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

Hepatic arterial infusion chemotherapy in patients with unresectble hepatocellular carcinoma: 3-year survival update

AIMS

Hepatic arterial infusion chemotherapy (HAIC) with oxaliplatin plus raltitrexed showed a promising response rate in patients with unresectable hepatocellular carcinoma (HCC) in a phase 2 trial. Here, we report the updated 3-year survival data after enrollment.

METHODS

In this prospective trial, we enrolled patients with intermediate and advanced unresectable HCC. The treatment was HAIC with raltitrexed plus oxaliplatin.

RESULTS

The objective responses were achieved in 19 (48.7%) of 39 patients in the intention-to-treat population. The median overall survival and progress-free survival were 11.2 and 6.5 months, respectively.

CONCLUSION

The 3-year survival update confirmed the antitumor activity and long-term survival benefit of HAIC with oxaliplatin plus raltitrexed in patients with unresectable HCC.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn identifier is ChiCTR-OOC-17014182.

Comprehensive Bioinformatics Analysis and Machine Learning of TTK as a Transhepatic Arterial Chemoembolization Resistance Target in Hepatocellular Carcinoma

Transhepatic arterial chemoembolization (TACE) is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). However, a significant proportion of patients are non-responders or poor responders to TACE. Therefore, our aim is to identify the targets of TACE responders or non-responders. GSE104580 was utilized to identify differentially expressed genes (DEGs) in TACE responders and non-responders. Following the protein-protein interaction (PPI) analysis, hub genes were identified using the MCC and MCODE plugins in Cytoscape software, as well as LASSO regression analysis. Gene set enrichment analysis (GSEA) was performed to investigate potential mechanisms. Subsequently, the hub genes were validated using data from The Cancer Genome Atlas (TCGA), the Cancer Cell Line Encyclopedia (CCLE), and The Human Protein Atlas (HPA) database. To evaluate the clinical significance of the hub genes, Kaplan-Meier (KM) survival and Cox regression analysis were employed. A total of 375 DEGs were identified, with 126 remaining following PPI analysis, and TTK, a dual-specificity protein kinase associated with cell proliferation, was ultimately identified as the hub gene through multiple screening methods. Data analysis from TCGA, CCLE, and HPA databases revealed elevated TTK expression in HCC tissues. GSEA indicated that the cell cycle, farnesoid X receptor pathway, PPAR pathway, FOXM1 pathway, E2F pathway, and ferroptosis could be potential mechanisms for TACE non-responders. Analysis of immune cell infiltration showed a significant correlation between TTK and Th2 cells. KM and Cox analysis suggested that HCC patients with high TTK expression had a worse prognosis. TTK may play a pivotal role in HCC patients' response to TACE therapy and could be linked to the prognosis of these patients.

Neutrophil-Lymphocyte Ratio Predicts Overall Survival in Patients With HCC Treated With Durvalumab Plus Tremelimumab

AIM

To investigate the prognostic impact of the neutrophil-to-lymphocyte ratio (NLR) on outcomes in patients with hepatocellular carcinoma (HCC) treated with durvalumab plus tremelimumab (Dur/Tre).

METHODS

A total of 182 patients with HCC who received Dur/Tre were included in the analysis. Univariate and multivariate survival analyses were conducted. Additionally, hazard ratio (HR) spline curve analysis was used to determine the optimal NLR cut-off values for predicting overall survival (OS).

RESULTS

The median progression-free survival (PFS) was 3.5 months (95% confidence interval [CI]: 2.7-4.4), whereas the median OS was not reached (95% CI: 12.1 months-not reached). Multivariate analysis demonstrated that treatment with Dur/Tre as a second-line therapy or beyond was independently associated with worse PFS (HR: 1.819; 95% CI: 1.230-2.688; p = 0.003). Furthermore, an NLR of ≥ 2.56 was identified as an independent predictor of reduced OS (HR: 1.919; 95% CI: 1.033-3.566; p = 0.039). The median OS was not reached (95% CI: 12.3 months-not reached) in patients with an NLR of < 2.56, compared with 12.1 months (95% CI: 9.0 months-not reached) in those with an NLR of ≥ 2.56 (p = 0.016). A Sankey diagram illustrating post-treatment outcomes revealed that a significantly larger proportion of patients with high NLRs did not proceed to subsequent therapies but instead received best supportive care (p = 0.046). Spline curve analysis showed that an NLR range of approximately 2.3-3.0 represents an appropriate cut-off for predicting OS.

CONCLUSIONS

The NLR is a significant prognostic biomarker for OS in patients with HCC treated with Dur/Tre.

MRI-based prediction of microvascular invasion/high tumor grade and adjuvant therapy benefit for solitary HCC ≤ 5 cm: a multicenter cohort study

OBJECTIVES

To develop and externally validate an MRI-based diagnostic model for microvascular invasion (MVI) or Edmondson-Steiner G3/4 (i.e., high-risk histopathology) in solitary BCLC 0/A hepatocellular carcinoma (HCC) ≤ 5 cm and to assess its performance in predicting adjuvant therapy benefits.

MATERIALS AND METHODS

This multicenter retrospective cohort study included 577 consecutive adult patients who underwent contrast-enhanced MRI and subsequent curative resection or ablation for solitary BCLC 0/A HCC ≤ 5 cm (December 2011 to January 2024) from four hospitals. For resection-treated patients, a diagnostic model integrating clinical and 50 semantic MRI features was developed against pathology with logistic regression analyses on the training set (center 1) and externally validated on the testing dataset (centers 2-4), with its utilities in predicting posttreatment recurrence-free survival (RFS) and adjuvant therapy benefit evaluated by Cox regression analyses.

RESULTS

Serum α-fetoprotein > 100 ng/mL (odds ratio (OR), 1.94; p = 0.006), non-simple nodular growth subtype (OR, 1.69; p = 0.03), and the VICT2 trait (OR, 4.49; p < 0.001) were included in the MVI or high-grade (MHG) trait, with testing set AUC, sensitivity, and specificity of 0.832, 74.0%, and 82.5%, respectively. In the multivariable Cox analysis, the MHG-positive status was associated with worse RFS (resection testing set HR, 3.55, p = 0.02; ablation HR, 3.45, p < 0.001), and adjuvant therapy was associated with improved RFS only for the MHG-positive patients (resection HR, 0.39, p < 0.001; ablation HR, 0.30, p = 0.005).

CONCLUSION

The MHG trait effectively predicted high-risk histopathology, RFS and adjuvant therapy benefit among patients receiving curative resection or ablation for solitary BCLC 0/A HCC ≤ 5 cm.

KEY POINTS

Question Despite being associated with increased recurrence and potential benefit from adjuvancy in HCC, microvascular invasion or Edmondson-Steiner grade 3/4 are hardly assessable noninvasively. Findings We developed and externally validated an MRI-based model for predicting high-risk histopathology, post-resection/ablation recurrence-free survival, and adjuvant therapy benefit in solitary HCC ≤ 5 cm. Clinical relevance Among patients receiving curative-intent resection or ablation for solitary HCC ≤ 5 cm, noninvasive identification of high-risk histopathology (MVI or high-grade) using our proposed MRI model may help improve individualized prognostication and patient selection for adjuvant therapies.

A Survey of Clinical Practices for Hepatocellular Carcinoma Among Experts at Tertiary Hospitals in China From 2020 to 2021

Background

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death in China. The rapid progress in systemic therapies has led to the approval of many therapeutic methods that have quickly changed clinical guidelines and practices. Because of the high heterogeneity of HCC, there are still some gaps between the guidelines and real-world clinical practice. The present study surveyed experts in China to investigate the current treatment concepts and clinical practice regarding HCC.

Methods

A questionnaire survey on the treatment concepts and clinical practice of HCC was administered to 310 experts with senior professional titles in 2020 and 312 experts in 2021. The results were analyzed and compared.

Results

For treating patients with resectable HCC, 28% of hepatobiliary surgeons indicated neoadjuvant therapy, and 7% chose systemic therapy ± locoregional therapy as 1 L therapy in 2021 compared with 20% and 1% in 2020. More experts chose adjuvant treatment within 1 month in 2021 compared with 2020, and 6 months and 12 months were the leading choices for the duration of adjuvant treatment. In 2021, 79% of surgeons and 19% of interventionalists were willing to conduct downstaging/conversion therapy for patients with potentially resectable HCC, and 78% chose tyrosine kinase inhibitors (TKI) + immunotherapy (IO) + locoregional therapy for cases in which R0 resection could not be achieved. For completely unresectable HCC, more experts preferred TKI + IO-based therapy as 1 L therapy in 2021 compared with 2020 (78% vs. 55%). The proportion of experts who indicated TKI + IO-based therapy as 2 L therapy increased from 32% in 2020 to 40% in 2021.

Conclusion

The survey results indicated that in 2021, compared with 2020, more experts opted to administer IO + TKI for the treatment of liver cancer, and more experts and patients were willing to participate in clinical research.

Proposal of discontinuation criteria of atezolizumab plus bevacizumab after curative conversion therapy for unresectable early-to-intermediate-stage hepatocellular carcinoma: a multicenter proof-of-concept study

BACKGROUND

Achieving complete response (CR) is a desirable goal in early-to-intermediate-stage hepatocellular carcinoma (HCC). While systemic and locoregional therapies show promise, optimal drug discontinuation criteria remain unclear. This study aims to investigate drug-off criteria for atezolizumab plus bevacizumab as a proof-of-concept study.

METHODS

This retrospective multicenter study included child-pugh class A patients with unresectable HCC without extrahepatic spread or macrovascular invasion who received atezolizumab plus bevacizumab as first-line therapy. Modified clinical CR (mCCR) was defined as CR per mRECIST with sustained normal alpha-fetoprotein (AFP) levels (< 10.0 ng/dl). Recurrence-free survival (RFS) and overall survival (OS) were analyzed based on the "drug-off" criteria defined by following: (1) mRECIST CR with locoregional therapies, (2) sustained normalization of AFP/AFP-L3/ des-gamma-carboxy prothrombin (DCP) for 12-24 weeks, and (3) complete tumor vascularity disappearance by contrast-enhanced ultrasonography (CEUS) or pathological curative resection.

RESULTS

The median follow-up was 16.5 months (95% CI 15.2-17.8). Among 51 patients achieving mCCR, 11 underwent surgery, with pathological CR in three cases. In contrast, viable lesions were observed in 7 of 40 cases assessed using CEUS. All patients meeting the drug-off criteria (n = 9) showed no recurrence and none of them experienced mortality, while 45.2% (19/42) of those not meeting the criteria experienced recurrence (median RFS: 12.8 months, p = 0.007). The median OS was not reached in dug-off criteria met patients (n = 9), 37.7 months (95% CI: NA) in non-criteria met patients (n = 42), and 27.1 months (95% CI 16.7-37.6) in non-mCCR patients (n = 184) (p < 0.001).

CONCLUSION

In patients with unresectable and TACE-unsuitable early-to-intermediate-stage HCC who met the drug-off criteria, significantly improved RFS and OS were observed compared those who did not meet the criteria. However, further validation studies are required to confirm the utility of the criteria.

Comparison Analysis of Lenvatinib Plus Transcatheter Arterial Chemoembolization Versus Atezolizumab Plus Bevacizumab as First-Line Therapy for Intermediate-Stage Hepatocellular Carcinoma Beyond the Up-to-Seven Criteria

BACKGROUND AND AIM

This study aimed to compare the therapeutic effects and safety of lenvatinib (LEN) plus transcatheter arterial chemoembolization (LEN-TACE) and atezolizumab plus bevacizumab (Atez/Bev) as the first-line therapies in patients with intermediate-stage hepatocellular carcinoma (HCC) beyond the up-to-seven criteria.

METHODS

We enrolled 768 patients with HCC treated with first-line systemic therapy, and 154 patients were enrolled and categorized into either the LEN-TACE therapy (n = 42) or Atez/Bev (n = 112) groups. After propensity score matching (PSM), 72 patients (LEN-TACE group, n = 36; Atez/Bev group, n = 36) were analyzed.

RESULTS

After PSM, the median progression-free survival showed no significant differences between the LEN-TACE and Atez/Bev groups (8.5 [95% confidence interval (CI): 6.1-10.7] months vs. 8.6 (95% CI: 5.3-12.1) months, respectively; p = 0.973). Regarding median overall survival (OS), no significant differences were noted between the LEN-TACE and Atez/Bev groups (37.3 [95% CI: 31.2-60.2] months vs. 32.4 (95% CI: 19.5-NE) months, respectively; p = 0.183). Regarding adverse events (AEs) of grade ≥ 3, no significant difference was observed between the two groups. Multivariate analysis revealed that the ALBI grade 1 and low AFP levels were independent factors for OS.

CONCLUSION

LEN-TACE therapy may be one of the effective treatment strategies in intermediate-stage HCC patients beyond the up-to-seven criteria.

Transarterial chemoembolization plus apatinib for unresectable hepatocellular carcinoma: a multicenter, randomized, open-label, phase III trial

BACKGROUND

This study aimed to assess the efficacy and safety of transarterial chemoembolization (TACE) in combination with apatinib (TACE-apatinib) for patients with unresectable hepatocellular carcinoma (HCC).

METHODS

This study was a multicenter, randomized, open-label, prospective, phase III trial. Patients with unresectable HCC were randomly assigned in a 1:1 ratio to receive either TACE-apatinib or TACE-alone treatment. Patients in the TACE-apatinib group began with a dosage of 500 mg/day of oral apatinib administered 4 days after the first TACE. The primary endpoint of this study was progression-free survival (PFS). The secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), time to untreatable (unTACEable) progression (TTUP), and safety assessment.

RESULTS

From November 1, 2018 to November 18, 2021, a total of 196 patients were randomly assigned to either the TACE-apatinib (n = 86) or TACE-alone (n = 92) group. The median PFS in the TACE-apatinib group was significantly longer than that of in the TACE-alone group (6.1 months vs. 3.4 months, p < 0.0001). The median OS was significantly prolonged in the TACE-apatinib group compared to the TACE-alone group (28.9 months vs. 24.0 months, p = 0.0005). The median TTUP in the TACE-apatinib group was 26.8 months, which was significantly longer than that of 20.1 months in the TACE-alone group (p = 0.0003). A significantly higher ORR and DCR were observed in the TACE-apatinib group compared to the TACE-alone group (ORR: 58.1% vs. 31.5%, p < 0.001; DCR: 87.2% vs. 69.6%, p = 0.004). Most of the treatment-related adverse events were grades 1-2, and no treatment-related deaths were observed.

CONCLUSIONS

Apatinib significantly improved the treatment effects of TACE for patients with unresectable HCC. TACE-apatinib could serve as a promising treatment option for this patient population, offering notable survival benefits while maintaining an acceptable safety profile.

TRIAL REGISTRATION

Chinese Clinical Trial Register, No. ChiCTR1800018621.

Sensitive Detection of Plasma Fibrinogen Chain A mRNA in Hepatocellular Carcinoma Using Semi-Nested RT-PCR

Background/Objectives: Hepatocellular carcinoma (HCC) remains a major cause of cancer-related mortality, with diagnostic limitations of existing biomarkers such as alpha-fetoprotein (AFP). This study evaluates plasma Fibrinogen chain A mRNA (FGA mRNA), alone and combined with AFP, for improving HCC diagnosis. Methods: A semi-nested RT-PCR assay was developed to quantify plasma FGA mRNA in 80 HCC patients and 74 controls (57 chronic liver disease [CLD] and 17 healthy donors [HDs]). Receiver operating characteristic (ROC) analysis was used to assess diagnostic performance, and logistic regression evaluated the combined biomarker model. Results: Plasma FGA mRNA levels were significantly higher in HCC patients than in CLD and HD controls (p < 0.0001). The area under the curve (AUC) for HCC vs. the combined control group (CLD + HD) was 0.721 (95% CI: 0.643-0.790), improving to 0.866 (95% CI: 0.782-0.927) when comparing HCC to HDs alone but declining for HCC vs. CLD (AUC = 0.678, 95% CI: 0.592-0.755). Combining FGA mRNA with AFP significantly enhanced diagnostic accuracy for HCC vs. CLD (AUC = 0.859, 95% CI: 0.790-0.913), with a sensitivity of 87.50% and specificity of 71.93%. In patients with low AFP levels (<20 ng/mL), the combined model identified 68.75% of HCC cases, outperforming AFP alone. Conclusions: FGA mRNA alone provides moderate diagnostic utility but substantially improves accuracy when combined with AFP, especially in low-AFP cases. This multi-biomarker approach holds promise for improving HCC detection and warrants further validation in larger cohorts.

Comparison of Surgical Resection and Radiofrequency Ablation for Early-Stage HCC Patients With Child-Pugh Class B

AIM

The aim of this study is to compare the clinical outcomes of surgical resection (SR) and radiofrequency ablation (RFA) in patients with early-stage hepatocellular carcinoma (HCC) and Child-Pugh Class B liver function.

METHODS

Among 7210 treatment-naïve HCC patients in our group between 2000 and 2021, this retrospective study included 41 and 456 patients who underwent SR and RFA, respectively. All included patients had Child-Pugh Class B liver function, an Eastern Cooperative Oncology Group (ECOG) performance status of ≤ 2, and early-stage HCC (≤ 3 nodules, ≤ 3 cm in diameter). To adjust for baseline imbalances between the two groups, we applied inverse probability of treatment weighting (IPTW) analysis. Recurrence-free survival (RFS) and overall survival (OS) were assessed using Kaplan-Meier survival analysis and Cox regression models.

RESULTS

Before IPTW analysis, significant differences were observed between the SR and RFA groups in Child-Pugh scores (p = 0.003), total bilirubin levels (p = 0.04), prothrombin time (p = 0.003), and the presence of ascites (p = 0.01), all of which were more favorable in the SR group. The SR group also had fewer tumors (p = 0.03) and larger tumor diameters (p = 0.002) compared to the RFA group. In the entire cohort, there were no significant differences in RFS between the two groups (p = 0.6). After IPTW analysis, the differences remained statistically nonsignificant (p = 0.4). Regarding OS, the difference was not observed between the two groups in the entire cohort (p = 0.5) and in the IPTW cohort (p = 0.9).

CONCLUSION

RFA appears to be as effective as SR in patients with early-stage HCC with the liver function of Child-Pugh Class B.

Combination of Hepatic Arterial Infusion Chemotherapy with Tyrosine Kinase Inhibitor Provides Better Survival in Advanced Hepatocellular Carcinoma Patients

Introduction

Hepatic arterial infusion chemotherapy (HAIC) and tyrosine kinase inhibitors (TKI) are widely used to treat unresectable hepatocellular carcinoma (HCC). This study investigated the benefits of combining TKI and HAIC in these patients.

Methods

We retrospectively analyzed patients with unresectable HCC treated at Linkou Chang Gung Memorial Hospital between March 2009 and February 2022. The patients were categorized into two groups: HAIC combined with TKI therapy and HAIC alone. Kaplan-Meier analysis, Cox proportional hazards models, and propensity score matching were applied.

Results

Among 130 patients, the combination therapy group showed significantly improved overall survival (OS) (20.2 versus 11.8 months, p = 0.000) and progression-free survival (PFS) (8.2 versus 3.6 months, p = 0.011) compared to the HAIC-only group. These advantages persisted after propensity score matching with improved OS (20.2 vs 12.9 months, p = 0.001) and extrahepatic PFS (12.4 vs 5.5 months, p = 0.008). Combination therapy improved PFS in the stage IV portal vein thrombosis (PVT) subgroup. TKI combination therapy, more than nine HAIC cycles, and post-HAIC transarterial chemoembolization (TACE) were independent predictors of improved OS.

Conclusion

Combining HAIC with TKI therapy improves survival outcomes compared to HAIC alone in patients with unresectable HCC, especially in cases with extrahepatic spread and PVT. Sequential TACE following HAIC therapy further enhances survival benefits.

Predictive value of intra-hepatectomy ICGR15 of the remnant liver for post-hepatectomy liver failure in hemi-hepatectomy: a prospective study

BACKGROUND AND OBJECTIVE

Post-hepatectomy liver failure (PHLF) is one of the major complications following hepatectomy for hepatocellular carcinoma (HCC). Early identification and precise prediction of PHLF are essential for effective management. This study aimed to evaluate the predictive value of intra-hepatectomy indocyanine green retention rate at 15 min (ICGR15) for the remnant liver for grade B/C PHLF in HCC patients undergoing hemi-hepatectomy.

METHODS

This prospective study recruited 31 HCC patients who underwent hemi-hepatectomy. ICGR15 was measured at three time points: pre-hepatectomy, intra-hepatectomy (for the remnant liver), and post-hepatectomy. The primary endpoint was the occurrence of grade B/C PHLF according to ISGLS criteria. Logistic regression analysis was employed to evaluate the predictive performance of each parameter and to conduct risk assessment. The XGBoost algorithm was utilized to compare the predictive values of various parameters by calculating the mean Shap values.

RESULTS

Among the study participants, 25.8% (8 patients) developed grade B/C PHLF. The intra-hepatectomy ICGR15 for remnant liver exhibited the highest predictive accuracy for grade B/C PHLF, with a ROC-AUC of 0.864 and a PR-AUC of 0.791. The optimal threshold for ICGR15-intra was established at 19.8%. Patients with ICGR15-intra value of 19.8% or higher were found at significantly increased risk of grade B/C PHLF (OR[95% CI] = 3.602[1.437-6.750], P value = 0.004), and experienced a higher incidence of severe post-hepatectomy complications.

CONCLUSION

Intra-hepatectomy ICGR15 for the remnant liver was an important predictor of grade B/C PHLF in patients undergoing hemi-hepatectomy for HCC. An intra-hepatectomy ICGR15 threshold of 19.8% might effectively identify patients at high risk of developing grade B/C PHLF and severe post-hepatectomy complications, helping surgeons' final decision-making on the table.

Development of a chitosanase 3-like protein 1 assay kit and study of its application in patients with hepatocellular carcinoma

OBJECTIVE

The detection kit for plasma Chitinase-3-like Protein 1 was developed using the magnetic bead chemiluminescence method, in order to investigate the diagnostic value of DD, FDP, CHI3L1, AFP-L3 and PIVKA-II in hepatocellular carcinoma.

METHOD

The CHI3L1 detection kit was developed using the chemiluminescence method. The luminescence value obtained from the chemiluminescence analyzer was utilized for sensitive detection of CHI3L1, and the performance of the kit was evaluated accordingly. Moreover, this study enrolled 200 patients with hepatocellular carcinoma who were treated at the Oncology Department of the Affiliated Hospital of Jiangnan University between August 2022 and November 2023 as study subjects, while 100 healthy individuals undergoing physical examinations during the same period served as a control group. The plasma CHI3L1 levels in these subjects were measured using our institute's developed kit. Simultaneously, DD, FDP, AFP-L3, and PIVKA-II levels were assessed in all subjects to investigate their relationship with general pathology in patients with hepatocellular carcinoma. Additionally, ROC curves were generated to evaluate both single and combined detections' diagnostic efficacy for hepatocellular carcinoma.

RESULT

The serological index changes of DD, FDP, AFP-L3, PIVKA-II, and CHI3L1 were not associated with patient gender. The concentrations of AFP-L3 and PIVKA-II in the 45-59 age group were significantly higher than in other groups (P < 0.05). Additionally, DD, CHI3L1, and PIVKA-II levels were markedly elevated in patients with tumors > 5 cm, medium-to-high differentiation, nerve invasion, lymph node metastasis, or distant metastasis. In advanced liver cancer (stages III-IV), DD, FDP, and CHI3L1 concentrations were significantly higher than in early-stage patients (stages I-II). For single diagnostic analysis, the AUC for CHI3L1 was 0.923, while the combined AUC for all five indices was 0.961, indicating greater diagnostic value when used together. The CHI3L1 chemiluminescence detection kit had a minimum detection limit of 1.50 ng/mL, with precision and accuracy within 10%, and R > 0.99. Compared to a clinical reference kit, the correlation coefficient (R) was 0.994, meeting clinical performance evaluation criteria.

CONCLUSION

The CHI3L1 chemiluminescence kit developed meets clinical requirements. CHI3L1 can be used as an indicator for early screening of liver cancer, and the detection value of combined five indicators DD, FDP, AFP-L3, PIVKA-II and CHI3L1 is higher than that of single detection.

A nationwide investigation on imaging follow-up after Locoregional therapy for hepatocellular carcinoma in China: Current practices and challenges

PURPOSE

To investigate the perspectives of interventional radiologists in China on imaging follow-up protocols and adherence to treatment response criteria for hepatocellular carcinoma (HCC) following locoregional therapies (LRT), with a particular focus on identifying gaps and proposing strategies to bridge the discrepancy between clinical guidelines and real-world practice.

MATERIALS AND METHODS

The web-based survey was conducted among members of Chinese Society of Radiology and Zhongda Radiology Alliance between 1st October 2024 to 30th November 2024, via WPS Office survey tool. The frequencies and percentages of responses were summarized as n (%), and a chi-squared test was employed to compare the responses among diagnostic radiologists, interventional radiologists, and interventional physicians.

RESULTS

A total of 604 respondents from 325 hospitals in 31 provinces were analyzed. Of the respondents, 72.7 % (439/604) believed that the same imaging modality should be used for follow-up after conventional transarterial chemoembolization (cTACE) and other LRT for HCC. Among these respondents, contrast-enhanced computed tomography (CE-CT) (57.2 %, 251/439) was the most preferred imaging modality for initial follow-up, and hepatobiliary contrast-enhanced MRI (63.1 %, 277/439) for subsequent follow-up examinations. For respondents (27.3 %, 165/604) who believed that follow-up strategies should be tailored to the type of LRT, CE-CT was most commonly recommended for post-cTACE HCC, both for initial (64.2 %, 106/165) and subsequent (60.6 %, 100/165) follow-up. For HCC treated with other LRT, the majority of respondents preferred extracellular contrast-enhanced MRI for initial follow-up (55.8 %, 92/165) and hepatobiliary contrast-enhanced MRI for subsequent follow-up (61.2 %, 101/165). The most recommended time frame for initial follow-up was "within 1-2 months" among all respondents. However, significant differences in the recommended time frame were observed among diagnostic radiologists, interventional radiologists, and interventional physicians (P < 0.001). Notably, more than 95 % of the respondents who selected 'unclear' were diagnostic radiologists. The most recommended monitoring frequency was every 3-4 months (46.0 %, 278/604) for viable lesions and every 5-6 months (32.9 %, 199/604) for nonviable lesions. Regarding adherence to treatment response criteria, mRECIST (32.0 %, 193/604) and LR-TRA (v2017/v2024) (24.2 %, 146/604) were commonly adopted in clinical practice. Nevertheless, a significant proportion of respondents (25.2 %, 152/604) indicated that none of these criteria were applied in their clinical practice.

CONCLUSION

CE-CT performed within 1-2 months was the most preferred modality and time frame for initial follow-up. Significant variability remains in follow-up frequency and treatment response criteria for post-LRT HCC, highlighting the need for further standardization of imaging follow-up protocols and structured treatment response assessment to optimize post-LRT management in clinical practice.

Systemic therapy plus HAIC versus systemic therapy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) exhibits synergistic anticancer effects with systemic therapy in treating hepatocellular carcinoma (HCC). The approach combining systemic therapy and HAIC is likely to establish a new survival benchmark for advanced HCC. However, related evidence is still lacking.

METHOD

PubMed, Embase, Cochrane Library, and Web of Science were searched from January 1990 to July 2024. The extracted data were pooled using fixed- or random-effects models and expressed as hazard ratios (HRs) or risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Meta-regression, subgroup analysis, prognostic factor analysis, correlation analysis, as well as trial sequential analysis were further conducted.

RESULT

Seventeen trials involving 3070 participants were included. Patients receiving HAIC combined systemic therapy displayed superior overall survival (OS) (HR, 0.52; 95% CI, 0.48-0.58), progression-free survival (PFS) (HR, 0.54; 95% CI, 0.46-0.63), objective response rate (ORR) (RR, 2.20; 95% CI, 1.77-2.72) and disease control rate (RR, 1.21; 95% CI, 1.14-1.29) over systemic therapy. Combining HAIC resulted in higher incidences of grade ≥3 manageable adverse events. Subgroup analyses showed that HAIC could bring significant survival improvement for almost all specific populations; however, patients without portal vein tumor thrombosis might not benefit from it (HR, 0.74; 95% CI, 0.53-1.03). Prognostic factor analyses found extra HAIC was a protective factor for both OS (HR, 0.42; 95% CI, 0.34-0.51) and PFS (HR, 0.44; 95% CI, 0.36-0.53). Correlation analyses demonstrated a robust association between ORR and OS when applying systemic therapy with HAIC ( P -value = 0.031). In addition, trial sequential analyses visually showed the present data were compelling to draw reliable conclusions.

CONCLUSION

With manageable toxicity, integrating HAIC with systemic therapy could bring favorable survival benefits for HCC patients. Further evidence is necessary to standardize the integration of HAIC with first-line systemic therapy.

A precise surgical planning system for hepatectomy coupled with liver tissue in the hepato-portal vein territories

Background

With the advancement of precise hepatic resection and three-dimensional (3D) reconstruction technology, there is a growing emphasis on precision in liver surgery. However, during hepatic resection, thick hepatic veins may appear in the portal vein basin, and injury to thick hepatic veins may cause residual hepatic stasis, resulting in impaired liver function, or even failure. Therefore, we developed a new computer-assisted hepatic surgical planning system that integrates the portal and hepatic vein basins. This system is designed to achieve oncological safety and preserve functional hepatic tissues by reducing ischemic volume (IV), congested volume (CV), and transection surface area (TSA), leaving the residual liver with less ischemic volume, sludge volume, and cross-sectional area, thereby optimizing postoperative outcomes.

Methods

Contrast-enhanced computed tomography (CT) datasets from 20 patients at The First Affiliated Hospital of Ningbo University were analyzed for 3D reconstruction. Using a pseudorandom number generator algorithm, 140 liver occupancy models were established with seven points selected from each case. Three distinct surgical simulation strategies were compared: hepatic-portal venous territory integration, anatomical portal territory resection, and non-anatomical resection (NAR) (1-cm margin), the liver occupancy models were compared with the three types of surgical planning. Quantitative parameters, including Resected Index (RI, resected volume/total liver volume), Ischemic Index (II, residual ischemic volume/total liver volume), Congestion Index (CI, residual CV/total liver volume), and transection surface ratio (TSR, cross-sectional area/total liver surface area), were analyzed to evaluate the value of the surgical planning system.

Results

Compared with portal vein basin anatomical hepatectomy, the integrated method had smaller RI [8.09 (3.00, 20.12) vs. 18.9 (2.84, 42.29), P<0.05], CI [1.14 (0.37, 3.68) vs. 3.39 (0.35, 13.26), P<0.05], II [2.28 (0.82, 7.10) vs. 3.39 (0.35, 13.26), P<0.05], and TSR [14,417.13 (7,462.02, 32,715.68) vs. 73,739.52 (47,559.78, 102,632.74), P<0.05]. When compared to NAR, the integration strategy achieved reduced II [1.15 (0.46, 3.43) vs. 7.63 (3.00, 24.16), P<0.05], CI [1.14 (0.37, 3.68) vs. 7.67 (2.16, 22.98), P<0.05], and RI [2.28 (0.82, 7.10) vs. 15.28 (4.46, 47.14), P<0.05].

Conclusions

In this study, we established a surgical planning system coordinating portal perfusion territories with hepatic venous drainage basins. The computational planning system significantly improves surgical precision by reducing residual ischemic volume, venous congestion, and parenchymal transection area.

Advances in application of serum biomarkers for screening and early diagnosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents a major global health challenge, with early detection through surveillance of high-risk populations remaining critical for improving clinical outcomes. Serum biomarkers play a crucial role in the early detection of HCC. Currently, commonly used serological markers for HCC include alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin, and the Lens culinaris agglutinin-reactive fraction of AFP. Other potential biomarkers under investigation include glypican-3, osteopontin, alpha-L-fucosidase, Dickkopf-1, heat shock protein 90α, and Golgi protein 73. With the advancement of liquid biopsy technologies, novel markers such as circulating tumor DNA, circulating tumor cells, microRNAs, and long non-coding RNAs have emerged as promising tools for early screening and diagnosis of HCC. This review aims to summarize the research progress and clinical applications of these biomarkers related to liver cancer, providing scientific evidence to enhance early diagnosis rates, improve prognosis, and ultimately reduce HCC-related mortality.

Hepatic Arterial Infusion Chemotherapy for Hepatocellular Carcinoma: A Three-Dimensional Visualization Perspective

In Asia, hepatic arterial infusion chemotherapy is an alternative therapeutic option for hepatocellular carcinoma (HCC). However, the current application of HAIC lacks precision, as drug dosages are typically calculated based solely on body surface area. This approach often results in underdosing for patients with larger liver tumors or greater liver volume and overdosing for those with smaller liver tumors or reduced liver volume. Consequently, determining drug dosages according to the specific target volume requiring treatment may enhance individualized and standardized therapy for HCC, aligning with the principles of precision oncology.

Predictive factors and prognostic models for Hepatic arterial infusion chemotherapy in Hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a prevalent and lethal cancer, often diagnosed at advanced stages where traditional treatments such as surgical resection, liver transplantation, and locoregional therapies provide limited benefits. Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment modality for advanced HCC, enhancing anti-tumor efficacy through targeted drug delivery while minimizing systemic side effects. However, the heterogeneous nature of HCC leads to variable responses to HAIC, highlighting the necessity for reliable predictive indicators to tailor personalized treatment strategies. This review explores the factors influencing HAIC success, including patient demographics, tumor characteristics, biomarkers, genomic profiles, and advanced imaging techniques such as radiomics and deep learning models. Additionally, the synergistic potential of HAIC combined with immunotherapy and molecular targeted therapies is examined, demonstrating improved survival outcomes. Prognostic scoring systems and nomograms that integrate clinical, molecular, and imaging data are discussed as superior tools for individualized prognostication compared to traditional staging systems. Understanding these predictors is essential for optimizing HAIC efficacy and enhancing survival and quality of life for patients with advanced HCC. Future research directions include large-scale prospective studies, integration of multi-omics data, and advancements in artificial intelligence to refine predictive models and further personalize treatment approaches.

Accurate quantification of cell-free Ceruloplasmin mRNA as a biomarker for early detection of hepatocellular carcinoma

Accurate and early detection of hepatocellular carcinoma (HCC) is critical for improving patient outcomes. Current biomarkers like AFP have limited sensitivity, necessitating novel diagnostic markers. A novel semi-nested RT-PCR assay was developed to quantify circulating Ceruloplasmin (CP) mRNA in peripheral blood. This method co-amplifies CP mRNA and an internal control (IC) gene, followed by DNA melting analysis to distinguish and quantify CP mRNA. CP mRNA levels were significantly higher in the HCC group (median: 3.37) compared to both the CLD group (0.24, p = 0.0066) and the HD group (0.17, p < 0.0001). Further analysis using ROC curves highlighted the diagnostic performance of the assay. For differentiating HCC from CLD, the area under the ROC curve (AUC) was 0.704, with 50.98% sensitivity and 95.24% specificity. In comparison to HD, the AUC was 0.812, with 74.51% sensitivity and 80.65% specificity. Against the combined control group (CLD and HD), the AUC was 0.768, with 50.98% sensitivity and 96.15% specificity. Additionally, in 59.1% of HCC cases with AFP levels below 20 ng/mL, CP mRNA levels were elevated, indicating that CP mRNA could help detect a substantial proportion of AFP-negative HCC cases. This study, the first comprehensive clinical investigation of cell-free CP mRNA for HCC diagnosis, demonstrates its potential as a sensitive and specific non-invasive biomarker. Further validation in larger cohorts is needed to confirm its clinical utility.

Matching-Adjusted Indirect Comparison of Arterial FOLFOX and Atezolizumab-Bevacizumab in Unresectable Hepatocellular Carcinoma

Introduction

A previous phase 3 FOHAIC-1 study demonstrated that hepatic arterial infusion chemotherapy (HAIC) of FOLFOX regimen displayed favorable outcomes in advanced hepatocellular carcinoma (HCC) patients, including those with high-risk features (main portal tumor invasion and >50% liver infiltration). This study aimed to compare the treatment efficacy of HAIC-FOLFOX versus atezolizumab-bevacizumab in HCC patients.

Methods

Individual patient data from the Chinese FOHAIC-1 study and aggregate data from the global IMbrave150 study were used to conduct an anchored matching-adjusted indirect comparison. Hazard ratios (HR) and restricted mean survival times (RMST) were calculated to assess survival differences. Landmark analysis was performed to evaluate time-sensitive treatment effects, and simulated treatment comparison (STC) was conducted as a sensitivity analysis. Rates of treatment-related adverse events (TRAEs) and TRAE-related discontinuations were also compared.

Results

After matching baseline characteristics, HAIC showed a numerical OS benefit (HR 0.57, 95% CI, 0.30-1.08) and similar PFS benefit (HR 0.79, 95% CI, 0.43-1.47) compared to atezolizumab-bevacizumab in the overall population. In high-risk patients, HAIC demonstrated significantly improved OS (HR 0.30, 95% CI, 0.12-0.72) and 2.89-month longer RMST compared to atezolizumab-bevacizumab (95% CI, 0.15-5.64 months). Additionally, HAIC showed superior PFS (HR 0.25, 95% CI, 0.10-0.64) and 2.88-month longer RMST over atezolizumab-bevacizumab (95% CI, 0.90-4.86). Landmark analysis in the high-risk group revealed that HAIC was associated with significant improvements in both OS (HR 0.32, 95% CI, 0.13-0.79) and PFS (HR 0.24, 95% CI, 0.09-0.63) during the 0-12 months following treatment initiation. Sensitivity analysis using the anchored STC analysis yielded consistent results. HAIC was associated with lower rates of grade 3-4 TRAEs and TRAE-related discontinuation in both the overall population and the high-risk group.

Conclusion

HAIC treatment provided superior survival benefits and a favorable safety profile compared to atezolizumab-bevacizumab in high-risk HCC patients.

The Effect of MAFLD on Hepatocarcinogenesis in HBeAg-negative Patients with Undetectable HBV-DNA under NA Therapy: A Multicenter Study

Objective The progression of liver fibrosis and a male sex are risk factors for hepatocarcinogenesis under nucleos(t)ide analog (NA) therapy. Metabolic dysfunction-associated fatty liver disease (MAFLD) is a risk factor for hepatocarcinogenesis. This study aimed to investigate the factors involved in hepatocarcinogenesis during NAs therapy, including MAFLD. Methods This study is a retrospective study [observation period: median 9.4 years (2.1-19.6 years)]. The subjects were 164 patients taking NAs for more than 2 years and were hepatitis B envelope antigen (HBeAg)-negative with undetectable hepatitis B virus (HBV)-DNA. The patient had no history of hepatocellular carcinoma (HCC). We investigated the profile of HCC onset after NAs therapy using a decision tree analysis Results HCC developed in 20.7% (34/164) of the patients during the observation period. The prevalence of MAFLD was significantly higher in the HCC group than in the non-HCC group (64.7% vs. 43.9%, p=0.03). In particular, in the low-medium risk group classified by PAGE-B, MAFLD increased the risk of HCC development. According to a multivariate analysis, fibrosis-4 (FIB-4) index≥2.67, a male sex, and MAFLD (OR 2.4, 95%CI 1.0-6.0, p=0.04) were independent factors associated with the onset of HCC. In a decision tree analysis, MAFLD was the second classifier for the onset of HCC, next to the FIB-4 index (MAFLD 62.5%, non-MAFLD 28.5%). Conclusions We found that MAFLD was an independent risk factor for HCC in HBeAg-negative patients with undetectable HBV-DNA after NAs therapy. We further revealed that MAFLD was the second-best classifier for hepatocarcinogenesis, next to the FIB-4 index. MAFLD therefore appears to have a synergistic effect on hepatocarcinogenesis with hepatic fibrosis.

Efficacy and safety of lenvatinib-transcatheter arterial chemoembolization sequential therapy for hepatocellular carcinoma within the up-to-seven criteria

AIM

The efficacy of sequential therapy with lenvatinib and transcatheter arterial chemoembolization (LEN-TACE) has been previously reported. This study aimed to evaluate the efficacy and safety of LEN-TACE compared with TACE in patients with hepatocellular carcinoma (HCC) within the up-to-seven criteria.

METHODS

Between 2017 and 2024, 90 patients were enrolled and categorized into either LEN-TACE sequential therapy (n = 32) or TACE (n = 58). After propensity score matching (PSM), patients were categorized into the LEN-TACE (n = 29) and TACE groups (n = 29). Progression-free survival, therapeutic response, and adverse events were assessed.

RESULTS

After PSM, although there was no significant difference in the objective response rate (ORR) between the LEN-TACE and TACE groups (ORR 93.1% vs. 82.7%, respectively; p = 0.226), PFS with LEN-TACE was significantly higher than with TACE (10.7 [95% confidence interval (CI): 7.6-NE] months versus 7.1 (95% CI: 4.8-10.0) months, respectively; p = 0.030). In the subanalysis, ORR was significantly different between the groups for nodules other than simple ones (100.0% vs. 62.5%, respectively; p = 0.039). No patients in the LEN-TACE group had disease progression, and the sustained complete response rate was 60% 1 year after TACE treatment.

CONCLUSIONS

LEN-TACE sequential therapy may be a beneficial treatment for HCC within the up-to-seven criteria, especially for tumors other than the simple nodular type.

Development of a Nomogram for Prognostic Prediction of Large Hepatocellular Carcinoma With HBV After TACE Combined Conversion Therapy

Background

Surgical resection (SR) following transarterial chemoembolization (TACE) is a promising option for large hepatocellular carcinoma (LHCC) with HBV, and identification of these patients at high-risk of prognosis may help individualized treatment.

Purpose

To develop and validate pre- and postoperative prognostic nomograms integrating clinico-therapeutic-pathological features for predicting overall survival (OS) after TACE combined therapy.

Materials and Methods

Between May 2010 and October 2021, 255 consecutive patients with LHCC receiving conversion therapy of TACE combined with Lenvatinib plus PD-1 inhibitors were included from three tertiary-care hospitals. In the derivation cohort (n=201), the Cox regression analysis for developing nomograms for OS (time from initial TACE to death). In the testing cohort (n = 54), two models' performance was compared with five major staging systems.

Results

The preoperative nomogram included alpha-fetoprotein (AFP, HR: 0.486; 95% CI: 0.266-0.886; P = 0.019) and albumin- bilirubin (ALBI) grade (HR: 0.323; 95% CI: 0.181-0.578; P < 0.001) and the postoperative nomogram, included AFP (HR: 0.501; 95% CI: 0.271-0.925; P = 0.027), ALBI grade (HR: 0.356; 95% CI: 0.192-0.659; P = 0.001), MVI (HR: 0.086; 95% CI: 0.024-0.192; P < 0.001), and response to TACE combined therapy (HR: 3.367; 95% CI: 1.479-7.721; P = 0.004). The testing dataset C-indexes of the pre- (0.715) and postoperative (0.912) nomograms were higher than all five staging systems (0.589-0.483; all P < 0.001). Two prognostically distinct risk strata were identified according to these nomograms (all P < 0.001).

Conclusion

Based on 255 patients receiving TACE combined conversion therapy for LHCC, we developed and validated two nomograms for predicting OS, with superior performances than five major staging systems and effective survival stratification.

Chronological changes in etiology, pathological and imaging findings in primary liver cancer from 2001 to 2020

PURPOSE

To achieve a historical perspective, the chronological changes in primary liver cancer over a 20-year period were investigated at a single institution, focusing on shifts in etiology and the impact on imaging and pathological findings using The Liver Imaging Reporting and Data System.

MATERIALS AND METHODS

A retrospective study of surgically resected primary liver cancer in 680 patients from 2001 to 2020 resulted in 434 patients with 482 nodules being analyzed. Dynamic contrast-enhanced computed tomography imaging and the Liver Imaging Reporting and Data System 2018 classification were employed. Two pathologists and two radiologists independently evaluated specimens and images.

RESULTS

This study highlighted a significant decline in cases of viral hepatitis and cirrhosis in primary liver cancer patients but an increase in intrahepatic cholangiocarcinoma and scirrhous hepatocellular carcinoma. Notably, there was a rise in non-viral hepatitis cases, potentially pointing toward an increase in steatohepatitic hepatocellular carcinoma cases in the future. Intrahepatic cholangiocarcinoma, scirrhous hepatocellular carcinoma and steatohepatitic hepatocellular carcinoma tumors exhibited slightly different distributions in the Liver Imaging Reporting and Data System classification compared with ordinary hepatocellular carcinoma, which may reflect the presence of fibrosis and lipid in tumor parenchyma.

CONCLUSIONS

Consistent with past reports, this study demonstrated the emergence of primary liver cancer against a backdrop of non-viral and non-cirrhotic liver. Liver Imaging Reporting and Data System has been consistently useful in diagnosing primary liver cancer; however, among the histological subtypes of hepatocellular carcinoma, an increase is anticipated in scirrhous hepatocellular carcinoma and steatohepatitic hepatocellular carcinoma, which may present imaging findings different from those of ordinary hepatocellular carcinoma. This development may necessitate a reevaluation of the current approach for diagnosing and treating hepatocellular carcinoma based solely on imaging.

Cinobufacini Inhibits Survival and Metastasis of Hepatocellular Carcinoma via c-Met Signaling Pathway

OBJECTIVE

To investigate the anti-tumor effects of cinobufacini (CINO) on hepatocellular carcinoma (HCC) induced by des-gamma-carboxy-prothrombin (DCP) and to uncover the underlying mechanisms.

METHODS

The inhibitory effect of CINO on HCC cell proliferation was evaluated using the cell counting kit-8 method, and the apoptosis rate was quantified using flow cytometry. Immunofluorescence and Western blot analyses were used to investigate the differential expression of proteins associated with cell growth, apoptosis, migration, and invasion pathways after CINO treatment. The therapeutic potential of CINO for HCC was confirmed, and the possibility of combining cinobufacini with c-Met inhibitor for the treatment of primary HCC was further validated by in vivo experiments.

RESULTS

Under the induction of DCP, CINO inhibited the activity of HCC cells, induced apoptosis, and inhibited migration and invasion. Upon the induction of DCP, CINO regulated c-Met activation and the activation of the phosphatidylinositol-3 kinase/protein kinase B (PI3K/AKT) and mitogen-activated protein kinase kinase/extracellular signal-regulated kinase (MEK/ERK) pathways. In a mouse model of HCC, CINO exhibited significant antitumor effects by inhibiting the phosphorylation of c-Met and the downstream PI3K/AKT and MEK/ERK pathways in tumor tissues.

CONCLUSIONS

CINO inhibited HCC cell growth, promoted apoptosis, and suppressed HCC cell invasion and migration by targeting c-Met and PI3K/AKT and MEK/ERK signaling pathways under DCP induction.

Low Intrahepatic Distant Recurrence Rate Following RFA Using Linear Mode in Patients With Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Radiofrequency ablation (RFA) can be utilized in elderly patients and those with cirrhosis with reduced functional liver reserve as it is less invasive. The arfa RFA system is the first system to offer a linear mode. However, the differences in performance between the linear and existing (nonlinear) modes remain unknown.

AIM

This retrospective observational study compared the performance of the linear (linear group) and nonlinear RFA modes (nonlinear group) in HCC.

METHODS

Data of 425 patients with one to three HCC tumors measuring ≤ 3 cm who underwent RFA were analyzed. Recurrence (local and distant), survival, and complication rates between the linear and nonlinear groups were determined.

RESULTS

The intrahepatic distant recurrence rate was lower in the linear group than in the nonlinear group (p < 0.05). Multivariate analysis showed that the high platelet count, low AFP-L3 levels, initial case, and linear mode were independent factors associated with a low intrahepatic distant recurrence rate following RFA. Liver disease-related survival, HCC survival, overall survival of the initial HCC, local recurrence, and complication rates were comparable between the linear and nonlinear groups.

CONCLUSION

The linear mode of the RFA protocol results in a lower intrahepatic distant recurrence rate compared with the nonlinear protocol.

Proton beam therapy in the management of hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. Photon radiotherapy shows efficacy in treating HCC but carries risks of high exit dose and radiation-induced liver disease. Additionally, HCCs with portal vein tumor thrombosis (PVTT) have a poor prognosis and are associated with higher risk of death. In recent years, proton beam therapy (PBT) has emerged as a novel treatment with the ability to downstage HCC for liver transplant (LT).

AREAS COVERED

This review will provide an overview of dosimetric benefits of PBT, efficacy of PBT in treating HCC, downstaging HCC-PVTT for LT, and a comparison of PBT with other non-surgical techniques. A search of PubMed until 3 September 2024 was conducted using free search and the following keywords: hepatocellular carcinoma, proton beam therapy, portal vein tumor thrombosis, local ablative therapy, trans-arterial chemoembolization, stereotactic body radiotherapy, Y-90 radioembolization.

EXPERT OPINION

Various clinical trials using PBT have shown promising tumor local control and overall survival rates. PBT is mostly safe and efficacious for downstaging HCC-PVTT for LT. PBT has also been shown to be non-inferior to various other treatment modalities. Future research should focus on combinations of PBT with other modalities.

High Plasma Alpha-Fetoprotein Level Is Associated With Early Postoperative Complications in Patients With Hepatocellular Carcinoma in Southern Vietnam During 2018-2023: A Cross-Sectional Study

Background and Aims

Liver tumor resection surgery for HCC treatment causes postoperative complications that affect long-term outcomes and the patient's quality of life. We performed this study to determine the early complication rate and predictive value of plasma AFP for early postoperative complications in HCC patients.

Methods

We performed a cross-sectional, longitudinal descriptive study on 98 HCC patients treated with radical surgery from March 2018 to March 2023. We included all patients > 16 years old, indicated and undergoing liver resection using the Ton That Tung method, had HCC histopathology results, and agreed to participate in the study group. Pregnant or breastfeeding females, having portal vein thrombosis, or not meeting the study criteria were excluded from this study. The main complications were collected during the postoperative stay. All patients were divided into two groups: Group 1 (n = 26) was the group with complications, Group 2 (n = 72) was the group without complications.

Results

There were 26 patients (26.5%) who had complications after surgery, of which liver function failure accounted for 4.1% (4 patients) and ascites accounted for 12.3% (12 patients). Alcoholism, hepatitis virus infection, low platelets, increased plasma AFP, and high Child-Pugh score were independent factors related to the complications after surgery, p < 0.05. ALBI index, Child-Pugh score, and plasma AFP concentration predicted postoperative complications with AUC of 0.677, 0.777, and 0.834, respectively (p < 0.01).

Conclusion

The rate of complications after surgery was 26.5%. Plasma AFP concentration was a good predictor of postoperative complications.

Comparison of prognostic accuracy of HCC staging systems in patients undergoing TACE

PURPOSE

To compare the prognostic power of commonly used staging systems of hepatocellular carcinoma (HCC) for predicting overall survival after transarterial chemoembolization (TACE).

MATERIALS AND METHODS

This retrospective single center study included patients with HCC who underwent TACE between 2008 and 2019 in a single tertiary care center. After initial screening of 408 consecutive patients, 317 patients with HCC treated with conventional or drug-eluting beads-TACE were included. Five HCC staging systems (Barcelona Clinic Liver Cancer, Hong Kong Liver Cancer, Japan Integrated Staging, Cancer of the Liver Italian Program and Okuda) were compared using Kaplan Meier survival analysis and a log-rank test with overall survival (OS) as the study endpoint. Uni- and multivariate analyses of system-specific variables were applied to stratify outcomes and compare the ability to predict OS of patients after TACE. Four different measures were used to assess the homogeneity (Likelihood ratio:LR), discriminatory ability (linear trend:LT and C-index) and explanatory ability (Akaike Information Criterion:AIC).

RESULTS

The OS of the total cohort was 29.8 months. In terms of prognostic stratification, the BCLC staging system had the best performance (LT: 8.209, LR: 26.639, AIC: 317, c-index: 0.818) compared to HKLC (LT: 10.919, LR: 25.802, AIC: 443, c-index: 0.835), JIS (LT: 4.611, LR: 16.880, AIC: 449, c-index: 0.548), CLIP (LT: 6.738, LR: 13.109, AIC: 501, c-index: 0.782), and Okuda (LT: 7.185, LR: 0.760. LR: 16.356, AIC: 487, c-index: 0.760).

CONCLUSION

Across five commonly utilized international staging systems, the BCLC staging system demonstrated the greatest prognostic accuracy with respect to predicting OS of patients undergoing TACE.

Systemic Therapy Combined with Locoregional Therapy in Intermediate-stage Hepatocellular Carcinoma

Recent advances in systemic therapy for hepatocellular carcinoma are remarkable. The treatment goal for advanced hepatocellular carcinoma is to prolong survival, while for intermediate-stage hepatocellular carcinoma, it is to achieve a cancer-free and drug-free status. Patients unsuitable for transarterial chemoembolization may benefit from prior systemic therapy with lenvatinib or atezolizumab plus bevacizumab. The TACTICS-L trial, a prospective phase II trial, demonstrated favorable progression-free and overall survival by lenvatinib-transarterial chemoembolization sequential therapy. The REPLACEMENT trial, a multicenter, prospective, single-arm phase II trial, confirmed combination immunotherapy efficacy with atezolizumab plus bevacizumabin a population exceeding up-to-seven criteria. In a proof-of-concept study, atezolizumab plus bevacizumab plus curative therapy showed a 35% complete response rate and 23% drug-free status in intermediate-stage hepatocellular carcinoma patients with a tumor burden exceeding up-to-seven criteria.

Myeloid cell path to malignancy: insights into liver cancer

Clinically approved treatments for advanced liver cancer often lack potency because of the heterogeneous characteristics of hepatocellular carcinoma (HCC). This complexity is largely driven by context-dependent inflammatory responses brought on by diverse etiologies, such as metabolic dysfunction-associated steatohepatitis (MASH), the genetic makeup of cancer cells, and the versatile adaptability of immune cells, such as myeloid cells. In this review, we discuss the evolutionary dynamics of the immune landscape, particularly that of liver-resident Kupffer cells (KCs), TREM2+, and SPP1+ macrophages with an active role during liver disease progression, which eventually fuels hepatocarcinogenesis. We highlight exploitable immunomodulatory avenues amenable to mitigate both the inherent pathological characteristics of liver cancers and the associated external factors that favor malignancy, paving a roadmap toward improving the management and therapeutic outcome for patients with HCC.

Long-term results of dynamic tumor-tracking stereotactic body radiotherapy with real-time monitoring using a gimbal-mounted linac for liver tumors: a multicenter observational study

BACKGROUND

Despite advancements in liver tumor treatments, a persistent need remains for minimally invasive therapies with high efficacy and long-term outcomes. In a previous multicenter phase II study, the safety and efficacy of dynamic tumor-tracking stereotactic body radiotherapy with real-time monitoring of liver tumors were evaluated using a gimbal-mounted system. Herein, we report the updated long-term results of this technique.

METHODS

This observational study examined patients with a single liver tumor, respiratory movement of at least 10 mm, performance status of 0-2, and Child-Pugh score of < 9. Patients who agreed to participate in the trial underwent dynamic tumor-tracking stereotactic body radiotherapy (prescribed dose, 40 Gy in five fractions for the planning target volume [D95]; 70% of the maximum dose). The primary endpoint was the 4-year overall survival rate. Secondary endpoints included 4-year local control and progression-free survival rates and the incidence of adverse events.

RESULTS

Between September 2015 and March 2019, 48 patients (median age, 74 years; median tumor diameter, 17.5 mm) underwent dynamic tumor-tracking stereotactic body radiotherapy. All lesions were successfully treated (hepatocellular carcinoma, 39 patients; liver metastases, 9 patients). The median observation period was 46 months, and the 4-year overall survival, local control, and progression-free survival rates were 67.4%, 97.9%, and 29.1%, respectively. Eight patients had grade 3 hepatobiliary enzyme elevation, hematologic toxicity, or hyponatremia; none had grade ≥ 4 adverse events.

CONCLUSION

These findings demonstrate the long-term safety and efficacy of dynamic tumor-tracking stereotactic body radiotherapy for liver tumors, with an excellent local control rate.

Current impact in the treatment of advanced hepatocellular carcinoma: The challenge remains

Hepatocellular carcinoma remains a significant cause of mortality worldwide, particularly among patients with liver cirrhosis. In most cases, surveillance in cirrhotic patients is neglected, leading to a diagnosis when the neoplasm is at an advanced stage. Within this context, Zhou et al carried out a network meta-analysis to demonstrate the effectiveness of hepatic arterial infusion chemotherapy, concluding that it is a superior approach compared to sorafenib and transarterial chemoembolization in the treatment of advanced hepatocellular carcinoma. Unfortunately, the meta-analysis in question lacks methodological rigor, preventing the authors from making more definitive assertions. Additionally, we understand that transarterial chemoembolization, when properly indicated, is a highly effective therapeutic option, and that sorafenib, given the results of new therapies based on immune checkpoint inhibitors, is no longer the recommended drug for the treatment of these patients. Therefore, we believe the use of hepatic arterial infusion chemotherapy is increasingly limited and lacks strong scientific support.

The efficacy of transcatheter arterial chemoembolization for hepatocellular carcinoma: is the alteration of the inflammation index important?

Introduction

Transcatheter arterial chemoembolization (TACE) is widely applied for locoregional malignant lesions control in intermediate and selected advanced hepatocellular carcinoma (HCC). Various inflammation indices, such as neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammatory index (SII), and Lymphocyte-to-C Reactive Protein Ratio (LCR) have been explored as tools for predicting the efficacy of TACE. However, the role and predictive value for dynamic changes of peripheral inflammatory indicators pre- and post-TACE remains unclear.

Objective

To explore the association between the alteration in inflammatory index and the efficacy and prognosis of TACE and to provide more evidence for early prediction of the efficacy of TACE.

Methods

This was a retrospective single-center study. HCC patients who received TACE as initial treatment were enrolled. The relationship between the alteration of inflammation indices (calculated as post-TACE minus pre-TACE measurements) and TACE efficacy and prognosis was investigated. Progression-free survival (PFS) was the primary endpoint, and treatment efficacy was evaluated based on mRECIST criteria.

Results

Before propensity score matching (PSM), the change in LMR was significantly associated with treatment effective rate, with the unelevated ΔLMR group achieving a 79.4% treatment effective rate compared to 36.4% in the elevated group (p < 0.001). The estimated median PFS was 9.7 months and 4.5 months in the unelevated and elevated group, with a significant difference (p = 0.016). After PSM, the treatment effective rate was 48.7 and 38.5% (p = 0.214), and the estimated median PFS was 8.9 and 5.5 months (p = 0.173) for the unelevated and elevated group, respectively.

Conclusion

Our study demonstrated that alteration of indices of peripheral inflammation, including ΔNLR, ΔLMR, ΔSII, and ΔPLR, may not be valuable prognostic markers for HCC patients who received TACE.

Development and validation of a dynamic prognostic nomogram for conditional survival in hepatocellular carcinoma: an analysis from the Korea Liver Cancer Registry

Compared to overall survival, conditional survival is a more relevant measure of prognosis in surviving patients over time. This study developed and validated a nomogram-based dynamic prognostic model to predict the conditional survival estimates of patients with hepatocellular carcinoma (HCC) through an analysis of a nationwide cancer registry. This retrospective cohort study included 2492 patients with HCC registered in the Korea Liver Cancer Registry. Patients underwent hepatic resection (HR) from 2008 to 2017, were followed up until December 2019, and were divided into development and validation cohorts. Univariate and multivariate Cox regression analyses were conducted to determine the risk factors for conditional survival of patients who underwent HR. The patients were scored based on the Cox regression coefficients; the nomogram was predicted by calculating the survival probability with Cox model. Our dynamic prognostic model nomogram for predicting conditional overall survival demonstrated Harrell's C-index of 0.622 and 0.674 in the development and validation sets; for conditional disease-specific survival, it was 0.623 and 0.686 in the development and validation sets. The prediction power of the model is applicable in clinical practice. Factors incorporated in our nomogram included age, albumin, the ADV score, lymph node metastasis, and T stage in American Joint Commission on Cancer staging system. We developed and validated a nomogram to predict conditional survival estimates for overall survival and disease-specific survival. The proposed nomogram incorporating the ADV score presents a more accurate and useful prognostic prediction for patients with HCC who received HR.

Risk Factors for Intrahepatic Distant Recurrence After Radiofrequency Ablation for Hepatocellular Carcinoma

AIM

The incidence of intrahepatic distant recurrence (IDR) of hepatocellular carcinoma (HCC) still remains high after radiofrequency ablation (RFA). However, serum alpha-fetoprotein (AFP) has insufficient screening power. This study aimed to identify risk factors for IDR in patients with post-RFA HCC.

METHOD

A total of 112 patients with early-stage HCC who underwent RFA were divided into the IDR (n = 51) and non-IDR groups (n = 61). Serum samples were analyzed within 2 months after RFA.

RESULTS

The mean follow-up duration was 30.1 months. The recurrence-free survival rates at 1, 3, and 5 years were 20.8%, 42.4%, and 54.2%, respectively. The 1- and 5-year overall survival rates were 97.3% and 87.3%, respectively. Univariate and multivariate analyses revealed that the neutrophil-to-lymphocyte ratio [NLR, hazard ratio (HR) 2.40; 95% confidence interval (CI) 1.44-3.99] and lens culinaris agglutinin a-reactive fraction of alpha-fetoprotein (AFP-L3, (HR 1.02; 95% CI 1.01-1.04) were independently associated with post-RFA IDR. The cumulative recurrence rates at 5 years in the high NLR (≥ 2.24) and high AFP-L3 (≥ 0.2 ng/mL) groups were significantly higher than those in the low NLR (< 2.24) and low AFP-L3 (< 0.2 ng/mL) groups, respectively. The predictive accuracies of NLR, AFP-L3, and a composite index based on AFP-L3, and NLR for IDR were 66.2% (37.3% sensitivity, 95.1% specificity), 64.3% (47.1% sensitivity, 80.3% specificity), and 75.6% (68.6% sensitivity, 75.4% specificity), respectively.

CONCLUSION

The combined model had significantly better prediction performance than either NLR or AFP-L3 alone. The NLR combined with an absolute AFP-L3 level is an effective marker for IDR in patients with post-RFA HCC.

Protocol of the IMPACT study: randomized, multicenter, phase 3 study evaluating the efficacy of immunotherapy (Atezolizumab) plus anti-VEGF therapy (Bevacizumab) in combination with transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma

BACKGROUND

Atezolizumab plus bevacizumab is recommended as a first-line treatment for unresectable hepatocellular carcinoma (uHCC). A subgroup analysis of the IMbrave150 trial showed shorter overall survival (OS) in uHCC patients with stable disease (SD) than patients with complete response (CR) or partial response (PR) after atezolizumab plus bevacizumab. Improving OS in patients with SD is an unmet medical need. Transcatheter arterial chemoembolization (TACE) may enhance treatment efficacy by controlling intrahepatic lesions and activating anti-tumor immunity. The IMPACT study aims to evaluate whether combining atezolizumab plus bevacizumab with TACE improves OS in patients with SD.

METHODS

IMPACT is a multicenter, phase 3 study being conducted in Japan, recruiting uHCC patients aged ≥ 18 years with Barcelona Clinic Liver Cancer stage A (single tumor ≥ 5 cm only, TACE unsuitable), stage B (TACE unsuitable) or stage C (excluding Vp3 or 4), Child-Pugh A liver function, and no prior systemic therapy. After 12 weeks of atezolizumab plus bevacizumab treatment as induction therapy, patients are being divided into two cohorts based on response: a randomized cohort for patients who achieve SD, or an atezolizumab plus bevacizumab followed by curative conversion (ABC-conversion) cohort for patients who achieve CR or PR. Patients in the randomized cohort are receiving atezolizumab plus bevacizumab and intrahepatic control TACE (Group A), or continuing atezolizumab plus bevacizumab (Group B). Patients in the ABC-conversion cohort are receiving atezolizumab plus bevacizumab. All cohorts can be considered for curative conversion therapies for residual tumors if these therapies are considered curative, in the patient's best interests, and deemed necessary by the investigator. The primary endpoint is OS for the randomized cohort and conversion rate for the ABC-conversion cohort. Secondary endpoints in both cohorts include progression-free survival, objective response rate, duration of response, time to CR, and safety. The study is expected to last 6.5 years from June 2023.

DISCUSSION

IMPACT is evaluating the efficacy of combination therapy with atezolizumab plus bevacizumab and TACE, as well as exploring the efficacy of curative conversion therapy. The results should contribute to establishing a response-guided treatment strategy for uHCC by determining optimal treatment according to the therapeutic effect of atezolizumab plus bevacizumab.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT), identifier: jRCTs051230037. Registered 13 June 2023.

PROTOCOL VERSION

8 May 2024; version 1.4.

Potential indications for liver transplant in Child-Pugh A and Model for End-stage Liver Disease exception for hepatocellular carcinoma in Japan

AIM

In 2019, expanded criteria for hepatocellular carcinoma (HCC), known as 5-5-500 (size ≤5 cm, number ≤5, alpha-fetoprotein ≤500 ng/mL), as well as Model for End-stage Liver Disease (MELD) exception, were implemented in Japan. In the present study, we evaluated liver transplantation indications and the Japanese allocation policy for HCC.

METHODS

Adults with HCC were evaluated between January 2013 and December 2017 in a multicenter study in Japan. The patients were aged ≤65 years, in line with the limits of Japanese transplant center limits.

RESULTS

HCC patients (n = 289) were classified as Child-Pugh A (74%), B (18%), or C (8%). Of these, 178 (62%) and 185 (64%) met the Milan and 5-5-500 criteria, respectively. The respective 1- and 5-year overall survival rates of patients who met the criteria were 100% and 88.1% in Child-Pugh A, 91.7% and 30.6% in B, and 72.9% and 0% in C without access to liver transplantation. For Child-Pugh A patients, we developed a risk score using the Child-Pugh score, des-gamma-carboxy prothrombin, tumor-node-metastasis stage grade, as well as albumin-bilirubin and albumin-bilirubin tumor-node-metastasis stage , which predicted worse prognosis. Additionally, we showed the characteristics of patients who achieved MELD exception points high enough to receive an organ: survival at least 2 years after waitlist registration, relatively good liver functional reserve, and sufficient tumor control with multiple treatments.

CONCLUSIONS

High-risk patients, identified by our scoring system and albumin-bilirubin tumor-node-metastasis stage ≥2 in Child-Pugh A, should be considered for liver transplantation eligibility. The allocation policy for HCC should be revised based on precise evaluations on a regular basis.

Lenvatinib plus Pembrolizumab Combined with Transarterial Chemoembolization in Intermediate-Stage Hepatocellular Carcinoma

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Assessment of Macrovascular Invasion in Advanced Hepatocellular Carcinoma: Clinical Implications and Treatment Outcomes with Systemic Therapy

Introduction

Macrovascular invasion (MVI) is a strong prognostic factor for advanced hepatocellular carcinoma (HCC). The current criteria for radiological assessment are unclear in evaluating the impact of MVI on systemic therapy. In this study, we standardized the assessment of MVI and validated its clinical relevance.

Methods

Clinical data were collected from patients with advanced HCC and MVI who received first-line systemic therapy at four medical centers in Japan. First, we used MVI progressive disease (MVI-PD) to track MVI progression and Response Evaluation Criteria in Solid Tumors version 1.1 progressive disease (RECIST v1.1-PD) to evaluate tumor enlargement other than MVI and the appearance of new lesions. Next, we assessed the prognostic value of MVI-PD and RECIST v1.1-PD.

Results

Of the 207 advanced HCC patients with MVI, 189 received appropriate imaging evaluation. Forty (21.2%) patients had MVI-PD and RECIST v1.1-PD, 51 (27.0%) had prior MVI-PD, and 61 (32.3%) had prior RECIST v1.1-PD. In a landmark analysis, the prognosis of 163 patients who survived more than 3 months was analyzed based on the assessment of imaging response during the first 3 months. The median overall survival (OS) was 5.4 months in those who had MVI-PD and RECIST v1.1-PD, 7.4 months in those who had RECIST v1.1-PD only, 7.2 months in those who had MVI-PD only, and 19.7 months in patients who had neither (p < 0.001). The correlation coefficients between progression-free survival and OS in patients with appropriate imaging assessments were similar for MVI-PD (0.515) and RECIST v1.1-PD (0.498).

Conclusion

Our findings demonstrate the link between MVI progression and poor OS in systemic therapy for advanced HCC, emphasizing the importance of an accurate method for assessing MVI progression.

Efficacy of durvalumab plus tremelimumab treatment for unresectable hepatocellular carcinoma in immunotherapy era clinical practice

AIM

Since the development of tremelimumab plus durvalumab (Dur/Tre) for unresectable hepatocellular carcinoma (uHCC), it has been used as not only an initial but also later line treatment in clinical practice. This study aimed to elucidate clinical prognostic factors for progression-free survival (PFS) in Dur/Tre treatment cases.

METHODS

Enrolled were 183 uHCC patients treated with Dur/Tre from 2023 to May 2024 (median age, 74 years; male patients, 152; Child-Pugh class A:B, 150:33; Barcelona Clinic Liver Cancer stage B:C, 59:124; initial line use, 64). Clinical factors with prognostic influence on PFS in these patients were retrospectively evaluated.

RESULTS

The median observation period was 7.2 months (interquartile range, 3.2-10.4). History of atezolizumab plus bevacizumab (Atz/Bev) treatment was the only significant prognostic factor for PFS at introduction of Dur/Tre in multivariate analysis (hazard ratio 2.040, p = 0.028) (median PFS: without vs. with = 5.6 vs. 2.7 months, p < 0.001). Although immune-mediated adverse events (imAE) occurrence was only significant in univariate analysis, when objective response and disease control rates were examined according to imAE positivity (any grade) at the time of analysis, those were noted in 14.4% and 39.2%, respectively, of patients without imAE, while in patients with imAE (any grade), they were noted in 18.2% and 56.1%, respectively (p = 0.523 and p = 0.038, respectively).

CONCLUSION

History of Atz/Bev treatment may be an independent clinical factor for poor PFS at Dur/Tre introduction.

A concise review of updated global guidelines for the management of hepatocellular carcinoma: 2017-2024

Many guidelines for hepatocellular carcinoma (HCC) have been published and are regularly updated worldwide. HCC management involves a broad range of treatment options and requires multidisciplinary care, resulting in significant heterogeneity in management practices across international communities. To support standardized care for HCC, we systematically appraised 13 globally recognized guidelines and expert consensus statements, including five from Asia, four from Europe, and four from the United States. These guidelines share similarities but reveal notable discrepancies in surveillance strategies, treatment allocation, and other recommendations. Geographic differences in tumor biology (e.g., prevalence of viral hepatitis, alcohol-related liver disease, or metabolic dysfunction-associated steatotic liver disease) and disparities in available medical resources (e.g., organ availability, healthcare infrastructure, and treatment accessibility) complicate the creation of universally applicable guidelines. Previously, significant gaps existed between Asian and Western guidelines, particularly regarding treatment strategies. However, these differences have diminished over the years. Presently, variations are often more attributable to publication dates than to regional differences. Nonetheless, Asia-Pacific experts continue to diverge from the Barcelona Clinic Liver Cancer system, particularly with respect to surgical resection and locoregional therapies, which are viewed as overly conservative in Western guidelines. Advancements in systemic therapies have prompted ongoing updates to these guidelines. Given that each set of guidelines reflects distinct regional characteristics, strengths, and limitations, fostering collaboration and mutual complementarity is essential for addressing discrepancies and advancing global HCC care.

Nomogram to Predict Tumor Remnant of Small Hepatocellular Carcinoma after Microwave Ablation

RATIONALE AND OBJECTIVES

This investigation sought to create a nomogram to predict the ablation effect after microwave ablation in patients with hepatocellular carcinoma, which can guide the selection of microwave ablation for small hepatocellular carcinomas.

METHODS

In this two-center retrospective study, 233 patients with hepatocellular carcinoma treated with microwave ablation (MWA) between January 2016 and December 2023 were enrolled and analyzed for their clinical baseline data, laboratory parameters, and MR imaging characteristics. Logistic regression analysis was used to screen the features, and clinical and imaging feature models were developed separately. Finally, a nomogram was established. All models were evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, and decision curve analysis (DCA).

RESULTS

Two models and a nomogram were developed to predict ablation outcomes after MWA based on a training set (n = 182, including complete ablation: 136, incomplete ablation: 46) and an external validation set (n = 51, complete ablation: 36, incomplete ablation: 15). The clinical models and nomogram performed well in the external validation cohort. The AUC of the nomogram was 0.966 (95% CI: 0.944- 0.989), with a sensitivity of 0.935, a specificity of 0.882, and an accuracy of 0.896.

CONCLUSIONS

Combining clinical data and imaging features, a nomogram was constructed that could effectively predict the postoperative ablation outcome in hepatocellular carcinoma patients undergoing MWA, which could help clinicians provide treatment options for hepatocellular carcinoma patients.

Association of serum lactate dehydrogenase with prognosis and tumor metabolism in patients with hepatocellular carcinoma treated with atezolizumab plus bevacizumab therapy

PURPOSE

Treatment outcomes are predicted by analyzing peripheral blood markers such as serum lactate dehydrogenase (LDH). We conducted this study to investigate whether serum LDH levels can predict the prognosis of patients treated with atezolizumab plus bevacizumab (ATZ/BEV) therapy for hepatocellular carcinoma (HCC) and whether LDH levels correlate with metabolic changes.

METHODS

We enrolled 66 HCC patients treated with ATZ/BEV. Based on the change in serum LDH levels before and after treatment, the patients were divided into two groups, and the prognosis of each group was examined. Moreover, the association of LDH levels with tumor metabolism was analyzed by fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT).

RESULTS

There were 32 patients categorized as the LDH-decrease group. Kaplan-Meier survival analysis indicated worse progression-free survival (PFS) in the LDH-increase group than in the LDH-decrease group (p = 0.0029). Multivariate analysis showed that an increase in the LDH level was an independent risk factor for worse PFS (p = 0.0045). The baseline LDH level correlated significantly with a high maximum standardized uptake value of 18F-FDG, according to the PET/CT findings. Transcriptomic analyses of specimens resected after ATZ/BEV therapy showed downregulated mitochondria-related pathways.

CONCLUSION

Serum LDH levels are a potential prognostic marker and an indicator of tumor metabolism.

Transarterial Chemoembolization for Patients With Hepatocellular Carcinoma Using Miriplatin Without the Need for Hydration

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with a rising incidence. The most common therapeutic choice for HCC is transarterial chemoembolization (TACE). While the standard protocol of TACE adopts cisplatin, the application of cisplatin needs hydration before and after the procedure to alleviate adverse effects on kidney function. Miriplatin, a lipophilic platinum complex, enables the omission of periprocedural hydration compared to cisplatin-based TACE. This study aimed to compare the survival benefit between miriplatin-based TACE and cisplatin-based TACE. Briefly, a retrospective cohort study in a single hospital was designed. Patients with HCC complicated by vascular invasion or distant metastasis were excluded. Background variability was adjusted using a propensity score matching; then, overall survival rates were compared using the Gehan-Breslow-Wilcoxon test. As a result, cisplatin and miriplatin were administered to 166 and 120 patients in TACE procedures. After adjusting baseline characteristics using a propensity score including age, sex, tumor burden, functional hepatic reserve, baseline year, and HbA1c, a pair of 99-patient cohorts was generated. Overall survivals did not differ significantly, despite poorer serum creatinine at baseline (0.89 vs. 0.74 mg/dL, p < 0.0001) and fewer patients being prepared for TACE through prehydration (18 patients vs. 38 ones, p = 0.0025) in the miriplatin group than in the cisplatin group. The median survival time was 1490 days for the miriplatin group and 1,830 days for the cisplatin group (p = 0.4022; ratio = 0.814; 95% confidence interval 0.546-1.215). In conclusion, miriplatin will benefit patients with HCC who cannot tolerate perioperative hydration.

Long-Term Outcomes of Transarterial Chemoembolization plus Ablation versus Surgical Resection in Patients with Large BCLC Stage A/B HCC

RATIONALE AND OBJECTIVES

Large hepatocellular carcinoma (HCC) exhibits heterogeneous morphologies and varied responses to treatment. We evaluated outcomes of patients with different large HCC classifications receiving surgical resection (SR) or transarterial chemoembolization plus ablation (TA).

MATERIALS AND METHODS

Patients with HCC ≥ 5 cm receiving SR or TA between May 2016 and December 2020 at one center were analyzed retrospectively and with propensity score matching (PSM). Overall survival (OS) and progression-free survival (PFS) of the 2 treatment groups were compared. Tumors were classified according to imaging morphology and gross pathology: Type I, simple nodular; Type II, simple nodular with extranodular growth or confluent multinodular; Type III, infiltrative.

RESULTS

Of 644 patients, 374 met the inclusion criteria (300 received SR and 74 received TA). Before PSM, median follow-up was 51.2 (IQR 29.6-65.3) months, and the SR group had longer OS (HR 2.13, 95% CI 1.44-3.15, p<0.001) and PFS (HR 2.31, 95% CI 1.66-3.20, p<0.001) than the TA group; after PSM these differences were not significant (all p>0.05). Infiltrative HCC (Type III) was an independent negative prognostic factor for OS and PFS. Within both treatment groups, patients with infiltrative HCC had shorter OS and PFS than patients with non-infiltrative HCC (Types I and II) (all p<0.001).

CONCLUSION

For patients with HCC ≥ 5 cm, tumor classification is an important prognostic factor. In patients with non-infiltrative HCC, TA and SR had comparable OS after PSM. For patients with infiltrative HCC, TA and SR had limited efficacy.

Validation of an albumin-indocyanine green-based China liver cancer staging system to evaluating resectable hepatocellular carcinoma patients and comparison with the Child-Pugh-based China liver cancer staging system

Aim

Here, the utility of an albumin-indocyanine green-based China liver cancer (CNLC) staging system (ALICE-CNLC) as a tool for the prognostic assessment of hepatocellular carcinoma (HCC) patients was evaluated, comparing this system to the Child-Pugh score-based CNLC staging system.

Methods

The cohort for this study included 331 patients with HCC who had undergone hepatectomy at Jinhua Municipal Central Hospital Medical Group in China from April 2012-June 2021 and had postoperative pathology-confirmed HCC. Kaplan-Meier survival curves were generated, with log-rank tests used to examine prognostic factors. Univariate and multivariate analyses were used for identification of outcome predictors using Cox proportional hazards regression.

Results

The prediction of overall survival (OS) by the ALICE-CNLC system for patients with stage Ia disease was markedly better than that for patients with stage Ib and IIa disease (P=0.010, P=0.026), while the latter groups did not differ significantly (P=0.796). The ALICE-CNLC system predicted the 3-year recurrence-free survival (RFS) rates for patients with stage Ia, Ib, and IIa disease to be 50.4%, 47.7%, and 25%, respectively, with significant differences among the groups (P=0.033, P<0.001, and P=0.043). These results were similar to those of the CNLC staging system.The OS and RFS did not differ significantly between the same grades of patients evaluated with the ALICE-CNLC and CNLC staging systems.

Conclusion

The ALICE-CNLC and CNLC staging systems did not show significant differences in predicting the prognosis of patients with HCC who have undergone hepatectomy.

Hepatic artery infusion chemotherapy: A resurgence

In this manuscript, we comment on the article by Zhou et al, who assessed the efficacy of hepatic arterial infusion chemotherapy (HAIC) and its combination strategies for advanced hepatocellular carcinoma (HCC) using network meta-analysis methodology. We focus specifically on the potential advantages and role of HAIC in the treatment algorithm for advanced HCC. However, there remains numerous knowledge gaps before the role of HAIC can be established. There is significant heterogeneity of HAIC regimes with difficult interpretation of the clinical outcomes. Additionally, there is a lack of direct comparative data between HAIC, systemic chemotherapy, novel immunotherapies and targeted therapies. The underlying biochemical mechanisms that might explain the efficacy of HAIC and its effect on the HCC microenvironment requires further research. In the developing era of nanotechnology and targeted drug delivery systems, there is potential for integration of HAIC with novel technologies to effectively treat advanced HCC whilst minimising systemic complications.