Preoperative Alfa-Fetoprotein and Fibrinogen Predict Hepatocellular Carcinoma Recurrence After Liver Transplantation Regardless of the Milan Criteria: Model Development with External Validation

Preoperative prediction model of microvascular invasion in patients with hepatocellular carcinoma

BACKGROUND

Microvascular invasion (MVI) is an adverse factor for the prognosis of patients with hepatocellular carcinoma (HCC). We aimed to construct a preoperative prediction model for MVI, thereby providing a reference for clinicians in formulating treatment options for HCC.

METHODS

A total of 360 patients with non-metastatic HCC were retrospectively enrolled. We used logistic regression analysis to screen out independent risk factors for MVI and further constructed a predictive model for MVI. The performance of the model was evaluated by receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

Logistic regression analysis revealed that fibrinogen (>4 g/L) (OR: 6.529), alpha-fetoprotein (≥ 400 ng/mL) (OR: 2.676), cirrhosis (OR: 2.25), tumor size (OR: 1.239), and poor tumor border (OR: 3.126) were independent risk factors of MVI. The prediction model of MVI had C-index of 0.746 and 0.772 in the training and validation cohorts, respectively. The calibration curves showed good agreement between actual and predicted MVI risk. Finally, DCA reveals that this model has good clinical utility.

CONCLUSION

The nomogram-based model we established can predict the preoperative MVI well and provides reference for surgeons to make clinical treatment decisions.

Constant light exposure and/or pinealectomy increases susceptibility to trichloroethylene-induced hepatotoxicity and liver cancer in male mice

Exposure to light at night, pineal gland impairment, and the environmental pollutant trichloroethylene (TCE) have serious implications for health and contribute to illness, including liver cancer. The adverse effect of the association of continuous exposure to light with decreased melatonin levels and TCE-induced toxicity is not disclosed in target organs. This work explored the role of light and pineal impairment in increasing susceptibility to liver toxicity and cancer upon exposure to TCE. Male albino mice were divided into groups as follows: control group (12-h light/12-h dark cycle), constant light (24-h light), pinealectomized (Pnx) mice, sham surgically treated group, TCE-treated groups subjected to two doses (500 and 1000 mg/kg) at two different light regimens, and combination of Pnx and TCE-treated mice kept at a 12-h light/12-h dark cycle. Melatonin levels were significantly decreased in both Pnx mice and TCE-treated animals at both light regimens. Aspartate transaminase, alanine aminotransferase, activities, and serum bilirubin levels were significantly elevated, whereas albumin levels were markedly decreased in Pnx mice, TCE-treated mice, and the combination group. Histopathological investigations reflected changes in liver function parameters indicating liver injury and induction of cancer. These effects were accompanied by significant increase of the liver cancer biomarker alpha-fetoprotein and the expression of the metastatic markers CD44, TGFβ-1, and VEGF, along with increased oxidative stress indicators and inflammatory cytokines (IL-6, IL-1β, and TNF-α) in both Pnx and TCE-treated mice and the combination group at both light regimens. Taken together, our findings indicated that low melatonin levels, exposure to constant light, and the combination of both factors increases susceptibility to the toxic and carcinogenic effects of TCE on the liver.

Different Models to Predict the Risk of Recurrent Hepatocellular Carcinoma in the Setting of Liver Transplantation

Simple Summary

Liver transplantation is considered the first-choice curative therapy for hepatocellular carcinoma in the early phase of the disease, when surgical resection is not possible. Even when implementing restrictive criteria to select patients for liver transplantation, there is a risk of recurrence in the transplanted liver, influencing the long-term outcome and prognosis. As it is challenging to predict the individual risk of recurrence, there is a need for validated and predictive scoring systems to use to stratify patients before and/or after liver transplantation. Most of the proposed scorings include biological markers for tumour behavior, in addition to the number and size of tumoral nodules. In this review, we discuss different published models to assess the risk of recurrent hepatocellular carcinoma after transplantation. Our aim is to refine clinical decisions about prioritization and listing for liver transplantation, to better inform patients and provide an appropriate surveillance strategy to influence their prognosis.

Abstract

Liver transplantation is the preferred therapeutic option for non-resectable hepatocellular carcinoma in early-stage disease. Taking into account the limited number of donor organs, liver transplantation is restricted to candidates with long-term outcomes comparable to benign indications on the waiting list. Introducing the morphometric Milan criteria as the gold standard for transplant eligibility reduced the recurrence rate. Even with strict patient selection, there is a risk of recurrence of between 8 and 20% in the transplanted liver, and this is of even greater importance when using more expanded criteria and downstaging protocols. Currently, it remains challenging to predict the risk of recurrence and the related prognosis for individual patients. In this review, the recurrence-risk-assessment scores proposed in the literature are discussed. Currently there is no consensus on the optimal model or the implications of risk stratification in clinical practice. The most recent scorings include additional biological markers for tumour behavior, such as alfa-foetoprotein, and the response to locoregional therapies, in addition to the number and diameter of tumoral nodules. The refinement of the prediction of recurrence is important to better inform patients, guide decisions about prioritization and listing and implement individualized surveillance strategies. In the future, this might also provide indications for tailored immunosuppressive therapy or inclusion in trials for adjuvant treatment.

The AGH score is a predictor of disease-free survival and targeted therapy efficacy after liver transplantation in patients with hepatocellular carcinoma

BACKGROUND

Liver transplantation (LT) is the "cure" therapy for patients with hepatocellular carcinoma (HCC). However, some patients encounter HCC recurrence after LT. Unfortunately, there is no effective methods to identify the LT patients who have high risk of HCC recurrence and would benefit from adjuvant targeted therapy. The present study aimed to establish a scoring system to predict HCC recurrence of HCC patients after LT among the Chinese population, and to evaluate whether these patients are suitable for adjuvant targeted therapy.

METHODS

Clinical data of HCC patients who underwent LT from March 2015 to June 2019 were retrospectively collected and analyzed.

RESULTS

A total of 201 patients were included in the study. The multivariate Cox analysis suggested that preoperative alpha fetoprotein (AFP) > 200 µg/L (HR = 2.666, 95% CI: 1.515-4.690; P = 0.001), glutamyl transferase (GGT) > 96 U/L (HR = 1.807, 95% CI: 1.012-3.224; P = 0.045), and exceeding the Hangzhou criteria (HR = 2.129, 95% CI: 1.158-3.914; P = 0.015) were independent risk factors for poor disease-free survival (DFS) in patients with HCC who underwent LT. We established an AFP-GGT-Hangzhou (AGH) scoring system based on these factors, and divided cases into high-, moderate-, and low-risk groups. The differences in overall survival (OS) and disease-free survival (DFS) rates among the three groups were significant (P < 0.05). The efficacy of the AGH scoring system to predict DFS was better than that of the Hangzhou criteria, UCSF criteria, Milan criteria, and TNM stage. Only in the high-risk group, we found that lenvatinib significantly improved prognosis compared with that of the control group (P < 0.05).

CONCLUSIONS

The AGH scoring system provides a convenient and effective way to predict HCC recurrence after LT in HCC patients in China. Patients with a high-risk AGH score may benefit from lenvatinib adjuvant therapy after LT.

Prognostic significance of inflammation-based score in patients with hepatocellular carcinoma after liver transplantation

BACKGROUND

Recent studies have revealed that combining of the platelet to lymphocyte ratio (PLR) and the neutrophil to lymphocyte ratio (NLR) [(combination of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio (CNP)] links with dismal prognosis in diverse cancers. Here, we elucidated the prognostic significance of CNP, acting as a novel inflammation-based score, for predicting the survival of hepatocellular carcinoma (HCC) patients following liver transplantation.

METHOD

We retrospectively recruited 100 patients with HCC who met the Hangzhou criteria for liver transplantation. The Kaplan-Meier approach, univariate, and multivariate assessments were employed to examine prognostic factors. We determined the optimal cutoff values for NLR, PLR, and haematological parameters using the receiver operating characteristic (ROC) curve evaluation. On the basis of the ROC curve, the optimal cutoff values for PLR and NLR were 3.4 and 114.6, discretely. Patients with increased NLR (>3.4) and high PLR (>114.6) scored 2, while one or none scored 1 or 0, respectively.

RESULTS

Distinct differences were reported between CNP and Fibrinogen (P = 0.002), White blood cell (P = 0.048), NLR (P < 0.001), and PLR (P < 0.001). Based on the findings of Kaplan-Meier assessments, the CNP score linked to dismal overall survival (OS; P < 0.0001), as well as recurrence-free survival (RFS; P < 0.0001) in HCC patients after liver transplantation. Furthermore, multivariate assessments indicated that the CNP score was an independent prediction factor for OS (P = 0.002) and RFS (P < 0.001) in HCC patients after liver transplantation.

CONCLUSION

The CNP score can be considered as an effective predictor of survival events in HCC patients after liver transplantation.

Evaluation of the Alpha-Fetoprotein Model for Predicting Recurrence and Survival in Patients With Hepatitis B Virus (HBV)-Related Cirrhosis Who Received Liver Transplantation for Hepatocellular Carcinoma

Introduction: The alpha-fetoprotein (AFP) model is superior to the Milan criteria in predicting the recurrence of hepatocellular carcinoma (HCC) after liver transplantation in European and Latin American populations. The purpose of this study was to determine the predictive value of the AFP model in Chinese hepatitis B virus (HBV)-related cirrhosis HCC patients. Methods: A total of 189 patients with HBV-related cirrhotic HCC were included. The recurrence rate and survival rate were estimated, and predictability was assessed by the Net Reclassification Improvement (NRI) method. Results: Of the 189 patients, patients with an AFP score >2 had a higher recurrence rate at 5 years (48.94 vs. 13.53%, p < 0.05) and lower survival rate (43.96 vs. 68.97%, p < 0.05). Considering patients within the Milan criteria, a higher 5-year recurrence rate and lower survival rate were observed in patients with an AFP model score >2 points compared to patients with a score of ≤ 2 points (recurrence rate: 58.75 vs. 12.98%, p < 0.05; survival rate: 28.57 vs. 67.41%, p = 0.047). NRI analysis showed that the AFP model exhibited superior predictability as compared to the Milan criteria. Conclusions: The AFP model may be used as a selection tool for Chinese HBV patients who require liver transplantation due to HCC.

Systematic review: risk prediction models for recurrence of hepatocellular carcinoma after liver transplantation

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is a significant clinical problem associated with poor surgical outcomes. This study aims to summarize the current evidence on risk prediction models of HCC recurrence after LT. PubMed and EMBASE were searched to May 25, 2019, for relevant articles. Studies originally designed to develop or validate a risk prediction model for HCC recurrence after LT were included. Two independent authors summarized the study characteristics and evaluated the risk of bias and applicability concerns in the included studies. From 26 included studies, 18 original risk prediction models were determined, but only five models were externally validated. The average number of predictors involved in the construction of risk models was three. The most frequently employed predictors were alpha-fetoprotein, tumor size, vascular invasion, tumor number, tumor differentiation, and neutrophil-lymphocyte ratio. Most studies showed good discriminatory performance (AUC >0.75). The overall quality of the included studies was generally low. Most of the original models lacked the highly recommended external and prospective validation in diverse populations. The AFP model was the well-validated preoperative risk model that can stratify patients into high- and low-risk groups.

DNA methylation of SOCS1/2/3 predicts hepatocellular carcinoma recurrence after liver transplantation

DNA methylation status of SOCS1/SOCS2/SOCS3 is intensely involved in the development and progression of hepatocellular carcinoma (HCC). This study explored its prognostic value for HCC recurrence after liver transplantation (LT). Clinical data from 62 HCC patients who underwent LT at our centre were retrospectively collected. The SOCS1/2/3 methylation level were determined using next generation sequencing. Overall, 244 methylated sites at the SOCS1/2/3 promoter were identified. Multivariate analysis yielded the methylated sites SOCS2-1-90 (Chromosome 12, Position 93963982; HR 0.386, 95% CI 0.149-0.998) and SOCS1-1-68 (Chromosome 16, Position 11350699; HR 4.376, 95% CI 1.324-14.459) as independent predictors of post-LT HCC recurrence. Patients were divided into highly- and lowly methylated groups according to the median SOCS1-1-68 (0.95%) and SOCS2-1-90 (1.05%) methylation levels. Highly methylated SOCS2-1-90 was associated with significantly lower AFP levels (P = 0.008), decreased proportion of maximal tumour size > 8 cm (P = 0.02), and better pathological grading (P = 0.06). Conversely, patients in the highly methylated SOCS1-1-68 group had higher AFP levels (P = 0.043). Kaplan-Meier analyses revealed that patients with highly methylated SOCS2-1-90 had increased recurrence free survival (RFS) and overall survival (OS) rates when compared with those with lowly methylated SOCS2-1-90 (P = 0.0041 and 0.012, respectively). Nevertheless, the correlation between methylated SOCS1-1-68 and cumulative recurrence rates was less pronounced (P = 0.098). Subgroup analyses demonstrated that patients meeting the Milan criteria, UCSF criteria, Metroticket 2.0 Model or Hangzhou criteria with highly methylated SOCS2-1-90 had the best RFS rates. DNA methylation of SOCS2-1-90 is a novel biomarker for predicting post-transplant HCC recurrence.

Postoperative albumin-bilirubin grade and albumin-bilirubin change predict the outcomes of hepatocellular carcinoma after hepatectomy

Background

The albumin-bilirubin (ALBI) grade is an index that could objectively evaluate liver function. The purpose of this study was to evaluate the prognostic value of postoperative ALBI (post-ALBI) grade and ALBI changes (△ALBI) after hepatectomy in patients with hepatocellular carcinoma (HCC).

Methods

The clinical and pathological data of 300 patients with HCC who underwent hepatectomy in the Third Affiliated Hospital of Sun Yat-Sen University from January 19, 2009 to December 25, 2014, were analyzed retrospectively. According to the test data, the patients were divided into post-ALBI grade I, post-ALBI grade II, and post-ALBI grade III groups. According to the receiver operating characteristic curves (ROC), the patients were divided into △ALBI (△ALBI >0.71) high and low groups (△ALBI ≤0.71). Baseline clinical data, recurrence-free survival (RFS) and overall survival (OS) rates were compared between the groups.

Results

The 1-, 3-, and 5-year RFS rates and OS rates of patients with post-ALBI grade III were significantly reduced in comparison to those with post-ALBI grade II (P<0.001 both). Between the △ALBI groups, patients with low △ALBI level had significantly reduced 1-, 3-, and 5-year RFS rates and OS rates compared to those with a high △ALBI level (P<0.001 both). Multivariate analyses indicated that higher post-ABLI grade and △ALBI level were significantly independent predictors of an inferior OS and RFS (P<0.05).

Conclusions

This study confirmed for the first time that post-ALBI grade and △ALBI could predict the prognosis of patients with HCC after hepatectomy.

Seven-senescence-associated gene signature predicts overall survival for Asian patients with hepatocellular carcinoma

BACKGROUND

Cellular senescence is a recognized barrier for progression of chronic liver diseases to hepatocellular carcinoma (HCC). The expression of a cluster of genes is altered in response to environmental factors during senescence. However, it is questionable whether these genes could serve as biomarkers for HCC patients.

AIM

To develop a signature of senescence-associated genes (SAGs) that predicts patients’ overall survival (OS) to improve prognosis prediction of HCC.

METHODS

SAGs were identified using two senescent cell models. Univariate COX regression analysis was performed to screen the candidate genes significantly associated with OS of HCC in a discovery cohort (GSE14520) for the least absolute shrinkage and selection operator modelling. Prognostic value of this seven-gene signature was evaluated using two independent cohorts retrieved from the GEO (GSE14520) and the Cancer Genome Atlas datasets, respectively. Time-dependent receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive accuracy of the seven-SAG signature and serum α-fetoprotein (AFP).

RESULTS

A total of 42 SAGs were screened and seven of them, including KIF18B, CEP55, CIT, MCM7, CDC45, EZH2, and MCM5, were used to construct a prognostic formula. All seven genes were significantly downregulated in senescent cells and upregulated in HCC tissues. Survival analysis indicated that our seven-SAG signature was strongly associated with OS, especially in Asian populations, both in discovery and validation cohorts. Moreover, time-dependent ROC curve analysis suggested the seven-gene signature had a better predictive accuracy than serum AFP in predicting HCC patients’ 1-, 3-, and 5-year OS.

CONCLUSION

We developed a seven-SAG signature, which could predict OS of Asian HCC patients. This risk model provides new clinical evidence for the accurate diagnosis and targeted treatment of HCC.