Prediction of recurrence and prognosis in patients with hepatocellular carcinoma after resection by use of CLIP score

Establishment and Validation of the LI-RADS Morphologic Type II Hepatocellular Carcinoma Early Recurrence Risk Scoring System

BACKGROUND

Tumor morphology links to early recurrence of hepatocellular carcinoma. Controversy exists regarding the recurrence risk of Liver Imaging Reporting and Data System morphologic Type II hepatocellular carcinoma. This study aims to explore risk factors for early recurrence of Type II hepatocellular carcinoma.

METHODS

Retrospective analysis of hepatocellular carcinoma patients who underwent curative resection and preoperative contrast-enhanced MRI from June 2016 to June 2020. Our patients formed the development set, and hepatocellular carcinoma patients from the TCIA database served as validation. Univariable and multivariable Cox regression identified independent risk factors for early recurrence. A risk scoring system was established for risk stratification, and an early recurrence prediction model was developed and validated.

RESULTS

95 Type II hepatocellular carcinoma patients were in the development set, and 29 cases were in the validation set. Early recurrence rates were 33.7% and 37.9%, respectively. Multivariate analysis revealed age, histological grade, AFP, and intratumoral hemorrhage as independent risk factors for early recurrence. The model's diagnostic performance for early recurrence was AUC = 0.817 in the development set. A scoring system classified patients into low-risk (scores ≤ 3) and high-risk (scores > 3) groups. The high-risk group had significantly lower recurrence-free survival (40.0% vs 73.2%, P = 0.001), consistent with the validation set (25.0% vs 73.3%, P = 0.028).

CONCLUSIONS

The risk scoring system demonstrated excellent discrimination and predictive ability, aiding clinicians in assessing early recurrence risk and identifying high-risk individuals effectively.

Robotic liver resection for hepatocellular carcinoma: analysis of surgical margins and clinical outcomes from a western tertiary hepatobiliary center

This study was undertaken to determine surgical outcomes of patients undergoing robotic hepatectomy for hepatocellular carcinoma (HCC) and to investigate the correlation between tumor distance to margin and perioperative outcomes, as well as overall survival (OS). To our knowledge, this study represents the largest series of robotic liver resection for HCC in North America. We retrospectively analyzed 58 consecutive patients who underwent robotic liver resection for HCC. Patients were further stratified by tumor distance to margin (≤ 1 mm, 1.1-9.9 mm, ≥ 10 mm) and their clinical outcomes including OS were compared. A majority of patients attained a greater than 1 mm tumor distance to margin (81%). There were no differences in tumor size between patient cohorts who attained ≤ 1 mm, 1.1-9.9 mm, and ≥ 10 mm margins. There were no differences in pre-, intra-, and postoperative outcomes among the three cohorts. Cost variables of interest were also similar. OS was highest in the > 10 mm margin cohort, and this was statistically significant at 3 and 5 years. Robotic HCC resection was associated with adequate tumor distance to margin. Wide margins ≥ 10 mm are associated with the best OS.

Prediction of tumor response via a pretreatment MRI radiomics-based nomogram in HCC treated with TACE

Objectives

To develop and validate a pre-transcatheter arterial chemoembolization (TACE) MRI-based radiomics model for predicting tumor response in intermediate-advanced hepatocellular carcinoma (HCC) patients.

Materials

Ninety-nine intermediate-advanced HCC patients (69 for training, 30 for validation) treated with TACE were enrolled. MRI examinations were performed before TACE, and the efficacy was evaluated according to the mRECIST criterion 3 months after TACE. A total of 396 radiomics features were extracted from T2-weighted pre-TACE images, and least absolute shrinkage and selection operator (LASSO) regression was applied to feature selection and model construction. The performance of the model was evaluated by receiver operating characteristic (ROC) curves, calibration curves, and decision curves.

Results

The AFP value, Child-Pugh score, and BCLC stage showed a significant difference between the TACE response (TR) and non-TACE response (nTR) patients. Six radiomics features were selected by LASSO and the radiomics score (Rad-score) was calculated as the sum of each feature multiplied by the non-zero coefficient from LASSO. The AUCs of the ROC curve based on Rad-score were 0.812 and 0.866 in the training and validation cohorts, respectively. To improve the diagnostic efficiency, the Rad-score was further integrated with the above clinical indicators to form a novel predictive nomogram. Results suggested that the AUC increased to 0.861 and 0.884 in the training and validation cohorts, respectively. Decision curve analysis showed that the radiomics nomogram was clinically useful.

Conclusion

The radiomics and clinical indicator-based predictive nomogram can well predict TR in intermediate-advanced HCC and can further be applied for auxiliary diagnosis of clinical prognosis.

Key Points

• The therapeutic outcome of TACE varies greatly even for patients with the same clinicopathologic features.

• Radiomics showed excellent performance in predicting the TACE response.

• Decision curves demonstrated that the novel predictive model based on the radiomics signature and clinical indicators has great clinical utility.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07910-0.

Predicting hepatocellular carcinoma recurrences: A data-driven multiclass classification method incorporating latent variables

Hepatocellular carcinoma (HCC), a malignant form of cancer, is frequently treated with surgical resections, which have relatively high recurrence rates. Effective recurrence predictions enable physicians' timely detections and adequate therapeutic measures that can greatly improve patient care and outcomes. Toward that end, predictions of early versus late HCC recurrences should be considered separately to reflect their distinct onset time horizons, clinical causes, underlying clinical etiology, and pathogenesis. We propose a novel Bayesian network-based method to predict different HCC recurrence outcomes by considering the respective recurrence evolution paths. Typical patient information obtained in early stages is insufficiently informative to predict recurrence outcomes accurately, due to the lack of subsequent patient progression information. Our method alleviates such information deficiency constraints by incorporating an independent latent variable, dominant recurrence type, to regulate recurrence outcome predictions (early, late, or no recurrence). We use a real-world HCC data set to evaluate the proposed method, relative to three prevalent benchmark techniques. Overall, the results show that our method consistently and significantly outperforms all the benchmark techniques in terms of accuracy, precision, recall, and F-measures. For increased robustness, we use another data set to perform an out-of-sample evaluation and obtain similar results. This study thus contributes to HCC recurrence research and offers several implications for clinical practice.

Prediction early recurrence of hepatocellular carcinoma eligible for curative ablation using a Radiomics nomogram

BACKGROUND

Predicting early recurrence (ER) after radical therapy for HCC patients is critical for the decision of subsequent follow-up and treatment. Radiomic features derived from the medical imaging show great potential to predict prognosis. Here we aim to develop and validate a radiomics nomogram that could predict ER after curative ablation.

METHODS

Total 184 HCC patients treated from August 2007 to August 2014 were included in the study and were divided into the training (n = 129) and validation(n = 55) cohorts randomly. The endpoint was recurrence free survival (RFS). A set of 647 radiomics features were extracted from the 3 phases contrast enhanced computed tomography (CECT) images. The minimum redundancy maximum relevance algorithm (MRMRA) was used for feature selection. The least absolute shrinkage and selection operator (LASSO) Cox regression model was used to build a radiomics signature. Recurrence prediction models were built using clinicopathological factors and radiomics signature, and a prognostic nomogram was developed and validated by calibration.

RESULTS

Among the four radiomics models, the portal venous phase model obtained the best performance in the validation subgroup (C-index = 0.736 (95%CI:0.726-0.856)). When adding the clinicopathological factors to the models, the portal venous phase combined model also yielded the best predictive performance for training (C-index = 0.792(95%CI:0.727-0.857) and validation (C-index = 0.755(95%CI:0.651-0.860) subgroup. The combined model indicated a more distinct improvement of predictive power than the simple clinical model (ANOVA, P < 0.0001).

CONCLUSIONS

This study successfully built a radiomics nomogram that integrated clinicopathological and radiomics features, which can be potentially used to predict ER after curative ablation for HCC patients.

Is there an optimal staging system or liver reserve model that can predict outcome in hepatocellular carcinoma?

Background

Many staging systems and liver reserve models have been proposed to predict hepatocellular carcinoma (HCC) prognosis. However, there is no consensus as to which model provides the best prognostic value. We aimed to investigate the prognostic role of 8 noninvasive models including the albumin-bilirubin index (ALBI), AST to platelet ratio index (APRI), Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP) system, Child-Pugh (CP) class, Fibrosis-4 (FIB-4) score, model for end-stage liver disease (MELD) score, and platelet-albumin-bilirubin index (PALBI) in patients with HCC.

Methods

This is a retrospective study of 900 HCC patients. Patients who underwent transplantation were excluded. The Kaplan-Meier method was used to estimate the survival probabilities. Multivariate cox proportional hazard models were used to calculate the survival trend. P<0.05 was considered significant. The area under receiver operating characteristic curve (AUC) was calculated to test the discriminatory power over 1- and 3-year mortality and recurrence.

Results

For predicting 1- and 3-year mortality, the CLIP score provided the highest AUC value, followed by the BCLC stage and the PALBI grade. For predicting 3-year recurrence, the CLIP score demonstrated the highest discriminative power followed by the PALBI grade, ALBI grade and BCLC system. However, all included models were found to be poor predictors for recurrence.

Conclusions

The CLIP score is more accurate prognostic model to predict mortality and recurrence than the BCLC stage. Regarding the liver reserve models, the PALBI is the most accurate prognostic models among 6 models to predict mortality and recurrence.

Prognostic impact of surgical margin in patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND

Surgical margin is an important prognostic factor in hepatectomy for patients with hepatocellular carcinoma (HCC). But the extent of surgical margins is still controversial. Our study was designed to systematically evaluate the prognosis of different width of resection margin.

METHODS

We conducted comprehensive searches of electronic databases including PubMed, MEDLINE, EMBASE, Cochrane, and the ISI Web of Science for relevant studies. A meta-analysis was performed by RevMan 5.3 software.

RESULTS

A total of 7 studies comprising 1932 patients were included. The patients with wider surgical margin were significantly higher than those with narrow surgical margin on 3-year overall survival (odds ratio [OR]: 1.58, 95% confidence interval (95% CI): 1.21-2.06, P = .0008), 5-year overall survival (OR: 1.76, 95% CI: 1.20-2.59, P = .004), 1-year disease-free survival (DFS)/recurrence-free survival (RFS) (OR: 1.43, 95% CI: 1.12-1.82, P = .005), 3-year DFS/RFS (OR: 1.66, 95% CI: 1.35-2.03, P < .00001), and 5-year DFS/RFS (OR: 1.69, 95% CI: 1.37-2.08, P < .00001). There was no significant difference in the 1-year overall survival rate for the 2 groups (OR: 1.24, 95% CI: 0.89-1.72, P = .20).

CONCLUSION

In comparison with the narrow surgical margin group (<1 cm), the wide surgical margin (≥1 cm) can significantly improve the prognosis in patients with HCC.

Prediction of early recurrence of hepatocellular carcinoma within the Milan criteria after radical resection

Approximately 50% hepatocellular carcinoma patients meeting the Milan criteria utilized to develop an improved prognostic model for predicting the recurrence in these patients. Using univariate and multivariate analysis, cytokeratin-19 and glypican-3 expression patterns, tumor number and histological grading from eight putative prognostic factors comprised the risk factor scoring model to predict the tumor recurrence. In the training cohort, the area under roc curve (AUC) value of the model was 0.715 [95% confidence interval (CI) = 0.645-0.786, P<0.001], which was the highest among all the parameters. The performance of the model was assessed using an independent validation cohort, wherein the AUC value was 0.760 (95% CI=0.647-0.874, P<0.001), which was higher than the other factors. The results indicated that model had high performance with adequate discrimination ability. Moreover, it significantly improved the predictive capacity for the recurrence in patients with hepatocellular carcinoma within the Milan criteria after radical resection.

Survival and prognostic factors after adjuvant 131iodine-labeled lipiodol for hepatocellular carcinoma: a retrospective analysis of 106 patients over 20 years

OBJECTIVE

Hepatocellular carcinoma (HCC) has high recurrence rate after curative treatment. The aim of the present study was to report our experience with adjuvant use of ¹³¹I-lipiodol after curative treatment of HCC in terms of recurrence and survival in a large cohort of patients with a long follow-up.

METHODS

All patients treated with ¹³¹I-lipiodol after curative treatment of HCC in two French centers from 1991 to 2009 were included in a retrospective cohort study.

RESULTS

One hundred and six patients were included. The median (range) follow-up was 6 years (0.3-22). Forty-three patients (41%) had cirrhosis. Recurrence-free survival rates at 1, 2, 5, 10, and 20 years were 73, 57, 40, 30, and 14%, respectively. Cirrhosis was an independent predictive factor of recurrence [RR = 1.18, 95% CI (1.11-3.02), p = 0.019]. Overall, survival rates at 1, 2, 5, 10, and 20 years were 90, 83, 59, 37, and 23%, respectively. Prognostic factors were recurrence [RR = 2.73, 95% CI (1.35-5.54); p = 0.005], age over 60 years (RR = 1.91, 95% CI [1.02-3.61]; p = 0.044), and tumor number over 3 [RR = 3.31, 95% CI (1.25-8.77); p = 0.016].

CONCLUSION

Our results suggest that the effect of ¹³¹I-lipiodol after curative treatment of HCC could be related to a beneficial impact on risk factors of early tumor recurrence. This could be evaluated in further studies using modern radioembolization methods.

Risk Factors and Post-Resection Independent Predictive Score for the Recurrence of Hepatitis B-Related Hepatocellular Carcinoma

BACKGROUND

Independent risk factors associated with hepatitis B (HBV)-related hepatocellular carcinoma (HCC) after resection remains unknown. An accurate risk score for HCC recurrence is lacking.

METHODS

We prospectively followed up 200 patients who underwent liver resection for HBV-related HCC for at least 2 years. Demographic, biochemical, tumor, virological and anti-viral treatment factors were analyzed to identify independent risk factors associated with recurrence after resection and a risk score for HCC recurrence formulated.

RESULTS

Two hundred patients (80% male) who underwent liver resection for HBV-related HCC were recruited. The median time of recurrence was 184 weeks (IQR 52-207 weeks) for the entire cohort and 100 patients (50%) developed HCC recurrence. Stepwise Cox regression analysis identified that one-month post resection HBV DNA >20,000 IU/mL (p = 0.019; relative risk (RR) 1.67; 95% confidence interval (C.I.): 1.09-2.57), the presence of lymphovascular permeation (p<0.001; RR 2.69; 95% C.I.: 1.75-4.12), microsatellite lesions (p<0.001; RR 2.86; 95% C.I.: 1.82-4.51), and AFP >100ng/mL before resection (p = 0.021; RR 1.63; 95% C.I.: 1.08-2.47) were independently associated with HCC recurrence. Antiviral treatment before resection (p = 0.024; RR 0.1; 95% C.I.: 0.01-0.74) was independently associated with reduced risk of HCC recurrence. A post-resection independent predictive score (PRIPS) was derived and validated with sensitivity of 75.3% and 60.6% and specificity of 55.7% and 79.2%, to predict the 1- and 3-year risks for the HCC recurrence respectively with the hazard ratio of 2.71 (95% C.I.: 2.12-3.48; p<0.001). The AUC for the 1- and 3-year prediction were 0.675 (95% C.I.: 0.6-0.78) and 0.746 (95% C.I.: 0.69-0.82) respectively.

CONCLUSION

Several tumor, virological and biochemical factors were associated with a higher cumulative risk of HCC recurrence after resection. PRIPS was derived for more accurate risk assessment. Regardless of the HBV DNA level, antiviral treatment should be given to patients before resection to reduce the risk of recurrence.

Establishment and Validation of SSCLIP Scoring System to Estimate Survival in Hepatocellular Carcinoma Patients Who Received Curative Liver Resection

BACKGROUND AND AIMS

There is no prognostic model that is reliable and practical for patients who have received curative liver resection (CLR) for hepatocellular carcinoma (HCC). This study aimed to establish and validate a Surgery-Specific Cancer of the Liver Italian Program (SSCLIP) scoring system for those patients.

METHODS

668 eligible patients who underwent CLR for HCC from five separate tertiary hospitals were selected. The SSCLIP was constructed from a training cohort by adding independent predictors that were identified by Cox proportional hazards regression analyses to the original Cancer of the Liver Italian Program (CLIP). The prognostic performance of the SSCLIP at 12 and 36-months was compared with data from existing models. The patient survival distributions at different risk levels of the SSCLIP were also assessed.

RESULTS

Four independent predictors were added to construct the SSCLIP, including age (HR = 1.075, 95%CI: 1.019-1.135, P = 0.009), albumin (HR = 0.804, 95%CI: 0.681-0.950, P = 0.011), prothrombin time activity (HR = 0.856, 95%CI: 0.751-0.975, P = 0.020) and microvascular invasion (HR = 19.852, 95%CI: 2.203-178.917, P = 0.008). In both training and validation cohorts, 12-month and 36-month prognostic performance of the SSCLIP were significantly better than those of the original CLIP, model of end-stage liver disease-based CLIP, Okuda and Child-Turcotte-Pugh score (all P < 0.05). The stratification of risk levels of the SSCLIP showed an enhanced ability to differentiate patients with different outcomes.

CONCLUSIONS

A novel SSCLIP to predict survival of HCC patients who received CLR based on objective parameters may provide a refined, useful prognosis algorithm.

Classification and staging of hepatocellular carcinoma: an aid to clinical decision-making

Classification and staging of hepatocellular carcinoma in a way that allows optimal treatment selection is challenging. This article summarizes some of the classification and staging schemes and discusses the conceptual framework that guides optimal treatment selection for each patient. The article does not exhaustively discuss each staging system proposed in the last three decades, but rather reviews the most commonly used staging systems, evaluates the rationale behind some of the newer staging systems, and compares them focusing on their use in clinical decision-making, notably choice of therapy.

Liver stiffness value-based risk estimation of late recurrence after curative resection of hepatocellular carcinoma: development and validation of a predictive model

BACKGROUND

Preoperative liver stiffness (LS) measurement using transient elastography (TE) is useful for predicting late recurrence after curative resection of hepatocellular carcinoma (HCC). We developed and validated a novel LS value-based predictive model for late recurrence of HCC.

METHODS

Patients who were due to undergo curative resection of HCC between August 2006 and January 2010 were prospectively enrolled and TE was performed prior to operations by study protocol. The predictive model of late recurrence was constructed based on a multiple logistic regression model. Discrimination and calibration were used to validate the model.

RESULTS

Among a total of 139 patients who were finally analyzed, late recurrence occurred in 44 patients, with a median follow-up of 24.5 months (range, 12.4-68.1). We developed a predictive model for late recurrence of HCC using LS value, activity grade II-III, presence of multiple tumors, and indocyanine green retention rate at 15 min (ICG R15), which showed fairly good discrimination capability with an area under the receiver operating characteristic curve (AUROC) of 0.724 (95% confidence intervals [CIs], 0.632-0.816). In the validation, using a bootstrap method to assess discrimination, the AUROC remained largely unchanged between iterations, with an average AUROC of 0.722 (95% CIs, 0.718-0.724). When we plotted a calibration chart for predicted and observed risk of late recurrence, the predicted risk of late recurrence correlated well with observed risk, with a correlation coefficient of 0.873 (P<0.001).

CONCLUSION

A simple LS value-based predictive model could estimate the risk of late recurrence in patients who underwent curative resection of HCC.

Noninvasive fibrosis indices predict intrahepatic distant recurrence of hepatitis B-related hepatocellular carcinoma following radiofrequency ablation

BACKGROUNDS & AIMS

Intrahepatic recurrence of hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) occurs as a result of direct dissemination or de novo oncogenesis. Hepatocellular carcinogenesis is related to the progression of cirrhosis, and noninvasive fibrosis scoring systems reflect the severity of hepatic fibrosis. Hence, the aim of this study was to elucidate the correlation between noninvasive fibrosis indices and intrahepatic distant recurrence (IDR) of HCC after RFA.

METHODS

Patients with hepatitis B virus (HBV)-related, solitary HCC undergoing RFA were prospectively enrolled. Noninvasive serum fibrosis indices were calculated at the time of RFA. IDR was defined as recurrent HCC beyond >2 cm from the ablation margin of RFA. Predictors of IDR and overall survival were analysed by a Cox regression model.

RESULTS

Two hundred forty-six patients received RFA as initial treatment, and the median follow-up duration was 19.7 months (IQR, 11.9-29.8). Among these cases, 133 (45.9%) showed IDR after RFA. In multivariable analysis, serum alpha-fetoprotein (AFP) (HR, 1.000; 95% CI, 1.000-1.001; P = 0.001) and age-platelet index (API) (1.19; 1.01-1.39; P = 0.033) were independent predictors of IDR. In particular, patients with API ≤7 showed a significantly higher recurrence-free survival rate than patients with API >7 (P = 0.004). With regard to overall survival, male sex (4.69; 1.52-14.52; P = 0.007), serum bilirubin (2.78; 1.31-5.90; P = 0.008) and AFP (1.000; 1.000-1.001; P = 0.006) were significantly correlated with shortened survival.

CONCLUSION

High levels of AFP and API predict IDR of HBV-related HCC after RFA. Therefore, noninvasive fibrosis indices could play an important role in predicting IDR of HCC following percutaneous ablation.

Hepatocellular carcinoma: focus on different aspects of management

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third cause of cancer-related mortality worldwide. Its incidence is clearly arising comprised by the prevalence of major risk factors mainly hepatitis B and hepatitis C. The population at risk is composed of chronic liver patients at the stage of extensive fibrosis or cirrhosis. The monitoring programs of this population have allowed early detection of disease management to promote a radical therapy. Understanding the carcinogenic process and the mastery of the staging systems remain essential keys in diagnosis and treatment of HCC. Recent advances in diagnosis and new treatments have made important impacts on the disease by increasing survival rates and improving quality of life for HCC patients. This paper outlines the different management aspects of HCC which include epidemiology, prevention, carcinogenesis, staging systems, diagnosis, surveillance, and the treatment.

Long-term results of laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: a case-matched analysis

BACKGROUND

Laparoscopic hepatectomy (LH) is established as a safe and feasible treatment option for liver tumors. However, whether the adoption of laparoscopic approach for malignant tumors, such as hepatocellular carcinoma (HCC), will compromise the long-term result is still unknown. This study was designed to evaluate the long-term results of LH compared with a cohort of case-matched open hepatectomy (OH).

METHODS

Thirty-three patients who underwent LH for HCC in our institution between June 2004 and March 2010 were recruited. A group of 50 patients who underwent OH for HCC during the same period was identified by matching to magnitude of operation, size of tumor, site of tumor, and the absence of concomitant local ablation or major procedure. The perioperative outcomes, disease recurrence, and survival of the two groups of patients were determined and compared.

RESULTS

LH resulted in less operative complications (6.1% vs. 24%, P = 0.033) and shorter median hospital stay (5 vs. 7 days, P < 0.0005) but required longer operative time compared with OH (225 vs. 195 min, P = 0.019). There was no difference between LH and OH in recurrence rate (45.5% vs. 38%, P = 0.499). The 1-, 3-, and 5-year overall survival were 86.9%, 81.8%, and 76% for LH and 98%, 80.6%, and 76.1% for OH respectively (P = 0.646). The 1-, 3-, and 5-year disease-free survival were 78.8%, 51%, and 45.3% for LH and 69.2%, 55.9%, and 55.9% for OH, respectively (P = 0.849).

CONCLUSIONS

Compared with OH, LH for HCC has similar long-term outcomes, but it has short-term advantages of less operative complications and shorter hospital stay.

Laser ablation for small hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and is increasingly detected at small size (<5 cm) owing to surveillance programmes in high-risk patients. For these cases, curative therapies such as resection, liver transplantation, or percutaneous ablation have been proposed. When surgical options are precluded, image-guided tumor ablation is recommended as the most appropriate therapeutic choice in terms of tumor local control, safety, and improvement in survival. Laser ablation (LA) represents one of currently available loco-ablative techniques: light is delivered via flexible quartz fibers of diameter from 300 to 600 μm inserted into tumor lesion through either fine needles (21g Chiba needles) or large-bore catheters. The thermal destruction of tissue is achieved through conversion of absorbed light (usually infrared) into heat. A range of different imaging modalities have been used to guide percutaneous laser ablation, but ultrasound and magnetic resonance imaging are most widely employed, according to local experience and resource availability. Available clinical data suggest that LA is highly effective in terms of tumoricidal capability with an excellent safety profile; the best results in terms of long-term survival are obtained in early HCC so that LA can be proposed not only in unresectable cases but, not differently from radiofrequency ablation, also as the first-line treatment.

Pre-operative predictors of post-hepatectomy recurrence of hepatocellular carcinoma: can we predict earlier?

BACKGROUNDS AND PURPOSE

To determine the predictors for recurrence in patients receiving curative hepatectomy for hepatocellular carcinoma (HCC).

METHODS

From January 2001 to July 2007, all patients having hepatectomy for first occurrence HCC with curative intent were identified from a prospectively collected database. Prognostic factors for recurrence and survival after resection were analyzed.

RESULTS

A total of 235 patients were included. With a median follow-up of 50.2 (0.07-125.1) months, the recurrence rate was 57.0%. The 1-, 3-, and 5-year overall survival rates were 83.9%, 66.0%, and 58.1% respectively. Multivariate analysis demonstrated that multi-focal lesions (HR: 2.93, P < 0.001), alpha-fetoprotein (AFP) level greater than 100 ng/ml (HR: 1.74, P = 0.002) and history of tumor rupture (HR: 2.84, P = 0.003) were independent risk factors for recurrence of HCC after hepatectomy.

CONCLUSIONS

Predictors for HCC recurrence can be identified before operation. These important parameters should be considered before and after contemplating curative resection for HCC patients and for risk stratification in future clinical trials for neoadjuvant or post-resection adjuvant therapy. The possible use of neoadjuvant or adjuvant treatment to improve survival should be addressed by further trials.

IGFBP7 downregulation is associated with tumor progression and clinical outcome in hepatocellular carcinoma

Insulin-like growth factor-binding protein 7 (IGFBP7) functions in several cellular processes including proliferation, senescence and apoptosis. This study analyzed IGFBP7 function in hepatocellular carcinoma (HCC) cells by gene manipulation and investigated the prognostic significance of IGFBP7 expression in clinical HCC samples. In this study, we investigated changes in malignant potential such as cell growth and invasiveness in an HCC cell line, PLC/PRF/5, after transfection with shRNA against IGFBP7. The extent of apoptosis and cell cycle progression were examined after the transfection. The correlation between immunohistochemically determined IGFBP7 expression and long-term postoperative prognosis after curative resection was also investigated in clinical HCC specimens obtained from 104 patients. PLC/PRF/5 cells transfected with shRNA against IGFBP7 showed significantly more rapid growth and stronger invasiveness than control cells. Annexin V assays showed that the IGFBP7-depleted cells were significantly more resistant to apoptosis than the control cells, and showed decreased expression of cleaved caspase-3 and PARP. Cell cycle progression was more rapid in the IGFBP7-suppressed cells. In clinical HCC specimens, IGFBP7 expression was judged as positive in 67 patients (64.4%) and negative in the remaining 37 patients (35.6%). The IGFBP7 downregulation correlated significantly with poor postoperative prognosis, and IGFBP7 status was identified as an independent significant prognostic factor. Our results indicated that IGFBP7 expression correlated significantly with the malignant potential in HCC cells, suggesting that the expression could be a useful prognostic marker for HCC.

Hepatocellular carcinoma: MR staging and therapeutic decisions

Staging of hepatocellular carcinoma (HCC) represents a controversial and complex topic, since prognosis is largely dependent on several variables other than tumor extension, such liver function and general clinical conditions. Up to now, there is no agreement regarding the most reliable clinical staging system for HCC. Ideally, the staging system should be simple and easily obtainable and should not be influenced by differences in patient populations. So far, in Western countries, the Barcelona Clinic for Liver Cancer (BCLC) staging system represents the most frequently adopted classification. It is simple and guides the clinicians through the therapeutic decision process. Magnetic resonance imaging represents the most proper imaging modality for correct staging of HCC, providing high accuracy in evaluating tumor extension as well as tumor response to treatment (after percutaneous ablation, transarterial chemoembolization, or molecular-targeted therapy). The present review describes the most frequently used staging systems and the treatment options that are recommended for the different stages of the disease.

Vascular invasion in hepatocellular carcinoma: is there a correlation with MRI?

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the commonest malignancies worldwide. Prognosis is predicted by size at diagnosis, vascular invasion and tumour proliferation markers. This study investigates if MRI features of histologically proven HCCs correlate with vascular invasion.

METHODS

Between 2006 and 2008, 18 consecutive patients, with a total of 27 HCCs, had comprehensive MRI studies performed at our institution within a median of 36 days of histology sampling. Each lesion was evaluated independently on MRI by 3 radiologists (blinded to both the radiology and histopathology reports) using a 5-point confidence scale for 23 specific imaging features. The mean of the rating scores across readers was calculated to determine interobserver consistency. The most consistent features were then used to examine the value of features in predicting vascular invasion, using a χ(2 )test for trend, having eliminated those features without sufficient variability.

RESULTS

22 of the 23 imaging features showed sufficient variability across lesions. None of these significantly correlated with the presence of vascular invasion, although a trend was identified with the presence of washout in the portal venous phase on MRI and the median size of lesions, which was greater with vascular invasion.

CONCLUSION

This study suggests that no single MRI feature accurately predicts the presence of vascular invasion in HCCs, although a trend was seen with the presence of washout in the portal venous phase post gadolinium. Larger prospective studies are required to investigate this further.

Predictors of microscopic portal vein invasion by hepatocellular carcinoma: measurement of portal perfusion defect area ratio

OBJECTIVE

Microscopic portal vein invasion (PVI) by cancer cells is a poor prognostic factor after hepatic resection for hepatocellular carcinoma (HCC). The aim of this study is to predict PVI preoperatively in patients with HCC.

METHODS

We studied 46 hepatectomized patients who had HCC without any portal venous invasion detected during preoperative radiographic evaluation. We defined the portal perfusion defect area ratio (PPDAR) as the following: the quotient of the maximal portal perfusion defect area, on computed tomography during arterio-portography (CTAP) is divided by the maximal tumor area on magnetic resonance imaging (MRI) or CT.

RESULTS

The median PPDAR was 1.3 (mean 1.4 +/- 1.1; ranged from 0.7 to 5.8). The incidence of PVI was 4.5% in patients with a PPDAR <1.3, 35.7% in those with a PPDAR of 1.3-1.6, 70% in those with a PPDAR > or = 1.6 (P = 0.0005). When analyzing the preoperative value of different cut-off points for the PPDAR, the lowest P-value by Fisher's exact test was achieved when the PPDAR threshold was 1.6 (P = 0.0012). The sensitivity was 58%, and specificity was 91% with this cut-off value. On univariate analyses, factors that significantly correlated with PVI were PPDAR (P = 0.0012), serum levels of des-gamma-carboxy prothrombin (P = 0.033), and tumor size (P = 0.0126). On multivariate analysis, PPDAR was the only significant independent predictor of PVI.

CONCLUSION

Our study shows that PPDAR is a new concept, which is useful in predicting PVI and that a value > or = 1.6 is predictive of PVI.

Prognosis of hepatocellular carcinoma accompanied by microscopic portal vein invasion

AIM: To investigate the prognostic factors in patients with hepatocellular carcinoma (HCC) accompanied by microscopic portal vein invasion (PVI).

METHODS: Of the 267 patients with HCC undergoing hepatic resection at Aso Iizuka Hospital, 71 had PVI. After excluding 16 patients with HCC that invaded the main trunk and the first and second branches of the portal vein, 55 patients with microscopic PVI were enrolled.

RESULTS: The patients with HCC accompanied by microscopic invasion were divided into two groups: solitary PVI (PVI-S: n = 44), and multiple PVIs (PVI-M: n = 11). The number of portal vein branches invaded by tumor thrombi was 5.4 ± 3.8 (2-16) in patients with PVI-M. In cumulative survival, PVI-M was found to be a significantly poor prognostic factor (P = 0.0019); while PVI-M and non-anatomical resection were significantly poor prognostic factors in disease-free survival (P = 0.0213, and 0.0115, respectively). In patients with PVI-M, multiple intrahepatic recurrence was more common than in the patients with PVI-S (P = 0.0049). In patients with PVI-S, non-anatomical resection was a significantly poor prognostic factor in disease-free survival (P = 0.0370). Operative procedure was not a significant prognostic factor in patients with PVI-M.

CONCLUSION: The presence of PVI-M was a poor prognostic factor in patients with HCC, accompanied by microscopic PVI. Anatomical resection is recommended in these patients with HCC. Patients with HCC and PVI-M may also be good candidates for adjuvant chemotherapy.

Laser ablation of hepatocellular carcinoma-A review

A wide range of local thermal ablative therapies have been developed in the treatment of non resectable hepatocellular carcinoma (HCC) in the last decade. Laser ablation (LA) and radiofrequency ablation (RFA) are the two most widely used of these. This article provides an up to date overview of the role of laser ablation in the local treatment of HCC. General principles, technique, image guidance and patient selection are discussed. A review of published data on treatment efficacy, long term outcome and complication rates of laser ablation is included and comparison with RFA made. The role of laser ablation in combination with transcatheter arterial chemoembolization is also discussed.

Survival of patients with hepatocellular carcinoma in cirrhosis: a comparison of BCLC, CLIP and GRETCH staging systems

BACKGROUND

A major problem in assessing the likelihood of survival of patients with hepatocellular carcinoma (HCC) arises from a lack of models capable of predicting outcome accurately.

AIM

To compare the ability of the Italian score (CLIP), the French classification (GRETCH) and the Barcelona (BCLC) staging system in predicting survival in patients with HCC.

METHODS

We included 406 consecutive patients with cirrhosis and HCC. Seventy-eight per cent of patients had hepatitis C. Independent predictors of survival were identified using the Cox model.

RESULTS

One-hundred and seventy-eight patients were treated, while 228 were untreated. The observed mortality was 60.1% in treated patients and 84.9% in untreated patients. Among treated patients, albumin, bilirubin and performance status were the only independent variables significantly associated with survival. Mortality was independently predicted by bilirubin, alpha-fetoprotein and portal vein thrombosis in untreated patients. CLIP achieved the best discriminative capacity in the entire HCC cohort and in the advanced untreatable cases, while BCLC was the ablest in predicting survival in treated patients.

CONCLUSIONS

Overall predictive ability of BCLC, CLIP and GRETCH staging systems was not satisfactory, and was not uniform for treated patients and untreated patients. None of the scoring systems provided confident prediction of survival in individual patients.

Comparison of seven staging systems in cirrhotic patients with hepatocellular carcinoma in a cohort of patients who underwent radiofrequency ablation with complete response

BACKGROUND AND AIMS

Many staging systems for hepatocellular carcinoma (HCC) have been proposed but the best tool for staging of HCC remains controversial. The aim of the present study was to identify the best staging system evaluating the predictive ability for outcome for each of the seven different staging systems applied in a homogeneous group of patients who underwent percutaneous radiofrequency ablation (RFA).

METHODS

We analyzed retrospectively 112 patients with HCC and cirrhosis treated with percutaneous RFA from January, 1998 to April, 2005. Response to treatment after 30 days and for long-term follow-up was evaluated with computed tomography (CT) or magnetic resonance imaging (MRI) and serum alpha-fetoprotein level (AFP). All of the 112 patients were grouped according to each one of the seven different staging systems: Okuda, TNM, BCLC, CLIP, GRETCH, CUPI, JIS.

RESULTS

The mean follow-up time of the 112 patients submitted to RFA was 24 months (range 3-92 months) with survival rates at 1, 3, and 5 yr of 82%, 40%, and 18%, respectively. Univariate and multivariate analyses showed that factors related to survival were Child-Pugh score (P

CONCLUSIONS

The BCLC staging system shows a superior discriminatory power in our cohort of HCC patients who underwent RFA; moreover, it can give important prognostic information after complete response to treatment. Our study confirms the validity of the BCLC staging system in patients with HCC in cirrhosis.

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MESH Headings

• Aged
• Carcinoma, Hepatocellular/classification
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/mortality
• Carcinoma, Hepatocellular/surgery
• Catheter Ablation
• Female
• Humans
• Liver Cirrhosis/complications
• Liver Neoplasms/classification
• Liver Neoplasms/complications
• Liver Neoplasms/mortality
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Neoplasm Staging
• Prognosis
• Survival Rate
• Treatment Outcome

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Affiliation(s)

Alfredo Guglielmi Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy
Andrea Ruzzenente
Silvia Pachera
Alessandro Valdegamberi
Marco Sandri
Mirko D'Onofrio
Calogero Iacono

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A novel prognostic nomogram is more accurate than conventional staging systems for predicting survival after resection of hepatocellular carcinoma

BACKGROUND

Prediction of survival after resection of hepatocellular carcinoma (HCC) remains difficult. Numerous staging systems have been devised for purposes of risk classification; we sought to identify the optimal staging system to predict postoperative survival.

STUDY DESIGN

One hundred eighty-four patients who underwent primary complete resection of HCC at our institution between 1989 and 2002 were classified according to 8 contemporary staging systems. The ability of these systems to predict relative survival for randomly selected pairs of patients was quantified using the Harrel's concordance index. A novel prognostic nomogram was constructed using prognostically relevant variables.

RESULTS

After a median followup of 46 months for surviving patients, the median overall survival was 38 months. The concordance indices for the existing staging systems ranged from 0.54 to 0.59. Only the 2002 American Joint Commission on Cancer system demonstrated a concordance index with a 95% confidence interval exceeding 0.5, indicating that the ability of conventional systems to predict relative survival of randomly selected pairs of patients was generally no better than chance. We developed a novel nomogram based on patient age, serum alpha-fetoprotein level, operative blood loss, resection margin status, tumor size, satellite lesions, and vascular invasion. The nomogram demonstrated a markedly superior concordance index of 0.74 (95% CI, 0.68 to 0.80). A separate nomogram for prediction of recurrence-free survival was also generated.

CONCLUSIONS

Contemporary staging systems for HCC do not accurately predict postoperative outcomes. Our prognostic nomogram provides a mechanism for accurate prediction of survival and risk stratification and will require validation at other hepatobiliary centers.

Phase 2 study of erlotinib in patients with unresectable hepatocellular carcinoma

BACKGROUND

Growth factor overexpression, including epidermal growth factor receptor (EGFR) expression, is common in hepatocellular cancers. Erlotinib is a receptor tyrosine kinase inhibitor with specificity for EGFR. The primary objective of this study was to determine the proportion of hepatocellular carcinoma (HCC) patients treated with erlotinib who were alive and progression-free (PFS) at 16 weeks of continuous treatment.

METHODS

Patients with unresectable HCC, no prior systemic therapy, performance status (PS) of 0, 1, or 2, and Childs-Pugh (CP) cirrhosis A or B received oral erlotinib 150 mg daily for 28-day cycles. Tumor response was assessed every 2 cycles by using Response Evaluation Criteria in Solid Tumors (RECIST; National Cancer Institute Cancer Therapy Evaluation Program, Bethesda, Md) criteria. Patients accrued to either "low" or "high" EGFR expression cohorts; each cohort had stopping rules applied when there was a lack of efficacy.

RESULTS

Forty HCC patients were enrolled. Median age was 64 years (range, 33-83 years), sex distribution was 32 males and 8 females, performance scores were 40% PS 0, 55% PS 1, Childs-Pugh distribution was 75% A and 20% B. There were no complete or partial responses; however, 17 of 40 patients achieved stable disease at 16 weeks of continuous therapy. The PFS at 16 weeks was 43%, and the median overall survival (OS) was 43 weeks (10.75 months). No patients required dose reductions of erlotinib. No correlation between EGFR expression and outcome was found.

CONCLUSIONS

Results of this study indicated that single-agent erlotinib is well tolerated and has modest disease-control benefit in HCC, manifested as modestly prolonged PFS and OS when compared with historical controls.

Cancer of the Liver Italian Program (CLIP) score for staging hepatocellular carcinoma

AIM

To assess the prognostic ability of the Cancer of the Liver Italian Program (CLIP) score in patients with hepatocellular carcinoma after a longer follow up.

METHODS

The updated survival data were derived from an analysis that was performed on two joined sets of data. The first set was collected retrospectively in 1995 and was used to perform an exploratory prognostic factor analysis (the CLIP-03 study), that produced the CLIP score. The second set of data was collected prospectively for the CLIP-01 randomized clinical trial.

RESULTS

Out of 912 overall patients, analysis was performed on 650 patients whose records contained all informationregarding prognostic factors. The median survival of the whole group of patients was 17.7 months and the 5-year survival rate was 10.7%. The median survival of the patients was inversely proportional to the CLIP score: the higher the CLIP score the worse the survival.

CONCLUSIONS

The CLIP score keeps good prognostic and discriminative abilities after a longer follow up and remains one the most useful prognostic system for hepatocellular carcinoma.

Radio frequency ablation for hepatocellular carcinoma in cirrhotic patients: prognostic factors for survival

BACKGROUND

Radio frequency ablation (RFA) of hepatocellular carcinoma has proved to be useful in local control of tumor. A few data on survival after treatment are available in literature. The aim of the study was to evaluate factors related to survival and to identify different classes of risk after radio frequency ablation.

METHODS

Ninety-eight cirrhotic patients with 145 hepatocellular carcinomas were treated with radio frequency ablation from January 1998 to May 2004. In 55 patients, cirrhosis was in Child-Pugh class A, and in 43, in class B. Tumor was single in 60 and multiple in 38; mean tumor number was 1.5 (range 1-3). Tumor size ranged from 1.5 to 6.0 cm, mean 3.8 cm. Mean follow up period was 24.9 months. Radio frequency ablation was performed with expandable type needle with percutaneous approach under real-time ultrasound guidance. For statistical analysis, univariate and multivariate analysis were performed.

RESULTS

Complete ablation of the tumor was achieved in 85.5% of lesions. Survival, 1 and 3 years, was 76.7 and 36.6%, respectively. Univariate analysis showed that Cancer of the Liver Italian Program (CLIP) score, tumor growth pattern, alpha-fetoprotein level, and complete tumor necrosis, were factors significantly related to poor survival. Multivariate analysis identified that factors related to poor survival were alpha-fetoprotein level >100 ng/ml, Child-Pugh class B, and incomplete tumor necrosis with a hazard ratio of 4.0, 2.7, and 3.8, respectively. After complete ablation, median survival was 38 months in patients with Child-Pugh class A cirrhosis and alpha-fetoprotein level < or =100 ng/ml, 22 months for patient with Child-Pugh class B cirrhosis and alpha-fetoprotein < or =100 ng/ml, and 9 months for patient with Child-Pugh class A cirrhosis and alpha-fetoprotein >100 ng/ml (P < 0.01).

CONCLUSIONS

Complete necrosis and absence of residual tumor positively affect survival after RFA. In patients with Child-Pugh A cirrhosis and alpha-fetoprotein level < or =100 radio frequency, ablation have results, 55% after 3 years, that are comparable to those of surgical resection. Patients with Child-Pugh B cirrhosis and/or alpha-fetoprotein >100 ng/ml showed less satisfactory results, and in these patients, multimodality treatment or other treatments should be considered.

Comparison of clinical staging systems in predicting survival of hepatocellular carcinoma patients receiving major or minor hepatectomy

AIM

To compare the utility of seven commonly used staging systems in the prediction of survival among patients with hepatocellular carcinoma (HCC) undergoing major or minor hepatectomy.

METHODS

All patients were classified by the Okuda, the TNM, the CLIP, the BCLC, the CUPI, the JIS and the MELD classifications to estimate the probabilities of survival. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated using linear trend chi(2) tests and from the area under the receiver operating characteristic (ROC) curve.

RESULTS

In our patient cohort, the log-rank test and the linear trend chi(2) test of the CLIP and JIS systems gave better results than did the other staging systems. The discriminatory ability of the CLIP and JIS staging for death, evaluated by ROC curve areas, was also better. In the subgroups of major hepatectomy patients with a non-cirrhotic liver or minor hepatectomy patients with a cirrhotic liver, the CLIP and JIS systems showed similar better performances in these three tests. The discriminatory ability of the CLIP system was the best in major hepatectomy patients with a non-cirrhotic liver while JIS score discriminated best in minor hepatectomy patients with a cirrhotic liver.

CONCLUSION

Among the seven staging systems, the CLIP and JIS systems perform better than do the others. While the CLIP system should be considered to stage major hepatectomy patients, the JIS system could be chosen to stage minor hepatectomy patients.

Significance and relationship between infiltrating inflammatory cell and tumor angiogenesis in hepatocellular carcinoma tissues

AIM: To investigate the relationship between infiltrating inflammatory cell and tumor angiogenesis in hepatocellular carcinoma (HCC) tissues and their clinicopathological features.

METHODS: The paraffin-embedded specimens from 70 cases with HCC were stained using EliVision immunohistochemistry with mAbs against CD68, tryptase, and CD34. The counts of tumor-associated macrophage (TAM), mast cell (MC) and tumor microvessel (MV) were performed in the tissue sections.

RESULTS: The mean counts of TAM, MC, and MV in HCC tissues were significantly higher than those in pericarcinomatous liver tissues (TAM: 69.31 ± 11.58 vs 40.23 ± 10.36; MC: 16.74 ± 5.67 vs 7.59 ± 4.18; MV: 70.11 ± 12.45 vs 38.52 ± 11.16, P<0.01). The MV count in the patients with metastasis was markedly higher than that with non-metastasis (P < 0.01). In addition, the MC count in the patients with poorly differentiated HCC was obviously higher than that with well differentiated HCC (P < 0.01). The correlation analysis showed that the TAM count was significantly correlated with the count of MV (r ＝ 0.712, P < 0.01), and the MC count was obviously correlated with the MV count (r ＝ 0.336, P < 0.05).

CONCLUSION: TAM and MC might be closely related to the enhancement of tumor angiogenesis. The MV count might be associated with tumor invasion and metastasis. Moreover, the MC count might be associated with tumor differentiation and prognosis of HCC.

Local recurrence is an important prognostic factor of hepatocellular carcinoma

AIM: To clarify the importance of complete treatment by PEIT.

METHODS: A total of 140 previously untreated cases of HCC were enrolled in this study from 1988 to 2002. The inclusion criteria were: a solitary tumor less than 4 cm in diameter or multiple tumors, fewer than four in number and less than 3 cm in diameter, without extrahepatic metastasis or vessel invasion. As general principles for the treatment of HCC, the patients underwent transcatheter arterial chemoembolization (TACE) prior to PEIT. After the initial treatment of the patients, ultrasonography and computed tomography were performed, and measurement of serum levels of α-fetoprotein (AFP) was determined. When tumor recurrences were detected, PEIT and/or TACE were repeated whenever the hepatic functional reserve of the patient permitted. We then analyzed the variables that could influence prognosis, including tumor size and number, the serum levels of AFP, the parameters of hepatic function (albumin, bilirubin, ALT, hepaplastin test, platelet number, and indocyanine green retention at 15 min [ICG-R15]), combined therapy with TACE, distant recurrence, and local recurrence.

RESULTS: Univariate analysis identified the ICG test, serum levels of AFP and albumin, tumor size and number, and local recurrence, but not distant recurrence, as significant prognostic variables. In multivariate analysis using those five parameters, the ICG test, tumor size, tumor number, and local recurrence were identified as significant prognostic factors. In both univariate and multivariate analyses, the relative risk for the ICG test was the highest, followed by local recurrence.

CONCLUSION: We found that local recurrence is an independent prognostic factor of HCC, indicating that achieving complete treatment for HCC on first treatment is important for improving the prognosis of patients with HCC.

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review

BACKGROUND

Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC.

METHODS

On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed.

RESULTS

Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate.

CONCLUSION

TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.

Staging for liver cancer

This article focuses on the development of prognostic scores, their use in the management of cancer patients, and how they are different from staging systems. It is underlined that the development of a prognostic score is a dynamic process. The score can be modified by incorporating new prognostic features provided that appropriate methodology is followed. The peculiarity of hepatocellular carcinoma patients are addressed, and each individual prognostic systems for hepatocellular carcinoma is presented and discussed.

Prognostic Evaluation of the New American Joint Committee on Cancer/International Union Against Cancer Staging System for Hepatocellular Carcinoma: Analysis of 112 Cirrhotic Patients Resected for Hepatocellular Carcinoma

BACKGROUND

In 2002, the American Joint Committee on Cancer and the International Union Against Cancer redefined the T-classification for hepatocellular carcinoma, shifting the cutoff value for tumor size from 2 to 5 cm and giving more emphasis to vascular invasion.

METHODS

A retrospective cohort study was conducted on 223 consecutive patients with hepatocellular carcinoma observed between 1990 and 2002. One hundred twelve were resected and considered for retrospective analysis. Univariate and multivariate analyses were performed on several clinicopathologic variables. After classification according to each staging system, the long-term survival of different stages was compared. The prognostic value of each staging system was further evaluated by entering each stage, in turn, into the Cox regression model with other clinicopathologic variables. The median follow-up was 19 months.

RESULTS

On multivariate analysis, the viral etiology of cirrhosis and the presence of multiple nodules were independent prognostic factors. When the new staging system was entered into the multivariate analysis, it was the only independent factor (P = .02). When stratified according to the old tumor-node-metastasis system, there were no significant differences in the survival between stage I and II (P = .14) or between stage IIIA and IVA (P = .33); only the survival of stage II and IIIA was different (P < .01). When stratified according to the new tumor-node-metastasis system, there were significant differences between stage I and II (71.7% vs. 54.7%; P = .02).

CONCLUSIONS

The new staging system is a more reliable and objective method for T classification. It is easy to use in clinical practice and is better at stratifying curatively resected patients with respect to prognosis.

Critical evaluation of the different staging systems for hepatocellular carcinoma

BACKGROUND

Diagnostic and therapeutic options for hepatocellular carcinoma (HCC) have improved substantially in recent years. A number of new palliative and potentially curative treatment strategies are now available. However, evaluation of the therapeutic modalities and assessment of the prognosis of HCC remain difficult owing to the lack of consensus on a single staging system and the availability of a number of new staging systems, each claiming to be the most appropriate.

METHODS

The most frequently used staging systems for HCC are presented here. Their ability to stratify patients into different treatment groups and to define prognosis are discussed. In addition, the advantages and disadvantages of each system are analysed.

RESULTS AND CONCLUSION

None of the currently used staging systems fulfils all the requirements for stratification of patients with HCC into groups of different prognosis and therapeutic recommendations. An international agreement on a single staging system is urgently needed in order to permit comparable randomized clinical trials. Only in this way will the outcome for those with HCC be improved.

Prognosis of hepatocellular carcinoma in anti-HCV positive cirrhotic patients: a single-centre comparison amongst four different staging systems

BACKGROUND

Epidemiological studies have foreseen an increase in the incidence of hepatocellular carcinoma (HCC) in the near future and it is estimated that this trend will mostly affect hepatitis C virus (HCV) positive cirrhotic patients. Therefore, accuracy of HCC staging is an important clinical issue.

AIM

To investigate the prognostic usefulness of a series of newly proposed HCC prognostic systems such as the Cancer of the Liver Italian Program (CLIP) score, the Groupe d'Etude et de Traitement du Carcinome Hépatocellulaire (GRETCH) model and the Barcelona Clinic Liver Cancer (BCLC) staging classification when compared with the usefulness of a known staging system such as the Okuda staging system in a group of anti-HCV positive cirrhotic patients with HCC seen at a single centre.

METHODS

Okuda stage, CLIP score, GRETCH model and BCLC stages were retrospectively computed in 81 anti-HCV positive cirrhotic patients with HCC. We evaluated and compared the ability of these methods to assess survival prognosis.

RESULTS

As of December 2001, 51 patients had died and overall median survival was 18 months. All the staging systems were able to identify various patient subgroups with different survival. The CLIP score, the GRETCH model and the BCLC staging classification were better at characterizing the 1-year prognosis of the patients when compared with the Okuda staging system, whilst the 3-year prognostic evaluation was improved only by using the CLIP score or the BCLC staging classification.

CONCLUSIONS

The prognostic value and usefulness of the CLIP score, the GRETCH model and the BCLC staging classification was reproduced in a single-centre analysis of anti-HCV positive HCC cirrhotic patients. These scores provided a prognostic assessment of our patients which is superior to what was obtained by the Okuda staging system.

Modified CLIP using PIVKA-II for evaluating prognosis after hepatectomy for hepatocellular carcinoma

AIMS

The new staging system proposed by the Cancer of the Liver Italian Program (CLIP) for hepatocellular carcinoma (HCC) accounts for both liver dysfunction and tumour characteristics. The present study was designed to analyze UICC TNM stage, CLIP and modified CLIP in 91 patients who underwent hepatic resection for HCC.

METHODS

In the modified CLIP, scoring of AFP was replaced by that of protein induced by vitamin K absence or antagonist II (PIVKA-II; predictive value, > or = 400 mAU/ml).

RESULTS

After hepatic resection, 54 patients developed recurrent tumours. High PIVKA-II was a significant determinant of recurrence (p<0.05). However, a high score of the modified CLIP as well as those other staging systems did not correlate with tumour-recurrence rate. Univariate analysis showed that high TNM score, CLIP score and our modified CLIP score were significant predictors of poor prognosis. Multivariate Cox's analysis revealed that high PIVKA-II and high modified CLIP score were associated with higher risk for disease-free and overall survival as well as high TNM stage.

CONCLUSIONS

Compared with the original CLIP, our modified CLIP was a better predictor of prognosis of HCC patients who underwent hepatic resection.

Role of preoperative selective portal vein embolization in two-step curative hepatectomy for hepatocellular carcinoma

AIM: To determine the feasibility and role of ultrasound-guided preoperative selective portal vein embolization (POSPVE) in the two-step hepatectomy of patients with advanced primary hepatocellular carcinoma (HCC).

METHODS: Fifty patients with advanced HCC who were not suitable for curative hepatectomy were treated by ultrasound-guided percutaneous transhepatic POSPVE with fine needles. The successful rate, side effects and complications of POSPVE, changes of hepatic lobe volume and two-step curative hepatectomy rate after POSPVE were observed.

RESULTS: POSPVE was successfully performed in 47 (94.0%) patients. In patients whose right portal vein branches were embolized, their right hepatic volume decreased and left hepatic volume increased gradually. The ratio of right hepatic volume to total hepatic volume decreased from 62.4% before POSPVE to 60.5%, 57.2% and 52.8% after 1, 2 and 3 weeks respectively. The side effects included different degree of pain in liver area (38 cases), slight fever (27 cases), nausea and vomiting (9 cases). The level of aspartate alanine transaminase (AST), alanine transaminase (ALT) and total bilirubin (TBIL) increased after POSPVE, but returned to preoperative level in 1 week. After 2-4 weeks, two-step curative hepatectomy for HCC was successfully performed on 23 (52.3%) patients. There were no such severe complications as ectopic embolization, local hemorrhage and bile leakage.

CONCLUSION: Ultrasound-guided percutaneous transhepatic POSPVE with fine needles is feasible and safe. It can extend the indications of curative hepatectomy of HCC, and increase the safety of hepatectomy.

Inhibitory mechanism on proliferation of hepatocellular carcinoma cell line by tetrandrine

AIM

To study the mechanism of tetrandrine (TTD) on proliferation and apoptosis of hepatic cell carcinoma (HCC) cell line.

METHODS

MTT colorimetry was used to evaluate the influence of TTD on proliferation of cells. Flow cytometry was used to test reactive oxygen species (ROS) levels in cells. Electrophoresis in 1.5% agarose gels was used to assess the DNA laddering.

RESULTS

Proliferation rate of HCC cell line stimulated by 10 and 20 μmol/L TTD at 24 h, 48 h, and 72 h was 90.1±1.0%, 77.5±2.0%, 70.2±2.9% and 56.6±1.6%, 61.6±2.0% and 47.2±1.9%, respectively (F = 40.025, P<0.001). O₂^- and H₂O₂. generated by HCC cell lines incubated with 0, 10 and 20 μmol/L TTD for 2 hours were 35 and 24.5%, 36.6 and 40.5%, 63.2 and 84.6%, respectively. Typical DNA ladder was observed after the cell line was incubated in 20 μmol/L TTD for 48 hours.

CONCLUSION

TTD can induce the apoptosis of ROS of hepatic cell carcinoma cell line by generation of ROS in a dose dependent manner.

Construction and expression of recombined human AFP eukaryotic expression vector

AIM: To construct a recombined human AFP eukaryotic expression vector for the purpose of gene therapy and target therapy of hepatocellular carcinoma (HCC).

METHODS: The full length AFP-cDNA of prokaryotic vector was digested, and subcloned to the multi-clony sites of the eukaryotic vector. The constructed vector was confirmed by enzymes digestion and electrophoresis, and the product expressed was detected by electrochemiluminescence and immunofluorescence methods.

RESULTS: The full length AFP-cDNA successfully cloned to the eukaryotic vector through electrophoresis, 0.9723 IU/mL AFP antigen was detected in the supernatant of AFP-CHO by electrochemiluminescence method. Compared with the control groups, the differences were significant (P < 0.05). AFP antigen molecule was observed in the plasma of AFP-CHO by immunofluorescence staining.

CONCLUSION: The recombined human AFP eukaryotic expression vector can express in CHO cell line. It provides experimental data for gene therapy and target therapy of hepatocellular carcinoma.

Percutaneous cryoablation in treatment of liver cancer: a report of 31 cases

AIM

To describe the indication, efficacy and clinical significance of percutaneous cryoablation in the treatment of liver malignancy.

METHODS

Total 31 patients with histologically or clinically confirmed primary or metastatic malignancies were treated pucutaneously under ultrasound guidance using the cryocare surgical system from July 2001 to January 2002. All patients were followed up to determine the serum tumor marker, and reveal CT scans, MRI images or utra-sound images.

RESULTS

This therapy was performed in 31 patients including 26 cases with Child A liver reserve, 4 cases with Child B and 1 cases with Child C. There were 21 cases of primary liver cancer and 10 metastastic liver cancer. AFP positive small liver cancer became AFP negative in 80% patients. The rate of completely concreted necrosis in small hepatic cancer with negative AFP was 66.7%, shown by CT or MRI. The curative rate for metastasis liver cancer was 50% at CT, MRI or tumor marker level.

CONCLUSION

Percutaneous cryoablation is a kind of new palliative treatment for liver carcinoma. It is minimally invasive, safe and effective especially for patients with unresectable liver cancer.

Effect of arsenic trioxide on rat hepatocarcinoma and its renal cytotoxicity

AIM: To study the effect of arsenic trioxide (As₂O₃) on rat experimental hepatocarcinoma and its renal cytotoxicity.

METHODS: The hepatocarcinoma model was established by diethaylnitrosamine perfusion in stomach of 120 Wistar rats, and the treatment began at the end of 20 weeks. Before the treatment, the rat models were randomly divided into 5 groups. In the treatment groups, three doses of As₂O₃ were injected into rat abdominal cavity, the total time of drug administration was 4 weeks. Cisplatin control or the blank group was injected into abdominal cavity with equal amount of cisplatin or saline at the same time, respectively. On the 7^th, 14^th and 28^th day after the treatment, the hepatocarcinoma nodules were obtained and the morphologic changes of hepatocarcinoma cells were observed under light and electron microscopes; Immunohistochemistry (S-P methods) was employed to detect the expression of bcl-2, bax and PCNA in hepatocarcinoma tissues; flow cytometry (TUNEL assay) was used to detect the apoptosis of liver cancer cells and the change of cytokinetics. On the 28^th day, the kidneys were obtained and their histologic changes were observed under light microscope, and immunohistochemistry (SP stain) was also employed to detect the expression of bcl-2 and PCNA. Cisplatin and saline solution were used as the control.

RESULTS: As₂O₃ could induce the apoptosis of rat liver cancer cells and exhibited typical morphologic changes. The incidence of apoptosis of hapatocarcinoma cells was elevated (P = 0.001). The elevation was the most higher in the group of middle-dose of As₂O₃ (1 mg·kg^-1), significantly higher than that of the other arsenic groups and the controls (P = 0.001). Large dose of As₂O₃ (5 mg·kg^-1) was able to arise the incidence of apoptosis, but also produced a large amount of necrosis and inflammatory reaction. Middle dose of As₂O₃ dramatically increased the cell number in G2/M phase (P = 0.0001), and apoptosis happened apparently. The expression of bcl-2 and bax was related to the dose of As₂O₃. With the up-regulation of apoptotic incidence, the ratio of bcl-2/bak decreased. But the incidence of apoptosis was not the highest status and the ratio of bcl-2/bax was at the lowest when the highest-dose of As₂O₃ was used. There was significant difference among the PCNA indexes (PCNA L1) of the five groups. Of them, three arsenic groups all showed decrease of different degrees, and this down-regulation was most obvious in group A. There was significant difference among the three groups (P = 0.016). Under the light microscope, the rat kidney in the cisplatin group exhibited tubular epithelium swelling and degeneration, protein casts in collecting tubules; While all arsenic groups didn’t show the significant changes (P = 0.013). In the arsenic groups, the expression of bcl-2 in the renal tubular epithelium was increased (P = 0.005), no obvious changes happened to PCNA L1. But in the group of cisplatin, the PCNA L1 increased significantly (P = 0.001).

CONCLUSION: As₂O₃ can induce apoptosis of rat hepatocellular carcinoma cells. And there is optimum dose; too high dose will induce the cytotoxic effect, while certain dose of As₂O₃ is able to block the cell cycle at G2/M phase. As₂O₃ had the most remarkable influence on G2/M cells, and it can also induce apoptosis to cells at other phases. As₂O₃ can restrain the proliferation of rat hepatocellular carcinoma cells, in a dose-time dependent manner. Compared with cisplatin, As₂O₃ didn’t show obvious renal toxicity, which was related to the increasing expression of bcl-2 in renal tubular epithelium, the inhibition of apoptosis and the anti-oxidation effects.

Gene expression profiles of hepatoma cell line HLE

AIM: To investigate the global gene expression of cancer related genes in hepatoma cell line HLE using Atlas Human Cancer Array membranes with 588 well-characterized human genes related with cancer and tumor biology.

METHODS: Hybridization of cDNA blotting membrane was performed with ³²P-labeled cDNA probes synthesized from RNA isolated from Human hepatoma cell line HLE and non-cirrhotic normal liver which was liver transplantation donor. AtlasImage, a software specific to array, was used to analyze the result. The expression pattern of some genes identified by Atlas arrays hybridization was confirmed by reverse transcription polymerase chain reaction (RT-PCR) in 24 pairs of specimens and Northern blot of 4 pairs of specimens.

RESULTS: The differential expression of cell cycle/growth regulator in hepatocellular carcinoma (HCC) showed a stronger tendency toward cell proliferation with more than 1.5-fold up-regulation of Cyclin C, ERK5, ERK6, E2F-3, TFDP-2 and CK4. The anti-apoptotic factors such as Akt-1 were up-regulated, whereas the promotive genes of apoptosis such as ABL2 were down-regulated. Among oncogene/tumors suppressors, SKY was down-regulated. Some genes such as Integrin beta 8, Integrin beta 7, DNA-PK, CSPCP, byglycan, Tenacin and DNA Topo were up-regulated. A number of genes, including LAR, MEK1, eps15, TDGF1, ARHGDIA were down-regulated. In general, expression of the cancer progression genes was up-regulated, while expression of anti-cancer progression genes was down-regulated. These differentially expressed genes tested with RT-PCR were in consistent with cDNA array findings.

CONCLUSION: Investigation of these genes in HCC is helpful in disclosing molecular mechanism of pathogenesis and progression of HCC. For the first time few genes were discovered in HCC. Further study is required for the precise relationship between the altered genes and their correlation with the pathogenesis of HCC.