Treatment allocation in hepatocellular carcinoma: Assessment of the BCLC algorithm

Prognosis of transarterial chemoembolization-sorafenib compared to transarterial chemoembolization-alone in hepatocellular carcinoma stage C: a systematic review

BACKGROUND

This systematic review aims to compare the prognosis of treatment transarterial chemoembolization (TACE) combined with sorafenib and TACE-alone in patients with hepatocellular carcinoma (HCC) with Barcelona clinic liver cancer-stage C (BCLC-C).

MATERIALS AND METHODS

A systematic search was conducted on five electronic databases: PubMed, ScienceDirect, Cochrane, Embase, and Scopus. Studies were included if they compared overall survival (OS) of TACE-Sorafenib to TACE-alone in patients with HCC BCLC-C within the 2019-2023 timeframe. We excluded studies consisting of conference abstracts, letters, editorials, guidelines, case reports, animal studies, trial registries, and unpublished work. The selected articles were evaluated from August 2023 to September 2023. The journal's quality was assessed with NOS for a non-randomized controlled trial.

RESULTS

This systematic review included four studies following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). All four studies compared the OS of 401 patients with TACE-sorafenib to TACE-alone. Two studies compared time-to-progression (TTP), one study compared progression-free survival (PFS), and two studies compared disease control rate (DCR). There were various population criteria, TACE techniques used, risk factors, follow-up time, and adverse events. The collected evidence generally suggested that the combination of TACE-sorafenib is superior compared to TACE-alone. Due to a lack of essential data for the included study, a meta-analysis couldn't be performed.

CONCLUSION

The results of this systematic review suggested that TACE-sorafenib combination therapy in patients with HCC BCLC-C improves OS superior compared to TACE-alone, without a notable increase in adverse events.

Impact of Thrombocytopenia on Survival in Patients with Hepatocellular Carcinoma: Updated Meta-Analysis and Systematic Review

BACKGROUND

Platelets (PLT) have a role in the pathogenesis, progression, and prognosis of hepatocellular carcinoma (HCC) and could represent a readily measurable laboratory parameter to enhance the comprehensive evaluation of HCC patients.

METHODS

The PubMed, Web of Science, and Scopus databases were searched with a focus on survival as well as patient and tumor-specific characteristics in correlation to reported PLT counts. Survival outcomes were analyzed with both common-effect and random-effects models. The hazard ratio (HR) and its 95% confidence interval (CI) from analyzed trials were incorporated. Studies that did not provide survival data but focused on platelet count correlation with HCC characteristics were reviewed.

RESULTS

In total, 26 studies, including a total of 9403 patients, met our criteria. The results showed that thrombocytopenia in HCC patients was associated with poor overall survival (common-effect HR = 1.15, 95% CI: 1.06-1.25; random-effect HR = 1.30, 95% CI: 1.05-1.63). Moreover, three studies reveal significant correlations between PLT indices and tumor characteristics such as size, foci number, and etiology of HCC development.

CONCLUSION

Our meta-analysis confirmed that PLT count could act as a prognostic marker in HCC, especially with a PLT count cut off <100 × 103/mm3. Further prospective studies focusing on the role of PLT in clearly defined subgroups are necessary.

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

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

Radiation Segmentectomy for Hepatocellular Carcinoma

The application of trans-arterial radioembolization (TARE) with Yttrium-90, historically a palliative treatment option for patients with advanced hepatocellular carcinoma (HCC), is evolving. Radiation segmentectomy (RADSEG), the segmental delivery of an ablative radiation dose, is a treatment option for patients with earlier-stage HCC. This review presents an in-depth exploration of RADSEG, emphasizing its technical considerations, dosimetry advancements, and patient selection. The integration of RADSEG into the Barcelona Clinic Liver Cancer (BCLC) paradigm will be highlighted. RADSEG outcomes concerning safety and efficacy will be explored and compared with traditional locoregional cancer treatments like trans-arterial chemoembolization (TACE), percutaneous thermal ablation, and surgical resection, with an eye on future directions and considerations.

Machine learning-based clinical decision support system for treatment recommendation and overall survival prediction of hepatocellular carcinoma: a multi-center study

The treatment decisions for patients with hepatocellular carcinoma are determined by a wide range of factors, and there is a significant difference between the recommendations of widely used staging systems and the actual initial treatment choices. Herein, we propose a machine learning-based clinical decision support system suitable for use in multi-center settings. We collected data from nine institutions in South Korea for training and validation datasets. The internal and external datasets included 935 and 1750 patients, respectively. We developed a model with 20 clinical variables consisting of two stages: the first stage which recommends initial treatment using an ensemble voting machine, and the second stage, which predicts post-treatment survival using a random survival forest algorithm. We derived the first and second treatment options from the results with the highest and the second-highest probabilities given by the ensemble model and predicted their post-treatment survival. When only the first treatment option was accepted, the mean accuracy of treatment recommendation in the internal and external datasets was 67.27% and 55.34%, respectively. The accuracy increased to 87.27% and 86.06%, respectively, when the second option was included as the correct answer. Harrell's C index, integrated time-dependent AUC curve, and integrated Brier score of survival prediction in the internal and external datasets were 0.8381 and 0.7767, 91.89 and 86.48, 0.12, and 0.14, respectively. The proposed system can assist physicians by providing data-driven predictions for reference from other larger institutions or other physicians within the same institution when making treatment decisions.

Chemoembolization Plus Ablation: Current Status

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The treatment landscape for HCC has evolved significantly over the past decade, with several modalities available to treat various stages of disease. The Barcelona Clinic Liver Cancer (BCLC) system provides a foundation for treatment guidance. However, given the complex nature of HCC, a more nuanced approach is often required, especially for lesions sized between 3 and 5 cm. This review aims to analyze the available treatments for early-stage HCC lesions between 3 and 5 cm, with a focus on the therapeutic potential and efficacy of transarterial chemoembolization (TACE)-ablation. Additional therapies including TACE, ablation, transarterial radioembolization, and surgical resection are also reviewed and compared with TACE-ablation. TACE-ablation is a viable therapeutic option for early-stage HCC lesions between 3 and 5 cm. Surgical resection remains the gold standard. Although recent studies suggest radiation segmentectomy may be a curative approach for this patient population, further studies are needed to compare the relative efficacies between TACE-ablation and radiation segmentectomy.

Update on Locoregional Therapies for Liver Cancer: Radiation Segmentectomy

Over 900,000 people worldwide were diagnosed with liver cancer in 2022 alone, with hepatocellular carcinoma (HCC) accounting for 75-85% of cases. Treatment for HCC includes some combination of systemic therapies, surgery, liver transplantation, ablation, and intra-arterial therapies with transarterial chemoembolization (TACE) or transarterial radioembolization (TARE). Currently, the Barcelona Clinic Liver Cancer (BCLC) guidelines have acknowledged liver transplantation, surgical resection, and thermal ablation as curative therapies in very early to early stage HCC (BCLC-0 and BCLC-A). While these modalities are the preferred curative treatments for a very early to early stage disease, there are challenges associated with these options, such as organ availability and patient eligibility. Current data shows the role of radiation segmentectomy as a curative therapeutic option for very early to early stage HCC that is unresectable and not amenable to ablation. As future data continues to elucidate the ability for radiation segmentectomy to achieve complete pathologic necrosis, the goal is for the BCLC staging model to acknowledge its role as a curative treatment in this patient population and incorporate it into the ever-evolving guidelines.

Potential missed opportunities for diagnosis of lymphoepithelioma-like intrahepatic cholangiocarcinoma: report of a rare case

Lymphoepithelioma-like intrahepatic cholangiocarcinoma (LEL-ICC) is a rare distinctive variant of liver cancer with unique epidemiological and pathological characteristics, including dense lymphocyte infiltration. We herein describe a 67-year-old Chinese man with LEL-ICC. The patient had undergone endoscopic extraction of a bile duct stone 1 month prior. Contrast-enhanced abdominal computed tomography (CT) revealed a 2.5- × 2.5- × 1.5-cm low-density mass located in a covert part of the left lateral segment of the liver. Contrast-enhanced magnetic resonance imaging revealed a hyperintense lesion on T2-weighted and diffusion-weighted images of the left lateral liver, with similar size and signal characteristics in the arterial and portal venous phases. The patient subsequently underwent left lateral laparoscopic hepatectomy. The results of postoperative pathology and immunohistochemistry allowed for the definitive diagnosis. In situ hybridization using an Epstein-Barr virus-encoded RNA probe revealed extensive reactivity in the tumor cell nuclei, supporting a diagnosis of LEL-ICC. The patient was recurrence-free at 12 months postoperatively as shown by CT. A literature review indicated that in middle-aged patients with Epstein-Barr virus infection, a liver mass with a well-defined margin and a combination of hypervascularity and delayed intratumoral enhancement on CT and magnetic resonance imaging may suggest a diagnosis of LEL-ICC.

Treatment of hepatocellular carcinoma with macroscopic vascular invasion: A systematic review and network meta-analysis

BACKGROUND

This study aimed to evaluate the outcomes of different treatments for patients with hepatocellular carcinoma (HCC) and macroscopic vascular invasion.

METHODS

A systematic review and meta-analysis of comparative studies was performed to evaluate various treatment modalities for HCC with macroscopic vascular invasion, including liver resection (LR), liver transplantation (LT), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), radiotherapy (RT), radiofrequency ablation (RFA), and antineoplastic systemic therapy (AnST).

RESULTS

After applying the selection criteria, 31 studies were included. The surgical resection (SR) group (including LR and LT) had a similar mortality rate to the non-surgical resection (NS) group (RD = -0.01; 95% CI -0.05 to 0.03). The SR group had a higher rate of complications (RD = 0.06; 95% CI 0.00 to 0.12) but a higher 3-year overall survival (OS) rate than the NS group (RD = 0.12; 95% CI 0.05 to 0.20). The network analysis revealed that the overall survival was lower in the AnST group. LT and LR had similar survival benefits. The meta-regression suggested that SR has a greater impact on the survival of patients with impaired liver function.

DISCUSSION

Most likely, LT has a significant impact on long-term survival and consequently would be a better option for HCC with macroscopic vascular invasion in patients with impaired liver function. LT and LR offer a higher chance of long-term survival than NS alternatives, although LR and LR are associated with a higher risk of procedure-related complications.

First- and Second-Line Treatments for Patients with Advanced Hepatocellular Carcinoma in China: A Systematic Review

Chinese national guidelines recommend various systemic therapies for patients with advanced hepatocellular carcinoma (HCC), but optimal treatment selection remains uncertain. To summarize the evidence supporting the systemic treatment of Chinese patients with advanced HCC, we performed a systematic review using a literature search of PubMed, Embase, China National Knowledge Infrastructure, and the Chinese Scientific Journal Database between 1 January 2009 and 15 June 2021, and abstracts from ASCO 2020, ASCO GI 2021, ESMO 2020, and ESMO GI 2020. The inclusion criteria were: Chinese patients aged ≥18 years with advanced HCC; first- or second-line systemic therapy; an evaluation of the efficacy or safety outcomes; and a randomized controlled, non-randomized controlled, prospective, or retrospective design. Thirty reports were identified for the following therapies: the single-agent tyrosine kinase inhibitor (TKI; n = 10), single-agent programmed death-1 (PD-1) inhibitor (n = 4), chemotherapy (n = 5), PD-1/programmed death-ligand 1 (PD-L1) inhibitor plus TKI (n = 6), PD-1/PD-L1 inhibitor plus bevacizumab or biosimilar (n = 4), and PD-1/PD-L1 inhibitor plus chemotherapy (n = 1). The heterogeneity between the studies precluded statistical analysis and the data were summarized using tables. In the first-line setting, evidence supported the use of atezolizumab or sintilimab plus bevacizumab or a biosimilar. There remains insufficient evidence to determine the optimal approved TKI-based therapeutic option, and active controlled trials in the second-line setting were lacking.

Association between serum midkine levels and tumor size in Indonesian hepatocellular carcinoma patients: a cross-sectional study

Background: The incidence of liver cancer is increased worldwide with 75%–85% are diagnosed as hepatocellular carcinoma (HCC). Current practice has low sensitivity limitations to diagnose the early stages of HCC, thus urging the need for a biomarker with higher sensitivity to detect HCC, specifically in the early stage. This study aimed to determine the association between Midkine levels and progressiveness of hepatocellular carcinoma (HCC), according to tumor size, Barcelona Clinic Liver Cancer (BCLC), and presence of portal venous thrombosis.

Methods: This cross-sectional study involved 100 patients in Adam Malik General Hospital diagnosed with HCC, collected with a consecutive sampling method, whose diagnosis were confirmed by findings of hypervascular on arterial phase imaging and portal vein or delayed phase washout triple-phase CT Scan. Samples are later categorized according to Barcelona Clinic Liver Cancer (BCLC) stages, tumor size, and presence of portal venous thrombosis. Blood samples were drawn to measure serum Midkine using ELISA. Kruskal-Wallis and Mann-Whitney U tests were conducted to determine the difference of Midkine levels based on tumor size, BCLC staging, and presence of portal venous thrombosis.

Results: Serum Midkine level shows a significant difference over tumor size (p=0.014), no significant difference found compared to BCLC stages and presence of portal venous thrombosis.

Conclusion: Serum Midkine levels are associated with the tumor size of HCC, thus helping physicians determine treatment plans.

Hepatitis B Virus-Associated Hepatocellular Carcinoma

Hepatitis B virus (HBV) is DNA-based virus, member of the Hepadnaviridae family, which can cause liver disease and increased risk of hepatocellular carcinoma (HCC) in infected individuals, replicating within the hepatocytes and interacting with several cellular proteins. Chronic hepatitis B can progressively lead to liver cirrhosis, which is an independent risk factor for HCC. Complications as liver decompensation or HCC impact the survival of HBV patients and concurrent HDV infection worsens the disease. The available data provide evidence that HBV infection is associated with the risk of developing HCC with or without an underlying liver cirrhosis, due to various direct and indirect mechanisms promoting hepatocarcinogenesis. The molecular profile of HBV-HCC is extensively and continuously under study, and it is the result of altered molecular pathways, which modify the microenvironment and lead to DNA damage. HBV produces the protein HBx, which has a central role in the oncogenetic process. Furthermore, the molecular profile of HBV-HCC was recently discerned from that of HDV-HCC, despite the obligatory dependence of HDV on HBV. Proper management of the underlying HBV-related liver disease is fundamental, including HCC surveillance, viral suppression, and application of adequate predictive models. When HBV-HCC occurs, liver function and HCC characteristics guide the physician among treatment strategies but always considering the viral etiology in the treatment choice.

The clinical management of hepatocellular carcinoma worldwide: A concise review and comparison of current guidelines: 2022 update

Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second leading cause of cancer-related mortality worldwide. This review is an updated version that summarizes comprehensive guidelines published from January 2001 to January 2022 worldwide with a focus on the clinical management of HCC. The electronic databases MEDLINE, the Chinese SinoMed, and the Japanese CiNii were systematically searched. A total of 22 characteristic guidelines for HCC management were ultimately included, including 1 international guideline, 11 guidelines from Asia, 5 from Europe, 4 from the America, and 1 from Australia. If guidelines were published in multiple versions, the most recent update was included, and surveillance, diagnosis, and treatment were compared. The composition of and recommendations in current guidelines on HCC varied, so these guidelines were regrouped and diagnostic and treatment algorithms were summarized graphically to provide the latest information to clinicians. The diagnostic criteria were grouped into 2 categories: a "Size-based pathway" and a "Non-size-based pathway". The treatment criteria were summarized according to different treatment algorithms, and mainstream treatment options were reviewed. Findings from comparison of current guidelines might help target and concentrate efforts to improve the clinical management of HCC. However, further studies are needed to improve the management and outcomes of HCC. More straightforward or refined guidelines would help guide doctors to make better decisions in the treatment of HCC in the future.

Molecular and genetic markers in hepatocellular carcinoma: In silico analysis to clinical validation (current limitations and future promises)

Hepatocellular carcinoma (HCC) is the second cause of cancer-related mortality. The diagnosis of HCC depends mainly on α-fetoprotein, which is limited in its diagnostic and screening capabilities. There is an urgent need for a biomarker that detects early HCC to give the patients a chance for curative treatment. New targets of therapy could enhance survival and create future alternative curative methods. In silico analysis provides both; discovery of biomarkers, and understanding of the molecular pathways, to pave the way for treatment development. This review discusses the role of in silico analysis in the discovery of biomarkers, molecular pathways, and the role the author has contributed to this area of research. It also discusses future aspirations and current limitations. A literature review was conducted on the topic using various databases (PubMed, Science Direct, and Wiley Online Library), searching in various reviews, and editorials on the topic, with overviewing the author’s own published and unpublished work. This review discussed the steps of the validation process from in silico analysis to in vivo validation, to incorporation into clinical practice guidelines. In addition, reviewing the recent lines of research of bioinformatic studies related to HCC. In conclusion, the genetic, molecular and epigenetic markers discoveries are hot areas for HCC research. Bioinformatics will enhance our ability to accomplish this understanding in the near future. We face certain limitations that we need to overcome.

Lymphoepithelioma-like Hepatocellular Carcinoma: a Case Report and Review of Literature

We report a case of hepatic lymphoepithelioma-like carcinoma-hepatocellular carcinoma subtype (LEL-HCC) in a 41-year-old man with chronic hepatitis C virus (HCV) infection. The patient presented with abdominal pain and further assessment revealed a hypoechoic mass on ultrasonography. Serum alpha-fetoprotein (AFP) was 13·6 ng/dl. The patient was diagnosed as hepatocellular carcinoma based on the established triphasic computed tomography (TCT) diagnostic criteria and he underwent a surgical resection of the mass. Microscopic examination showed sheets and cords of malignant epithelial cells intermixed with heavy lymphoid infiltrate, with more than 100 tumor-infiltrating lymphocytes (TILs) per 10 high-power-field (HPF). Based on immunohistochemical studies, the malignant cells were positive for Hep Par 1 and glypican 3, focally positive for cytokeratin 7 (CK7), and negative for cytokeratin 20 (CK20). TILs were diffusely positive for cluster of differentiation 3 CD3 with an approximately equal CD4/CD8 ratio. The patient was recurrence free at 25 months after surgery, as evident by CT and serum alpha-fetoprotein level. LEL-HCC is a rare variant of HCC with a relatively better prognosis. Exploring the potential for immune modulator-based therapy in this subset of tumors is highly recommended.

Evolving Treatment of Advanced Hepatocellular Carcinoma in the Asia-Pacific Region: A Review and Multidisciplinary Expert Opinion

Simple Summary

For years, the systemic therapies sorafenib and lenvatinib have represented standard of care for first-line treatment of advanced hepatocellular carcinoma (HCC). The recent approval of atezolizumab in combination with bevacizumab heralded the arrival of immunotherapy for first-line treatment of advanced HCC, and the field is growing, with other combination immunotherapies under investigation. Focusing on the Asia–Pacific region, where drug availability and reimbursement systems differ widely, this article reviews the evolving treatment landscape and summarises the authors’ expert opinion on therapeutic decision-making to optimise outcomes in advanced HCC.

Abstract

Hepatocellular carcinoma (HCC) is the fourth most common driver of cancer-related death globally, with an estimated 72% of cases in Asia. For more than a decade, first-line systemic treatments for advanced or unresectable HCC were limited to the multi-targeted kinase inhibitors sorafenib and, more recently, lenvatinib. Now, treatment options have expanded to include immunotherapy, as exemplified by the immune checkpoint inhibitor (ICI) atezolizumab combined with the antiangiogenic agent bevacizumab. Additional combinations of ICIs with kinase inhibitors, other ICIs, or antiangiogenic agents are under investigation, further supporting the new era of immunotherapy for first-line treatment of advanced or unresectable HCC. We describe this evolving landscape and provide expert opinion on therapeutic best practices in the Asia–Pacific region, where different costs of, and patient access to, treatment are a challenge. With the combination of atezolizumab plus bevacizumab likely to become the clinical standard of care, optimising treatment sequence and ensuring patient access to newer therapies remain priorities. Cost containment and treatment sequencing may be facilitated by characterisation of predictive positive and negative biomarkers. With these considerations in mind, this review and expert opinion focused on advanced HCC in the Asia–Pacific region offers perspectives of multiple stakeholders, including physicians, payer systems, and patients.

The Evolving Role of Immune Checkpoint Inhibitors in Hepatocellular Carcinoma Treatment

Hepatocellular carcinoma (HCC) is one of most common cancers and the fourth leading cause of death worldwide. Commonly, HCC development occurs in a liver that is severely compromised by chronic injury or inflammation. Liver transplantation, hepatic resection, radiofrequency ablation (RFA), transcatheter arterial chemoembolization (TACE), and targeted therapies based on tyrosine protein kinase inhibitors are the most common treatments. The latter group have been used as the primary choice for a decade. However, tumor microenvironment in HCC is strongly immunosuppressive; thus, new treatment approaches for HCC remain necessary. The great expression of immune checkpoint molecules, such as programmed death-1 (PD-1), cytotoxic T-lymphocyte antigen 4 (CTLA-4), lymphocyte activating gene 3 protein (LAG-3), and mucin domain molecule 3 (TIM-3), on tumor and immune cells and the high levels of immunosuppressive cytokines induce T cell inhibition and represent one of the major mechanisms of HCC immune escape. Recently, immunotherapy based on the use of immune checkpoint inhibitors (ICIs), as single agents or in combination with kinase inhibitors, anti-angiogenic drugs, chemotherapeutic agents, and locoregional therapies, offers great promise in the treatment of HCC. This review summarizes the recent clinical studies, as well as ongoing and upcoming trials.

Optimizing Survival and the Changing Landscape of Targeted Therapy for Intermediate and Advanced Hepatocellular Carcinoma: A Systematic Review

BACKGROUND

Systemic therapy for hepatocellular carcinoma (HCC) consisting of the tyrosine kinase inhibitor sorafenib has remained unchanged for over a decade, although results from phase III targeted therapy trials have recently emerged. This review considers available phase III evidence on the use and sequencing of targeted therapy for intermediate and advanced non-locoregional therapy (LRT) eligible HCC and discusses implications for clinical practice.

METHODS

Published and presented literature on phase III data reporting on targeted therapy for advanced HCC that was not eligible for loco-regional therapies was identified using the key search terms "hepatocellular cancer" AND "advanced" AND "targeted therapy" AND "phase III" OR respective aliases (PRISMA).

RESULTS

Ten phase III trials assessed targeted therapy first-line and eight following sorafenib. In the first-line, atezolizumab plus bevacizumab statistically significantly improved overall survival (OS) and patient-reported outcomes (PROs) compared with sorafenib, while lenvatinib demonstrated non-inferior OS. Following progression on sorafenib, statistically significant OS improvements over placebo were seen for cabozantinib and regorafenib in unselected patients and for ramucirumab in those with baseline α-fetoprotein≥400 ng/mL. Based on improved OS and PROs, atezolizumab plus bevacizumab appears to be a preferred first-line treatment option for intermediate or advanced non-LRT eligible HCC. Phase III data informing sequencing of later lines of treatment is lacking. Therefore, sequencing principles are proposed that can be used to guide treatment selection.

CONCLUSIONS

Ongoing trials will continue to inform optimal therapy. Multiple targeted therapies have improved OS in intermediate or advanced non-LRT eligible HCC, although optimal sequencing is an area of ongoing investigation.

Characteristics and Prognosis of Hepatocellular Carcinoma in Multi-Transfused Patients with β-Thalassemia. Experience of a Single Tertiary Center

Background/Aim

The incidence of hepatocellular carcinoma (HCC) in patients with transfusion dependent thalassemia (TDT) has been increasing, where viral hepatitis and iron overload are the two established HCC risk factors. The aim of this study was to investigate the etiological factors of HCC development and to evaluate the possible factors associated with survival in our cohort of TDT patients with HCC.

Methods

Records of patients with TDT diagnosed with HCC from 2008 to 2018 were reviewed. Liver iron concentration (LIC) has been assessed by the signal-intensity-ratio MRI. The diagnosis of HCC was made by a 3-phase contrast magnetic resonance imaging (MRI) and patients were staged and treated for HCC according to Barcelona Clinic Liver Cancer (BCLC) grading system.

Results

Forty-two TDT patients with HCC have been included. Most of them (78.5%) were anti-HCV positive, 59.5% HCV-RNA positive, and 16.5% had serological markers of resolved HBV infection. Patients with HCV infection have been treated successfully with either Peg-IFNa±Ribavirin or with the new direct antivirals (DAAs). At the time of HCC diagnosis, all patients with chronic HCV infection were HCV-RNA negative, 78.5% had underlying cirrhosis, and the vast majority (98%) had average or mild elevated LIC values. According to the BCLC system, patients were classified as 0-A: 28.5%, B: 57% and C-D: 14.5%. HCC has been treated with loco-regional treatment in 78.5% of our patients, while the rest have received sorafenib. Twenty-eight patients (66.5%) died due to HCC with a median survival time of 6 months (range: 2-60). Using the Cox proportional hazard model, the only factors associated with poor survival were BCLC stages C and D.

Conclusions

In conclusion, BCLC staging is the main prognostic factor of survival in patients with TDT who develop HCC.

Image-guided chemistry altering biology: An in vivo study of thermoembolization

RATIONALE

Advances in image-guided drug delivery for liver cancer have shown a significant survival benefit. However, incomplete treatment is common and residual disease is often found in explanted liver specimens. In addition, the need to treat a malignancy from multiple mechanisms at the same time for optimal outcomes is becoming more widely appreciated. To address this, we hypothesized that an exothermic chemical reaction could be performed in situ. Such a strategy could in principle combine several angles of attack, including ischemia, hyperthermia, acidic protein denaturation, and metabolic modulation of the local environment.

METHODS

The University of Texas MD Anderson Cancer Center Institutional Animal Care and Use Committee approved this study. Outbred swine (25-35 kg, 5 control and 5 experimental) were treated under general anesthesia. Embolization was performed with coaxial microcatheter technique in a segmental hepatic arterial branch using either ethiodized oil as control or with thermoembolic solutionBlood samples were obtained before, immediately after, and the day following the procedure just before CT scans and euthanasia. Livers were explanted and samples were obtained for histologic analysis.

RESULTS

All animals survived the procedure and laboratory values of the control and experimental groups remained within normal limits. The control group had a diffuse or cloudy pattern of attenuation on follow-up CT scan the day after, consistent with gradual antegrade sinusoidal transit of the embolic material. The experimental group had clearly defined vascular casts with some degree of peripheral involvement. At histology, the control group samples had the appearance of normal liver, whereas the experimental group had coagulative necrosis in small pale, punctate areas extending several hundred microns away from the treated vessels and a brisk inflammatory response just outside the margins.

CONCLUSION

In situ chemistry via thermoembolization shows early promise as a fundamentally new tactic for image-guided therapy of solid tumors.

First In Vivo Test of Thermoembolization: Turning Tissue Against Itself Using Transcatheter Chemistry in a Porcine Model

PURPOSE

Embolotherapies are commonly used for management of primary liver cancer. Explant studies of treated livers, however, reveal an untreated tumor in a high fraction of cases. To improve on this, we propose a new concept referred to as thermoembolization. In this technique, the embolic material reacts in local tissues. Highly localized heat energy is released simultaneously with the generation of acid in the target vascular bed. Combined with ischemia, this should provide a multiplexed attack. We report herein our initial results testing the feasibility of this method in vivo.

MATERIALS AND METHODS

Institutional approval was obtained, and three outbred swine were treated in a segmental hepatic artery branch (right or left medial lobe) with thermoembolic material (100, 400, or 500 µL). Solutions (2 or 4 mol/L) of an acid chloride were made using ethiodized oil as the vehicle. Animals were housed overnight, scanned by CT, and euthanized. Necropsy samples of treated tissue were obtained for histologic analysis.

RESULTS

All animals survived the procedure. Vascular stasis occurred rapidly in all cases despite the small volumes used. The lower concentration (2 mol/L) penetrated more distally than the 4 mol/L solution. At CT the following day, vascular casts of ethiodized oil were observed, indicating recanalization had not occurred. Histology specimens demonstrated coagulative necrosis centered on the vessel lumen extending for several hundred microns with a peripheral inflammatory infiltrate.

CONCLUSIONS

Thermoembolization is a new technique for embolization with initial promise. However, results indicate much work must be done to optimize the technique.

The clinical management of hepatocellular carcinoma worldwide: A concise review and comparison of current guidelines from 2001 to 2017

Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second leading cause of cancer-related mortality worldwide. In this review, we made a review on current guidelines published from January 2001 to June 2017 worldwide with a focus on the clinical management of HCC. The electronic databases MEDLINE, the Chinese SinoMed, and the Japanese CiNii were systematically searched. A total of 18 characteristic guidelines for HCC management were finally included, including 8 guidelines from Asia, 5 from Europe, and 5 from the United States of America (USA). If guidelines were published in multiple versions, the most recent update was included, and surveillance, diagnosis, and treatment were compared. The composition of and recommendations in current guidelines on HCC varied, so these guidelines were regrouped and diagnostic and treatment algorithms were summarized graphically to provide the latest information to clinicians. The diagnostic criteria were grouped into 2 categories of a "Size-based pathway" and a "Non-size-based pathway." The treatment criteria were divided into 4 categories: i) Criteria based on the Barcelona Clinic Liver Cancer staging system; ii) Criteria based on the modified Union of International Cancer Control staging system; iii) Criteria based on the Child-Pugh class of liver function; and iv) Criteria based on tumor resectability. Findings from comparison of current guidelines might help target and concentrate efforts to improve the clinical management of HCC. However, further studies are needed to improve the management and outcomes of HCC. More straightforward or refined guidelines would help guide doctors to make better decisions in the treatment of HCC in the future.

Radioembolization in Advanced Hepatocellular Carcinoma

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 68-year-old man with a remote history of alcohol abuse presented with vague abdominal pain. A review of systems suggested the patient had an Eastern Cooperative Oncology Group performance status 1 (restriction of strenuous physical activity). There were no physical examination findings of note. Laboratory studies disclosed Child-Pugh A liver status (no ascites; no encephalopathy; total bilirubin, 1 mg/dL; albumin, 3.5 g/dL; and international normalized rato, 1.2). The alpha-fetoprotein was mildly elevated (19.5 ng/mL). Magnetic resonance imaging with contrast disclosed an infiltrative mass with extensive malignant right and left portal vein thrombosis ( Fig 1A ) with cavernous transformation of the portal vein. The infiltrative mass ( Fig 2A ) was biopsied, revealing hepatocellular carcinoma. No distant metastases were found on a bone scintigraphy or computerized tomography scan. Given these features, this patient was classified as Barcelona Clinic for Liver Cancer stage C. The patient was referred for management of advanced hepatocellular carcinoma.

Patients with advanced hepatocellular carcinoma need a personalized management: A lesson from clinical practice

The Barcelona Clinic Liver Cancer (BCLC) advanced stage (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population, where sorafenib alone is the recommended treatment. In this study, our aim was to assess treatment and overall survival (OS) of BCLC C patients subclassified according to clinical features (performance status [PS], macrovascular invasion [MVI], extrahepatic spread [EHS] or MVI + EHS) determining their allocation to this stage. From the Italian Liver Cancer database, we analyzed 835 consecutive BCLC C patients diagnosed between 2008 and 2014. Patients were subclassified as: PS1 alone (n = 385; 46.1%), PS2 alone (n = 146; 17.5%), MVI (n = 224; 26.8%), EHS (n = 51; 6.1%), and MVI + EHS (n = 29; 3.5%). MVI, EHS, and MVI + EHS patients had larger and multifocal/massive HCCs and higher alpha-fetoprotein (AFP) levels than PS1 and PS2 patients. Median OS significantly declined from PS1 (38.6 months) to PS2 (22.3 months), EHS (11.2 months), MVI (8.2 months), and MVI + EHS (3.1 months; P < 0.001). Among MVI patients, OS was longer in those with peripheral than with central (portal trunk) MVI (11.2 vs. 7.1 months; P = 0.005). The most frequent treatments were: curative approaches in PS1 (39.7%), supportive therapy in PS2 (41.8%), sorafenib in MVI (39.3%) and EHS (37.3%), and best supportive care in MVI + EHS patients (51.7%). Independent prognostic factors were: Model for End-stage Liver Disease score, Child-Pugh class, ascites, platelet count, albumin, tumor size, MVI, EHS, AFP levels, and treatment type.

CONCLUSION

BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. PS1 alone is not sufficient to include a patient into this stage. The remaining patients should be subclassified according to PS and tumor features, and new patient-tailored therapeutic indications are needed. (Hepatology 2018;67:1784-1796).

Adherence to Barcelona Clinic Liver Cancer guidelines in field practice: Results of Progetto Epatocarcinoma Campania

BACKGROUND AND AIM

The Barcelona Clinic Liver Cancer (BCLC) algorithm is the standard system for clinical management of hepatocellular carcinoma (HCC). Data on adherence to this therapeutic paradigm are scarce. This field practice study aimed to provide a description of HCC cirrhotic patients in Southern Italy, to evaluate the adherence to BCLC guidelines and its impact on patients' survival.

METHODS

We analyzed the region-wide Italian database of Progetto Epatocarcinoma Campania, which includes data of HCC cirrhotic patients, prospectively collected from January 2013 to December 2015 in 16 regional centers.

RESULTS

Overall, 1008 HCC patients were enrolled: 70.6% patients received therapies recommended by BCLC algorithm, while 29.4% underwent different treatments. Among patients who were treated in adherence to guidelines, a higher rate of diagnosis on surveillance programs, better liver function, lower rate of alpha-fetoprotein > 200 ng/mL, more early-stage and monofocal HCC, lower frequency of nodules > 5 cm, portal vein thrombosis and metastases were observed. The overall survival was evaluated according to HCC stage and no differences between groups and patients managed differently were found. The multivariate analysis showed that non-adherence to treatment guidelines was independently associated to the BCLC stage B, Child-Pugh classes B and C, and the presence of neoplastic thrombosis and metastases.

CONCLUSION

Adherence to BCLC algorithm in field practice was high in early and end-stage HCC patients, but it was poor in intermediate and advanced patients.

Adherence to Barcelona Clinic Liver Cancer therapeutic algorithm for hepatocellular carcinoma in the daily practice: a multicenter cohort study from Argentina

BACKGROUND AND AIM

Adherence to the Barcelona Clinic Liver Cancer (BCLC) staging algorithm for the treatment of hepatocellular carcinoma is challenging in the daily practice. We aimed to analyze adherence to BCLC along with its effect on patient survival.

PATIENTS AND METHODS

A cohort study was conducted in 14 hospitals from Argentina including patients with newly diagnosed hepatocellular carcinoma (2009-2016). Adherence was considered when the first treatment was the one recommended by the BCLC.

RESULTS

Overall, 708 patients were included. At diagnosis, BCLC stages were as follows: stage 0 4%, A 43%, B 22%, C 9% and D 22%. Overall, 53% of the patients were treated according to BCLC, 24% were undertreated, and 23% overtreated. Adherence to BCLC increased to 63% in subsequent treatments. Independent factors associated with adherence to BCLC were the presence of portal hypertension [odds ratio: 1.63; 95% confidence interval (CI): 1.11-2.39] and BCLC stage C (odds ratio: 0.32; 95% CI: 0.12-0.72). In a multivariable model adjusting for portal hypertension and BCLC stages, adherence to BCLC showed improved survival (hazard ratio: 0.67; 95% CI: 0.52-0.87).

CONCLUSION

Adherence to BCLC represents a challenge in the daily practice, with almost half of the patients being treated accordingly, showing that the decision-making process should be tailored to each individual patient.

Assessment of the discriminating value of the 8th AJCC stage grouping for hepatocellular carcinoma

BACKGROUND

This study seeks to validate the discriminating value of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for Hepatocellular carcinoma (HCC) amongst patients registered within the surveillance, epidemiology and end results (SEER) database.

METHODS

Through SEER*Stat program, SEER database (2010-2013) was queried and 8th AJCC stage groups were reconstructed. Overall and cancer-specific survival analyses according to both 7th and 8th editions were conducted through Kaplan-Meier analysis/log-rank testing and multivariate analysis was conducted through a Cox proportional model.

RESULTS

For overall and cancer-specific survival assessment according to the 8th edition, P values for pair wise comparisons among different stages were significant (<0.001) in all comparisons except for stage IB vs. II/stage IIIB vs. stage IVA. A modified AJCC 8th staging system was suggested through collapsing stages IB/II into one stage and stages IIIB/IVA into one stage. Overall and cancer-specific survivals were compared according to this modified system and pair wise P value was significant in all comparisons (P < 0.001).

CONCLUSION

There is a minimal improvement in discriminating value for the 8th edition compared to the 7th edition; however, notable overlap in outcomes is still observed between stages IB/II and IIIB/IVA. A modified AJCC 8th system collapsing these overlapping stages may be more clinically relevant.

Effect of smoking on survival of patients with hepatocellular carcinoma

BACKGROUND & AIMS

Lifestyle factors such as smoking, obesity and physical activity have gained interest in the field of hepatocellular carcinoma. These factors play a significant role in the development of hepatocellular carcinoma. Several studies revealed the impact of tobacco consumption on the development of hepatocellular carcinoma and its synergistic effects with viral etiologies (hepatitis B and C). The effects of smoking on survival in patients with a diagnosed hepatocellular carcinoma have not yet been investigated in a Western cohort where hepatitis C infection is a major risk factor.

METHODS

Using data from a prospective cohort of patients with hepatocellular carcinoma who were followed at the University Hospital of Bern, Switzerland, survival was compared by Kaplan-Meier analysis in smokers and nonsmokers, and multivariate Cox regression was applied to control for confounding variables.

RESULTS

Of 238 eligible hepatocellular carcinoma patients, 64 were smokers at the time of inclusion and 174 were nonsmokers. Smokers had a significant worse overall survival than nonsmokers (hazard ratio 1.77, 95% confidence interval: 1.22-2.58, P=.003). Analysis of patients according to their underlying liver disease, revealed that smoking, and not nonsmoking, affected survival of hepatitis B virus and C virus-infected patients only. In this subgroup, smoking was an independent predictor for survival (hazard ratio 2.99, 95% confidence interval: 1.7-5.23, P<.001) and remained independently predictive when adjusted for confounding variables.

CONCLUSIONS

This study shows that smoking is an independent predictor of survival in hepatitis B virus/hepatitis C virus-infected patients with hepatocellular carcinoma.

A new use for an old index: preoperative high-density lipoprotein predicts recurrence in patients with hepatocellular carcinoma after curative resections

Background

Hepatocellular carcinoma has high incidence and mortality worldwide. Liver is the site of most metabolic biotransformation, which could reflect the status of cells. Most plasma apolipoproteins, endogenous lipids and lipoproteins are synthesized in the liver. Therefore, the effects of lipid metabolites on prognosis of HCC deserved to be explored.

Methods

We prospectively included 58 healthy donors (HD), 50 chronic hepatitis (CH) patients and a training cohort of 189 patients with HCC who underwent curative resections at Zhongshan Hospital from January 2012 to August 2012. We identified the optimal HDL_PO cutoff value at 0.98 mmol/L and used it to stratify patients into low- or high-HDL_PO groups for the entire cohort and four low-recurrent-risk subgroups. We also included an independent validation group of 182 HCC patients to validate this cutoff value. Prognostic values of HDL_PO and other factors were determined by Kaplan–Meier curves and the Cox proportional hazards model.

Results

The low-HDL_PO group had a higher median tumor grade (P = 0.020) and a higher recurrence rate (P = 0.032). Results of multivariate analysis showed that preoperative γ-glutamyl transpeptidase (GGT) and HDL_PO were independent predictors of recurrence. Moreover, the predictive value of HDL_PO was retained in four low-recurrent-risk subgroups. As expected, clinicopathologic characteristics and predictive values were similar in the validation and training cohorts.

Conclusions

HDL_PO is an accessible predictor of HCC recurrence after liver resections that can help identify patients who need more careful monitoring and follow-up care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12944-017-0509-3) contains supplementary material, which is available to authorized users.

(90) Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes

BACKGROUND

The purpose of this study is to assess operative, post-operative, and long-term outcomes in patients who underwent radiation lobectomy (RL) for tumor control and/or hypertrophy of small future liver remnant (FLR) prior to resection.

METHODS

Right lobar +/- segment 4 radioembolization was performed prior to lobectomy/tri-segmentectomy in patients with hepatic tumor but inadequate FLR. Parenchymal/tumor volumes were calculated from pre/post-RL imaging; FLR/%FLR hypertrophy were determined. Complications were graded by the Clavien-Dindo classification.

RESULTS

Thirteen patients (HCC n = 10, cholangiocarcinoma n = 2, mCRC n = 1) underwent RL prior to resection. The median time between RL and post-RL imaging was 40 days (23-190 days); the median time to resection was 86 days (30-210 days). Median FLR increased significantly [pre: 33% (22-43%); post: 43% (29-69%), P < 0.01] to yield a median %FLR hypertrophy of 30% (4-105%). The median hospital stay after resection was 4 days (3-11 days). Transient hepatobiliary toxicities normalized post-operatively. Ninety-two percent of resected tumors had >50% pathologic necrosis. Median follow up time after surgery was 604 days (144-1,416 days); one death occurred.

CONCLUSIONS

In this preliminary study, radiation lobectomy was a safe and effective method to achieve remnant liver hypertrophy while providing tumor control. This approach may facilitate safe resection and favorable post-operative outcomes.J. Surg. Oncol. 2016;114:99-105. © 2016 Wiley Periodicals, Inc.