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Ho SY, Liu PH, Hsu CY, Huang YH, Liao JI, Su CW, Hou MC, Huo TI. Tumor burden score as a new prognostic surrogate in patients with hepatocellular carcinoma undergoing radiofrequency ablation: role of albumin-bilirubin (ALBI) grade vs easy ALBI grade. Expert Rev Gastroenterol Hepatol 2022; 16:903-911. [PMID: 35999514 DOI: 10.1080/17474124.2022.2117156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Tumor burden score (TBS) was proposed to represent tumor burden in solid tumors, including hepatocellular carcinoma (HCC). The prognostic role of TBS in HCC patients in relation to recently introduced liver reserve markers, albumin-bilirubin (ALBI) grade, and easy (EZ)-ALBI grade, is unclear. We aimed to investigate the feasibility of TBS in HCC patients undergoing radiofrequency ablation (RFA). RESEARCH DESIGN AND METHODS A total of 576 treatment-naïve patients with HCC undergoing RFA were analyzed. The multivariate Cox analysis was used to identify independent predictors associated with tumor recurrence and long-term survival. RESULTS Patients with high TBS had increased risk of tumor recurrence and mortality compared with those with low TBS. The Cox analysis showed that serum ɑ-fetoprotein (AFP) level >20 ng/mL, medium and high TBS, ALBI grade 2 and grade 3, EZ-ALBI grade 2 and grade 3 were associated with tumor recurrence and decreased patient survival (all p <0.05). In addition, TBS can reliably stratify tumor recurrence and overall survival in different ALBI and EZ-ALBI grade groups. CONCLUSIONS TBS is a simple and feasible prognostic surrogate to predict tumor recurrence and survival in HCC patients undergoing RFA. Its prognostic ability remains stable in patients with variable liver functional reserve.
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Affiliation(s)
- Shu-Yein Ho
- Division of Gastroenterology and Hepatology, Min-Sheng General Hospital, Taoyuan, Taiwan.,Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hong Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chia-Yang Hsu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,VA Sierra Nevada Health Care System, Reno, Nevada, USA
| | - Yi-Hsiang Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jia-I Liao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Wei Su
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Teh-Ia Huo
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
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52
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Ho SY, Liu PH, Hsu CY, Huang YH, Liao JI, Su CW, Hou MC, Huo TI. Radiofrequency Ablation versus Transarterial Chemoembolization for Hepatocellular Carcinoma within Milan Criteria: Prognostic Role of Tumor Burden Score. Cancers (Basel) 2022; 14:4207. [PMID: 36077743 PMCID: PMC9454855 DOI: 10.3390/cancers14174207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 12/01/2022] Open
Abstract
Tumor burden score (TBS), estimated by the diameter and number of tumor nodules, was recently proposed to assess the tumor burden in hepatocellular carcinoma (HCC). We aimed to evaluate the prognostic impact of TBS on HCC patients within the Milan criteria undergoing radiofrequency ablation (RFA) or transarterial chemoembolization (TACE). A total of 883 patients undergoing RFA and TACE were included. The multivariate Cox proportional hazards model was used to determine independent prognostic predictors in different patient cohorts. The TACE group had significantly higher TBS compared with the RFA group. The RFA group had better long-term survival than the TACE group in patients within the Milan criteria in univariate survival analysis. In the Cox model, serum α-fetoprotein (AFP) > 20 ng/mL, performance status 1−2, medium and high TBS, albumin−bilirubin (ALBI) grade 2 and grade 3 were independent predictors linked with mortality (all p < 0.001). Overall, TACE was not an independent predictor; among patients with low TBS, TACE was independently associated with decreased survival compared with RFA (p = 0.034). Conclusions: TBS is a feasible prognostic marker for HCC patients within the Milan criteria. TACE may be an effective treatment alternative for these patients. Among patients with low TBS, RFA should be considered the priority treatment modality.
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Affiliation(s)
- Shu-Yein Ho
- Division of Gastroenterology and Hepatology, Min-Sheng General Hospital, Taoyuan 89502, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
| | - Po-Hong Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Chia-Yang Hsu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- VA Sierra Nevada Health Care System, Reno, NV 89502, USA
| | - Yi-Hsiang Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
| | - Jia-I Liao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Chien-Wei Su
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Teh-Ia Huo
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
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53
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Moazzam Z, Lima HA, Alaimo L, Endo Y, Shaikh CF, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Impact of tumor burden score on timing and patterns of recurrence after curative-intent resection of hepatocellular carcinoma. Surgery 2022; 172:1448-1455. [PMID: 36031442 DOI: 10.1016/j.surg.2022.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The ability to predict the incidence, timing, and site of recurrence can be beneficial to select surgical candidates and inform appropriate postoperative surveillance. We sought to identify factors associated with risk and timing of recurrence after resection of hepatocellular carcinoma based on differences in tumor burden score. METHODS Patients who underwent curative-intent liver resection for hepatocellular carcinoma between 2000 and 2020 were identified from an international multi-institutional database. The incidence, timing, and pattern of recurrence was examined relative to traditional clinicopathological factors, as well as tumor burden score using hazard rates and multivariable analysis. RESULTS Among 1,994 patients (tumor burden score, low: n = 511, 25.6% vs medium: n = 1,286, 64.5% vs high: n = 197, 9.9%), the incidence of recurrence at 5 years was 50.4% (95% confidence interval 47.9-53.0); risk of recurrence varied relative to hepatocellular carcinoma tumor burden score (low: 36.0% vs medium: 54.4% vs high: 62.5%, P < .001). Although intrahepatic recurrence was much more common in low tumor burden score (low: n = 106, 84.1% vs medium: n = 335, 71.7% vs high: n = 48, 56.5%; P < .001), extrahepatic recurrence was more common in high tumor burden score (low: n = 18, 14.3% vs medium: n = 121, 25.9% vs high: n = 37, 43.5%; P < .001). The peak hazard rate for intrahepatic recurrence among patients with a high tumor burden score was almost double the peak hazard noted among patients with a low tumor burden score (low: 0.047, 42.0 months vs medium: 0.051, 6.6 months vs high: 0.094, 15.0 months). Of note, the patients with high tumor burden score were also more likely to recur earlier (≤24 months) (low: n = 227, 44.4% vs medium: n = 686, 53.3% vs high: n = 144, 73.1%) with multiple tumors (low: n = 50, 36.5% vs medium: n = 271, 56.1% vs high: n = 52, 70.3%) and larger lesions (low: 1.8 [interquartile range 1.2-3.0] cm vs medium: 2.0 [interquartile range 1.3-3.0] cm vs high: 2.5 [interquartile range 1.6-4.4] cm) (all P < .001). On multivariable analysis, high tumor burden score remained independently associated with risk of recurrence (referent, low; medium: hazard ratio = 1.49 [95% confidence interval 1.19-1.88], P = .001; high: hazard ratio = 1.95 [95% confidence interval 1.41-2.69]; P < .001]. CONCLUSION Tumor burden score was independently associated with higher risk of recurrence. Patients who underwent resection of high tumor burden score lesions were more likely to recur early with multiple tumors and at an extrahepatic site. Tumor burden score is an important tool in assessing risk, timing, and pattern of recurrence after resection of hepatocellular carcinoma.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/ZoraysM
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Department of Surgery, University of Verona, Italy
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatibiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | | | - Tom Hugh
- Department of Surgery, School of Medicine, University of Sydney, NSW, Australia
| | | | - Itaru Endo
- Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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54
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Tsilimigras DI, Aziz H, Pawlik TM. Critical Analysis of the Updated Barcelona Clinic Liver Cancer (BCLC) Group Guidelines. Ann Surg Oncol 2022; 29:7231-7234. [PMID: 35854026 DOI: 10.1245/s10434-022-12242-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA.
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55
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Individual and joint influence of cytokeratin 19 and microvascular invasion on the prognosis of patients with hepatocellular carcinoma after hepatectomy. World J Surg Oncol 2022; 20:209. [PMID: 35725470 PMCID: PMC9210815 DOI: 10.1186/s12957-022-02632-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate the individual and combined associations of cytokeratin 19 (CK19) and microvascular invasion (MVI) with prognosis of patients with hepatocellular carcinoma (HCC). METHODS Clinicopathological data on 352 patients with HCC who underwent radical resection at our hospital between January 2013 and December 2015 were retrospectively analyzed. Patients were divided into four groups: CK19(-)/MVI(-), CK19(-)/MVI(+), CK19(+)/MVI(-), and CK19(+)/MVI(+). RESULTS Of the 352 HCC patients, 154 (43.8%) were CK19(-)/MVI(-); 116 (33.0%), CK19(-)/MVI(+); 31 (8.8%), CK19(+)/MVI(-); and 51 (14.5%), CK19(+)/MVI(+). The disease-free survival of CK19(-)/MVI(-) patients was significantly higher than that of CK19(-)/MVI(+) patients and CK19(+)/MVI(+) patients. Similar results were observed for overall survival. CK19(+)/MVI(+) patients showed significantly lower overall survival than the other three groups. CONCLUSIONS CK19 expression and MVI predict poor prognosis after radical resection of HCC, and the two markers jointly contribute to poor OS. Combining CK19 and MVI may predict post-resection prognosis better than using either factor on its own.
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56
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Wang J, Chen Z, Wang L, Feng S, Qiu Q, Chen D, Li N, Xiao Y. A new model based inflammatory index and tumor burden score (TBS) to predict the recurrence of hepatocellular carcinoma (HCC) after liver resection. Sci Rep 2022; 12:8670. [PMID: 35606395 PMCID: PMC9126887 DOI: 10.1038/s41598-022-12518-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/04/2022] [Indexed: 02/08/2023] Open
Abstract
To establish a model based on inflammation index and tumor burden score (TBS) to predict recurrence of hepatocellular carcinoma (HCC) after liver resection. A retrospective study was performed on 217 patients who diagnosed HCC underwent liver resection at Xiangya Hospital Central South University from June 1, 2017 to June 1, 2019. According to the receiver operating characteristic (ROC) curve, the optimal cut-off value of inflammatory index and the TBS was determined by the Youden index. Prediction performance was compared by the area under the receiver operating characteristic curve (AUC). Cox regression analysis was used to determine the risk factors for the recurrence of HCC after liver resection. According to the independent risk factors of the patients, a prediction model for HCC was established based on inflammation index and tumor burden score (TBS).The prediction performance of the model was compared with single index (TBS group and NLR group) and traditional HCC stage models (TNM stage and BCLC stage). MLR = 0.39, NLR = 2.63, PLR = 134, SII = 428 and TBS = 8.06 are the optimal cut-off values. AUC of SII, PLR, NLR, MLR and TBS were 0.643, 0.642, 0.642, 0.618 and 0.724respectively. MVI (P = 0.005), satellite nodule (P = 0.017), BCLC B-C stage (P = 0.013), NLR > 2.63 (P = 0.013), TBS > 8.06 (P = 0.017) are independent risk factors for the recurrence of HCC after liver resection. According to this study, the optimal inflammatory index NLR combined with TBS was obtained. The AUC of NLR-TBS model was 0.762, not only better than NLR group (AUC = 0.630) and TBS group (AUC = 0.671), also better than traditional BCLC (AUC = 0.620) and TNM (AUC = 0.587) stage models. Interestingly, we found that NLR and TBS should be good prognostic factor for recurrence of HCC after liver resection. The NLR-TBS model based the best inflammatory index (NLR) and TBS have a better prediction performance and the prediction performance of NLR-TBS model not only better than NLR group and TBS group, but better than BCLC and TNM stage models.
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Affiliation(s)
- Jianhua Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zeguo Chen
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Liheng Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Sijia Feng
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Qixuan Qiu
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Dongdong Chen
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Nianfeng Li
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China.
| | - Yao Xiao
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China.
- International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, 410008, China.
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57
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Zhang XF, Xue F, Bagante F, Ratti F, Marques HP, Silva S, Soubrane O, Lam V, Poultsides GA, Popescu I, Grigorie R, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Lv Y, Pawlik TM. Non-transplantable Recurrence After Resection for Transplantable Hepatocellular Carcinoma: Implication for Upfront Treatment Choice. J Gastrointest Surg 2022; 26:1021-1029. [PMID: 34797558 DOI: 10.1007/s11605-021-05206-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/13/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify the preoperative risk factors for prediction of non-transplantable recurrence (NTR) after tumor resection for early-stage hepatocellular carcinoma (HCC) to assist in patient selection relative to upfront liver resection (LR) versus liver transplantation (LT). METHODS Patients who underwent curative resection for transplantable HCC and chronic liver disease were identified from an international multi-institutional database. NTR was defined as recurrence beyond the Milan or UCSF criteria, and the preoperative risk factors of NTR were investigated. RESULTS Among 293 patients with transplantable HCC within Milan criteria and 320 within UCSF criteria, 113 (38.6%) and 131 (40.9%) patients developed tumor recurrence, respectively. Among patients who recurred, NTR was present in 32 (28.3%) patients within Milan and 35 (26.7%) within UCSF criteria. When either Milan or UCSF criteria was adopted, three preoperative risk factors including liver cirrhosis, tumor size > 3 cm, and multiple lesions were consistently identified as risk factors associated with NTR after curative resection. By summing up the three factors, a scoring model was established and the incidence of NTR among patients with 0, 1 or ≥ 2 risk factors incrementally increased from 4.5%, 13.3% to 20.5% when Milan criteria was used, and from 4.5%, 12.4% to 33.9% when UCSF criteria was adopted. The model demonstrated very good discriminatory power on internal validation (n = 5,000) (c-index 0.689 for Milan criteria, and 0.715 for UCSF criteria). CONCLUSIONS Whereas surgical resection may be optimal first-line treatment for patients with no or one risk factor, patients with ≥ 2 risk factors should be considered for upfront liver transplantation.
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Affiliation(s)
- Xu-Feng Zhang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Feng Xue
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Fabio Bagante
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Silvia Silva
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | - Razvan Grigorie
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | | | - Yi Lv
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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58
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Lian D, Wang W, Liu L, Wang J, Rao S, Zhou J. CT volumetry helps predict prognosis of large hepatocellular carcinoma after resection. Clin Radiol 2022; 77:e599-e605. [PMID: 35483982 DOI: 10.1016/j.crad.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
Abstract
AIM To determine whether the tumour volume measurement on preoperative contrast-enhanced computed tomography (CT) could be used to predict the overall survival patients with large hepatocellular carcinoma (>5 cm) after resection. MATERIALS AND METHODS This study included 171 patients with surgically confirmed hepatocellular carcinoma who underwent preoperative CT. The largest diameter, the product of the axial dimension, tumour volume, and tumour-to-liver volume ratio (TTLVR) on CT images were measured and calculated. The univariate and multivariate Cox proportional hazard ratio regression models were used to identify the impact of the tumour burden-related risk factors on overall survival. RESULTS In multivariate analysis, TTLVR (p=0.042) and major vascular invasion (p=0.006) were independently associated with overall survival of patients with hepatocellular carcinoma after the resection. The group in which the patients had a low TTLVR showed higher cumulative survival rates than patients with a TTLVR (p=0.004). Patients with a low TTLVR (≤26.23%) and absence of major vascular invasion had significantly higher cumulative survival rates compared to those patients with hepatocellular carcinoma with either or both the risk factors (p=0.001). CONCLUSION A higher TTLVR in combination with the presence of major vascular invasion was associated with poorer overall survival in patients with large hepatocellular carcinoma after resection.
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Affiliation(s)
- D Lian
- Department of Radiology, Xiamen Branch, Zhongshan Hospital, Fudan University, No. 668 Jinhu Road, Huli District, Xiamen 361015, China
| | - W Wang
- Department of Radiology, Cancer Center, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - L Liu
- Department of Radiology, Cancer Center, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - J Wang
- Department of Radiology, Cancer Center, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - S Rao
- Department of Radiology, Cancer Center, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China.
| | - J Zhou
- Department of Radiology, Xiamen Branch, Zhongshan Hospital, Fudan University, No. 668 Jinhu Road, Huli District, Xiamen 361015, China.
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Li H, Liu R, Qiu H, Huang Y, Liu W, Li J, Wu H, Wang G, Li D. Tumor Burden Score Stratifies Prognosis of Patients With Intrahepatic Cholangiocarcinoma After Hepatic Resection: A Retrospective, Multi-Institutional Study. Front Oncol 2022; 12:829407. [PMID: 35330712 PMCID: PMC8940520 DOI: 10.3389/fonc.2022.829407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background The prognostic significance of tumor burden score (TBS) on patients who underwent curative-intent resection of intrahepatic cholangiocarcinoma (ICC) has not been evaluated. The present study aimed to investigate the impact of TBS and its synergistic effect with CA19-9 (combination of TBS and CA19-9, CTC grade) on long-term outcomes. Methods Patients who underwent radical resection of ICC between 2009 and 2017 were retrospectively identified from a multi-center database. The overall survival (OS) and recurrence-free survival (RFS) were examined in relation to TBS, serum preoperative CA19-9, and CTC grade. Results A total of 650 patients were included in our study (509 in the derivation cohort and 141 in the validation cohort). Kaplan–Meier curves showed that both TBS and CA19-9 levels were strong predictors of survival outcomes. Patients with elevated TBS grade or elevated CA19-9 were associated with worse OS and RFS (both p < 0.001). As expected, CTC grade also performed well in predicting long-term outcomes. Patients with low TBS/low CA19-9 (CTC grade 1) were associated with the best OS as well as RFS, while high TBS/high CA19-9 (CTC grade 3) correlated to the worst outcomes. In the validation cohort, TBS grade, preoperative CA19-9, and CTC grade also stratified prognosis among patients (p < 0.001 for each). Conclusions Both tumor morphology (tumor burden) and tumor-specific biomarker (serum CA19-9) were important when evaluating prognosis of patients with resectable ICC. Serum CA19-9 and TBS showed a synergistic effect on prognostic evaluation. CTC grade was a promising tool in stratifying prognosis of ICC patients after curative resection.
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Affiliation(s)
- Hui Li
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Rongqiang Liu
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Haizhou Qiu
- Department of Liver Surgery & Liver Transplantation, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Huang
- Department of Liver Surgery & Liver Transplantation, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenbin Liu
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Jiaxin Li
- Department of Liver Surgery & Liver Transplantation, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Wu
- Department of Liver Surgery & Liver Transplantation, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Genshu Wang
- Department of Hepatic Surgery and Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dewei Li
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
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Müller L, Hahn F, Auer TA, Fehrenbach U, Gebauer B, Haubold J, Zensen S, Kim MS, Eisenblätter M, Diallo TD, Bettinger D, Steinle V, Chang DH, Zopfs D, Pinto dos Santos D, Kloeckner R. Tumor Burden in Patients With Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Head-to-Head Comparison of Current Scoring Systems. Front Oncol 2022; 12:850454. [PMID: 35280804 PMCID: PMC8904349 DOI: 10.3389/fonc.2022.850454] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/28/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives Recently, several scoring systems for prognosis prediction based on tumor burden have been promoted for patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). This multicenter study aimed to perform the first head-to-head comparison of three scoring systems. Methods We retrospectively enrolled 849 treatment-naïve patients with HCC undergoing TACE at six tertiary care centers between 2010 and 2020. The tumor burden score (TBS), the Six-and-Twelve score (SAT), and the Seven-Eleven criteria (SEC) were calculated based on the maximum lesion size and the number of tumor nodes. All scores were compared in univariate and multivariate regression analyses, adjusted for established risk factors. Results The median overall survival (OS) times were 33.0, 18.3, and 12.8 months for patients with low, medium, and high TBS, respectively (p<0.001). The median OS times were 30.0, 16.9, and 10.2 months for patients with low, medium, and high SAT, respectively (p<0.001). The median OS times were 27.0, 16.7, and 10.5 for patients with low, medium, and high SEC, respectively (p<0.001). In a multivariate analysis, only the SAT remained an independent prognostic factor. The C-Indexes were 0.54 for the TBS, 0.59 for the SAT, and 0.58 for the SEC. Conclusion In a direct head-to-head comparison, the SAT was superior to the TBS and SEC in survival stratification and predictive ability. Therefore, the SAT can be considered when estimating the tumor burden. However, all three scores showed only moderate predictive power. Therefore, tumor burden should only be one component among many in treatment decision making.
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Affiliation(s)
- Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Alexander Auer
- Department of Radiology, Charité – University Medicine Berlin, Berlin, Germany
| | - Uli Fehrenbach
- Department of Radiology, Charité – University Medicine Berlin, Berlin, Germany
| | - Bernhard Gebauer
- Department of Radiology, Charité – University Medicine Berlin, Berlin, Germany
| | - Johannes Haubold
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Sebastian Zensen
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Moon-Sung Kim
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michel Eisenblätter
- Department of Diagnostic and Interventional Radiology, Freiburg University Hospital, Freiburg, Germany
| | - Thierno D. Diallo
- Department of Diagnostic and Interventional Radiology, Freiburg University Hospital, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Verena Steinle
- Department of Diagnostic and Interventional Radiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - De-Hua Chang
- Department of Diagnostic and Interventional Radiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - David Zopfs
- Department of Radiology, University Hospital Cologne, Cologne, Germany
| | | | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Papaconstantinou D, Hewitt DB, Brown ZJ, Schizas D, Tsilimigras DI, Pawlik TM. Patient stratification in hepatocellular carcinoma: impact on choice of therapy. Expert Rev Anticancer Ther 2022; 22:297-306. [PMID: 35157530 DOI: 10.1080/14737140.2022.2041415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION HCC comprises around 60 to 80% of all primary liver cancers and exhibits wide geographical variability. Appropriate treatment allocation needs to include both patient and tumor characteristics. AREAS COVERED Current HCC classification systems to guide therapy are either liver function-centric and evaluate physiologic liver function to guide therapy or prognostic stratification classification systems broadly based on tumor morphologic parameters, patient performance status, and liver reserve assessment. This review focuses on different classification systems for HCC, their strengths, and weaknesses as well as the use of artificial intelligence in improving prognostication in HCC. EXPERT OPINION Future HCC classification systems will need to incorporate clinic-pathologic data from a multitude of sources and emerging therapies to develop patient-specific treatment plans targeting a patient's unique tumor profile.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Greece
| | - D Brock Hewitt
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Zachary J Brown
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Medical School, Greece
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
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62
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Ho SY, Liu PH, Hsu CY, Huang YH, Liao JI, Su CW, Hou MC, Huo TI. A New Tumor Burden Score and Albumin-Bilirubin Grade-Based Prognostic Model for Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:649. [PMID: 35158917 PMCID: PMC8833827 DOI: 10.3390/cancers14030649] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023] Open
Abstract
The prognosis of hepatocellular carcinoma (HCC) varies widely due to variable tumor extent and liver reserve. We aimed to develop and validate a new prognostic model based on tumor burden score (TBS) and albumin-bilirubin (ALBI) grade for HCC. We prospectively identified 3794 HCC patients who were randomized into derivation and validation groups. Survival predictors were evaluated by a multivariate Cox model. The TBS-ALBI system allocated two points for high TBS and ALBI grade 3, and one point each for the presence of ascites, serum α-fetoprotein ≥ 400 ng/mL, vascular invasion or distant metastasis, performance status 2-4, medium TBS, and ALBI grade 2, with a maximal score of 8 points. Significant survival differences were found across different TBS-ALBI score groups in the validation cohort (all p < 0.001). The TBS-ALBI system had the lowest corrected Akaike information criterion (AICc) and the highest homogeneity compared with other proposed staging models. The discriminative ability of the TBS-ALBI system was consistently stable across different viral etiologies, cancer stages, and treatment strategies. Conclusions: This new TBS-ALBI system is a feasible and robust prognostic system in comparison with other systems; it is a user-friendly tool for long-term outcome assessment independent of treatment modality and cancer stage in HCC.
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Affiliation(s)
- Shu-Yein Ho
- Division of Gastroenterology and Hepatology, Min-Sheng General Hospital, Taoyuan 330, Taiwan;
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
| | - Po-Hong Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Chia-Yang Hsu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Veterans Affairs Sierra Nevada Healthcare System, Reno, NV 89502, USA
| | - Yi-Hsiang Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
| | - Jia-I Liao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Chien-Wei Su
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Teh-Ia Huo
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan; (P.-H.L.); (C.-Y.H.); (Y.-H.H.); (J.-I.L.); (C.-W.S.); (M.-C.H.)
- Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
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Byun D, Lee SG, Kim H, You Y, Jung J, Jang JH, Lee MS, Kim CN, Cho BS, Kang YJ. Prognostic value of preoperative protein-induced vitamin K absence or antagonist II after liver resection for hepatitis B-related hepatocellular carcinoma: a nationwide multicenter study. Ann Surg Treat Res 2022; 103:271-279. [DOI: 10.4174/astr.2022.103.5.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/18/2022] [Accepted: 09/01/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dahn Byun
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Seul Gi Lee
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Hyeyoung Kim
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Yunghun You
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Jaehag Jung
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Je Ho Jang
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Moon-Soo Lee
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Chang-Nam Kim
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Byung Sun Cho
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
| | - Yoon-Jung Kang
- Department of Surgery, Daejeon Eulji Medical Center, Eulji University College of Medicine, Daejeon, Korea
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Screening Hub Genes of Hepatocellular Carcinoma Based on Public Databases. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:7029130. [PMID: 34737790 PMCID: PMC8563136 DOI: 10.1155/2021/7029130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 12/24/2022]
Abstract
Tumor recurrence and metastasis often occur in HCC patients after surgery, and the prognosis is not optimistic. Hence, searching effective biomarkers for prognosis of is of great importance. Firstly, HCC-related data was acquired from the TCGA and GEO databases. Based on GEO data, 256 differentially expressed genes (DEGs) were obtained firstly. Subsequently, to clarify function of DEGs, clusterProfiler package was used to conduct functional enrichment analyses on DEGs. Protein-protein interaction (PPI) network analysis screened 20 key genes. The key genes were filtered via GEPIA database, by which 11 hub genes (F9, CYP3A4, ASPM, AURKA, CDC20, CDCA5, NCAP, PRC1, PTTG1, TOP2A, and KIFC1) were screened out. Then, univariate Cox analysis was applied to construct a prognostic model, followed by a prediction performance validation. With the risk score calculated by the model and common clinical features, univariate and multivariate analyses were carried out to assess whether the prognostic model could be used independently for prognostic prediction. In conclusion, the current study screened HCC prognostic gene signature based on public databases.
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65
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Ho SY, Liu PH, Hsu CY, Ko CC, Huang YH, Su CW, Lee RC, Tsai PH, Hou MC, Huo TI. Tumor burden score as a new prognostic marker for patients with hepatocellular carcinoma undergoing transarterial chemoembolization. J Gastroenterol Hepatol 2021; 36:3196-3203. [PMID: 34159651 DOI: 10.1111/jgh.15593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/26/2021] [Accepted: 06/20/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Size and number are major determinants of tumor burden in hepatocellular carcinoma (HCC). Patients with HCC undergoing transarterial chemoembolization (TACE) have variable outcomes due to heterogeneity of tumor burden. Recently, tumor burden score (TBS) was proposed to evaluate the extent of tumor involvement. However, the prognostic accuracy of TBS has not been well evaluated in HCC. This study aimed to assess its prognostic role in HCC patients undergoing TACE. METHODS A total of 935 treatment-naïve HCC patients receiving TACE were retrospectively analyzed. Multivariate Cox proportional hazards model was used to determine independent prognostic predictors. RESULTS Tumor burden score tended to increase with increasing size and number of tumors in study patients. The Cox model showed that serum creatinine ≥ 1.2 mg/dL (hazard ratio [HR]: 1.296, 95% confidence interval [CI]: 1.077-1.559, P = 0.006), serum α-fetoprotein ≥ 400 ng/dL (HR: 2.245, 95% CI: 1.905-2.645, P < 0.001), vascular invasion (HR: 1.870, 95% CI: 1.520-2.301, P < 0.001), medium TBS (HR: 1.489, 95% CI: 1.206-1.839, P < 0.001) and high TBS (HR: 2.563, 95% CI: 1.823-3.602, P < 0.001), albumin-bilirubin (ALBI) grade 2-3 (HR: 1.521, 95% CI: 1.291-1.792, P < 0.001), and performance status 1 (HR: 1.362, 95% CI: 1.127-1.647, P < 0.001) and status 2 (HR: 1.553, 95% CI: 1.237-1.948, P < 0.001) were associated with increased mortality. Patients with high TBS had poor overall survival in Barcelona Clinic Liver Cancer stage B/C and different ALBI grades. CONCLUSIONS Tumor burden score is a feasible new prognostic surrogate marker of tumor burden in HCC and can well discriminate survival in patients undergoing TACE across different baseline characteristics.
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Affiliation(s)
- Shu-Yein Ho
- Division of Gastroenterology and Hepatology, Min-Sheng General Hospital, Taoyuan City, Taiwan.,Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hong Liu
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chia-Yang Hsu
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chih-Chieh Ko
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Wei Su
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Rheun-Chuan Lee
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Hsing Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Teh-Ia Huo
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
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66
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State-of-the-art surgery for hepatocellular carcinoma. Langenbecks Arch Surg 2021; 406:2151-2162. [PMID: 34405284 DOI: 10.1007/s00423-021-02298-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most commonly diagnosed primary liver tumor with an increasing incidence worldwide. Management of patients with HCC is largely dictated by the presence of cirrhosis, disease stage, underlying liver function, and patient performance status. PURPOSE We provide an update on key aspects of surgical treatment options for patients with HCC. RESULTS & CONCLUSIONS: Liver resection and transplantation remain cornerstone treatment options for patients with early-stage disease and constitute the only potentially curative options for HCC. Selection of patients for surgical treatment should include a thorough evaluation of tumor characteristics and biology, as well as evidence-based use of various available treatment options to achieve optimal long-term outcomes for patients with HCC.
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67
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Takayama T, Yamazaki S, Matsuyama Y, Midorikawa Y, Shiina S, Izumi N, Hasegawa K, Kokudo N, Sakamoto M, Kubo S, Kudo M, Murakami T, Nakashima O. Prognostic grade for resecting hepatocellular carcinoma: multicentre retrospective study. Br J Surg 2021; 108:412-418. [PMID: 33793713 DOI: 10.1093/bjs/znaa109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Surgical treatment for hepatocellular carcinoma (HCC) is advancing, but a robust prediction model for survival after resection is not available. The aim of this study was to propose a prognostic grading system for resection of HCC. METHODS This was a retrospective, multicentre study of patients who underwent first resection of HCC with curative intent between 2000 and 2007. Patients were divided randomly by a cross-validation method into training and validation sets. Prognostic factors were identified using a Cox proportional hazards model. The predictive model was built by decision-tree analysis to define the resection grades, and subsequently validated. RESULTS A total of 16 931 patients from 795 hospitals were included. In the training set (8465 patients), four surgical grades were classified based on prognosis: grade A1 (1236 patients, 14.6 per cent; single tumour 3 cm or smaller and anatomical R0 resection); grade A2 (3614, 42.7 per cent; single tumour larger than 3 cm, or non-anatomical R0 resection); grade B (2277, 26.9 per cent; multiple tumours, or vascular invasion, and R0 resection); and grade C (1338, 15.8 per cent; multiple tumours with vascular invasion and R0 resection, or R1 resection). Five-year survival rates were 73.9 per cent (hazard ratio (HR) 1.00), 64.7 per cent (HR 1.51, 95 per cent c.i. 1.29 to 1.78), 50.6 per cent (HR 2.53, 2.15 to 2.98), and 34.8 per cent (HR 4.60, 3.90 to 5.42) for grades A1, A2, B, and C respectively. In the validation set (8466 patients), the grades had equivalent reproducibility for both overall and recurrence-free survival (all P < 0.001). CONCLUSION This grade is used to predict prognosis of patients undergoing resection of HCC.
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Affiliation(s)
- T Takayama
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - S Yamazaki
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Y Matsuyama
- Department of Biostatistics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Y Midorikawa
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - S Shiina
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - N Izumi
- Department of Gastroenterology, Musashino Red Cross Hospital, Tokyo, Japan
| | - K Hasegawa
- Department of Hepato-biliary-pancreatic Surgery, School of Medicine, University of Tokyo, Tokyo, Japan
| | - N Kokudo
- Department of Hepato-biliary-pancreatic Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - M Sakamoto
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - S Kubo
- Department of Hepato-biliary-pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - M Kudo
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-Sayama, Japan
| | - T Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - O Nakashima
- Department of Clinical Laboratory Medicine, Kurume University Hospital, Kurume, Japan
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Tsilimigras DI, Pawlik TM. Prognostication in hepatocellular carcinoma: is it a burden or a ticket? Br J Surg 2021; 108:337-339. [PMID: 33734326 DOI: 10.1093/bjs/znaa167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 01/13/2023]
Affiliation(s)
- D I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - T M Pawlik
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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69
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Elfadaly AN, Tsilimigras DI, Hyer JM, Paro A, Bagante F, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Impact of Tumor Burden Score on Conditional Survival after Curative-Intent Resection for Hepatocellular Carcinoma: A Multi-Institutional Analysis. World J Surg 2021; 45:3438-3448. [PMID: 34341844 DOI: 10.1007/s00268-021-06265-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of tumor burden score (TBS) on conditional survival (CS) among patients undergoing curative-intent resection of hepatocellular carcinoma (HCC) has not been examined to date. METHODS Patients who underwent liver resection of HCC between 2000 and 2017 were identified from a multi-institutional database. The impact of TBS and other clinicopathologic factors on 3-year conditional survival (CS3) was examined. RESULTS Among 1,040 patients, 263 (25.3%) patients had low TBS, 668 (64.2%) had medium TBS and 109 (10.5%) had high TBS. TBS was strongly associated with OS; 5-year OS was 39.0% among patients with high TBS compared with 61.1% and 79.4% among patients with medium and low TBS, respectively (p < 0.001). While actuarial survival decreased as time elapsed from resection, CS increased over time irrespective of TBS. The largest differences between 3-year actuarial survival and CS3 were noted among patients with high TBS (5-years postoperatively; CS3: 78.7% vs. 3-year actuarial survival: 30.7%). The effect of adverse clinicopathologic factors including high TBS, poor/undifferentiated tumor grade, microvascular invasion, liver capsule involvement, and positive margins on prognosis decreased over time. CONCLUSIONS CS rates among patients who underwent resection for HCC increased as patients survived additional years, irrespective of TBS. CS estimates can be used to provide important dynamic information relative to the changing survival probability after resection of HCC.
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Affiliation(s)
- Ahmed N Elfadaly
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alessandro Paro
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | | | - Itaru Endo
- Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Ding G, Zeng Y, Yang D, Zhang C, Mao C, Xiao E, Kang Y, Shang J. Silenced lncRNA DDX11-AS1 or up-regulated microRNA-34a-3p inhibits malignant phenotypes of hepatocellular carcinoma cells via suppression of TRAF5. Cancer Cell Int 2021; 21:179. [PMID: 33752668 PMCID: PMC7983398 DOI: 10.1186/s12935-021-01847-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/20/2021] [Indexed: 01/06/2023] Open
Abstract
Background Studies have discussed long noncoding RNA DDX11-AS1 (DDX11-AS1)-mediated downstream mechanism in hepatocellular carcinoma (HCC). The goal of this study was to investigate the regulatory mechanism of DDX11-AS1-mediated microRNA-34a-3p (miR-34a-3p)/tumor necrosis factor receptor-associated factor 5 (TRAF5) axis on HCC cells. Methods DDX11-AS1, miR-34a-3p and TRAF5 expression levels in HCC were detected. The correlation of DDX11-AS1, miR-34a-3p and TRAF5 in HCC patients was analyzed by Pearson test. HCC cells were transfected with corresponding plasmid/oligonucleotide, and cell proliferation, migration, invasion, apoptosis and tumor formation ability were detected. Bioinformatics software, dual luciferase report experiment and RNA-pull down experiment analysis were applied to verify the targeting relationship between DDX11-AS1, miR-34a-3p and TRAF5. Results Elevated DDX11-AS1 and TRAF5 and reduced miR-34a-3p exhibited in HCC. Silenced DDX11-AS1 or up-regulated miR-34a-3p inhibited the proliferation, migration, invasion, promoted apoptosis of HCC cells and repressed the tumor growth in nude mice. In addition, DDX11-AS1 bound to miR-34a-3p to target TRAF5. Silencing TRAF5 or elevating miR-34a-3p expression mitigated up-regulated DDX11-AS1-mediated promotion of tumor growth. Conclusion Silenced DDX11-AS1 or up-regulated miR-34a-3p inhibits HCC cell growth via elevation of TRAF5, which could be of great benefit to find early diagnostic markers for HCC patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12935-021-01847-6.
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Affiliation(s)
- Gangqiang Ding
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China.
| | - Yanli Zeng
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Dongqiang Yang
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Can Zhang
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Chongshan Mao
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Erhui Xiao
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Yi Kang
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Key Laboratory for Liver Disease, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, 450003, Henan, China
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Tsilimigras DI, Sahara K, Hyer JM, Diaz A, Moris D, Bagante F, Guglielmi A, Ruzzenente A, Alexandrescu S, Poultsides G, Sasaki K, Aucejo F, Ejaz A, Cloyd JM, Pawlik TM. Trends and outcomes of simultaneous versus staged resection of synchronous colorectal cancer and colorectal liver metastases. Surgery 2021; 170:160-166. [PMID: 33674128 DOI: 10.1016/j.surg.2021.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/22/2020] [Accepted: 01/25/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The objective of this study was to assess trends in the use as well as the outcomes of patients undergoing simultaneous versus staged resection for synchronous colorectal liver metastases. METHODS Patients undergoing resection for colorectal liver metastases between 2008 and 2018 were identified using a multi-institutional database. Trends in use and outcomes of simultaneous resection of colorectal liver metastases were examined over time and compared with that of staged resection after propensity score matching. RESULTS Among 1,116 patients undergoing resection for colorectal liver metastases, 690 (61.8%) patients had synchronous disease. Among them, 314 (45.5%) patients underwent simultaneous resection, while 376 (54.5%) had staged resection. The proportion of patients undergoing simultaneous resection for synchronous colorectal liver metastases increased over time (2008: 37.2% vs 2018: 47.4%; ptrend = 0.02). After propensity score matching (n = 201 per group), patients undergoing simultaneous resection for synchronous colorectal liver metastases had a higher incidence of overall (44.8% vs 34.3%; P = .03) and severe complications (Clavien-Dindo ≥III) (16.9% vs 7.0%; P = .002) yet comparable 90-day mortality (3.5% vs 1.0%; P = .09) compared with patients undergoing staged resection. The incidence of severe morbidity decreased over time (2008: 50% vs 2018: 11.1%; ptrend = 0.02). Survival was comparable among patients undergoing simultaneous versus staged resection of colorectal liver metastases (3-year overall survival: 66.1% vs 62.3%; P = .67). Following simultaneous resection, severe morbidity and mortality increased incrementally based on the extent of liver resection and complexity of colectomy. CONCLUSION While simultaneous resection was associated with increased morbidity, the incidence of severe morbidity decreased over time. Long-term survival was comparable after simultaneous resection versus staged resection of colorectal liver metastases.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. https://twitter.com/DTsilimigras
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dimitrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Department of Surgery, University of Verona, Italy
| | | | | | | | | | - Kazunari Sasaki
- Department of General Surgery, Cleveland Clinic Foundation, OH
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, OH
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
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Tsilimigras DI, Hyer JM, Diaz A, Bagante F, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Synergistic Impact of Alpha-Fetoprotein and Tumor Burden on Long-Term Outcomes Following Curative-Intent Resection of Hepatocellular Carcinoma. Cancers (Basel) 2021; 13:cancers13040747. [PMID: 33670174 PMCID: PMC7916953 DOI: 10.3390/cancers13040747] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The prognostic role of tumor burden score (TBS) relative to pre-operative α -fetoprotein (AFP) levels among patients undergoing curative-intent resection of HCC has not been examined. METHODS Patients who underwent curative-intent resection of HCC between 2000 and 2017 were identified from a multi-institutional database. The impact of TBS on overall survival (OS) and cumulative recurrence relative to serum AFP levels was assessed. RESULTS Among 898 patients, 233 (25.9%) patients had low TBS, 572 (63.7%) had medium TBS and 93 (10.4%) had high TBS. Both TBS (5-year OS; low TBS: 76.9%, medium TBS: 60.9%, high TBS: 39.1%) and AFP (>400 ng/mL vs. <400 ng/mL: 48.5% vs. 66.1%) were strong predictors of outcomes (both p < 0.001). Lower TBS was associated with better OS among patients with both low (5-year OS, low-medium TBS: 68.0% vs. high TBS: 47.7%, p < 0.001) and high AFP levels (5-year OS, low-medium TBS: 53.7% vs. high TBS: not reached, p < 0.001). Patients with low-medium TBS/high AFP had worse OS compared with individuals with low-medium TBS/low AFP (5-year OS, 53.7% vs. 68.0%, p = 0.003). Similarly, patients with high TBS/high AFP had worse outcomes compared with patients with high TBS/low AFP (5-year OS, not reached vs. 47.7%, p = 0.015). Patients with high TBS/low AFP and low TBS/high AFP had comparable outcomes (5-year OS, 47.7% vs. 53.7%, p = 0.24). The positive predictive value of certain TBS groups relative to the risk of early recurrence and 5-year mortality after HCC resection increased with higher AFP levels. CONCLUSION Both TBS and serum AFP were important predictors of prognosis among patients with resectable HCC. Serum AFP and TBS had a synergistic impact on prognosis following HCC resection with higher serum AFP predicting worse outcomes among patients with HCC of a certain TBS class.
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Affiliation(s)
- Diamantis I. Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.I.T.); (J.M.H.); (A.D.); (F.B.)
| | - J. Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.I.T.); (J.M.H.); (A.D.); (F.B.)
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.I.T.); (J.M.H.); (A.D.); (F.B.)
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.I.T.); (J.M.H.); (A.D.); (F.B.)
- Department of Surgery, University of Verona, 37134 Verona, Italy;
| | - Francesca Ratti
- Department of Surgery, Ospedale San Raffaele, 20132 Milano, Italy; (F.R.); (L.A.)
| | - Hugo P. Marques
- Department of Surgery, Curry Cabral Hospital, 1069-166 Lisbon, Portugal;
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, 92110 Clichy, France;
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney 2145, Australia;
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, 022328 Bucharest, Romania; (I.P.); (S.A.)
| | - Sorin Alexandrescu
- Department of Surgery, Fundeni Clinical Institute, 022328 Bucharest, Romania; (I.P.); (S.A.)
| | - Guillaume Martel
- Department of Surgery, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (G.M.); (A.W.)
| | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (G.M.); (A.W.)
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney 2006, Australia;
| | - Luca Aldrighetti
- Department of Surgery, Ospedale San Raffaele, 20132 Milano, Italy; (F.R.); (L.A.)
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan;
| | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.I.T.); (J.M.H.); (A.D.); (F.B.)
- Correspondence: ; Tel.: +1-614-293-8701; Fax: +1-614-293-4063
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Tsilimigras DI, Pawlik TM. ASO Author Reflections: Tumor Burden in Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2021; 28:1979-1980. [PMID: 33393044 DOI: 10.1245/s10434-020-09419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Tsilimigras DI, Hyer JM, Bagante F, Guglielmi A, Ruzzenente A, Alexandrescu S, Poultsides G, Sasaki K, Aucejo F, Pawlik TM. Resection of Colorectal Liver Metastasis: Prognostic Impact of Tumor Burden vs KRAS Mutational Status. J Am Coll Surg 2020; 232:590-598. [PMID: 33383214 DOI: 10.1016/j.jamcollsurg.2020.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prognostic impact of colorectal liver metastasis (CRLM) morphologic characteristics relative to KRAS mutational status after hepatic resection remains ill defined. STUDY DESIGN Patients undergoing hepatectomy for CRLM between 2001 and 2018 were identified using an international multi-institutional database. Tumor burden score (TBS) was defined as distance from origin on a Cartesian plane that incorporated maximum tumor size (x-axis) and number of lesions (y-axis). Impact of TBS on overall survival (OS) relative to KRAS status (wild type [wtKRAS] vs mutated [mutKRAS]) was assessed. RESULTS Among 1,361 patients, the median number of metastatic lesions was 2 (interquartile range [IQR] 1-3), and median size of the largest metastatic lesion was 3.0 cm (IQR 2.0-5.0 cm), resulting in a median TBS of 4.1 (IQR 2.8-6.1); KRAS status was wtKRAS (n = 420, 30.9%), mutKRAS (n = 251, 18.4%), and unknown (n = 690, 50.7%). Overall median and 5-year OS were 49.5 months (95%CI 45.2-53.8) and 43.2%, respectively. In examining the entire cohort, TBS was associated with long-term prognosis (5-year OS, low TBS: 49.4% vs high TBS: 36.7%), as was KRAS mutational status (5-year OS, wtKRAS: 48.2% vs mutKRAS: 31.1%; unknown KRAS: 44.0%)(both p < 0.01). Among patients with wtKRAS tumors, TBS was strongly associated with improved OS (5-year OS, low TBS: 59.1% vs high TBS: 38.4%, p = 0.002); however, TBS failed to discriminate long-term prognosis among patients with mutKRAS tumors (5-year OS, low TBS: 37.4% vs high TBS: 26.7%, p = 0.19). In fact, patients with high TBS/wtKRAS CRLM had comparable outcomes to patients with low TBS/mutKRAS tumors (5-year OS, 38.4% vs 37.4%, respectively; p = 0.59). On multivariable analysis, while TBS was associated with OS among patients with wtKRAS CRLM (hazard ratio 1.43, 95%CI 1.02-2.00; p = 0.03), TBS was not an independent predictor of survival among patients with mutKRAS CRLM (HR 1.36, 95%CI 0.92-1.99; p = 0.12). CONCLUSIONS While TBS was associated with survival among patients with wtKRAS tumors, CRLM morphology was not predictive of long-term outcomes among patients with mutKRAS CRLM.
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Affiliation(s)
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; University of Verona, Verona, Italy
| | | | | | | | | | | | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
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Tsilimigras DI, Hyer JM, Paredes AZ, Moris D, Sahara K, Guglielmi A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Soubrane O, Koerkamp BG, Endo I, Sasaki K, Aucejo F, Zhang XF, Pawlik TM. Tumor Burden Dictates Prognosis Among Patients Undergoing Resection of Intrahepatic Cholangiocarcinoma: A Tool to Guide Post-Resection Adjuvant Chemotherapy? Ann Surg Oncol 2020; 28:1970-1978. [PMID: 33259043 DOI: 10.1245/s10434-020-09393-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/04/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION While tumor burden (TB) has been associated with outcomes among patients with hepatocellular carcinoma, the role of overall TB in intrahepatic cholangiocarcinoma (ICC) remains poorly defined. METHODS Patients undergoing curative-intent resection of ICC between 2000 and 2017 were identified from a multi-institutional database. The impact of TB on overall (OS) and disease-free survival (DFS) was evaluated in the multi-institutional database and validated externally. RESULTS Among 1101 patients who underwent curative-intent resection of ICC, 624 (56.7%) had low TB, 346 (31.4%) medium TB, and 131 (11.9%) high TB. OS incrementally worsened with higher TB (5-year OS; low TB: 48.3% vs medium TB: 29.8% vs high TB: 17.3%, p < 0.001). Similarly, patients with low TB had better DFS compared with medium and high TB patients (5-year DFS: 38.3% vs 18.7% vs 6.9%, p < 0.001). On multivariable analysis, TB was independently associated with OS (medium TB: HR = 1.40, 95% CI 1.14-1.71; high TB: HR = 1.89, 95% CI 1.46-2.45) and DFS (medium TB, HR = 1.61, 95% CI 1.33-1.96; high TB: HR = 2.03, 95% CI 1.56-2.64). Survival analysis revealed an excellent prognostic discrimination using the TB among the external validation cohort (3-year OS; low TB: 44.8%, medium TB: 29.3%; high TB: 23.3%, p = 0.03; 3-year DFS: low TB: 32.7%, medium TB: 10.7%; high TB: 0%, p < 0.001). While neoadjuvant chemotherapy was not associated with survival across the TB groups, receipt of adjuvant chemotherapy was associated with increased survival among patients with high TB (5-year OS: 24.4% vs 13.4%, p = 0.02). CONCLUSION Overall TB dictated prognosis among patients with resectable ICC. TB may be used as a tool to help guide post-resection treatment strategies.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Federico Aucejo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Overall Tumor Burden Dictates Outcomes for Patients Undergoing Resection of Multinodular Hepatocellular Carcinoma Beyond the Milan Criteria. Ann Surg 2020; 272:574-581. [PMID: 32932309 DOI: 10.1097/sla.0000000000004346] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of the current study was to define surgical outcomes after resection of multinodular hepatocellular carcinoma (HCC) beyond the Milan criteria, and develop a prediction tool to identify which patients likely benefit the most from resection. BACKGROUND Liver resection for multinodular HCC, especially beyond the Milan criteria, remains controversial. Rigorous selection of the best candidates for resection is essential to achieve optimal outcomes after liver resection of advanced tumors. METHODS Patients who underwent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. Patients were categorized according to Milan criteria status. Pre- and postoperative overall survival (OS) prediction models that included HCC tumor burden score (TBS) among patients with multinodular HCC beyond Milan criteria were developed and validated. RESULTS Among 1037 patients who underwent resection for HCC, 164 (15.8%) had multinodular HCC beyond the Milan criteria. Among patients with multinodular HCC, 25 (15.2%) patients experienced a serious complication and 90-day mortality was 3.7% (n = 6). Five-year OS after resection of multinodular HCC beyond Milan criteria was 52.8%. A preoperative TBS-based model (5-year OS: low-risk, 73.7% vs intermediate-risk, 45.1% vs high-risk, 13.1%), and postoperative TBS-based model (5-year OS: low-risk, 80.1% vs intermediate-risk, 37.2% vs high-risk, not reached) categorized patients into distinct prognostic groups relative to long-term prognosis (both P < 0.001). Pre- and postoperative models could accurately stratify OS in an external validation cohort (5-year OS; low vs medium vs high risk; pre: 66.3% vs 25.2% vs not reached, P = 0.012; post: 61.4% vs 42.5% vs not reached, P = 0.045) Predictive accuracy of the pre- and postoperative models was good in the training (c-index; pre: 0.68; post: 0.71), internal validation (n = 2000 resamples) (c-index, pre: 0.70; post: 0.72) and external validation (c-index, pre: 0.67; post 0.68) datasets. TBS alone could stratify patients relative to 5-year OS after resection of multinodular HCC beyond Milan criteria (c-index: 0.65; 5-year OS; low TBS: 70.2% vs medium TBS: 54.7% vs high TBS: 16.7%; P < 0.001). The vast majority of patients with low and intermediate TBS were deemed low or medium risk based on both the preoperative (98.4%) and postoperative risk scores (95.3%). CONCLUSION Prognosis of patients with multinodular HCC was largely dependent on overall tumor burden. Liver resection should be considered among patients with multinodular HCC beyond the Milan criteria who have a low- or intermediate-TBS.
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Moris D, Shaw BI, McElroy L, Barbas AS. Using Hepatocellular Carcinoma Tumor Burden Score to Stratify Prognosis after Liver Transplantation. Cancers (Basel) 2020; 12:E3372. [PMID: 33202588 PMCID: PMC7697953 DOI: 10.3390/cancers12113372] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains a mainstay of treatment for hepatocellular carcinoma (HCC). Tumor factors such as size and number of tumors define eligibility for LT using the Milan criteria. The tumor burden score (TBS) incorporates both tumor number and size into a single continuous variable and has been used to differentiate prognosis among patients undergoing resection for HCC. The objective of the present study was to evaluate the ability of the TBS to predict overall and recurrence-free survival in patients undergoing LT for HCC. The Scientific Registry of Transplant Recipients (SRTR) was used to analyze all liver transplants for HCC, with initial tumor size data from 2004 to 2018. There were 12,486 patients in the study period. In the unadjusted analyses, patients with a high TBS had worse overall (p < 0.0001) and recurrence-free (p < 0.0001) survival. In the adjusted analyses, a high TBS was associated with a greater hazard ratio (HR) of death (HR = 1.21; 95%CI, [1.13-1.30]; p < 0.001) and recurrence (HR = 1.49; 95%CI [1.3-1.7]; p < 0.001). When we superimposed the TBS on the Milan criteria, we saw that a higher TBS was associated with a higher hazard of recurrence at values that were either all within (HR = 1.20; 95%CI, [1.04-1.37]; p = 0.011) or variably within (HR = 1.53; 95%CI, [1.16-2.01]; p = 0.002) the Milan criteria. In conclusion, the TBS is a promising tool in predicting outcomes in patients with HCC after LT.
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Affiliation(s)
- Dimitrios Moris
- Box 3512, DUMC, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA; (B.I.S.); (L.M.); (A.S.B.)
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Tsilimigras DI, Hyer JM, Diaz A, Moris D, Bagante F, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Impact of time-to-surgery on outcomes of patients undergoing curative-intent liver resection for BCLC-0, A and B hepatocellular carcinoma. J Surg Oncol 2020; 123:381-388. [PMID: 33174627 DOI: 10.1002/jso.26297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The impact of a prolonged time-to-surgery (TTS) among patients with resectable hepatocellular carcinoma (HCC) is not well defined. METHODS Patients who underwent curative-intent hepatectomy for BCLC-0, A and B HCC between 2000 and 2017 were identified using a multi-institutional database. The impact of prolonged TTS on overall survival (OS) and disease-free survival (DFS) was examined. RESULTS Among 775 patients who underwent resection for HCC, 537 (69.3%) had early surgery (TTS < 90 days) and 238 (30.7%) patients had a delayed surgery (TTS ≥ 90 days). Patient- and tumor-related characteristics were similar between the two groups except for a higher proportion of patients undergoing major liver resection in the early surgery group (31.3% vs. 23.8%, p = .04). The percentage of patients with delayed surgery varied from 8.8% to 59.1% among different centers (p < .001). Patients with TTS < 90 days had similar 5-year OS (63.7% vs. 64.9; p = .79) and 5-year DFS (33.5% vs. 42.4; p = .20) with that of patients with TTS ≥ 90 days. On multivariable analysis, delayed surgery was not associated with neither worse OS (BCLC-0/A: adjusted hazards ratio [aHR] = 0.90; 95% confidence interval [CI]: 0.65-1.25 and BCLC-B: aHR = 0.72; 95%CI: 0.30-1.74) nor DFS (BCLC-0/A: aHR = 0.78; 95%CI: 0.60-1.01 and BCLC-B: aHR = 0.67; 95% CI: 0.36-1.25). CONCLUSION Approximately one in three patients diagnosed with resectable HCC had a prolonged TTS. Delayed surgery was not associated with worse outcomes among patients with resectable HCC.
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Affiliation(s)
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Demetrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | | | - Itaru Endo
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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79
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Huo TI, Liu PH, Hsu CY. Tumour burden score for hepatocellular carcinoma: Is it an authentic prognostic marker? Br J Surg 2020; 107:e625. [PMID: 32955113 DOI: 10.1002/bjs.11927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/25/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Teh-Ia Huo
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Taipei, Taiwan.,Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Po-Hong Liu
- Faculty of Medicine, Taipei, Taiwan.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chia-Yang Hsu
- Faculty of Medicine, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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80
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Tsilimigras DI, Mehta R, Guglielmi A, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Recurrence beyond the Milan criteria after curative-intent resection of hepatocellular carcinoma: A novel tumor-burden based prediction model. J Surg Oncol 2020; 122:955-963. [PMID: 32602143 DOI: 10.1002/jso.26091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/13/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Accurate prediction of recurrence patterns of hepatocellular carcinoma (HCC) may allow for prioritization of patients for resection or transplantation as well as guide post-resection surveillance strategies. METHODS Patients who underwent curative-intent R0 resection for HCC between 2000 and 2017 were identified using a multi-institutional database. A prognostic model that incorporated HCC tumor burden score (TBS) to predict recurrence beyond the Milan criteria (MC) was developed and validated. RESULTS Among 718 patients who underwent R0 resection for HCC, 185 (25.8%) recurred within and 110 (15.3%) beyond the MC. On multivariable analysis, AFP more than 400 ng/mL (hazard ratio [HR] = 2.26; 95% confidence interval [CI]: 1.27-4.02), lymphovascular invasion (HR = 2.00; 95% CI: 1.14-3.50), and TBS (HR = 1.08; 95% CI: 1.03-1.12) were associated with recurrence beyond the MC. A weighted TBS-based score was constructed: [0.074*TBS + 0.692*lymphovascular invasion (yes: 1, no: 0) + 0.816*AFP > 400 (yes:1, no:0)]. Patients with a low, medium, and high TBS-based risk score had a 5-year incidence of recurring beyond the MC of 16.2%, 28.6%, and 47.2%, respectively (P < .001). The predictive accuracy of the model was very good in the training (C-index: 0.761) and validation (C-index: 0.706) datasets and outperformed the previously reported clinical risk score (CRS; C-index: 0.680). CONCLUSION A TBS-based model accurately predicted recurrence beyond MC after curative-intent resection of HCC and outperformed the CRS. Incorporating TBS allows for better risk stratification and identifies patients in need of closer surveillance.
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Affiliation(s)
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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81
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Wigmore SJ. Advances in liver surgery. Br J Surg 2020; 107:788-789. [DOI: 10.1002/bjs.11624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 12/23/2022]
Affiliation(s)
- S J Wigmore
- Medical Research Council Centre for Inflammation Research, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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