JSH Consensus-Based Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma: 2014 Update by the Liver Cancer Study Group of Japan

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

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

Influence of Gadoxetate Disodium on Oxygen Saturation and Heart Rate during Dynamic Contrast-enhanced MR Imaging

PURPOSE

To investigate whether gadoxetate disodium affects peripheral capillary oxygen saturation (SpO2) and/or heart rate (HR) during dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging in patients with liver diseases.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, who waived the requirement for informed consent. Four hundred fifty-eight patients (171 women [mean age, 66.5 years; range, 23-87 years] and 287 men [mean age, 61.1 years; range, 25-89 years]) who underwent liver DCE MR imaging with gadoxetate disodium (0.025 mmol per kilogram of body weight) from October 28, 2013, to June 24, 2014, were included in this study. They were monitored for SpO2 and HR during DCE MR imaging. Motion artifact severity was graded by using a five-point scale, and transient severe motion (TSM) was defined by a score of at least 4. The association between TSM and baseline predictors was assessed, and HR and SpO2 at each postcontrast phase were compared with those at the precontrast phase in the TSM and non-TSM groups.

RESULTS

Four hundred thirty-six patients were included in the non-TSM group, and 22 were included in the TSM group. Although the motion score was the worst at the arterial phase, the observed mean differences in SpO2 and HR between the precontrast phase and the arterial phase were less than 1% and 5 beats per minute, respectively (mean SpO2 ± standard deviation for the non-TSM group, 96.7% ± 1.8 vs 96.9% ± 1.8 [P = .11]; SpO2 for the TSM group, 96.4% ± 1.6 vs 96.1% ± 1.6 [P > .99]) (HR for the non-TSM group, 68.9 beats per minute ± 12.4 vs 70.9 beats per minute ± 12.1 [P < .0001]; HR for the TSM group, 75.0 beats per minute ± 11.8 vs 79.9 beats per minute ± 10.2 [P < .0001]).

CONCLUSION

Intravenous gadoxetate disodium (a weight-based dose) does not cause changes in SpO2 and HR that lead to image quality degradation.

Surveillance, diagnosis, treatment, and outcome of liver cancer in Japan

BACKGROUND

Hepatocellular carcinoma (HCC) is the fifth most common type of cancer and the third leading cause of cancer-related death worldwide. HCC is most common in Asia, but its prevalence is rapidly increasing in Western countries; consequently, HCC is a global medical issue that urgently needs to be addressed. Japan is the only developed country that has experienced both hepatitis B-related and hepatitis C-related HCC and has a long history of innovation when it comes to new diagnostic and therapeutic modalities, such as computed tomography angiography, anatomical resection, ablation, and transarterial chemoembolization. Among these innovations, a nationwide surveillance program was well established by the 1980s, and such a long-term national program does not exist anywhere else in the world.

SUMMARY

More than 60% of the initially detected HCCs in Japan are Barcelona Clinic Liver Cancer stage 0 or A, which can undergo curative therapies such as resection, ablation, or transplantation. The recent 5-year survival rate of HCC patients in Japan was 43% and the median survival time was 50 months. In addition, both incidence and mortality rates are drastically declining as a result of the successful surveillance program, careful diagnostic flow, and extensive repeated treatments.

KEY MESSAGE

Japan's successful model in the surveillance, diagnosis, and treatment of HCC should be adopted as widely as possible to improve the survival of HCC patients worldwide.

Imaging Modalities for Assessment of Treatment Response to Nonsurgical Hepatocellular Carcinoma Therapy: Contrast-Enhanced US, CT, and MRI

Tumor response and time to progression have been considered pivotal for surrogate assessment of treatment efficacy for patients with hepatocellular carcinoma (HCC). Recent advancements in imaging modalities such as contrast-enhanced ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are playing an important role in assessing the therapeutic effects of HCC treatments. According to some HCC clinical guidelines, post-therapeutic evaluation of HCC patients is based exclusively on contrast-enhanced dynamic imaging criteria. The recommended techniques are contrast-enhanced CT or contrast-enhanced MRI. Contrast-enhanced US is employed more in the positive diagnosis of HCC than in post-therapeutic monitoring. Although contrast enhancement is an important finding on imaging, enhancement does not necessarily depict the same phenomenon across modalities. We need to become well acquainted with the characteristics of each modality, including not only contrast-enhanced CT and MRI but also contrast-enhanced US. Many nonsurgical treatment options are now available for unresectable HCC, and accurate assessment of tumor response is essential to achieve favorable outcomes. For the assessment of successful radiofrequency ablation (RFA), the achievement of a sufficient ablation margin as well the absence of tumor vascular enhancement is essential. To evaluate the response to transcatheter arterial chemoembolization (TACE), enhanced tumor shrinkage is relied on as a measure of antitumor activity. Here, we give an overview of the current status of imaging assessment of HCC response to nonsurgical treatments including RFA and TACE.

Surveillance and diagnostic algorithm for hepatocellular carcinoma proposed by the Liver Cancer Study Group of Japan: 2014 update

Surveillance and diagnostic algorithms for hepatocellular carcinoma (HCC) have already been described in guidelines published by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver and the European Organisation for Research and Treatment of Cancer (EASL-EORTC), and the Japan Society of Hepatology (JSH), but the content of these algorithms differs slightly. The JSH algorithm mainly differs from the other two algorithms in that it is highly sophisticated and considers the functional imaging techniques of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRI (EOB-MRI) and Sonazoid contrast-enhanced ultrasound (CEUS) to be very important diagnostic modalities. In contrast, the AASLD and EASL-EORTC algorithms are less advanced and suggest that a diagnosis be made based solely on hemodynamic findings using dynamic CT/MRI and biopsy findings. A consensus meeting regarding the JSH surveillance and diagnostic algorithm was held at the 50th Liver Cancer Study Group of Japan Congress, and a 2014 update of the algorithm was completed. The new algorithm reaffirms the very important role of EOB-MRI and Sonazoid CEUS in the surveillance and diagnosis of liver cancer and is more sophisticated than those currently used in the United States and Europe. This is now an optimized algorithm that can be used to diagnose early-stage to classical HCC easily and highly accurately.

Transarterial chemoembolization failure/refractoriness: JSH-LCSGJ criteria 2014 update

In the 2010 version of the Japan Society of Hepatology (JSH) consensus-based treatment algorithm for the management of hepatocellular carcinoma (HCC), transarterial chemoembolization (TACE) failure/refractoriness was defined assuming the use of superselective lipiodol TACE, which has been widely used worldwide and particularly in Japan, and areas with lipiodol deposition were considered to be necrotic. However, this concept is not well accepted internationally. Furthermore, following the approval of microspheres, an embolic material that does not use lipiodol, in February 2014 in Japan, the phrase 'lipiodol deposition' needed to be changed to 'necrotic lesion or viable lesion'. Accordingly, the respective section in the JSH guidelines was revised to define TACE failure as an insufficient response after ≥2 consecutive TACE procedures that is evident on response evaluation computed tomography or magnetic resonance imaging after 1-3 months, even after chemotherapeutic agents have been changed and/or the feeding artery has been reanalyzed. In addition, the appearance of a higher number of lesions in the liver than that recorded at the previous TACE procedure (other than the nodule being treated) was added to the definition of TACE failure/refractoriness. Following the discussion of other issues concerning the continuous elevation of tumor markers, vascular invasion, and extrahepatic spread, descriptions similar to those in the previous version were approved. The revision of these TACE failure definitions was approved by over 85% of HCC experts.

Characteristics of long-term survivors following sorafenib treatment for advanced hepatocellular carcinoma: report of a workshop at the 50th Annual Meeting of the Liver Cancer Study Group of Japan

BACKGROUND

Little data are available on the long-term survival of patients treated with sorafenib for advanced hepatocellular carcinoma (HCC).

SUMMARY

During a consensus workshop at the 50th annual meeting of the Liver Cancer Study Group of Japan held in Kyoto (June 5-6, 2014), experts met to discuss the characteristics of long-term (>3 years) survivors of advanced HCC following sorafenib treatment. A total of 70 long-term survivors following sorafenib treatment at eight institutions were included, and the long-term survival rate (>3 years) at each institution ranged from 2.6 to 6.9% (mean, 4.5). The long-term survival-related factors presented can be categorized as follows: (1) conversion options, including hepatic resection following successful sorafenib treatment, (2) additional salvage options when progressive disease is confirmed, (3) long-term sorafenib treatment, (4) effective post-sorafenib options to prolong postprogression survival, and (5) good pretreatment liver function. Sorafenib monotherapy exceeding 3 years is rare, and most of the patients receiving sorafenib required other treatment modalities in the form of multidisciplinary therapy.

CONCLUSION

The overview obtained from the workshop reflects the pattern of management in practice for long-term survivors following sorafenib treatment for HCC in Japan and may also provide valuable information for other countries.

Validation of the criteria of transcatheter arterial chemoembolization failure or refractoriness in patients with advanced hepatocellular carcinoma proposed by the LCSGJ

BACKGROUND

Transcatheter arterial chemoembolization (TACE) failure or refractoriness is an indication for sorafenib therapy in patients with advanced hepatocellular carcinoma. The study evaluated the validity of the definition of TACE failure or refractoriness as proposed by the Liver Cancer Study Group of Japan (LCSGJ) through a retrospective analysis of sorafenib treatment.

METHODS

Out of 265 patients with advanced hepatocellular carcinoma who were treated with sorafenib at our hospital, 45 experienced TACE failure or refractoriness and were included in this study and retrospectively analyzed.

RESULTS

Multivariate analysis only identified the number of ineffective TACE procedures performed before starting sorafenib treatment as significant factors. Overall survival (OS) after starting sorafenib was statistically longer in patients treated with ≤2 consecutive ineffective TACE procedures before sorafenib administration than in patients treated with ≥3 consecutive ineffective TACE procedures (p < 0.005). This result matched the LCSGJ criteria.

CONCLUSION

In patients treated with sorafenib, OS was extended with ≤2 consecutive ineffective TACE procedures compared to that with ≥3 consecutive ineffective TACE procedures. Thus, if tumors are uncontrolled, TACE should not be repeated. The result of this study supports the definition of TACE failure or refractoriness proposed by the LCSGJ.

Ultrasound fusion imaging of hepatocellular carcinoma: a review of current evidence

With advances in technology, imaging techniques that entail fusion of sonography and CT or MRI have been introduced in clinical practice. Ultrasound fusion imaging provides CT or MRI cross-sectional multiplanar images that correspond to the sonographic images, and fusion imaging of B-mode sonography and CT or MRI can be displayed simultaneously and in real time according to the angle of the transducer. Ultrasound fusion imaging helps us understand the three-dimensional relationship between the liver vasculature and tumors, and can detect small liver tumors with poor conspicuity. This fusion imaging is attracting the attention of operators who perform radiofrequency ablation (RFA) for the treatment of hepatic malignancies because this real-time, multimodality comparison can increase monitoring and targeting confidence during the procedure. When RFA with fusion imaging was performed on small hepatocellular carcinomas (HCCs) with poor conspicuity, it was reported that the rates of technical success and local tumor progression were 94.4-100% and 0-8.3%. However, there have been no studies comparing fusion imaging guidance and contrast-enhanced sonography, CT or MRI guidance in ablation. Fusion imaging-guided RFA has proved to be effective for HCCs that are poorly defined on not only conventional B-mode sonography but also contrast-enhanced sonography. In addition, fusion imaging could be useful to assess the treatment response of RFA because of three-dimensional information. Here, we give an overview of the current status of ultrasound fusion imaging for clinical application in the liver.