A multicentre comparison between Child Pugh and Albumin-Bilirubin scores in patients treated with sorafenib for Hepatocellular Carcinoma

Development and External Validation of Web-Based Models to Predict the Prognosis of Remnant Gastric Cancer after Surgery: A Multicenter Study

BACKGROUND

Remnant gastric cancer (RGC) is a rare malignant tumor with poor prognosis. There is no universally accepted prognostic model for RGC.

METHODS

We analyzed data for 253 RGC patients who underwent radical gastrectomy from 6 centers. The prognosis prediction performances of the AJCC7th and AJCC8th TNM staging systems and the TRM staging system for RGC patients were evaluated. Web-based prediction models based on independent prognostic factors were developed to predict the survival of the RGC patients. External validation was performed using a cohort of 49 Chinese patients.

RESULTS

The predictive abilities of the AJCC8th and TRM staging systems were no better than those of the AJCC7th staging system (c-index: AJCC7th vs. AJCC8th vs. TRM, 0.743 vs. 0.732 vs. 0.744; P>0.05). Within each staging system, the survival of the two adjacent stages was not well discriminated (P>0.05). Multivariate analysis showed that age, tumor size, T stage, and N stage were independent prognostic factors. Based on the above variables, we developed 3 web-based prediction models, which were superior to the AJCC7th staging system in their discriminatory ability (c-index), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (AIC, BIC), and model stability (time-dependent ROC curves). External validation showed predictable accuracies of 0.780, 0.822, and 0.700, respectively, in predicting overall survival, disease-specific survival, and disease-free survival.

CONCLUSIONS

The AJCC TNM staging system and the TRM staging system did not enable good distinction among the RGC patients. We have developed and validated visual web-based prediction models that are superior to these staging systems.

Albumin - bilirubin (ALBI) versus Child-Turcotte-Pugh (CTP) in prognosis of HCC after stereotactic body radiation therapy

Background

Child-Turcotte-Pugh (CTP) score extensively used to assess hepatic function, predicting postoperative outcome of hepatocellular carcinoma (HCC) patients. Lately, the albumin–bilirubin (ALBI) grade has been identified to be a predictor of overall survival of HCC patients. In this investigation, we compared the pre-SBRT ALBI and CTP scores with the prognosis of patients with HCC.

Methods

This cohort study included 594 HCC patients who treated with SBRT. Overall survival (OS) rates were measured from treatment date to death date or last follow-up. We compared ALBI score with the CTP score in predicting long-term survival.

Results

The average follow-up time was 21 months (1 to 82 months). The CTP and ALBI ratings have discriminatory for long-term survival across the groups. CTP class was significantly related to OS, with a median OS of 29.9 months in CTP-A, 11.5 in CTP-B (P < 0.0001). ALBI grade is also significantly related to OS, with a median OS of 53.0 months in ALBI-1, 19.5 months in ALBI-2, and 6.5 months in ALBI-3(P < 0.0001). Within CTP-A class, CTP score-A5/A6 and ALBI grade has a similar predictive power (all P < 0.001). However, both CTP score and ALBI grade have no predictive power in CTP ≥ B7 class (all P>0.05).

Conclusions

To assess liver dysfunction in HCC patients before SBRT, traditional CTP classification is a necessary but imperfect tool for assessing HCC liver injury. The ALBI score is a more objective, discriminatory and evidence-based approach in CTP-A groups, and need to be validated in CTP ≥ B7 class.

Prognostic value of pretreatment albumin to bilirubin ratio in patients with hepatocellular cancer: A meta-analysis

BACKGROUND

Hepatic function is closely associated with prognosis in patients with hepatocellular cancer (HCC). In this study, a meta-analysis of the published studies was performed to assess the prognostic value of ALBI grade in HCC patients.

METHODS

Databases, including PubMed, EMbase, Web of Science, and Cochrane Library were retrieved up to August 2018. The primary outcome was OS and secondary outcome was DFS, the prognostic impact of which was assessed by using hazard ratio (HRs) with corresponding 95% confidence intervals (CIs). The enrolled studies were analyzed by using STATA version 12.0 software.

RESULTS

A total of 22,911 patients with HCC in 32 studies were included. Our results demonstrated that high pretreatment ALBI is associated with poor OS (HR = 1.719, 95%CI: 1.666-1.771, P = .000, univariate results; HR = 1.602, 95%CI: 1.470-1.735, P = .000, multivariate results) and poor DFS (HR = 1.411, 95%CI: 1.262-1.561, P = .000, univariate results; HR = 1.264, 95%CI: 1.042-1.485, P = .000, multivariate results). Meanwhile, when the analysis was stratified into subgroups, such as treatment methods, sample size, geographic area, and ALBI grade, the significant correlation in ALBI and poor long-term survival was not altered.

CONCLUSION

High pretreatment ALBI is closely associated with poor prognosis in HCC, and High ALBI should be treated as an ideal predictor during hepatocellular therapy.

A radiomics-based nomogram for the preoperative prediction of posthepatectomy liver failure in patients with hepatocellular carcinoma

OBJECTIVES

To develop and validate a radiomics-based nomogram for the preoperative prediction of posthepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

One hundred twelve consecutive HCC patients who underwent hepatectomy were included in the study pool (training cohort: n = 80, validation cohort: n = 32), and another 13 patients were included in a pilot prospective analysis. A total of 713 radiomics features were extracted from portal-phase computed tomography (CT) images. A logistic regression was used to construct a radiomics score (Rad-score). Then a nomogram, including Rad-score and other risk factors, was built with a multivariate logistic regression model. The discrimination, calibration and clinical utility of nomogram were evaluated.

RESULTS

The Rad-score could predict PHLF with an AUC of 0.822 (95% CI, 0.726-0.917) in the training cohort and of 0.762 (95% CI, 0.576-0.948) in the validation cohort; however, the approach could not completely outmatch the existing methods (CP [Child-Pugh], MELD [Model of End Stage Liver Disease], ALBI [albumin-bilirubin]). The individual predictive nomogram that included the Rad-score, MELD and performance status (PS) showed better discrimination with an AUC of 0.864 (95% CI, 0.786-0.942), which was higher than the AUCs of the conventional methods (nomogram vs CP, MELD, and ALBI at P < 0.001, P < 0.005, and P < 0.005, respectively). In the validation cohort, the nomogram discrimination was also superior to those of the other three methods (AUC: 0.896; 95% CI, 0.774-1.000). The calibration curves showed good agreement in both cohorts, and the decision curve analysis of the entire cohort revealed that the nomogram was clinically useful. A pilot prospective analysis showed that the radiomics nomogram could predict PHLF with an AUC of 0.833 (95% CI, 0.591-1.000).

CONCLUSIONS

A nomogram based on the Rad-score, MELD, and PS can predict PHLF.

Are we SHARP enough? The importance of adequate patient selection in sorafenib treatment for hepatocellular carcinoma

BACKGROUND

Upon FDA/EMEA registration for hepatocellular carcinoma (HCC), sorafenib received a broader therapeutic indication than the eligibility criteria of the landmark SHARP trial. This allowed treatment of SHARP non-eligible patients in daily clinical practice.

AIM

To assess sorafenib efficacy and safety in SHARP eligible and non-eligible patients, and determine the validity of the current therapeutic indication as described by the FDA/EMEA.

PATIENTS AND METHODS

Consecutive patients treated with sorafenib for advanced HCC at two Dutch tertiary referral centers between 2007 and 2016 were analyzed retrospectively. Primary outcome was overall survival (OS). Secondary outcomes were time to progression (TTP), response rate, adverse events and reasons for discontinuation. Outcomes were compared between SHARP eligible and non-eligible patients.

RESULTS

One hundred and ninety-three of 257 (75%) patients were SHARP eligible. SHARP eligible patients (9.5 months, 95% CI 7.7-11.3) had a longer median OS than non-eligible patients (5.4 months, 95% CI 3.6-7.1) (log-rank p < .001). SHARP non-eligible patients were more often Child-Pugh B, had higher AST and ALT levels and developed more grade 3-4 liver dysfunction (44 versus 23%, p < .001) during treatment. SHARP ineligibility remained the strongest predictor of OS (HR 1.78, 95% CI 1.32-2.41) and an independent predictor of TTP (HR 1.45, 95% CI 1.05-2.00) in multivariable analysis.

CONCLUSIONS

Landmark trial outcomes of sorafenib for HCC are reproducible in daily practice, provided that the SHARP eligibility criteria are respected. Based on the findings of this and previous studies, sorafenib usage should be restricted to Child-Pugh A patients.

Sorafenib as first-line therapy in patients with advanced Child-Pugh B hepatocellular carcinoma-a meta-analysis

BACKGROUND

Sorafenib has demonstrated survival benefit in first-line treatment of advanced hepatocellular carcinoma (HCC); utility of sorafenib in patients with advanced HCC and Child-Pugh B (CP-B) liver function remains a subject of debate.

METHODS

A systematic review identified studies using first-line sorafenib in patients with advanced HCC and CP-A/B liver function. Meta-regression analysis comprising linear regression was conducted to explore the association between the baseline factors and overall survival (OS). Differences between efficacy/safety and tolerability parameters were explored using meta-analysis.

RESULTS

Thirty studies (12 Asian) comprising 8678 patients (August 2002 - September 2012) were included (four randomised controlled trials, 26 cohort studies). Median age was 61 years and 83% were men. Hepatitis B/C status was positive in 35%/22%, respectively. The CP status was available for 8577 patients (99%); CP-A, 79% and CP-B, 19%. Median OS on sorafenib for entire cohort was 7.2 months; 8.8 months in CP-A and 4.6 months in CP-B. Multivariable meta-regression analysis showed significant negative association between OS and proportion of patients with the Eastern Cooperative Oncology Group performance status 2 (P = 0.04) and CP-B liver function (P = 0.001). Among four studies reporting multivariable comparison of the CP status, CP-B was associated with significantly worse OS (P < 0.001). There were no differences in the response rate to sorafenib between patients with CP-A (4.6%) and CP-B (4.2%) liver function. Safety and tolerability were similar; 35% of patients with CP-A/B liver function developed grade III/IV adverse events (P = 0.7). Meta-regression analysis showed similar rates of treatment discontinuation without progression (P = 0.31) and treatment-related death (P = 0.94) in patients with CP-B liver function.

CONCLUSION

CP-B liver function (versus CP-A) is associated with worse OS (but the similar response rate, safety and tolerability of first-line sorafenib, is unlikely to be clinically meaningful).

Using the Albumin-Bilirubin (ALBI) grade as a prognostic marker for radioembolization of hepatocellular carcinoma

Background

The Child-Pugh (CP) class is a commonly used scoring system to measure liver function in patients with hepatocellular carcinoma (HCC). We correlate the Albumin-Bilirubin (ALBI) grading system and CP to overall survival in our HCC patients receiving radioembolization.

Methods

We retrospectively evaluated patients who received radioembolization for HCC between the years 2009-2014. We evaluated the albumin and bilirubin levels in our patients prior to receiving their first (n=124) radioembolization. The ALBI grades were calculated from these data with the formula (log₁₀ bilirubin ×0.66) + (albumin × -0.085) and correlated to outcomes using Mantel-Cox Log analysis. These statistical comparisons were duplicated with CP classes.

Results

Median survival differences between CP class A and B and between ALBI grade 1 and 2 were 4.7 and 9.9 months, respectively. A subset of ALBI grades 1 and 2 were identified within our CP class A patients with a median survival difference of 9.9 months.

Conclusions

ALBI is a more sensitive marker of liver function than CP in the setting of mild dysfunction. Using ALBI, we identified a subset of patients that have significantly better outcomes from Y-90 radioembolization than previously identified with CP.

Comparison of platelet-albumin-bilirubin (PALBI), albumin-bilirubin (ALBI), and child-pugh (CP) score for predicting of survival in advanced hcc patients receiving radiotherapy (RT)

Purpose

This work evaluated the prognostic performance of Child-Pugh (CP), albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) scores in hepatocellular carcinoma (HCC) patients undergoing radiotherapy (RT).

Results

The study included 174 consecutive patients with 63% at CP A5 (n = 110) and 34% at CP A6 (n = 64). The median ALBI score was −2.39 (range: −3.61 to −1.41) with 34.5% at grade A1 (n = 60) and 65.5% at grade A2 (n = 114). The median PALBI score was −2.39 (range −3.39 to −1.24) with 33.3% at grade 1 (n = 58), 41.4% at grade 2 (n = 72) and 25.3% at grade 3 (n = 44). With a median follow-up of 21.7 months, the median OS of the entire cohort was 22.2 months. OS was significantly associated with the PALBI grade (p = 0.002) and for the ALBI grade (p = 0.00495), but not for the CP score (p = 0.46). The PALBI grade has a significantly higher AUC compared than the ALBI grade or CP scores in predicting OS. The PALBI grade was predictive of CP score decline ≥2 (20% grade 3 vs. 5.3% grade 1/2 p = 0.05) but the ALBI and CP scores were not.

Conclusion

Among CP A HCC patients receiving radiotherapy, the PALBI and ALBI grade maybe a better prognostic tool than the CP score. The role of PALBI in predicting liver toxicity warranted further exploration.

Methods

We retrospectively reviewed HCC patients treated with individualized hypo-fractionated radiotherapy (IHRT) using stereotactic technique from 2006 to 2015. We collected CP, ALBI and PALBI scores prior to treatment and analyzed their correlation with overall survival (OS) and liver toxicity.

A nomogram integrating hepatic reserve and tumor characteristics for hepatocellular carcinoma following curative liver resection

BACKGROUND

Because of the mutual influence of liver dysfunction and malignancy, overall survival (OS) is a composite clinical endpoint in hepatocellular carcinoma (HCC). We developed a nomogram integrating albumin-bilirubin (ALBI) grade, a new index of hepatic reserve, and tumor characteristics of HCC for predicting OS following curative liver resection.

METHODS

The nomogram was built to estimate the probabilities of 1, 3, and 5-y OS based on training cohort of 709 HCC, which was validated in an international independent dataset. The prognostic value of the nomogram was determined by concordance index (C-index), time-dependent receiver operating characteristics (tdROC), and decision curves, comparing with ALBI grade alone, the Cancer of the Liver Italian Program (CLIP), the Barcelona Clinic Liver Cancer (BCLC), and Okuda staging systems.

RESULTS

Independent factors derived from multivariable Cox analysis of the training cohort to predict OS were tumor grade, microvascular invasion, tumor size and ALBI grade which were assembled into nomogram. The calibration curves for probability of OS showed optimal agreement between nomogram-prediction and actual observation, which was tested in validation cohort. The C-index, tdROC and decision curves showed the nomogram was superior to CLIP, ALBI grade, BCLC and Okuda. The patients could also be stratified into low, intermediate risk, and high risk of the mortality by the normogram in both development and validation cohorts.

CONCLUSIONS

The nomogram integrating hepatic reserve and tumor characteristics provided a highly accurate estimation of OS in patients with HCC after curative liver resection, contributing to assess patient prognosis.

Novel Albumin-Bilirubin Grade-Based Risk Prediction Model for Patients with Hepatocellular Carcinoma Undergoing Chemoembolization

BACKGROUND

Recently, albumin-bilirubin (ALBI) grade has been suggested as a better surrogate for hepatic functional reserve for patients with hepatocellular carcinoma (HCC).

AIMS

We developed and validated a novel prediction model to predict outcome for HCC patients who underwent transcatheter arterial chemoembolization (TACE) as a first-line therapy.

METHODS

From a multivariate Cox regression model for overall survival, five objective variables (ALBI grade), the Barcelona clinic liver cancer (BCLC) stage, response after the first TACE session, Alpha-fetoprotein level, and sex were chosen and the ABRAS score was developed from the derivation cohort (n = 476) and scored to generate an 8-point risk prediction model. The model's prognostic performance was assessed in the randomly assigned internal validation set (n = 475) and external validation set (n = 243).

RESULTS

The ALBI grade was able to stratify patient survival within the same Child-Pugh class. The time-dependent area under receiver operating characteristics curves (AUROCs) for overall survival at 1 and 3 years were 0.78 and 0.73 in the training set, 0.78 and 0.71 in the internal validation set, and 0.70 and 0.65 in the external validation set, respectively. When stratified by BCLC stage, ABRAS score at a cutoff point of more than 3, 4, and 5 for BCLC stage 0/A, B, and C could identify subset of patients with dismal prognosis.

CONCLUSION

ABRAS score was useful in estimating prognosis for patients who underwent TACE as a first-line therapy. This score can be useful in planning and guiding treatment strategies with TACE, which warrants prospective validation.

Combining albumin-bilirubin score with future liver remnant predicts post-hepatectomy liver failure in HBV-associated HCC patients

BACKGROUND AND AIMS

Accurate assessment of liver functional reserve pre-operatively is vital for safe hepatic resection. The ALBI score is a new model for assessing liver function. This study aimed to evaluate the value of combining ALBI score with sFLR in predicting post-operative morbidity and PHLF in HCC patients who underwent hepatectomy.

METHODS

Patients undergoing three-dimensional CT reconstruction prior to hepatectomy for HCC between January 2015 and January 2017 were enrolled. The values of the CP score, ALBI score and sFLR in predicting post-operative outcomes were evaluated.

RESULTS

A total of 229 HCC patients were enrolled; 24 (10.5%) experienced major complications and 21 (9.2%) developed PHLF. The incidence of major complications and PHLF increased with increasing ALBI grade. The ALBI grade classified patients with CP grade A into two subgroups with different incidences of PHLF (P=.029). sFLR and ALBI scores were identified as independent predictors of PHLF. The AUC values for the CP score, ALBI score, sFLR and sFLR×ALBI for predicting major complications were 0.600, 0.756, 0.660 and 0.790 respectively. The AUC values of the CP score, ALBI score, sFLR and sFLR×ALBI for predicting PHLF were 0.646, 0.738, 0.758 and 0.884 respectively.

CONCLUSIONS

The ALBI score showed superior predictive value of post-operative outcomes over CP score, and the combination of sFLR and ALBI score was identified as a stronger predictor of post-operative outcomes than the sFLR or ALBI score alone.

ALBI versus Child-Pugh grading systems for liver function in patients with hepatocellular carcinoma

BACKGROUND

The prognostic performance of the albumin-bilirubin (ALBI) grade in hepatocellular carcinoma (HCC) as an objective method of assessing liver function was investigated.

METHODS

Data from 2099 patients with HCC in Korea were collected and analyzed retrospectively. The discriminative performance of ALBI grade was compared with Child-Pugh (C-P) grade for different stages or treatments.

RESULTS

The median follow up duration was 16.2 months (range: 1.0-124.9). The median survival times were 49.7 months for C-P grade A (65.8%), 12.4 months for C-P grade B (25.5%), and 4.2 months for C-P grade C (8.6%) (P < 0.001). The median survival times were 84.2 months for ALBI grade 1 (32.8%), 25.5 months for ALBI grade 2 (53.5%), and 7.7 months for ALBI grade 3 (13.7%) (P < 0.001). In early UICC stages, ALBI grade showed better discriminative performance than C-P grade. In curative treatments, ALBI grade also showed better discriminative performance than C-P grade (Harrell's C: 0.624 (C-P grade) vs 0.667 [ALBI grade]).

CONCLUSIONS

ALBI grade provided better prognostic performance in survival analysis and better distribution of the grades than C-P grade in HCC, suggesting that ALBI grade could be a good alternative grading system for liver function in patients with HCC.

Value of the albumin-bilirubin score in the evaluation of hepatitis B virus-related acute-on-chronic liver failure, liver cirrhosis, and hepatocellular carcinoma

The aim of the present study was to investigate the value of the albumin-bilirubin (ALBI) score in the assessment of the disease conditions of hepatitis B virus (HBV)-related acute-on-chronic liver failure (HBV-ACLF), HBV-related liver cirrhosis (HBV-LC) and HBV-related hepatocellular carcinoma (HBV-HCC). A total of 395 patients with HBV-ACLF, HBV-LC, or HBV-HCC were retrospectively studied. The ALBI, Child-Turcotte-Pugh (CTP), and Model for End-Stage Liver Disease (MELD) scores of the patients were calculated, and the relationships between the ALBI score and the CTP and MELD scores were investigated. Furthermore, the ALBI grading was tested for the evaluation of the severity and stages of HBV-ACLF, HBV-LC, and HBV-HCC, especially when classifying the clinical stages of HBV-ACLF. The mean ALBI scores of the HBV-ACLF, HBV-LC, and HBV-HCC patients were -1.17±0.55, -1.76±0.66 and -2.59±0.62, respectively; the mean CTP scores were 10.70±1.81, 8.19±1.25 and 5.81±1.22, respectively; and the mean MELD scores were 19.93±7.44, 11.10±4.39 and 7.01±3.22, respectively. The ALBI scores were positively correlated with the CTP and MELD scores. The mean ALBI score and the frequency of grade 3 disease were higher in HBV-ACLF patients than in patients with HBV-LC or HBV-HCC. A later HBV-ACLF stage resulted in a higher frequency of ALBI grades of 3. In conclusion, ALBI scores exhibited parallel tendencies to the CTP and MELD scores in HBV-ACLF, HBV-LC, and HBV-HCC patients; thus, ALBI grading may be a simple but applicable method for the evaluation of the functional status of patients with HBV-related end-stage liver diseases.

PET/CT with 18F Fluorocholine as an Imaging Biomarker for Chronic Liver Disease: A Preliminary Radiopathologic Correspondence Study in Patients with Liver Cancer

Purpose To determine the relationship between hepatic uptake at preoperative fluorine 18 (¹⁸F) fluorocholine combined positron emission tomography (PET) and computed tomography (CT) and the histopathologic features of chronic liver disease in patients with Child-Pugh class A or B disease who are undergoing hepatic resection for liver cancer. Materials and Methods Forty-eight patients with resectable liver tumors underwent preoperative ¹⁸F fluorocholine PET/CT. Mean liver standardized uptake value (SUV_mean) measurements were obtained from PET images, while histologic indexes of inflammation and fibrosis were applied to nontumor liver tissue from resection specimens. Effects of histopathologic features on liver SUV_mean were examined with analysis of variance. Results Liver SUV_mean ranged from 4.3 to 11.6, correlating significantly with Knodell histologic activity index (ρ = -0.81, P < .001) and several clinical indexes of liver disease severity. Liver SUV_mean also differed significantly across groups stratified by necroinflammatory severity and Metavir fibrosis stage (P < . 001). The area under the receiver operating characteristic curve for ¹⁸F fluorocholine PET/CT detecting Metavir fibrosis stage F1 or higher was 0.89 ± 0.05, with an odds-ratio of 3.03 (95% confidence interval: 1.59, 5.88) and sensitivity and specificity of 82% and 93%, respectively. Conclusion Correlations found in patients undergoing hepatic resection for liver cancer between liver ¹⁸F fluorocholine uptake and histopathologic indexes of liver fibrosis and inflammation support the use of ¹⁸F fluorocholine PET/CT as a potential imaging biomarker for chronic liver disease. ^© RSNA, 2018.

Liver Function Assessment Using Albumin-Bilirubin Grade for Patients with Very Early-Stage Hepatocellular Carcinoma Treated with Radiofrequency Ablation

BACKGROUND/AIM

Assessment of liver function is essential for management of hepatocellular carcinoma (HCC). Recently, albumin-bilirubin (ALBI) grade has been reported as a useful tool for assessing hepatic reserve in patients with HCC. The objective of this study was to determine whether ALBI grade could be used to predict the overall survival of very early-stage HCC patients treated with radiofrequency ablation (RF ablation).

METHODS

A cohort of 368 patients with very early-stage HCC treated with RF ablation was retrospectively analyzed. The overall survival and recurrence-free survival were calculated in groups classified by ALBI grade and Child-Pugh score.

RESULTS

Overall survival of patients with ALBI grade 1 was better than that of patients with ALBI grade 2 (5-year survival rate 88.5 vs. 73.8%, P < 0.001). In multivariable-adjusted model, ALBI grade was found to be an independent factor associated with overall survival (hazard ratio 2.44; 95% confidence interval 1.43-4.15). ALBI grade was able to stratify patients with distinct overall survival among patients within the same Child-Pugh score (5-year survival rate for Child-Pugh score 5: 88.5 vs. 76.6%, P = 0.002; for Child-Pugh score 6: 88.9 vs. 70.1%, P = 0.064). In contrast, Child-Pugh score was unable to stratify patients with distinct overall survival within the same ALBI grade.

CONCLUSIONS

Among patients with very early-stage HCC treated with RF ablation, ALBI grade was a good stratifying biomarker. ALBI grade was better tool for assessing liver function than Child-Pugh score for very early-stage HCC treated with RF ablation.

Differences in the impact of prognostic factors for hepatocellular carcinoma over time

The aim of the present study was to evaluate the prognostic significance of serum markers that reflect tumor progression, liver function, or liver fibrosis in patients with hepatocellular carcinoma (HCC), focusing on how their impact changes over time after diagnosis. Alpha‐fetoprotein (AFP), des‐gamma‐carboxy prothrombin (DCP), albumin‐bilirubin (ALBI) score, aspartate aminotransferase to platelet ratio index (APRI), and FIB‐4 index were measured at the time of initial non‐recurrent HCC diagnosis in 1669 patients between 1997 and 2016. Survival rates after diagnosis were compared after stratifying patients by these markers. Time‐dependent receiver‐operating characteristics (ROC) analysis was carried out to assess how these markers predict patient survival or death. Serum AFP and DCP levels, ALBI score, and APRI and FIB‐4 index were strongly correlated with HCC progression, liver function, and degree of liver fibrosis, respectively. Survival rates after diagnosis were significantly different when patients were stratified by these markers. In the time‐dependent ROC analysis, AFP and DCP had a high prognostic impact within 3 years of diagnosis but the impact decreased thereafter. In contrast, APRI and FIB‐4 index had higher prognostic impact 10 years after diagnosis. ALBI score had a high prognostic impact throughout the study period. Time‐dependent ROC analysis clearly showed changes in the prognostic importance of serum markers based on the duration after diagnosis. Whereas the prognostic impact of tumor progression markers was strong in the short term, liver fibrosis markers had higher prognostic impact long after diagnosis. Liver function had constant prognostic impact on patient survival after diagnosis.

Using Indocyanine Green Extraction to Predict Liver Function After Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma

PURPOSE

To test the hypothesis that mid-treatment measures of the retention of indocyanine green after 15 minutes (ICGR15) would improve the prediction of posttreatment liver function in the setting of hepatocellular carcinoma.

METHODS AND MATERIALS

Between 2006 and 2015, 144 patients with hepatocellular carcinoma received 175 courses of stereotactic body radiation therapy (SBRT). Patient data, such as age, sex, portal vein thrombosis, cirrhosis, Child-Pugh (CP) score, prior liver-directed therapies, and liver function tests, including albumin-bilirubin (ALBI) and ICG clearance, and dosimetric data, such as tumor volume and radiation dose, were collected. Toxicity was evaluated as a 2-point increase in CP score or a change in ALBI score at 3 months from start of SBRT. Logistic or linear regression was used to build toxicity prediction models based on patient and tumor characteristics and ICG clearance variables. Performance of the models for the binary CP outcome was summarized using area under the curve and receive operating characteristic curves. Likelihood ratio tests were used to evaluate whether the model fit improved after incorporating the ICG variable information.

RESULTS

In multivariable analysis age, baseline ICGR15, and change in ICGR15 were associated with toxicity defined by increased CP score. For the continuous ALBI outcome, being female, having cirrhosis, and increasing radiation dose were associated with increased toxicity. When incorporating ICGR15 into these models, an increase in ICGR15 from baseline to mid-treatment was most consistently significantly associated with an increase in toxicity.

CONCLUSIONS

Incorporation of ICGR15 variables significantly improves the prediction of post-SBRT liver function. The use of ICGR15 can facilitate the delivery of the maximum safe dose of radiation for patients with hepatocellular carcinoma and has the potential to improve uncomplicated tumor control and survival.

COE inhibits vasculogenic mimicry in hepatocellular carcinoma via suppressing Notch1 signaling

ETHNOPHARMACOLOGICAL RELEVANCE

Vasculogenic mimicry (VM) has been suggested to be present in various malignant tumors and associated with tumor nutrition supply and metastasis, leading to poor prognosis of patients. Notch1 has been demonstrated to contribute to VM formation in hepathocellular carcinoma (HCC). Celastrus orbiculatus extract (COE), a mixture of 11 terpenoids isolated from the Chinese Herb Celastrus orbiculatus Vine, has been suggested to be effective in cancer treatment.

AIM OF THE STUDY

In the current study, experiments were carried out to examine the effect of COE on VM formation and HCC tumor growth both in vitro and in vivo.

MATERIALS AND METHODS

CCK-8 assay and Nikon live-work station were used to observe the viability of malignant cells treated with COE. Cell invasion was examined using Transwell. Matrigel was used to establish a 3-D culture condition for VM formation. Changes of mRNA and protein expression were examined by RT-PCR and Western Blot respectively. Tumor growth in vivo was monitored using in vivo fluorescence imaging device. PAS-CD34 dual staining and electron microscopy were used to observe VM formation. Immunohistochemical staining (IHC) was used to examine Notch1 and Hes1 expression in tumor tissues.

RESULTS

Results showed that COE can inhibit HCC cells proliferation and invasion in a concentration-dependent manner. VM formation induced by TGF-β1 was blocked by COE. In mouse xenograft model, COE inhibited tumor growth and VM formation. Both in vitro and in vivo studies showed that COE can downregulate expression of Notch1 and Hes1.

CONCLUSION

The current results indicate that COE can inhibit VM formation and HCC tumor growth by downregulating Notch1 signaling. This study demonstrates that COE is superior to other anti-angiogenesis agents and can be considered as a promising candidate in HCC treatment.

Albumin-Bilirubin (ALBI) Grade as Part of the Evidence-Based Clinical Practice Guideline for HCC of the Japan Society of Hepatology: A Comparison with the Liver Damage and Child-Pugh Classifications

AIM/BACKGROUND

The purpose of this study was to evaluate the validity of 3 classifications for assessing liver function, the liver damage and Child-Pugh classifications and the newly proposed albumin-bilirubin (ALBI) grade, in order to examine the feasibility of evaluating hepatic function using ALBI grade with the hepatocellular carcinoma (HCC) treatment algorithm used in Japan.

METHODS

We analyzed the medical records of 3,495 Japanese HCC patients admitted from 2000 to 2015, which were comprised of 1,580 patients hospitalized in the Ehime Prefecture area and used as a training cohort (Ehime group), and 1,915 others who were used for validation (validation group). ALBI score used for grading (≤-2.60 = grade 1, greater than -2.60 to ≤-1.39 = grade 2, greater than -1.39 = grade 3) as well as clinical features and prognosis (Japan Integrated Staging [JIS], modified JIS, ALBI-TNM [ALBI-T] score) were retrospectively investigated.

RESULTS

For prediction of liver damage A, the values for sensitivity and specificity, positive predictive and negative predictive values, and positive and negative likelihood ratios of ALBI-1 and Child-Pugh A were similar among the 2 groups. Akaike information criterion results showed that prognosis based on ALBI grade/ALBI-T score was better than that based on liver damage/modified JIS score and Child-Pugh/JIS score (22,291.8/21,989.4, 22,379.6/22,076.0, 22,392.1/22,075.1, respectively). The cutoff values for ALBI score for indocyanine green retention rate at 15 min (ICG-R15) <10, <20, and <30% were -2.623 (area under the curve [AUC]: 0.798), -2.470 (AUC: 0.791), and -2.222 (AUC: 0.843), respectively. The distribution of ICG-R15 (<10%, 10 to <20%, 20 to <30%, and ≥30%) for ALBI grade 1 was similar to that for liver damage A. There were only small differences with regard to therapeutic selection with the Japanese HCC treatment algorithm between liver damage and ALBI grade.

CONCLUSION

ALBI grade is a useful and easy classification system for assessment of hepatic function for therapeutic decision making.

Comparison Between Child-Turcotte-Pugh and Albumin-Bilirubin Scores in Assessing the Prognosis of Hepatocellular Carcinoma After Stereotactic Ablative Radiation Therapy

PURPOSE

To evaluate the prognostic performance of the Child-Turcotte-Pugh (CTP) score and the albumin-bilirubin (ALBI) score in hepatocellular carcinoma (HCC) patients treated using stereotactic ablative radiation therapy (SABR).

METHODS AND MATERIALS

This retrospective study evaluated the data of patients with HCC who underwent SABR between December 2007 and June 2015. We collected pretreatment CTP and ALBI scores and analyzed their correlation with survival and liver toxicity.

RESULTS

This study included 152 HCC patients: 78.3% of CTP class A and 21.7% of CTP class B. The median ALBI score was -2.49 (range, -3.67 to -0.84) with 39.5% of grade 1, 56.6% of grade 2, and 3.9% of grade 3. The CTP classification and ALBI grade were significantly associated with overall survival (P<.001). Albumin-bilirubin grade (1 vs 2) had a trend to stratify CTP class A patients into 2 risk groups of mortality (P=.061). Combined CTP class and ALBI score could predict development of radiation-induced liver disease (2.4% in CTP A-ALBI < -2.76, 15.1% in CTP A-ALBI ≥ -2.76, and 25.8% in CTP B).

CONCLUSION

Albumin-bilirubin score is a potential predictor for both survival and liver toxicity. Complementary use of CTP and ALBI score could predict the risk of post-SABR liver toxicity. Further prospective studies are necessary before use of the ALBI score can become part of daily practice.

The albumin-bilirubin grade improves hepatic reserve estimation post-sorafenib failure: implications for drug development

BACKGROUND

Drug development in hepatocellular carcinoma (HCC) is limited by disease heterogeneity, with hepatic reserve being a major source of variation in survival outcomes. The albumin-bilirubin (ALBI) grade is a validated index of liver function in patients with HCC.

AIM

To test the accuracy of the ALBI grade in predicting post-sorafenib overall survival (PSOS) in patients who permanently discontinued treatment.

METHODS

From a prospectively maintained international database of 447 consecutive referrals, we derived 386 eligible patients treated with sorafenib within Barcelona Clinic Liver Cancer C stage (62%), 75% of whom were of Child class A at initiation. Clinical variables at sorafenib discontinuation were analysed for their impact on post-sorafenib overall survival using uni- and multivariable analyses.

RESULTS

Median post-sorafenib overall survival of the 386 eligible patients was 3.4 months and median sorafenib duration was 2.9 months, with commonest causes of cessation being disease progression (68%) and toxicity (24%). At discontinuation, 92 patients (24%) progressed to terminal stage, due to worsening Child class to C in 40 (10%). Median post-sorafenib overall survival in patients eligible for second-line therapies (n = 294) was 17.5, 7.5 and 1.9 months according respectively to ALBI grade 1, 2 and 3 (P < 0.001).

CONCLUSIONS

The ALBI grade at sorafenib discontinuation identifies a subset of patients with prolonged stability of hepatic reserve and superior survival. This may allow improved patient selection for second-line therapies in advanced HCC.