Living donor liver transplantation for Barcelona clinic liver cancer (BCLC) intermediate-stage hepatocellular carcinoma

Prognostic value of neutrophil-to-lymphocyte ratio in patients with hepatocellular carcinoma receiving curative therapies: a systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The prognostic significance of the neutrophil-to-lymphocyte ratio (NLR) in HCC patients has been extensively studied; however, the prognostic value of NLR in HCC patients undergoing curative treatment remains unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to comprehensively evaluate the precise significance of preoperative and postoperative NLR in predicting the prognosis of HCC patients receiving curative treatment.

METHODS

We conducted a comprehensive search of the PubMed, Cochrane Library, Embase, and Web of Science databases from inception to August 2024. Studies that included univariate and multivariate analyses evaluating the association between NLR and survival outcomes in HCC patients undergoing resection, transplantation, or ablation were included. The prognostic value of NLR in HCC patients receiving curative treatment was analyzed by calculating pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 43 studies involving 9,952 patients were included. Meta-analysis revealed that higher NLR was significantly associated with worse overall survival (OS) (HR = 1.55, 95% CI = 1.39-1.75, P < 0.001), recurrence-free survival (RFS) (HR = 1.77, 95% CI = 1.49-2.10, P < 0.001), and disease-free survival (DFS) (HR = 1.42, 95% CI = 1.25-1.63, P < 0.001) in HCC patients undergoing curative treatment. Subgroup analysis demonstrated a significant association between NLR and poor OS, independent of geographic region, type of survival analysis, preoperative or postoperative measurement, treatment modality, or NLR cutoff value. Publication bias and sensitivity analyses confirmed the robustness of these findings.

CONCLUSION

Elevated NLR is significantly associated with poorer OS, RFS, and DFS in HCC patients receiving curative treatment. Future research should focus on validating the optimal NLR threshold and exploring its predictive ability in different clinical settings.

Comparison of various liver cancer staging systems in predicting prognosis after initial transcatheter arterial chemoembolization: a retrospective study from China

Background

Hepatocellular carcinoma (HCC) constitutes approximately 75-85% of primary liver cancers and is a heavy burden on public health. Many innovative prediction systems have integrated radiomics, artificial intelligence, pathological information, or even genetic information for the stratification and prognosis prediction of patients with HCC. However, these systems still lack practical and clinical applications. Classical HCC staging systems remain the mainstream tool for stratification and prediction of treatment efficacy to date; although, variable characteristics and emphases between different classical HCC staging systems render its clinical selection inconsistent and therefore may be unreliable. In this study, we aimed to compare the predictive performance of classical liver cancer staging systems, including China Liver Cancer (CNLC), Barcelona Clinic Liver Cancer (BCLC), Hong Kong Liver Cancer (HKLC), modified Japanese Integrated Staging (mJIS), modified Cancer of the Liver Italian Program (mCLIP), and Tumor-Node-Metastasis (TNM) staging system, for the efficacy and prognosis of transcatheter arterial chemoembolization (TACE) in HCC patients.

Methods

A total of 148 patients with HCC who received TACE as the initial therapy between 02/01/2019 and 08/31/2022 were retrospectively included. Patients' clinical information, laboratory and imaging data, were collected. Cox regression analysis was applied to identify independent risk factors for progression-free survival (PFS) and overall survival (OS). Six liver cancer staging systems, including the CNLC, BCLC, HKLC, mJIS, mCLIP, and TNM staging system, were applied for the staging of every enrolled patient. The PFS and OS of patients with HCC following initial TACE in different staging systems were assessed, and the predictive performance of different systems was evaluated using the concordance index.

Results

The presence of portal vein tumor thrombus (PVT), alpha fetoprotein (AFP) ≥400 ng/mL, and ineffective initial TACE treatment were independent risk factors for overall disease progression, while the presence of PVT and ineffective initial TACE treatment were independent risk factors for death. In the prediction of PFS and OS, CNLC, BCLC, HKLC, mJIS, and mCLIP all showed good predictive ability, but the predictive ability of the TNM staging system was relatively poor.

Conclusions

The CNLC, BCLC, HKLC, mJIS, and mCLIP staging systems provide comparable predictive value for the prognosis after the initial TACE, while the TNM staging system has poor predictive ability due to its exclusion of hepatic function.

Current role and perspectives of living donor liver transplantation for hepatocellular carcinoma: systematic review of the past 20 years

Hepatocellular carcinoma (HCC) poses a significant global health challenge, and liver transplantation (LT) remains the best curative option. Living donor liver transplantation (LDLT) emerged as a potential solution to organ scarcity, reducing waitlist times. This comprehensive review explores LDLT practices, focusing on patient selection criteria and oncologic outcomes. A systematic review following PRISMA guidelines included 50 studies (2004-2023) with 8062 patients. Data encompassed baseline characteristics, HCC features, and oncologic outcomes. Further analysis categorized results by geography and publication year. Heterogeneity in patient demographics, tumor burden, and transplant characteristics was observed. Recent LDLT series demonstrated a shift towards refined selection criteria, increased neoadjuvant treatment, and improved oncologic outcomes. Geographic disparities revealed unique challenges in Eastern and Western practices. LDLT proves effective for HCC, addressing donor shortages. Evolving practices highlight the importance of refining inclusion criteria and optimizing tumor management. While geographic differences exist, LDLT, when judiciously applied, offers promising outcomes.

Intermediate-stage hepatocellular carcinoma: refining substaging or shifting paradigm?

This review explores the evolution of cancer staging, focusing on intermediate hepatocellular carcinoma (HCC), and the challenges faced by physicians. The Barcelona Clinic Liver Cancer (BCLC) staging system, introduced in 1999, was designed to address the limitations associated with providing accurate prognostic information for HCC and allocating specific treatments, to avoid overtreatment. However, criticism has emerged, particularly regarding the intermediate stage of HCC (BCLC-B) and its heterogeneous patient population. To overcome this limitation, various subclassification systems, such as the Bolondi and Kinki criteria, have been proposed. These systems are aimed at refining categorizations within the intermediate stage and have demonstrated varying degrees of success in predicting outcomes through external validation. This study discusses the shift in treatment paradigms, emphasizing the need for a more personalized approach rather than strictly adhering to cancer stages, without dismissing the relevance of staging systems. It assesses the available treatment options for intermediate-stage HCC, highlighting the importance of considering surgical and nonsurgical options alongside transarterial chemoembolization for optimal outcomes. In conclusion, the text advocates for a paradigm shift in staging systems prioritizing treatment suitability over cancer stage. This reflects the evolving landscape of HCC management, where a multidisciplinary approach is crucial for tailoring treatments to individual patients, ultimately aiming to improve overall survival.