Surgery for Hepatocellular Carcinoma: Does It Improve Survival?

Burden of liver cancer mortality by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities

BACKGROUND

Understanding how specific populations are affected by liver cancer is important for identifying priorities, policies, and interventions to mitigate health risks and reduce disparities. This study aims to provide comprehensive analysis of rates and trends in liver cancer mortality for different racial and ethnic populations in the USA nationally and at the county level from 2000 to 2019.

METHODS

We applied small-area estimation methods to death registration data from the US National Vital Statistics System and population data from the US National Center for Health Statistics to estimate liver cancer mortality rates by county, racial and ethnic population, and year (2000-19) in the USA. Race and ethnicity were categorised as non-Latino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and non-Hispanic White (White). Estimates were adjusted using published misclassification ratios to correct for inaccuracies in race or ethnicity as recorded on death certificates, and then age-standardised. Mortality rate estimates are presented for all county and racial and ethnic population combinations with a mean annual population greater than 1000.

FINDINGS

Nationally, the age-standardised liver cancer mortality rate increased between the years 2000 (4·2 deaths per 100 000 population [95% uncertainty interval 4·1-4·3]) and 2016 (6·0 per 100 000 [5·9-6·1]), followed by a stabilisation in rates from 2016 to 2019 (6·1 per 100 000 [6·0-6·2]). Similar trends were observed across the AIAN, Black, Latino, and White populations, whereas the Asian population showed an overall decrease across the 20-year study period. Qualitatively similar trends were observed in most counties; however, the mortality rate and the rate of change varied substantially across counties, both within and across racial and ethnic populations. For the 2016-19 period, mortality continued to increase at a substantial rate in some counties even while it stabilised nationally. Nationally, the White population had the lowest mortality rate in all years, while the racial and ethnic population with the highest rate changed from the Asian population in 2000 to the AIAN population in 2019. Racial and ethnic disparities were substantial: in 2019, mortality was highest in the AIAN population (10·5 deaths per 100 000 [9·1-12·0]), notably lower for the Asian (7·5 per 100 000 [7·1-7·9]), Black (7·6 per 100 000 [7·3-7·8]), and Latino (7·7 per 100 000 [7·5-8·0]) populations, and lowest for the White population (5·5 [5·4-5·6]). These racial and ethnic disparities in mortality were prevalent throughout the country: in 2019, mortality was higher in minoritised racial and ethnic populations than in the White population living in the same county in 408 (87·7%) of 465 counties with unmasked estimates for the AIAN population, 604 (90·6%) of 667 counties for the Asian population, 1207 (81·2%) of 1486 counties for the Black population, and 1073 (73·0%) of 1469 counties for the Latino population.

INTERPRETATION

Although the plateau in liver cancer mortality rates in recent years is encouraging, mortality remains too high in many locations throughout the USA, particularly for minoritised racial and ethnic populations. Addressing population-specific risk factors and differences in access to quality health care is essential for decreasing the burden and disparities in liver cancer mortality across racial and ethnic populations and locations.

FUNDING

US National Institutes of Health (Intramural Research Program, National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; Intramural Research Program, National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research).

Screening for aberrantly methylated and differentially expressed genes in nonalcoholic fatty liver disease of hepatocellular carcinoma patients with cirrhosis

Background

Nonalcoholic fatty liver disease (NAFLD) as the leading chronic liver disease worldwide causes hepatic fibrosis, cirrhosis and hepatocellular carcinoma (HCC). The aim of this study was to find potential aberrantly methylated and differentially expressed genes in NAFLD of HCC patients with cirrhosis.

Methods

DNA methylation data, mRNA expression data, and the corresponding clinical information of HCC were downloaded from the Cancer Genome Atlas (TCGA, tissue sample) database. HCC patients with cirrhosis were divided into two groups according to the presence of NAFLD. The differentially expressed genes (DEGs) and differentially methylated genes (DMGs) were obtained.

Results

By overlapping 79 up-regulated genes and 1020 hypomethylated genes, we obtained 5 hypomethylated-highly expressed genes (Hypo­HGs). By overlapping 365 down-regulated genes and 481 hypermethylated genes, we identified 13 hypermethylated-lowly expressed genes (Hyper-LGs). Survival analysis of these 18 MDEGs indicated that the expression of DGKK and HOXD9 was significantly correlated with the overall survival time of NAFLD patients.

Conclusions

We identified several candidate genes whose expressions were regulated by DNA methylation of NAFLD of HCC with cirrhosis, which may provide a new field in understanding the clinical pathological mechanism of NAFLD of HCC with cirrhosis.

Long-Term Survival and Curative-Intent Treatment in Hepatitis B or C Virus-Associated Hepatocellular Carcinoma Patients Diagnosed during Screening

Background: We initiated a prospective screening trial in patients with hepatitis to diagnose HCC in the early stage and to evaluate the impact on long-term survival. Methods: From 1993−2006, 10,372 patients with chronic hepatitis B (14%), hepatitis C (81%), or both (5%) were enrolled in an HCC screening program. All patients underwent liver biopsy at enrollment. Transabdominal ultrasonography and serum alpha-fetoprotein were evaluated every 6 months. Abnormal screening results led to axial imaging and tumor biopsy. Results: Cirrhosis was confirmed on biopsy in 2074 patients (20%). HCC was diagnosed in 1016 patients (9.8%), all of whom had cirrhosis (49.0% HCC incidence in patients with cirrhosis). HCC was diagnosed at the initial screening in 165 patients (16.2%) and on follow-up in 851 patients (83.8%). The HCC diagnosis median time during follow-up screening was 6 years (range 4−10). Curative-intent treatment (resection, ablation, or transplant) was performed in 713 patients (70.2%). Overall survival at 5 and 10 years in those 713 patients was 30% and 4%, respectively, compared to no 5-year survivors in the 303 patients with advanced-stage disease (p < 0.001). Cause of death at 5 years in the 713 patients treated with curative intent was HCC in 371 patients (52%), progressive cirrhosis in 116 patients (16%), and other causes in 14 patients (2%). At 10 years, 456 patients (64%) had died from HCC, 171 (24%) from progressive cirrhosis, and 57 (8%) from other causes. Conclusions: Our screening program diagnosed early-stage HCC, permitting curative-intent treatment in 70%, but the 10-year survival rate is 4% due to HCC recurrence and progressive cirrhosis.

Black race is independently associated with underutilization of transplantation for clinical T1 hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality. Operative management of early disease includes ablation, resection, and transplantation. We compared the operative management of early-stage HCC in patients stratified by race.

METHODS

We identified patients with cT1 HCC and Charlson-Deyo score 0-1 in the National Cancer Database (2004-2016). We compared operative/non-operative management by race, adjusting for clinicodemographic variables. We performed marginal standardization of logistic regression to ascertain adjusted probabilities of resection or transplantation in patients under 70 years of age with insurance.

RESULTS

A total of 25,029 patients were included (White = 20,410; Black = 4619). After adjusting for clinico demographic variables, Black race was associated with a lower likelihood of undergoing operative intervention (OR 0.89,p = 0.009). Black patients were more likely to undergo resection (OR 1.23,p < 0.001) and less likely to undergo transplantation (OR 0.60,p < 0.001). Marginal standardization models demonstrated Black race was associated with increased probability of resection in patients >50yrs, with private insurance/Medicare, and lower probability of transplantation regardless of age or insurance payor.

CONCLUSION

Black race is associated with lower rates of hepatic transplantation and higher rates of hepatic resection for early HCC regardless of age or insurance payor. The etiology of these disparities is multifactorial and correcting the root causes represents a critical area for improvement.

Feasibility of marker-less stereotactic body radiotherapy for hepatocellular carcinoma

BACKGROUND

The feasibility of marker-less stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC) has not yet been established, and, thus, was examined in the present study.

MATERIAL AND METHODS

We retrospectively investigated patients who received marker-less SBRT for locally untreated HCC tumors between July 2005 and December 2018. Radiotherapy planning CT was performed under fixation with vacuum cushions and abdominal compression. The clinical target volume (CTV) was equivalent to the gross tumor volume (GTV). The internal target volume (ITV) margin to CTV was determined from calculations based on the motion of the diaphragm. The planning target volume (PTV) margin to ITV was 5-6 mm. In the set-up, radiotherapy planning CT and linac-integrated cone-beam CT performed in the same imaging and fixation settings were merged by referring to the anatomical components surrounding target tumors. The primary endpoint was the 3-year cumulative local tumor progression rate. The upper limit of the 95% confidence interval for the 3-year cumulative local tumor progression rate was less than 7.0%, which was interpreted as favorable local control and feasible for marker-less SBRT. Local tumor progression was assessed by mRECIST.

RESULTS

We reviewed 180 patients treated with 35-40 Gy/5 fractions. The median follow-up time for the local tumor progression of censored tumors was 32.3 months (range, 0.3-104). The 3-year cumulative local tumor progression rate was 3.0% (95% CI, 1.1-6.5%). The 3-year overall survival rate was 71.6% (95% CI, 63.5-78.2%). Regarding acute hematologic toxicities, grade 3 hypoalbuminemia and thrombocytopenia were detected in 1 (0.6%) and 5 (2.9%) patients, respectively. Treatment-related death from SBRT was not observed. SBRT was initiated within 7 days after radiotherapy planning CT for 84% (152/180) of patients.

CONCLUSIONS

Marker-less SBRT for HCC achieved favorable local control that fulfilled the threshold. This result suggests that marker-less SBRT with appropriate settings is a feasible treatment strategy.

Hepatocellular Carcinoma Tumor Microenvironment and Its Implications in Terms of Anti-tumor Immunity: Future Perspectives for New Therapeutics

PURPOSE

Hepatocellular cancer is an insidious tumor that is often diagnosed in a later stage of life. The tumor microenvironment is the key to tumorigenesis and progression. Many cellular and non-cellular components orchestrate the intricate process of hepatocarcinogenesis. The most important feature of hepatocellular cancer is the immune evasion process. The present review aims to summarize the key components of the tumor microenvironment in the immune evasion process.

METHODS

Google Scholar and PubMed databases have been searched for the mesh terms "Hepatocellular carcinoma" or "Liver Cancer" and "microenvironment." The articles were reviewed and the components of the tumor microenvironment were summarized.

RESULTS

The tumor microenvironment is composed of tumor cells and non-tumoral stromal and immune cells. HCC tumor microenvironment supports aggressive tumor behavior, provides immune evasion, and is an obstacle for current immunotherapeutic strategies. The components of the tumor microenvironment are intratumoral macrophages (tumor-associated macrophages (TAM)), bone marrow-derived suppressor cells, tumor-associated neutrophils (TAN), fibroblasts in the tumor microenvironment, and the activated hepatic stellate cells.

CONCLUSION

There are intricate mechanisms that drive hepatocarcinogenesis. The tumor microenvironment is at the center of all the complex and diverse mechanisms. Effective and multistep immunotherapies should be developed to target different components of the tumor microenvironment.

Recent Improvements in Racial Disparity in the Treatment of Hepatocellular Carcinoma: How Times Have Changed

BACKGROUND

Race has been shown to impact receipt of and outcomes following hepatobiliary surgery. We sought to determine if racial disparities in the management of hepatocellular carcinoma persist.

METHODS

Information on patients with hepatocellular carcinoma diagnosed between 2012 and 2016 was obtained from the Surveillance, Epidemiology, and End Results database. The sample was stratified by race/ethnicity, and associations between tumor characteristics, treatment, and survival were assessed.

RESULTS

Of 33,672 patients, the mean age was 65 years, and 77% were male. By race, 17,150 (51%) were white, 4755 (14%) black, 6850 (20%) Hispanic, and 4917 (15%) Asian. When assessing the likelihood of treatment versus no treatment for tumors less than 5 cm, no difference was observed between whites and blacks in any year, but Hispanics were less likely than whites to receive treatment in most years. Asians were more likely to receive treatment every year. When assessing the likelihood of transplant versus surgical resection, blacks were less likely than whites to undergo transplant in all years except 2016. Hispanics were equally likely, while Asians were less likely to undergo transplant in all years. For years 2012 to 2016 collectively, Asians had better 5-year survival rates than other races after undergoing ablation and resection. No difference in the risk of death was observed among blacks, whites, or Hispanics after undergoing ablation, resection, or transplant.

CONCLUSION

Racial disparities for blacks and Hispanics have improved. Although Asians were less likely to undergo transplant, they had better survival after undergoing resection or ablation.

Local control by salvage stereotactic body radiotherapy for recurrent/residual hepatocellular carcinoma after other local therapies

Background: To clarify local control by salvage stereotactic body radiotherapy (SBRT) for recurrent/residual hepatocellular carcinoma (HCC) compared with initial definitive SBRT for local treatment-naïve HCC.Material and methods: We retrospectively investigated HCC patients that received SBRT between July 2005 and December 2017. We classified HCC tumors as the initial definitive SBRT group (Arm-1; initial definitive SBRT, Arm-2; initial definitive planned SBRT following transarterial chemoembolization (TACE)) and salvage SBRT group (Arm-3; salvage SBRT for recurrent/residual tumors after TACE, Arm-4; salvage SBRT for recurrent/residual tumors after radiofrequency ablation (RFA), Arm-5; salvage SBRT for recurrent/residual other than Arm-3 or Arm-4). Local control was evaluated by mRECIST.Results: We reviewed 389 HCC tumors of 323 patients treated by 35-40 Gy/5 fr. The median follow-up time for local recurrence of tumors was 34.8 months (range, 6.5-99.2). The cumulative local recurrence rates at 3 years of Arm-1-5 were 1.4% (95% CI, 0.3-4.4%), 5.0% (95% CI, 1.6-11.5%), 12.4% (95% CI, 5.7-21.9%), 14.8% (95% CI, 3.3-34.3%) and 7.3% (95% CI, 1.9-18.0%), respectively. The cumulative local recurrence rates at 3 years of initial definitive treatment and salvage treatment groups were 2.8% (95% CI, 1.1-5.6%) and 11.1% (95% CI, 6.3-17.3%), respectively (p=.004). On multivariate analysis, salvage treatment and the tumor diameter were significant risk factors of local recurrence (p = .02, p < .001 respectively). Estimated overall survival at 3 years for all patients in initial definitive treatment and salvage treatment groups were 71.5% (95% CI, 63.4-78.1%) and 66.1% (95% CI, 56.4-74.2%), respectively (p = .20). No treatment-related death caused by SBRT was observed.Conclusions: This analysis showed local control of salvage SBRT for recurrent/residual HCC was significantly worse than that of initial definitive SBRT for local treatment-naïve HCC. However, local control of salvage SBRT was relatively good, and salvage SBRT is one of the favorable treatment options for recurrent/residual HCC.

Cirrhosis Patients with Nonalcoholic Steatohepatitis Are Significantly Less Likely to Receive Surveillance for Hepatocellular Carcinoma

BACKGROUND

Disparities in receipt of hepatocellular carcinoma (HCC) surveillance contribute to disparities in overall survival outcomes.

AIM

We aim to evaluate disparities in receipt of routine HCC surveillance among patients with cirrhosis in a large urban safety-net hospital.

METHODS

Consecutive adults (age ≥ 18) with cirrhosis from July 1, 2014, to December 31, 2015, were retrospectively evaluated to determine rates of receiving appropriate HCC surveillance within 6 months and 1 year after diagnosis of cirrhosis. Rates of HCC surveillance were stratified by sex, race/ethnicity, and liver disease etiology. Multivariate Cox proportional hazards models were utilized to evaluate for predictors of receiving appropriate HCC surveillance.

RESULTS

Among 157 cirrhosis patients enrolled [hepatitis C virus (HCV): 29.9%, hepatitis B virus: 13.4%, alcoholic cirrhosis: 44.6%, nonalcoholic steatohepatitis (NASH): 8.9%], mean age of cirrhosis diagnosis was 53.8 ± 9.0 years. Among these patients, 49% received (n = 77) HCC surveillance within 6 months and 78% (n = 123) were surveyed within 1 year of cirrhosis diagnosis. On multivariate analyses, patients with NASH cirrhosis were significantly less likely to receive HCC surveillance compared with chronic HCV cirrhosis patients (HR 0.44, 95% CI 0.19-0.99, p < 0.05). No significant sex-specific or race/ethnicity-specific disparities in receipt of HCC surveillance were observed.

CONCLUSION

Among a diverse safety-net hospital population, sub-optimal HCC surveillance rates were observed: Only 49% of cirrhosis patients received HCC surveillance within 6 months, and 78% of cirrhosis patients received HCC surveillance within 1 year. Differences in rates of HCC screening by liver disease etiology were observed.

Hepatocellular carcinoma: early-stage management challenges

Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.

Physician-Patient Communication is Associated With Hepatocellular Carcinoma Screening in Chronic Liver Disease Patients

BACKGROUND

Patients with chronic liver disease are at high risk for developing liver cancer. Factors associated with screening awareness and doctor-patient communication regarding liver cancer were examined.

STUDY

Four hundred sixty-seven patients with chronic liver disease at a tertiary-care clinic participated in a phone survey regarding awareness of cancer screening, doctor-patient communication, and health behaviors. Medical records were retrospectively reviewed for data on liver disease etiology and dates of liver imaging tests.

RESULTS

Seventy-nine percent of patients reported awareness of liver cancer screening, and 50% reported talking to their doctor about liver cancer. Patients with higher education, abstinence from alcohol, and liver cirrhosis were more likely to be aware of liver cancer screening (P=0.06, 0.005, <0.0001). Whites, patients with higher education, and those with cirrhosis were more likely to talk to their doctor about liver cancer (P=0.006; P=0.09, <0.0001). Awareness of liver cancer screening (79%) was similar to that of colorectal cancer screening (85%), lower than breast cancer screening (91%), and higher than prostate cancer screening (66%). Patients who were aware of liver cancer screening and reported talking to their doctor about liver cancer were significantly more likely to receive consistent liver surveillance (odds ratio, 4.81; 95% confidence interval, 2.62-8.84 and odds ratio, 1.97; 95% confidence interval, 1.19-3.28, respectively).

CONCLUSIONS

Our study demonstrates the importance of effective physician communication with chronic liver disease patients on the risks of developing liver cancer and the importance of regular screening, especially among nonwhites and patients with lower education.

Early stage hepatocellular carcinoma in the elderly: A SEER database analysis

BACKGROUND

Scarce evidence exists regarding the management of elderly patients (≥70years) with hepatocellular carcinoma (HCC). This study assessed the presentation and outcomes of elderly patients with early stage HCC.

METHODS

Patient with early stage HCC (T1/T2N0M0), ≥70years, diagnosed between 2004 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity score matching (for receipt of localized treatment) was performed considering baseline characteristics (age, gender, race, tumor (T) stage, tumor size, fibrosis score, alpha fetoprotein level and histological subtype).

RESULTS

A total of 6693 patients were identified. The median age group was 75-80years, and 2457 patients received local treatment (either surgical or non-surgical treatment). Both before and after propensity score matching, cancer-specific and overall survival (P<0.0001 for all) were better in the local treatment group. When stratifying the overall survival according to age group (70-80years vs. >80years) in the post matching cohort, patients treated with local treatment have better overall survival than those not treated regardless of the age group (P<0.0001 for both groups). In multivariate analysis of the matched population: local treatment, normal AFP and age (70-80years) were associated with better overall survival (P<0.0001, P<0.0001, P=0.047; respectively).

CONCLUSION

Within the known limitations of the current SEER analysis, it may be cautiously suggested that elderly patients with early HCC should be properly selected for potentially curative local therapies. Prospective confirmation of these results should be conducted.

Role of liver-directed local tumor therapy in the management of hepatocellular carcinoma with extrahepatic metastases: a SEER database analysis

BACKGROUND

This study assessed the prognostic impact of the liver-directed local tumor therapy in the management of hepatocellular carcinoma (HCC) with extrahepatic metastases.

METHODS

Metastatic HCC patients diagnosed between 2004 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity-matched analysis was performed considering baseline characteristics (age, gender, race, histology, TNM stage, site of metastases, fibrosis score and alpha fetoprotein).

RESULTS

A total of 2529 patients were identified. The median age was 65 years, and 151 patients received liver-directed local treatment (either surgical treatment or local destructive treatment). Both before and after propensity score matching, cancer-specific and overall survival (p < 0.0001 for all) were better in the liver-directed local therapy group. When the overall survival was stratified by the type of local treatment (surgical resection versus destructive treatment), both types of treatment improved overall survival (p < 0.0001 for both). In multivariate analysis of the matched population, the only factor correlated with better survival receiving is local therapy (p < 0.0001).

CONCLUSION

This analysis suggests that liver-directed local treatment may play a role -in addition to systemic treatment- in the management of selected patients with metastatic HCC. Further prospective randomized controlled trials are needed to confirm or deny this hypothesis.

Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics

BACKGROUND

We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H).

METHODS

A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models.

RESULTS

We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01).

CONCLUSIONS

Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.

Reappraisal of evidence of microscopic portal vein involvement by hepatocellular carcinoma cells with stratification of tumor size

BACKGROUND

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death internationally, it is necessary to reappraise evidences of HCC cells involving the portal vein, especially considering tumor size.

MATERIALS AND METHODS

Histopathological evidence and dynamic evidences of radiology and cytology from publication were collected and analyzed.

RESULTS

Frequencies of microscopic portal vein involvement (MPVI) and microscopic intrahepatic metastasis (MIM) in resected specimens with single nodule HCC were lower than that of multi nodule HCC, although not significantly. Early HCC (≤1.5 cm) was with extremely low to 0 frequencies of MPVI and MIM. HCC >5 cm showed a tendency of flowing HCC cells into portal vein, which was coincident with significantly high frequency (64.1 %) of MPVI for HCC >5 cm. There were no significant difference of frequencies of MPVI and MIM between groups of tumor ≤2, ≤3, and ≤5 cm.

CONCLUSIONS

Single nodule HCC >5 cm needs anatomic resection and the root of portal vein should be firstly ligated because of tendency of flowing HCC cells into portal vein. For single nodule HCC ≤2 cm, there was a risk of about 16.2 % of MPVI, and a risk of about 16.2-26.4 % of MPVI for those single nodule HCC ≤5 cm, however, there was a risk of extremely low to 0 of MPVI for early HCC (≤1.5 cm). Surgeons have to balance liver reserve and risk of MPVI for HCC ≤5 cm before deciding anatomic or nonanatomic resection.

Molecular targeted therapy in hepatocellular carcinoma: from biology to clinical practice and future

OPINION STATEMENT

Hepatocellular carcinoma (HCC) is one of the most lethal cancers globally, particularly in certain regions of the world. Although the major risk factors for HCC have been identified, the specific mechanisms driving hepatocarcinogenesis remain unclear. Sorafenib is the only systemic therapy that has demonstrated an overall survival benefit in patients with advanced HCC and does so primarily through antiangiogenic activity. However, that actual benefit is still relatively small. Extensive research has focused on targeting dysfunctional molecular pathways in HCC. Despite promising preclinical and early-phase studies, other agents have failed to expand upon the efficacy of sorafenib in large-scale randomized trials. As the development of treatment options in the post-sorafenib setting is ongoing, more efforts are being focused on (1) evaluation of molecular agents targeting pathogenic, HCC-specific pathways; (2) the combination of targeted and cytotoxic therapies in selected subgroups; and (3) the combination of systemic and locoregional therapies in various settings. This article provides a review of recently completed and ongoing studies of molecular targeted agents in HCC, including a brief description of the biologic rationale behind these agents.

Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis

BACKGROUND & AIMS

Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors.

METHODS

Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model.

RESULTS

Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69).

CONCLUSION

By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.

Hepatic radioembolization as a bridge to liver surgery

Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.

Patients with nodular regenerative hyperplasia should be considered for hepatocellular carcinoma screening

The incidence of hepatocellular carcinoma (HCC) appears to be increasing across the globe. Well-established protocols for screening are available, and the most common underlying liver problem associated with the development of HCC is cirrhosis. However, with few exceptions, patients without cirrhosis are generally not screened for HCC. Nodular regenerative hyperplasia (NRH) is not associated with the development of significant fibrosis or impaired liver synthetic function. The major clinical impact of NRH appears to be in the development of portal hypertension. Patients with NRH are also not recommended to undergo routine screening for the development of HCC. This report describes a case of a 44-year-old woman with NRH found to have de novo HCC. Emerging evidence suggest a possible pathogenetic relationship between NRH and HCC. The case described here and our review of the published work suggests that additional studies regarding the epidemiological association between NRH and HCC may change the current notion that NRH is not a premalignant lesion, and further studies assessing the utility of routine screening of NRH patients for HCC should be considered.

Prospective screening increases the detection of potentially curable hepatocellular carcinoma: results in 8,900 high-risk patients

OBJECTIVES

Historically, only 10% of patients with hepatocellular carcinoma (HCC) are diagnosed with early-stage, potentially curable disease. In this study, chronic hepatitis virus-infected patients were prospectively screened to determine: (i) the proportion of patients diagnosed with potentially curable HCC, and (ii) survival following curative therapy.

METHODS

The study included 8900 chronic hepatitis virus-infected patients enrolled in a prospective screening programme, of whom 1335 (15.0%) were infected with hepatitis B virus (HBV), 7120 (80.0%) with hepatitis C virus (HCV), and 445 (5.0%) with both HBV and HCV. Screening was conducted every 6 months and included serum alpha-fetoprotein (AFP) measurement and ultrasonography. Curative treatments included liver transplantation, resection, radiofrequency ablation and/or ethanol injection.

RESULTS

Hepatocellular carcinoma was diagnosed in 765 (8.6%) patients. Of 1602 patients with cirrhosis, 758 (47.3%) developed HCC. Curative treatment was possible in 523 (68.4%) of the 765 HCC patients. Two- and 5-year rates of overall survival in the curative treatment group were 65% and 28%, respectively, compared with 10% and 0% in the advanced disease group (P < 0.001).

CONCLUSIONS

Prospective screening of patients at high risk for the development of HCC increases the proportion of patients diagnosed with potentially curable disease. This may result in an increase in the number of longterm survivors. Screening strategies should focus on patients with chronic HBV or HCV infection who have progressed to cirrhosis because more than 40% of these patients will develop HCC.

Hepatocellular carcinoma in children: epidemiology and the impact of regional lymphadenectomy on surgical outcomes

BACKGROUND

Factors influencing survival in children with HCC have not been studied. The objective of this study was to identify prognostic factors in pediatric HCC, and to determine whether regional lymphadenectomy is associated with improved survival.

METHODS

We performed a retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER) registry. All patients <20 years old diagnosed with HCC from 1973-2009 were included. Disease-specific survival was compared using Kaplan-Meier statistics and Cox proportional-hazards regression.

RESULTS

We identified 238 patients (139 Male: 99 Female). Overall, 112 (47%) received an operation (resection/transplantation). Observed mortality and adjusted hazard of disease-specific death was greater for females (HR=2.07, p=0.013) and older children. Among operative patients, 44% were documented to have a regional lymphadenectomy. Although demographic factors did not differ between lymphadenectomy and non-lymphadenectomy groups, patients who underwent lymphadenectomy had a greater proportion of metastatic disease (24% vs. 15%) and fibrolamellar HCC (53% vs. 31%). Five-year survival for lymphadenectomy patients was superior to non-lymphadenectomy (70% vs. 57%). Adjusted mortality for lymphadenectomy was also improved relative to non-lymphadenectomy (HR=0.26, p=0.013).

CONCLUSIONS

HCC in children is associated with poor survival, especially among children older than 4 years and girls. In surgical candidates, regional lymphadenectomy may be associated with improved survival.

Tumour size and differentiation predict survival after liver resection for hepatocellular carcinoma arising from non-cirrhotic and non-fibrotic liver: a case-controlled study

AIMS

The aims of this study were to assess the outcomes of patients who underwent potentially curative hepatic resection for hepatocellular carcinoma (HCC) in a background of non-cirrhotic/non-fibrotic livers, and to determine prognostic factors that influenced survival.

METHODS

Over a 15-year period, all patients undergoing hepatectomy for HCC were identified. Collated data included demographics, laboratory analysis, operative findings and histo-pathological data. Survival differences between these factors following liver resection were determined.

RESULTS

57 patients were included with a median age of 70 years. The majority of patients underwent a hemi-hepatectomy or more radical resection (n = 37). Overall R0 resection rate was 90.4% (n = 51). The overall morbidity and mortality rates were 26.3% and 3.5%, respectively. The median follow-up period was 28 months. The 1-, 3- and 5- year disease-free survival was 65.4%, 41.8% and 39.1%, and the overall survival was 73.5%, 49.6% and 39.5%, respectively. AFP (p = 0.039) was the only predictor of poorer disease-free survival on univariate analysis. On multi-variable analysis, poorly differentiated tumour and large tumour size were independent predictors of overall survival.

CONCLUSIONS

Liver resection is a feasible treatment option for HCC in non-cirrhotic/non-fibrotic livers with good survival outcome. Tumour size and differentiation are adverse predictors of outcome in these patients.

Surgical resection versus liver transplant for patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is a major worldwide health problem, involving more than half a million new patients yearly, with a different incidence in different parts of the world. Hepatocellular carcinoma develops in about 80% of cirrhotic patients, and cirrhosis is considered the strongest predisposing factor for it. Surgical resection and liver transplantation are conventional treatment modalities that can offer long-term survival for patients with hepatocellular carcinoma.

OBJECTIVES

To assess the benefits and harms of surgical resection compared with those of liver transplantation in patients with hepatocellular carcinoma.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (SCI-EXPANDED) at ISI Web of Science (last search February 2013). We also searched the abstracts from annual meetings of the American Society of Clinical Oncology, the American Association for the Study of Liver Diseases (AASLD), and the European Association for the Study of the Liver (EASL), provided through The Cochrane Hepato-Biliary Group until February 2013.

SELECTION CRITERIA

Randomised clinical trials comparing surgical resection and hepatic transplantation.

DATA COLLECTION AND ANALYSIS

The search strategies were run and two authors individually evaluated whether the retrieved studies fulfilled the inclusion criteria.

MAIN RESULTS

No randomised clinical trials comparing surgical resection and liver transplantation as the major methods of treating hepatocellular carcinoma were found.

AUTHORS' CONCLUSIONS

There are no randomised clinical trials comparing surgical resection and liver transplantation for hepatocellular carcinoma treatment.

Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: effect of patient and nonpatient factors

The delivery of treatment for hepatocellular carcinoma (HCC) could be influenced by the place of HCC diagnosis (hospitalization versus outpatient), subspecialty referral following diagnosis, as well as physician and facility factors. We conducted a study to examine the effect of patient and nonpatient factors on the place of HCC diagnosis, referral, and treatment in Veterans Administration (VA) hospitals in the United States. Using the VA Hepatitis C Clinical Case Registry, we identified hepatitis C virus (HCV)-infected patients who developed HCC during 1998-2006. All cases were verified and staged according to Barcelona Clinic Liver Cancer (BCLC) criteria. The main outcomes were place of HCC diagnosis, being seen by a surgeon or oncologist, and treatment. We examined factors related to these outcomes using hierarchical logistic regression. These factors included HCC stage, HCC surveillance, physician specialty, and facility factors, in addition to risk factors, comorbidity, and liver disease indicators. Approximately 37.2% of the 1,296 patients with HCC were diagnosed during hospitalization, 31.0% were seen by a surgeon or oncologist, and 34.3% received treatment. Being seen by a surgeon or oncologist was associated with surveillance (adjusted odds ratio [aOR] = 1.47; 95% CI: 1.20-1.80) and varied by geography (1.74;1.09-2.77). Seeing a surgeon or oncologist was predictive of treatment (aOR = 1.43; 95% CI: 1.24-1.66). There was a significant increase in treatment among patients who received surveillance (aOR = 1.37; 95% CI: 1.02-1.71), were seen by gastroenterology (1.65;1.21-2.24), or were diagnosed at a transplant facility (1.48;1.15-1.90).

CONCLUSION

Approximately 40% of patients were diagnosed during hospitalization. Most patients were not seen by a surgeon or oncologist for treatment evaluation and only 34% received treatment. Only receipt of HCC surveillance was associated with increased likelihood of outpatient diagnosis, being seen by a surgeon or oncologist, and treatment.

Resection of hepatocellular cancer ≤2 cm: results from two Western centers

Asian series have shown a 5-year survival rate of ≈70% after resection of hepatocellular carcinoma (HCC) ≤2 cm. Western outcomes with resection have not been as good. In addition, ablation of HCC ≤2 cm has been shown to achieve competitive results, leaving the role of resection in these patients unclear. Records of patients undergoing resection at two Western centers between January 1990 and December 2009 were reviewed. Patients with a single HCC ≤2 cm on pathologic analysis were included. Thirty clinical variables including demographics, liver function, tumor characteristics, nature of the surgery, and the surrounding liver were examined. An exploratory statistical analysis was conducted to determine variables associated with recurrence and survival. The study included 132 patients with a median follow-up of 37.5 months. There was one (<1%) 90-day mortality. There were 32 deaths with a median survival of 74.5 months and a 5-year survival rate of 70% (63% in patients with cirrhosis). The median time to recurrence was 31.6 months and the 5-year recurrence rate was 68%. Presence of satellites (hazard ratio [HR], 2.46; P = 0.031) and platelet count <150,000/μL (HR, 2.37; P = 0.026) were independently associated with survival. Presence of satellites (HR, 2.79; P = 0.003), cirrhosis (HR, 2.3; P = 0.010), and nonanatomic resection (HR, 1.79; P = 0.031) were independently associated with recurrence. Patients with a single HCC ≤2 cm and platelet count ≥150,000/μL achieved a median survival of 138 months and a 5-year survival rate of 8%, respectively.

CONCLUSION

Resection of HCC ≤2 cm is safe and achieves excellent results in Western centers. Recurrence continues to be a significant problem. Presence of satellites, platelet count, anatomic resection, and cirrhosis are associated with outcomes after resection, even among such early tumors. Resection should continue to be considered a primary treatment modality in patients with small HCC and well-preserved liver function.

Proton therapy for hepatocellular carcinoma

Proton radiotherapy has seen an increasing role in the treatment of hepatocellular carcinoma (HCC). Historically, external beam radiotherapy has played a very limited role in HCC due to a high incidence of toxicity to surrounding normal structures. The ability to deliver a high dose of radiation to the tumor is a key factor in improving outcomes in HCC. Advances in photon radiotherapy have improved dose conformity and allowed dose escalation to the tumor. However, despite these advances there is still a large volume of normal liver that receives a considerable radiation dose during treatment. Proton beams do not have an exit dose along the beam path once they enter the body. The inherent physical attributes of proton radiotherapy offer a way to maximize tumor control via dose escalation while avoiding excessive radiation to the remaining liver, thus increasing biological effectiveness. In this review we discuss the physical attributes and rationale for proton radiotherapy in HCC. We also review recent literature regarding clinical outcomes of using proton radiotherapy for the treatment of HCC.

Survival after diagnosis of hepatocellular carcinoma and potential impact of treatment in a hepatitis B or C infected cohort

AIM

  Little is known about the patterns of care and the impact of hepatocellular carcinoma (HCC) treatment on health outcomes at a population level. We conducted a population-based cohort study to examine HCC survival trends among people diagnosed with hepatitis B (HBV) or hepatitis C virus (HCV) infection, to determine predictors of receiving potentially curative therapy for HCC, and to examine the impact of HCC treatment on survival in New South Wales, Australia.

METHODS

  The Kaplan-Meier method was used to estimate survival, logistic regression to determine predictors of potentially curative therapy and Cox proportional hazards models to determine the impact of HCC treatment on survival. Years of potential life lost (YPLL) were calculated.

RESULTS

  During the period 1993-2007, 1081 cases of HCC were diagnosed. Median survival increased from 10.4 months during 1993-1997 to 18.4 months during 1998-2002, with no further improvement thereafter. Younger age at diagnosis (<65 years), being Asian-born and having multiple comorbid conditions increased the odds of receiving curative therapy. The effect of HCC treatment on the risk of mortality was similar between the HBV- and HCV-related HCC groups. Tumor-specific therapies had adjusted hazard ratios ranging 0.06-0.25 and palliative/supportive therapy alone had adjusted hazard ratios ranging 0.76-1.08. The average YPLL per person was 23.3.

CONCLUSION

  The burden of viral hepatitis-related HCC is substantial. Despite treatment advances in recent years, there has been no significant improvement in HCC survival. Efforts to improve HCC screening and early diagnosis are required to deliver curative treatment which clearly has a survival advantage.

Hepatocellular carcinoma screening in a hepatitis B virus-infected Korean population

BACKGROUND

Hepatocellular carcinoma (HCC) screening has been recommended for hepatitis B virus (HBV)-infected individuals in an effort to detect HCC at a sufficiently early stage to provide potentially curative treatments. The study reported here is the first to address the rate of HCC screening use in an HBV endemic area.

METHODS

Data were collected from 11,147 adults aged ≥40 years who participated in the 2007-2009 Korea National Health and Nutrition Examination Survey and had a valid HBV surface antigen test. Current HCC screening was defined as either receiving an ultrasonography or an α-fetoprotein measurement in the past year. Prevalence estimates were weighted.

RESULTS

The response rate was 78.4 %, and 436 cases of HBV infection were identified. The overall seroprevalence of the HBV surface antigen was 4.1 % [95 % confidence interval (CI) 3.9-4.4 %]. Of the 436 HBV-infected subjects, only 23.2 % (95 % CI 19.5 -27.4 %) were aware that they had been infected, and approximately 27 % (27.1 %; 95 %CI 23.2-to 31.5 %) were up to date with their HCC screening tests; more than half (52.9 %, 95 % CI 48.2-57.5) had never been screened. In a multivariate analysis that included various sociodemographic variables, only self-reported awareness of HBV infection was significantly associated with current HCC screening tests (odds ratio 2.82; 95 % CI 1.64-4.84).

CONCLUSIONS

Adoption of HCC screening as a standard practice among HBV-infected Korean adults aged ≥40 years is suboptimal. Evidence-based programs in communities and education for both healthcare providers and HBV-infected persons are needed to improve the implementation of HCC screening in clinical practice.

Potentially curative treatment in patients with hepatocellular cancer--results from the liver cancer research network

BACKGROUND

The extent to which potentially curative therapies are used in patients with hepatocellular cancer (HCC) and their related outcomes are unknown in the US.

AIM

To determine the rate and outcomes of potentially curative treatment in patients with HCC.

METHODS

Eleven US centers followed patients with HCC between 2001 and 2007. We determined rates of liver transplantation, surgical resection, or tumour ablation during follow-up, examined differences in adjusted survival of patients receiving these treatments, and determined the factors associated with receipt of potentially curative treatment.

RESULTS

Of the 267 patients, 76 (28%) patients had early HCC, defined as Child A or B cirrhosis, with a solitary HCC or ≤ 3 nodules, each ≤ 3 cm. Of these, 53 (69.7%) received curative treatment. Thirty six percent of patients with non-early HCC received curative treatment. Compared to patients with non-early HCC who did not receive curative treatment, patients with early HCC and curative treatment had the best survival [hazard ratio, HR = 0.19 (95% CI, 0.08-0.42)] followed by patients with advanced HCC who received curative treatment [HR = 0.37 (95% CI, 0.22-0.64)]. Baseline performance status was significantly associated with receipt of curative treatment as well as survival after adjusting for demographics, clinical characteristics, and HCC stage.

CONCLUSIONS

In this multicenter database, most of the patients with early HCC received potentially curative treatment. However, only 28% of patients had early HCC. One-third of patients with non-early HCC also underwent curative therapy. Potentially curative treatment improved survival and this effect was seen in patients with early as well as non-early HCC.

Epidemiology and surveillance of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most frequently occurring malignancies and has a high mortality rate. The incidence of HCC differs greatly according to the geographic area. East and Southeast Asia, as well as middle and West Africas have the highest prevalence of HCC. The risk factors for developing HCC are well known and include cirrhosis, hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, alcohol consumption, smoking, diabetes, and nonalcoholic steatohepatitis. Cirrhosis is the most significant risk factor, and there is a correlation between the degree of noninvasively measured liver fibrosis and the risk of HCC occurrence. HBV exerts carcinogenic effects by several mechanisms, including host genome integration, and studies have revealed that HBV replication predicts HCC development. HCV induces multistep carcinogenesis from inflammation, to fibrosis and liver cancer. HCC is an appropriate target for surveillance programs for early cancer detection. Currently, liver ultrasonography (US) combined with serum alpha-fetoprotein (AFP, a biomarker of HCC) measurement every 6 months is the standard method of HCC surveillance. Although US is the most widely used tool, its sensitivity in detecting early HCC (i.e., within the Milan criteria) during surveillance is only 63%. AFP is the representative biomarker for both HCC surveillance and diagnosis; however, the unsatisfactory performance of AFP as a surveillance tool means that a novel biomarker or combination with other serum markers is required. Des-gamma-carboxy prothrombin and AFP-L3 are candidate biomarkers that are complementary to AFP. The strategies of HCC surveillance vary in different countries according to the healthcare system, the resources available, and health insurance coverage. Many studies have shown that the rate of early cancer detection and rate of application of curative therapies were increased, as was the survival time, by HCC surveillance, which should now become a part of standard care, rather than just a recommendation. Improved US technology and the discovery of new biomarkers are necessary to make further progress in HCC surveillance.

Current opinion on the role of resection and liver transplantation for hepatocellular cancer

Hepatocellular carcinoma (HCC) represents one of the most common cancers worldwide with rising incidence in developed countries. The best treatment options with curative intent for patients with HCC are liver resection or transplantation, although the role of hepatic ablative therapies has also been recognized. Surgical resection has emerged as the primary treatment in carefully selected patients of HCC. With the advances in surgical and radiological techniques, the perioperative mortality has been reduced to less than 5 % depending on the extent of resection and hepatic reserve. The role of liver transplantation (LT) as the mainstay of treatment for the majority of patients with HCC has evolved in the last few decades. Historically, the Milan criteria have been considered the gold standard for selecting patients; more expanded selection criteria to include those with more advanced tumors have been implemented in recent years. Living donor liver transplantation (LDLT) has emerged as a way to expand the donor pool and has influenced the role of transplantation for HCC, especially in communities with little access to cadaveric transplantation. Salvage transplantation is an alternative option as it allows a window for the biologically less favorable lesions to declare tumor behavior. Salvage transplantation also decreases the burden on transplant resources. Sirolimus, a novel immunosuppressant drug with anti-tumor effect, may have a role in limiting the severity of recurrent disease after transplantation for HCC, and play an important role in the future management of transplant recipients. This article examines the literature on current status of management of HCC.

Hepatocellular carcinoma screening rates vary by etiology of cirrhosis and involvement of gastrointestinal sub-specialists

BACKGROUND

Regular screening of cirrhotic patients for hepatocellular carcinoma (HCC) has been suboptimal, but there is little data regarding specific risk factors for reduced screening.

METHODS

From 1996 to 2010, patients with cirrhosis were retrospectively identified from outpatient gastroenterology and primary care practices. Data was obtained from the diagnosis of cirrhosis until the time of elevated alpha-fetoprotein (AFP) or lesion suspicious for HCC, death, liver transplantation, or end of the data collection period. Recommended screening was defined as abdominal imaging (ultrasound, contrast-enhanced CT, or MRI) with or without serum alpha-fetoprotein (AFP) at least once every 12 months based on professional guidelines.

RESULTS

One hundred fifty-six patients with cirrhosis were identified. The etiologies of cirrhosis were viral hepatitis (n = 65), alcohol (n = 40), non-alcoholic steatohepatitis (NASH) (n = 27), and non-viral, non-alcoholic, non-NASH cirrhosis (n = 24). Of the 156 patients, 51% received recommended screening for HCC. Patients with NASH cirrhosis received recommended screening significantly less (p = 0.016) than cirrhotics with viral hepatitis, alcoholic cirrhosis, or non-viral, non-alcoholic, non-NASH cirrhosis and were less likely to receive gastroenterology referral (p < 0.001). Additionally, 20 patients were diagnosed with cirrhosis incidentally during a surgical procedure. These patients were significantly less likely to receive recommended HCC screening than those diagnosed non-surgically (10.0 vs. 56.6%; p < 0.001). Screening was significantly more likely to occur in patients seen regularly by a gastrointestinal subspecialist (66.7 vs. 22.8%; p < 0.001).

CONCLUSIONS

Patients with NASH cirrhosis and incidentally discovered cirrhosis have low rates of HCC screening and are referred less often to gastroenterologists. These data suggest a need for increased education about NASH cirrhosis and better systems of communication among general practitioners, surgeons, and gastroenterologists.

Molecular targets and oxidative stress biomarkers in hepatocellular carcinoma: an overview

Hepatocellular carcinoma (HCC) is a complex and heterogeneous tumor with multiple genetic aberrations. Several molecular pathways involved in the regulation of proliferation and cell death are implicated in the hepatocarcinogenesis. The major etiological factors for HCC are both hepatitis B virus (HBV) and hepatitis C virus infection (HCV). Continuous oxidative stress, which results from the generation of reactive oxygen species (ROS) by environmental factors or cellular mitochondrial dysfunction, has recently been associated with hepatocarcinogenesis. On the other hand, a distinctive pathological hallmark of HCC is a dramatic down-regulation of oxido-reductive enzymes that constitute the most important free radical scavenger systems represented by catalase, superoxide dismutase and glutathione peroxidase. The multikinase inhibitor sorafenib represents the most promising target agent that has undergone extensive investigation up to phase III clinical trials in patients with advanced HCC. The combination with other target-based agents could potentiate the clinical benefits obtained by sorafenib alone. In fact, a phase II multicenter study has demonstrated that the combination between sorafenib and octreotide LAR (So.LAR protocol) was active and well tolerated in advanced HCC patients. The detection of molecular factors predictive of response to anti-cancer agents such as sorafenib and the identification of mechanisms of resistance to anti-cancer agents may probably represent the direction to improve the treatment of HCC.

Therapeutic options for intermediate-advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies, ranking the sixth in the world, with 55% of cases occurring in China. Usually, patients with HCC did not present until the late stage of the disease, thus limiting their therapeutic options. Although surgical resection is a potentially curative modality for HCC, most patients with intermediate-advanced HCC are not suitable candidates. The current therapeutic modalities for intermediate-advanced HCC include: (1) surgical procedures, such as radical resection, palliative resection, intraoperative radiofrequency ablation or cryosurgical ablation, intraoperative hepatic artery and portal vein chemotherapeutic pump placement, two-stage hepatectomy and liver transplantation; (2) interventional treatment, such as transcatheter arterial chemoembolization, portal vein embolization and image-guided locoregional therapies; and (3) molecularly targeted therapies. So far, how to choose the therapeutic modalities remains controversial. Surgeons are faced with the challenge of providing the most appropriate treatment for patients with intermediate-advanced HCC. This review focuses on the optional therapeutic modalities for intermediate-advanced HCC.

Current approaches to the treatment of early hepatocellular carcinoma

For patients with early-stage hepatocellular carcinoma (HCC), potentially curative treatment options exist, including liver transplantation, surgical resection, and ablation therapy. These treatments are associated with survival benefits, and outcomes are optimized by identification of appropriate patients. However, further studies are needed to definitively confirm optimal treatment approaches for all patients. Treatment patterns vary in different parts of the world as a result of geographic differences in the incidence and presentation of the disease. In particular, because of successful screening programs, a high proportion of tumors that are identified in Japan are amenable to curative treatments, which are appropriate in a smaller proportion of patients in the west, although screening is now widely carried out in industrialized countries. Differences in the applicability of transplantation are also evident between the west and Asia. Although existing treatments for early-stage HCC are supported by considerable evidence, there remain significant data gaps. For example, further data, ideally from randomized controlled trials, are needed regarding: the use of neoadjuvant and adjuvant therapy to decrease the rate of recurrence after resection or ablation, further investigation of the role of chemoprevention following resection, and prospective analysis of outcomes of living donor compared with deceased donor liver transplantation.

Herbal compound "Songyou Yin" reinforced the ability of interferon-alfa to inhibit the enhanced metastatic potential induced by palliative resection of hepatocellular carcinoma in nude mice

Background

Liver resection is a widely accepted treatment for hepatocellular carcinoma (HCC). Our previous clinical study showed that the rate of palliative resection was 34.0% (1958-2008, 2754 of 8107). However, the influence of palliative resection on tumor metastasis remains controversial. The present study was conducted to evaluate the effect of palliative resection on residual HCC and to explore interventional approaches.

Methods

Palliative resection was done in an orthotopic nude mice model of HCC (MHCC97H) with high metastatic potential. Tumor growth, invasion, metastasis, lifespan, and some molecular alterations were examined in vivo and in vitro. Mice that underwent palliative resection were treated with the Chinese herbal compound "Songyou Yin," interferon-alfa-1b (IFN-α), or their combination to assess their effects.

Results

In the palliative resection group, the number of lung metastatic nodules increased markedly as compared to the sham operation group (14.3 ± 4.7 versus 8.7 ± 3.6, P < 0.05); tumor matrix metalloproteinase 2 (MMP2) activity was elevated by 1.4-fold, with up-regulation of vascular endothelial growth factor (VEGF) and down-regulation of tissue inhibitor of metalloproteinase 2 (TIMP2). The sera of mice undergoing palliative resection significantly enhanced cell invasiveness by 1.3-fold. After treatment, tumor volume was 1205.2 ± 581.3 mm³, 724.9 ± 337.6 mm³, 507.6 ± 367.0 mm³, and 245.3 ± 181.2 mm³ in the control, "Songyou Yin," IFN-α, and combination groups, respectively. The combined therapy noticeably decreased the MMP2/TIMP2 ratio and prolonged the lifespan by 42.2%. Moreover, a significant (P < 0.001) reduction of microvessel density was found: 43.6 ± 8.5, 34.5 ± 5.9, 23.5 ± 5.6, and 18.2 ± 8.0 in the control and treatment groups, respectively.

Conclusion

Palliative resection-stimulated HCC metastasis may occur, in part, by up-regulation of VEGF and MMP2/TIMP2. "Songyou Yin" reinforced the ability of IFN-α to inhibit the metastasis-enhancing potential induced by palliative resection, which indicated its potential postoperative use in patients with HCC.

Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States

Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended but may not be performed. The extent and determinants of HCC surveillance are unknown. We conducted a population-based United States cohort study of patients over 65 years of age to examine use and determinants of prediagnosis surveillance in patients with HCC who were previously diagnosed with cirrhosis. Patients diagnosed with HCC during 1994-2002 were identified from the linked Surveillance, Epidemiology, and End-Results registry-Medicare databases. We identified alpha-fetoprotein (AFP) and ultrasound tests performed for HCC surveillance, and examined factors associated with surveillance. We identified 1,873 HCC patients with a prior diagnosis of cirrhosis. In the 3 years before HCC, 17% received regular surveillance and 38% received inconsistent surveillance. In a subset of 541 patients in whom cirrhosis was recorded for 3 or more years prior to HCC, only 29% received routine surveillance and 33% received inconsistent surveillance. Among all patients who received regular surveillance, approximately 52% received both AFP and ultrasound, 46% received AFP only, and 2% received ultrasound only. Patients receiving regular surveillance were more likely to have lived in urban areas and had higher incomes than those who did not receive surveillance. Before diagnosis, approximately 48% of patients were seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation; they were approximately 4.5-fold and 2.8-fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. Geographic variation in surveillance was observed and explained by patient and physician factors.

CONCLUSION

Less than 20% of patients with cirrhosis who developed HCC received regular surveillance. Gastroenterologists/hepatologists or physicians with an academic affiliation are more likely to perform surveillance.

Adaptive management of liver cancer radiotherapy

Adaptive radiation therapy for liver cancer has the potential to reduce normal tissue complications and enable dose escalation, allowing the potential for tumor control in this challenging site. Using adaptive techniques to tailor treatment margins to reflect patient-specific breathing motions and image-guidance techniques can reduce the high dose delivered to surrounding normal tissues while ensuring that the prescription dose is delivered to the tumor. Several treatment planning and delivery techniques have been developed for use in the liver, including a margin to encompass the full breathing motion, mean position techniques, which evaluate the probability of tumor location during breathing, breath hold, gating, and tracking. Patient selection, clinical workflow, and quality assurance must be considered and developed before integrating these techniques into clinical practice.

Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States

BACKGROUND

Racial, ethnic, and socioeconomic disparities in the survival of patients with hepatocellular carcinoma (HCC) continue to exist. The authors of this report hypothesized that these differences result from inequities in access to care and in response to therapy.

METHODS

Patients with HCC (n = 20,920) were identified from the Surveillance, Epidemiology, and End Results (SEER) database, and patients who underwent liver transplantation for HCC (n = 4735) were identified from the United Network for Organ Sharing (UNOS) database. Clinical and pathologic factors were compared after patients were stratified by race and ethnicity.

RESULTS

The survival of patients with HCC improved over time for all racial, ethnic, and income groups (P < .001). Black and low income individuals had the poorest long-term survival (P < .001). On multivariate analysis, black race was predictive of the poorest survival (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09-1.22; P < .001), whereas Asian race was associated with the best survival (HR, 0.87; 95% CI, 0.83-0.91; P < .001). After liver transplantation, black patients had the worst graft survival and overall survival (median survival [MS], 30.5 months and 39.7 months, respectively; P < .001), whereas Hispanics had the best survival (MS, 83.4 months and 86.6 months, respectively; P < .001). In a multivariate analysis of transplantation patients, race and ethnicity were associated significantly with outcome.

CONCLUSIONS

Significant racial and ethnic disparities in the outcome of patients with HCC persist despite the receipt of comparable treatment. The authors concluded that further investigations are warranted to identify the reasons for the stark disparity in outcomes between black patients and Hispanic patients after liver transplantation for HCC.

Blockade of Wnt-1 signaling leads to anti-tumor effects in hepatocellular carcinoma cells

BACKGROUND

Hepatocellular carcinoma (HCC) is an aggressive cancer, and is the third leading cause of cancer death worldwide. Standard therapy is ineffective partly because HCC is intrinsically resistant to conventional chemotherapy. Its poor prognosis and limited treatment options make it critical to develop novel and selective chemotherapeutic agents. Since the Wnt/beta-catenin pathway is essential in HCC carcinogenesis, we studied the inhibition of Wnt-1-mediated signaling as a potential molecular target in HCC.

RESULTS

We demonstrated that Wnt-1 is highly expressed in human hepatoma cell lines and a subgroup of human HCC tissues compared to paired adjacent non-tumor tissues. An anti-Wnt-1 antibody dose-dependently decreased viability and proliferation of Huh7 and Hep40 cells over-expressing Wnt-1 and harboring wild type beta-catenin, but did not affect normal hepatocytes with undetectable Wnt-1 expression. Apoptosis was also observed in Huh7 and Hep40 cells after treatment with anti-Wnt-1 antibody. In these two cell lines, the anti-Wnt-1 antibody decreased beta-catenin/Tcf4 transcriptional activities, which were associated with down-regulation of the endogenous beta-catenin/Tcf4 target genes c-Myc, cyclin D1, and survivin. Intratumoral injection of anti-Wnt-1 antibody suppressed in vivo tumor growth in a Huh7 xenograft model, which was also associated with apoptosis and reduced c-Myc, cyclin D1, and survivin expressions.

CONCLUSION

Our results suggest that Wnt-1 is a survival factor for HCC cells, and that the blockade of Wnt-1-mediated signaling may offer a potential pathway-specific therapeutic strategy for the treatment of a subgroup of HCC that over-expresses Wnt-1.

Survival differences by race/ethnicity and treatment for localized hepatocellular carcinoma within the United States

Racial differences among hepatocellular carcinoma survival have been reported, but the etiology behind these disparities remains unclear. Using multi-variable logistic regression analysis, our restrospective cohort study investigated the demographic disparities in survival among localized hepatocellular carcinoma in the United States. From 1998 to 2001, 2,776 cases of localized hepatocellular carcinoma were identified. Significant racial/ethnic disparities in overall survival and utilization of therapies were identified. Compared with non-Hispanic white males, black females were 56% less likely to survive 3 years (OR 0.44; 95% CI 0.21-0.93). Treatment-specific models also demonstrated disparities, e.g., compared with non-Hispanic whites, Asians receiving transplantation were 77% more likely to survive 3 years (OR, 1.77; 95% CI 1.28-2.44). There are significant racial/ethnic disparities in 3-year survival among patients with localized hepatocellular carcinoma. These differences are partially explained by demographic differences in utilization of therapy and in stage-specific survival for each therapy.

Current management strategy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) still remains a considerable challenge for surgeons. Surgery, including liver transplantation, is the most important therapeutic approach for patients with this disease. HCC is frequently diagnosed at advanced stages and has a poor prognosis with a high mortality rate even when surgical resection has been considered potentially curative. This brief report summarizes the current status of the management of this malignancy and includes a short description of new pharmacological approaches in HCC treatment.

Prognostic determinants for survival after resection/ablation of a large hepatocellular carcinoma

BACKGROUND

Liver resection of large hepatocellular carcinomas (HCC), measuring at least 10 cm remains a controversial debate. Multiple studies on HCCs treated with surgical resection and/or ablation had shown variable results with 5-year survival rates ranging from 0% to 54.0%. The aim of this study was to evaluate the survival of patients with HCCs measuring at least 10 cm and to identify the potential prognostic variables affecting the outcome.

METHODS

Retrospective analysis was performed on the prospectively updated HCC database. A total of 44 patients with tumours measuring 10 cm or more were 'curatively' treated with surgical resection with or without ablation. Patient demographics, clinical, surgical, pathology and survival data were collected and analysed.

RESULTS

Thirty-one patients received surgical resection alone. Thirteen other patients were treated with a combination of surgical resection and ablation. The median follow-up duration was 14.5 months. The overall median survival at 1, 3 and 5 years were 66.4%, 38.1% and 27.8%, respectively. The median time to tumour recurrence was 10.7 months and the 1, 3 and 5-year disease-free survival were 49.6%, 23.9% and 19.1%, respectively. Univariate analysis demonstrated cirrhosis, microvascular invasion, poor tumour differentiation and ethnicity to adversely affect survival. For overall survival, only cirrhosis, poor tumour differentiation and ethnicity were significant on multivariate analysis. Portal vein tumour thrombus, microvascular invasion and ethnicity were identified on univariate analysis to significantly affect disease-free survival.

CONCLUSION

Surgical treatment offers good survival to patients with large HCCs (> or = 10 cm). Both cirrhosis and poor tumour differentiation are independent variables prognostic of adverse survival.