Influence of coexisting cirrhosis on outcomes after partial hepatic resection for hepatocellular carcinoma fulfilling the Milan criteria: an analysis of 293 patients

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Surgical Implications for Nonalcoholic Steatohepatitis-Related Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is an aggressive form of liver cancer that arises in a background of chronic hepatic injury. Metabolic syndrome-associated fatty liver disease (MAFLD) and its severe form, nonalcoholic steatohepatitis (NASH), are increasingly common mechanisms for new HCC cases. NASH-HCC patients are frequently obese and medically complex, posing challenges for clinical management. In this review, we discuss NASH-specific challenges and the associated implications, including benefits of minimally invasive operative approaches in obese patients; the value of y90 as a locoregional therapy; and the roles of weight loss and immunotherapy in disease management. The relevant literature was identified through queries of PubMed, Google Scholar, and clinicaltrials.gov. Provider understanding of clinical nuances specific to NASH-HCC can improve treatment strategy and patient outcomes.

Diagnostic performance of non-invasive liver fibrosis scores in patients with early-intermediate hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) arises in individuals with underlying liver disease. Diagnosing the degree of hepatic fibrosis helps to determine the severity of the underlying liver disease and may influence therapeutic decisions in HCC patients. Non-invasive fibrosis scores can be used to estimate the degree of fibrosis in liver disease patients, but most of these scores were developed in patients with viral hepatitis and without HCC. This study explored the ability of the Fibrosis-4 Index (FIB-4), the AST/Platelet Ratio Index (APRI), and the AST/ALT ratio to diagnose or exclude advanced fibrosis (METAVIR F3/4 versus F0-2) in patients with early-intermediate, potentially resectable HCC.

METHODS

We retrospectively reviewed 119 patients who underwent hepatic resection for HCC at a tertiary centre (2007-2019), 75 of whom had advanced fibrosis (prevalence 63%). Histological assessment of the surgical liver specimen was used as a reference standard for the degree of fibrosis.

RESULTS

Overall diagnostic performance was highest for the FIB-4 Index, with an area under the receiver operating characteristic curve (AUROC) of 0.82, compared with 0.78 for APRI, and 0.56 for the AST/ALT ratio. Using established cut-off values, FIB-4 achieved a 90% positive predictive value at the higher cut-off (3.25) and a 90% negative predictive value at the lower cut-off (1.45).

CONCLUSION

The FIB-4 Index could reliably diagnose or exclude advanced fibrosis in patients with early-intermediate HCC, and may thus have a role in guiding therapeutic decisions in these patients.

Exploring the factors affecting the occurrence of postoperative MVI and the prognosis of hepatocellular carcinoma patients treated with hepatectomy: A multicenter retrospective study

OBJECTIVE

To investigate the influencing factors affecting the occurrence of microvascular invasion (MVI) and the prognosis of hepatocellular carcinoma (HCC) patients treated with hepatectomy, and to explore how MVI affects prognosis in subgroups with different prognostic factors.

METHODS

Clinical data of a total of 1633 patients treated surgically for HCC in four treatment centers were included, including 754 patients with MVI. By using the Cox risk regression model and the Mann-Whitney U-test, the common independent influences on prognosis and MVI were made clear. The incidence of MVI in various subgroups was then examined, as well as the relationship between MVI in various subgroups and prognosis.

RESULTS

The Cox risk regression model showed that MVI, Child-Pugh classification, alpha-fetoprotein (AFP), hepatocirrhosis, tumor diameter, lymphocyte-to-monocyte ratio (LMR), and, Barcelona clinic liver cancer (BCLC) grade were independent determinants of overall survival (OS), and MVI, AFP, hepatocirrhosis, tumor diameter, and LMR were influencing determinants for disease-free survival (DFS). The receiver operating characteristic (ROC) curve showed that MVI was most closely associated with patient prognosis compared to other prognostic factors. AFP, hepatocirrhosis, tumor diameter, and LMR were discovered to be common influences on the prognosis of patients with HCC and MVI when combined with the results of the intergroup comparison of MVI. After grouping, it was showed that patients with hepatocirrhosis, positive AFP (AFP ≥ 20 ng/mL), tumor diameter >50 mm, and LMR ≤3.4 had a significantly higher incidence of MVI than patients in other subgroups, and all four subgroups of MVI-positive patients had higher rates of early recurrence and mortality (p < 0.05).

CONCLUSIONS

MVI was found to be substantially linked with four subgroups of HCC patients with hepatocirrhosis, positive AFP, tumor diameter >50 mm, and LMR ≤3.4, and the prognosis of MVI-positive patients in all four subgroups tended to be worse.

Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study

BACKGROUND

To evaluate the impact of tumor size on the perioperative and long-term outcomes of liver resection for hepatocellular carcinoma (HCC).

METHODS

We reviewed the patients' data who underwent liver resection for HCC between November 2009 and 2019. Patients were divided into 3 groups according to the tumor size. Group I: HCC < 5 cm, Group II: HCC between 5 to 10 cm, and Group III: HCC ≥ 10 cm in size.

RESULTS

Three hundred fifteen patients were included in the current study. Lower platelets count was noted Groups I and II. Higher serum alpha-feto protein was noted in Group III. Higher incidence of multiple tumors, macroscopic portal vein invasion, nearby organ invasion and presence of porta-hepatis lymph nodes were found in Group III. More major liver resections were performed in Group III. Longer operation time, more blood loss and more transfusion requirements were found in Group III. Longer hospital stay and more postoperative morbidities were noted in Group III, especially posthepatectomy liver failure, and respiratory complications. The median follow-up duration was 17 months (7-110 months). Mortality occurred in 100 patients (31.7%) and recurrence occurred in 147 patients (46.7%). There were no significant differences between the groups regarding recurrence free survival (Log Rank, p = 0.089) but not for overall survival (Log Rank, p = 0.001).

CONCLUSION

HCC size is not a contraindication for liver resection. With proper selection, safe techniques and standardized care, adequate outcomes could be achieved.

Scientific Hepatectomy for Hepatocellular Carcinoma

With advances in imaging technology and surgical instruments, hepatectomy can be perfectly performed with technical precision for hepatocellular carcinoma (HCC). However, the 5-year tumor recurrence rates remain greater than 70%. Thus, the strategy for hepatectomy needs to be reappraised based on insights of scientific advances. Scientific evidence has suggested that the main causes of recurrence after hepatectomy for HCC are mainly related to underlying cirrhosis and the vascular spread of tumor cells that basically cannot be eradicated by hepatectomy. Liver transplantation and systemic therapy could be the solution to prevent postoperative recurrence in this regard. Therefore, determining the severity of liver cirrhosis for choosing the appropriate surgical modality, such as liver transplantation or hepatectomy, for HCC and integrating newly emerging immune-related adjuvant and/or neoadjuvant therapy into the strategy of hepatectomy for HCC have become new aspects of exploration to optimize the strategy of hepatectomy. In this new area, hepatectomy for HCC has evolved from a pure technical concept emphasizing anatomic resection into a scientific concept embracing technical considerations and scientific advances in underlying liver cirrhosis, vascular invasion, and systemic therapy. By introducing the concept of scientific hepatectomy, the indications, timing, and surgical techniques of hepatectomy will be further scientifically optimized for individual patients, and recurrence rates will be decreased and long-term survival will be further prolonged.

Mixed Hepatocellular Cholangiocarcinoma: A Comparison of Survival between Mixed Tumors, Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma from a Single Center

BACKGROUND

Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy, followed by intrahepatic cholangiocarcinoma (ICC). In addition, there is a mixed form for which only limited data are available. The aim of this study was to compare recurrence and survival of the mixed form within the cohorts of patients with HCC and ICC from a single center.

METHODS

Between January 2008 and December 2020, all patients who underwent surgical exploration for ICC, HCC, or mixed hepatocellular cholangiocarcinoma (mHC-CC) were included in this retrospective analysis. The data were analyzed, focusing on preoperative and operative details, histological outcome, and tumor recurrence, as well as overall and recurrence-free survival.

RESULTS

A total of 673 surgical explorations were performed, resulting in 202 resections for ICC, 344 for HCC (225 non-cirrhotic HCC, ncHCC; 119 cirrhotic HCC, cHCC), and 14 for mHC-CC. In addition, six patients underwent orthotopic liver transplant (OLT) in the belief of dealing with HCC. In 107 patients, tumors were irresectable (resection rate of 84%). Except for the cHCC group, major or even extended liver resections were required. Vascular or visceral extensions were performed regularly. Overall survival (OS) was highly variable, with a median OS of 17.6 months for ICC, 26 months for mHC-CC, 31.8 months for cHCC, and 37.2 months for ncHCC. Tumor recurrence was common, with a rate of 45% for mHC-CC, 48.9% for ncHCC, 60.4% for ICC, and 67.2% for cHCC. The median recurrence-free survival was 7.3 months for ICC, 14.4 months for cHCC, 16 months for mHC-CC, and 17 months for ncHCC. The patients who underwent OLT for mHC-CC showed a median OS of 57.5 and RFS of 56.5 months.

CONCLUSIONS

mHC-CC has a comparable course and outcome to ICC. The cholangiocarcinoma component seems to be the dominant one and, therefore, may be responsible for the prognosis. 'Accidental' liver transplant for mHC-CC within the Milan criteria offers a good long-term outcome. This might be an option in countries with no or minor organ shortage.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Outcome after Resection for Hepatocellular Carcinoma in Noncirrhotic Liver-A Single Centre Study

Liver cirrhosis is the most common risk factor for the development of hepatocellular carcinoma (HCC). However, 10 to 15% of all HCC arise in a non-cirrhotic liver. Few reliable data exist on outcome after liver resection in a non-cirrhotic liver. The aim of this single-centre study was to evaluate the outcome of resection for HCC in non-cirrhotic liver (NC-HCC) and to determine prognostic factors for overall (OS) and intrahepatic recurrence-free (RFS) survival. From 2008 to 2020, a total of 249 patients were enrolled in this retrospective study. Primary outcome was OS and RFS. Radiological and pathological findings, such as tumour size, number of nodules, Tumour-, Nodes-, Metastases- (TNM) classification and vascular invasion as well as extent of surgical resection and laboratory liver function were collected. Here, 249 patients underwent liver resection for NC-HCC. In this case, 50% of patients underwent major liver resection, perioperative mortality was 6.4%. Median OS was 35.4 months (range 1-151 months), median RFS was 10.5 months (range 1-128 moths). Tumour diameter greater than three centimetres, multifocal tumour disease, vascular invasion, preoperative low albumin and increased alpha-fetoprotein (AFP) values were associated with significantly worse OS. Our study shows that resection for NC-HCC is an acceptable treatment approach with comparatively good outcome even in extensive tumours.

Histological Severity of Cirrhosis Influences Surgical Outcomes of Hepatocellular Carcinoma After Curative Hepatectomy

Background

Hepatocellular carcinoma (HCC) is frequently associated with cirrhosis. The present study investigated the impact of histological severity of cirrhosis on surgical outcomes for HCC and further developed novel nomograms to predict postoperative recurrence and survival.

Methods

A total of 1524 consecutive patients undergoing curative hepatectomy for HCC between 1999 and 2015 were retrospectively studied. Cirrhotic severity was histologically staged according to the Laennec staging system. Short- and long-term outcomes were investigated. Recurrence-free survival (RFS) and overall survival (OS) predictive nomograms were constructed based on the results of multivariate analysis. The predictive accuracy of the nomograms was measured by the concordance index (C-index) and calibration.

Results

Patients in the severe cirrhosis group had significantly higher morbidity and mortality rates than patients in the no, mild, and moderate cirrhosis groups. The 5-year RFS and OS rates were 36.8% and 64.5%, respectively, in the no cirrhosis group, compared to 34.8% and 60.4% in the mild cirrhosis group, 17.3% and 43.4% in the moderate cirrhosis group, and 6.1% and 20.1% in the severe cirrhosis group. Long-term survival outcomes were significantly worse as cirrhotic severity was increased. The C-index was 0.727 for the RFS nomogram and 0.746 for the OS nomogram. Calibration curves showed good agreement between actual observations and nomogram predictions. The 2 nomograms had a superior discriminatory ability to predict RFS and OS compared to other staging systems.

Conclusion

Histological severity of cirrhosis significantly affected surgical outcomes in HCC patients undergoing curative hepatectomy. The novel nomograms, including histological severity of cirrhosis, showed an accurate prediction of postoperative recurrence and survival.

Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma

BACKGROUND

Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC.

METHODS

An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained.

RESULTS

Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality.

CONCLUSION

One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.

Radiation Segmentectomy for the Treatment of Solitary Hepatocellular Carcinoma: Can Outcomes Be Compared to Surgical Resection?

PURPOSE

To investigate outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR) as a quality endeavor.

MATERIALS AND METHODS

A multisite, retrospective, analysis of treatment-naïve patients who received either RS or SR was performed. Inclusion criteria were solitary HCC ≤8 cm, Eastern Cooperative Oncology Cohort performance status 0-1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time-to-progression (TTP), and overall survival were assessed. Outcomes were censored for liver transplantation.

RESULTS

123 patients were included (RS:57, SR:66). Tumor size, Child-Pugh class, ALBI score, platelet count, and fibrosis stage were significantly different between cohorts (p≤0.01). Grade ≥3 adverse events per Clavien-Dindo classification occurred in 0 RS vs 13(20%) SR patients. Target tumor progression occurred in 3(5%) RS and 5(8%) SR patients, and overall progression in 19(33%) RS and 21(32%) SR patients. Median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95%CI:15.5-28.2 and 95%CI:18.5-40.3, p=0.03). Overall TTP subgroup analyses showed no difference between cohorts with fibrosis stage 3-4 (p=0.26) and platelets <150x10⁹/L (p=0.29). The overall progression hazard ratio for RS vs SR was not significant per multivariate cox regression analysis (1.16, 95%CI:0.51-2.63, p=0.71). Median overall survival was not reached for either cohort. Propensity scores were calculated but were too dissimilar for matching.

CONCLUSION

Radiation segmentectomy and surgical resection are performed in different patient populations, which limits comparison. Radiation segmentectomy approaches surgical resection outcomes, with a lower incidence of major adverse events, in patients who are not eligible for hepatectomy.

Prognostic Influence of Spontaneous Tumor Rupture in Patients With Hepatocellular Carcinoma After Hepatectomy: A Meta-Analysis of Observational Studies

Objective: This study aims to comprehensively analyze the influence of spontaneous tumor rupture on the prognosis of hepatocellular carcinoma patients following hepatic resection.

Methods: We systematically searched four online electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, for eligible studies published from inception to March 2021. The main endpoints were overall survival (OS) and disease-free survival (DFS).

Results: This meta-analysis included 21 observational articles with 57,241 cases. The results revealed that spontaneous tumor rupture was associated with worse OS (hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.33–2.05) and DFS (HR, 1.42; 95% CI, 1.12–1.80) in resectable hepatocellular carcinoma patients. This phenomenon was observed in most subgroups, which were classified by recorded survival time, age, country, alpha-fetoprotein (AFP) concentration, liver cirrhosis, and microvascular invasion. However, in subgroups of macrovascular invasion positive, spontaneous tumor rupture was not a risk factor for OS (HR, 1.55; 95% CI, 0.99–2.42) and DFS (HR, 1.23; 95% CI, 0.91–1.65) in hepatocellular carcinoma patients after hepatectomy. For macrovascular invasion negative, compared with non-ruptured hepatocellular carcinoma patients, ruptured hepatocellular carcinoma patients exhibited worse prognosis for OS (HR, 1.55; 95% CI, 0.99–2.42) and DFS (HR, 1.23; 95% CI, 0.91–1.65) following hepatectomy.

Conclusions: Spontaneous tumor rupture was a prognostic risk factor for hepatocellular carcinoma patients after hepatic resection. However, in macrovascular invasion patients, spontaneous tumor rupture was not a prognostic risk factor.

Effect of Severity of Liver Cirrhosis on Surgical Outcomes of Hepatocellular Carcinoma After Liver Resection and Microwave Coagulation

BACKGROUND

Liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) are both considered as radical treatments for small hepatocellular carcinoma (HCC). However, it is still unclear whether to select LR or PMCT in HCC patients with different degrees of liver cirrhosis. The purpose of this study was to compare the efficacy of LR and PMCT in the treatment of solitary and small HCC accompanied with different degrees of liver cirrhosis.

METHODS

In this study, 230 patients with solitary HCC lesions ≤ 3 cm and Child-Pugh A liver function were retrospectively reviewed. Among these patients, 122 patients underwent LR, and 108 received PMCT. The short- and long-term outcomes were compared between these two procedures. Severity of liver cirrhosis was evaluated by using clinical scoring system (CSS) as previously published. Subgroup analysis based on CSS was performed to evaluate the effect of severity of liver cirrhosis on surgical outcomes after LR and PMCT.

RESULTS

There was no mortality within 90 days in both groups. Major complications were significantly more frequent in the LR group than in the PMCT group (18.8% vs. 4.6%, p<0.001). However, LR provided better surgical outcomes than PMCT. The 5-year overall survival (OS) rates for the LR and PMCT groups were 65.2% and 42%, respectively (p=0.006), and the corresponding disease-free survival (DFS) rates were 51.7% and 31.5%, respectively (p=0.004). Nevertheless, subgroup analysis showed that PMCT provided long-term outcomes that were similar to LR and lower surgical complications in HCC patients with CSS score≥4.

CONCLUSIONS

LR may provide better OS and DFS rates than PMCT for patients with solitary HCC lesions ≤ 3 cm and Child-Pugh A liver function irrespective of liver cirrhosis. PMCT should be viewed as the optimal treatment for solitary and small HCC with severe cirrhosis.

Impact of Postoperative Complications on Long-Term Survival of Hepatocellular Carcinoma Patients After Liver Resection

Objective

The effect of postoperative complications including red blood cell transfusion (BT) on long-term survival for hepatocellular carcinoma (HCC) is unknown. The purpose of this study was to define the relationship between postoperative complications and long-term survival in patients with HCC.

Methods

Postoperative complications of 1251 patients who underwent curative liver resection for HCC were classified, and their recurrence-free survival (RFS) and cumulative overall survival (OS) were investigated.

Results

Any complications occurred in 503 patients (40%). Five-year RFS and 5-year OS in the complication group were 21% and 56%, respectively, significantly lower than the respective values of 32% (P &lt; 0.001) and 68% (P &lt; 0.001) in the no-complication group (n = 748). Complications related to RFS were postoperative BT [hazard ratio (HR): 1.726, 95% confidence interval (CI): 1.338–2.228, P &lt; 0.001], pleural effusion (HR: 1.434, 95% CI: 1.200–1.713, P &lt; 0.001) using Cox proportional-hazard model. Complications related to OS were postoperative BT (HR: 1.843, 95% CI: 1.380–2.462, P &lt; 0.001), ascites (HR: 1.562, 95% CI: 1.066–2.290, P = 0.022), and pleural effusion (HR: 1.421, 95% CI: 1.150–1.755, P = 0.001).

Conclusions

Postoperative complications were factors associated with poor long-term survival. Postoperative BT and pleural effusion were noticeable complications that were prognostic factors for both RFS and OS.

Non-cirrhotic hepatocellular carcinoma in chronic viral hepatitis: Current insights and advancements

Primary liver cancers carry significant morbidity and mortality. Hepatocellular carcinoma (HCC) develops within the hepatic parenchyma and is the most common malignancy originating from the liver. Although 80% of HCCs develop within background cirrhosis, 20% may arise in a non-cirrhotic milieu and are referred to non-cirrhotic-HCC (NCHCC). NCHCC is often diagnosed late due to lack of surveillance. In addition, the rising prevalence of non-alcoholic fatty liver disease and diabetes mellitus have increased the risk of developing HCC on non-cirrhotic patients. Viral infections such as chronic Hepatitis B and less often chronic hepatitis C with advance fibrosis are associated with NCHCC. NCHCC individuals may have Hepatitis B core antibodies and occult HBV infection, signifying the role of Hepatitis B infection in NCHCC. Given the effectiveness of current antiviral therapies, surgical techniques and locoregional treatment options, nowadays such patients have more options and potential for cure. However, these lesions need early identification with diagnostic models and multiple surveillance strategies to improve overall outcomes. Better understanding of the NCHCC risk factors, tumorigenesis, diagnostic tools and treatment options are critical to improving prognosis and overall outcomes on these patients. In this review, we aim to discuss NCHCC epidemiology, risk factors, and pathogenesis, and elaborate on NCHCC diagnosis and treatment strategies.

Rethinking the Barcelona clinic liver cancer guidelines: Intermediate stage and Child-Pugh B patients are suitable for surgery?

According to Barcelona Clinic Liver Cancer recommendations, intermediate stage hepatocellular carcinomas (stage B) are excluded from liver resection and are referred to palliative treatment. Moreover, Child-Pugh B patients are not usually candidates for liver resection. However, many hepatobiliary centers in the world manage patients with intermediate stage hepatocellular carcinoma or Child-Pugh B cirrhosis with liver resection, maintaining that hepatic resection is not contraindicated in selected patients with non-early-stage hepatocellular carcinoma and without normal liver function. Several studies demonstrate that resection provides the best survival benefit for selected patients in very early/early and even in intermediate stages of Barcelona Clinic Liver Cancer classification, and this treatment gives good results in the setting of multinodular, large tumors in patients with portal hypertension and/or Child-Pugh B cirrhosis. In this review we explore this controversial topic, and we show through the literature analysis how liver resection may improve the short- and long-term survival rate of carefully selected Barcelona Clinic Liver Cancer B and Child-Pugh B hepatocellular carcinoma patients. However, other large clinical studies are needed to clarify which patients with intermediate stage hepatocellular carcinoma are most likely to benefit from liver resection.

Sub-Classification of Cirrhosis Affects Surgical Outcomes for Early Hepatocellular Carcinoma Independent of Portal Hypertension

Severity of liver cirrhosis is distinct from clinical portal hypertension because there exist different degrees of liver cirrhosis in hepatocellular carcinoma (HCC) patients without significant clinical portal hypertension. Whether severity of cirrhosis affects surgical outcomes for HCC patients in absence of portal hypertension or not remains unclear. This study aims to analyze the effect of cirrhotic severity on surgical outcomes for HCC patients with hepatitis B virus (HBV) infection in absence of portal hypertension. This retrospective study enrolled 166 patients who underwent curative resection for a single HCC ≤5 cm in absence of portal hypertension between February 2011 and December 2013. Liver cirrhosis was sub-classified into no/mild (no/F4A) and moderate/severe (F4B/F4C) according to the Laennec scoring system. The surgical outcomes and complications were analyzed. The surgical mortality was zero in this study. Major complications were apparently higher in the F4B/F4C group than in the no/F4A group (17.0% vs 7.4%, p <0.001). The 1-year, 3-year and 5-year overall survival (OS) rates were 98.5, 88.1 and 80%, respectively, in the no/F4A group, which were significantly higher than those in the F4B/F4C group (98.0, 69.2 and 54.7%, p = 0.001). Microscopic vascular invasion, absence of tumor capsule and severity of liver cirrhosis were independent risk factors of surgical outcomes for HCC patients without portal hypertension. In conclusion, severity of liver cirrhosis affected surgical outcomes for early-stage HCC patients independent of portal hypertension.

Elevated serum alpha-fetoprotein levels are associated with poor prognosis of hepatocellular carcinoma after surgical resection: A systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

The relationship between the alpha-fetoprotein (AFP) level and the prognosis of hepatocellular carcinoma (HCC) after surgical resection remains unknown. This study aims to assess this relationship.

PATIENTS AND METHODS

PubMed and Web of Science were systematically utilised. Meta-analysis was conducted for the outcomes of the recurrence-free survival (RFS) and the overall survival (OS) by comparing the high AFP group with the low AFP group.

RESULTS

The studies included 61 manuscripts with 35,461 patients. The summary hazard ratio (HR) for RFS was 1.501 (95% CI 1.355-1.662; Z = 7.81, P < 0.00001) when comparing the high AFP group with the low AFP group. Sensitivity analysis only included adjusted HRs, with the summary HR being 1.563 (95% CI 1.381-1.768; Z = 7.10, P < 0.00001). The summary HR for OS was 1.565 (95% CI 1.439-1.701; Z = 10.52, P < 0.00001) when comparing two AFP groups. Sensitivity analysis showed that the summary HR was 1.611 (95% CI 1.456-1.782; Z = 9.24, P < 0.00001).

CONCLUSION

Our meta-analysis indicated that elevated serum AFP levels are associated with poor prognosis of HCC after surgical resection.

Post-hepatectomy liver failure after hepatic resection for hepatocellular carcinoma: a single center experience

PURPOSE

Post-hepatectomy liver failure (PHLF) is one of the most feared morbidities after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to investigate the incidence and predictors of PHLF after LR for HCC and its impact on survival outcomes.

METHODS

We reviewed the patients who underwent LR for HCC during the period between January 2010 and 2019.

RESULTS

Two hundred sixty-eight patients were included. Patients were divided into two groups according to the occurrence of PHLF, defined according to ISGLS. The non-PHLF group included 138 patients (51.5%), while the PHLF group included 130 patients (48.5%). Two hundred forty-six patients (91.8%) had hepatitis C virus. Major liver resections were more performed in the PHLF group (40 patients (30.8%) vs. 18 patients (13%), p = 0.001). Longer operation time (3 vs. 2.5 h, p = 0.001), more blood loss (1000 vs. 500 cc, p = 0.001), and transfusions (81 patients (62.3%) vs. 52 patients (37.7%), p = 0.001) occurred in PHLF group. The 1-, 3-, and 5-year Kaplan-Meier overall survival rates for the non-PHLF group were 93.9%, 79.5%, and 53.9% and 73.2%, 58.7%, and 52.4% for the PHLF group, respectively (log rank, p = 0.003). The 1-, 3-, and 5-year Kaplan-Meier disease-free survival rates for the non-PHLF group were 77.7%, 42.5%, and 29.4%, and 73.3%, 42.9%, and 25.3% for the PHLF group, respectively (log rank, p = 0.925). Preoperative albumin, bilirubin, INR, and liver cirrhosis were significant predictors of PHLF in the logistic regression analysis.

CONCLUSION

Egyptian patients with HCC experienced higher PHLF incidence after LR for HCC. PHLF significantly affected the long-term survival of those patients.

Treatment effect of radiofrequency ablation versus liver transplantation and surgical resection for hepatocellular carcinoma within Milan criteria: a population-based study

OBJECTIVES

Restricted mean survival time (RMST) has been increasingly used to assess the treatment effect. We aimed to evaluate a treatment effect of radiofrequency ablation (RFA) versus liver transplantation (LT) and surgical resection (SR) for hepatocellular carcinoma (HCC) within Milan criteria by using an adjusted RMST.

METHODS

A total of 7,218 HCC patients (RFA, 3,327; LT, 2,332; SR 1,523) within Milan criteria were eligible for this retrospectively study. The RMST using inverse probability of treatment weighting (IPTW) adjustment were applied to estimate the treatment effect between RFA and LT, RFA, and SR groups.

RESULTS

The 3-, 5-, and 10-year IPTW-adjusted difference in RMST of OS for LT over RFA were + 4.5, + 12.4, and + 36.3 months, respectively. For SR versus RFA group, the survival benefit was + 2.3, + 6.1, and + 15.8 months at 3, 5, and 10 years, respectively. But the incremental survival benefit of SR over RFA was only half than that of LT over RFA. In the subgroup of solitary tumor ≤ 2 cm, the adjusted RMST of RFA versus SR was comparable with no statistical differences. Beyond that, in comparison with RFA, a notably greater efficacy of LT and SR was consistently across all subgroups with solitary HCC > 2.0 cm, AFP positive or negative, and fibrosis score 0-4 or 5-6.

CONCLUSIONS

RMST provides a measure of absolute survival benefit at a specific time point. Using IPTW-adjusted RMST, we showed that the incremental survival benefit of SR over RFA was about half than that of LT over RFA.

KEY POINTS

• The restricted mean survival time offers an intuitive, clinically meaningful interpretation to quantify the treatment effect than the hazard ratio. • Liver transplantation and surgical resection provided better overall survival compared to radiofrequency ablation for HCC patients within Milan criteria, but RFA and SR provide equivalent long-term overall survival for solitary HCC ≤ 2 cm. • The incremental survival benefit of surgical resection over radiofrequency ablation was only half than that of liver transplantation over radiofrequency ablation.

Prognostic nomogram for hepatocellular carcinoma with fibrosis of varying degrees: a retrospective cohort study

Background

Hepatocellular carcinoma (HCC) is a common and biologically aggressive malignancy linked to cirrhotic and pre-cirrhotic changes in the liver. We analyzed degrees of fibrosis in affected patients as indices of survival, to establish an effective prognostic nomogram.

Methods

Eligible patients with HCC and hepatic fibrosis, of varying degrees, were selected from the Surveillance, Epidemiology, and End Results (SEER) database for propensity score matching (PSM). The prognostic value of data was determined using Kaplan-Meier and Cox proportional hazards model. A nomogram based on variables derived from multivariate analyses was established and subjected to internal validation. Its predictive accuracy was tested by concordance index (C-index) and calibration plots.

Results

In this propensity score-matched cohort, advanced fibrosis/cirrhosis (vs. none-to-moderate fibrosis) correlated with poorer survival [hazard ratio (HR): 1.131, 95% confidence interval (CI): 1.032-1.240; P=0.009]. Multivariate analysis identified the following as independent risk factors for HCC: age >63 years, higher fibrosis score, American Joint Cancer Committee (AJCC) stages T3-4, distant metastasis (M1), tumor size >1 cm, major vascular invasion, and elevated alpha-fetoprotein (AFP) level. A nomogram that integrated these factors offered a superior prognostic prediction for HCC patients (C-index: 0.749, 95% CI: 0.7485-0.7495) relative to conventional tumor staging the AJCC tumor-node-metastasis (TNM) staging system (0.730). In calibration plots, optimal agreement between nomogram-predicted and observed survival was evident.

Conclusions

Increased fibrosis was an independent risk factor for survival of HCC patients. A prognostic nomogram integrating fibrosis score and other independent risk factors offered more accurate depictions in this regard.

Systematic review of outcomes and meta-analysis of risk factors for prognosis after liver resection for hepatocellular carcinoma without cirrhosis

Long-term overall survival (OS) after liver resection for non-cirrhotic hepatocellular carcinoma (NCHCC) has been reported recently. The aim of this study was to review outcomes systematically and analyze risk factors for survival after surgical resection for HCC without cirrhosis. A literature search was performed of the PubMed and Embase databases for papers published between January 1995 and October 2012, which focused on hepatic resection for HCC without underlying cirrhosis. Cochrane systematic review methodology was used for this review. Outcomes were OS, operative mortality and disease-free survival (DFS). Pooled hazard ratios (HR) were calculated using the random effects model for parameters considered as potential prognostic factors. Totally, 26 retrospective case series were eligible for inclusion. The 1-, 3- and 5-year OS rate after surgical resection of NCHCC ranged from 62% to 100%, 46.3%-78.0%, and 30%-64%, respectively. The corresponding DFS rates ranged from 48.7% to 84%, 31.0%-66.0%, and 24.0%-58.0%, respectively. Five variables were related to poor survival: multiple tumors (HR 1.68, 95%CI 1.25-2.11); larger tumor size (HR 2.66, 95%CI 1.69-3.63); non-clear resection margin (R0 resection) (HR 3.52, 95%CI 1.63-5.42); poor tumor stage (HR 2.61, 95%CI 1.64-3.58); and invasion of the lymphatic vessels (HR 4.85, 95%CI 2.67-7.02). In sum, hepatic resection provides excellent OS rates for patients with NCHCC, and results have tended to improve recently. Risk factors for poor prognosis comprise multiple tumors, lager tumor size, non-R0 resection and invasion of the lymphatic vessels.

Impact of diseased liver parenchyma on perioperative outcome among patients with hepatocellular carcinoma undergoing hepatectomy: Experience from a developing country

INTRODUCTION

Limited data can be found about surgical outcome of patients with hepatocellular carcinoma (HCC) arising in non-diseased liver. The study aim was to compare short- and long-term outcomes among HCC patients with normal and diseased liver parenchyma, undergoing potentially curative liver resection in a developing country.

MATERIALS AND METHODS

From November 2001 until January 2017, 228 patients with HCC underwent curative-intent hepatectomy at the University Clinic for Digestive Surgery. From that number, 190 patients were eligible for analysis. Diseased liver (DL) was present in 112 patients while 78 patients had HCC in non-diseased liver (NDL).

RESULTS

Median age, sex, ASA score, the presence of extrahepatic disease and lobar distribution of tumors were similar in both groups. The number of tumors was higher in DL group, while tumor diameter was higher in NDL group. Anatomic liver resection and major liver resections were performed more commonly in NDL than in DL group (66.7 vs 47.4%, p = 0.008; 33.3 vs. 15.2%, p = 0.003). Postoperative morbidity was significantly higher in DL group (p = 0.004). Overall survival was statistically longer in NDL group (p = 0.024). By univariate analysis potential prognostic factors for long-term survival were identified: presence of chronic HCV infection, presence of cirrhosis, Child-Pugh score B and operative time longer than 240 min. The last two were confirmed by multivariate analysis as independent negative prognostic factors for overall survival.

CONCLUSION

Liver resection in patients with HCC arising in non-diseased livers, despite of need for extended hepatectomies, provides favorable long-term prognosis.

Characteristics and survival of hepatocellular carcinoma in non-cirrhotic liver

INTRODUCTION

the characteristics, screening, and survival of hepatocellular carcinoma (HCC) for patients without cirrhosis have not been fully studied.

METHODS

A retrospective cohort study was performed in non-cirrhotic patients with histological HCC, between January 2004 and October 2018. Their characteristics, treatment, follow-up and overall survival were described.

RESULTS

25 of the 332 patients with HCC met the inclusion criteria (7.5%), 76% were males and the median age was 69.9 years. The main etiology of liver disease was the hepatitis B virus (HBV) (32%), followed by non-alcoholic steatohepatitis (NASH) (20%). Liver fibrosis was mild (0-1) in 44% of cases. The nodule was diagnosed by ultrasonography in 32% of cases, 60% were found incidentally and 8% due to clinical symptoms. The Barcelona Clinic Liver Cancer (BCLC) staging was 0 in 4% of cases, A in 88%, B in 4% and C in 4%. The main initial treatment was surgical resection (76%) and 8% refused to be treated. Percutaneous ethanol injection, chemoembolization, sorafenib and palliative care were each performed in 4% of cases. There were some complications in 21% of patients treated with surgery, half of them were severe. The median follow-up was 22.2 (2.9-150.6) months and 56% were in remission and the median overall survival was 57.4 ± 29.8 months. The overall cumulative survival at 1, 3 and 5 years was 84%, 61.6% and 47.9%, respectively.

CONCLUSION

7.5% of HCC presented without cirrhosis and almost half of patients had mild fibrosis. HBV was the main cause of HCC, followed by NASH. The most frequent BCLC stage at diagnosis was early stage and surgery was the most common treatment. Overall cumulative survival at 5 years was almost 50%.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

BACKGROUND AND AIMS

Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients.

METHODS

We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding.

RESULTS

We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23-1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99-1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21-3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31-2.00).

CONCLUSIONS

Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Resection vs Transplant Listing for Hepatocellular Carcinoma: An Intention-to-Treat Analysis

BACKGROUND

Liver transplantation (LT) and liver resection (LR) are curative treatment options for patients with hepatocellular carcinoma within the Milan criteria. Severe organ shortage dictates the preference for LR. Our aim was to provide an intention-to-treat retrospective comparison of survival between patients who were placed on waiting lists for LT and those who underwent LR.

METHODS

The medical records of patients with hepatocellular carcinoma within the Milan criteria treated by LR or listed for LT between 2007 and 2016 were reviewed. We performed intention-to-treat analyses of overall survival and recurrence.

RESULTS

There were 54 patients on the waiting list for LT, and 30 of them underwent LR. Thirteen of the 54 patients (24%) were not transplanted because of disease-related mortality or tumor progression. The median waiting time to transplantation was 304 days. The 90-day mortality was higher in transplanted patients (9.8% vs 3.3%, P = .003). Intention-to-treat survival was similar for the LT and LR groups (5-year survival, 47.8% vs 55%, respectively, P = .185). There was a trend toward improved 5-year disease-free survival for listed patients (56.2% vs 26.3% for patients undergoing LR, P = .15).

CONCLUSION

Intention-to-treat survival is similar in patients undergoing LR and those on waiting lists for LT. There is a 24% risk to drop from the transplant list. The higher perioperative mortality among patients undergoing LT is balanced by a higher tumor recurrence rate after LR.

Serum GP73 predicts posthepatectomy outcomes in patients with hepatocellular carcinoma

BACKGROUND AND AIMS

Serum GP73 is a useful biomarker in assessing hepatic fibrosis degree. The aim of this study was to evaluate the predictive value of serum GP73 level for posthepatectomy short-term outcomes in hepatocellular carcinoma (HCC) patients.

METHODS

A total of 280 patients undergoing liver resection for HCC between October 2015 and April 2018 were included in this study. Detailed preoperative clinicopathological data were collected and GP73 levels in serum obtained the day before hepatectomy were examined. Receiver operating characteristic (ROC) analysis was used to calculate the optimal cutoff of GP73, and independent risk factors for postoperative outcomes was assessed by logistic regression model.

RESULTS

The mean GP73 level in patients was 111.8 ± 153.3 ng/mL. Serum GP73 levels were correlated with the METAVIR fibrosis score. Overall complications occurred in 145 patients and major complications developed in 29 patients. ROC analysis demonstrated that the predictive power of serum GP73 for postoperative outcomes was greater than the Child-Pugh score, ALBI score, FIB-4 index and APRI score. The optimal value of serum GP73 to predict overall complications and major complications was 80.9 and 79.2 respectively. Serum GP73 levels were independent factors affecting the incidence of overall complications (odds ratio [OR], 3.996; 95% CI 2.152-7.421; P < 0.001) and major complications (OR, 4.970; 95% CI 1.654-14.934; P = 0.004) by multivariate analysis.

CONCLUSION

Serum GP73 is a useful tool to stratify HCC patients and to predict short-term outcomes after hepatectomy.

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.

Packed red blood cell donor age affects overall survival in transfused patients undergoing hepatectomy for non-hepatocellular malignancy

BACKGROUND

Patients undergoing hepatectomy often require packed red blood cell (PRBC) transfusion, which has been associated with worse oncologic outcomes. However, limited data exist regarding the impact of PRBC donor factors. We hypothesized that PRBC donor age impacts survival after hepatectomy for non-hepatocellular malignancies.

METHODS

Patients who underwent hepatectomy for non-hepatocellular malignancy from 2005 to 2014 were retrospectively evaluated. Impact of clinicopathologic and PRBC factors on oncologic outcomes were assessed.

RESULTS

Of 149 identified patients, 76 received a perioperative PRBC transfusion (median 2 units). Transfusion was associated with increased median length of stay (8 vs. 6 days; p < 0.01) and median operative blood loss (700 vs. 350 mL; p < 0.01) versus non-transfused, respectively. In transfused patients, receipt of PRBC from older donors compared to younger resulted in decreased RFS (0.94 vs. 2.63 years, respectively; p = 0.02) and OS (1.94 vs. 3.44 years, respectively; p = 0.6). The PRBC donor age was an independent predictor of decreased recurrence free survival on multivariate analysis (HR 2.5, p = 0.04).

CONCLUSIONS

In patients undergoing hepatectomy for non-hepatocellular malignancies and receiving perioperative transfusion, PRBC donor age may impact survival and warrants further investigation.

Nomograms to Predict the Disease-free Survival and Overall Survival after Radiofrequency Ablation for Hepatocellular Carcinoma

Objective The purpose of this study was to construct nomograms for the disease-free survival (DFS) and overall survival (OS) of post-radiofrequency ablation (RFA) patients with hepatocellular carcinoma (HCC). Furthermore, we compared the prognostic predictive ability of these nomograms for estimating per-patient outcomes with that of traditional staging systems. Methods We retrospectively enrolled 298 patients in the training set and 272 patients in the validation set who underwent RFA for HCC. The nomograms for the DFS and OS were constructed from the training set using the multivariate Cox proportional hazards model. The discriminatory accuracy of the models was compared with traditional staging systems by analyzing the Harrell's C-index. Results The DFS nomogram was developed based on the tumor size, tumor number, aspartate aminotransferase (AST), albumin, age, and α-fetoprotein. The OS nomogram was developed based on the tumor size, the model for end-stage liver disease, AST, and albumin. Our DFS and OS nomograms had good calibration and discriminatory abilities in the training set, with C-indexes of 0.640 and 0.692, respectively, that were greater than those of traditional staging systems. The C-indexes of our DFS and OS nomograms were also greater than those of traditional staging systems in the validation set, with C-indexes of 0.614 and 0.657, respectively. RFA patients were stratified into low- and high-risk groups based on the median nomogram scores. High-risk patients receiving surgical resection (SR) were associated with a better DFS and OS than those undergoing RFA. However, the DFS and OS were similar between the low-risk RFA and SR groups. Conclusion We constructed reliable and useful nomograms that accurately predict the DFS and OS after RFA for early-stage HCC patients. These graphical tools are easy to use and will assist physicians during the therapeutic decision-making process.

Impact of hepatocellular carcinoma heterogeneity on computed tomography as a prognostic indicator

We assessed the relationship between the heterogeneity of HCC on preoperative non-contrast-enhanced CT and patient prognosis. The heterogeneity of CT images from 122 patients was assessed and texture feature parameters such as mean, standard deviation (SD), entropy, mean of the positive pixels (MPP), skewness, and kurtosis were obtained using filtration. The relationship between CT texture features and 5-year overall survival (OS) or disease-free survival (DFS) was assessed. Multivariate regression analysis was performed to evaluate the independence of texture feature from clinical or pathological parameters. The Kaplan-Meier curves for OS or DFS was significantly different between patient groups dichotomized by cut-off values for all CT texture parameters with filtration at at least one filter level. Multivariate regression analysis showed the independence of most CT texture parameters on clinical and pathological parameters for OS with filtration at at least one filter level and without filtration except kurtosis. SD, entropy, and MPP with coarse filter, and skewness without filtration showed a significant correlation for DFS. CT texture features of non-contrast-enhanced CT images showed a relationship with HCC prognosis. Multivariate regression analysis showed the possibility of CT texture feature increase the prognostic prediction of HCC by clinical and pathological information.

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.

Impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation for hepatocellular carcinoma: a meta-analysis

Abstracts Objective: To evaluate the impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation for hepatocellular carcinoma (HCC).

METHODS

We searched medical literature databases to identify appropriate studies assessing the impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation from January 1962 to April 2014. Study inclusion criteria were the existence of a control group, a sufficiently long follow-up period and reporting of survival outcomes. We then performed a meta-analysis of these studies.

RESULTS

Our search identified 12 studies from among a possible 1105. A total of 1504 patients were included in our analysis. There was no significant heterogeneity among the studies. In the meta-analysis, preoperative locoregional therapy was not statistically significant in affecting five-year survival rates following liver transplantation (hazard ratio [HR] = 1.06; 95% confidence interval [CI] = 0.82-1.38). For patients meeting the Milan criteria, preoperative locoregional therapy did not affect survival rates following liver transplantation (HR =1.04, 95% CI =0.74-1.45). The recurrence-free survival rate also had no association with preoperative locoregional therapy (HR =1.02, 95% CI =0.70-1.50).

CONCLUSION

Our meta-analysis suggests that preoperative locoregional therapy has no impact on survival following liver transplantation for HCC.

Blood Transfusions and Tumor Biopsy May Increase HCC Recurrence Rates after Liver Transplantation

Introduction. Beneath tumor grading and vascular invasion, nontumor related risk factors for HCC recurrence after liver transplantation (LT) have been postulated. Potential factors were analyzed in a large single center experience. Material and Methods. This retrospective analysis included 336 consecutive patients transplanted for HCC. The following factors were analyzed stratified for vascular invasion: immunosuppression, rejection therapy, underlying liver disease, age, gender, blood transfusions, tumor biopsy, caval replacement, waiting time, Child Pugh status, and postoperative complications. Variables with a potential prognostic impact were included in a multivariate analysis. Results. The 5- and 10-year patient survival rates were 70 and 54%. The overall 5-year recurrence rate was 48% with vascular invasion compared to 10% without (p < 0.001). Univariate analysis stratified for vascular invasion revealed age over 60, pretransplant tumor biopsy, and the application of blood transfusions as significant risk factors for tumor recurrence. Blood transfusions remained the only significant risk factor in the multivariate analysis. Recurrence occurred earlier and more frequently in correlation with the number of applied transfusions. Conclusion. Tumor related risk factors are most important and can be influenced by patient selection. However, it might be helpful to consider nontumor related risk factors, identified in the present study for further optimization of the perioperative management.

Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

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

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

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

Contradicting interplay between insulin-like growth factor-1 and miR-486-5p in primary NK cells and hepatoma cell lines with a contemporary inhibitory impact on HCC tumor progression

In this study, an impaired natural killer (NK) cell cytolytic activity in 135 hepatocellular carcinoma (HCC) patients parallel to a reduced expression level of insulin-like growth factor (IGF)-1 in NK cells of HCC patients has been revealed. Ectopic expression of miR-486-5p, a direct upstream regulator of IGF-1, restored the endogenous level of IGF-1 in NK cells of HCC patients, thus augmenting its cytolytic activity against Huh7 cells in an opposite manner to the IGF-1 siRNAs. Unorthodoxly, over-expression of miR-486-5p in target hepatocytes resulted in the repression of IGF-1, suppression of Huh7 cells proliferation and viability in a similar pattern to the IGF-1 siRNAs. Therefore, this study highlights a potential role of IGF-1 in modulating cytolytic potential of NK cells of HCC patients. miR-486-5p acts in a cell-specific manner, differentially modulating IGF-1 expression in NK cells and their target hepatocytes with a contemporary inhibitory impact on HCC progression.

The FIB-4 score predicts postoperative short-term outcomes of hepatocellular carcinoma fulfilling the milan criteria

BACKGROUND

The fibrosis score 4 (FIB-4) score is a useful tool to determine the degree of hepatic fibrosis. Liver fibrosis and cirrhosis are well-known predictors of postoperative complications after hepatectomy. This study examined the impact of FIB-4 on postoperative short-term outcomes of patients with hepatocellular carcinoma (HCC).

METHODS

Three hundred and fifty patients undergoing hepatectomy for HCC between 2008 and 2013 were enrolled. The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the FIB-4. Univariate and multivariate analysis was performed to identify the risk factors. The correlation of the preoperative FIB-4 value with clinicopathological parameters was examined.

RESULTS

Postoperative complications were observed in 202 (57.7%) patients. The optimal cutoff value of the FIB-4 was set at 2.88 and 3.85 for postoperative complications and intraoperative blood loss respectively. It was also an independent prognostic factor for postoperative complications (hazard ratio [HR], 1.202; 95% CI, 1.076-1.344; P = 0.001) and intraoperative blood loss (HR, 1.196; 95% CI, 1.091-1.343; P < 0.001) by multivariate analysis. The FIB-4 was significantly correlated with age, liver function, coagulation function, blood loss, intraoperative blood transfusion (all P < 0.05).

CONCLUSION

Preoperative FIB-4 is a useful index to predict postoperative outcomes in patients with HCC. The FIB-4 should be assessed routinely for hepatocellular carcinoma patients.

Bioinformatics microarray analysis and identification of gene expression profiles associated with cirrhotic liver

Cirrhosis is the endpoint of liver fibrosis that is accompanied by limited regeneration capacity and complications and is the ultimate cause of death in many patients. Despite this, few studies have thoroughly looked at the gene expression profiles in the cirrhotic liver. Hence, this study aims to identify the genes that were differentially expressed in the cirrhotic liver and to explore the putative related signaling pathway and interaction networks. The gene expression profiles of cirrhotic livers and noncirrhotic livers were examined and compared using microarray gene analysis. Proteins encoded by the differentially expressed genes were analyzed for functional clustering and signaling pathway involvement using MetaCore bioinformatics analyses. The Gene Ontology analysis as well as the Kyoto encyclopedia of Genes and Genomes pathway analysis were also performed. A total of 213 significant genes were differentially expressed at more than a two-fold change in cirrhotic livers as compared to noncirrhotic livers. Of these, 105 upregulated genes and 63 downregulated genes were validated through MetaCore bioinformatics analyses. The signaling pathways and major functions of proteins encoded by these differentially expressed genes were further analyzed; results showed that the cirrhotic liver has a unique gene expression pattern related to inflammatory reaction, immune response, and cell growth, and is potentially cancer related. Our findings suggest that the microarray analysis may provide clues to the molecular mechanisms of liver cirrhosis for future experimental studies. However, further exploration of areas regarding therapeutic strategy might be possible to support metabolic activity, decrease inflammation, or enhance regeneration for liver cirrhosis.

Risk Factors and Post-Resection Independent Predictive Score for the Recurrence of Hepatitis B-Related Hepatocellular Carcinoma

BACKGROUND

Independent risk factors associated with hepatitis B (HBV)-related hepatocellular carcinoma (HCC) after resection remains unknown. An accurate risk score for HCC recurrence is lacking.

METHODS

We prospectively followed up 200 patients who underwent liver resection for HBV-related HCC for at least 2 years. Demographic, biochemical, tumor, virological and anti-viral treatment factors were analyzed to identify independent risk factors associated with recurrence after resection and a risk score for HCC recurrence formulated.

RESULTS

Two hundred patients (80% male) who underwent liver resection for HBV-related HCC were recruited. The median time of recurrence was 184 weeks (IQR 52-207 weeks) for the entire cohort and 100 patients (50%) developed HCC recurrence. Stepwise Cox regression analysis identified that one-month post resection HBV DNA >20,000 IU/mL (p = 0.019; relative risk (RR) 1.67; 95% confidence interval (C.I.): 1.09-2.57), the presence of lymphovascular permeation (p<0.001; RR 2.69; 95% C.I.: 1.75-4.12), microsatellite lesions (p<0.001; RR 2.86; 95% C.I.: 1.82-4.51), and AFP >100ng/mL before resection (p = 0.021; RR 1.63; 95% C.I.: 1.08-2.47) were independently associated with HCC recurrence. Antiviral treatment before resection (p = 0.024; RR 0.1; 95% C.I.: 0.01-0.74) was independently associated with reduced risk of HCC recurrence. A post-resection independent predictive score (PRIPS) was derived and validated with sensitivity of 75.3% and 60.6% and specificity of 55.7% and 79.2%, to predict the 1- and 3-year risks for the HCC recurrence respectively with the hazard ratio of 2.71 (95% C.I.: 2.12-3.48; p<0.001). The AUC for the 1- and 3-year prediction were 0.675 (95% C.I.: 0.6-0.78) and 0.746 (95% C.I.: 0.69-0.82) respectively.

CONCLUSION

Several tumor, virological and biochemical factors were associated with a higher cumulative risk of HCC recurrence after resection. PRIPS was derived for more accurate risk assessment. Regardless of the HBV DNA level, antiviral treatment should be given to patients before resection to reduce the risk of recurrence.

Severity of cirrhosis should determine the operative modality for patients with early hepatocellular carcinoma and compensated liver function

BACKGROUND

The optimum operative treatment for early hepatocellular carcinoma (HCC) in patients with compensated liver function remains controversial. This study aimed to assess the impact of the severity of cirrhosis on survival after liver resection (LR) and to determine the importance of the severity of cirrhosis in operative decision-making for early HCC.

METHODS

The records of 307 patients with HCC with a solitary tumor ≤5 cm undergoing either LR or liver transplantation (LT) were reviewed retrospectively. The Child-Pugh class A patients in the LR group were stratified according to the severity of cirrhosis. Survival of each subgroup was compared with that of the LT group.

RESULTS

Both the recurrence-free survival (RFS) and disease-specific survival (DSS) in the LR group were worse than those in the LT group. Stratification of the Child A patients in the LR group yielded 5-year RFS and DSS rates of 71% and 86%, respectively, for the cirrhosis-free subgroup, 58% and 79% for the mild cirrhosis subgroup, and 25% and 45% for the moderate/severe cirrhosis subgroup. There were no differences in the rates of RFS and DSS between either the cirrhosis-free or mild cirrhosis subgroup and the LT group, whereas the subgroup with moderate/severe cirrhosis had poorer RFS and DSS rates than the LT group.

CONCLUSION

LR is the best treatment for early HCC in patients without cirrhosis or with mild cirrhosis and compensated liver function, whereas LT is recommended for those with moderate/severe cirrhosis, even if their liver function is well compensated.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: 10-year single-center experience

BACKGROUND

Liver resection in cirrhotic patients reported to have higher morbidity and mortality rates compared to non-cirrhotic patients. Recently, there is increased acceptance of laparoscopic approach in liver surgery. However, few reports evaluated laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) in cirrhotic patients. The aim of this study is to evaluate our experience of LLR for HCC and to compare perioperative and long-term outcomes between patients with and without liver cirrhosis (LC).

METHODS

A retrospective analysis of 232 patients who underwent LLR for HCC between 2004 and 2013 was carried out. Patients were divided into two groups according to the pathological status of their liver parenchyma, in terms of presence or absence of LC.

RESULTS

LC group had 141 patients, and non-LC group had 91 patients. There were no statistically significant differences between both groups regarding operation time, blood loss, transfusion requirements, intraoperative complications, hospital stay, and postoperative complications. Long-term oncologic outcomes were comparable between both groups regarding the recurrence rates (p = 0.067), overall survival (OS) rates (p = 0.908), and disease-free survival (DFS) rates (p = 0.197). The 1-, 3-, 5-, and 7-year OS were 91.7, 85.5, 79.4, and 70.1% in LC group, and 93.9, 86, 79.5, and 72.3% in non-LC group. The 1-, 3-,5-, and 7-year DFS were 75.3, 52.4, 42.6, and 32.7% in LC group, and 74.1, 57.6, 55.3, 50.2% in non-LC group.

CONCLUSIONS

LLR for HCC is feasible in patients with LC. Cirrhotic patients showed comparable perioperative and long-term outcomes to non-cirrhotic patients.

Outcomes of liver resection for hepatocellular carcinoma in liver transplantation era

AIMS

Surgical treatment for early-stage hepatocellular carcinoma (HCC) is toward transplantation. However, liver resection remains the major surgical treatment for HCC in Asia. This study is to examine the results of liver resection when liver transplantation became an option of treatment for early-stage HCC.

METHODS

In this retrospective cohort study, 1639 patients with resectable HCC were reviewed and divided into two groups. In the 1st period (2002-2005), all 679 patients received liver resection. In the 2nd period (2006-2010), 916 patients had liver resection and 44 patients jointed liver transplantation program. The results of treatment in these two periods were analyzed.

RESULTS

The characteristics of tumors were the most important factors of tumor recurrence after liver resection. Liver function reserve, characteristics of tumors, and surgeons' endeavor were all independent factors for overall survival after liver resection. When the patients with oligo-nodular tumors or portal hypertension with low platelet count had liver transplantation rather than liver resection in the 2nd period, the survival rates in the 2nd period were improved. When the patients in the 1st period with low platelet count (≤105 × 10(3)/uL) were subtracted, the 5-year survival rate of the patients with one-segmentectomy for small-sized HCC in the 1st period was similar to those in the 2nd period and transplant patients.

CONCLUSIONS

The outcomes of liver resection were improved while liver transplantation was performed for the patients with suspicious portal hypertension. Platelet count, 105 × 10(3)/uL, could be a watershed for early stage HCC patients to undergo liver resection or liver transplantation.

Surgical resection and liver transplantation for hepatocellular carcinoma

With a better understanding of the natural history of hepatocellular carcinoma (HCC) and the improvement in imaging, locoregional therapies, surgical techniques, and postoperative care, patients with HCC are now managed by a multidisciplinary team. Partial hepatic resection can be curative in patients developing HCC in the setting of normal liver parenchyma and in patients with early cirrhosis but well-preserved hepatic synthetic function. Liver transplantation offers the best long-term survival and lowest incidence of tumor recurrence in select patients with HCC and underlying cirrhosis. This article discusses the role of surgical resection and liver transplantation in the management of HCC.