Screening for hepatocellular carcinoma

Community-based screening for hepatocellular carcinoma in elderly residents in a hepatitis B- and C-endemic area

BACKGROUND AND AIM

The aim of the present study was to elucidate a reasonable model and the efficacy of hepatocellular carcinoma (HCC) screening on an elderly population.

METHODS

Two-stage HCC screening was conducted in a hepatitis C virus (HCV)-endemic area. First, participants underwent blood tests for hepatitis B surface antigen (HBsAg), anti-HCV antibody, serum α-fetoprotein (AFP), aspartate aminotransferase, alanine aminotransferase, and platelet count. Patients who were abnormal for any of the six markers were enrolled for second-stage ultrasonography. Suspected cases were referred for confirmation. HCC cases were followed for 4 years. All patients were linked to national mortality and cancer register databases to identify newly-developed HCC, 30 months after screening.

RESULTS

A total of 461 males and 541 females were screened for HCC, with 15.1% testing positive for HBsAg and 44.3% positive for anti-HCV. Among them, 619 (61.8%) met the criteria of ultrasonographic screening; 527 (85.1%) responded, and 16 confirmed HCC (male/female = 8/8, 68.8±8 years) cases were detected. All tumor diameters were less than 5 cm, and six were less than 2 cm. AFP and thrombocytopenia were two independent predictive factors of HCC. The overall survival rates of detected cases were 93.8% and 56.3% was 1 and 4 years, respectively. The only good prognostic predictor was "underwent curative treatment". Another seven non-HCC residents developed HCC after screening, and five of these were with either thrombocytopenia or AFP elevation.

CONCLUSION

Under economical consideration, AFP and platelet count should be feasible screening markers of risk identification. Early detection and prompt treatment results in good prognosis in an aged population.

Clinical utility of prothrombin induced by vitamin K absence in the detection of hepatocellular carcinoma in Indian population

BACKGROUND

Alpha-fetoprotein (AFP) is a well known widely used biomarker for the detection of hepatocellular carcinoma (HCC); however, it suffers from a low sensitivity and specificity. Protein or prothrombin induced by vitamin K absence or antagonist II (PIVKA-II) is another tumor marker elevated in HCC but not extensively used.

AIM

Evaluation of PIVKA-II and AFP in diagnosing HCC in India.

PATIENTS AND METHODS

The study group consisted of 70 consecutive HCC patients, 38 patients with cirrhosis, 30 patients with chronic hepatitis, and 30 normal healthy subjects. All patients were evaluated for PIVKA-II and AFP levels by ELISA.

RESULT

The mean plasma concentration of PIVKA-II in HCC, cirrhotic, chronic hepatitis patients and healthy controls was 101.07 ± 78.30 ng/ml, 2.45 ± 4.25 ng/ml, 1.50 ± 0.98 ng/ml and 0.79 ± 0.75 ng/ml, respectively. Receiver operating characteristic (ROC) curve was plotted for PIVKA-II and AFP. At a cutoff level of 9.2 ng/ml for PIVKA-II a sensitivity of 80% and a specificity of 92.1% was found, whereas AFP at a cutoff level of 13.02 ng/ml showed 72.9% sensitivity and 65.8% specificity. No significant relationship of plasma levels of PIVKA-II was observed in HCC with HBsAg/antiHCV positivity and associated portal vein thrombosis, but a positive correlation was seen with the tumor size (P = 0.001). However, no such significant association was found with AFP.

CONCLUSION

PIVKA-II was more sensitive and specific than AFP for diagnosing HCC in the Indian population.

Proteomics of hepatocellular carcinoma: serum vimentin as a surrogate marker for small tumors (<or=2 cm)

Small hepatocellular carcinomas (HCCs) can be effectively cured by surgery with good clinical outcomes. However, the conventional AFP marker is ineffective in detecting small tumors. Here we employed a proteomic profiling approach to identify a candidate marker for HCC (<or=2 cm) in tumor tissues and then evaluate its clinical feasibility in patients' sera. The study was divided into 2 phases. (i) Biomarker discovery: we collected 76 frozen liver tissues (40 HCC and 36 controls) for proteomics profiling. Candidate protein markers were identified by MALDI-TOF/TOF and confirmed by immunoblot and qPCR. (ii) Clinical evaluation: Selected biomarker was tested by ELISA for sensitivity and specificity using serum samples from a separate cohort of 152 subjects (88 HCC and 64 controls). Vimentin was found significantly overexpressed in HCC, in particular the small-size subgroup (<or=2 cm) with p < 0.01. When tested in the serum samples, vimentin level was significantly higher in small tumors than the non-neoplastic controls (AUC = 0.69 and p < 0.01). Further analysis suggested that elevated circulating vimentin level could detect small HCC at 40.91% sensitivity and 87.50% specificity. Moreover, vimentin was found to be superior to serum AFP assayed at different cut-offs in detecting small tumors. When combined with AFP, the detection sensitivity and specificity could be further enhanced to 58.77 and 98.15%, respectively. In conclusion, serum vimentin is a potential surrogate marker, either alone or in combination with AFP, for detection of small HCCs.

Evaluation of serum clusterin as a surveillance tool for human hepatocellular carcinoma with hepatitis B virus related cirrhosis

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is a common human cancer worldwide. The levels of serum clusterin in HCC patients and its potential diagnostic significance is not clear. We aimed to evaluate the clinical use of serum clusterin levels as a surveillance tool for HCC with hepatitis B virus (HBV) related cirrhosis.

METHODS

Twenty-two cases of healthy subjects, 31 cases of HBV carriers, 26 patients with chronic hepatitis B, 29 patients with cirrhosis, and 76 patients with HCC were enrolled in this study. Serum levels of clusterin were measured by a sandwich enzyme-linked immunosorbent assay.

RESULTS

The serum clusterin levels in HCC patients were significantly lower than that in healthy, HBV carriers and chronic hepatitis B, but statistically higher than in cirrhosis patients. Receiver operator characteristic (ROC) curve indicated that a serum clusterin value of 50 microg/mL yielded the best sensitivity (91%) and specificity (83%) for differentiating HCC patients with HBV-related cirrhosis from those with HBV-related cirrhosis. The optimal alpha fetoprotein (AFP) cutoff value was 15 ng/mL and was inferior to the clusterin value of 50 microg/mL, the area under the ROC curves being 0.937 versus 0.781, respectively (P < 0.05).

CONCLUSIONS

Serum clusterin was more sensitive and specific than serum AFP for differentiating HCC patients with HBV-related cirrhosis from those with HBV-related liver cirrhosis, and may be a useful surveillance tool of HCC based on HBV-related cirrhosis.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Hepatitis C prevalence in patients with hepatocellular carcinoma without cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) occurring in "noncirrhotic" hepatitis C virus (HCV)-infected patients has been reported; but the exact prevalence or incidence has not been described before.

METHODS

We conducted a systematic review of literature: Ovid was used to search the literature from January 1, 1990, to September 1, 2008. Articles containing "HCC" keywords (hepatocellular carcinoma, hepatoma, liver cancer) were combined with the word "cirrhosis" or "fibrosis" and with "absence" keywords [noncirrhotic, absence, without]. Two hundred articles were selected and screened according to predesigned exclusion and inclusion criteria.

RESULTS

Nineteen articles met the inclusion criteria. The estimated prevalence of noncirrhotic HCC ranged from 6.7% to 50.1%. The pooled prevalence estimates for HCV in noncirrhotic HCC ranged from 0% and 68.4% according to the geographic location. Reports from Japan had the highest estimated pooled prevalence of HCV (55.01%) followed by Italy (29.95%).

CONCLUSION

HCV can occur in patients with HCC without cirrhosis, but the true incidence and prevalence are very difficult to ascertain. Further studies are needed to define this group of patients.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for use of tumor markers in liver, bladder, cervical, and gastric cancers

BACKGROUND

Updated National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

METHODS

Published reports relevant to use of tumor markers for 4 cancer sites--liver, bladder, cervical, and gastric--were critically reviewed.

RESULTS

Alpha-fetoprotein (AFP) may be used in conjunction with abdominal ultrasound for early detection of hepatocellular carcinoma (HCC) in patients with chronic hepatitis or cirrhosis associated with hepatitis B or C virus infection. AFP concentrations >200 microg/L in cirrhotic patients with typical hypervascular lesions >2 cm in size are consistent with HCC. After a diagnosis of HCC, posttreatment monitoring with AFP is recommended as an adjunct to imaging, especially in the absence of measurable disease. Although several urine markers have been proposed for bladder cancer, none at present can replace routine cystoscopy and cytology in the management of patients with this malignancy. Some may, however, be used as complementary adjuncts to direct more effective use of clinical procedures. Although carcinoembryonic antigen and CA 19-9 have been proposed for use gastric cancer and squamous cell carcinoma antigen for use in cervical cancer, none of these markers can currently be recommended for routine clinical use.

CONCLUSIONS

Implementation of these recommendations should encourage optimal use of tumor markers for patients with liver, bladder, cervical, or gastric cancers.

Role of serum prothrombin induced by vitamin K absence or antagonist-II in the early detection of hepatocellular carcinoma in patients with chronic hepatitis B virus infection

OBJECTIVE

The role of serum prothrombin induced by vitamin K absence or antagonist-II (PIVKA-II) in the early detection of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B virus (HBV) infection has not yet been clearly identified. The purpose of the study was to evaluate the sensitivity and specificity of PIVKA-II, alone or in combination with alpha-fetoprotein (AFP), for the detection of HCC during surveillance, and to determine whether PIVKA-II was a significant risk factor for patient survival.

MATERIAL AND METHODS

During surveillance, 106 HCC cases and 100 non-HCC cases of chronic HBV infection were included. Sensitivity and specificity of AFP and PIVKA-II were obtained through cut-off values of 20 ng/ml and 40 mAU/ml, respectively. The Cox proportional hazards model was used to determine whether PIVKA-II would be a significant risk factor for patient survival.

RESULTS

The sensitivity rates of AFP and PIVKA-II were 57.5% (61/106) and 51.9% (55/106), respectively. Of 45 patients negative for AFP, 22 were positive for PIVKA-II. A combination of AFP and PIVKA-II increased the sensitivity to 78.3% (83/106). The specificities of AFP and PIVKA-II were 88.0% and 97.0%, respectively. PIVKA-II was not a significant risk factor for patient survival after multivariate analysis.

CONCLUSIONS

PIVKA-II can be used as a tumor marker for the early detection of HCC in patients with chronic HBV infection, especially in combination with AFP.

Review article: the management of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the leading cause of death in cirrhosis. A majority of patients present at an advanced stage with poor prognosis.

AIM

To review the current screening, diagnosis and management strategies involved in hepatocellular carcinoma.

METHODS

A literature search was performed using PubMed for publications with a predetermined search string to identify relevant studies.

RESULTS

Hepatocellular carcinoma is dramatically increasing in incidence that is mostly attributed to chronic hepatitis C and non-alcoholic fatty liver disease/non-alcoholic steatohepatitis and its clinical phenotype diabetes and obesity. Cirrhosis is the major predisposing risk factor and its presence necessitates close surveillance for hepatocellular carcinoma with serial imaging studies. Hepatocellular carcinoma can be diagnosed by its unique radiological behaviour of arterial enhancement and washout on delayed images. The Barcelona Clinic Liver Cancer staging classification system is a clinically useful algorithm for the management of patients with hepatocellular carcinoma. The simultaneous presence of cirrhosis in the patients complicates their management and monitoring for cirrhosis-related complications is important.

CONCLUSIONS

Early diagnosis and definitive treatment remains the key to long-term outcome. A multidisciplinary approach is critical to the successful management of hepatocellular carcinoma. Studies combining sorafenib with locoregional or other targeted molecular therapies are likely to improve responses and outcome.

Prognostic value of serum osteopontin in hepatocellular carcinoma patients treated with transarterial chemoembolization

BACKGROUND/AIMS

Osteopontin (OPN) is overexpressed in hepatocellular carcinoma (HCC) with postoperative recurrence or extrahepatic metastasis. However, its prognostic value in patients treated with transarterial chemoembolization (TACE) is unclear. We investigated the utility of serum OPN levels and changes therein as prognostic markers in HCC patients who have received TACE.

METHODS

Forty-six patients with HCC were enrolled. Serum OPN levels were measured before and 4 weeks after TACE. Serum biochemistry and computed tomography (CT) scans were analyzed. We evaluated baseline serum OPN levels and subsequent changes therein in relation to tumor responses and cumulative survival rates following TACE. A decreasing pattern was defined as a decrease after TACE of more than 10% relative to baseline levels. A "responder" was defined as a patient who exhibited a tumor necrosis rate of higher than 50% on the follow-up CT scan.

RESULTS

Higher initial serum OPN levels were associated with a large tumor, portal vein invasion, and an advanced tumor stage. Patients who had lower initial serum OPN levels and those who exhibited decreasing patterns after TACE tended to have more favorable tumor responses (P=0.043 and 0.055, respectively) and exhibited better cumulative survival rates (P=0.036 and 0.030, respectively). However, the initial serum OPN level and subsequent changes in serum OPN levels were not independent predictors for survival on multivariate analysis.

CONCLUSIONS

Serum OPN levels were significantly higher in patients with advanced HCC. In addition, HCC patients with low pretreatment serum OPN levels and those for whom serum OPN declined following TACE exhibited better tumor responses and survived for longer.

Multiphasic MDCT enhancement pattern of hepatocellular carcinoma smaller than 3 cm in diameter: tumor size and cellular differentiation

OBJECTIVE

The purpose of this study was to evaluate according to size and degree of cellular differentiation the multiphasic MDCT enhancement pattern of hepatocellular carcinoma (HCC) smaller than 3 cm in diameter in patients with cirrhosis.

MATERIALS AND METHODS

In 155 consecutively registered patients (126 men, 29 women; mean age, 58.4 years), 204 pathologically proven HCCs smaller than 3 cm were detected at multiphasic MDCT. Three radiologists in consensus classified the relative attenuation of the tumors compared with the surrounding liver parenchyma as hyperattenuation, isoattenuation, or hypoattenuation on biphasic (n = 86) and triphasic (n = 69) CT scans.

RESULTS

The prevalent enhancement patterns of HCC differed depending on tumor size. The prevalent pattern of HCC measuring 20-29 mm was arterial hyperattenuation with venous washout (47%, 47/101). The prevalent enhancement patterns of HCC smaller than 10 mm and HCC measuring 10-19 mm were isoattenuation during the arterial and portal venous phases (29%, 6/21) and hyperattenuation and isoattenuation during the arterial and portal venous phases (33%, 27/82). The typical HCC enhancement pattern (arterial hyperattenuation with venous washout) was identified in 48% (67/141) of the moderately and poorly differentiated HCCs and in 13% (8/63) of well-differentiated HCCs.

CONCLUSION

The prevalent enhancement patterns of HCC smaller than 3 cm on multiphasic MDCT scans differed depending on tumor size and cellular differentiation. HCCs smaller than 2 cm and well-differentiated HCCs frequently had atypical enhancement patterns.

Progression of alphafetoprotein before liver transplantation for hepatocellular carcinoma in cirrhotic patients: a critical factor

Liver transplantation (LT) for cirrhotic/Hepatocellular carcinoma (HCC) is associated with reduced survival in patients with poor histological features. Preoperative levels of alphafetoprotein (AFP) could predict negative biological features. AFP progression could be more relevant than static AFP levels in predicting LT outcomes. A total of 252 cirrhotic/HCC patients transplanted between 1985 and 2005 were reviewed. One hundred fifty-three patients were analyzed, 99 excluded (for nonsecreting tumors and/or salvage transplantation). Using receiver operating characteristics analysis for recurrence after LT, 'progression' of AFP was defined by >15 microg/L per month before LT. A total of 127 (83%) were transplanted under and 26 (16%) over this threshold. After 45 months of follow-up (median), 5-year overall survival (OS) and recurrence free-survival (RFS) were 72% and 69%, respectively. Five-year survival in the progression group was lower than the nonprogression group (OS 54% vs. 77%; RFS 47% vs. 74%). Multivariate analysis showed progression of AFP>15 microg/L per month and preoperative nodules>3 were associated with decreased OS. Progression group and age>60 years were associated with decreased RFS. Male gender, progression of AFP and size of tumor>30 mm were associated with satellite nodules and/or vascular invasion. In conclusion, increasing AFP>15 microg/L/month while waiting for LT is the most relevant preoperative prognostic factor for low OS/DFS. AFP progression could be a pathological preoperative marker of tumor aggressiveness.

Circulating Lamin B1 (LMNB1) biomarker detects early stages of liver cancer in patients

Hepatocellular carcinoma (HCC) is a major liver malignancy possessing a high mortality rate and is particularly prevalent in China and Asia. While surgery is the most effective treatment for liver tumor, about 80% of HCC patients are inoperable at presentation and die early due to late diagnosis. For early cancer detection, we employed a proteomic expression profiling approach to identify biomarkers for early stages of HCC and subsequently assessed the clinical feasibility of a novel marker in plasma. Frozen liver tissues from a retrospective cohort of 75 liver patients (39 HCCs, 20 cirrhosis, and 16 nondiseased subjects) were subjected to proteome-wide expression profiling by 2-DE. MALDI-TOF/TOF was used to identify differentially expressed proteins, which were further confirmed by immunoblotting, qPCR, and immunohistochemistry. Conventional RT-PCR was employed to further analyze the abundance of selected biomarker at mRNA level in a separate cohort of 63 plasma samples (35 HCCs, 16 liver cirrhosis, 12 healthy individuals). We successfully identified lamin B1 (LMNB1) that was significantly upregulated in HCC tumors and present in patients' plasma. LMNB1 functions in nuclear envelope lamina and possesses a transcriptional coregulatory activity having an important role in DNA replication, cellular aging, and stress responses. Clinically, the expression level of lamin B1 correlated positively with tumor stages, tumor sizes, and number of nodules. Our findings further showed elevation of circulating LMNB1 marker in plasma could detect early stages of HCC patients, with 76% sensitivity and 82% specificity. In conclusion, lamin B1 is a clinically useful biomarker for early stages of HCC in tumor tissues and plasma, and warrants further clinical investigation.

Association between MDM2-SNP309 and hepatocellular carcinoma in Taiwanese population

AIM: To investigate the risk association and compare the onset age of hepatocellular carcinoma (HCC) patients in Taiwan with different genotypes of MDM2-SNP309.

METHODS: We analyzed MDM2-SNP309 genotypes from 58 patients with HCC and 138 cancer-free healthy controls consecutively. Genotyping of MDM2-SNP309 was conducted by restriction fragment length polymorphism assay.

RESULTS: The proportion of homozygous MDM2-SNP309 genotype (G/G) in cases and cancer-free healthy controls was similar (17.2% vs 16.7%). Multivariate analysis showed that the risk of G/G genotype of MDM2-SNP309 vs wild-type T/T genotype in patients with HCC was not significant (OR = 1.265, 95% CI = 0.074-21.77) after adjustment for sex, hepatitis B or C virus infection, age, and cardiovascular disease/diabetes. Nevertheless, there was a trend that GG genotype of MDM2-SNP309 might increase the risk in HCC patients infected with hepatitis virus (OR = 2.568, 95% CI = 0.054-121.69). Besides, the homozygous MDM2-SNP309 genotype did not exhibit a significantly earlier age of onset for HCC.

CONCLUSION: Current data suggest that the association between MDM2-SNP309 GG genotype and HCC is not significant, while the risk may be enhanced in patients infected by hepatitis virus in Taiwan.

Serum α-fetoprotein levels in liver steatosis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a common disorder and becoming a leading cause of cirrhosis in the western world. The monitoring of the disease is challenging and the prognostic importance of α-fetoprotein (AFP) level elevation in NAFLD remains uncertain.

METHODS

Eighty-four patients were evaluated in the study. Patients with evidence of fatty liver in an abdominal ultrasonography performed for any reason were enrolled in the study. Degree of liver steatosis was graded into three groups. As a control group, patients without fatty liver or other liver diseases were included. All patients and controls were asked about prior hepatic diseases, consumption of alcohol, smoking, drug use, and a physical examination, biochemical analyses including liver function tests, different components of the metabolic syndrome, and the homeostasis model assessment-estimated insulin resistance (HOMA-IR) score were also performed.

RESULTS

Body mass index, aspartate aminotransferase, alanine aminotransferase, glucose, insulin, and HOMA-IR in patients with NAFLD were higher than in control group. Triglyceride, total cholesterol, low-density lipoprotein, and high-density lipoprotein cholesterol levels were higher in NAFLD group than in control group. A statistically significant increase in AFP levels was noted in patients with NAFLD (4.09 ± 1.68) when compared with healthy controls (2.95 ± 0.41) (P < 0.05). A statistically significant increase in AFP levels was noted in patients with grade 3 NAFLD (5.43 ± 1.51) when compared with grade 1 (2.92 ± 1.06) and grade 2 NAFLD groups (3.97 ± 1.45). Also, AFP was significantly higher in grade 2 NAFLD group than in grade 1 NAFLD group. AFP was correlated with NAFLD grade, but neither ALT nor AST showed correlation. According to multivariate analysis, correlation between NAFLD grade and serum AFP levels was independent from the other factors.

CONCLUSION

Patients with NAFLD have higher AFP levels than those without fatty liver changes. AFP levels rise as grade of liver steatosis increases. NAFLD should be among the differential diagnosis of elevated serum AFP levels.

Clinical application of an enzyme-linked immunosorbent assay detecting hepatoma-specific gamma-glutamyltransferase

AIM

To develop a sandwich enzyme-linked immunosorbent assay (ELISA) measuring hepatoma-specific datura stramonium agglutinin-tightly bounding gamma-glutamyltransferase (DSA-GGT) and evaluate its clinical application for hepatocellular carcinoma (HCC) diagnosis.

METHODS

Serum DSA-GGT concentrations were measured with the sandwich ELISA system in 96 patients with HCC, 240 patients with chronic liver diseases and 119 healthy subjects. The diagnostic performance of DSA-GGT for HCC was assessed using receiver operating characteristic (ROC) curves. The diagnostic accuracy of DSA-GGT was compared with serum alpha-fetoprotein (AFP).

RESULTS

The area under the ROC curve of DSA-GGT in discriminating patients with HCC from non-HCC was 0.865 (95% confidence interval: 0.818-0.915, P < 0.001). Serum DSA-GGT was positive in 67 out of 96 patients with HCC and 23 out of 240 patients with non-HCC diseases. The sensitivity and specificity of DSA-GGT and AFP for the diagnosis of HCC were 69.8% and 90.5%, and 72.9% and 89.1%, respectively. A higher sensitivity (93.8%) in the identification of HCC was observed by combining DSA-GGT and AFP.

CONCLUSION

The sandwich ELISA system showed good reliability and reproducibility, and using the measurement, we found that serum DSA-GGT was a valuable marker of HCC, as a usable complementary to AFP. The sensitivity for identifying HCC could be significantly improved by combining DSA-GGT and AFP, and the combination could be used in large-scale screening for HCC in susceptible individuals.

Significance of alpha-fetoprotein and des-gamma-carboxy prothrombin in patients with hepatocellular carcinoma undergoing hepatectomy

BACKGROUND

Alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) are well-known tumor markers of hepatocellular carcinoma (HCC). The aims of this study are to calculate the sensitivity/specificity of AFP and DCP measurement for the diagnosis of HCC, measure response rates of the markers following curative-intent resections, determine the correlations between the marker levels and clinicopathological prognostic variables, and determine the correlations between the marker levels before hepatectomy and those at diagnosis of recurrence.

METHODS

A retrospective cohort study of 714 consecutive patients with HCC undergoing hepatectomy was carried out.

RESULTS

The areas under the receiver operating characteristic curves were 0.79 versus 0.91 for AFP and DCP, respectively (P < 0.001). Positive AFP and DCP status became negative at 6 months post surgery in 184/229 (80.3%) and 245/246 (99.6%) patients, respectively (cutoff values being 20 ng/ml for AFP and 40 mAU/ml for DCP; P < 0.0001). No correlation was found between marker levels (rs = 0.23). The level of DCP, but not that of AFP, showed a close correlation with tumor size (rs = 0.51 and 0.19, respectively). They were associated with indices of tumor invasiveness without showing any specific associations. AFP and DCP levels in patients showing recurrence in </=6 months correlated with the levels measured before surgery (rs = 0.78 and 0.49, respectively) but not in those showing recurrence after 2 years (rs = 0.31 and 0.30, respectively).

CONCLUSIONS

DCP is a more accurate, albeit complementary, HCC marker than AFP. While the levels of both markers increased with advancing tumor growth, no specific associations were found. The marker values at recurrence indicated the type of recurrence.

Serum alpha-fetoprotein response as a surrogate for clinical outcome in patients receiving systemic therapy for advanced hepatocellular carcinoma

BACKGROUND

The role of serum alpha-fetoprotein (AFP) as a marker for treatment response in patients with hepatocellular carcinoma (HCC) receiving systemic therapy is poorly defined.

METHODS

A retrospective study was performed on patients with advanced HCC enrolled in five phase II clinical trials. Serum AFP was prospectively collected at baseline and at different time points through treatment in parallel with radiologic response and clinical outcome. Patients were separated into three groups based on a 50% change in serum AFP from baseline. Overall survival (OS), progression-free survival (PFS), and radiologic responses were compared between groups using log-rank and Wilcoxon tests.

RESULTS

Of 144 patients, 107 met the eligibility criteria. Eighteen patients experienced a >50% AFP decline, 57 patients had a >50% AFP increase, and 32 patients had a <50% change in serum AFP in either direction. Compared with patients with a <50% change in serum AFP (median PFS, 5.6 months), patients with a >50% AFP decrease had a longer PFS time (median, 16.9 months; p = .029), whereas those with a >50% increase had a shorter PFS time (median, 2.3 months; p = .038). Patients with a >50% rise in AFP had a shorter OS time than those with a <50% change (median, 6.3 months versus 11.1 months, respectively; p = .004), whereas a >50% AFP decrease was not associated with a significant difference in OS (median, 13.0 months; p = .87). AFP changes were significantly associated with radiologic response.

CONCLUSIONS

Our study suggests that serum AFP change during treatment may serve as a useful surrogate marker for clinical outcome in patients with advanced HCC receiving systemic therapy.

Metabolomic profiling of human urine in hepatocellular carcinoma patients using gas chromatography/mass spectrometry

With the technique of metabolomics, gas chromatography/mass spectrometry (GC/MS), urine or serum metabolites can be assayed to explore disease biomarkers. In this work, we present a metabolomic method to investigate the urinary metabolic difference between hepatocellular carcinoma (HCC, n - 20) male patients and normal male subjects (n - 20). The urinary endogenous metabolome was assayed using chemical derivatization followed by GC/MS. After GC/MS analysis, 103 metabolites were detected, of which 66 were annotated as known compounds. By a two sample t-test statistics with p < 0.05, 18 metabolites were shown to be significantly different between the HCC and control groups. A diagnostic model was constructed with a combination of 18 marker metabolites or together with alphafetoprotein, using principal component analysis and receiver-operator characteristic curves. The multivariate statistics of the diagnostic model yielded a separation between the two groups with an area under the curve value of 0.9275. This non-invasive technique of identifying HCC biomarkers from urine may have clinical utility.

Application of surveillance programs for hepatocellular carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is a potential target for cancer surveillance (or screening) as it occurs in well-defined, at-risk populations and curative therapy is possible only for small tumors. Surveillance has been recommended by regional liver societies and is practiced widely, but its benefits are not clearly established. Hepatic ultrasonography with or without alpha fetoprotein (AFP) performed every 6 months is the preferred program. Surveillance of HCC has been well shown to detect small tumors for curative treatment, which may be translated to improved patient survival. However, most studies are limited by lead-time bias, length bias for early diagnosis of small HCC, different tumor growth rates and poor compliance with surveillance. Cost-effectiveness of surveillance programs depends on the rate of small HCC detected 'accidentally' (routine imaging) in a comparator group, annual incidence of HCC with various etiologies, patient age and the availability of liver transplantation. The incremental cost-effectiveness for 6-monthly AFP and ultrasound has been estimated from approximately $US 26,000-74,000/quality adjusted life years (QALY). All cirrhotic patients are therefore recommended for HCC surveillance unless the disease is too advanced for any curative treatment. As chronic hepatitis B can develop into HCC without going through liver cirrhosis, high-risk non-cirrhotic chronic hepatitis B patients are also recommended for HCC surveillance. In conclusion, HCC surveillance could be effective at reducing disease-specific mortality with acceptable cost-effectiveness among selected patient groups, provided it is a well-organized program.

GP73, a resident Golgi glycoprotein, is sensibility and specificity for hepatocellular carcinoma of diagnosis in a hepatitis B-endemic Asian population

Golgi protein-73 (GP73) is a newly identified candidate serum marker for HCC, but GP73 study now is lesser in Asian population. The aims of this study were to determine how GP73 is detected in the serum of healthy, hepatitis B, cirrhosis and HCC by western blotting and RT-PCR, and to establish the sensitivity and specificity of serum GP73 protein and RNA for diagnosing HCC. Serum GP73 was detected by western blotting and RT-PCR, and quantified by densitometric analysis. GP73 was measured in serum from 124 patients with various forms of liver. AFP was tested using commercially available electrochemiluminescence immunoassay. The median sGP73 in patients with HBV-related HCC was significantly higher (P < 0.001) than in healthy individuals and in patients with other diseases. When sGP73 protein was used to detect HBV-related HCC, it had a sensitivity of 77.4% and a specificity of 83.9%, at the optimal cut-off value of 7.4 relative units. The area under the receiver-operating characteristic curve was 0.89. GP73 RNA in patients with HBV-related HCC had a sensitivity of 87.1% and a specificity of 83.9% and AUROC of 0.92. AFP in patients with HCC had a sensitivity of 48.4% and a specificity of 96.8% and AUROC of 0.77. GP73 protein and RNA can be found in the serum of patients with HBV-related HCC obviously higher than of other liver diseases in Asian. GP73 was better than AFP for the diagnosis of HBV-related HCC. RT-PCR is a more sensitive and superior method of quantification than Western blot. Furthermore, our data need to be confirmed in larger cohorts of patients.

Surface enhanced laser desorption/ionization profiling: New diagnostic method of HBV-related hepatocellular carcinoma

BACKGROUND AND AIM

To screen for serum biomarkers of HBV-related hepatocellular carcinoma (HCC) and HBV-related liver cirrhosis (LC) in an attempt to seek a new method for differential diagnosis of HCC and LC using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) techniques.

METHODS

Using SELDI-TOF-MS, serum proteins/peptide profiles on the immobilized metal ion affinity capture (IMAC) protein chips were obtained from 29 HCC patients and 30 LC patients. Discriminant analysis was carried out to establish new diagnostic methods using protein/peptide peaks with or without alpha-fetoprotein (AFP).

RESULTS

Forty-five protein/peptide peaks changed much more in the HCC group than they did in the LC group. Discriminant analysis using the Wilcoxon rank-sum test showed high sensitivity and specificity in distinguishing HCC from LC. The most significantly differentiating peak, 3892, offered 69.0% sensitivity, 83.3% specificity and 80% positive predictive value in distinguishing HCC and LC. Interestingly, six HCC patients with negative serum AFP were confirmed by peak 3892. The combination of multi-protein peaks (m/z = 9297, 29 941) with AFP offered an 82.8% sensitivity, 93.3% specificity and 92.3% positive predictive value, which was much better than AFP alone (P = 0.013).

CONCLUSIONS

Special proteins/peptides of serum may differentiate HBV-related HCC and HBV-related LC, indicating that SELDI-TOF-MS may be useful to distinguish HCC from LC with the proper discriminant analytical method. SELDI peak 3892 may be a complementary diagnostic marker to positive AFP for HCC and a potential marker for the diagnosis of AFP-negative HCC as well.

Liver transplantation for hepatocellular carcinoma without preoperative tumor biopsy

BACKGROUND

Progress in liver imaging has made pretransplantation tumor biopsy no longer systematic in patients with hepatocellular carcinoma (HCC).

OBJECTIVES

Our aim was to evaluate the accuracy of a preoperative diagnosis of HCC based on clinical and radiological findings in 102 cirrhotics qualified for liver transplantation (LT) between January 1995 and August 2003 at our institution.

METHODS

The diagnostic accuracy of our policy was assessed by comparing pretransplant diagnosis with the pathologic report of explanted livers.

RESULTS

Sensitivity, specificity, positive, and negative predictive values for the preoperative clinical and radiological diagnosis of HCC were 89%, 94.3%, 77%, and 93.3%, respectively. A false-positive preoperative diagnosis was made in 20 of 102 patients (19.6%) (dysplastic nodules [n=9], regenerative nodules [n=5] cholangiocellular carcinoma [n=1], hemangioma [n=1], and no lesion [n=4]). All tumors larger than 3 cm were correctly diagnosed, irrespective of serum alpha-fetoprotein (sAFP) levels. The risk of overestimating the diagnosis of HCC in the subgroup of patients with tumors less than 3 cm was conversely correlated with preliver transplantation sAFP (sAFP<or=100 ng/L: 28%; sAFP>100: 11%; sAFP>200: 0%).

CONCLUSION

In cirrhotics with nodules larger than 3 cm irrespective of sAFP or nodules less than 3 cm with sAFP greater than 200 ng/L, the pretransplant diagnosis of HCC can be made without performing biopsy. In other cases (i.e., nodules less than 3 cm and sAFP lower than 200 ng/L), histologic confirmation of HCC or a close follow-up imaging should be considered.

Dramatic down-regulation of oxidoreductases in human hepatocellular carcinoma hepG2 cells: proteomics and gene ontology unveiling new frontiers in cancer enzymology

BACKGROUND

Oxidoreductases are enzymes that catalyze many redox reactions in normal and neoplastic cells. Their actions include catalysis of the transformation of free, neutral oxygen gas into oxygen free radicals, superoxide, hydroperoxide, singlet oxygen and hydrogen peroxide. These activated forms of oxygen contribute to oxidative stress that modifies lipids, proteins, DNA and carbohydrates. On the other hand, oxidoreductases constitute one of the most important free radical scavenger systems typified by catalase, superoxide dismutase and glutathione peroxidase.In this work, proteomics, Gene Ontology mapping and Directed Acyclic Graphs (DAG) are employed to detect and quantify differential oxidoreductase enzyme expressions between HepG2 cells and normal human liver tissues.

RESULTS

For the set of bioinformatics calculations whose BLAST searches are performed using the BLAST program BLASTP 2.2.13 [Nov-27-2005], DAG of the Gene Ontology's Molecular Function annotations show that oxidoreductase activity parent node of the liver proteome contains 331 annotated protein sequences, 7 child nodes and an annotation score of 188.9, whereas that of HepG2 cells has 188 annotated protein sequences, 3 child nodes and an annotation score of only 91.9. Overwhelming preponderance of oxidoreductases in the liver is additionally supported by the isomerase DAGs: nearly all the reactions described in the normal liver isomerase DAG are oxidoreductase isomerization reactions, whereas only one of the three child nodes in the HepG2 isomerase DAG is oxidoreductase. Upon normalization of the annotation scores to the parent Molecular Function nodes, oxidoreductases are down-regulated in HepG2 cells by 58%.Similarly, for the set of bioinformatics calculations whose BLAST searches are carried out using BLASTP 2.2.15 [Oct-15-2006], oxidoreductases are down-regulated in HepG2 cells by 56%.

CONCLUSION

Proteomics and Gene Ontology reveal, for the first time, differential enzyme activities between HepG2 cells and normal human liver tissues, which may be a promising new prognostic marker of Hepatocellular carcinoma.Two independent sets of bioinformatics calculations that employ two BLAST program versions, and searched different databases, arrived at essentially the same conclusion: oxidoreductases are down-regulated in HepG2 cells by approximately 57%, when compared to normal human liver tissues. Down-regulation of oxidoreductases in hepatoma is additionally supported by Gene Ontology analysis of isomerises.

Serum messenger RNA as a biomarker and its clinical usefulness in malignancies

A number of biomarkers are used clinically and many protein-based assay methods are available. Improvements in the method to utilize specific antibodies have led to remarkable progress in clinical diagnosis using biomarkers. Proteomics studies to identify better biomarkers have been performed worldwide by using a protein-based comprehensive method. The detection rate of conventional biomarkers can not improve further. Now is a time that a breakthrough is needed. We previously proposed mRNA, which is circulating in the body, as a novel material for biomarkers. mRNA is an unexpectedly useful molecule, not only because it can detect genes with a low expression level in protein, but also because it can detect the expression from non-coding RNA precursor genes or gene products with limited secretion from the cells. Circulating mRNA has been thought to be unstable in blood containing RNase. We confirm that mRNA remains at the same level for 24 hours after blood sampling. Unlike DNA, the RNA molecule can reflect events in the human body which occurred within a day, resulting in an early diagnosis of diseases. We report the possibility to detect and quantify cancer-derived mRNAs circulating in human vessels. We introduce the detection of serum mRNA as a useful biomarker of human malignancies.

Expression of galectin-3 involved in prognosis of patients with hepatocellular carcinoma

AIMS

Galectins are multifunctional lectins binding to the beta-galactoside of glycoproteins that affect diverse physiological and pathophysiological processes such as development, inflammation and tumor growth. In hepatocellular carcinoma (HCC), the over-expression of galectin-1, 3, and 4 has been reported, although their function and correlation with tumor progression remain unknown. Thus, we aimed to assess the role of galectin-3 during HCC progression.

METHODS

Specimens were obtained during curative operations and used for immunohistochemical analysis of galectin-3 (n = 52), and statistically assessed for correlations with the clinical profiles and the prognoses of the patients. The serum galectin-3 levels from the patients with liver diseases including HCC were assessed by ELISA.

RESULTS

In total, galectin-3 expression was found in 34 of 52 tumors (65%) and was statistically correlated with histological differentiation and vascular invasion. Kaplan-Meier's analysis showed that patients with galectin-3 expression tended to relapse in the earlier phase and had worse overall survival. In particular, a higher expression rate of nuclear galectin-3 showed a markedly worse prognosis, and it was independent in the multivariate analysis for overall survival. Serum galectin-3 levels were significantly increased in HCC compared with chronic liver disease. The sensitivity and specificity of galectin-3 were equivalent to alpha-fetoprotein and Vitamin K absence or antagonist II, and the combination of HCC biomarkers with galectin-3 improved the diagnostic performance.

CONCLUSIONS

Galectin-3 expression was involved in the tumor progression and related to the prognosis of HCC. Our observations suggested that galectin-3 could be a novel tumor marker and therapeutic target.

Management of combined hepatocellular and cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver malignancy composed of cells with histopathological features of both cholangiocarcinoma (CC) and hepatocellular carcinoma (HCC). It reportedly accounts for 0.4-14.2% of all primary liver carcinomas, with incidence varying in different regions. The clinical features are similar to those of either HCC or CC. Preoperative noninvasive diagnosis of cHCC-CC with conventional radiography is difficult. Because the origin of cHCC-CC is from two different tumour entities, despite intensive preoperative imaging studies, most studied patients were misdiagnosed either as HCC or CC. Accurate preoperative diagnosis is important because the most appropriate treatment depends on the major component of the tumour (HCC or CC). A high index of suspicion, imaging studies (ultrasound, computed tomography, positron emission tomography), levels of serum tumour markers (alpha-fetoprotein, carbohydrate antigen 19-9), and histology assist case detection and treatment choice. Patients who qualify for surgery should have a partial hepatectomy with hilar lymph node dissection, which can result in 5-year survival rates exceeding 50%. The role of liver transplantation is not yet known.

Analysis of morphological vascular changes of hepatocellular carcinoma by microflow imaging using contrast-enhanced sonography

AIM

To determine whether the findings of microflow imaging (MFI), composed of a flash replenishment and a maximum intensity holding sequence, using contrast-enhanced sonography, correlate with the degree of histological differentiation of hepatocellular carcinoma (HCC).

METHODS

This study was approved by the institutional review board; patients gave informed consent. The samples comprised of 61 nodules histologically diagnosed as HCC: 20 well-differentiated, 26 moderately-differentiated, and 15 poorly-differentiated HCC. SonoVue was used as the ultrasound (US) contrast agent. The US equipment used was a SSA-770 A with the imaging mode set at MFI. MFI is an imaging method combining flash replenishment imaging and maximum intensity holding. Two independent readers (readers 1 and 2) classified the microflow images into four patterns: (i) normal pattern; (ii) cotton pattern; (iii) vascular pattern; and (iv) dead wood pattern. The results were compared with the degree of histopathological differentiation of the HCC.

RESULTS

In each of the 61 HCC, blood vessels in the tumor were clearly resolved down to their fine branches. With regard to the relationship between imaging patterns and thehistological findings, it was found (with high percentages) that the normal and cotton patterns were associated with well-differentiated HCC, that the vascular pattern was associated with moderately-differentiated HCC, and that the dead wood pattern was associated with poorly-differentiated HCC. If HCC with the normal and cotton patterns were assessed as well differentiated and those with the vascular or dead wood pattern were assessed as moderately or poorly differentiated, the sensitivity, specificity, and accuracy of these assessments were found to be 85%, 92.7%, and 90%, respectively, for reader 1, and 85%, 82.9%, and 83.6%, respectively, for reader 2.

CONCLUSION

The angioarchitecture and hemodynamics of HCC could be evaluated in detail using MFI. The results of this study demonstrate the feasibility of a non-invasive preoperative diagnosis of the histological differentiation of HCC using MFI.

Diagnosing and monitoring hepatocellular carcinoma with alpha-fetoprotein: new aspects and applications

Hepatocellular carcinoma is the 5th most common cancer in the world. Prognosis for this disease is poor since hepatocellular carcinoma is mostly diagnosed at an advanced stage. Serum alpha-fetoprotein (AFP) is one of the most common diagnostic markers for hepatocellular carcinoma. However, its diagnostic value is more and more questioned. Therefore, research has focussed on AFP related parameters (AFP mRNA and AFP glycoforms). The aim of this paper is to review the present knowledge on AFP and its related parameters in diagnosing and monitoring HCC. AFP related parameters can be arranged in two types: AFP mRNA and AFP glycoforms. AFP mRNA is a potentially prognostic marker and AFP mRNA assays are based on PCR techniques. The AFP glycoforms have diagnostic potential and assays are based on isoelectric focussing and lectin affinity electrophoretic methods. Up to now the diagnostic use of the AFP related parameters is limited. Although some of them are recommended as a complementary test, they cannot (yet) replace serum AFP as the golden standard of diagnostic markers for hepatocellular carcinoma.

Diagnosis and treatment of hepatocellular carcinoma

The diagnosis and treatment of hepatocellular carcinoma (HCC) have witnessed major changes over the past decade. Until the early 1990s, HCC was a relatively rare malignancy, typically diagnosed at an advanced stage in a symptomatic patient, and there were no known effective palliative or therapeutic options. However, the rising incidence of HCC in several regions around the world coupled with emerging evidence for efficacy of screening in high-risk patients, liver transplantation as a curative option in select patients, ability to make definitive diagnosis using high-resolution imaging of the liver, less dependency on obtaining tissue diagnosis, and proven efficacy of transarterial chemoembolization and sorafenib as palliative therapy have improved the outlook for HCC patients. In this article, we present a summary of the most recent information on screening, diagnosis, staging, and different treatment modalities of HCC, as well as our recommended management approach.

Hepatocarcinoma in viral and metabolic liver disease

It is becoming increasingly evident that children, like adults, with chronic viral or metabolic liver diseases are at risk for the development of hepatocarcinoma. The aims of this article are to review the risk factors for hepatocarcinoma in chronic viral or metabolic liver disease, outline potential pathogenic mechanisms of hepatocarcinoma, and describe surveillance strategies, clinical evaluation, and management of hepatocarcinoma in children.

Current role of ultrasound for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has a decisive influence on the prognosis of cirrhotic patients. Although α-fetoprotein (AFP) is a known and specific tumor maker for HCC, it is not suitable for the screening and surveillance of HCC because of its poor predictive value and low sensitivity. The use of imaging modalities is essential for the screening, diagnosis and treatment of HCC. Ultrasound (US) plays a major role among them, because it provides real-time and non-invasive observation by a simple and easy technique. In addition, US-guided needle puncture methods are frequently required for the diagnosis and/or treatment process of HCC. The development of digital technology has led to the detection of blood flow by color Doppler US, and the sensitivity for detecting tumor vascularity has shown remarkable improvement with the introduction of microbubble contrast agents. Moreover, near real-time 3-dimensional US images are now available. As for the treatment of HCC, high intensity focused ultrasound (HIFU) was developed as a novel technology that provides a transcutaneous ablation effect without needle puncture. These advancements in the US field have led to rapid progress in HCC management, and continuing advances are expected. This article reviews the current application of US for HCC in clinical practice.

Correlation between parametric imaging using contrast ultrasound and the histological differentiation of hepatocellular carcinoma

AIM

To determine whether parametric imaging correlates with the degree of histological differentiation of hepatocellular carcinoma (HCC).

METHODS

The samples comprised 49 nodules diagnosed histologically as HCC: 19 well differentiated (w-HCC), 22 moderately differentiated (m-HCC), and eight poorly differentiated (p-HCC). The ultrasound (US) equipment used was SSA-770 A (Toshiba Medical Systems, Otawara, Japan) and the contrast agent was SonoVue (Bracco, Milan, Italy). After 1.5 mL of SonoVue was injected intravenously and staining of the tumors and parenchyma was confirmed, microbubbles in the scanned volume were eliminated using high mechanical index (MI) scanning frames. The "arrival time (T(A)) images," reflecting beta-values, were displayed with color codes at the phase after reperfusion. Images at the phase when the staining reached a plateau (90-180 s) were used as "A images," reflecting A values. These images were compared between each histological grade of differentiation.

RESULTS

Analysis of T(A) images indicated that beta-values in m-HCC were higher than those in the adjacent non-tumor parenchyma in all 22 samples and also were significantly higher than in the other HCCs (P < 0.001 for w-HCC; P < 0.05 for p-HCC). Furthermore, beta-values in p-HCC samples had significantly larger variations in terms of time and space than in the other HCCs (P < 0.001 for w-HCC; P < 0.01 for m-HCC). Analysis of A images indicated that the A value for w-HCC was significantly higher than those for either m-HCC or p-HCC (P < 0.001).

CONCLUSION

Both T(A) and A images were useful for diagnosing the histological differentiation of HCC.

Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography

AIM

To investigate the diagnostic value for the diagnosis of small (1-2 cm) hepatic nodules detected by surveillance ultrasound in patients with cirrhosis using contrast-enhanced ultrasound (CEUS) compared with that of contrast-enhanced helical computed tomography (CECT).

METHODS

Seventy-two liver cirrhosis patients with 103 small hepatic nodules (1-2 cm) detected by surveillance ultrasound were enrolled in the present study. All patients underwent CEUS with SonoVue as well as CECT. Nodules which appeared by contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CECT were diagnosed as malignant (hepatocellular carcinoma [HCC]). Histopathology obtained from biopsy or surgery served as the gold standard.

RESULTS

According to the above diagnostic criteria, the sensitivity (i.e. rate of correct diagnosis of HCC) was 91.1% (51/56 HCC) for CEUS and the specificity (i.e. the rate of correct exclusion of HCC) was 87.2% (41/47 regenerative nodules [RN]).Therefore, the diagnostic accuracy of CEUS was 89.3% (92/103 all nodules). Using the same diagnostic criteria, the sensitivity, specificity and accuracy of CECT were 80.4% (45/56 HCC), 97.9% (46/47 RN), and 88.4% (91/103 all nodules). Overall, there was no significant difference between CEUS and CECT in the diagnostic confidence of small hepatic nodules. Eighty-six nodules (45 HCC and 41 RN) were correctly diagnosed by both modalities and six (five HCC and one RN) were misdiagnosed by both.

CONCLUSION

The ability of CEUS in the characterization of small nodules (1-2 cm) detected by surveillance US in patients with liver cirrhosis is similar to that of CECT.

Cost-effectiveness of the surveillance program of hepatocellular carcinoma depends on the medical circumstances

BACKGROUND AND AIM

The clinical features of hepatocellular carcinoma (HCC) and the medical environment are diverse in different geographic areas. The aim of this study is to evaluate the cost-effectiveness of the surveillance of HCC in different medical circumstances.

METHODS

The Markov model focused on variables that differ from country to country and may change in the future, especially in regards to the proportion of small HCC detected incidentally. The target population was 45-year-old patients with Child-Pugh class A cirrhosis, and the intervention was surveillance with ultrasonography every 6 months.

RESULTS

The additional cost of the surveillance was $US15 100, the gain in quality-adjusted life years (QALYs) was 0.50 years, and the incremental cost-effectiveness ratio (ICER) was $US29 900/QALY in a base-case analysis (annual incidence of HCC = 4%). If 40% of small HCC were detected incidentally without surveillance, the gain in QALY decreased to 0.15 and the ICER increased to $US47 900/QALY. The increase in the annual incidence of HCC to 8% resulted in the increase of QALYs to 0.81, and the decrease of the ICER to $US25 400/QALY. The adoption of liver transplantation increased the gain in QALYs and the ICER to 0.84 and $US59 900/QALY, respectively.

CONCLUSIONS

The gain in QALYs and the ICER due to the surveillance of HCC varies between different patient subgroups and it critically depends on the rate of small HCC detected incidentally without surveillance, as well as the annual incidence of HCC and the adoption of liver transplantation.

Treatment options for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is frequently diagnosed at advanced stages and has a high mortality rate. With improved survival of patients with cirrhotic liver disease and increased prevalence of chronic hepatitis C viral infections, a rise in the number of HCC cases is being reported worldwide. Early diagnosis and treatment can significantly improve the prognosis of patients with HCC. Although surgical resection is an important potentially curative therapy for liver tumors, in appropriately selected patients, liver transplantation has been shown to achieve excellent survival rates for a solid tumor. Locally ablative and locoregional therapies in the form of percutaneous ethanol injection, radiofrequency ablation, transcatheter arterial chemoembolization and transcatheter arterial radioembolization (TheraSphere) are viable options in patients with unresectable HCC. Unfortunately, the role of systemic therapy has been very limited in the treatment of these patients. Novel treatment options based on an improved understanding of the molecular pathogenesis of HCC are being explored. These targeted molecular therapies are aimed at growth factors and their receptors, intracellular signal transduction and cell cycle control. A substantial improvement in outcomes of intermediate and advanced stage HCC is expected with the advent of these targeted therapies, used in combination with surgical or locoregional therapies. Recent positive results from a large Phase III study of the receptor tyrosine kinase inhibitor, sorafenib, hold great promise in the treatment of HCC.

New perspectives and strategy research biomarkers for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Cirrhosis caused by hepatitis B virus, hepatitis C virus or chronic alcohol intake is associated with major risk. Systematic screening for HCC of asymptomatic patients with cirrhosis is needed for earlier detection of small tumors requiring treatment (liver transplantation, surgical resection, percutaneous techniques). The recommended screening strategy among cirrhotic patients is based on regular liver ultrasonography associated with serum alpha-fetoprotein (AFP) assay. As the performance of AFP is not satisfactory, additional tumoral markers are proposed (des-gamma-carboxyprothrombin, glycosylated AFP-L3 fraction). Currently, diagnosis of HCC in cirrhotic patients includes non-invasive tests (imaging after contrast administration, AFP assay); diagnostic biopsy is performed when imaging is limited. After treatment, tumor recurrence is assessed by regular follow-up (AFP assay and imaging). Despite the lack of accurate markers, recent developments in genomic and proteomic approaches will allow the discovery of new biomarkers for primary tumors, as well as for recurrence. This review summarizes the current state of biomarkers for screening, diagnosis and follow-up of HCC, and highlights new perspectives in the field.

Surveillance programme for hepatocellular carcinoma improves the survival of patients with chronic viral hepatitis

BACKGROUND

The survival benefit of surveillance for hepatocellular carcinoma (HCC) is controversial.

AIM

We aimed to examine the survival benefit of HCC surveillance in chronic viral hepatitis.

METHODS

Survivals of HCC patients related to chronic viral hepatitis from the Hepatology Clinic (surveillance group) were compared with those referred from other hospitals/clinics (no-surveillance group). Lead-time and length-time biases were adjusted based on tumour volume doubling times.

RESULTS

Among 579 patients (91% hepatitis B), 472 (82%) patients had HCC and 79 (17%) of these patients were referred from the surveillance programme. HCC was smaller (4.2 vs. 7.7 cm; P<0.001) and fewer in numbers (2.6 vs. 3.8, P=0.03) in the surveillance group vs. the no-surveillance group. Treatment by surgery (20 vs. 10%, P=0.007) and local ablative therapy (46 vs. 19%, P<0.001) were more frequent in the surveillance group than that in the no-surveillance group. The median survival of the surveillance group (88 weeks) was significantly longer than that of the no-surveillance group (26 weeks) (P<0.001). The adjusted cumulative survival at 2 years was significantly longer in the surveillance group if the tumour volume doubling time was <90 days (P=0.0352).

CONCLUSIONS

HCC surveillance can improve the survival of patients with chronic viral hepatitis B.

Apoptosis-inducing antitumor efficacy of hexokinase II inhibitor in hepatocellular carcinoma

Hypoxia stimulates hepatocellular carcinoma (HCC) cell growth via hexokinase (HK) II induction, and alternatively, HK II inhibition induces apoptosis by activating mitochondrial signaling. This study was to investigate whether the induction of HK II by hypoxia is associated with enhanced mitochondrial stability and to confirm the apoptosis-inducing efficacy of HK II inhibitor in an in vivo model of HCC. Mitochondrial stability was examined by treating isolated mitochondria with deoxycholate, a permeability-enhancing agent. Alteration of permeability transition pore complex composition was analyzed by immunoprecipitation and immunoblotting. An in vivo model of HCC was established in C3H mice i.d. implanted with MH134 cells. The antitumor efficacy of i.p. given 3-bromopyruvate (3-BrPA), a HK II inhibitor, was evaluated by measuring tumor volumes and quantifying apoptosis using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining and (99m)Tc-hydrazinonicotinamide-Annexin V scans. Hypoxia enhanced mitochondrial stability, and this was inhibited by 3-BrPA treatment. In particular, HK II levels in permeability transition pore complex immunoprecipitates were reduced after 3-BrPA treatment. In mice treated with 3-BrPA, mean tumor volumes and tumor volume growth were found to be significantly reduced. Moreover, percentages of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive cells were significantly increased in 3-BrPA-treated mice, and this apoptosis-inducing efficacy was reflected in vivo by (99m)Tc-hydrazinonicotinamide-Annexin V imaging. Our results show that hypoxia enhances mitochondrial stability via HK II induction and that HK II inhibitor treatment exhibits an in vivo antitumor effect by inducing apoptosis. Therefore, HK II inhibitors may be therapeutically useful for the treatment of advanced infiltrative hypovascular HCCs, which are growing in a hypoxic environment.

Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis

OBJECTIVES

Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.

METHODS

A Markov decision model was developed that compared three management strategies - immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression - for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model's strength was assessed with sensitivity analyses.

RESULTS

In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.

CONCLUSIONS

The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.