperative recurrence, highlighting the importance of preoperatively predicting MVI. Several studies attempted to identify preoperative predictive factors for MVI using tumor markers or preoperative imaging findings. Patients with HCC who are LT candidates are often treated while on the waiting list to prevent the progression of HCC or to reduce the measurable disease burden of HCC. The expanding repertoire of chemotherapeutic regiments suitable for patients with HCC should be further investigated. Conclusions: There are several criteria expanding Milan criteria, with the outcomes being comparable to those of patients included within the Milan criteria.

Clinical Applications of Artificial Intelligence (AI) in Human Cancer: Is It Time to Update the Diagnostic and Predictive Models in Managing Hepatocellular Carcinoma (HCC)?

In recent years, novel findings have progressively and promisingly supported the potential role of Artificial intelligence (AI) in transforming the management of various neoplasms, including hepatocellular carcinoma (HCC). HCC represents the most common primary liver cancer. Alarmingly, the HCC incidence is dramatically increasing worldwide due to the simultaneous "pandemic" spreading of metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD currently constitutes the leading cause of chronic hepatic damage (steatosis and steatohepatitis), fibrosis, and liver cirrhosis, configuring a scenario where an HCC onset has been reported even in the early disease stage. On the other hand, HCC represents a serious plague, significantly burdening the outcomes of chronic hepatitis B (HBV) and hepatitis C (HCV) virus-infected patients. Despite the recent progress in the management of this cancer, the overall prognosis for advanced-stage HCC patients continues to be poor, suggesting the absolute need to develop personalized healthcare strategies further. In this "cold war", machine learning techniques and neural networks are emerging as weapons, able to identify the patterns and biomarkers that would have normally escaped human observation. Using advanced algorithms, AI can analyze large volumes of clinical data and medical images (including routinely obtained ultrasound data) with an elevated accuracy, facilitating early diagnosis, improving the performance of predictive models, and supporting the multidisciplinary (oncologist, gastroenterologist, surgeon, radiologist) team in opting for the best "tailored" individual treatment. Additionally, AI can significantly contribute to enhancing the effectiveness of metabolomics-radiomics-based models, promoting the identification of specific HCC-pathogenetic molecules as new targets for realizing novel therapeutic regimens. In the era of precision medicine, integrating AI into routine clinical practice appears as a promising frontier, opening new avenues for liver cancer research and treatment.