Development and Validation of a Nomogram to Preoperatively Estimate Post-hepatectomy Liver Dysfunction Risk and Long-term Survival in Patients With Hepatocellular Carcinoma

Predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma: nomograms based on deep learning analysis of gadoxetic acid-enhanced MRI

OBJECTIVES

This study aimed to develop nomograms for predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC), using deep learning analysis of Gadoxetic acid-enhanced hepatobiliary (HBP) MRI.

METHODS

This retrospective study analyzed patients who underwent gadoxetic acid-enhanced MRI and hepatectomy for HCC between 2016 and 2020 at two referral centers. Using a deep learning algorithm, volumes and signal intensities of whole non-tumor liver, expected remnant liver, and spleen were measured on HBP images. Two multivariable logistic regression models were formulated to predict PHLF, defined and graded by the International Study Group of Liver Surgery: one based on whole non-tumor liver measurements (whole liver model) and the other on expected remnant liver measurements (remnant liver model). The models were presented as nomograms and a web-based calculator. Discrimination performance was evaluated using the area under the receiver operating curve (AUC), with internal validation through 1000-fold bootstrapping.

RESULTS

The study included 1760 patients (1395 male; mean age ± standard deviation, 60 ± 10 years), with 137 (7.8%) developing PHLF. Nomogram predictors included sex, gamma-glutamyl transpeptidase, prothrombin time international normalized ratio, platelets, extent of liver resection, and MRI variables derived from the liver volume, liver-to-spleen signal intensity ratio, and spleen volume. The whole liver and the remnant liver nomograms demonstrated strong predictive performance for PHLF (optimism-corrected AUC of 0.78 and 0.81, respectively) and symptomatic (grades B and C) PHLF (optimism-corrected AUC of 0.81 and 0.84, respectively).

CONCLUSION

Nomograms based on deep learning analysis of gadoxetic acid-enhanced HBP images accurately stratify the risk of PHLF.

KEY POINTS

Question Can PHLF be predicted by integrating clinical and MRI-derived volume and functional variables through deep learning analysis of gadoxetic acid-enhanced MRI? Findings Whole liver and remnant liver nomograms demonstrated strong predictive performance for PHLF with the optimism-corrected area under the curve of 0.78 and 0.81, respectively. Clinical relevance These nomograms can effectively stratify the risk of PHLF, providing a valuable tool for treatment decisions regarding hepatectomy for HCC.

Multivariable prognostic models for post-hepatectomy liver failure: An updated systematic review

BACKGROUND

Partial hepatectomy continues to be the primary treatment approach for liver tumors, and post-hepatectomy liver failure (PHLF) remains the most critical life-threatening complication following surgery.

AIM

To comprehensively review the PHLF prognostic models developed in recent years and objectively assess the risk of bias in these models.

METHODS

This review followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Three databases were searched from November 2019 to December 2022, and references as well as cited literature in all included studies were manually screened in March 2023. Based on the defined inclusion criteria, articles on PHLF prognostic models were selected, and data from all included articles were extracted by two independent reviewers. The PROBAST was used to evaluate the quality of each included article.

RESULTS

A total of thirty-four studies met the eligibility criteria and were included in the analysis. Nearly all of the models (32/34, 94.1%) were developed and validated exclusively using private data sources. Predictive variables were categorized into five distinct types, with the majority of studies (32/34, 94.1%) utilizing multiple types of data. The area under the curve for the training models included ranged from 0.697 to 0.956. Analytical issues resulted in a high risk of bias across all studies included.

CONCLUSION

The validation performance of the existing models was substantially lower compared to the development models. All included studies were evaluated as having a high risk of bias, primarily due to issues within the analytical domain. The progression of modeling technology, particularly in artificial intelligence modeling, necessitates the use of suitable quality assessment tools.

Development models to predict complication and prognosis following liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension

BACKGROUND

Postoperative complications are potential factors influencing the prognosis of patients with HCC combined with CSPH. This study aims to explore the risk factors affecting the occurrence of postoperative complications, investigate potential factors influencing long-term prognosis in these patients, and establish predictive models.

METHODS

From April 2018 to December 2021, a total of 190 patients with HCC combined with CSPH who underwent curative liver resection in our hospital were included, comprising 69 cases in the complication group and 121 cases in the non-complication group. LASSO-Logistic regression was employed to identify risk factors influencing postoperative complications and establish a predictive model. LASSO-Cox regression was used to determine prognostic factors for long-term outcomes in patients with HCC combined with CSPH and establish a predictive model.

RESULTS

LASSO regression selected variables including ALBI grade, preoperative ascites, major hepatectomy, and portal vein occlusion time >15 ​min. These variables were incorporated into logistic regression (P ​< ​0.05) to establish a nomogram for predicting postoperative complications, with a C-index of 0.723. Results from the multivariable Cox regression analysis showed that postoperative complications, maximum tumor diameter, and microvascular invasion were risk factors for recurrence, while postoperative complications, maximum tumor diameter, microvascular invasion, and prealbumin were risk factors for overall survival. The C-index values for the respective nomograms were 0.635 and 0.734. The calibration curves and ROC curves demonstrated good performance for all three nomograms.

CONCLUSIONS

The three nomograms achieved optimal predictive performance for postoperative complications, recurrence, and overall survival in patients with HCC combined with CSPH undergoing curative resection.

CT-based detection of clinically significant portal hypertension predicts post-hepatectomy outcomes in hepatocellular carcinoma

BACKGROUND

While the CT-based method of detecting clinically significant portal hypertension (CSPH) emerged as a noninvasive alternative for evaluating CSPH, its predictive ability for post-hepatectomy outcomes is unknown. Therefore, this study aimed to evaluate the impact of CT-based CSPH on outcomes following hepatectomy for hepatocellular carcinoma (HCC).

METHODS

This retrospective single-center study included patients with advanced chronic liver disease (ACLD) who underwent hepatectomy for very early or early-stage HCC between January 2017 and December 2018. CSPH was assessed using CT-based criteria, which included splenomegaly determined by deep learning-based spleen volume measurements with personalized reference thresholds, and the presence of gastroesophageal varices (GEV), spontaneous portosystemic shunt or ascites. Logistic regression and competing risk analyses were used to identify factors associated with severe post-hepatectomy liver failure (PHLF), hepatic decompensation, and liver-related death or transplantation. The predictive performance of existing models for PHLF was compared using both CT-based and conventional CSPH criteria (endoscopic GEV or splenomegaly with thrombocytopenia).

RESULTS

Among 593 patients (460 men; mean age 57.9 ± 9.3 years), 41 (6.9%) developed severe PHLF. The median follow-up period was 62 months. CT-based CSPH independently predicted severe PHLF (OR 7.672 [95% CI 3.209-18.346]), hepatic decompensation (subdistribution hazard ratio (sHR) 4.518 [1.868-10.929]), and liver-related death or transplantation (sHR 2.756 [1.315-5.773]). When integrated into existing models, CT-based CSPH outperformed conventional CSPH in predicting severe PHLF (AUC 0.724 vs. 0.694 for EASL algorithm (p = 0.036) and 0.854 vs. 0.830 for Wang's model (p = 0.011)).

CONCLUSIONS

CT-based CSPH is a strong predictor of poor post-hepatectomy outcomes in HCC patients with ACLD, offering a noninvasive surgical risk assessment tool.

KEY POINTS

Question Can CT-based detection of clinically significant portal hypertension (CSPH) serve as a noninvasive predictor of post-hepatectomy outcomes in hepatocellular carcinoma (HCC) patients? Findings CT-based CSPH independently predicted severe post-hepatectomy liver failure, hepatic decompensation, and liver-related death or transplantation, outperforming conventional CSPH criteria in predictive performance. Clinical relevance CT-based CSPH offers a noninvasive and effective tool for surgical risk assessment in HCC patients, potentially improving the selection of candidates for hepatectomy and optimizing patient outcomes.

The assessment of impaired liver function and prognosis in hepatocellular carcinoma

INTRODUCTION

The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

AREAS COVERED

This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

EXPERT OPINION

A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.

Addition of Immune Checkpoint Inhibitor Showed Better Efficacy for Infiltrative Hepatocellular Carcinoma Receiving Hepatic Arterial Infusion Chemotherapy and Lenvatinib: A Multicenter Retrospective Study

Purpose

The prognosis of infiltrative hepatocellular carcinoma (HCC) is dismal. Hepatic arterial infusion chemotherapy (HAIC) plus Lenvatinib (Len) and immune checkpoint inhibitor (ICI) have shown promising results for HCC. However, this three combination therapy on infiltrative HCC is unknown. In this study, we compared HAIC plus lenvatinib (Len) and programmed cell death protein-1 (PD-1) inhibitor with HAIC plus Len for infiltrative HCC.

Patients and Methods

This multi-center cohort study included patients with infiltrative HCC who received HAIC combined with Len (HAIC+Len group, n = 173) or HAIC combined with Len and PD-1 inhibitor (HAIC+Len+ICI group, n = 128) as the first-line treatment from January 2019 to December 2021. To balance any intergroup differences, one-to-one propensity score matching (PSM) was applied. Overall survival (OS) and progression-free survival (PFS) were compared between the two groups.

Results

After PSM, the median OS was 14.1 ± 1.0 and 16.1 ± 1.4 months in the HAIC+Len and HAIC+Len+ICI groups, respectively. The median PFS was 4.6 ± 0.4 months in the HAIC+Len group and 7.5 ± 0.8 months in the HAIC+Len+ICI group. The HAIC+Len+ICI group showed significantly better OS (hazard ratio [HR], 0.66; 95% CI, 0.49-0.90; P = 0.008) and PFS (HR, 0.53; 95% confident index [CI], 0.40-0.70; P < 0.001) compared with the HAIC+Len group. Subgroup analysis revealed that for OS in HCC without metastasis, the addition of PD-1 inhibitor was not significant (HR, 0.68; 95% CI, 0.43-1.07; P = 0.091). No difference was observed in OS between low (2-3 cycles) and high (4-6 cycles) level of HAIC cycles (HR, 0.99; 95% CI, 0.67-1.44; P = 0.938).

Conclusion

The HAIC+Len+ICI group had a longer PFS and OS compared with the HAIC+Len group, demonstrating an acceptable safety profile. This triple combination strategy may be an alternative treatment for infiltrative HCC management.

Multicenter propensity score-matched analysis to compare perioperative morbidity after laparoscopic or robotic complex hepatectomy for solitary hepatocellular carcinoma

BACKGROUND

Postoperative complications are vital factors affecting the prognosis of patients with hepatocellular carcinoma (HCC), especially for complex hepatectomy. The present study aimed to compare perioperative complications between laparoscopic and robotic complex hepatectomy (LCH vs. RCH).

METHODS

Patients with solitary HCC after complex hepatectomy were collected from a multicenter database. Propensity score-matched (PSM) analysis was adopted to control confounding bias. Multivariable analysis was performed to determine the prognostic factors.

RESULTS

436 patients were included. After PSM, 43 patients were included in both the LCH and RCH groups. The results showed that compared to LCH, RCH had lower rates of blood loss and transfusion, and lower postoperative 30-day and major morbidity, and post-hepatectomy liver failure (PHLF) (all P < 0.05). Additionally, the length of hospital stay was shorter in the RCH group (P = 0.026). Multivariable analysis showed RCH is an independent protective factor for reducing the 30-day morbidity, major morbidity and PHLF.

CONCLUSION

RCH has advantages over LCH in the minimally invasive treatment of complex HCC, as it can reduce the incidence of postoperative morbidity. Therefore, RCH should be considered for patients with HCC who require complex hepatectomy.

Establishment of nomogram to predict overall survival and cancer-specific survival of local tumor resection in patients with colorectal cancer liver metastasis with unresectable metastases: a large population-based analysis

BACKGROUND AND PURPOSE

The tumour-node metastasis (TNM) classification is a common model for evaluating the prognostic value of tumour patients. However, few models have been used to predict the survival outcomes of patients with colorectal cancer liver metastasis (CRLM) with unresectable metastases who received the primary local surgery. Thus, we utilized the Surveillance, Epidemiology, and End Results (SEER) database to establish novel nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) of these patients.

METHODS

Extracted primary data on CRLM patients by local surgery from SEER database. All prognostic factors of OS and CSS were determined by Cox regression analysis. The concordance index (C-index), receiver operating characteristic (ROC) curves and calibration curves were used to further evaluate the accuracy and discrimination of these nomograms. Decision curve analysis (DCA) was executed to evaluate the nomograms for the clinical net benefit. Risk stratification analysis (RSA) was used to evaluate the reliability of them in clinical.

RESULTS

3622 eligible patients were screened and assigned to training cohort (1812) or validation cohort (1810). The age, chemotherapy, tumour grade, primary tumour site, tumour size, lymph node positive rate (LNR), marital status, and carcinoembryonic antigen (CEA) were independent prognostic factors of OS. Additionally, the age, chemotherapy, tumour grade, primary tumour site, tumour size, LNR, and CEA were independent prognostic factors of CSS. The results of C-indexes and ROC curves indicated that the established nomograms exhibited better discrimination power than TNM classification. The calibration curves demonstrated excellent agreement between the predicted and actual survival rates for 1-, 3-, and 5 year OS and CSS. Meanwhile, the validation cohort demonstrated similar results. Background the clinic context, the DCA showed that these nomograms have higher net benefits, and the RSA showed that patients were further divided into low risk, medium risk, and high risk groups according to the predicted scores from nomograms. And, the Kaplan-Meier curve and log-rank test showed that the survival differences among the three groups are statistically significant.

CONCLUSIONS

The prognostic nomograms showed very high accuracy, identifiability, and clinical practicality in predicting the OS and CSS of CRLM patients with unresectable metastases treated by local surgery at 1-, 3-, and 5 years, which might improve individualized predictions of survival risks and help clinicians formulate treatment plans.

A novel surgical scheme for hepatectomy in hepatocellular carcinoma patients with clinically significant portal hypertension

OBJECTIVE

Clinically significant portal hypertension (CSPH) seriously affects the feasibility and safety of surgical treatment for hepatocellular carcinoma (HCC) patients. The aim of this study was to establish a new surgical scheme defining risk classification of post-hepatectomy liver failure (PHLF) to facilitate the surgical decision-making and identify suitable candidates for individual hepatectomy among HCC patients with CSPH.

BACKGROUNDS

Hepatectomy is the preferred treatment for HCC. Surgeons must maintain a balance between the expected oncological outcomes of HCC removal and short-term risks of severe PHLF and morbidity. CSPH aggravates liver decompensation and increases the risk of severe PHLF thus complicating hepatectomy for HCC.

METHODS

Multivariate logistic regression and stochastic forest algorithm were performed, then the independent risk factors of severe PHLF were included in a nomogram to determine the risk of severe PHLF. Further, a conditional inference tree (CTREE) through recursive partitioning analysis validated supplement the misdiagnostic threshold of the nomogram.

RESULTS

This study included 924 patients, of whom 137 patients (14.8%) suffered from mild-CSPH and 66 patients suffered from (7.1%) with severe-CSPH confirmed preoperatively. Our data showed that preoperative prolonged prothrombin time, total bilirubin, indocyanine green retention rate at 15 min, CSPH grade, and standard future liver remnant volume were independent predictors of severe PHLF. By incorporating these factors, the nomogram achieved good prediction performance in assessing severe PHLF risk, and its concordance statistic was 0.891, 0.850 and 0.872 in the training cohort, internal validation cohort and external validation cohort, respectively, and good calibration curves were obtained. Moreover, the calculations of total points of diagnostic errors with 95% CI were concentrated in 110.5 (range 76.9-178.5). It showed a low risk of severe PHLF (2.3%), indicating hepatectomy is feasible when the points fall below 76.9, while the risk of severe PHLF is extremely high (93.8%) and hepatectomy should be rigorously restricted at scores over 178.5. Patients with points within the misdiagnosis threshold were further examined using CTREE according to a hierarchic order of factors represented by the presence of CSPH grade, ICG-R15, and sFLR.

CONCLUSION

This new surgical scheme established in our study is practical to stratify risk classification in assessing severe PHLF, thereby facilitating surgical decision-making and identifying suitable candidates for individual hepatectomy.

Novel pretreatment nomograms based on pan-immune-inflammation value for predicting clinical outcome in patients with head and neck squamous cell carcinoma

Background

The prognostic value of an effective biomarker, pan-immune-inflammation value (PIV), for head and neck squamous cell carcinoma (HNSCC) patients after radical surgery or chemoradiotherapy has not been well explored. This study aimed to construct and validate nomograms based on PIV to predict survival outcomes of HNSCC patients.

Methods

A total of 161 HNSCC patients who underwent radical surgery were enrolled retrospectively for development cohort. The cutoff of PIV was determined using the maximally selected rank statistics method. Multivariable Cox regression and least absolute shrinkage and selection operator (LASSO) regression analyses were performed to develop two nomograms (Model A and Model B) that predict disease-free survival (DFS). The concordance index, receiver operating characteristic curves, calibration curves, and decision curve analysis were used to evaluate the nomograms. A cohort composed of 50 patients who received radiotherapy or chemoradiotherapy (RT/CRT) alone was applied for generality testing of PIV and nomograms.

Results

Patients with higher PIV (≥123.3) experienced a worse DFS (HR, 5.01; 95% CI, 3.25-7.72; p<0.0001) and overall survival (OS) (HR, 5.23; 95% CI, 3.34-8.18; p<0.0001) compared to patients with lower PIV (<123.3) in the development cohort. Predictors of Model A included age, TNM stage, neutrophil-to-lymphocyte ratio (NLR), and PIV, and that of Model B included TNM stage, lymphocyte-to-monocyte ratio (LMR), and PIV. In comparison with TNM stage alone, the two nomograms demonstrated good calibration and discrimination and showed satisfactory clinical utility in internal validation. The generality testing results showed that higher PIV was also associated with worse survival outcomes in the RT/CRT cohort and the possibility that the two nomograms may have a universal applicability for patients with different treatments.

Conclusions

The nomograms based on PIV, a simple but useful indicator, can provide prognosis prediction of individual HNSCC patients after radical surgery and may be broadly applicated for patients after RT/CRT alone.

Machine learning-based model for predicting tumor recurrence after interventional therapy in HBV-related hepatocellular carcinoma patients with low preoperative platelet-albumin-bilirubin score

Introduction

This study aimed to develop a prognostic nomogram for predicting the recurrence-free survival (RFS) of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients with low preoperative platelet-albumin-bilirubin (PALBI) scores after transarterial chemoembolization (TACE) combined with local ablation treatment.

Methods

We gathered clinical data from 632 HBV-related HCC patients who received the combination treatment at Beijing You'an Hospital, affiliated with Capital Medical University, from January 2014 to January 2020. The patients were divided into two groups based on their PALBI scores: low PALBI group (n=247) and high PALBI group (n=385). The low PALBI group was then divided into two cohorts: training cohort (n=172) and validation cohort (n=75). We utilized eXtreme Gradient Boosting (XGBoost), random survival forest (RSF), and multivariate Cox analysis to pinpoint the risk factors for RFS. Then, we developed a nomogram based on the screened factors and assessed its risk stratification capabilities and predictive performance.

Results

The study finally identified age, aspartate aminotransferase (AST), and prothrombin time activity (PTA) as key predictors. The three variables were included to develop the nomogram for predicting the 1-, 3-, and 5-year RFS of HCC patients. We confirmed the nomogram's ability to effectively discern high and low risk patients, as evidenced by Kaplan-Meier curves. We further corroborated the excellent discrimination, consistency, and clinical utility of the nomogram through assessments using the C-index, area under the curve (AUC), calibration curve, and decision curve analysis (DCA).

Conclusion

Our study successfully constructed a robust nomogram, effectively predicting 1-, 3-, and 5-year RFS for HBV-related HCC patients with low preoperative PALBI scores after TACE combined with local ablation therapy.

ALBI score combined with FIB-4 index to predict post-hepatectomy liver failure in patients with hepatocellular carcinoma

Post-hepatectomy liver failure (PHLF) is a potentially life-threatening complication following liver resection. Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease, which increases the risk of PHLF. This study aimed to investigate the ability of the combination of liver function and fibrosis markers (ALBI score and FIB-4 index) to predict PHLF in patients with HCC. Patients who underwent hepatectomy for HCC between August 2012 and September 2022 were considered for inclusion. Multivariable logistic regression analysis was used to identify factors associated with PHLF, and ALBI score and FIB-4 index were combined based on their regression coefficients. The performance of the combined ALBI-FIB4 score in predicting PHLF and postoperative mortality was compared with Child-Pugh score, MELD score, ALBI score, and FIB-4 index. A total of 215 patients were enrolled in this study. PHLF occurred in 35 patients (16.3%). The incidence of severe PHLF (grade B and grade C PHLF) was 9.3%. Postoperative 90-d mortality was 2.8%. ALBI score, FIB-4 index, prothrombin time, and extent of liver resection were identified as independent factors for predicting PHLF. The AUC of the ALBI-FIB4 score in predicting PHLF was 0.783(95%CI: 0.694-0.872), higher than other models. The ALBI-FIB4 score could divide patients into two risk groups based on a cut-off value of - 1.82. High-risk patients had a high incidence of PHLF of 39.1%, while PHLF just occurred in 6.6% of low-risk patients. Similarly, the AUCs of the ALBI-FIB4 score in predicting severe PHLF and postoperative 90-d mortality were also higher than other models. Preoperative ALBI-FIB4 score showed good performance in predicting PHLF and postoperative mortality in patients undergoing hepatectomy for HCC, superior to the currently commonly used liver function and fibrosis scoring systems.

Liver resection volume-dependent pancreatic strain following living donor hepatectomy

The liver and pancreas work together to recover homeostasis after hepatectomy. This study aimed to investigate the effect of liver resection volume on the pancreas. We collected clinical data from 336 living liver donors. They were categorized into left lateral sectionectomy (LLS), left lobectomy, and right lobectomy (RL) groups. Serum pancreatic enzymes were compared among the groups. Serum amylase values peaked on postoperative day (POD) 1. Though they quickly returned to preoperative levels on POD 3, 46% of cases showed abnormal values on POD 7 in the RL group. Serum lipase levels were highest at POD 7. Lipase values increased 5.7-fold on POD 7 in the RL group and 82% of cases showed abnormal values. The RL group's lipase was twice that of the LLS group. A negative correlation existed between the remnant liver volume and amylase (r = - 0.326)/lipase (r = - 0.367) on POD 7. Furthermore, a significant correlation was observed between POD 7 serum bilirubin and amylase (r = 0.379)/lipase (r = 0.381) levels, indicating cooccurrence with liver and pancreatic strain. Pancreatic strain due to hepatectomy occurs in a resection/remnant liver volume-dependent manner. It would be beneficial to closely monitor pancreatic function in patients undergoing a major hepatectomy.

Risk factor analysis and nomogram for predicting gastroparesis in patients with type 2 diabetes mellitus

Purpose

The incidence of gastroparesis is higher in individuals diagnosed with type 2 diabetes mellitus (T2DM) compared to the healthy individuals. Our study aimed to explore the risk factors for gastroparesis in T2DM and to establish a clinical prediction model (nomogram).

Methods

Our study enlisted 694 patients with T2DM from two medical centers over a period of time. From January 2020 to December 2022, 347 and 149 patients were recruited from the Beilun branch of Zhejiang University's First Affiliated Hospital in the training and internal validation cohorts, respectively. The external validation cohort consisted of 198 patients who were enrolled at Nanchang University's First Affiliated Hospital from October 2020 to September 2021. We conducted univariate and multivariate logistic regression analyses to select the risk factors for gastroparesis in patients with T2DM; subsequently,we developed a nomogram model. The performance of the nomogram was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis(DCA).

Results

Four clinical variables, including age, regular exercise, glycated hemoglobin level(HbA1c), and Helicobacter pylori (H. pylori) infection, were identified and included in the model. The model demonstrated excellent discrimination, with an AUC of 0.951 (95% CI = 0.925-0.978) in the training group, and 0.910 (95% CI = 0.859-0.961) and 0.875 (95% CI = 0.813-0.937) in the internal and external validation groups, respectively. The calibration curve showed good consistency between prediction of the model and observed gastroparesis. The DCA also demonstrated good clinical efficacy.

Conclusion

The nomogram model developed in this study showed good performance in predicting gastroparesis in patients with T2DM.

Prognosis and safety of laparoscopic hepatectomy for BCLC stage 0/A hepatocellular carcinoma with clinically significant portal hypertension: a multicenter, propensity score-matched study

BACKGROUND AND AIM

The latest Barcelona Clinic Liver Cancer (BCLC) staging system suggests considering surgery in patients with resectable BCLC stage 0/A hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH). This study aimed to evaluate the safety and short- and long-term outcomes of laparoscopic hepatectomy for BCLC stage 0/A HCC patients with CSPH.

METHODS

We retrospectively reviewed the medical records of 647 HCC patients in BCLC stage 0/A who were treated at five centers between January 2010 and January 2019. Among these patients, 434 underwent laparoscopic hepatectomy, and 213 underwent open hepatectomy. We used Kaplan-Meier analysis to compare the overall survival (OS) rate and recurrence-free survival (RFS) rate between patients with and without CSPH before and after propensity score matching (PSM). Multivariate Cox regression analysis was performed to identify prognostic factors for BCLC stage 0/A patients, and subgroup analyses were also conducted.

RESULTS

Among the 434 patients who underwent laparoscopic hepatectomy, 186 had CSPH and 248 did not. The Kaplan-Meier analysis showed that the OS and RFS rates were significantly worse in the CSPH group before and after PSM. Multivariate Cox regression analyses identified CSPH as a prognostic factor for poor OS and RFS after laparoscopic hepatectomy. However, CSPH patients treated laparoscopically had a better short- and long-term prognosis than those treated with open surgery.

CONCLUSIONS

CSPH has a negative impact on the prognosis of BCLC stage 0/A HCC patients after laparoscopic hepatectomy. Laparoscopic hepatectomy is still recommended for treatment, but careful patient selection is essential.

Development and Validation of a Prognostic Model for Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma Based on Preoperative Serum Prealbumin

Purpose

We aimed to develop a prognostic nomogram utilizing preoperative serum prealbumin levels to predict the overall survival (OS) in patients undergoing transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC).

Patients and Methods

A total of 768 individuals with unresectable HCC who underwent TACE at three medical facilities in Suzhou between January 2007 December 2018 were included. The patient cohort was assigned to a training set (n = 461) and a validation set (n = 307). Cox regression analysis identified independent prognostic factors, which were then used to construct a prognostic nomogram. Internal validation was performed in the testing group, and its effectiveness and capability were evaluated with reference to the concordance index (C-index), area under the curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

Independent risk factors identified through Cox regression analyses included the BCLC stage, cirrhosis, invasion, tumor number, preoperative serum PALB, performance status (PS), and tumor size. The nomogram demonstrated a C-index of 0.734 (95% confidence interval (CI): 0.710-0.758) in the training set and 0.717 (95% CI: 0.678-0.756) in the validation set, indicating strong discriminatory ability. The nomogram also demonstrated favorable discriminatory performance with AUC values of 0.873, 0.820, and 0.833 for 1-, 2-, and 3-year OS, respectively, in the training set, and 0.854, 0.765, and 0.724 in the validation set. The AUC value of the nomogram (0.843) was significantly higher than that of the four conventional staging systems. Moreover, calibration graphs confirmed a strong concordance between the predicted and observed results. Furthermore, DCA underscored the significant clinical utility of the nomogram. Additionally, the low-risk group exhibited considerably superior rates of survival compared to the high-risk group.

Conclusion

The developed nomogram demonstrated excellent prognostic capability, which served as a valuable tool for personalized clinical decision-making for patients with HCC.

Long-term prognostic benefit of adjuvant chemotherapy for patients with hepatoid adenocarcinoma of the stomach after radical resection: A national multicenter study

BACKGROUND

There is no consensus on whether adjuvant chemotherapy (AC) is effective for hepatoid adenocarcinoma of the stomach (HAS). The aim of this study was to investigate the relationship between AC and the long-term prognosis of patients with HAS.

METHODS

The clinicopathological data of 239 patients with primary HAS who underwent radical surgery from April 1, 2004 to December 31, 2019 in 14 centers in China were retrospectively analyzed. Patients were divided into the AC group (127 patients) and the nonadjuvant chemotherapy (NAC) group (112 patients).

RESULTS

Kaplan‒Meier (KM) analysis showed that there were no significant differences in the 1-year3-year overall survival rate (OS) and 1-year, 3-year recurrence-free survival rate (RFS) between the AC group and the NAC group (1-year OS: 85.6% vs. 79.8%, 3-year OS: 59.8% vs. 62.4%, 1-year RFS: 69.8% vs. 74.4%, 3-year RFS: 57.2% vs. 55.9%, all P > 0.05). The subpopulation treatment effect pattern plots (STEPP) did not show treatment heterogeneity of AC in patients with HAS. The proportions of local recurrence and metastasis sites in the two groups were similar. Although the smoothed hazard curves of the NAC and AC groups crossed, the peak hazard time was later in the AC group (5.9 and 4.7 months), and the peak hazard rate was lower (0.032 and 0.038, P = 0.987).

CONCLUSION

The current AC regimen may not significantly improve the survival of patients with HAS after radical surgery.

Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma

Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.

Nucleus-localized circSLC39A5 suppresses hepatocellular carcinoma development by binding to STAT1 to regulate TDG transcription

Accumulating evidence indicates that circular RNAs (circRNAs) are inextricably linked to cancer development. However, the function and mechanism of nucleus-localized circRNAs in hepatocellular carcinoma (HCC) still require investigation. Here, qRT-PCR and receiver-operating characteristic curve were used to detect the expression and diagnostic potential of circSLC39A5 for HCC. The biological function of circSLC39A5 in HCC was investigated in vitro and in vivo. Nucleoplasmic separation assay, fluorescence in situ hybridization, RNA pulldown, RNA immunoprecipitation, the HDOCK Server, the NucleicNet Webserver, crosslinking-immunoprecipitation, MG132 treatment, and chromatin immunoprecipitation were utilized to explore the potential molecular mechanism of circSLC39A5 in HCC. The results showed that circSLC39A5 was downregulated in both HCC tissues and plasma and was associated with satellite nodules and lymph node metastasis/vascular invasion. CircSLC39A5 was stably expressed in plasma samples under different storage conditions, showing good diagnostic potential for HCC (AUC = 0.915). CircSLC39A5 inhibited proliferation, migration, and invasion, facilitated the apoptosis of HCC cells, and was associated with low expression of Ki67 and CD34. Remarkably, circSLC39A5 is mainly localized in the nucleus and binds to the transcription factor signal transducer and activator of transcription 1 (STAT1), affecting its stabilization and expression. STAT1 binds to the promoter of thymine DNA glycosylase (TDG). Overexpression of circSLC39A5 elevates TDG expression and reverses the increase of proliferating cell nuclear antigen (PCNA) expression and the overactive cell proliferation caused by TDG silencing. Our findings uncovered a novel plasma circRNA, circSLC39A5, which may be a potential circulating diagnostic marker for HCC, and the mechanism by which nucleus-localized circSLC39A5 exerts a transcriptional regulatory role in HCC by affecting STAT1/TDG/PCNA provides new insights into the mechanism of circRNAs.

A novel nomogram based on preoperative parameters to predict posthepatectomy liver failure in patients with hepatocellular carcinoma

BACKGROUND

Posthepatectomy liver failure is one of the main causes of death in patients after hepatectomy. This study intends to establish a prediction model to predict the risk of posthepatectomy liver failure and provide a scientific basis for further reducing the incidence of posthepatectomy liver failure.

METHODS

This was a retrospective analysis of 1,172 patients with hepatocellular carcinoma undergoing partial hepatectomy. Using univariate and multivariate logistic regression analyses and stepwise regression, a prediction model for posthepatectomy liver failure was established based on the independent risk factors for posthepatectomy liver failure and validated by bootstrapping with 100 resamples, and the receiver operating characteristic curve was used to evaluate the predictive value of the prediction model.

RESULTS

The incidence rate of posthepatectomy liver failure was 22.7% (266/1172). The results showed that the indocyanine green retention rate at 15 minutes (odds ratio = 1.05, P = .002), alanine transaminase (odds ratio = 1.02, P < .001), albumin rate (odds ratio = 0.92, P < .001), total bilirubin (odds ratio = 1.04, P < .001), prothrombin time (odds ratio = 2.44, P < .001), aspartate aminotransferase-neutrophil ratio (odds ratio = 0.95, P < .001), and liver fibrosis index (odds ratio = 1.35, P < .001) were associated with posthepatectomy liver failure. These 7 independent risk factors for posthepatectomy liver failure were integrated into a nomogram prediction model, the predictive efficiency for posthepatectomy liver failure (area under the curve = 0.818, 95% confidence interval 0.789-0.848) was significantly higher than in other predictive models with a liver fibrosis index (area under the curve = 0.651), indocyanine green R15 (area under the curve = 0.669), albumin-bilirubin score (area under the curve = 0.709), albumin-indocyanine green evaluation score (area under the curve = 0.706), model for end-stage liver disease score (area under the curve = 0.636), and Child‒Pugh (area under the curve = 0.551) (all P < .001). The risk of posthepatectomy liver failure in the high-risk posthepatectomy liver failure group (score ≥152) was higher than that in the posthepatectomy liver failure low-risk group (score <152).

CONCLUSION

This study developed and validated a nomogram model to predict the risk of posthepatectomy liver failure before surgery that can effectively predict the risk of posthepatectomy liver failure in patients with hepatocellular carcinoma.

Nomogram predicting surgical risk of laparoscopic left-sided hepatectomy for hepatolithiasis

OBJECTIVE

To explore the surgical risk factors of laparoscopic left-sided hepatectomy for hepatolithiasis and establish and validate a nomogram to estimate the corresponding surgical risks.

METHODS

Patients with hepatolithiasis who underwent laparoscopic left-sided hepatectomy were retrospectively enrolled. Demographic data, clinicopathological parameters, and surgical factors were collected. Three hundred fifty-three patients were enrolled and randomly divided into training set (n=267) and validation set (n=86) by 3:1. Conversion to laparotomy was used as a surrogate index to evaluate the surgical risk. Univariate analysis was used to screen potential surgical risk factors, and multivariate analysis using logistic regression model was used to screen independent surgical risk factors. Nomogram predicting the surgical risks was established based on the independent risk factors. Discrimination, calibration, decision curve, and clinical impact analyses were used to evaluate the performance of the nomogram on the statistical and clinical aspects both in the training and validation sets.

RESULTS

Five independent surgical risk factors were identified in the training set, including recurrent abdominal pain, bile duct stricture, ASA classification ≥2, extent of liver resection, and biliary tract T tube drainage. No collinearity was found among these five factors, and a nomogram was established. Performance analyses of the nomogram showed good discrimination (AUC=0.850 and 0.817) and calibration (Hosmer-Lemeshow test, p=0.530 and 0.930) capabilities both in the training and validation sets. Decision curve and clinical impact analyses also showed that the prediction performance was clinically valuable.

CONCLUSIONS

A nomogram was established and validated to be effective in evaluating and predicting the surgical risk of patients undergoing laparoscopic left-sided hepatectomies for hepatolithiasis.

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

BACKGROUND

Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment.

METHODS

A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology.

RESULTS

Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination.

CONCLUSION

These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.

Effect of vessels that encapsulate tumor clusters (VETC) on the prognosis of different stages of hepatocellular carcinoma after hepatectomy

BACKGROUND

Vessels that encapsulate tumor clusters (VETC) is a newly discovered vascular pattern in hepatocellular carcinoma (HCC), representing high biological aggressiveness. However, it remains unclear whether the prognostic impact of VETC differs in patients with different staged HCC. This study aimed to evaluate the effect of VETC on the prognosis of patients with HCC at different stages after hepatectomy.

METHODS

Patients who underwent hepatectomy for HCC between January 2005 and December 2019 were assessed, and stratified according to their Barcelona Clinic Liver Cancer (BCLC) stage. Overall survival (OS) and disease-free survival (DFS) were compared between patients with and without VETC. Independent risk factors of OS and DFS were determined by multivariable Cox regression analyses.

RESULTS

A total of 837 consecutive patients undergoing curative hepatectomy were enrolled, and VETC pattern was found in 339 (40.5%) patients. The incidence of VETC in patients at BCLC-0, BCLC-A, BCLC-B and BCLC-C stage was 17.8%, 40.2%, 53.7% and 66.0%, respectively. In the entire patients, VETC+ patients had significantly lower OS and DFS than VETC- patients. After stratification of patients according to BCLC stage, VETC was associated with worse OS and DFS only in patients at BCLC-A and BCLC-B stages, but not in those at BCLC-0 and BCLC-C stages. Multivariable analyses also revealed that VETC was an independent risk factor for OS and DFS in both the patients at BCLC-A and BCLC-B stages.

CONCLUSIONS

VETC is associated with poor OS and DFS in patients with HCC at BCLC-A and BCLC-B stage after hepatectomy, but it does not affect the survival of patients with HCC at BCLC-0 and BCLC-C stage after hepatectomy.

Preoperative MRI-based multiparametric model for survival prediction in hepatocellular carcinoma patients with portal vein tumor thrombus following hepatectomy

PURPOSE

To develop a predictive model integrating clinical and MRI features for postoperative survival in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

METHOD

Between January 2008 and May 2021, consecutive HCC patients with PVTT who underwent preoperative contrast-enhanced MRI and surgical resection at a tertiary hospital were retrospectively enrolled. The MR images were independently reviewed by two blinded radiologists. Univariate and multivariate Cox regression analyses were performed to construct a prognostic score for overall survival (OS).

RESULTS

Ninety-four patients were included (mean age, 50.1 years; 84 men). During a median follow-up period of 15.3 months, 72 (76.6%) patients died (median OS, 15.4 months; median disease-free survival [DFS], 4.6 months). The sum size of the two largest tumors (hazard ratio [HR], 3.050; p < 0.001) and tumor growth subtype (HR, 1.928; p = 0.006) on MRI, serum albumin (HR, 0.948; p = 0.02), and age (HR, 0.978; p = 0.04) were associated with OS and incorporated in the prognostic score. Accordingly, patients were stratified into a high-risk or low-risk group, and the OS in the high-risk group was shorter than that in the low-risk group for the entire cohort (11.7 vs. 25.0 months, p < 0.001) and for patients with Cheng's type I (12.1 vs. 25.9 months, p = 0.002) and type II PVTT (11.7 vs. 25.0 months, p = 0.004). The DFS in the high-risk group was shorter than that in the low-risk group for the entire cohort (4.5 vs. 6.1 months, p = 0.001).

CONCLUSIONS

Based on the sum size of the two largest tumors, tumor growth subtype, albumin, and age, the prognostic score allowed accurate preoperative risk stratification in HCC patients with PVTT, independent of Cheng's PVTT classification.

Inflammation-related nomogram for predicting survival of patients with unresectable hepatocellular carcinoma received conversion therapy

BACKGROUND

The efficacy of conversion therapy for patients with unresectable hepatocellular carcinoma (HCC) is a common clinical concern.

AIM

To analyse the prognostic factors of overall survival (OS) in patients with unresectable HCC who received conversion therapy.

METHODS

One hundred and fifty patients who met the inclusion criteria were enrolled and divided into a training cohort (n = 120) and a validation cohort (n = 30). Using the independent risk factors in the training cohort, a nomogram model was constructed to predict OS for patients treated with transarterial chemoembolization following hepatic resection. The nomogram was internally validated with the bootstrapping method. The predictive performance of nomogram was assessed by Harrell’s concordance index (C-index), calibration plot and time-dependent receiver operating characteristic curves and compared with six other conventional HCC staging systems.

RESULTS

Multivariate Cox analysis identified that albumin, blood urea nitrogen, gamma-glutamyl transpeptidase to platelet ratio, platelet to lymphocyte ratio, macrovascular invasion and tumour number were the six independent prognostic factors correlated with OS in nomogram model. The C-index in the training cohort and validation cohort were 0.752 and 0.807 for predicting OS, which were higher than those of the six conventional HCC staging systems (0.563 to 0.715 for the training cohort and 0.458 to 0.571 for the validation cohort). The calibration plots showed good consistency between the nomogram prediction of OS and the actual observations of OS. Decision curve analyses indicated satisfactory clinical utility. With a total nomogram score of 196, patients were accurately classified into low-risk and high-risk groups. Furthermore, we have deployed the model into online calculators that can be accessed for free at https://ctmodelforunresectablehcc.shinyapps.io/DynNomapp/.

CONCLUSION

The nomogram achieved optimal individualized prognostication of OS in HCC patients who received conversion therapy, which could be a useful clinical tool to help guide postoperative personalized interventions and prognosis judgement.

Prognostic nomograms for HBV-related BCLC 0-a stage hepatocellular carcinoma incorporating aspartate aminotransferase to albumin ratio

BACKGROUND

Curative hepatectomy is currently the first-line treatment for hepatocellular carcinoma (HCC), but the prognosis is still not optimistic. The prediction model for prognosis of hepatitis B virus (HBV)-related BCLC 0-A stage HCC has not been well established. Therefore, we aimed to develop new nomograms to predict recurrence and survival in these patients.

METHODS

A total of 982 patients with HBV-related BCLC 0-A stage HCC who underwent curative hepatectomy at West China Hospital from February 2007 to February 2016 were retrospectively collected and randomly allocated to a training set and a validation set in a ratio of 4:1. Prognostic nomograms using data from the training set were developed using a Cox regression model and validated on the validation set.

RESULTS

We constructed nomograms based on independent factors for recurrence-free survival (RFS) (tumor size, satellite, microvascular invasion, capsular invasion, differentiation and aspartate aminotransferase to albumin ratio (ASAR)) and overall survival (OS) (gender, tumor size, satellite, microvascular invasion, differentiation, lymphocyte count, and ASAR). Compared with conventional HCC staging systems and other nomograms reported by previous literature, our ASAR integrated nomograms predicted RFS and OS with the highest C-indexes (0.682 (95%CI: 0.646-0.709), 0.729 (95%CI: 0.691-0.766), respectively) and had well-fitted calibration curves in the training set. Concurrently, the nomograms also obtained consistent results in the validation set. DCA revealed that our nomograms provided the largest clinical net benefits.

CONCLUSION

We first constructed ASAR integrated nomograms to predict the prognosis of HBV-related BCLC 0-A stage HCC patients after curative hepatectomy with good performance.

Proteomics profiling of nontumor liver tissues identifies prognostic biomarkers in hepatitis B-related hepatocellular carcinoma

Hepatocellular carcinoma (HCC) often occurs following chronic hepatitis B virus (HBV) infection, leading to high recurrence and a low 5-year survival rate. We developed an overall survival (OS) prediction model based on protein expression profiles in HBV-infected nontumor liver tissues. We aimed to demonstrate the feasibility of using protein expression profiles in nontumor liver tissues for survival prediction. A univariate Cox and differential expression analysis were performed to identify candidate prognostic factors. A multivariate Cox analysis was performed to develop the liver gene prognostic index (LGPI). The survival differences between the different risk groups in the training and validation cohorts were also estimated. A total of 363 patients, 159 in the training cohort, and 204 in the validation cohort were included. Of the 6478 proteins extracted from nontumor liver tissues, we identified 1275 proteins altered between HCC and nontumor liver tissues. A total of 1090 out of 6478 proteins were significantly related to OS. The prognostic values of the proteins in nontumor tissues were mostly positively related to those in the tumor tissues. Protective proteins were mainly enriched in the metabolism-related pathways. From the differentially expressed proteins, the top 10 most significant prognosis-related proteins were submitted for LGPI construction. In the training and validation cohorts, this LGPI showed a great ability for distinguishing patients' OS risk stratifications. After adjusting for clinicopathological features, the LGPI was an independent prognostic factor in the training and validation cohorts. We demonstrated the prognostic value of protein expression profiling in nontumor liver tissues. The proposed LGPI was a promising predictive model for estimating OS in HBV-related HCC.

The value of gadobenate dimeglumine-enhanced biliary imaging from the hepatobiliary phase for predicting post-hepatectomy liver failure in HCC patients

OBJECTIVES

To determine the value of gadobenate dimeglumine-enhanced biliary imaging from the hepatobiliary phase for predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

Patients with HCC who underwent gadobenate dimeglumine-enhanced hepatobiliary magnetic resonance imaging prior to hepatectomy were collected in two centers. The relative enhancement ratio of the biliary system (REB) and the liver to muscle ratio (LMR) were measured at the hepatobiliary phase. Potential risk factors for PHLF were analyzed by logistic regression. The capacity of the REB and LMR to predict PHLF was analyzed via receiver operating characteristic curve.

RESULTS

Of the 221 patients, post-hepatectomy liver failure occurred in 60 patients (27.1%). The REB was an independent risk factor for PHLF (odds ratio [OR] = 0.127 [0.047-0.348], p < 0.001). Although the LMR tended to be associated with PHLF (p = 0.063), it was not an independent risk factor in the multivariable analysis (OR = 0.624 [0.023-16.709], p = 0.779). Moreover, the area under the receiver operating characteristic curve of the REB and LMR was 0.87 and 0.60. The most appropriate cutoff value for the REB was 2.21. The HCC patients with the REB ≤ 2.21 had a higher incidence of post-hepatectomy liver failure than those with the REB > 2.21 (60.0% versus 8.5%, p < 0.001).

CONCLUSIONS

Gadobenate dimeglumine-enhanced biliary imaging from the hepatobiliary phase was valuable in predicting post-hepatectomy liver failure in HCC patients.

KEY POINTS

• The relative enhancement ratio of the biliary system (REB) was an independent risk factor for post-hepatectomy liver failure in HCC patients. • HCC patients with the REB ≤ 2.21 had significantly higher incidence of post-hepatectomy liver failure than those with the REB > 2.21 (60.0% versus 8.5%).

Development and validation of novel nomograms to predict survival of patients with tongue squamous cell carcinoma

BACKGROUND

There is no unified standard to predict postoperative survival in patients with tongue squamous cell carcinoma (TSCC), hence the urgency to develop a model to accurately predict the prognosis of these patients.

AIM

To develop and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) of patients with TSCC.

METHODS

A cohort of 3454 patients with TSCC from the Surveillance, Epidemiology, and End Results (SEER) database was used to develop nomograms; another independent cohort of 203 patients with TSCC from the Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, was used for external validation. Univariate and multivariate analyses were performed to identify useful variables for the development of nomograms. The calibration curve, area under the receiver operating characteristic curve (AUC) analysis, concordance index (C-index), net reclassification index (NRI), and decision curve analysis (DCA) were used to assess the calibration, discrimination ability, and clinical utility of the nomograms.

RESULTS

Eight variables were selected and used to develop nomograms for patients with TSCC. The C-index (0.741 and 0.757 for OS and CSS in the training cohort and 0.800 and 0.830 in the validation cohort, respectively) and AUC indicated that the discrimination abilities of these nomograms were acceptable. The calibration curves of OS and CSS indicated that the predicted and actual values were consistent in both the training and validation cohorts. The NRI values (training cohort: 0.493 and 0.482 for 3- and 5-year OS and 0.424 and 0.402 for 3- and 5-year CSS; validation cohort: 0.635 and 0.750 for 3- and 5-year OS and 0.354 and 0.608 for 3- and 5-year CSS, respectively) and DCA results indicated that the nomograms were significantly better than the tumor-node-metastasis staging system in predicting the prognosis of patients with TSCC.

CONCLUSION

Our nomograms can accurately predict patient prognoses and assist clinicians in improving decision-making concerning patients with TSCC in clinical practice.

Hepatocellular Carcinoma in Non-alcoholic Fatty Liver Disease: Current Progresses and Challenges

The rising global prevalence of metabolic diseases has increased the prevalence of non-alcoholic fatty liver disease (NAFLD), leading to an increase in cases of NAFLD-related hepatocellular carcinoma (HCC). To provide an updated literature review detailing epidemiology, risk factors, pathogenic pathways, and treatment strategies linked to NAFLD-related HCC, we conducted a literature search on PubMed from its inception to December 31, 2021. About 25% of the global population suffers from NAFLD. The annual incidence of HCC among NAFLD patients is approximately 1.8 per 1,000 person-years. Older age, male sex, metabolic comorbidities, unhealthy lifestyle habits (such as smoking and alcohol consumption), physical inactivity, genetic susceptibility, liver fibrosis, and degree of cirrhosis in NAFLD patients are important risk factors for NAFLD-related HCC. Therefore, low-calorie diet, moderate-intensity exercise, treatment of metabolic comorbidities, and cessation of smoking and alcohol are the main measures to prevent NAFLD-related HCC. In addition, all patients with advanced NAFLD-related fibrosis or cirrhosis should be screened for HCC. Immune suppression disorders and changes in the liver microenvironment may be the main pathogenesis of NAFLD-related HCC. Hepatic resection, liver transplantation, ablation, transarterial chemoembolization, radiotherapy, targeted drugs, and immune checkpoint inhibitors are used to treat NAFLD-related HCC. Lenvatinib treatment may lead to better overall survival, while immune checkpoint inhibitors may lead to worse overall survival. Given the specific risk factors for NAFLD-related HCC, primary prevention is key. Moreover, the same treatment may differ substantially in efficacy against NAFLD-related HCC than against HCC of other etiologies.

Development and external validation of a dynamic nomogram to predict the survival for adenosquamous carcinoma of the pancreas

Objective

We aimed to develop a nomogram to predict the survival and prognosis of adenosquamous carcinoma of the pancreas (ASCP).

Background

Adenosquamous carcinoma of the pancreas (ASCP) is a relatively rare histological subtype of pancreatic exocrine neoplasms. It was reported a worse survival in ASCP than in pancreatic adenocarcinoma (PDAC). Prediction of ASCP prognosis is of great importance.

Methods

Histologically confirmed ASCP patients from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program database were finally enrolled and divided into development and internal validation cohorts. Moreover, a multi-center cohort of 70 patients from China was registered as the external validation. A nomogram was developed based on independent predictors of ASCP determined in multivariable analysis.

Results

A total of 233 patients from SEER were finally included. Univariate and Multivariate analysis showed that tumor size, radiotherapy, chemotherapy, and lymph node ratio (LNR) were considered the independent prognostic indicators. We developed a nomogram according to these four parameters. The C index of the nomogram in the development cohort was 0.696. Through analysis of the area under the curve (AUC) of the different cohorts, we observed that the predictive efficacy of the nomogram for 1-, and 2-year overall survival (OS) were better than those of the American Joint Committee on Cancer (AJCC) TNM (8th) staging system both in the development and validation cohort. External validation confirmed that 1-year survival is 67.2% vs. 29.7%, similar to the internal cohort analysis.

Conclusion

The nomogram showed good performance in predicting the survival of ASCP. It could help surgeons to make clinical decisions and develop further plans.

Comparison of nomogram and machine-learning methods for predicting the survival of non-small cell lung cancer patients

BACKGROUND

Most patients with advanced non-small cell lung cancer (NSCLC) have a poor prognosis. Predicting overall survival using clinical data would benefit cancer patients by allowing providers to design an optimum treatment plan. We compared the performance of nomograms with machine-learning models at predicting the overall survival of NSCLC patients. This comparison benefits the development and selection of models during the clinical decision-making process for NSCLC patients.

METHODS

Multiple machine-learning models were used in a retrospective cohort of 6586 patients. First, we modeled and validated a nomogram to predict the overall survival of NSCLC patients. Subsequently, five machine-learning models (logistic regression, random forest, XGBoost, decision tree, and light gradient boosting machine) were used to predict survival status. Next, we evaluated the performance of the models. Finally, the machine-learning model with the highest accuracy was chosen for comparison with the nomogram at predicting survival status by observing a novel performance measure: time-dependent prediction accuracy.

RESULTS

Among the five machine-learning models, the accuracy of random forest model outperformed the others. Compared with the nomogram for time-dependent prediction accuracy with a follow-up time ranging from 12 to 60 months, the prediction accuracies of both the nomogram and machine-learning models changed as time varied. The nomogram reached a maximum prediction accuracy of 0.85 in the 60th month, and the random forest algorithm reached a maximum prediction accuracy of 0.74 in the 13th month.

CONCLUSIONS

Overall, the nomogram provided more reliable prognostic assessments of NSCLC patients than machine-learning models over our observation period. Although machine-learning methods have been widely adopted for predicting clinical prognoses in recent studies, the conventional nomogram was competitive. In real clinical applications, a comprehensive model that combines these two methods may demonstrate superior capabilities.

Quantitative parameters obtained from gadobenate dimeglumine-enhanced MRI at the hepatobiliary phase can predict post-hepatectomy liver failure and overall survival in patients with hepatocellular carcinoma

PURPOSE

To determine the value of the quantitative parameters obtained from gadobenate dimeglumine-enhanced magnetic resonance imaging (MRI) at the hepatobiliary phase for predicting post-hepatectomy liver failure and overall survival in patients with hepatocellular carcinoma.

METHOD

This multicenter retrospective study included 307 patients who underwent gadobenate dimeglumine-enhanced MRI. The quantitative liver-to-portal vein contrast ratio (LPC) and liver-spleen contrast ratio (LSC) at the hepatobiliary phase were measured. Logistic regression analyses were used to evaluate risk factors for post-hepatectomy liver failure. The capacity of the LPC and LSC to predict post-hepatectomy liver failure was evaluated via receiver operating characteristic (ROC) curve. The Cox proportional hazards regression was used to identify prognostic factors for overall survival (OS).

RESULTS

Post-hepatectomy liver failure was observed in 69 patients (22.5%). The LPC and LSC were independent risk factors for the development of post-hepatectomy liver failure, and the areas under the ROC curves of LPC and LSC were 0.882 and 0.782, respectively. The predictive performance of LPC for post-hepatectomy liver failure was superior to LSC. The LPC and LSC were also significant prognostic factors for OS. The cut-off values for the LPC and LSC were 1.07 and 0.89, respectively. The 5-year OS rate was higher in patients with LPC > 1.07 or LSC > 0.89 than in patients with LPC ≤ 1.07 or LSC ≤ 0.89.

CONCLUSIONS

The quantitative parameters obtained from gadobenate dimeglumine-enhanced MRI at the hepatobiliary phase were effective imaging biomarkers for predicting both post-hepatectomy liver failure and overall survival in patients with hepatocellular carcinoma.

Developmental artificial neural network model to evaluate the preoperative safe limit of future liver remnant volume for HCC combined with clinically significant portal hypertension

Background & aims: Finding a way to comprehensively integrate the presence and grade of clinically significant portal hypertension, amount of preserved liver function and extent of hepatectomy into the guidelines for choosing appropriate candidates to hepatectomy remained challenging. This study sheds light on these issues to facilitate precise surgical decisions for clinicians. Methods: Independent risk factors associated with grade B/C post-hepatectomy liver failure were identified by stochastic forest algorithm and logistic regression in hepatitis B virus-related hepatocellular carcinoma patients. Results: The artificial neural network model was generated by integrating preoperative pre-ALB, prothrombin time, total bilirubin, AST, indocyanine green retention rate at 15 min, standard future liver remnant volume and clinically significant portal hypertension grade. In addition, stratification of patients into three risk groups emphasized significant distinctions in the risk of grade B/C post-hepatectomy liver failure. Conclusion: The authors' artificial neural network model could provide a reasonable therapeutic option for clinicians to select optimal candidates with clinically significant portal hypertension for hepatectomy and supplement the hepatocellular carcinoma surgical treatment algorithm.

Epidemiological Characteristics of Primary Liver Cancer in Mainland China From 2003 to 2020: A Representative Multicenter Study

BACKGROUND

The contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to primary liver cancer (PLC) and their association with cancer aggressiveness remains uncertain in China, a country with half of global PLC. We aimed to characterize this using data from four representative medical centers.

METHODS

In total, 15,801 PLC patients were enrolled from the centers distributed in Easter5n, Southern, Northern, and Western China from 2003 to 2020. Of those, 7585 with curative surgery were involved in survival analysis. A nomogram was constructed using preoperative parameters to predict postoperative survival.

RESULTS

Hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma, and combined hepatocellular cholangiocarcinoma accounted for 93.0%, 4.3%, and 1.6% in PLC, respectively. The seropositivities of HBV and HCV were 84.4% and 3.2% in HCC, respectively. The seropositivity of anti-HCV antibody was significantly higher in HBV-negative than in HBV-positive HCC patients (13.2% vs. 1.1%). Compared to HCV-positive HCC (HCV-HCC), HBV-positive HCC (HBV-HCC) was associated with 12-year earlier onset, higher proportions of males, high α-fetoprotein, large tumor size, advanced Barcelona Clinic Liver Cancer (BCLC) stage, and vascular tumor thrombus. The proportions of HCC and HBV seropositivity increased, whereas that of anti-HCV decreased, from 2003 to 2020. Postoperative five-year survival rate was 73.5%, 64.1%, 34.9%, and 19.7% in HCC at BCLC stage 0, A, B, and C, respectively. The multivariate Cox regression analysis showed that HBV seropositivity, incomplete tumor capsule, vascular tumor thrombus, tumor diameter (≥3 cm), advanced BCLC stage (B+C), α-fetoprotein (≥20ng/ml), and direct bilirubin (>8µmol/L) contributed independently to shorter overall survival (OS); whereas post-operative radiofrequency ablation and second resection independently improved OS in HCC. HCV-HCC had a more favorable prognosis than did HBV-HCC (Log-rank test, P<0.001). A nomogram composed of age, gender, and the preoperative independent risk factors was accurate in predicting postoperative survival in HCC (C-index: 0.735; 95% confidence interval: 0.727-0.743).

CONCLUSION

HBV contributes to 84.4% of HCC in China, and actively promotes hepatocarcinogenesis and HCC progression. A favorable postoperative survival obtained in patients at the early BCLC stage highlights the importance of screening for early HCC in high-risk populations. Our preoperative prognosis prediction model is important in clinical decision-making.

Preoperative serum ctDNA predicts early hepatocellular carcinoma recurrence and response to systemic therapies

BACKGROUND

Circulating tumor DNA (ctDNA) can be useful in tumor diagnosis and surveillance. However, its value in hepatocellular carcinoma (HCC) patients receiving curative resection remains unknown. Here, we aim to determine the prognostic value of ctDNA in HCC patients.

METHODS

A prospective cohort enrolled 258 HCC patients who underwent curative liver resection from April 1, 2019, to September 31, 2020. Blood samples were collected before surgery for the detection of ctDNA.

RESULTS

The number of total mutant genes in ctDNA was associated with early tumor relapse (HR = 2.2, p < 0.001). We defined a gene set consisting of APC, ARID1A, CDKN2A, FAT1, LRP1B, MAP3K1, PREX2, TERT and TP53 as high-risk genes (HRGs) associated with early recurrence. Patients were classified into low-, median- and high-risk levels based on the number of mutant genes in the HRGs. High-risk patients had worse recurrence free survival, especially single-tumor patients (HR = 13.0, p < 0.001). The risk level and TNM stage were independently associated with tumor recurrence. A preoperative recurrence estimation nomogram based on those two factors was constructed and demonstrated good accuracy with a C index of 0.76 (95% CI 0.70-0.82). Patients preserved FAT1 or LRP1B variants but without TP53 variants had worse progression free survival for receiving lenvatinib combined with immune checkpoint inhibitors after recurrence (HR = 17.1, p < 0.001). Furthermore, RNA sequencing data revealed that ctDNA status was associated with tumor immune infiltration.

CONCLUSION

Preoperative serum ctDNA can be a practical noninvasive approach to predict recurrence after surgery and response to systemic therapies. ctDNA-guided HCC management should be recommended.

Performance of non-invasive biomarkers compared with invasive methods for risk prediction of posthepatectomy liver failure in hepatocellular carcinoma

BACKGROUND

Posthepatectomy liver failure (PHLF) is a rare but dreaded complication. The aim was to test whether a combination of non-invasive biomarkers (NIBs) and CT data could predict the risk of PHLF in patients who underwent resection of hepatocellular carcinoma (HCC).

METHODS

Patients with HCC who had liver resection between 2012 and 2020 were included. A relevant combination of NIBs (NIB model) to model PHLF risk was identified using a doubly robust estimator (inverse probability weighting combined with logistic regression). The adjustment variables were body surface area, ASA fitness grade, male sex, future liver remnant (FLR) ratio, difficulty of liver resection, and blood loss. The reference invasive biomarker (IB) model comprised a combination of pathological analysis of the underlying liver and hepatic venous pressure gradient (HVPG) measurement. Various NIB and IB models for prediction of PHLF were fitted and compared. NIB model performances were validated externally. Areas under the curve (AUCs) were corrected using bootstrapping.

RESULTS

Overall 323 patients were included. The doubly robust estimator showed that hepatitis C infection (odds ratio (OR) 4.33, 95 per cent c.i. 1.29 to 9.20; P = 0.001), MELD score (OR 1.26, 1.04 to 1.66; P = 0.001), fibrosis-4 score (OR 1.36, 1.06 to 1.85; P = 0.001), liver surface nodularity score (OR 1.55, 1.28 to 4.29; P = 0.031), and FLR volume ratio (OR 0.99, 0.97 to 1.00; P = 0.014) were associated with PHLF. Their combination (NIB model) was fitted externally (2-centre cohort, 165 patients) to model PHLF risk (AUC 0.867). Among 129 of 323 patients who underwent preoperative HVPG measurement, NIB and IB models had similar performances (AUC 0.753 versus 0.732; P = 0.940). A well calibrated nomogram was drawn based on the NIB model (AUC 0.740). The risk of grade B/C PHLF could be ruled out in patients with a cumulative score of less than 160 points.

CONCLUSION

The NIB model provides reliable preoperative evaluation with performance at least similar to that of invasive methods for PHLF risk prediction.

A Novel Nomogram for Predicting Postoperative Liver Failure After Major Hepatectomy for Hepatocellular Carcinoma

Background

Post-hepatectomy liver failure (PHLF) is the most common cause of mortality after major hepatectomy in hepatocellular carcinoma (HCC) patients. We aim to develop a nomogram to preoperatively predict grade B/C PHLF defined by the International Study Group on Liver Surgery Grading (ISGLS) in HCC patients undergoing major hepatectomy.

Study Design

The consecutive HCC patients who underwent major hepatectomy at the Eastern Hepatobiliary Surgery Hospital between 2008 and 2013 served as a training cohort to develop a preoperative nomogram, and patients from 2 other hospitals comprised an external validation cohort. Least absolute shrinkage and selection operator (LASSO) logistic regression was applied to identify preoperative predictors of grade B/C PHLF. Multivariable logistic regression was utilized to establish a nomogram model. Internal and external validations were used to verify the performance of the nomogram. The accuracy of the nomogram was also compared with the conventional scoring models, including MELD and ALBI score.

Results

A total of 880 patients who underwent major hepatectomy (668 in the training cohort and 192 in the validation cohort) were enrolled in this study. The independent risk factors of grade B/C PHLF were age, gender, prothrombin time, total bilirubin, and CSPH, which were incorporated into the nomogram. Good prediction discrimination was achieved in the training (AUROC: 0.73) and validation (AUROC: 0.72) cohorts. The calibration curve also showed good agreement in both training and validation cohorts. The nomogram has a better performance than MELD and ALBI score models.

Conclusion

The proposed nomogram showed more accurate ability to individually predict grade B/C PHLF after major hepatectomy in HCC patients than MELD and ALBI scores.

A Novel Predictive Scoring System for 90-Day Mortality among Patients with Hepatocellular Cell Carcinoma Receiving Major Hepatectomy

Simple Summary

Hepatocellular carcinoma (HCC) is a major malignancy correlated with many cancer-related deaths. Surgical intervention provides superior long-term survival; however, perioperative mortality is a major concern for clinicians while making treatment decisions, especially for major hepatectomy. Scoring systems for predicting 90-day mortality in patients with HCC undergoing major hepatectomy are not available. By using the stepwise selection of the multivariate Cox proportional hazards model, we divided the patients with HCC receiving major hepatectomy into four risk groups. The Chang Gung-PohAi predictive scoring system showed significant differences in the 90-day mortality rate among the four risk groups (very low risk: 2.42%, low risk: 4.09%, intermittent risk: 17.1%, and high risk 43.6%). The Chang Gung-PohAi predictive scoring system is a promising tool for predicting 90-day perioperative mortality in patients with HCC undergoing major hepatectomy.

Abstract

Purpose: Hepatocellular carcinoma (HCC) is a major malignancy and the common cause of cancer-related deaths. Surgical intervention provides superior long-term survival outcomes; however, perioperative mortality is a major concern for clinicians while making treatment decisions, especially for major hepatectomy. Scoring systems for predicting 90-day mortality in patients with HCC undergoing major hepatectomy are not available. Methods: This study used the Taiwan Cancer Registry Database that is linked to the National Health Insurance Research Database to analyze data of 60,250 patients with HCC who underwent major hepatectomy and determine risk factors to establish a novel predictive scoring system. By using the stepwise selection of the multivariate Cox proportional hazards model, we divided the patients with HCC undergoing major hepatectomy into four risk groups. Results: The Chang Gung-PohAi predictive scoring system exhibited significant differences in the 90-day mortality rate among the four risk groups (very low risk: 2.42%, low risk: 4.09%, intermittent risk: 17.1%, and high risk: 43.6%). Conclusion: The Chang Gung-PohAi predictive scoring system is a promising tool for predicting 90-day perioperative mortality in patients with HCC undergoing major hepatectomy.

TIPS improves outcomes in patients with HCC and symptomatic portal hypertension: a multi-institution experience

Background

Hepatocellular carcinoma (HCC) with symptomatic portal hypertension (SPH) has poor prognosis. A transjugular intrahepatic portosystemic shunt (TIPS) relieves SPH, but its application in HCC remains unclear. We evaluated TIPS efficacy in patients with HCC and SPH.

Methods

Pre- and post-TIPS Child–pugh(C–P) scores and stages in 123 HCC patients with SPH from three centers were compared. The impact of postoperative C–P stage indicators on overall survival (OS) was explored.

Results

Post-TIPS responses to SPH included complete response (CR) (92 [74.8%]), partial response (PR) (23 [18.7%]), and nonresponse (NR) (8 [6.5%]). The control (proportion of CR and PR) for SPH was 93.5%. Median C–P scores pre-TIPS and at one month post-TIPS were 8 (IQR 6–9) and 7 (IQR 6–8), respectively (P < 0.001). Forty-one (33.3%) patients had C–P downstaging; 73 (59.3%) had lowered C–P scores; and 73 (59.3%) received intrahepatic local therapy post-TIPS. The median OS was 10.7 (1.1–55.2) months. Among the five indicators of C–P stage, lower post-TIPS ascites grading [(0/1)/(2/3); P = 0.014, HR = 0.31 (95% CI: 0.12–0.79)] and bilirubin [< 34/ ≥ 34 µmol/L; P = 0.022, HR = 0.47 (95% CI: 0.23–0.82)] and prothrombin time prolongation < 6 s [< 6/ ≥ 6 s; P = 0.001, HR = 0.17 (95% CI: 0.06–0.47)] were independent protective indicators of OS. These three indicators were included in the nomogram model to predict survival probabilities.

Conclusions

TIPS is safe and effective for HCC with SPH. This procedure can relieve the symptoms, enable subsequent antitumor therapy, and bring survival benefits, possibly through improved liver function by reducing C–P stage.

Nomogram based on inflammation-related markers for predicting survival of patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND

Previous nomograms for hepatocellular carcinoma (HCC) did not include the neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte ratio (PLR). This study aimed to establish an effective nomogram capable of estimating the association between preoperative inflammatory factors and overall survival (OS) of HCC patients after hepatectomy.

AIM

To analyse the factors affecting the prognosis of HCC and establish a nomogram.

METHODS

A total of 626 HCC patients (410 training set patients from the First Affiliated Hospital of Anhui Medical University and 216 validation set patients from the First Affiliated Hospital of University of Science and Technology of China) underwent hepatectomy from January 2014 to December 2017 and were followed up every 3–6 mo. The nomogram was based on OS-related independent risk factors identified by Cox regression analysis. The C-index, calibration curve, and area under the curve (AUC) were used to evaluate the nomogram’s accuracy.

RESULTS

The 1-, 2- and 3-year OS rates were 79.0%, 68.0% and 45.4% in the training cohort (median OS = 34 mo) and 92.1%, 73.9% and 51.2% in the validation cohort (median OS = 38 mo). Higher α-fetoprotein [hazard ratio (HR) = 1.812, 95% confidence interval (CI): 1.343–2.444], NLR (HR = 2.480, 95%CI: 1.856–3.312) and PLR (HR = 1.974, 95%CI: 1.490–2.616), tumour size ≥ 5 cm (HR = 1.323, 95%CI: 1.002–1.747), and poor differentiation (HR = 3.207, 95%CI: 1.944–5.290) were significantly associated with shortened OS. The developed nomogram integrating these variables showed good reliability in both the training (C-index = 0.71) and validation cohorts (C-index = 0.75). For predicting 1-, 2- and 3-year OS, the nomogram had AUCs of 0.781, 0.743 and 0.706 in the training cohort and 0.789, 0.815 and 0.813 in the validation cohort. The nomogram was more accurate in predicting prognosis than the AJCC TNM staging system.

CONCLUSION

The prognostic nomogram combining pathological characteristics and inflammation indicators could provide a more accurate individualized risk estimate for the OS of HCC patients with hepatectomy.

Repeat hepatic resection versus radiofrequency ablation for recurrent hepatocellular carcinoma: retrospective multicentre study

BACKGROUND

The therapeutic value of repeat hepatic resection (rHR) or radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) is unknown. This study aimed to investigate the safety and efficacy of rHR or RFA.

METHODS

This was a retrospective multicentre study of patients with recurrent HCC within the Milan criteria who underwent rHR or RFA at nine university hospitals in China and Italy between January 2003 and January 2018. Survival after rHR or RFA was examined in unadjusted analyses and after propensity score matching (1 : 1).

RESULTS

Of 847 patients included, 307 and 540 underwent rHR and RFA respectively. Median overall survival was 73.5 and 67.0 months after rHR and RFA respectively (hazard ratio 1.01 (95 per cent c.i. 0.81 to 1.26)). Median recurrence-free survival was longer after rHR versus RFA (23.6 versus 15.2 months; hazard ratio 0.76 (95 per cent c.i. 0.65 to 0.89)). These results were confirmed after propensity score matching. RFA was associated with lower morbidity of grade 3 and above (0.6 versus 6.2 per cent; P < 0.001) and shorter hospital stay (8.0 versus 3.0 days, P < 0.001) than rHR.

CONCLUSION

rHR was associated with longer recurrence-free survival but not overall survival compared with RFA.

Liver Collagen Contents Are Closely Associated with the Severity of Cirrhosis and Posthepatectomy Liver Failure in Patients with Hepatocellular Carcinoma and Child-Pugh Grade A Liver Function

BACKGROUND

Hepatocellular carcinoma (HCC) is usually accompanied by different severities of cirrhosis, which is a risk factor for posthepatectomy liver failure (PHLF). Collagen proportional area (CPA) measurements can quantitatively determine the collagen contents of liver tissue. This study explored the impact of CPA on PHLF, and further investigated the correlation between CPA and a non-invasive method, namely cirrhotic severity scoring (CSS), previously proposed by our team.

METHODS

A total of 224 HCC patients with Child-Pugh grade A liver function undergoing hepatectomy between 2017 and 2019 were retrospectively studied. Quantitative digital image analysis of resected liver tissues was used for the CPA measurement. Risk factors for PHLF were subjected to univariate and multivariate analyses, and the correlation between CPA and CSS was analyzed.

RESULTS

Overall, 28 (12.5%) patients experienced PHLF. Patients with PHLF had higher CPA values than those without PHLF (p < 0.001). Multivariate analysis showed CPA and extent of hepatectomy to be independent risk factors for PHLF. CPA values were divided into four stages based on their quartiles (C1: < 6.6%; C2: 6.6-10.7%; C3: 10.7-18.0%; C4: ≥ 18.0%). The incidence of PHLF increased with increasing CPA stages (p < 0.001). Furthermore, CSS was significantly correlated with CPA (r = 0.720; p < 0.001). The incidence of PHLF also increased with increasing severity of cirrhosis evaluated by CSS (p < 0.001).

CONCLUSIONS

In HCC patients with Child-Pugh grade A liver function, cirrhosis could be staged by liver collagen contents, which significantly influenced PHLF. Furthermore, CSS was useful in the preoperative evaluation of cirrhotic severity.

Prognostic role of preoperative albumin-bilirubin score in posthepatectomy liver failure and mortality: a systematic review and meta-analysis

Posthepatectomy liver failure (PHLF) is a life-threatening complication after liver resection, resulting in an increased morbidity and mortality. Epidemiological evidence of the association between preoperative albumin-bilirubin (ALBI) score, a newly established model for assessing liver functional reserve, and the risk of PHLF and mortality remains controversial. A systematical search for relevant literature was performed in PubMed, Embase, and Web of Science databases from December 2014 to September 2020. Odds ratio (OR) value and 95% confidence interval (CI) were extracted or calculated to synthetically estimate the association of preoperative ALBI score with PHLF and mortality. Meta-analyses were performed using a random-effects model. Twelve studies with a total of 21,348 patients were included in this meta-analysis. It was indicated that, compared to patients with a lower preoperative ALBI grade, patients with a higher grade had a significantly elevated risk of PHLF (6 studies, 18,291 patients; OR = 2.48, 95%CI: 2.00-3.07) and mortality (4 studies15, 139 patients; OR = 2.35, 95% CI: 1.38-4.00). In addition, when it was expressed as a continuous variable, ALBI was also a significant predictor of PHLF (6 studies, 3,833 patients; OR = 3.16, 95% CI: 2.07-4.81, per 1-point increase in ALBI score). No significant publication biases were detected as suggested by funnel plots inspection and Begg's tests. The current meta-analysis demonstrates that preoperative elevated ALBI is associated with higher risk of PHLF and mortality after hepatectomy.

Nomogram for prediction of the international study Group of Liver Surgery (ISGLS) grade B/C Posthepatectomy liver failure in HBV-related hepatocellular carcinoma patients: an external validation and prospective application study

BACKGROUND

To develop a nomogram for predicting the International Study Group of Liver Surgery (ISGLS) grade B/C posthepatectomy liver failure (PHLF) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients.

METHODS

Patients initially treated with hepatectomy were included. Univariate regression analysis and stochastic forest algorithm were applied to extract the core indicators and reduce redundancy bias. The nomogram was then constructed by using multivariate logistic regression, and validated in internal and external cohorts, and a prospective clinical application.

RESULTS

There were 900, 300 and 387 participants in training, internal and external validation cohorts, with the morbidity of grade B/C PHLF were 13.5, 11.0 and 20.2%, respectively. The nomogram was generated by integrating preoperative total bilirubin, platelet count, prealbumin, aspartate aminotransferase, prothrombin time and standard future liver remnant volume, then achieved good prediction performance in training (AUC = 0.868, 95%CI = 0.836-0.900), internal validation (AUC = 0.868, 95%CI = 0.811-0.926) and external validation cohorts (AUC = 0.820, 95%CI = 0.756-0.861), with well-fitted calibration curves. Negative predictive values were significantly higher than positive predictive values in training cohort (97.6% vs. 33.0%), internal validation cohort (97.4% vs. 25.9%) and external validation cohort (94.3% vs. 41.1%), respectively. Patients who had a nomogram score < 169 or ≧169 were considered to have low or high risk of grade B/C PHLF. Prospective application of the nomogram accurately predicted grade B/C PHLF in clinical practise.

CONCLUSIONS

The nomogram has a good performance in predicting ISGLS grade B/C PHLF in HBV-related HCC patients and determining appropriate candidates for hepatectomy.

Construction prognosis model based on autophagy-related gene signatures in hepatocellular carcinoma

Aim: To develop robust and accurate prognostic biomarkers to help clinicians optimize therapeutic strategies. Materials & methods: Differentially prognosis-related autophagy genes were identified by bioinformatics analysis method. Results: Seven prognosis-related autophagy genes were more significantly related to the prognosis of hepatocellular carcinoma (HCC). Functional enrichment analysis demonstrated that these genes were mainly enriched in the autophagy pathway. BIRC5, HSPB8 and TMEM74 exhibited significant prognostic value for HCC. Besides, the risk score and BIRC5 have significant significance with clinicopathological significance of HCC. Conclusion: The research has identified a number of prognosis-related autophagy genes that associated with the survival and clinical stage of HCC. In addition, the prognostic model can be used to calculate the patient's risk score and these prognosis-related autophagy genes might serve as therapeutic targets.