Prognosis After Resection of Barcelona Clinic Liver Cancer (BCLC) Stage 0, A, and B Hepatocellular Carcinoma: A Comprehensive Assessment of the Current BCLC Classification

Analysis of the clinical efficacy of liver resection combined with adjuvant microwave coagulation for patients with hepatocellular carcinoma

Background

Liver resection has been widely applied as a curative measure in the treatment of hepatocellular carcinoma (HCC) patients. However, the high rate of postoperative recurrence observed following liver resection proposes a problem, the solution for which is yet to be well established. Microwave coagulation is a therapy that was recently proposed as an adjuvant tool. In this study, we intended to evaluate the effectiveness of microwave coagulation as an auxiliary therapeutic method for patients undergoing liver resection.

Methods

A total of 236 consecutive patients classified as Barcelona Clinic Liver Cancer (BCLC) stage A who had only one tumor were enrolled in this retrospective study, regardless of tumor size. Survival analyses were performed using the Kaplan-Meier method, and the statistical differences between patients who underwent liver resection with and without adjuvant microwave coagulation were examined by the log-rank test. To investigate the prognostic factors for OS, we carried out univariate and multivariate Cox regression analyses.

Results

Based on the Kaplan-Meier curves, patients who underwent surgical resection with intraoperative adjuvant microwave coagulator had prolonged recurrence-free survival time and showed better overall survival (OS) than those who underwent surgical resection alone, with OS at 1, 3, and 5 years of 77.8%, 33.2%, 12.6% vs. 58.2%, 15.5%, 9.7%, respectively (log-rank P<0.001). The univariate and multivariate analyses demonstrated that tumor size, albumin, bilirubin, Child-Pugh score, and treatment method had significant prognostic power for both PFS and OS. According to the subgroup analyses based on the tumor size, there were significant differences in PFS and OS among overall subsets between the liver resection with adjuvant microwave coagulator and liver resection only groups.

Conclusions

Liver resection combined with intraoperative adjuvant microwave coagulation had a better prognostic performance than treatment with liver resection alone. Adjuvant microwave coagulation should be suggested as an alternative treatment modality for BCLC stage A patients with a single tumor, regardless of its size.

Prediction Model for Intermediate-Stage Hepatocellular Carcinoma Response to Transarterial Chemoembolization

BACKGROUND

The outcome of intermediate-stage hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) is greatly heterogeneous. Current means for predicting HCC response to TACE are lacking.

PURPOSE

To investigate whether the combination of parameters derived from amide proton transfer (APT) and intravoxel incoherent motion (IVIM) imaging, and morphological characteristics of tumor can establish a better prediction model than the univariant model for HCC response to TACE.

STUDY TYPE

Prospective.

SUBJECTS

56 patients with intermediate-stage HCC (50 males and six females).

FIELD STRENGTH/SEQUENCES

3.0T; T₂ -weighted-fast spin echo, 3D liver acquisition with volume flex, single-shot fast spin echo-planar imaging (EPI), spin echo-EPI.

ASSESSMENT

Pretreatment APT signal intensities (SIs), apparent diffusion coefficient (ADC), true molecular diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) for tumor, peritumoral, and normal tissues were measured. Follow-up MRI scanning was performed, and the patients were classified as responders or nonresponders based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria.

STATISTICAL TESTS

The imaging parameters were compared among the three tissues and between the two groups using analysis of variance (ANOVA) or two-sample t-test. The prediction model's variables were derived from univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to explore the predictive performance.

RESULTS

Based on the logistic regression analysis results, we established a prediction model that integrated the APT SI and D values in the tumor tissue and the tumor size. ROC analyses revealed that the model was better able to predict tumor response to TACE (area under the ROC curve = 0.851) than the individual parameters on their own.

DATA CONCLUSION

A prediction model incorporating pretreatment APT SI, D in the tumor tissue and tumor size may be useful for predicting the response of intermediate-stage HCC to TACE.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 1 J. MAGN. RESON. IMAGING 2020;52:1657-1667.

Identifying optimal candidates for liver resection or transarterial chemoembolisation in patients with unresectable hepatocellular carcinoma

Background

Recommended as the first-line treatment for advanced unresectable hepatocellular carcinoma (HCC), sorafenib has been shown to prolong median overall survival (OS) for patients. However, advanced HCC sees high heterogeneity across patient groups. Recently, a growing number of studies have indicated surgical resection and transarterial chemoembolisation (TACE) to perform well in patients with portal vein tumor thrombosis (PVTT). The aim of this study was to compare the outcomes of liver resection and TACE and to identify prognostic factors related to OS for BCLC stage C patients with performance status (PS) 1 who have a single tumor but no vascular invasion or extrahepatic spread.

Methods

A total of 323 consecutive patients in BCLC stage C with PS 1 who had only one tumor and no vascular invasion or extrahepatic spread were enrolled in this retrospective study, regardless of tumor size. Survival analyses were performed using the Kaplan-Meier analysis, and statistical differences between the TACE and sorafenib groups were examined by the log-rank test. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.

Results

Based on the Kaplan-Meier curves, patients treated with surgical resection showed a better OS than those who underwent TACE, with OS at 1, 3, and 5 years (85.7%, 48.8%, and 33.3% vs. 66.6%, 21.8%, and 13.4%, respectively; log-rank P<0.001). Univariate and multivariate analyses demonstrated that tumor size, albumin, bilirubin, Child-Pugh score, and treatment method were significant prognostic factors for OS. According to the subgroup analyses based on tumor size, there were significant differences in OS among overall subsets between patients who underwent hepatectomy and those who underwent TACE therapy.

Conclusions

Liver resection had a better prognostic performance than TACE and should be put forward as an alternative treatment modality to TACE for BCLC stage C patients with PS 1 who have a single tumor and no vascular invasion or extrahepatic spread.

Comparison of radiofrequency ablation combined with sorafenib or sorafenib alone in patients with ECOG performance score 1: identifying optimal candidates

Background

Sorafenib has been recommended as the first-line treatment and shown to prolong the median overall survival (OS) of patients with advanced unresectable hepatocellular carcinoma (HCC). Recently, a growing number of earlier studies showed the application of radiofrequency ablation (RFA) plus sorafenib in patients diagnosed at the advanced-stage HCC. This study aimed to compare the outcomes of RFA plus sorafenib versus sorafenib alone and identify prognostic factors related to OS for BCLC stage C patients with PS 1 but without vascular invasion or extrahepatic spread.

Methods

A total of 276 consecutive patients in BCLC stage C with PS 1 but without vascular invasion or extrahepatic spread were enrolled in this retrospective study. Survival analyses were performed using the Kaplan-Meier analysis, and the log-rank test examined the statistical differences between the transarterial chemoembolization (TACE) and sorafenib groups. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.

Results

Based on the Kaplan-Meier curves, patients treated with RFA plus sorafenib showed better OS than those undergoing sorafenib, with respective OS at 1, 3 and 5 years (84.0%, 43.1%, 22.8% vs. 55.6%, 29.6%, 4.8%, Log-rank P<0.001). The univariate analysis and multivariate analysis showed that tumor size, tumor number, treatment method, albumin, bilirubin, and the Child-Pugh score were associated with OS. According to the subgroups analyses based on the tumor size and tumor number, there were significant differences in OS among overall subsets except in patients with tumor number ≥4 between RFA plus sorafenib and sorafenib therapy.

Conclusions

RFA plus sorafenib provided better prognostic performance than sorafenib, which should be suggested as an alternative treatment modality compared with sorafenib for BCLC stage C patients with PS 1 but without vascular invasion or extrahepatic spread.

Recurrence Patterns and Outcomes after Resection of Hepatocellular Carcinoma within and beyond the Barcelona Clinic Liver Cancer Criteria

BACKGROUND

Several investigators have advocated for extending the Barcelona Clinic Liver Cancer (BCLC) resection criteria to select patients with BCLC-B and even BCLC-C hepatocellular carcinoma (HCC). The objective of the current study was to define the outcomes and recurrence patterns after resection within and beyond the current resection criteria.

PATIENTS AND METHODS

Patients who underwent resection for HCC within (i.e., BCLC 0/A) and beyond (i.e. BCLC B/C) the current resection criteria between 2005 and 2017 were identified from an international multi-institutional database. Overall survival (OS), disease-free survival (DFS), as well as patterns of recurrence of patients undergoing HCC resection within and beyond the BCLC guidelines were examined.

RESULTS

Among 756 patients, 602 (79.6%) patients were BCLC 0/A and 154 (20.4%) were BCLC B/C. Recurrences were mostly intrahepatic (within BCLC: 74.3% versus beyond BCLC: 70.8%, p = 0.80), with BCLC B/C patients more often having multiple tumors at relapse (69.6% versus 49.4%, p = 0.001) and higher rates of early (< 2 years) recurrence (88.0% versus 75.5%, p = 0.011). During the first postoperative year, annual recurrence was 38.3% and 21.3% among BCLC B/C and BCLC 0/A patients, respectively; 5-year OS among BCLC 0/A and BCLC B/C patients was 76.9% versus 51.6% (p = 0.003). On multivariable analysis, only a-fetoprotein (AFP) > 400 ng/mL (HR = 1.84, 95% CI 1.07-3.15) and R1 resection (HR = 2.36, 95% CI 1.32-4.23) were associated with higher risk of recurrence among BCLC B/C patients.

CONCLUSIONS

Surgery can provide acceptable outcomes among select patients with BCLC B/C HCC. The data emphasize the need to further refine the BCLC treatment algorithm as well as highlight the need for surveillance protocols with a particular focus on the liver, especially for patients undergoing resection outside the BCLC criteria.

Comparison between Child-Pugh score and Albumin-Bilirubin grade in the prognosis of patients with HCC after liver resection using time-dependent ROC

Backgrounds

The Child-Pugh score is a scoring system used to measure liver function and predict postoperative outcomes in patients with hepatocellular carcinoma (HCC). Recently, the Albumin-Bilirubin (ALBI) grade has been proposed for the evaluation of hepatic reserve function in HCC. This study aimed to assess and compare the capability of ALBI grade and Child-Pugh score in predicting overall survival (OS).

Methods

A total of 196 consecutive HCC patients who treated with hepatectomy were enrolled in this retrospective study. The prognostic values of ALBI grade and Child-Pugh score in predicting postoperative OS were respectively estimated using the Kaplan-Meier method and time-dependent receiver operating curves (ROC). Univariate and multivariate Cox regression analyses were performed to investigate the prognostic factors for OS.

Results

Stratified by the Albumin-Bilirubin (ALBI) system, there were 81 (41.3%) patients with grade 1 and 115 (58.7%) patients with grade 2. The cumulative 1-, 3-, 5-year OS rates in patients with ALBI-1 were 82.7%, 51.5% and 35.5%, respectively. For patients with ALBI-2, the cumulative 1-, 3-, 5-year OS rates were 57.6%, 19.4% and 0%, respectively. Based on the Child-Pugh classification, 136 (69.4%) patients had a score of 5, and 60 (30.6%) patients had a score of 6. Patients with Child-Pugh-A5 showed a better OS than those with Child-Pugh-A6, with respective OS at 1, 3 and 5 years (72.7%, 29.2%, 20.3% vs. 53.9%, 21.1%, 0%, Log-rank P<0.001). Besides, the ALBI grade revealed two prognostic groups within Child-Pugh-A5 (P<0.001), while the Child-Pugh score did not distinguish ALBI-2 in different prognostic groups (P=0.705). The multivariate analysis indicated that both ALBI grade and Child-Pugh score could significantly stratify the patients with different OS [hazard ratio (HR), 3.088 and 1.783; 95% confidence interval (CI), 1.985 to 4.805 and 1.272 to 2.731; P<0.001 and P=0.032 for ALBI grade and Child-Pugh score, respectively]. Additionally, time-dependent ROC analysis in the entire cohort proved that the ALBI grade had a better discriminatory ability than the Child-Pugh score in predicting survival, especially for long-term outcomes. According to the subgroup analyses, the ALBI grade had a better discriminatory ability and survival prediction accuracy in overall subsets than the Child-Pugh score for the prediction of OS.

Conclusions

ALBI grade supplied better prognostic performance and distribution of liver function than Child-Pugh score in stratifying prognosis for HCC patients treated by hepatectomy. These results declared that ALBI grade could be an alternative liver function grading system for stratification in patients with HCC.

Prognosis after resection of single large hepatocellular carcinoma: Results from an Asian high-volume liver surgery center

Background & aims

In 2012, the Barcelona Clinic Liver Cancer (BCLC) system designated a single large hepatocellular carcinoma (SLHCC) (>5 cm) as BCLC stage A rather than stage B. However, a recent study from western countries reported that prognosis following liver resection (LR) among patients with SLHCC was similar to that among patients with BCLC stage B. We aim to evaluate the prognosis following LR among patients with SLHCC from an Asian high-volume liver surgery center.

Methods

Patients who underwent curative-intent LR for histologically proven HCC between 2011 and 2017 were enrolled using an HCC registry database. Overall survival (OS) among patients with BCLC stages 0, A, and B was examined. Patients with a SLHCC were classified as BCLC stage A1.

Results

Among 543 patients, 89 (16.4%) were BCLC stage 0, 289 (53.2%) were BCLC stage A, 92 (16.9%) were BCLC stage A1, and 73 (13.4%) were BCLC stage B. The median follow-up was 38 months. The five-year OS rates among patients with BCLC stages 0, A, A1, and B were 83.5%, 83.7%, 77.4%, and 55.4%, respectively (p<0.001). No difference in OS was noted for patients with BCLC stage A versus A1 (p = 0.11), even after adjusting for competing factors (hazard ratio = 0.97, 95% confidence interval = 0.53–1.79; p = 0.93).

Conclusion

Prognosis following LR among patients with SLHCC was similar to that among patients with BCLC stage A. The prognosis for SLHCC should thus be considered comparable to that for BCLC stage A.

Hepatocellular carcinoma tumour burden score to stratify prognosis after resection

BACKGROUND

Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have emphasized the need for further refinement and subclassification of this system.

METHODS

Patients who underwent hepatectomy with curative intent for BCLC-0, -A or -B hepatocellular carcinoma (HCC) between 2000 and 2017 were identified using a multi-institutional database. The tumour burden score (TBS) was calculated, and overall survival (OS) was examined in relation to TBS and BCLC stage.

RESULTS

Among 1053 patients, 63 (6·0 per cent) had BCLC-0, 826 (78·4 per cent) BCLC-A and 164 (15·6 per cent) had BCLC-B HCC. OS worsened incrementally with higher TBS (5-year OS 77·9, 61 and 39 per cent for low, medium and high TBS respectively; P < 0·001). No differences in OS were noted among patients with similar TBS, irrespective of BCLC stage (61·6 versus 58·9 per cent for BCLC-A/medium TBS versus BCLC-B/medium TBS, P = 0·930; 45 versus 13 per cent for BCLC-A/high TBS versus BCLC-B/high TBS, P = 0·175). Patients with BCLC-B HCC and a medium TBS had better OS than those with BCLC-A disease and a high TBS (58·9 versus 45 per cent; P = 0·005). On multivariable analysis, TBS remained associated with OS among patients with BCLC-A (medium TBS: hazard ratio (HR) 2·07, 95 per cent c.i. 1·42 to 3·02, P < 0·001; high TBS: HR 4·05, 2·40 to 6·82, P < 0·001) and BCLC-B (high TBS: HR 3·85, 2·03 to 7·30; P < 0·001) HCC. TBS could also stratify prognosis among patients in an external validation cohort (5-year OS 79, 51·2 and 28 per cent for low, medium and high TBS respectively; P = 0·010).

CONCLUSION

The prognosis of patients with HCC varied according to the BCLC stage but was largely dependent on the TBS.

Stem Cell Therapy for Hepatocellular Carcinoma: Future Perspectives

Hepatocellular carcinoma (HCC) is one of the most common types of cancer and results in a high mortality rate worldwide. Unfortunately, most cases of HCC are diagnosed in an advanced stage, resulting in a poor prognosis and ineffective treatment. HCC is often resistant to both radiotherapy and chemotherapy, resulting in a high recurrence rate. Although the use of stem cells is evolving into a potentially effective approach for the treatment of cancer, few studies on stem cell therapy in HCC have been published. The administration of stem cells from bone marrow, adipose tissue, the amnion, and the umbilical cord to experimental animal models of HCC has not yielded consistent responses. However, it is possible to induce the apoptosis of cancer cells, repress angiogenesis, and cause tumor regression by administration of genetically modified stem cells. New alternative approaches to cancer therapy, such as the use of stem cell derivatives, exosomes or stem cell extracts, have been proposed. In this review, we highlight these experimental approaches for the use of stem cells as a vehicle for local drug delivery.

Liver Tumor Microenvironment

The tumor microenvironment (TME) has recently been recognized as an important part of tumor development and growth. TME is a dynamic system orchestrated by immune, cancer and inflammatory cells, as well as the stromal tissue and surrounding extracellular matrix. While TME of primary hepatic tumors is usually characterized by a strong inflammatory background, the TME of liver metastases typically consists of otherwise healthy liver tissue. Chronic inflammation and hypoxia are key to the development and progression of primary liver cancer. The injury caused by chronic inflammation creates a condition of immune evasion that initiates a cascade of events that eventually leads to liver carcinogenesis.With liver metastases, primary tumors "prime" the target organs via secreting factors that induce expansion of myeloid cell populations and create a solid ground for successful cancer settlement. Once in the liver, metastatic cells begin a neovascularization process that is driven mainly by VEGF and FGF. Due to high mortality rates associated with liver cancer, as well as the limited effective treatment options for advanced disease, new therapies are urgently needed. Targeting a single molecule in a number of interactions between the tumor and the TME is highly unlikely to reduce tumor growth. Future trials should focus on combination therapies (i.e. targeted therapies combined with immunotherapy) to treat liver malignancies efficiently.

Texture analysis on gadoxetic acid enhanced-MRI for predicting Ki-67 status in hepatocellular carcinoma: A prospective study

Objective

To investigate the value of whole-lesion texture analysis on preoperative gadoxetic acid enhanced magnetic resonance imaging (MRI) for predicting tumor Ki-67 status after curative resection in patients with hepatocellular carcinoma (HCC).

Methods

This study consisted of 89 consecutive patients with surgically confirmed HCC. Texture features were extracted from multiparametric MRI based on whole-lesion regions of interest. The Ki-67 status was immunohistochemical determined and classified into low Ki-67 (labeling index ≤15%) and high Ki-67 (labeling index >15%) groups. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were applied for generating the texture signature, clinical nomogram and combined nomogram. The discrimination power, calibration and clinical usefulness of the three models were evaluated accordingly. Recurrence-free survival (RFS) rates after curative hepatectomy were also compared between groups.

Results

A total of 13 texture features were selected to construct a texture signature for predicting Ki-67 status in HCC patients (C-index: 0.878, 95% confidence interval: 0.791-0.937). After incorporating texture signature to the clinical nomogram which included significant clinical variates (AFP, BCLC-stage, capsule integrity, tumor margin, enhancing capsule), the combined nomogram showed higher discrimination ability (C-index: 0.936vs. 0.795, P<0.001), good calibration (P>0.05 in Hosmer-Lemeshow test) and higher clinical usefulness by decision curve analysis. RFS rate was significantly lower in the high Ki-67 group compared with the low Ki-67 group after curative surgery (63.27%vs. 85.00%, P<0.05).

Conclusions

Texture analysis on gadoxetic acid enhanced MRI can serve as a noninvasive approach to preoperatively predict Ki-67 status of HCC after curative resection. The combination of texture signature and clinical factors demonstrated the potential to further improve the prediction performance.