Korean Liver Cancer Association (KLCA) and National Cancer Center (NCC) Korea. 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Noninvasive identification of proliferative hepatocellular carcinoma on multiphase dynamic CT: quantitative and LI-RADS lexicon-based evaluation

OBJECTIVE

To identify proliferative hepatocellular carcinoma (HCC) preoperatively using quantitative measurements combined with the updated standard 2021 LI-RADS universal lexicon-based qualitative features on multiphase dynamic CT (MDCT).

METHODS

We retrospectively analyzed 273 patients (102 proliferative HCCs) who underwent preoperative MDCT with surgically confirmed HCC in two medical centers. Imaging features were evaluated according to the updated 2021 LI-RADS universal lexicon, and quantitative measurements were analyzed. All MDCT findings and clinical factors were compared. Four predictive models (clinical, CT quantitative-clinical, CT qualitative-clinical, and combinational models) were developed and validated in an external cohort for identifying proliferative HCC. ROC analysis was used to assess model performances. All models were tested in a subgroup of patients with a single lesion ≤ 5 cm (n = 124).

RESULTS

Both the CT quantitative-clinical and CT qualitative-clinical models effectively identified proliferative HCC in the training and external validation cohorts (all AUCs > 0.79). The combinational model, integrating one clinical (AFP ≥ 200 ng/mL), three qualitative (rim arterial phase hyperenhancement (APHE), non-smooth tumor margin, and incomplete or absent capsule), and one quantitative feature (standardized tumor-to-aorta density ratio in portal venous phase ≤ (- 0.13), showed significant improvement in the training cohort (AUC 0.871) and comparable performance in the validation cohort (AUC 0.870). Additionally, AFP ≥ 200 ng/mL and Rim APHE were significantly associated with HCC recurrence (p < 0.05).

CONCLUSIONS

The combinational model, integrating clinical, CT quantitative, and qualitative features, shows potential for the noninvasively preoperative prediction of proliferative HCC. Further validation is needed to establish its broader clinical utility.

KEY POINTS

Question Preoperative identification of proliferative HCC could influence patient treatment and prognosis, yet there is no CT-based universally applicable model to identify this subtype. Findings The updated standard 2021 LI-RADS universal lexicon-based features, in combination with quantitative MDCT measurements, could aid in the noninvasive detection of proliferative HCC. Clinical relevance The updated standard 2021 LI-RADS universal lexicon-based CT qualitative features and quantitative measurements may aid in identifying proliferative HCC and tumor recurrence, offering potential guidance for personalized treatment. Further studies are required to assess their generalizability to different clinical scenarios.

Predictability of clinical outcomes after external beam radiotherapy for hepatocellular carcinoma according to tumor marker dynamics

Signal changes after high dose irradiation on MRI make it difficult to assess the therapeutic response of hepatocellular carcinoma (HCC). To overcome the limitation of imaging work-up, our study predicted clinical outcomes through tumor marker dynamics in HCC after external beam radiotherapy (EBRT). As a single-center retrospective study, those who underwent conventional fractionated EBRT for viable HCC from 2010 to 2021 were analyzed. Patients with elevated tumor markers of AFP ≥ 10 ng/ml or PIVKA-II ≥ 30 mAU/ml before EBRT were enrolled. Remission of AFP, PIVKA-II, and MoRAL score (=11*√PIVKA-II + 2*√AFP) from pre-EBRT to post-EBRT at 1 month and 3 months was examined. For 1-year and 2-years OS, variables of tumor markers were examined using the receiver operation characteristics (ROC). Multivariate analyses of Cox-regression for OS were conducted. Among 111 patients, 34 patients were estimated to survive more than 2-years. In multivariate analyses for OS, tumor number (P = 0.004), portal vein tumor thrombus (P = 0.004), and Barcelona liver cancer staging (P < 0.001) were found to be significant. For 2-years OS, the degree of AFP remission at 3 months (rAFP_3M) had an AUC of 0.852 (95% CI: 0.758-0.946, P < 0.001), a sensitivity of 85.5%, and a specificity of 82.6% with a cut-off value of 3.7%. MoRAL score at 3 months (MoRAL_3M) had an AUC of 0.814 (95% CI: 0.728-0.900, P = 0.000), a sensitivity of 76.5%, and a specificity of 77.8% with a cut-off value of 111.64. In new multivariate analyses including the above significant factors plus either rAFP_3M or MoRAL_3M, rAFP_3M (P < 0.001) and MoRAL_3M (P < 0.001) were found to be independent prognostic factors in each model. This study confirmed the importance of the changed tumor marker after EBRT rather than the baseline value. Dynamic change of AFP and MoRAL score at post-EBRT 3 months could be recommended as potential indicators for clinical outcomes.

Synergistic Effects of Transarterial Chemoembolization and Lenvatinib on HIF-1α Ubiquitination and Prognosis Improvement in Hepatocellular Carcinoma

PURPOSE

A recent trial has shown that adding transarterial chemoembolization (TACE) to lenvatinib therapy results in enhanced therapeutic efficacy in hepatocellular carcinoma (HCC). We aimed to assess the effectiveness of the lenvatinib and TACE combination in a real-world clinical context for managing HCC and to elucidate the molecular pathways involved.

EXPERIMENTAL DESIGN

This retrospective analysis included 199 patients diagnosed with HCC and having intrahepatic lesions between 2018 and 2021. The cohort was divided into those who received lenvatinib plus TACE (n = 62, combination group) and those who received lenvatinib monotherapy (n = 137, monotherapy group). To further explore the underlying mechanisms, Huh-7 cells were exposed to lenvatinib or a vehicle for 48 hours under normoxic or hypoxic conditions.

RESULTS

Propensity score-matched analysis revealed a significant improvement in both overall survival (adjusted HR, 0.38; 95% confidence interval, 0.24-0.59; P < 0.001) and progression-free survival (adjusted HR, 0.41; 95% confidence interval, 0.26-0.64; P < 0.001) in the combination group compared with the monotherapy group. In laboratory experiments, under hypoxic conditions, lenvatinib notably attenuated hypoxia-inducible factor-1α (HIF-1α) protein levels in Huh-7 cells without altering its mRNA levels. Intriguingly, lenvatinib facilitated the mouse double minute 2 homolog-mediated ubiquitination and subsequent degradation of HIF-1α. Additionally, cell viability assays confirmed a significant decrease in Huh-7 cell survival following lenvatinib treatment under hypoxic conditions.

CONCLUSIONS

The combination of lenvatinib and TACE significantly improved survival in patients with HCC. The mechanistic foundation seems to be the lenvatinib-triggered degradation of HIF-1α via the mouse double minute 2 homolog-dependent ubiquitination pathway, highlighting a potential therapeutic target in HCC treatment.

The effect of continuous infusion chemotherapy through femoral artery catheterization on GP73, AFP-L3, and safety efficacy in liver cancer patients

This study examines the impact of continuous infusion chemotherapy via femoral artery catheterization on Golgi protein 73 (GP73) and alpha fetoprotein heterogeneity (AFP-L3) in liver cancer patients. A retrospective analysis was conducted on 108 liver cancer patients treated from January 2020 to December 2022, divided into two groups: transarterial chemoembolization (TACE) and continuous infusion regional arterial chemotherapy via femoral artery catheterization (CIFAC), with 54 patients in each group. Serum tumor markers, liver function, adverse reactions, quality of life, and 1-year survival rate were analyzed and compared between the two groups of patients. Prior to treatment, no significant differences were observed in tumor markers, liver function, and quality of life between groups (P > 0.05). After 60 and 90 days, the CIFAC group exhibited significantly lower levels of GP73, AFP, and AFP-L3 compared to TACE (P < 0.05). Additionally, CIFAC patients had lower levels of alanine aminotransferase (ALT), aspartate transaminase (AST), indocyanine green (ICG15) (P < 0.05), reduced adverse reactions (nausea, vomiting, etc.), and higher Karnofsky scores (P < 0.05). The one-year survival rate of the CIFAC group was significantly higher than that of the TACE group (P < 0.05). Continuous infusion chemotherapy through femoral artery catheterization can help reduce serum tumor marker levels, improve liver function, and reduce adverse reactions in liver cancer patients.

Differential Infiltration of T-Cell Populations in Tumor and Liver Tissues Predicts Recurrence-Free Survival in Surgically Resected Hepatocellular Carcinoma

Background/Objectives: Liver and tumor-infiltrating T cells in hepatocellular carcinoma (HCC) are heterogeneous, comprising the CD69+ tissue-resident T-cell and the CD69- circulating T-cell populations. However, the impact of these distinct T-cell populations on patient prognosis is unclear; hence, further studies are needed. Methods: Tumor and distant liver tissues from 57 HCC patients with various chronic liver disease etiologies were analyzed. Single-cell dissociation and flow cytometry were used to assess CD69+ and CD69- T-cell populations and their correlation with recurrence-free survival (RFS). Results: CD69+/CD69- subpopulations within CD4+ and CD8+ T cells varied by patient and alcohol etiology. CD69- populations among CD4+ T cells were less frequent in both tumor and non-tumor tissues of alcohol-related HCC patients (p < 0.05). Higher frequencies of CD69-CD4+ and CD8+ T cells in tumors and CD69+CD103+CD8+ T cells in liver tissues were associated with better RFS. CD69- T cells expressed lower PD-1 levels, indicating less exhaustion, with PD-1 expression inversely correlated with CD69- frequency. PD-1 expression was higher in CD69-CD4+ T cells in alcohol-related HCC. Conclusions: We provided a detailed analysis of the heterogeneous characteristics of tumor- and liver-infiltrating T cells in HCC, emphasizing the distinct roles of CD69+ and CD69- cell populations and their impact on RFS. CD69+ T cells were associated with immune exhaustion and tumor aggressiveness, whereas CD69- T cells appeared to significantly contribute to the influence of alcohol intake on the immune landscape of HCC in the tumor microenvironment. However, further research should validate these findings in larger cohorts to enhance our understanding.

The Critical Role of Regulatory T Cells in Immune Tolerance and Rejection Following Liver Transplantation: Interactions With the Gut Microbiome

Liver transplantation (LT) is the ultimate treatment for patients with end-stage liver disease or early hepatocellular carcinoma. In the context of LT, because of the unique immunological characteristics of human liver allograft, 5%-20% of selected LT recipients can achieve operational tolerance. Nonetheless, there remains a risk of rejection in LT patients. Maintaining immune homeostasis is thus crucial for improving clinical outcomes in these patients. In mechanism, several immune cells, including dendritic cells, Kupffer cells, myeloid-derived suppressor cells, hepatic stellate cells, regulatory B cells, and CD4 + regulatory T cells (Treg), contribute to achieving tolerance following LT. In terms of Treg, it plays a role in successfully minimizing immunosuppression or achieving tolerance post-LT while also reducing the risk of rejection. Furthermore, the gut microbiome modulates systemic immune functions along the gut-liver axis. Recent studies have explored changes in the microbiome and its metabolites under various conditions, including post-LT, acute rejection, and tolerance. Certain functional microbiomes and metabolites exhibit immunomodulatory functions, such as the augmentation of Treg, influencing immune homeostasis. Therefore, understanding the mechanisms of tolerance in LT, the role of Treg in tolerance and rejection, as well as their interactions with gut microbiome, is vital for the management of LT patients.

Comparison of initial treatments for resectable hepatocellular carcinoma within Milan criteria: an observational study based on a nationwide survey

Purpose

Treatment options for hepatocellular carcinoma (HCC) vary according to known guidelines among liver resection (LR), liver transplantation (LT), radiofrequency ablation (RFA), and transarterial chemoembolization (TACE). This study aimed to compare the outcomes of initial treatment for patients with resectable HCC within Milan criteria (MC) via nationwide data.

Methods

Patients with resectable HCC (Child-Pugh class A; platelet count, ≥100,000/µL) within MC from the Korean Liver Cancer Association databank were analyzed, retrospectively. Outcomes according to initial treatment and subgroups according to tumor size and number were analyzed. Overall survival (OS) rates after initial treatment were compared.

Results

A total of 3,241 patients who underwent LR (n = 1,371), LT (n = 12), RFA (n = 679), or TACE (n = 1,179) were included. The 5-year OS rates differed significantly between the groups (P < 0.05), except for LT (LR, 84.9%; LT, 82.5%; RFA, 76.2%; and TACE, 59.9%). For patients with a single tumor of any size, the 5-year OS rates of the LR group were significantly higher than RFA and TACE groups. For patients with multiple tumors, the 5-year OS rates were 78.2%, 100%, 74.3%, and 53.0% for the LR, LT, RFA, and TACE groups, respectively, but without significant difference between LR and RFA (P = 0.86).

Conclusion

For resectable HCC within MC, the LR had the highest OS rate for a single tumor of any size. LR and RFA showed no significant differences in OS rate for multiple tumors. LR has a much more optimistic outlook for HCC within MC.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Construction of a survival prediction model for patients with hepatocellular carcinoma (HCC) based on real clinical data: a single-center retrospective study

Background

Given the rising incidence of hepatocellular carcinoma (HCC) globally, especially in China, information about independent risk factors for survival and disease prognosis of the illness is scarce. In the field of HCC research, there is an urgent need for a scientific basis to enhance the accuracy of clinical diagnosis, optimize the course of therapy, and accurately predict the prognosis. Against this backdrop, the objective of this work was to develop a scientific, efficient, and methodical nomogram to forecast the survival prognosis of HCC.

Methods

A real-world study collected clinical data from January 1, 2011, to December 31, 2019, for individuals with HCC. Overall survival (OS) was determined using Kaplan-Meier analysis. Independent risk variables were identified using Cox proportional hazards regression. A nomogram predicting 1-, 3-, and 5-year OS was created. The reliability of the predictions of the model was assessed using receiver operating characteristic (ROC), calibration, and decision curve analysis (DCA).

Results

Data from 1,128 HCC cases showed 1-, 3-, and 5-year OS rates were 86.3%, 65.3%, and 43.1%, respectively. Univariate Cox regression identified 13 variables influencing HCC survival including age, HCC screening status, hepatitis C virus (HCV) status, nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) status, liver cirrhosis, elevated alpha-fetoprotein (AFP), Child-Pugh grade, tumor size, tumor number, treatment method, tumor thrombus, and extrahepatic metastasis (P<0.05). Multivariate analysis confirmed HCC screening status, tumor size, ALD, Child-Pugh classification, and therapy method as independent prognostic factors (P<0.05). The nomogram achieved an area under the ROC curve (AUC) of 0.868. Calibration curves of the 1-, 3-, and 5-year survival times and the DCA curve confirmed its predictive accuracy.

Conclusions

Patients without HCC screening, tumor size >5 cm, ALD, Child-Pugh grade C, and conservative treatment had a poor survival prognosis. A nomogram based on these risk variables provides a reliable tool for predicting the survival chances of patients with HCC.

Risk of Hepatocellular Carcinoma Decreases After Antiviral Therapy-Induced HBsAg Seroclearance

BACKGROUND

Antiviral therapy (AVT) reduces the risk of hepatitis B virus-related hepatocellular carcinoma (HCC).

AIMS

The difference in risk of HCC after hepatitis B surface antigen (HBsAg) seroclearance to the AVT status was explored.

METHODS

Patients with chronic hepatitis B who achieved HBsAg seroclearance were retrospectively evaluated. The primary outcome was the development of HCC after HBsAg seroclearance.

RESULTS

Of the study population, 1280 (84.2%) and 241 (15.8%) patients achieved HBsAg seroclearance without (spontaneous clearance group) and with AVT (AVT-induced clearance group), respectively. HCC cumulative incidence was comparable between the two groups (hazard ratio [HR] = 0.461; log-rank test, p = 0.197), whereas it was significantly lower in the AVT-induced HBsAg clearance group than in the spontaneous HBsAg clearance group in inverse probability of treatment weighting analysis (HR = 0.442; log-rank test, p = 0.004). In multivariate analysis, spontaneous HBsAg clearance, albumin-bilirubin (ALBI) grade ≥ 2, cirrhosis, and platelet count < 50 × 109/L were independently associated with the increased risk of HCC. The newly established antiviral therapy, cirrhosis, ALBI, and platelet count (ACAP) scores had a C-index of 0.765, and the time-dependent areas under the curve of HCC prediction at 5 and 8 years were 0774 and 0.823, respectively.

CONCLUSION

The risk of HCC differed according to the AVT status after HBsAg seroclearance.

Efficacy and safety of image-guided hypofractionated radiotherapy for hepatocellular carcinoma with portal vein tumor thrombosis: a retrospective, multicenter study

BACKGROUND

External beam radiation therapy (RT) has shown promising effects for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) in recent studies. However, there is still a lack of consensus on the optimal RT scheme for PVTT treatment. We evaluated the efficacy and safety of image-guided 10-fraction hypofractionated RT in these patients.

METHODS

Between January 2016 and March 2022, a total of 95 HCC patients with PVTT received 10-fraction hypofractionated image-guided radiation therapy (IGRT) at two institutes, and 69 patients were analyzed. Follow-up imaging was performed at three-month intervals after the completion of RT. The extent of PVTT was described according to the Liver Cancer Study Group of Japan classification: Vp1 = segmental portal vein branch, Vp2 = right/left anterior/posterior portal vein, Vp3 = right/left portal vein, and Vp4 = main portal vein. Response evaluation was performed using Response Evaluation Criteria in Solid Tumors, version 1.1. Freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) were calculated from the start date of RT.

RESULTS

The median prescribed dose of 50 Gy (range: 40-50 Gy; biologically effective dose [BED]: 56-75Gy10) was delivered in 10 fractions. In this cohort, 4.3% of patients had Vp1, 20.3% had Vp2, 37.7% had Vp3, and 37.7% had Vp4. Median Planning target volume was 105.3 cc (interquartile range [IQR], 74.1-179.4 cc). Fifty-two (75.4%) patients received 50 Gy. With a median follow-up of 10.2 months (IQR, 6-21 months), the median OS was 20.3 months, and 1-year FFLP, PFS, and OS rates were 88.7%, 26.9%, and 62.2%, respectively. At 3 months follow-up, 13.0% had a complete response, 36.2% had a partial response, 46.4% had a stable disease and 4.4% had a progressive disease. In the multivariate analysis, alpha-fetoprotein level ≥ 600 IU/ml (hazard ratio [HR] 2.06, p = 0.03), Child-Pugh Class B or C (HR 2.30, p = 0.02), and stage IVA or IVB (4.05, p = 0.02) were significantly related to OS. During the follow-up period, there were 2 (2.9%) cases of grade ≥ 3 toxicity: grade 3 liver enzyme elevation (n = 1), and acute cholangitis (n = 1).

CONCLUSIONS

Hypofractionated RT demonstrated promising local PVTT control and OS rates with acceptable toxicity. These data suggest that 10-fraction image-guided hypofractionated RT (BED: 56-75 Gy10) is a feasible treatment option for PVTT in HCC patients.

Developing a novel predictive model for identifying risk factors associated with being lost to follow-up among high-risk patients for recurrence following radical resection of hepatocellular carcinoma: the first report

BACKGROUND

Follow-up is essential especially for patients who are at a high risk of recurrence after radical resection of hepatocellular carcinoma (HCC). The aim of this study was to develop a predictive model aimed at identifying the risk factors associated with being lost to follow-up (LTFU) in high-risk patients for recurrence following radical resection of HCC.

METHODS

The retrospective study was conducted at our institution between October 2018 to May 2023. The patients who underwent radical liver resection for HCC and had high-risk factors for recurrence were categorized into an LTFU group and a control group. Multivariate logistic regression analysis was utilized to determine risk factors and construct a nomogram predictive model.

RESULTS

A total of 352 patients were included and subsequently classified into two distinct groups: the LTFU group (n = 123, 34.94%) and the control group (n = 229, 65.06%). Logistic regression analysis was then conducted to explore the potential associations between various factors and the occurrence of LTFU. The findings identified several independent risk factors for LTFU, including smoking (odds ratio, OR = 1.823, 95% confidence interval, CI 1.086-3.060, p = 0.023); residing more than 200 km away from the hospital (OR = 1.857, 95% CI 1.105-3.121, p = 0.019); having an unstable profession (OR = 1.918, 95% CI 1.112-3.311, p = 0.019); and lacking medical insurance (OR = 5.921, 95% CI 1.747-20.071, p = 0.004); the presence of liver cirrhosis (OR = 2.161, 95% CI 1.153-4.048, p = 0.016); an operation time less than 240 min (OR = 2.138, 95% CI 1.240-3.688, p = 0.006); and the absence of postoperative adjuvant therapy (OR = 2.641, 95% CI 1.504-4.637, p = 0.001). Based on these seven significant factors, a main effects model was established, designated as the Wei-LTFU model, which achieved an area under the curve value of 0.744 (95% CI 0.691-0.798) in predicting the likelihood of LTFU.

CONCLUSION

A main effects model, namely the Wei-LTFU model, incorporating the seven significant factors was formulated to predict the likelihood of LTFU occurrence, ultimately aiming to assist healthcare workers in developing effective strategies to improve follow-up outcomes for patients.

Risk of Variceal Bleeding in Patients Receiving Atezolizumab-Bevacizumab Treatment for Hepatocellular Carcinoma

BACKGROUND AND AIMS

Real-world data on the variceal bleeding (VB) risk in patients receiving atezolizumab-bevacizumab (Atezo-Bev) treatment remain limited. This study aimed to assess the risk of VB and identify risk factors in patients with advanced hepatocellular carcinoma (HCC) receiving Atezo-Bev treatment.

METHODS

This retrospective study included 640 patients with HCC who underwent endoscopy before Atezo-Bev treatment at two hospitals in Korea. The primary outcome was the occurrence of VB, with non-VB events considered as competing events.

RESULTS

Of the 640 patients, the mean age was 61.3 years, and 528 (82.5%) patients were male. The main aetiology of HCC was chronic hepatitis B virus (69.5%), and 563 (88.0%) had BCLC stage C. Portal vein invasion (PVI) was present in 313 (48.9%). During a median follow-up of 5.6 months, 45 (7.0%) patients developed VB. The cumulative incidence of VB was 6.3% at 6 months and 7.4% at 12 months. No patient died from VB. Multivariable analysis revealed that the main PVI (subdistribution hazard ratio [SHR]: 3.49, 95% confidence interval [CI]: 1.63-7.44), low platelet count (SHR: 0.994, 95% CI: 0.99-1.00), a history of gastrointestinal (GI) bleeding (SHR: 3.70, 95% CI: 1.49-9.16) and varices needing treatment (VNT; SHR: 2.67, 95% CI: 1.26-5.64) increased the risk of VB.

CONCLUSION

A low platelet count, main PVI, history of GI bleeding and VNT were significant risk factors for VB in patients receiving Atezo-Bev treatment for HCC. Identifying these factors can guide clinicians in assessing and managing VB risk in clinical settings.

Higher Risk of Proteinuria with Atezolizumab plus Bevacizumab than Lenvatinib in First-Line Systemic Treatment for Hepatocellular Carcinoma

Introduction

Proteinuria presents a challenging complication during systemic therapy for hepatocellular carcinoma (HCC). This study aims to identify risk factors for proteinuria in patients with HCC treated with atezolizumab plus bevacizumab (Atezo/Bev) or lenvatinib (LEN) as first-line systemic treatment.

Methods

A retrospective analysis was conducted on 622 consecutive patients with unresectable HCC who received Atezo/Bev or LEN as first-line systemic treatment between October 2013 and October 2022. Cumulative incidence of proteinuria was estimated using Kaplan-Meier curves and compared using log-rank tests. Risk factors for proteinuria were identified using Cox proportional-hazard models, along with propensity score-matched and subgroup analyses.

Results

Among 367 patients treated with Atezo/Bev and 255 with LEN, the cumulative incidence of proteinuria at 12 months was 27.5%. In the multivariable analysis, Atezo/Bev treatment (adjusted HR [aHR]: 1.57; 95% CI: 1.03-2.42), diabetes (aHR: 1.64; 95% CI: 1.03-2.61), hypertension (aHR: 2.27; 95% CI: 1.04-4.97), Child-Pugh class B (aHR: 3.43; 95% CI: 1.34-8.78), macrovascular invasion (MVI; aHR: 1.58; 95% CI: 1.04-2.38), and an estimated glomerular filtration rate ≤60 mL/min/1.73 m2 (aHR: 3.21; 95% CI: 1.84-5.62) were identified as risk factors for proteinuria. A higher risk of proteinuria in Atezo/Bev patients compared with LEN was consistently observed in the PS-matched cohort, particularly pronounced in subgroups with MVI (HR: 2.84; 95% CI: 1.23-6.54) compared with those without MVI (HR: 1.31; 95% CI: 0.69-2.47).

Conclusions

Patients treated with Atezo/Bev as first-line systemic treatment for HCC exhibited a higher risk of proteinuria compared with those with LEN, particularly when accompanied by MVI.

Unraveling the immune-activated tumor microenvironment correlated with clinical response to atezolizumab plus bevacizumab in advanced HCC

Background & Aims

Despite atezolizumab plus bevacizumab being a standard treatment for advanced hepatocellular carcinoma (HCC), a significant proportion of patients do not achieve durable benefit. This study aimed to identify predictive biomarkers for this therapy by investigating the role of immune activation within the tumor microenvironment (TME).

Methods

We characterized the intratumoral TME of patients with advanced HCC treated with atezolizumab plus bevacizumab using single cell transcriptomics on pretreatment tumor biopsies from 12 patients. To complement and support these findings, we integrated our single cell data with publicly available bulk RNA-sequencing data from independent clinical trial cohorts.

Results

Patients who responded to combination therapy with atezolizumab plus bevacizumab demonstrated an immune-activated TME, marked by enhanced cytotoxicity and a tumor-specific T cell response. These patients also exhibited an increased proportion of inflammatory cytokine-enriched tumor-associated macrophage clusters with stronger interactions with T cells, an increased population of conventional dendritic cells, and activated antigen-presenting function in tumor endothelial cells. When publicly available bulk RNA-sequencing data from independent clinical trial cohorts were analyzed, these immune activation features were associated with improved progression-free survival (median 10.8 months, 95% CI: 7.3-not reached versus 5.5 months, 95% CI: 4.0-6.7; p <0.001).

Conclusions

These findings suggest that the existence of an activated immune TME before treatment is crucial for a favorable clinical response in patients with HCC treated with atezolizumab plus bevacizumab.

Impact and implications

Only a subset of patients with HCC benefit from combination therapy with atezolizumab plus bevacizumab, limiting its clinical utility. In this study, we used single cell RNA analysis to identify TME features associated with a clinical response to this therapy. Our findings suggest that a pre-existing immune-activated TME is crucial for predicting the response to atezolizumab plus bevacizumab. Specifically, features such as enhanced T cell cytotoxicity, inflammatory cytokine-enriched macrophage clusters, active antigen presentation in endothelial cells, and an increased presence of dendritic cells may aid patient selection and inform therapeutic strategies.

Effectiveness of noncontrast-abbreviated magnetic resonance imaging in a real-world hepatocellular carcinoma surveillance

OBJECTIVES

Noncontrast-abbreviated magnetic resonance imaging (NC-AMRI) is emerging as a promising alternative to ultrasound (US) for surveillance of hepatocellular carcinoma (HCC) in at-risk patients. We aimed to assess the effectiveness of NC-AMRI in a real-world surveillance population, and to evaluate the appropriateness of NC-AMRI in selected patients with inadequate prior US.

MATERIALS AND METHODS

This retrospective study included Child-Pugh class A or B adults with chronic hepatitis B or cirrhosis from any cause who underwent NC-AMRI between December 2018 and August 2022. Early- and very early-stage detection, receipt of curative treatment, and false referral were evaluated. Subgroup analysis was performed for patients with inadequate prior US examinations. Descriptive statistics were used.

RESULTS

Among the 1853 patients (mean age, 58.8 years; 1045 males), 68 HCCs developed in 61 (61/1853, 3.3%, 95% confidence interval: 2.5-4.2) patients. The proportions of early- and very early-stage detection were 95.1% (58/61, 72.2-100.0) and 70.5% (43/61, 51.0-95.0); receipt of curative treatment, 67.2% (41/61, 48.2-91.2); and proportion of false referral, 12.9% (9/70, 5.9-24.4). Among the 375 patients with inadequate prior US, the proportions of early- and very early-stage detection were 94.7% (18/19, 56.2-100.0) and 57.9% (11/19, 28.9-100.0); receipt of curative treatment, 52.6% (10/19, 25.2-96.8); and proportion of false referrals, 17.4% (4/23, 4.7-44.5).

CONCLUSION

NC-AMRI may be an effective HCC surveillance modality given the results related to early- and very early-stage detection, receipt of curative treatment, and false referral. NC-AMRI can be an alternative HCC surveillance strategy, especially for patients with inadequate prior US examinations.

KEY POINTS

Question There is insufficient evidence to support the use of noncontrast-abbreviated MRI as an effective surveillance tool in large real-life populations under surveillance. Findings Using noncontrast-abbreviated MRI, most patients who developed HCCs during surveillance were diagnosed at an early stage, with an acceptable false referral rate of 12.9%. Clinical relevance Noncontrast-abbreviated MRI is an effective HCC surveillance modality, especially for patients with inadequate prior ultrasound examinations.

Assessing the Validity of the AASLD Surgical Treatment Algorithm in Patients with Early-Stage Hepatocellular Carcinoma

Background/Aims

The aim of this study was to investigate the effect of a surgical treatment algorithm recently proposed by the American Association for the Study of Liver Diseases (AASLD) on survival outcomes in patients with early-stage hepatocellular carcinoma (HCC) and identify effective alternative treatment modalities when liver transplantation (LT) is not available.

Methods

We studied the clinical data of 1,442 patients who were diagnosed with early-stage HCC (a single lesion measuring 2-5 cm in size or 2 to 3 lesions measuring ≤3 cm in size) between 2013 and 2018 and classified as Child-Turcotte-Pugh (CTP) A or B. Analyses were separately performed for individuals recommended for resection (single lesion, CTP A and no clinically significant portal hypertension) and those recommended for LT (single lesion with impaired liver function such as CTP B or clinically significant portal hypertension or multiple lesions).

Results

Of 791 patients recommended for surgical resection, 85.8% underwent resection. The 5-year survival rate was higher for patients who underwent surgical resection than for those who received other treatments (89.4% vs 72.3%). Among 651 patients recommended for LT, only 3.4% underwent the procedure. The most common alternative treatment modalities were transarterial therapy (39.3%) followed by resection (28.9%) and ablation (27.8%). The overall survival rate associated with transarterial therapy was lower than that for resection and ablation, whereas that of the latter two treatments were comparable.

Conclusions

The survival outcomes of treatment strategies that most closely aligned with the algorithm proposed by the AASLD were superior to those of alternative treatment approaches. However, LT in patients with early-stage HCC can be challenging. When LT is not feasible, resection and ablation can be considered first-line alternative options.

Radiofrequency ablation versus stereotactic body radiotherapy for recurrent hepatocellular carcinoma: a multicenter, propensity score matching analysis

PURPOSE

This study aimed at analyzing and comparing the clinical efficacy and prognosis of stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) in the treatment of recurrent hepatocellular carcinoma (RHCC).

METHODS

Clinicopathological data of RHCC patients who underwent RFA or SBRT as treatment from three medical centers were retrospectively reviewed. The survival outcomes of patients who underwent SBRT were compared with those who underwent RFA. Using the Kaplan-Meier method, survival curves for the two groups of patients were generated, and the log-rank test was used to compare survival differences. Propensity score matching (PSM) analysis was used to match patients of the SBRT and RFA groups in a 1:1 ratio.

RESULTS

The SBRT group had a significantly better overall survival (OS) than the RFA group and no statistical differences were found in disease-free survival (DFS) in the two groups before and after PSM. After PSM, subgroup analysis demonstrated that, compared with the RFA group, the SBRT group had a significantly better OS in terms of tumor location in the subphrenic or subcapsular area, tumor size > 2.5 cm, and tumor proximity to major vessels ≤ 1 cm.

CONCLUSIONS

SBRT appears to be an effective priority to RFA for RHCC patients especially when RFA is not feasible due to tumor location, size, and proximity to major vessels.

Recent advances and issues in imaging modalities for hepatocellular carcinoma surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Early detection via surveillance plays a crucial role in enabling curative treatment and improving survival rates. Since the initial randomized controlled trial, biannual ultrasound (US) has been established as the standard surveillance method because of its accessibility, safety, and low cost. However, US has some limitations, including operator dependency, suboptimal sensitivity for early-stage HCC, and challenges such as a limited sonic window that may result in inadequate examination. Alternative imaging modalities, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), have demonstrated higher sensitivity for detecting very early-stage HCC. Recent advancements, such as low-dose CT with deep learning-based reconstruction, have enhanced the safety and feasibility of CT-based surveillance by reducing radiation exposure and amount of contrast media. MRI, particularly with gadoxetic acid or abbreviated protocols, offers superior tissue contrast and sensitivity, although its accessibility and cost remain challenges. Tailored surveillance strategies based on individual risk profiles and integration of advanced imaging technologies have the potential to enhance the detection performance and cost-effectiveness. This review highlights the recent developments in imaging technologies for HCC surveillance, focusing on their respective strengths and limitations.

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

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

Microwave ablation vs. liver resection for patients with hepatocellular carcinomas

BACKGROUNDS/AIMS

Microwave ablation (MWA) is an emerging ablative therapy that surpasses previous methods by achieving higher temperatures and creating larger ablation zones within shorter periods. This study compared the therapeutic outcomes of MWA with those of liver resection in real-world clinical practice.

METHODS

A total of 178 patients with 259 nodules who underwent MWA or liver resection between January 2015 and July 2023 were enrolled. Local tumor progression (LTP)-free survival, overall progression (OP)-free survival, and overall survival (OS) were assessed based on the treatment modality for the index nodule.

RESULTS

Of the 178 patients, 134 with 214 nodules underwent MWA, and 44 with 45 nodules underwent liver resection. The median follow-up period was 2.0±1.5 years. The annual incidence of LTP was 3.7% for MWA and 1.4% for liver resection. Treatment modality did not significantly affect LTP-free survival (hazard ratio, 0.61; 95% confidence interval, 0.14-2.69; P=0.511). For nodules larger than 3 cm, LTP-free survival was not affected by the treatment modality. Similarly, OP-free survival and OS were not influenced by treatment modality.

CONCLUSIONS

MWA and liver resection demonstrated comparable treatment outcomes in terms of local tumor control, overall recurrence, and survival. MWA may be an alternative treatment option for select patients; however, further studies are necessary to generalize these findings.

Dynamic Peripheral T-Cell Analysis Identifies On-Treatment Prognostic Biomarkers of Atezolizumab plus Bevacizumab in Hepatocellular Carcinoma

Introduction

Variability in response to atezolizumab plus bevacizumab (AB) treatment of hepatocellular carcinoma (HCC) underscores the critical need for the development of effective biomarkers. We sought to identify peripheral blood biomarkers reflecting response to AB treatment.

Methods

We analyzed dynamic changes in peripheral blood mononuclear cells from a prospective, multicenter cohort of 65 patients with HCC, using flow cytometry to evaluate the T-cell population before and 3 weeks after the first AB treatment.

Results

We found a unique response of the CD8+ T cells in terms of both frequency and phenotype, in contrast to CD4+ T cells and regulatory T cells. Notably, CD8+ T cells showed significant changes in expression of Ki-67 and T-cell immunoreceptors with Ig and ITIM domains (TIGIT). These distinct responses were observed particularly in the programmed cell death receptor-1 (PD-1)+ subpopulation of CD8+ T cells. Interestingly, the baseline differentiation status of PD-1+CD8+ T cells, particularly the central memory T-cell subset, correlated positively with greater proliferation (higher Ki-67 expression) of PD-1+CD8+ T cells after treatment. Moreover, effector memory cells expressing CD45RA correlated negatively with the increase in TIGIT+/PD-1+CD8+ T cells. The increase in TIGIT+/CD8+ T cells was associated with the development of immune-related adverse events, whereas increase in Ki-67+/PD-1+CD8+ T cells was associated with the better objective response rate. Importantly, dynamic shifts of Ki-67+/PD-1+CD8+ T cells and TIGIT+/CD8+ T cells significantly predicted progression-free survival and overall survival, as confirmed by multivariate analysis.

Conclusion

These findings highlight the potential of dynamic changes in CD8+ T cells as an on-treatment prognostic biomarker. Our study underscores the value of peripheral blood profiling as a noninvasive and practical method for predicting the clinical outcomes of AB treatment in patients with HCC.

Hepatocellular carcinoma in Korea: an analysis of the 2016-2018 Korean Nationwide Cancer Registry

BACKGROUNDS/AIMS

Hepatocellular carcinoma (HCC) is the sixth most common cancer and second leading cause of cancer-related deaths in South Korea. This study evaluated the characteristics of Korean patients newly diagnosed with HCC in 2016-2018.

METHODS

Data from the Korean Primary Liver Cancer Registry (KPLCR), a representative database of patients newly diagnosed with HCC in South Korea, were analyzed. This study investigated 4,462 patients with HCC registered in the KPLCR in 2016-2018.

RESULTS

The median patient age was 63 years (interquartile range, 55-72). 79.7% of patients were male. Hepatitis B infection was the most common underlying liver disease (54.5%). The Barcelona Clinic Liver Cancer (BCLC) staging system classified patients as follows: stage 0 (14.9%), A (28.8%), B (7.5%), C (39.0%), and D (9.8%). The median overall survival was 3.72 years (95% confidence interval, 3.47-4.14), with 1-, 3-, and 5-year overall survival rates of 71.3%, 54.1%, and 44.3%, respectively. In 2016-2018, there was a significant shift toward BCLC stage 0-A and Child-Turcotte-Pugh liver function class A (P<0.05), although survival rates did not differ by diagnosis year. In the treatment group (n=4,389), the most common initial treatments were transarterial therapy (31.7%), surgical resection (24.9%), best supportive care (18.9%), and local ablation therapy (10.5%).

CONCLUSIONS

Between 2016 and 2018, HCC tended to be diagnosed at earlier stages, with better liver function in later years. However, since approximately half of the patients remained diagnosed at an advanced stage, more rigorous and optimized HCC screening strategies should be implemented.

Cytokine-Induced Killer Cell Immunotherapy Reduces Recurrence in Patients with Early-Stage Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

Cytokine-induced killer (CIK) cell immunotherapy has shown promise in reducing recurrence and improving survival outcomes in hepatocellular carcinoma (HCC). We evaluated the efficacy and safety of CIK cell therapy in a real-world clinical setting.

METHODS

A retrospective analysis was conducted on 49 patients who received CIK cell therapy after curative resection or radiofrequency ablation, compared with 49 matched control patients via 1:1 propensity score matching. The primary endpoint was recurrence-free survival (RFS), and the secondary endpoint was overall survival (OS).

RESULTS

The median follow-up durations were 19.1 months for the immune cell group and 67.7 months for the control group. In univariable analysis, the immune cell group demonstrated a prolonged RFS than the control group (hazard ratio [HR], 0.32; 95% CI, 0.15-0.71; log-rank p = 0.001). The median RFS was not reached in the immune cell group but was 48.62 months in the control group. A multivariable Cox regression model identified CIK cell therapy as a significant factor associated with a reduced risk of HCC recurrence (adjusted HR, 0.32; 95% CI, 0.15-0.71; p = 0.005). The median OS was not reached in either group; no significant differences in OS were observed between the immune cell and control groups (log-rank p = 0.082). The overall incidence of adverse events was low, and no Grade 3 or 4 events were reported.

CONCLUSIONS

Adjuvant CIK cell immunotherapy after curative treatment significantly prolongs RFS in early-stage HCC patients. Further research regarding the broader applications of CIK cell immunotherapy in HCC is warranted.

Tenofovir Is Associated With a Better Prognosis Than Entecavir for Hepatitis B Virus-Related Hepatocellular Carcinoma

BACKGROUND AND AIMS

Whether tenofovir or entecavir has different effects on the prevention of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) in secondary and tertiary preventive settings is still a matter of debate. This study aimed to compare the long-term prognosis of HCC between tenofovir and entecavir in patients with chronic hepatitis B.

METHODS

Chronic hepatitis B patients diagnosed with HCC between November 2008 and December 2018 and treated with either entecavir or tenofovir at a tertiary center in Korea were included. The effect of tenofovir compared with entecavir on the prognosis of HBV-related HCC was assessed using multivariable-adjusted Cox and propensity score (PS)-matched analyses. Various predefined subgroup analyses were conducted.

RESULTS

During a median follow-up period of 3.0 years, the mortality rate for entecavir-treated patients (n = 3469) was 41.2%, while tenofovir-treated patients (n = 3056) had a mortality rate of 34.6%. Overall survival (OS) was better in the tenofovir group (adjusted hazard ratio [aHR], 0.79; P < .001), which were consistently observed in the PS-matched analysis. The magnitude of the risk difference in OS was more prominent 2 years after the diagnosis of HCC (aHR, 0.50; P < .001) than 2 years before (aHR, 0.88; P = .005), and it was more pronounced in patients with earlier HCC stages. In all subgroups, except for those with shorter life expectancy, such as those with compromised liver function, tenofovir was associated with better OS compared with entecavir.

CONCLUSIONS

Among patients with HBV-related HCC, those treated with tenofovir had a better prognosis than those treated with entecavir, particularly among those with prolonged survival.

A machine learning model to predict liver-related outcomes after the functional cure of chronic hepatitis B

BACKGROUND & AIMS

The risk of hepatocellular carcinoma (HCC) and hepatic decompensation persists after hepatitis B surface antigen (HBsAg) seroclearance. This study aimed to develop and validate a machine learning model to predict the risk of liver-related outcomes (LROs) following HBsAg seroclearance.

METHODS

A total of 4,787 consecutive patients who achieved HBsAg seroclearance between 2000 and 2022 were enrolled from six centers in South Korea and a territory-wide database in Hong Kong, comprising the training (n = 944), internal validation (n = 1,102), and external validation (n = 2,741) cohorts. Three machine learning-based models were developed and compared in each cohort. The primary outcome was the development of any LRO, including HCC, decompensation, and liver-related death.

RESULTS

During a median follow-up of 55.2 (IQR 30.1-92.3) months, 123 LROs were confirmed (1.1%/person-year) in the Korean cohort. The model with the best predictive performance in the training cohort was selected as the final model (designated as PLAN-B-CURE), which was constructed using a gradient boosting algorithm and seven variables (age, sex, diabetes, alcohol consumption, cirrhosis, albumin, and platelet count). Compared to previous HCC prediction models, PLAN-B-CURE showed significantly superior accuracy in the training cohort (c-index: 0.82 vs. 0.63-0.70, all p <0.001; area under the receiver-operating characteristic curve: 0.86 vs. 0.62-0.72, all p <0.01; area under the precision-recall curve: 0.53 vs. 0.13-0.29, all p <0.01). PLAN-B-CURE showed a reliable calibration function (Hosmer-Lemeshow test p >0.05) and these results were reproduced in the internal and external validation cohorts.

CONCLUSION

This novel machine learning model consisting of seven variables provides reliable risk prediction of LROs after HBsAg seroclearance that can be used for personalized surveillance.

IMPACT AND IMPLICATIONS

Using large-scale multinational data, we developed a machine learning model to predict the risk of liver-related outcomes (i.e., hepatocellular carcinoma, decompensation, and liver-related death) after the functional cure of chronic hepatitis B (CHB). The new model named PLAN-B-CURE was constructed using seven variables (age, sex, alcohol consumption, diabetes, cirrhosis, serum albumin, and platelet count) and a gradient boosting machine algorithm, and it demonstrated significantly better predictive accuracy than previous models in both the training and validation cohorts. The inclusion of diabetes and significant alcohol intake as model inputs suggests the importance of metabolic risk factor management after the functional cure of CHB. Using seven readily available clinical factors, PLAN-B-CURE, the first machine learning-based model for risk prediction after the functional cure of CHB, may serve as a basis for individualized risk stratification.

Hepatic Resection for Hepatocellular Carcinoma

Hepatic resection has long been considered the preferred treatment for hepatocellular carcinoma (HCC) when feasible, but its role, as well as the outcomes is evolving rapidly. This article explores the impact of the changing demographics of HCC, reviews current criteria for resection, considers the roles of liver transplantation and nonsurgical locoregional therapies vis-a-vis resection, highlights the potential of new systemic therapies (particularly immune checkpoint inhibitors) to improve outcomes, details the common complications associated with resection, and discusses recurrence of HCC after resection and its management.

Temporal trends of liver cancer burden, comparative analysis of risk factors and trend forecasts to 2024 in China, USA, the Republic of Korea, and Mongolia: an analysis based on multiple data sources from Global Burden of Disease 2019, the Global Cancer Observatory, and Cancer Incidence in Five Continents

Background

Liver cancer represents a significant burden of disease globally, with variations in liver cancer status among countries. In this study, we aimed to evaluate the epidemiological burden of liver cancer in four representative countries - China, the USA, the Republic of Korea, and Mongolia - and cover the highest number of incidence cases, the highest prevalence rates and the burden in developed countries. In addition, we intended to predict the trends in liver cancer in these countries over the next six years.

Methods

We collected epidemiological data on liver cancer from the Global Burden of Disease 2019, the Global Cancer Observatory, and Cancer Incidence in Five Continents databases to conduct data source triangulation. We calculated time trends using Joinpoint regression and predicted incidence rates using an autoregressive integrated moving average model. Aetiological studies were conducted for different countries based on changes in incidence causes.

Results

Between 1990-2019, age-standardised rates (ASR) values for liver cancer declined globally. The downward trend was most pronounced in China, where the average annual percentage change of age-standardised incidence rate (ASIR) reached -3.13 (95% confidence interval (CI) = -2.90, -3.35), much higher than the world average of -1.16 (95% CI = -0.96, -1.36). The ASIR in the USA continued improving and reached 5.23 × 105 in 2019. With age, the ASR for liver cancer in various countries generally shows an upward trend. Hepatitis B virus (HBV) remains the main causative agent of liver cancer in China and Korea. In Mongolia, both HBV and hepatitis C virus account for a large proportion of liver cancer. In the USA, the proportion of liver cancer cases from alcohol consumption has increased annually.

Conclusions

The ASR for liver cancer has declined over the past 30 years in most countries but has worsened in some due to ageing and unhealthy lifestyles.

Canadian Association of Radiologists Cancer Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Cancer Expert Panel is made up of physicians from the disciplines of radiology, medical oncology, surgical oncology, radiation oncology, family medicine/general practitioner oncology, a patient advisor, and an epidemiologist/guideline methodologist. The Expert Panel developed a list of 29 clinical/diagnostic scenarios, of which 16 pointed to other CAR guidelines. A rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of the remaining 13 scenarios. Recommendations from 21 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop the recommendation for these scenarios. During recommendation formulation, one additional scenario was mapped to an existing CAR guideline scenario, leaving 12 scenarios with new recommendations. The guideline focuses on cancer diagnosis and does not cover cancer staging, follow-up, and surveillance. This guideline presents the methods of development and the referral recommendations for suspected pancreatic cancer, suspected liver cancer, incidental liver mass, incidental colon mass or suspected colon cancer, suspected anal cancer, suspected penile cancer, suspected cervical cancer, suspected endometrial/uterine cancer, suspected vulvar cancer, suspected vaginal cancer, suspected haematologic malignancies, and suspected skin cancer. The guideline also points to other CAR guidelines for suspected neck, thyroid, brain, lung, intracardiac/pericardial, esophageal/gastric, renal, adrenal, bladder, testicular, prostate and ovarian cancers, suspected soft tissue mass or tumour, suspected bone tumour, suspected bone tumour --myeloma, suspected spine tumours, and incidental lung cancer.

Repeat laparoscopic hepatectomy versus radiofrequency ablation for recurrent hepatocellular carcinoma: A multicenter, propensity score matching analysis

This study aimed at analyzing and comparing the clinical efficacy and prognosis of repeat laparoscopic hepatectomy (r-LH) and radiofrequency ablation (RFA) in treating recurrent hepatocellular carcinoma (RHCC). Clinicopathological data of RHCC patients who underwent r-LH or RFA as treatment from three medical centers were retrospectively reviewed. Baseline characteristics at the recurrence time after initial hepatectomy and clinical outcomes following treatment of RHCC were compared between the two groups. Using the Kaplan-Meier method, survival curves for the two groups of patients were generated, and the log-rank test was used to compare survival differences. Propensity score matching (PSM) analysis was used to match patients of the r-LH and RFA groups in a 1:1 ratio. A total of 272 patients were enrolled, including 133 patients who underwent r-LH and 139 patients who received RFA. After PSM, 76 patients were matched in each study group. Compared with the r-LH group, the RFA group had shorter hospitalization and fewer postoperative complications. However, the r-LH group had significantly better overall survival (OS) and disease-free survival (DFS) than the RFA group before and after PSM. Subgroup analysis demonstrated that RHCC patients with solitary tumor or those with tumors located near the diaphragm, visceral surface or vessels, had survival benefits from r-LH. When tumor diameter ≤ 5 cm, r-LH appears to be an effective priority to RFA with a significantly higher OS and DFS rate in treating RHCC patients, especially for patients with solitary tumor and those with tumors located near the diaphragm, visceral surface or vessels.

The Prognostic Value of CRP/Alb Ratio in Predicting Overall Survival for Hepatocellular Carcinoma Treated with Transcatheter Intra-Arterial Therapy Combined with Molecular-Targeted Agents and PD-1/PD-L1 Inhibitors

Purpose

This study aimed to evaluate the prognostic value of C-reactive protein to albumin (CRP/Alb) ratio in hepatocellular carcinoma (HCC) treated with transcatheter intra-arterial therapy combined with molecular targeted agents (MTAs) and programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors.

Methods

Medical records of 271 consecutive patients with HCC receiving this combination therapy in China between 2019 and 2023 were retrospectively analyzed. Prognostic factors for progression-free survival (PFS) and overall survival (OS) were identified using univariate and multivariate Cox regression analyses. The discriminatory capability of inflammation-based prognostic scores-including the CRP/Alb ratio, C-reactive protein and alpha-fetoprotein in immunotherapy (CRAFITY) score, modified Glasgow prognostic score (mGPS), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII)-was assessed using the area under the curve (AUC).

Results

A total of 133 patients met the inclusion criteria. The optimal cutoff value for the binary classification of CRP/Alb ratio in predicting OS, as determined using X-tile software, was 0.02. Multivariate analysis identified the CRP/Alb ratio (hazard ratio [HR] = 2.61, p < 0.001), tumor size (HR = 2.45, p = 0.018), and extrahepatic metastases (HR = 1.93, p = 0.015) as independent predictors of OS. For PFS, significant factors included Eastern Cooperative Oncology Group Performance Status (HR = 1.55, p = 0.033) and macrovascular invasion (HR = 1.48, p = 0.046). Patients with higher CRP/Alb ratios were more likely to experience fever and fatigue. The CRP/Alb ratio demonstrated significantly higher AUCs than PLR and SII at 24 months (all p < 0.05) and showed comparable AUCs to CRAFITY score and mGPS at 12, 24, and 36 months.

Conclusion

The CRP/Alb ratio is a valuable prognostic marker for predicting OS and treatment-related adverse events in HCC patients receiving transcatheter intra-arterial therapy combined with MTAs and PD-1/PD-L1 inhibitors. This ratio can be used as a simple and reliable biomarker for assessing prognosis and guiding patient selection in clinical practice.

The Cancer Clinical Library Database (CCLD) from the Korea-Clinical Data Utilization Network for Research Excellence (K-CURE) Project

The common data model (CDM) has found widespread application in healthcare studies, but its utilization in cancer research has been limited. This article describes the development and implementation strategy for Cancer Clinical Library Databases (CCLDs), which are standardized cancer-specific databases established under the Korea-Clinical Data Utilization Network for Research Excellence (K-CURE) project by the Korean Ministry of Health and Welfare. Fifteen leading hospitals and fourteen academic associations in Korea are engaged in constructing CCLDs for 10 primary cancer types. For each cancer type-specific CCLD, cancer data experts determine key clinical data items essential for cancer research, standardize these items across cancer types, and create a standardized schema. Comprehensive clinical records covering diagnosis, treatment, and outcomes, with annual updates, are collected for each cancer patient in the target population, and quality control is based on six-sigma standards. To protect patient privacy, CCLDs follow stringent data security guidelines by pseudonymizing personal identification information and operating within a closed analysis environment. Researchers can apply for access to CCLD data through the K-CURE portal, which is subject to Institutional Review Board and Data Review Board approval. The CCLD is considered a pioneering standardized cancer-specific database, significantly representing Korea's cancer data. It is expected to overcome limitations of previous CDMs and provide a valuable resource for multicenter cancer research in Korea.

A comprehensive study on the feasibility and diagnostic potential of fluctuation imaging in liver tumor assessment

Ultrasound (US) is a widely used technique for liver disease but has limitations in distinguishing tumors. This study evaluates the clinical efficacy of fluctuational imaging (FLI), a new US method that detects the fluttering sign in liver tumors. We conducted a prospective exploratory study with 120 participants diagnosed with liver tumors through histopathology or standard imaging. Both FLI and US were performed, capturing approximately 100 image frames within a 10-second breath-hold to create a color-coded FLI map. The fluttering sign, shown by yellow to red area in tumors, was primarily analyzed in the largest tumor in cases with multiple tumors. Eleven participants were excluded due to non-visibility of tumor in B-mode US (n = 3), not a hepatic tumor (n = 1) or motion artifact affecting FLI map creation (n = 7). The final cohort comprised 70 hemangiomas, 17 hepatocellular carcinomas, 7 cholangiocarcinomas, 11 metastases, 3 angiomyolipomas, and 1 cortical adenoma. The fluttering sign was observed in 57.1% (40/70) of hemangiomas, significantly higher than the 12.8% (5/39) in other tumor types (P < 0.001). Mixed or hypoechoic hemangiomas showed an 86.1% incidence (31/38) of the fluttering sign, significantly more than hyperechoic hemangiomas (28.1%, 9/32) (P < 0.001). FLI significantly detects the fluttering sign in hepatic hemangiomas, especially mixed or hypoechoic types, enhancing its diagnostic value.

International perspectives on LI-RADS

Given the crucial role of imaging in HCC diagnosis, LI-RADS CT/MRI was developed to standardize the imaging interpretation and reporting of HCC in patients at risk for HCC and categorize hepatic observations on an ordinal scale according to the likelihood of HCC. LI-RADS has since been expanded to include 5 algorithms: LI-RADS US Surveillance, contrast-enhanced US (CEUS) LI-RADS, LI-RADS CT/MRI, and LI-RADS Treatment Response Assessment. LI-RADS has been adopted broadly in North America, however with less ubiquitous adoption outside of North America. Further elucidation of the perceived strengths and weakness of the LI-RADS algorithm, as it pertains to various geographic regions, will continue to inform a future system that may be more readily adopted globally. Therefore, the aim of this article is to summarize HCC risk factors and imaging guidelines in select geographically disparate regions, and to solicit feedback from liver imaging experts on the limitations and barriers to adoption of LI-RADS algorithms in their patient populations.

Albumin-Bilirubin Grade as a Valuable Predictor of Recurrence and Prognosis in Patients with Hepatocellular Carcinoma Following Radiofrequency Ablation

Background/Objectives: Radiofrequency ablation (RFA) is an important local treatment for hepatocellular carcinoma (HCC). This study aimed to evaluate the characteristics of tumor recurrence after RFA and analyze predictors of tumor recurrence and survival in patients with HCC. Methods: We retrospectively reviewed data from treatment-naïve patients with HCC who underwent RFA for HCC treatment between 2008 and 2017 at four tertiary hospitals in South Korea. Results: A total of 636 patients with HCC treated with RFA were enrolled in the study. The mean age was 66.3 ± 10.4 years, with 75.0% of patients being male. Most patients (96.7%) had underlying liver cirrhosis, and viral hepatitis (types B and C) accounted for most cases. The average maximum tumor size was 2.2 ± 0.9 cm, with 84.3% of tumors being single lesions. During the follow-up period, 331 patients experienced recurrence, with 95.5% of cases being intrahepatic and one-fifth occurring at the RFA site. Most patients underwent RFA or transarterial chemoembolization as subsequent therapy for recurrence. Multivariate analysis revealed that age, the albumin-bilirubin (ALBI) grade, and Child-Pugh class B status were independent factors associated with tumor recurrence. Only the ALBI grade was significantly associated with mortality. Additionally, the ALBI grade differentiated between recurrence-free survival and overall survival in the Kaplan-Meier survival curve. Conclusions: The ALBI grade was independently associated with tumor recurrence and prognosis in patients with HCC following RFA. This grading system can help clinicians identify high-risk patients, optimize treatment strategies, and enhance patient care.

Improved survival with second-line hepatic arterial infusion chemotherapy after atezolizumab-bevacizumab failure in hepatocellular carcinoma

Background

There is no established second-line treatment for hepatocellular carcinoma (HCC) following atezolizumab-bevacizumab (ate-beva) failure. This study assessed the efficacy of hepatic arterial infusion chemotherapy (HAIC) as a salvage therapy by comparing survival outcomes and treatment responses between HAIC as a first-line treatment and as a second-line option after ate-beva failure.

Materials and Methods

We retrospectively analyzed 100 patients with advanced HCC treated with HAIC between March 2022 and July 2024. Patients were categorized into two groups: those who received HAIC as initial therapy (first-line HAIC group) and those who received HAIC following ate-beva failure (post-ate-beva group). Survival outcomes were assessed with Kaplan-Meier curves and log-rank tests, and factors associated with survival were identified through Cox regression analysis.

Results

The post-ate-beva group exhibited longer overall survival (OS) (median OS 12.4 months) compared to the first-line HAIC group (median OS 6.8 months) (p = 0.073). Progression-free survival (PFS) was significantly superior in the post-ate-beva group (median PFS 8.2 months) compared to the first-line HAIC group (median PFS 3.1 months) (p = 0.018). The objective response rate was also notably higher in the post-ate-beva group than in the first-line HAIC group (35.3% vs. 18.1%, p = 0.031). In multivariate analysis, HAIC following ate-beva failure, compared to first-line HAIC, was significantly associated with favorable outcomes for both OS (p = 0.014) and PFS (p = 0.006).

Conclusion

The superior survival outcomes and treatment responses observed in the post-ate-beva group suggest that HAIC may be an effective second-line treatment option for advanced HCC following ate-beva therapy failure. However, due to the retrospective nature and small sample size of the study, further prospective studies with larger patient populations are needed to strengthen the evidence.

Multicenter Study on Transarterial Chemoembolization Combined with Radiofrequency Ablation for Early-Stage Hepatocellular Carcinoma: Primary versus Recurrent HCC

Purpose

To evaluate the efficacy of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) for both primary and recurrent early-stage hepatocellular carcinoma (HCC) and to analyze the significant prognostic factors.

Patients and Methods

Data from patients with early-stage primary or recurrent HCC who underwent TACE plus RFA between August 2019 and May 2024 were collected from three major general hospitals. 158 patients were divided into a primary group and a recurrent group on the basis of their baseline characteristics. Compared the objective response rate (ORR), 1-, 3-, and 5-year progression-free survival (PFS) rates, 1-, 3-, and 5-year overall survival (OS) rates, and complication rate between the two groups. Multivariate analyses were used to evaluate the factors influencing PFS and OS.

Results

One hundred fifty-eight patients were enrolled. The ORRs of the primary and recurrent groups were 98.2% and 95.1%, respectively, with no statistically significant difference (χ2= 2.032, Ρ = 0.362). The primary group having a significantly longer PFS time than the recurrent group (Ρ < 0.001). However, there was no significant difference in the 1-, 3-, and 5-year OS rates between the two groups (Ρ = 0.218). Multivariate analysis revealed that primary or recurrent HCC and the Child‒Pugh score were significant prognostic factors for PFS, whereas the serum albumin level was a significant prognostic factor for OS.

Conclusion

TACE plus RFA has similar clinical efficacy and safety for both primary and recurrent early HCC. Compared with patients with primary HCC, those with recurrent disease had significantly shorter PFS times.

Prognostic significance of combined PD-L1 expression in malignant and infiltrating cells in hepatocellular carcinoma treated with atezolizumab and bevacizumab

Background

Programmed death-ligand 1 (PD-L1) expression is abundant not only in malignant cells but also in infiltrating cells within the tumor microenvironment (TME) of hepatocellular carcinoma (HCC). This study explored the association between PD-L1 expression in TME and outcomes in HCC patients treated with atezolizumab plus bevacizumab (AB), emphasizing the implications of PD-L1 expression in both malignant and tumor-infiltrating cells.

Methods

This study included 72 patients with HCC who underwent percutaneous core needle liver biopsy before AB treatment between September 2020 and December 2023. PD-L1 expression on tumor tissues was assessed using the combined positive score (CPS) with cutoff values of 1 and 10, utilizing antibody clone 22C3 (Dako).

Results

The distribution of PD-L1 CPS included 24 patients with CPS <1, 33 patients with CPS 1-10, and 15 patients with CPS ≥10. Significant differences in overall survival (OS) were observed across the three groups, with CPS ≥10 showing the highest survival rates (p = 0.010). Patients with CPS ≥10 had better OS than those with CPS <10 (median OS 14.8 vs. 8.3 months, P = 0.046), and CPS ≥1 had better OS than CPS <1 (P = 0.021). For progression-free survival (mPFS), the CPS ≥10 group had the highest median PFS of 11.0 months among the three groups (P = 0.044). Objective response rates (ORR) were higher in the PD-L1 CPS ≥10 group than in the 1-10 and <1 group (53.3%, 27.3%, and 16.7%, respectively; P = .047). Multivariate analysis identified that PD-L1 expression ≥10 and ≥1 were associated with favorable outcomes regarding OS (hazard ratio [HR] 0.283, P = .027 and HR 0.303, P = .006, respectively).

Conclusions

Combined analysis of PD-L1 expression in malignant and tumor-infiltrating cells can be a promising biomarker for the prognosis of HCC patients treated with AB.

Contrast vector imaging for differential diagnosis of focal liver lesions: Analysis of tumoral vascular structures and flow characteristics

PURPOSE

To assess the efficacy of contrast vector imaging (CVI) in detecting tumoral vascular structures and flow characteristics of focal liver lesions (FLLs) for differential diagnosis.

MATERIALS AND METHODS

In this prospective study, 65 participants with FLLs underwent CEUS using SonoVue with high-frame-rate imaging technique between July 2019 and October 2020. CVI was obtained by post-processing arterial cine imaging of CEUS. Tumoral vascular structures, velocity histogram, and mean velocities were compared among hepatocellular carcinoma (HCC), non-HCC malignancies, and benign tumors using the Chi-square and Kruskal-Wallis tests, respectively. The areas under the receiver operating characteristic curve (AUC) of CEUS in determining HCC probability was compared to that of CEUS with CVI using a z-test.

RESULTS

CVI was technically successful in 52 of 65 (80%) participants (19 HCCs, 13 non-HCC malignancies, and 20 benign tumors). The detectability of tumoral vascular structures was significantly higher in CEUS with CVI, compared to CEUS alone (46.2% [24/52] vs. 100.0% [52/52], p<0.001). On CEUS with CVI, complex intratumoral and peripheral vessels were frequent in HCCs (100% of HCCs, 46.2% of non-HCC malignancies, and 70.0% of benign tumors), while detour vessels were frequent in non-HCC malignancies (none of HCCs, 53.8% of non-HCC malignancies, and 10.0% of benign tumors) (p<0.001). The mean velocity of HCC (26.3 mm/s) was the highest, while that of non-HCC malignancy (20.6 mm/s) was the lowest (p<0.001). CEUS with CVI showed higher AUC, compared to CEUS in both reviewers (0.851 vs. 0.963, p = 0.005 for reviewer 1; 0.853 vs. 0.982, p = 0.023 for reviewer 2).

CONCLUSION

CEUS with CVI better visualized vascular structures and flow characteristics of FLLs, and showed better diagnostic performance in determining HCC probability than CEUS.

APASL clinical practice guidelines on systemic therapy for hepatocellular carcinoma-2024

In Asia-Pacific region, hepatocellular carcinoma is a serious health threat attributing to over 600,000 deaths each year and account for over 70% of global cases. Clinically, the major unmet needs are recurrence after curative-intent surgery, liver transplantation or local ablation and disease progression in those with hepatocellular carcinoma not eligible for resection or failed locoregional therapy. In the recent few years, new targeted therapy and immune-checkpoint inhibitors have been registered as systemic therapy to address these issues. Notably, new forms of systemic therapy, either as first-line or second-line therapy for unresectable hepatocellular or those not eligible for locoregional therapy, are now available. New data is also emerging with the use of systemic therapy to prevent hepatocellular carcinoma recurrence after curative-intent resection or local ablation therapy and to retard disease progression after locoregional therapy. In the future, further implementation of immune-checkpoint inhibitors and other forms of immunotherapy are expected to bring a new paradigm to the management of hepatocellular carcinoma. New insight related to immune-related adverse events with the use of immunotherapy has allso enabled optimization of the therapeutic approach to patients with hepatocellular carcinoma. The purpose of this clinical practice guideline is to provide an up-to-date recommendation based on clinical evidence and experience from expert Asia-Pacific key opinion leaders in the field of hepatocellular carcinoma. Three key questions will be addressed, namely: (1) Which patients with hepatocellular carcinoma should be considered for systemic therapy? (2) Which systemic therapy should be used? (3) How should a patient planned for immune checkpoint-based systemic therapy be managed and monitored?

Prognostic Efficacy of the Albumin-Bilirubin Score and Treatment Outcomes in Hepatocellular Carcinoma: A Large-Scale, Multi-Center Real-World Database Study

Introduction

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality globally, with treatment outcomes closely tied to liver function. This study evaluates the prognostic utility of the albumin-bilirubin (ALBI) score compared to the traditional Child-Pugh (CP) grading, leveraging real-world evidence from a large-scale, multi-center database.

Methods

The Liver Cancer IN Korea (LINK) research network, a multi-center initiative, retrospectively collected electronic health records from three academic hospitals in South Korea, encompassing HCC patients diagnosed between 2015 and 2020. Inclusion criteria mandated at least one HCC treatment and excluded patients with other primary cancer diagnoses. The study followed patients until death, the last visit, or June 2021, employing standardized data processing and rule-based algorithms for data consistency. The prognostic efficacy of ALBI scores and CP scores was compared through time-dependent receiver operating characteristic (ROC) curves and the inverse probability censoring weighting method.

Results

From 25,248 newly diagnosed patients, 10,297 were included, with 65.82% having hepatitis B etiology and a mean follow-up of 27.49 months. Patients' classification by modified ALBI (mALBI) grade at diagnosis revealed: grade 1 (48.87%), 2a (20.50%), 2b (24.54%), and 3 (5.17%), with a minimal percentage missing (0.92%). Transarterial therapy (54.07%) and tyrosine kinase inhibitors (84.14% as the first-line systemic therapy) were predominant treatments. The ALBI score demonstrated greater prognostic efficacy than the CP score in long-term outcomes, with time-dependent area under the ROC curve analysis showing a score of 0.71 for ALBI versus 0.67 for CP at 60 months. Furthermore, higher mALBI grades were significantly associated with poorer survival outcomes, as indicated by both univariate and multivariate Cox proportional regression model analyses (p < 0.001).

Conclusions

The study confirmed the ALBI score's superior prognostic ability over the CP score, especially evident in long-term outcomes, suggesting a shift toward more nuanced liver function assessment tools in real-world clinical practice.

New strategy of LI-RADS v2018 to improve the sensitivity for small hepatocellular carcinoma ≤ 3.0 cm on extracellular-contrast enhanced MRI

INTRODUCTION

We aimed to modify LI-RADS version 2018 to improve sensitivity and determine the value of the combination of high alpha-fetoprotein (AFP) levels for small HCC (sHCC, ≤ 30 mm) diagnosis.

METHODS

A total of 984 patients at high risk for HCC, with 1204 observations (including 997 small observations ≤ 30 mm), who underwent extracellular contrast-enhanced MRI were enrolled from five independent centers. Blinded readers evaluated the LI-RADS features and categorized each observation according to the LI-RADS v2018, modified LI-RADS and EASL. Odds ratios of LI-RADS major features (MFs) and several high AFP levels for sHCC diagnosis were analyzed using multivariable logistic regression. The modified LR-5 criteria was developed by including no APHE at any size with two MFs, and non-rim APHE with one MF (≥ 10 mm) or with two MFs (< 10 mm). The diagnostic performance of each version of the LR-5 was compared using generalized estimating equations.

RESULTS

APHE, washout, enhancing capsule and five high AFP levels were independently associated with sHCC. In three datasets, the modified LI-RADS had higher sensitivities for sHCC (76.8 ∼ 85.5 % vs. 73.7 ∼ 75.9 %, P < 0.05) to the LR-5 v2018. The modified LI-RADS with AFP ≥ 200 ng/mL as an additional feature or as an alternative to threshold growth provided higher sensitivities for sHCC than LI-RADS v2018 (82.1 ∼ 90.1 % vs. 73.7 ∼ 75.9 %, all P < 0.05), modified LI-RADS (82.1 ∼ 90.1 % vs. 76.8 ∼ 85.5 %, all P < 0.05) and EASL version 2018 (82.1 ∼ 90.1 % vs. 73.3 ∼ 74.7 %, all P < 0.05), with comparable specificities (all P > 0.05).

CONCLUSION

The new strategy of LI-RADS v2018 provides significantly higher sensitivity and comparable specificity than those of LI-RADS v2018 for sHCC diagnosis on ECA-MRI.

Identification of macrotrabecular-massive hepatocellular carcinoma through multiphasic CT-based representation learning method

BACKGROUND

Macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) represents an aggressive subtype of HCC and is associated with poor survival.

PURPOSE

To investigate the performance of a representation learning-based feature fusion strategy that employs a multiphase contrast-enhanced CT (mpCECT)-based latent feature fusion (MCLFF) model for MTM-HCC identification.

METHODS

A total of 206 patients (54 MTM HCC, 152 non-MTM HCC) who underwent preoperative mpCECT with surgically confirmed HCC between July 2017 and December 2022 were retrospectively included from two medical centers. Multiphasic radiomics features were extracted from manually delineated volume of interest (VOI) of all lesions on each mpCECT phase. Representation learning based MCLFF model was built to fuse multiphasic features for MTM HCC prediction, and compared with competing models using other fusion methods. Conventional imaging features and clinical factors were also evaluated and analyzed. Prediction performance was validated by ROC analysis and statistical comparisons on an internal validation and an external testing dataset.

RESULTS

Fusion of radiomics features from the arterial phase (AP) and portal venous phase (PAP) using MCLFF demonstrated superior performance in MTM HCC prediction, with a higher AUC of 0.857 compared with all competing models in the internal validation set. Integration of multiple radiological or clinical features further improved the overall performance, with the highest AUCs of 0.857 and 0.836 respectively achieved in the internal validation and external testing set.

CONCLUSIONS

Multiphasic radiomics features of AP and PVP fused by the MCLFF have demonstrated substantial potential in the accurate prediction of MTM HCC. Clinical factors and Radiological features in mpCECT contribute incremental values to the developed MCLFF strategy.

Comparison of adjuvant treatment regimens for high-risk hepatocellular carcinoma: a Bayesian network meta analysis and systematic review

Background

The five-year recurrence rate for patients with hepatocellular carcinoma (HCC) is as high as 70%. Patients with high-risk recurrence factors experience significantly poorer prognosis. Local regional therapies, including transarterial chemoembolisation (TACE), hepatic arterial infusion chemotherapy (HAIC), radiotherapy, and emerging immunotherapy, are commonly used adjuvant treatment options. We conducted an indirect comparison of these adjuvant therapies for such patients.

Methods

We conducted a systematic search in public databases for relevant studies and assessed the efficacy and safety of the corresponding therapies by consolidating disease-free survival (DFS), overall survival (OS), and adverse events (AEs).

Results

A total of eight randomised controlled trials were ultimately included. The Gelman-Rubin plot and kernel density estimation indicate that the stability of the combined model is satisfactory.

Conclusion

immunotherapy is not inferior to local regional therapies in delaying tumour recurrence, however, the higher incidence of AEs remains a significant concern. Adjuvant radiotherapy demonstrated superior efficacy in delaying tumour recurrence compared to adjuvant TACE, although further support from phase III clinical trial evidence is required.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024576316.

Liver resection and transplantation in the era of checkpoint inhibitors

Immune checkpoint inhibitors (ICIs) have revolutionised the treatment landscape for advanced hepatocellular carcinoma (HCC). The combination of atezolizumab and bevacizumab has demonstrated efficacy, establishing a new standard of care for advanced HCC. Neoadjuvant studies have shown promising results with high response rates, increasing research into ICIs' role. In the peri-operative setting, in addition to adjuvant and neo-adjuvant therapies, strategies for "downstaging" and "bridging" patients to liver transplantation (LT) are being investigated, broadening the eligible candidate pool. Furthermore, therapeutic advances have reshaped conversion strategies for hepatic resection, with emerging evidence indicating a role for adjuvant immunotherapy in patients at high risk of postoperative recurrence. In LT, concerns have arisen over the potential conflict between immunosuppression needs and the immune-enhancing effects of ICIs, with reports of severe rejection. However, liver-specific factors may lessen rejection risks, prompting exploration into the safety of pre-transplant ICI administration. Moreover, ongoing trials must prioritise patient selection and vigilant management protocols. Despite the remarkable progress in immunotherapy, the intricate molecular interactions within the tumour microenvironment and their implications on oncogenic pathways remain incompletely understood. This highlights the need for specialised expertise to effectively integrate immunotherapy into the surgical management of HCC. Key challenges include ensuring safety, optimising oncological outcomes, managing the risk of graft rejection in transplant recipients, and refining patient selection criteria. In this review, we aim to provide a comprehensive overview of the evolving role of immunotherapy in the surgical management of HCC, discussing the rationale for its application in both pre- and post-surgical contexts, leveraging current clinical experience, identifying potential limitations, and envisioning future applications. By integrating existing knowledge and highlighting areas for further investigation, this review seeks to inform clinical practice and guide future research endeavours.

Diagnostic performance of Sonazoid-enhanced CEUS in identifying definitive hepatocellular carcinoma in cirrhotic patients according to KLCA-NCC 2022 and APASL 2017 guidelines

OBJECTIVE

This study aims to assess the diagnostic performance of Sonazoid-contrast-enhanced ultrasound (CEUS) in identifying definitive HCC within hepatic nodules in cirrhotic patients, comparing the KLCA-NCC 2022 and APASL 2017 diagnostic guidelines.

MATERIALS AND METHODS

This retrospective study analyzed cirrhotic patients who underwent Sonazoid-CEUS for liver lesion evaluation between October 2019 and October 2023. HCC diagnosis was based on the KLCA-NCC 2022 and APASL 2017 guidelines. Inter-reader agreement on CEUS imaging features and the diagnostic accuracy of the guidelines were evaluated. Sensitivity and specificity comparisons were made using McNemar's test.

RESULTS

Among 400 patients with 432 lesions, CEUS showed excellent inter-reader consistency in detecting arterial phase hyperenhancement and Kupffer defects. The KLCA-NCC 2022 criteria notably enhanced sensitivity to 96.2%, with specificity and accuracy of 93.8% and 95.8%, respectively. APASL 2017 achieved the highest sensitivity at 97.8%, although specificity dropped to 46.9%, resulting in an accuracy of 90.3%. The KLCA-NCC 2022 guidelines demonstrated significantly higher specificity than APASL 2017 (p < 0.001), while APASL 2017 exhibited the highest sensitivity at 97.8%. Notably, the KLCA-NCC 2022 guidelines also demonstrated an impressive positive predictive value of 98.9%.

CONCLUSION

Sonazoid-enhanced CEUS, particularly when applied using the KLCA-NCC 2022 guidelines, is an effective diagnostic tool for HCC.

CRITICAL RELEVANCE STATEMENT

Perfluorobutane CEUS, particularly in accordance with the KLCA-NCC 2022 guidelines, emerges as a valuable adjunct for diagnosing HCC in cirrhotic patients. It demonstrates superior positive predictive value and specificity compared to APASL 2017, underscoring its potential as an effective diagnostic tool.

KEY POINTS

Contrast-enhanced (CE)US using Sonazoid with KLCA-NCC 2022 guidelines is highly effective for HCC diagnosis. KLCA-NCC 2022 criteria showed high accuracy, 96.2% sensitivity, and 98.9% PPV. CEUS demonstrated excellent inter-reader consistency in detecting arterial phase hyperenhancement and Kupffer defects.

Stage dependent microbial dynamics in hepatocellular carcinoma and adjacent normal liver tissues

The interactive pathway of the gut-liver axis underscores the significance of microbiome modulation in the pathogenesis and progression of various liver diseases, including hepatocellular carcinoma (HCC). This study aims to investigate the disparities in the composition and functionality of the hepatic microbiota between tumor tissues and adjacent normal liver tissues, and their implications in the etiology of HCC. We conducted a comparative analysis of the hepatic microbiome between adjacent normal liver tissues and tumor tissues from HCC patients. Samples were categorized according to the modified Union for International Cancer Control (mUICC) staging system into Non-tumor, mUICC stage I, mUICC stage II, and mUICC stage III groups. Microbial richness and community composition were analyzed, and phylogenetic profiles were examined to identify significantly altered microbial taxa among the groups. Predicted metabolic pathways were analyzed using PICRUSt2. Our analysis did not reveal significant differences in microbial richness and community composition with the development of HCC. However, phylogenetic profiling identified significantly altered microbial taxa among the groups. Sphingobium, known for degrading polychlorinated biphenyls (PCBs), exhibited a significantly negative correlation with clinical indices in HCC patients. Conversely, Sphingomonas, a gut bacterium associated with various liver diseases, showed a positive correlation. Predicted metabolic pathways suggested a correlation between atrazine degradation and valine, leucine, and isoleucine biosynthesis with mUICC stage and tumor size. Our results underscore the critical link between hepatic microbial composition and function and the HCC tumor stage, suggesting a potentially pivotal role in the development of HCC. These findings highlight the importance of targeting the hepatic microbiome for therapeutic strategies in HCC.