Prognostic factors after hepatic resection for hepatocellular carcinoma with hepatitis C viral infection: univariate and multivariate analysis

Infiltrative Vessel Co-optive Growth Pattern Induced by IQGAP3 Overexpression Promotes Microvascular Invasion in Hepatocellular Carcinoma

PURPOSE

Microvascular invasion (MVI) is a major unfavorable prognostic factor for intrahepatic metastasis and postoperative recurrence of hepatocellular carcinoma (HCC). However, the intervention and preoperative prediction for MVI remain clinical challenges due to the absent precise mechanism and molecular marker(s). Herein, we aimed to investigate the mechanisms underlying vascular invasion that can be applied to clinical intervention for MVI in HCC.

EXPERIMENTAL DESIGN

The histopathologic characteristics of clinical MVI+/HCC specimens were analyzed using multiplex immunofluorescence staining. The liver orthotopic xenograft mouse model and mechanistic experiments on human patient-derived HCC cell lines, including coculture modeling, RNA-sequencing, and proteomic analysis, were used to investigate MVI-related genes and mechanisms.

RESULTS

IQGAP3 overexpression was correlated significantly with MVI status and reduced survival in HCC. Upregulation of IQGAP3 promoted MVI+-HCC cells to adopt an infiltrative vessel co-optive growth pattern and accessed blood capillaries by inducing detachment of activated hepatic stellate cells (HSC) from the endothelium. Mechanically, IQGAP3 overexpression contributed to HCC vascular invasion via a dual mechanism, in which IQGAP3 induced HSC activation and disruption of the HSC-endothelial interaction via upregulation of multiple cytokines and enhanced the trans-endothelial migration of MVI+-HCC cells by remodeling the cytoskeleton by sustaining GTPase Rac1 activity. Importantly, systemic delivery of IQGAP3-targeting small-interfering RNA nanoparticles disrupted the infiltrative vessel co-optive growth pattern and reduced the MVI of HCC.

CONCLUSIONS

Our results revealed a plausible mechanism underlying IQGAP3-mediated microvascular invasion in HCC, and provided a potential target to develop therapeutic strategies to treat HCC with MVI.

Transcriptome analysis creates a new era of precision medicine for managing recurrent hepatocellular carcinoma

The high incidence of hepatocellular carcinoma (HCC) recurrence negatively impacts outcomes of patients treated with curative intent despite advances in surgical techniques and other locoregional liver-targeting therapies. Over the past few decades, the emergence of transcriptome analysis tools, including real-time quantitative reverse transcription PCR, microarrays, and RNA sequencing, has not only largely contributed to our knowledge about the pathogenesis of recurrent HCC but also led to the development of outcome prediction models based on differentially expressed gene signatures. In recent years, the single-cell RNA sequencing technique has revolutionized our ability to study the complicated crosstalk between cancer cells and the immune environment, which may benefit further investigations on the role of different immune cells in HCC recurrence and the identification of potential therapeutic targets. In the present article, we summarized the major findings yielded with these transcriptome methods within the framework of a causal model consisting of three domains: primary cancer cells; carcinogenic stimuli; and tumor microenvironment. We provided a comprehensive review of the insights that transcriptome analyses have provided into diagnostics, surveillance, and treatment of HCC recurrence.

Prognostic Value of CD8+ Lymphocytes in Hepatocellular Carcinoma and Perineoplastic Parenchyma Assessed by Interface Density Profiles in Liver Resection Samples

Hepatocellular carcinoma (HCC) often emerges in the setting of long-standing inflammatory liver disease. CD8 lymphocytes are involved in both the antitumoral response and hepatocyte damage in the remaining parenchyma. We investigated the dual role of CD8 lymphocytes by assessing density profiles at the interfaces of both HCC and perineoplastic liver parenchyma with surrounding stroma in whole-slide immunohistochemistry images of surgical resection samples. We applied a hexagonal grid-based digital image analysis method to sample the interface zones and compute the CD8 density profiles within them. The prognostic value of the indicators was explored in the context of clinicopathological, peripheral blood testing, and surgery data. Independent predictors of worse OS were a low standard deviation of CD8+ density along the tumor edge, high mean CD8+ density within the epithelial aspect of the perineoplastic liver-stroma interface, longer duration of surgery, a higher level of aspartate transaminase (AST), and a higher basophil count in the peripheral blood. A combined score, derived from these five independent predictors, enabled risk stratification of the patients into three prognostic categories with a 5-year OS probability of 76%, 40%, and 8%. Independent predictors of longer RFS were stage pT1, shorter duration of surgery, larger tumor size, wider tumor-free margin, and higher mean CD8+ density in the epithelial aspect of the tumor-stroma interface. We conclude that (1) our computational models reveal independent and opposite prognostic impacts of CD8+ cell densities at the interfaces of the malignant and non-malignant epithelium interfaces with the surrounding stroma; and (2) together with pathology, surgery, and laboratory data, comprehensive prognostic models can be constructed to predict patient outcomes after liver resection due to HCC.

Prognostic Implication of a Novel Metabolism-Related Gene Signature in Hepatocellular Carcinoma

Background

Hepatocellular carcinoma (HCC) is one of the main causes of cancer-associated deaths globally, accounts for 90% of primary liver cancers. However, further studies are needed to confirm the metabolism-related gene signature related to the prognosis of patients with HCC.

Methods

Using the “limma” R package and univariate Cox analysis, combined with LASSO regression analysis, a metabolism-related gene signature was established. The relationship between the gene signature and overall survival (OS) of HCC patients was analyzed. RT-qPCR was used to evaluate the expression of metabolism-related genes in clinical samples. GSEA and ssGSEA algorithms were used to evaluate differences in metabolism and immune status, respectively. Simultaneously, data downloaded from ICGC were used as an external verification set.

Results

From a total of 1,382 metabolism-related genes, a novel six-gene signature (G6PD, AKR1B15, HMMR, CSPG5, ELOVL3, FABP6) was constructed based on data from TCGA. Patients were divided into two risk groups based on risk scores calculated for these six genes. Survival analysis showed a significant correlation between high-risk patients and poor prognosis. ROC analysis demonstrated that the gene signature had good predictive capability, and the mRNA expression levels of the six genes were upregulated in HCC tissues than those in adjacent normal liver tissues. Independent prognosis analysis confirmed that the risk score and tumor grade were independent risk factors for HCC. Furthermore, a nomogram of the risk score combined with tumor stage was constructed. The calibration graph results demonstrated that the OS probability predicted by the nomogram had almost no deviation from the actual OS probability, especially for 3-year OS. Both the C-index and DCA curve indicated that the nomogram provides higher reliability than the tumor stage and risk scores. Moreover, the metabolic and immune infiltration statuses of the two risk groups were significantly different. In the high-risk group, the expression levels of immune checkpoints, TGF-β, and C-ECM genes, whose functions are related to immune escape and immunotherapy failure, were also upregulated.

Conclusions

In summary, we developed a novel metabolism-related gene signature to provide more powerful prognostic evaluation information with potential ability to predict the immunotherapy efficiency and guide early treatment for HCC.

Elevated serum alpha-fetoprotein levels are associated with poor prognosis of hepatocellular carcinoma after surgical resection: A systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

The relationship between the alpha-fetoprotein (AFP) level and the prognosis of hepatocellular carcinoma (HCC) after surgical resection remains unknown. This study aims to assess this relationship.

PATIENTS AND METHODS

PubMed and Web of Science were systematically utilised. Meta-analysis was conducted for the outcomes of the recurrence-free survival (RFS) and the overall survival (OS) by comparing the high AFP group with the low AFP group.

RESULTS

The studies included 61 manuscripts with 35,461 patients. The summary hazard ratio (HR) for RFS was 1.501 (95% CI 1.355-1.662; Z = 7.81, P < 0.00001) when comparing the high AFP group with the low AFP group. Sensitivity analysis only included adjusted HRs, with the summary HR being 1.563 (95% CI 1.381-1.768; Z = 7.10, P < 0.00001). The summary HR for OS was 1.565 (95% CI 1.439-1.701; Z = 10.52, P < 0.00001) when comparing two AFP groups. Sensitivity analysis showed that the summary HR was 1.611 (95% CI 1.456-1.782; Z = 9.24, P < 0.00001).

CONCLUSION

Our meta-analysis indicated that elevated serum AFP levels are associated with poor prognosis of HCC after surgical resection.

Development and validation of a CTNNB1-associated metabolic prognostic model for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a heterogeneous malignancy closely related to metabolic reprogramming. We investigated how CTNNB1 mutation regulates the HCC metabolic phenotype and thus affects the prognosis of HCC. We obtained the mRNA expression profiles and clinicopathological data from The Cancer Genome Atlas (TCGA), the International Cancer Genomics Consortium (ICGC) and the Gene Expression Omnibus database (GSE14520 and GSE116174). We conducted gene set enrichment analysis on HCC patients with and without mutant CTNNB1 through TCGA dataset. The Kaplan‐Meier analysis and univariate Cox regression analysis assisted in screening metabolic genes related to prognosis, and the prognosis model was constructed using the Lasso and multivariate Cox regression analysis. The prognostic model showed good prediction performance in both the training cohort (TCGA) and the validation cohorts (ICGC, GSE14520, GSE116174), and the high‐risk group presented obviously poorer overall survival compared with low‐risk group. Cox regression analysis indicated that the risk score can be used as an independent predictor for the overall survival of HCC. The immune infiltration in different risk groups was also evaluated in this study to explore underlying mechanisms. This study is also the first to describe an metabolic prognostic model associated with CTNNB1 mutations and could be implemented for determining the prognoses of individual patients in clinical practice.

The prognostic value of aspartate aminotransferase-to-lymphocyte ratio index in early-stage hepatocellular carcinoma after hepatectomy: A propensity-score matched analysis

BACKGROUND

An elevated preoperative aspartate aminotransferase-to-lymphocyte ratio index (ALRI) may predict poor survival in various cancers. However, the prognostic value of aminotransferase-to-lymphocyte ratio index (ALRI) in patients with hepatocellular carcinoma (HCC) remains to be determined.

MATERIALS AND METHODS

A retrospective cohort study was conducted among 983 patients with HCC in our hospital from February 2007 to March 2016. A propensity-score matching (PSM) was performed to correct the selection bias and confounding factors. The risk of death and recurrence was plotted over aminotransferase-to-lymphocyte ratio index (ALRI) using the locally weighted scatterplot smoothing (LOWESS)-smoothed fit curve. Time-dependent receiver operating characteristic (ROC) and Kaplan-Meier method analysis was utilized to the role of aminotransferase-to-lymphocyte ratio index (ALRI) in HCC. Multivariate analysis was conducted to identify independent prognostic factors associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

With the increase of aminotransferase-to-lymphocyte ratio index (ALRI), the risk of recurrence and death in HCC patients increases. In time-dependent ROC analysis, the AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year OS were 0.668 (95% CI: 0.596-0.740), 0.605 (95% CI: 0.560-0.649) and 0.613 (95% CI: 0.570-0.656), respective. The AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year RFS were 0.598 (95% CI: 0.555-0.641), 0.590 (95% CI: 0.552-0.628) and 0.604 (95% CI: 0.562-0.646), respectively. HCC patients with high aminotransferase-to-lymphocyte ratio index (ALRI) had a poor overall survival. Moreover, cox regression analysis revealed that aminotransferase-to-lymphocyte ratio index (ALRI) was an independent factor affecting the prognosis of HCC patients.

CONCLUSIONS

Elevated preoperative aminotransferase-to-lymphocyte ratio index (ALRI) is a noninvasive, simple, and effective predictor in the prognosis of patients with HCC.

Major Hepatectomy in Elderly Patients with Large Hepatocellular Carcinoma: A Multicenter Retrospective Observational Study

Background

With an increase in life expectancy and improvement of surgical safety, more elderly patients with hepatocellular carcinoma (HCC), even with large tumors, are now considered for hepatectomy. This study aimed to clarify the impact of age on short- and long-term outcomes after major hepatectomy (≥3 segments) for large HCC (≥5 cm).

Patients and Methods

Using a multicenter database, patients who underwent curative-intent major hepatectomy for large HCC between 2006 and 2016 were identified. Postoperative morbidity and mortality, overall survival (OS) and recurrence-free survival (RFS) were compared between the elderly (≥65 years) and younger (<65 years) patients. Univariable and multivariable Cox-regression analyses were performed to identify the risk factors of OS and RFS in the entire and elderly cohorts, respectively.

Results

Of 830 patients, 92 (11.1%) and 738 (88.9%) were elderly and younger patients, respectively. There were no significant differences in postoperative 30-day mortality and morbidity between the two groups (5.4% vs 2.6% and 43.5% vs 38.3%, both P>0.05). The 5-year OS and RFS rates in elderly patients were also comparable to younger patients (35.0% vs 33.2% and 20.0% vs 20.8%, both P>0.05). In the entire cohort, multivariable Cox-regression analyses identified that old age was not independently associated with OS and RFS. However, in the elderly cohort, preoperative alpha-fetoprotein level >400 μg/L, multiple tumors, macrovascular invasion and microvascular invasion were independently associated with decreased OS and RFS.

Conclusion

Carefully selected elderly patients benefited from major hepatectomy for large HCC as much as younger patients, and their long-term prognosis was determined by preoperative alpha-fetoprotein level, tumor number and presence of macro- or micro-vascular invasion.

A novel signature based on microvascular invasion predicts the recurrence of HCC

Background and objectives

In hepatocellular carcinoma (HCC) patients, microvascular invasion (MVI) is associated with worse outcomes regardless of treatment. No single reliable preoperative factor exists to predict MVI. The aim of the work described here was to develop a new MVI− based mRNA biomarker to differentiate between high and low risk patients.

Methods

Using The Cancer Genome Atlas (TCGA) database, we collected data from 315 HCC patients, including mRNA expression and complete clinical data. We generated a seven-mRNA signature to predict patient outcomes. The mRNA signature was validated using the GSE36376 cohort. Finally, we tested the formula in our own 53 HCC patients using qPCR for the seven mRNAs and analyzing the computed tomography (CT) features.

Results

This seven‐mRNA signature significantly correlated with length of recurrence-free survival (RFS) and overall survival (OS) for both the training and validation groups. RFS and OS were briefer in high risk versus low risk patients. A Kaplan–Meier analysis also indicated that survival time was significantly shortened in the high risk group versus the low risk group. Time-dependent receiver operating characteristic analysis demonstrated good predictive performance for the seven-mRNA signature. The mRNA signature also acts as an independent factor according to a Multivariate analysis. Our results are consistent with the seven-mRNA formula risk score.

Conclusion

Our research showed a novel seven-mRNA biomarker based on MVI predicting RFS and OS in HCC patients. This mRNA signature can stratify patients into subgroups based on their risk of recurrence to help guide individualized treatment and precision management in HCC.

Comprehensive analysis reveals a metabolic ten-gene signature in hepatocellular carcinoma

Background

Due to the complicated molecular and cellular heterogeneity in hepatocellular carcinoma (HCC), the morbidity and mortality still remains high level in the world. However, the number of novel metabolic biomarkers and prognostic models could be applied to predict the survival of HCC patients is still small. In this study, we constructed a metabolic gene signature by systematically analyzing the data from The Cancer Genome Atlas (TCGA), Gene Expression Omnibus (GEO) and International Cancer Genome Consortium (ICGC).

Methods

Differentially expressed genes (DEGs) between tumors and paired non-tumor samples of 50 patients from TCGA dataset were calculated for subsequent analysis. Univariate cox proportional hazard regression and LASSO analysis were performed to construct a gene signature. The Kaplan–Meier analysis, time-dependent receiver operating characteristic (ROC), Univariate and Multivariate Cox regression analysis, stratification analysis were used to assess the prognostic value of the gene signature. Furthermore, the reliability and validity were validated in four types of testing cohorts. Moreover, the diagnostic capability of the gene signature was investigated to further explore the clinical significance. Finally, Go enrichment analysis and Gene Set Enrichment Analysis (GSEA) have been performed to reveal the different biological processes and signaling pathways which were active in high risk or low risk group.

Results

Ten prognostic genes were identified and a gene signature were constructed to predict overall survival (OS). The gene signature has demonstrated an excellent ability for predicting survival prognosis. Univariate and Multivariate analysis revealed the gene signature was an independent prognostic factor. Furthermore, stratification analysis indicated the model was a clinically and statistically significant for all subgroups. Moreover, the gene signature demonstrated a high diagnostic capability in differentiating normal tissue and HCC. Finally, several significant biological processes and pathways have been identified to provide new insights into the development of HCC.

Conclusion

The study have identified ten metabolic prognostic genes and developed a prognostic gene signature to provide more powerful prognostic information and improve the survival prediction for HCC.

Identification of Crucial Genes Associated With Immune Cell Infiltration in Hepatocellular Carcinoma by Weighted Gene Co-expression Network Analysis

The dreadful prognosis of hepatocellular carcinoma (HCC) is primarily due to the low early diagnosis rate, rapid progression, and high recurrence rate. Valuable prognostic biomarkers are urgently needed for HCC. In this study, microarray data were downloaded from GSE14520, GSE22058, International Cancer Genome Consortium (ICGC), and The Cancer Genome Atlas (TCGA). Differentially expressed genes (DEGs) were identified among GSE14520, GSE22058, and ICGC databases. Weighted gene co-expression network analysis (WGCNA) was used to establish gene co-expression modules of DEGs, and genes of key modules were examined to identify hub genes using univariate Cox regression in the ICGC cohort. Expression levels and time-dependent receiver operating characteristic (ROC) and area under the curve (AUC) were determined to estimate the prognostic competence of the hub genes. These hub genes were also validated in the Gene Expression Profiling Interactive Analysis (GEPIA) and TCGA databases. TIMER algorithm and GSCALite database were applied to analyze the association of the hub genes with immunocytotic infiltration and their pathway enrichment. Altogether, 276 DEGs were identified and WGCNA described a unique and significantly DEGs-associated co-expression module containing 148 genes, with 10 hub genes selected by univariate Cox regression in the ICGC cohort (BIRC5, FOXM1, CENPA, KIF4A, DTYMK, PRC1, IGF2BP3, KIF2C, TRIP13, and TPX2). Most of the genes were validated in the GEPIA databases, except IGF2BP3. The results of multivariate Cox regression analysis indicated that the abovementioned hub genes are all independent predictors of HCC. The 10 genes were also confirmed to be associated with immune cell infiltration using the TIMER algorithm. Moreover, four-gene signature was developed, including BIRC5, CENPA, FOXM1, DTYMK. These hub genes and the model demonstrated a strong prognostic capability and are likely to be a therapeutic target for HCC. Moreover, the association of these genes with immune cell infiltration improves our understanding of the occurrence and development of HCC.

Daily decrease of post-operative alpha-fetoprotein by 9% discriminates prognosis of HCC: A multicenter retrospective study. Aging (Albany NY). 2019;11:11111-11123. [PMID: 31829979 PMCID: PMC6932889 DOI: 10.18632/aging.102513]

Background: Mixed evidence challenges preoperative alpha-fetoprotein (AFP) as an independent prognostic factor for patients with hepatocellular carcinoma (HCC) after hepatectomy.

Results: Daily post-operative decrease of AFP by 9% as compared to the preoperative level (A09) were selected as the Cut-off. The Kaplan-Meier curve showed that A09 was significantly different for OS (P=0.043) and RFS (P=0.03). A decrease in risk by 54% was observed for OS and 32% for RFS in the at-risk population (A09>9%). A better concordance was observed after adding A09 into TNM and BCLC staging systems. Moreover, a consistent concordance was observed in the internal (FDZS5:0.63; FDZS3:0.608) and external (FDZS5:0.85; FDZS3:0.762) validation cohorts, suggesting its prognostic value in HCC population with elevated AFP.

Conclusions: Decrease in perioperative serum AFP rather than preoperative AFP is an independent prognostic factor for HCC patients after hepatectomy. Cut-off A09 significantly discriminates overall and recurrence-free survival and could be interpret into TNM and BCLC staging systems to improve the stratification power for HCC patients with elevated AFP.

Methods: Kaplan-Meier curve depicted the differences of overall survival (OS) and recurrence-free survival (RFS). Nomogram and concordance were employed to evaluate the superiority of the current staging system.

Predictors of 5 year survival rate in hepatocellular carcinoma patients

Background

Hepatocellular carcinoma (HCC) is one of the most common primary hepatic malignancies and growing challenges of global health. In this study, for the first time in Iran, we investigated the 5-year survival rate and prognostic factors in patients with HCC.

Materials and Methods

In this historical cohort study, we examined the medical records of 227 HCC patients who were registered in the central tumor registry of our institution from September 2007 to September 2017. Demographic data, clinical parameters, received treatments, and survival curves from time of diagnosis were evaluated. Kaplan-Meier was used for univariate analysis, and multivariable analysis was performed by Cox regression.

Results

A total of 208 (91.63%) patients were dead. The 5-year survival rate was estimated 19 (8.37%). The average follow-up in this study was 14.3 months. Overall median survival rate was 12.1 months. Univariate analysis showed that tumor size, metastasis, number of involved lymph node, hepatitis type, and treatment were significantly related to the survival rate, and Cox regression analysis revealed that the tumor size >3 cm (hazard ratio [HR] = 3.06, 95% confidence interval [CI] = 1.68-4.97; P = 0.027), involved lymph nodes >2 (HR = 4.12, 95% CI = 2.66-6.38; P = 0.001), metastasis (HR = 3.87, 95% CI = 3.13-6.54; P = 0.011), combination therapy with surgery and chemotherapy (HR = 0.4, 95% CI = 0.15-0.79; P = 0.023), and coinfection with hepatitis B virus and hepatitis C virus (HR = 2.11, 95% CI = 1.81-4.6; P = 0.036) are the most relevant prognostic factors with 5-year survival rate in patients with HCC.

Conclusion

Results of this study will help estimate survival rates for patients with HCC according to their clinical status.

Clinicopathological Distinction of Low-AFP-Secreting vs. High-AFP-Secreting Hepatocellular Carcinomas

Ilntroduction and aims. We aimed to investigate the clinical and pathological differences between low-AFP-secreting (AFP < 20 ng/mL) and high-AFP-secreting (AFP ≥ 20 ng/mL) hepatocellular carcinomas in patients who undergo liver transplant (LT).

MATERIAL AND METHODS

We evaluated 145 patients who underwent deceased donor LT for HCC from January 1, 2005 until August 1, 2015 at the Johns Hopkins Hospital.

RESULTS

Median pre-LT AFP in the entire cohort was 13 ng/mL (IQR 6-59). Using serum AFP cutoff of 20 ng/mL, 61 (42%) patients had high-AFP-secreting tumors and 84 (58%) had low-AFP-secreting tumors. Patients with high-AFP-secreting tumors had larger lesions (3 cm vs. 2.4 cm, p = 0.024), and were more likely to have microvascular-invasion (36.1% vs. 20.2%, p = 0.02) and poor-differentiation (18% vs. 4.8%, p = 0.01), and tumor recurrence following LT (28% vs. 6%, p < 0.001). The 1-year, 3-year, and 5-year recurrence-free survival for patients in the low-AFP-secreting group compared to the high-AFP-secreting group were 100%, 92%, 92% vs. 81.3%, 71.3%, 68.5% respectively (p = 0.0003).

CONCLUSION

AFP is a suboptimal predictor of tumor recurrence following liver transplant in HCC patients. However, it can have some value in distinguishing more aggressive forms of HCC (high-AFP-secreting) that are associated with higher tumor recurrence. Novel tumor biomarkers are needed that can enhance predicting tumor recurrence following LT based on tumor biology.

Can Hepatocellular Carcinoma (HCC) Produce Unconventional Metastases? Four Cases of Extrahepatic HCC

Aims and background

Extrahepatic spread of hepatocellular carcinoma (HCC) diagnosed during the clinical course of the disease is not frequent; however, with the prolonged survival of HCC patients, the incidence of extrahepatic metastases seems to be increasing.

Methods and study design

We present four unusual cases of extrahepatic metastasis from HCC: the first concerns a patient who underwent a liver transplantation for HCC with cirrhosis and three years later developed metastases in the lung and the left orbit; the second is that of a patient who developed an extraperitoneal pararectal metastasis; in the third case a large osteolytic lesion developed on the left iliac bone, and in the fourth case we found an isolated metastasis in the left mandible.

Results and conclusions

These cases offer important information related to the unusual biology of isolated metastases from HCC after successful treatment of the primary cancer.

Current state and clinical outcome in Turkish patients with hepatocellular carcinoma

AIM

To investigate clinical, etiological, and prognostic features in patients with hepatocellular carcinoma.

METHODS

Patients with hepatocellular carcinoma who were followed-up from 2001 to 2011 were included in the study. The diagnosis was established by histopathological and/or radiological criteria. We retrospectively reviewed clinical and laboratory data, etiology of primary liver disease, imaging characteristics and treatments. Child-Pugh and Barcelona Clinic Liver Cancer stage was determined at initial diagnosis. Kaplan-Meier survival analysis was done to find out treatment effect on survival. Risk factors for vascular invasion and overall survival were investigated by multivariate Cox regression analyses.

RESULTS

Five hundred and forty-five patients with hepatocellular carcinoma were included in the study. Viral hepatitis was prevalent and 68 patients either had normal liver or were non-cirrhotic. Overall median survival was 16 (13-19) mo. Presence of extrahepatic metastasis was associated with larger tumor size (OR = 3.19, 95%CI: 1.14-10.6). Independent predictor variables of vascular invasion were AFP (OR = 2.95, 95%CI: 1.38-6.31), total tumor diameter (OR = 3.14, 95%CI: 1.01-9.77), and hepatitis B infection (OR = 5.37, 95%CI: 1.23-23.39). Liver functional reserve, tumor size/extension, AFP level and primary treatment modality were independent predictors of overall survival. Transarterial chemoembolization (HR = 0.38, 95%CI: 0.28-0.51) and radioembolization (HR = 0.36, 95%CI: 0.18-0.74) provided a comparable survival benefit in the real life setting. Surgical treatments as resection and transplantation were found to be associated with the best survival compared with loco-regional treatments (log-rank, P < 0.001).

CONCLUSION

Baseline liver function, oncologic features including AFP level and primary treatment modality determines overall survival in patients with hepatocellular carcinoma.

Development and Validation of a Three-gene Prognostic Signature for Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the leading cause of cancer-related death worldwide, because recurrence often occurs in most HCC patients undergoing hepatectomy. It is necessary to identify patients with high risk for recurrence and adopt effective therapies. An obstacle to monitor patients at high risk for poor prognosis has been the lack of useful predictive biomarkers. Fortunately, recent progress in system biology allows to screen the biomarkers for HCC prognosis in a high-throughput manner. In this study, we performed systematic Kaplan-Meier survival analysis of the whole mRNA transcriptomics based on the Cancer Genome Atlas project (TCGA) and developed a three-gene prognostic signature composing of three genes UPB1, SOCS2 and RTN3. The model was validated in two independent microarray data sets retrieved from Gene Expression Omnibus (GEO) and the expression pattern of these three predictive genes in HCC was confirmed by western blot and immunohistochemistry with our HCC samples. In conclusion, our results showed that this three-gene signature has prognostic value for HCC patients.

Survival analysis after liver resection for hepatocellular carcinoma: A consecutive cohort of 1002 patients

BACKGROUND AND AIM

The improvements in surgical technique and perioperative management in the recent decades may warrant revisit for survival outcomes and prognostic factors after liver resection for hepatocellular carcinoma (HCC). This study aimed to analyze the survival outcomes after liver resection for HCC for a consecutive cohort of 1002 patients.

METHODS

This study was performed by analyzing the clinicopathological and follow-up data of 1002 consecutive patients who underwent liver resection for HCC from April 2001 to December 2013. Prognostic factors were investigated by univariate and multivariate analysis, using the Cox's proportional hazards model.

RESULTS

The overall incidence of postoperative complications was 16.1% (n = 161), with an in-hospital mortality rate of 0.3% (n = 3). The rates of 1-, 3-, and 5-year overall survival were 91.9%, 78.9%, and 69.5%, while the rates of 1-, 3-, and 5-year recurrence-free survival were 71.7%, 51.7%, and 43.7%, respectively. Multivariate analysis showed that patient age, platelet count, intraoperative estimated blood loss (EBL), tumor number, Edmond-Steiner grade, microvascular invasion, major vessel invasion, and intrahepatic metastasis were independent significant prognostic factors affecting the overall survival. Platelet count, intraoperative EBL, maximal tumor size, major vessel invasion, capsule formation, intrahepatic metastasis, cirrhosis, and the pathological stage were independent prognostic factors for recurrence-free survival.

CONCLUSIONS

Survival of patients with HCC after resection should be stratified by various perioperative clinicopathological factors. Platelet count and intraoperative EBL could be considered as one of the powerful predictors of the prognosis and recurrence of HCC in such patients.

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

BACKGROUND

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

METHODS

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

RESULTS

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p = 0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p = 0.115).

CONCLUSION

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

Prognostic significance of AKR1B10 gene expression in hepatocellular carcinoma and surrounding non-tumorous liver tissue

When assessing outcome in hepatocellular carcinoma (HCC), it is important to consider prognostic factors in background non-tumorous liver tissue as well as in the tumor, since multiple occurrence is associated with background liver status such as hepatitis. The current study aimed to elucidate molecular prognostic predictors that have an association with HCC background non-tumorous tissue. Microarray expression profiling identified aldo-keto reductase family 1, member B10 (AKR1B10) as a putative non-tumorous prognostic factor, and AKR1B10 gene expression was investigated in 158 curatively resected HCC cases by reverse transcription-quantitative polymerase chain reaction. AKR1B10 expression (AKR1B10 value/GAPDH value × 1,000) was significantly higher in tumor tissue (median, 9.2200; range, 0.0003-611.0200; n=158) than in the corresponding non-tumorous tissue (median, 0.5461; range, 0.0018-69.0300; n=158) (P<0.001). When the samples were grouped according to AKR1B10 expression in tumor tissue relative to non-tumorous tissue, tumor<non-tumorous expression (n=26) significantly correlated with poor recurrence-free survival (P=0.0074) and overall survival (OS) (P<0.0001), and was an independent prognostic factor for OS (P=0.0011) in a multivariate analysis. The ratio of AKR1B10 messenger RNA levels in HCC and corresponding non-tumorous tissues may predict prognosis after curative hepatectomy, with low expression in HCC tissue relative to non-tumorous tissue indicative of poor prognosis.

A pre-operative clinical model to predict microvascular invasion and long-term outcome after resection of hepatocellular cancer: The Australian experience

BACKGROUND

Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI).

METHODS

Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified.

RESULTS

The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI.

CONCLUSION

MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

Blood loss and outcomes after resection of colorectal liver metastases

BACKGROUND

The influence of intraoperative blood loss (IBL) on long-term outcomes of patients undergoing liver resection for colorectal cancer liver metastases (CRLM) remains not well defined.

MATERIALS AND METHODS

A total of 433 patients who underwent curative-intent hepatic resection for CRLM between 2000 and 2013 at Johns Hopkins were identified. Demographics, IBL data, and long-term outcomes were collected and analyzed. Clinicopathologic predictors of IBL and the association of IBL and outcomes were assessed.

RESULTS

The median patient age was 54 y (interquartile range, 44-64), most patients were male (58.9%; n = 255). At surgery, the median IBL was 400 mL (range, 10-5100 mL). Two-hundred eighty-seven patients (66.3%) had an IBL of >250 mL. Factors associated with increased IBL (>250 mL) on multivariate analysis were male sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.68-4.09; P < 0.001), tumor size >3 cm (OR, 1.88; 95% CI, 1.18-2.99; P = 0.008), and major hepatic resection (OR, 3.08; 95% CI, 1.92-4.92; P < 0.001). At a median follow-up time of 30.6 mo, the median survival times were 70.5, 56.4, and 36.9 mo for IBL <250, 250-1000, and >1000 mL, respectively (P = 0.004). IBL >250 mL remained an independent prognostic factor of overall survival in multivariate analysis (hazard ratio, 1.41; 95% CI, 1.01-1.97; P = 0.04) after adjusting for other factors including the receipt of blood transfusion.

CONCLUSIONS

The magnitude of IBL during CRLM resection was related to biologic characteristics of the tumor and the extent of surgery. Increased IBL during CRLM resection was an independent prognostic factor for worse patient survival. Furthermore, a dose-response relationship between increasing IBL and worsening survival was evident.

Multiplication of alpha-fetoprotein and protein induced by vitamin K absence-II is a powerful predictor of prognosis and recurrence in hepatocellular carcinoma patients after a hepatectomy

AIM

To evaluate the oncological implications of multiplication of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonists-II (PIVKA-II) in patients with hepatocellular carcinoma (HCC).

METHODS

Data were prospectively collected from 516 consecutive patients who underwent a curative primary hepatectomy for HCC between 1998 and 2010. The AP-factor (AFP × PIVKA-II) was evaluated in relation to 2-year survival outcomes by receiver-operator curve analysis to determine the cut-off values. Patient survival, recurrence-free survival and risk factors were analyzed in accordance with the preoperative AP-factor.

RESULTS

The AP-factor was categorized into three groups depending on the serum concentrations of AFP and PIVKA-II as follows: AP1 (n = 206; AFP < 200 ng/mL and PIVKA-II < 100 mAU/mL), AP2 (n = 152; AFP × PIVKA-II < 10(5) ) and AP3 (n = 158; AFP × PIVKA-II ≥ 10(5) ). The AP-factor was found to be significantly related to pathological factors such as differentiation, portal vein invasion, hepatic vein invasion and intrahepatic metastasis. Multivariate analysis was performed to identify the risk factors for survival and recurrence. Albumin, AP-factor and pathological factors including portal vein invasion, hepatic vein invasion and intrahepatic metastasis are independent risk factors for survival. Tumor number, AP-factor, and a non-cancerous liver were determinants of recurrence.

CONCLUSION

The AP-factor is closely related to differentiation and microscopic vascular invasion, and was selected by multivariate analysis as an independent factor for survival and recurrence, in HCC. Patients hopeful of obtaining good outcomes after a hepatectomy could be selected by the AP-factor evaluation.

Clinicopathological characteristics of hepatitis B surface antigen-negative and hepatitis C antibody-negative hepatocellular carcinoma

The present study investigated the clinicopathological characteristics of resected hepatitis B virus surface antigen (HBs-Ag)-negative, hepatitis C virus antibody (HCV-Ab)-negative hepatocellular carcinoma (NBNC HCC). The clinicopathological characteristics of 164 patients with NBNC HCC, 144 patients with HBs-Ag-positive HCC (HBV group) and 550 patients with HCV-Ab-positive HCC (HCV group) were compared. In the NBCN HCC group, 61 patients succumbed after 2 years. Subsequently, NBCN HCC patients were compared according to survival time (<2 years, 39 patients vs. ≥2 years, 64 patients) to identify prognostic factors. Finally, the clinicopathological characteristics of NBNC HCC were compared according to history of alcohol abuse/pathological results: Non-alcoholic steatohepatitis HCC (NASH group, 40 patients), alcohol abuse HCC (AL group, 80 patients) and other HCCs (non-NASH/non-AL group, 44 patients). Age, diabetes prevalence and body mass index were significantly higher for NBNC HCC compared with virus-related HCC. Among stage II cases, the prognosis was significantly better for the NBNC compared with that for the HCV group. A high α-fetoprotein level, poorly differentiated HCC and advanced liver fibrosis were independent risk factors for the prognosis of NBNC HCC. The proportion of female patients was significantly higher among NASH compared with AL HCC patients. The cumulative survival rates following surgery were similar in the NASH, AL and non-NASH/non-AL groups. NBNC HCC is considered to be a lifestyle disease, with better prognosis for stage II patients. The prognostic factors for NBNC HCC patients undergoing hepatectomy were similar to those with virus-related HCC and did not differ according to alcohol abuse history or pathological results.

Serosal invasion strongly associated with recurrence after curative hepatic resection of hepatocellular carcinoma: a retrospective study of 214 consecutive cases

The purpose of this study was to clarify the individual prognostic factors after curative and primary resection of hepatocellular carcinoma (HCC).Reliable prognostic factors and tumor staging for HCC have been required to predict an appropriate prognosis. However, in HCC, no staging system has received universal acceptance, and several tumor factors seem to relate to HCC prognosis, but they are not definitive. At present, few studies have mentioned the importance of serosal invasion as a prognostic factor.A retrospective search of our database identified 214 consecutive patients who underwent primary and curative hepatectomy for HCC at our department between January 1998 and December 2011. Risk factors for recurrence-free survival (RFS) and overall survival (OS) were analyzed with Cox proportional hazard model, Kaplan-Meier method, and log-rank tests.Multivariate analyses showed that serosal invasion (hazard ratio [HR], 2.75; P = 0.0005) and vascular invasion (HR, 1.71; P = 0.0331) were independently correlated with RFS. Serosal invasion was significantly correlated with HCC recurrence (P = 0.0230). The Kaplan-Meier method and log-rank tests revealed that the patients with serosal invasion showed significantly worse prognosis both in RFS (P < 0.0001) and OS (P = 0.0016).Serosal invasion should be regarded as a strong independent predictor for recurrence in curatively resected HCC cases.

Triple positive tumor markers predict recurrence and survival in early stage hepatocellular carcinoma

AIM

Hepatectomy is feasible for patients with hepatocellular carcinoma (HCC) with good hepatic function who meet the Milan criteria. Several studies have indicated that tumor markers of HCC, α-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP percentage and protein induced by vitamin K absence/antagonist-II were good predictors of malignant potential. It is important to identify highly malignant cases of HCC, and the aim of this study was to clarify the impact of triple positive tumor markers as the prognostic factors for early stage HCC within the Milan criteria.

METHODS

This study investigated 199 patients who underwent hepatectomy for HCC within the Milan criteria between January 2001 and May 2009. Cumulative recurrence-free survival (RFS), overall survival (OS) and clinicopathological parameters were analyzed according to the number of positive tumor markers.

RESULTS

In patients with triple positive tumor markers, 5-year RFS and OS was poor (17.1 and 61.4%, respectively). Multivariate analyses revealed independent risk factors for recurrence to be hepatitis C virus antibody positivity, non-initial treatment for HCC and triple positive tumor markers, and the independent risk factors for OS were high indocyanine green retention rate at 15 min value, maximum tumor size and triple positive tumor markers. Pathologically invasive growth, microvascular invasion and moderate to poor differentiation were significantly related to the number of the three tumor markers.

CONCLUSION

Triple positive tumor markers for early stage HCC within the Milan criteria showed poor prognosis and malignant characteristics. These markers could be a useful predictor for the degree of malignant potential in early stage HCC.

N-myc downstream-regulated gene 1: Diverse and complicated functions in human hepatocellular carcinoma (Review)

N-myc downstream-regulated gene 1 (NDRG1) has been reported to be a multifunctional protein associated with carcinogenesis and tumor progression. However, the cellular function of NDRG1 remains elusive in human hepatocellular carcinoma (HCC). No NDRG1 expression is observed in normal liver tissue. Overexpression of NDRG1 has been observed in human HCC, particularly with aggressive invasion, metastasis, poor differentiation and short patient survival. In addition, recent studies have shown that NDRG1 exhibits an inhibitory effect on HCC growth in vitro and in vivo, which contrasts with previous reports indicating that NDRG1 promotes the proliferation and invasion of HCC cell lines. Further studies have shown that the localization of NDRG1 is variable, translocating to the nucleus or membrane according to the cell state, which may relate to the diverse function of NDRG1. The present study reviews our current knowledge with regard to the functions of NDRG1 in HCC and other types of human cancer.

Identification of novel serum biomarkers of hepatocellular carcinoma using glycomic analysis

The altered N-glycosylation of glycoproteins has been suggested to play an important role in the behavior of malignant cells. Using glycomics technology, we attempted to determine the specific and detailed N-glycan profile for hepatocellular carcinoma (HCC) and investigate the prognostic capabilities. From 1999 to 2011, 369 patients underwent primary curative hepatectomy in our facility and were followed up for a median of 60.7 months. As normal controls, 26 living Japanese related liver transplantation donors were selected not infected by hepatitis B and C virus. Their mean age was 40.0 and 15 (57.7%) were male. We used a glycoblotting method to purify N-glycans from preoperative blood samples from this cohort (10 μL serum) which were then identified and quantified using mass spectrometry (MS). Correlations between the N-glycan levels and the clinicopathologic characteristics and outcomes for these patients were evaluated. Our analysis of the relative areas of all the sugar peaks identified by MS, totaling 67 N-glycans, revealed that a proportion had higher relative areas in the HCC cases compared with the normal controls. Fourteen of these molecules had an area under the curve of greater than 0.80. Analysis of the correlation between these 14 N-glycans and surgical outcomes by univariate and multivariate analysis identified G2890 (m/z value, 2890.052) as a significant recurrence factor and G3560 (m/z value, 3560.295) as a significant prognostic factor. G2890 and G3560 were found to be strongly correlated with tumor number, size, and vascular invasion.

CONCLUSION

Quantitative glycoblotting based on whole serum N-glycan profiling is an effective approach to screening for new biomarkers. The G2890 and G3560 N-glycans determined by tumor glycomics appear to be promising biomarkers for malignant behavior in HCCs. (HEPATOLOGY 2013;).

Analysis of the risk factors for early death due to disease recurrence or progression within 1 year after hepatectomy in patients with hepatocellular carcinoma

Background

Liver resection for hepatocellular carcinoma (HCC) has the highest local controllability among all local treatments and results in a good survival rate. However, the recurrence rates of HCC continue to remain high even after curative hepatectomy Moreover, it has been reported that some patients with HCC have an early death due to recurrence. We analyzed the preoperative risk factors for early cancer death.

Methods

Between 1997 and 2009, 521 consecutive patients who underwent hepatectomy for HCC at our center were assigned to group ED (death due to HCC recurrence or progression within 1 year after hepatectomy) and group NED (alive over 1 year after hepatectomy). Risk factors for early cancer death were analyzed.

Results

Group ED included 48 patients, and group NED included 473 patients. The cause of death included cancer progression (150; 78.1%), operation-related (1; 0.5%), hepatic failure (15; 7.8%), and other (26; 13.5%). Between the ED and NED groups, there were significant differences in albumin levels, Child-Pugh classifications, anatomical resections, curability, tumor numbers, tumor sizes, macroscopic vascular invasion (portal vein and hepatic vein), alpha-fetoprotein (AFP) levels, AFP-L3 levels, protein induced by vitamin K absence or antagonism factor II (PIVKA-II) levels, differentiation, microscopic portal vein invasion, microscopic hepatic vein invasion, and distant metastasis by univariate analysis. Multivariate analysis identified specific risk factors, such as AFP level > 1,000 ng/ml, tumor number ≥ 4, tumor size ≥ 5 cm, poor differentiation, and portal vein invasion. With respect to the preoperative risk factors such as AFP level, tumor number, and tumor size, 3 (1.1%) of 280 patients with no risk factors, 12 (7.8%) of 153 patients with 1 risk factor, 24 (32.9%) of 73 patients with 2 factors, and 9 (60.0%) of 15 patients with 3 risk factors died within 1 year of hepatectomy (p < 0.0001).

Conclusions

Hepatectomy should be judiciously selected for patients with AFP level > 1,000 ng/ml, tumor number ≥ 4, and tumor size ≥ 5 cm, because patients with these preoperative risk factors tend to die within 1 year after hepatectomy; these patients might be better treated with other therapy.

Significance of HBV cccDNA and clinical factors in evaluating prognosis of hepatocelluar carcinoma following surgical resection

AIM: To investigate the correlation of HBV cccDNA and clinical factors with the survival of patients with hepatocellular carcinoma (HCC) after hepatectomy.

METHODS: A retrospective analysis was carried out in 60 HCC patients who underwent radical operation from 2003 to 2006 at our hospital. Serum HBV DNA and covalently closed circular DNA (cccDNA) levels were detected by real-time PCR. In 55 patients with complete follow-up data, serum HBV DNA, cccDNA in liver tissue and clinical characteristics were retrospectively analyzed. The overall survival and recurrence-free survival (RFS) were calculated using the Kaplan-Meier method. All the data were analyzed using Log-rank test and Cox regression model.

RESULTS: HBV cccDNA was positive in only one serum sample (1/35) and in 20% (11/55) of tumor tissues. There was a significant correlation between intrahepatic cccDNA in tumor tissue and total HBV DNA in serum (r = 0.364, P = 0.006). The 1-, 3-, 5-year overall survival and RFS rates for 55 patients after HCC resection were 73%, 51% and 38%, and 63%, 29% and 19%, respectively. The independent prognostic factor influencing RFS was the level of intrahepatic cccDNA in tumor tissue. The independent prognostic factors influencing overall survival were tumor numbers and vessel invasion.

CONCLUSION: HCC patients with solitary tumor and without vessel invasion showed a higher overall survival. HCC patients with an intrahepatic HBV cccDNA level of less than 1 000 copies/μg had a higher RFS.

Duration of hepatic vascular inflow clamping and survival after liver resection for hepatocellular carcinoma

BACKGROUND

The aim of this study was to evaluate the influence of the duration of hepatic vascular inflow clamping (Pringle time) on the survival of patients with any type of liver background (not only cirrhosis) undergoing liver resection for hepatocellular carcinoma (HCC).

METHODS

Patients who underwent liver resection between April 2000 and December 2008 for HCC using the Pringle manoeuvre were identified retrospectively from an institutional database and divided into two groups: group 1 had a Pringle time of 60 min or less, and group 2 a Pringle time of more than 60 min. Univariable and multivariable analyses were performed to identify predictors of postoperative survival. Kaplan-Meier analysis was used to compare overall survival between the groups.

RESULTS

A total of 357 patients were enrolled; 242 patients had a Pringle time of 60 min or less (group 1), and 115 patients had a Pringle time of more than 60 min (group 2). Patients in group 2 had a shorter overall survival than those in group 1 (P = 0·010). Univariable analyses showed that type of HCC (primary versus recurrent), maximum tumour diameter, hepatic venous infiltration, platelet count, serum protein induced by vitamin K absence or antagonist II level, blood loss (700 ml or less versus more than 700 ml), duration of operation (300 min or less versus more than 300 min) and Pringle time (60 min or less versus more than 60 min) were predictive of postoperative survival. Multivariable analysis indicated that only Pringle time was associated with postoperative survival (odds ratio 1·83, 95 per cent confidence interval 1·08 to 3·10; P = 0·024).

CONCLUSION

Longer Pringle time is an important predictor of shorter postoperative survival in patients undergoing liver resection for HCC.

Risk factors for residual tumor after resection of hepatocellular carcinoma

AIM: To identify the clinicopathological risk factors correlated with residual tumor in hepatocellular carcinoma (HCC) patients after resection.

METHODS: From January 2001 to April 2007, 766 HCC patients who had undergone resection were included in this research. Lipiodol angiography was performed within 2 mo after surgery and followed by post-Lipiodol computed tomography (CT) 4 wk later for all 766 patients to monitor tumor in the remnant liver. Tumor detected within the first 3-mo postoperative period was defined as residual tumor. Patients were divided into 2 groups: disease or disease-free within the first 3 mo after surgery. Risk factors for residual tumor were investigated among various clinicopathological variables.

RESULTS: A total of 63 (8.22%) patients were found to have residual tumor after surgery. Three independent factors associated with residual tumor were identified by multivariate analysis: preoperative serum α -fetoprotein (AFP) level [odds ratio (OR) = 1.68 (95% confidence interval (CI): 1.20-2.36)], tumor size [OR = 1.73 (95% CI: 1.29-2.31)] and microvascular invasion [OR = 1.91 (95% CI: 1.12-3.24)].

CONCLUSION: Residual tumor is related to AFP level, tumor size and microvascular invasion. Patients at high risk should undergo closer follow-up and could be candidates for multimodality therapy.

[Surgical treatment of liver cancer: experience of the A Coruña UHC (Spain)]

INTRODUCTION

Liver cancer (LC) is one of the most frequent tumours, in which the potentially curative treatment is surgery: partial surgical resection or liver transplant.

OBJECTIVES

To determine the morbidity and mortality, survival, and their associated factors in patients with LC, according to the type of surgical treatment: partial surgical resection or liver transplant.

MATERIAL AND METHODS

A retrospective, observational follow-up study of LC patients diagnosed and treated from June 1994 to December 2007. A descriptive analysis of the variables was performed, as well as a Kaplan- Meier survival analysis and Cox regression.

RESULTS

The incidence of tumour recurrence in the 150 transplant patients was 13.3%, with a survival at 1, 3, and 5 years of 89.3%, 73.1% and 61.4%, respectively. The multivariate analysis showed that only the histological grade/differentiation was an independent risk factor. In the 33 patients with partial surgical resection, the incidence of tumour was 51.5%, with a survival at 1, 3, and 5 years of 90.9%, 60.2%, and 38.6%, respectively. A significantly higher mortality was observed in patients with higher tumour and TNM staging.

CONCLUSIONS

The survival throughout follow-up was higher in liver transplant, and tumour recurrence was more frequent in patients with partial surgical resection. The survival results in transplanted patients are consistent with the Spanish and European Liver Transplant Register and with the United Network for Organ Sharing register.

Preoperative tumor marker doubling time is a useful predictor of recurrence and prognosis after hepatic resection of hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

It is important to identify prognostic factors in patients with hepatocellular carcinoma (HCC) before hepatectomy. No previous studies have addressed the predictive efficacy of the preoperative doubling times of alpha-fetoprotein (AFP) and protein induced by vitamin K absence (PIVKA-II).

METHODS

A total of 210 HCC patients who underwent a hepatic resection between 1998 and 2006 were prospectively evaluated. Serum AFP and PIVKA-II levels were measured at least twice before surgery to calculate the doubling times. Nineteen clinical factors that can be examined preoperatively, including the doubling times of AFP and PIVKA-II were investigated to identify prognostic factors for disease-free and overall survival after hepatectomy.

RESULTS

There was no relationship between preoperative levels and doubling times of AFP and PIVKA-II. In a multivariate analysis, patients with a doubling time of AFP ≤30 days and PIVKA-II ≤16 days showed a significantly worse disease-free (P = 0.02, P = 0.03, respectively) and overall survival (P < 0.0001, P = 0.03, respectively).

CONCLUSIONS

In HCC patients, the doubling times of preoperative serum AFP or PIVKA-II levels are useful tools to predict early postoperative recurrence and a poor prognosis.

Prospective evaluation of microscopic extension using whole-mount preparation in patients with hepatocellular carcinoma: Definition of clinical target volume for radiotherapy

BACKGROUND

To define the clinical target volume (CTV) for radiotherapy in patients with hepatocellular carcinoma (HCC).

METHODS

A prospective study was conducted to histologically evaluate the presence and the distance of microscopic extension (ME) for resected HCC on the basis of examination of whole-mount preparations of carcinoma tissue sections.

RESULTS

A total of 380 whole-mount slides prepared from tumor samples of 76 patients with HCC were examined. Patients with elevated pretreatment AFP levels exhibited higher risk of ME as compared to those with normal pretreatment AFP levels (93.9% vs. 69.8%, P < 0.01). ME positivity was 16.7% for Grade 1, 79.1% for Grade 2, and 96.3% for Grade 3 tumors (P < 0.01). The mean distance of ME was 0.0 ± 0.1 mm (range 0-0.2 mm) for Grade 1, 0.9 ± 0.9 mm (range 0-4.5 mm) for Grade 2, and 1.9 ± 1.9 mm (range 0-8.0 mm) for Grade 3 tumors (P < 0.01).

CONCLUSIONS

The CTV margins for tumor Grades 1, 2, and 3 HCC, are recommended to be 0.2 mm, 4.5 mm, and 8.0 mm beyond the gross tumor margin, respectively, to account for possible ME of the tumors in all patients.

Expressions of nucleoside diphosphate kinase (nm23) in tumor tissues are related with metastasis and length of survival of patients with hepatocellular carcinoma

OBJECTIVE

To evaluate the relationship of expressions of nucleoside diphosphate kinase (nm23) and proliferating cell nuclear antigen (PCNA), as well as apoptosis, with the prognosis of HCC patients by analyzing their pathological and clinical data.

METHODS

The expressions of nm23 and PCNA were analyzed by immunohistochemistry and the apoptotic phenomena were detected by TUNEL technique in the liver samples from 43 HCC tissues, 39 para-neoplastic tissues, and 10 normal tissues. The mean apoptosis index (AI) and proliferative index (PI) in individual sample were calculated.

RESULTS

As shown by the detection, 32.6% of carcinomas had negative nm23 signal in tumor tissues, whereas all para-neoplastic and normal tissues had positive nm23. The AI in nm23 positive HCC was significantly higher than that in nm23 negative one, with statistical difference (P<0.05). Furthermore, the expressions of nm23, and the values of AI and PI were contrastively analyzed with some main pathological and clinical data of HCC. It revealed that HCC with extrahepatic metastasis showed remarkable correlation with the negative nm23 (P=0.013) and higher PI values of HCC (P=0.015). The disease-free survival in HCC patients with negative nm23 expression was significantly poorer than that in patients with positive nm23 expression.

CONCLUSIONS

These data suggest that expressions of nm23 protein in tumor tissues are correlated with occurrences of metastasis and length of survival of the HCC patients, which may be an indicator for their prognosis.

Concurrent and subsequent radiofrequency ablation combined with hepatectomy for hepatocellular carcinomas

Partial hepatectomy has long been the standard treatment modality for patients with hepatocellular carcinoma (HCC), although the majority of patients with HCCs are not candidates for curative resection. Radiofrequency ablation (RFA) has been widely used as the preferred locoregional therapy. RFA and hepatectomy can be complementary to each other for the treatment of multifocal HCCs. Combining hepatectomy with RFA permits the removal of larger tumors while simultaneously ablating any smaller residual tumors. By using this combination treatment, more patients might become candidates for curative resection. For treating recurrent tumors involving the liver after hepatectomy, RFA has been performed recently instead of transcatheter arterial chemoembolization or ethanol ablation. Many retrospective studies on the combination of RFA and hepatectomy demonstrate favorable results of effectiveness and safety. However, further investigation of prospective design will be needed to confirm these encouraging results.

Role of alpha-fetoprotein in hepatocellular carcinoma: prognostication, treatment monitoring or both?

Despite recent breakthroughs in the treatment for both early and advanced hepatocellular carcinoma, the development of markers for prognostication and treatment monitoring remains to be explored. Serum alpha-fetoprotein has been frequently measured at diagnosis and serially during treatment by clinicians for decades, with an aim for prognostication of disease and monitoring of treatment response. In this review, the evidence regarding the prognostic value of serum alpha-fetoprotein and the value of serial alpha-fetoprotein in the monitoring of treatment efficacy will be discussed, with emphasis on recent data.

Surgical resection versus laparoscopic radiofrequency ablation in patients with hepatocellular carcinoma and Child-Pugh class a liver cirrhosis

BACKGROUND

This study compared two homogeneous groups of patients submitted to either surgical resection (HR) or laparoscopic radiofrequency ablation (LRFA) for the treatment of hepatocellular carcinoma (HCC). When compatible with the liver functional reserve, HR remains the treatment of choice for HCC, while LRFA seems to be a promising, less invasive alternative. We thus compared HR or LRFA for short- and long-term outcomes in patients with a single HCC nodule and Child-Pugh class A liver cirrhosis.

METHODS

We enrolled 152 cirrhotic patients out of 372 cases consecutively evaluated for HCC. Enrolled patients with similar baseline characteristics underwent HR (n = 78) or LRFA (n = 74), in both cases with intraoperative ultrasonography, and they were then followed for similar durations (mean +/- standard deviation, 36.2 +/- 23.5 months for HR vs. 38.2 +/- 28.4 for LRFA). Outcomes included short- and long-term morbidity, HCC recurrence, and overall survival.

RESULTS

Short-term morbidity was far higher in the HR group while, during follow-up, HCC recurrence (mainly local) was more frequent in patients treated with LRFA. More importantly, baseline alfa-fetoprotein levels and early HCC recurrence after treatment greatly influenced overall survival, while the use of HR or LRFA did not predict it. On the other hand, HCC recurrence was found to be determined by the surgical approach and ultrasound characteristics of the tumor.

CONCLUSIONS

Our data were obtained from a large number of HCC cases and support similar survival rates after HR or LRFA for single HCC nodules on Child-Pugh class A liver cirrhosis, despite a marked increase in HCC recurrence rates after LRFA.

Surgery in the patient with liver disease

The advent of liver transplantation has greatly improved the long-term survival of patients with decompensated cirrhosis, and surgery is now performed more frequently in patients with advanced liver disease. The estimation of perioperative mortality is limited by the retrospective nature of and biased patient selection in the available clinical studies. The overall experience is that, in patients with cirrhosis, use of the Child classification and Model for End-Stage Liver Disease (MELD) score provides a reasonably precise estimation of perioperative mortality. Careful preoperative preparation and monitoring to detect complications early in the postoperative course are essential to improve outcomes.

High serum des-gamma-carboxy prothrombin level predicts poor prognosis after radiofrequency ablation of hepatocellular carcinoma

BACKGROUND

Currently, surgical resection is considered the first-line treatment for early stage hepatocellular carcinoma (HCC). Radiofrequency ablation (RFA) has been an alternative choice for unresectable HCC. However, RFA is expected to have similar therapeutic efficacy for early stage HCC with fewer invasions.

METHODS

The authors retrospectively analyzed 199 patients who underwent surgery and 209 patients who underwent RFA for HCC with a maximum diameter of < or = 3 cm and tumors numbering < or = 3. All patients were complicated with Child-Pugh A cirrhosis.

RESULTS

The 3- and 5-year survival rates of the resection (90.3%, 79.0%, respectively) and RFA groups were similar (87.4%, 74.8). The 1- and 3-year tumor recurrence-free survival rates of the resection group (83.1%, 51.0%, respectively) were higher than in the RFA group (82.7%, 41.8%; P = .011). Multivariate analysis identified prothrombin time > or = 80% (hazard ratio [HR], 2.72; 95% confidence interval [CI], 1.56-4.74; P < .001) as an independent prognostic factor for survival in the resection group. Des-gamma-carboxy prothrombin (DCP) <100 arbitrary units (AU)/L (HR, 5.49; CI, 2.23-13.5; P < .001) and platelet count > or = 1.0 x 10(5) (HR, 2.70; CI, 1.24-5.88; P = .012) were significant markers in the RFA group. Among patients with DCP > or = 100 AU/L, treatment procedure (HR, 1.26; CI, 1.04-1.53; P = .020) was a significant prognostic factor for survival.

CONCLUSIONS

High DCP levels reflect the biologic aggressiveness and progression of HCC tumors. In the aforementioned cases, we recommend surgical resection rather than RFA for such patients.

Influence of the etiology of liver cirrhosis on the response to combined intra-arterial chemotherapy in patients with advanced hepatocellular carcinoma. Cancer Chemother Pharmacol. 2009;64:109-114. [PMID: 18979100 DOI: 10.1007/s00280-008-0851-2]

PURPOSE

We have previously reported that intra-arterial chemotherapy prolongs the survival of patients with advanced HCC (aHCC); however, whether the response to intra-arterial chemotherapy depends on the etiology of underlying liver cirrhosis (LC) is still unknown.

AIM

The aim of this study was to assess any influences of the etiology of LC on the response to combined intra-arterial chemotherapy for aHCC.

METHODS

A total of 53 adult Japanese LC patients (46 men and 7 women) with aHCC were treated with combined intra-arterial chemotherapy between 2002 and 2007 at our hospital. All of the patients had a Japan Integrated Staging (JIS) score of 3 or 4. Their tumors were inoperable according to computed tomography findings. Combined intra-arterial chemotherapy was administered via the proper hepatic artery every 5 days for 4 weeks and the chemotherapy regimen was continued for as long as possible.

RESULTS

There were 15 patients with HBV infection (B-LC group), 29 patients with HCV infection (C-LC group), and nine patients with alcoholic cirrhosis (A-LC group). The percentage of patients with a complete or partial response after 4 weeks of chemotherapy was 0% in the B-LC group versus 31.0% in the C-LC group and 44.4% in the A-LC group. The survival of the A-LC and C-LC groups was significantly longer than that of the B-LC group with the median survival time being 688, 368, and 211 days, respectively.

CONCLUSIONS

Combined intra-arterial chemotherapy might be more effective for aHCC in patients with A-LC or C-LC than in patients with B-LC.

Relationship between microvessel count and post-hepatectomy survival in patients with hepatocellular carcinoma

AIM: To elucidate the relationship between the microvessel count (MVC) by CD34 analyzed by immunohistochemical method and prognosis in hepatocellular carcinoma (HCC) patients who underwent hepatectomy based on our preliminary study.

METHODS: We examined relationships between MVC and clinicopathological factors in 128 HCC patients. The modified Japan Integrated Staging score (mJIS) was applied to examine subsets of HCC patients.

RESULTS: Median MVC was 178/mm², which was used as a cut-off value. MVC was not significantly associated with any clinicopathologic factors or postoperative recurrent rate. Lower MVC was associated with poor disease-free and overall survivals by univariate analysis (P = 0.039 and P = 0.087, respectively) and lower MVC represented an independent poor prognostic factor in disease-free survival by Cox’s multivariate analysis (risk ratio, 1.64; P = 0.024), in addition to tumor size, vascular invasion, macroscopic finding and hepatic dysfunction. Significant differences in disease-free and overall survivals by MVC were observed in HCC patients with mJIS 2 (P = 0.046 and P = 0.0014, respectively), but not in those with other scores.

CONCLUSION: Tumor MVC appears to offer a useful prognostic marker of HCC patient survival, particularly in HCC patients with mJIS 2.