BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update

Prompt initiation of durvalumab and tremelimumab for unresectable hepatocellular carcinoma in patients with chronic active hepatitis B: a phase 2 clinical trial

BACKGROUND

Chronic hepatitis B virus (HBV) infection is an etiology of HCC, but clinical trials using immune checkpoint inhibitors (ICIs) usually exclude patients with chronic active hepatitis B (serum HBV viral load > 2000 IU/mL). This study examined the safety and efficacy of concurrently administering the ICI and anti-HBV medications in this patient population.

METHODS

In this single-arm phase 2 clinical trial, we enrolled patients with advanced HCC and untreated chronic active hepatitis B. Patients received 1500 mg of durvalumab every 4 weeks alone or in combination with 300 mg of tremelimumab on day 1 (the STRIDE regimen). Anti-HBV treatment with entecavir was simultaneously initiated. The primary endpoint was the rate of HBV reactivation.

RESULTS

We enrolled 30 patients, whose mean baseline HBV viral load was 770,986 IU/mL. No patients experienced HBV reactivation or HBV-associated hepatitis. Hepatitis flare was noted in 8 (26.7%) patients, but none of them were associated with HBV reactivation. The objective tumor response rate was 10% and 25% for the durvalumab treatment alone and the STRIDE regimen, respectively.

CONCLUSION

For patients with chronic active hepatitis B, ICI therapy could be promptly initiated as long as anti-HBV medications were administered simultaneously.

CLINICAL TRIAL REGISTRATION

NCT04294498.

Adjuvant PD-1 inhibitors improve recurrence and survival outcomes in high-risk hepatocellular carcinoma patients after curative hepatectomy

BACKGROUND

Hepatocellular carcinoma (HCC) is the most prevalent malignancy in China, with liver resection recognized as the primary curative intervention. However, HCC patients face an elevated risk of recurrence, thereby significantly impacting prognosis.

PURPOSE

This study aimed to assess the impact of adjuvant programmed cell death protein-1 (PD-1) inhibitors on survival outcomes in patients with HCC who are at high risk for postoperative recurrence following curative hepatectomy.

MATERIALS AND METHODS

Among the 199 study participants, 77 received adjuvant PD-1 inhibitors. Propensity score matching (PSM) was used to balance baseline differences between patients who received adjuvant PD-1 inhibitors and those who did not. Assessment of overall survival (OS) and recurrence-free survival (RFS) was conducted using Kaplan-Meier curves, while Cox regression analysis was employed to identify prognostic factors influencing survival.

RESULTS

After PSM, the 1-year and 2-year RFS were 87.1% and 74.2% in the PD-1 inhibitors group and 44.6% and 37.8% in non-PD-1 inhibitors group (p < 0.001). The 1-year and 2-year OS were 98.5% and 95.7% in the PD-1 inhibitors group compared with 90.7% and 77.0% in non-PD-1 inhibitors group (p = 0.004). Multivariable analyses demonstrated that the use of adjuvant PD-1 inhibitors was significantly associated with improved RFS and OS. Subgroup analysis indicated that adjuvant PD-1 inhibitors group achieved longer RFS than the non-PD-1 inhibitors group in patients without adjuvant transarterial chemoembolization (TACE).

CONCLUSION

The administration of adjuvant PD-1 inhibitors may effectively reduce the risk of tumor recurrence and improve survival in HCC patients with high risk of recurrence after curative hepatectomy.

Tracing specificity of immune landscape remodeling associated with distinct anticancer treatments

Immune cells within the tumor microenvironment impact cancer progression, resistance, response to treatments. Despite remarkable outcomes for some cancer patients, immunotherapies remain unsatisfactory for others. Here, we designed an experimental setting using the Alb-R26 Met "inside-out" mouse model, faithfully recapitulating molecular features of liver cancer patients, to explore the effects of distinct anticancer targeted therapies on the tumor immune landscape. Using two treatments in clinical trials for different cancer types, Decitabine and MEK+BCL-XL blockage, we show their capability to trigger tumor regression in Alb-R26 Met mice and to superimpose distinct profiles of immune cell types and immune-checkpoints, impacting immunotherapy response. A machine learning approach processing tumor imaging and immune profile data identified a putative signature predicting tumor treatment response in mice and patients. Outcomes exemplify how the tumor immune microenvironment is differentially reshaped by distinct anticancer agents and highlight the importance of measuring its modulation during treatment to optimize oncotherapy and immunotherapy combinations.

Latin American expert opinion letter on the feasibility of systemic therapies in combination with locoregional therapies for hepatocellular carcinoma

Recent advances in the systemic treatment of advanced hepatocellular carcinoma (HCC) with immunotherapy have once again reignited discussion over the role of combined therapy in earlier stages. This year, different international meetings have presented recent results from clinical trials on adjuvant therapy alone (IMBrave-050) and combined with transarterial chemoembolization (EMERALD-1 and LEAP-12). Increased enthusiasm for the use of adjuvant and neoadjuvant therapy for liver transplantation, surgery, and local-regional treatment of HCC has been shown. However, the initial results from these trials should be interpreted cautiously as we wait for final analyses and effects on overall survival. In this position paper from the special interest group from the Latin American Association for the Study of Liver Diseases (ALEH), we underline the caveats of the applicability of these potential treatments in our region, explore points of agreement, and highlight areas of uncertainty. Moreover, we underscore the role of hepatologists in the clinical decision-making process and management of these patients.

Paracancerous binuclear hepatocytes assessed by computer program is a novel biomarker for short term recurrence of hepatocellular carcinoma after surgery

Hepatocellular carcinoma (HCC) is notorious for its high likelihood of recurrence even after radical surgery, which calls for effective adjuvant therapy based on more precise patient selection. The decline of the abundance of binuclear hepatocytes (ABH) in paracancerous liver tissues has been reported to indicate pathological changes in liver cells, leading to short-term recurrence within 2 years. In this research, we analyzed 34 HCC patients and 22 patients underwent liver surgery for non-HCC diseases. An ImageJ script was used to assess binuclear hepatocytes in the HE-staining specimens of paracancerous liver tissues. ABH significantly decreased in HCC patients and indicated poorer outcomes. Immunohistochemistry (IHC) assays suggested ploidy-related regulation of arginase 1 (ARG1) expression. Our findings suggested computer-assisted assessment of ABH as a possible biomarker for short-term HCC recurrence.

Predicting hepatocellular carcinoma response to TACE: A machine learning study based on 2.5D CT imaging and deep features analysis

OBJECTIVES

Prior to the commencement of treatment, it is essential to establish an objective method for accurately predicting the prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). In this study, we aimed to develop a machine learning (ML) model to predict the response of HCC patients to TACE based on CT images analysis.

MATERIALS AND METHODS

Public dataset from The Cancer Imaging Archive (TCIA), uploaded in August 2022, comprised a total of 105 cases, including 68 males and 37 females. The external testing dataset was collected from March 1, 2019 to July 1, 2022, consisting of total of 26 patients who underwent TACE treatment at our institution and were followed up for at least 3 months after TACE, including 22 males and 4 females. The public dataset was utilized for ResNet50 transfer learning and ML model construction, while the external testing dataset was used for model performance evaluation. All CT images with the largest lesions in axial, sagittal, and coronal orientations were selected to construct 2.5D images. Pre-trained ResNet50 weights were adapted through transfer learning to serve as a feature extractor to derive deep features for building ML models. Model performance was assessed using area under the curve (AUC), accuracy, F1-Score, confusion matrix analysis, decision curves, and calibration curves.

RESULTS

The AUC values for the external testing dataset were 0.90, 0.90, 0.91, and 0.89 for random forest classifier (RFC), support vector classifier (SVC), logistic regression (LR), and extreme gradient boosting (XGB), respectively. The accuracy values for the external testing dataset were 0.79, 0.81, 0.80, and 0.80 for RFC, SVC, LR, and XGB, respectively. The F1-score values for the external testing dataset were 0.75, 0.77, 0.78, and 0.79 for RFC, SVC, LR, and XGB, respectively.

CONCLUSION

The ML model constructed using deep features from 2.5D images has the potential to be applied in predicting the prognosis of HCC patients following TACE treatment.

Harnessing Plasma Biomarkers to Predict Immunotherapy Outcomes in Hepatocellular Carcinoma: The Role of cfDNA, ctDNA, and Cytokines

Immunotherapy has improved survival in patients with advanced hepatocellular carcinoma (HCC); yet, objective radiological responses occur in only about 20% of cases, suggesting variable benefits. This study aimed to identify serologic markers predictive of response to immune checkpoint inhibitors (ICIs). A cohort of 38 advanced HCC patients receiving immunotherapy was prospectively analyzed. Levels of cell-free DNA (cfDNA), circulating tumor DNA (ctDNA), and cytokines were measured pre-treatment and three months post-treatment initiation. Genomic profiling of ctDNA was also conducted. Baseline levels of cfDNA and ctDNA effectively discriminated HCC patients based on their radiological response to ICIs. Additionally, individuals with pathologic mutations in the CDKN2A gene exhibited significantly reduced survival. Patients with progressive disease (PD) as their best radiological response had significantly fewer copy number variations (CNVs) than those with a radiological response. Furthermore, levels of IL10, PD1, and TGFβ assessed after three months of treatment showed significant variations correlating with survival status. In conclusion, the analysis of cfDNA, ctDNA, and cytokines may improve treatment selection for HCC patients by predicting their expected response to immunotherapies.

Prediction Model of Survival in Unresectable HCC with Central Bile Duct Invasion Receiving TACE After Biliary Drainage: TEMP Score

Purpose

Central bile duct invasion (BDI) by hepatocellular carcinoma (HCC) is rare and associated with poor prognosis, lacking treatment guidelines. While transarterial chemoembolization (TACE) is often used for unresectable cases, determining optimal candidates post-biliary drainage is controversial. We aim to develop a prognostic prediction model for unresectable HCC (uHCC) patients with central BDI receiving sequential TACE after successful biliary drainage.

Patients and Methods

We retrospectively analyzed 267 uHCC patients with central BDI receiving successful biliary drainage and sequential TACE from seven tertiary centers (2015-2021), divided into training (n=187) and validation (n=80) sets. Using Cox proportional-hazards regression model, we identified key prognostic indicators for overall survival (OS) and constructed a prediction model.

Results

Pre-TACE total bilirubin (TBil) values, extrahepatic spread (EHS), multiple intrahepatic tumors (MIT), and portal vein tumor thrombus (PVTT) were identified as the significant clinical indicators for OS. These four parameters were included in a novel prediction model, named TEMP score, which could successfully categorize patients in the training set into three distinct risk grades with median OS of 26.9, 9.4, and 5.8 months, respectively. The TEMP score predicted the time-dependent areas under the receiver operating characteristic curves for OS at 6 months, 1 year, and 2 years of 0.813/0.907, 0.833/0.782, and 0.838/0.811 in the training and validation sets, with corresponding C-indices of 0.812/0.929, 0.829/0.761, and 0.818/0.791, respectively, outperforming other currently available models in both cohorts. The calibration curve of the model for predicting OS presented good consistency between observations and predictions in both the training set and validation set.

Conclusion

The TEMP score effectively stratifies the prognosis of uHCC patients with central BDI who have undergone successful bile drainage and sequential TACE, helping to identify those who may benefit from TACE treatment.

What Is the Optimal Locoregional Approach for Recurrent Hepatocellular Carcinoma?

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Effectiveness of noncontrast-abbreviated magnetic resonance imaging in a real-world hepatocellular carcinoma surveillance

OBJECTIVES

Noncontrast-abbreviated magnetic resonance imaging (NC-AMRI) is emerging as a promising alternative to ultrasound (US) for surveillance of hepatocellular carcinoma (HCC) in at-risk patients. We aimed to assess the effectiveness of NC-AMRI in a real-world surveillance population, and to evaluate the appropriateness of NC-AMRI in selected patients with inadequate prior US.

MATERIALS AND METHODS

This retrospective study included Child-Pugh class A or B adults with chronic hepatitis B or cirrhosis from any cause who underwent NC-AMRI between December 2018 and August 2022. Early- and very early-stage detection, receipt of curative treatment, and false referral were evaluated. Subgroup analysis was performed for patients with inadequate prior US examinations. Descriptive statistics were used.

RESULTS

Among the 1853 patients (mean age, 58.8 years; 1045 males), 68 HCCs developed in 61 (61/1853, 3.3%, 95% confidence interval: 2.5-4.2) patients. The proportions of early- and very early-stage detection were 95.1% (58/61, 72.2-100.0) and 70.5% (43/61, 51.0-95.0); receipt of curative treatment, 67.2% (41/61, 48.2-91.2); and proportion of false referral, 12.9% (9/70, 5.9-24.4). Among the 375 patients with inadequate prior US, the proportions of early- and very early-stage detection were 94.7% (18/19, 56.2-100.0) and 57.9% (11/19, 28.9-100.0); receipt of curative treatment, 52.6% (10/19, 25.2-96.8); and proportion of false referrals, 17.4% (4/23, 4.7-44.5).

CONCLUSION

NC-AMRI may be an effective HCC surveillance modality given the results related to early- and very early-stage detection, receipt of curative treatment, and false referral. NC-AMRI can be an alternative HCC surveillance strategy, especially for patients with inadequate prior US examinations.

KEY POINTS

Question There is insufficient evidence to support the use of noncontrast-abbreviated MRI as an effective surveillance tool in large real-life populations under surveillance. Findings Using noncontrast-abbreviated MRI, most patients who developed HCCs during surveillance were diagnosed at an early stage, with an acceptable false referral rate of 12.9%. Clinical relevance Noncontrast-abbreviated MRI is an effective HCC surveillance modality, especially for patients with inadequate prior ultrasound examinations.

Healthcare Disparities in the Treatment and Outcomes of Hepatocellular Carcinoma in South Africa

BACKGROUND

The impact of healthcare disparities on the outcomes for hepatocellular carcinoma (HCC) has not been explored in South Africa. This study aims to evaluate and compare the presentation, treatment, and outcomes of HCC in a cohort of patients treated in the public and private sectors.

METHODS

The records of 551 consecutive patients treated at a public hospital compared to those of 51 treated in the private sector from 1 December 2001 to 29 February 2024 were retrospectively reviewed.

RESULTS

Patients managed in the public sector were significantly younger (mean age: 49.6 ± 14.8 vs. 59.6 ± 14.3 years, p < 0.00001) and more likely to have hepatitis B virus (HBV)-related HCC (62.1% vs. 17.6%, p < 0.00001). The prevalence of multifocal disease (59.2% vs. 15.7%, p < 0.00001), portal vein tumor thrombosis (44.6% vs. 5.9%, p < 0.00001), and pulmonary metastases (16.2% vs. 3.9%, p = 0.0143) was significantly higher in public sector patients. A significantly higher number of public sector patients received best supportive care as their only treatment (69.7% vs. 15.7%, p < 0.00001). A higher proportion of private sector patients were treated with curative-intended therapies (ablation, liver resection, and liver transplantation) and transarterial modalities. Median survival was lower in public sector patients (68 [IQR: 25-232] vs. 703 [IQR: 388-1327] days, p < 0.001). There was no difference in survival between public and private sector patients treated with curative-intended therapies.

CONCLUSIONS

In the public sector, patients present with more advanced HCC, which limits their access to curative-intended therapies, resulting in lower survival. Patients treated with curative-intended therapies have similar survival rates in the public and private sectors. With the introduction of universal health coverage through the National Health Insurance program in South Africa, these data highlight the gaps in HCC care in the public sector, where health initiatives such as HBV vaccination, early treatment of HBV, patient education, and screening of at-risk patients should be prioritized.

Impact of compliance to postoperative regular follow-up on long-term prognosis after curative resection for hepatocellular carcinoma: A multicenter analysis

BACKGROUND

Despite advances in surgical treatment, high recurrence after surgery remains a challenge for patients with hepatocellular carcinoma (HCC). This study aimed to investigate the association between compliance to regular follow-up and long-term oncological outcomes among patients undergoing curative resection for HCC.

METHODS

This multicenter study included patients who underwent curative resection for early-stage HCC between January 2012 and December 2021 at 12 liver surgery centers. Patients were stratified into a regular follow-up group (follow-up every 2-3 months for the first 2 years and every 3-6 months thereafter) and an irregular/no follow-up group. Overall survival (OS), time to recurrence (TTR), and post-recurrence survival (PRS) were compared between the two groups.

RESULTS

Among 1544 patients, 786 (50.9 %) underwent regular follow-up during postoperative follow-up. The regular follow-up group had better OS (median: 113.4 vs. 94.5 months, P = 0.010) and PRS (median: 37.9 vs. 16.3 months, P < 0.001) than the irregular/no follow-up group, although TTR was comparable (median: 61.4 vs. 66.2 months, P = 0.161). Furthermore, patients in the regular follow-up group had a lower incidence of tumor beyond the Milan criteria at recurrence (41.6 % vs. 50.4 %, P = 0.013) and were more likely to receive curative treatments for recurrence (56.1 % vs. 49.3 %, P = 0.061). On multivariate analysis, compliance to regular follow-up was an independent factor associated with better OS [hazard ratio (HR) = 0.777, 95 % confidence interval (CI): 0.663-0.910, P = 0.002] and PRS (HR = 0.523, 95 % CI: 0.428-0.638, P < 0.001).

CONCLUSIONS

Compliance to regular follow-up improved OS and PRS after curative resection for HCC, highlighting the importance of postoperative regular follow-up for early detection of recurrence and timely intervention.

Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

CD161, a promising prognostic biomarker in hepatocellular carcinoma, correlates with immune infiltration

Background

CD161, encoded by the killer cell lectin-like receptor B1 (KLRB1) gene, exhibits varied roles among different tumors. This study aimed to explore both the potential value of CD161 as a prognostic biomarker for hepatocellular carcinoma (HCC) and its association with immune cell infiltration.

Methods

A total of 109 HCC patients who underwent surgery were retrospectively analyzed. Immunohistochemistry, bioinformatic analyses, and statistical measurements were used to investigate the associations between CD161 expression, immune cell infiltration, and clinical outcomes in both public databases and in-house cohorts.

Results

CD161 was highly expressed at both protein and mRNA levels in adjacent normal tissues compared to tumor tissues of HCC patients. Meanwhile, CD161 was enriched in HCC cases characterized by smaller tumor sizes (≤5 cm) and the absence of portal vein tumor thrombus. Individuals with high CD161 expression showed extended overall survival (OS) and relapse free survival (RFS) compared to those with lower CD161 levels. CD161 was identified as an independent prognostic indicator for both OS and RFS. In addition, the enrichment analysis indicated a close correlation between CD161 and immune response, as well as between CD161 and the signaling pathways of cytokines and chemokines, implying its role in immune regulation during cancer development. Specifically, CD161 expression was positively associated with immunomodulators and tumor-infiltrating immune cells, especially CD8+T cells, CD4+T cells, and dendritic cells. Multiple public databases showed that patients with high CD161 expression were more likely to derive benefits from immunotherapy.

Conclusion

CD161 was identified as a promising prognostic biomarker for HCC, as its expression indicates a favorable prognosis. Additionally, CD161 is closely linked to high infiltration of immune cells, participates in the regulation of the tumor immune microenvironment, and holds promise as a potential biomarker for predicting the efficacy of immunotherapy.

Prognostic Value of the Vascular Lake Phenomenon in Large Hepatocellular Carcinoma Following Conventional TACE: A Retrospective Study

RATIONALE AND OBJECTIVES

The study aimed to evaluate risk factors related to the vascular lake phenomenon (VLP) and its impact on prognosis in patients with large hepatocellular carcinoma (HCC) (≥5 cm) undergoing Conventional transarterial chemoembolization (cTACE).

PATIENTS AND METHODS

This study included 149 patients with large HCC who initially underwent cTACE from July 2021 to July 2023. The univariate and multivariate analyses were conducted to find risk factors related to VLP. The overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and postoperative complications were compared between the VLP group and the non-VLP group. The propensity score matching (PSM) was used to reduce selection bias.

RESULTS

Among the 149 patients (mean age 65±12 years; 120 male), 50 patients were in the VLP group. The VLP group had a significantly higher positive rate of Hepatitis B surface Antigen (HBsAg) (p=.006). After PSM, VLP was an independent factor associated with OS (p=.002, HR 0.39, 95% CI: 0.21, 0.72) and PFS (p=.002, HR 0.50, 95% CI: 0.32, 0.78). The VLP group showed significantly longer OS (19.1 months vs. 13.4 months, p=.005), longer PFS (11.2 months vs. 6.5 months, p=.006), higher ORR (34.0% vs 14.0%, p=.019), and higher DCR (62.0% vs 26.0%, p<.001) than the non-VLP group.

CONCLUSION

The presence of VLP in large HCC may correlate with a higher rate of HBsAg positivity. It can indicate improved survival outcomes and treatment response underwent cTACE treatment.

SUMMARY

In hepatocellular carcinoma with a diameter greater than 5 cm, the presence of preoperative vascular lake phenomenon indicates better transarterial chemoembolization efficacy.

Personalized MRD Assessment in Perisurgical ctDNA for Prognostic Prediction in Hepatocellular Carcinoma

PURPOSE

Detecting residual disease is a critical clinical requirement in the perisurgical management of patients with resectable hepatocellular carcinoma (HCC). Previous studies focused on specific genomic regions exhibiting limited sensitivity and failed to meet the minimal residual disease (MRD) testing threshold. We introduce a next-generation sequencing-based assay, informed by baseline samples, facilitating MRD detection in hepatectomized patients with HCC and offering prognostic predictions.

EXPERIMENTAL DESIGN

This study involved 88 patients with HCC who underwent surgical resections from January 2016 to May 2016 in Zhongshan Hospital, Fudan University. Tumor and normal tissue samples were collected during surgery, whereas plasma samples were obtained both before surgery and up to 7 days after surgery. Using a next-generation sequencing-based personalized ctDNA assay, we analyzed the MRD in both presurgical and postsurgical blood samples and its correlation with prognosis.

RESULTS

With a median follow-up period of 80.7 months, our findings demonstrated significant correlations between presurgical ctDNA tumor fractions, postsurgical plasma MRD status, and both recurrence-free survival and overall survival. Postsurgical MRD status emerged as the most significant risk factor for cancer recurrence (HR = 2.162; 95% confidence interval, 1.09-4.30; P = 0.027) compared with other clinical characteristics in multivariate Cox regression analysis. Notably, MRD status showed potential as a prognostic indicator among clinically low-recurrent-risk patients, such as those with Barcelona Clinic Liver Cancer stages 0 to A or China Liver Cancer Staging stages I to II.

CONCLUSIONS

Evaluating personalized MRD provided crucial prognostic insights into recurrence-free survival and overall survival. It efficiently identified patients at high risk of recurrence, even among those initially perceived as low-risk cases. See related commentary by Pinato et al., p. 955.

Assessing the Validity of the AASLD Surgical Treatment Algorithm in Patients with Early-Stage Hepatocellular Carcinoma

Background/Aims

The aim of this study was to investigate the effect of a surgical treatment algorithm recently proposed by the American Association for the Study of Liver Diseases (AASLD) on survival outcomes in patients with early-stage hepatocellular carcinoma (HCC) and identify effective alternative treatment modalities when liver transplantation (LT) is not available.

Methods

We studied the clinical data of 1,442 patients who were diagnosed with early-stage HCC (a single lesion measuring 2-5 cm in size or 2 to 3 lesions measuring ≤3 cm in size) between 2013 and 2018 and classified as Child-Turcotte-Pugh (CTP) A or B. Analyses were separately performed for individuals recommended for resection (single lesion, CTP A and no clinically significant portal hypertension) and those recommended for LT (single lesion with impaired liver function such as CTP B or clinically significant portal hypertension or multiple lesions).

Results

Of 791 patients recommended for surgical resection, 85.8% underwent resection. The 5-year survival rate was higher for patients who underwent surgical resection than for those who received other treatments (89.4% vs 72.3%). Among 651 patients recommended for LT, only 3.4% underwent the procedure. The most common alternative treatment modalities were transarterial therapy (39.3%) followed by resection (28.9%) and ablation (27.8%). The overall survival rate associated with transarterial therapy was lower than that for resection and ablation, whereas that of the latter two treatments were comparable.

Conclusions

The survival outcomes of treatment strategies that most closely aligned with the algorithm proposed by the AASLD were superior to those of alternative treatment approaches. However, LT in patients with early-stage HCC can be challenging. When LT is not feasible, resection and ablation can be considered first-line alternative options.

Current impact in the treatment of advanced hepatocellular carcinoma: The challenge remains

Hepatocellular carcinoma remains a significant cause of mortality worldwide, particularly among patients with liver cirrhosis. In most cases, surveillance in cirrhotic patients is neglected, leading to a diagnosis when the neoplasm is at an advanced stage. Within this context, Zhou et al carried out a network meta-analysis to demonstrate the effectiveness of hepatic arterial infusion chemotherapy, concluding that it is a superior approach compared to sorafenib and transarterial chemoembolization in the treatment of advanced hepatocellular carcinoma. Unfortunately, the meta-analysis in question lacks methodological rigor, preventing the authors from making more definitive assertions. Additionally, we understand that transarterial chemoembolization, when properly indicated, is a highly effective therapeutic option, and that sorafenib, given the results of new therapies based on immune checkpoint inhibitors, is no longer the recommended drug for the treatment of these patients. Therefore, we believe the use of hepatic arterial infusion chemotherapy is increasingly limited and lacks strong scientific support.

Final Results of a Multicenter Prospective Study of Stereotactic Body Radiation Therapy for Previously Untreated Solitary Primary Hepatocellular Carcinoma (The STRSPH Study)

PURPOSE

To report final results of a prospective study of stereotactic body radiation therapy (SBRT) in patients with previously untreated solitary primary hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

This prospective, single-arm, multicenter phase 2 trial recruited patients with HCC who were unsuitable for, or refused, surgery and radiofrequency ablation, with 3-year overall survival rates as the primary endpoint and survival outcomes and adverse events as secondary endpoints. The prescribed SBRT dose was 40 Gy in 5 fractions. The final data were analyzed in November 2022.

RESULTS

Between 2014 and 2018, 36 patients (median age, 73.5 years) were registered; enrollment was closed before full recruitment due to slow accrual. Overall, 34 patients were analyzed for efficacy evaluation after excluding 2 patients. The median tumor size was 2.3 cm. The median follow-up times for all patients and for survivors were 49 and 56 months, respectively. The 3-year overall survival rate was 82% (95% confidence interval, 65%-92%). The 3-year local control rate was 93% (95% confidence interval, 76%-98%). Grade 3 or higher SBRT-related nonlaboratory toxicities were observed in 4 patients (11%). No grade 5 adverse events were observed.

CONCLUSIONS

Final results of this phase 2 trial suggest the efficacy and safety of SBRT for newly diagnosed early-stage HCC that is unfit for other local therapies. Although this study was underpowered by the small number of registrations, the excellent results indicate that SBRT may be an alternative option for the management of early-stage HCC.

Identification of candidates with hepatocellular carcinoma to receive TACE combined with MWA by assessing tumor burden and radiologic features

Background

There is still no noninvasive, automated, and accurate model for guiding physicians in the decision-making of transarterial chemoembolization combined with microwave ablation (TACE-MWA) in intermediate-stage hepatocellular carcinoma (HCC).

Objectives

To develop a prognostic score based on the tumor burden and radiomic features for the prediction of the long-term survival of patients with intermediate-stage HCC after TACE-MWA.

Methods

From June 2008 to October 2022, a total of 2189 consecutive patients from seven tertiary-care hospitals with intermediate-stage HCC who received initial TACE combined with MWA were enrolled. Among them, 2189 were divided into training cohort (N = 1753), and internal test cohort (N = 436) in a single center, and 316 patients were assigned to external test cohort in another 6 centers. A prognostic scoring system was constructed using tumor burden and radiologic features (TBR) and compared with conventional predicting systems.

Results

In training cohort, multivariate Cox regression analysis suggested that tumor burden (hazard ratio (HR), 0.693; 95% confidence interval (CI): 0.505, 0.814; 1 point per 1.0 increase, p = 0.024), radiologic features (HR, 0.349; 95% CI: 0.236, 0.517; p < 0.001), and alpha-fetoprotein (HR, 1.629; 95% CI: 1.280, 2.073; p < 0.001) were independent prognostic factors for OS. A prognostic model that comprises TBR was built, which showed significantly higher AUC values than other clinical stagings in all three cohorts. Moreover, the TBR score provided greater net benefit across the range of reasonable threshold probabilities than other models. Based on cutoff values of 32 and 74 centiles of the TBR score, the cohort was divided into low-, middle-, and high-risk strata, which provide consistent performance in survival discrimination across different patient subgroups.

Conclusion

The TBR score serves as an efficient instrument for risk stratification, guiding the course of adjuvant targeted and immunotherapies for HCC patients undergoing TACE-MWA combined treatment.

Design

A retrospective, multi-institutional study.

A new standard for HCC: The high stakes of TACE-immunotherapy combinations

Transarterial chemoembolization (TACE) has long been the standard for intermediate-stage hepatocellular carcinoma (HCC), but two recent phase 3 trials have redefined treatment paradigms. The EMERALD-11 and LEAP-0122 trials demonstrated significant progression-free survival improvement with TACE combined with durvalumab/bevacizumab or pembrolizumab/lenvatinib, respectively, but doubts remain regarding the patient selection and the toxicity of these novel combinations.

The efficacy of transcatheter arterial chemoembolization for hepatocellular carcinoma: is the alteration of the inflammation index important?

Introduction

Transcatheter arterial chemoembolization (TACE) is widely applied for locoregional malignant lesions control in intermediate and selected advanced hepatocellular carcinoma (HCC). Various inflammation indices, such as neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammatory index (SII), and Lymphocyte-to-C Reactive Protein Ratio (LCR) have been explored as tools for predicting the efficacy of TACE. However, the role and predictive value for dynamic changes of peripheral inflammatory indicators pre- and post-TACE remains unclear.

Objective

To explore the association between the alteration in inflammatory index and the efficacy and prognosis of TACE and to provide more evidence for early prediction of the efficacy of TACE.

Methods

This was a retrospective single-center study. HCC patients who received TACE as initial treatment were enrolled. The relationship between the alteration of inflammation indices (calculated as post-TACE minus pre-TACE measurements) and TACE efficacy and prognosis was investigated. Progression-free survival (PFS) was the primary endpoint, and treatment efficacy was evaluated based on mRECIST criteria.

Results

Before propensity score matching (PSM), the change in LMR was significantly associated with treatment effective rate, with the unelevated ΔLMR group achieving a 79.4% treatment effective rate compared to 36.4% in the elevated group (p < 0.001). The estimated median PFS was 9.7 months and 4.5 months in the unelevated and elevated group, with a significant difference (p = 0.016). After PSM, the treatment effective rate was 48.7 and 38.5% (p = 0.214), and the estimated median PFS was 8.9 and 5.5 months (p = 0.173) for the unelevated and elevated group, respectively.

Conclusion

Our study demonstrated that alteration of indices of peripheral inflammation, including ΔNLR, ΔLMR, ΔSII, and ΔPLR, may not be valuable prognostic markers for HCC patients who received TACE.

A real-world study of the efficacy of second-line treatment of unresectable hepatocellular carcinoma with esophagogastric varices after progression on first-line lenvatinib combined with PD-1 inhibitor

PURPOSE

The incidence and mortality of hepatocellular carcinoma are still high according to National Cancer Center of China. Atezolizumab plus bevacizumab has become one of the standard regimens for the first-line treatment of unresectable hepatocellular carcinoma. However, some patients still use lenvatinib in combination with immunotherapy instead of a standard "atezolizumab-bevacizumab" regimen as a lower risk of bleeding in patients with esophagogastric varices. However, there is no evidence for second-line therapy after progression on lenvatinib combined with PD-1 inhibitor in unresectable hepatocellular carcinoma till now. Herein, we aim to investigate second-line treatment among these patients.

PATIENTS AND METHODS

Thirty-three patients with unresectable hepatocellular carcinoma with esophagogastric varices were admitted to the Second Affiliated Hospital of Nanchang University from January 2019 to December 2023. They were treated with lenvatinib in combination with PD-1 inhibitor as first line. The efficacy was conducted according to the RECIST1.1 criteria. The endpoints included objective response rate (ORR), disease control rate (DCR), median overall survival (OS), and median progression free survival (PFS).

RESULTS

We identified a total of 225 patients with unresectable hepatocellular carcinoma with esophagogastric varices who received first-line lenvatinib in combination with PD-1 inhibitor, of whom 33 (14.7%) received second-line therapy. 21 patients (63.6%) were treated with regorafenib combined with PD-1 inhibitor, 6 patients (18.2%) with apatinib plus PD-1 inhibitor, 4 patients (12.1%) with bevacizumab plus PD-1 inhibitor, and the remaining 2 patients with regorafenib or sorafenib as monotherapy, respectively. Of the 33 patients, 2 (6.1%) were evaluated as partial response (PR), 16 (48.5%) had stable disease (SD), and 15 (45.4%) experienced progression (PD). The ORR was 6.1%, and the DCR was 54.6%. Median PFS was 4.5 months, median OS was 7.2 months, and the 12-month OS rate was 27.3%. Overall survival follow-up was done in 37 patients without second line treatment whose baseline levels were matched with those of the treatment group. The OS was 7.2 months in second line treatment group versus 3.0 months in control group (p = 0.04). As for different treatments in a second line, The ORR of regorafenib in combination with PD-1 inhibitor was 9.5%, the DCR was 47.6%, the median PFS was 4.2 months, and the median OS was 5.9 months. None of the patients treated with apatinib plus PD-1 inhibitor got PR, the DCR was 83.3%, the median PFS was 8.7 months, and the median OS was 9.1 months. None of the patients treated with bevacizumab plus PD-1 inhibitor got PR, the DCR was 25.0%, the median PFS was 2.2 months, and the median OS was 6.0 months.

CONCLUSION

The second-line treatment of unresectable hepatocellular carcinoma with esophagogastric varices after progression on first-line lenvatinib combined with PD-1 inhibitor is effective. Regorafenib or apatinib combined with PD-1 inhibitor might be the preferred options.

Software-based versus visual assessment of the minimal ablative margin in patients with liver tumours undergoing percutaneous thermal ablation (COVER-ALL): a randomised phase 2 trial

BACKGROUND

Tumour coverage with an optimal minimal ablative margin is crucial for improving local control of liver tumours following thermal ablation. The minimal ablative margin has traditionally been assessed through visual inspection of co-registered CT images. However, rates of local tumour control after thermal ablation are highly variable with visual assessment. We aimed to assess the use of a novel software-based method for minimal ablative margin assessment that incorporates biomechanical deformable image registration and artificial intelligence (AI)-based autosegmentation.

METHODS

The COVER-ALL randomised, phase 2, superiority trial was conducted at The University of Texas MD Anderson Cancer Center (Houston, TX, USA). Patients aged 18 years or older with up to three histology-agnostic liver tumours measuring 1-5 cm and undergoing CT-guided thermal ablation were enrolled. Thermal ablation was performed with the aim of achieving a minimal ablative margin of 5 mm or greater. Patients were randomly assigned (1:1) to the experimental group (software-based assessment) or the control group (visual assessment) by use of dynamic minimisation to balance covariates. Randomisation was performed intraprocedurally after placement of the ablation applicator. Assessment of oncological outcomes and adverse events were masked to treatment allocation. All analyses were conducted on an intention-to-treat basis. The primary endpoint was the minimal ablative margin on post-ablation intraprocedural CT. A preplanned interim analysis for superiority was done at 50% patient enrolment. Adverse events were recorded with the Common Terminology Criteria for Adverse Events. This trial is registered with ClinicalTrials.gov (NCT04083378), and recruitment is complete.

FINDINGS

Patients were enrolled and treated with thermal ablation between June 15, 2020, and Oct 5, 2023. 26 patients were randomly assigned to the control group (mean age 58·1 [SD 14·8] years; 18 [69%] male and eight [31%] female; 11 [42%] colorectal cancer liver metastasis; median tumour diameter 1·7 cm [IQR 1·3-2·3]) and 24 to the experimental group (mean age 60·5 [14·4] years; 16 [67%] male and eight [33%] female; ten [42%] colorectal cancer liver metastasis; median tumour diameter 1·8 cm [1·5-2·5]). The interim analysis showed a mean minimal ablative margin of 2·2 mm (SD 2·8) in the control group and 5·9 mm (2·7) in the experimental group (p<0·0001), prompting halting of enrolment in the control group. A further 50 patients were enrolled to a non-randomised experimental group (mean age 56·5 [SD 11·7] years; 27 [54%] male and 23 [46%] female; 30 [60%] colorectal cancer liver metastasis; median tumour diameter 1·5 cm [IQR 1·3-2·2]); among these patients, the mean minimal ablative margin was 7·2 mm (SD 2·8). Grade 1-3 adverse events were reported in five (5%) of 100 patients: three (12%) of 26 in the control group and two (3%) of 74 in the experimental groups. No grade 4-5 adverse events or treatment-related deaths were reported.

INTERPRETATION

Software-based assessment during CT-guided thermal ablation of liver tumours is safe and significantly improves the minimal ablative margin compared to visual assessment. Adoption of software-based assessment as a standard component of thermal ablation should be considered to achieve the intended minimal ablative margin.

FUNDING

US National Institutes of Health and US National Cancer Institute.

Evaluating Sorafenib (SORA-2) as Second-Line Treatment for Unresectable Hepatocellular Carcinoma: A European Retrospective Multicenter Study

BACKGROUND/OBJECTIVES

Systemic treatment for unresectable hepatocellular carcinoma (HCC) has rapidly advanced, with immune checkpoint inhibitors now the preferred first-line option. However, with multiple agents available and no established treatment sequence, selecting the most suitable second-line (2L) therapy remains challenging. While sorafenib is frequently chosen for 2L treatment, comprehensive data supporting its use is limited. This study evaluates the effectiveness of sorafenib as 2L therapy and factors influencing outcomes following first-line treatment failure in advanced HCC patients.

METHODS

This is a retrospective, multicenter study, including 81 patients with unresectable HCC from 12 European centers who received sorafenib as 2L treatment. Median overall survival (mOS), median progression-free survival (mPFS), radiological response to treatment, and toxicity were evaluated. Univariable and multivariable analyses were performed to identify potential predictors of clinical benefit.

RESULTS

In this cohort, some patients were treated with 2L sorafenib mOS for 7.4 months (95% CI: 6.6-13.6) and other patients were treated with mPFS for 3.7 months (95% CI: 3.0-4.8). Multivariable analysis revealed the best median OS for patients with CP A and AFP levels < 400 ng/mL (15.5 months). Adverse events (AE) of grade ≥ 3 were reported in 59.4% of patients.

CONCLUSIONS

In this real-world cohort of European patients with unresectable HCC, the outcome of sorafenib treatment in the 2L setting was comparable to that of the other established 2L treatment options in patients with preserved liver function and good performance status. This study contributes to the understanding of the role of sorafenib in the 2L setting and underscores the need for further research to identify predictive factors for response and survival in order to optimize treatment algorithms for advanced HCC.

Radiation Segmentectomy or Ablative External Beam Radiation Therapy as Initial Treatment for Solitary Hepatocellular Carcinoma: A Multicenter Experience

Purpose

Radiation segmentectomy (RS) and ablative external beam radiation therapy (EBRT) are now accepted, definitive, local therapies for hepatocellular carcinoma (HCC). This report aimed to describe the clinical outcomes of RS and EBRT for treatment-naïve, solitary, HCC.

Methods

A multicenter retrospective review was performed of all patients treated with RS or EBRT from March 2016 through September 2023. Inclusion criteria were initial treatment for solitary HCC ≤8 cm and absence of macrovascular invasion or extrahepatic disease. Outcomes were censored for liver transplantation (LT).

Results

Eighty-six patients (RS: 58; EBRT: 28) met inclusion criteria. The EBRT cohort had older patients (median 76 vs 66 years, p < 0.001), larger tumors (median 3.7 vs 2.4 cm, p < 0.001), and worse performance status (p = 0.02). The RS cohort had more patients with ≥ grade 3 liver fibrosis (p < 0.001). Radiologic complete response (rCR) was achieved in 97% of RS and 82% of EBRT patients (p = 0.02). Median time to rCR was 1 month (95% CI: 0.9-1.1) after RS and 7 months (95% CI: 6-7) after EBRT (p < 0.001). The 1-year local control was 97% vs 93% for RS and EBRT, respectively (p = 0.80). Subsequent LT was performed in 48% of RS and 11% of EBRT patients with tumor complete pathologic response rates of 76% (n=22/28) and 33% (n=1/3), respectively. Progression free survival at 1-year was 87% after RS vs 80% after EBRT (p = 0.26). 1- and 2-year overall survival was 88% and 85% after RS vs 84% and 59% after EBRT (p = 0.34).

Conclusion

RS and EBRT are effective therapies for solitary HCC. Treatment should be determined via multidisciplinary discussion based on individual patient characteristics.

Does the hepatologist still need to rely on aminotransferases in clinical practice? A reappraisal of the role of a classic biomarker in the diagnosis and clinical management of chronic liver diseases

Aminotransferases, particularly alanine aminotransferase (ALT), are commonly used in the detection, diagnosis, and management of chronic liver diseases. ALT, a sensitive and cost-effective marker of liver injury, remains pivotal in predicting clinical outcomes and guiding interventions in several chronic liver diseases including metabolic dysfunction-associated steatotic liver disease, and chronic viral hepatitis. This study aims to explore the evolving role of ALT as a biomarker. A comprehensive review of evidence was conducted, focusing on studies evaluating ALT thresholds, diagnostic accuracy, and integration with non-invasive liver assessment tools. Special emphasis was given to novel approaches, including artificial intelligence-driven algorithms. Expert opinions from hepatology care perspectives were considered to assess the practical implications of refining ALT-based diagnostic strategies. ALT levels are influenced by diverse factors such as age, gender, and metabolic risks, challenging the use of specific thresholds as biomarker of disease and prognosis. Emerging evidence suggests redefining ALT ranges to enhance sensitivity and accuracy in detecting liver abnormalities. The integration of ALT with advanced non-invasive diagnostic tools, artificial intelligence, and comprehensive patient assessments can optimize early detection of liver disease, thus reducing underdiagnosis, particularly in asymptomatic or vulnerable populations. This work highlights the urgency to tailor the diagnostic approaches in primary and specialized care, ensuring timely and targeted intervention to effectively address the global burden of liver diseases.

Characteristics and Survival Outcomes of Hepatocellular Carcinoma After the Fontan Operation

BACKGROUND

The Fontan operation is a surgical procedure to palliate single ventricle congenital heart disease. Hepatocellular carcinoma (HCC) is a rare complication of Fontan-associated liver disease (FALD).

OBJECTIVES

The authors aim to examine characteristics of individuals with Fontan circulation diagnosed with HCC and to describe tumor characteristics, treatment, and survival outcomes of these patients.

METHODS

This was a multicenter retrospective case-control study of adults with Fontan circulation between 2005 and 2021. HCC cases were included based on histology or imaging-based diagnosis. Controls were randomly selected in a 3:1 ratio from the center in which the case was derived. Descriptive statistics were used to compare groups and Kaplan-Meier survival analysis was performed.

RESULTS

There were 58 cases of HCC diagnosed at a median age of 31 (IQR: 26-38) years. Diagnosis was made at very early or early stage disease in 68%. Compared to controls, cases had higher prevalence of advanced FALD including varices, ascites, splenomegaly, and decreased platelets. Treatment with curative intent (combined heart-liver transplantation, resection, or ablation) was performed in 41%. Survival at 1 year was 78.9% and highest among those diagnosed at very early or early stage. Over half were undergoing active surveillance at diagnosis, which showed a nonsignificant trend toward higher survival (P = 0.088).

CONCLUSIONS

We describe the clinical characteristics, treatment, and survival in patients with FALD-HCC. Results suggest that adults with FALD-HCC diagnosed with early stage disease may have survival benefit. Our findings underscore the importance of HCC screening for early detection in individuals after the Fontan operation.

Protocol of the IMPACT study: randomized, multicenter, phase 3 study evaluating the efficacy of immunotherapy (Atezolizumab) plus anti-VEGF therapy (Bevacizumab) in combination with transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma

BACKGROUND

Atezolizumab plus bevacizumab is recommended as a first-line treatment for unresectable hepatocellular carcinoma (uHCC). A subgroup analysis of the IMbrave150 trial showed shorter overall survival (OS) in uHCC patients with stable disease (SD) than patients with complete response (CR) or partial response (PR) after atezolizumab plus bevacizumab. Improving OS in patients with SD is an unmet medical need. Transcatheter arterial chemoembolization (TACE) may enhance treatment efficacy by controlling intrahepatic lesions and activating anti-tumor immunity. The IMPACT study aims to evaluate whether combining atezolizumab plus bevacizumab with TACE improves OS in patients with SD.

METHODS

IMPACT is a multicenter, phase 3 study being conducted in Japan, recruiting uHCC patients aged ≥ 18 years with Barcelona Clinic Liver Cancer stage A (single tumor ≥ 5 cm only, TACE unsuitable), stage B (TACE unsuitable) or stage C (excluding Vp3 or 4), Child-Pugh A liver function, and no prior systemic therapy. After 12 weeks of atezolizumab plus bevacizumab treatment as induction therapy, patients are being divided into two cohorts based on response: a randomized cohort for patients who achieve SD, or an atezolizumab plus bevacizumab followed by curative conversion (ABC-conversion) cohort for patients who achieve CR or PR. Patients in the randomized cohort are receiving atezolizumab plus bevacizumab and intrahepatic control TACE (Group A), or continuing atezolizumab plus bevacizumab (Group B). Patients in the ABC-conversion cohort are receiving atezolizumab plus bevacizumab. All cohorts can be considered for curative conversion therapies for residual tumors if these therapies are considered curative, in the patient's best interests, and deemed necessary by the investigator. The primary endpoint is OS for the randomized cohort and conversion rate for the ABC-conversion cohort. Secondary endpoints in both cohorts include progression-free survival, objective response rate, duration of response, time to CR, and safety. The study is expected to last 6.5 years from June 2023.

DISCUSSION

IMPACT is evaluating the efficacy of combination therapy with atezolizumab plus bevacizumab and TACE, as well as exploring the efficacy of curative conversion therapy. The results should contribute to establishing a response-guided treatment strategy for uHCC by determining optimal treatment according to the therapeutic effect of atezolizumab plus bevacizumab.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT), identifier: jRCTs051230037. Registered 13 June 2023.

PROTOCOL VERSION

8 May 2024; version 1.4.

A systematic review and meta-analysis of the comparison of laparoscopic radiofrequency ablation to percutaneous radiofrequency ablation for hepatocellular carcinoma

Background

The comparative evaluation of laparoscopic and percutaneous techniques for liver radiofrequency ablation remains unexplored. This study aims to determine the most effective ablation technique and patient selection for hepatocellular carcinoma (HCC) by analyzing the efficacy and safety of laparoscopic radiofrequency ablation (LRFA) versus percutaneous radiofrequency ablation (PRFA).

Methods

Two investigators (Y-QW and PZ) independently performed a literature search in the Cochrane Library, PubMed, Web of Science and Embase databases. Study quality was assessed using the Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. Meta-analysis was conducted with Review Manager 5.4, applying either fixed- or random-effects models depending on study heterogeneity. The chi-square test (χ²) and I² statistics were employed for heterogeneity analysis.

Results

Eight publications involving 1059 patients were included. Among them, 456 underwent LRFA and 603 underwent PRFA. LRFA showed a significantly better 3-year RFS than PRFA (OR: 1.89, 95% CI: 1.27-2.83, p = 0.002), the incidence rate of local recurrence was significantly fewer in the LRFA group (OR: 0.40, 95% CI: 0.23-0.69, p = 0.0010), but the postoperative hospital stay time was slightly shorter in the PFRA group (MD = 1.30; 95% CI 0.26 to 2.35; p=0. 01). Patients in the LRFA group had no significant difference in total postoperative complications, ablation success rates, overall survival (OS) and 1,5-year disease-free survival (DFS).

Conclusion

Both LRFA and PRFA are effective treatments for HCC. LRFA shows better oncologic outcomes, including lower local recurrence and improved mid-term DFS. PRFA is simpler, less invasive and shorter hospital stays. The choice should be tailored to individual patient needs, considering tumor characteristics, comorbidities, and available expertise. Future research should focus on large-scale, prospective trials to validate these findings.

Systematic review and registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024601797.

Long-term outcomes of Yttrium-90 transarterial radioembolization for patients with hepatocellular carcinoma

AIMS

We retrospectively assessed the long-term outcomes of Yttrium-90 (90Y) transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC), focusing on overall survival (OS), radiological response, and safety.

METHODS

We included patients with HCC treated with 90Y TARE at a single center between January 2012 and December 2021 with measurable lesions and a minimum of 2 years of follow-up. Only the former was analyzed for patients with multiple TARE. The primary endpoints were long-term OS, radiological response, and safety; the secondary endpoints included predictors of OS and response, with emphasis on dosimetry. The collected data included demographics, laboratory test results, liver function, and tumor staging. Radiological response was evaluated 3-6 months post-TARE using the modified RECIST (mRECIST) criteria. OS was calculated from TARE until death or censoring. Univariate logistic regression was used to identify the predictors of complete radiological response and OS. Dosimetry was analyzed to determine correlations with mRECIST response.

RESULTS

Among 142 patients (median age 66.8, cirrhotic 92.3%; M: F = 121:21), a median OS of 16.68 months was achieved, with a complete radiological response in 31% (44/142). OS was strongly correlated with radiological response (p < 0.001). Absorbed dose ≥ 234.6 Gy was associated with complete response (p = 0.017) but not with survival (p = 0.102). Rising alpha-fetoprotein levels (p = 0.017) and worsening Child-Pugh scores post-TARE (p = 0.044) were independent predictors of mortality.

CONCLUSION

A complete radiological response is crucial for long-term survival, highlighting the need for dosimetry optimization in TARE for HCC.

The Emerging Role of Histotripsy in Liver Cancer Treatment: A Scoping Review

BACKGROUND/OBJECTIVE

Hepatocellular carcinoma (HCC) is an aggressive disease that is known to be resistant to conventional chemotherapy and radiotherapy. While surgical resection and transarterial therapy can improve overall survival, the biological aspects of HCC contribute to the complexity of its management and limit the effectiveness of current treatment options. The purpose of this scoping review is to identify the limitations of the currently available therapies for HCC and explore the emerging role that histotripsy could play in addressing these limitations, with the intent of informing the direction of future research and clinical management.

METHODS

The PRISMA checklist for scoping reviews was followed to structure this review, and a systematic search was conducted in the following online databases: PubMed/MEDLINE (National Library of Medicine), Embase (Elsevier), and Scopus (Elsevier).

RESULTS

The current evidence supports that histotripsy offers several key advantages that address the limitations of the current treatment strategies for HCC. Clinical trials have highlighted the ability of this technology to destroy solid tumors and induce remission with minimal side effects. In addition, current preclinical studies point to the potent immunostimulatory effects of histotripsy, including the induction of abscopal effects. This poses significant promise in treating tumor metastasis as well as improving clinical regimens by combining histotripsy with immunotherapy. Future research should aim to overcome the current limitations of histotripsy and enhance clinical outcomes for patients. This review examines existing treatments for HCC, emphasizing the promising potential of combining histotripsy with immunotherapy to target the metastatic and advanced stages of the disease.

Neoadjuvant immune checkpoint inhibitors for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of liver cancer. HCC treatment is challenging; surgical resection is the primary curative treatment for early-stage disease, but recurrence rates are high. Immune checkpoint inhibitors (ICIs) are a promising neoadjuvant treatment that can reduce recurrence rates and mortality after surgery and achieve complete/partial responses. Clinical trials provide strong evidence for the efficacy and safety of ICI monotherapy for neoadjuvant HCC treatment.

QSAR-Based Drug Repurposing and RNA-Seq Metabolic Networks Highlight Treatment Opportunities for Hepatocellular Carcinoma Through Pyrimidine Starvation

Background/Objectives: The molecular heterogeneity and metabolic flexibility of Hepatocellular Carcinoma (HCC) pose significant challenges to the efficacy of systemic therapy for advanced cases. Early screening difficulties often delay diagnosis, leading to more advanced stages at presentation. Combined with the inconsistent responses to current systemic therapies, HCC continues to have one of the highest mortality rates among cancers. Thus, this paper seeks to contribute to the development of systemic therapy options through the consideration of HCC's metabolic vulnerabilities and lay the groundwork for future in vitro studies. Methods: Transcriptomic data were used to calculate single and double knockout options for HCC using genetic Minimal Cut Sets. Furthermore, using QSAR modeling, drug repositioning opportunities were assessed to inhibit the selected genes. Results: Two single knockout options that were also annotated as essential pairs were found within the pyrimidine metabolism pathway of HCC, wherein the knockout of either DHODH or TYMS is potentially disruptive to proliferation. The result of the flux balance analysis and gene knockout simulation indicated a significant decrease in biomass production. Three machine learning algorithms were assessed for their performance in predicting the pIC50 of a given compound for the selected genes. SVM-rbf performed the best on unseen data achieving an R2 of 0.82 for DHODH and 0.81 for TYMS. For DHODH, the drugs Oteseconazole, Tipranavir, and Lusutrombopag were identified as potential inhibitors. For TYMS, the drugs Tadalafil, Dabigatran, Baloxavir Marboxil, and Candesartan Cilexetil showed promise as inhibitors. Conclusions: Overall, this study suggests in vitro testing of the identified drugs to assess their capabilities in inducing pyrimidine starvation on HCC.

Model Predicting Survival in Intermediate-Stage HCC Patients Reclassified for TACE Based on the 2022 BCLC Criteria

Background/Objectives: The Barcelona Clinic Liver Cancer (BCLC) staging system for hepatocellular carcinoma (HCC) was updated in 2022 to refine patient stratification, particularly in patients with intermediate-stage (BCLC B) HCC. Although transarterial chemoembolization (TACE) remains a key treatment for these patients, there is no prognostic model for survival outcomes based on the pretreatment factors of patients who meet the updated 2022 BCLC indications for TACE. The aim of this study was to develop a pretreatment risk model predicting overall survival (OS) in patients with intermediate-stage HCC and reclassified as candidates for TACE according to the updated 2022 BCLC criteria. Methods: This retrospective study included 658 HCC patients treated with first-line TACE according to the updated BCLC 2022 guidelines. Pretreatment factors such as the Child-Pugh score, tumor burden (up-to-11 criteria), bilobar tumor involvement, and serum alpha-fetoprotein (AFP) levels were analyzed. Cox proportional hazards models were used to identify significant predictors of OS, with these factors subsequently incorporated into a risk prediction model. Results: Significant predictors of OS included Child-Pugh score ≥ 7, bilobar tumor involvement, beyond up-to-11 criteria, and AFP ≥ 400 ng/mL. A risk model was developed using these factors, stratifying patients into low-, intermediate-, and high-risk groups. The median OS in the low-, intermediate-, and high-risk groups was 53, 35, and 21 months, respectively. Conclusions: The proposed pretreatment risk prediction model may be useful for predicting OS and guiding TACE candidacy in intermediate-stage HCC patients based on the updated 2022 BCLC guidelines.

The relationship between systemic therapies and low skeletal muscle mass in patients with intermediate and advanced hepatocellular carcinoma

Background

Low skeletal muscle mass (LSMM) has been associated with poor prognosis in hepatocellular carcinoma (HCC) patients receiving systemic therapy. However, its impact across different treatment regimens remains unclear.

Methods

A retrospective study analyzed 714 patients with intermediate and advanced HCC, divided into immunotherapy (I, n=85), target-immunotherapy combination (I+T, n=545), and targeted therapy (T, n=84) groups based on treatment. Skeletal muscle was assessed via computed tomography (CT) at the third lumbar vertebral level (L3) before and after 3 months of treatment. LSMM was evaluated by the third lumbar skeletal muscle index (L3-SMI) using a predefined threshold. Patients were stratified by baseline values and treatment changes. Kaplan-Meier and Cox models were used to compare overall survival (OS) and progression-free survival (PFS).

Results

There was no significant difference in the loss of muscle mass among the three groups of LSMM patients; whereas, non-LSMM(NLSMM) patients in group T lost more muscle mass than those in group I (P=0.040).In the I+T group, patients who achieved an objective response (ORR) had less muscle mass loss than those without (P=0.013), while the changes in muscle mass for patients in the I group and T group were unrelated to treatment response. Baseline or post-treatment LSMM was associated with poorer median OS, especially in the I+T group. Progressive LSMM was linked to shorter median PFS (4.9 vs 5.7 months) and OS (9.8 vs 16.5 months), with similar results in the I+T group (mPFS, 4.2 vs. 5.8 months; mOS, 9.7 vs 16.1 months). Patients with LSMM had a higher incidence of treatment-related SAEs, particularly ascites and fatigue.

Conclusion

In patients with combined LSMM in hepatocellular carcinoma, muscle loss did not significantly differ between those treated with I, I+T, and T; however, T treatment contributed to muscle mass loss in NLSMM patients. Greater muscle loss correlated with poorer treatment outcomes and increased SAEs, and baseline, post-treatment, and progressive LSMM were linked to significantly worse prognoses, particularly with combined treatment regimens.

Integrating CT Radiomics and Clinical Features to Optimize TACE Technique Decision-Making in Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

To develop a decision framework integrating computed tomography (CT) radiomics and clinical factors to guide the selection of transarterial chemoembolization (TACE) technique for optimizing treatment response in non-resectable hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was performed on 151 patients [33 conventional TACE (cTACE), 69 drug-eluting bead TACE (DEB-TACE), 49 degradable starch microsphere TACE (DSM-TACE)] who underwent TACE for HCC at a single tertiary center. Pre-TACE contrast-enhanced CT images were used to extract radiomic features of the TACE-treated liver tumor volume. Patient clinical and laboratory data were combined with radiomics-derived predictors in an elastic net regularized logistic regression model to identify independent factors associated with early response at 4-6 weeks post-TACE. Predicted response probabilities under each TACE technique were compared with the actual techniques performed.

RESULTS

Elastic net modeling identified three independent predictors of response: radiomic feature "Contrast" (OR = 5.80), BCLC stage B (OR = 0.92), and viral hepatitis etiology (OR = 0.74). Interaction models indicated that the relative benefit of each TACE technique depended on the identified patient-specific predictors. Model-based recommendations differed from the actual treatment selected in 66.2% of cases, suggesting potential for improved patient-technique matching.

CONCLUSIONS

Integrating CT radiomics with clinical variables may help identify the optimal TACE technique for individual HCC patients. This approach holds promise for a more personalized therapy selection and improved response rates beyond standard clinical decision-making.

Analysis of a modified surgical desirability of outcome ranking (mDOOR) among patients undergoing surgery for Hepatocellular carcinoma

BACKGROUND

Composite measures represent a validated method for evaluating surgical care quality. We defined a modified Desirability Of Outcome Ranking (mDOOR) and compared it with textbook outcome (TO).

METHODS

In this cohort study, patients undergoing curative-intent surgery for HCC were identified from an international cohort. The performance and agreement of mDOOR, TO, and other measures of postoperative course with respect to overall survival (OS) were compared using Harrell's Concordance-index (C-index) and Cohen's kappa.

RESULTS

Among 2181 patients, 77.6 % (n = 1692) achieved the most desirable outcome (i.e., DOOR1), whereas roughly one-half of patients achieved TO (n = 1,171, 53.7 %). Patients with lower mDOOR had a better 5-year OS compared with patients with higher mDOOR (64.7 % vs. 51.9 %; p < 0.001). On multivariable analysis, higher mDOOR was associated with worse OS (HR 1.35, 95%CI 1.28-1.44; p < 0.001). The mDOOR demonstrated improved performance compared with the comprehensive complication index (C-index: 0.696 vs. 0.649; p < 0.001) and the Accordion score (C-index: 0.696 vs. 0.653; p = 0.002).

CONCLUSION

Roughly 4 out of 5 patients achieved the most desirable outcome. Higher mDOOR was associated with worse long-term outcomes. A composite outcome ranking may provide more insight on surgical outcomes, complementing traditional metrics.

Predicting the complexity of minimally invasive liver resection for hepatocellular carcinoma using machine learning

BACKGROUND

Despite technical advancements, minimally invasive liver surgery (MILS) for hepatocellular carcinoma (HCC) remains challenging. Nonetheless, effective tools to assess MILS complexity are still lacking. Machine learning (ML) models could improve the accuracy of such tools.

METHODS

Patients who underwent curative-intent MILS for HCC were identified using an international database. An XGBoost ML model was developed to predict surgical complexity using clinical and radiological characteristics.

RESULTS

Among 845 patients, 186 (22.0 %) were classified as high-risk patients. In this subgroup, median Charlson Comorbidity Index (CCI) (5.0, IQR 3.0-7.0 vs. 2.0, IQR 2.0-5.0, p < 0.001) and tumor burden score (TBS) (median 4.12, IQR 3.0-5.1 vs. 4.22, IQR 3.2-7.1, p < 0.001) were higher. The model was able to effectively predict complexity of surgery in both the training and testing cohorts with high discriminating power (ROC-AUC: 0.86, 95%CI 0.82-0.89 vs. 0.73, 95%CI 0.65-0.81). The most influential variables were CCI, TBS, BMI, extent of resection, and sex. Patients predicted to have a complex surgery were more likely to develop severe complications (OR 4.77, 95%CI 1.82-13.9, p = 0.002). An easy-to-use calculator was developed.

CONCLUSION

Preoperative ML-prediction of complex MILS for HCC may improve preoperative planning, resource allocation, and patient outcomes.

Multicenter Belgian prospective registry on minimally invasive and open liver surgery (BReLLS): experience from 1342 consecutive cases

PURPOSE

Minimally invasive liver surgery (MILS) still appears to be adopted with significant variability. We aimed to investigate the diffusion, indications, and short-term outcomes of MILS compared to the open approach.

METHODS

A prospective registry of all liver resections performed for any indication and using any technique between January 1, 2017, and December 31, 2019, was established (BReLLS) and analyzed.

RESULTS

A total of 1342 consecutive liver resections were included, 684 (51%) MILS and 658 (49%) open procedures. MILS was not attempted due to technical complexity in the 46.2% of cases, followed by previous abdominal surgery (22.5%). Patients undergoing MILS had a higher proportion of benign indications and of hepatocellular carcinomas, patients affected by liver cirrhosis with portal hypertension and a lower proportion of major hepatectomies (all p < 0.001). After propensity-score matching, MILS showed better results in terms of surgery duration (p < 0.001), blood loss (p = 0.015), complication rate (p < 0.001), rate of Clavien-Dindo grade ≥ 3 complications (p = 0.012), comprehensive complication index (p < 0.001), length of stay (p < 0.001), readmissions (p = 0.016). Centers performing over 50 liver resections per year had a higher proportion of overall MILS cases (p < 0.001), a similar proportion of major resections (p = 0.362), but a higher prevalence of MILS major resections (p = 0.004), lower 90-day mortality rates (p < 0.001), lower overall complication rates (p < 0.001), and shorter hospital length of stay (p < 0.001).

CONCLUSION

MILS was the preferred technique in half of the cases, particularly in patients with cirrhosis and portal hypertension, and benign lesions. It provided superior short-term outcomes compared to the open approach for both minor and major liver resections in selected patients.

Changes in the presentation and characteristics OF HCV related hepatocellular carcinoma in the era of direct acting antiviral therapy: A retrospective study

BACKGROUND

Hepatocellular carcinoma (HCC) is the sixth common malignancy worldwide. In Egypt, the main cause of HCC is hepatitis C virus (HCV)-related cirrhosis. After the successful mass treatment program of HCV in 2018 with direct-acting antivirals (DAAs) therapy, a large percentage of patients have been treated and effectively achieved sustained virological response (SVR). Recently, some studies claimed that HCCs that developed after treatment with DAAs have more aggressive behavior. Purpose of the study is to detect the possible change of HCC pattern before and after DAAs era and its effect on overall survival (OS).

METHODS

428 naïve HCC patients were divided into 2 groups: Group I HCC patients not treated with DAAs and Group II HCC patients treated with DAAs. Then we compared demographic, clinical, radiological, and laboratory characteristics between both groups.

RESULTS

Group II had improved liver function tests, including serum bilirubin, albumin, and international normalized ratio, than Group I (p < 0.001, p < 0.001, p < 0.001, respectively). They had a lower level of liver aminotransferases. Group II showed a larger infiltrative pattern of HCC, with a high incidence of portal vein thrombosis (p = 0.003, p < 0.001, p = 0.048, respectively). Group II received more curative or palliative treatment options, while 55 % of Group I received the best supportive care. There was no significant difference in 1-year and 2-years OS between both group, except that group II patients had better 2-year OS in subgroup BCLC stage C.

CONCLUSION

The tumor pattern has changed into a more aggressive phenotype after DAAs. DAAs have succeeded in preserving the liver condition. However, they did not demonstrate any protective effect on the OS of the patients. There is a strong need for strict screening program for early detection of HCC in the early stages, that are eligible for curative options, after HCV treatment of DAAs.

90Y-Transarterial Radioembolization Combined with Immune Checkpoint Inhibitors in Hepatocellular Carcinoma: A Systematic Review

BACKGROUND

Transarterial radioembolization with yttrium-90 (90Yt-TARE) and immune checkpoint inhibitors (ICIs) are emerging as treatment modalities for intermediate to advanced hepatocellular carcinoma (HCC) based on randomized controlled trials. Herein, we systematically reviewed the published literature on the effects of 90Yt-TARE and ICIs combined on clinical outcomes of HCC.

METHODS

Medical databases of PubMed, Embase, and Cochrane Library were systematically searched for all studies assessing the use of concomitant immunotherapy of ICI with TARE in patients with HCC. Patient characteristics, treatment protocols, treatment outcomes, treatment adverse events, and survival outcomes were extracted after the screening phase. The primary outcomes were overall survival (OS) and patient-free survival (PFS), while the secondary outcomes were imaging objective response (OR) and adverse events.

RESULTS

Among 3432 reviewed, ten studies were included in this systematic review, including four randomized controlled trials and six retrospective studies. These consisted of 413 patients with HCC, and seven studies included patients with Child-Pugh A or B7 scores. Most studies allowed advanced or intermediate HCC stages, but only two specified BCLC stages (B and C). Median tumor sizes ranged from 56 to 78.5 mm. Various agents with different administration schedules were used as ICIs for immunotherapy by different studies for the combination of 90Yt-TARE with ICIs. Median OS ranged from 16.2 to 27 months between different studies while the PFS also ranged from 5.6 to 13.3 months. The OR rates according to imaging-based response assessments were reported between 31 and 89%, and the incidence rate of any grade toxicities was between 50 and 80%.

CONCLUSION

Concomitant treatment with 90Yt-TARE and ICIs has shown promising results in the treatment of patients with HCC. Further studies are required to reach a consensus on the optimal treatment protocol and the outcome of these treatments for patients with intermediate to advanced HCC.

Prediction of treatment response and outcome of transarterial chemoembolization in patients with hepatocellular carcinoma using artificial intelligence: A systematic review of efficacy

PURPOSE

To perform a systematic literature review of the efficacy of different AI models to predict HCC treatment response to transarterial chemoembolization (TACE), including overall survival (OS) and time to progression (TTP).

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines until May 2, 2024.

RESULTS

The systematic review included 23 studies with 4,486 HCC patients. The AI algorithm receiver operator characteristic (ROC) area under the curve (AUC) for predicting HCC response to TACE based on mRECIST criteria ranged from 0.55 to 0.97. Radiomics-models outperformed non-radiomics models (AUCs: 0.79, 95 %CI: 0.75-0.82 vs. 0.73, 0.61-0.77, respectively). The best ML methods used for the prediction of TACE response for HCC patients were CNN, GB, SVM, and RF with AUCs of 0.88 (0.79-0.97), 0.82 (0.71-0.89), 0.8 (0.60-0.87) and 0.8 (0.55-0.96), respectively. Of all predictive feature models, those combining clinic-radiologic features (ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement) had higher AUCs compared with models based on clinical characteristics alone (0.79, 0.73-0.89; p = 0.04 for CT + clinical, 0.81, 0.75-0.88; p = 0.017 for MRI + clinical versus 0.6, 0.55-0.75 in clinical characteristics alone).

CONCLUSION

Integrating clinic-radiologic features enhances AI models' predictive performance for HCC patient response to TACE, with CNN, GB, SVM, and RF methods outperforming others. Key predictive clinic-radiologic features include ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement. Multi-institutional studies are needed to improve AI model accuracy, address heterogeneity, and resolve validation issues.

Localized hepatocellular carcinoma: Is liver-directed therapy alone as efficacious as surgical resection?

OBJECTIVE

Studies of the efficacy of nonsurgical methods of liver-directed therapy (percutaneous microwave or radiofrequency ablation, transarterial bland embolization, chemoembolization, and/or radioembolization) in the treatment of hepatocellular cancer lack contemporaneous comparative surgical cohorts. The role of these methods of liver-directed therapy as destination treatment in hepatocellular cancer is not well defined.

METHODS

We queried our institutional registry for patients undergoing resection or liver-directed therapy alone for clinical stage I to IVa hepatocellular cancer between 2012 and 2022. Multivariable regression and Cox modeling were used to identify factors associated with resection and all-cause mortality. Patients undergoing resection were 1:3 propensity matched for age, Mayo End-Stage Liver Disease score and clinical stage to those undergoing liver-directed therapy. Kaplan-Meier methods were used to compare 5-year disease-specific and overall survival for matched cohorts.

RESULTS

Three hundred thirty patients met inclusion criteria; 45 underwent resection, and 285 liver-directed therapy. On multivariable regression, factors associated with resection included age (adjusted odds ratio: 0.96, P = .007) and Mayo End-Stage Liver Disease score (adjusted odds ratio: 0.92, P = .033). On Cox modeling, factors associated with mortality-risk included Mayo End-Stage Liver Disease score (adjusted hazards ratio: 1.03, P = .01), advanced clinical stage (stage III adjusted hazards ratio: 1.9, P = .002), and resection (adjusted hazards ratio: 0.43, P = .001). Forty-five patients undergoing resection were matched to 135 undergoing liver-directed therapy. On Kaplan-Meier comparison of matched cohorts, patients undergoing resection demonstrated improved overall survival (38.1 vs 8.4%, P = .015) but disease-specific survival similar to that for those undergoing liver-directed therapy (84.0 vs 74.0%, P = .095).

CONCLUSION

Liver-directed therapy is effective as treatment for patients with localized hepatocellular cancer providing disease-specific survival similar to that provided by surgical resection.

Combining Radioembolization and Immune Checkpoint Inhibitors for the Treatment of Hepatocellular Carcinoma: The Quest for Synergy

Hepatocellular carcinoma is a leading and increasing contributor to cancer-related death worldwide. Recent advancements in both liver-directed therapies in the form of yttrium-90 (90Y) radioembolization (RE) and systemic therapy in the form of immune checkpoint inhibitors (ICI) have expanded treatment options for patients with an otherwise poor prognosis. Despite these gains, ICIs and 90Y-RE each have key limitations with low objective response rates and persistent hazard of out-of-field recurrence, respectively, and overall survival remains low. However, each therapy's strength may mitigate the other's weakness, making them potentially ideal partners for combination treatment strategies. This review discusses the scientific and clinical rationale for combining 90Y-RE with ICIs, highlights early clinical trial data on its safety and effectiveness, and proposes key issues to be addressed in this emerging field. With optimal strategies, combination therapies can potentially result in increasing likelihood of durable and curative outcomes in later stage patients.

Clinical efficacy and safety of transarterial chemoembolization combined with targeted therapy and PD1 inhibitors in patients with advanced liver cancer

Objective

To investigate the clinical efficacy and safety of transarterial chemoembolization(TACE) combined with targeted therapy and PD1 inhibitors in patients with advanced liver cancer.

Methods

This was a retrospective study. A total of 120 patients with advanced primary liver cancer admitted to Affiliated Hospital of Hebei University were randomly divided into two groups, with 60 patients in each group from May 2020 to May 2023. Patients in the control group received conventional TACE, and those in the experimental group received 200 mg camrelizumab once every 21 days and oral lenvatinib mesylate capsules once daily in addition to TACE. Compared the clinical efficacy, levels of tumor markers, T lymphocyte subsets, and adverse drug reactions after treatment and the improvement of quality of life(QOL) before and after treatment between the two groups of patients.

Results

The overall response rate(ORR) was 80% in the experimental group and 62% in the control group, and the difference was statistically significant(p=0.03); the incidence of adverse reactions was 28% in the experimental group and 25% in the control group, with no significant difference between the two groups(p=0.68); the improvement rate of QOL score was significantly increased(p=0.03) and the deterioration rate was significantly decreased(p=0.01) in the experimental group compared with those in the control group, respectively.

Conclusion

TACE combined with targeted therapy and PD1 inhibitors is significantly effective to improve the cellular immune function with no significant increase in the incidence of adverse reactions, making it an effective and safe treatment option for patients with liver cancer.

Survival Outcomes of Radiofrequency Ablation for Intrahepatic Cholangiocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) Database: Comparison with Radiotherapy and Resection

PURPOSE

To determine effectiveness of radiofrequency ablation for treatment of intrahepatic cholangiocarcinoma (iCCA) using a population-based database.

MATERIALS AND METHODS

Data were extracted from Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2020 to include 194 patients who underwent ablation for iCCA. Data on patient demographics, overall survival (OS), and cancer-specific survival were retrieved. Factors associated with survival were evaluated. Comparison between ablation and surgical resection (n = 2,653) or external beam radiotherapy (n = 1,068) was performed.

RESULTS

In the ablation group, patients diagnosed and treated after 2010 demonstrated improved OS than that in the 2000-2009 subgroup (median OS, 32 vs 21 months; hazard ratio, 0.50; 95% CI, 0.33-0.75; P = .001). Additional factors associated with OS included tumor size (≤3 cm vs >3 cm; P = .049) and tumor stage (P < .001). For patients diagnosed after 2010, the 1-, 3-, and 5-year OS were 82.8% (95% CI, 74.8%-88.4%), 43.5% (95% CI, 33.5%-53.1%), and 23.7% (95% CI, 15.3%-33.5%), respectively. Patients with local disease (1-year OS, 87.8%; 95% CI, 78.6%-93.3%) demonstrated improved OS compared with patients with regional (1-year OS, 81.3%; 95% CI, 52.5%-93.5%) and distant disease (50.2%; 95% CI, 34.0%-78.8%; P < .001). For tumors ≤3 cm, ablation and surgical resection offered comparable survival benefits (P = .561), although both were better than radiotherapy (P < .0001).

CONCLUSIONS

Survival of patients with iCCA who underwent thermal ablation has improved over the last 10 years. For tumors ≤3 cm, ablation could be as effective as resection with careful candidate selection, and may be considered front-line compared with radiotherapy in certain patient populations. Patient selection based on tumor size and disease stage could improve survival outcomes.