Clinicopathologic risk factors for recurrence after a curative hepatic resection for hepatocellular carcinoma

The appropriate method of hepatectomy for hepatocellular carcinoma within University of California San Francisco (UCSF) criteria through neural network analysis

BACKGROUND

This study aimed to find effective treatments for the patient within UCSF criteria.

METHODS

This study enrolled 1006 patients meeting UCSF criteria, undergoing hepatic resection (HR), divided into two groups: single tumor group and multiple tumors group. We compared and analyzed the risk factors between these two groups' long-term outcomes, through log-rank test, cox proportional hazards model and using neural network analysis to identify the independent risk factors.

RESULTS

The 1-, 3-, and 5-year OS rates in single tumor were significantly higher than multiple tumors (95.0%, 73.2% and 52.3% versus 93.9%, 69.7% and 38.0%, respectively, p < 0.001). The 1-, 3- and 5-year RFS rates were 90.3%, 60.7%, and 40.1% in single tumor and 83.4%, 50.7% and 23.8% in multiple tumors, respectively (p < 0.001). And tumor type, anatomic resection and MVI were the independent risk factors for the patient within UCSF criteria. MVI was the most important risk factor affecting OS and RFS rates in neural network analysis. The method of hepatic resection and the number of tumors were also affected OS and RFS rates.

CONCLUSION

The anatomic resection should be applied to the patient within UCSF criteria, especially for the patient was in single tumor with MVI-negative.

A web-based nomogram model for predicting the overall survival of hepatocellular carcinoma patients with external beam radiation therapy: A population study based on SEER database and a Chinese cohort

BACKGROUND

External beam radiation therapy (EBRT) for hepatocellular carcinoma (HCC) is rarely used in clinical practice. This study aims to develop and validate a prognostic nomogram model to predict overall survival (OS) in HCC patients treated with EBRT.

METHOD

We extracted eligible data of HCC patients between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Those patients were randomly divided into a training cohort (n=1004) and an internal validation cohort (n=429), and an external validation cohort composed of a Chinese cohort (n=95). A nomogram was established based on the independent prognostic variables identified from univariate and multivariate Cox regression analyses. The effective performance of the nomogram was evaluated using the concordance index (C-index), receiver operating characteristic curve (ROC), and calibration curves. The clinical practicability was evaluated using decision curve analysis (DCA).

RESULTS

T stage, N stage, M stage, AFP, tumor size, surgery, and chemotherapy were independent prognostic risk factors that were all included in the nomogram to predict OS in HCC patients with EBRT. In the training cohort, internal validation cohort, and external validation cohort, the C-index of the prediction model was 0.728 (95% confidence interval (CI): 0.716-0.740), 0.725 (95% CI:0.701-0.750), and 0.696 (95% CI:0.629-0.763), respectively. The 6-, 12-,18- and 24- month areas under the curves (AUC) of ROC in the training cohort were 0.835 、0.823 、0.810, and 0.801, respectively; and 0.821 、0.809 、0.813 and 0.804 in the internal validation cohort, respectively; and 0.749 、0.754 、0.791 and 0.798 in the external validation cohort, respectively. The calibration curves indicated that the predicted value of the prediction model performed well. The DCA curves showed better clinical practicability. In addition, based on the nomogram, we established a web-based nomogram to predict the OS of these patients visually.

CONCLUSION

Based on the SEER database and an independent external cohort from China, we established and validated a nomogram to predict OS in HCC patients treated with EBRT. In addition, for the first time, a web-based nomogram model can help clinicians judge the prognoses of these patients and make better clinical decisions.

DJ-1/FGFR-1 Signaling Pathway Contributes to Sorafenib Resistance in Hepatocellular Carcinoma

Sorafenib is the first-line therapeutic regimen targeting against advanced or metastatic stage of hepatocellular carcinoma (HCC). However, HCC patients at these stages will eventually fail sorafenib treatment due to the drug resistance. At present, molecular mechanisms underlying sorafenib resistance are not completely understood. Our past studies have shown that DJ-1 is upregulated in HCC, while DJ-1 knockdown inhibits HCC xenograft-induced tumor growth and regeneration, implying that DJ-1 may be a potential target in for HCC treatment. However, whether DJ-1 plays a regulatory role between tumor cells and vascular endothelial cells and whether DJ-1 contributes to sorafenib resistance in HCC cells are largely unclear. To address these questions, we have performed a series of experiments in the current study, and we found that (1) DJ-1, one of the molecules secreted from HCC cells, promoted angiogenesis and migration of vascular endothelial cells (i.e., ECDHCC-1), by inducing phosphorylation of fibroblast growth factor receptor-1 (FGFR-1), phosphorylation of mTOR, phosphorylation of ERK, and phosphorylation of STAT3; (2) downregulation of FGFR1 inhibited tube formation and migration of ECDHCC-1 cells stimulated by DJ-1; (3) FGFR1 knockdown attenuated the phosphorylation of FGFR1 and impaired the activity of Akt, ERK, and STAT3 signals induced by DJ-1 in ECDHCC-1 cells; (4) knocking down FGFR1 led to the elevated expression of proapoptotic molecules but deceased level of antiapoptotic molecules in sorafenib-resistant HCC cells; and (5) Downregulation of FGFR1 suppressed tumor growth and angiogenesis of sorafenib-resistant HCC cells in vivo. Altogether, our results hinted that DJ-1 plays vital roles in tumor microenvironment in HCC development, and DJ-1/FGFR1 signaling pathway may be a therapeutic target for overcoming sorafenib resistance in treating HCC patients at the late stage.

"Logic-Based Medicine" Is More Feasible than "Evidence-Based Medicine" in the Local Treatment for Hepatocellular Carcinoma

The optimal type of surgery (e.g., anatomic or non-anatomic resection) or radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is still under debate despite numerous comparative studies based on overall survival. This debate continues not only because these endpoints are influenced by non-surgical factors, such as liver function, but because the definition of non-anatomic resection for HCC has remained unclear. The optimal surgery could be logically determined based on the mechanism of local intrahepatic metastasis, that is, the drainage of tumour blood flow (TBF), because HCC spreads locally through tumour blood flowing to the peri-tumourous liver parenchyma. Since TBF is clearly demonstrated by CT scan under hepatic arteriography, the surgical margin can be determined individually based on the drainage of TBF without deteriorating local curability. Controversy regarding RFA and surgery does not result from the curability of treatment itself but from the lack of scientific evidence on safety margins. Based on proper concepts and self-evident truths, an algorithm of loco-regional treatment for HCC is proposed.

CYP3A4 Gene Is a Novel Biomarker for Predicting a Poor Prognosis in Hepatocellular Carcinoma

BACKGROUND/AIM

Project HOPE (High-tech Omics-based Patient Evaluation) began in 2014 using integrated gene expression profiling (GEP) of cancer tissues as well as diathesis of each patient who underwent operation at our Institution. The aim of this study was to identify novel genes displaying altered gene expression related to the survival and early recurrence after hepatectomy for hepatocellular carcinoma (HCC) using the results of integrated GEP analysis.

MATERIALS AND METHODS

The present study included 92 patients. Genes with aberrant expression were selected by the difference of expression levels with ≥10-fold change between tumor and non-tumor tissues.

RESULTS

GEP analysis showed that down-regulation was frequently observed in the PRSS8 (64%), CYP3A4 (61%) and EPCAM (57%) genes. Multivariate analysis revealed tumor stage ≥II (p=0.008) and down-regulation of the CYP3A4 gene (p=0.036) as independent predictor for overall survival. Furthermore, multivariate analysis identified maximum tumor diameter ≥74mm (p=0.008), presence of intrahepatic-metastasis (p=0.020), and down-regulation of CYP3A4 gene (p=0.019) as independent predictors for early recurrence.

CONCLUSION

CYP3A4 was identified as a novel tumor suppressor gene related to a poor prognosis in HCC.

Liver resection of hepatocellular carcinoma in patients with portal hypertension and multiple tumors

AIM

Liver resection for hepatocellular carcinoma (HCC) has been recommended only for patients with a single tumor without portal hypertension. We aimed to validate this treatment strategy that is based on by the Barcelona Clinic Liver Cancer staging system.

METHODS

Patients undergoing liver resection were divided into two groups: patients with single HCC without portal hypertension (Group 1) and those with at least one factors of portal hypertension and multiple tumors, up to three lesions each ≤3 cm (Group 2). We compared survival and postoperative complications between the two groups.

RESULTS

The median overall and recurrence-free survival periods of patients in Group 1 (n = 695) were 8.5 years (95% confidence interval [CI], 6.6-9.0) and 2.4 years (2.2-2.7), respectively, and were significantly longer compared with those of patients in Group 2 (n = 197) (5.6 years [95% CI, 4.8-6.7], P = 0.001, and 1.9 years [1.6-2.1], P < 0.001). On multivariate analysis, the independent factors for overall survival were hepatitis C virus infection (hazard ratio, 1.29 [95% CI, 1.02-1.65], P = 0.032), multiple tumors (1.42 [1.01-1.98], P = 0.040), and vascular invasion (1.66 [1.31-2.10], P < 0.001). Frequency of morbidity (23 [3.3%] patients vs 11 [5.5%] patients, P = 0.143) and mortality (3 [0.4%] patients vs 2 [1.0%] patients, P = 0.305) was not significantly different between the two groups.

CONCLUSIONS

Patients with HCC with portal hypertension and/or multiple tumors could be candidates for liver resection due to the safety of the procedure.

The down-regulation of the CYP2C19 gene is associated with aggressive tumor potential and the poorer recurrence-free survival of hepatocellular carcinoma

Project HOPE (High-tech Omics-based Patient Evaluation) began in 2014 using integrated gene expression profiling (GEP) of cancer tissues as well as diathesis of each patient who underwent an operation at our institution. The aim of this study was to clarify the association between the expression of cytochrome P450s (CYP) genes and recurrence of hepatocellular carcinoma (HCC). The present study included 92 patients. Genes with aberrant expression were selected based on a ≥10-fold difference in the expression between tumor and non-tumor tissues. The GEP analysis showed that the down-regulated genes in tumor tissue were CYP3A4 in 56 patients (61%), CYP2C8 in 44 patients (48%), CYP2C19 in 30 patients (33%), CYP2D6 in 11 patients (12%), CYP3A5 in 7 patients (8%) and CYP1B1 in 2 patients (2%). There was no patients with down-regulation of the CYP17A1 gene. A multivariate analysis revealed that the presence of microscopic portal invasion (hazard ratio [HR] 2.57, 95% confidence interval [CI] 1.30–5.05 P = 0.006), the presence of intrahepatic-metastasis (HR 3.09 95% CI 1.52–6.29 P = 0.002) and down-regulation of the CYP2C19 gene (HR 3.69 95% CI 1.83–7.46 P < 0.001) were independent predictors for the recurrence-free survival (RFS). The down-regulation of the CYP2C19 gene were correlated with the RFS in HCC.

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study

BACKGROUND

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm).

METHODS

We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival.

RESULTS

Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival.

CONCLUSION

Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Strong enhancement by IGF1-R antagonists of hepatocellular carcinoma cell migration inhibition by Sorafenib and/or vitamin K1

PURPOSE

Emerging evidence indicates that combining Sorafenib with vitamin K1 (VK1) may result in a synergistic inhibition of hepatocellular carcinoma (HCC) cell migration and proliferation. Despite this synergy, its benefits may be limited due to drug resistance resulting from cross-talk with the tumor microenvironment. Insulin-like growth factor-1 (IGF1) signaling acts as an important modulator of HCC cell growth, motility and drug resistance. Therefore, we aimed to explore the effects of Sorafenib in combination with VK1 and/or IGF1-R antagonists on HCC cells.

METHODS

Scratch wound migration assays were performed to assess the motility of HCC-derived PLC/PRF/5, HLF and Hep3B cells. The synergistic, additive or antagonistic effects of Sorafenib, VK1 and IGF1-R antagonists on HCC cell motility were assessed using CompuSyn software. The effects mediated by these various compounds on HCC cytoskeleton organization were evaluated using DyLight 554 Phalloidin staining. Proliferation and migration-associated signaling pathways were analyzed in PLC/PRF/5 cells using Erk1/2 and Akt activation kits and Western blotting (Mek, JNK, Akt, Paxillin and p38), respectively.

RESULTS

The effects of the IGF1-R antagonists GSK1838705A and OSI-906 on HCC cell migration inhibition after Sorafenib and/or VK1 administration, individually or in combination, were evaluated. We found a synergistic effect in PLC/PRF/5, HLF and Hep3B cells for combinations of fixed doses of GSK1838705A or OSI-906 together with different doses of Sorafenib and/or VK1. The levels of synergy were found to be stronger at higher Sorafenib and/or VK1 concentrations and lower or absent at lower concentrations, with some variation among the different cell lines tested. In addition, we found that in PLC/PRF/5 and HLF cells IGF1-R blockage strongly enhanced the reduction and redistribution of F-actin induced by Sorafenib and/or VK1 through alterations in the phosphorylation levels of some of the principal proteins involved in the MAPK signaling cascade, which is essential for cell migration.

CONCLUSIONS

Our results indicate that modulation of the efficacy of Sorafenib through combinations with VK1 and/or IGF1-R antagonists results in synergistic inhibition of HCC cell migration.

Elevated ZC3H15 increases HCC growth and predicts poor survival after surgical resection

Zinc finger CCCH-type containing 15 (ZC3H15), also known as DRG family regulatory protein 1 (DFRP1), is a highly conserved eukaryotic protein that associates with active translation machinery. The aim of our study was to explore the clinical relevance and intrinsic functions of ZC3H15 in hepatocellular carcinoma (HCC). We constructed a cohort with 261 tumor and matched normal tissues from HCC patients. ZC3H15 protein and mRNA levels were determined using immunohistochemistry, western blot analysis, and quantitative polymerase chain reaction. ZC3H15 was highly expressed in the majority of HCC cases, and high ZC3H15 levels were significantly associated with high serum a-fetoprotein (AFP) levels (>20 ng/mL) and vascular invasion. Kaplan-Meier and Cox regression data indicated that elevated ZC3H15 was an independent predictor for HCC-specific disease-free survival (hazards ratio [HR], 1.789; 95% confidence interval [95% CI], 1.298-2.466 [P=0.0004]) and overall survival (HR, 1.613; 95% CI, 1.120-2.322 [P=0.0101]). Interaction of ZC3H15 with TRAF2 increased activation of NFκB signaling. These results suggest ZC3H15 is an independent prognostic marker in HCC patients that is clinicopathologically associated with tumor invasion and serum AFP levels.

Impact of diabetes mellitus on the prognosis of patients with hepatocellular carcinoma after curative hepatectomy

BACKGROUND

The influence of diabetes mellitus (DM) on the prognosis of patients with hepatocellular carcinoma (HCC) remains controversial. Here we investigated the impact of DM on the prognosis of such patients after curative hepatectomy.

METHODS

A consecutive cohort of 505 patients with HCC (134 with DM, 371 without) underwent curative hepatectomy were retrospectively evaluated. Postoperative morbidity and mortality, overall survival (OS) and disease-free survival (DFS) were compared between patients with or without DM. Independent prognostic predictors were identified using the Cox proportional hazards model.

RESULTS

Patients with or without DM showed similar morbidity and 30- and 90- day mortality after curative hepatectomy (all P>0.05), as well as similar DFS at 1, 3, 5 years (P = 0.781). However, the group of patients with DM showed significantly lower OS at 1, 3, 5 years than the group without DM (P = 0.038). Similar results were obtained in the propensity-matched cohort. Cox multivariate analysis identified DM as an independent predictor of poor OS, but not of poor DFS. We repeat compared OS and DFS for DM and non-DM subgroups defined according to the presence or absence of hepatitis B virus infection and cirrhosis. Similar results were obtained in all subgroups except the non-cirrhotic subgroup which showed patients with and without DM had similar OS.

CONCLUSIONS

DM does not significantly affect the postoperative morbidity or mortality or the DFS of patients with HCC after curative hepatectomy. It is, however, associated with significantly lower OS, especially in patients with cirrhosis.

DJ-1 knockdown inhibits growth and xenograft‑induced tumor generation of human hepatocellular carcinoma cells

The aim of this study was to identify potential downstream effectors of the oncogene DJ-1 in hepatocellular carcinoma (HCC) cell lines, and examine its role in the Akt signaling pathway and HCC oncogenesis. Expression of the DJ-1 protein was assessed by immunoblotting in several human HCC cell lines. Knockdown of DJ-1 was achieved by transfecting DJ-1-specific short hairpin RNAs into the HepG2 HCC cell line. The effect of DJ-1 downregulation on phosphatase and tensin homolog (PTEN) and phosphorylated Akt was evaluated. In addition, cell cycle, proliferation, adhesion and invasion were analyzed in the DJ-1 knockdown of HepG2 cells. The growth of HepG2‑induced tumor was evaluated in a nude mouse model after DJ-1 silencing. Stable DJ-1 knockdown was achieved in HepG2 cells using a shRNA eukaryotic expression vector. Downregulation of DJ-1 increased PTEN expression but decreased phosphorylation of Akt in HepG2 cells. In addition, DJ-1 knockdown resulted in the decreased proliferation, adhesion and invasion of HepG2 cells in vitro, and inhibited the growth of HepG2-induced tumor in vivo. DJ-1 knockdown altered the malignant behavior of HepG2 cells, potentially through the Akt signaling pathway, suggesting a crucial role for DJ-1 in the oncogenesis of HCC.

Triple positive tumor markers predict recurrence and survival in early stage hepatocellular carcinoma

AIM

Hepatectomy is feasible for patients with hepatocellular carcinoma (HCC) with good hepatic function who meet the Milan criteria. Several studies have indicated that tumor markers of HCC, α-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP percentage and protein induced by vitamin K absence/antagonist-II were good predictors of malignant potential. It is important to identify highly malignant cases of HCC, and the aim of this study was to clarify the impact of triple positive tumor markers as the prognostic factors for early stage HCC within the Milan criteria.

METHODS

This study investigated 199 patients who underwent hepatectomy for HCC within the Milan criteria between January 2001 and May 2009. Cumulative recurrence-free survival (RFS), overall survival (OS) and clinicopathological parameters were analyzed according to the number of positive tumor markers.

RESULTS

In patients with triple positive tumor markers, 5-year RFS and OS was poor (17.1 and 61.4%, respectively). Multivariate analyses revealed independent risk factors for recurrence to be hepatitis C virus antibody positivity, non-initial treatment for HCC and triple positive tumor markers, and the independent risk factors for OS were high indocyanine green retention rate at 15 min value, maximum tumor size and triple positive tumor markers. Pathologically invasive growth, microvascular invasion and moderate to poor differentiation were significantly related to the number of the three tumor markers.

CONCLUSION

Triple positive tumor markers for early stage HCC within the Milan criteria showed poor prognosis and malignant characteristics. These markers could be a useful predictor for the degree of malignant potential in early stage HCC.

18F-FDG-PET/CT predicts the distribution of microsatellite lesions in hepatocellular carcinoma

This study was conducted to investigate whether fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) is useful for predicting the distance of intrahepatic metastases and microvascular invasion from the main tumor and the pattern of postoperative recurrence. A total of 89 consecutive patients who underwent ¹⁸F-FDG PET/CT prior to liver resection for hepatocellular carcinoma (HCC) between April, 2006 and December, 2011 were enrolled in this study. The distance between the microsatellite lesion and the main nodule (microsatellite distance) was analyzed and measured pathologically. The correlation between maximal standardized uptake values (SUVmax) and microsatellite distance was analyzed and the independent risk factors for microsatellite distance >1 cm were assessed. The postoperative recurrence patterns were divided into no recurrence, intrahepatic recurrence and extrahepatic recurrence. SUVmax and the distribution of microsatellite lesions were compared among these groups. The postoperative recurrence patterns were also analyzed according to the SUVmax and the microsatellite lesion pattern. SUVmax was found to be significantly correlated with the distance from the microsatellite lesion to the main nodule (r=0.57, P<0.0001). On the multivariate analysis of microsatellite distance >1 cm, the only significant factor was SUVmax [P=0.002; hazard ratio=1.60; 95% confidence interval (CI): 1.23-2.26]. The optimal cutoff value of SUVmax for microsatellite distance >1 cm was 8.8. The mean SUVmax and the microsatellite distance were highest in patients with postoperative extrahepatic metastases (8.6 and 9,160 μm, respectively). In conclusion, the SUVmax of ¹⁸F-FDG PET/CT reflects microsatellite distance and the patterns of postoperative recurrence in HCC. Therefore, ¹⁸F-FDG PET/CT may be a useful imaging modality for determining the resection margin and the treatment protocol for HCC.

Identification and expression profiles of genes and protens in SMMC-7721 cells

In the study presented here, we first evaluated effect of CDDP on liver cancer cells SMMC-7721 apoptosis and motility capacity. Then, we evaluate inhibitory effect of CDDP on tumour growth and its possible molecular mechanism in liver cancer mice model. Results showed that the apoptosis rate of cells decreased with increasing CDDP. Analysis of the effect of the CDDP on cell cycle was performed by flow cytometry and results show a dose-dependent increase in the percentage of cells in the S-phase of the cell cycle, with a decrease in the percentage of cells in the G1 and G2/M phases. CDDP did not close the wound even after 48 h, as opposed to untreated cells (0 mg/l). Similarly, the migratory and invasion capacity of SMMC-7721 cells was also reduced after treatment with CDDP, as evaluated by a transwell assay. Animal experiment indicated that CDDP administration could increase blood WBC, total protein, albumin and A/G, decrease blood alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase levels in hepatocellular carcinomas mice. Immunohistochemistry analysis showed that positive expression of Fas and Bax proteins in the medicine-treated (II, III) group was significantly higher, whereas the expression of NF-κB, P53, Bcl-2 proteins was significantly lower than those of the control group. Gene expression analysis using Real time PCR methods revealed a significant up-regulation in the expression levels of Bax mRNA in the medicne-treated (II, III) group when compared to untreated control. In contrast, CDDP-treated group showed a significant down regulation in the expression levels of Bcl-2 mRNA as compared to untreated control group. These results are in agreement with immunohistochemistry data. Our observations indicate that CDDP has damaged effects on liver tumour cells SMMC-7721 including apoptosis, motility and cell cycle under in vitro. CDDP can enhance pro-apoptosis gene Fas, Bax expression, decrease anti-apoptosis genes Bcl-2 expression, and mutant genes P53, NF-κB proteins expression.

A re-emerging marker for prognosis in hepatocellular carcinoma: the add-value of fishing c-myc gene for early relapse

Hepatocellular carcinoma is one leading cause of cancer-related death and surgical resection is still one of the major curative therapies. Recently, there has been a major effort to find mechanisms involved in carcinogenesis and early relapse. c-myc gene abnormality is found in hepatocarcinogenesis. Our aim was to analyze the role of c-myc as prognostic factor in terms of overall survival and disease-free survival and to investigate if c-myc may be an important target for therapy. We studied sixty-five hepatocellular carcinomas submitted to surgical resection with curative intent. Size, macro-microvascular invasion, necrosis, number of nodules, grading and serum alfa-fetoprotein level were registered for all cases. We evaluated the c-myc aberrations by using break-apart FISH probes. Probes specific for the centromeric part of chromosome 8 and for the locus specific c-myc gene (8q24) were used to assess disomy, gains of chromosomes (polysomy due to polyploidy) and amplification. c-myc gene amplification was scored as 8q24/CEP8 > 2. Statistical analysis for disease-free survival and overall survival were performed. At molecular level, c-myc was amplified in 19% of hepatocellular carcinoma, whereas showed gains in 55% and set wild in 26% of cases. The 1- and 3-year disease-free survival and overall survival for disomic, polysomic and amplified groups were significantly different (p=0.020 and p=.018 respectively). Multivariate analysis verified that the AFP and c-myc status (amplified vs. not amplified) were significant prognostic factors for overall patients survival. c-myc gene amplification is significantly correlated with disease-free survival and overall survival in patients with hepatocellular carcinoma after surgical resection and this model identifies patients with risk of early relapse (≤12 months). We suggest that c-myc assessment may be introduced in the clinical practice for improving prognostication (high and low risk of relapse) routinely and may have be proposed as biomarker of efficacy to anti-c-myc targeted drugs in clinical trials.

miR-17-5p as a novel prognostic marker for hepatocellular carcinoma

OBJECTIVES

miRNAs are frequently deregulated in cancer and have shown promise as tissue-based markers for cancer classification and prognostication. Emerging evidence indicates that miR-17-5p plays an important role in carcinogenesis. However, the expression of miR-17-5p in HCC tissues and its clinical relevance has not been systematically studied yet, and whether miR-17-5p expression has influence on prognosis of HCC is still unknown. In this study, we investigate the expression and clinical significance of miR-17-5p in human HCC.

METHODS

The expression levels of miR-17-5p were measured in 120 paired hepatocellular carcinoma (HCC) and paracarcinomatous liver tissues (PCLTs) derived from patients who underwent hepatic resection by qRT-PCR. Furthermore, the correlation of miR-17-5p levels with clinicopathologic variables and prognosis was analyzed.

RESULTS

miR-17-5p was significantly upregulated in HCCs (p < .001). Furthermore, HCC with metastasis had higher miR-17-5p levels than that without metastasis (p < .001). Importantly, the elevated expression of miR-17-5p correlated with multiple tumor nodules (p = .046), worse Edmondson-Steiner grade (p = .024), vein invasion (p = .001), shortened overall survival (p = .012), and disease-free survival (p = .011) of HCC. Multivariable Cox regression analysis revealed that miR-17-5p was an independent risk factor for overall survival and disease-free survival (p = .002 and p = .042, respectively).

CONCLUSION

miR-17-5p is highly elevated in HCC, especially in HCC with metastasis. miR-17-5p can serve as a novel prognostic marker for HCC.

Hepatocellular carcinoma in cirrhotic patients with portal hypertension: is liver resection always contraindicated?

AIM

To analyze the outcome of hepatocellular carcinoma (HCC) resection in cirrhosis patients, related to presence of portal hypertension (PH) and extent of hepatectomy.

METHODS

A retrospective analysis of 135 patients with HCC on a background of cirrhosis was submitted to curative liver resection.

RESULTS

PH was present in 44 (32.5%) patients. Overall mortality and morbidity were 2.2% and 33.7%, respectively. Median survival time in patients with or without PH was 31.6 and 65.1 mo, respectively (P = 0.047); in the subgroup with Child-Pugh class A cirrhosis, median survival was 65.1 mo and 60.5 mo, respectively (P = 0.257). Survival for patients submitted to limited liver resection was not significantly different in presence or absence of PH. Conversely, median survival for patients after resection of 2 or more segments with or without PH was 64.4 mo and 163.9 mo, respectively (P = 0.035).

CONCLUSION

PH is not an absolute contraindication to liver resection in Child-Pugh class A cirrhotic patients, but resection of 2 or more segments should not be recommended in patients with PH.

Multikinase inhibitor sorafenib transiently promotes necrosis after radiofrequency ablation in rat liver but activates growth signals

AIM

To investigate the effects of sorafenib when combined with radiofrequency ablation treatment in liver tissue, the necrosis volume, tissue repair and hepatocellular growth signals were analyzed in rats. Radiofrequency ablation (RFA) is a widely applied treatment for hepatocellular carcinoma (HCC). Radiofrequency ablation is combined with the multi-tyrosinkinase-inhibitor sorafenib in ongoing clinical trials. Whether this combination treatment affects liver tissue repair is unknown.

MATERIALS AND METHODS

Male Sprague Dawley (SD) rats received RFA or sham puncture with concomitant sorafenib (5mg/kg qd from day 2) or vehicle. Necrosis volume was calculated from resected specimens. Proliferation and micro vessel density were determined by Ki67 and CD31 immunofluorescence, respectively. mRNA expression of hepatocyte growth factor (HGF), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) was quantified.

RESULTS

While ablation size was identical in all treatment groups at day 1, sorafenib treated animals showed sustained necroses (219 ± 24 vs. 88 ± 52 mm(3) in controls; P = 0.03), elevated alanine aminotransferase (ALT) and elevated glutamate dehydrogenase (GLDH) (76 ± 37 vs. 47 ± 58 mm(3); P=0.50) at day 3. By day 7 necrosis volumes equalized for the treatment groups. Ki67 and CD31 staining showed reduced proliferation and micro vessel density at days 1 and 3 following sorafenib. Growth factors HGF and EGF were significantly overexpressed in liver tissue after sorafenib.

CONCLUSION

Sorafenib initially promotes necrosis after RFA in liver tissue. The delay in tissue repair is overcome at day 7 presumably by transient compensatory overexpression of growth signals. Based on these data from animal studies further investigation of adjuvant sorafenib in humans is warranted.

Preoperative tumor marker doubling time is a useful predictor of recurrence and prognosis after hepatic resection of hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

It is important to identify prognostic factors in patients with hepatocellular carcinoma (HCC) before hepatectomy. No previous studies have addressed the predictive efficacy of the preoperative doubling times of alpha-fetoprotein (AFP) and protein induced by vitamin K absence (PIVKA-II).

METHODS

A total of 210 HCC patients who underwent a hepatic resection between 1998 and 2006 were prospectively evaluated. Serum AFP and PIVKA-II levels were measured at least twice before surgery to calculate the doubling times. Nineteen clinical factors that can be examined preoperatively, including the doubling times of AFP and PIVKA-II were investigated to identify prognostic factors for disease-free and overall survival after hepatectomy.

RESULTS

There was no relationship between preoperative levels and doubling times of AFP and PIVKA-II. In a multivariate analysis, patients with a doubling time of AFP ≤30 days and PIVKA-II ≤16 days showed a significantly worse disease-free (P = 0.02, P = 0.03, respectively) and overall survival (P < 0.0001, P = 0.03, respectively).

CONCLUSIONS

In HCC patients, the doubling times of preoperative serum AFP or PIVKA-II levels are useful tools to predict early postoperative recurrence and a poor prognosis.

Role of surgical resection for pulmonary metastasis of hepatocellular carcinoma

INTRODUCTION

The lung is one of the most important organs affected by metastasis of hepatocellular carcinoma. However, pulmonary metastasectomy for hepatocellular carcinoma has not been well documented. The aim of this study was to evaluate long-term outcome after pulmonary metastasectomy due to metastasis of hepatocellular carcinoma.

METHODS

Between January 1998 and December 2008, 41 patients underwent pulmonary metastasectomy. Retrospective reviews of medical records and telephone surveys were conducted to identify risk factors of long-term survival.

RESULTS

Median time between a complete remission of hepatocellular carcinoma and pulmonary metastasectomy was 11 (4-105) months. During median 25-month follow-up time after metastasectomy, hepatocellular carcinoma recurred in 33 patients. Overall survival rate was 66.9±10% in all 41 patients and disease free survival was 24.5±10% in 24 patients who had no viable hepatocellular carcinoma in the liver preoperatively. An analysis of recurrence revealed that survival was better in patients whose recurrence was limited to either in the liver or lungs compared to that in patients whose recurrence took place in the distant organ other than the liver or lungs (extrahepatic/extrapulmonary metastasis) (p=0.004, log-rank).

CONCLUSIONS

Pulmonary metastasectomy for hepatocellular carcinoma can be performed safely without major morbidity. Recurrence at organs other than the liver or lung was found to result in poor survival, which suggests that a careful search for distant metastasis at other locations is mandatory for patient selection. This study demonstrated that pulmonary metastasectomy can play an important role in selected patients with pulmonary metastasis of hepatocellular carcinoma.

The impact of anatomical resection for hepatocellular carcinoma that meets the Milan criteria

BACKGROUND

The aim of this study was to analyze the impact of anatomical resection for hepatocellular carcinoma (HCC) that meets the Milan criteria.

METHODS

Between 1990 and 2006, 322 consecutive patients with HCC who met the Milan criteria underwent curative resection (R0) and were classified into two groups: Group A (patients with a single HCC, with a tumor diameter of 5 cm or less) and Group B (patients with multiple tumors, no more than three tumor nodules, each with a diameter of 3 cm or less). Patient survival (PS), recurrence-free survival rates (RFS), and risk factors were analyzed.

RESULTS

Univariate analysis revealed that in Group A, anatomical resection was the significant factor related to PS, while anatomical resection was that related to RFS. Multivariate analysis showed that in Group A, anatomical resection was a significant favorite factor associated with PS and RFS. Univariate analysis for Group B revealed that anatomical resection was the significant factor related to PS, while that related to RFS was the anatomical resection. Multivariate analysis showed that anatomical resection was a significant favorite factor for only RFS in Group B.

CONCLUSION

Anatomical resection improved the surgical outcome of the patients with HCC which met the Milan criteria.

Yes-associated protein is an independent prognostic marker in hepatocellular carcinoma

BACKGROUND

Yes-associated protein (YAP), a downstream target of the Hippo signaling pathway, was recently linked to hepatocarcinogenesis in a mouse hepatocellular carcinoma (HCC) model. The objective of the current study was to investigate the clinical significance of YAP in HCC and its prognostic values in predicting survival and tumor recurrence.

METHODS

The authors collected 177 pairs of tumor and adjacent nontumor tissue from HCC patients with definitive clinicopathologic and follow-up data. YAP expression was determined by immunohistochemistry, Western blot analysis, and quantitative polymerase chain reaction. Association of YAP with each clinicopathologic feature was analyzed by Pearson chi-square test, and HCC-specific disease-free survival and overall survival by Kaplan-Meier curves and log-rank test. Multivariate Cox regression analyses of YAP in HCC were also performed.

RESULTS

YAP was expressed in the majority of HCC cases (approximately 62%) and mainly accumulated in the tumor nucleus. Overexpression of YAP in HCC was significantly associated with poorer tumor differentiation (Edmonson grade; P = .021) and high serum alpha-fetoprotein (AFP) level (P < .001). Kaplan-Meier and Cox regression data indicated that YAP was an independent predictor for HCC-specific disease-free survival (hazards ratio [HR], 1.653; 95% confidence interval [95% CI], 1.081-2.528 [P = .02]) and overall survival (HR, 2.148; 95% CI, 1.255-3.677 [P = .005]).

CONCLUSIONS

YAP is an independent prognostic marker for overall survival and disease-free survival times of HCC patients and clinicopathologically associated with tumor differentiation and serum AFP level. It is a potential therapeutic target for this aggressive malignancy.

Yes-associated protein is an independent prognostic marker in hepatocellular carcinoma

BACKGROUND

Yes-associated protein (YAP), a downstream target of the Hippo signaling pathway, was recently linked to hepatocarcinogenesis in a mouse hepatocellular carcinoma (HCC) model. The objective of the current study was to investigate the clinical significance of YAP in HCC and its prognostic values in predicting survival and tumor recurrence.

METHODS

The authors collected 177 pairs of tumor and adjacent nontumor tissue from HCC patients with definitive clinicopathologic and follow-up data. YAP expression was determined by immunohistochemistry, Western blot analysis, and quantitative polymerase chain reaction. Association of YAP with each clinicopathologic feature was analyzed by Pearson chi-square test, and HCC-specific disease-free survival and overall survival by Kaplan-Meier curves and log-rank test. Multivariate Cox regression analyses of YAP in HCC were also performed.

RESULTS

YAP was expressed in the majority of HCC cases (approximately 62%) and mainly accumulated in the tumor nucleus. Overexpression of YAP in HCC was significantly associated with poorer tumor differentiation (Edmonson grade; P = .021) and high serum alpha-fetoprotein (AFP) level (P < .001). Kaplan-Meier and Cox regression data indicated that YAP was an independent predictor for HCC-specific disease-free survival (hazards ratio [HR], 1.653; 95% confidence interval [95% CI], 1.081-2.528 [P = .02]) and overall survival (HR, 2.148; 95% CI, 1.255-3.677 [P = .005]).

CONCLUSIONS

YAP is an independent prognostic marker for overall survival and disease-free survival times of HCC patients and clinicopathologically associated with tumor differentiation and serum AFP level. It is a potential therapeutic target for this aggressive malignancy.

Surgical resection versus laparoscopic radiofrequency ablation in patients with hepatocellular carcinoma and Child-Pugh class a liver cirrhosis

BACKGROUND

This study compared two homogeneous groups of patients submitted to either surgical resection (HR) or laparoscopic radiofrequency ablation (LRFA) for the treatment of hepatocellular carcinoma (HCC). When compatible with the liver functional reserve, HR remains the treatment of choice for HCC, while LRFA seems to be a promising, less invasive alternative. We thus compared HR or LRFA for short- and long-term outcomes in patients with a single HCC nodule and Child-Pugh class A liver cirrhosis.

METHODS

We enrolled 152 cirrhotic patients out of 372 cases consecutively evaluated for HCC. Enrolled patients with similar baseline characteristics underwent HR (n = 78) or LRFA (n = 74), in both cases with intraoperative ultrasonography, and they were then followed for similar durations (mean +/- standard deviation, 36.2 +/- 23.5 months for HR vs. 38.2 +/- 28.4 for LRFA). Outcomes included short- and long-term morbidity, HCC recurrence, and overall survival.

RESULTS

Short-term morbidity was far higher in the HR group while, during follow-up, HCC recurrence (mainly local) was more frequent in patients treated with LRFA. More importantly, baseline alfa-fetoprotein levels and early HCC recurrence after treatment greatly influenced overall survival, while the use of HR or LRFA did not predict it. On the other hand, HCC recurrence was found to be determined by the surgical approach and ultrasound characteristics of the tumor.

CONCLUSIONS

Our data were obtained from a large number of HCC cases and support similar survival rates after HR or LRFA for single HCC nodules on Child-Pugh class A liver cirrhosis, despite a marked increase in HCC recurrence rates after LRFA.

Recurrence patterns after hepatectomy of hepatocellular carcinoma: implication of Milan criteria utilization

BACKGROUND

Bridge hepatectomy followed by salvage liver transplantation has been proposed for patients with hepatocellular carcinoma (HCC) and preserved liver function.

METHODS

Data were prospectively collected for 501 consecutive patients who underwent curative primary hepatectomy for HCC between 1990 and 2006. Patient survival, disease-free survival (DFS), recurrence patterns, and risk factors were analyzed in patients classified according to the Milan criteria.

RESULTS

Patients were divided into two groups on the basis of whether their disease was within the Milan criteria (group 1, n = 321) or not (group 2, n = 180). Group 1 patient survival and DFS rates were 73.6% and 40.6% at 5 years. Recurrence was observed in 160 group 1 patients (49.8%); in 42 (26.3%) of these 160 patients, the recurrence exceeded the Milan criteria. No recurrence was noted in 145 group 1 patients (45.2%). Group 2 patient survival and DFS rates were 52.2% and 23.2%, respectively, at 5 years. Recurrence was noted in 116 patients (64.4%); recurrence in 58 (50.0%) of these patients was within the Milan criteria. In group 2, no recurrence was noted in 55 patients (30.6%). In group 1, indocyanine green retention rate at 15 minutes of >15%, nonanatomical resection, and multiple tumors were statistically significant risk factors for survival; 10-year patient survival was 78.5% for patients with no risk factors and 64.9% for patients with a single risk factor.

CONCLUSIONS

The Milan criteria should be used to recommend hepatectomy for patients with HCC; however, it is important to consider the high recurrence rate after hepatectomy and the possible requirement of salvage transplantation.

Decreased expression of inhibitor of growth 4 correlated with poor prognosis of hepatocellular carcinoma

OBJECTIVE

Inhibitor of growth 4 (ING4) is a candidate tumor suppressor that plays an important role in tumor growth and angiogenesis. Here, we examined the expression of ING4 in hepatocellular carcinoma (HCC) tissues and analyzed its correlation with the progression of HCC.

METHODS

Specimens from 136 HCC patients were determined immunohistochemically for ING4 expression. The correlation of ING4 levels with clinicopathologic variables, prognosis, and metastatic potential was analyzed. Among the 136 cases, 36 paired HCC and paracarcinomatous liver tissue specimens were analyzed for ING4 expression levels by real-time quantitative reverse transcription-PCR and Western blotting. MVD was determined by CD34 immunostaining to test whether it correlated with ING4 protein expression level.

RESULTS

The ING4 mRNA and protein levels were significantly lower in HCC than paracarcinomatous liver tissue from both real-time quantitative reverse transcription-PCR and Western blotting (P = 0.039 and 0.012, respectively). Importantly, the ING4 protein level correlated with the Edmondson-Steiner grade (P = 0.035), vein invasion (P = 0.015), and microvessel density (P = 0.005). Survival and metastasis analysis indicated that HCC patients with lower ING4 expression had poorer overall survival and disease-free survival than those with high expression (P = 0.0001 and 0.0065; respectively). Multivariable Cox regression analysis revealed that the ING4 expression level was an independent factor for prognosis (hazard risk, 9.63; P = 0.001).

CONCLUSIONS

ING4 expression is down-regulated in HCC tissues. ING4 expression level correlates with prognosis and metastatic potential, which suggests that ING4 is a candidate prognostic marker of HCC.

Adjuvant treatments for resectable hepatocellular carcinoma

Hepatocellular carcinoma often recurs even after curative resection. Although some encouraging data showing improvements in recurrence-free times have been reported with the use of intraarterial 131I-lipiodol infusion, retinoids, interferon, or immunotherapy after hepatectomy, there is no consensus regarding standard adjuvant therapy for resectable hepatocellular carcinoma. A novel target agent, sorafenib, which has recently become a standard of care for advanced disease, may also be promising in an adjuvant setting to prevent early recurrence after curative surgery. In future trials, it will be important to identify appropriate target populations for each type of adjuvant approach; that is, an agent with definitive antitumor activity for high-risk patients, and one that shows chemoprevention for low-risk patients.

Relationship between microvessel count and post-hepatectomy survival in patients with hepatocellular carcinoma

AIM: To elucidate the relationship between the microvessel count (MVC) by CD34 analyzed by immunohistochemical method and prognosis in hepatocellular carcinoma (HCC) patients who underwent hepatectomy based on our preliminary study.

METHODS: We examined relationships between MVC and clinicopathological factors in 128 HCC patients. The modified Japan Integrated Staging score (mJIS) was applied to examine subsets of HCC patients.

RESULTS: Median MVC was 178/mm², which was used as a cut-off value. MVC was not significantly associated with any clinicopathologic factors or postoperative recurrent rate. Lower MVC was associated with poor disease-free and overall survivals by univariate analysis (P = 0.039 and P = 0.087, respectively) and lower MVC represented an independent poor prognostic factor in disease-free survival by Cox’s multivariate analysis (risk ratio, 1.64; P = 0.024), in addition to tumor size, vascular invasion, macroscopic finding and hepatic dysfunction. Significant differences in disease-free and overall survivals by MVC were observed in HCC patients with mJIS 2 (P = 0.046 and P = 0.0014, respectively), but not in those with other scores.

CONCLUSION: Tumor MVC appears to offer a useful prognostic marker of HCC patient survival, particularly in HCC patients with mJIS 2.

Outcomes of hepatic resection for a single large hepatocellular carcinoma

BACKGROUND

The proper role of surgical resection, given the various treatment modalities available, needs to be further clarified in patients with a single large hepatocellular carcinoma (HCC). To evaluate the role of surgical resection in this group of patients, we studied the long-term outcomes of patients that received hepatic resection for a single large (> 5-10 cm in diameter) HCC.

METHODS

The clinicopathologic data and long-term outcomes of 61 patients with a single large HCC (> 5-10 cm in diameter; L group) were compared with those of 169 patients with a single small HCC (< or = 5 cm; S group). Prognostic factors were evaluated by univariate and multivariate analysis.

RESULTS

Operative mortality rates were low in both groups (0.6% in group S and 1.6% in group L), and the incidence of postoperative hepatic failure was rare even in group L (1.6%). The cumulative 5-year overall survival rate in group S was 59.0%, whereas in group L it was 52.9% (p = 0.385), and the corresponding cumulative 5-year disease-free survival rates were 44.1% and 31.7%, respectively (p = 0.063). Child class B was found to predict poor overall and disease-free survival by multivariate analysis versus Child class A in both groups. The presence of microvascular invasion was also identified as a significant prognostic factor, but it only affected disease-free survival in the two groups.

CONCLUSIONS

Single large HCCs do not require a large extent of hepatic resection and the associated increased risk of postoperative liver failure. The long-term survival of patients with a single large HCC is as good as that of patients with a single small HCC. We conclude that hepatic resection is a safe and effective therapy for single large HCCs.

Liver resection for HCC with cirrhosis: surgical perspectives out of EASL/AASLD guidelines

EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.

Patterns and clinicopathologic features of extrahepatic recurrence of hepatocellular carcinoma after curative resection

BACKGROUND

Little is known about the metastatic pattern in patients with extrahepatic metastasis after the removal of primary hepatocellular carcinoma (HCC). The aim of the present study was to determine the clinicopathologic characteristics and prognosis of patients with extrahepatic metastasis from HCC according to the recurrence pattern.

METHODS

Among the patients who underwent hepatic resection for HCC between 1981 and 2001, 80 patients had no recurrence; 221 patients had intrahepatic recurrence, and 47 patients experienced extrahepatic metastasis within a mean follow-up period of 4.8 +/- 3.7 years (+/-SD; range, 2-15 years). The pattern of extrahepatic metastasis after hepatic resection was divided into pattern I (first recurrence in the liver and then spread outside the liver after repetitive intrahepatic recurrences and repetitive locoregional treatments), pattern II (simultaneous recognition of intrahepatic and extrahepatic recurrences), and pattern III (extrahepatic, but no intrahepatic, lesions at first recurrence).

RESULTS

There were significant differences in proportions of patients with invasion of the portal vein, hepatic vein, or inferior vena cava, intrahepatic metastases, and tumor stage between patients with intra- and extrahepatic metastases. The disease-free survival and extrahepatic metastasis-free survival in pattern I were better than pattern II. Survival after extrahepatic metastasis did not correlate with the 3 patterns.

CONCLUSION

Although long-term overall survival was better in patients with pattern I of extrahepatic recurrences, prognosis was poor in all patterns once extrahepatic metastasis developed.

Portal hypertension: contraindication to liver surgery?

INTRODUCTION

In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients.

METHODS

Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it.

RESULTS

Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival.

CONCLUSIONS

Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Portal hypertension: contraindication to liver surgery?

INTRODUCTION

In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients.

METHODS

Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it.

RESULTS

Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival.

CONCLUSIONS

Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

High expression of insulin-like growth factor binding protein-3 is correlated with lower portal invasion and better prognosis in human hepatocellular carcinoma

Insulin-like growth factor binding protein-3 (IGFBP-3) modulates cell proliferation of various cancer cell types. However, it remains unclear how IGF-IGFBP-3-signaling is involved in growth and progression of hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the role of IGFBP-3 in HCC. Type 1 receptor for IGF (IGF-1R) was expressed at various levels in the seven lines examined, but IGF-2R was not expressed. Of the seven lines, the growth of HAK-1B, KIM-1, KYN-2 and HepG2 cells was stimulated in a dose-dependent manner by the exogenous addition of IGF-I or IGF-II, but the HAK-1A, KYN-1 and KYN-3 cell lines showed no growth. Exogenous addition of IGFBP-3 markedly blocked IGF-I and IGF-II-stimulated cell growth of KYN-2 and HepG2 cells, and moderately stimulated that of KIM-1 and HAK-1B cells, but no growth of the KYN-1, KYN-3 and HAK-1A cell lines was observed. IGF-I enhanced the phosphorylation of IGF-1R, Akt and Erk1/2 in KYN-2 cells, and coadministration of IGFBP-3 blocked all types of activation by IGF-I investigated here. In contrast, no such activation by IGF-I was detected in KYN-3 cells. IGFBP-3 also suppressed IGF-I-induced cell invasion by KYN-2 cells. Moreover, we were able to observe the apparent expression of IGFBP-3 in KYN-3 cells, but not in the other six cell lines. Furthermore reduced expression of IGFBP-3, but not that of IGF-1R, was significantly correlated with tumor size, histological differentiation, capsular invasion and portal venous invasion. Low expression of IGFBP-3 was independently associated with poor survival. IGFBP-3 could be a molecular target of intrinsic importance for further development of novel therapeutic strategy against HCC.

Liver resection for hepatocellular carcinoma on cirrhosis: analysis of mortality, morbidity and survival—a European single center experience

AIMS

To evaluate short- and long-term results of liver resections and prognostic factors in cirrhotic patients with hepatocellular carcinoma.

STUDY DESIGN

A single-unit, retrospective study analyzing 216 patients with histologically confirmed cirrhosis who underwent hepatic resection for hepatocellular carcinoma. All clinico-pathologic and follow-up data were collected prospectively.

RESULTS

Child A patients had a significantly lower in-hospital mortality rate compared to Child B-C: 4.7 vs 21.3% (p=0.0003). Overall morbidity rate was 38.4%; multiple logistic regression analysis identified liver function, hepatic pedicle clamping time, number of nodes and transfusion rate as independent predictors for post-operative complications. Overall and disease-free 5-year survival rates were 34.1 and 25.2%. Multivariate analysis showed that Child A, radical resection, tumour size < or =5 cm and, absence of vascular invasion were independent prognostic factors for long-term survival. No significant differences in overall and disease-free survival were found according to the type of resection (anatomic vs non-anatomic).

CONCLUSIONS

Patients with preserved liver function and small-size, single-node hepatocellular carcinomas are the best candidates for hepatic resection.

Liver transplantation for malignancy

Liver transplantation for hepatic malignancies has emerged from an exotic and desperate approach to a well-documented and proven treatment modality for these unfortunate patients. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, <10% of all liver transplants performed are for hepatocellular cancer (HCC). There is no controversy that hepatoblastoma is an excellent indication in pediatric patients with unresectable tumors. Similarly, liver transplantation for HCC in the adult population yields good results for patients whose tumor masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumors can be reliably selected to benefit from the procedure. Adjunctive procedures like radiofrequency ablation, chemoembolization, or cryotherapy might be indicated to limit tumor progression for patients on waiting lists. Epitheloid hemangioendothelioma is also an appropriate indication for liver transplantation, unlike angiosarcoma. Metastatic liver disease is not an indication for liver transplantation, with the exception of cases in which the primary is a neuroendocrine tumor, for which liver transplantation can result in long-term survival and even cure in a number of patients. And finally, while gallbladder cancers are never an indication for liver transplantation, rare cases of cholangiocellular cancer might qualify if aggressive combination therapies, including chemotherapy and radiotherapy followed by OLT, are carried through. Survival in these selected patients can approach that for patients with cholestatic liver disease.

Modified CLIP using PIVKA-II for evaluating prognosis after hepatectomy for hepatocellular carcinoma

AIMS

The new staging system proposed by the Cancer of the Liver Italian Program (CLIP) for hepatocellular carcinoma (HCC) accounts for both liver dysfunction and tumour characteristics. The present study was designed to analyze UICC TNM stage, CLIP and modified CLIP in 91 patients who underwent hepatic resection for HCC.

METHODS

In the modified CLIP, scoring of AFP was replaced by that of protein induced by vitamin K absence or antagonist II (PIVKA-II; predictive value, > or = 400 mAU/ml).

RESULTS

After hepatic resection, 54 patients developed recurrent tumours. High PIVKA-II was a significant determinant of recurrence (p<0.05). However, a high score of the modified CLIP as well as those other staging systems did not correlate with tumour-recurrence rate. Univariate analysis showed that high TNM score, CLIP score and our modified CLIP score were significant predictors of poor prognosis. Multivariate Cox's analysis revealed that high PIVKA-II and high modified CLIP score were associated with higher risk for disease-free and overall survival as well as high TNM stage.

CONCLUSIONS

Compared with the original CLIP, our modified CLIP was a better predictor of prognosis of HCC patients who underwent hepatic resection.

Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B

BACKGROUND

Chronic hepatitis B infection may cause liver cancer (hepatocellular carcinoma (HCC)). Alpha-fetoprotein (AFP) and liver ultrasonography (US) are used to screen these patients for HCC. It is uncertain whether screening is worthwhile.

OBJECTIVES

To review randomized trials on screening for HCC with alpha-fetoprotein and/or liver ultrasonography among people with hepatitis B surface antigen (HBsAg) whether asymptomatic or with clinical liver disease.

SEARCH STRATEGY

Relevant reports were searched from electronic databases until August 2002 (The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, HealthStar, and the Chinese Medical Literature Electronic Databases, MedCyber) supplemented with manual searches on the bibliographies of papers found and communication to people familiar with chronic hepatitis B.

SELECTION CRITERIA

Randomized trials on screening for liver cancer were included irrespective of language. Studies were excluded if the hepatitis B status was uncertain, if patients were not adequately followed, if the screening tests were not sensitive, widely-used ones, or if the test was used for diagnosis rather than screening for HCC.

DATA COLLECTION AND ANALYSIS

We analyzed independently all the studies considered for inclusion. We wrote to the relevant authors for further information. Data were analyzed with Peto's odds ratio (OR) with 95% confidence interval (CI).

MAIN RESULTS

Two trials met the selection criteria. One trial (n = 18,816) compared bi-annual AFP plus US screening with no screening for five years. No data on all-cause mortality were available. The two groups did not differ significantly regarding HCC mortality (OR 0.81; 95% CI 0.54 to 1.22). Number of patients with HCC was significantly increased in the screeened group (OR 1.37; 95% CI 1.00 to 1.88). Most HCCs in the screened group, but none in the control group, were at an early stage. The survival rate of patients with resected HCC in the screened group reached 52.7% after three and five years, but was 0% for those in the control group. The authors' estimated lead-time for HCC was 5.4 months, suggesting that screening prolonged the survival of HCC. Another trial (n = 1069) compared AFP plus US versus AFP screening, but could not decide which approach was superior due to the small sample size (number of detected HCC: OR 0.74; 95% CI 0.26 to 2.12).

REVIEWER'S CONCLUSIONS

There are not enough quality trials to support or refute screening of HBsAg-positive patients for HCC. It is possible that screening may be effective, but also that harm caused by screening/treatment may outweigh any gain. More and better-designed large randomized trials are required.