Application of radiofrequency ablation for the treatment of intermediate-stage hepatocellular carcinoma

Percutaneous radiofrequency ablation for stage B1 of modified Bolondi’s subclassification for intermediate-stage hepatocellular carcinoma

Background

Hepatocellular carcinoma is considered  the most common cause of hepatic focal lesions in Egypt. TACE is still the recommended treatment approach for patients in the intermediate stage. In the current research, we evaluated the safety and efficacy of percutaneous radiofrequency ablation (RFA) for a selected category in the intermediate stage (BCLC stage B).

Methods

This prospective study was conducted in the Department of Gastroenterology, Hepatology, Faculty of Medicine, Beni-Suef University between September 2022, and March 2024. In addition to AFP, Pelviabdominal ultrasound and computerized tomography (CT) were used for HCC diagnosis. According to the Child–Pugh score plus Milan and up-to-7 criteria, we used Modified Bolondi’s Subclassification (Kinki Criteria), to sub-classifies the BCLC B stage into B1/B2/B3 subcategories. Radiofrequency ablation was done in the interventional ultrasound unit. Treatment efficacy was assessed 6 months after tumor ablation.

Results

One hundred twenty participants were enrolled in our research trial, 72 (60%) were within the intermediate stage, and 48 (40%) had early-stage HCC. Most of our patients were males, 78 (65%). All the early-stage-HCC patients were Child–Pugh Score A (n = 48), while the intermediate-stage (BCLC B) group was classified in both Child–Pugh Score A (n = 59) and B (n = 16). Within the intermediate group (BCLC-stage B), All enrolled cases fell within category “B1” within the Kinki Criteria. Logistic regression analysis illustrated that the pre-treatment level of Platelet count and post-treatment level of AFP shows a statistically significant prediction effect on treatment response rate with p-value (0.028 and 0.007 respectively).

Conclusion

percutaneous radiofrequency ablation is considered an effective treatment option for the B1 subcategory according to Kinki Criteria for intermediate-stage HCC (BCLC-B1) but long-term follow-up is recommended.

Long-term outcome and eligibility of radiofrequency ablation for hepatocellular carcinoma over 3.0 cm in diameter

Percutaneous radiofrequency ablation (RFA) is effective for the treatment of small hepatocellular carcinoma (HCC) with a diameter ≤ 3.0 cm. The present study aimed to elucidate the prognostic factors and clarify the indication of treatment for RFA outcomes in patients with HCC with a diameter > 3.0 cm. Among 2188 patients with HCC who underwent RFA, 100 patients with HCC with a diameter > 3.0 cm were enrolled in this study between August, 2000 and August, 2021. We analyzed local therapeutic efficacy, long-term outcomes, and prognostic factors in patients with HCC with a diameter > 3.0 cm. Among all patients, 77 patients achieved complete ablation in one session. There were no treatment-related deaths or major complications. Local tumor recurrence occurred in 48% (n = 48) of the patients, and distant tumor recurrence occurred in 82% (n = 82) of the patients during the study period. The survival rates at 1-, 3-, 5-, 10-, and 15- years were 93.0%, 66.0%, 40.0%, 15.5%, and 10.2%, respectively. Cox proportional hazards regression analysis confirmed that distant tumor recurrence, Child-Pugh class B, and pre-ablation des-γ-carboxy prothrombin (DCP) levels ≥ 200 mAU/mL were independent unfavorable prognostic factors with a hazard ratio of 3.34 (95% CI, 1.57-7.11; P = 0.002), 2.43 (95% CI, 1.35-4.37; P = 0.003), and 1.83 (95% CI, 1.14-2.93; P = 0.012), respectively. In conclusion, patients with HCC with a diameter > 3.0 cm with Child-Pugh class A and DCP levels < 200 mAU/mL might be eligible for RFA treatment.

Overall survival and toxicity of hepatocellular carcinoma Barcelona Clinic Liver Cancer B patients receiving Y90 radioembolization: analysis of the radiation-emitting SIR-spheres in non-resectable liver tumor (RESiN) registry

BACKGROUND

To evaluate overall survival (OS), progression-free survival (PFS) and toxicity after resin Yttrium-90 (Y-90) radioembolization in Barcelona Clinic Liver Cancer B (BCLC B) hepatocellular carcinoma (HCC) patients using the Bolondi subgroup classification.

METHODS

A total of 144 BCLC B patients were treated between 2015-2020. Patients were broken into 4 subgroups by tumor burden/liver function tests with 54, 59, 8 and 23 in subgroups 1, 2, 3 and 4. OS and PFS were calculated with Kaplan-Meier analysis with 95% confidence intervals. Toxicities were assessed using Common Terminology Criteria for Adverse Events (CTCAE) v5.

RESULTS

Prior resection and chemoembolization were performed in 19 (13%) and 34 (24%) of patients. There were no deaths within 30 days. Median OS and PFS for the cohort were 21.5 and 12.4 months. Median OS was not reached for subgroup 1 at a mean 28.8 months, and was 24.9, 11.0 and 14.6 months for subgroups 2-4 (χ2=19.8, P=0.0002). PFS by BCLC B subgroup was 13.8, 12.4, 4.5, and 6.6 months (χ2=16.8, P=0.0008). The most common Grade 3 or 4 toxicities were elevated bilirubin (n=16, 13.3%) and decreased albumin (n=15, 12.5%). Grade 3 or greater bilirubin (32% vs. 10%, P=0.03) and albumin (26% vs. 10%, P=0.03) toxicity were more common in the subgroup 4 patients.

CONCLUSIONS

The Bolondi subgroup classification stratifies OS, PFS and development of toxicity in patients treated with resin Y-90 microspheres. OS in subgroup 1 approaches 2.5 years and Grade 3 or greater hepatic toxicity profile in subgroups 1-3 is low.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada

BACKGROUND

Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.

METHODS

A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.

RESULTS & CONCLUSION

The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Recurrence after percutaneous radiofrequency ablation of hepatocellular carcinoma: Analysis of the pattern and risk factors

Background

Hepatocellular carcinoma (HCC) frequently relapses after minimally invasive treatment. This study aimed to observe the influencing factors of different recurrence patterns after radiofrequency ablation (RFA) for the treatment of recurrence.

Methods

The medical records of HCC patients who underwent RFA between January 2010 and January 2019 were retrospectively reviewed. HCC recurrence is classified into three types: local tumour progression (LTP), intrahepatic distant metastasis, and extrahepatic metastasis. Risk factors, overall survival (OS), and disease-free survival (DFS) were assessed for each modality. Among the risk factors are age, gender, liver function tests, blood tests, and tumour size. The OS and DFS curves were measured by the Kaplan-Meier method.

Results

406 patients who had undergone RFA were included in the study. The median survival for OS and DFS were 120 and 43.6 months. During follow-up, 39, 312, and 55 patients developed LTP, intrahepatic distant metastasis, and extrahepatic metastatic recurrence, respectively. The independent risk factors for each type were as follows: WBC > 5.55*109/L was an independent risk factor for local recurrence. Multiple tumours, extrahepatic metastases, and AFP > 200 ng/ml were used for intrahepatic metastases. Age (P = 0.030), recurrence pattern (P < 0.001) and Child-Pugh class B (P = 0.015) were independent predictors of OS.

Conclusions

According to our classification, each pattern of recurrence has different risk factors for recurrence, OS, and DFS.

Trial Designs for Integrating Novel Therapeutics into the Management of Intermediate-Stage Hepatocellular Carcinoma

Intermediate-stage hepatocellular carcinoma (HCC) consists of heterogeneous groups of patients in terms of tumor burden and organ function reserves. Although liver-directed therapy (LDT), including trans-catheter arterial chemoembolization, radiofrequency ablation or even surgical resection, is the recommended frontline treatment modality, intrahepatic and distant failures are common. The recent advances in systemic treatment, notably the introduction of immune checkpoint inhibitor (ICI)-based therapy, have significantly improved the objective tumor response rate, quality of response and overall survival in patients with recurrent and advanced HCC. Whether the combination of systemic treatment and LDT can further improve the outcome of patients with intermediate-stage HCC is currently being extensively evaluated. In this article, the recent clinical trials incorporating different ICI-based combinations with different LDT for intermediate-stage HCC were reviewed focusing on trial design issues, including patient selection, endpoint definition, and biomarker development. The strength and caveats of different combination strategies and novel biomarker development were discussed.

Oncological Outcomes of Operative Microwave Ablation for Intermediate Stage Hepatocellular Carcinoma: Experience in 246 Consecutive Patients

BACKGROUND

Few clinical studies concerning the efficacy of microwave ablation for intermediate stage hepatocellular carcinoma have been published. Our purpose was to examine perioperative and long-term outcomes after operative microwave ablation for intermediate stage hepatocellular carcinoma.

METHODS

This retrospective study included 246 patients who had undergone operative microwave ablation for intermediate stage hepatocellular carcinoma in our institute between January 2001 and December 2017. We analyzed overall and recurrence-free survival and used the Cox proportional hazard model to evaluate potential prognostic factors.

RESULTS

The overall median follow-up time was 51 months. The 1-, 3-, 5-, and 10-year overall survival rates were 98%, 74%, 51%, and 28%, respectively, whereas the 1-, 3-, 5-, and 10-year recurrence-free survival rates were 80%, 32%, 18%, and 10%, respectively. The major complication rate (Clavien-Dindo classification IIIa or above) after operative microwave ablation was 7%, with no procedure-related mortality. Multivariate analysis identified beyond up-to-7 criteria (the sum of the largest tumor's diameter in cm and the total number of tumors), Child-Pugh grade B, and serum alpha-fetoprotein concentration ≥ 100 ng/mL as independent risk factors for overall survival after operative microwave ablation. The overall survival of patients within up-to-7 and Child-Pugh grade A was better than that of the remaining patients, 5-year overall survivals being 67% and 37%, respectively (P < 0.001).

CONCLUSIONS

Operative microwave ablation is safe and effective in patients with intermediate stage hepatocellular carcinoma. In particular, patients within up-to-7 and Child-Pugh grade A can be expected to have better long-term outcomes after operative microwave ablation.

Combined radiofrequency ablation or microwave ablation with transarterial chemoembolization can increase efficiency in intermediate-stage hepatocellular carcinoma without more complication: a systematic review and meta-analysis

OBJECTIVES

Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely used in combination with transarterial chemoembolization (TACE) for intermediate-stage hepatocellular carcinoma (HCC) in clinical practice. We aim to compare the efficacy and safety of TACE combined with RFA or MWA versus TACE monotherapy for intermediate-stage HCC.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for relevant studies. The outcomes included overall survival (OS), progression-free survival (PFS), local tumor control (LTC) rate, and major complication. Subgroup analysis for different TACE combination therapies was performed.

RESULTS

Ten studies with 1799 patients with intermediate-stage HCC were included. The pooled hazard ratio (HR) for OS was in favor of TACE combination therapy (HR, 0.50, 95% confidence interval [CI], 0.40-0.62). Specifically, the TACE combination therapy was associated with higher 1-, 3-, and 5-year OS rates. Regarding tumor progression, the TACE combination therapy showed significantly better PFS (HR, 0.47, 95% CI, 0.37-0.61) and higher 1-, 2- and 3-year PFS rates than TACE monotherapy. The pooled odds ratio (OR) for the LTC was also in favor of TACE combination therapy (OR, 0.36, 95% CI, 0.24-0.53). No significant difference was found between the two groups regarding the major complication rate (OR, 1.26, 95% CI, 0.74-2.16). These results were consistent across subgroups of TACE + RFA versus TACE and TACE + MWA versus TACE.

CONCLUSION

TACE combined with RFA or MWA can provide significantly better OS, PFS and LTC than TACE monotherapy for patients with intermediate-stage HCC, without increasing the risk of major complications.

Image-guided locoregional non-intravascular interventional treatments for hepatocellular carcinoma: Current status

Hepatocellular carcinoma (HCC) is one of the most deadly and frequent cancers worldwide, although great advancement in the treatment of this malignancy have been made within the past few decades. It continues to be a major health issue due to an increasing incidence and a poor prognosis. The majority of patients have their HCC diagnosed at an intermediate or advanced stage in theUSA or China. Curative therapy such as surgical resection or liver transplantation is not considered anoption of treatment at these stages.

Transarterial chemoembolization (TACE), the most widely used locoregional therapeutic approach, used to be the mainstay of treatment for cases with unresectable cancer entities. However, for those patients with hypovascular tumors or impaired liver function reserve, TACE is a suboptimal treatment option. For example, embolization does not result in complete coverage of a hypovascular tumor, and may rather promotes postoperative tumor recurrence, or leave residual tumor, in these TACE-resistance patients. In addition, TACE carries a higher risk of hepatic decompensation in patients with poor liver function or reserve.

Non-vascular interventional locoregional therapies for HCC include radiofrequency ablation (RFA), microwave ablation (MWA), high-intensity focused ultrasound (HIFU), laser-induced thermotherapy (LITT), cryosurgical ablation (CSA), irreversible Electroporation (IRE), percutaneous ethanol injection (PEI), and brachytherapy. Recent advancements in these techniques have significantly improved the treatment efficacy of HCC and expanded the population of patients who qualify for treatment. This review embraces the current status of imaging-guided locoregional non-intravascular interventional treatments for HCCs, with a primary focus on the clinical evaluation and assessment of the efficacy of combined therapies using these interventional techniques.

A validation study of combined resection and ablation therapy for multiple hepatocellular carcinoma

AIM

To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report.

MATERIALS AND METHODS

A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed.

RESULTS

There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761).

CONCLUSIONS

The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

Real-Time Internal Steam Pop Detection during Radiofrequency Ablation with a Radiofrequency Ablation Needle Integrated with a Temperature and Pressure Sensor: Preclinical and Clinical Pilot Tests

A radiofrequency ablation (RFA) needle integrated with a temperature sensor (T-sensor) and pressure sensor (P-sensor) is designed and utilized for real-time internal steam pop monitoring during RFA. The characteristics of the sensor-integrated RFA needle (sRFA-needle) are investigated quantitatively using a pressure chamber system, and the feasibility and usability of the needle in preclinical and clinical trials is demonstrated. The sharp changes in the temperature and normalized pressure sensor signals induced by the abrupt release of hot and high-pressure steam can be clearly monitored during the steam pop phenomena. The basic mechanism of the preliminary steam pop is hypothesized and verified using in situ ultrasound imaging data and computational analysis data of the RFA procedure. Moreover, the usability of the system in clinical trials is investigated, and the steam pop phenomena during the RFA procedure are detected using T-sensor and P-sensor. The results confirm that the sensor integration on the medical needle can provide critical data for safer and more effective medical practices.

Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other's work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

Treatment Selection for Early to Intermediate Hepatocellular Carcinoma

Many guidelines and standard therapies have been published for the treatment of hepatocellular carcinoma (HCC). Multiple options for the treatment of early to intermediate-stage HCC have resulted in several differences between the guidelines. In addition, more than a few non-standard therapies have been used in a real-world clinical setting. Radiofrequency ablation or chemotherapy, including hepatic arterial infusion chemotherapy and molecular target agents, are sometimes selected for the treatment of intermediate HCC, whereas in many guidelines, the recommended therapy for these patients is transcatheter arterial chemoembolization. The present status of these topics is reviewed and summarized.

Nonsurgical management of advanced hepatocellular carcinoma: a clinical practice guideline

Background

Practice guidelines based on a systematic review of the literature regarding the nonsurgical management of hepatocellular carcinoma (hcc) in North America are lacking. Resection and transplantation are the foundations for cure of hcc; however, most patients are diagnosed at an advanced stage, precluding those curative treatments. A number of local or regional therapies are used and are followed by systemic therapy for advanced or progressive disease. Other treatments are available, but their efficacy, compared with those standards, is not well known.

Methods

First, systematic review questions were developed. Literature searches of the medline, embase, and Cochrane library databases (January 2000 to July 2018 or January 2005 to July 2018 depending on the question) were conducted; in addition, abstracts from the 2018 annual meeting of the American Society of Clinical Oncology were reviewed. A practice guideline was drafted that was then scrutinized by internal and external reviewers.

Results

Seventy-seven studies were included in the guideline: no guidelines, two systematic reviews, and seventy-five primary studies published in full (including one pooled analysis). Five recommendations were developed.

Conclusions

There is no evidence for or against the use of local or regional interventions other than transarterial chemoembolization for the treatment of intermediate- or advanced-stage hcc. Furthermore, there is no evidence to support the addition of sorafenib to any local or regional therapy. Sorafenib or lenvatinib are recommended for first-line systemic treatment of intermediate-stage hcc. Regorafenib or cabozantinib provide survival benefits when given as second-line treatment. Antiviral treatment is recommended in individuals with advanced hcc who are positive for the hepatitis B surface antigen.

The Application Comparison of Contrast-Enhanced Ultrasound and Contrast-Enhanced Computed Tomography in Radiofrequency Ablation Treatment for Hepatocellular Carcinoma

Objective: To compare the application value of contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT) in radiofrequency ablation (RFA) for treatment of hepatocellular carcinoma (HCC). Methods: A total of 112 patients with primary HCC were enrolled for the treatment of RFA and they were randomly equally divided into the CEUS group and CECT group. The gender, age, and number and maximum diameter of tumors between the two groups were compared. The median duration of follow-up was 27.0 months and the clinical outcomes were compared. Results: The average examination time period before ablation, of guiding needle insertion and of ablation in the CEUS group were significantly shorter than those in the CECT group (p < 0.05). The complete ablation rate of the CEUS group was significantly higher than that of the CECT group (86.36% vs. 73.17%, χ² = 4.618, p = 0.032). There was no comparative difference in the incidence of complications (including fever, infection, pain, and liver injury) between the two groups (p > 0.05). The relapse rate of the CEUS group was lower and the survival rate was higher than that in the CECT group (p < 0.05). Conclusions: Compared with the CECT, the RFA for treatment of HCC guided by the CEUS shorten the time of examination and treatment. The immediate postoperative assessment can improve the overall complete ablation rate, reduce the relapse rate, and increase the survival rate, which provides insights for the clinical application.

Ablation for hepatocellular carcinoma: beyond the standard indications

Hepatocellular carcinoma (HCC), the most common primary liver neoplasia, represents the fifth most common malignant disease in men. Percutaneous ablation treatment is recommended among the treatments suggested for HCC patients in the very early/early stage. In the last decade, very important results in terms of survival benefits have been obtained with local ablative therapies, also outside the standard indications, thanks to many technical innovations. In particular, important results of ablation as a safe and effective technique have been obtained in the treatment of intermediate- or advanced-stage patients with HCC, and in the treatment of unfavourable tumour locations. Moreover, awareness is growing regarding the necessity of overcoming the rigidity of traditional guidelines in the treatment of HCC due to the complexity of patients with HCC, focusing on Precision Medicine. In this context, it is important to know the standard and non-standard indications of ablation in the treatment of HCC in order to offer the best therapeutic option tailored for each patient. The aim of this study was to analyse the possible clinical applications of ablative therapies for HCC patients, beyond the traditional indications recommended in the most widespread clinical practice guidelines for the management of HCC.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Treatment of Intermediate-Stage Hepatocellular Carcinoma in Japan: Position of Curative Therapies

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is the standard therapy for intermediate-stage (IM) hepatocellular carcinoma (HCC). However, IM-HCC includes various clinical conditions, and various therapies were conducted in practice. In this study, we retrospectively analyzed the actually conducted treatments for IM-HCC and their efficacies to elucidate the treatment strategies suitable for IM-HCC.

METHODS

This study included 627 IM-HCC of 5,260 HCC from 9 hospitals. We examined the treatment strategies of these patients and analyzed the efficacy of each therapy with the Cox proportional hazard model and propensity score-matched analysis.

RESULTS

Liver resection, radiofrequency ablation (RFA), and TACE were performed in 165, 108, and 351 patients, respectively. Liver resection and RFA were preferably selected in cases of Barcelona Clinic Liver Cancer (BCLC)-B1/B2, and patient survival was significantly longer than in those treated with TACE (p< 0.0001). However, no beneficial effect of these active therapies was observed in cases of BCLC-B3/B4. Multivariate analysis revealed that surgical resection (hazard ratio = 0.384) and RFA (hazard ratio = 0.597) were negative risk factors for survival. Propensity score-matching analysis revealed that -survival of RFA-treated patients was longer than that of TACE-treated patients (p = 0.036).

CONCLUSION

RFA and surgical resection were effective for IM-HCC, particularly in BCLC-B1/B2 cases.

A new prediction model for prognosis of patients with intermediate-stage HCC after conventional transarterial chemoembolization: an internally validated study

Purpose: The prognosis of patients with intermediate-stage hepatocellular carcinoma (HCC) treated by conventional TACE (cTACE) is greatly heterogeneous. This study aimed to develop a new survival prediction model to help select patients who would benefit better from cTACE treatment. Methods: We collected data of 848 treatment-naïve patients with BCLC B HCC who received cTACE as first-line therapy. The prognostic model's variables were derived from univariate and multivariate Cox regression analyses. The concordance index (C-statistic) calculated through cross-validation and bootstrap resampling was used for the model selection. The calibration of our final prediction model was also assessed. Results: The model showed a better discrimination ability than Bolondi's BCLC B1-B4 subclassification to predict the prognosis of BCLC B patients (C-statistic, 0.66 vs. 0.60; difference, 0.05, 95% CI, 0.03-0.07). In cross-validation, bootstrap resampling demonstrated that the model maintained sufficiently discriminant (an average of C-statistic, 0.66; 95% CI, 0.65-0.68). The model calibration was accurate in predicting survival of patients matched well with the observed outcomes. On the basis of the improved survival of 18 months or more as the responding patient, the observations of patients in each response category (responder and non-responder) were fair-moderately matched with those predicted by the model (κ=0.40, P<0.001). Conclusions: Based on clinically available features of patient, tumor and liver function, we developed an alternative prediction model with better performance than the Bolondi's substaging system for intermediate HCC patients after cTACE, which could help define the distinct subgroup of BCLC B patients who are suitable for cTACE treatment.

Prognostic significance of lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization and radiofrequency ablation

Background

Hepatocellular carcinoma (HCC) ranks fifth among malignancies globally. Previous studies have shown that systemic inflammatory response, platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are associated with poor prognosis of various types of cancer.

Materials and methods

Radiofrequency ablation (RFA) was performed using an internal cooling electrode with a 2- or 3-cm exposed tip. The LMR was calculated as the ratio of lymphocytes to monocytes. In order to explore the influence of pretreatment with PLR and LMR on survival of HCC patients undergoing transcatheter arterial chemoembolization (TACE) and RFA, 204 cases with HCC which accepted RFA and TACE were retrospectively analyzed and assigned into 2 groups based on optimal cutoff values for LMR (low: ≤2.13 or high: >2.13) and PLR (low: ≤95.65 or high: >95.65).

Results

Patients with a lower PLR had a longer overall survival (OS) compared to those with a higher PLR (median OS, 20 versus 13 months), and patients with a higher LMR had a longer OS than those with a lower LMR (OS, 22 versus 10 months). Multivariate logistic regression analysis was performed using Cox proportional hazards regression analysis for multiple prognostic factors and identified PLR and LMR as prognostic factors for OS of HCC cases.

Conclusion

We conclude that PLR and LMR, whose detection is generally available and affordable, may be novel noninvasive circulating markers to potentially assist doctors assess the prognosis of patients.

Prognostic significance of the CRP/Alb and neutrophil to lymphocyte ratios in hepatocellular carcinoma patients undergoing TACE and RFA

Background

The C‐reactive protein (CRP)/albumin (Alb) ratio (CAR) is a basic inflammatory factor that has been related to poor survival of patients with various tumors. Our research retrospectively examined the relationship between the CAR and the prognosis of hepatocellular carcinoma (HCC).

Methods

This study included 172 patients with HCC who were treated with transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA).

Results

The CAR was weakly related to the neutrophil/lymphocyte ratio (NLR, r = .159, P = .037) and the lymphocyte/monocyte ratio (LMR, r = −.263, P = .001). The Glasgow Prognostic Score (GPS) (0/1‐2) was related to liver cirrhosis (P = .003), tumor number (P = .02), Child‐Pugh grade (P = .001), the platelet/lymphocyte ratio (PLR, P = .006), and the LMR (P = .021). Correlation analysis demonstrated that an elevated CAR was markedly correlated with the tumor size (P = .019), alpha‐fetoprotein (AFP) level (P = .033), thrombosis of the portal vein (P = .004), the NLR (P = .036), and the LMR (P = .001). Multivariate analysis indicated that the prognosis of the CAR‐High and NLR‐High cohort (mOS = 7 months) was significantly worse than those of the CAR‐High or NLR‐High cohort (mOS = 15 months) and the CAR‐Low and NLR‐Low cohort (mOS = 26.5 months).

Conclusions

Combination of the NLR and the CAR represents a convenient, quick, and noninvasive biological marker that could improve prognostic prediction in patients with HCC.

Adherence to Barcelona Clinic Liver Cancer guidelines in field practice: Results of Progetto Epatocarcinoma Campania

BACKGROUND AND AIM

The Barcelona Clinic Liver Cancer (BCLC) algorithm is the standard system for clinical management of hepatocellular carcinoma (HCC). Data on adherence to this therapeutic paradigm are scarce. This field practice study aimed to provide a description of HCC cirrhotic patients in Southern Italy, to evaluate the adherence to BCLC guidelines and its impact on patients' survival.

METHODS

We analyzed the region-wide Italian database of Progetto Epatocarcinoma Campania, which includes data of HCC cirrhotic patients, prospectively collected from January 2013 to December 2015 in 16 regional centers.

RESULTS

Overall, 1008 HCC patients were enrolled: 70.6% patients received therapies recommended by BCLC algorithm, while 29.4% underwent different treatments. Among patients who were treated in adherence to guidelines, a higher rate of diagnosis on surveillance programs, better liver function, lower rate of alpha-fetoprotein > 200 ng/mL, more early-stage and monofocal HCC, lower frequency of nodules > 5 cm, portal vein thrombosis and metastases were observed. The overall survival was evaluated according to HCC stage and no differences between groups and patients managed differently were found. The multivariate analysis showed that non-adherence to treatment guidelines was independently associated to the BCLC stage B, Child-Pugh classes B and C, and the presence of neoplastic thrombosis and metastases.

CONCLUSION

Adherence to BCLC algorithm in field practice was high in early and end-stage HCC patients, but it was poor in intermediate and advanced patients.