BCLC stage B is a better designation for single large hepatocellular carcinoma than BCLC stage A

Assessment of Tumor Burden Score as a Feasible and Reliable Tool for Prognosis Prediction for Hepatocellular Carcinoma Undergoing Hepatectomy: A Multicenter, Retrospective Study

Background

Maximum diameter and number are the main parameters of tumor burden in hepatocellular carcinoma (HCC). Tumor burden score (TBS) shows its distinguished ability to stratify patients with HCC undergoing transcatheter arterial chemoembolization (TACE). However, the prognostic accuracy of TBS in HCC undergoing liver resection and its association with the BCLC stage has not been well evaluated.

Methods

A total of 3044 treatment-naïve HCC patients from six independent medical centers undergoing liver resection were retrospectively analyzed. Survival analyses were conducted by plotting Kaplan-Meier curves and the Log rank test. We further investigated whether the tumor burden score was a feasible subclassification criterion across the BCLC stage. Then, we also used TBS to identify HCC patients beyond BCLC criteria who could benefit most from surgical resection. Finally, univariate and multivariate cox analysis was used to determine independent prognostic predictors.

Results

About 44.2% (n=1343) of patients had low TBS, 38.8% (n=1182) had intermediate TBS and 17% (n=519) had high TBS. Overall survival (OS) and recurrence-free survival deteriorated incrementally with increasing TBS (P<0.0001). Subgroup analysis indicated that there was a significant survival difference among the three TBS groups across the BCLC stage (P<0.0001). Low TBS group of patients beyond BCLC criteria reported acceptable outcomes compared to intermediate TBS group patients within BCLC criteria, even better than high TBS group (5-year OS: 64.3%, 69.8%, and 56.3%). Finally, low TBS was identified as an independent protective prognostic factor.

Conclusion

Tumor burden score is a feasible and reliable prognostic tool for prognosis prediction and clinical decisions.

Conventional and machine learning-based risk scores for patients with early-stage hepatocellular carcinoma

BACKGROUND/AIMS

The performance of machine learning (ML) in predicting the outcomes of patients with hepatocellular carcinoma (HCC) remains uncertain. We aimed to develop risk scores using conventional methods and ML to categorize early-stage HCC patients into distinct prognostic groups.

METHODS

The study retrospectively enrolled 1,411 consecutive treatment-naïve patients with the Barcelona Clinic Liver Cancer (BCLC) stage 0 to A HCC from 2012 to 2021. The patients were randomly divided into a training cohort (n=988) and validation cohort (n=423). Two risk scores (CATS-IF and CATS-INF) were developed to predict overall survival (OS) in the training cohort using the conventional methods (Cox proportional hazards model) and ML-based methods (LASSO Cox regression), respectively. They were then validated and compared in the validation cohort.

RESULTS

In the training cohort, factors for the CATS-IF score were selected by the conventional method, including age, curative treatment, single large HCC, serum creatinine and alpha-fetoprotein levels, fibrosis-4 score, lymphocyte-tomonocyte ratio, and albumin-bilirubin grade. The CATS-INF score, determined by ML-based methods, included the above factors and two additional ones (aspartate aminotransferase and prognostic nutritional index). In the validation cohort, both CATS-IF score and CATS-INF score outperformed other modern prognostic scores in predicting OS, with the CATSINF score having the lowest Akaike information criterion value. A calibration plot exhibited good correlation between predicted and observed outcomes for both scores.

CONCLUSION

Both the conventional Cox-based CATS-IF score and ML-based CATS-INF score effectively stratified patients with early-stage HCC into distinct prognostic groups, with the CATS-INF score showing slightly superior performance.

Resection Postradioembolization in Patients With Single Large Hepatocellular Carcinoma

OBJECTIVE

The aim of this study was to evaluate the efficacy of yttrium-90 transarterial radioembolization (TARE) to convert to resection initially unresectable, single, large (≥5 cm) hepatocellular carcinoma (HCC).

BACKGROUND

TARE can downsize cholangiocarcinoma to resection but its role in HCC resectability remains debatable.

METHODS

All consecutive patients with a single large HCC treated between 2015 and 2020 in a single tertiary center were reviewed. When indicated, patients were either readily resected (upfront surgery) or underwent TARE. TARE patients were converted to resection (TARE surgery) or not (TARE-only). To further assess the effect of TARE on the long-term and short-term outcomes, a propensity score matching analysis was performed.

RESULTS

Among 216 patients, 144 (66.7%) underwent upfront surgery. Among 72 TARE patients, 20 (27.7%) were converted to resection. TARE-surgery patients received a higher mean yttrium-90 dose that the 52 remaining TARE-only patients (211.89±107.98 vs 128.7±36.52 Gy, P <0.001). Postoperative outcomes between upfront-surgery and TARE-surgery patients were similar. In the unmatched population, overall survival at 1, 3, and 5 years was similar between upfront-surgery and TARE-surgery patients (83.0%, 60.0%, 47% vs 94.0%, 86.0%, 55.0%, P =0.43) and compared favorably with TARE-only patients (61.0%, 16.0% and 9.0%, P <0.0001). After propensity score matching, TARE-surgery patients had significantly better overall survival than upfront-surgery patients ( P =0.021), while disease-free survival was similar ( P =0.29).

CONCLUSION

TARE may be a useful downstaging treatment for unresectable localized single large HCC providing comparable short-term and long-term outcomes with readily resectable tumors.

Does size matter for resection of giant versus non-giant hepatocellular carcinoma? A meta-analysis

BACKGROUND

Research on long-term survival after resection of giant (≥ 10 cm) and non-giant hepatocellular carcinoma (HCC) (< 10 cm) has produced conflicting results.

AIM

This study aimed to investigate whether oncological outcomes and safety profiles of resection differ between giant and non-giant HCC.

METHODS

PubMed, MEDLINE, EMBASE, and Cochrane databases were searched. Studies designed to investigate the outcomes of giant vs non-giant HCC were included. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were postoperative complications and mortality rates. All studies were assessed for bias using the Newcastle-Ottawa Scale.

RESULTS

24 retrospective cohort studies involving 23747 patients (giant = 3326; non-giant = 20421) who underwent HCC resection were included. OS was reported in 24 studies, DFS in 17 studies, 30-d mortality rate in 18 studies, postoperative complications in 15 studies, and post-hepatectomy liver failure (PHLF) in six studies. The HR was significantly lower for non-giant HCC in both OS (HR 0.53, 95%CI: 0.50-0.55, P < 0.001) and DFS (HR 0.62, 95%CI: 0.58-0.84, P < 0.001). No significant difference was found for 30-d mortality rate (OR 0.73, 95%CI: 0.50-1.08, P = 0.116), postoperative complications (OR 0.81, 95%CI: 0.62-1.06, P = 0.140), and PHLF (OR 0.81, 95%CI: 0.62-1.06, P = 0.140).

CONCLUSION

Resection of giant HCC is associated with poorer long-term outcomes. The safety profile of resection was similar in both groups; however, this may have been confounded by reporting bias. HCC staging systems should account for the size differences.

Seven centimeters as an optimal cutoff value for prognosis stratification in large monofocal hepatocellular carcinoma

PURPOSE

Barcelona Clinic Liver Cancer (BCLC) guidelines designate monofocal hepatocellular carcinoma (HCC) > 2 cm as BCLC A, and large monofocal HCC is defined at > 5 cm. We aimed to evaluate the optimal cutoff value for large monofocal HCC based on prognosis stratification.

METHODS

From 2011 to 2018, 3055 patients with newly diagnosed HCC, who were managed in our institution, including 868 patients with monofocal HCC > 2 cm and 330 patients with BCLC B, were enrolled in this retrospective study.

RESULTS

Monofocal HCC > 5 cm patients had worse overall survival (OS) than monofocal HCC 2-5 cm patients (5-year OS: 54% vs. 57%; p = 0.047), confirmed by multivariate analysis (hazard ratio (HR): 1.492, 95% confidence interval (CI): 1.055-2.110; p = 0.024). Monofocal HCC > 5 cm patients had better OS than BCLC B HCC patients (5-year OS: 54% vs. 25%; p < 0.001), confirmed by multivariate analysis (HR: 0.670, 95% CI: 0.481-0.934; p = 0.018). Using 7 cm as the monofocal HCC cutoff value resulted in worse OS than monofocal HCC 2-7 cm (5-year OS: 50% vs. 57%; p = 0.02), confirmed by multivariate analysis (HR: 1.625, 95% CI: 1.039-2.540; p = 0.033). Monofocal HCC > 7 cm patients had better OS than BCLC B patients (p = 0.006). However, no significant difference was identified in the multivariate analysis (HR: 0.726; 95% CI: 0.473-1.115; p = 0.144).

CONCLUSIONS

The prognosis of monofocal HCC > 7 cm was similar to that of BCLC B, indicating that 7 cm represents an optimal cutoff value for prognosis stratification in large monofocal HCC.

Prognostic Analysis of Single Large Hepatocellular Carcinoma Following Radical Resection: A Single-Center Study

Objective

To investigate the survival and independent prognostic factors for single large hepatocellular carcinoma (SLHCC) after surgical resection.

Methods

Patients with SLHCC who underwent radical resection from January 2013 to December 2017 were retrospectively analyzed. The Kaplan-Meier method was used to analyze the overall survival (OS) rate and recurrence-free survival (RFS) rates. Cox forward stepwise regression was performed to analyze the independent prognostic factors.

Results

A total of 485 cases were included. The average age was 51.2±11.2 years, 88.9% had a history of hepatitis B virus infection, and most patients had normal liver function. The average tumor diameter was 8.8±3.0 cm. The 1-, 3-, and 5-year OS and RFS rates were 76.8%, 56.7%, and 45.7%, and 61.0%, 46.2%, and 34.7%, respectively. Multivariate analysis showed that liver cirrhosis (HR=1.456, P=0.004), total bilirubin (TB) ≥17.1 μmol/L (HR=1.437, P=0.011), glutamyl transferase (GGT) >60 U/L (HR=1.438, P=0.020), lactate dehydrogenase (LDH) >225 U/L (HR=1.442, P=0.007), blood loss ≥400 mL (HR=1.339, P=0.027), microvascular invasion (MVI) (HR=1.492, P=0.004), satellite lesions (HR=1.859, P<0.0001) and Edmondson-Steiner grade III+IV (HR=1.740, P=0.018) were independent risk factors for reduced OS in SLHCC patients. Sex (HR=1.763, P=0.003), liver cirrhosis (HR=1.382, P=0.007), GGT >60 U/L (HR=1.512, P=0.003), LDH >225 U/L (HR=1.480, P=0.002), MVI (HR=1.545, P=0.001), and satellite lesions (HR=1.564, P=0.001) were independent risk factors for reduced RFS. OS and RFS nomograms were constructed using risk factors with C-index values of 0.692 (95% CI: 0.659-0.724) and 0.659 (95% CI: 0.623-0.693), respectively. The Hosmer-Leme test demonstrated the good fit of both nomograms.

Conclusion

Surgical resection is the standard and effective treatment for SLHCC patients. Sex, liver cirrhosis, TB≥17.1 μmol/L, GGT>60 U/L, LDH>225 U/L, blood loss≥400 mL, MVI, Edmondson-Steiner grade III+IV, and satellite lesions were found to be independent prognostic factors in SLHCC patients following radical resection. The OS and RFS nomograms accurately predicted the prognosis of SLHCC patients.

Comparison of the Efficacy and Safety of Transarterial Chemoembolization Plus Microwave Ablation versus Surgical Resection in Patients with Solitary Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

Background

The liver resection for solitary large hepatocellular carcinoma (SLHCC) remains controversial due to the high risk of complications and recurrence after resection. This study aimed to compare the efficacy and safety of transcatheter arterial chemoembolization (TACE) plus microwave ablation (MWA) with resection for SLHCC.

Methods

We retrospectively analyzed a total of 148 patients who were treated with either TACE-MWA (n = 94) or resection (n = 54) for SLHCC (≥5 cm). A matched cohort composed of 86 patients was included after propensity score matching (PSM). The primary endpoint was overall survival (OS), and the secondary endpoints were progression-free survival (PFS) and safety.

Results

The TACE-MWA group was older with higher ALT and AST (all P < 0.05). After PSM, the 1-, 3-, and 5-year OS were 100%, 80.3%, and 51.0% in the TACE-MWA group, and 88.3%, 66.7%, and 39.4% in the liver resection group, respectively. The 1-, 3-, and 5-year PFS were 76.7%, 48.8%, and 19.6% in the TACE-MWA group, and 72%, 40.2%, and 22.6% in the liver resection group, respectively. There was no significant difference in OS and PFS between the two groups (all P > 0.05). For SLHCC patients with tumor size ≥7cm, TACE-MWA showed favorable OS than liver resection. The TACE-MWA group exhibited a lower rate of major complications and shorter hospital stay than the resection group.

Conclusion

TACE-MWA showed comparable efficacy to liver resection in patients with SLHCC, but better safety and shorter hospital stay. TACE-MWA might provide a longer OS than liver resection for SLHCC patients with tumor size ≥7cm.

Extending Surgical Resection for Hepatocellular Carcinoma Beyond Barcelona Clinic for Liver Cancer (BCLC) Stage A: A Novel Application of the Modified BCLC Staging System

Objective

We aimed to prognosticate survival after surgical resection of HCC stratified by stage with amalgamation of the modified Barcelona Clinic Liver Cancer (BCLC) staging system and location of tumour.

Methods

This single-institutional retrospective cohort study included patients with HCC who underwent surgical resection between 1st January 2000 to 30th June 2016. Participants were divided into 6 different subgroups: A-u) Within MC with Unilobar lesions; A-b) Within MC + Bilobar lesions; B1-u) Out of MC + within Up-To-7 + Unilobar lesions; B1-b) Out of MC + within Up-to-7 + Bilobar lesions; B2-u) Out of MC + Out of Up-To-7 + Unilobar lesions; B2-b) Out of MC + Out of Up-To-7 + Bilobar lesions. A separate survival analysis was conducted for solitary HCC lesions according to three subgroups: A-S (Within MC); B1-S (Out of MC + within Up-To-7); B2-S (Out of MC + out of Up-To-7).

Results

A total of 794 of 1043 patients with surgical resection for HCC were analysed. Groups A-u (64.6%), A-b (58.4%) and B1-u (56.2%) had 5-year cumulative overall survival (OS) rates above 50% after surgical resection and median OS exceeding 60 months (P = 0.0001). The 5-year cumulative recurrence-free survival rates (RFS) were 40.4% (group A-u), 38.2% (group A-b), 36.3% (group B1-u), 24.6% (group B2-u), and 7.3% (group B2-b)(P=0.0001). For solitary lesions, the 5-year OS for the subgroups were A-S (65.1%), B1-S (56.0%) and B2-S (47.1%) (P = 0.0003). Compared to A-S, there was also a significant trend towards relatively poorer OS as the lesion sizes increased in B1-S (HR 1.46, 95% CI 1.03–2.08) and B2-S (HR 1.65, 95% CI 1.25–2.18).

Conclusion

We adopted a novel approach combining the modified BCLC B sub-classification and dispersion of tumour to show that surgical resection in intermediate stage HCC can be robustly prognosticated. We found that size prognosticates resection outcomes in solitary tumours.

The impact of tumor burden at the initial hepatectomy on the recurrence-to-death survival after repeat surgical resection/radiofrequency ablation: a retrospective study

Background

Previous studies have reported the surgical resection (SR) and radiofrequency ablation (RFA) could achieve comparable recurrence-to-death survival (RTDS). However, the impact of primary tumor burden on RTDS of patients with recurrent hepatocellular carcinoma (HCC) following SR or RFA has not been clarified.

Methods

From January 2009 to March 2015, 171 patients who underwent initial hepatectomy and second curative treatments in West China Hospital were retrospectively analyzed. Survival analysis was performed by the Kaplan–Meier method. Risk factors were identified using the Cox proportional hazard model.

Results

At initial hepatectomy, 96 patients (56.1%) were diagnosed with HCC within the Milan criteria (MC), and 75 patients (43.9%) were HCC beyond the MC. The clinicopathological features and re-treatment methods of recurrent HCC were similar between patients with primary HCC within or beyond the MC. Patients with primary HCC within the MC had longer recurrence time (31.4 ± 24.2 months vs. 20.2 ± 16 months, P < 0.001). The 1- and 3- year RTDS within and beyond the MC group were 88.8%, 57.6% and 79.0%, 46.3%, respectively (P = 0.093). In multivariate analysis, the recurrence time, tumor size and AFP > 400 ng/mL at the time of recurrence were associated with RTDS.

Conclusions

The primary tumor burden had no impact on RTDS, but had an impact on recurrence time. The recurrence time had an impact on RTDS and might be a good index to reflect the biology of recurrent HCC.

Chemoembolization for Single Large Hepatocellular Carcinoma with Preserved Liver Function: Analysis of Factors Predicting Clinical Outcomes in a 302 Patient Cohort

The purpose of this study was to define the role of transcatheter arterial chemoembolization (TACE) in patients with a single large hepatocellular carcinoma (HCC) and define the patient groups benefiting from TACE. Treatment-naïve patients with preserved liver function who received TACE as the first-line treatment for single large (>5 cm) HCC without macrovascular invasion and extrahepatic metastasis between 2007 and 2019 were retrospectively analyzed. Overall survival, progression-free survival, radiologic tumor response, complications, and predictors of survival were analyzed using multivariate analysis, and then a pretreatment risk-prediction model was created using the four predictive factors of tumor size, tumor type, ALBI grade, and ECOG performance status. Patients with scores of 0 (n = 54), 1-2 (n = 170), and 3-6 (n = 78) according to the model were classified as low-, intermediate-, and high-risk, respectively. The corresponding median OS values were 141, 55, and 28 months, respectively. The percentage of major complications increased as tumor size increased (4-21%). Asymptomatic, nodular HCC patients with a tumor size of 5-7 cm and ALBI grade 1 benefited the most from TACE. By contrast, the value of TACE in the treatment of single huge HCC (>10 cm) with high complication rates remains unclear.

Tumor size may influence the prognosis of solitary hepatocellular carcinoma patients with cirrhosis and without macrovascular invasion after hepatectomy

Hepatocellular carcinoma (HCC) is usually associated with varying degrees of cirrhosis. Among cirrhotic patients with solitary HCC in the absence of macro-vascular invasion, whether tumor size drives prognosis or not after hepatectomy remains unknown. This study aimed to investigate the prognostic impact of tumor size on long-term outcomes after hepatectomy for solitary HCC patients with cirrhosis and without macrovascular invasion. A total of 813 cirrhotic patients who underwent curative hepatectomy for solitary HCC and without macrovascular invasion between 2001 and 2014 were retrospectively studied. We set 5 cm as the tumor cut-off value. Propensity score matching (PSM) was performed to minimize the influence of potential confounders including cirrhotic severity that was histologically assessed according to the Laennec staging system. Recurrence-free survival (RFS) and overall survival (OS) were compared between the two groups before and after PSM. Overall, 464 patients had tumor size ≤ 5 cm, and 349 had tumor size > 5 cm. The 5-year RFS and OS rates were 38.3% and 61.5% in the  ≤ 5 cm group, compared with 25.1% and 59.9% in the > 5 cm group. Long-term survival outcomes were significantly worse as tumor size increased. Multivariate analysis indicated that tumor size > 5 cm was an independent risk factor for tumor recurrence and long-term survival. These results were further confirmed in the PSM cohort of 235 pairs of patients. In cirrhotic patients with solitary HCC and without macrovascular invasion, tumor size may significantly affect the prognosis after curative hepatectomy.

Monofocal hepatocellular carcinoma: How much does size matter?

BACKGROUND & AIMS

According to the Barcelona Clinic Liver Cancer (BCLC) staging system, monofocal hepatocellular carcinoma (HCC) is classified as early (BCLC A) irrespective of its size, even though controversies still exist regarding staging and treatment of large tumours. We aimed at evaluating the appropriate staging and treatment for large (>5 cm) monofocal (HCC).

METHODS

From the Italian Liver Cancer database, we selected 924 patients with small early monofocal HCC (2-5 cm; SEM-HCC), 163 patients with larger tumours (>5 cm; LEM-HCC) and 1048 intermediate stage patients (BCLC B).

RESULTS

LEM-HCC patients had a worse overall survival (OS) than SEM-HCC (31.0 vs 49.0 months; P < .0001), and this was confirmed at multivariate analysis (HR 1.63, 95% CI 1.29-2.05; P < .0001). The small difference in OS between LEM-HCC and BCLC B patients (31.0 vs 27.0 months; P = .03) disappeared in the multivariate model (HR 0.98, 95% CI 0.77-1.25; P = .89). In all monofocal tumours, treatment was the strongest independent predictor of survival, with a progressively decreasing survival benefit moving from "curative" to "palliative" therapies. The survival of resected patients with LEM-HCC was significantly shorter than that of SEM-HCC (44.0 vs 78.0 months; P = .002), but liver resection provided the highest survival benefit in both groups compared to other treatments.

CONCLUSIONS

Monofocal HCC larger than 5 cm should not be staged as BCLC A and either a different staging system or a different subgrouping of patients (e.g. BCLC AB) should be used. Liver resection, if feasible, remains the recommended treatment for all these patients.

Development and Validation of Nomograms Based on Gamma-Glutamyl Transpeptidase to Platelet Ratio for Hepatocellular Carcinoma Patients Reveal Novel Prognostic Value and the Ratio Is Negatively Correlated With P38MAPK Expression

Background

Early prediction of recurrence and death risks is significant to the treatment of hepatocellular carcinoma (HCC) patients. We aimed to develop and validate prognosis nomogram models based on the gamma-glutamyl transpeptidase (GGT)-to-platelet (PLT) ratio (GPR) for HCC and to explore the relationship between the GPR and inflammation-related signaling pathways.

Methods

All data were obtained from 2000 to 2012 in the Affiliated Hospital of Qingdao University. In the training cohort, factors included in the nomograms were determined by univariate and multivariate analyses. In the training and validation cohorts, the concordance index (C-index) and calibration curves were used to assess predictive accuracy, and receiver operating characteristic curves were used to assess discriminative ability. Clinical utility was evaluated using decision curve analysis. Moreover, improvement of the predictive accuracy of the nomograms was evaluated by calculating the decision curve analysis, the integrated discrimination improvement, and the net reclassification improvement. Finally, the relationship between the GPR and inflammation-related signaling pathways was evaluated using the independent-samples t-test.

Results

A larger tumor size and higher GPR were common independent risk factors for both disease-free survival (DFS) and overall survival (OS) in HCC (P < 0.05). Good agreement between our nomogram models' predictions and actual observations was detected by the C-index and calibration curves. Our nomogram models showed significantly better performance in predicting the HCC prognosis compared to other models (P < 0.05). Online webserver and scoring system tables were built based on the proposed nomogram for convenient clinical use. Notably, including the GPR greatly improved the predictive ability of our nomogram models (P < 0.05). In the validation cohort, p38 mitogen-activated protein kinase (P38MAPK) expression was significantly negatively correlated with the GPR (P < 0.01) and GGT (P = 0.039), but was not correlated with PLT levels (P = 0.063). And we found that P38MAPK can regulate the expression of GGT by quantitative real-time PCR and Western blotting experiments.

Conclusions

The dynamic nomogram based on the GPR provides accurate and effective prognostic predictions for HCC, and P38MAPK-GGT may be a suitable therapeutic target to improve the prognosis of HCC patients.

Therapy of Intermediate-Stage Hepatocellular Carcinoma: Current Evidence and Clinical Practice

Intermediate-stage Hepatocellular Carcinoma (HCC) represents a wide range of disease burden. Patients with different levels of liver function, tumor size, and number of lesions may all have intermediate-stage disease according to the Barcelona Clinic Liver Cancer (BCLC) staging system. Several minimally invasive image-guided locoregional therapies are available for the treatment of intermediate-stage HCC, including conventional transarterial chemoembolization (cTACE), drug-eluting bead TACE (DEB-TACE), yttrium-90 radioembolization (Y-90 RE), thermal ablation, bland embolization, and combination therapy. Available clinical evidence points to cTACE as the current gold standard for the locoregional treatment of intermediate-stage HCC. DEB-TACE is at best non-inferior to cTACE in terms of survival benefit. Y-90 RE is a maturing therapy, and some institutions have adopted it as first-line therapy for intermediate-stage HCC. Thermal ablation combined with TACE may be used in select patients, while bland embolization has only limited evidence for its use. The combination of locoregional therapy with VEGF inhibitors or immune checkpoint inhibitors has also been explored. This article will examine in detail the clinical evidence supporting available locoregional treatment options for intermediate-stage HCC.

Prognostic Stratification Based on a Novel Nomogram for Solitary Large Hepatocellular Carcinoma After Curative Resection

Solitary large hepatocellular carcinoma (SLHCC) is a specific subtype of HCC with unique characteristics. It is of great interest to assess and stratify the prognosis of SLHCCs after curative resection. In this study, we tried to construct a prognostic nomogram for SLHCC following curative resection through a retrospective analysis of 202 SLHCC cases. Seven prognostic factors were identified and integrated to establish a novel prognostic nomogram, which included tumor size, microvascular invasion, tumor differentiation, Ki67 (%), α-fetoprotein (AFP), carbohydrate antigen 125 (CA125), and HBsAg status. The Harrell's concordance index (C-index) of the nomogram for overall survival (OS) in the training, validation, and whole sets was 0.752, 0.703, and 0.733, respectively. Furthermore, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve of the nomogram for predicting 1-, 3-, and 5-year OS indicated that the nomogram had an optimal discrimination of the prognostic prediction for SLHCC. The total score of each patient was calculated based on the nomogram, and patients were divided into three subgroups: low-risk group (total score ≦ 107), medium-risk group (107 < total score ≤ 125), and high-risk group (total score > 125). The 1-, 3-, and 5-year OS rates of the low-risk, medium-risk, and high-risk groups in the whole set were 89.3 vs. 70.1 vs. 33.3%, 76.6 vs. 37.8 vs. 14.5%, and 69.8 vs. 25.1 vs. 12.5%, respectively (P < 0.001). Similar results were shown in terms of the recurrence-free survival (RFS) rate. By analyzing 101 cases of recurrent tumors, transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA)/surgery was found to prolong patient survival when compared to TACE alone in the low-risk group, but not in the medium/high-risk group. In conclusion, our prognostic nomogram successfully stratifies the prognosis for SLHCC after curative resection, which deserves further study in future clinical practice.

Single Large Nodule (>5 cm) Prognosis in Hepatocellular Carcinoma: Kinship with Barcelona Clinic Liver Cancer (BCLC) Stage A or B?

Background

The aim of the present study was to evaluate the prognosis among patients with a single large hepatocellular carcinoma (HCC) >5 cm compared with other patients in Barcelona Clinic Liver Cancer (BCLC) stage A or stage B.

Material/Methods

Data on patients with BCLC stage A/B HCC were collected between 2008 and 2012. BCLC stage A was subclassified as A1 (single tumor, 2–5 cm, or 2–3 nodules ≤3 cm), or A2 (single tumor >5 cm). Overall survival (OS) was evaluated and compared.

Results

Among 1005 patients with HCC, 455 were stage A1, 188 were stage A2, and 362 were stage B. The OS of stage A2 patients was significantly worse than that of stage A1 patients (median survival, 30.6 vs. 43.2 months, p<0.001), and was similar to that of stage B patients (median survival, 30.6 vs. 33.5 months, p=0.519). After surgical resection, OS was statistically distinct between stage A1+A2 and B (median survival, 51.2 vs. 36.0 months, p=0.001), and between stage A1 and A2+B (median survival, 54.4 vs. 36.8 months, p<0.001). In contrast, when treated by transarterial chemoembolization, there was no difference in OS between patients with stage A1+A2 HCC and patients with stage B HCC (median survival, 32.4 vs. 31.3 months, p=0.310), whereas patients with stage A1 HCC showed a significantly more favorable OS than those with stage A2+B HCC (median survival, 39.6 vs. 31.8 months, p=0.023). On multivariable analysis, the groupings that showed significantly different associations with OS were BCLC stage A2+B vs. A1 (hazard ratio 1.6, p<0.001) rather than stage B vs. A1+A2.

Conclusions

Patients with solitary HCC >5 cm had a comparable survival with BCLC stage B. HCC >5 cm should therefore be classified as an intermediate stage.

Transarterial chemoembolization combined with radiofrequency ablation for solitary large hepatocellular carcinoma ranging from 5 to 7 cm: an 8-year prospective study

PURPOSE

This prospective study was performed to investigate long-term (8-year) survival in patients with solitary large hepatocellular carcinoma (HCC) ranging from 5 to 7 cm who underwent transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) and identify factors that significantly affected outcomes.

METHODS

Forty-eight patients with large HCC (36 men, 12 women; mean age, 57.0 ± 11.2 [range, 37-82] years) without fever or signs of infection were enrolled. All patients were treated with TACE + RFA. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Prognostic factors were assessed using the Cox hazards regression method.

RESULTS

The median OS duration was 47.0 months, and the 1-, 3-, 5-, and 8-year OS rates were 73%, 57%, 53%, and 27%, respectively. The median DFS duration was 9.05 (3.99-12.01) months, and the 1-, 3-, and 5-year DFS rates were 35%, 9%, and 0%, respectively. Cox hazards regression analysis revealed that the Child-Pugh class, platelet count, lymphocyte-to-monocyte ratio (LMR), and DFS were independent predictive factors of OS (p = 0.000, 0.003, 0.020, and 0.000, respectively). The LMR and platelet-to-lymphocyte ratio (PLR) were independent predictive factors of recurrence (p = 0.046 and 0.016, respectively).

CONCLUSION

TACE + RFA may be a safe and effective treatment for selected solitary large HCC ranging from 5 to 7 cm. Measurement of the LMR (> 4) and PLR (≤ 100) in peripheral blood before the intervention might help to identify which patients with solitary large HCC are suitable for TACE + RFA. Registration number: ChiCTR-TRC-12002768 ( https://www.chictr.org.cn ).

A-G Score Associated With Outcomes in Solitary Hepatocellular Carcinoma Patients After Hepatectomy

Aim: The study aimed to investigate the clinical significance of preoperative alpha-fetoprotein (AFP) and gamma-glutamyl transferase (GGT) (A-G score) on hepatocellular carcinoma (HCC) patients.

Methods: A total of 474 solitary HCC patients were included. Survival analysis was evaluated by Kaplan-Meier method. Prognostic factors were analyzed in a multivariate model. The comparison of the predictive value of AFP, GGT, and A-G score was performed by receiver operating characteristic curve (ROC) analysis and decision curve analysis (DCA).

Results: Of the 474 patients, 137(28.9%), 241(50.8%), and 96(20.3%) patients were assigned to A-G score 0, 1, and 2, respectively. In multivariate analysis, A-G score, tumor size, microvascular invasion, tumor differentiation, satellite lesion, and state of HBV infection were independently predictive factors for RFS of solitary HCC patients. The A-G score could significantly stratify solitary HCC patients with a distinguished prognosis. The 1-, 3-, and 5-year RFS and OS among patients with A-G score 1 was better than that of patients with A-G score 2 and worse than that of patients with A-G score 0(all p < 0.05). Based on the result from the ROC analysis and DCA analysis, the A-G score appeared to be superior to either AFP or GGT alone in the prediction of prognosis of solitary HCC patients. In the subgroup analysis, the A-G score could accurately predict the prognosis of solitary HCC patients without MVI or with liver cirrhosis.

Conclusions: Preoperative A-G score could effectively and simply predict prognosis of solitary HCC patients after hepatectomy, especially for those with non-MVI solitary HCC or those with liver cirrhosis.

Total tumor volume as a prognostic value for survival following liver resection in patients with hepatocellular carcinoma. Retrospective cohort study

BACKGROUND

Total tumor volume (TTV) can provide a simplified parameter in describing the tumor burden by incorporating the size and number of tumor nodules into one continuous variable. The aim of the study was to evaluate the prognostic value of TTV in resection of hepatocellular carcinoma (HCC).

METHODS

Patients who underwent liver resection for HCC between 2012 and 2017 were retrospectively analyzed. Patients were divided into a group with TTV ≤65.5 cm³ (which nearly equal to a single tumor with a diameter of 5 cm), and another group with TTV > 65.5 cm³.

RESULTS

Two hundred and four patients were included in this study (108 patients had TTV ≤ 65.5cm3, and 96 patients had TTV > 65.5 cm³). Ninety patients (44.1%) were within Milan and 114 patients (55.9%) were beyond Milan criteria. Eighteen patients (15.8%) of beyond Milan criteria had TTV ≤ 65.5 cm³, with a median survival of 32 months which is comparable to a median survival of patients with TTV< 65.5 cm³ (38 months, P = 0.38). TTV-based Cancer of Liver Italian Program (CLIP) score gained the highest value of likelihood ratio 114.7 and the highest Concordance-index 0.73 among other prognostic scoring and staging systems. In multivariate analysis, independent risk factors for diminished survival were serum AFP level >400 ng/ml, TTV >65.5 cm³, microvascular invasion, postoperative decompensation (all P values < 0.05).

CONCLUSION

TTV is a feasible prognostic measure to describe the tumor burden in patients with HCC. TTV-CLIP score may provide good prognostic value for resection of HCC than other staging systems.

Appraisal of a Model to Estimate Survival in Ambulatory Patients with Hepatocellular Carcinoma Classified as Barcelona Clinic Liver Cancer Stage B

Background/Aims

Patients with an intermediate stage of hepatocellular carcinoma (HCC) represent a highly heterogeneous population; therefore, many models have been proposed to predict the survival of these patients. The aim of this study was to evaluate the prognostic performance of a novel subclassification for tumors classified as Barcelona Clinic Liver Cancer (BCLC) stage B using the Model to Estimate Survival in Ambulatory HCC patients (MESIAH).

Methods

This analysis was based on 377 patients with HCC treated at Seoul National University Hospital (training cohort) and 189 patients at the Soonchunhyang University Bucheon Hospital (validation cohort). Four subclassification systems were tested: MESIAH; original BCLC B subclassification (B1, B2, B3, and B4); modified model A (B1, B2, and B3+B4); and modified model B (B1, B2+B3, and B4).

Results

Median survival progressively decreased from stage B1 through stages B2 to B3 according to the new MESIAH subclassification (p<0.001). Moreover, significantly different survival among contiguous stages was observed. In the multivariable Cox regression, the MESIAH subclassification was an independent predictor of overall survival (p<0.001). In terms of discrimination and calibration, MESIAH performed better than the original BCLC B subclassification, modified model A and modified model B.

Conclusions

The MESIAH model would be an effective tool for stratifying heterogeneous BCLC stage B cancer, and the ability of this model to predict survival is better than that of the other previously proposed models.

Prognosis after resection of single large hepatocellular carcinoma: Results from an Asian high-volume liver surgery center

Background & aims

In 2012, the Barcelona Clinic Liver Cancer (BCLC) system designated a single large hepatocellular carcinoma (SLHCC) (>5 cm) as BCLC stage A rather than stage B. However, a recent study from western countries reported that prognosis following liver resection (LR) among patients with SLHCC was similar to that among patients with BCLC stage B. We aim to evaluate the prognosis following LR among patients with SLHCC from an Asian high-volume liver surgery center.

Methods

Patients who underwent curative-intent LR for histologically proven HCC between 2011 and 2017 were enrolled using an HCC registry database. Overall survival (OS) among patients with BCLC stages 0, A, and B was examined. Patients with a SLHCC were classified as BCLC stage A1.

Results

Among 543 patients, 89 (16.4%) were BCLC stage 0, 289 (53.2%) were BCLC stage A, 92 (16.9%) were BCLC stage A1, and 73 (13.4%) were BCLC stage B. The median follow-up was 38 months. The five-year OS rates among patients with BCLC stages 0, A, A1, and B were 83.5%, 83.7%, 77.4%, and 55.4%, respectively (p<0.001). No difference in OS was noted for patients with BCLC stage A versus A1 (p = 0.11), even after adjusting for competing factors (hazard ratio = 0.97, 95% confidence interval = 0.53–1.79; p = 0.93).

Conclusion

Prognosis following LR among patients with SLHCC was similar to that among patients with BCLC stage A. The prognosis for SLHCC should thus be considered comparable to that for BCLC stage A.

Clinical characteristics analysis of 1180 patients with hepatocellular carcinoma secondary to hepatitis B, hepatitis C and alcoholic liver disease

Objective

To determine the clinical and liver stiffness characteristics of a cohort of Chinese patients with Hepatocellular carcinoma in different stages of Barcelona clinic liver cancer.

Methods

Details of 1180 patients with Hepatocellular carcinoma referred from October 2014 to November 2017 were collected retrospectively. Demographic data, etiology, clinical, and biochemical details were retrospectively analyzed. The changes of liver stiffness in different etiologies and different stages of Barcelona clinic liver cancer were especially analyzed.

Results

The onset age was 60.33 ± 9.11 (range 24‐84) years, 9 cases were ≤40 years, 572 cases were 41‐60 years, males accounted for 83.92%, females accounted for 16.08%; 599 cases were ≥61 years, males accounted for 78.25%, females accounted for 21.75%. Compared with males, the proportion of females ≥61 is higher than that of men. Majority (n = 787; 66.69%) had HBV infection; second commonest cause was HCV infection (n = 217; 18.39%). More patients with HBV infection were 41‐60 years (69.06%) and were younger than HCV patients. There was no statistical difference in etiology, age, gender, and distribution of diabetes mellitus among different Barcelona clinic liver cancer stages (P > .05). The overall Hepatocellular carcinoma (HCC) was found to be positively correlated with alkaline phosphatase, γ‐glutamyltransferase, and alpha‐fetoprotein and liver stiffness measurement values from stage A to stage D (P < .05). ANOVA analysis showed that the overall liver stiffness measurement among the four BCLC stages was found to be statistically significant different in HBV‐infected and HCV‐infected HCC patients.

Conclusion

Majority (99.24%) were patients aged >40 years old. Male is a high incidence population. In etiological analysis, HBV dominates HCC occurrence, HBV‐, HCV‐, and alcohol‐associated HCC have distinct clinical and biochemical characteristics, necessitating different screening policies to optimize HCC surveillance and management.

Prognosis After Resection of Barcelona Clinic Liver Cancer (BCLC) Stage 0, A, and B Hepatocellular Carcinoma: A Comprehensive Assessment of the Current BCLC Classification

BACKGROUND

Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have questioned the prognostic stratification of this classification schema, as well as the proposed treatment allocation of patients with a single large tumor.

METHODS

Patients who underwent curative-intent hepatectomy for histologically proven hepatocellular carcinoma (HCC) between 1998 and 2017 were identified using an international multi-institutional database. Overall survival (OS) among patients with BCLC stage 0, A, and B was examined. Patients with a single large tumor were classified as BCLC stage A1 and were independently assessed.

RESULTS

Among 814 patients, 68 (8.4%) were BCLC-0, 310 (38.1%) were BCLC-A, 279 (34.3%) were BCLC-A1, and 157 (19.3%) were BCLC-B. Five-year OS among patients with BCLC stage 0, A, A1, and B HCC was 86.2%, 69.0%, 56.9%, and 49.9%, respectively (p < 0.001). Among patients with very early- and early-stage HCC (BCLC 0, A, and A1), patients with BCLC stage A1 had the worst OS (p = 0.0016). No difference in survival was noted among patients undergoing surgery for BCLC stage A1 and B HCC (5-year OS: 56.9% vs. 49.9%; p = 0.259) even after adjusting for competing factors (hazard ratio 0.83, 95% confidence interval 0.54-1.28; p = 0.40).

CONCLUSION

Prognosis following liver resection among patients with BCLC-A1 HCC was similar to patients presenting with BCLC-B tumors. Surgery provided acceptable long-term outcomes among select patients with BCLC-B HCC. Designation into BCLC stage B should not be considered an a priori contraindication to surgery.

A modified staging of early and intermediate hepatocellular carcinoma based on single tumour >7 cm and multiple tumours beyond up-to-seven criteria

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging system is the most widely used staging system for hepatocellular carcinoma (HCC). However, the classifications of early (BCLC-A) and intermediate (BCLC-B) stage HCC remain controversial.

AIM

To refine the staging of BCLC-A and -B.

METHODS

A total of 986 patients with HCC undergoing liver resection from two institutions formed the training cohort, and 694 from another institution were the validation cohort. Time-dependent receiver operating characteristic (ROC) curve analysis was performed to evaluate the performance of tumour size in predicting overall survival (OS), and determined the optimised cut-off. Discriminatory performance was evaluated using Harrell's concordance index (C-index).

RESULTS

Patients with multiple tumours exceeding Milan criteria but within up-to-seven criteria had similar OS and disease-free survival (DFS) to those with multiple tumours meeting Milan criteria, and were assigned to the modified BCLC-A stage. The area under the ROC curve of tumour size for predicting OS was 0.778, and the diameter of 7 cm was the optimal cut-off to identify patients with single tumours who had higher OS than BCLC-B stage patients. Due to the similar OS, patients with single HCCs >7 cm were assigned to the modified BCLC-B stage. The C-indexes of the modified BCLC classification for OS and DFS were higher compared to the original version. The findings were supported by the validation cohort.

CONCLUSIONS

The modified staging of BCLC-A and -B, based on single tumour >7 cm and multiple tumours beyond up-to-seven criteria, could be more accurate to predict the prognosis of HCC patients. Liver resection could benefit patients with resectable multifocal HCCs beyond the Milan criteria.

The Prognosis of Single Large Hepatocellular Carcinoma Was Distinct from Barcelona Clinic Liver Cancer Stage A or B: The Role of Albumin-Bilirubin Grade

BACKGROUND/AIMS

Whether single large hepatocellular carcinoma (SLHCC) is classified as Barcelona Clinic Liver Cancer (BCLC) stage A or B is still controversial. We aimed to compare the clinical manifestations, treatment modalities, and prognoses among patients with SLHCC and those in BCLC stage A and B.

METHODS

We enrolled 2,285 treatment-naive hepatocellular carcinoma (HCC) patients with BCLC stage A or B from October 2007 to December 2015. Factors in terms of prognoses were analyzed by multivariate analysis.

RESULTS

We enrolled 1,210, 466, and 609 patients in a BCLC-A, SLHCC, and BCLC-B group, respectively. After a median follow-up duration of 21.2 months, 898 patients had died. The cumulative 5-year survival rates were 57.0, 42.6, and 27.3% for patients in the BCLC-A, SLHCC, and BCLC-B groups, respectively, which were significantly different (p < 0.001). Multivariate analysis indicated that the following independent risk factors were associated with poor prognosis: age > 65 years, alkaline phosphatase > 100 U/L, creatinine > 1.0 mg/dL, alpha-fetoprotein > 20 mg/mL, noncurative treatment, albumin-bilirubin (ALBI) grade, and HCC staging. Subgroup analysis also confirmed that patients in the SLHCC group had a survival rate intermediate to those in the BCLC-A and BCLC-B groups. However, for patients in the SLHCC group and with ALBI grade 1, outcomes were close to those in the BCLC-A group, especially in the setting of curative treatment. For those with ALBI grades 2 or 3, the prognoses were similar to those of the SLHCC and BCLC-B groups.

CONCLUSION

Patients in the SLHCC group had an overall survival rate intermediate to those of the BCLC-A and BCLC-B groups. It is suggested that the SLHCC group could be classified as occupying a different stage from the BCLC stages A and B. The ALBI grade could help to stratify SLHCC into a different prognostic group. However, the results need to be validated externally in other regions of the world.

The Impact of Tumor Differentiation on the Prognosis of HBV-Associated Solitary Hepatocellular Carcinoma Following Hepatectomy: A Propensity Score Matching Analysis

AIM

The role of tumor differentiation in the prognosis of hepatocellular carcinoma (HCC) after hepatectomy remains controversial. The present study aimed to classify the impact of tumor differentiation on solitary hepatitis B viral (HBV)-associated HCC using propensity score matching analysis.

METHODS

Between January 2009 and March 2015, the data of 721 HCC patients in West China Hospital were prospectively collected and analyzed. Propensity matching analysis was applied to overcome the imbalance in baseline characteristics. Survival analysis was performed using the Kaplan-Meier method. Risk factors were identified by the Cox proportional hazards model.

RESULTS

All HCC patients were classified into the moderately well-differentiated HCCs group (group A, n = 442, 61.3%) or poorly differentiated HCCs group (group B, n = 279, 38.7%). Patients with poorly differentiated HCCs commonly had a larger tumor size, more advanced tumors, and a higher alpha-fetoprotein (AFP) level. Patients with poorly differentiated HCCs had a poorer recurrence-free survival and overall survival before and after propensity score matching analysis. Poorly differentiated tumors, positive serum hepatitis B viral e antigen, positive hepatitis B virus deoxyribonucleic acid load, tumor size, microvascular invasion, and AFP > 400 ng/ml were risk factors of a poor outcome.

CONCLUSIONS

Our propensity model provided strong evidence that a poorly differentiated tumor had a negative impact on the recurrence and long-term survival of solitary HBV-associated HCCs after curative hepatectomy. Antiviral therapy might improve their prognosis.

Nomograms to Predict the Individual Survival of Patients with Solitary Hepatocellular Carcinoma after Hepatectomy

Background/Aims

Solitary hepatocellular carcinoma (HCC) is a subgroup of HCCs. We aimed to establish nomograms for predicting the survival of solitary HCC patients after hepatectomy.

Methods

A total of 538 solitary HCC patients were randomly classified into training and validation sets. A Cox model was used to identify predictors of overall survival (OS) in the training set. A nomogram was generated based on these predictors and was validated using the validation set.

Results

Tumor size, microvascular invasion, and major vascular invasion were significantly associated with OS in the training set. Nomograms were developed based on these predictors in the multivariate analysis. The C-index was 0.75 for the OS nomogram and 0.72 for the recurrence-free survival nomogram. Compared to the index of conventional staging systems for predicting survival (0.71 for Barcelona Clinic Liver Cancer, 0.66 for the seventh American Joint Committee on Cancer, 0.68 for Cancer of the Liver Italian Program, and 0.70 for Hong Kong Liver Cancer), the index of the OS nomogram was significantly higher. Moreover, the calibration curve fitted well between the predicted and observed survival rate. Similarly, in the validation set, the nomogram discrimination was superior to those of the four staging systems (p<0.001).

Conclusions

The nomograms demonstrated good discrimination performance in predicting 3- and 5-year survival rates for solitary HCCs after hepatectomy.

Incorporation of alpha-fetoprotein(AFP) into subclassification of BCLC C stage hepatocellular carcinoma according to a 5-year survival analysis based on the SEER database

PURPOSE

To evaluate the effect of serum alpha-fetoprotein(AFP) on prognosis of patients with hepatocellular carcinoma (HCC) and put forward a proposal to modify BCLC staging system and the recommended treatment of patients with stage C.

RESULTS

AFP positive was an independent poor prognostic factor of HCC. Race, pathological grade, T stage, M stage were also regarded to be significant predicted factors for poorer prognosis. When combining AFP status with AJCC stage, patients with A1 disease had a worse prognosis compared with those with A0 disease within each stage. Patients with A1 disease of each T/N stage had a worse prognosis than patients with A0 disease of the respective stage, and the prognosis of patients with A1 disease with lower T stages was worse or similar to that of patients with A0 disease of higher T stages.

MATERIALS AND METHODS

We performed a retrospective study of all patients histologically diagnosed HCC from January 1, 2004, through December 31, 2008, from the SEER database.

CONCLUSIONS

AFP can be used as a subclassification index to modify the AJCC staging system of HCC. Since BCLC stage is the most widely used staging system, we recommend routine pre-treatment AFP testing as standard of care in HCC and incorporate AFP status into the BCLC staging system to modify the recommended treatment of patients with stage C.

Comparison of the Efficacy and Prognostic Factors of Transarterial Chemoembolization Plus Microwave Ablation versus Transarterial Chemoembolization Alone in Patients with a Large Solitary or Multinodular Hepatocellular Carcinomas

Objective

To evaluate the efficacy and prognostic factors associated with transcatheter arterial chemoembolization (TACE) combined with microwave ablation (MWA) versus TACE alone for a large solitary or multinodular hepatocellular carcinomas (HCCs).

Materials and Methods

This retrospective study involved 258 patients with a large solitary or multinodular HCCs (not more than 10 tumors) who underwent TACE + MWA (n = 92) or TACE alone (n = 166) between July 2011 and April 2015. Local tumor control, survival outcomes, and complications were compared between the two groups. Prognostic factors for time to progression (TTP) and overall survival (OS) were evaluated by univariate and multivariate analyses.

Results

The median duration of follow-up was 21.2 months (range, 4–45 months). The median TTP and OS were 12.5 months and 26.6 months, respectively, for the TACE + MWA group and 6.7 months and 17.1 months, respectively, for the TACE group (p < 0.001). The 1-, 2-, and 3-year OS rates were 85.9, 59.8, and 32.6%, respectively, for the TACE + MWA group and 59.0, 40.4, and 11.4%, respectively, for the TACE group (p < 0.001). The corresponding recurrence rates were 47.8, 78.3, and 94.6% for the TACE + MWA group, respectively, and 74.7, 96.4, and 97.6%, respectively, for the TACE group (p < 0.001). Logistic regression analyses showed that the treatment method, tumor size, and tumor number were significant prognostic factors for TTP and OS.

Conclusion

TACE + MWA appears to have more advantages compared to TACE in prolonging OS, with a satisfactory TTP, for inpatients with solitary large or multinodular HCCs. Treatment method, tumor size, and tumor number are significant prognostic factors for TTP and OS. Further randomized, multi-center, prospective trials are required to confirm the findings of this study.

Surgical resection improves long-term survival of patients with hepatocellular carcinoma across different Barcelona Clinic Liver Cancer stages

Objectives

Surgical resection remains a controversial treatment for hepatocellular carcinoma (HCC) within different Barcelona Clinic Liver Cancer (BCLC) stages. The objective of this study was to evaluate the long-term outcome of patients undergoing surgical resection (SR) compared to non-surgical treatments across different BCLC stages.

Patients and methods

One thousand four hundred forty-three HCC patients within BCLC 0, A, B and C stages were identified. Overall survival was compared by log-rank test among patients within different BCLC stages and among patients receiving different treatments (SR vs locoregional therapy [LRT] vs best supportive care). Propensity score matching analysis was introduced to mitigate the confounding biases between the groups.

Results

The median survival time of the patients diminished from early, intermediate to advanced BCLC stages (BCLC 0-A 43 [range 0-100] months vs BCLC B 32 [range 0-100] months vs BCLC C 27 [range 0-90] months, all p<0.05). Patients undergoing SR presented with better liver function and more favorable tumor status and, consequently, displayed significant better overall survival than patients receiving LRT or best supportive care at different BCLC stages. In adjusted cohort after propensity score matching, patients who were surgically treated consistently had more favorable outcome than those who were non-curatively treated across different BCLC stages (median survival [range]: BCLC stage B: resection 45 [0-100] months vs LRT 36 [0-81] months, p=0.002; BCLC stage C: resection 39 [3-77] months vs LRT 27 [0-54] months, p=0.003).

Conclusion

Surgical resection should be considered as a radical treatment for selected HCC patients regardless of the BCLC stages when appropriate.

The role of liver resection in the management of intermediate and advanced stage hepatocellular carcinoma. A systematic review

BACKGROUND

The ideal management for patients with intermediate and advanced stage hepatocellular carcinoma (HCC) is controversial. The main purpose of this systematic review is to examine the role of liver resection in patients with intermediate stage HCC (multinodular HCCs) and in advanced stage HCC [mainly patients with portal vein tumor thrombosis (PVTT)].

METHODS

A systematic search of the literature was performed in Pud Med and the Cochrane Library from 01.01.2000 to 30.06.2016.

RESULTS

Twenty-three articles with 2412 patients with multinodular HCCs were selected. Also, 29 studies with 3659 patients with HCCs with macrovascular invasion were selected. In patients with multinodular HCCs the median post-operative morbidity was 25% and the 90-day mortality was 2.7%. The median survival was 37 months and the 5-year survival 35%. The 5-year survival was much better for patients with a number of HCCs ≤3 vs. HCCs >3 (49% vs. 23%). In patients with macrovascular invasion, who underwent hepatic resection, the median post-operative morbidity was 33% and the in-hospital mortality 2.7%. The median survival was 15 months. The 3 and 5year survival was 33% and 20% respectively. Moreover a significant difference in survival was noted according to PVTT stage: 5- year survival for distal PVTT, PVTT of the main intrahepatic PV branch and PVTT extending to the main PV was 45%, 19% and 14.5% respectively.

CONCLUSIONS

Liver resection in patients with multinodular HCCs and HCCs with PVTT offers satisfactory long-term survival and should be considered in selected patients.

Hepatocellular carcinoma in elderly: Clinical characteristics, treatments and outcomes compared with younger adults

The number of elderly patients diagnosed with hepatocellular carcinoma (HCC) is expected to increase. The present study aims to evaluate the role of age on treatments and outcome of HCC patients. 1530 patients firstly diagnosed with HCC were retrospectively included and classified as older (≥65 years, n = 318, 21%) and younger patients (<65 years, n = 1212, 79%). The two groups were compared with clinical characteristics, tumor burden, Barcelona Clinics Liver Cancer (BCLC) stage, treatments and long-term prognosis. Elderly patients were more HCV infected, had more diabetes, poorer performance status, and were less aggressively treated. The proportion of HCC within BCLC stage 0-A, B or C was similar between the two groups, but elderly patients were more presented with BCLC stage D. The overall survival of older patients was poorer compared to younger patients before and after propensity score matching. However, elderly patients were less often effectively treated with surgery and loco-regional therapies across different BCLC stages. After stratified by BCLC stages or treatments, older patients showed comparable long-term outcome to younger patients. Performance status, BCLC stages and effective treatments, rather than age, was independent factors determining prognosis in the whole cohort and only elderly patients by multivariate analysis. In conclusion, older could have comparable survival to younger patients within the same tumor stage or after similar treatments. Thus, equally active treatments should be encouraged to elderly patients.

Optimizing stage of single large hepatocellular carcinoma: A study with subgroup analysis by tumor diameter

This study aims to refine the designation for single hepatocellular carcinoma (HCC) >5 cm by comparing the postresection prognosis of these patients with those who have a single-tumor ≤5 cm and those with stage B.Patients with a single-tumor were classified into subgroups based on diameter. Of the 1132 patients analyzed, 426 had a single-tumor >2 and ≤5 cm; 229, a single-tumor >5 and ≤8 cm; 52, a single-tumor >8 and < 10 cm; 150, a single-tumor ≥10 cm; and 275, stage B.Hospital mortality and complications increased with tumor size among the single-tumor subgroups and median survival decreased with increasing of tumor size. Overall survival (OS) among patients with a single-tumor >5 cm was significantly lower than among patients with a single-tumor >2 and ≤5 cm (P ≤ .001), but significantly higher than among patients with clearly stage B (P ≤ .001). Patients with a single-tumor >5 and ≤8 cm showed lower OS than patients with a single-tumor >2 and ≤5 cm (P < .001). Patients with a single-tumor >8 and <10 cm or a single-tumor ≥10 cm showed lower OS than patients with a single-tumor >5 and ≤8 cm (P = .033 and .006), and similar OS to patients with stage B (P = .323).Patients with a single-tumor >5 and ≤8 cm may be assigned to a new stage between early and intermediate. Patients with a single-tumor >8 cm may be assigned to intermediate stage.

Microwave ablation in primary and secondary liver tumours: technical and clinical approaches

Thermal ablation is increasingly being utilised in the treatment of primary and metastatic liver tumours, both as curative therapy and as a bridge to transplantation. Recent advances in high-powered microwave ablation systems have allowed physicians to realise the theoretical heating advantages of microwave energy compared to other ablation modalities. As a result there is a growing body of literature detailing the effects of microwave energy on tissue heating, as well as its effect on clinical outcomes. This article will discuss the relevant physics, review current clinical outcomes and then describe the current techniques used to optimise patient care when using microwave ablation systems.

Survival Analysis of Single Large (>5 cm) Hepatocellular Carcinoma Patients: BCLC A versus B

Background & Aims

Single large (>5 cm) hepatocellular carcinoma (HCC) is classified as Barcelona Liver Clinic (BCLC) stage early stage (A). Yet, controversies exist whether single large HCC can be considered as early stage. We have analyzed long-term outcome to see which stage is appropriate for these patients.

Methods

From 2005 to 2006, 1,546 consecutive patients who were newly diagnosed as HCC (BCLC A or B) at four tertiary hospitals in Korea were analyzed. BCLC A was sub-classified into A1 (single 2–5 cm), A2 (2–3 nodules ≤3 cm), and A3 (single >5 cm). BCLC B1 included patients beyond-Milan criteria, and within up-to-7 criterion. Survival prediction between subgroupings (1: A1 + A2 + A3 vs. B1 and 2: A1 + A2 vs. A3 + B1) was compared based on c-index and Akaike information criterion (AIC).

Results

The 5-year overall survival (OS) rate was 62.3, 58.6, 36.8, and 42.0% for A1, A2, A3 and B1, respectively. In multivariate Cox-regression analysis, OS was significantly different between A3 + B1 vs. A1 + A2 (hazard ratio [HR] 1.85; P<0.001), but not between A1 + A2 + A3 vs. B1 (HR 1.19; P = 0.258). For A3, surgical resection showed superior OS over transarterial chemoembolization. Survival prediction was superior in subgrouping 2 (AIC 5727.2; c-index 0.652) than subgrouping 1 (AIC 5766.3; c-index 0.619) even after inverse probability weighting.

Conclusions

This large scale long-term follow-up data shows that single large tumor should be considered as intermediate stage in terms of prognosis. However, in terms of treatment, resection might be the first line treatment option.

Surgery and Hepatocellular Carcinoma

The optimal surgical strategy for hepatocellular carcinoma (HCC) is under active debate. Bio-markers of the liver functional reserve as well as volumetric analysis of the future liver remnant are essential for safe liver resection of HCC. The present algorithms applied to surgical strategies for HCC are not ideal because many patients who could potentially undergo safe resection are deemed liver transplant candidates in Western countries, whereas the opposite is the case in Eastern countries. In addition, there is too much focus on expanded criteria for patients with HCC to undergo liver transplantation. The transplantation benefit for patients with HCC should be considered based not only on the individual's benefit, but also on the effect of other patients waiting for LT for other indications.

A simple prognostic score system predicts the prognosis of solitary large hepatocellular carcinoma following hepatectomy

Solitary large hepatocellular carcinomas (SLHCC) form a heterogeneous group of patients with different survival probabilities. The aim of our study was to develop a simple prognostic index for identifying prognostic subgroups of SLHCC patients.A retrospective analysis of clinical data from 268 patients with operable SLHCC was conducted to investigate prognostic factors and to construct a score system based on risk factors. A Cox proportional hazard regression analysis was used to evaluate the variables associated with prognosis. Survival analyses were performed using Kaplan-Meier survival curves.Three variables remained in the final multivariate model: platelet to lymphocyte ratio (PLR), microvascular invasion (MVI), and tumor size with hazard ratios equal to 1.004 (95% confidence interval: 1.001-1.006), 1.092 (1.044-1.142), and 2.233 (1.125-2.233), respectively. A score of 1 was assigned to each risk factor. Patient scores were determined based on these risk factors; thus, the scores ranged between 0 and 3. Ultimately, three categories (0, 1-2, 3) were defined. Patients with scores of 3 had a 5-year survival rate of 25.4%, whereas patients with a score of 0 had a 5-year survival rate of 52.1%. The prognosis significantly worsened as the score increased. Similar results were found among cirrhotic and noncirrhotic patients.Our simple prognostic index successfully predicts SLHCC survival.

Subclassification of patients with solitary hepatocellular carcinoma based on post-hepatectomy survival: a large retrospective study

Official guidelines group together all cases of solitary hepatocellular carcinoma (HCC) without macroscopic vascular invasion, regardless of tumor size. Here, we examined whether this is justified based on overall survival (OS) after hepatic resection (HR). Patients with newly diagnosed solitary HCC treated by initial HR from January 2004 to October 2013 were classified into six groups based on tumor size (in 2-cm increments). Combining adjacent categories with similar OS led to three groups: ≤5 cm (n = 426), >5 and ≤8 cm (n = 229), and >8 cm (n = 202). Among all patients, median survival time was 62 months, and OS was 95 % at 1 year, 73 % at 3 years, and 54 % at 5 years. Patients in the ≤5 cm group showed significantly higher OS (P < 0.001) and lower tumor recurrence (P = 0.004) than those in the >5 and ≤8 cm group, who in turn showed significantly higher OS (P = 0.003) and lower tumor recurrence (P = 0.021) than those in the >8 cm group. Our results suggest that patients with solitary HCC should be subclassified based on tumor size for more accurate prognosis. We propose defining solitary HCC tumors >5 and ≤8 cm as "large" and tumors >8 cm as "huge".