Natural history and prognostic factors of primary hepatocellular carcinoma: study of 70 untreated patients

Radiotherapy for bone metastases of hepatocellular carcinoma: a hybrid systematic review with meta-analyses

INTRODUCTION

External beam radiation therapy (EBRT) is commonly used as a palliative treatment for bone metastases of hepatocellular carcinoma (HCC). We planned a hybrid systematic review that meta-analyzed the efficacy and feasibility of EBRT and reviewed the literature to answer specific clinical questions.

METHODS

The PubMed, Medline, Embase, and Cochrane Library databases were searched through 1 December 2021. Primary endpoints were overall survival (OS) and response rate (RR). Secondary endpoints were comparative data, including treatment response and survival related to dose escalation, number of metastases, and fractionation scheme. Formal pooled analyses were performed on the primary endpoints, and the secondary endpoints were systematically reviewed. Complications were also reviewed.

RESULTS

Nineteen studies involving 1613 patients with HCC and bone metastases were included. The median OS was 6 months (range: 3-13 months). The pooled one-year OS was 23.1% (95% confidence interval [CI]: 18.4-28.6); pooled pain RR was 81.5% (95% CI: 76.4-85.7) and of pain complete remission was 26.5% (95% CI: 21.7-32.0). Pain response might be related to dose escalation, considering the moderate consistency of results and plausibility, with a low-quality grade of evidence^†. Considering the indeterminate results, we cannot suggest that dose escalation is correlated with OS. The oligometastasis status might be related to better OS, considering the high consistency of results and plausibility with low to moderate quality of evidence. Hypofractionated EBRT might yield comparable efficacy to conventional EBRT, with a low-quality grade of evidence. There were few complications of grade ≥3, except for hematologic complications, which ranged from 11.5to 34%.

CONCLUSION

EBRT is an efficient and feasible palliative option. Clinical consideration of hematologic complications is necessary. Future studies are needed to increase the quality of evidence for actual clinical questions. ^†Reference to a system of the American Society for Radiation Oncology primary liver cancer clinical guidelines.

Hepatocellular Carcinoma (HCC) in North-Western India: A Retrospective Study Focusing on Epidemiology, Risk Factors, and Survival

BACKGROUND

Hepatocellular carcinoma (HCC) is an aggressive tumour with unpredictable outcome. It is fourth most common cause of cancers in India. However, information on HCC is inadequate in India. Therefore, the purpose of study is to determine overall survival for patients diagnosed with HCC and association between various predictive factors and survival.

METHODS

Retrospectively 59 patients of HCC presenting to the radiotherapy out-patient department of our institute from April 2015 to April 2018 were included in the study.

RESULTS

The median overall survival (OS) was 5 months ranging from 0 to 13 months. Majority of patients were in advance stage (III/IV). All patient died by 13 months. None of the possible predictive factors were found to be significantly associated with survival (p > 0.05) by univariate analysis. However, age < 59 years, male gender, KPS ≤ 60, AFP ≥ 400, cirrhosis, multifocality, tumour size > 10 cm, advance stage (IIIB/IV), Child-Pugh score B/C, CLIP score ≥ 4, and raised bilirubin level had poorer survival compared to other predictive factors. Median survival was better in patient treated with TACE followed by sorafenib + palliative care group (9 months) then sorafenib + palliative care and palliative care alone group (5 and 4 months respectively). Although results were not statistically significant (p = 0.133). Amongst all possible variables, highest hazard was found with multifocal lesion (2.058) and results were statistically significantly (p = 0.045, 95% confidence interval: 0.922 to 4.590) as compared to unifocal lesion with median survival period of 7 vs 9.5 months by Kaplan-Meier survival curve analysis using log rank test.

CONCLUSION

Multifocality was independent predicator for poor survival in HCC. Further clinical studies are necessary to improve the outcomes of patients with high risk features.

Status of inflammation in relation to health related quality of life in hepatocellular carcinoma patients

PURPOSE

Both Inflammation and health-related quality of life (HRQoL) are independent prognosticators in HCC patients. We hypothesized that inflammation can cause impairment in HRQoL and investigated the correlation between inflammatory status and HRQoL in HCC patients.

METHODS

Clinical, laboratory and HRQoL (using EORTC QLQ-C30, QLQ-HCC18, C30 and HCC18 index-scores) data were prospectively collected from HCC patients at diagnosis. Correlation analyses were performed between HRQoL and inflammation-based markers including C-reactive protein (CRP), CRP/albumin ratio (CRP/alb), Glasgow Prognostic Score (GPS), Inflammation-Based Index (IBI) and Prognostic Index (PI).

RESULTS

Among 445 HCC patients, higher inflammatory states were significantly correlated with worse HRQoL. For CRP and CRP/alb ratio, the HRQoL factors with higher correlations included C30 and HCC18 index-scores, certain QLQ-C30 domains and items ('physical functioning', 'role functioning', 'fatigue', 'pain', 'appetite loss') and QLQ-HCC18 items ('fatigue', 'body image', 'nutrition' and 'abdominal swelling'), where the Pearson's correlation coefficients were up to 0.416. Multivariate analyses indicated that worse HRQoL factors were significantly correlated with worse scores in GPS, IBI and PI.

CONCLUSION

In HCC patients, inflammatory status correlates with HRQoL at presentation. In particular, relatively stronger correlations with CRP-based markers have been observed in HRQoL scales that assess constitutional symptoms (QLQ-C30 'physical functioning', 'role functioning', 'fatigue', 'appetite loss' and QLQ-HCC18 'fatigue' and 'nutrition') and tumor burden (QLQ-C30 'pain' and QLQ-HCC18 'abdominal swelling' and 'body image'). Future studies are warranted to evaluate whether intervention that reduces inflammation could improve HRQoL in HCC patients.

Correlations of health-related quality of life with serum inflammatory indicators IL-8 and mIBI in patients with hepatocellular carcinoma

Purpose

Health-related quality of life (HRQoL) is a significant prognostic factor for overall survival in hepatocellular carcinoma (HCC) patients, and this is independent of stage and liver function. Inflammation plays a significant role in HCC development and progression. It was hypothesized that the inflammatory status of HCC patients may affect their HRQoL. The relationship between HRQoL and inflammatory status was explored using indicators IL-8 level and modified inflammation-based index (mIBI, based on IL-8, C-reactive protein, and albumin).

Methods

From 2007-2011, HCC patients were enrolled prospectively. Baseline HRQoL assessment utilized the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-HCC18; clinical and laboratory data were collected at diagnosis. Two summary indices, C30 and HCC18 index-scores, were calculated. Correlation analyses were performed between HRQoL and inflammatory markers.

Results

In the 445 patients studied, significant correlations were found between IL-8 levels and EORTC QLQ-C30, QLQ-HCC18, C30, and HCC18 index-scores. The strongest correlated factors were those reflective of constitutional symptoms, namely QLQ-C30 "appetite loss" (with Pearson's correlation coefficient, r=0.322, P<0.0001); QLQ-C30 "fatigue" (r=0.311, P<0.0001); QLQ-C30 "role functioning" (r=-0.305, P<0.0001); QLQ-HCC18 "nutrition" (r=0.317, P<0.0001); and QLQ-HCC18 "fatigue" (r=0.306, P<0.0001). In addition, moderate but significant correlations were also observed with HCC18 index score (r=0.321, P<0.0001), and C30 index score (r=0.306, P<0.0001). HRQoL factors were also significantly correlated with mIBI.

Conclusion

Baseline HRQoL using the conventional assessments of EORTC QLQ-C30 and QLQ-HCC18, as well as C30 and HCC18 index-scores, significantly correlated with inflammatory indicators (IL-8 level and mIBI) in HCC patients. Among the strongest correlations were those between IL-8 level and the two index-scores, as well as HRQoL aspects that represent constitutional symptoms. When paralleled with molecular findings, traditional HRQoL assessment in HCC has gained a new level of understanding: pattern recognition within an HRQoL instrument could potentially identify patients with more severe inflammatory state.

Untreated hepatocellular carcinoma in Egypt: outcome and prognostic factors

Background

Hepatocellular carcinoma (HCC) is a common cancer worldwide as well as in Egypt with hepatitis C and B, alcohol and aflatoxins being the commonest risk factors.

Aim

The objective of this study was to assess the prognostic factors affecting overall survival (OS) of untreated HCC in Egypt.

Methods

This retrospective study was conducted at Tanta Cancer Center, Egypt where 288 HCC cases who received no specific therapy and were followed-up until death were identified. The impact of possible prognostic factors on OS was assessed using the log-rank test (univariate analyses) and Cox regression method (multivariate analysis).

Results

The median OS of untreated HCC was 2.3 months (95% confidence interval: 1.9–2.6). The 1, 3, 6, 12, 24 months OS rates were 84%, 42%, 21%, 9%, and 3%, respectively. All cases had died by 46 months. Male sex, advanced Child-Pugh class, the clinical presentation of ascites, cough, fatigue, and the presence of metastases were associated with poor survival (P<0.05 for all). In multivariate analysis; cough, presence of ascites, and Child-Pugh class were independent predictors of poor survival.

Conclusion

OS in untreated HCC in Egypt is very short. Many factors interact to produce this dismal survival.

Phase III randomized controlled trial comparing the survival of patients with unresectable hepatocellular carcinoma treated with nolatrexed or doxorubicin

PURPOSE

The study objective was to compare the overall survival (OS) of patients with unresectable or metastatic hepatocellular carcinoma (HCC) treated with nolatrexed (NOL) or doxorubicin (DOX).

PATIENTS AND METHODS

Patients from North America, Europe, and South Africa (N = 445) with HCC were randomly assigned to receive NOL or DOX. Eligible patients had Karnofsky performance status (KPS) > or = 60%, Cancer of the Liver Italian Program (CLIP) score < or = 3, and adequate organ function. Primary end point was OS. Secondary end points included progression-free survival (PFS), objective response rates, and safety. The treatment groups were well-balanced with regards to age, sex, ethnic origin, and underlying liver disease. Randomization was stratified according to KPS and CLIP score.

RESULTS

At the time of the final analysis, 377 patients had died. Median OS was 22.3 weeks for NOL and 32.3 weeks for DOX (P = .0068). The hazard ratio was 0.753 in favor of DOX. Objective response rate (complete response [CR] plus partial response [PR]) was 1.4% for NOL and 4.0% for DOX. Median PFS was 12 weeks for NOL and 10 weeks for DOX (P = .7091). Median time to treatment failure was 8.4 weeks for NOL and 9.1 weeks for DOX (P = .0969). Grade 3 and 4 stomatitis, vomiting, diarrhea, and thrombocytopenia were more common in the NOL arm. Alopecia was more common in the DOX arm. More patients were withdrawn from study for toxicity in the NOL arm than in the DOX arm.

CONCLUSION

NOL showed minimal activity in this phase III trial. Further exploration at this dose and schedule in HCC is not warranted.

A simple prognostic scoring system for patients with unresectable hepatocellular carcinoma treated by chemo-embolization

BACKGROUND

Hepatocellular carcinoma (HCC) comprises heterogeneous groups of patients with differing outcomes.

METHODS

In order to attempt to identify patient sub-sets, we retrospectively examined the records of 750 patients with biopsy-proven unresectable HCC, who were treated with hepatic artery chemo-embolization and were followed till death. We used the Cox proportional hazard model, as it was neutral with respect to prejudged cut-off between short and long survival.

RESULTS

On univariate analysis, we found a shorter survival to be associated with male gender, presence of cirrhosis, portal hypertension, portal vein thrombosis and elevations of bilirubin, GGTP, ALKP, AFP, DCP, PT and albumin. Five factors were found to be statistically significant (p<0.05) on multivariate analysis, namely presence of cirrhosis or ascites and elevations of AFP, ALKP or GGTP. We developed a simplified scoring system based upon the sum of the hazard ratios of each of these five factors. By combining the two factors with the heaviest hazard ratios from our multivariable analysis, namely AFP (+ = >100 ng/mL) and ALKP (+ = >100 IU/mL), we found a simple parsimonious prognostic tool, which segregated the patients into survival groups, namely AFP- ALKP-; either AFP+ or ALKP+; and AFP+ ALKP+; these three groups corresponded to a 24-month survival of 70%, 32% and 12%, respectively.

CONCLUSION

we found that only two lab functions, AFP and ALKP levels, in our large HCC patient cohort undergoing hepatic artery chemo-embolization, had prognostic significance.

Simple clinical prognostic model for hepatocellular carcinoma in developing countries and its validation

PURPOSE

More than 80% of hepatocellular carcinomas (HCCs) worldwide occur in developing countries, especially in Asia. It often presents at an advanced stage beyond treatment. In this circumstance, a simple prognostic model is useful. Previous prognostic models require radiologic and laboratory investigations that are not readily available in developing countries. Our aim is to formulate and then validate a simple clinical prognostic model for HCC in an Asian population using only clinical parameters and with serum alpha-fetoprotein (AFP) as the sole laboratory test.

PATIENTS AND METHODS

Cox regression modeling was performed on several clinical parameters and serum AFP level in 397 patients with HCC who received only supportive care in Singapore. A later group of 324 HCC patients from an Asia-Pacific-wide randomized trial was then used to validate the model.

RESULTS

Ascites, physical performance status, and serum AFP were independently predictive of survival. Cox analysis yielded a simple score based on these three variables that categorizes patients into low-, medium-, and high-risk groups with 6-month survivals of 43%, 21%, and 5%, respectively. The prospective validation data provided corresponding estimates of 33%, 15%, and 3% and give confirmation of the utility of the simple model.

CONCLUSION

We have formulated and prospectively validated a simple prognostic score for untreated HCC that only requires a clinical evaluation for ascites and physical performance status and measurement of serum AFP. This simple model is particularly apt for developing country circumstances and can also be used to select patients for treatment trials.

Efficacy of an implanted drug delivery system for advanced hepatocellular carcinoma using 5-fluorouracil, epirubicin and mitomycin C

BACKGROUND

In order to assess the efficacy of repeated hepatic arterial infusion (HAI) therapy for advanced hepatocellular carcinoma, we administered HAI therapy using 5-fluorouracil, epirubicin and mitomycin C, with an implanted drug delivery system.

METHODS AND RESULTS

Thirty-seven patients received HAI therapy with a response rate of 21.6%. The 6-month and 1-year survival rates were 67.6 and 29.7%, respectively. Responders to HAI therapy showed significantly longer survival than non-responders, while patients with mild liver dysfunction tended to survive longer than those with severe dysfunction. Neither tumour thrombosis of the main trunk of the portal vein nor extrahepatic metastases were considered to constitute contraindications for HAI therapy. Catheter-related trouble occurred in eight patients and biloma in one patient, but other side effects were transient and tolerable. These patients received HAI therapy as outpatients for an average of 79.6% of the entire course of therapy.

CONCLUSIONS

Hepatic arterial infusion therapy proved effective for patients with advanced hepatocellular carcinoma in terms of improving survival and outpatient rates.