Comparison between hepatocellular carcinoma prognostic scores: A 10-year single-center experience and brief review of the current literature

Predictors of Hepatocellular Carcinoma Early Recurrence in Patients Treated with Surgical Resection or Ablation Treatment: A Single-Center Experience

Introduction: Hepatocellular carcinoma (HCC) is the sixth most diagnosed malignancy and the fourth leading cause of cancer-related death worldwide, with poor overall survival despite available curative treatments. One of the most crucial factors influencing survival in HCC is recurrence. The current study aims to determine factors associated with early recurrence of HCC in patients with BCLC Stage 0 or Stage A treated with surgical resection or local ablation. Materials and Methods: We retrospectively enrolled 58 consecutive patients diagnosed with HCC within BCLC Stage 0 or Stage A and treated either by surgical resection or local ablation with maximum nodule diameter < 50 mm. In the first year of follow-up after treatment, imaging was performed regularly one month after treatment and then every three months. Each case was discussed collectively by the Liver Multidisciplinary Group to decide diagnosis, treatment, follow-up, and disease recurrence. Variables resulting in statistically significant difference were then studied by Cox regression analysis; univariately and then multivariately based on forward stepwise Cox regression. Results are represented in hazard ratio (H.R.) with 95% confidence interval (C.I.). Results: There was no statistically significant difference in recurrence rates (34.8 vs. 45.7%, log-rank test, p = 0.274) between patients undergoing surgical resection and local ablation, respectively. Early recurrence was associated with male gender (HR 2.5, 95% C.I. 1.9−3.1), nodule diameter > 20 mm (HR 4.5, 95% C.I. 3.9−5.1), platelet count < 125 × 103 cell/mm3 (HR 1.6, 95% C.I. 1.2−1.9), platelet-lymphocyte ratio < 95 (HR 2.1, 95% C.I. 1.7−2.6), lymphocyte-monocyte ratio < 2.5 (HR 1.9, 95% C.I. 1.4−2.5), and neutrophil-lymphocyte ratio > 2 (HR 2.7, 95% C.I. 2.2−3.3). Discussion and Conclusions: Our results are in line with the current literature. Male gender and tumor nodule dimension are the main risk factors associated with early HCC recurrence. Platelet count and other combined scores can be used as predictive tools for early HCC recurrence, although more studies are needed to define cut-offs.

Tumor Size, Not Small Vessel Invasion, Predicts Survival in Patients With Hepatocellular Carcinoma

OBJECTIVES

The 8th edition American Joint Committee on Cancer (AJCC) staging system for hepatocellular carcinoma (HCC) has been criticized for failing to stratify patients. We aimed to reassess and modify the tumor staging criteria for HCC.

METHODS

Three independent study cohorts were collected and analyzed.

RESULTS

The initial cohort consists of 103 patients with HCC. By Kaplan-Meier survival analysis, the 8th edition failed to distinguish between T1b and T2. Only tumor size and large vessel invasion, but not small vessel invasion or other histopathologic parameters, predicted HCC survival. We modified the T staging criteria by eliminating small vessel invasion while emphasizing tumor size in the middle categories (T2 and T3), which achieved more even distribution of cases and significantly improved risk stratifications (P < .001). This modification was then validated in a cohort of 250 consecutive patients from Mount Sinai Hospital and an online Surveillance, Epidemiology, and End Results data set comprising 9,685 patients, which showed similar results. Small vessel invasion was not an independent prognostic factor in either validation cohort.

CONCLUSIONS

Our study showed that tumor size, but not small vessel invasion, predicts survival in patients with HCC. We suggest incorporating our modified T staging criteria in future AJCC revisions.

MicroRNAs Related to TACE Treatment Response: A Review of the Literature from a Radiological Point of View

Hepatocellular Carcinoma (HCC) is the sixth most common cancer in the world. Patients with intermediate stage (Barcelona Clinic Liver Cancer, B stage) hepatocellular carcinoma (HCC) have been able to benefit from TACE (transarterial chemoembolization) as a treatment option. MicroRNAs (miRNAs), i.e., a subclass of non-coding RNAs (ncRNAs), participate in post-transcriptional gene regulation processes and miRNA dysfunction has been associated with apoptosis resistance, cellular proliferation, tumor genesis, and progression. Only a few studies have investigated the role of miRNAs as biomarkers predicting TACE treatment response in HCC. Here, we review the studies’ characteristics from a radiological point of view, also correlating data with radiological images chosen from the cases of our institution.

Nomograms Incorporating the CNLC Staging System Predict the Outcome of Hepatocellular Carcinoma After Curative Resection

Purpose

Prediction models of postoperative outcomes of patients with hepatocellular carcinoma (HCC) after surgery based on the China liver cancer (CNLC) staging system are rare. This study aimed to compare the prognostic abilities of CNLC, Tumor-Node-Metastasis (TNM) 8th edition, and Barcelona Clinic Liver Cancer (BCLC) staging systems for HCC after curative resection. We developed two nomograms incorporating the CNLC staging system to predict the postoperative recurrence-free survival (RFS) and overall survival (OS) of HCC patients.

Patients and methods

The prognostic abilities of the CNLC, TNM and BCLC staging systems for HCC after curative resection were compared using receiver operating characteristic (ROC) curves. Two nomograms incorporating five selected risk factors were constructed based on multivariate Cox regression in the primary cohort of 312 HCC patients. It was validated with an independent validation cohort of 130 HCC patients. The predictive performance and discrimination ability of the two nomograms were further evaluated and compared with those of the TNM and BCLC staging systems.

Results

The CNLC staging system had a higher area under the receiver operating characteristic curve (AUROC) value for both OS (AUC=0.692) and RFS (AUC=0.673) than the TNM (ROC=0.667 for OS and 0.652 for RFS) and BCLC (ROC=0.671 for OS and 0.670 for RFS) staging systems. The independent predictors of OS (cirrhosis, gamma-glutamyl transpeptidase (GGT), tumor differentiation and CNLC staging system) and RFS (α-fetoprotein (AFP) and CNLC staging system) were incorporated into the two nomograms. The OS and RFS nomograms consistently outperformed the TNM and BCLC staging systems in the primary cohort. These results were verified in the validation cohort. In the 442 patients with HCC, the RFS nomogram could predict early recurrence very well.

Conclusion

The two proposed nomograms incorporating the CNLC staging system can predict the outcomes of patients with HCC after curative hepatectomy in clinical practice.

Hepatobiliary Scintigraphy and Glass 90Y Radioembolization with Personalized Dosimetry: Dynamic Changes in Treated and Nontreated Liver

Background: The functional changes that occur over time in the liver following ⁹⁰Y-radioembolization (RE) using personalized dosimetry (PD) remain to be investigated. Methods: November 2016–October 2019: we retrospectively included hepatocellular carcinoma (HCC) patients treated by ⁹⁰Y-glass RE using PD, who underwent hepatobiliary scintigraphy (HBS) at baseline and at 15 days, 1, 2, 3, and 6 months after RE. Results: There were 16 patients with unilobar disease (100%) included, and 64 HBS were performed. Whole liver function significantly decreased over time. The loss was maximal at 2 weeks: −32% (p = 0.002) and remained below baseline at 1 (−15%; p = 0.002), 2 (−25%; p < 0.001), and 3 months (−16%; p = 0.027). No radioembolization-induced liver disease was observed. Treated liver function strongly decreased to reach −64% (p < 0.001) at 2 months. Nontreated liver function decreased at 2 weeks (−21%; p = 0.027) and remained below baseline before reaching +20% (p = 0.002) and +59% (p < 0.001) at 3 and 6 months, respectively. Volumetric and functional changes exhibited parallel evolutions in the treated livers (p = 0.01) but independent evolutions in the nontreated livers (p = 0.08). Conclusion: RE using PD induces significant regional changes in liver function over time. As early as 15 days following RE, both the treated and nontreated livers showed a decreased function. Nontreated liver function recovered after 3 months and greatly increased afterwards.

Metformin Actions on the Liver: Protection Mechanisms Emerging in Hepatocytes and Immune Cells against NASH-Related HCC

Nonalcoholic fatty liver disease (NAFLD) is strongly linked to the global epidemic of obesity and type 2 diabetes mellitus (T2DM). Notably, NAFLD can progress from the mildest form of simple steatosis to nonalcoholic steatohepatitis (NASH) that increases the risk for hepatocellular carcinoma (HCC), which is a malignancy with a dismal prognosis and rising incidence in the United States and other developed counties, possibly due to the epidemic of NAFLD. Metformin, the first-line drug for T2DM, has been suggested to reduce risks for several types of cancers including HCC and protect against NASH-related HCC, as revealed by epidemical studies on humans and preclinical studies on animal models. This review focuses on the pathogenesis of NASH-related HCC and the mechanisms by which metformin inhibits the initiation and progression of NASH-related HCC. Since the functional role of immune cells in liver homeostasis and pathogenesis is increasingly appreciated in developing anti-cancer therapies on liver malignancies, we discuss both the traditional targets of metformin in hepatocytes and the recently defined effects of metformin on immune cells.

Safety and Efficacy of Physical Thermal Ablation Combined Sorafenib for Hepatocellular Carcinoma: A Meta-analysis

BACKGROUND AND AIMS

To compare the efficacy and safety of physical thermal ablation (PTA), including radiofrequency ablation (RFA) and microwave ablation (MWA), combined with sorafenib and physical thermal ablation alone for the control and treatment of hepatocellular carcinoma (HCC) according to the available literature.

METHODS

Comprehensive searches were performed on PubMed, Embase, CNKI, the Cochrane Library, China Biomedical Literature Database (known as CBM), Weipu Journal, and Wanfang Database. Meta-analysis was performed using Revman 5.3 software.

RESULTS

A total of 15 studies, consisting of 2,227 HCC patients, were selected and included in this meta-analysis. Compared with the RFA-alone group, the patients in the RFA+sorafenib group had longer 1-, 2-, and 3-year overall survival (all p<0.05), better overall efficacy (p<0.0001), longer radiofrequency interval (p<0.001), and lower 2-year recurrence rate (p=0.02). The 1-year overall survival (p=0.003) and overall efficacy (p=0.002) of the MWA+sorafenib group were also higher than those of the MWA-alone group. The incidences of adverse reactions in the RFA+sorafenib group, such as hand-foot skin reactions (p<0.001), diarrhea and constipation (p=0.0001), hypertension (p=0.009), and alopecia (p<0.001), were significantly higher than those in the RFA-alone group.

CONCLUSIONS

RFA or MWA combined with sorafenib has produced a better therapeutic effect on HCC than physical thermal ablation alone; however, adverse reactions have been obvious. It is necessary to evaluate the safety of combination therapy, and pay close attention to the adverse reactions that develop in patients.

Modeling Hepatocellular Carcinoma Cells Dynamics by Serological and Imaging Biomarkers to Explain the Different Responses to Sorafenib and Regorafenib

Simple Summary

Systemic therapy in advanced hepatocellular-carcinomas (HCC) has limited benefits, but some patients show partial responses (PR) and a few even a complete response (CR). Understanding the biological mechanisms could help clinicians in decision-making. Aim of this study was to develop a physic-mathematical model to investigate tumor dynamics using α-fetoprotein (AFP) and protein induced by vitamin K absence-II (PIVKA-II) measures combined with digital imaging. The model was set-up in three prototype patients with CR/PR to sorafenib and PR to regorafenib, and then applied in seven patients with different types of response. Overall, the rate constant of cancer cells production ranged between 0.250–0.372 C × day⁻¹. During therapy, neo-angiogenesis reduction was higher in four CR than in four PR or stable disease (SD) and in two non-responders (median: 83.2% vs. 29.4% vs. 2.0%). Tumor vasculature decay appeared accelerated in CR. We conclude that modeling serological and imaging biomarkers could help personalization of systemic therapy.

Abstract

In advanced HCC, tyrosine-kinase inhibitors obtain partial responses (PR) in some patients and complete responses (CR) in a few. Better understanding of the mechanism of response could be achieved by the radiomic approach combining digital imaging and serological biomarkers (α-fetoprotein, AFP and protein induced by vitamin K absence-II, PIVKA-II) kinetics. A physic-mathematical model was developed to investigate cancer cells and vasculature dynamics in three prototype patients receiving sorafenib and/or regorafenib and applied in seven others for validation. Overall four patients showed CR, two PR, two stable-disease (SD) and two progressive-disease (PD). The rate constant of cancer cells production was higher in PD than in PR-SD and CR (median: 0.398 vs. 0.325 vs. 0.316 C × day⁻¹). Therapy induced reduction of neo-angiogenesis was greater in CR than in PR-SD and PD (median: 83.2% vs. 29.4% and 2.0%), as the reduction of cell-proliferation (55.2% vs. 7.6% and 0.7%). An additional dose-dependent acceleration of tumor vasculature decay was also observed in CR. AFP and cancer cells followed the same kinetics, whereas PIVKA-II time/dose dependent fluctuations were influenced also by tissue ischemia. In conclusion, pending confirmation in a larger HCC cohort, modeling serological and imaging biomarkers could be a new tool for systemic therapy personalization.

Advanced Techniques in the Percutaneous Ablation of Liver Tumours

Percutaneous ablation is an accepted treatment modality for primary hepatocellular carcinoma (HCC) and liver metastases. The goal of curative ablation is to cause the necrosis of all tumour cells with an adequate margin, akin to surgical resection, while minimising local damage to non-target tissue. Aside from the ablative modality, the proceduralist must decide the most appropriate imaging modality for visualising the tumour and monitoring the ablation zone. The proceduralist may also employ protective measures to minimise injury to non-target organs. This review article discusses the important considerations an interventionalist needs to consider when performing the percutaneous ablation of liver tumours. It covers the different ablative modalities, image guidance, and protective techniques, with an emphasis on new and advanced ablative modalities and adjunctive techniques to optimise results and achieve satisfactory ablation margins.

Transarterial Radioembolization of Hepatocellular Carcinoma, Liver-Dominant Hepatic Colorectal Cancer Metastases, and Cholangiocarcinoma Using Yttrium90 Microspheres: Eight-Year Single-Center Real-Life Experience

Liver tumors are common and may be unamenable to surgery or ablative treatments. Consequently, other treatments have been devised. To assess the safety and efficacy of transarterial radioembolization (TARE) with Yttrium-90 for hepatocellular carcinoma (HCC), liver-dominant hepatic colorectal cancer metastases (mCRC), and cholangiocarcinoma (CCA), performed according to current recommendations, we conducted a single-center retrospective study in 70 patients treated with TARE (HCC, n = 44; mCRC, n = 20; CCA, n = 6). Safety and toxicity were assessed using the National Cancer Institute Common Terminology Criteria. Treatment response was evaluated every 3 months on imaging studies using Response Evaluation Criteria in Solid Tumors (RECIST) or mRECIST criteria. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. The median delivered dose was 1.6 GBq, with SIR-Spheres® or TheraSphere® microspheres. TARE-related grade 3 adverse events affected 17.1% of patients. Median follow-up was 32.1 months. Median progression-free survival was 5.6 months and median overall time from TARE to death was 16.1 months and was significantly shorter in men. Progression-free survival was significantly longer in women (HR, 0.49; 95%CI, 0.26-0.90; p = 0.031). Risk of death or progression increased with the number of systemic chemotherapy lines. TARE can be safe and effective in patients with intermediate- or advanced-stage HCC, CCA, or mCRC refractory or intolerant to appropriate treatments.