Pathology of hepatocellular carcinoma in Japan. 232 Consecutive cases autopsied in ten years

Limited utility of routine bone scintigraphy in the staging of patients with hepatocellular carcinoma: A cross-sectional study

INTRODUCTION AND OBJECTIVES

The most widely used staging system for hepatocellular carcinoma (HCC) is the Barcelona Liver Clinic Cancer (BCLC) system, which considers tumor burden, performance status, and liver function. Tumor burden is assessed with cross sectional imaging of the abdomen and chest, controversy surrounds the routine use of bone scintigraphy (BS) for detecting extrahepatic metastases. This study evaluated the role of BS in staging HCC in Mexican patients.

PATIENTS AND METHODS

Retrospective cross-sectional study of all adults with HCC at a Mexican referral center from 2000 to 2018. Staging included abdominal computed tomography (CT) or magnetic resonance imaging, chest CT, and BS. The main outcome was the impact of BS on staging and/or therapy plans.

RESULTS

Among 238 patients, 2 with fibrolamellar variant and 44 with incomplete data were excluded. Median age was 66 years, 84 % had cirrhosis, and the predominant etiology was hepatitis C virus (43 %). BCLC stages were distributed as follows: A (14 %), B (7 %), C (68 %), and D (11 %). Extrahepatic disease was present in 18 %; only 8 % patients had a positive BS. Among the positive cases, 4 were true positives, but they did not alter staging or therapy plans.

CONCLUSIONS

Routine BS in HCC staging demonstrated low yield, with a notable rate of false positives. Considering the implications of extrahepatic disease, BS may be justified for liver transplant candidates outside conventional criteria. Our study highlights the limited role of BS in early-stage HCC and advocates for a more selective utilization.

Prevalence, management and outcomes of pulmonary metastases in hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) presents a significant global health burden, with varying survival rates across regions. The presence of pulmonary metastases (PM) in HCC predicts a poorer prognosis, yet the global understanding of the progression and management is limited.

METHODS

This study aims to systematically review the burden of PM in HCC, document current treatment approaches, and evaluate treatment effectiveness through meta-analysis. A comprehensive literature search was conducted across multiple databases. Articles were screened, and data extraction was performed independently by two reviewers. Statistical analyses were conducted to synthesise data and assess treatment outcomes.

RESULTS

A total of 82 articles were included, comprising a population of 3241 participants with documented PM. Our analysis revealed a linear relationship between the HCC population size and the occurrence of PM (p < 0.005). Surgical intervention demonstrated the lowest hazard ratio (0.128) and significantly improved survival rates compared to other treatment modalities. However, data quality limitations underscore the need for further research to delineate patient subsets benefitting from surgical intervention for PM.

CONCLUSION

Our findings advocate for continued investigation into PM management strategies, notably the role of surgical resection alongside systemic therapies, to improve outcomes in HCC patients with PM.

Pink-on-pink: hepatocellular carcinoma metastatic to oncocytic carcinoma of the thyroid

Hepatocellular carcinoma typically metastasizes within the liver and may involve extrahepatic sites such as the lungs, adrenal glands, and bones at advanced stages. However, hepatocellular carcinoma metastasis to the thyroid is very uncommon and tumor-to-tumor metastasis from a hepatocellular cancer to a thyroid neoplasm is extremely rare. In this report, we present a case of a 70-year-old man with a hepatocellular carcinoma metastasizing to oncocytic thyroid carcinoma, emphasizing the importance of clinical history and of a multidisciplinary approach, as well as the usefulness of site-specific immunohistochemical markers, in diagnosing and managing cases of Rosai's metastasis, especially when donor and recipient neoplasms share similar histologic features.

Simultaneous gastric, pancreatic, and renal metastasis from poorly differentiated hepatocellular carcinoma

Common extrahepatic metastasis sites of hepatocellular carcinoma (HCC) are the lungs, adrenal glands, and bones. Herein, we report a rare case of metastatic gastric, pancreatic, and renal tumors from HCC simultaneously, and review the relevant literature. A 75-year-old woman presented with right hypochondralgia, appetite loss, and weight loss. Computed tomography revealed suspected metastatic liver, lung, and renal tumors. A blood test revealed a leukocyte count of 26,210/μL and a high inflammatory reaction. As sepsis was suspected, the patient was referred to our hospital. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging revealed a hypovascular liver tumor that was suspected to be metastatic. Upper gastrointestinal endoscopy revealed two suspected metastatic gastric tumors. Liver and gastric tumor biopsies revealed poor carcinoma in both. The patient's condition gradually worsened and she died on day 8 of the illness. Based on autopsy findings, the patient was finally diagnosed with metastatic gastric and renal tumors originating from HCC. Additionally, a metastatic pancreatic tumor originating from the HCC was identified during autopsy. The pathological diagnosis of the pulmonary lesion was primary lung adenocarcinoma. In conclusion, HCC should be suspected in cases with multiple metastases of unknown primary lesions.

Clinical Outcomes of Switching from Zoledronic Acid to Denosumab for the Management of Severe Bone Metastasis from Hepatocellular Carcinoma: A Single-Center, Open-Label, Prospective Intervention Trial

Background

Zoledronic acid reduces the risk of bone metastasis, but denosumab is a better option for treating bone metastases. However, few studies have evaluated the use of denosumab to treat bone metastasis originating from hepatocellular carcinoma. This study aimed to assess the clinical outcomes of switching from zoledronic acid to denosumab for treating bone metastasis in patients with hepatocellular carcinoma.

Methods

This prospective study enrolled 10 patients with HCC and bone metastases. The levels of type 1 collagen cross-linked N-telopeptide (NTx) and tumor growth remained abnormal in these patients despite administration of zoledronic acid for over 3 months. We switched from zoledronic acid to 120 mg denosumab every 4 weeks and evaluated the clinical outcomes, including changes in the NTx level, pain level, and activities of daily living, as well as adverse events, after each administration.

Results

Urinary NTx clearance was normal in all patients. The average urinary NTx clearance increased from 13.2 to 21.2 nmol BCE/nmol · Cre (P = 0.54) after the switch to denosumab. Serum NTx levels were abnormal in all cases. The serum NTx level decreased from 142 nmol BCE/L to 126 nmol BCE/L (P = 0.56). The answers to questionnaires on pain and activities of daily living did not change significantly. Some patients showed elevated transaminase levels, but this was not due to the drug switch.

Conclusion

Switching to denosumab did not show a significant change of the pain and activity of daily living for the patients with severe bone metastasis from hepatocellular carcinoma, in whom the efficacy of zoledronic acid was limited.

Hepatocellular Carcinoma with Hepatic Vein and Inferior Vena Cava Invasion

Hepatocellular carcinoma (HCC) invades intrahepatic vessels causing tumor thrombosis. Infrequently, there is involvement of the hepatic vein (HV) and inferior vena cava (IVC). In this review, we summarize the epidemiology, classification, clinical features, and management of HCC with HV and IVC invasion. While the involvement of HV and IVC usually portends an overall poor survival, selected patients may be candidates for aggressive treatment and thus improving outcomes.

Image-Guided Ablation Therapies for Extrahepatic Metastases from Hepatocellular Carcinoma: A Review

The most common sites of extrahepatic metastases from hepatocellular carcinoma (HCC) are the lungs, intra-abdominal lymph nodes, bones, and adrenal glands, in that order. Although systemic therapies are a common treatment for patients with extrahepatic metastases, local ablative therapies for the extrahepatic metastatic lesions can be performed in selected patients. In this article, the literature on image-guided thermal ablation for metastasis to each organ was reviewed to summarize the current evidence. Radiofrequency ablation was the most commonly evaluated technique, and microwave ablation, cryoablation, and percutaneous ethanol injection were also utilized. The local control rate of thermal ablation therapy was relatively favorable, at approximately 70-90% in various organs. The survival outcomes varied among the studies, and several studies reported that the absence of viable intrahepatic lesions was associated with improved survival rates. Since only retrospective data from relatively small studies has been available thus far, more robust studies with prospective designs and larger cohorts are desired to prove the usefulness of thermal ablation for extrahepatic metastases from HCC.

A case of clear cell-hepatocellular carcinoma accidentally found in the gallbladder wall after laparoscopic resection of gallbladder empyema: Beware of the liver bed

INTRODUCTION AND IMPORTANCE

Hepatocellular carcinoma (HCC) invading the gallbladder is a rare scenario, even in the context of an advanced tumor. The clear cell variant of HCC (CC-HCC) is also rare. However, CC-HCC is more frequent in women and those with liver cirrhosis, and the standard definition is the presence of transparent cytoplasm in at least 50 % of tumor cells.

CASE PRESENTATION

An accidental finding of HCC was made during histological examination of a gallbladder empyema specimen from a 74 year-old male patient. The tumor was found to be invading the wall of the gallbladder. On post-operative imaging, the HCC was identified in liver segments 4b, 5 and 6, with extensive portal vein thrombosis; without other distant spread. The tumor in our case was almost exclusively comprised of clear cells (>90 %); therefore, it was classified as CC-HCC.

CLINICAL DISCUSSION

Tumors are rarely discovered along with acute cholecystitis. Furthermore, HCC rarely invades the wall of the gallbladder. HCC with clear cell histology should be distinguished from other regional and metastatic tumors of similar morphology.

CONCLUSION

In this particular case, we provide an unusual circumstance in which HCC invaded the gallbladder wall and was found by chance in a specimen obtained after a cholecystectomy. Malignancy remains an under-recognized clinical scenario that is easily overlooked when assessing patients presenting with cholecystitis. We report our case with an additional focus on the findings of computed tomography (CT) as well as the clinicopathological characteristics pertinent to this distinctive histologic pattern of CC-HCC.

A nomogram based on multi-modal ultrasound for prediction of microvascular invasion and recurrence of hepatocellular carcinoma

OBJECTIVE

To establish and validate a nomogram based on multi-modal ultrasound for preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC), and to assess the ability thereof to stratify recurrence-free survival (RFS).

METHODS

A total of 287 HCC patients undergoing surgical resection were prospectively enrolled, including 210 patients in the training cohort and 77 patients in the test cohort. All patients underwent conventional ultrasound, contrast-enhanced ultrasonography, and shear wave elastography examinations within one week before surgery. Taking histopathological examination result as the reference standard, independent factors associated with MVI in HCC were determined by logistic regression and a nomogram was established and further evaluated. The Kaplan-Meier method was used to analyze the prognostic value of histologic MVI status and nomogram-predicted MVI status.

RESULTS

Multivariate analysis showed that tumor diameter, echogenicity, tumor shape, arterial phase peritumoral enhancement and enhancement level in portal venous phase were independent predictors of MVI (all p < 0.05). The nomogram based on these variables showed good discrimination and calibration with the areas under the receiver operating characteristic curve (AUC) of 0.821 (0.762-0.870) and 0.789 (0.681-0.874) in the training and test cohorts. There was a significant difference in RFS between the nomogram-predicted MVI positive and the nomogram-predicted MVI negative groups in training and test cohorts (p < 0.001 and p = 0.004 respectively).

CONCLUSIONS

The multimodal ultrasound features were effective imaging markers for preoperative prediction of MVI of HCC and the nomogram might be an effective tool to stratify the risk of recurrence and guide the individualized treatment of HCC.

Surgical Treatment of Postoperative Abdominal Metastases of Hepatocellular Carcinoma: 10-Year Experience in a Single Center

Objective

The significance of surgical treatment was analyzed by retrospectively collecting data on the re-resection of intra-abdominal metastases after hepatocellular carcinoma (HCC) surgery in our center over the past 10 years.

Methods

The clinical and pathological data of 15 patients who developed intra-abdominal metastases after HCC resection and underwent re-resection from January 2010 to January 2020 were collected to analyze the patients' characteristics and prognosis.

Results

Of the 15 cases of abdominal metastasis, the majority (8 cases) had greater omental metastasis. There were 4 cases of mesenteric metastases, 1 case of abdominal wall metastasis, 1 case of mesenteric plus rectal wall metastasis, and 1 case of colon and mesenteric metastasis. The 1-year, 3-year, and 5-year disease-free survival (DFS) rates were 31.1%, 23.3%, and 11.7%, respectively. The 1-year, 3-year, and 5-year overall survival rates were 93.3%, 28.7%, and 19.1%, respectively. Three patients are currently surviving disease-free, with survival times of 130.4 months, 43.3 months, and 9.4 months, respectively.

Conclusion

Although the current guidelines do not recommend surgical resection as the preferred treatment for postoperative abdominal metastases of HCC, surgical resection is recommended for patients with limited or solitary metastasis in the abdominal cavity.

Development of a novel prognostic nomogram for the early recurrence of liver cancer after curative hepatectomy

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant cancers worldwide. Curative resection is an effective treatment but HCC recurrence rates remain high. This study aimed to establish a novel prognostic nomogram to assess the risk of recurrence in patients following curative resection.

METHODS

A total of 410 patients undergoing HCC curative resection were recruited from the Guangdong Provincial People's Hospital (GDPH). The cohort was divided into a training group (n=291) and a validation group (n=97). The risk factors for HCC early recurrence within 1 year of curative hepatectomy were identified. Finally, a multivariate prognostic nomogram was developed and validated.

RESULTS

Age, tumor number, tumor capsule, portal vein tumor thrombi, pathological grade, vascular tumor emboli, activated partial thromboplastin time (APTT), and tumor size were identified as independent prognostic risk factors for HCC early recurrence within 1 year of curative hepatectomy. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.806 [95% confidence interval (CI): 0.755 to 0.857; P<0.001], and no AUC/ROC statistical difference was detected between the training and validation sets.

CONCLUSIONS

The nomogram effectively predicted postoperative HCC recurrence within 1 year after curative hepatectomy, which may be a useful tool for the postoperative treatment or follow up for HCC patients.

Long-term survival of 11 years with multidisciplinary therapy for hepatocellular carcinoma metastasis to the ovary and peritoneum: a case report

We herein report a rare case of HCC metastases to the ovary and peritoneum in a 61-year-old female patient who has achieved 11-year survival with multidisciplinary therapy. The patient was diagnosed with HCC during balloon angioplasty performed for Budd-Chiari syndrome in 1994 and underwent partial hepatectomy twice. Five years after the second hepatectomy, allochronic recurrence of a single nodule detected in S8 was treated by radiofrequency ablation, followed by percutaneous ethanol injection therapy and stereotactic body radiotherapy. However, her α-fetoprotein level rose to 1862 ng/mL within one year and computed tomography revealed a large pelvic tumor suggesting HCC metastasis to the ovary. The subsequent laparotomy revealed one 11-cm left ovarian tumor, one small right ovarian nodule, and numerous peritoneal nodules. Bilateral salpingo-oophorectomy and peritoneal resection of as many nodules as possible were performed. Combination therapy with intravenous 5-fluorouracil plus cisplatin and ramucirumab monotherapy effectively suppressed tumor progression with maintenance of hepatic functional reserve, and she has achieved long-term survival of 11 years, illustrating that multidisciplinary therapy with favorable hepatic functional reserve maintenance can contribute to long-term survival in HCC with extrahepatic spread.

Imaging of gallbladder metastasis

Gallbladder metastasis (GM) is a rare condition, often with a late diagnosis or detected upon autopsy. There is no extensive literature on the imaging diagnosis of GM. Here we present a comprehensive review of the literature with the aim of helping to interpret the clinical findings and imaging features of such patients. Few studies on GM are reported in literature. GM by melanoma accounts for about 55.6% of cases. The remaining cases origin from breast cancer (13.6%), hepatocellular carcinoma (13.6%), renal cell carcinoma (6.8%), lung cancer (4.5%), lymphoma (3.5%) and gastric cancer (2.4%). The most common clinical presentation of GM is abdominal pain from cholecystitis due to obstruction of the cystic duct. The main ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) findings that clinicians and radiologists should consider in their everyday medical activity were discussed. The diagnosis of GM was often achieved through a combination of more than one imaging modality. In more than 90% of cases, the diagnosis of GM is often late and combined with other organs involvement in the terminal stage of the malignancy. The knowledge of the clinical features and different imaging techniques through careful evaluation of the gallbladder can help to achieve early diagnosis and avoid misdiagnosis or false negative results.

18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography Detected Inguinal Lymph Nodal Metastasis from Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) usually metastasizes to the regional abdominal lymph node, lungs, and bones. Nonregional lymph node involvement by HCC in the absence of regional lymph nodes is rare. We describe the ¹⁸F-fluorodeoxyglucose positron-emission tomography-computed tomography findings of an HCC patient with histopathologically proven inguinal lymph nodal metastasis in the absence of regional lymph nodal metastases.

A case of resected hepatocellular carcinoma with gallbladder metastasis

Background

Advanced hepatocellular carcinoma (HCC) can often spread as intrahepatic metastases. Extrahepatic metastasis (e.g., lung, lymph nodes, and bones) is rare, and gallbladder metastasis from HCC is extremely rare.

Case presentation

A 66-year-old woman who presented with right hypochondrial pain was referred to our hospital for further examination of a liver tumor. The blood chemistry data showed elevated levels of serum α-fetoprotein (AFP) (3730 ng/mL), protein induced by vitamin K absence or antagonist II (PIVKA-II) (130 mAU/mL), and carcinoembryonic antigen (CEA) (358.6 ng/mL). Hepatitis B surface antigen and hepatitis C virus antibody were negative. Dynamic computed tomography (CT) showed a tumor measuring 12 × 7 cm in the right lobe of the liver. This tumor was contrast-enhanced in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase. A well-enhanced tumor was found in the gallbladder. No regional lymph nodes were enlarged. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated that the liver tumor showed a pattern of early enhancement and washout. The gallbladder tumor was also detected as an enhanced mass. Endoscopic retrograde cholangiography (ERC) showed compression of the left hepatic duct due to the liver tumor. The patient was diagnosed with simultaneous HCC and gallbladder cancer. Right hepatic trisectionectomy and caudate lobectomy with extrahepatic bile duct resection were performed. Histopathological examination of the resected liver specimen showed a poorly differentiated HCC cell component with a trabecular and solid growth, and diffuse invasion of the portal vein. The same tumor cells were found in the gallbladder, but no continuity with the liver tumor was identified. Immunohistochemistry of the liver tumor and gallbladder was positive for AFP, Glypican 3, and CK7, and negative for CK19. The final pathological diagnosis was the gallbladder metastasis from HCC. A follow-up diagnostic image 33 months after surgery showed a mass in the upper lobe of the left lung. The patient underwent left upper lobectomy. Postoperative pathology revealed that the lung lesion was a metastasis of HCC. The patient was still alive with lung metastasis and was being treated with a molecular-targeting drug in good health 42 months after the initial surgery.

Conclusions

The standard treatment for advanced HCC with extrahepatic metastases is molecularly targeted drugs, but surgery is also an option if the lesion can be resected en bloc without remnants.

Hepatic vein tumor thrombosis in patients with hepatocellular carcinoma: Prevalence and clinical significance

BACKGROUND

There is strong evidence that portal vein tumor thrombosis (PVTT) is associated with poor survival in patients with hepatocellular carcinoma (HCC). However, data regarding the clinical significance of hepatic vein tumor thrombosis (HVTT) is rare, particularly in Western patients.

OBJECTIVE

To determine the HVTT prevalence in a Western patient population and its impact on survival.

METHODS

We included 1310 patients with HCC treated in our tertiary referral center between January 2005 and December 2016. HVTT and PVTT were diagnosed with contrast-enhanced cross-sectional imaging. Overall survival (OS) was calculated starting from the initial HCC diagnosis, and in a second step, starting from the first appearance of vascular invasion.

RESULTS

We observed macrovascular invasion (MVI) in 519 patients who suffered from either isolated HVTT (n = 40), isolated PVTT (n = 352), or both combined (HVTT + PVTT) (n = 127). Calculated from the initial HCC diagnosis, the median OS for patients with isolated HVTT was significantly shorter than that of patients without MVI (13.3 vs. 32.5 months, p < 0.001). Calculated from the first appearance of MVI, the median OS was similar among patients with isolated HVTT (6.5 months), isolated PVTT (5 months), and HVTT + PVTT (5 months). Multivariate analysis confirmed HVTT as an independent risk factor for poor survival.

CONCLUSIONS

HVTT may be more common than typically reported. In most patients, it was accompanied by PVTT. Isolated HVTT occurred less frequently and later than isolated PVTT; however, once developed, it had the same deleterious impact on survival. Therefore, patients with HVTT should be classified as advanced stage of HCC.

Tissue Diagnosis Is Associated With Worse Survival in Hepatocellular Carcinoma: A National Cancer Database Analysis

BACKGROUND

Biopsy to achieve tissue diagnosis (TD) of hepatocellular carcinoma (HCC) risks needle tract seeding. With chest wall and peritoneal recurrences reported, TD could worsen cancer outcomes. We investigated HCC outcomes after TD compared to clinical diagnosis (CD), hypothesizing that TD adversely affects overall survival (OS).

METHODS

The National Cancer Database (NCDB) Participant User File for liver cancer was reviewed, including patients with nonmetastatic HCC treated with major hepatectomy or transplantation. Clinical diagnosis patients were matched 1:1 to TD patients per propensity score. Survival was examined in the unmatched and matched cohorts.

RESULTS

Of 172 283 cases, 16 366 met inclusion criteria. Mean age was 60.8 years, 12 100 (73.9%) were male, and 48.4% of patients received hepatectomies. Clinical diagnosis occurred in 70.4% of cases, and 29.6% underwent TD. Cox regression confirmed the diagnostic method as an independent predictor of OS in addition to age, Charlson-Deyo score, grade, delay of surgery, lymphovascular invasion, nodal stage, and procedure type, favoring transplantation over hepatectomy. After propensity matching on these factors, 4251 patients were matched from each group. In the matched cohort, patients with TD had a significantly lower OS than patients with CD (median: 65.5 vs. 85.6 ± 2.7 months, P < .001). The corresponding 5-year survival was lower in the TD group (47.6% vs. 60.9% P < .001).

CONCLUSION

Hepatocellular carcinoma patients with preoperative TD had decreased OS compared to CD, which persisted after propensity matching. This study supports avoiding biopsy for HCC whenever possible.

Usefulness and limitation of indocyanine green fluorescence for detection of peritoneal recurrence after hepatectomy for hepatocellular carcinoma: a case report

Background

Peritoneal recurrence of hepatocellular carcinoma (HCC) after hepatectomy occurs rarely, accounting for less than 1% of all recurrences. Reported causes of such dissemination include a history of rupture of the original HCC, needle biopsy or puncture treatment, and surgical procedures. There is no consensus on the optimal treatment strategy for peritoneal dissemination. There have been few reports on assisting resection of peritoneal dissemination by using indocyanine green (ICG) fluorescence.

Case presentation

A 57-year-old man underwent posterior sectionectomy for HCC. Six months later, computed tomography revealed multiple nodules suspected of indicating peritoneal dissemination. Various preoperative imaging studies demonstrated only four nodules, the doubling time of the tumors being rapid at 22 days. The nodules were therefore resected. ICG (0.5 mg/kg) was injected intravenously 2 days before the procedure, enabling identification of the nodules by their brightness in the operative field under near-infrared lighting. A total of eight lesions were detected during the procedure and resected, some of which had not been identified by preoperative imaging studies. We diagnosed peritoneal dissemination of HCC based on the pathological findings and their similarity to those of the original HCC. We concluded that the recurrences were likely attributable to exposure of the tumor to the serosa at the time of the original operation.

Conclusions

Although ICG fluorescence is useful for identifying peritoneal dissemination of HCC, attention should be paid to the difficulty in detecting deep lesions and occurrence of false positives.

A case report on a large, peduncular intra-abdominal hepatocellular carcinoma extending into the retroperitoneum

Here, we discuss a relatively uncommon presentation of a hepatocellular carcinoma and discuss its preoperative planning and surgical intervention required to reach complete resection.

Outcomes of resection for hepatocellular carcinoma with macroscopic bile duct tumour thrombus: A propensity score matched study

The incidence of hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is low, and related studies, especially studies on long-term survival, are uncommon. The present study aimed to evaluate the clinicopathological characteristics, prognostic factors and postoperative long-term outcomes of BDTT in patients with HCC. The clinicopathological characteristics and postoperative long-term outcomes of patients with HCC both with and without BDTT were compared before and after propensity score matching (PSM). Prognostic risk factors were assessed by Cox proportional hazards regression analyses after PSM. Tumour stages in the BDTT group were significantly higher than those in the group without BDTT (P=0.001). Overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in the group without BDTT than in the BDTT group before PSM (P<0.001 and P=0.003, respectively). However, no significant difference in OS or RFS was found between the two groups after PSM (P=0.249 and P=0.121, respectively). Moreover, the median OS and RFS times of the BDTT patients who underwent tumour thrombectomy and bile duct resection were not significantly different (P=0.891 and P=0.787, respectively). In the multivariate analysis, macrovascular invasion (HR, 3.701; 95% CI, 1.313-9.10.437; P=0.013) was the only independent predictor of OS. Although the clinicopathological characteristics of the BDTT group suggested more advanced stage disease and poorer oncological outcomes than the group without BDTT, BDTT was not a poor prognostic factor for patients with HCC who underwent liver resection. Curative resection is recommended for patients with HCC and BDTT, even for those with poor liver function, after proper perioperative management in order to achieve good long-term survival.

Diagnosis, treatment and prognosis of hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus

Although tumor thrombus (TT) infringement of the inferior vena cava (IVC) and right atrium (RA) is rarely observed in hepatocellular carcinoma (HCC), the prognosis for this condition is extremely poor, with a median survival time of several months, given that the condition is often diagnosed at an advanced tumor stage or combined with multiple systemic metastases. Furthermore, there is no established effective treatment for the condition. However, some investigators insist that active treatment, including surgery, chemotherapy (systemic or intra-arterial), radiation therapy, best supportive care or a combination of these, may help prolong overall survival time in these patients. The management of patients with advanced HCC and a TT extending into the RA and IVC is extremely difficult and risky. To this end, the present review assessed the literature on the clinical features and treatments of this condition in recent years, with the aim of providing assistance for clinical work.

Colon metastasis from hepatocellular carcinoma: a case report and literature review

Background

Hepatocellular carcinoma (HCC) is a malignant tumor with frequent intrahepatic metastases; extrahepatic metastases are not rare but less frequent compared to intrahepatic ones. The most frequent sites of extrahepatic metastases are the lungs, followed by the lymph nodes, bones, and adrenal glands. Case report covering gastrointestinal (GI) tract involvement from HCC is limited.

Case presentation

A 60-year-old man was referred to us in May 2019 with a diagnosis of sigmoid colon tumor. The patient had a history of HCC and had received two stages of open resections for the primary and the abdominal metastasis successively and many times of transcatheter arterial chemoembolization (TACE). The sigmoid colon tumor received Hartmann procedure after abdominal enhanced computerized tomography (CT) scan and colonoscopy, while postoperative pathology and immunohistochemistry identified it as extrahepatic colonic metastasis from HCC.

Conclusions

The ratio of extrahepatic metastasis to the digestive tract was very low, and the majority was upper gastrointestinal involvement because of direct invasion or intraperitoneal implantation. TACE may be the risk factor of retrograde hematogenous metastasis to the downstream colon.

Keywords

Hepatocellular carcinoma; Extrahepatic metastases; Colon metastasis; Transcatheter arterial chemoembolization

Repeated Perforation of the Gallbladder in a Patient with Hepatocellular Carcinoma Receiving Lenvatinib

A 59-year-old man who was receiving lenvatinib as a third-line tyrosine kinase inhibitor to treat hepatocellular carcinoma and multiple bone metastases complained of general fatigue four months after starting lenvatinib. A blood examination showed unexpectedly elevated serum C-reactive protein (CRP) levels. Computed tomography (CT) revealed rupture of the gallbladder wall, indicating gallbladder perforation. After conservative treatment, the patient received lenvatinib again under informed consent; however, one month later, CT revealed repeated rupture of the gallbladder wall. Gallbladder perforation had again been induced by lenvatinib. For this reason, lenvatinib is strongly considered a causative drug for gallbladder perforation.

Hemorrhagic Gastric Metastasis from Hepatocellular Carcinoma Successfully Treated Using Coil Embolization of the Left Gastric Artery

A 62-year-old man initially underwent transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma (HCC). One year after the initial treatment, he developed anemia. Upper gastrointestinal endoscopy revealed irregularly elevated tumors in the lower anterior gastric body, which were diagnosed to be metastasis from HCC. Left gastric artery coil embolization was performed to prevent sustained bleeding, and his anemia partially improved. In addition to direct invasion, hematogenous metastasis to the stomach from HCC is possible and therefore should be considered during treatment. Transcatheter arterial embolization for gastric metastasis is an effective treatment method which achieves a good degree of hemostasis in patients without any surgical indications.

Hepatocellular carcinoma with duodenal invasion resected subsequent to multimodal therapies: A case report

•

Hepatocellular carcinoma (HCC) with duodenal invasion is a very rare occurrence.

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Aggravated disease condition of HCC with duodenal invasion usually makes surgical treatment not advisable.

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We present the first case of HCC with duodenal invasion resected following a multimodal therapy that included sorafenib.

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Partial hepatectomy in conjunction with partial duodenectomy was selected to lessen surgical stress.

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Surgical resection should be taken into consideration as a therapeutic choice even in progressive HCC disease condition.

Introduction

Gastrointestinal (GI) involvement in hepatocellular carcinoma (HCC) is uncommon. In particular, HCC with duodenal invasion is known to be a rare condition. In such cases, surgical indication has been generally negative except in few reported cases. To our knowledge, this report describes the first case of HCC with duodenal invasion, resected by hepatectomy accompanied by pancreas-preserving partial duodenectomy (HPPD) following multimodal therapies including systemic sorafenib administration.

Case presentation

A 65-year-old man had been repeatedly treated for multiple HCCs by transarterial chemoembolization (TACE) and sorafenib. However, the main tumor formerly ruptured began to involve his duodenum, causing GI bleeding. The collateral vessels from the pancreatic and omental branches entered the tumor and nullified the transarterial hemostatic embolization. Hence, HPPD was performed to preserve the major Vater papilla. Histopathological examination revealed poorly-to -moderately differentiated HCC cells invading the duodenum.

Discussion and conclusion

HPPD treatment successfully removed HCC with duodenal invasion achieving viable tumor clearance status (R0). We underline the importance of achieving viable tumor clearance status at any time during the treatment course of patients with advanced HCC as this approach may be the only approach to enable HCC patients with duodenal invasion to resume a healthy life.

Jiedu Granule Combined with Transcatheter Arterial Chemoembolization and Gamma Knife Radiosurgery in Treating Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

BACKGROUND

The potential advantages of Jiedu granule (a compound Chinese herbal medicine) combined therapeutic strategies compared with non-Jiedu granule therapeutic strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remain unclear. Thus, the purpose of the study was to investigate the safety and efficacy of Jiedu granule for HCC with PVTT.

METHODS

We retrospectively reviewed the clinical data of 190 patients (94 for non-Jiedu and 96 for Jiedu) with HCC and PVTT from March 2012 to October 2016. Patients were followed up by outpatient examination and telephone till November 2018.

RESULTS

It was statistically insignificant between the two groups in baseline characteristics. Procedure-related adverse events (AEs) were observed and compared and most of them were not serious which were easily controlled or subsided naturally. No AE-induced death happened. The median overall survival (OS) rates in the single TACE plus GKR and Jiedu granule combined group were 11.3 months (95% CI: 9.168-13.435) and 15.8 months (95% CI: 13.244-18.339), respectively (p = 0.00047).

CONCLUSIONS

Jiedu granule combined with TACE plus GKR is safe in HCC patients with PVTT and this Chinese herbal medicine is worthy to be promoted because of better prognosis which needs further research.

Sonographic diagnosis of thyroid metastasis from hepatocellular carcinoma

Metastasis to the thyroid is very rare in hepatocellular carcinoma (HCC) and only a few cases have been reported. Herein, we report a rare case of metastatic HCC to the thyroid in a 63-year-old man and discuss the various radiologic findings. Computed tomography (CT) revealed a heterogeneous enhancing mass that had invaded the thyroid cartilage in the left upper thyroid, compressing the airway. Ultrasonography (US) showed a heterogeneous hypoechoic mass with increased vascularity in the peripheral portion. The mass showed focal intense uptake on positron emission tomography-computed tomography (PET-CT). The patient underwent US-guided core needle biopsy and the final diagnosis was metastatic HCC.

Acute haemoperitoneum due to small bowel metastases from hepatocellular carcinoma in a long term survivor following previous rupture

We report a 75-year old patient, presenting with acute abdomen and hemorrhagic shock. He provided history of right hemihepatectomy performed 5 years ago, for ruptured hepatocellular carcinoma on a background of Hepatitis B virus associated liver cirrhosis. A computerized tomography scan showed 5 cm-sized mass exophytic lesion, in the small bowel with haemoperitoneum. An emergency laparotomy and small bowel resection, with primary anastomosis was performed. Histology showed Hep Par 1 stain reactive cells, on the serosal surface of the small bowel. A final diagnosis of metastatic hepatocellular carcinoma was made.

Metastasis of Hepatocellular Carcinoma to the Esophagus: Case Report and Review

A follow-up endoscopy in a 71-year-old Japanese man who had undergone a left lateral segmentectomy for HCC two years ago revealed an approximately 2 cm in diameter pedunculated polypoid mass in the middle part of the thoracic esophagus. Immunohistochemical staining of the endoscopic biopsy revealed a metastatic HCC esophageal tumor. As the patient's disease could be radically removed by preoperative examinations, we resected the metastatic esophageal tumor via right thoracotomy and esophagogastrostomy reconstruction. Histological examination of the resected specimen revealed that the esophageal tumor was compatible with a HCC metastasis. This is an extremely rare case of a solitary metastasis to the esophagus from HCC in the literature.

Comprehensive treatments for hepatocellular carcinoma with portal vein tumor thrombosis

Portal vein tumor thrombosis (PVTT) is one of the most common complications in hepatocellular carcinoma (HCC). HCC with PVTT usually indicates poor prognosis, which has a number of characteristics including a rapidly progressive disease course, worse liver function, complications connected with portal hypertension, and poorer tolerance to treatment. The exact mechanisms of PVTT remain unknown, even though some concerned signal transduction or molecular pathways have been identified. In western countries, sorafenib is the only recommended therapeutic strategy regardless of PVTT types. However, multiple treatment options including transhepatic arterial chemoembolization, hepatectomy, radiotherapy, and sorafenib available in the clinic. In this review, we enumerate and discuss therapeutics against patients with HCC having PVTT available in the clinic and put forward directions for future research.

Transarterial chemoembolization combined with computed tomography-guided 125iodine implantation enhances survival in hepatocellular carcinoma patients with portal vein tumor thrombus

We conducted a retrospective study to evaluate the safety and efficacy of transarterial chemoembolization (TACE) combined with computed tomography-guided 125iodine implantation (TACE-125iodine) in hepatocellular carcinoma (HCC) patients with type B portal vein tumor thrombus (PVTT). From medical records, we determined that 50 patients who received 125iodine implantation 4-7 days after the first TACE session showed better survival than 50 patients who received only TACE (median survival, 13.1 vs. 6.0 months; P<0.01). Moreover, the PVTT control rate was higher in the TACE-125iodine than TACE alone group (78% vs. 18%; P<0.01). Multivariate analysis demonstrated that the TACE-125iodine procedure was an independent prognostic factor for overall survival. We also observed that bilirubin levels were increased at 4 weeks, indicating that 125iodine seeding in the PVTT beneficially impacted the small bile duct, which is proximal to the portal vein. No severe adverse events were observed in patients that received 125iodine seed implantation, and the mild adverse events were successfully treated. This study shows that TACE-125iodine therapy enhances patient survival with minimal adverse events. It is also more affordable than sorafenib, which is currently the recommended therapy for advanced HCC patients with PVTT.

A Clinico-Pathologic Study of Clear-Cell Hepatocellular Carcinoma

We reviewed the pathologic and clinical features of 7 cases of clear-cell hepatocellular carcinomas. Tumor cells had a typical clear, empty cytoplasm due to prominent accumulation of glycogen and lipid droplets, as demonstrated by ultrastructural study in one of our cases. Follow-up of the 7 patients did not confirm the better prognosis of this tumor reported by other investigators. The clinical course of our cases was more unfavorable than that of the other 130 cases of usual hepatocellular carcinomas treated at this Institute.

240 Hepatocellular Carcinomas: Ultrasound Features, Tumor Size, Cytologic and Histologic Patterns, Serum Alpha-Fetoprotein and HBs Ag

Two hundred and forty cases of hepatocellular carcinomas (HCC), diagnosed by ultrasonography and fine needle biopsy, were studied. The following parameters were investigated: 1. echo features (240 cases) – hypoechoic, 54; hyperechoic, 56; complex, 112; isoechoic with halo, 18; 2. tumor size (240 cases) – single tumor under 4.5 cm, 30; single tumor over 4.5 cm, 74; multiple masses or diffuse, 136; 3. cytologic pattern (240 cases) – well and medium differentiated, 144; pleomorphic, 43; poorly differentiated, 28; unclassified, 25; 4. histologic pattern (157 cases) – trabecular, 74; solid, 42; acinar, 1; mixed, 2; unclassified, 38; 5. alpha-fetoprotein (AFP) level (185 cases) – under 20 ng/ml, 79; between 20 and 320 ng/ml, 40; over 320 ng/ml, 66; 6. HBs Ag (208 cases) – present in 56 cases; 7. cirrhosis (102 cases) –present in 79 cases. Some of the above parameters were correlated with one another. There was: 1. a highly significant frequency of the hypoechoic feature among small HCC; 2. a percentage of AFP-producing tumors increasing with tumor size; 3. no relationship between AFP production and cytologic or histologic pattern; 4. no relationship between tumor size and cytologic or histologic pattern. However, among the small HCC, all the 9 HCC with a diameter of less than 3 cm showed a trabecular pattern and well-differentiated cells. Cirrhosis was present in every patient with a small HCC. Since the discovery of a small HCC is an incidental ultrasonographic finding in the context of severe liver disease, ultrasonographic monitoring of cirrhotic patients is the best available strategy to screen for small HCC.

Pattern Analysis of Serum alpha-fetoprotein in the Early Diagnosis of Hepatocellular Carcinoma in Liver Cirrhosis

In a surveillance program for hepatocellular carcinoma (HCC), serum alpha-fetoprotein (AFP) was determined every 4 months in 164 patients with liver cirrhosis. Ultrasonography (US) was performed yearly or as dictated by abnormal AFP levels.

During a follow-up of 32.5 ± 20.8 months HCC was identified by US in 16 patients. In 9 of them the AFP levels rose steadily over 4 months, increasing 7, 8 and 12 months in 3 cases before the lesion became detectable by US. In 4 patients tumors developed despite persistently normal AFP levels. Nine more patients showed abnormal fluctuations of AFP but HCC was not detected.

AFP sensitivity was higher at a low cutoff point (40 ng/ml) while specificity of the test appeared higher at the 200 ng/ml cutoff point. An AFP value rising steeply over a few months appeared more reliable than a fixed preset threshold in indicating carcinomatous transformation.

Screening for AFP can be expected to uncover about 3/4 of HCC developing in cirrhotics with few false-positive reactions. The test may have a unique role in identifying a subset of liver tumors whose early expression is AFP production.

Surface Engineering of Nanoparticles for Targeted Delivery to Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-associated deaths worldwide. There is a lack of efficient therapy for HCC; the only available first-line systemic drug, sorafenib, can merely improve the average survival by two months. Among the efforts to develop an efficient therapy for HCC, nanomedicine has drawn the most attention, owing to its unique features such as high drug-loading capacity, intrinsic anticancer activities, integrated diagnostic and therapeutic functionalities, and easy surface engineering with targeting ligands. Despite its tremendous advantages, no nanomedicine can be effective unless it successfully targets the tumor site, which is a challenging task. In this review, the features of HCC are described, and the physiological hurdles that prevent nanoparticles from targeting HCC are discussed. Then, the surface physicochemical factors of nanoparticles that can influence targeting efficiency are discussed. Finally, a thorough description of the physiological barriers that nanomedicine must conquer before uptake by HCC cells if possible is provided, as well as the surface engineering approaches to nanomedicine to achieve targeted delivery to HCC cells. The physiological hurdles and corresponding solutions summarized in this review provide a general guide for the rational design of HCC targeting nanomedicine systems.

Defining the role of palliative radiotherapy in bone metastasis from primary liver cancer: An analysis of survival and treatment efficacy

Aims and background

Primary liver cancer is the fourth leading cause of cancer-related death worldwide and is still associated with a poor prognosis. Hepatocellular carcinoma and cholangiocarcinoma are known to cause bone metastasis resulting in pain, neurologic impairment and risk of fracture. Palliative radiotherapy is the treatment of choice in symptomatic bone lesions and is usually performed as percutaneous fractionated radiotherapy.

Methods and study design

From June 1987 to December 2009, 41 patients (median age, 64 years) with bone metastasis received radiotherapy in our department. The analyzed patients were treated for 67 sites of bone lesions. We analyzed the applied fractionation schedules and the preferred sites of metastasis and symptoms, evaluated the therapeutic outcome in terms of symptomatic improvement, and described the prognosis of these patients.

Results

Main indication for palliative radiotherapy was pain in 94% of all cases. Most frequent radiation protocols were 10 × 3 Gy (20 patients) and 20 × 2 Gy (19 patients). Median applied overall dose was 39 Gy (range, 4–48 Gy) and median single dose was 2.5 Gy (range, 1.8–4 Gy). The median duration of the radiotherapeutic treatment was 15 days (range, 2–24 days) and in 12 cases treatment was discontinuated. The overall response rate to palliative radiotherapy in bone metastasis was 77%. Median overall survival in both cholangiocarcinoma and hepatocellular carcinoma patients was 4.2 months after initiation of radiotherapy (range, 0.2–38.9).

Conclusions

Considering the poor prognosis of patients with bone metastasis in hepatocellular carcinoma and cholangiocarcinoma, with a poor median survival of 3.7–5.0 months according to our study and existing literature, shorter radiotherapy schedules or even single-fraction irradiation can be considered.

Unusual Presentation of Metastatic Hepatocellular Carcinoma in an HIV/HCV Coinfected Patient: Case Report and Review of the Literature

Hepatocellular carcinoma (HCC) is an increasing cause of mortality in human immunodeficiency virus (HIV) seropositive patients. Concurrent infection with HIV may accelerate the progression from cirrhosis to HCC. Viral hepatitis and alcohol abuse are the main risk factors for HCC in developed countries. Exposure to these risk factors is common among HIV-infected patients. We report the case of a 43-year-old woman affected by HCC, with unusual soft tissue metastases (left masseter muscle) and HIV/HCV coinfection. The usual route of metastatic spread from classic HCC is hematogenous, with the most common extrahepatic site being the lung. Our case, besides the unusual distant metastatic site, showed very rapid clinical progression, as has been commonly observed in HIV-infected patients with HCC. The case series of HCC in HIV-positive individuals published to date does not cumulatively exceed 70 subjects.

Can Hepatocellular Carcinoma (HCC) Produce Unconventional Metastases? Four Cases of Extrahepatic HCC

Aims and background

Extrahepatic spread of hepatocellular carcinoma (HCC) diagnosed during the clinical course of the disease is not frequent; however, with the prolonged survival of HCC patients, the incidence of extrahepatic metastases seems to be increasing.

Methods and study design

We present four unusual cases of extrahepatic metastasis from HCC: the first concerns a patient who underwent a liver transplantation for HCC with cirrhosis and three years later developed metastases in the lung and the left orbit; the second is that of a patient who developed an extraperitoneal pararectal metastasis; in the third case a large osteolytic lesion developed on the left iliac bone, and in the fourth case we found an isolated metastasis in the left mandible.

Results and conclusions

These cases offer important information related to the unusual biology of isolated metastases from HCC after successful treatment of the primary cancer.

Optimal surgical strategy for hepatocellular carcinoma with portal vein tumor thrombus: a propensity score analysis

OBJECTIVES

The optimal surgical resection method for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) that maximizes both safety and long-term outcome has not yet been determined. The aim of this study was to compare the clinical outcomes following peeling off versus en bloc resection for PVTT.

METHODS

From 2005 to 2012, 252 patients with HCC and type I/II PVTT who underwent hepatic resection were divided into two groups according to whether they received en bloc resection (n = 113) or peeling off resection (n = 139). The clinical outcomes were compared before and after propensity score matching.

RESULTS

The propensity model matched 113 patients with en bloc resection for further analyses. After matching, overall survival (OS) and disease-free survival (DFS) rates were significantly increased in the en bloc group compared with the peeling off group (p = 0.011 and p = 0.015). A multivariate analysis indicated that en bloc resection independently improved both OS and DFS (HR = 1.471, 95% CI: 1.071-2.018, p = 0.017 and HR = 1.415, 95% CI: 1.068-1.874, P=0.016). The adverse events were not significantly different between the two groups. However, the peeling off group showed a significantly increased recurrence rate of vascular invasion compared with the en bloc group (23.9% vs. 9.7%, p = 0.005). Similar results were also demonstrated prior to the matched analysis.

CONCLUSIONS

An en bloc resection is safe and confers a survival advantage compared with a peeling off resection in HCC patients with PVTT; thus, en bloc resection should be recommended as a standard treatment for these patients when possible.

Imaging Features on Contrast-Enhanced Ultrasound and Clinical Characteristics of Hepatitis B Virus-Related Combined Hepatocellular-Cholangiocarcinoma: Comparison with Hepatitis B Virus-Related Hepatocellular Carcinoma

The objective of this study was to compare the clinical characteristics and imaging features on contrast-enhanced ultrasound (CEUS) of hepatitis B virus (HBV)-related combined hepatocellular-cholangiocarcinoma (CHC) and hepatocellular carcinoma (HCC). Thirty-one pathologically proven CHCs were included and 31 HCCs were randomly selected as controls. Elevated carbohydrate antigen (CA) 19-9 alone and simultaneous elevation of α-fetoprotein and CA19-9 were more frequent in CHC than in HCC patients (p = 0.004 and 0.029, respectively). On CEUS, homogeneous, heterogeneous and peripheral irregular rim-like enhancement was illustrated in 8 (25.8%), 12 (38.7%) and 11 (35.5%) CHCs and in 6 (19.4%), 23 (74.1%) and 2 (6.5%) HCCs, respectively (p = 0.007). Multivariate logistic regression analysis revealed CA19-9 elevation (p = 0.011, odds ratio [OR] = 6.545) and peripheral irregular rim-like enhancement on CEUS (p = 0.017, OR = 7.718) were independent variables. A receiver operating characteristic curve was plotted and the area under the curve was 0.740. CHC should be watched for in HBV-infected patients with liver tumor manifesting peripheral irregular rim-like enhancement on CEUS, accompanied by CA19-9 elevation.

Clinical effects and safety of intra-arterial infusion therapy of cisplatin suspension in lipiodol combined with 5-fluorouracil versus sorafenib, for advanced hepatocellular carcinoma with macroscopic vascular invasion without extra-hepatic spread: A prospective cohort study

Although sorafenib and hepatic arterial infusion chemotherapy (HAIC) have been proven to improve prognosis in hepatocellular carcinoma (HCC) patients with macroscopic vascular invasion (MVI), the most appropriate approach remains unclear. The present multicenter, non-randomized, prospective cohort study aimed to compare the efficacy and safety of HAIC and sorafenib in patients with advanced HCC and MVI, without extra-hepatic spread (EHS) and Child-Pugh class A disease. The present study was performed between April 2008 and March 2014, and 64 HCC patients with MVI, without EHS and Child-Pugh class A disease were registered. Of these patients, 44 were treated with HAIC and 20 with sorafenib. HAIC involved cisplatin (50 mg fine powder in 5-10 ml lipiodol) and a continuous infusion of 5-fluorouracil (FU) (1,500 mg/5 days), which is referred to as new 5-FU and cisplatin therapy (NFP). The primary outcome was progression-free survival, and the secondary outcome was overall survival (OS). Clinical factors influencing OS and the therapeutic effect were identified using univariate and multivariate analyses. There were no differences in clinical factors between the two groups. The median progression-free survival was 5.1 and 9.5 months in the sorafenib and NFP groups, respectively (P=0.001). The complete response (CR) or partial response (PR) rates were 10 and 71% in the sorafenib and NFP groups, respectively (P<0.001). The median OS in the sorafenib and NFP groups was 13.2 and 30.4 months, respectively (P=0.013). Multivariate analysis revealed that the independent predictors of survival were Child-Pugh score (5, P=0.022, 95% CI, 0.191-0.892), grade of portal vein invasion (brunch, P=0.009, 95% CI, 0.220-0.752), and therapeutic effect (CR or PR, P<0.001, 95% CI, 0.220-0.752), and the independent predictor of therapeutic effect was therapeutic regimen (NFP, P<0.001, 95% CI, 0.006-0.199). NFP should be the first choice for patients with advanced HCC and MVI, without EHS and Child-Pugh A disease.

Loss of Kaiso expression in breast cancer cells prevents intra-vascular invasion in the lung and secondary metastasis

The metastatic activity of breast carcinomas results from complex genetic changes in epithelial tumor cells and accounts for 90% of deaths in affected patients. Although the invasion of the local lymphatic vessels and veins by malignant breast tumor cells and their subsequent metastasis to the lung, has been recognized, the mechanisms behind the metastatic activity of breast tumor cells to other distal organs and the pathogenesis of metastatic cancer are not well understood. In this study, we utilized derivatives of the well-established and highly metastatic triple negative breast cancer (TNBC) cell line MDA-MB-231 (MDA-231) to study breast tumor metastasis in a mouse model. These MDA-231 derivatives had depleted expression of Kaiso, a POZ-ZF transcription factor that is highly expressed in malignant, triple negative breast cancers. We previously reported that Kaiso depletion attenuates the metastasis of xenografted MDA-231 cells. Herein, we describe the pathological features of the metastatic activity of parental (Kaiso^positive) versus Kaiso^depleted MDA-231 cells. Both Kaiso^positive and Kaiso^depleted MDA-231 cells metastasized from the original tumor in the mammary fat pad to the lung. However, while Kaiso^positive cells formed large masses in the lung parenchyma, invaded large pulmonary blood vessels and formed secondary metastases and large tumors in the distal organs, Kaiso^depleted cells metastasized only to the lung where they formed small metastatic lesions. Importantly, intravascular invasion and secondary metastases in distal organs were not observed in mice xenografted with Kaiso^depleted cells. It thus appears that the lung may constitute a barrier for less invasive breast tumors such as the Kaiso^depleted TNBC cells; this barrier may limit tumor growth and prevents Kaiso^depleted TNBC cells from invading the pulmonary blood vessels and forming secondary metastases in distal organs.

Clinical outcome and prognostic factors in hepatocellular carcinoma patients with bone metastases medicated with zoledronic acid

AIMS

We retrospectively analyzed the clinical outcome and prognostic parameters in patients with hepatocellular carcinoma (HCC) and bone metastases who had received treatment with zoledronic acid (ZOL).

METHODS

Ninety-nine HCC patients with bone metastases who had been treated with ZOL were enrolled in this retrospective cohort study. We analyzed the prognostic factors, including serum N-telopeptide of type I collagen (NTX) levels, as bone metabolism markers.

RESULTS

The median overall survival (OS) time was 11.5 months. Child-Pugh grade A (P = 0.004) and intrahepatic tumor stage (IHTS) T0-3 (P = 0.010) correlated significantly with favorable OS. In 46 patients with grade A and T0-3, receiver operating characteristic curve analysis defined 16 nmol BCE/L serum NTX as the cut-off level for median OS. Multivariate analysis identified baseline serum NTX <16 nmol BCE/L (P = 0.045) as the only significant and independent determinant of OS.

CONCLUSION

Low baseline serum NTX level correlated with favorable outcome in bone metastatic HCC patients with Child-Pugh grade A and IHTS T0-3 treated with ZOL.

Recurrent Hepatocellular Carcinoma in the Right Adrenal Gland 11 Years After Liver Transplantation for Hepatocellular Carcinoma: a Case Report and Literature Review

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and extrahepatic metastases are typically found during disease progression. The incidence of adrenal metastasis (AM) from HCC in autopsy series ranges from 4.6 to 12.5%, and it is the second most common site of metastasis after the lungs. To date, there have been few reports of patients who underwent adrenalectomy for isolated AM from HCC after liver transplantation (LT). A woman aged 55 years was referred to our clinic for the evaluation of a right adrenal mass that was detected by abdominal ultrasonography at another center. She had undergone liver transplantation secondary to HCC and acute liver failure due to cryptogenic liver cirrhosis 138 months previously. She had been followed up for 5 years following LT after which she declined to continue with further follow-up. After radiologic and biochemical evaluation, she underwent adrenalectomy and the histopathologic examination revealed a 10 × 8 × 7-cm adrenal mass, which was considered to be an isolated AM from HCC. To our knowledge, this is the first case of isolated AM from HCC in the literature that was diagnosed 138 months after liver transplantation. Isolated AM from HCC after LT is rare and might be detected a long time after LT. Curative surgical resection of isolated metachronous AM from HCC in the absence of disseminated disease might provide for an acceptable disease-free period after adrenalectomy.

Can the Contrast-Enhanced Ultrasound Washout Rate Be Used to Predict Microvascular Invasion in Hepatocellular Carcinoma?

The objective of this study was to investigate use of the washout rate of hepatocellular carcinoma on contrast-enhanced ultrasound (CEUS) for pre-operative determination of the presence of microvascular invasion. The study included 271 patients who underwent liver resection for hepatocellular carcinoma between April 2008 and December 2012, and were examined with contrast-enhanced ultrasound before surgery. Patients were followed up at 3-mo intervals for 3 y. Four washout patterns were classified according to the start time of washout: rapid, portal, delayed and slow. Rapid washout, presence of two or more tumors and tumor size ≥5 cm were identified as independent pre-operative predictors of microvascular invasion on multivariate analysis. Recurrence rates for patients with none, one, two or three predictors were 22.6%, 34.7%, 57.6% and 75.0%, respectively. In combination with tumor number and tumor size, contrast-enhanced ultrasound washout rate may have a role in identifying hepatocellular carcinoma patients with microvascular invasion.