Prognostic values of vascular endothelial growth factor and matrix metalloproteinase-2 in hepatocellular carcinoma after radiotherapy

Sintilimab plus bevacizumab combined with radiotherapy as first-line treatment for hepatocellular carcinoma with portal vein tumor thrombus: A multicenter, single-arm, phase 2 study

BACKGROUND AND AIMS

Systemic treatments are listed as first-line therapies for HCC with portal vein tumor thrombus (PVTT), resulting in modest efficacy. We aimed to evaluate the efficacy and safety of sintilimab plus bevacizumab combined with radiotherapy in HCC with PVTT and to identify prognostic biomarkers.

APPROACH AND RESULTS

This open-label, multicenter, single-arm, phase 2 clinical trial was conducted at 3 tertiary hospitals in China. A total of 46 patients with HCC with PVTT were enrolled. All the patients received the first cycle of i.v. sintilimab (200 mg, day 1) plus bevacizumab (15 mg/kg, day 1) within 3 days after enrollment. Radiotherapy (30-50 Gy/10 fractions) was administered after 2 cycles of Sin-Bev. Sin-Bev was disrupted during radiotherapy and resumed 2 weeks after radiotherapy and continued every 3 weeks thereafter until disease progression, unacceptable toxicity, or withdrawal of consent. The primary end point was objective response rate. Patients obtained an objective response rate of 58.7% and a disease control rate of 100%. After a median follow-up time of 26.0 months (95% CI: 24.0-26.0), the median OS was 24.0 months (95% CI: 19.0 to not applicable) and the median progression-free survival was 13.8 months (95% CI: 12.0-21.0), respectively. No unexpected adverse events or treatment-related deaths occurred. Mutations of PCTMD1 were predictive of shorter OS and progression-free survival.

CONCLUSIONS

Sintilimab plus bevacizumab combined with radiotherapy provides favorable treatment response and survival outcomes along with an acceptable safety profile in the first-line setting for patients with HCC with PVTT (ClinicalTrials.gov Identifier: NCT05010434).

Evaluation of models to predict prognosis in patients with advanced hepatocellular carcinoma treated with TACE combined with apatinib

BACKGROUND

The HAP, Six-and-Twelve, Up to Seven, and ALBI scores have been substantiated as reliable prognostic markers in patients presenting with intermediate and advanced hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) treatment. Given this premise, our research aims to assess the predictive efficacy of these models in patients with intermediate and advanced HCC receiving a combination of TACE and Apatinib. Additionally, we have conducted a meticulous comparative analysis of these four scoring systems to discern their respective predictive capacities and efficacies in combined therapy.

METHODS

Performing a retrospective analysis on the clinical data from 200 patients with intermediate and advanced HCC, we studied those who received TACE combined with Apatinib at the First Affiliated Hospital of the University of Science and Technology of China between June 2018 and December 2022. To identify the factors affecting survival, the study performed univariate and multivariate Cox regression analyses, with calculations of four different scores: HAP, Six-and-Twelve, Up to Seven, and ALBI. Lastly, Harrell's C-index was employed to compare the prognostic abilities of these scores.

RESULTS

Cox proportional hazards model results revealed that the ALBI score, presence of portal vein tumor thrombus (PVTT, )and tumor size are independent determinants of prognostic survival. The Kaplan-Meier analyses showed significant differences in survival rates among patients classified by the HAP, Six-and-Twelve, Up to Seven, and ALBI scoring methods. Of the evaluated systems, the HAP scoring demonstrated greater prognostic precision, with a Harrell's C-index of 0.742, surpassing the alternative models (P < 0.05). In addition, an analysis of the area under the AU-ROC curve confirms the remarkable superiority of the HAP score in predicting short-term survival outcomes.

CONCLUSION

Our study confirms the predictive value of HAP, Six-and-Twelve, Up to Seven, and ALBI scores in intermediate to advanced Hepatocellular Carcinoma (HCC) patients receiving combined Transarterial Chemoembolization (TACE) and Apatinib therapy. Notably, the HAP model excels in predicting outcomes for this specific HCC subgroup.

Radiation Therapy With Combination Therapy of Immune Checkpoint Inhibitors and Antiangiogenic Therapy for Hepatocellular Carcinoma

PURPOSE

Immune checkpoint inhibitors (ICIs) combined with antiangiogenic therapy have limited efficacy in treating advanced hepatocellular carcinoma (HCC). The synergistic effect of systemic therapy and radiation therapy (RT) might resolve this problem. We aimed to investigate the effect of RT on the treatment outcomes of ICIs and antiangiogenic combination therapy in patients with advanced-stage HCC.

METHODS AND MATERIALS

This retrospective observational study analyzed the medical records of 194 patients with Barcelona Clinic Liver Cancer stage C HCC who were admitted to our center from August 2018 to June 2022 and received ICIs combined with antiangiogenic therapy as the first-line treatment. Patients who were administered RT for tumor thrombus or symptomatic metastases within 8 weeks of the commencement of combination therapy were allocated to the RT group, whereas those who did not receive RT were assigned to the non-radiation therapy (NRT) group. Propensity score matching was used to mitigate selection bias. The primary endpoints were progression-free survival (PFS) and overall survival (OS). The secondary endpoints included objective response rate, disease control rate (DCR), local PFS, out-of-field PFS, and treatment-related adverse events.

RESULTS

A total of 76 patients diagnosed with advanced-stage HCC and treated with ICIs and antiangiogenic therapy were included in the study, with 33 patients in the RT group and 43 patients in the non-RT group. After propensity score matching, 29 matched patient pairs were generated. The median follow-up was 15.5 months, and the RT sites were mainly located on the tumor thrombus (55.2%) and extrahepatic metastatic lesions (48.3%). The median PFS was 8.3 months (95% CI, 5.4-11.3) in the RT group and 4.2 months (95% CI, 3.4-5.0) in the NRT group (P < .001). The median OS was not reached in the RT group and was 9.7 months (95% CI, 4.1-15.3) in the NRT group (P = .002). The objective response rate was 75.9% (95% CI, 56.5-89.7) in the RT group and 24.1% (95% CI, 10.3-43.5) in the NRT group (P < .001). The DCR was 100% in the RT group and 75.9% (95% CI, 56.5-89.7) in the NRT group (P = .005). The median local PFS and out-of-field PFS were 13.2 months (95% CI, 6.3-20.1) and 10.8 months (95% CI, 7.0-14.7), respectively. RT was an independent prognostic factor for PFS (hazard ratio = 0.33; 95% CI, 0.17-0.64; P < .001) and OS (hazard ratio = 0.28; 95% CI, 0.11-0.68; P = .005), respectively. The rates of any grade treatment-related adverse events were similar between the 2 groups.

CONCLUSIONS

In comparison to the combination of ICIs and antiangiogenic therapy, the inclusion of RT has been observed to improve the DCR and survival outcomes in patients with advanced-stage HCC. The safety profile of this triple therapy was satisfactory.

Urinary biomarkers for hepatocellular carcinoma: current knowledge for clinicians

Hepatocellular carcinoma (HCC) is the most predominant primary liver cancer, causing many illnesses and deaths worldwide. The insidious clinical presentation, difficulty in early diagnosis, and the highly malignant nature make the prognosis of HCC extremely poor. The complex and heterogeneous pathogenesis of HCC poses significant challenges to developing therapies. Urine-based biomarkers for HCC, including diagnostic, prognostic, and monitoring markers, may be valuable supplements to current tools such as serum α-fetoprotein (AFP) and seem promising for progress in precision medicine. Herein, we reviewed the major urinary biomarkers for HCC and assessed their potential for clinical application. Molecular types, testing platforms, and methods for building multimolecule models in the included studies have shown great diversity, thus providing abundant novel tools for future clinical transformation and applications.

Combined radiotherapy and immune checkpoint inhibition for the treatment of advanced hepatocellular carcinoma

Hepatocellular Carcinoma (HCC) is one of the most common cancers and a leading cause of cancer related death worldwide. Until recently, systemic therapy for advanced HCC, defined as Barcelona Clinic Liver Cancer (BCLC) stage B or C, was limited and ineffective in terms of long-term survival. However, over the past decade, immune check point inhibitors (ICI) combinations have emerged as a potential therapeutic option for patients with nonresectable disease. ICI modulate the tumor microenvironment to prevent progression of the tumor. Radiotherapy is a crucial tool in treating unresectable HCC and may enhance the efficacy of ICI by manipulating the tumor microenvironment and decreasing tumor resistance to certain therapies. We herein review developments in the field of ICI combined with radiotherapy for the treatment of HCC, as well as look at challenges associated with these treatment modalities, and review future directions of combination therapy.

Efficacy and safety of PD1/PDL1 inhibitors combined with radiotherapy and anti-angiogenic therapy for solid tumors: A systematic review and meta-analysis

BACKGROUND

The triple combination of programmed cell death 1 (PD1)/programmed cell death ligand 1 (PDL1) inhibitors, radiotherapy (RT), and anti-angiogenesis agents has been widely used in the treatment of solid tumors and has shown positive efficacy. We conducted a meta-analysis to evaluate the efficacy and safety of PD1/PDL1 inhibitors combined with anti-angiogenic agents and RT for the treatment of solid cancers.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from inception to October 31, 2022. Studies involving patients with solid cancers who received PD1/PDL1 inhibitors combined with RT and anti-angiogenic agents treatment that reported overall response rate, complete remission rate, disease control rate, and adverse events (AEs) were included. A random-effects or fixed-effects model was used for the pooled rates, and 95% confidence intervals (CIs) were determined for all outcomes. The quality of the included literature was assessed using the methodological index for nonrandomized studies critical appraisal checklist. Egger test was used to assess the publication bias in the included studies.

RESULTS

Ten studies (4 nonrandomized controlled trials and 6 single-arm trials), including 365 patients, were identified and included in the meta-analysis. The pooled overall response rate after treatment with PD1/PDL1 inhibitors combined with RT and anti-angiogenic agents was 59% (95% CI: 48-70%), whereas the disease control rate and complete remission rate were 92% (95% CI: 81-103%) and 48% (95% CI: 35-61%), respectively. Moreover, the meta-analysis showed that compared with triple-regimen, monotherapy or dual-combination treatment did not improve overall survival (hazard ratio = 0.499, 95% CI: 0.399-0.734) and progression-free survival (hazard ratio = 0.522, 95% CI: 0.352-0.774). The pooled rate of grade 3 to 4 AEs was 26.9% (95% CI: 7.8%-45.9), and the common AEs to triple therapy included leukopenia (25%), thrombocytopenia (23.8%), fatigue (23.2%), gastrointestinal discomfort (22%), increased alanine aminotransferase (22%), and neutropenia (21.4%).

CONCLUSION

In the treatment of solid tumors, PD1/PDL1 inhibitors combined with RT and anti-angiogenic drugs achieved a positive response and better survival benefits than monotherapy or dual therapy. In addition, combination therapy is tolerable and safe.

REGISTRATION

PROSPERO ID: CRD42022371433.

Recurrence Outcome in Hepatocellular Carcinoma within Milan Criteria Undergoing Microwave Ablation with or without Transarterial Chemoembolization

Background and Objectives: The recurrence outcome in patients who underwent microwave ablation (MWA) with or without transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) within Milan criteria remains unclear. The aim of this retrospective study was to identify the predictive factors of recurrence in these patients. Materials and Methods: From May 2018 to April 2021, 66 patients with HCC within Milan criteria were enrolled. Local tumor progression (LTP) and recurrence-free survival (RFS) were evaluated. Univariate and multivariate analyses were used to evaluate the risk factors of recurrence. The propensity score analysis was conducted to reduce potential confounding bias. Results: During the median follow-up of 25.07 months (95% confidence interval [CI], 21.85, 28.28), the median time to LTP and RFS were 20.10 (95%CI, 14.67, 25.53) and 13.03 (95%CI, 6.36, 19.70) months. No group difference (MWA vs. MWA + TACE) was found in 1-year cumulative LTP (p = 0.575) and RFS (p = 0.515), but meaningful significant differences were found in two-year recurrence (LTP, p = 0.007 and RFS, p = 0.037). Univariate and multivariate analyses revealed that treatment received before ablation was an independent risk factor of LTP (hazard ratio [HR] 4.37, 95%CI, 1.44, 13.32) and RFS (HR 3.41, 95%CI, 1.49, 7.81). Conclusions: The LTP and RFS in the MWA group were similar to that in the MWA combined with TACE. For HCC within Milan criteria, both groups preferentially selected MWA. More endeavor and rigorous surveillance should be taken to relapse prevention, in patients who have received previous treatment.

Leveraging Blood-Based Diagnostics to Predict Tumor Biology and Extend the Application and Personalization of Radiotherapy in Liver Cancers

While the incidence of primary liver cancers has been increasing worldwide over the last few decades, the mortality has remained consistently high. Most patients present with underlying liver disease and have limited treatment options. In recent years, radiotherapy has emerged as a promising approach for some patients; however, the risk of radiation induced liver disease (RILD) remains a limiting factor for some patients. Thus, the discovery and validation of biomarkers to measure treatment response and toxicity is critical to make progress in personalizing radiotherapy for liver cancers. While tissue biomarkers are optimal, hepatocellular carcinoma (HCC) is typically diagnosed radiographically, making tumor tissue not readily available. Alternatively, blood-based diagnostics may be a more practical option as blood draws are minimally invasive, widely availability and may be performed serially during treatment. Possible blood-based diagnostics include indocyanine green test, plasma or serum levels of HGF or cytokines, circulating blood cells and genomic biomarkers. The albumin–bilirubin (ALBI) score incorporates albumin and bilirubin to subdivide patients with well-compensated underlying liver dysfunction (Child–Pugh score A) into two distinct groups. This review provides an overview of the current knowledge on circulating biomarkers and blood-based scores in patients with malignant liver disease undergoing radiotherapy and outlines potential future directions.

Angiogenesis and immune checkpoint dual blockade in combination with radiotherapy for treatment of solid cancers: opportunities and challenges

Several immune checkpoint blockades (ICBs) capable of overcoming the immunosuppressive roles of the tumor immune microenvironment have been approved by the US Food and Drug Administration as front-line treatments of various tumor types. However, due to the considerable heterogeneity of solid tumor cells, inhibiting one target will only influence a portion of the tumor cells. One way to enhance the tumor-killing efficiency is to develop a multiagent therapeutic strategy targeting different aspects of tumor biology and the microenvironment to provide the maximal clinical benefit for patients with late-stage disease. One such strategy is the administration of anti-PD1, an ICB, in combination with the humanized monoclonal antibody bevacizumab, an anti-angiogenic therapy, to patients with recurrent/metastatic malignancies, including hepatocellular carcinoma, metastatic renal cell carcinoma, non-small cell lung cancer, and uterine cancer. Radiotherapy (RT), a critical component of solid cancer management, has the capacity to prime the immune system for an adaptive antitumor response. Here, we present an overview of the most recent published data in preclinical and clinical studies elucidating that RT could further potentiate the antitumor effects of immune checkpoint and angiogenesis dual blockade. In addition, we explore opportunities of triple combinational treatment, as well as discuss the challenges of validating biomarkers and the management of associated toxicity.

High expression of MMP28 indicates unfavorable prognosis in pancreatic cancer

To investigate the expression pattern and diagnostic performance of matrix metalloproteinase 28 (MMP28) in pancreatic cancer (PC).The RNA-seq data of PC and normal pancreas tissue were acquired from The Cancer Genome Atlas (TCGA) and Genotype-Tissue Expression. Clinical information of PC that included prognostic data was obtained from TCGA. Later, Fisher exact test was applied for comparison of different clinicopathological features between high and low expression of MMP28 in PC. Afterwards, Kaplan-Meier survival analysis and Cox analysis (univariate and multivariate analysis) were used to explore the prognostic performance of MMP28 in PC cohort. Finally, gene set enrichment analysis (GSEA) revealed the potential signaling pathways related to high expression of MMP28 in PC.Upregulation of MMP28 was identified in PC tissue compared to normal pancreas tissue (P < .001). Overexpression of MMP28 was related to histological grade (P < .001), M classification (P = .014), and survival status (P = .028). Kaplan-Meier survival analysis revealed that high level of MMP28 implied unfavorable prognosis in PC (P = .002). Multivariate analysis confirmed that MMP28 was an independent risk factor in PC (hazard rate = 1.308, P = .018). Our GSEA analysis found that signaling pathways including glycolysis, p53 pathway, notch signaling, estrogen response late, cholesterol homeostasis, estrogen response early, mitotic spindle, and transforming growth factor beta signaling were enriched in the group with higher MMP28 expression.High expression of MMP28 could be identified in PC, which also served as an independent risk element for PC.

Combinational Immunotherapy for Hepatocellular Carcinoma: Radiotherapy, Immune Checkpoint Blockade and Beyond

The systemic treatment landscape for advanced hepatocellular carcinoma (HCC) has experienced tremendous paradigm shift towards targeting tumor microenvironment (TME) following recent trials utilizing immune checkpoint blockade (ICB). However, limited success of ICB as monotherapy mandates the evaluation of combination strategies incorporating immunotherapy for improved clinical efficacy. Radiotherapy (RT) is an integral component in treatment of solid cancers, including HCC. Radiation mediates localized tumor killing and TME modification, thereby potentiating the action of ICB. Several preclinical and clinical studies have explored the efficacy of combining RT and ICB in HCC with promising outcomes. Greater efforts are required in discovery and understanding of novel combination strategies to maximize clinical benefit with tolerable adverse effects. This current review provides a comprehensive assessment of RT and ICB in HCC, their respective impact on TME, the rationale for their synergistic combination, as well as the current potential biomarkers available to predict clinical response. We also speculate on novel future strategies to further enhance the efficacy of this combination.

Platelets and Hepatocellular Cancer: Bridging the Bench to the Clinics

Growing interest is recently being focused on the role played by the platelets in favoring hepatocellular cancer (HCC) growth and dissemination. The present review reports in detail both the experimental and clinical evidence published on this topic. Several growth factors and angiogenic molecules specifically secreted by platelets are directly connected with tumor progression and neo-angiogenesis. Among them, we can list the platelet-derived growth factor, the vascular endothelial growth factor, the endothelial growth factor, and serotonin. Platelets are also involved in tumor spread, favoring endothelium permeabilization and tumor cells' extravasation and survival in the bloodstream. From the bench to the clinics, all of these aspects were also investigated in clinical series, showing an evident correlation between platelet count and size of HCC, tumor biological behavior, metastatic spread, and overall survival rates. Moreover, a better understanding of the mechanisms involved in the platelet-tumor axis represents a paramount aspect for optimizing both current tumor treatment and development of new therapeutic strategies against HCC.

Apatinib Combined With Transarterial Chemoembolization in Patients With Hepatocellular Carcinoma and Portal Vein Tumor Thrombus: A Multicenter Retrospective Study

PURPOSE

Studies focusing on the effects of combined transcatheter arterial chemoembolization (TACE) + the tyrosine kinase inhibitor apatinib in the treatment of patients with hepatocellular carcinoma (HCC), with the location and extent of portal vein tumor thrombus (PVTT) assessed as the main variable, are rare. This multicenter, retrospective, controlled study was performed to compare the efficacy and tolerability of TACE + apatinib and TACE alone in patients with HCC and PVTT.

METHODS

We retrospectively analyzed data from patients with nonresectable HCC and PVTT who underwent treatment with TACE + apatinib or TACE alone between January 2015 and January 2016. Outcomes in patients who underwent TACE + apatinib were compared with the outcomes of patients who underwent TACE alone, by using the Kaplan-Meier method, according to PVTT type: PVTT in the main portal vein (type A), PVTT in the first-order portal vein branch (type B), and PVTT in second- or lower-order portal vein branches (type C).

FINDINGS

One hundred eighty-eight patients were included in the analysis; 85 underwent treatment with TACE + apatinib and 103 underwent treatment with TACE. TACE + apatinib was associated with a significantly greater median survival compared with TACE alone in patients with PVTT type B (12.2 vs 7.5 months; P < 0.001) or type C (13.7 vs 7.2 months; P = 0.006). Along with treatment strategies and α-fetoprotein, the absence of main PVTT was an independent factor predictive of survival on uni- and multivariate analysis. Apatinib-related grade 3 adverse events occurred in 27 patients (31.8%).

IMPLICATIONS

TACE + apatinib can be of potential benefit to patients with advanced HCC with tumor thrombus in the first- and lower-order portal vein branches. Adverse events with apatinib need to be monitored during application, despite the manageable appearance.

Radiotherapy as valid modality for hepatocellular carcinoma with portal vein tumor thrombosis

Although the current standard treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is sorafenib, many previous studies have established the need for a reliable local modality for PVTT control, which is a major cause of liver function deterioration and metastasis. Additionally, there is growing evidence for the prognostic significance of PVTT classification according to the location of tumor thrombosis. Favorable outcomes can be obtained by applying local modalities, including surgery or transarterial chemoembolization, especially in second-order or distal branch PVTT. Rapid control of PVTT could maintain or improve liver function and reduce intrahepatic as well as distant metastasis. Radiotherapy (RT) is one of the main locoregional treatment modalities in oncologic fields, but has rarely been used in HCC because of concerns regarding hepatic toxicity. However, with the development of advanced techniques, RT has been increasingly applied in HCC management. Randomized studies have yet to definitively prove the benefit of RT, but several comparative studies have justified the application of RT in HCC. The value of RT is especially noticeable in HCC with PVTT; several prospective and retrospective studies have reported favorable outcomes, including a 40% to 60% objective response rate and median overall survival of 15 mo to 20 mo in responders. In this review, we evaluate the role of RT as an alternative local modality in HCC with PVTT.

A double suicide gene system driven by vascular endothelial growth factor promoter selectively kills human hepatocellular carcinoma cells

The aim of the present study was to investigate the selective killing effect on hepatocellular carcinoma (HCC) cells of an adenovirus (Ad)-mediated cytosine deaminase (CD) in combination with thymidine kinase (TK) suicide gene system, driven by the vascular endothelial growth factor promoter (VEGFp), in vitro and in vivo. A double suicide gene system with VEGFp, named Ad-VEGFp-CDglyTK, was constructed and transfected into human HCC cells (BEL-7402 or HepG2; the latter cell type is deficient in VEGF) and human umbilical vein vascular endothelial cells (HUVEC). Green fluorescent protein expression was detected by fluoroscopy to verify transfection efficiency, and CDglyTK gene expression was detected by reverse transcription-polymerase chain reaction (PCR). The selective killing effect of Ad-VEGFp-CDglyTK was measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and flow cytometry (FCM) in vitro and by xenograft studies in vivo. PCR revealed that the transgenic CDglyTK gene was expressed in BEL-7402 cells and HUVEC, but not in HepG2 cells. The cell survival rate significantly decreased in line with increasing concentrations of the prodrugs, ganciclovir (GCV) alone, 5-fluorocytosine (5-FC) alone or a combination of the two, in HUVEC and BEL-7402 cells with the transfected CDglyTK gene, but not in untransfected HUVEC or BEL-7402 cells, or in transfected or untransfected HepG2 cells. This result was additionally confirmed by FCM. GCV and 5-FC inhibited the HUVEC and BEL-7402 cells containing the transfected CDglyTK gene and also inhibited adjacent unmodified cells via the 'bystander effect'. No similar results were observed in HepG2 cells. Compared with the control group, tumors with the transfected CDglyTK gene were smaller and the microvessel density of the tumor tissue was significantly decreased. It was concluded that a combination TK/GCV and CD/5-FC suicide gene system driven by VEGFp may provide a promising treatment strategy for HCC.

Proangiogenic factors in the development of HCC in alcoholic cirrhosis

Alcoholic liver disease, the most common cause of liver cirrhosis, is associated with an increased risk for hepatocellular carcinoma. Angiogenic factors have been implicated in pathophysiology of cirrhosis, and of hepatocellular carcinoma, and in particular of alcoholic liver cirrhosis, due to alcohol induced hypoxia associated with increased hepatic oxygen consumption. In one study, it was found that among genetic polymorphisms in proangiogenic factors, KDR and VEFGA may confer an increased risk of HCC, in patients with ALD. There is need of further studies of the proangiogenic factors in HCC, in order to help us define their use as prognostic markers and also as markers of response to treatment.

Repeated-measures implication of hepatocellular carcinoma biomarkers in living donor liver transplantation

OBJECTIVE

Hepatocellular carcinoma (HCC) and its recurrence are major problems in living donor liver transplantation (LDLT). Several biomarkers have been used to investigate this event. We conducted a prospective controlled study to determine the activities of the basic fibroblast growth factor (FGF-2), survivin, Ki67, endostatin, and vascular endothelial growth factor (VEGF) in different conditions before, early after, and late after LDLT with and without HCC recurrence.

METHODS

Fifty patients with virus-related HCC who underwent LDLT were enrolled in this 2-year cross-sectional study. During the study period, recurrent HCC was identified in 9 patients (study group, n = 9) and 41 patients (control group, n = 41) had no recurrence after LDLT. The mean time to HCC recurrence was 587.11 ± 398.64 days (range, 90-1352 days). Microvascular invasion (MVI) was found in 66.7% (6/9) of the recipients, as determined on pathological examination. The serum biomarkers were investigated by using enzyme-linked immunosorbent assay at the different LDLT stages.

RESULTS

The serum levels of the biomarkers significantly correlated with LDLT and HCC recurrence in the repeated-measures analysis (F = 31.676, P = 0.000). Significant differences were observed in the effects of all biomarkers (F = 85.313, P = 0.000) and the time to HCC recurrence after LDLT (F = 3.178, P = 0.046). The biomarkers, ordered by the observed power of the test for HCC recurrence after LDLT, were FGF-2 (1.000) > survivin (0.999) > Ki67 (0.949) > endostatin (0.411) > VEGF (0.305).

CONCLUSIONS

Different biomarker activities may be implicated in the pathogenesis of HCC recurrence after LDLT. Oncogenes may not exist in the new graft but may still be present in the peripheral blood. The timing of HCC recurrence and impact of MVI in the explanted liver requires confirmation in larger studies with a longer follow-up.