A simplified prediction model for early intrahepatic recurrence after hepatectomy for patients with unilobar hepatocellular carcinoma without macroscopic vascular invasion: An implication for adjuvant therapy and postoperative surveillance

Tumor necrosis as a predictor of early tumor recurrence after resection in patients with hepatoma

BACKGROUND

Tumor necrosis is a significant risk factor affecting patients' prognosis after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to develop a model with tumor necrosis as a variable to predict early tumor recurrence in HCC patients undergoing LR.

MATERIALS AND METHODS

Patients who underwent LR between 2010 and 2018 for newly diagnosed HCC but did not receive neoadjuvant therapy were enrolled in this retrospective study. Six predictive factors based on pathological features-tumor size > 5 cm, multiple tumors, high-grade tumor differentiation, tumor necrosis, microvascular invasion, and cirrhosis-were chosen a priori based on clinical relevance to construct a multivariate logistic regression model. The variables were always retained in the model. The impact of each variable on early tumor recurrence within one year of LR was estimated and visualized using a nomogram. The nomogram's performance was evaluated using calibration plots with bootstrapping.

RESULTS

Early tumor recurrence was observed in 161 (21.3%) patients. The concordance index of the proposed nomogram was 0.722. The calibration plots showed good agreement between nomogram predictions and actual observations of early recurrence.

CONCLUSION

We developed a nomogram incorporating tumor necrosis to predict early recurrence of HCC after LR. Its predictive accuracy is satisfactory.

Value of Non-tumoral Liver Volume in the Prognosis of Large Hepatocellular Carcinoma Patients After R0 Resection

BACKGROUND AND AIMS

Hepatectomy is an effective treatment for selected patients with large hepatocellular carcinoma (HCC). This study aimed to develop a nomogram incorporating non-tumoral liver volume (non-TLV) and liver function markers to predict the patients' overall survival (OS) and disease-free survival (DFS).

METHODS

Data of 198 consecutive large HCC patients who underwent hepatectomy at the Zhongshan Hospital Xiamen University were collected. Another 68 patients from the Mengchao Hepatobiliary Surgery Hospital served as an external validation cohort. The nomograms were developed based on the independent prognostic factors screened by multivariate Cox regression analyses. Concordance index (C-index), calibration curves, and time-dependent receiver operating characteristic (ROC) curves were used to measure the discrimination and predictive accuracy of the models.

RESULTS

High HBV DNA level, low non-TLV/ICG, vascular invasion, and a poorly differentiated tumor were confirmed as independent risk factors for both OS and DFS. The model established in this study predicted 5-year post-operative survival and DFS in good agreement with the actual observation confirmed by the calibration curves. The C-indexes of the nomograms in predicting OS and DFS were 0.812 and 0.823 in the training cohort, 0.821 and 0.846 in the internal validation cohort, and 0.724 and 0.755 in the external validation cohort. The areas under the ROC curves (AUCs) of nomograms for predicted OS and DFS at 1, 3, and 5 year were 0.85, 0.86, 0.83 and 0.76, 0.76, 0.63, respectively.

CONCLUSIONS

Nomograms with non-TLV/ICG predicted the prognosis of single large HCC patients accurately and effectively.

Pre-operative MRI features predict early post-operative recurrence of hepatocellular carcinoma with different degrees of pathological differentiation

PURPOSE

To investigate the value of pre-operative gadoxetate disodium (Gd-EOB-DTPA) enhanced MRI predicting early post-operative recurrence (< 2 years) of hepatocellular carcinoma (HCC) with different degrees of pathological differentiation.

METHODS

Retrospective analysis of pre-operative MR imaging features of 177 patients diagnosed as suffering from HCC and that underwent radical resection. Multivariate logistic regression assessment was adopted to assess predictors for HCC recurrence with different degrees of pathological differentiation. The area under the curve (AUC) of receiver operating characteristics (ROC) was utilized to assess the diagnostic efficacy of the predictors.

RESULTS

Among the 177 patients, 155 (87.5%) were males, 22 (12.5%) were females; the mean age was 49.97 ± 10.71 years. Among the predictors of early post-operative recurrence of highly-differentiated HCC were an unsmooth tumor margin and an incomplete/without tumor capsule (p = 0.037 and 0.033, respectively) whereas those of early post-operative recurrence of moderately-differentiated HCC were incomplete/without tumor capsule, peritumoral enhancement along with peritumoral hypointensity (p = 0.006, 0.046 and 0.004, respectively). The predictors of early post-operative recurrence of poorly-differentiated HCC were peritumoral enhancement, peritumoral hypointensity, and tumor thrombosis (p = 0.033, 0.006 and 0.021, respectively). The AUCs of the multi-predictor diagnosis of early post-operative recurrence of highly-, moderately-, and poorly-differentiated HCC were 0.841, 0.873, and 0.875, respectively. The AUCs of the multi-predictor diagnosis were each higher than for those predicted separately.

CONCLUSIONS

The imaging parameters for predicting early post-operative recurrence of HCC with different degrees of pathological differentiation were different and combining these predictors can improve the diagnostic efficacy of early post-operative HCC recurrence.

A Multiparametric Fusion Radiomics Signature Based on Contrast-Enhanced MRI for Predicting Early Recurrence of Hepatocellular Carcinoma

Objectives

The postoperative early recurrence (ER) rate of hepatocellular carcinoma (HCC) is 50%, and no highly reliable predictive tool has been developed yet. The aim of this study was to develop and validate a predictive model with radiomics analysis based on multiparametric magnetic resonance (MR) images to predict early recurrence of HCC.

Methods

In total, 302 patients (training dataset: n = 211; validation dataset: n = 91) with pathologically confirmed HCC who underwent preoperative MR imaging were enrolled in this study. Three-dimensional regions of interest of the entire lesion were accessed by manually drawing along the tumor margins on the multiple sequences of MR images. Least absolute shrinkage and selection operator Cox regression were then applied to select ER-related radiomics features and construct radiomics signatures. Univariate analysis and multivariate Cox regression analysis were used to identify the significant clinico-radiological factors and establish a clinico-radiological model. A predictive model of ER incorporating the fusion radiomics signature and clinico-radiological risk factors was constructed. The diagnostic performance and clinical utility of this model were measured by receiver-operating characteristic (ROC), calibration curve, and decision curve analyses.

Results

The fusion radiomics signature consisting of 6 radiomics features achieved good prediction performance (training dataset: AUC = 0.85, validation dataset: AUC = 0.79). The predictive model of ER integrating clinico-radiological risk factors and the fusion radiomics signature improved the prediction efficacy with AUCs of 0.91 and 0.87 in the training and validation datasets, respectively. Furthermore, the nomogram and ER risk stratification system based on the predictive model demonstrated encouraging predictions of the individualized risk of ER and gave three risk groups with low, intermediate, or high risk of ER.

Conclusions

The proposed predictive model incorporating clinico-radiological factors and the fusion radiomics signature derived from multiparametric MR images may be an effective tool for the individualized prediction of postoperative ER in patients with HCC.

Long-Term Survival and Risk Factors in Patients with Hepatitis B-Related Hepatocellular Carcinoma: A Real-World Study

A retrospective cohort study was conducted to collect 465 patients with hepatitis B-related hepatocellular carcinoma who had undergone radical hepatectomy from January 1, 2012, to August 31, 2018, at the First Affiliated Hospital of the University of Science and Technology of China. The clinical, pathological, and follow-up information was collected to compare the basic characteristics of death and nondeath after radical resection. Kaplan-Meier curves were used for survival analysis and male and female subgroup analysis. The multivariate Cox proportional-hazards regression model was used to analyze independent risk factors related to postoperative death. Of the 465 patients with radical resection of hepatitis B-related hepatocellular carcinoma, 132 died, and 1-, 3-, and 5-year cumulative survival rates after operation were 92.1%, 78%, and 64%, respectively. In the male and female subgroup, 115 and 17 patients died, respectively. The 1-, 3-, and 5-year cumulative survival rates were 92.6%, 77.0%, and 62.6%, respectively, in men, and 89.6%, 78.8%, and 70.2%, respectively, in women. Multivariate Cox proportional-hazards regression analysis showed that microvascular invasion (MVI), Edmondson III/IV, BCLC stage B, and total bilirubin (TB) > 20.5 μmol/L were independent risk factors in patients with hepatitis B-related hepatocellular carcinoma after radical hepatectomy.

The Significance of Systemic Inflammation Markers in Intrahepatic Recurrence of Early-Stage Hepatocellular Carcinoma after Curative Treatment

Simple Summary

This retrospective study using the prospectively collected registry data of newly diagnosed, previously untreated hepatocellular carcinoma (HCC) evaluates the significance of systemic inflammatory markers (SIMs) to intrahepatic recurrence (IHR) after curative treatment. Out of 4076 patients who met the inclusion criteria, 52.6% experienced IHR. SIMs, including pre-treatment platelet-to-lymphocyte ratio (PLR), post-treatment changes of neutrophil-to-lymphocyte ratio PLR, and lymphocyte-to-monocyte ratio were significantly associated with the prognosis of early-stage HCC patients who received initial curative treatment. The prognostic significances of SIMs were consistent for IHR-free survival, early and late IHR, and overall survival.

Abstract

Systemic inflammatory markers (SIMs) are known to be associated with carcinogenesis and prognosis of hepatocellular carcinoma (HCC). We evaluated the significance of SIMs in intrahepatic recurrence (IHR) of early-stage HCC after curative treatment. This study was performed using prospectively collected registry data of newly diagnosed, previously untreated HCC between 2005 and 2017 at a single institution. Inclusion criteria were patients with Barcelona Clinic Liver Cancer stage 0 or A, who underwent curative treatment. Pre-treatment and post-treatment values of platelet, neutrophil, lymphocyte, monocyte, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) were analyzed with previously well-known risk factors of HCC to identify factors associated with IHR-free survival (IHRFS), early IHR, and late IHR. Of 4076 patients, 2142 patients (52.6%) experienced IHR, with early IHR in 1018 patients (25.0%) and late IHR in 1124 patients (27.6%). Pre-treatment platelet count and PLR and post-treatment worsening of NLR, PLR, and LMR were independently associated with IHRFS. Pre-treatment platelet count and post-treatment worsening of NLR, PLR, and LMR were significantly related to both early and late IHR. Pre-treatment values and post-treatment changes in SIMs were significant factors of IHR in early-stage HCC, independent of previously well-known risk factors of HCC.

Prediction of early recurrence of hepatocellular carcinoma after resection based on Gd-EOB-DTPA enhanced magnetic resonance imaging: a preliminary study

BACKGROUND

Early recurrence (ER) after radical resection of hepatocellular carcinoma (HCC) affects the prognosis of patients. Gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) can improve the detection rate of small HCC. This study innovatively introduces a new quantitative index combined with qualitative index to compare the differences in clinical and imaging characteristics between ER and non-ER groups and evaluate the feasibility of Gd-EOB-DTPA-enhanced MRI in predicting ER.

METHODS

A total of 68 patients with HCC confirmed by operation and pathology in the Shandong Cancer Hospital and Institute were included retrospectively. All participants were examined by Gd-EOB-DTPA-enhanced MRI within 3 weeks before surgery. Regular follow-up was performed every 2 months within 1 year after operation. Among them, 18 cases with new lesions were in ER group, and 50 cases without new lesions were in non-ER group. The clinical and imaging data of the 2 groups were collected, and the differences of clinical data and preoperative MRI signs between the ER group and non-ER group were compared. The predictive factors of ER after HCC were analyzed by multivariate logistic regression.

RESULTS

The quantitative parameter lesion-to-liver contrast enhancement ratio (LLCER) can predict the pathological grade of HCC (P=0.023). The results of univariate analysis between the ER group and non-ER group showed that there were significant differences in pathological grade (P=0.008), lesion morphology (P=0.011), peritumoral low signal intensity in hepatobiliary phase (HBP) (P<0.001), satellite nodules (P<0.001), and LLCER (P<0.001) between the 2 groups. Multivariate logistic regression analysis showed that HBP peritumoral low signal intensity [odds ratio (OR) =7.214, 95% confidence interval (CI): 1.230-42.312, P=0.029], satellite nodules (OR =9.198, 95% CI: 1.402-60.339, P=0.021), and parameter LLCER value (OR =0.906, 95% CI: 0.826-0.995, P=0.039) were independent predictors of ER of HCC after resection.

CONCLUSIONS

Preoperative Gd-EOB-DTPA enhanced MRI has important predictive value for early recurrence after radical resection of hepatocellular carcinoma.

Weighted Gene Coexpression Network Analysis in Mouse Livers following Ischemia-Reperfusion and Extensive Hepatectomy

In mouse models, the recovery of liver volume is mainly mediated by the proliferation of hepatocytes after partial hepatectomy that is commonly accompanied with ischemia-reperfusion. The identification of differently expressed genes in liver following partial hepatectomy benefits the better understanding of the molecular mechanisms during liver regeneration (LR) with appliable clinical significance. Briefly, studying different gene expression patterns in liver tissues collected from the mice group that survived through extensive hepatectomy will be of huge critical importance in LR than those collected from the mice group that survived through appropriate hepatectomy. In this study, we performed the weighted gene coexpression network analysis (WGCNA) to address the central candidate genes and to construct the free-scale gene coexpression networks using the identified dynamic different expressive genes in liver specimens from the mice with 85% hepatectomy (20% for seven-day survial rate) and 50% hepatectomy (100% for seven-day survial rate under ischemia-reperfusion condition compared with the sham group control mice). The WGCNA combined with Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) enrichment analyses pinpointed out the apparent distinguished importance of three gene expression modules: the blue module for apoptotic process, the turquoise module for lipid metabolism, and the green module for fatty acid metabolic process in LR following extensive hepatectomy. WGCNA analysis and protein-protein interaction (PPI) network construction highlighted FAM175B, OGT, and PDE3B were the potential three hub genes in the previously mentioned three modules. This work may help to provide new clues to the future fundamental study and treatment strategy for LR following liver injury and hepatectomy.

Systematic review and meta-analysis of validated prognostic models for resected hepatocellular carcinoma patients

BACKGROUND

Many prognostic models for Hepatocellular Carcinoma (HCC) have been developed to inform patients and doctors about individual prognosis. Previous reviews of these models were qualitative and did not assess performance at external validation. We assessed the performance of prognostic models for HCC and set a benchmark for biomarker studies.

METHODS

All externally validated models predicting survival for patients with resected HCC were systematically reviewed. After selection, we extracted descriptive statistics and aggregated c-indices using meta-analysis.

RESULTS

Thirty-eight validated prognostic models were included. Models used on average 7 (IQR:4-9) prognostic factors. Tumor size, tumor number, and vascular invasion were almost always included. Alpha-fetoprotein (AFP) was commonly incorporated since 2007. Recently, the more subjective items ascites and encephalopathy have been dropped. Eight established models performed poor to moderate at external validation, with a pooled C-index below 0.7; including the Barcelona Clinic Liver Cancer (BCLC) system, the American Joint Committee on Cancer (AJCC) 7th edition, the Cancer of the Liver Italian (CLIP) Program, and the Japan Integrated Staging (JIS) score. Out of 24 prognostic models predicting OS, only 6 (25%) had good performance at external validation with pooled C-indices above 0.7; the Li-post (0.77), Li-OS (0.74), Yang-pre (0.74), Yang-post (0.76), Shanghai-score (0.70), and Wang-nomogram (0.71). Models improved over time, but overall performance and study quality remained low.

CONCLUSIONS

Six validated prognostic models demonstrated good performance for predicting survival after resection of HCC. These models can guide patients and doctors and are a benchmark for future models incorporating novel biomarkers.

Preoperative predictors of early recurrence after resection for hepatocellular carcinoma

BACKGROUND

To assess preoperative image tumor characteristics and alpha-fetoprotein (AFP) levels to predict early recurrence after liver resection (LR) for hepatocellular carcinoma (HCC).

METHODS

This retrospective study's enrolled patients underwent LR for newly diagnosed HCC between 2011 and 2018. Multivariate logistic regression analyses using the Akaike information criterion were adopted to construct a nomogram to predict early recurrence (i.e. recurrence within 1 year). The performance of this nomogram was evaluated using calibration plots with bootstrapping.

RESULTS

Early recurrence was identified in 99 patients (11.2%). Four predictive factors, namely an AFP level of >400 ng/mL; image-diagnosed tumor characteristics, including a tumor size of > 5 cm; vascular invasion; and multiple tumors were adopted in the final model of the early recurrence nomogram, with a concordance index of 0.67. The calibration plots showed good agreement between the nomogram predictions and the actual observations of early recurrence.

CONCLUSION

We have developed a simple nomogram with preoperative image tumor characteristics and AFP levels to predict the early recurrence of HCC after LR.

Artificial neural network model to predict post-hepatectomy early recurrence of hepatocellular carcinoma without macroscopic vascular invasion

BACKGROUND

The accurate prediction of post-hepatectomy early recurrence (PHER) of hepatocellular carcinoma (HCC) is vital in determining postoperative adjuvant treatment and monitoring. This study aimed to develop and validate an artificial neural network (ANN) model to predict PHER in HCC patients without macroscopic vascular invasion.

METHODS

Nine hundred and three patients who underwent curative liver resection for HCC participated in this study. They were randomly divided into derivation (n = 679) and validation (n = 224) cohorts. The ANN model was developed in the derivation cohort and subsequently verified in the validation cohort.

RESULTS

PHER morbidity in the derivation and validation cohorts was 34.8 and 39.2%, respectively. A multivariable analysis revealed that hepatitis B virus deoxyribonucleic acid load, γ-glutamyl transpeptidase level, α-fetoprotein level, tumor size, tumor differentiation, microvascular invasion, satellite nodules, and blood loss were significantly associated with PHER. These factors were incorporated into an ANN model, which displayed greater discriminatory abilities than a Cox's proportional hazards model, preexisting recurrence models, and commonly used staging systems for predicting PHER. The recurrence-free survival curves were significantly different between patients that had been stratified into two risk groups.

CONCLUSION

When compared to other models and staging systems, the ANN model has a significant advantage in predicting PHER for HCC patients without macroscopic vascular invasion.

Prognostic impact of adjuvant chemolipiodolization and treatment frequency on patients with hepatocellular carcinoma after hepatectomy: Prospective study with historical control group

BACKGROUND

Reducing or minimizing metastatic recurrence is a consideration in prolongation of survival of patients with hepatocellular carcinoma. We previously proposed single adjuvant chemolipiodolization (ACL) as a possible adjuvant treatment. The current study aims to further improve prognosis by performing ACL three times (sequential-ACL).

METHODS

We examined the prognostic impact of sequential-ACL compared with our historical cohort groups: resection alone (non-ALC) and single-ACL. We evaluated recurrence-free survival (RFS), recurrence pattern, and overall survival. Multivariate prognostic analyses were used to adjust baseline bias between three treatment groups.

RESULTS

Non-ACL (n = 64), single-ACL (n = 137), and sequential-ACL (n = 95) showed 40, 54, and 62% of two-year RFS rates (P = 0.03 and P = 0.007 compared with non-ACL). Recurrence pattern beyond Milan criteria was frequently observed in the non-ACL group (P = 0.003). Five-year overall survival rates of these three groups were 53, 69, and 77% (P = 0.02 and 0.002 compared with non-ACL). Single- and sequential-ACL were selected as independent favorable factors for five-year overall survival; their hazard ratios (95% confidence interval) were 0.61 (0.37-0.99) and 0.48 (0.26-0.86). However, compared with single-ACL, there was no additional prognostic effects of sequential-ACL.

CONCLUSIONS

Single- and sequential-ACL treatment both showed better RFS and overall survival with minimized recurrence patterns than resection alone. There was not sufficient additional benefit by sequential-ACL, however, over single-ACL. Single-ACL might therefore be appropriate as an adjuvant therapy.

Single-center experience on actual mid-term (≥5 years) and long-term (≥10 years) survival outcome in patients with hepatocellular carcinoma after curative hepatectomy: A bimodal distribution

Analysis for actual mid-term (≥5 years) and long-term (≥10 years) survivors with hepatocellular carcinoma (HCC) following curative hepatectomy are rarely reported in the literature.This retrospective study aims to study the mid- and long-term survival outcome and associated prognostic factors following curative hepatectomy for HCC in a tertiary referral center.The clinical data of 325 patients who underwent curative hepatectomy for HCC were reviewed. They were stratified into 3 groups for comparison (Group 1, overall survival <5 years; Group 2, overall survival ≥5, and <10 years; Group 3, overall survival ≥10 years). Favorable independent prognostic factors for mid- and long-term survival were analyzed.A bimodal distribution of actual survival outcome was observed, with short-term (<5 years) survival of 52.7% (n = 171), mid-term survival of 18.1% (n = 59), and long-term survival of 29.2% (n = 95). Absence of microvascular invasion (OR 3.690, 95% CI: 1.562-8.695) was independent good prognostic factor for mid-term survival. Regarding long-term overall survival, young age (OR 1.050, 95% CI: 0.920-0.986), ASA grade ≤2 (OR 3.746, 95% CI: 1.325-10.587), high albumin level (OR 1.008, 95% CI: 0.920-0.986), solitary tumor (OR 3.289, 95% CI: 1.149-7.625) and absence of microvascular invasion (OR 4.926, 95% CI: 2.192-11.111) were independent good prognostic factors.Curative hepatectomy results in bimodal actual survival outcome with favorable long-term survival rate of 29.2%. Favorable independent prognostic factors (age, ASA grade, albumin level, tumor number, and microvascular invasion) are identified for overall survival.