Induction of complete tumor necrosis may reduce intrahepatic metastasis and prolong survival in patients with hepatocellular carcinoma undergoing locoregional therapy: a prospective study

Recurrence in patients with totally necrotic nodules of hepatocellular carcinoma after liver transplantation: "totally" an inaccurate description

Purpose

Total necrosis of hepatocellular carcinoma (HCC) achieved via locoregional treatment (LRT) is considered to indicate a lack of tumor viability. Nonetheless, there is insufficient evidence of recurrence after liver transplantation (LT) in patients with such a status. The aim of this study was to investigate the prognosis of patients diagnosed with totally necrotic nodules upon explant hepatectomy after LT.

Methods

We conducted a retrospective study of patients diagnosed with totally necrotic nodules after LT for HCC. A total of 165 patients with HCC who underwent living- or deceased-donor LT from 2000 to 2020 in our hospital were included.

Results

A total of 5 patients (3.0%) exhibited HCC recurrence during a median follow-up of 84 months (range, 4-243 months) after LT. The 5-year overall and recurrence-free survival rates of these patients were 92.8% and 92.2%, respectively. Four patients in the HCC-recurrence group (80.0%) died even after further treatment, including transarterial chemoembolization, surgery, and systemic treatment. Both univariate and multivariate analyses of clinicopathological factors identified a maximum diameter of the totally necrotic nodules of >5 cm as the only factor associated with tumor recurrence following LT (P = 0.005 and P = 0.009, respectively).

Conclusion

Total necrosis of HCC via LRT yielded excellent survival outcomes for patients undergoing LT. Nevertheless, patients with large tumors should be considered at high risk of recurrence after LT, suggesting the need for their active surveillance during the follow-up period.

Optimal time point of response assessment for predicting survival is associated with tumor burden in hepatocellular carcinoma receiving repeated transarterial chemoembolization

OBJECTIVES

Objective response rate (ORR) under mRECIST criteria after transarterial chemoembolization (TACE) is a well-perceived surrogate endpoint of overall survival (OS). However, its optimal time point remains controversial and may be influenced by tumor burden. We aim to investigate the surrogacy of initial/best ORR in relation to tumor burden.

METHODS

A total of 1549 eligible treatment-naïve patients with unresectable hepatocellular carcinoma (HCC), Child-Pugh score ≤ 7, and performance status score ≤ 1 undergoing TACE between January 2010 and May 2016 from 17 academic hospitals were retrospectively analyzed. Based on "six-and-twelve" criteria, tumor burden was graded as low, intermediate, and high if the sum of the maximum tumor diameter and tumor number was ≤ 6, > 6 but ≤ 12, and > 12, respectively.

RESULTS

Both initial and best ORRs interacted with tumor burden. Initial and best ORRs could equivalently predict and correlate with OS in low (adjusted HR, 2.55 and 2.95, respectively, both p < 0.001; R = 0.84, p = 0.035, and R = 0.97, p = 0.002, respectively) and intermediate strata (adjusted HR, 1.81 and 2.22, respectively, both p < 0.001; R = 0.74, p = 0.023, and R = 0.9, p = 0.002, respectively). For high strata, only best ORR exhibited qualified surrogacy (adjusted HR, 2.61, p < 0.001; R = 0.70, p = 0.035), whereas initial ORR was not significant (adjusted HR, 1.08, p = 0.357; R = 0.22, p = 0.54).

CONCLUSIONS

ORR as surrogacy of OS is associated with tumor burden. For patients with low/intermediate tumor burden, initial ORR should be preferred in its early availability upon similar sensitivity, whereas for patients with high tumor burden, best ORR has optimal sensitivity. Timing of OR assessment should be tailored according to tumor burden.

KEY POINTS

• This is the first study utilizing individual patient data to comprehensively analyze the surrogacy of ORR with a long follow-up period. • Optimal timing of ORR assessment for predicting survival should be tailored according to tumor burden. • For patients with low and intermediate tumor burden, initial ORR is optimal for its timeliness upon similar sensitivity with best ORR. For patients with high tumor burden, best ORR has optimal sensitivity.

Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis

PURPOSE

To evaluate the effectiveness comparing the combination of TACE with local ablative therapy and monotherapy on the treatment of HCC using meta-analytical techniques.

METHODS

Randomized controlled trials and clinical studies comparing TACE plus local ablative therapy with monotherapy for HCC were included in this meta-analysis. Response rate, 1-, 2-, 3-, and 5-year survival rate, and overall survival (OS) were analyzed and compared.

RESULTS

Eighteen studies included a total of 2,120 patients with HCC 1,071 and 1,049 patients for treatment with combination therapy and monotherapy, respectively. The combination therapy group had a significantly better survival in terms of 1-, 2-, 3-, and 5-year survival rate (RR 1.10, 95 % CI 1.03–1.18, P = 0.005; RR 1.20, 95 % CI 1.10–1.30, P < 0.0001; RR 1.43, 95 % CI 1.18–1.73, P < 0.0001; RR 1.40, 95 % CI 1.22–1.61, P < 0.0001, respectively), OS (HR 0.66, 95 % CI 0.51–0.85, P = 0.001), and response rate (RR 1.54, 95 % CI 1.09–2.18, P = 0.013) than that monotherapy group in patients with HCC.

CONCLUSIONS

The meta-analysis indicates that the combination of TACE with local ablative therapy was superior to monotherapy in the treatment for patients with HCC.

Differential prognostic impact of renal insufficiency on patients with hepatocellular carcinoma: a propensity score analysis and staging strategy

BACKGROUND AND AIM

Renal insufficiency (RI) can coexist in patients with hepatocellular carcinoma (HCC). This study analyzed the prognostic impact of RI on patients with HCC and determined the optimal staging strategy for these patients.

METHODS

RI was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m(2). A total of 502 and 1701 HCC patients with and without RI, respectively, were enrolled. One-to-one matched patient cohorts according to treatments were built by using the propensity model. The prognostic ability of the Cancer of the Liver Italian Program, Barcelona Clinic Liver Cancer, Japan Integrated Scoring, and Taipei Integrated Scoring (TIS) systems in HCC patients with RI was compared by using the Akaike information criterion (AIC).

RESULTS

For patients undergoing percutaneous ablation and transarterial chemoembolization (TACE), RI was significantly associated with decreased long-term survival (P = 0.001 and 0.004, respectively). In patients receiving resection and other treatments, there were no significant survival differences between patients with and without RI. With similar demographics generated in the propensity model, significantly decreased survival was found in patients with RI in the TACE group (P = 0.018), but not in the resection, percutaneous ablation, and other treatment groups. Among HCC patients with RI, the TIS system had the lowest AIC value.

CONCLUSIONS

RI is often present in patients with HCC and predicts a poor outcome in patients undergoing TACE. The survival of HCC patients receiving resection, percutaneous ablation, and other treatments is not affected by RI. The TIS staging system is a more feasible prognostic model for HCC patients with RI.

Comparison of surgical resection and transarterial chemoembolization for hepatocellular carcinoma beyond the Milan criteria: a propensity score analysis

BACKGROUND

Treatment for patients with intermediate-stage hepatocellular carcinoma (HCC) is controversial. This study compared the long-term survival of patients beyond the Milan criteria who received surgical resection (SR) or transarterial chemoembolization (TACE).

METHODS

A total of 268 and 455 HCC patients beyond the Milan criteria undergoing SR and TACE, respectively, were retrospectively evaluated. After propensity score analysis to adjust for baseline differences, 146 pairs of matched patients were selected from each treatment arm. Long-term survival was compared by the Kaplan-Meier method. Independent prognostic predictors were determined by the Cox proportional hazards model.

RESULTS

Long-term survival was significantly better for the SR group by univariate survival analysis (P < .001). In the Cox model, SR was identified as an independent predictor of better prognosis (hazard ratio = 0.3, 95% confidence interval [95% CI]: 0.23-0.4; P < .001). Despite similar baseline characteristics in the propensity score model, patients who underwent SR had significantly better survival than patients who underwent TACE (P < .001). Patients receiving TACE had 2.56-fold increased risk of long-term mortality in the propensity model (95% CI: 1.73-3.78). The SR and TACE groups had comparable 30- and 90-day posttreatment mortality. The Cox model consistently disclosed the significant superiority of SR in terms of long-term survival in the propensity score model (P < .001).

CONCLUSIONS

For HCC patients beyond the Milan criteria, SR is considered equally safe as TACE and provides better long-term survival. SR may be regarded as the priority treatment for these patients.

Simultaneous injection of autologous mononuclear cells with TACE in HCC patients; preliminary study

BACKGROUND

The discovery of the pluripotent stem cells made the prospect of cell therapy and tissue regeneration a clinical reality, especially with the evidence of contribution of the stem cells of bone marrow origin in hepatic regeneration. Infusion of bone marrow stem cells before trans-arterial chemoembolization may help to increase liver volume and consequently increase hepatic reserve in patients with HCC, and this may improve the outcome of this procedure.

MATERIALS AND METHODS

Four Child B class patients with unresectable hepatocellular carcinoma treated by transarterial chemoembolization were injected with autologous bone marrow mononuclear layer containing stem cell in the hepatic artery feeding the contralateral lobe of the liver in the same session, follow-up of the patients was done by doing liver profile and CT liver volumetry before the surgery and 3 months later.

RESULTS

We observed that patients receiving stem cell therapy simultaneously with TACE had shown a significant improvement in biological and volumetric parameters of liver function compared to those historically reported of patients receiving TACE only who usually shows deterioration of liver parameters.

CONCLUSION

BMC infusion into the hepatic artery synchronized with TACE for patients with chronic liver disease complicated with HCC is safe, feasible, and demonstrated an improvement in both biological and radiological volumetric parameters.

Prognostic prediction across a gradient of total tumor volume in patients with hepatocellular carcinoma undergoing locoregional therapy

Background

The size and number of tumors are important prognostic indicators for hepatocellular carcinoma (HCC). However, it is difficult to assess the prognosis for patients with a variable number and size of tumors. By combining these two factors, we investigated the role and prognostic accuracy of total tumor volume (TTV) for HCC.

Methods

A total of 786 patients undergoing locoregional therapy (transarterial chemoembolization, percutaneous radiofrequency ablation and acetic acid or ethanol injection) for HCC were prospectively evaluated.

Results

The mean and median TTV was 177 cm³ (range, 0.1-3,591 cm³) and 21 cm³, respectively. Of all, 38%, 29%, 15%, 7% and 11% of patients had TTV of <10 cm³, 10-50 cm³, 50-200 cm³, 200-500 cm³ and >500 cm³, respectively. TTV was significantly larger in patients with higher serum α-fetoprotein (AFP) levels or with vascular invasion. The Child-Turcotte-Pugh score, performance status, vascular invasion, AFP level and TTV were significant independent prognostic predictors in the Cox proportional hazards model. After adjustment, patients with TTV 50-200 cm³ (relative risk [RR]: 1.74, p = 0.009), 200-500 cm³ (RR: 2.15, p = 0.006) and >500 cm³ (RR: 3.92, p < 0.001) had a significantly increased mortality risk in comparison to patients with TTV <10 cm³.

Conclusions

TTV is a feasible prognostic predictor across a wide gradient and can be used to predict the mortality risk of HCC. Selecting appropriate cutoffs of TTV may help refine the design of cancer staging system and treatment planning. Future clinical trials of HCC may include this parameter for mortality risk stratification.

The MELD-Na is an independent short- and long-term prognostic predictor for hepatocellular carcinoma: a prospective survey

BACKGROUND AND AIM

Serum sodium has been suggested to incorporate into the model for end-stage liver disease to enhance its prognostic ability for cirrhosis. A mathematical equation based on model for end-stage liver disease and sodium, known as "MELD-Na", was developed for outcome prediction for cirrhosis. The severity of liver cirrhosis is a key component to predict survival in patients with hepatocellular carcinoma. This study investigated the prognostic role of MELD-Na for hepatocellular carcinoma.

PATIENTS AND METHODS

A total of 535 unselected hepatocellular carcinoma patients were prospectively enrolled to evaluate the performance of MELD-Na.

RESULTS

The MELD-Na was better than model for end-stage liver disease in predicting 6-month mortality by comparing the area under receiver operating characteristic curve (0.782 vs. 0.761, p=0.101). MELD-Na, but not model for end-stage liver disease, was an independent predictor associated with 6-month mortality in multivariate logistic regression analysis (odds ratio: 1.14, p=0.001). In the survival analysis, MELD-Na also independently predicted mortality, with an additional risk of 4.3% per unit increment of the score (p<0.001). Patients with MELD-Na scores between 10 and 20 and scores >20 had 2.1-fold (p<0.001) and 7.5-fold (p<0.001) risk of mortality, respectively, compared to patients with a score <10 in the Cox proportional hazard model.

CONCLUSION

The MELD-Na score is a feasible and independent prognostic predictor for both short- and long-term outcome predictions in patients with hepatocellular carcinoma.

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy

BACKGROUND

The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation.

METHODS

We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy.

RESULTS

The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months.

CONCLUSION

The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.

The model for end-stage liver disease based cancer staging systems are better prognostic models for hepatocellular carcinoma: a prospective sequential survey

OBJECTIVE

Liver cirrhosis is a major component in staging for hepatocellular carcinoma (HCC). The model for end-stage liver disease (MELD) is a better prognostic predictor for cirrhotic patients compared to the Child-Turcotte-Pugh (CTP) system, which is a parameter in Cancer of Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), and Japan Integrated Scoring (JIS) system.

AIM

To investigate if the MELD-based models have a better prognostic ability.

METHODS

In the MELD-based model, the CTP class was replaced with MELD score at cutoffs of <10, 10-14, and >14. The modified systems were prospectively compared with the original counterpart in 430 consecutive HCC patients. Using 6-month mortality as the end point, the area under receiver operating characteristic curve (AUC) between the original and modified system was compared sequentially on a 3-monthly basis.

RESULTS

At the final inspection, the modified CLIP and JIS system had a significantly higher AUC compared to the original system (0.92 vs 0.893 for CLIP, P < 0.018; 0.88 vs 0.842 for JIS, P= 0.002), but there was no significant difference for the BCLC system (0.848 vs 0.841, P= 0.561). Survival analysis showed modified CLIP and JIS, and to a lesser extent, modified BCLC system, had a higher homogeneity likelihood ratio and discriminatory ability linear trend, and a lower Akaike information criterion in the Cox multivariate model, indicating a better discriminatory ability for different stage categories.

CONCLUSIONS

The MELD-based CLIP and JIS staging systems have an improved predictive ability compared to the original system and are feasible models for HCC staging in the MELD era.

Cytoplasmic accumulation of connexin32 protein enhances motility and metastatic ability of human hepatoma cells in vitro and in vivo

Connexins have long been believed to suppress tumour development during carcinogenesis by exerting gap junctional intercellular communication (GJIC). Although GJIC is abrogated in hepatocellular carcinoma (HCC), connexin32 (Cx32) protein tends to remain expressed in cytoplasm, but not in cell-cell contact areas; thus, it is incapable of forming gap junctions. Hypothesising that cytoplasmic Cx32 protein that has accumulated in HCC should have its proper functions, which are independent of GJIC, we established an inducible expression system of Cx32 in human HuH7 HCC cells, which were unable to support the formation of Cx32-mediated gap junctions, so that Cx32 protein could be overexpressed by doxycycline (Dox) withdrawal. Although the established clone HuH7 Tet-off Cx32 cells exhibited a 4-fold increase in Cx32 expression after Dox withdrawal, none of them were dye-coupled, and Cx32 protein was retained in the Golgi apparatus. However, the proliferation rate of the HuH7 Tet-off Cx32 cells was significantly higher in the Dox-free medium than in the Dox-supplemented one. Transwell assays also revealed that Dox withdrawal enhanced serum-stimulated motility and invasiveness into Matrigel of the HuH7 Tet-off Cx32 cells. Furthermore, when HuH7 Tet-off Cx32 cells were xenografted into the liver of SCID mice, only the mice to which no Dox was administered developed metastatic lesions, indicating that overexpression of cytoplasmic Cx32 protein induced metastasis of HuH7 cells. Our results suggest that, while Cx32-mediated GJIC suppresses the development of HCCs, cytoplasmic Cx32 protein exerts effects favourable for HCC progression, such as invasion and metastasis, once the cells have acquired a malignant phenotype.

Fever and infectious complications after percutaneous acetic acid injection therapy for hepatocellular carcinoma: incidence and risk factor analysis

BACKGROUND

Ultrasound-guided percutaneous acetic acid injection (PAI) therapy is effective for hepatocellular carcinoma (HCC). Posttreatment fever (>37.5 degrees C) may occur owing to acetic acid-induced tumor necrosis, but its incidence and clinical significance are not clear.

METHODS

A total of 402 treatment sessions in 127 consecutive patients undergoing PAI for HCC were prospectively studied. The incidence and risk factors associated with post-PAI fever were analyzed.

RESULTS

There were 37 (9.2%) episodes of fever occurring in 29 HCC patients after PAI. Patients who developed fever more often had large-sized (3.5+/-1.3 cm vs. 2.7+/-1.2 cm, P=0.0002) tumor and a higher injection volume (2.6+/-0.1 mL vs. 2.2+/-0.1 mL, P=0.001) of acetic acid compared with those without fever. Multivariate logistic regression analysis showed that tumor size >3 cm was the only significant predictor associated with occurrence of posttreatment fever (odds ratio: 4.4, 95% confidence interval: 2.2-8.9, P<0.001). Three patients, all of whom had HCC diameter >3 cm, had 4 episodes of bacteremia after treatment; one of them developed liver abscess that required percutaneous drainage.

CONCLUSIONS

Fever after PAI is not an uncommon event. Patients with tumor size >3 cm have a higher risk of posttreatment fever. Bacteremia and significant infectious complication could occur in a minority of patients. Prophylactic antibiotics before treatment may be necessary for high-risk patients.

The sequential changes of the model for end-stage liver disease score correlate with the severity of liver cirrhosis in patients with hepatocellular carcinoma undergoing locoregional therapy

BACKGROUND

The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. It is not clear whether MELD correlates with liver functional reserve that changes over time. This study investigated the correlation of sequential changes between MELD and Child-Turcotte-Pugh (CTP) scores in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 192 HCC patients undergoing transarterial chemoembolization or percutaneous injection therapy were studied.

RESULTS

The MELD and CTP scores of study patients at pretreatment, early (median, 2 wk) and late (median, 8 wk) stage after treatment were 10.1+/-3.5, 12.9+/-3.2, and 11.7+/-3.1, and 6.2+/-1.1, 7.5+/-1.1, and 6.9+/-1.2, respectively. There was a significant correlation of the serial changes for the period between pretreatment and early stage (rho=0.605, P<0.001), and between early to late stage (rho=0.512, P<0.001) after treatment. The corresponding increase and decrease of MELD score was 2.1 and 2.0, respectively, per unit change of the CTP score. The correlation was still significant in the stratified analysis according to various clinical parameters. In the Cox multivariate model, tumor size >5 cm [relative risk (RR)=2.58, P<0.001], multiple HCCs (RR=1.78, P=0.013), CTP class B or C (RR=3.06, P<0.001), and MELD score >15 (RR=2.17, P=0.023) were independent poor prognostic predictors.

CONCLUSIONS

Serial determinations of the MELD score well correlate with the changes of CTP score. The MELD score may be useful in measuring liver functional reserve and outcome prediction in HCC patients undergoing locoregional therapy.

Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): safety, tumor response, and survival

PURPOSE

To present safety and efficacy results obtained in treatment of a cohort of patients with unresectable hepatocellular carcinoma (HCC) with use of 90Y microspheres (TheraSphere).

PATIENTS AND METHODS

Forty-three consecutive patients with HCC were treated with 90Y microspheres over a 4-year period. Patients were treated by liver segment or lobe on one or more occasions based on tumor distribution, liver function, and vascular flow dynamics. Patients were followed for adverse events, objective tumor response, and survival. Patients were stratified into three risk groups according to method of treatment and risk stratification (group 0, segmental; group 1, lobar low-risk; group 2, lobar high-risk) and Okuda and Child-Pugh scoring systems.

RESULTS

Based on follow-up data from 43 treated patients, 20 patients (47%) had an objective tumor response based on percent reduction in tumor size and 34 patients (79%) had a tumor response when percent reduction and/or tumor necrosis were used as a composite measure of tumor response. There was no statistical difference among the three risk groups with respect to tumor response. Survival times from date of diagnosis were different among the risk groups (P < .0001). Median survival times were 46.5 months, 16.9 months, and 11.1 months for groups 0, 1, and 2, respectively. Median survival times of 24.4 months and 12.5 months by Okuda scores of I and II, respectively, were achieved (mean, 25.8 months vs 13.1). Patients had median survival times of 20.5 months and 13.8 months according to Child class A and class B/C disease, respectively (mean, 22.7 months vs 13.6 months). Patients classified as having diffuse disease exhibited decreased survival and reduced tumor response. There were no life-threatening adverse events related to treatment.

CONCLUSIONS

Use of 90Y microspheres (TheraSpheres) provides a safe and effective method of treatment for a broad spectrum of patients presenting with unresectable HCC. Further investigation is warranted.

Local therapeutic treatments for focal liver disease

Patients diagnosed with primary hepatic malignancies or metastases to the liver remain a difficult population to treat. A small percentage of these people can undergo surgical resection or transplantation. The remaining nonsurgical aggregate does not often benefit from conventional radiation and chemotherapy; minimally invasive means either to cure or palliate these patients are a requirement for complete cancer care. This article discusses image-guided local therapies used to treat this difficult patient population, focusing predominantly on radiofrequency ablation.

Percutaneous ablation therapy for hepatocellular carcinoma: current practice and future perspectives

Worldwide, hepatocellular carcinoma (HCC) is a common, refractory, malignant tumor. Surgical resection is feasible in only a few patients, because of limited hepatic reserve and multifocality of tumors at diagnosis. Percutaneous ablation therapies, including injection of ethanol (PEI) or acetic acid (PAI), radiofrequency ablation (RFA), and microwave coagulation therapy (MCT), have been the major treatments for unresectable HCC in the past decade. PEI is well established for small (<3 cm) HCC, and PAI is equally as effective as PEI, but with fewer treatment sessions. RFA has recently been suggested to have excellent tumor-ablating ability because it produces a fixed and predictable tumor necrosis zone. Although RFA is also effective for medium-sized HCC, the overall complication rate may be higher than previously assumed. MCT is similar to RFA in its clinical application and potential adverse effects. A combination approach using percutaneous ablation therapy and transcatheter arterial embolization was shown to be effective for large HCC. Other approaches, such as injection of hot saline or yttrium-90 microspheres, cryoablation, or interstitial laser photocoagulation, are less often used nowadays. Multimodal, image-guided, tailored therapy, rather than a fixed treatment algorithm, might be more practical for unresectable HCC. In conclusion, although longterm survival is possible in selected patients with HCC, the overall prognosis remains suboptimal, especially in patients with unfavorable tumor characteristics. While newer anti-tumor therapies with improved efficacy are needed, information about a more rational approach to the use of existing therapeutic options may help to enhance treatment strategies for HCC.

Determination of the optimal model for end-stage liver disease score in patients with small hepatocellular carcinoma undergoing loco-regional therapy

The model for end-stage liver disease (MELD) has been a prevailing system to prioritize cirrhotic patients awaiting liver transplantation. An "exceptional" MELD score of 20 and 24 points is assigned for stage T1 and T2 patients with small hepatocellular carcinoma (HCC), respectively. However, this strategy is based on scarce data and the optimal score for these patients remains uncertain. We investigated 238 patients with small HCC who were candidates for liver transplantation and underwent arterial chemoembolization or percutaneous injection therapy using acetic acid or ethanol. Tumor stage (P = .001) and Child-Turcotte-Pugh (CTP) class (P < .001) were independent risk factors predicting tumor progression or death in survival analysis. The risk of disease progression in HCC patients stratified by tumor stage was mapped and equated with the risk of mortality of 456 cirrhotic patients without HCC. The 6- and 12-month rates of disease progression were 4% and 6%, respectively, for stage T1 HCC patients (n = 50; mean MELD: 9.5). These rates were close to and no higher than the mortality rate in MELD category 8-12 at the corresponding time period (7.1% and 11.3%, respectively; n = 141). For stage T2 patients (n = 188; mean MELD: 9.3), the corresponding rates were 5.3% and 13.8%, respectively, which were close to and no higher than the mortality rate in MELD category 10-14 (9.0% and 13.9%, respectively, n = 166). In conclusion, the risk of disease progression is quite low for selected HCC patients undergoing loco-regional therapy. A lower MELD score may be suggested to be equivalent to the risk of short- and mid-term mortality in the cirrhosis group.