Impact of Steatosis on Prognosis of Patients with Early-Stage Hepatocellular Carcinoma After Hepatic Resection

Conventional and machine learning-based risk scores for patients with early-stage hepatocellular carcinoma

BACKGROUND/AIMS

The performance of machine learning (ML) in predicting the outcomes of patients with hepatocellular carcinoma (HCC) remains uncertain. We aimed to develop risk scores using conventional methods and ML to categorize early-stage HCC patients into distinct prognostic groups.

METHODS

The study retrospectively enrolled 1,411 consecutive treatment-naïve patients with the Barcelona Clinic Liver Cancer (BCLC) stage 0 to A HCC from 2012 to 2021. The patients were randomly divided into a training cohort (n=988) and validation cohort (n=423). Two risk scores (CATS-IF and CATS-INF) were developed to predict overall survival (OS) in the training cohort using the conventional methods (Cox proportional hazards model) and ML-based methods (LASSO Cox regression), respectively. They were then validated and compared in the validation cohort.

RESULTS

In the training cohort, factors for the CATS-IF score were selected by the conventional method, including age, curative treatment, single large HCC, serum creatinine and alpha-fetoprotein levels, fibrosis-4 score, lymphocyte-tomonocyte ratio, and albumin-bilirubin grade. The CATS-INF score, determined by ML-based methods, included the above factors and two additional ones (aspartate aminotransferase and prognostic nutritional index). In the validation cohort, both CATS-IF score and CATS-INF score outperformed other modern prognostic scores in predicting OS, with the CATSINF score having the lowest Akaike information criterion value. A calibration plot exhibited good correlation between predicted and observed outcomes for both scores.

CONCLUSION

Both the conventional Cox-based CATS-IF score and ML-based CATS-INF score effectively stratified patients with early-stage HCC into distinct prognostic groups, with the CATS-INF score showing slightly superior performance.

Prognostic Nutritional Index as a Prognostic Factor for Very Early-Stage Hepatocellular Carcinoma

INTRODUCTION

Field factors play more important roles in predicting the outcomes of patients compared with tumor factors in early-stage hepatocellular carcinoma (HCC). However, the prognostic ability of noninvasive serum marker scores for hepatic fibrosis and liver functional reserve on very early-stage HCC is still not yet determined. We aimed to investigate the performance of these serum marker scores in predicting the prognoses of patients with very early-stage HCC.

METHODS

A total of 446 patients with very early-stage HCC from 2012 to 2022 were retrospectively enrolled. Serum biomarkers and prognostic scores determining overall survival (OS) were analyzed by Cox proportional hazards model. We compared the Akaike information criterion among the prognostic nutritional index (PNI), aspartate aminotransferase-to-platelet ratio index, albumin-bilirubin (ALBI) score, EZ (easy)-ALBI score, modified ALBI score, fibrosis-4 score, and lymphocyte-to-monocyte ratio to determine the predictability on the OS.

RESULTS

After a median follow-up of 41.0 months (interquartile range 36.9-45.1 months), 81 patients died, with a 5-year OS rate of 71.0%. Among the noninvasive serum marker scores, PNI had the best performance in predicting the OS with the lowest Akaike information criterion (846.407) compared with other scores. Moreover, we stratified the patients into high-risk (PNI <45) and low-risk (PNI ≥45) groups. It showed that the 5-year OS rates were 83.4% and 60.8% in the low-risk and high-risk PNI groups, respectively ( P < 0.001).

DISCUSSION

PNI had the best performance in predicting the OS for patients with very early-stage HCC.

Impact of Thrombocytopenia on Survival in Patients with Hepatocellular Carcinoma: Updated Meta-Analysis and Systematic Review

BACKGROUND

Platelets (PLT) have a role in the pathogenesis, progression, and prognosis of hepatocellular carcinoma (HCC) and could represent a readily measurable laboratory parameter to enhance the comprehensive evaluation of HCC patients.

METHODS

The PubMed, Web of Science, and Scopus databases were searched with a focus on survival as well as patient and tumor-specific characteristics in correlation to reported PLT counts. Survival outcomes were analyzed with both common-effect and random-effects models. The hazard ratio (HR) and its 95% confidence interval (CI) from analyzed trials were incorporated. Studies that did not provide survival data but focused on platelet count correlation with HCC characteristics were reviewed.

RESULTS

In total, 26 studies, including a total of 9403 patients, met our criteria. The results showed that thrombocytopenia in HCC patients was associated with poor overall survival (common-effect HR = 1.15, 95% CI: 1.06-1.25; random-effect HR = 1.30, 95% CI: 1.05-1.63). Moreover, three studies reveal significant correlations between PLT indices and tumor characteristics such as size, foci number, and etiology of HCC development.

CONCLUSION

Our meta-analysis confirmed that PLT count could act as a prognostic marker in HCC, especially with a PLT count cut off <100 × 103/mm3. Further prospective studies focusing on the role of PLT in clearly defined subgroups are necessary.

Novel predictive nomograms based on aspartate aminotransferase‑to‑platelet ratio index for hepatocellular carcinoma with post‑operative adjuvant transarterial chemoembolization

The clinical significance of systemic inflammation assessed with laboratory analysis of blood samples has been validated in a variety of cancers. The present study was conducted to investigate prognostic significance of preoperative aspartate aminotransferase-to-platelet ratio index (APRI) for the outcome of hepatocellular carcinoma (HCC) patients receiving post-operative adjuvant transarterial chemoembolization (PATACE). A total of 201 patients who underwent PATACE were retrospectively analyzed. A nomogram for HCC was developed using predictors based on multivariate Cox models, and bootstrapping was performed for validation. According to the ROC curve, which was used to divide patients into two cohorts: High APRI group (APRI>1.02) and Low APRI group (APRI≤1.02). In subgroup survival analysis, patients with a relatively low APRI had significantly longer disease-free survival (DFS) and overall survival (OS) than patients with a relatively high APRI, regardless of Barcelona Clinic Liver Cancer (BCLC) stages (BCLC 0/A or BCLC B/C, both P<0.05); while in China liver cancer staging I/II and TNM I/II stage patients, relatively low APRI was associated with improved DFS and OS (both P<0.05). Multivariate Cox models demonstrated that APRI and BCLC stages were independent prognostic factors of DFS and OS (both P<0.05). Nomograms for DFS and OS were constructed, respectively. Calibration curve analysis showed that the standard curve fitted well with the predicted curve. Time-receiver operating characteristic curve analysis revealed that the nomogram had high efficiency. Decision curve analysis demonstrated the high clinical value of the nomogram. APRI is an independent prognostic factor of DFS and OS in HCC patients receiving PATACE, and the combination of APRI with the HCC staging system can refine risk stratification to provide a more accurate prognostic assessment for the outcome of patients receiving PATACE.

Nonalcoholic steatohepatitis-related hepatocellular carcinoma: pathogenesis and treatment

Nonalcoholic fatty liver disease (NAFLD), including its more severe manifestation, nonalcoholic steatohepatitis (NASH), has a global prevalence of 20-25% and is a major public health problem. Its incidence is increasing in parallel to the rise in obesity, diabetes and metabolic syndrome. Progression from NASH to NASH-related hepatocellular carcinoma (HCC) (~2% of cases per year) is influenced by many factors, including the tissue and immune microenvironment, germline mutations in PNPLA3, and the microbiome. NASH-HCC has unique molecular and immune traits compared with other aetiologies of HCC and is equally prevalent in men and women. Comorbidities associated with NASH, such as obesity and diabetes mellitus, can prevent the implementation of potentially curative therapies in certain patients; nonetheless, outcomes are similar in patients who receive treatment. NASH-HCC at the early to intermediate stages is managed with surgery and locoregional therapies, whereas advanced HCC is treated with systemic therapies, including anti-angiogenic therapies and immune-checkpoint inhibitors. In this Review, we present the latest knowledge of the pathogenic mechanisms and clinical management of NASH-HCC. We discuss data highlighting the controversy over varying responses to immune-checkpoint inhibitors according to underlying aetiology and suggest that the future of NASH-HCC management lies in improved surveillance, targeted combination therapies to overcome immune evasion, and identifying biomarkers to recognize treatment responders.

Entecavir versus tenofovir on prognosis of hepatitis B virus-related hepatocellular carcinoma after curative hepatectomy

BACKGROUND

There is still controversy about whether tenofovir disoproxil fumarate (TDF) and entecavir (ETV) have different effects on the outcomes of patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC).

AIMS

The aim of this study was to compare the prognoses between ETV and TDF treatment among patients with HBV-related HCC after hepatectomy.

METHODS

An analysis was done on data from the Taiwan Cancer Registry, which was linked to Taiwan National Health Insurance Research Database, for the years 2011-2016. We identified 7107 patients with HBV-related HCC after curative hepatectomy, and 25.3% of them used ETV or TDF after surgery. After propensity score overlap weighting, 1797 patients treated with ETV (n = 1365) or TDF (n = 432) were included for analyses. Cox proportional hazards models were used to compare the efficacy of ETV and TDF for recurrence and overall survival (OS).

RESULTS

After hepatectomy, the recurrence rate per 100 person-years was 14.87 for the ETV group and 9.25 for the TDF group. The risk of recurrence was similar in the TDF group and the ETV group (HR [95% CI]: 0.91 [0.69-1.19; p = 0.479]), as was the risk of all-cause mortality (HR [95% CI]: 0.67 [0.42-1.07]; p = 0.091). When considering early recurrence (<2 years) and late recurrence (≧2 years), the TDF and ETV groups showed no significant differences. Subgroup analyses and sensitivity analyses demonstrated consistent results.

CONCLUSION

Both TDF and ETV showed similar health benefits in terms of recurrence and OS in patients with HBV-related HCC patients after hepatectomy.

Optical Biomedical Imaging Reveals Criteria for Violated Liver Regenerative Potential

To reduce the risk of post-hepatectomy liver failure in patients with hepatic pathologies, it is necessary to develop an approach to express the intraoperative assessment of the liver's regenerative potential. Traditional clinical methods do not enable the prediction of the function of the liver remnant. Modern label-free bioimaging, using multiphoton microscopy in combination with second harmonic generation (SHG) and fluorescence lifetime imaging microscopy (FLIM), can both expand the possibilities for diagnosing liver pathologies and for assessing the regenerative potential of the liver. Using multiphoton and SHG microscopy, we assessed the structural state of liver tissue at different stages of induced steatosis and fibrosis before and after 70% partial hepatectomy in rats. Using FLIM, we also performed a detailed analysis of the metabolic state of the hepatocytes. We were able to determine criteria that can reveal a lack of regenerative potential in violated liver, such as the presence of zones with reduced NAD(P)H autofluorescence signals. Furthermore, for a liver with pathology, there was an absence of the jump in the fluorescence lifetime contributions of the bound form of NADH and NADPH the 3rd day after hepatectomy that is characteristic of normal liver regeneration. Such results are associated with decreased intensity of oxidative phosphorylation and of biosynthetic processes in pathological liver, which is the reason for the impaired liver recovery. This modern approach offers an effective tool that can be successfully translated into the clinic for express, intraoperative assessment of the regenerative potential of the pathological liver of a patient.

Tenofovir versus entecavir for tertiary prevention of hepatocellular carcinoma in chronic hepatitis B infection after curative therapy: A systematic review and meta-analysis

Entecavir (ETV) and Tenofovir disoproxil fumarate (TDF) are the first-line drugs for the treatment of chronic hepatitis B virus (HBV). However, the impact of these two antiviral agents on the outcome of HBV-related hepatocellular carcinoma (HCC) after curative therapy remains to be explored. The purpose of the present study was to compare the effect of ETV and TDF on recurrence and mortality after curative treatment for HBV-related HCC. A comprehensive literature search of multiple electronic databases was conducted from 2000 to January 2022 for studies comparing ETV and TDF for HBV-related HCC patients after curative therapy. The adjusted hazard ratios (aHR) were pooled using a random-effects model. A total of nine studies with 5298 patients were included in the final meta-analysis. TDF was associated with a lower risk of HCC recurrence [aHR 0.73, 95% confidence interval (CI) 0.65-0.81] compared to HCC. TDF reduced the risk of late recurrence compared to ETV (aHR 0.58, 95% CI 0.45-0.76) but not early recurrence (aHR 0.88, 95% CI 0.76-1.02). The mortality risk was also lower with TDF compared to ETV (aHR 0.62, 95% CI 0.50-0.77). TDF was associated with a lower risk of recurrence and mortality than ETV after resection or ablation of HBV-related HCC. Further prospective randomized controlled studies are warranted to validate these results.

Hepatic Arterial Infusion Chemotherapy Followed by Lipiodol Infusion for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: A Single-Center Experience

Background and Objectives: To evaluate the effectiveness of hepatic arterial infusion chemotherapy (HAIC) followed by lipiodol infusion in advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Materials and Methods: Thirty-two patients with advanced HCC and PVTT who received HAIC with regimens of cisplatin, mitomycin-C, and 5-fluorouracil followed by lipiodol infusion were enrolled. The primary efficacy endpoint was tumor response rate. The modified Response Evaluation Criteria in Solid Tumors (mRECIST) was used for assessment of treatment response. The secondary endpoints were overall survival (OS) and progression free survival (PFS). Prognostic factors for survival also were evaluated. Results: The median OS and PFS were 11.9 and 9.5 months, respectively. Seventeen patients (53.1%) achieved objective response, and 23 patients (71.9%) achieved disease control. The length of survival in the responder and disease control groups was longer than in the non-responder and progressive disease groups after two cycles of HAIC (responder vs. non-responder: 16.5 vs. 7.9 months, p = 0.001; disease control vs. progressive disease: 12.3 vs. 5.6 months, p < 0.001) and after completing HAIC (responder vs. non-responder: 15.7 vs. 6.9 months, p = 0.001; disease control vs. progressive disease: 13.6 vs. 6.9 months, p < 0.001). Better survival was associated with Child-Pugh A liver function (p = 0.013), with early response to two HAIC cycles (p = 0.009), and with response (p = 0.02) and disease control (p = 0.001) after completing HAIC treatment. Conclusion: HAIC followed by lipiodol infusion is a safe and feasible treatment for advanced HCC with PVTT. Patients with early response could continue HAIC treatment with expected prolonged survival.

Hepatic Resection for Hepatocellular Carcinoma in Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of 7226 Patients

Objective

To systematically review and compare the overall (OS) and disease-free (DFS) survival after hepatic resections for hepatocellular carcinoma (HCC) of patients with nonalcoholic fatty liver disease (NAFLD) versus other risk factors.

Background

Different clinical and tumor characteristics are associated with HCC in the setting of NAFLD in comparison to other risk factors. It is still unclear whether these differences impact patient survival after radical hepatectomies.

Methods

Randomized controlled trials and observational studies published in the English literature between July 1980 and June 2020 were searched using multiple databases. Patients' baseline characteristics and the hazard ratios (HRs) of the OS and DFS were extracted and meta-analyses were performed.

Results

Fifteen retrospective cohort studies with a total of 7226 patients were included. Among them, 1412 patients (19.5%) had NAFLD and 5814 (80.4%) had other risk factors (eg, viral hepatitis B or C, alcoholic cirrhosis, or cryptogenic cirrhosis). Summary statistics showed that patients with NAFLD had better DFS (HR = 0.81; 95% CI: 0.70-0.94; P = 0.006) and OS (HR = 0.78; 95% CI: 0.67-0.90; P = 0.001) than the control group. Subgroups analyses also indicated that the OS favored NAFLD patients versus patients with viral hepatitis B or C (HR = 0.80; 95% CI: 0.67-0.96; P = 0.017) or alcoholic and cryptogenic cirrhosis (HR = 0.68; 95% CI: 0.47-1.0; P = 0.05).

Conclusion

After hepatic resections for HCC, NAFLD patients have better DFS and OS than patients with other risk factors. Subgroup analysis and meta-regression suggested that the survival advantage of NAFLD patients was more pronounced in studies published after 2015 and from Asian centers.

Tertiary Prevention of HCC in Chronic Hepatitis B or C Infected Patients

Simple Summary

Hepatocellular carcinoma (HCC) recurrence is the major obstacle concerning patients’ survival. Tertiary prevention by antiviral therapies could reduce HCC recurrence rate in both chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infected patients. In chronic hepatitis B (CHB) patients, nucleos(t)ide analogues (Nuc) provide a more effective HCC tertiary prevention effect than an interferon (IFN)-based regimen. In chronic hepatitis C (CHC) patients, the tertiary prevention effect by direct acting antiviral agents (DAAs) was reported non-inferior to that by IFN-based therapy. Chronic hepatitis C patients left untreated had the worst survival benefit as well as shorted recurrence-free interval than those treated by either type of antiviral regimen. Although the risk of HCC recurrence could only be decreased but not diminished by antiviral therapies due to host and microenvironmental factors beyond virus infection, antiviral therapy helps to preserve and improve liver function which makes multi-modality anticancer treatment feasible to improve survival.

Abstract

Hepatocellular carcinoma (HCC) ranks as a leading cause of common cancer and cancer-related death. The major etiology of HCC is due to chronic hepatitis virus including HBV and HCV infections. Scheduled HCC surveillance in high risk populations improves the early detection rate and the feasibility of curative treatment. However, high HCC recurrence rate still accounts for the poor prognosis of HCC patients. In this article, we critically review the pathogenesis of viral hepatitis-related hepatocellular carcinoma and the evidence of tertiary prevention efficacy by current available antiviral treatment, and discuss the knowledge gap in viral hepatitis-related HCC tertiary prevention.

Circ_0001175 Promotes Hepatocellular Carcinoma Cell Proliferation and Metastasis by Regulating miR-130a-5p

Objective

Many aberrantly expressed circular RNAs (circRNAs) play important roles in the development and progression of hepatocellular carcinoma (HCC). However, the exact function of circ_0001175 in HCC cells is unknown. Our study aimed to investigate the expression characteristics of circ_0001175 in HCC and its effects on the proliferation, migration and invasion of HCC cells, and to explore the potential mechanism.

Materials and Methods

Quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot were carried out to detect circ_0001175, microRNA-130a-5p (miR-130a-5p) and sorting nexin 5 (SNX5) expressions in HCC tissues and cells; cell counting kit-8 (CCK-8), BrdU and Transwell assays were conducted to detect the proliferation, migration and invasion of HCC cells. A lung metastasis model in nude mice was used to examine the effect of circ_0001175 on the metastasis of HCC cells in vivo. Bioinformatics prediction, luciferase reporter gene experiment, Ago2-RIP experiment and RNA pull-down assay were adopted to identify the binding relationships among circ_0001175, miR-130a-5p and SNX5.

Results

Circ_0001175 and SNX5 expressions were up-regulated in HCC tissues and cell lines, while miR-130a-5p expression was down-regulated. Abnormal expressions of circ_0001175, miR-130a-5p and SNX5 were associated with poor clinicopathological features of HCC patients; circ_0001175 facilitated HCC cell proliferation, migration and invasion in vitro and promoted lung metastasis in vivo; miR-130a-5p inhibited the above malignant biological behaviors of HCC cells, and it could reverse the function of circ_0001175. SNX5 was identified as a target gene of miR-130a-5p, and circ_0001175 could sponge miR-130a-5p and up-regulate the expression of SNX5 in HCC cells.

Conclusion

Circ_0001175 is highly expressed in HCC and facilitates HCC progression through regulating miR-130a-5p/SNX5 axis.

Assessment of the Outcomes of Intrahepatic Cholangiocarcinoma After Ultrasound-Guided Percutaneous Microwave Ablation Based on Albumin-Bilirubin Grade

OBJECTIVE

To determine whether albumin-bilirubin (ALBI) grade could be used to predict the outcomes of patients with intrahepatic cholangiocarcinoma (ICC) who underwent ultrasound-guided percutaneous microwave ablation (MWA).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. We studied 52 treatment-naïve patients with 74 ICC lesions according to the Milan criteria who subsequently underwent MWA from April 2011 to March 2018. Overall survival (OS) and recurrence-free survival (RFS) were compared in groups classified by Child-Pugh score and ALBI grade, which were statistically analyzed with the log-rank test. Cox proportional hazard regression analyses were used to determine the prognostic factors for survival in patients with ICC.

RESULTS

The median follow-up time was 21.2 months (3.2-78.7 months). Seventeen patients died during this period. After MWA, the cumulative 1-, 3-, and 5-year OS rates were 87.4%, 51.4%, and 35.2%, respectively, and the cumulative 1-, 3-, and 5-year RFS rates were 68.9%, 56.9%, and 56.9%, respectively. The major complication rate was 3.8% (2/52). Stratified according to ALBI grade, the cumulative 1-, 3-, and 5-year OS rates were 95.5%, 72.4%, and 72.4% for patients with ALBI grade 1 and 62.5%, 40.6%, and 36.3% for patients with ALBI grade 2, respectively, showing a significant difference (P = 0.006). Multivariate analysis results showed that older age (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.11-2.82; P = 0.002), tumor size ≥ 3 cm in diameter (HR: 11.33, CI: 2.24-34.52; P = 0.021) and ALBI grade (HR: 8.23, CI: 1.58-58.00; P = 0.004) may be predictors of poor OS.

CONCLUSION

ALBI grade was validated as a significant biomarker for predicting survival in ICC patients within the Milan criteria who underwent MWA.

A comparison of prognoses between surgical resection and radiofrequency ablation therapy for patients with hepatocellular carcinoma and esophagogastric varices

There has been insufficient investigation of the differences in long-term outcomes between surgical resection (SR) and radiofrequency ablation (RFA) among patients with hepatocellular carcinoma (HCC) and esophagogastric varices (EGV). We retrospectively enrolled 251 patients with treatment-naïve HCC and EGV who underwent SR or RFA as a first-line treatment. Prognostic factors were analyzed using a Cox proportional hazards model. A total of 68 patients underwent SR, and the remaining 183 patients received RFA. Patients who underwent SR were younger, had better liver functional reserves, and had larger tumors. After a median follow-up duration of 45.1 months, 151 patients died. The cumulative 5-year overall survival (OS) rate was significantly higher among patients who underwent SR than those treated with RFA (66.7% vs. 36.8%, p < 0.001). Multivariate analysis showed that age > 65 years, multiple tumors, RFA, albumin bilirubin grade > 1, and the occurrence of major peri-procedural morbidity were the independent risk factors that are predictive of poor OS. In conclusion, SR could be recommended as a first-line treatment modality for HCC patients with EGV if the patients are carefully selected and liver function is well preserved.

Multi-energy computed tomography and material quantification: Current barriers and opportunities for advancement

Computed tomography (CT) technology has rapidly evolved since its introduction in the 1970s. It is a highly important diagnostic tool for clinicians as demonstrated by the significant increase in utilization over several decades. However, much of the effort to develop and advance CT applications has been focused on improving visual sensitivity and reducing radiation dose. In comparison to these areas, improvements in quantitative CT have lagged behind. While this could be a consequence of the technological limitations of conventional CT, advanced dual-energy CT (DECT) and photon-counting detector CT (PCD-CT) offer new opportunities for quantitation. Routine use of DECT is becoming more widely available and PCD-CT is rapidly developing. This review covers efforts to address an unmet need for improved quantitative imaging to better characterize disease, identify biomarkers, and evaluate therapeutic response, with an emphasis on multi-energy CT applications. The review will primarily discuss applications that have utilized quantitative metrics using both conventional and DECT, such as bone mineral density measurement, evaluation of renal lesions, and diagnosis of fatty liver disease. Other topics that will be discussed include efforts to improve quantitative CT volumetry and radiomics. Finally, we will address the use of quantitative CT to enhance image-guided techniques for surgery, radiotherapy and interventions and provide unique opportunities for development of new contrast agents.

Comparison of prognosis between surgical resection and transarterial chemoembolization for patients with solitary huge hepatocellular carcinoma

Background

For patients with solitary huge (>10 cm in size) hepatocellular carcinoma (HCC) and without major vascular invasion, the treatment efficacy between surgical resection (SR) and transarterial chemoembolization (TACE) is not well studied. We aimed to compare the prognoses between SR and TACE for patients with solitary huge HCC.

Methods

We enrolled 143 patients with treatment-naïve, solitary HCC (>10 cm) who had received either SR or TACE treatment between 2007–2016. Factors of overall survival (OS) were analyzed by multivariate analysis. Propensity scores matching (PSM) method was adopted to adjust baseline demographic differences for further analysis.

Results

Ninety patients underwent SR and 53 patients received TACE. After a median follow-up of 17.0 (interquartile range 7.7–45.6) months, 83 patients had died. The cumulative 5-year OS rate was 44.7% and 11.7% for the SR group and the TACE group, respectively (P<0.001). A multivariate analysis showed that TACE [hazard ratio (HR): 3.515, 95% confidence interval (CI): 2.202–5.610, P<0.001], and albumin-bilirubin (ALBI) grade >1 (HR: 2.181, 95% CI: 1.343–3.543, P=0.002) were the independent risk factors associated with poorer OS. After PSM, 37 pairs of matched patients were selected from each treatment arm. After matching, patients who underwent SR still evinced a significantly higher OS than did those who underwent TACE (P=0.010).

Conclusions

SR provided a better OS than did TACE for patients with solitary huge (≥10 cm) HCC. As such, SR is recommended as the therapeutic priority for these patients.

Liver stiffness measured by acoustic radiation force impulse elastography predicted prognoses of hepatocellular carcinoma after radiofrequency ablation

The prognostic factors of patients who undergo radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is not fully elucidated. We aimed to investigate the role of liver stiffness (LS) and spleen stiffness (SS) measured by acoustic radiation force impulse (ARFI) elastography in determining the prognoses of patients with HCC after RFA. We prospectively enrolled 173 patients with HCC who underwent ARFI elastography for measurement of LS and SS on the same day of RFA. Overall survival (OS), recurrence-free survival (RFS) after adjusting for competing mortality, and presence of hepatic decompensation were investigated. Patients with LS > 1.5 m/s had significantly shorter OS and RFS than their counterparts. Anti-viral treatment (hazard ratio [HR]: 0.396, p = 0.015) and LS > 1.5 m/s (HR 4.105, p = 0.028) correlated with OS by a multivariate analysis. Besides, serum alpha fetoprotein >10 ng/mL and LS > 1.5 m/s independently predicted poorer RFS. On the other hand, anti-viral treatment (HR: 0.315, p = 0.010), creatinine > 1.5 mg/dL (HR: 9.447, p = 0.006), and SS > 2.7 m/s (HR: 2.869, p = 0.044) predicted a higher risk of hepatic decompensation. In conclusion, LS but not SS measured by ARFI elastography predicted tumor recurrence and OS in RFA-treated HCC; whereas, SS predicted development of hepatic decompensation in these patients.

Predictive value of the albumin-bilirubin grade on long-term outcomes of CT-guided percutaneous microwave ablation in intrahepatic cholangiocarcinoma

PURPOSE

To assess the efficacy of the albumin-bilirubin (ALBI) grade on assessing long-term outcomes of computed tomography (CT)-guided percutaneous microwave ablation (CT-PMWA) in the treatment of patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

Between April 2011 and March 2018, 78 patients who underwent CT-PMWA were enrolled in this study. Overall survival (OS) and recurrence-free survival (RFS) were compared in the groups stratified by the ALBI grade and Child-Pugh score. Cox proportional hazard regression analyses were performed to determine independent predictors of OS and RFS.

RESULTS

After a median follow-up of 22.7 months (range 1-86.7 months), 67 patients had died. The cumulative 1-, 3-, and 5-year OS rates were 89.5%, 52.2%, and 35.0%, respectively. Stratified by the ALBI grade, the cumulative 1-, 3-, and 5-year OS rates were 100%, 69.2%, and 25.6% for patients with the grade 1, respectively. For patients with the ALBI grade 2, the cumulative 1-, 3-, and 5-year OS rates were 41.0%, 10.3%, and 10.3%, respectively. Patients with a hepatic function of the ALBI grade 1 had significantly higher OS rates than patients with the ALBI grade 2 (p < .001). The multivariate analysis showed tumor size (Hazard Ratio[HR] 95% Confidence Interval[CI]:9.03[1.01-80.52], p = .049) and the ALBI grade (HR[95%CI]:9.56[1.58-58.00], p = .014) were associated with OS, and tumor size (HR: 2.03[0.69-8.04], p = .049) was associated with RFS.

CONCLUSIONS

The preliminary data of this study showed the ALBI grade was effective to predict long-term outcomes of CT-PMWA in ICCs. Further study is necessary to validate our results by a large, multi-center patient cohort.

Albumin-bilirubin grade may determine the outcomes of patients with very early stage hepatocellular carcinoma after radiofrequency ablation therapy

BACKGROUND

To assess long-term prognoses of patients with solitary hepatocellular carcinoma (HCC) < 2 cm (the Barcelona Clinic Liver Cancer, BCLC stage 0) after radiofrequency ablation (RFA).

METHODS

We retrospectively enrolled 271 patients with BCLC stage 0 HCC who had undergone RFA at Taipei Veterans General Hospital from 2002 to 2016. Factors determining poor overall survival (OS) and recurrence after RFA were analyzed by Cox proportional hazards model.

RESULTS

After a median follow-up duration of 43.4 months, 76 patients had died. The cumulative 5- and 10-year OS rates were 67.1% and 56.4%, respectively. Multivariate analysis disclosed age > 65 years (hazard ratio [HR] 1.608, 95% confidence interval, [CI] 1.015-2.545; p = 0.043), platelet count < 100,000/mm (HR 1.704, 95% CI 1.027-2.828; p = 0.039), and albumin-bilirubin (ALBI) grade 2 or 3 (HR 2.191, 95% CI 1.261-3.805; p = 0.005) were the independent risk factors predicting worse OS. One-hundred twelve patients had tumor recurrence after undergoing RFA. Multivariate analysis showed that ALBI grade 2 or 3 (HR 1.825, 95% CI 1.288-2.585; p = 0.001) was the only one independent risk factor associated with poor recurrence-free survival (RFS) after RFA. Most of the subgroup analyses also demonstrated that patients with ALBI grade 2 or 3 had poorer OS and RFS than those with ALBI grade 1.

CONCLUSION

For patients with BCLC stage 0 HCC, RFA could provide a long-term outcome with a 10-year overall survival rate of 56.4%. Moreover, the ALBI grade can discriminate prognosis in such patients.

Aspartate aminotransferase-to-platelet ratio index predicts prognosis of hepatocellular carcinoma after postoperative adjuvant transarterial chemoembolization

BACKGROUND AND AIM

To investigate the value of the aspartate aminotransferase-to-platelet ratio index (APRI) and build a new nomogram for hepatocellular carcinoma (HCC) patients undergoing postoperative adjuvant transarterial chemoembolization (PATACE).

METHODS

We retrospectively reviewed 351 patients with HCC undergoing PATACE. We collected baseline HCC patient characteristics to obtain the risk factors for determining poor disease-free survival (DFS) and early time to recurrence (TTR) after PATACE. The multivariate Cox proportional hazards model was used to build new nomogram based on significant prognostic factors of outcomes.

RESULTS

We generated the cutoff value of the APRI as 0.50 using the X-tile to distinguish patients with different outcomes in the whole cohort. Two hundred seventeen patients with high APRI had poorer survival (P<0.001) than did 134 patients with low APRI. Furthermore, a nomogram, including tumor size, alanine aminotransferase (ALT) level, white blood cell counts, Barcelona Clinic Liver Cancer grade, and APRI was built for DFS, while factors including hepatitis B surface antigen, tumor size, ALT, microvascular invasion, and APRI was built for TTR. Internal validation with 500 bootstrapped sample sets had a good concordance index of 0.729 for DFS and 0.730 for TTR. Additionally, nomogram based on APRI conferred more prognostic value than previous biomarkers.

CONCLUSION

High APRI was associated with worse survival and shorter TTR for HCC patients undergoing PATACE. This simple nomogram based on APRI conferred personalized survival and recurrence data for HCC patients undergoing PATACE.

Esophageal varices are not predictive of patient prognosis after surgical resection of hepatocellular carcinoma

OBJECTIVE

The predictive value of esophageal varices (EV) in determining the patient outcome in hepatocellular carcinoma (HCC) remains unresolved. We aimed to assess the impact of EV on the prognosis of HCC patients after surgical resection.

MATERIALS AND METHODS

We consecutively enrolled 446 treatment-naive HCC patients who underwent surgical resection and esophagogastroduodenoscopy from 2003 to 2015. Prognostic factors were analyzed using the Cox proportional hazards model and a propensity score matching analysis.

RESULTS

A total of 89 (20.0%) HCC patients presented with EV. Compared with those without EV, patients with EV had poorer preservation of liver function and higher rates of cirrhosis in the nontumor part of liver specimens. After a median follow-up period of 34.6 months (25-75 percentiles; 12.8-59.3 months), 130 patients had died. The cumulative 5-year overall survival (OS) rates were 62.3 and 70.6% in patients with and without EV, respectively (P=0.102). A multivariate analysis showed that serum albumin level less than or equal to 4 g/dl (P=0.020), α-fetoprotein level greater than 20 ng/ml (P<0.001), as well as the presence of vascular invasion (P<0.001), but not the presence of EV, were independent risk factors associated with poor OS. Moreover, 67 patients were matched in each group using the one-to-one nearest-neighbor matching method. After matching, the OS rates were comparable between HCC patients with and without EV.

CONCLUSION

EV is not an independent risk factor predictive of poor prognosis for HCC patients after resection surgery if they have well-preserved liver function.

The Prognosis of Single Large Hepatocellular Carcinoma Was Distinct from Barcelona Clinic Liver Cancer Stage A or B: The Role of Albumin-Bilirubin Grade

BACKGROUND/AIMS

Whether single large hepatocellular carcinoma (SLHCC) is classified as Barcelona Clinic Liver Cancer (BCLC) stage A or B is still controversial. We aimed to compare the clinical manifestations, treatment modalities, and prognoses among patients with SLHCC and those in BCLC stage A and B.

METHODS

We enrolled 2,285 treatment-naive hepatocellular carcinoma (HCC) patients with BCLC stage A or B from October 2007 to December 2015. Factors in terms of prognoses were analyzed by multivariate analysis.

RESULTS

We enrolled 1,210, 466, and 609 patients in a BCLC-A, SLHCC, and BCLC-B group, respectively. After a median follow-up duration of 21.2 months, 898 patients had died. The cumulative 5-year survival rates were 57.0, 42.6, and 27.3% for patients in the BCLC-A, SLHCC, and BCLC-B groups, respectively, which were significantly different (p < 0.001). Multivariate analysis indicated that the following independent risk factors were associated with poor prognosis: age > 65 years, alkaline phosphatase > 100 U/L, creatinine > 1.0 mg/dL, alpha-fetoprotein > 20 mg/mL, noncurative treatment, albumin-bilirubin (ALBI) grade, and HCC staging. Subgroup analysis also confirmed that patients in the SLHCC group had a survival rate intermediate to those in the BCLC-A and BCLC-B groups. However, for patients in the SLHCC group and with ALBI grade 1, outcomes were close to those in the BCLC-A group, especially in the setting of curative treatment. For those with ALBI grades 2 or 3, the prognoses were similar to those of the SLHCC and BCLC-B groups.

CONCLUSION

Patients in the SLHCC group had an overall survival rate intermediate to those of the BCLC-A and BCLC-B groups. It is suggested that the SLHCC group could be classified as occupying a different stage from the BCLC stages A and B. The ALBI grade could help to stratify SLHCC into a different prognostic group. However, the results need to be validated externally in other regions of the world.

Multicentre study of the prognostic impact of preoperative bodyweight on long-term prognosis of hepatocellular carcinoma

BACKGROUND

Whether preoperative bodyweight is associated with long-term prognosis in patients after liver resection for hepatocellular carcinoma (HCC) is controversial. This study aimed to investigate the relationship of patient weight with long-term recurrence and overall survival (OS) after curative liver resection for HCC.

METHODS

Data for patients with HCC who underwent curative liver resection between 2000 and 2015 in five centres in China were analysed retrospectively in three groups according to their preoperative BMI: underweight (BMI 18·4 kg/m² or less), normal weight (BMI 18·5-24·9 kg/m² ) and overweight (BMI 25·0 kg/m² or above). Patients' baseline characteristics, operative variables and long-term survival outcomes were compared. Univariable and multivariable Cox regression analyses were performed to identify risk factors for OS and recurrence-free survival (RFS) after resection.

RESULTS

Of 1524 patients, 107 (7·0 per cent) were underweight, 891 (58·5 per cent) were of normal weight and 526 (34·5 per cent) were overweight. Univariable analyses showed that underweight and overweight patients had poorer OS (both P < 0·001) and RFS (both P < 0·001) than patients of normal weight. Multivariable Cox regression analysis also identified both underweight and overweight to be independent risk factors for OS (hazard ratio (HR) 1·22, 95 per cent c.i. 1·19 to 1·56, P = 0·019; and HR 1·57, 1·36 to 1·81, P < 0·001, respectively) and RFS (HR 1·28, 1·16 to 1·53, P = 0·028; and HR 1·34, 1·17 to 1·54, P < 0·001).

CONCLUSION

Underweight and overweight patients appear to have a worse prognosis than those of normal weight following liver resection for HCC.

Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices

BACKGROUNDS AND AIMS

There is no consensus on screening for high-risk esophageal varices (HRV) in patients with hepatocellular carcinoma (HCC). Here, we aimed to investigate the prevalence and risk factors of HRV in patients with HCC and to assess the combination of albumin-bilirubin grade and platelet count (ALBI-PLT score) for predicting compensated patients who do not need unnecessary endoscopic screening for HRV.

METHODS

The ALBI-PLT score was calculated by adding the ALBI grade and points for platelet count (1 point if platelet count >150,000/mm³ and 2 points if ≤150,000/mm³). The predictive value of the ALBI-PLT score for HRV was analyzed in 887 compensated patients enrolled from October 2007 to April 2014 (study cohort). This was validated in 215 compensated patients from May 2014 to December 2015 (validation cohort).

RESULTS

In the study cohort, the rates of HRV were 2.9% and 21.1% in compensated HCC patients with an ALBI-PLT score of 2 and >2, respectively. The negative predictive values of the ALBI-PLT score for predicting HRV were 97.1% and 98.1% in the study and validation cohorts, respectively. For compensated patients who did not receive endoscopic screening at the time of HCC diagnosis, the 5-year cumulative variceal hemorrhage rate was lower in patients with an ALBI-PLT score of 2 than in those with an ALBI-PLT score >2 (1.7% vs 9.1%, P = .007).

CONCLUSION

In patients with HCC with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices is not recommended for these patients.

Management consensus guideline for hepatocellular carcinoma: 2016 updated by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality in Taiwan. To help clinical physicians to manage patients with HCC, the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan produced the management consensus guideline for HCC.

METHODS

The recommendations focus on nine important issues on management of HCC, including surveillance, diagnosis, staging, surgery, local ablation, transarterial chemoembolization/transarterial radioembolization/hepatic arterial infusion chemotherapy, systemic therapy, radiotherapy, and prevention.

RESULTS

The consensus statements were discussed, debated and got consensus in each expert team. And then the statements were sent to all of the experts for further discussion and refinement. Finally, all of the experts were invited to vote for the statements, including the level of evidence and recommendation.

CONCLUSION

With the development of the management consensus guideline, HCC patients could benefit from the optimal therapeutic modality.

Hepatocellular Carcinoma: Nomograms Based on the Albumin-Bilirubin Grade to Assess the Outcomes of Radiofrequency Ablation

Purpose To construct a nomogram with the albumin-bilirubin (ALBI) grade to assess the long-term outcomes of patients with early-stage hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA). Materials and Methods This retrospective study was approved by the institutional review board, and informed consent was waived. We studied 622 treatment-naïve patients with HCC according to the Milan criteria who subsequently underwent RFA from 2002 to 2013. Baseline characteristics were collected to identify the risk factors for determination of poor overall survival after RFA. The multivariate Cox proportional hazards model based on significant prognostic factors of overall survival was used to construct the nomogram. Results After a median follow-up time of 35.7 months, 190 patients had died. The cumulative 5- and 10-year overall survival rates were 63.1% and 48.7%, respectively. Stratified according to ALBI grade, the cumulative 5- and 10-year survival rates were 80.0% and 67.9% for patients with grade 1, respectively, and 48.6% and 35.1% for those with grades 2-3, respectively (P < .001). Multivariate analysis results showed that patient age older than 65 years, a prothrombin time international normalized ratio greater than 1.1, α-fetoprotein level greater than 20 ng/mL, multiple tumors, and ALBI grade 2 or 3 were associated with overall mortality. A nomogram was developed on the basis of these five variables. Internal validation with 200 bootstrapped sample sets had a good concordance index of 0.770 (95% confidence interval: 0.633, 0.876). Conclusion This simple nomogram based on the ALBI grade offers personalized long-term survival data for patients with early-stage HCC who undergo RFA. ^© RSNA, 2017 Online supplemental material is available for this article.

The impact of esophagogastric varices on the prognosis of patients with hepatocellular carcinoma

Whether or not esophagogastric varices (EGV) could determine the outcomes of patients with hepatocellular carcinoma (HCC) is still unclear. A total of 990 treatment-naive HCC patients who received an esophagogastroduodenoscopy at the time of HCC diagnosis were retrospectively enrolled. The factors in terms of prognosis were analyzed by Cox proportional hazards model and propensity score matching analysis. Among the enrolled patients, 480 (48.5%) patients had EGV. Patients with EGV had a significantly lower cumulative 5-year survival rate than those without EGV (24.9% versus 46.4%, p < 0.001). It was confirmed by a multivariate analysis and propensity score matching analysis. Stratified by tumor stage, the patients with EGV had lower survival rates than the patients without EGVs in all Barcelona Clinic Liver Cancer stages except stage D. Moreover, the patients with EGV had lower survival rates than those without EGV, both by curative or non-curative treatment modalities. In conclusion, EGV was an independent risk factor predicting poor prognosis for the patients with HCC by multivariate analysis, propensity score matching analysis, and subgroup analysis.

Thrombocytopenia and the outcomes of hepatectomy for hepatocellular carcinoma: a meta-analysis

BACKGROUND

Recently, increasing studies have revealed the association of inflammatory parameters, such as preoperative platelet count, and the prognosis of hepatocellular carcinoma (HCC). However, the link between the platelet count and the prognosis of patients with HCC after hepatic resection is still controversial.

METHODS

We searched PubMed, Web of Science, EMBASE, and CBM for relevant trials and analyzed outcomes with random-effects model. The hazard ratio (HR) and its 95% confidence interval (CI) were calculated.

RESULTS

In total, 31 studies, including a total of 10,730 patients, met our criteria. The results showed that thrombocytopenia in HCC patients was associated with poor overall survival (HR = 1.47, 95% CI: 1.21-1.78), disease-free survival (HR = 1.36, 95% CI: 1.08-1.72), and a high risk of cancer recurrence (HR = 1.41, 95% CI: 1.22-1.62), but a low risk of extrahepatic metastasis (HR = 0.55, 95% CI: 0.47-0.63).

CONCLUSIONS

The meta-analysis revealed that preoperative platelet count could act as a significant biomarker in the prognosis of HCC, especially a platelet count of <100 × 10³/mm³. Additional high-quality trials are needed, considering the low-quality studies analyzed.

The impact of clinically significant portal hypertension on the prognosis of patients with hepatocellular carcinoma after radiofrequency ablation: a propensity score matching analysis

OBJECTIVES

To assess the impact of clinically significant portal hypertension (CSPH) on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA).

METHODS

We retrospectively enrolled 280 treatment-naïve early-stage HCC patients who had Child-Pugh grade A or B and received upper gastrointestinal endoscopy at the time of HCC diagnosis. CSPH was defined as (1) a platelet count < 100,000/mm³ associated with splenomegaly and/or (2) the presence of oesophageal/gastric varices by endoscopy. Factors determining poor overall survival and recurrence after RFA were analysed by Cox proportional hazards model and propensity score matching analysis.

RESULTS

A total of 192 (68.6 %) patients had CSPH. The cumulative 5-year survival rates were 50.6 % and 76.7 % in patients with and without CSPH, respectively (p = 0.015). Based on multivariate analysis, age > 65 years (hazard ratio (HR) 1.740, p = 0.025), serum albumin levels ≤ 3.5 g/dL (HR 3.268, p < 0.001) and multiple tumours (HR 1.693, p = 0.046), but not CSPH, were independent risk factors associated with poor overall survival after RFA. Moreover, the overall survival rates were comparable between patients with and without CSPH after adjusting for confounding factors via propensity score matching analysis.

CONCLUSIONS

CSPH was not associated with poor outcomes after RFA.

KEY POINTS

• CSPH was common in HCC patients who underwent RFA therapy. • CSPH was not an independent risk factor in determining poor prognosis. • Serum albumin level was more important to determine the outcomes.