Role of surgery in the treatment of primary carcinoma of the liver: a 31-year experience

Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial

INTRODUCTION

Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched.

METHODS AND ANALYSIS

This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival.

ETHICS AND DISSEMINATION

This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT02261415.

Utility of viscoelastic coagulation testing in liver surgery: a systematic review

BACKGROUND

The objective of the current study was to summarize and evaluate all published evidence regarding viscoelastic testing in the field of liver surgery.

METHODS

A systematic search of the literature was performed using Medline/PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases. The following keywords were used:"Thromboelastography", "Thromboelastometry", "Viscoelastic tests OR testing", "Sonoclot Devices", "Point-of-care tests OR testing", "Coagulation OR Haemostasis OR Hemostasis", "Liver OR Hepatic Surgery", "Cirrhosis."

RESULTS

A total of 12 studies analyzing 348 patients who underwent viscoelastic testing of coagulation during liver surgery for benign or malignant diseases were included; 7 (58.3%) studies reported on the use of thromboelastography (TEG), and 5 (41.7%) reported on rotational thromboelastometry (ROTEM). Viscoelastic testing (TEG and ROTEM) identified normo-, hyper- and hypo-coagulable status in 77% (n = 268/348), 18.4% (n = 64/348), and 4.6% (n = 16/348) of patients, respectively. In contrast, conventional coagulation tests indicated normo-coagulability in 111 patients (34.2% out of 325) and hypo-coagulability in 214 (65.8% out of 325) patients following liver resection. No patient (0% out of 291) experienced postoperative hemorrhage, whereas 5.8% (n = 17/291) experienced postoperative thromboembolic events.

CONCLUSIONS

Global viscoelastic testing may be a reasonable adjunct to conventional coagulation testing to provide a more robust assessment of the coagulation status of patients undergoing liver surgery.

Medial Open Transversus Abdominis Plane (MOTAP) Catheters Reduce Opioid Requirements and Improve Pain Control Following Open Liver Resection: A Multicenter, Blinded, Randomized Controlled Trial

OBJECTIVE

Conventional management of pain following open liver resection involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. The objective of this trial was to assess the efficacy of a regional technique called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia compared with IV PCA.

METHODS

This was a blinded, randomized, controlled parallel-arm trial conducted at 2 high-volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, 2 catheters were placed after resection: one in the plane between internal oblique and transversus abdominis and the other in the posterior rectus sheath. Patients were randomized to receive ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours. All patients received IV PCA with hydromorphone as part of a multimodality analgesia program. Primary outcome was opioid use over the first 48 hours.

RESULTS

One hundred fifty-three patients were included in the analysis (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine-equivalent vs 49.2 mg, P = 0.033) and at 72 hours (median 50.0 vs 66.4 mg, P = 0.046). Pain scores at rest and with coughing were significantly lower at all time points in patients who received ROP (P = 0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (P = 0.035). There was no difference between groups in complications [ROP 20 (28.2%) vs NS 26 (31.7%), P = 0.63].

CONCLUSION

MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection with subcostal incisions.

The dual-inhibitory effect of miR-338-5p on the multidrug resistance and cell growth of hepatocellular carcinoma

Chemotherapeutic treatments against hepatocellular carcinoma (HCC) are necessary for both inoperable patients to improve prospects for survival and surgery patients to improve the outcome after surgical resection. However, multidrug resistance (MDR) is a major obstacle to obtaining desirable results. Currently, increasing the chemotherapy sensitivity of tumor cells or discovering novel tumor inhibitors is an effective therapeutic strategy to solve this issue. In the present study, we uncovered the dual-inhibitory effect of miR-338-5p: on the one hand, it could downregulate ABCB1 expression and sensitize HCC cells to doxorubicin and vinblastine by directly targeting the 3′-untranslated region (3′-UTR) of ABCB1, while, on the other hand, it could suppress the proliferation of HCC cells by directly targeting the 3′-UTR of EGFR and reducing EGFR expression. Since EGFR regulates ABCB1 levels, the indirect action of miR-338-5p in ABCB1 modulation was revealed, in which miR-338-5p inhibits ABCB1 expression by targeting the EGFR/ERK1/2 signaling pathway. These data indicate that the miR-338-5p/EGFR/ABCB1 regulatory loop plays a critical role in HCC, and a negative correlation between miR-338-5p and EGFR or ABCB1 was also detected in HCC clinical samples. In conclusion, these findings reveal a critical role for miR-338-5p in the regulation of MDR and proliferation of HCC, suggesting the potential therapeutic implications of miR-338-5p in HCC treatment.

A small RNA molecule inhibits the growth of liver cancer cells while also making the cells sensitive to the anti-cancer drugs. These twin effects of the natural microRNA miR-338-5p were discovered by researchers in China, led by Chunzhu Li and Jin Ren at the Center for Drug Safety Evaluation and Research in Shanghai. MicroRNAs control gene activity by interacting with the messenger RNA copies of genes that guide synthesis of the proteins the genes encode. The research identified a gene whose expression miR-338-5p inhibits to restrict the growth of hepatocellular carcinoma – the most common form of liver cancer. This is also one of the most drug-resistant forms of liver cancer. A different gene whose activity miR-338-5p controls to sensitize cells to chemotherapeutic drugs was also identified. Using miR-338-5p to treat liver cancer warrants further investigation.

Progress of liver resection for hepatocellular carcinoma in Taiwan

Taiwan is a well-known endemic area of hepatitis B. Hepatocellular carcinoma (HCC) has consistently been the first or second highest cause of cancer death over the past 20 years. This review article describes the progress of liver resection for HCC in Taiwan in the past half century. The mortality rate for HCC resection was 15-30% in Taiwan in the 1970s. The rate decreased to 8-12% in the early 1990s, and it declined to <1-3% recently. The development of new operative instruments, and surgical techniques, increased knowledge of liver anatomy and pathophysiology after hepatectomy, and more precise patient selection have contributed to this improvement. The use of intermittent hepatic inflow blood occlusion, a restrictive blood transfusion policy and intraoperative ultrasonography, have also led to substantial improvements in resectability and safety for HCC resection in Taiwan. Advances in non-operative modalities for HCC treatment have also helped to improve long-term outcomes of HCC resection. Technical innovations have allowed the application of complex procedures such as mesohepatectomy, unroofing hepatectomy, major portal vein thrombectomy, hepatic vein reconstruction in resection of the cranial part with preservation of the caudal part of the liver, and inferior vena cava and right atrium tumor thrombectomy under cardiopulmonary bypass. In selected patients, including patients with end-stage renal failure, renal graft recipients, patients with portal hypertension, hypersplenic thrombocytopenia and/or associated gastroesophageal varices, octogenarian, ruptured HCC, recurrent HCC and metastatic HCC can also be resected with satisfactory survival benefits. We conclude that the results of liver resection for HCC in Taiwan are improving. The indications for HCC resection continue extending with lower the surgical risks and increasing the long-term survival rate.

Mesohepatectomy Versus Extended Hemihepatectomies for Centrally Located Liver Tumors: A Meta-Analysis

The comparison of Mesohepatectomy (MH) with conventional extended hemihepatectomies (EH) for patients with centrally located liver tumors (CLLTs) were inconsistent. Our aims were to systemically compare MH with EH and to determine whether MH can achieve a similar clinical outcome as EH through this meta-analysis. PubMed/Medline, EMBASE, Web of Knowledge and Cochrane Library were searched updated to June 11, 2016. Blood loss and operation time favored MH in elder patients (mean difference [MD] for blood loss: -692.82 ml, 95% CI: -976.72 to -408.92 ml, P < 0.001; MD for operation time: -78.75 min, 95% CI: -107.66 to -49.81, P < 0.001). Morbidity rate (29.2%, 95% CI: 24.1 to 34.8%), mortality rate (2.0%, 95% CI: 1.2 to 3.3%) and overall survival (median OS 38.2 m, 95% CI: 34.0 to 42.8 m) of MH were comparable with those of EH. The low liver failure rate favored MH (odds ratio [OR]: 0.29, 95% CI: 0.09 to 0.88, P = 0.03). For MH, bile leakage was the most common surgical complication (MH vs. EH: 13.5% vs. 6.7%, P = 0.016), while for EH, it was wound infection (MH vs. EH: 6.9% vs. 15.7%, P < 0.001). Thus MH might be in general safe and feasible for treating CLLTs with a similar clinical outcome as EH.

New Evidence and Perspectives on the Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Portal vein tumor thrombosis (PVTT) is an intractable condition but common phenomenon in hepatocellular carcinoma (HCC). HCC patients with PVTT may have worse liver function, a higher chance of comorbidity related to portal hypertension, lower tolerance to treatment and poorer prognoses. In Western guidelines, patients are offered palliative treatment with sorafenib or other systemic agents because HCC with PVTT is grouped together with metastatic HCC during the planning of its management. In recent years, various treatment options have become available for patients with HCC and PVTT. Therapy has also shifted toward evidence-based treatment. However, policies for the management of HCC with PVTT have not been established. This comprehensive literature review aims to present current and available management options for patients with HCC and PVTT. Evidence is mainly based on studies published after 2010.

Treatment of hepatocellular carcinoma with portal vein tumor thrombus: advances and challenges

Portal vein tumor thrombus is a frequent, challenging complication in hepatocellular carcinoma. Hepatocellular carcinoma patients with portal vein tumor thrombus may show worse liver function, less treatment tolerance and worse prognosis than patients without portal vein tumor thrombus, and they may be at higher risk of comorbidity related to portal hypertension. Western and some Asian guidelines stratify hepatocellular carcinoma with portal vein tumor thrombus together with metastatic hepatocellular carcinoma and therefore recommend only palliative treatment with sorafenib or other systemic agents. In recent years, more treatment options have become available for hepatocellular carcinoma patients with portal vein tumor thrombus, and an evidence-based approach to optimizing disease management and treatment has become more widespread. Nevertheless, consensus policies for managing hepatocellular carcinoma with portal vein tumor thrombus have not been established. This comprehensive literature review, drawing primarily on studies published after 2010, examines currently available management options for patients with hepatocellular carcinoma and portal vein tumor thrombus.

Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid

BACKGROUND

Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection.

METHODS

In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration.

RESULTS

No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA.

CONCLUSIONS

There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.

Redox/pH dual stimuli-responsive degradable Salecan-g-SS-poly(IA-co-HEMA) hydrogel for release of doxorubicin

Salecan is a novel water-soluble extracellular β-glucan and possesses excellent physicochemical and biological properties. Here, redox/pH dual stimuli-responsive hydrogel based on Salecan grafted with itaconic acid (IA) and 2-hydroxyethyl methacrylate (HEMA) were prepared using disulfide-functionalized crosslinker N,N-bis(acryloyl)cystamine (BAC) for controlled drug delivery. The introduction of carboxylic groups endows the system with pH-sensitive character, swelling behavior of the hydrogel was conducted by changing the pH and Salecan content. It was demonstrated that DOX was efficiently loaded into the hydrogels and released in a controlled fashion via pH-control and swelling-shrinking mechanism. More importantly, DOX-loaded hydrogels showed dose dependent cytotoxicity toward A549 cell, and efficient cell killing was observed. Furthermore, a key point of this study was that the presence of disulfide linkage in system favored the degradation of hydrogels in the reductive environment. These results highlight the potential of Salecan-g-SS-poly(IA-co-HEMA) hydrogel as a novel system for the controlled release of anti-cancer drugs.

PLA-based thermogel for the sustained delivery of chemotherapeutics in a mouse model of hepatocellular carcinoma

This work represents the first time that poly(PEG/PPG/PLA urethane) has been used for the delivery of drugs to tumours in vivo and the encouraging results point to the potential for further development of this thermogel platform for anti-cancer applications.

Current Status of Hepatic Arterial Infusion Chemotherapy

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) is frequently used to treat advanced hepatocellular carcinoma (HCC) in Asian countries. However, there is a lack of evidence supporting the use of HAIC.

SUMMARY

Many studies report high response rates in patients with advanced HCC receiving HAIC, and clinical responses translate to survival benefits. Therefore, prediction of an antitumor response is important in selecting appropriate treatments. There are no proven post-sorafenib therapeutic measures or procedures for HCC patients with poor liver function, and HAIC is one of the few options for patients in these situations. Despite studies showing its effectiveness, the use of HAIC for treatment of advanced HCC is unclear because convincing data from large-scale randomized clinical trials are lacking. For HAIC to become a standard treatment for HCC, such trials must establish its efficacy compared with other HCC therapies; prediction of antitumor response in HAIC may aid trial design, and a multi-center, open-labelled, randomized clinical trial of HAIC in advanced HCC is currently in progress. Optimization of HCC treatment protocols and regimens is also required.

KEY MESSAGE

We think that both HAIC and sorafenib are effective treatments for advanced HCC, and this review presents evidence supporting this contention.

Cavitation-enhanced back projection for acoustic rib detection and attenuation mapping

High-intensity focused ultrasound allows for minimally invasive, highly localized cancer therapies that can complement surgical procedures or chemotherapy. For high-intensity focused ultrasound interventions in the upper abdomen, the thoracic cage obstructs and aberrates the ultrasonic beam, causing undesired heating of healthy tissue. When a phased array therapeutic transducer is used, such complications can be minimized by applying an apodization law based on analysis of beam path obstructions. In this work, a rib detection method based on cavitation-enhanced ultrasonic reflections is introduced and validated on a porcine tissue sample containing ribs. Apodization laws obtained for different transducer positions were approximately 90% similar to those obtained using image analysis. Additionally, the proposed method provides information on attenuation between transducer elements and the focus. This principle was confirmed experimentally on a polymer phantom. The proposed methods could, in principle, be implemented in real time for determination of the optimal shot position in intercostal high-intensity focused ultrasound therapy.

Emerging HIFU applications in cancer therapy

High intensity focused ultrasound (HIFU), is a promising, non-invasive modality for treatment of tumours in conjunction with magnetic resonance imaging or diagnostic ultrasound guidance. HIFU is being used increasingly for treatment of prostate cancer and uterine fibroids. Over the last 10 years a growing number of clinical trials have examined HIFU treatment of both benign and malignant tumours of the liver, breast, pancreas, bone, connective tissue, thyroid, parathyroid, kidney and brain. For some of these emerging indications, HIFU is poised to become a serious alternative or adjunct to current standard treatments--including surgery, radiation, gene therapy, immunotherapy, and chemotherapy. Current commercially available HIFU devices are marketed for their thermal ablation applications. In the future, lower energy treatments may play a significant role in mediating targeted drug and gene delivery for cancer treatment. In this article we introduce currently available HIFU systems, provide an overview of clinical trials in emerging oncological targets, and briefly discuss selected pre-clinical research that is relevant to future oncological HIFU applications.

Preparation and therapeutic evaluation of (188)Re-thermogelling emulsion in rat model of hepatocellular carcinoma

Radiolabeled Lipiodol^® (Guerbet, Villepinte, France) is routinely used in hepatoma therapy. The temperature-sensitive hydrogel polyethylene glycol-b-poly-DL-lactic acid-co-glycolic acid-b-polyethylene glycol triblock copolymer is used as an embolic agent and sustained drug release system. This study attempted to combine the polyethylene glycol-b-poly-DL-lactic acid-co-glycolic acid-b-polyethylene glycol hydrogel and radio-labeled Lipiodol to form a new radio-thermogelling emulsion, rhenium-188–N,N’-1,2-ethanediylbis-L-cysteine diethyl-ester dihydrochloride–Lipiodol/hydrogel (¹⁸⁸Re-ELH). The therapeutic potential of ¹⁸⁸Re-ELH was evaluated in a rodent hepatoma model. Rhenium-188 chelated with N,N’-1,2-ethanediylbis-L-cysteine diethyl-ester dihydrochloride was extracted with Lipiodol to obtain rhenium-188–N,N’-1,2-ethanediylbis-L-cysteine diethyl-ester dihydrochloride–Lipiodol (¹⁸⁸Re-EL), which was blended with the hydrogel in equal volumes to develop ¹⁸⁸Re-ELH. The ¹⁸⁸Re-ELH phase stability was evaluated at different temperatures. Biodistribution patterns and micro-single-photon emission computed tomography/computed tomography images in Sprague Dawley rats implanted with the rat hepatoma cell line N1-S1 were observed after in situ tumoral injection of ~3.7 MBq ¹⁸⁸Re-ELH. The therapeutic potential of ¹⁸⁸Re-EL (48.58±3.86 MBq/0.1 mL, n=12) was evaluated in a 2-month survival study using the same animal model. The therapeutic effects of ¹⁸⁸Re-ELH (25.52±4.64 MBq/0.1 mL, n=12) were evaluated and compared with those of ¹⁸⁸Re-EL. The responses were assessed by changes in tumor size and survival rates. The ¹⁸⁸Re-ELH emulsion was stable in the gel form at 25°C–35°C for >52 hours. Biodistribution data and micro-single-photon emission computed tomography/computed tomography images of the ¹⁸⁸Re-ELH group indicated that most activity was selectively observed in hepatomas. Long-term ¹⁸⁸Re-ELH studies have demonstrated protracted reductions in tumor volumes and positive effects on the survival rates (75%) of N1-S1 hepatoma-bearing rats. Conversely, the 2-month survival rate was 13% in the control sham group. Therapeutic responses differed significantly between the two groups (P<0.005). Thus, the hydrogel enhanced the injection stability of ¹⁸⁸Re-EL in an animal hepatoma model. Given the synergistic results, direct ¹⁸⁸Re-ELH intratumoral injection is a potential therapeutic alternative for hepatoma treatment.

Medial open transversus abdominis plane (MOTAP) catheters for analgesia following open liver resection: study protocol for a randomized controlled trial

BACKGROUND

The current standard for pain control following liver surgery is intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. We have developed a modification of a regional technique called medial open transversus abdominis plane (MOTAP) catheter analgesia. The MOTAP technique involves surgically placed catheters through the open surgical site into a plane between the internal oblique muscle and the transverse abdominis muscle superiorly. The objective of this trial is to assess the efficacy of this technique.

METHODS/DESIGN

This protocol describes a multicentre, prospective, blinded, randomized controlled trial. One hundred and twenty patients scheduled for open liver resection through a subcostal incision will be enrolled. All patients will have two MOTAP catheters placed at the conclusion of surgery. Patients will be randomized to one of two parallel groups: experimental (local anaesthetic through MOTAP catheters) or placebo (normal saline through MOTAP catheters). Both groups will also receive IV PCA. The primary endpoint is mean cumulative postoperative opioid consumption over the first 2 postoperative days (48 hours). Secondary outcomes include pain intensity, patient functional outcomes, and the incidence of complications.

DISCUSSION

This trial has been approved by the ethics boards at participating centres and is currently enrolling patients. Data collection will be completed by the end of 2014 with analysis mid-2015 and publication by the end of 2015.

TRIAL REGISTRATION

The study is registered with http://clinicaltrials.gov ( NCT01960049; 23 September 2013).

Identification of candidate biomarkers for hepatocellular carcinoma in plasma of HCV-infected cirrhotic patients by 2-D DIGE

BACKGROUND

The current methods available for screening and detecting hepatocellular carcinoma (HCC) have insufficient sensitivity and specificity, and only a low percentage of diagnosis of small tumours is based on these assays. Because HCC is usually asymptomatic at potentially curative stages, identification of biomarkers for the early detection of HCC is essential to improve patient survival.

AIM

The aim of this study was to identify candidate markers for HCC development in the plasma from hepatitis C virus (HCV)-infected cirrhotic patients.

METHODS

We compared protein expression profiles of plasma samples from HCV-infected cirrhotic patients with and without HCC, using two-dimensional fluorescence difference gel electrophoresis (2-D DIGE) coupled with MALDI-TOF/TOF mass spectrometry. The 2-D DIGE results were analysed statistically using Decyder™ software, and verified by western blot and enzyme-linked immunosorbent assay (ELISA).

RESULTS

In the plasma of HCV-infected HCC patients, we observed decreased expression of complement component 9, ficolin-3 (FCN3), serum amyloid P component (SAP), fibrinogen-gamma and immunoglobulin gamma-1 chain, and increased expression of vitronectin (VTN) and galectin-3 binding protein (G3BP) by DIGE analysis. ELISA confirmed DIGE results for VTN and G3BP but not for SAP or FCN3 in a larger patient population.

CONCLUSIONS

The proteins VTN and SAP are candidate biomarkers for HCC development in HCV-infected cirrhotic patients.

Multidisciplinary treatments for hepatocellular carcinoma with major portal vein tumor thrombus

In recent years, various treatment options have become available for patients with hepatocellular carcinoma (HCC) according to the degree of background liver damage, tumor diameter and other factors associated with disease progression. Therapy has also shifted toward evidence-based treatment. Policies for the management of HCC with portal vein tumor thrombus, which has been considered an intractable condition, have not been established. Surgical resection was previously positioned as the treatment of choice, but the outcomes after resection alone were found to be disappointing. At present, multiple interdisciplinary treatments, combining resection with intra-arterial chemotherapy, radiotherapy, systemic chemotherapy and/or immunotherapy, are used on a trial-and-error basis since no standard regimens have been developed. Clinical trials of surgery combined with transarterial chemoembolization, hepatic arterial infusion of chemotherapy and radiation have obtained improved 5-year survival rates of 21.5-56 %. The safety of surgical resection in HCC with major portal vein tumor thrombus has improved, but the optimal type(s) and timing of auxiliary therapy to use in combination with resection remain to be defined.

Overexpression of endothelin 1 triggers hepatocarcinogenesis in zebrafish and promotes cell proliferation and migration through the AKT pathway

Hepatocarcinogenesis commonly involves the gradual progression from hepatitis to fibrosis and cirrhosis, and ultimately to hepatocellular carcinoma (HCC). Endothelin 1 (Edn1) has been identified as a gene that is significantly up-regulated in HBx-induced HCC in mice. In this study, we further investigated the role of edn1 in hepatocarcinogenesis using a transgenic zebrafish model and a cell culture system. Liver-specific edn1 expression caused steatosis, fibrosis, glycogen accumulation, bile duct dilation, hyperplasia, and HCC in zebrafish. Overexpression of EDN1 in 293T cells enhanced cell proliferation and cell migration in in vitro and xenotransplantation assays and was accompanied with up-regulation of several cell cycle/proliferation- and migration-specific genes. Furthermore, expression of the unfolded protein response (UPR) pathway-related mediators, such as spliced XBP1, ATF6, IRE1, and PERK, was also up-regulated at both the RNA and protein levels. In the presence of an EDN1 inhibitor or an AKT inhibitor, these increases were diminished and the EDN1-induced migration ability also was disappeared, suggesting that the EDN1 effects act through activation of the AKT pathway to enhance the UPR and subsequently activate the expression of downstream genes. Additionally, p-AKT is enhanced in the edn1 transgenic fish compared to the GFP-mCherry control. The micro RNA miR-1 was found to inhibit the expression of EDN1. We also observed an inverse correlation between EDN1 and miR-1 expression in HCC patients. In conclusion, our data suggest that EDN1 plays an important role in HCC progression by activating the PI3K/AKT pathway and is regulated by miR-1.

Tumour size and differentiation predict survival after liver resection for hepatocellular carcinoma arising from non-cirrhotic and non-fibrotic liver: a case-controlled study

AIMS

The aims of this study were to assess the outcomes of patients who underwent potentially curative hepatic resection for hepatocellular carcinoma (HCC) in a background of non-cirrhotic/non-fibrotic livers, and to determine prognostic factors that influenced survival.

METHODS

Over a 15-year period, all patients undergoing hepatectomy for HCC were identified. Collated data included demographics, laboratory analysis, operative findings and histo-pathological data. Survival differences between these factors following liver resection were determined.

RESULTS

57 patients were included with a median age of 70 years. The majority of patients underwent a hemi-hepatectomy or more radical resection (n = 37). Overall R0 resection rate was 90.4% (n = 51). The overall morbidity and mortality rates were 26.3% and 3.5%, respectively. The median follow-up period was 28 months. The 1-, 3- and 5- year disease-free survival was 65.4%, 41.8% and 39.1%, and the overall survival was 73.5%, 49.6% and 39.5%, respectively. AFP (p = 0.039) was the only predictor of poorer disease-free survival on univariate analysis. On multi-variable analysis, poorly differentiated tumour and large tumour size were independent predictors of overall survival.

CONCLUSIONS

Liver resection is a feasible treatment option for HCC in non-cirrhotic/non-fibrotic livers with good survival outcome. Tumour size and differentiation are adverse predictors of outcome in these patients.

Clinical implications of deregulated CDK4 and Cyclin D1 expression in patients with human hepatocellular carcinoma

Deregulated cell cycle can contribute to the unscheduled proliferation in cancer cells. Overexpression of cell cycle regulators CDK4 and Cyclin D1 has been reported in many cancers. The aim of this study is to determine the clinical implications of CDK4 and Cyclin D1 in hepatocellular carcinoma (HCC). The levels of mRNA and protein were analyzed by quantitative real-time RT-PCR and immunohistochemistry, respectively, in 59 paired HCC and the neighboring noncancer tissues. The relationship between CDK4 and Cyclin D1 expression, clinicopathological parameters, and prognosis was investigated. Our data demonstrated that the mRNA level of CDK4 was up-regulated (p = 0.019), while that of Cyclin D1 was down-regulated (p = 0.002), in HCC. Immunohistochemical data confirmed that CDK4 protein was increased in 73 % and Cyclin D1 protein was decreased in 66 % of HCC samples. Overexpression of CDK4 was correlated with HBV (p = 0.054, borderline significant), tumor size (p = 0.014), and stage (p = 0.010). The Kaplan-Meier survival curves showed that high CDK4 was correlated with a poor survival rate (I vs. II, p < 0.001; I vs. III, p < 0.001). Univariate analysis showed that tumor size (p = 0.002), stage (p = 0.021), and high CDK4 score (I vs. II-III, p < 0.001) were significant prognostic factors. Multivariate analysis showed that tumor size (p = 0.007) and high CDK4 score (I vs. II-III, p < 0.001) were independent factors for overall survival of HCC. The expression of Cyclin D1 was not correlated with CDK4 expression, tumor grades, survival rate, and any clinicopathological parameters. CDK4 could provide a clinical prognostic marker for HCC progression.

Synthesis and application of 188Re-MN-16ET/Lipiodol in a hepatocellular carcinoma animal model

INTRODUCTION

Hepatocellular carcinoma is the most common form of primary hepatic carcinoma. A new N(2)S(2) tetradentate ligand, N-[2-(triphenylmethyl)thioethyl]-3-aza-19-ethyloxycarbonyl-3-[2-(triphenylmethyl)thioethyl]octadecanoate (H(3)MN-16ET), was introduced and labeled with (188)Re to create (188)Re-MN-16ET in the Lipiodol phase. The potential of (188)Re-MN-16ET/Lipiodol for hepatoma therapy was evaluated in a hepatocellular carcinoma animal model of Sprague-Dawley rats implanted with the N1S1 cell line.

METHODS

Synthesis of H(3)MN-16ET was described, and characterization was identified by infrared, nuclear magnetic resonance and mass spectra. We compared the effects of transchelating agents (glucoheptonate or tartaric acid) and a reducing agent (stannous chloride) on the complexing of (188)Re-perrhenate and H(3)MN-16ET. Twenty-four rats implanted with hepatoma were injected with 3.7 MBq/0.1 ml of (188)Re-MN-16ET/Lipiodol or (188)Re-MN-16ET via transcatheter arterial embolization. Biodistribution experiments and single-photon emission computed tomography imaging were performed to investigate tumor accumulation.

RESULTS

H(3)MN-16ET was proved to easily conjugate with the Re isotope and showed good solubility in Lipiodol. The radiochemical purity of (188)Re-MN-16ET/Lipiodol with 10 mg tartaric acid and stannous chloride was shown to be more than 90%. The major distribution sites of (188)Re-MN-16ET in Sprague-Dawley rats were hepatoma and the liver. However, the radioactivity at the tumor site postadministered with (188)Re-MN-16ET was quickly decreased from 9.15±0.23 (at 1 h) to 2.71%±0.18% of injected dose/g (at 48 h). The biodistribution and micro-single-photon emission computed tomography/computed tomography image data showed that (188)Re-MN-16ET/Lipiodol was selectively retained at the tumor site, with 11.55±1.44, 13.16±1.46 and 10.67%±0.95% of injected dose/g at 1, 24 and 48 h postinjection, respectively. The radioactivity in normal liver tissue was high but significantly lower than that of the tumors.

CONCLUSION

H(3)MN-16ET is a suitable tetradentate ligand for (188)Re labeling. From the animal data, we suggest that (188)Re-MN-16ET/Lipiodol has the potential to be a therapeutic radiopharmaceutical for hepatoma treatment.

Treatment of small hepatocellular carcinomas with US-guided high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) is a noninvasive method that can cause complete coagulation necrosis without requiring the insertion of any instruments. The purpose of this study was to evaluate the safety and efficacy of HIFU treatment for small liver cancers without performing transcatheter arterial chemoembolization (TACE) or rib resection. HIFU ablation was performed without rib resection or the aid of TACE or percutaneous ethanol injection (PEI) in 12 patients with hepatocelullar carcinoma. The HIFU system (Chongqing Haifu Tech, Chongqing, China) was used under ultrasound guidance. All 12 patients completed the treatment without experiencing any adverse events. Complete coagulation was achieved by applying the sonications from the intercostal space when the tumor was located in the right lobe. After treatment, serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels were significantly higher than the baseline values; these levels recovered within 1 week. C-reactive protein (CRP) levels increased 1 week after treatment but decreased within 1 month. An epidural anesthetic provided sufficient pain suppression during the procedure. Edema of the subcutaneous tissue was detected in five cases, but the edema disappeared within 1 month. None of the patients developed acute hepatic failure, liver abscess or renal dysfunction. In conclusion, HIFU is effective for the treatment of patients with small liver cancer.

Findings of multidetector row computed tomography of HCCs treated by HIFU ablation

PURPOSE

We evaluated the efficacy of high-intensity focused ultrasound (HIFU) ablation for hepatocellular carcinoma (HCC), and a long-term study by follow-up multidetector-row computed tomography (CT) was conducted to evaluate the changes occurring in the treatment area following the HIFU ablation.

MATERIALS AND METHODS

HIFU ablation was carried out in 14 patients with small HCCs (≤3 lesions, ≤3cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under ultrasound guidance. The evaluations were performed by follow-up CT at 1 week, 1, 3, 6 and 12 months after the HIFU ablation.

RESULTS

HIFU ablation was carried out successfully in 11 of the 14 patients. At 1 week after the HIFU, a peripheral rim enhancement was found in all cases (100%). This finding was persistent in 6 of the 11 cases (54.5%) at 1 month, and in 1 of the 11 (9%) cases at 3 months after HIFU ablation. In all cases, the rim enhancement disappeared by 6 or 12 months after the HIFU ablation. At the 12 months follow-up, a decrease in the diameter of the ablated lesions was found. The enhancement around the treated area was found to be persistent at the 12 months follow-up in the one case of recurrence of the treated site in which the safety margin was not sufficiently wide. During the follow-up period, there were 2 cases with residual of HCC tumors. We performed radiofrequency ablation (RFA) for these residual tumors after the HIFU ablation.

CONCLUSION

To ascertain the cause of the peripheral enhancement on follow-up CT images after the HIFU ablation, in particular, to determine whether it might be caused by residual tumor or recurrence at the treated site, careful follow-up is important, especially in cases where the safety margin of the ablated area was not sufficiently wide.

Usefulness of US-CT 3D dual imaging for the planning and monitoring of hepatocellular carcinoma treatment using HIFU

PURPOSE

We evaluated the safety and usefulness of high-intensity focused ultrasound (HIFU) assisted by ultrasound-computed tomography three-dimensional (US-CT 3D) dual imaging for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

HIFU ablation was performed in 13 patients with small HCC (≤3 lesions, ≤3 cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under ultrasound guidance. By transferring the sagittal or axial plane of the 3D US and the CT volume data into the ZioM900, multiplanar reconstruction images were displayed in a manner resembling conventional monitor US to assist the HIFU treatment.

RESULTS

Overall, 69% (9/13) of the patients in whom good visualization using B-mode sonography could not be obtained because of the influence of multi-reflections, rib shadows, and unclear tumor margins were successfully treated under the guidance of US-CT 3D dual imaging. In 5 of the 13 patients, multi-reflections were responsible for the poor visualization. In 2 cases, the tumor was poorly visualized because of a rib shadow. In one case, the margin of the tumor was too unclear to be detected using ultrasography. The 3D US images obtained as part of the US-CT 3D dual imaging had a high resolution and were useful for examining the area of HCC invasion and for determining the extent of the ablation area. The CT images, which are not influenced by bone shadows or multi-reflections, were useful for detecting the tumors and for visualizing the presence of the intestines in the sonication zone. HIFU treatments were successfully performed in all the patients with the assistance of US-CT 3D dual imaging.

CONCLUSION

US-CT 3D dual imaging is useful for HIFU treatment for HCC, compensating for the occasionally poor visualization provided by US monitor.

Decreased expression of p39 is associated with a poor prognosis in human hepatocellular carcinoma

The aims of this study are to investigate the relationship between p39 expression and clinicopathological parameters of hepatocellular carcinoma (HCC) and to evaluate the prognostic value of p39 for HCC patients. Real-time quantitative PCR and immunohistochemistry was used to measure p39 expression in tumor and adjacent nontumor samples. Relationships of p39 expression with clinical parameters and patient survival were analyzed. Real-time quantitative RT-PCR showed that the quantity of p39 mRNA in cancerous tissue was significantly lower than that in nontumor tissue (P < 0.001). Immunohistochemistry data confirmed that p39 protein was reduced in 64% of HCC. p39 expression was not influenced by chronic alcohol exposure or cirrhosis. Reduction in p39 was correlated with the HBV (P = 0.039), HCV (P = 0.011), and histological grade (P < 0.001). HCC patients with lower p39 expression had poorer overall survival rate than that with high expression (HR, 2.868; 95% CI, 1.451-5.670; P = 0.002). Together with other results, these results reveal that p39 expression was reduced in HCC tissue. p39 could be a useful clinical prognostic marker for hepatocellular carcinoma patients.

Identification of proteins differentially expressed between capillary endothelial cells of hepatocellular carcinoma and normal liver in an orthotopic rat tumor model using 2-D DIGE

Hepatocellular carcinoma (HCC) is one of the deadliest cancers with few treatment options. It is a hypervascular tumor in which angiogenesis plays a critical role in its progression. Tumor capillary endothelial cells (TECs) in HCC are known to originate from liver sinusoid endothelial cells, which then go through a capillarization process to become morphologically as well as functionally different TECs. In this work, we investigated proteins differentially expressed between freshly isolated TECs and sinusoid endothelial cells from well-formed rat HCC using 2-D DIGE coupled with MALDI-TOF/TOF MS. Thirty-eight unique proteins were identified to be differentially expressed more than twofold between the two endothelial cell types. Amongst the differentially expressed proteins, two novel endothelial markers, EH domain-containing protein 3 and galectin-3, were confirmed by Western blot and immunohistochemistry in both rat and human HCC samples. We showed that EH domain-containing protein 3 is significantly down-regulated in TECs, but galectin-3 is up-regulated. We propose possible roles of these two proteins in tumor vessel development in HCC.

Evaluating the potential of (188)Re-ECD/lipiodol as a therapeutic radiopharmaceutical by intratumoral injection for hepatoma treatment

BACKGROUND/OBJECTIVES

Intratumoral injection of a radiopharmaceutical is a potential modality to treat liver tumors. Rhenium-188 ((188)Re) was used to chelate with ethyl cysteinate dimer (ECD) in lipiodol solution to form (188)Re-ECD/lipiodol, which was then evaluated for its therapeutic potential in a rodent hepatoma model.

MATERIALS AND METHODS

Male Sprague-Dawley rats were implanted with N1-S1 hepatoma cells orthotopically and randomly divided into two groups. Group 1 (n = 29) and group 2 (n = 10) received (188)Re-ECD/lipiodol (30.4 +/- 21.8 MBq/0.1 mL) and 0.1 mL of normal saline by intratumoral injection, respectively. Three rats in group 1 were imaged by micro-single-photon emission computed tomography/computed tomography scan to evaluate the biodistribution pattern. All rats were monitored for change of tumor size and survival rate after 2 months.

RESULTS

The in vitro stability test showed that (188)Re-ECD was well-retained in the lipiodol phase for 48 hours. The biodistribution image revealed that radioactivity was retained well in hepatomas 24 hours postinjection. Long-term studies demonstrated that rats treated with (188)Re-ECD/Lipiodol had smaller tumor volumes and a better survival rate, compared to the control group. At the end of observation, the survival rates in groups 1 and 2 were 62% and 20%, respectively (p < 0.05).

CONCLUSIONS

(188)Re-ECD/lipiodol via direct intratumoral injection shows potential for treating hepatoma and warrants further clinical trials.

Second and third hepatectomies for recurrent hepatocellular carcinoma are justified

BACKGROUND

Liver resection is the main curative treatment for hepatocellular carcinoma (HCC), but recurrence rates are high. The remnant liver is the most common site of recurrence, but the role of repeat hepatectomy in the treatment of recurrent HCC is controversial.

METHODS

Patients who underwent curative hepatectomy for HCC and subsequent repeat hepatectomy for recurrent HCC between 1990 and 2007 were reviewed retrospectively. Clinicopathological characteristics, and early- and long-term outcomes of patients who had a first, second, third and fourth hepatectomy were compared.

RESULTS

Some 1177 patients underwent a first hepatectomy for HCC, and 149, 35 and eight patients respectively had a second, third and fourth hepatectomies for recurrence. There were no significant differences in early postoperative outcomes after first and repeat hepatectomies. Five-year disease-free and overall survival rates after first, second and third hepatectomies were 43.6, 31.8 and 33.8 per cent (P = 0.772), and 52.4, 56.4 and 59.4 per cent (P = 0.879), respectively. Patients undergoing second and third hepatectomies for recurrence had better survival rates than those who did not have a repeat hepatectomy, but not those after fourth hepatectomy.

CONCLUSION

Second and third hepatectomies seem justified for hepatic recurrence of HCC. The role of fourth hepatectomy needs further investigation.

Preparation and evaluation of 99mTc(CO)3-labeled pentadecanoic acid derivative and its suspension in lipiodol

Abstract Transarterial embolization by the intra-arterial administration of 131I-lipiodol is a modality used in the treatment of liver cancer. Long-chain fatty acids, being highly lipophilic, are also known to localize in the liver, thus constituting favorable vectors for this modality of treatment. Toward this, we envisaged the derivatization of 15-bromopentadecanoic acid, rendering it suitable for incorporation of a tridentate chelating moiety, for radiolabeling with the [99mTc(CO)3(H2O)3]+ precursor. The complex prepared, being lipophilic, was expected to behave as a lipiodol surrogate. The radiolabeled complex could be obtained in >95% radiochemical yield, as characterized by high-performance liquid chromatography. The intravenous injection of the radiolabeled complex in mice resulted in 23.5% +/- 4.3% uptake of injected dose (ID) organ in the liver at 3 hours postinjection. However, the uptake of the lipiodol suspension of the complex at 3 hours postinjection in the liver was found to be 43.8 +/- 13.4% ID/organ, when injected via the portal vein.

The liver hanging manoeuvre

The liver hanging manoeuvre (LHM) facilitates the anterior approach (AA), which is one of the most important innovations in the field of major hepatic resections. The AA confers some definite advantages over the classical approach, in that it provides for: less haemorrhage; less tumoral manipulation and rupture; better haemodynamic stability by avoiding any twisting of the inferior vena cava; reduced ischaemic damage of the liver remnant, and better survival for patients with hepatocellular carcinoma (HCC). The LHM makes the AA easier because it serves as a guide to the correct anatomical transection plane and elevates the deep parenchymal plane. The LHM is a safe technique, in which minor complications have been reported in < or = 7% of patients and >90% feasibility has been demonstrated in experienced centres. Over the years, different variants of the LHM have been developed to facilitate almost all anatomical liver resections. In view of its advantages, feasibility and safety, the LHM should be considered for most anatomical hepatectomies.

Adjuvant transcatheter arterial chemoembolization improves efficacy of hepatectomy for patients with hepatocellular carcinoma and portal vein tumor thrombus

PURPOSE

To study the value of postoperative transcatheter arterial chemoembolization (TACE) to improve the efficacy of hepatectomy and tumor thrombus removal for patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

EXPERIMENTAL DESIGN

From January 1996 to December 2004, 126 patients with HCC and PVTT were randomly assigned into 2 groups: a control group and a TACE group. The control group underwent liver resection combined with PVTT removal, and the TACE group underwent liver resection combined with adjuvant TACE after surgery. Survival time in the 2 groups was studied.

RESULTS

The 2 groups were comparable with regard to all clinicopathologic data. The median survival time was 13 months (95% confidence interval [CI] 6.25 to 19.75 months) for the TACE group and 9 months (95% CI 6.90 to 11.10 months) for the control group. Estimated survival rates for 1, 3 and 5 years were better in the TACE group (50.9%, 33.8%, 21.5%; respectively) than the control group (33.3%, 17.0%, 8.5%, respectively; log rank P = .0094).

CONCLUSIONS

Postoperative TACE enhances the effect of liver resection combined with PVTT removal for HCC patients with PVTT.

Techniques for liver parenchymal transection in liver resection

BACKGROUND

Blood loss during elective liver resection is one of the main factors affecting the surgical outcome. Different parenchymal transection techniques have been suggested to decrease blood loss.

OBJECTIVES

To assess the benefits and risks of the different techniques of parenchymal transection during liver resections.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (March 2008).

SELECTION CRITERIA

We considered for inclusion all randomised clinical trials comparing different methods of parenchymal dissection irrespective of the method of vascular occlusion or any other measures used for lowering blood loss.

DATA COLLECTION AND ANALYSIS

Two authors identified the trials and extracted the data on the population characteristics, bias risk, mortality, morbidity, blood loss, transection speed, and hospital stay independently of each other. We calculated the odds ratio (OR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals based on 'interntion-to-treat analysis' or 'available case analysis' using RevMan 5.

MAIN RESULTS

We included seven trials randomising 556 patients. The comparisons include CUSA (cavitron ultrasound surgical aspirator) versus clamp-crush (two trials); radiofrequency dissecting sealer (RFDS) versus clamp-crush (two trials); sharp dissection versus clamp-crush technique (one trial); and hydrojet versus CUSA (one trial). One trial compared CUSA, RFDS, hydrojet, and clamp-crush technique. The infective complications and transection blood loss were greater in the RFDS than clamp-crush. There was no difference in the blood transfusion requirements, intensive therapy unit (ITU) stay, or hospital stay in this comparison. There was no significant differences in the mortality, morbidity, markers of liver parenchymal injury or liver dysfunction, ITU, or hospital stay in the other comparisons. The blood transfusion requirements were lower in the clamp-crush technique than CUSA and hydrojet. There was no difference in the transfusion requirements of clamp-crush technique and sharp dissection. Clamp-crush technique is quicker than CUSA, hydrojet, and RFDS. The transection speed of sharp dissection and clamp-crush technique was not compared. There was no clinically or statistically significant difference in the operating time between sharp dissection and clamp-crush techniques. Clamp-crush technique is two to six times cheaper than the other methods depending upon the number of surgeries performed each year.

AUTHORS' CONCLUSIONS

Clamp-crush technique is advocated as the method of choice in liver parenchymal transection because it avoids special equipment, whereas the newer methods do not seem to offer any benefit in decreasing the morbidity or transfusion requirement.

Mesohepatectomy for hepatocellular carcinoma: a study of 256 patients

BACKGROUND

Mesohepatectomy is a rarely used operative procedure to treat liver cancer because of its technical complexity. In patients with hepatocellular carcinoma (HCC) with a viral hepatitic/cirrhotic background, this procedure can be used to resect the tumor with adequate margins, while at the same time preserve as much functioning hepatic parenchyma as possible. This retrospective study aimed to evaluate the early results and late survival outcomes of mesohepatectomy in HCC.

MATERIALS AND METHODS

From 1996 to 2005, 256 patients with HCC situated at the central liver segments (Couinaud segments IV, V, VIII+/-I) were treated with mesohepatectomy. The treatment outcomes of these patients were retrospectively analyzed.

RESULTS

The in-hospital mortality rate was 0.4%, but the postoperative morbidity rate was 28.1%. The 1-, 3-, and 5-year overall survival rates were 77.0, 49.8, and 35.1%, while the 1-, 3-, and 5-year disease-free survival rates were 59.1, 28.8, and 17.0%, respectively. Multivariate analyses showed the significant factors for overall survival were tumor size>8 cm, vascular invasion, and alpha fetoprotein (AFP)>5,000 ng/ml; and for disease-free survival were tumor size>8 cm, vascular invasion, tumor number (three or more), AFP>5,000 ng/ml.

CONCLUSION

Mesohepatectomy is a safe and effective treatment for a centrally situated HCC with a viral hepatitic/cirrhotic background.

Central hepatectomy: the golden mean for treating central liver tumors?

The treatment of patients with central liver tumors involving segments 4, 5 and 8 is a difficult clinical problem. These tumors often straddle Cantlie's line and involve parts of both lobes of the liver. The traditional management of such tumors is to perform either an extended right or an extended left hepatectomy. However, extended hepatectomies are associated with greater morbidity and mortality, mainly due to increased risk of postoperative liver failure. Central hepatectomy (or mesohepatectomy) may be superior to extended hepatectomy, because it conserves more liver parenchyma. However, the operation can be tedious and may result in increased blood loss, and was therefore infrequently used. Recommendations for its application for centrally located tumors are not clear. The aim of our study is to evaluate the evidence supporting central hepatectomy as a safe procedure for the management of central hepatic tumors, and to describe the effectiveness of central hepatectomy compared to extended hepatectomy. We present herein two patients who underwent central hepatectomy and systematically review the English literature until December 2006. We found 13 studies of multisegmental (> or = 2 segments) central liver resection that included at least four patients. Only three retrospective non-randomized studies have looked at central hepatectomy in comparison to lobar or extended hepatectomy, and no clear consensus emerges. To date, there is insufficient evidence to categorically state that central hepatectomy is superior to extended hepatectomy, thus the use of all approaches can be justified. However, if central hepatectomy can be performed without excessive blood loss, then it should be preferred, as it is less extensive and results in greater functional remnant liver. Additionally, it would clearly be superior in patients with cirrhosis.

Three-dimensional conformal radiotherapy of unresectable hepatocellular carcinoma patients for whom transcatheter arterial chemoembolization was ineffective or unsuitable

OBJECTIVES

To evaluate 3-dimensional conformal radiotherapy (3D-CRT) of unresectable hepatocellular carcinoma (HCC) patients for whom transcatheter arterial chemoembolization (TACE) was ineffective or unsuitable, and to determine whether tumor response and portal vein thrombosis (PVT) response to treatment were prognostic factors for overall survival.

METHODS

From July 2001 to June 2005, 70 unresectable HCC patients were treated with 3D-CRT; PVT was present in 41 patients. A daily radiation dose ranging from 2 to 3 Gy was administered using 6 or 15 MV x-rays to deliver a total dose between 44 and 54 Gy.

RESULTS

Of 70 patients, follow-up computed tomography showed that primary tumor responses were complete response (CR) in 4 (5.7%) patients, partial response (PR) in 34 (48.6%), no response (NR) in 28 (37.1%), and progressive disease (PD) in 4 (8.6%). Of 41 patients with PVT, PVT responses were CR in 4 (9.7%) patients, PR in 12 (29.3%), NR in 20 (48.8%), and PD in 5 (12.2%). The median survival times were 18.0 and 20.1 month in the primary tumor and the PVT responders (CR + PR), respectively, which were longer than the 6.8 and 7.2 months in the primary tumor and the PVT nonresponders (NR + PD), respectively.

CONCLUSIONS

3D-CRT was associated with a 54.3% objective response rate for primary tumors and a 39.0% objective response rate for PVT. Both primary tumor and PVT responses were found to be prognostic factors for overall survival. The present results suggest 3D-CRT is a practical treatment option in HCC patients for whom TACE is ineffective or unsuitable.

Comparison of clinical staging systems in predicting survival of hepatocellular carcinoma patients receiving major or minor hepatectomy

AIM

To compare the utility of seven commonly used staging systems in the prediction of survival among patients with hepatocellular carcinoma (HCC) undergoing major or minor hepatectomy.

METHODS

All patients were classified by the Okuda, the TNM, the CLIP, the BCLC, the CUPI, the JIS and the MELD classifications to estimate the probabilities of survival. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated using linear trend chi(2) tests and from the area under the receiver operating characteristic (ROC) curve.

RESULTS

In our patient cohort, the log-rank test and the linear trend chi(2) test of the CLIP and JIS systems gave better results than did the other staging systems. The discriminatory ability of the CLIP and JIS staging for death, evaluated by ROC curve areas, was also better. In the subgroups of major hepatectomy patients with a non-cirrhotic liver or minor hepatectomy patients with a cirrhotic liver, the CLIP and JIS systems showed similar better performances in these three tests. The discriminatory ability of the CLIP system was the best in major hepatectomy patients with a non-cirrhotic liver while JIS score discriminated best in minor hepatectomy patients with a cirrhotic liver.

CONCLUSION

Among the seven staging systems, the CLIP and JIS systems perform better than do the others. While the CLIP system should be considered to stage major hepatectomy patients, the JIS system could be chosen to stage minor hepatectomy patients.

Combination therapy of intraarterial 5-fluorouracil and systemic interferon-alpha for advanced hepatocellular carcinoma with portal venous invasion

BACKGROUND

Hepatocellular carcinoma (HCC) with portal venous invasion (PVI) has a very poor prognosis, with a median survival of 3 months and virtually no survival at 1 year. The combination of intraarterial 5-fluorouracil (FU) and systemic interferon-alpha (IFNalpha) was recently reported to be effective against HCC with PVI, but these were small pilot studies.

METHODS

One hundred and sixteen patients with HCC with PVI received IFNalpha (5,000,000 U intramuscularly on Days 1, 3, and 5 of each week of treatment) and 5-FU (500 mg into hepatic artery on Days 1-5 of the first and second week of each 4-week cycle). The therapy was either terminated at the end of the first cycle in cases with progressive disease, or continued for at least 3 cycles, when responses to treatment were evaluated by Eastern Cooperative Oncology Group criteria. The survival rate was compared with that of historical controls (n = 40).

RESULTS

Nineteen (16%) patients showed complete response and another 42 (36%) showed partial response. Adverse events were limited to nausea and appetite loss. The survival rates at 12 and 24 months among overall patients were 34% and 18%, respectively, in contrast to 15% and 5% among the historical controls. Survival rates at 12 and 24 months were 81% and 59% among complete responders, respectively, and 43% and 18% among partial responders.

CONCLUSION

The combination therapy with 5-FU and IFN was safe, and substantially improved the survival rate among the complete responders. These results provide a rationale for future randomized controlled trials.

Results of three-dimensional conformal radiotherapy and thalidomide for advanced hepatocellular carcinoma

PURPOSE

To evaluate the effectiveness of three-dimensional conformal radiotherapy and thalidomide in the treatment of advanced hepatocellular carcinoma.

METHODS

Between 1999 and 2003, 121 patients (mean age, 54.4 +/- 12.4 years; range, 20-81 years) with advanced hepatocellular carcinoma received three-dimensional conformal radiotherapy and thalidomide. Radiation was delivered in 1.5 Gy fractions twice daily for 5 days a week, for a total dose of 45-75 Gy. Mean treatment volume was 429.52 +/- 408.50 cm(3) (range, 26.89-2284.82 cm(3)). Thalidomide was given concomitantly: 200 mg/day in 109 patients, 300 mg/day in 8 patients and 400 mg/day in 4 patients. Treatment responses, survival rates and factors affecting survival were analyzed.

RESULTS

Treatment responses were observed in 61% of the patients. Liver cirrhosis (P = 0.001) and tumor size (P = 0.001) significantly affected the tumor responses. Overall survival at 6, 12 and 24 months was 84.8, 60.0 and 44.6%, respectively. On univariate analysis, liver cirrhosis (P = 0.003), Karnofsky performance status (P = 0.007), tumor size (P < 0.001), portal vein tumor thrombosis (P < 0.001) and alpha-fetoprotein level (P = 0.003) were shown to significantly affect survival. On multivariate analysis, only thrombosis (P = 0.039) and alpha-fetoprotein level (P = 0.006) were shown to be factors affecting survival.

CONCLUSIONS

Three-dimensional conformal radiotherapy with thalidomide seems to be effective in the treatment of advanced hepatocellular carcinoma.

Perioperative parenteral tranexamic acid in liver tumor resection: a prospective randomized trial toward a "blood transfusion"-free hepatectomy

OBJECTIVE

To examine the feasibility of a real "blood transfusion"-free hepatectomy in a large group of patients with liver tumors.

SUMMARY BACKGROUND DATA

Bleeding control and blood transfusion remains problematic in liver resection. A real "blood transfusion"-free hepatectomy in a large group of patients has rarely been reported. The impact of tranexamic acid (TA), an antifibrinolytic agent, on blood transfusion in liver resection is unknown.

METHODS

A prospective double-blind randomized trial was performed on elective liver tumor resections. In group A, TA 500 mg was intravenously administered just before operation followed by 250 mg, every 6 hours, for 3 days. In group B, only placebo was given. The patients' background, blood transfusion rates, and early postoperative results in the 2 groups were compared. Factors that influenced blood requirement were analyzed.

RESULTS

There were 108 hepatectomies in group A and 106 hepatectomies in group B. The patients' backgrounds, operative procedures, and hepatectomy extent did not significantly differ between the 2 groups. Although the differences of the operative morbidity and postoperative stay were not significant, a significantly lower amount of operative blood loss, lower blood transfusion rate, shorter operative time, and lower hospital costs were found in group A patients. No patient in group A received blood transfusion. No hospital mortality occurred in either group. Tumor size and use of TA were independent factors that influenced blood transfusion.

CONCLUSIONS

Perioperative parenteral use of TA reduced the amount of operative blood loss and the need for blood transfusion in elective liver tumor resection. A real "blood transfusion"-free hepatectomy may be feasible with the assistance of parenteral TA.

Risk factors for immediate post-operative fatal recurrence after curative resection of hepatocellular carcinoma

AIM: To investigate the clinicopathological risk factors for immediate post-operative fatal recurrence of hepatocellular carcinoma (HCC), which may have practical implication and contribute to establishing high risk patients for pre- or post-operative preventive measures against HCC recurrence.

METHODS: From June 1994 to May 2004, 269 patients who received curative resection for HCC were reviewed. Of these patients, those who demonstrated diffuse intra-hepatic or multiple systemic recurrent lesions within 6 mo after surgery were investigated (fatal recurrence group). The remaining patients were designated as the control group, and the two groups were compared for clinicopathologic risk factors.

RESULTS: Among the 269 patients reviewed, 30 patients were enrolled in the fatal recurrence group. Among the latter, 20 patients showed diffuse intra-hepatic recurrence type and 10 showed multiple systemic recurrence type. Multivariate analysis between the fatal recurrence group and control group showed that pre-operative serum alpha-fetoprotein (AFP) level was greater than 1 000 μg/L (  P= 0.02; odds ratio = 2.98), tumor size greater than 6.5 cm (P  = 0.03; OR = 2.98), and presence of microvascular invasion (P  = 0.01; OR = 4.89) were the risk factors in the fatal recurrence group. The 48.1% of the patients who had all the three risk factors and the 22% of those who had two risk factors experienced fatal recurrence within 6 mo after surgery.

CONCLUSION: Three distinct risk factors for immediate post-operative fatal recurrence of HCC after curative resection are pre-operative serum AFP level > 1 000 μg/L, tumor size > 6.5 cm, and microvascular invasion. The high risk patients with two or more risk factors should be the candidates for various adjuvant clinical trials.

Hepatectomy as Treatment of Choice for Hepatocellular Carcinoma in Elderly Cirrhotic Patients

In recent decades liver resection has become a safe procedure; however, the outcome of hepatectomies in aged cirrhotic patients is often uncertain. To elucidate early and long-term outcomes of hepatectomy for HCC in the elderly, we studied 241 cirrhotic patients who underwent liver resection for HCC between 1985 and 2003. According to their age at the time of surgery, patients were divided into two groups: aged > 70 years (64 patients) and aged < or = 70 years (177 patients). Operative mortality was 3.1% in the elderly and 9.6% in the younger group (p = 0.113). Postoperative morbidity and liver failure rates were higher in the younger group (42.4% versus 23.4%, p = 0.0073; 12.9% versus l.6%, p = 0.0065). Five-year survival rates are 48.6% in the elderly group and 32.3% in the younger group (p = 0.081). Considering only radical resections in Child-Pugh A patients, survival remains similar in the two groups (p = 0.072). Disease-free survival is not different in the two groups. A survival analysis performed according to the tumor diameter shows a better survival for elderly Child-Pugh A patients with HCC larger than 5 cm radically resected (50.8% versus 16.1% 5-year survival, p = 0.034). In univariate analysis, tumor size is not a prognostic factor in the elderly, whereas younger patients with large tumors have a worse outcome. Age by itself is not a contraindication for surgery, and selected cirrhotic patients with HCC who are 70 years of age or older could benefit from resection, even in the presence of large tumors. Long-term results of liver resections for HCC in the elderly may be even better than in younger patients.

An integrated data analysis approach to characterize genes highly expressed in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the major causes of cancer deaths worldwide. New diagnostic and therapeutic options are needed for more effective and early detection and treatment of this malignancy. We identified 703 genes that are highly expressed in HCC using DNA microarrays, and further characterized them in order to uncover novel tumor markers, oncogenes, and therapeutic targets for HCC. Using Gene Ontology annotations, genes with functions related to cell proliferation and cell cycle, chromatin, repair, and transcription were found to be significantly enriched in this list of highly expressed genes. We also identified a set of genes that encode secreted (e.g. GPC3, LCN2, and DKK1) or membrane-bound proteins (e.g. GPC3, IGSF1, and PSK-1), which may be attractive candidates for the diagnosis of HCC. A significant enrichment of genes highly expressed in HCC was found on chromosomes 1q, 6p, 8q, and 20q, and we also identified chromosomal clusters of genes highly expressed in HCC. The microarray analyses were validated by RT-PCR and PCR. This approach of integrating other biological information with gene expression in the analysis helps select aberrantly expressed genes in HCC that may be further studied for their diagnostic or therapeutic utility.

Advanced hepatocellular carcinoma: treatment with high-intensity focused ultrasound ablation combined with transcatheter arterial embolization

PURPOSE

To evaluate ultrasonographically (US)-guided high-intensity focused ultrasound ablation combined with transcatheter arterial chemoembolization (TACE) in the treatment of stage IVA hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. From November 1998 to May 2000, 50 consecutive patients with stage IVA HCC (TNM classification, T4N0-1M0) were alternately enrolled in one of two treatment groups: group 1 (n = 26), in which TACE was performed alone, and group 2 (n = 24), in which transcutaneous ablation of HCC with high-intensity focused ultrasound was performed 2-4 weeks after TACE. The tumors were 4-14 cm in diameter (mean, 10.5 cm). Immediate therapeutic effects were assessed at follow-up with Doppler US and computed tomography or magnetic resonance imaging. All patients were followed up for 3-24 months (mean, 8 months) to observe long-term therapeutic effects and complications in both groups. Tumor reduction rates, median survival time, and cumulative survival rates in both groups were calculated by using the unpaired Student t test and Kaplan-Meier method.

RESULTS

No severe complication was observed after focused ultrasound ablation, and no unexpected side effects were noted after TACE. Follow-up images showed absence or reduction of blood supply in the lesions after focused ultrasound ablation when compared with blood supply after TACE alone. The median survival time was 11.3 months in group 2 and 4.0 months in group 1 (P = .004). The 6-month survival rate was 80.4%-85.4% in group 2 and 13.2% in group 1 (P = .002), and the 1-year survival rate was 42.9% and 0%, respectively. Median reductions in tumor size as a percentage of initial tumor volume at 1, 3, 6, and 12 months after treatment, respectively, were 28.6%, 35.0%, 50.0%, and 50.0% in group 2 and 4.8%, 7.7%, 10.0%, and 0% in group 1 (P < .01).

CONCLUSION

The combination of high-intensity focused ultrasound ablation and TACE is a promising approach in patients with advanced-stage HCC, but large-scale randomized clinical trials are necessary for confirmation.