Small Hepatocellular Carcinoma With Low Tumor Marker Expression Benefits More From Anatomical Resection Than Tumors With Aggressive Biology

Safety and efficacy of laparoscopic portal territory fluorescence navigation-guided anatomical liver resection in hepatocellular carcinoma patients

BACKGROUND

The clinical effectiveness of classic anatomical resection (CAR) of the liver for hepatocellular carcinoma (HCC) has been controversial. Laparoscopic Portal Territory fluorescence navigation-guided anatomical liver resection (LPTAR) has been increasingly applied in clinical practice. However, evidence on the safety and efficacy of LPTAR is lacking.

METHODS

A retrospective cohort study of patients who underwent laparoscopic hepatectomy from December 2018 to December 2022 was conducted. Propensity score matching (PSM) was employed to match patients who underwent LPTAR with patients who underwent CAR. Differences in recurrence-free survival (RFS), overall survival (OS), and perioperative data were evaluated between the LPTAR and CAR groups. Cox regression models were used for univariate and multivariate analyses, as well as subgroup analyses.

RESULTS

Of the 234 patients included in this study, 70 underwent LRTAR, and 164 underwent CAR. After 1:1 PSM, each group contained 59 patients, and perioperative parameters were better in the LPTAR group. Specifically, the LPTAR group had wider resection margins (13.00 cm vs. 11.00 cm, P = 0.023), less blood loss (200 ml vs. 320 ml, P = 0.010), and fewer postoperative complications (33.90% vs. 57.62%, P = 0.016) than did the CAR group. The RFS rates of patients with HCC was also increased by LPTAR. The 1-, 3-, and 5-year RFS rates of the LPTAR group were significantly higher than those of the CAR group (P = 0.002).

CONCLUSION

Accurate preoperative planning and standardized LPTAR technical criteria prolonged RFS in HCC patients, improved the safety of surgery, and reduced surgical stress.

TRAIL REGISTRATION

The study has been prospective registered at Chinese Clinical Trial Registry (https://www.chictr.org.cn/, ChiCTR2400087661).

Development and validation of a dynamic prognostic nomogram for conditional survival in hepatocellular carcinoma: an analysis from the Korea Liver Cancer Registry

Compared to overall survival, conditional survival is a more relevant measure of prognosis in surviving patients over time. This study developed and validated a nomogram-based dynamic prognostic model to predict the conditional survival estimates of patients with hepatocellular carcinoma (HCC) through an analysis of a nationwide cancer registry. This retrospective cohort study included 2492 patients with HCC registered in the Korea Liver Cancer Registry. Patients underwent hepatic resection (HR) from 2008 to 2017, were followed up until December 2019, and were divided into development and validation cohorts. Univariate and multivariate Cox regression analyses were conducted to determine the risk factors for conditional survival of patients who underwent HR. The patients were scored based on the Cox regression coefficients; the nomogram was predicted by calculating the survival probability with Cox model. Our dynamic prognostic model nomogram for predicting conditional overall survival demonstrated Harrell's C-index of 0.622 and 0.674 in the development and validation sets; for conditional disease-specific survival, it was 0.623 and 0.686 in the development and validation sets. The prediction power of the model is applicable in clinical practice. Factors incorporated in our nomogram included age, albumin, the ADV score, lymph node metastasis, and T stage in American Joint Commission on Cancer staging system. We developed and validated a nomogram to predict conditional survival estimates for overall survival and disease-specific survival. The proposed nomogram incorporating the ADV score presents a more accurate and useful prognostic prediction for patients with HCC who received HR.

Comparison of the diagnostic efficacy between imaging features and iodine density values for predicting microvascular invasion in hepatocellular carcinoma

Background

In recent years, studies have confirmed the predictive capability of spectral computer tomography (CT) in determining microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC). Discrepancies in the predicted MVI values between conventional CT imaging features and spectral CT parameters necessitate additional validation.

Methods

In this retrospective study, 105 cases of small HCC were reviewed, and participants were divided into MVI-negative (n=53, Male:48 (90.57%); mean age, 59.40 ± 11.79 years) and MVI-positive (n=52, Male:50(96.15%); mean age, 58.74 ± 9.21 years) groups using pathological results. Imaging features and iodine density (ID) obtained from three-phase enhancement spectral CT scans were gathered from all participants. The study evaluated differences in imaging features and ID values of HCC between two groups, assessing their diagnostic accuracy in predicting MVI occurrence in HCC patients. Furthermore, the diagnostic efficacy of imaging features and ID in predicting MVI was compared.

Results

Significant differences were noted in the presence of mosaic architecture, nodule-in-nodule architecture, and corona enhancement between the groups, all with p-values < 0.001. There were also notable disparities in IDs between the two groups across the arterial phase, portal phase, and delayed phases, all with p-values < 0.001. The imaging features of nodule-in-nodule architecture, corona enhancement, and nonsmooth tumor margin demonstrate significant diagnostic efficacy, with area under the curve (AUC) of 0.761, 0.742, and 0.752, respectively. In spectral CT analysis, the arterial, portal, and delayed phase IDs exhibit remarkable diagnostic accuracy in detecting MVI, with AUCs of 0.821, 0.832, and 0.802, respectively. Furthermore, the combined models of imaging features, ID, and imaging features with ID reveal substantial predictive capabilities, with AUCs of 0.846, 0.872, and 0.904, respectively. DeLong test results indicated no statistically significant differences between imaging features and IDs.

Conclusions

Substantial differences were noted in imaging features and ID between the MVI-negative and MVI-positive groups in this study. The ID and imaging features exhibited a robust diagnostic precision in predicting MVI. Additionally, our results suggest that both imaging features and ID showed similar predictive efficacy for MVI.

Early identification of hepatocellular carcinoma patients at high-risk of recurrence using the ADV score: a multicenter retrospective study

BACKGROUND

Postoperative recurrence is a vital reason for poor 5-year overall survival in hepatocellular carcinoma (HCC) patients. The ADV score is considered a parameter that can quantify HCC aggressiveness. This study aimed to identify HCC patients at high-risk of recurrence early using the ADV score.

METHODS

The medical data of consecutive HCC patients undergoing hepatectomy from The First Affiliated Hospital of Nanjing Medical University (TFAHNJMU) and Nanjing Drum Tower Hospital (NJDTH) were retrospectively reviewed. Based on the status of microvascular invasion and the Edmondson-Steiner grade, HCC patients were divided into three groups: low-risk group (group 1: no risk factor exists), medium-risk group (group 2: one risk factor exists), and high-risk group (group 3: coexistence of two risk factors). In the training cohort (TFAHNJMU), the R package nnet was used to establish a multi-categorical unordered logistic regression model based on the ADV score to predict three risk groups. The Welch's T-test was used to compare differences in clinical variables in three predicted risk groups. NJDTH served as an external validation center. At last, the confusion matrix was developed using the R package caret to evaluate the diagnostic performance of the model.

RESULTS

350 and 405 patients from TFAHNJMU and NJDTH were included. HCC patients in different risk groups had significantly different liver function and inflammation levels. Density maps demonstrated that the ADV score could best differentiate between the three risk groups. The probability curve was plotted according to the predicted results of the multi-categorical unordered logistic regression model, and the best cut-off values of the ADV score were as follows: low-risk ≤ 3.4 log, 3.4 log < medium-risk ≤ 5.7 log, and high-risk > 5.7 log. The sensitivities of the ADV score predicting the high-risk group (group 3) were 70.2% (99/141) and 78.8% (63/80) in the training and external validation cohort, respectively.

CONCLUSION

The ADV score might become a valuable marker for screening patients at high-risk of HCC recurrence with a cut-off value of 5.7 log, which might help surgeons, pathologists, and HCC patients make appropriate clinical decisions.

Research progress of protein induced by vitamin K absence or antagonist II in liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common pathologic type of primary liver cancer. Liver transplantation (LT) is a radical strategy for treating patients with early-stage HCC, which may lead to a better prognosis compared to hepatectomy and ablation. However, survival of patients who develop HCC recurrence after LT is short, and early recurrence is the most common cause of death. Thus, efficient biomarkers are also needed in LT to guide precision therapy to improve patient prognosis and 5-year survival. Protein induced by vitamin K absence or antagonist II (PIVKA-II) is an abnormal prothrombin that cannot activate coagulation, and it is significantly increased in patients with HCC, obstructive jaundice, and those taking vitamin K antagonists. Over the past decades, substantial progress has been made in the study of PIVKA-II in diagnosing, surveilling, and treating HCC, but its role in LT still needs to be elaborated. In this review, we focused on the role of PIVKA-II as a biomarker in LT for HCC, especially its relationship with clinicopathologic features, early recurrence, long-term survival, and donor-recipient selection.

A multicenter propensity score analysis of significance of hepatic resection type for early-stage hepatocellular carcinoma

BACKGROUND

The impact of hepatic resection type on long-term oncological prognosis of patients with early-stage hepatocellular carcinoma (HCC) has not been systematically investigated. We sought to determine risk factors, recurrence patterns, and survival outcomes after anatomical resection (AR) versus non-anatomical resection (NAR) for early-stage HCC.

METHODS

From a prospectively collected multicenter database, consecutive patients undergoing curative hepatectomy for early-stage HCC were identified. Recurrence patterns, overall survival (OS), recurrence-free survival (RFS), and risk factors were investigated in patients undergoing AR versus NAR using propensity score matching (PSM), subgroup analysis, and COX regression analysis.

RESULTS

A total of 3585 patients with early-stage HCC were enrolled, including 1287 and 2298 in the AR and NAR groups, respectively. After PSM, the OS and RFS of patients in the AR group were 58.8% and 42.7%, which were higher than those in the NAR group (52.2% and 30.6%, both p < 0.01). The benefits of AR were consistent across most subgroup analyses of OS and RFS. Multivariable COX regression analysis showed that AR was independently associated with better OS and RFS. Notably, although recurrence patterns were comparable, the risk factors for recurrence were not identical for AR versus NAR. Microvascular invasion and narrow resection margin were only associated with a higher recurrence rate after NAR.

CONCLUSIONS

This study demonstrated that AR decreases the risk of tumor recurrence and improves OS and RFS in patients with early-stage HCC. AR should be adopted as long as such a surgical maneuver is feasible for initial treatment of early-stage HCC.

The State of Systematic Therapies in Clinic for Hepatobiliary Cancers

Hepatobiliary cancer (HBC) includes hepatocellular carcinoma and biliary tract carcinoma (cholangiocarcinoma and gallbladder carcinoma), and its morbidity and mortality are significantly correlated with disease stage. Surgery is the cornerstone of curative therapy for early stage of HBC. However, a large proportion of patients with HBC are diagnosed with advanced stage and can only receive systemic treatment. According to the results of clinical trials, the first-line and second-line treatment programs are constantly updated with the improvement of therapeutic effectiveness. In order to improve the therapeutic effect, reduce the occurrence of drug resistance, and reduce the adverse reactions of patients, the treatment of HBC has gradually developed from single-agent therapy to combination. The traditional therapeutic philosophy proposed that patients with advanced HBC are only amenable to systematic therapies. With some encouraging clinical trial results, the treatment concept has been revolutionized, and patients with advanced HBC who receive novel systemic combination therapies with multi-modality treatment (including surgery, transplant, TACE, HAIC, RT) have significantly improved survival time. This review summarizes the treatment options and the latest clinical advances of HBC in each stage and discusses future direction, in order to inform the development of more effective treatments for HBC.

Surgical Strategies Affect the Long-Term Prognosis of Patients with Hepatocellular Carcinoma Adjacent to the Left Branch of the Portal Vein

Purpose

When hepatocellular carcinoma (HCC) is closely associated with the left branch of the portal vein, there is still controversy regarding the surgical approach.

Methods

This study enrolled 330 HCC patients with tumors adjacent to the left branch of the portal vein. Among them, 85 patients underwent left hemihepatectomy (LH), while the remaining 235 underwent liver lobectomy (LL), which included left medial segmentectomy or left lateral sectionectomy. Perioperative complications, time to recurrence and overall survival (OS) were compared using propensity score matching.

Results

LH resulted in a lower 5-year recurrence rate and higher 5-year OS rate than LL (56.5% vs 74.0%, p=0.002; 67.4% vs 53.5%, p=0.029). The LL group showed a higher tendency for early recurrence (ER) and intrahepatic recurrence (IR). The cumulative IR rates at 1- 3-, and 5-years for the LH group and the LL group were 17.0%, 36.7%, 45.1% and 33.8%, 57.1%, 63.7%, respectively, with a p-value of 0.007. There was no statistically significant difference in the cumulative ER rates between the two groups at 1-, 3-, and 5- years. Furthermore, the LH group and the LL group had similar perioperative complications, and no cases of liver failure occurred.

Conclusion

LH, compared to LL, reduced the IR rate and ER rate in HCC patients with tumor adjacent to the left branch of the portal vein. It improved the OS outcome of the patients, and there was no significant difference in perioperative complications between the two groups.

Protein induced by vitamin K absence or antagonist II: Experience to date and future directions

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer with high mortality. The realization of precision medicine in HCC relies upon efficient biomarkers. Protein induced by vitamin K absence or antagonist II (PIVKA-II) is an immature prothrombin with insufficient coagulation activity, overexpressing in HCC cells. Previous evidence confirmed the role of PIVKA-II in screening and diagnosing HCC. However, the increased PIVKA-II was observed not only in HCC, but also in non-HCC individuals such as vitamin K deficiency. The joint detection of PIVKA-II and other biomarkers could significantly improve diagnostic accuracy in HCC. Furthermore, PIVKA-II serves as a valuable prognostic predictor, transplantation eligibility, resectability, tumor recurrence, therapeutic efficacy, and malignant tumor behaviors. Additionally, PIVKA-II represents a potential target for agent development to establish new therapeutic strategies. Besides HCC, PIVKA-II also serves as a biomarker of vitamin K status. In this review, we assess the role of PIVKA-II in diagnosis, prediction, and treatment. Over the past decades, substantial progress has been achieved in the application of PIVKA-II. Exploration and innovation are required for further advances in the field of PIVKA-II investigation.

Donor sex and donor-recipient sex disparity do not affect hepatocellular carcinoma recurrence after living donor liver transplantation

Purpose

Studies have yielded contradictory results on whether donor sex and donor-recipient sex disparity affect hepatocellular carcinoma (HCC) recurrence after living donor liver transplantation (LDLT). The present study assessed whether donor sex or donor-recipient sex disparity affects HCC recurrence after LDLT at a high-volume center.

Methods

This study included 772 HCC patients who underwent LDLT between January 2006 and December 2015 at Asan Medical Center. Patients were divided into 4 groups based on the sex of the donor and recipient: male-to-male (n = 490, 63.5%), male-to-female (n = 75, 9.7%), female-to-male (n = 170, 22.0%), and female-to-female (n = 37, 4.8%).

Results

Disease-free survival (DFS; P = 0.372) and overall survival (OS; P = 0.591) did not differ significantly among the 4 groups. DFS also did not differ significantly between LDLT recipients with male and female donors (P = 0.792) or between male and female recipients (P = 0.084). After patient matching with an α-FP/des-γ-carboxy prothrombin/tumor volume score cutoff of 5logs, donor-recipient sex disparity did not significantly affect DFS (P = 0.598) or OS (P = 0.777). There were also no differences in DFS in matched LDLT recipients with male and female donors (P = 0.312) or between male and female recipients (P = 0.374).

Conclusion

Neither donor sex nor donor-recipient sex disparity significantly affected posttransplant HCC recurrence.

Predicting post-resection recurrence by integrating imaging-based surrogates of distinct vascular patterns of hepatocellular carcinoma

Background & Aims

Distinct vascular patterns, including microvascular invasion (MVI) and vessels encapsulating tumour clusters (VETC), are associated with poor outcomes of hepatocellular carcinoma (HCC). Imaging surrogates of these vascular patterns potentially help to predict post-resection recurrence. Herein, a prognostic model integrating imaging-based surrogates of these distinct vascular patterns was developed to predict postoperative recurrence-free survival (RFS) in patients with HCC.

Methods

Clinico-radiological data of 1,285 patients with HCC from China undergoing surgical resection were retrospectively enrolled from seven medical centres between 2014 and 2020. A prognostic model using clinical data and imaging-based surrogates of MVI and VETC patterns was developed (n = 297) and externally validated (n = 373) to predict RFS. The surrogates (i.e. MVI and VETC scores) were individually built from preoperative computed tomography using two independent cohorts (n = 360 and 255). Whether the model's stratification was associated with postoperative recurrence following anatomic resection was also evaluated.

Results

The MVI and VETC scores demonstrated effective performance in their respective training and validation cohorts (AUC: 0.851-0.883 for MVI and 0.834-0.844 for VETC). The prognostic model incorporating serum alpha-foetoprotein, tumour multiplicity, MVI score, and VETC score achieved a C-index of 0.748-0.764 for the developing and external validation cohorts and generated three prognostically distinct strata. For patients at model-predicted medium risk, anatomic resection was associated with improved RFS (p <0.05). By contrast, anatomic resection had no impact on RFS in patients at model-predicted low or high risk (both p >0.05).

Conclusions

The proposed model integrating imaging-based surrogates of distinct vascular patterns enabled accurate prediction for RFS. It can potentially be used to identify HCC surgical candidates who may benefit from anatomic resection.

Impact and implications

MVI and VETC are distinct vascular patterns of HCC associated with aggressive biological behaviour and poor outcomes. Our multicentre study provided a model incorporating imaging-based surrogates of these patterns for preoperatively predicting RFS. The proposed model, which uses imaging detection to estimate the risk of MVI and VETC, offers an opportunity to help shed light on the association between tumour aggressiveness and prognosis and to support the selection of the appropriate type of surgical resection.

Validation of quantitative prognostic prediction using ADV score for resection of hepatocellular carcinoma: A Korea-Japan collaborative study with 9200 patients

BACKGROUND

A score derived from the concentrations of α-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP) and tumor volume (TV), called ADV score, has been shown to be prognostic of hepatocellular carcinoma (HCC) recurrence following hepatic resection (HR) or liver transplantation.

METHODS

This multicenter, multinational validation study included 9200 patients who underwent HR from 2010 to 2017 at 10 Korean and 73 Japanese centers, and were followed up until 2020.

RESULTS

AFP, DCP, and TV showed weak correlations (ρ ≤ .463, r ≤ .189, p < .001). Disease-free survival (DFS), overall survival (OS), and post-recurrence survival rates were dependent on 1.0 log and 2.0 log intervals of ADV scores (p < .001). Receiver operating characteristic (ROC) curve analysis showed that ADV score cutoffs of 5.0 log for DFS and OS yielded the areas under the curve ≥ .577, with both being significantly prognostic of tumor recurrence and patient mortality at 3 years. ADV score cutoffs of ADV 4.0 log and 8.0 log, derived through K-adaptive partitioning method, showed higher prognostic contrasts in DFS and OS. ROC curve analysis showed that an ADV score cutoff of 4.2 log was suggestive of microvascular invasion, with both microvascular invasion and an ADV score cutoff of 4.2 log showing similar DFS rates.

CONCLUSIONS

This international validation study demonstrated that ADV score is an integrated surrogate biomarker for post-resection prognosis of HCC. Prognostic prediction using ADV score can provide reliable information that can assist in planning treatment of patients with different stages of HCC and guide individualized post-resection follow-up based on the relative risk of HCC recurrence.

Quantitative Prediction of Posttransplant Hepatocellular Carcinoma Prognosis Using ADV Score: Validation with Korea-Nationwide Transplantation Registry Database

OBJECTIVE

The aim of this study is to validate the prognostic impact of ADV score (α-fetoprotein [AFP]-des-γ-carboxyprothrombin [DCP]-tumor volume [TV] score) for predicting prognosis of hepatocellular carcinoma (HCC) following liver transplantation (LT).

BACKGROUND

ADV score has been reported as a prognostic surrogate biomarker of HCC following LT and hepatectomy.

METHODS

The study patients were 1599 LT recipients selected from the Korean Organ Transplantation Registry database.

RESULTS

Deceased-donor and living-donor LTs were performed in 143 and 1456 cases, respectively. Weak correlation was present among AFP, DCP, and TV. The viable HCC group showed ADV score-dependent disease-free survival (DFS) and overall patient survival (OS) rates from 1log to 10log (p<0.001). Prognosis of complete pathological response group was comparable to that of ADV score <1log (p≥0.099). ADV score cutoff of 5log (ADV-5log) for DFS and OS was obtained through receiver operating characteristic curve analysis with area under the curve ≥0.705. Both ADV-5log and Milan criteria were independent risk factors for DFS and OS, and their prognostic impacts were comparable to each other. Combination of these two factors resulted in further prognostic stratification, showing hazard ratios for DFS and OS as 2.98 and 2.26 respectively for one risk factor and 7.92 and 8.19 respectively for two risk factors (p<0.001). ABO-incompatible recipients with ADV score ≥8log or two risk factors showed higher recurrence rates.

CONCLUSIONS

This validation study revealed that ADV score is a reliable surrogate biomarker for posttransplant HCC prognosis, which can be used for selecting LT candidates and guiding risk-based posttransplant follow-up surveillance.

Systemic analysis identifying PVT1 / DUSP13 axis for microvascular invasion in hepatocellular carcinoma

BACKGROUND

Microvascular invasion (MVI) is an independent detrimental risk factor for tumor recurrence and poor survival in hepatocellular carcinoma (HCC). Competitive endogenous RNA (ceRNA) networks play a pivotal role in the modulation of carcinogenesis and progression among diverse tumor types. However, whether the ceRNA mechanisms are engaged in promoting the MVI process in patients with HCC remains unknown.

METHODS

A ceRNA regulatory network was constructed based on RNA-seq data of patients with HCC from The Cancer Genome Atlas (TCGA) database. In total, 10 hub genes of the ceRNA network were identified using four algorithms: "MCC," "Degree," "Betweenness," and "Stress." Transcriptional expressions were verified by in situ hybridization using clinical samples. Interactions between ceRNA modules were validated by luciferase reporting assay. Logistic regression analysis, correlation analysis, enrichment analysis, promoter region analysis, methylation analysis, and immune infiltration analysis were performed to further investigate the molecular mechanisms and clinical transformation value.

RESULTS

The ceRNA regulatory network featuring a tumor invasion phenotype consisting of 3 long noncoding RNAs, 3 microRNAs, and 93 mRNAs was constructed using transcriptional data from the TCGA database. Systemic analysis and experimentally validation identified a ceRNA network (PVT1/miR-1258/DUSP13 axis) characterized by lipid regulatory potential, immune properties, and abnormal methylation states in patients with HCC and MVI. Meanwhile, 28 transcriptional factors were identified as potential promotors of PVT1 with 3 transcriptional factors MXD3, ZNF580, and KDM1A promising as therapeutic targets in patients with HCC and MVI. Furthermore, miR-1258 was an independent predictor for MVI in patients with HCC.

CONCLUSION

The PVT1/DUSP13 axis is significantly associated with MVI progression in HCC patients. This study provides new insight into mechanisms related to lipids, immune phenotypes, and abnormal epigenetics in oncology research.

Prognostic impact of surgical margins for hepatocellular carcinoma according to preoperative alpha-fetoprotein level

BACKGROUND

HCC are known to have satellite nodules and microvascular invasions requiring sufficient margins. An alpha-fetoprotein (AFP) level >100 ng/mL is associated with worse pathological features in HCC. In practice, large resection margins, particularly >1 cm, are infrequently retrieved on the specimens.

METHODS

397 patients from 5 centres were included from 2012 to 2017. The primary endpoint was time-to-recurrence in relation to AFP level (> or <100 ng/ml) as well as surgical margins (> or <1 cm). The secondary endpoint was overall survival (OS).

RESULTS

The median follow-up was 25 months. In Low AFP group, median time to recurrence (TTR) for patients with margins <1 cm was 36 months and for patients with margins ≥1 cm was 34 months (p = 0.756), and overall survival (OS) was not significantly different according to margins (p = 0.079). In High-AFP group, patients with margins <1 cm had a higher recurrence rate than patients with margins ≥1 cm (p = 0.016): median TTR for patients with margins <1 cm was 8 months whereas it was not reached for patients with margins ≥1 cm. Patients with margins <1 cm had a significantly worse OS compared to the patients with margins ≥1 cm (p = 0.043).

CONCLUSION

Preoperative AFP level may help determine margins to effectively treat high AFP tumours. For low-AFP tumours, margins didn't have an impact on TTR or OS.

Pure laparoscopic versus open left lateral sectionectomy for hepatocellular carcinoma: A propensity score matching analysis

Backgrounds/Aims

Anatomical resection has superior oncologic outcomes over non-anatomical resection in hepatocellular carcinoma, and left lateral sectionectomy is the simplest and easiest perform anatomical resection procedure among liver resections. The purpose of this study was to find out the safety and feasibility of pure laparoscopic left lateral sectionectomy (PLLLS) for hepatocellular carcinoma.

Methods

Patients who underwent left lateral sectionectomy at a tertiary referral hospital, from August 2007 to April 2019 were enrolled in this retrospective study. After matching the 1 : 3 propensity score, 17 open and 51 pure laparoscopic cases were selected out of 102 cases of total left lateral resection for hepatocellular carcinoma. The group was analyzed in terms of patient demographics, preoperative data, and postoperative outcomes.

Results

During the study period, there was no open conversion case. The mean operative time and complication were not statistically significant different between the two groups. There was no statistically significant difference in disease-free survival and overall survival had no statistical between the two groups. There were no mortality cases, and postoperative hospital stay was significantly shorter in the PLLLS group than in the open left lateral sectionectomy (OLLS) group.

Conclusions

The oncologic outcomes and complication rate were the same in the PLLLS and OLLS groups. However, the hospital stay was shorter in the PLLLS group than in the OLLS group. The present study findings demonstrate that the PLLLS is a safe and feasible procedure for hepatocellular carcinoma.

Microvascular Invasion in Hepatocellular Carcinoma: A Review of Its Definition, Clinical Significance, and Comprehensive Management

Hepatocellular carcinoma (HCC) is one of the most common types of malignancies in the world, and most HCC patients undergoing liver resection relapse within five years. Microvascular invasion (MVI) is an independent factor for both the disease-free survival and overall survival of HCC patients. At present, the definition of MVI is still controversial, and a global consensus on how to evaluate MVI precisely is needed. Moreover, this review summarizes the current knowledge and clinical significance of MVI for HCC patients. In terms of management, antiviral therapy, wide surgical margins, and postoperative transcatheter arterial chemoembolization (TACE) could effectively reduce the incidence of MVI or improve the disease-free survival and overall survival of HCC patients with MVI. However, other perioperative management practices, such as anatomical resection, radiotherapy, targeted therapy and immune therapy, should be clarified in future investigations.

Anatomical vs nonanatomical liver resection for solitary hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND

The long-term survival of patients with solitary hepatocellular carcinoma (HCC) following anatomical resection (AR) vs non-anatomical resection (NAR) is still controversial. It is necessary to investigate which approach is better for patients with solitary HCC.

AIM

To compare perioperative and long-term survival outcomes of AR and NAR for solitary HCC.

METHODS

We performed a comprehensive literature search of PubMed, Medline (Ovid), Embase (Ovid), and Cochrane Library. Participants of any age and sex, who underwent liver resection, were considered following the following criteria: (1) Studies reporting AR vs NAR liver resection; (2) Studies focused on primary HCC with a solitary tumor; (3) Studies reporting the long-term survival outcomes (> 5 years); and (4) Studies including patients without history of preoperative treatment. The main results were overall survival (OS) and disease-free survival (DFS). Perioperative outcomes were also compared.

RESULTS

A total of 14 studies, published between 2001 and 2020, were included in our meta-analysis, including 9444 patients who were mainly from China, Japan, and Korea. AR was performed on 4260 (44.8%) patients. The synthetic results showed that the 5-year OS [odds ratio (OR): 1.19; P < 0.001] and DFS (OR: 1.26; P < 0.001) were significantly better in the AR group than in the NAR group. AR was associated with longer operating time [mean difference (MD): 47.08; P < 0.001], more blood loss (MD: 169.29; P = 0.001), and wider surgical margin (MD = 1.35; P = 0.04) compared to NAR. There was no obvious difference in blood transfusion ratio (OR: 1.16; P = 0.65) or postoperative complications (OR: 1.24, P = 0.18).

CONCLUSION

AR is superior to NAR in terms of long-term outcomes. Thus, AR can be recommended as a reasonable surgical option in patients with solitary HCC.

Quantitative Prognostic Prediction Using ADV Score for Hepatocellular Carcinoma Following Living Donor Liver Transplantation

BACKGROUND

We assessed the prognostic impact of the ADV score (α-fetoprotein [AFP]-des-γ-carboxyprothrombin [DCP]-tumor volume [TV] score) for predicting hepatocellular carcinoma (HCC) recurrence and patient survival after living donor liver transplantation (LDLT).

METHODS

This study included 843 HCC patients who underwent LDLT between January 2006 and December 2015 at Asan Medical Center. These cases were divided into treatment-naïve (TN, n = 256]) and pretransplant-treated (PT, n = 587 [69.6%]) groups.

RESULTS

There were weak or nearly no correlations among AFP, DCP, and TV. There existed high correlations between the pretransplant and explant findings regarding tumor number, size, and ADV score. Right lobe grafts were implanted in 760 (90.2%) patients. HCC recurrence and all-cause patient death occurred in 182 (15.9%) and 126 (15.0%) respectively during the follow-up period for 75.6 ± 35.5 months. The 5-year tumor recurrence (TR) and overall patient survival (OS) rates were 21.5% and 86.2%, respectively. The PT group showed higher TR (p < 0.001) and lower OS rates (p < 0.001). TR and OS were closely correlated with both pretransplant and explant ADV scores in the TN and PT groups. The ADV score enabled further prognostic stratification of the patients within and beyond the Milan, UCSF, and Asan Medical Center criteria. Compared with the 7 pre-existing selection criteria, ADV score with a cutoff of 5log showed the highest prognostic contrast regarding TR and OS.

CONCLUSIONS

Our prognostic prediction model using ADV scores is an integrated quantitative surrogate biomarker for posttransplant prognosis in HCC patients and can provide reliable information that assists the decision-making for LDLT.

What is the optimal surgical treatment for hepatocellular carcinoma beyond the debate between anatomical versus non-anatomical resection?

The optimal type of hepatectomy for hepatocellular carcinoma (HCC)-anatomical or non-anatomical resection-remains controversial despite numerous comparative studies. There are common fundamental issues in published studies comparing anatomical resection with non-anatomical resection: (1) confounding by indication, (2) setting primary outcomes, and (3) a lack of a clear definition of non-anatomical resection. This degrades the quality of the comparison of the two types of surgery. To measure the therapeutic effect of hepatectomy, it is essential to understand the accumulated knowledge underlying these issues, such as the mechanism of hepatocellular carcinoma spread, tumor blood flow drainage theory, and the three patterns of hepatocellular carcinoma recurrence: (1) local intrahepatic metastasis, (2) systemic metastasis, and (3) multicentric carcinogenesis recurrence. Based on evidence that the incidence of local intrahepatic metastasis was so low it was almost negligible, the therapeutic effect of anatomical resection on the oncological survival was determined to be similar to that of non-anatomical resection. Recent research progress demonstrating the clinical impact of subclinical dissemination of HCC after surgery may stimulate new debate on the optimal surgical treatment for HCC beyond the comparison of anatomical and non-anatomical resection.

Prognostic Accuracy of the ADV Score Following Resection of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

BACKGROUND

We assessed the prognostic accuracy of ADV score (α-fetoprotein [AFP]-des-γ-carboxyprothrombin [DCP]-tumor volume [TV] score) following resection of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).

METHODS

This was a retrospective observational study. This study included 147 patients who underwent hepatic resection for HCC with PVTT. They were followed up for ≥ 66 months or until patient death.

RESULTS

The grades of PVTT were Vp1 in 121 (14.3%), Vp2 in 41 (27.9%), Vp3 in 71 (48.3%), and Vp4 in14 (9.5%) cases. Preoperative HCC treatment was performed in 48 (32.7%) patients. R0 and R1 resections were performed in 119 (81.0%) and 28 (19.0%) cases, respectively. The 5-year tumor recurrence, HCC-specific survival, and post-recurrence survival rates were 79.2%, 43.5%, and 25.4%, respectively. Neither PVTT grade nor history of preoperative HCC treatment was a significant prognostic indicator. Stratification in accordance with ADV scores of 1log- and 3log-intervals resulted in high prognostic accuracy in predicting tumor recurrence and patient survival. Following cluster analysis, the cutoff for ADV score was determined at 9log and was more prognostically significant in terms of tumor recurrence and patient survival than surgical curability or microvascular invasion. Further comparisons revealed that prognostic prediction with an ADV score cutoff at 9log was more accurate than that using the Eastern Hepatobiliary Surgery Hospital-PVTT score.

CONCLUSIONS

ADV score is an integrated surrogate biomarker for post-resection prognosis in HCC with PVTT. Our prognostic prediction model using ADV scores provides reliable post-resection prognosis for patients with various grades of these tumors.

Anatomic versus non-anatomic resection of hepatocellular carcinoma with microvascular invasion: A systematic review and meta-analysis

The efficacy of anatomical resection (AR) and non-anatomical resection (NR) in the treatment of hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI) remains unknown. This study compared the safety and outcomes of these surgical procedures. A systematic literature search was conducted. The main outcomes were overall survival (OS), disease-free survival (DFS). Overall hazard ratio (HR) was calculated from Kaplan-Meier plots and outcomes using random-effects models. There was no significant difference in postoperative complications between the AR and NR groups (risk ratio [RR]: 0.92, 95% confidence interval [CI]: 0.72-1.17, p = 0.496). OS was higher with AR at 1 year (RR: 0.66, 95% CI: 0.45-0.98, p = 0.037), 3 years (RR: 0.64, 95% CI: 0.50-0.82, p = 0.000), and 5 years (RR: 0.76, 95% CI: 0.65-0.89, p = 0.001). AR was associated with a higher OS rate (HR: 0.62, 95% CI: 0.47-0.82, p = 0.001). AR was associated with improved DFS at 1 year (RR: 0.65, 95% CI: 0.52 to 0.82, p = 0.000), 3 years (RR: 0.75, 95% CI: 0.66 to 0.86, p = 0.000), and 5 years (95% CI: 0.75 to 0.94, p = 0.002). Compared with NR, AR had significant advantages on overall HR of DFS (HR: 0.64, 95% CI: 0.45 to 0.91, p = 0.012). In conclusion, AR was associated with higher rates of OS and DFS in HCC patients with MVI. Thus, for well-presented liver function HCC patients which are predicted to have positive MVI, AR is recommended.

Central Hepatectomy Versus Major Hepatectomy for Centrally Located Hepatocellular Carcinoma: A Propensity Score Matching Study

BACKGROUND

In terms of anatomical liver sectionectomy approaches, both a central hepatectomy (CH) and major hepatectomy (MH) are feasible options for a centrally located hepatocellular carcinoma (HCC).

METHODS

We retrospectively reviewed the surgical outcomes of central HCC patients who underwent CH or MH. MH includes hemihepatectomy or trisectionectomy, whereas CH involves a left medial sectionectomy, right anterior sectionectomy, or central bisectionectomy. The surgical outcomes were compared before and after propensity score matching (PSM).

RESULTS

A total of 233 patients were enrolled, including 132 in the CH group and 101 in the MH group. The MH group cases were pathologically more advanced and had poorer overall survival rates than the CH group. After PSM, 68 patients were selected into each group, both of which showed similar overall and recurrence-free survival outcomes. The CH group showed a tendency for a longer operation time; however, other perioperative outcomes were similar between the two groups. Multivariate analyses of our matched HCC patients revealed that the type of surgery (CH or MH) was not an independent prognostic factor. More patients in the matched CH group experienced a repeat hepatectomy for recurrence and no patients in this group underwent a preoperative portal vein embolization.

CONCLUSIONS

The short- and long-term surgical outcomes of CH and MH for a centrally located HCC are similar under a matched clinicopathological background. CH has the advantage of not requiring a preoperative portal vein embolization and increased chances of conducting a repeat hepatectomy for recurrence.

Prediction of Post-resection Prognosis Using the ADV Score for Huge Hepatocellular Carcinomas ≥13 cm

Background/Aims

Multiplication of α-fetoprotein, des-γ-carboxy prothrombin, and tumor volume (ADV score) is a surrogate marker for post-resection prognosis of hepatocellular carcinoma (HCC). This study aimed to validate the predictive power of the ADV score-based prognostic prediction model for patients with solitary huge HCC.

Methods

Of 3,018 patients, 100 patients who underwent hepatic resection for solitary HCC ≥13 cm between 2008 and 2012 were selected.

Results

The median tumor diameter and tumor volume were 15.0 cm and 886 mL, respectively. Tumor recurrence and overall survival (OS) rates were 70.7% and 66.0% at one year and 84.9% and 34.0% at five years, respectively. Microvascular invasion (MVI) was the only independent risk factor for disease-free survival (DFS) and OS. DFS and OS, stratified by ADV score with 1-log intervals, showed significant prognostic contrasts (P=0.007 and P=0.017, respectively). DFS and OS, stratified by ADV score with a cut-off of 8-log, showed significant prognostic contrasts (P=0.014 and P=0.042, respectively). The combination of MVI and ADV score with a cut-off of 8-log also showed significant prognostic contrasts in DFS (P<0.001) and OS (P=0.001) considering the number of risk factors. Prognostic contrast was enhanced after combining the MVI and ADV score.

Conclusions

The prognostic prediction model with the ADV score could reliably predict the risk of tumor recurrence and long-term patient survival outcomes in patients with solitary huge HCC ≥13 cm. The results of this study suggest that our prognostic prediction models can be used to guide surgical treatment and post-resection follow-up for patients with huge HCCs.

Near-Infrared Fluorescence Imaging and Photodynamic Therapy for Liver Tumors

Surgery with fluorescence equipment has improved to treat the malignant viscera, including hepatobiliary and pancreatic neoplasms. In both open and minimally invasive surgeries, optical imaging using near-infrared (NIR) fluorescence is used to assess anatomy and function in real time. Here, we review a variety of publications related to clinical applications of NIR fluorescence imaging in liver surgery. We have developed a novel nanoparticle (indocyanine green lactosome) that is biocompatible and can be used for imaging cancer tissues and also as a drug delivery system. To date, stable particles are formed in blood and have an ~10–20 h half-life. Particles labeled with a NIR fluorescent agent have been applied to cancer tissues by the enhanced permeability and retention effect in animals. Furthermore, this article reviews recent developments in photodynamic therapy with NIR fluorescence imaging, which may contribute and accelerate the innovative treatments for liver tumors.

Salvage living donor liver transplantation for hepatocellular carcinoma recurrence after hepatectomy: Quantitative prediction using ADV score

BACKGROUND

Salvage liver transplantation is a definite treatment for recurrent hepatocellular carcinoma (HCC) after hepatectomy. ADV score is calculated by multiplying α-fetoprotein and des-γ-carboxyprothrombin concentrations and tumor volume. Prognostic accuracy of ADV score was assessed in patients undergoing salvage living donor liver transplantation (LDLT) and their outcomes were compared with patients undergoing primary LDLT.

METHODS

This study was a retrospective, single-center, case-controlled study. Outcomes were compared in 125 patients undergoing salvage LDLT from 2007 to 2018 and in 500 propensity score-matched patients undergoing primary LDLT.

RESULTS

In patients undergoing salvage LDLT, median intervals between hepatectomy and tumor recurrence, between first HCC diagnosis and salvage LDLT, and between hepatectomy and salvage LDLT were 12.0, 37.2, and 29.3 months, respectively. Disease-free survival (DFS, P = .98) and overall survival (OS, P = .44) rates did not differ significantly in patients undergoing salvage and primary LDLT. Pretransplant and explant ADV scores were significantly predictive of DFS and OS in patients undergoing salvage and primary LDLT (P < .001). DFS after prior hepatectomy (P = .52) and interval between hepatectomy and LDLT (P = .82) did not affect DFS after salvage LDLT. Milan criteria and ADV score were independently prognostic of DFS and OS following salvage LDLT, and prognosis of patients within and beyond Milan criteria could be further stratified by ADV score.

CONCLUSIONS

Risk factors and posttransplant outcomes were similar in patients undergoing salvage and primary LDLT. ADV score is surrogate biomarker for posttransplant prognosis in salvage and primary LDLT recipients. Prognostic model incorporating ADV scores can help determine whether to perform salvage LDLT.

Validation of prognostic impact of ADV score for resection of hepatocellular carcinoma: analysis using Korea Liver Cancer Registry Database

Purpose

We aimed to validate the prognostic predictive power of ADV score (α-FP-des-γ-carboxyprothrombin [DCP]-tumor volume [TV] score, calculated as α-FP [ng/mL] × DCP [mAU/mL] × TV [mL] and expressed in log₁₀) for predicting patient survival after resection of hepatocellular carcinoma (HCC).

Methods

This study included 1,390 patients with HCC registered in the Korea Liver Cancer Registry. Patients underwent hepatic resection between 2008 and 2012 and were followed up until December 2016. They were divided into 4 groups according to the number of tumors and preoperative treatment.

Results

There was no significant correlation among α-FP, DCP, and TV values (r² ≤ 0.04, P < 0.001). In group 1 with single treatment-naive tumor (n = 1,154), patient stratification with postoperative ADV 1log-interval and cutoffs of 5log, 7log, and 10log showed great prognostic contrast (P < 0.001). In group 2 with multiple treatment-naive tumors (n = 170), patient stratification with postoperative ADV 1log-interval and above-mentioned 3 cutoffs also showed great prognostic contrast (P < 0.001). In group 3 (n = 50) and group 4 (n = 16) with preoperative-treated tumors, patient stratification with postoperative ADV 1log-interval and above-mentioned 3 cutoffs showed noticeable prognostic contrast (P ≤ 0.031). Preoperative ADV score based on preoperative findings also showed great prognostic contrast in 1,106 patients preoperatively diagnosed as having single treatment-naive tumor (P < 0.001). Confining patients to tumor-node-metastasis stages I and II (n = 1,072) as well as Barcelona Clinic Liver Cancer stage 0 and A (n = 862), postoperative ADV cutoffs showed further prognostic stratification.

Conclusion

This validation study strongly suggests that ADV score is an integrated surrogate marker for postresection prognosis in patients with HCC.

Anatomic versus non-anatomic resection for hepatocellular carcinoma, do we have an answer? A meta-analysis

BACKGROUND

Anatomic resection (AR) is widely performed for hepatocellular carcinoma (HCC), but it is generally not considered superior to non-anatomic resection (NAR) in terms of prognosis. So we compared the prognosis of AR with that of NAR for HCC.

METHODS

We searched for articles about AR versus NAR for HCC published between January 1998 and December 2018 in PubMed, Cochrane Library, EMBASE and Wanfang database. Meta-analysis was performed on patient characteristics, tumor characteristics, operative characteristics, perioperative outcomes and long-term outcomes.

RESULTS

A total of 38 studies involving 9122 patients were included: 5062 were in the AR group and 4060 in the NAR group. Only one study included in our meta-analysis was randomized controlled trial, and others were comparative cohort studies. The AR group had an advantage over NAR group in the aspect of age, liver cirrhosis level and liver reserve function; but had a disadvantage in the aspect of tumor size, AFP level, operation time, blood loss, microvascular invasion, pathological differentiation and postoperative complication. The AR group gained 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS) benefits versus NAR group, but there was significant heterogeneity between groups in terms of patient and tumor characteristics.

CONCLUSION

AR is superior to NAR regarding the long-term outcomes considering the relatively acceptable heterogeneity. More prospective randomized controlled trials are required to further confirm the actual effect of AR or NAR on survival for HCC with less heterogeneity.

Impact of Surgical Margin on the Prognosis of Early Hepatocellular Carcinoma (≤5 cm): A Propensity Score Matching Analysis

Aim: The influence of surgical margin on the prognosis of patients with early solitary hepatocellular carcinoma (HCC) (≤5 cm) is undetermined.

Methods: The data of 904 patients with early solitary HCC who underwent liver resection were collected for recurrence-free survival (RFS) and overall survival (OS). Propensity score matching (PSM) was performed to balance the potential bias.

Results: Log-rank tests showed that 2 mm was the best cutoff value to discriminate the prognosis of early HCC. Liver resection with a >2 mm surgical margin distance (wide-margin group) led to better 5-year RFS and OS rate compared with liver resection with a ≤2 mm surgical margin distance (narrow-margin group) among patients both before (RFS: 59.1% vs. 39.6%, P < 0.001; OS: 85.3% vs. 73.7%, P < 0.001) and after PSM (RFS: 56.3% vs. 41.0%, P < 0.001; OS: 83.0% vs. 75.0%, P = 0.010). Subgroup analysis showed that a wide-margin resection significantly improved the prognosis of patients with microvascular invasion (RFS: P < 0.001; OS: P = 0.001) and patients without liver cirrhosis (RFS: P < 0.001; OS: P = 0.001) after PSM. Multivariable Cox regression analysis revealed that narrow-margin resection is associated with poorer RFS [hazard ratio (HR) = 1.781, P < 0.001), OS (HR = 1.935, P < 0.001], and early recurrence (HR = 1.925, P < 0.001).

Conclusions: A wide-margin resection resulted in better clinical outcomes than a narrow-margin resection among patients with early solitary HCC, especially for those with microvascular invasion and without cirrhosis. An individual strategy of surgical margin should be formulated preoperation according to both tumor factors and background liver factors.

"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.

Prognostic and Therapeutic Implications of Microvascular Invasion in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a morbid condition for which surgical and ablative therapy are the only options for cure. Nonetheless, over half of patients treated with an R0 resection will develop recurrence. Early recurrences within 2 years after resection are thought to be due to the presence of residual microscopic disease, while late recurrences > 2 years after resection are thought to be de novo metachronous HCCs arising in chronically injured liver tissue. Microvascular invasion (MVI) is defined as the presence of micrometastatic HCC emboli within the vessels of the liver, and is a critical determinant of early recurrence and survival. In this review, we summarize the pathogenesis and clinical relevance of MVI, which correlates with adverse biological features, including high grade, large tumor size, and epithelial-mesenchymal transition. Multiple classification schemas have been proposed to capture the heterogeneous features of MVI that are associated with prognosis. However, currently, MVI can only be determined based on surgical specimens, limiting its clinical applicability. Going forward, advances in axial imaging technologies, molecular characterization of biopsy tissue, and novel serum biomarkers hold promise as future methods for non-invasive MVI detection. Ultimately, MVI status may be used to help clinicians determine treatment plans, particularly with respect to surgical intervention, and to provide more accurate prognostication.

Is the anatomical resection necessary for single hepatocellular carcinoma smaller than 3 cm?: single-center experience of liver resection for a small HCC

Backgrounds/Aims

The superiority of anatomical resection (AR) for a small HCC remains controversial. In this study, we investigated the clinical outcomes after AR and non-anatomical liver resection (NAR) for single HCC smaller than 3 cm and the risk factors for HCC recurrence.

Methods

A total of 116 consecutive patients who underwent liver resection for single HCC (<3 cm) between Jan 2006 and Dec 2015 were included in this study. The medical records of these patients were reviewed and analyzed retrospectively.

Results

There was no significant difference in tumor recurrence and survival between AR and NAR group. Multivariate analysis showed that hepatitis B (p=0.035, HR=8.72), presence of satellite nodule (p=0.029, HR=3.97) and microvascular invasion (MVI) (p=0.039, HR=2.79) were independent risk factors for early recurrence within 1 year. The overall recurrence was independently related to the presence of satellite nodule (p=0.001, HR=4.98) and background liver cirrhosis (p=0.032, HR=1.96). In patients with MVI, HCC recurrence was significantly more frequent in width of safety margin <1 cm group than ≥1 cm group (p=0.049).

Conclusions

The outcomes of NAR are comparable with those of AR in single HCC smaller than 3 cm. The presence of satellite nodule, MVI and hepatitis B are the independent risk factors for early recurrence, however overall recurrence is correlated with background liver cirrhosis and the presence of satellite nodule rather than pathobiologic factors in single HCC smaller than 3 cm. Hepatic resection with sufficient margin (≥1 cm) is recommended for decreasing risk of recurrence in patients with suspected MVI.

Validation of the OncoHepa test, a multigene expression profile test, and the tumor marker-volume score to predict postresection outcome in small solitary hepatocellular carcinomas

Purpose

OncoHepa test is a multigene expression profile test developed for assessment of hepatocellular carcinoma (HCC) prognosis. Multiplication of α-FP, des-γ-carboxy prothrombin (DCP) and tumor volume (TV) gives the α-FP-DCP-volume (ADV) score, which is also developed for assessment of HCC prognosis.

Methods

The predictive powers of OncoHepa test and ADV score were validated in 35 patients who underwent curative hepatic resection for naïve solitary HCCs ≤5 cm.

Results

Median tumor diameter was 3.0 cm. Tumor recurrence and patient survival rates were 28.6% and 100% at 1 year, 48.6% and 82.9% at 3 years, and 54.3% and 71.4% at 5 years, respectively. The site of first tumor recurrence was the remnant liver in 18, lung in 1, and the peritoneum in 1. All patients with HCC recurrence received locoregional treatment. OncoHepa test showed marginal prognostic significance for tumor recurrence and patient survival. ADV score at 4log also showed marginal prognostic difference with respect to tumor recurrence and patient survival. Combination of these 2 tests resulted in greater prognostic significance for both tumor recurrence (P = 0.046) and patient survival (P = 0.048).

Conclusion

Both OncoHepa test and ADV score have considerably strong prognostic power, thus individual and combined findings of OncoHepa test and ADV score will be helpful to guide postresection surveillance in patients with solitary HCCs ≤5 cm.

Prognostic Prediction Models for Resection of Large Hepatocellular Carcinoma: A Korean Multicenter Study

BACKGROUND

We developed a prognostic prediction model (PPM) using 4 factors for hepatic resection (HR) of large hepatic cellular carcinoma (HCC). Multiplication of α-fetoprotein (AFP), des-γ-carboxy prothrombin, and tumor volume (TV) (ADV score) is a surrogate marker for post-resection prognosis. This study intended to validate the predictive power of 4-factor PPM and to develop new ADV score-based PPM.

METHODS

A total of 526 patients who underwent HR for solitary HCC ≥ 8 cm were selected from 9 Korean institutions between 2008 and 2014.

RESULTS

Median tumor diameter and TV were 11.0 cm and 398 mL, respectively. Tumor recurrence and patient survival rates were 53.0 and 78.4% at 1 year and 70.2 and 49.3% at 5 years, respectively. Independent risk factors for both tumor recurrence and patient survival included AFP ≥ 100 ng/mL, hypermetabolic FDG-positron emission tomography (PET), microvascular invasion and satellite nodules, which comprised 4 factors of the PPM. Five subgroups based on the number of involved risk factors exhibited significant differences in tumor recurrence and patient survival. ADV score cutoff was set at 7log (ADV7log) after cluster prognostic analysis. Patient grouping according to combination of ADV7log and FDG-PET findings (ADV7log-PET) exhibited significant differences in tumor recurrence and patient survival, comparable to those of the 4-factor PPM.

CONCLUSIONS

Two PPMs using 4 risk factors and ADV7log-PET could reliably predict the risk of early HCC recurrence and long-term survival outcomes in patients who underwent HR for large HCC. We believe that these PPMs can guide surgical treatment for large HCCs from preoperative HR planning to post-resection follow-up.

Innovative treatment for hepatocellular carcinoma (HCC)

Indocyanine green (ICG) is not new in the field of liver surgery. Early studies performed in the 1980s and 1990s revealed the value of the ICG clearance test in predicting post-hepatectomy morbidity and mortality. ICG clearance and retention tests are crucial for determining precise liver function before liver surgery and offer several benefits for safe surgery. Whereas ICG is well-known and has long history in medicine, recent progress in infrared light technology over the last decade has highlighted another feature of ICG. For example, ICG fluorescence-guided surgery may change the next generation of liver surgery. In the near future, ICG with near-infrared (NIR) light photodynamic therapy (PDT) is expected to become a new treatment method for hepatocellular carcinoma (HCC). Furthermore, several aspects of the mechanisms of ICG accumulation in HCC cells have been revealed by important basic research studies. New imaging technologies and mechanistic findings keep ICG in the spotlight. In this article, we review three recently described topics of ICG which may contribute to the development of innovative and new treatments method for HCC, fluorescence-guided surgery, mechanism of ICG accumulation in HCC cells, PDT for HCC.