Multifocal manifestation does not affect vascular invasion of hepatocellular carcinoma: implications for patient selection in liver transplantation

High Inflammatory Factor Grading Predicts Poor Disease-Free Survival in AJCC Stage I-II Hepatocellular Carcinoma Patients After R0 Resection

Purpose

In this study, we established the inflammatory factor grade system (IFGs) based on the hepatocellular carcinoma (HCC) microenvironment to investigate the role of inflammatory factor grade (IFG) in predicting the prognosis of patients with American Joint Committee on Cancer (AJCC) stage I-II.

Patients and methods

We enrolled 87 HCC patients with AJCC stage I-II who underwent R0 resection between 2000 and 2012 and had paraffin-embedded specimens. Immunohistochemistry (IHC) was performed to investigate the expression of 12 inflammatory factors and then to establish the IFGs (grade A or B) based on the IHC data. Subsequently, Kaplan-Meier and Cox univariate/multivariate survival analyses were performed to examine the potential prognostic significance.

Results

Higher IFG (IFG-B) is significantly associated with greater tumor size (P=0.037), and IFG-B predicts a worse disease-free survival (DFS, P<0.001). Moreover, a platelet count (PLT) ≤100×10⁹/L, tumor size ≥5 cm, poor tumor differentiation, and IFG-B are independent risk factors for DFS.

Conclusion

Overall, by establishing a grading system for the level of inflammatory factors in the HCC microenvironment, IFG-B can effectively predict poor DFS in AJCC stage I-II HCC patients after R0 resection.

Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome

The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2-4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

A scoring model based on neutrophil to lymphocyte ratio predicts recurrence of HBV-associated hepatocellular carcinoma after liver transplantation

BACKGROUND

Neutrophil to lymphocyte ratio (NLR) has been proposed to predict prognosis of hepatocellular carcinoma (HCC). However, the cut-off values are empirical. We determined the optimal cut-off value to predict HCC recurrence after liver transplantation (LT) and further established a scoring model based on NLR.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed the outcome of 101 HBV-associated HCC patients undergoing LT. Preoperative risk factors for tumor recurrence were evaluated by univariate analysis. By using ROC analysis, NLR≥3 was considered elevated. The disease-free survival (DFS) and overall survival (OS) for patients with high NLR was significantly worse than that for patients with normal NLR (the 5-year DFS and OS of 28.5% and 19.5% vs. 64.9% and 61.8%, respectively; P<0.001). Univariate analysis revealed that tumor size >5 cm, tumor number >3, macrovascular invasion, AFP≥400 µg/L, NLR≥3, and HBV-DNA level >5 log10 copies/mL were preoperative predictors of DFS. Cox regression analysis showed macrovascular invasion, tumor number, and high NLR were independent prognostic factors. We then established a preoperative prognostic score based on multivariate analysis. Each factor was given a score of 1. Area under the ROC curve of the score was 0.781. All nine patients with score 3 developed recurrence within 6 months after LT. Of 71 patients without vascular invasion, three patients with both tumor number >3 and NLR≥3 developed recurrence within 14 months after LT while the 5-year DFS and OS for patients with a score of 0 or 1 were 68.1% and 62.8%, respectively.

CONCLUSIONS/SIGNIFICANCE

Preoperative elevated NLR significantly increases the risk of recurrence in patients underwent LT for HCC. Patients with both NLR≥3 and tumor number >3 are not a good indication for LT. Our score model may aid in the selection of patients that would most benefit from transplantation for HCC.

Microvascular invasion in hepatocellular carcinoma: is it predictable with pretransplant MRI?

OBJECTIVE

The purpose of this article is to correlate clinicopathologic and MRI parameters with the presence of microvascular invasion at histopathologic examination in patients with hepatocellular carcinoma (HCC) who are undergoing liver transplantation.

MATERIALS AND METHODS

In this retrospective single-center study, we assessed 60 patients (47 men and 13 women; mean age, 58 years) with HCC who underwent liver transplantation and pretransplant MRI (performed within 90 days before liver transplantation). Two observers analyzed the following tumor parameters in consensus: number, size, T1 and T2 signal intensity, margins, presence of capsule or pseudocapsule, distance to closest vessel, distance to liver capsule, and quantitative tumor enhancement. The size and number of HCCs, tumor differentiation, and the presence or absence of microvascular invasion were determined at histopathologic examination. Odds ratios (ORs) were calculated and logistic regression analysis was performed to assess the utility of these clinicopathologic and imaging parameters for predicting microvascular invasion.

RESULTS

None of the clinical parameters or morphologic and enhancement MRI features of HCC was predictive of microvascular invasion. Tumor multifocality, on both MRI and pathologic examination, was the only variable that predicted microvascular invasion (OR = 2.43 and p = 0.013 for MRI; OR = 1.94 and p = 0.013 for pathologic examination). The presence of three or more tumors on MRI and four or more tumors at pathologic examination had high specificity (88.2% and 91.2%, respectively) for the prediction of microvascular invasion.

CONCLUSION

Tumor multifocality on MRI was the only parameter that correlated significantly with microvascular invasion. All other MRI tumor characteristics failed to predict microvascular invasion.