Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int. 2010;4:439-474. [PMID: 20827404 DOI: 10.1007/s12072-010-9165-7]

Diagnostic performance and interreader agreement of CEUS LI-RADS in ≤ 30 mm liver nodules with different experienced radiologists

PURPOSE

To explore the diagnostic performance and interreader agreement of CEUS LI-RADS in diagnosing ≤ 30 mm liver nodules with different experienced radiologists.

METHODS

Between January 2018 and October 2020, 244 patients at high-risk for HCC who underwent CEUS were enrolled. Two novice radiologists and two expert radiologists independently evaluated LI-RADS categories and main features. Kappa (κ) and Kendall's tests were employed to evaluate the interreader agreement of CEUS LI-RADS. The diagnostic performance was determined based on sensitivity, specificity, accuracy, PPV and NPV.

RESULTS

The interreader agreement for arterial phase hyperenhancement, late and mild washout, early washout, and rim hyperenhancement was moderate to almost perfect (κ, 0.44-0.93) among the different levels of radiologists. The interreader agreement for the LI-RADS categories was substantial to almost perfect (κ, 0.78-0.88). However, the interreader agreement for marked washout was fair to moderate (κ, 0.28-0.50). When CEUS LR-5 was used as a diagnostic criterion for HCC, there were no statistical differences in sensitivity, specificity, accuracy, PPV and NPV among the radiologists (p > 0.05), except for the differences between Reader 4 and the remaining three radiologists in terms of accuracy and sensitivity (p < 0.05).

CONCLUSION

CEUS LI-RADS has good diagnostic agreement for ≤ 30 mm liver nodules among experienced radiologists.

Minimally invasive surgery versus percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma: Results from a high-volume liver surgery center in East Asia

BACKGROUND & AIMS

The outcomes of minimally invasive surgery (MIS) vs. percutaneous radiofrequency ablation (RFA) in treating early-stage hepatocellular carcinoma (HCC) remain inconclusive. This study thus aimed to compare the outcomes of both treatments for early-stage HCCs.

METHODS

This retrospective study consecutively enrolled patients with newly diagnosed early-stage HCCs treated with MIS or percutaneous RFA between 2011 and 2018. Outcomes were compared between the MIS and RFA groups both before and after 1:1 propensity score matching (PSM).

RESULTS

A total of 119 and 481 patients underwent MIS and percutaneous RFA, respectively. Patients undergoing percutaneous RFA exhibited older age (p = 0.007) and higher rates of Child-Pugh class B (p < 0.001) and multifocal disease (p < 0.001). The median overall survival (OS) was 73.7 months in the MIS group, which was significantly higher than that for the RFA group of 65.1 months (p = 0.003). 50% HCC recurrence after MIS was not reached. The mean recurrence-free survival (RFS) was 49.6 months for the MIS group, which was significantly higher than the RFA group of 41.3 months (p < 0.001). On multivariate analysis, age ≥65 (HR: 1.61; 95% CI: 1.13-2.31, p = 0.009), RFA (HR: 2.21; 95% CI: 1.14-4.29, p = 0.019), and Child-Pugh class B (HR: 2.03; 95% CI: 1.29-3.21, p = 0.002) remained risk factors for OS, and RFA (HR: 2.18; 95% CI: 1.42-3.35; p < 0.001) remained a risk factor for RFS. After PSM, 103 patients were included in each group. No significant difference in OS was identified (p = 0.198), but RFS was higher in the MIS group than the RFA group (p = 0.003). Severe postoperative complications occurred at the same rate (1%) in both groups (p > 0.99).

CONCLUSION

After PSM, severe postoperative complication and OS rates were found to be comparable between the MIS and RFA groups, but RFS was higher in the MIS group than the RFA group, suggesting that MIS may have better outcomes for patients with early-stage HCC.

Circulating Let-7 Family Members as Non-Invasive Biomarkers for Predicting Hepatocellular Carcinoma Risk after Antiviral Treatment among Chronic Hepatitis C Patients

HCC, a leading cause of cancer-related mortality, is diagnosed at advanced stages. Although antiviral therapy has reduced the risk of HCC among chronic hepatitis C (CHC) patients, the risk of HCC remains, thus, highlighting the unmet need for continuous surveillance. Therefore, stable and cost-effective biomarkers, such as circulating microRNAs, must be identified. We aimed to clarify whether serum levels of the Let-7 family can predict HCC risk in patients with CHC using univariate and multivariate Cox’s proportional hazards model. We analyzed the sera of 54 patients with CHC who developed HCC after antiviral therapy and compared the data with those of 173 patients without HCC development. The Let-7 family (except for let-7c) exhibited significant negative correlations with the fibrosis score (r = −0.2736 to −0.34, p = 0.0002 to <0.0001). After Cox’s regression model was used to adjust for age, sex, HCV genotype, and FIB-4 ≥ 3.25, patients with CHC with let-7i median ≥ −1.696 (adjusted hazard ratio [aHR] = 0.31, 95% CI: 0.08−0.94, p = 0.0372) in the sustained virologic response (SVR) groups and ≥−1.696 (aHR = 0.09, 95% CI: 0.08−0.94, p = 0.0022) in the non-SVR group were less likely to develop HCC. Thus, circulating let-7i can be used for early CHC surveillance in patients with HCC risk after antiviral treatment.

The Value of Color Doppler Ultrasound and CT Combined with Serum AFP Examination in the Diagnosis of Hepatocellular Carcinoma

Objective

To evaluate the value of the combination of color Doppler ultrasound, computed tomography (CT), and serum tumor marker alpha-fetoprotein (AFP) examination in the diagnosis of hepatocellular carcinoma (HCC).

Methods

98 patients with HCC (malignant tumor group) and 50 liver lesion patients (benign control group), were selected for the study, and retrospective statistical methods were used to evaluate the diagnostic values of the three examinations on hepatocellular carcinoma.

Results

(1) When comparing color Doppler ultrasound blood flow parameters, the hepatic artery diameter, peak flow velocity, minimum flow velocity, and resistance index (RI) of hepatocellular carcinoma were significantly higher than those of the benign control group (P < 0.05), while the portal vein flow velocity was significantly lower than that of the control group (P < 0.05). (2) Enhanced CT imaging of hepatocellular carcinoma lesions showed mostly outflow-type enhancement changes, with high- or slightly high-density shadowing and uneven enhancement in the arterial phase, relatively low density and withdrawal of enhancement in the portal vein phase and delayed phase. (3) The serum AFP level of hepatocellular carcinoma patients was significantly higher than that of the benign control group (P < 0.01). (4) The sensitivity of color Doppler ultrasound, CT, and serum AFP alone for the diagnosis of HCC was 79.59%, 85.71%, and 66.33%, and the accuracy was 83.78%, 87.16%, and 74.32%, respectively, while the combination of the three tests could significantly increase the sensitivity to 96.94% and the accuracy to 93.92%, compared with each individual test (P < 0.01).

Conclusion

Color Doppler ultrasound and CT combined with serum AFP examination could significantly improve the sensitivity and accuracy of hepatocellular carcinoma diagnosis, reduce misdiagnosis, and facilitate early diagnosis and clinical early intervention.

Typical and Atypical Imaging Findings of Hepatocellular Carcinoma on Multiphasic MDCT Scan in Histologically Proved Cases

Objective The purpose of this study was to find out the incidence of typical and atypical radiological imaging findings of hepatocellular carcinoma (HCC) on multiphase multidetector computed tomography (MDCT) scans in histologically proven cases.

Materials and Methods A multiphase computed tomography study of 73 patients with histologically proven HCC was evaluated by a radiologist. Our multiphasic protocol was composed of precontrast, arterial, portal, and delayed venous phases. The reviewers analyzed the CT images for tumor size, enhancement patterns of HCC in different phases, relative timing of washout, internal cystic changes, and presence of dysmorphic intratumoral vessel aneurysms or arteriovenous shunt.

Results Most of the cases (95.9%) showed typical enhancement patterns in MDCT, i.e., enhancements in the arterial phase with the portal or delayed venous phase contrast washout. Three cases (4.9%) out of 73 HCC showed enhancements in the portal phase and washout in the delayed venous phase. Seven cases out of total 73 HCC (9.5%) patients showed heterogeneous enhancements in both arterial and portal phases and contrast washout in the delayed venous phase. Venous thrombosis was noted in about 44 cases (60%) out of total 73 patients, in which portal vein thrombosis was more common than hepatic veins/inferior vena cava.

Conclusion Most of the HCC show typical enhancement patterns, i.e., heterogeneous enhancements in the arterial phase and washout in the portal venous phase when we use MDCT. These findings are higher than those described previously. However, in our study, the main difference with MDCT was lower frequency of intratumoral pseudoaneurysm and bile duct invasion, and intratumoral fat and calcification (atypical character of HCC) were not found which were rare findings in previous study.

Identification of the suitable candidates for EOB-MRI with the high risk of the presence of non-hypervascular hypointense nodules in patients with HCV infection

OBJECTIVES

Non-hypervascular hypointense nodules (NHHNs) depicted by gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) have a high likelihood of progressing to hepatocellular carcinoma (HCC). The presence of NHHNs is a strong risk factor for HCC development in patients with chronic hepatitis C virus (HCV) infection after the achievement of sustained virologic response (SVR). However, it is difficult for all patients with HCV infection to undergo EOB-MRI for NHHN detection. We therefore explored serum markers that potentially indicate the presence of NHHNs.

METHODS

Three serum markers, alpha-fetoprotein (AFP), FIB-4 index, and Wisteria floribunda agglutinin-positive Mac-2 binding protein glycan isomer (M2BPGi), were measured in 481 patients with HCV infection and no history of HCC who underwent EOB-MRI. The associations between these serum marker levels and the presence of NHHNs were investigated.

RESULTS

All three markers were associated with the presence of NHHNs. M2BPGi predicted the presence of NHHNs more accurately than AFP and FBB-4 index; M2BPGi had the highest area under the receiver operating characteristic curve. Multivariate analysis identified male gender and high M2BPGi as factors associated with the presence of NHHNs. When patients were stratified by the degree of liver fibrosis, M2BPGi increased with the progression of fibrosis. In addition, NHHNs were more prevalently detected in patients with higher M2BPGi (COI > 3.46) in patients with similar fibrosis degree.

CONCLUSIONS

M2BPGi is a serum marker that potentially identifies HCV patients with high risk of the presence of NHHNs, for whom EOB-MRI should be considered.

KEY POINTS

• Non-hypervascular hypointense nodule on EOB-DTPA-enhanced MRI is pre-HCC nodule with high likelihood of progressing to HCC, which is a strong predictor for HCC that develops after the eradication of HCV in patients with HCV infection. • It is difficult for all patients with HCV infection to undergo EOB-MRI for NHHN detection due to limited access, limited availability of MRI equipment, and high costs. • Serum Wisteria floribunda agglutinin-positive Mac-2 binding protein glycan isomer (M2BPGi) levels effectively indicate the presence of NHHNs and can be used to identify patients with high risk of their presence, for whom EOB-DTPA-enhanced MRI should be considered.

Machine Learning-Based Personalized Prediction of Hepatocellular Carcinoma Recurrence After Radiofrequency Ablation

Background and Aims

Radiofrequency ablation (RFA) is a widely accepted, minimally invasive treatment for hepatocellular carcinoma (HCC). This study aimed to develop a machine learning (ML) model to predict the risk of HCC recurrence after RFA treatment for individual patients.

Methods

We included a total of 1778 patients with treatment-naïve HCC who underwent RFA. The cumulative probability of overall recurrence after the initial RFA treatment was 78.9% and 88.0% at 5 and 10 years, respectively. We developed a conventional Cox proportional hazard model and 6 ML models-including the deep learning-based DeepSurv model. Model performance was evaluated using Harrel's c-index and was validated externally using the split-sample method.

Results

The gradient boosting decision tree (GBDT) model achieved the best performance with a c-index of 0.67 from external validation, and it showed a high discriminative ability in stratifying the external validation sample into 2, 3, and 4 different risk groups (P < .001 among all risk groups). The c-index of DeepSurv was 0.64. In order of significance, the tumor number, serum albumin level, and des-gamma-carboxyprothrombin level were the most important variables for the prediction of HCC recurrence in the GBDT model. Also, the current GBDT model enabled the output of a personalized cumulative recurrence prediction curve for each patient.

Conclusion

We developed a novel ML model for the personalized risk prediction of HCC recurrence after RFA treatment. The current model may lead to the personalization of effective follow-up strategies after RFA treatment according to the risk stratification of HCC recurrence.

The diagnostic value of contrast-enhanced ultrasound LI-RADS for hepatocellular carcinoma in patients with cirrhosis and chronic hepatitis B

PURPOSE

To explore the diagnostic value of American College of Radiology Contrast-Enhanced Ultrasound-Liver Imaging Reporting and Data System (ACR-CEUS-LI-RADS) for hepatocellular carcinoma (HCC) in patients with cirrhosis and chronic hepatitis B.

METHODS

A total of 205 patients at high risk of HCC with solitary hepatic nodule were enrolled and retrospectively analyzed. All patients were over 18 years old and had a single lesion with a diameter < 50 mm. Lesions were categorized according to size and contrast enhancement patterns in the arterial, portal venous and late phases. Diagnostic efficacy of CEUS LI-RADS for HCC, and the rate of non-HCC malignancies in the LR-M class were compared between patients with cirrhosis and chronic hepatitis B.

RESULTS

Of all 205 nodules (median nodule size was 34 mm), 142 (69.3%) were HCC. Of the 127 (61.9%) LR-5 category nodules, 95.8% (92/96) nodules were corresponded to HCC in cirrhosis, while 61.3% (19/31) nodules were corresponded to HCC in chronic hepatitis B (P = 0.000). Positive predictive value (PPV) of LR-5 category for HCC was 95.8% in cirrhosis and 61.3% in chronic hepatitis B (P = 0.000). More category of LR-4 nodules were proved to be HCC in patients with cirrhosis than chronic hepatitis B (80.0% vs 8.3%, P = 0.000). Of 41 LR-M category nodules, more non-HCC malignancies were found in chronic hepatitis B (76.0%) than that in cirrhosis (25.0%, P = 0.001).

CONCLUSIONS

The LR-5 category is highly specific for the diagnosis of HCC in patients with cirrhosis. However, LR-5 category nodules require further CT or MRI examination or histological confirmation in patients with chronic hepatitis B for its unsatisfactory PPV for HCC.

Liver Imaging Reporting and Data System: Review of Pros and Cons

The American College of Radiology has released the Liver Imaging Reporting and Data System (LI-RADS) scheme which categorizes focal liver lesions (FLLs) in patients at risk for hepatocellular carcinoma (HCC) according to the degree of risk of nodules to be HCC. It subgroups FLL in LR-1 (definitely benign), LR-2 (probably benign), LR-3 (intermediate probability of malignancy), LR-4 (probably HCC), LR-5 (definitely HCC), and LR-M (probable malignancy not specific for HCC). Computed tomography/magnetic resonance imaging (CT/MRI) and contrast enhanced ultrasound (CEUS) LI-RADS diagnostic algorithm have the goal to standardize the acquisition, interpretation, reporting, and data collection for imaging examinations in patients at risk for HCC. Nevertheless, there remain controversial issues that should be dealt with. The aim of this review is to discuss the pros and cons of the interpretation and reporting part of CT/MRI and CEUS LI-RADS diagnostic algorithm to permit future refinements of the scheme and optimize patient and nodule management.

Preoperative predictors of non-transplantable recurrence after resection for early-stage hepatocellular carcinoma: application in an East Asian cohort

A French study found that three preoperative factors (i.e. alpha-fetoprotein (AFP) > 100 ng/ml, image-diagnosed tumor number > 1, and cirrhosis) could predict non-transplantable recurrence (NTR) after liver resection (LR) for early-stage hepatocellular carcinoma (HCC). We aimed to evaluate whether this model could be applicable in an East Asian cohort from a country in which the majority of patients undergo living donor liver transplantation (LT). This retrospective study enrolled consecutive patients who underwent LR for transplantable HCC between 2011 and 2018 in our institution. The occurrence of NTR after LR was analyzed in a competing risks analysis, with death and transplantable recurrence as competing events. A total of 309 patients were included. The five-year overall survival and recurrence-free survival were 79.0% and 51.4%, respectively (median follow-up: 32.0 months). Recurrence was noted in 94 (30.4%) patients. NTR was noted in 35 (11.3%) patients. Univariate analysis showed that cirrhosis (sub-distribution hazard ratio (SHR) = 2.301, 95% CI = 1.046-5.065; p = 0.038) and image-diagnosed tumor number > 1 (SHR = 2.32; 95% CI = 1.11-4.86; p = 0.026) were associated with NTR, whereas AFP > 100 ng/ml (SHR = 1.56; 95% CI = 0.59-4.10; p = 0.37) was not associated with NTR. In the presence of 0, 1, and 2 factors (i.e. cirrhosis or image-diagnosed tumor number > 1), the NTR rates were 7.2%, 10.8%, and 29.0%, respectively. The results showed that the French model was applicable to our cohort. In the presence of two factors (i.e. cirrhosis and image-diagnosed tumor number > 1), risks and benefits of upfront LT could be discussed with the patient and the living donor.

The combination of transcatheter arterial chemoembolisation (TACE) and thermal ablation versus TACE alone for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the sixth most common cancer worldwide. Hepatic resection is regarded as the curative therapy for hepatocellular carcinoma. However, only about 20% of people with hepatocellular carcinoma are candidates for resection, which highlights the importance of effective nonsurgical therapies. Until now, transcatheter arterial chemoembolisation (TACE) is the most common palliative therapy for hepatocellular carcinoma, but its clinical benefits remain unsatisfactory. During recent years, some studies have reported that the combination of TACE plus thermal ablation can confer a more favourable prognosis than TACE alone. However, clear and compelling evidence to prove the beneficial or harmful effects of the combination of TACE and thermal ablation therapy is lacking.

OBJECTIVES

To assess the beneficial and harmful effects of the combination of thermal ablation with TACE versus TACE alone in people with hepatocellular carcinoma.

SEARCH METHODS

We performed searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science. We endeavoured to identify relevant randomised clinical trials also in the China National Knowledge Infrastructure (CNKI) and Wanfang databases. We searched trial registration websites for ongoing studies. We also handsearched grey literature sources. The date of last search was 22 December 2020.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing the combination of TACE plus thermal ablation versus TACE alone for hepatocellular carcinoma, no matter the language, year of publication, publication status, and reported outcomes.

DATA COLLECTION AND ANALYSIS

We planned to use standard methodological procedures expected by Cochrane. We planned to calculate risk ratios (RRs) with the corresponding 95% confidence intervals (CIs). For time-to-event variables, we planned to use the methods of survival analysis and express the intervention effect as a hazard ratio (HR) with 95% Cl. If the log HR and the variance were not directly reported in reports, we planned to calculate them indirectly, following methods for incorporating summary time-to-event data into meta-analysis. We planned to assess the risk of bias of the included studies using the RoB 2 tool. We planned to assess the certainty of evidence with GRADE and present the evidence in a summary of findings table.

MAIN RESULTS

Out of 2224 records retrieved with the searches, we considered 135 records eligible for full-text screening. We excluded 21 of these records because the interventions used were outside the scope of our review or the studies were not randomised clinical trials. We listed the remaining 114 records, reporting on 114 studies, under studies awaiting classification because we could not be sure that these were randomised clinical trials from the information in the study paper. We could not obtain information on the registration of the study protocol for any of the 114 studies. We could not obtain information on study approval by regional research ethics committees, either from the study authors or through our own searches of trial registries. Corresponding authors did not respond to our enquiries about the design and conduct of the studies, except for one from whom we did not receive a satisfactory response. We also raised awareness of our concerns to editors of the journals that published the 114 studies, and we did not hear back with useful information. Moreover, there seemed to be inappropriate inclusion of trial participants, based on cancer stage and severity of liver disease, who should have obtained other interventions according to guidelines from learned societies. Accordingly, we found no confirmed randomised clinical trials evaluating the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma for inclusion in our review. We identified five ongoing trials, by handsearching in clinical trial websites.

AUTHORS' CONCLUSIONS

We could not find for inclusion any confirmed randomised clinical trials assessing the beneficial or harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma. Therefore, our results did not show or reject the efficiency of the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma. We need trials that compare the beneficial and harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma, not eligible for treatments with curative intent (liver transplantation, ablation surgical resection) and who have sufficient liver reserve, as assessed by the Child Pugh score, and who do not have extrahepatic metastases. Therefore, future trial participants must be classified at Barcelona Clinic Liver Cancer Stage B (intermediate stage) (BCLC-B) or an equivalent, with other staging systems.

Cartilage oligomeric matrix protein as a non-invasive biomarker for diagnosis of hepatocellular carcinoma in patients with liver cirrhosis

Aim

The current study purposed to evaluate serum COMP (Cartilage oligomeric matrix protein) as a diagnostic marker for HCC in patients with cirrhosis and to correlate it with other parameters of disease progression.

Background

COMP is known to promote fibrosis in various tissues. Emerging evidence shows that COMP plays critical roles in tumor development. It can serve as a fibrosis and cancer biomarkers.

Methods

The study included 24 subjects who serve as the healthy control, 24 cirrhotic patients without HCC, and 24 HCC patients with cirrhosis. All participants were subjected to liver function tests, AFP, calculation of fibrotic indices (APRI and FIB-4), and serum COMP by ELISA.

Results

COMP was significantly increased in cirrhotic patients when compared to healthy controls and in HCC patients when compared to cirrhotic patients and healthy controls. A significant positive correlation was observed between COMP and APRI and FIB-4 in cirrhotic and HCC patients. Based on receiver operating characteristic (ROC) curve analysis, COMP had an area under curve (AUC) of 0.943 with 87.5% sensitivity and 79.2% specificity for diagnosis of HCC in cirrhotic patients. In combination with AFP, the sensitivity was increased to 100%.

Conclusion

COMP might act as a promising non-invasive biomarker for HCC either alone or in combination with AFP. It was correlated with the degree of fibrosis and associated with advanced cancer staging.

Comparison of liver cancer incidence and survival by subtypes across seven high-income countries

International comparison of liver cancer survival has been hampered due to varying standards and degrees for morphological verification and differences in coding practices. This article aims to compare liver cancer survival across the International Cancer Benchmarking Partnership's (ICBP) jurisdictions whilst trying to ensure that the estimates are comparable through a range of sensitivity analyses. Liver cancer incidence data from 21 jurisdictions in 7 countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the United Kingdom) were obtained from population-based registries for 1995-2014. Cases were categorised based on histological classification, age-groups, basis of diagnosis and calendar period. Age-standardised incidence rate (ASR) per 100 000 and net survival at 1 and 3 years after diagnosis were estimated. Liver cancer incidence rates increased over time across all ICBP jurisdictions, particularly for hepatocellular carcinoma (HCC) with the largest relative increase in the United Kingdom, increasing from 1.3 to 4.4 per 100 000 person-years between 1995 and 2014. Australia had the highest age-standardised 1-year and 3-year net survival for all liver cancers combined (48.7% and 28.1%, respectively) in the most recent calendar period, which was still true for morphologically verified tumours when making restrictions to ensure consistent coding and classification. Survival from liver cancers is poor in all countries. The incidence of HCC is increasing alongside the proportion of nonmicroscopically verified cases over time. Survival estimates for all liver tumours combined should be interpreted in this context. Care is needed to ensure that international comparisons are performed on appropriately comparable patients, with careful consideration of coding practice variations.

Impact of Revision of the LR-M Criteria on the Diagnostic Performance of Contrast-Enhanced Ultrasound LI-RADS

This study was aimed at revising the LI-RADS M category (LR-M) criteria to improve the diagnostic performance categories LR-5 and LR-M of the contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) Version 2017. We enrolled 264 patients (264 nodules) with a risk for hepatocellular carcinoma (HCC). The nodules were assigned specific CEUS LI-RADS categories. Washout onset times for all nodules were noted. The diagnostic performance of LR-5 and LR-M was analyzed based on the different early washout criterion for the LR-M category. The positive predictive values in LR-5, LR-4 and LR-3 were 98.6%, 72.2% and 16.7%, respectively, and that for non-HCC malignancies in LR-M was 25.0%. Patients in the LR-M category were reclassified using 45 s as the early washout criterion. LR-5 had higher sensitivity (65.5% vs. 76.2%, p = 0.012) and area under the receiver operating characteristic curve (0.80 vs. 0.85, p = 0.001) for HCC diagnosis after reclassification. LR-M also had higher specificity (71.4% vs. 81.3%, p = 0.010) in diagnosing non-HCC malignancies after reclassification. Our findings suggest CEUS LR-5 is effective for HCC diagnosis. The use of 45 s as the time criterion of early washout for LR-M can improve LR-5 and LR-M performance in the diagnosis of HCC and non-HCC malignancies, respectively.

The characteristics of patients with macrovascular invasion in hepatocellular carcinoma: when East meets West

PURPOSE

To evaluate the prevalence and extension of macrovascular invasion (MaVI) in a large cohort of hepatocellular carcinoma (HCC) patients and analyze the association between MaVI and overall survival (OS).

METHODS

From 2011 to 2018, 2540 patients with newly diagnosed HCC who were managed in our institution were enrolled in this retrospective study. Tumor invasion of the intrahepatic branches of the portal or hepatic veins was defined as peripheral MaVI. Tumor invasion of the main portal vein or inferior vena cava was defined as central MaVI.

RESULTS

MaVI prevalence was 16.2% (n = 411). Among patients with Barcelona Clinic Liver Cancer (BCLC) stage C and Child-Pugh class A, 165 patients presented with peripheral MaVI and 89 patients with central MaVI. The median OS was 13.2 months (95% confidence interval [CI]: 11.4-15.4) in the peripheral MaVI group and 6.6 months (95% CI: 3.6-9.5) in the central MaVI group (p < 0.001). In patients with BCLC stage C and Child-Pugh class B or BCLC stage D, 68 patients presented with peripheral MaVI and 89 patients with central MaVI. The median OS was 3.6 months (95% CI: 3.1-4.2) in the peripheral MaVI group and 2.8 months (95% CI: 2.1-3.4) in the central MaVI group (p = 0.674).

CONCLUSION

The extension of MaVI significantly affected patient survival only in those with BCLC stage C and Child-Pugh class A. In patients with BCLC stage C and Child-Pugh class B or BCLC stage D, survival was poor irrespective of MaVI status.

Guidewire-catheter induced hydrodissection to assist radiofrequency ablation for subcapsular hepatocellular carcinoma with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion

PURPOSE

We aimed to evaluate the usefulness of guidewire-catheter induced hydrodissection (GIH) to assist radiofrequency ablation (RFA) for subcapsular hepatocellular carcinoma (HCC) with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

METHODS

This retrospective study included 17 patients with small subcapsular HCC ineligible for ultrasonography-guided RFA who received RFA under guidance of fluoroscopy and cone-beam computed tomography immediately after iodized oil transarterial chemoembolization (TACE) between April 2011 and January 2016. In the study patients, creation of artificial ascites to protect the perihepatic structures failed due to perihepatic adhesion and GIH was attempted to separate the perihepatic structures from the ablation zone. The technical success rate of GIH, technique efficacy of RFA with GIH, local tumor progression (LTP), peritoneal seeding, and complications were evaluated.

RESULTS

The technical success rate of GIH was 88.24% (15 of 17 patients). Technique efficacy was achieved in all 15 patients receiving RFA with GIH. During an average follow-up period of 48.1 months, LTP developed in three patients. Cumulative LTP rates at 1, 2, 3, and 5 years were 13.3%, 20.6%, 20.6%, and 20.6%, respectively. No patient had peritoneal seeding. Two of the 15 patients receiving RFA with GIH had a CIRSE grade 3 liver abscess, but none had complications associated with thermal injury to the diaphragm or abdominal wall near the ablation zone.

CONCLUSION

GIH can be a useful method to assist RFA for subcapsular HCC with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

Effectiveness of individual audio-visual coaching, respiratory modulated stereotactic body radiotherapy for localized hepatocellular carcinoma: Analysis of 29 cases from a single academic radiotherapy center

Objectives:

Recently, Stereotactic Body Radiotherapy (SBRT) has been suggested for managing hepatocellular carcinoma (HCC) curatively. Thus, we conducted this clinical study to evaluate retrospectively the effect of individualized audio-visual (AV) coaching, respiratory modulated SBRT.

Materials and Methods:

Between 2014 and 2018, 29 patients with inoperable Barcelona Clinic Liver Cancer (BCLC) stage 0-B HCC received AV coaching, respiratory-modulated SBRT. We constructed a task-oriented multidisciplinary team to establish a standard operation process of respiratory modulation procedures and developed our AV coaching devices. In the training period, a goodness-of-fit test was applied individually. SBRT was delivered with a total dose of 40–54 Gy in 5–6 fractions individually. Freedom from local progression (FFLP) and overall survival (OS) were estimated using SPSS (version 17, SPSS Inc., Chicago, IL, USA) life tables.

Results:

The patient characteristics were as follows: 32.7 ± 16 mm in maximum tumor diameter (range 11–94); BCLC stage 0: 3.4%, BCLC A: 48.3%, BCLC B: 48.3%; Child-Pugh classification A: 86.2%, Child-Pugh classification B: 13.8%, and a median of 2 prior liver-directed treatments (range 0–7). One-, 2-, and 3-year rates of FFLP of SBRT were 96.6%, 96.6%, and 96.6%, respectively. One-, 2-, and 3-year rates of OS were 81.5%, 72.4%, and 67.2%, respectively. No adverse event (AE) occurred in 41.4% of patients, 48.3% developed grade (G) 1–2 AE, 10.3% had G3 AE and none had G4-5 AE.

Conclusion:

Respiration-modulated SBRT is a promising noninvasive treatment option for patients with inoperable and localized HCC. Our data show that SBRT provides comparable tumor control to historical curative options like surgery and radiofrequency ablation of localized tumors. Thus, we are conducting a further prospective clinical trial with the intent to demarcate the clinical effectiveness of SBRT in a larger population of patients with HCC.

Outcome of Hepatocellular Carcinoma Detected During Surveillance: Comparing USA and Japan

BACKGROUND & AIMS

Differences in outcomes of hepatocellular carcinoma (HCC) between countries have been largely attributed to variation in the conduct of surveillance and subsequent HCC treatment eligibility. However, differences in outcomes among those detected under surveillance have not been well described. We compared characteristics and prognosis between patients with surveillance-detected HCC from the United States (US) and Japan.

METHODS

Patients in whom initial HCC was detected under surveillance between January 2006 and December 2015 from two centers in the US and two from Japan were included. Survival was compared between patients from the US and Japan using multivariable Cox regression analysis and propensity-score matched analysis. We performed subgroup analyses by liver disease etiology, tumor stage, and type of HCC treatment.

RESULTS

Of 3788 HCC patients, 1797 (47.4%) were diagnosed under surveillance, 715 from the US and 1082 from Japan. Patients from the US diagnosed under surveillance had worse liver dysfunction and larger tumor burden than those from Japan. In multivariate analysis, US patients with surveillance-detected HCC had significantly worse survival than those from Japan (HR 1.17, 95% CI 1.00-1.35), which was also observed in propensity-score matched analysis. However, this difference was no longer significant after adjusting for treatment type (HR 1.07, 95% CI 0.92-1.25). When stratified by treatment type, survival was comparable between the two countries except lower survival among patients who underwent resection in the US versus Japan.

CONCLUSIONS

Prognosis of patients with surveillance-detected HCC is poorer in the US than Japan, primarily driven by differences in treatment delivery. Studies are necessary to elucidate reasons for these differences.

MRI is the most commonly used imaging modality for HCC screening at a tertiary care transplant center

PURPOSE

In this study, we describe the patterns of hepatocellular carcinoma (HCC) screening with imaging and factors associated with imaging modality selection in a tertiary care transplant center.

METHODS

This was a retrospective study where all adult patients with cirrhosis and/or chronic hepatitis B virus infection referred for HCC screening with ultrasound (US), CT or MRI were identified during 2017. The association between imaging methods, demographic/clinical data were analyzed by uni- and multivariate analysis.

RESULTS

A total of 1437 patients were included (median age 61y, 59% male, median BMI 27.5 kg/m², median AFP 3.4 ng/mL, 37% with HCV and 87% with cirrhosis). Index screening imaging method utilization included MRI (51%), US (33%) and CT (16%). Use of US as the index imaging modality for screening was significantly associated with race/ethnicity [Odds Ratio (OR) 1.71-2.01, all p < 0.05] in multivariate analysis. Presence of cirrhosis (OR 0.29, p < 0.001) and referral by a hepatologist (OR 0.23, p < 0.001) were associated with screening with MRI in the multivariate analysis; while gender, age, BMI, etiology and income at ZIP code of residence were not significantly associated with imaging modality selection. HCC was observed in 62 patients (prevalence 4.3%). Rate of HCC detection was significantly higher with MRI vs US (5.9% vs. 1.5%, p = 0.001).

CONCLUSION

MRI was the most frequently used modality (> 50%) for HCC screening in our tertiary care center, in contrast with the current practice guidelines. Race/ethnicity, cirrhosis and referral by a hepatologist were associated with the imaging method used for HCC screening.

The Persistence of Hepatitis C Virus Infection in Hepatocytes Promotes Hepatocellular Carcinoma Progression by Pro-Inflammatory Interluekin-8 Expression

Background: A large amount of epidemiological evidence indicates that persistent HCV infection is the main risk factor for HCC. We aimed to study the effects of persistent HCV infection on the interaction of the virus and host cell to identify cancer gene profiles. Methods: Next-generation sequencing (NGS) was used to identify differentially expressed genes between uninfected Huh7.5.1 control cells, short-term HCV (S-HCV), early long-term HCV (eL-HCV), and long-term HCV (L-HCV) infections, which were analyzed using different dynamic bioinformatics and analytic tools. mRNA expression was validated and quantified using q-PCR. One hundred ninety-six serum samples of HCV patients with IFN/RBV treatment were used to study chemokine levels. Results: S-HCV activates an inflammatory response and drives cell death and apoptosis through cell cycle arrest via MAPK signaling. L-HCV promotes cell growth and alters cell adhesion and chemokine signaling via CXCL8-mediated-SRC regulation. A total of 196 serum samples from the HCV and HCV-HCC cohorts demonstrated significantly upregulated pro-inflammatory CXCL8 in non-SVR (persistent HCV infection) patients in the HCV-HCC group. Conclusions: Persistent infection with HCV induced pro-inflammatory CXCL8 and the oncogene SRC, thereby triggering and promoting hepatocarcinogenesis. CXCL8 may be a potential biomarker for monitoring HCV-related HCC progression.

Perfluorobutane contrast-enhanced ultrasonography for the diagnosis of HCC: a systematic review and meta-analysis

OBJECTIVES

Perfluorobutane ultrasound contrast agent as a new type of contrast agent has a good performance in the diagnosis of hepatocellular carcinoma (HCC). This study aim to evaluate the accuracy and reliability of Perfluorobutane contrast-enhanced ultrasonography (P-CEUS) in the diagnosis of HCC with a systematic review and meta-analysis.

METHODS

Web of Science, EMBASE, Cochrane, Clinical Key, Wan Fang, CBM and CNKI databases were systematically searched and checked for studies using P-CEUS in HCC, from 2007 to 2020. Data necessary to construct 2 × 2 contingency tables were extracted from included studies. The QUADAS tool was utilized to assess the methodologic quality of the studies. Meta-analysis included data pooling, subgroup analyses, meta-regression and investigation of publication bias was comprehensively performed.

RESULTS

Nine studies were included in this meta-analysis and the overall diagnostic accuracy in characterization of HCC was as follows: pooled sensitivity, 0.90 (95% confidence interval: 0.82-0.95); pooled specificity, 0.97 (0.93-0.98); pooled positive likelihood ratio, 27.2 (14.1 to - 52.3); and pooled negative likelihood ratio, 0.10 (0.06-0.18). The area under the comprehensive receiving operation characteristic curve was 0.98 (0.97-0.99).

CONCLUSION

The sensitivity and specificity of P-CEUS are more valuable than other imaging techniques (such as computer tomography or magnetic resonance imaging). However, due to the large differences in the data samples collected in this study, statistical heterogeneity results. P-CEUS can significantly improve the diagnostic efficiency of previous contrast-enhanced ultrasound for HCC. PROSPERO registration number: PROSPERO (CRD42020200040).

Preoperative predictors of early recurrence after resection for hepatocellular carcinoma

BACKGROUND

To assess preoperative image tumor characteristics and alpha-fetoprotein (AFP) levels to predict early recurrence after liver resection (LR) for hepatocellular carcinoma (HCC).

METHODS

This retrospective study's enrolled patients underwent LR for newly diagnosed HCC between 2011 and 2018. Multivariate logistic regression analyses using the Akaike information criterion were adopted to construct a nomogram to predict early recurrence (i.e. recurrence within 1 year). The performance of this nomogram was evaluated using calibration plots with bootstrapping.

RESULTS

Early recurrence was identified in 99 patients (11.2%). Four predictive factors, namely an AFP level of >400 ng/mL; image-diagnosed tumor characteristics, including a tumor size of > 5 cm; vascular invasion; and multiple tumors were adopted in the final model of the early recurrence nomogram, with a concordance index of 0.67. The calibration plots showed good agreement between the nomogram predictions and the actual observations of early recurrence.

CONCLUSION

We have developed a simple nomogram with preoperative image tumor characteristics and AFP levels to predict the early recurrence of HCC after LR.

Validation of an alpha-fetoprotein model to predict recurrence after liver resection for hepatocellular carcinoma

To validate a previously reported alpha-fetoprotein (AFP) model (including three variables: preoperative image-diagnosed tumor number and size and AFP level) for the prediction of recurrence in hepatocellular carcinoma (HCC) patients who have undergone liver resection (LR). This retrospective study enrolled patients who underwent curative LR for newly diagnosed HCC in our institution between 2011 and 2018. The probabilities of overall survival (OS) and recurrence were compared according to the aforementioned AFP model. A total of 838 patients were included. AFP score ≥ 3 versus ≤ 2 independently predicted recurrence and OS. However, net reclassification improvements (NRI) indicated that the AFP model was not superior to the Barcelona Clinic Liver Cancer (BCLC) system for predicting 1-year recurrence (p = 0.746). Relatedly, we developed a modified AFP model based on our cohort. The modified AFP score ≥ 3 versus ≤ 2 independently predicted recurrence and OS. However, NRI again indicated that the modified AFP model was not superior to the BCLC system for predicting 1-year recurrence (p = 0.69). Patients with a modified AFP score ≤ 2 had a risk of recurrence similar to that of patients with a modified AFP score ≥ 3 in BCLC stage 0-A (p = 0.57). However, patients with a modified AFP score ≤ 2 had a lower risk of recurrence than patients with a modified AFP score ≥ 3 in BCLC stage B-C (p = 0.02). The original AFP model was not feasible in our cohort. However, the modified AFP model may be useful for predicting recurrence in BCLC B-C patients who underwent LR in our cohort.

Development of an AI system for accurately diagnose hepatocellular carcinoma from computed tomography imaging data

BACKGROUND AND AIMS

Computed tomography (CT) scan is frequently used to detect hepatocellular carcinoma (HCC) in routine clinical practice. The aim of this study is to develop a deep-learning AI system to improve the diagnostic accuracy of HCC by analysing liver CT imaging data.

METHODS

We developed a deep-learning AI system by training on CT images from 7512 patients at Henan Provincial Peoples' Hospital. Its performance was validated on one internal test set (Henan Provincial Peoples' Hospital, n = 385) and one external test set (Henan Provincial Cancer Hospital, n = 556). The area under the receiver-operating characteristic curve (AUROC) was used as the primary classification metric. Accuracy, sensitivity, specificity, precision, negative predictive value and F1 metric were used to measure the performance of AI systems and radiologists.

RESULTS

AI system achieved high performance in identifying HCC patients, with AUROC of 0.887 (95% CI 0.855-0.919) on the internal test set and 0.883 (95% CI 0.855-0.911) on the external test set. For internal test set, accuracy was 81.0% (76.8-84.8%), sensitivity was 78.4% (72.4-83.7%), specificity was 84.4% (78.0-89.6%) and F1 (harmonic average of precision and recall rate) was 0.824. For external test set, accuracy was 81.3% (77.8-84.5%), sensitivity was 89.4% (85.0-92.8%), specificity was 74.0% (68.5-78.9%) and F1 was 0.819. Compared with radiologists, AI system achieved comparable accuracy and F1 metric on internal test set (0.853 versus 0.818, P = 0.107; 0.863 vs. 0.824, P = 0.082) and external test set (0.805 vs. 0.793, P = 0.663; 0.810 vs. 0.814, P = 0.866). The predicted HCC risk scores by AI system in HCC patients with multiple tumours and high fibrosis stage were higher than those with solitary tumour and low fibrosis stage (tumour number: 0.197 vs. 0.138, P = 0.006; fibrosis stage: 0.183 vs. 0.127, P < 0.001). Radiologists' review showed that the accuracy of saliency heatmaps predicted by algorithms was 92.1% (95% CI: 89.2-95.0%).

CONCLUSIONS

AI system achieved high performance in the detection of HCC compared with a group of specialised radiologists. Further investigation by prospective clinical trials was necessitated to verify this model.

Screening, clinical features and prognostic analysis of liver cirrhosis-related hepatocellular carcinoma

OBJECTIVE

To explore the impact of the screening interval and methods on cirrhosis-related hepatocellular carcinoma (HCC) detection and to analyse the clinical features and prognosis of HCC.

MATERIALS AND METHODS

We recruited 3000 patients diagnosed with liver cirrhosis, who had been treated at the First Affiliated Hospital of Anhui Medical University from January 2016 to January 2020. The time of admission was divided into 3- (group A, 539 cases), 6- (group B, 1012 cases), and 12-month screening groups (group C, 1449 cases). We compared the detection rate of small HCCs in each group and analysed the clinical characteristics and prognosis of the patients with HCC.

RESULTS

We detected a total of 124 HCC cases, including 41 cases of small HCC: 21, 14, and 6 cases in groups A, B, and C, respectively. The detection rate was 3.9% (21/539) in group A, which was significantly higher than that in groups B and C (χ² = 31.186, p < .001). Single small, right liver lobe, and alpha-fetoprotein-negative HCCs accounted for 90.2%, 73.2%, and 68.3%, respectively. We detected vascular invasion and lymph node metastasis in one and three cases, respectively. The average survival time of patients in the small HCC group was significantly higher than that in the non-small-HCC group (35.68 ± 12.95 vs. 22.87 ± 11.42 months) (t = 5.623, p < .001).

CONCLUSIONS

Screening patients with a history of liver cirrhosis at intervals of 3 months can increase the detection rate of small HCCs. Early detection can provide more patients with an opportunity for radical treatment and prolong their survival.

The growth rate of hepatocellular carcinoma is different with different TNM stages at diagnosis

BACKGROUND

Hepatocellular carcinoma (HCC) progresses fast and has a poor prognosis, but the growth rate in different TNM stages is not clear. The present study was to estimate the growth rate of HCC with different TNM stages at diagnosis.

METHODS

Baseline demographics and tumor characteristics were analyzed for 10145 patients in Surveillance, Epidemiology, and End Results (SEER) Program-registered HCC. Multiple linear regression models were used for age adjustment with patient race, sex, marital status, and HCC grade.

RESULTS

The age at diagnosis was younger in Caucasians and males. The adjusted average age of patients with stage I HCC was 65.26 years. The adjusted age of patients with stage II, IIIA, IIIB, and IIIC was -0.17, -0.25, -0.29, and -0.55 adjusted-year younger compared with patients with stage I HCC (all P < 0.001). The adjusted average age of patients with T1 was 65.26 years. The age adjustment was -0.17, -0.26, and -0.55 respectively (all P < 0.001) for T2, T3 or T4 tumors without distant metastases.

CONCLUSIONS

These findings demonstrated that the more advanced the HCC stage at diagnosis, the younger the age at diagnosis and the faster the HCC growth from tumor occurrence.

Efficacy and Safety of Transarterial Chemoembolization in Elderly Patients of Advanced Hepatocellular Carcinoma With Portal Vein Tumor Thrombus: A Retrospective Study

Objective

The aim of the current study was to evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) in elderly patients diagnosed as advanced hepatocellular carcinoma (HCC) accompanied with different types of portal vein tumor thrombosis (PVTT).

Methods

Elderly HCC patients aged 70-year-old and above from January 2015 to December 2019 were included in this retrospective study. Efficacy data including OS, PFS, DCR, and ORR and safety data were collected in the indicated groups. Outcomes of HCC patients in the TACE group were compared with those patients in the best supportive care (BSC) group. Subgroup analyses were also conducted in the patients with different types of PVTT.

Results

Among 245 elderly HCC patients, 124 were enrolled in this study. Out of these, 50.0% (n=62) underwent BSC treatment while 50.0% (n=62) underwent TACE. There were no major differences in the baseline characteristics of the two treatment groups. TACE treatment was associated with better median OS compared with BSC alone (11.30 m vs. 7.80 m; P<0.001). Subgroup analyses showed that patients with type I and type II PVTT could benefit from TACE compared with BSC, based on that OS was 14.30 m vs. 7.80 m (P=0.007) and 13.00 m vs. 8.00 m (P=0.002), respectively. The DCR in the TACE group was 62.90%, and 17.74% in the BSC group (p<0.001). The proportion of ORR in TACE group was 35.48%, while 0.00% in the BSC group (p<0.001). Multivariable analyses showed that patients undergoing TACE treatment had 52% lower odds of mortality compared with patients undergoing BSC treatment (HR: 0.48; 95%CI: 0.32-0.72). Similarly, the media PFS was improved following TACE treatment (7.50 m vs. 4.00 m; P<0.001). TACE could significantly prolong the PFS in both type I and type II PVTT subgroups, without greatly significant improvement in type III PVTT patients (4.50 m vs. 2.70 m; P=0.103). Type III PVTT patients in the TACE group had more AEs than type I and type II PVTT patients. According to multivariable analyses, PVTT types (type III vs. type I-II) (HR: 2.18; 95%CI: 1.29-3.70; P=0.004), tumor diameter (>5 cm vs. ≤5 cm) (HR: 1.94; 95%CI: 1.28-2.93; P=0.002), and treatment (TACE vs. BSC) (HR: 0.48; 95%CI: 0.32-0.72; P<0.001) were independent indicators of overall survival.

Conclusions

In elderly advanced HCC patients with PVTT, palliative TACE treatment can be an accessible effective measure to improve the OS and PFS for both type I and type II PVTT patients.

Consensus of Minimally Invasive and Multidisciplinary Comprehensive Treatment for Hepatocellular Carcinoma - 2020 Guangzhou Recommendations

In China, the majority of patients with hepatocellular carcinoma (HCC) result from long-term infection of hepatitis B. Pathologically, HCC is characterized by rich blood supply, multicentric origins, early vascular invasion and intrahepatic metastasis. Therefore, HCC is not a local disease but a systemic disease at the beginning of its occurrence. For this reason, a comprehensive treatment strategy should be adopted in the management of HCC, including local treatments (such as surgical resection, radiofrequency ablation, microwave ablation, chemical ablation and cryoablation, etc.), organ-level treatments [such as transcatheter arterial infusion of chemotherapy and transcatheter arterial chemoembolization (TACE)], and systemic treatments (such as immunotherapy, antiviral therapy and molecular targeted therapy, etc.). This consensus sets forth the minimally-invasive and multidisciplinary comprehensive guideline of HCC, focusing on the following eight aspects (1) using hepaticarteriography, CT hepatic arteriography (CTHA), CT arterial portography (CTAP), lipiodol CT (Lp-CT), TACE-CT to find the intrahepatic lesion and make precise staging (2) TACE combined with ablation or ablation as the first choice of treatment for early stage or small HCC, while other therapies are considered only when ablation is not applicable (3) infiltrating HCC should be regarded as an independent subtype of HCC (4) minimally-invasive comprehensive treatment could be adopted in treating metastatic lymph nodes (5) multi-level subdivision of M-staging should be used for individualized treatment and predicting prognosis (6) HCC with severe hepatic decompensation is the only candidate criterion for liver transplantation (7) bio-immunotherapy, traditional Chinese medicine therapy, antiviral therapy, and psychosocial and psychopharmacological interventions should be advocated through the whole course of HCC treatment (8) implementation of multicenter randomized controlled trials of minimally-invasive therapy versus surgery for early and intermediate stage HCC is recommended.

Radiofrequency ablation versus repeat hepatectomy in the treatment of recurrent hepatocellular carcinoma in subcapsular location: a retrospective cohort study

Background

Repeat hepatectomy and radiofrequency ablation (RFA) are widely used to treat early recurrent hepatocellular carcinoma (RHCC) located in the subcapsular region, but the optimal treatment strategy remains to be controversial.

Methods

A total of 126 RHCC patients in the subcapsular location after initial radical hepatectomy were included in this study between Dec 2014 and Jan 2018. These patients were divided into the RFA group (46 cases) and the repeat hepatectomy group (80 cases). The primary endpoints include repeat recurrence-free survival (rRFS) and overall survival (OS), and the secondary endpoint was complications. The propensity-score matching (PSM) was conducted to minimize the bias. Complications were evaluated using the Clavien-Dindo classification, and severe complications were defined as classification of complications of ≥grade 3.

Results

There were no significant differences in the incidence of severe complications were observed between RFA group and repeat hepatectomy group in rRFS and OS both before (1-, 2-, and 3-year rRFS rates were 65.2%, 47.5%, and 33.3% vs 72.5%, 51.2%, and 39.2%, respectively, P = 0.48; 1-, 2-, and 3-year OS rates were 93.5%, 80.2%, and 67.9% vs 93.7%, 75.8%, and 64.2%, respectively, P = 0.92) and after PSM (1-, 2-, and 3-year rRFS rates were 68.6%, 51.0%, and 34.0% vs 71.4%, 42.9%, and 32.3%, respectively, P = 0.78; 1-, 2-, and 3-year OS rates were 94.3%, 82.9%, and 71.4% vs 88.6%, 73.8%, and 59.0%, respectively, P = 0.36). Moreover, no significant differences in the incidence of severe complications were observed between the RFA group and repeat hepatectomy group.

Conclusion

Both repeat hepatectomy and RFA are shown to be effective and safe for the treatment of RHCC located in the subcapsular region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02277-4.

The Role of Protease-Activated Receptor 2 in Hepatocellular Carcinoma after Hepatectomy

Background and Objectives: Protease activated receptor-2 (PAR2) is elevated in a variety of cancers and has been promoted as a potential therapeutic target. However, the clinical and prognostic values of PAR2 in hepatocellular carcinoma (HCC) are poorly characterized. This study aimed to evaluate the expression of PAR2 in HCC tissues and examine the prognostic value of PAR2 after resection in HCC. Materials and Methods: Two hundred and eight resected specimens were collected from HCC patients at Kaohsiung Chang Gung Memorial Hospital. PAR2 protein expression was assessed by western blotting in HCC tissues and matched normal tissues. The correlation between PAR2 expression and clinicopathological parameters was analyzed. Disease-free survival (DFS) and overall survival (OS) were compared using the log-rank test. A Cox regression model was used to identify independent prognostic factors. Results: PAR2 was expressed at higher levels in HCC tissues than the paired adjacent nontumor tissues. High expression of PAR2 was associated with advanced tumor, node, metastasis (TNM )stage and histological grade. Kaplan-Meier analysis indicated high PAR2 expression was associated with poorer DFS and OS compared to low PAR2 expression. Multivariate analyses indicated high PAR2 expression [hazard ratio (HR), 1.779, p = 0.006), α-fetoprotein (AFP) (HR, 1.696, p = 0.003), liver cirrhosis (HR, 1.735, p = 0.002), and advanced TNM stage (HR, 2.061, p < 0.001) were prognostic factors for DFS, and advanced TNM stage (HR, 2.741, p < 0.001) and histological grade (HR, 2.675, p = 0.002) and high PAR2 expression (HR, 1.832, p = 0.012) were significant risk factors for OS. In subgroup analyses, the combination of PAR2 expression and serum AFP provided improved prognostic ability for OS and DFS. Conclusion: Combination PAR2 and AFP predict HCC outcomes after resection. PAR2 represents a potentially clinically relevant biomarker for HCC.

Real-time virtual sonography-assisted radiofrequency ablation in liver tumors with conspicuous or inconspicuous images or peritumoral landmarks under ultrasonography

Objectives

The objectives of this study were to determine the primary technique effectiveness (PTE), to compare the complete response and local recurrence rates between conspicuous and inconspicuous tumors using single and switching electrodes of real-time virtual sonography (RVS)-assisted radiofrequency ablation (RFA) in conspicuous and inconspicuous hepatic tumors under conventional ultrasonography (US).

Subjects and method

We compared the complete ablation of inconspicuous tumors with and without anatomical landmark (N = 54) with conspicuous liver tumors (N = 272). Conventional US imaging was done initially, and then these images were fused with CT or MRI arterial-venous-wash-out cross-sectional studies and synchronized with real-time US images.

Results

RVS-assisted RFA was technically feasible in all patients. The PTE rate after the first ablation was 94% (245/261) for conspicuous tumors, 88% (7/8) in inconspicuous tumors with landmark, and 78% (36/46) in inconspicuous tumors without landmark. The complete response (p = 0.1912 vs. p = 0.4776) and local recurrence rate (p = 0.1557 vs. p = 0.7982) were comparable in conspicuous tumors of both HCC and liver metastasis group when single or multiple switching was used. The cumulative local recurrence in the conspicuous and inconspicuous tumors of the HCC group (p = 0.9999) was almost parallel after 12 (10% vs. 4%) and 24 (13% vs. 4%) months of follow-up. In the liver metastasis group, the cumulative local recurrence for conspicuous tumors (p = 0.9564) was nearly equal after 12 and 24 months of monitoring (24% vs. 27%) while no recurrence was incurred for the inconspicuous tumors.

Conclusion

RVS-assisted RFA is an effective tool for the treatment of conspicuous and inconspicuous HCC and hepatic metastasis.

Evaluation of serum alpha fetoprotein-L3 as an accuracy novel biomarker for the early diagnosis of hepatocellular carcinoma in Egyptian Patients

Background

Most Hepatocellular Carcinomas (HCCs) are diagnosed at an advanced stage. However, HCC early diagnosis is complicated by the coexistence of inflammation and cirrhosis. The unsatisfactory sensitivity and specificity of Alpha-fetoprotien (AFP) for screening of early-stage HCC paved the way for new novel biomarkers to complement AFP such as AFP-L3. The aim of this study was the Evaluation of alpha fetoprotein-L3 (AFP-L3) as earlier marker in diagnosis of hepatocellular carcinoma in Egyptian patients. This study was conducted on 80 patients categorized into 2 groups; group 2 (40 patients with chronic active hepatitis) and group 3 (40 patients with HCC). HCC diagnosis was done by clinical, triphasic CT and positive US for focal lesion, in addition to 20 healthy individuals as controls (group 1).

Results

The median range of AFP and AFP-L3 were highly statistically significant difference between HCC group and other groups [p < 0.001]. In this study ALT, AST, Total & direct bilirubin and albumin results showed highly significant differences between HCC group and other groups. Serum AFP-L3 shows sensitivity 100%, specificity 100%, positive predictive value 100% and negative predictive value 100% with AUC = 1 in HCC cases.

Conclusion

Serum AFP-L3 may serve as a diagnostic biomarker for the detection of early stage of HCC and show higher sensitivity than AFP.

Real-World Data on Clinical Outcomes of Patients with Liver Cancer: A Prospective Validation of the National Cancer Centre Singapore Consensus Guidelines for the Management of Hepatocellular Carcinoma

INTRODUCTION

Real-world management of patients with hepatocellular carcinoma (HCC) is crucially challenging in the current rapidly evolving clinical environment which includes the need for respecting patient preferences and autonomy. In this context, regional/national treatment guidelines nuanced to local demographics have increasing importance in guiding disease management. We report here real-world data on clinical outcomes in HCC from a validation of the Consensus Guidelines for HCC at the National Cancer Centre Singapore (NCCS).

METHOD

We evaluated the NCCS guidelines using prospectively collected real-world data, comparing the efficacy of treatment received using overall survival (OS) and progression-free survival (PFS). Treatment outcomes were also independently evaluated against 2 external sets of guidelines, the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC).

RESULTS

Overall treatment compliance to the NCCS guidelines was 79.2%. Superior median OS was observed in patients receiving treatment compliant with NCCS guidelines for early (nonestimable vs. 23.5 months p < 0.0001), locally advanced (28.1 vs. 22.2 months p = 0.0216) and locally advanced with macrovascular invasion (10.3 vs. 3.3 months p = 0.0013) but not for metastatic HCC (8.1 vs. 6.8 months p = 0.6300), but PFS was similar. Better clinical outcomes were seen in BCLC C patients who received treatment compliant with NCCS guidelines than in patients with treatment only allowed by BCLC guidelines (median OS 14.2 vs. 7.4 months p = 0.0002; median PFS 6.1 vs. 4.0 months p = 0.0286). Clinical outcomes were, however, similar for patients across all HKLC stages receiving NCCS-recommended treatment regardless of whether their treatment was allowed by HKLC.

CONCLUSION

The high overall compliance rate and satisfactory clinical outcomes of patients managed according to the NCCS guidelines confirm its validity. This validation using real-world data considers patient and treating clinician preferences, thus providing a realistic analysis of the usefulness of the NCCS guidelines when applied in the clinics.

Role of modern radiotherapy in managing patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Several treatment options are available for managing HCC patients, classified roughly as local, local-regional, and systemic therapies. The high post-monotherapy recurrence rate of HCC urges the need for the use of combined modalities to increase tumor control and patient survival. Different international guidelines offer treatment recommendations based on different points of view and classification systems. Radiotherapy (RT) is a well-known local-regional treatment modality for managing many types of cancers, including HCC. However, only some of these treatment guidelines include RT, and the role of combined modalities is rarely mentioned. Hence, the present study reviewed clinical evidence for the use of different combined modalities in managing HCC, focusing on modern RT's role. Modern RT has an increased utility in managing HCC patients, mainly due to two driving forces. First, technological advancement (e.g., stereotactic body radiotherapy and advanced proton-beam therapy) enables precise delivery of radiation to increase tumor control and reduce side effects in the surrounding normal tissue. Second, the boom in developing target therapies and checkpoint-blockade immunotherapy prolongs overall survival in HCC patients, re-emphasizing the importance of local tumor control. Remarkably, RT combines with systemic therapies to generate the systemic therapy augmented by radiotherapy effect, a benefit now being actively investigated.

Surgical resection significantly promotes the overall survival of patients with hepatocellular carcinoma: a propensity score matching analysis

Background

The benefits of surgical resection (SR) for various Barcelona Clinic Liver Cancer (BCLC) stages of hepatocellular carcinoma (HCC) remain unclear. We investigated the risk factors of overall survival (OS) and survival benefits of SR over nonsurgical treatments in patients with HCC of various BCLC stages.

Methods

Overall, 2316 HCC patients were included, and their clinicopathological data and OS were recorded. OS was analyzed by the Kaplan-Meier method and Cox regression analysis. Propensity score matching (PSM) analysis was performed.

Results

In total, 66 (2.8%), 865 (37.4%), 575 (24.8%) and 870 (35.0%) patients had BCLC stage 0, A, B, and C disease, respectively. Furthermore, 1302 (56.2%) of all patients, and 37 (56.9%), 472 (54.6%), 313 (54.4%) and 480 (59.3%) of patients with BCLC stage 0, A, B, and C disease, respectively, died. The median follow-up duration time was 20 (range 0–96) months for the total cohort and was subdivided into 52 (8–96), 32 (1–96), 19 (0–84), and 12 (0–79) months for BCLC stages 0, A, B, and C cohorts, respectively. The risk factors for OS were (1) SR and cirrhosis; (2) SR, cirrhosis, and Child–Pugh (C–P) class; (3) SR, hepatitis B virus (HBV) infection, and C–P class; and (4) SR, HBV infection, and C–P class for the BCLC stage 0, A, B, and C cohorts, respectively. Compared to non-SR treatment, SR resulted in significantly higher survival rates in all cohorts. The 5-year OS rates for SR vs. non-SR were 44.0% versus 28.7%, 72.2% versus 42.6%, 42.6% versus 36.2, 44.6% versus 23.5%, and 41.4% versus 15.3% (all P values < 0.05) in the total and BCLC stage 0, A, B, and C cohorts, respectively. After PSM, SR resulted in significantly higher survival rates compared to non-SR treatment in various BCLC stages.

Conclusions

SR conferred significant survival benefits to patients with HCC of various BCLC stages and should be considered a recommended treatment for select HCC patients, especially patients with BCLC stage B and C disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01807-4.

Cistanche tubulosa Phenylethanoid Glycosides Induce Apoptosis of Hepatocellular Carcinoma Cells by Mitochondria-Dependent and MAPK Pathways and Enhance Antitumor Effect through Combination with Cisplatin

Cistanche tubulosa is a type of Chinese herbal medicine and exerts various biological functions. Previous studies have been demonstrated that Cistanche tubulosa phenylethanoid glycosides (CTPG) exhibit antitumor effects on a variety of tumor cells. However, the antitumor effects of CTPG on HepG2 and BEL-7404 hepatocellular carcinoma (HCC) cells are still elusive. Our study showed that CTPG significantly inhibited the growth of HepG2 and BEL-7404 cells through the induction of cell cycle arrest and apoptosis, which was associated with the activation of MAPK pathways characterized by the up-regulated phosphorylation of p38, JNK, and ERK1/2 and mitochondria-dependent pathway characterized by the reduction of mitochondrial membrane potential. The release of cytochrome c and the cleavage of caspase-3, -7, -9, and PARP were subsequently increased by CTPG treatment. Moreover, CTPG significantly suppressed the migration of HepG2 through reducing the levels of matrix metalloproteinase-2 and vascular endothelial growth factor. Interestingly, CTPG not only enhanced the proliferation of splenocytes but also reduced the apoptosis of splenocytes induced by cisplatin. In H22 tumor mouse model, CTPG combined with cisplatin further inhibited the growth of H22 cells and reduced the side effects of cisplatin. Taken together, CTPG inhibited the growth of HCC through direct antitumor effect and indirect immunoenhancement effect, and improved the antitumor efficacy of cisplatin.

Hepatitis C-positive Black patients develop hepatocellular carcinoma at earlier stages of liver disease and present with a more aggressive phenotype

BACKGROUND

In the United States, mortality after a diagnosis of hepatocellular carcinoma (HCC) is higher in patients who are Black than in patients of other racial groups. The objective of this study was to clarify factors contributing to this disparity by analyzing liver and tumor characteristics in patients with HCC who have a history of hepatitis C virus (HCV) infection.

METHODS

Records of patients with HCV and HCC at the authors' institution from 2003 to 2018 were retrospectively reviewed. Race and ethnicity were self-identified. Imaging, laboratory, and pathologic features were compared between Black and non-Black cohorts.

RESULTS

Among 1195 individuals with HCC, 390 identified as Black. At the time of HCC diagnosis, Black patients had better liver function, as measured by Child-Pugh score, Model of End-Stage Liver Disease score, histology of nontumor tissue, and fibrosis-4 (FIB-4) score (all P < .05). FIB-4 scores were <3.25 in 31% of Black patients. In addition, Black patients had less early stage HCC (20.2% vs 32.3%; P < .05), larger tumors (median [interquartile range]: 3.5 cm [2.2-6.2 cm] vs 3.1 cm [2.1-5.1 cm]; P < .01), more multiple tumors (median, [interquartile range]: 1 tumor [1-3 tumors] vs 1 tumor [1-2 tumors]; P = .03), more poorly differentiated tumors (30.3% vs 20.5%; P < .05), and more microvascular invasion (67.2% vs 56.5%; P < .05).

CONCLUSIONS

Black patients with HCV exposure develop HCC at earlier stages of liver disease than members of other racial groups. Nearly one-third would not qualify for HCC screening using the common FIB-4 cirrhosis threshold. Practice guidelines that stress HCC surveillance for cirrhotic patients with HCV may need to be revised to be more inclusive for Black patients. In addition, tumors in Black patients carry worse prognostic features, and molecular studies are needed to characterize their biologic properties.

Living Donor Liver Transplantation: The Optimal Curative Treatment for Hepatocellular Carcinoma Even Beyond Milan Criteria

Introduction:

Liver transplantation offers the most reasonable expectation for curative treatment for hepatocellular carcinoma. Living-donor liver transplantation represents a treatment option, even in patients with extended Milan criteria. This study aimed to evaluate the outcomes of hepatocellular carcinoma patients, particularly those extended Milan criteria.

Materials and Patients:

All HCC patients who received liver transplant for HCC were included in this retrospective study. Clinical characteristics including perioperative data and survival data (graft and patient) were extracted from records. Univariate and multivariate analyses was performed to identify significant prognostic factors for survival, postoperative complications and recurrence.

Results:

Two-hundred and two patients were included. The median age was 54.8 years (IQR 53-61). Fifty-one patients (25.3%) underwent deceased donors liver transplantation and 151 patients (74.7%) underwent living donor liver transplantation. Perioperative mortality rate was 5.9% (12 patients). Recurrent disease occurred in 43 patients (21.2%). The overall 1-year and 5-year survival rates were 90.7% and 75.6%, respectively. Significant differences between patients beyond Milan criteria compared to those within Milan criteria were not found. Alpha-fetoprotein level >300 ng/mL, vascular invasion, and bilobar tumor lesions were independent negative prognostic factors for survival.

Conclusion:

Liver transplantation is the preferred treatment for hepatocellular carcinoma and it has demonstrated an excellent potential to cure even in patients with beyond Milan criteria. This study shows that the Milan criteria alone are not sufficient to predict survival after transplantation. The independent parameters for survival prediction are Alpha-Fetoprotein-value and status of vascular invasion.

Characteristics and prognosis of patients with large well-differentiated hepatocellular carcinoma who have undergone resection

BACKGROUND

Large well-differentiated hepatocellular carcinoma (HCC) ≥ 3 cm (defined as atypical HCC) is uncommon. We evaluated the characteristics and outcomes of atypical HCC patients underwent liver resection (LR).

METHODS

This retrospective study enrolled patients who underwent LR for HCC from 2007 to 2017. Patient characteristics and overall survival (OS) were compared between patients with atypical HCC and patients with typical HCC (moderate-to-undifferentiated HCC ≥ 3 cm).

RESULTS

Among 598 patients, 51 (8.5%) had atypical HCC. Patients with atypical HCC had higher rates of non-hepatitis B or C infections (p = 0.02) and American Joint Committee on Cancer T1 pathology (p < 0.001), a lower rate of alpha-fetoprotein >20 ng/ml (p < 0.001) and a longer OS (p < 0.001) than those with typical HCC. Multivariate analysis showed that atypical HCC was associated with OS (HR = 0.50, 95% CI = 0.27-0.91, p = 0.02).

CONCLUSIONS

Patients with atypical HCC have a higher rate of non-hepatitis B or C infections and a lower rate of aggressive tumor biologic behavior. Atypical HCC is an independent predictor of OS.

Chinese expert consensus on technical recommendations for the standard operation of drug-eluting beads for transvascular embolization

Liver cancer is among the 10 most common tumors globally. In China, liver cancer ranks 4^th for prevalence and 3^rd for mortality among all malignant tumors. With respect to the treatment of primary liver cancer, there are a number of therapies currently available, including surgical resection, liver transplantation, ablation, transarterial chemoembolization (TACE), systemic chemotherapy, radiation therapy, targeted drug therapy and immunotherapy. Clinical practice and research have shown that, compared with conventional TACE (cTACE), drug-eluting bead TACE (DEB-TACE) can achieve a higher response rate and longer survival time in patients with primary liver cancer. Compared with that of cTACE, DEB-TACE has more favorable basic conditions for achieving uniformity, which could facilitate the standardization of operation techniques. China is the country with the highest incidence of primary liver cancer, accounting for more than 50% of the global patients, and its etiology and epidemiology in Chinese patients differ from those in Europeans and Americans. Therefore, experts in China have drafted these technical recommendations for the standard operation of drug-eluting beads for the treatment of liver cancer on the basis of accumulated abundant clinical experience and evidence-based medical data.

Adherence to the modified Barcelona Clinic Liver Cancer guidelines: Results from a high-volume liver surgery center in East Asias

Background and aims

The Barcelona Clinic Liver Cancer (BCLC) staging system is the most widely applied staging system for hepatocellular carcinoma (HCC) and is recommended for treatment allocation and prognostic prediction. The BCLC guidelines were modified in 2018 to indicate that Child-Pugh A without any ascites is essential for all stages except stage D. This study sought to provide a description of patients with HCC treated at a high-volume liver surgery center in Taiwan where referral is not needed and all treatment modalities are available and reimbursed by the National Health Insurance program. As such, certain variables that could modulate treatment decisions in clinical practice, including financial constraints, the availability of treatment procedures, and the expertise of the hospital, could be excluded. The study further sought to evaluate the adherence to the modified BCLC guidelines.

Methods

This was a retrospective study with prospectively collected data. 1801 consecutive patients with de novo HCC were enrolled through our institution from 2011–2017.

Results

There were 302 patients with stage 0, 783 with stage A, 242 with stage B, 358 with stage C, and 116 with stage D HCC. Treatment adhering to the modified BCLC guidelines recommendations was provided to 259 (85.8%) stage 0 patients, 606 (77.4%) stage A patients, 120 (49.6%) stage B patients, 93 (26.0%) stage C patients, and 83 (71.6%) stage D patients.

Conclusions

We reported treatment adhering to the modified BCLC guidelines at a high-volume liver surgery center in Taiwan. We found that non-adherence to the modified BCLC staging system was common in treating stage B and C patients.

Liver resection in elderly patients with hepatocellular carcinoma: age does matter

Increasing proportions of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment have been noted. We aim to evaluate the impact of elderly age on outcomes of liver resection (LR) for HCC. This retrospective study enrolled 1004 patients with HCC who underwent curative LR in our institution from 2007 to 2017, dividing them into three groups according to age (18-59 years, n = 461; 60-74 years, n = 447; ≥ 75 years, n = 96). Elderly patients were defined as those ≥ 75 years old. Outcomes were then compared among the three groups, with a multivariate competing risk model used to estimate cause-specific subdistribution hazard ratios (SHRs) for HCC- and non-HCC-related deaths. The OS was significantly lower in the elderly than younger patients. However, recurrence-free survival was similar among the three groups. The cumulative incidence of HCC-related death was similar among the three groups; however, the cumulative incidence of non-HCC-related death was significantly higher in the elderly than younger patients. Moreover, the multivariate analysis showed that elderly age was not an independent variable associated with HCC-related death. However, elderly age was an independent variable associated with non-HCC-related death. The 60-year SHR for non-HCC-related death increased with increasing age. The elderly patients had significantly worse OS after LR than the younger patients, possibly due to the cumulative incidence of non-HCC-related death being significantly higher among the elderly than among the younger patients. Elderly patients should be more stringently selected for LR.

Survival comparison between radiofrequency ablation and surgical resection for patients with small hepatocellular carcinoma: A systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate and compare the long-term therapeutic efficacy of radiofrequency ablation (RFA) versus that of surgical resection in small hepatocellular carcinoma (HCC).

METHODS

Relevant articles in English from PubMed, EMBASE, and the Cochrane Library were retrieved. Pooled hazard ratios (HRs) were calculated to assess the prognostic value of RFA compared with that of surgical resection.

RESULTS

A total of 19 studies involving 15,071 patients were included. The combined HRs (95% confidence interval [CI]) of RFA for recurrence/relapse-free survival (RFS) and overall survival (OS) were 1.55 (95% CI = 1.29-1.86, I2 = 72.5%) and 1.61 (95% CI = 1.29-2.01, I2 = 60.4%), respectively, compared with surgical resection. In subgroup analyses according to study design, both RFS and OS of the prospective subgroups showed statistical significance, and no statistical heterogeneity existed between studies.

CONCLUSION

Our clinical data suggest that surgical resection offers better long-term oncologic outcomes than RFA.

Functional Role of Novel Indomethacin Derivatives for the Treatment of Hepatocellular Carcinoma Through Inhibition of Platelet-Derived Growth Factor

BACKGROUND

Several studies suggested anticancer potential of NSAIDs. Therefore, we aimed to evaluate novel indomethacin derivatives for the treatment of hepatocellular carcinoma.

METHODS

The molecular docking of derivatives was carried out for prediction of inhibitory effect on PDGFR-α using pass online software, followed by cytotoxicity study by performing MTT assay. The disease was induced with N-Nitrosodiethylamine (200 mg/kg, i.p.) followed by 2-acetylaminofluorene orally for two weeks. After 12 weeks of induction, treatment was given for one week and blood was collected for determination of biochemical parameters and tumor markers. Liver samples were isolated for immunohistochemistry, histopathology, and gene expression study for VEGF.

RESULTS

JI-MT has shown maximum inhibitory activity for PDGFRα in docking study also showed good cytotoxic effect in the HepG2 cell line and based on the IC₅₀ values, JI-MT was selected for in-vivo study. We have found statistically significant reduction in body weight gain, number of nodules and liver weight to body weight ratio with treatment with JI-MT. Hepatoprotective role of JI-MT has been observed in tumor-specific markers like α-fetoprotein levels, carcinoembryonic antigen and PDGF-α levels. Liver markers like ALT, ALP, AST, LDH and total bilirubin levels were found to be reduced with treatments. Also, on histopathological examination, the protective effect of JI-MT was observed. Treatment also showed increased expression of P53 in immunohistochemical analysis and up-regulation of VEGF gene by JI-MT.

CONCLUSION

From the present study, we can conclude that JI-MT has potential in treatment of HCC by the virtue of PDGFRα inhibitory activity.

Clinicopathological and prognostic value of preoperative lymphocyte to monocyte ratio for hepatocellular carcinoma following curative resection: A meta-analysis including 4,092 patients

BACKGROUND

Previous studies have reported that lymphocyte-to-monocyte ratio (LMR) had novel prognostic value in hepatocellular carcinoma (HCC). The purpose of this meta-analysis was to synthetically evaluate the prognostic role of preoperative LMR in HCC patients following curative resection.

METHODS

Eligible studies were acquired through searching Pubmed, Web of Science, Cochrane Library and EMbase update to September 2019. Merged hazard ratios (HRs) and 95% confidence intervals (CIs) were applied as effect sizes.

RESULTS

A total of ten studies containing 4,092 patients following liver resection were enrolled in this meta-analysis. The pooled results demonstrated that preoperative elevated LMR indicated superior survival outcome (HR: 0.58, 95% CI: 0.34-0.96, P = .035) and recurrence-free survival (RFS)/disease-free survival/time to recurrence (HR = 0.76, 95% CI: 0.58-0.98, P = .034). The significant prognostic role of preoperative LMR was detected in the subgroup of all publication year, country of origin, sample sizes <300, TNM stage of I-IV and LMR cut-off value ≤4. Furthermore, high LMR was significantly associated with male, high AFP, large tumor size, incomplete tumor capsule, advanced TNM stage and BCLC stage, and presence of PVTT.

CONCLUSION

Elevated preoperative LMR indicated superior survival outcome in HCC patients following curative resection, and might serve as a novel prognostic biomarker.

Comparison of LI-RADS with other non-invasive liver MRI criteria and radiological opinion for diagnosing hepatocellular carcinoma in cirrhotic livers using gadoxetic acid with histopathological explant correlation

AIM

To establish the diagnostic accuracy of the Liver Imaging Reporting and Data System (LI-RADS) for hepatocellular carcinoma (HCC) and compare its performance to that of international criteria from European Assofor the Study of the Liver (EASL), Japan Society of Hepatology (JSH), Asian Pacific Association for the Study of the Liver (APASL), and Organ Procurement and Transplantation Network (OPTN), and to the reporting radiologist's overall opinion regarding the probability of a nodule being a HCC by correlating with a histological diagnosis from whole liver explants.

MATERIALS AND METHODS

The present single-centre, retrospective review selected participants based on the following criteria: adults (≥18 years) listed for liver transplantation in 2014/2015, with liver cirrhosis at the time of magnetic resonance imaging (MRI) with hepatocyte specific contrast agent, and at least one liver lesion ≥10 mm on MRI with histology from subsequent liver explant for comparison. Each lesion was assessed against international criteria and given a "radiologist opinion" score of 1-5 (1 = definitely benign, 5 = definitely HCC).

RESULTS

Total 268 patient records were reviewed, with 105 eligible lesions identified from 47 patients. Median lesion size was 15.5 mm (range 10-68 mm). Sensitivity (%), specificity (%), and positive predictive value (PPV; %) for LI-RADS LR5 was 45, 89, and 89, for LI-RADS LR4+5 + TIV was 61, 80, and 86, for EASL was 44, 86 and 86, for JSH/APASL was 64, 81, and 87, for OPTN was 36, 90, and 88, and for "radiologist impression" of probably or definitely HCC was 79, 79, and 88 respectively.

CONCLUSIONS

MRI has moderate sensitivity and good specificity for the diagnosis of HCC with considerable variation depending on criteria used. OPTN criteria have the best specificity, but low sensitivity. "Radiologist opinion" gives highest overall accuracy with increases in sensitivity and reduction in specificity when compared to the imaging criteria.

Comparison between Milan and UCSF criteria for liver transplantation in patients with hepatocellular carcinoma: a systematic review and meta-analysis

Background

Liver transplantation is the main treatment for hepatocellular carcinoma (HCC). However, because of the limited supply of transplant organs, it is necessary to adopt a criterion that selects patients who will achieve adequate survival after transplantation. The aim of this review is to compare the two main staging criteria of HCC for the indication of liver transplantation (Milan and UCSF) and to analyze the post-transplantation survival rate at 1, 3 and 5 years.

Methods

This is a systematic review and meta-analysis in which scientific articles from 5 databases (PubMed, Lilacs, Embase, Central, and Cinahl) were analyzed. The studies included in the review consisted of liver transplantation in patients with HCC in different subgroups according to donor type (deceased × living), population (eastern × western) and tumor evaluation (radiological × pathological) and adopted the Milan or UCSF criteria for the indication of the procedure.

Results

There was no significant difference between the Milan and UCSF criteria in the overall survival rate at 1, 3 or 5 years, and the overall estimated value found was 1.03 [0.90, 1.17] at 1 year, 1.06 [0.96, 1.16] at 3 years and 1.04 [0.96, 1.12] at 5 years. Regarding the analysis of the subgroups, no significant difference was observed in any of the subgroups with a follow-up of 1, 3 or 5 years.

Conclusions

Both the Milan and UCSF criteria have equivalent survival rate. Thus, less restrictive method would not result in a great loss in the final overall survival rate and would benefit a greater number of patients.

Ideal Surgical Margin to Prevent Early Recurrence After Hepatic Resection for Hepatocellular Carcinoma

BACKGROUNDS AND AIMS

Postoperative early recurrence after hepatic resection for hepatocellular carcinoma (HCC) poses a challenge to surgeons, and the effect of a surgical margin is still controversial. This study aimed to identify an ideal margin to prevent early recurrence.

METHODS

A total of 226 consecutive patients who underwent primary curative hepatic resection for solitary and primary HCC were enrolled. The definition of early recurrence was determined using the minimum P value approach. Logistic regression analysis was used to identify the risk factors of early recurrence. The receiver-operating characteristic (ROC) curve was used to identify the optimal cut-off of the surgical margin and early recurrence.

RESULTS

Recurrence within 8 months induced the poorest overall survival (P = 2×10^-15). ROC analysis showed that the optimal cut-off value of the surgical margin was 7 mm. The risk factors of early recurrence (≤ 8-month recurrence) were preoperative alpha-fetoprotein levels ≥ 100 ng/ml (Odds ratio [OR] 4.92 [2.28-10.77], P < 0.0001) and a surgical margin < 7 mm (OR 3.09 [1.26-8.85], P = 0.01) by multivariable analysis. The probability of early recurrence ranged from 5.0% in the absence of any factors to 43.5% in the presence of both factors. Among patients with alpha-fetoprotein levels ≥ 100 ng/ml, non-capsule formation, or microvascular invasion, there was a significant difference in 5-year overall survival between surgical margins of < 7 mm and ≥ 7 mm.

CONCLUSIONS

A > 7-mm margin is important to prevent early recurrence. Patients with HCC and alpha-fetoprotein levels > 100 ng/ml, non-capsule formation, or microvascular invasion may have a survival benefit from a ≥ 7-mm margin.

Measurement of Cyclin D2 (CCND2) Gene Promoter Methylation in Plasma and Peripheral Blood Mononuclear Cells and Alpha-Fetoprotein Levels in Patients with Hepatitis B Virus-Associated Hepatocellular Carcinoma

Background

Alpha-fetoprotein (AFP) is widely used to screen for hepatocellular carcinoma (HCC). However, the use of this biomarker has been challenged due to its low sensitivity and high rate of false negatives. In this study, we evaluated the diagnostic capability of cyclin D2 (CCND2) promoter methylation in patients with HCC related to hepatitis B virus (HBV).

Material/Methods

Using methylation-specific PCR and quantitative real-time PCR, we measured methylation status and mRNA levels of CCND2 in plasma and peripheral blood mononuclear cells (PBMCs) from 275 subjects: 75 patients with chronic hepatitis B (CHB), 47 with liver cirrhosis (LC), 118 with HCC, and 35 healthy controls (HCs).

Results

The methylation rate of the CCND2 promoter was significantly higher in HCC patients than in patients without HCC (P<0.001). Furthermore, advanced HCC (TNM III/IV) was associated with a significantly higher frequency of CCND2 methylation and lower CCND2 mRNA levels than early-stage disease (TNM I/II; P<0.05). Combined measurement of CCND2 methylation and AFP yielded significantly higher sensitivity and area under the curve (AUC) than AFP alone in distinguishing patients with HCC from subjects with LC and CHB (P<0.001).

Conclusions

CCND2 methylation may be useful for predicting HCC progression. In addition, combined measurement of CCND2 methylation and AFP could serve as a non-invasive diagnostic marker for patients with HBV-related HCC.