Hepatocellular carcinoma in elderly patients: beneficial therapeutic efficacy using percutaneous ethanol injection therapy

Selective internal radiation therapy in older patients with hepatocellular carcinoma: a retrospective analysis

BACKGROUND

Selective internal radiation therapy (SIRT) is applied to hepatocellular carcinoma (HCC), a disease with increased incidence in the elderly. However, SIRT has rarely been specifically studied in elderly population. The aim of this study was to investigate efficacy and safety of SIRT in elderly HCC patients.

METHODS

We studied retrospectively data from patients treated with SIRT for HCC. Clinical and laboratory data were retrieved. We used 70-years old as threshold between younger and elderly populations, to compare outcomes.

RESULTS

A total of 222 patients treated with SIRT for HCC were studied, of which 134 patients were younger and 88 older. Median overall survival (OS) was not significantly different between younger and elderly group: 15.6 months (95% CI, 11.7-19.5) and 14.8 months (95% CI, 9.4-20.3) (P = 0.86). Age was not associated with OS in multivariable analysis, with a Hazard ratio of 1.09 (95% CI, 0.82-1.45, P = 0.55). Results of progression-free survival and responses were also similar in both groups. Toxicities were similar between the two groups, including the occurrence of radioembolization-induced liver disease (11.5 vs. 11.4%, P = 0.97).

CONCLUSION

SIRT appears to be a well-tolerated treatment with the same efficacy in elderly compared to younger patients in HCC. Our study is the first to study its impact with glass microspheres. This warrants confirmation in large prospective studies.

Review of clinical tumor ablation advance in Asia

Tumor ablation has been widely applied in Asia, accounting for 44.65% of clinical studies worldwide. We reviewed 5853 clinical studies to provide insight on the advance of tumor ablation in Asia chronologically and geographically among different techniques and organs. Since 1998, tumor ablation application has dramatically evolved in Asia. All kinds of ablation techniques, including percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation (LA), cryoablation (CA), high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE), have been applied, with the first application of PEI and the most popular application of RFA. Twenty-five countries and one district in Asia have applied tumor ablation in various organs, including liver, lung, uterus, thyroid, kidney, pancreas, bone, prostate, breast, adrenal gland, lymph node parathyroid, esophagus, etc. Due to the high incidence of tumors as well as advanced economy and technology, East Asia accounted for 93.87% of studies, led by China (45.00%), Japan (32.72%), South Korea (12.10%), and Taiwan (4.03%). With the enrichment of evidence from large-scale multicenter and randomized control studies, China and South Korea have issued several guidelines on tumor ablation for liver, lung, and thyroid, which provided recommendations for global standardization of tumor ablation techniques. Therefore, Asia has made active contribution to global tumor ablation therapy.KeypointsKey point 1: Asia accounted for 44.65% of clinical studies worldwide on tumor ablation.Key point 2: Twenty-five countries and one district in Asia have used tumor ablation in various organs, and East Asia accounted for 93.87% of studies, led by China (45.00%), Japan (32.72%), South Korea (12.10%), and Taiwan (4.03%).Key point 3: China and South Korea have issued several guidelines on tumor ablation for liver, lung, and thyroid, which provided recommendations for global standardization of tumor ablation techniques.

New landscapes and horizons in hepatocellular carcinoma therapy

Hepatocellular carcinoma (HCC), is the sixth most frequent form of cancer and leads to the fourth highest number of deaths each year. HCC results from a combination of environmental factors and aging as there are driver mutations at oncogenes which occur during aging. Most of HCCs are diagnosed at advanced stage preventing curative therapies. Treatment in advanced stage is a challenging and pressing problem, and novel and well-tolerated therapies are urgently needed. We will discuss further advances beyond sorafenib that target additional signaling pathways and immune checkpoint proteins. The scenario of possible systemic therapies for patients with advanced HCC has changed dramatically in recent years. Personalized genomics and various other omics approaches may identify actionable biochemical targets, which are activated in individual patients, which may enhance therapeutic outcomes. Further studies are needed to identify predictive biomarkers and aberrantly activated signaling pathways capable of guiding the clinician in choosing the most appropriate therapy for the individual patient.

A Review of Hepatocellular Carcinoma in Elderly Patients Focused on Management and Outcomes

Recent studies report a significant age-specific increase in hepatocellular carcinoma (HCC) development among persons over 75 years old. Therefore, there is an urgent need to determine the optimal treatment strategy in elderly patients with HCC. This systemic review examines the clinical characteristics, efficacy, and safety of first-line treatment modalities. The literature was searched regarding epidemiology and clinical outcomes in elderly patients (age ≥75 years) undergoing first-line treatment for HCC. Causative or comorbid conditions of HCC in elderly patients differed from those in younger patients. Radiofrequency ablation may be effective and safe in early stages. Surgical resection may also be feasible in the early stages for selected patients. Transarterial chemoembolization may be safe and effective for intermediate HCC, and sorafenib may be feasible in elderly patients with advanced HCC. Prospective randomized trials are needed to establish the treatment strategy for elderly patients with HCC.

Cirrhotic patients and older people

The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities, and age is a risk factor for mortality in cirrhotic patients. The incidence of non-alcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients < 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed. This review suggests that comorbidities have a considerable impact on older cirrhotic patients.

Geriatric assessment as a predictor of postoperative complications in elderly patients with hepatocellular carcinoma

BACKGROUND

Older patients are considered to have increased risk for complications after major surgery, but age alone is not a reliable predictor of postoperative complications. However, no universal screening test adequately predicts postoperative complications in older patients. This prospective study recorded pertinent baseline geriatric assessment variables to identify risk factors for postoperative complications in hepatocellular carcinoma (HCC) for patients aged ≥70 years who undergo hepatectomy.

METHODS

We retrospectively analyzed 71 consecutive patients ≥70 years of age. Patients had geriatric assessments of baseline and later cognition, nutritional and functional status, and burden of comorbidities, completed preoperatively and at 1, 3, and 6 months postoperatively. Postoperative morbidities were recorded.

RESULTS

Postoperative morbidities developed in 18 patients (25 %). Univariate analysis identified serum albumin, operating time and blood loss, cirrhosis, geriatric 8 (G8), and Mini Nutritional Assessment as possible risk factors for postoperative complications, but only G8 < 14 survived multivariate analysis as an independent predictor of complications.

CONCLUSIONS

Our findings indicate that the G8 score, based on patients' nutritional assessments, is a useful screening method for older HCC patients who qualify for elective liver resection. Preoperative G8 scores can help forecast postoperative complications in older HCC patients. Future studies with larger numbers of patients, limited to HCC and liver resections, are needed to verify our results.

Management strategies for hepatocellular carcinoma: old certainties and new realities

Hepatocellular carcinoma (HCC) is a highly prevalent disease ranking among the ten most common cancers worldwide with increasing trend of incidence in most developed countries. The great healthcare costs and economic burden of HCC dictate proper preventive interventions as well as surveillance and screening programs to decrease disease incidence and allow early diagnosis. HCC treatment outcomes are affected by several variables, including liver function, patient's performance status, and tumor stage. In line with the Barcelona Clinic Liver Cancer (BCLC) staging curative treatments, such as surgery or radio-frequency ablation, are indicated in early-stage HCC (BCLC-A), and the noncurative treatments are indicated in intermediate and advanced stages of HCC (BCLC-B, C). Transarterial chemoembolization (TACE) represents the treatment of choice for intermediate-stage HCC with Child-Pugh A cirrhosis, and the long-term survival after liver transplantation is inferior to that of early-stage HCCs. In advanced-stage HCC or when complete necrosis is not achieved or early recurrence after TACE develops, individualized treatments such as systemic treatment or combined radiation therapy are indicated. The increasing knowledge of the genomic landscape of HCC and the development of molecular-targeted therapies is heading toward expanding the armamentarium for HCC management.

Comparison of treatment safety and patient survival in elderly versus nonelderly patients with advanced hepatocellular carcinoma receiving sorafenib combined with transarterial chemoembolization: a propensity score matching study

Aims

This retrospective study was carried out to compare the outcomes between elderly (≥70 years of age) and nonelderly patients (<70 years of age) with advanced hepatocellular carcinoma (HCC) who received sorafenib combined with transarterial chemoembolization (TACE).

Methods

88 patients with a confirmed diagnosis of advanced HCC were enrolled in this study. Of these, 24 elderly patients were matched with 48 nonelderly patients at a 1:2 ratio using propensity score matching to minimize selection bias. The related adverse events and survival benefits were compared between the two groups.

Results

Sorafenib combined with TACE was equally well tolerated in both age groups, and grade 3 or 4 adverse events were similarly observed in 54.2% of elderly and 50.0% of nonelderly patients (P = 0.739). There were no significant differences in survival time between the elderly and nonelderly patients (P = 0.876). Significant prognostic factors for overall survival as identified by multivariate analysis were the Child–Pugh score and portal vein invasion.

Conclusions

Sorafenib combined with TACE may be well tolerated and effective in elderly patients with advanced HCC. Age alone is not a parameter for the treatment of advanced HCC patients.

Long-term outcome of elderly patients (75 years or older) with hepatocellular carcinoma

AIM

The aim of this study was to evaluate the long-term outcome of elderly patients with hepatocellular carcinoma (HCC) aged 75 years or older.

METHODS

The study included 422 patients with HCC, who were divided into two age groups: 75 years or older (n = 140) and younger than 75 (n = 282). Outcomes were compared between the two groups.

RESULTS

The number of elderly patients treated with supportive care alone (33 patients; 24%) was significantly higher than younger patients (30 patients; 11%, P < 0.01). The 1-, 3-, 5- and 7-year overall survival rates of the elderly patients (81%, 55%, 39% and 23%, respectively) were worse than those of younger patients (85%, 64%, 49% and 36%, respectively, P = 0.042). However, the overall survival rate of the elderly group after excluding 63 patients treated with supportive care alone, was similar to that of the younger group (P = 0.615). Multivariate analysis identified age, total bilirubin levels, albumin levels, serum des-γ-carboxy prothrombin levels, tumor size, number of HCC nodules, vascular invasion, extrahepatic metastasis and treatment modality as independent and significant factors of overall survival.

CONCLUSION

Advanced age is a negative prognostic factor in patients with HCC due to the tendency for frequent use of conservative treatment rather than locoregional or surgical treatment.

Comparison of the survival and tolerability of radioembolization in elderly vs. younger patients with unresectable hepatocellular carcinoma

BACKGROUND & AIMS

The European Network on Radioembolization with Yttrium-90 resin microspheres study group (ENRY) conducted a retrospective study to evaluate the outcomes among elderly (≥ 70 years) and younger patients (<70 years) with unresectable hepatocellular carcinoma (HCC) who received radioembolization at 8 European centers.

METHODS

Patients with confirmed diagnosis of unresectable HCC who either progressed following resection or locoregional treatment and/or who were considered poor candidates for chemoembolization were evaluated by a multidisciplinary team for radioembolization with (90)Y-resin microspheres (SIR-Spheres; Sirtex Medical). The survival outcome and all adverse events were compared between the two age groups.

RESULTS

Between 2003 and 2009, 128 elderly and 197 younger patients received radioembolization. Patients in both groups had similar demographic characteristics. Many elderly and younger patients alike had multinodular, BCLC stage C disease, invading both lobes (p = 0.648). Elderly patients had a lower tumor burden, a smaller median target liver volume (p = 0.016) and appeared more likely to receive segmental treatment (p = 0.054). Radioembolization was equally well tolerated in both cohorts and common procedure-related adverse events were predominantly grade 1-2 and of short duration. No significant differences in survival between the groups were found (p = 0.942) with similar median survival in patients with early, intermediate or advanced BCLC stage disease.

CONCLUSIONS

Radioembolization appears to be as well-tolerated and effective for the elderly as it is for younger patients with unresectable HCC. Age alone should not be a discriminating factor for the management of HCC patients.

Hepatocellular carcinoma in the elderly: clinical characteristics, treatment, survival analysis in Korean patients older than 70 years

The prevalence of hepatocellular carcinoma (HCC) has increased in recent years. However, HCC remains poorly characterized in elderly patients, and comprehensive data are limited. This study aimed to investigate the clinical characteristics, prognostic features and survival outcome of elderly HCC patients. We retrospectively analyzed 992 HCC patients treated at Dongsan Hospital from January 2003 to December 2007. The patients were divided into two age groups: < 70 yr (n = 813) and ≥ 70 yr (n = 179). Elderly HCC patients, compared to younger patients, had significantly higher incidence of females (31.3% vs 18.9%, P = 0.001), hepatitis C-related disease (HCV antibody positivity 26.3% vs 9.2%, P = 0.001) and comorbid condition (53.6% vs 32.1%), but lower rates of hepatitis B-related disease (HBs antigen positivity 31.3% vs 69.4%, P = 0.001). There were no significant differences in underlying liver function, stage and survival outcomes. Factors significantly influencing the prognosis of HCC were Child-Pugh grade, number of HCC, level of alpha-fetoprotein, presence of metastasis. The survival outcome of older patients with HCC was not different from that of younger patients. There were no differences between groups in independent factors influencing the prognosis of HCC. Therefore, determining the optimal management strategy for elderly HCC patients is important to improve survival and long-term outcomes.

Evaluation of transarterial chemoembolization combined with percutaneous ethanol ablation for large hepatocellular carcinoma

AIM: To assess the effects of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol ablation (PEA) in patients with large hepatocellular carcinoma (HCC).

METHODS: A total of 63 patients with unresectable large HCC were treated with TACE followed by PEA. The largest dimension of the tumors ranged from 5.3 cm to 17.8 cm. The survival rates, acute effects, toxicity and prognostic factors were analyzed.

RESULTS: The cumulative survival rates at 1, 3 and 5 years were 59.4%, 28.4% and 15.8%, respectively (a median survival of 27.7 mo). Tumor area was reduced by more than 50% in 30 (47.6%) cases. In 56 cases with increased α-fetoprotein (AFP) values, AFP level was declined by more than 75%. The combined therapy was generally well tolerated. Only two patients died from variceal bleeding associated with the therapy. The Cox proportional hazards model showed that the number of tumors, the tumor margin and the ethanol dose were independent prognostic factors.

CONCLUSION: The combined TACE and PEA therapy is a promising approach for unresectable large HCC.

Simultaneous injection of autologous mononuclear cells with TACE in HCC patients; preliminary study

BACKGROUND

The discovery of the pluripotent stem cells made the prospect of cell therapy and tissue regeneration a clinical reality, especially with the evidence of contribution of the stem cells of bone marrow origin in hepatic regeneration. Infusion of bone marrow stem cells before trans-arterial chemoembolization may help to increase liver volume and consequently increase hepatic reserve in patients with HCC, and this may improve the outcome of this procedure.

MATERIALS AND METHODS

Four Child B class patients with unresectable hepatocellular carcinoma treated by transarterial chemoembolization were injected with autologous bone marrow mononuclear layer containing stem cell in the hepatic artery feeding the contralateral lobe of the liver in the same session, follow-up of the patients was done by doing liver profile and CT liver volumetry before the surgery and 3 months later.

RESULTS

We observed that patients receiving stem cell therapy simultaneously with TACE had shown a significant improvement in biological and volumetric parameters of liver function compared to those historically reported of patients receiving TACE only who usually shows deterioration of liver parameters.

CONCLUSION

BMC infusion into the hepatic artery synchronized with TACE for patients with chronic liver disease complicated with HCC is safe, feasible, and demonstrated an improvement in both biological and radiological volumetric parameters.

Optimal treatment increased survival of hepatocellular carcinoma patients detected with community-based screening

BACKGROUND AND AIM

The early detection of hepatocellular carcinoma (HCC) and opportunity to select appropriate treatment are important benefits of HCC screening. Our aim in the present study was to investigate the survival rate, prognostic factors and treatment effects in HCC patients of community-based screening.

METHODS

Community-based ultrasound (US) screening for HCC in adults with platelet counts (< 150 x 10(3)/mm(3)) and/or alpha fetoprotein (AFP) > 20 ng/mL was conducted in 2002 and 2004. As per the Barcelona Clinic Liver Cancer (BCLC) stage, 90 cases of intermediate or earlier stage HCC were detected and 88 cases had sufficient information for analysis (49 men and 39 women, aged 65.8 +/- 9.6 years). The tumor diameter was mostly less than 5 cm (76.1%). The follow up was continued until June 2008.

RESULTS

The 4-year overall survival rate was 46.8%. Old age (> or = 70 years) (P = 0.046), later stage of HCC (intermediate vs earlier) (P = 0.012), low platelet count (< 100 x 10(3)/mm(3)) (P = 0.013) and refusal of modern treatment (P = 0.026) were independent poor prognostic factors. Curative treatment increased survival in patients of all ages. Both curative treatment and transcatheter arterial embolization (TAE) increased survival in cases of intermediate HCC. However, treatment benefits were not found for patients with (very) early stage HCC.

CONCLUSIONS

Early detection and prompt treatment of HCC leads to increased survival. For elderly patients this benefit was seen only for early stage cases receiving curative treatment. Differences between treatment types for patients with (very) early stage HCC might emerge with a longer follow-up period.

Radiofrequency ablation therapy for hepatocellular carcinoma in elderly patients

BACKGROUND AND AIM

With the aging of society, the number of elderly patients with hepatocellular carcinoma (HCC) has been increasing in Japan. The Government of Japan defines elderly as being over 65 and has divided the elderly into two stages: the first elderly stage (< 75 years old) and the second elderly stage (> or = 75). We investigated the efficacy and safety of radiofrequency ablation therapy (RFA) in patients in the second elderly stage in comparison with other HCC patients, retrospectively.

METHODS

Two hundred six patients with HCC, who were within the Milan criteria, with low-grade performance status (0 or 1) and a Child-Pugh classification of A or B were enrolled. All were treated with RFA from January 2000 to December 2008 as an initial therapy and were divided into elderly HCC group (e-HCC group; > or = 75, n = 63) and non e-HCC group (< 75, n = 143), and their clinical data and survival rates were compared.

RESULTS

Age and the level of protein induced by vitamin K absence or antagonist (PIVKA-II) were higher in the e-HCC group as compared with the non e-HCC group (78.3 +/- 3.2 vs 64.2 +/- 7.5 years, 676.3 +/- 2643.7 vs 142.4 +/- 442.2 mAU/mL: P < 0.01, respectively). There were no significant differences for Child-Pugh class, tumor node metastasis stage, and Japan Integrated Stage score and in survival rates after 3, and 5 years between the groups (e-HCC group: 82.5% and 49.7%, respectively; non e-HCC group: 78.3% and 57.5%, respectively). There were no severe complications in the e-HCC group.

CONCLUSIONS

Elderly HCC patients, who have good performance status, should be treated in the same manner and with the same strategy as young HCC patients.

Thermal ablation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infection. Patients with cirrhosis are at the highest risk of developing HCC and should be monitored every 6 months to diagnose the tumour at an early, asymptomatic stage. Patients with early-stage HCC should be considered for any of the available curative therapies, including surgical resection, liver transplantation and percutaneous image-guided ablation. Liver transplantation is the only option that provides cure of both the tumour and the underlying chronic liver disease. However, the lack of sufficient liver donation greatly limits its applicability. Resection is the treatment of choice for HCC in non-cirrhotic patients, who account for about 5% of the cases in western countries. However, in patients with cirrhosis, candidates for resection have to be carefully selected to reduce the risk of postoperative liver failure. It has been shown that a normal bilirubin concentration and the absence of clinically significant portal hypertension are the best predictors of excellent outcomes after surgery. However, less than 5% of cirrhotic patients with HCC fit these criteria. Image-guided percutaneous ablation is the best therapeutic choice for non-surgical patients with early-stage HCC. While ethanol injection has been the seminal percutaneous technique, radiofrequency ablation has emerged as the most effective method for local tumour destruction and is currently used as the primary ablative modality at most institutions.

A primer on transarterial, chemical, and thermal ablative therapies for hepatic tumors

BACKGROUND

Surgical resection is the only potentially curative approach for patients with primary and metastatic liver tumors. Unfortunately, most patients with hepatic malignancy are precluded from resection due to multifocal disease, anatomic limitations, inadequate functional liver reserve, extrahepatic metastases, or medical comorbidities. Consequently, several methods of tumor ablation have been developed as alternate treatment strategies for patients with unresectable hepatic tumors or as adjuncts in total cancer therapy. The purpose of this review is to inclusively define the various ablation modalities available (transarterial, chemical, and thermal ablative), and to describe the procedures, general applications, and reported outcomes.

DATA SOURCES

A MEDLINE and CINAHL search of the English-language literature was performed on transarterial, chemical, and thermal ablative therapies.

CONCLUSIONS

Presently, radiofrequency thermal ablation is the most widely applicable liver-directed modality for hepatic tumor ablation, enabling treatment of primary and metastatic tumors. However, other transarterial and thermoablative techniques are available with accumulating data for their use. Lacking at present are studies that define the role and potential benefit of the various liver-directed modalities in the treatment algorithm for hepatic tumors.

Characteristics at presentation and outcome of hepatocellular carcinoma (HCC) in the elderly. A study of the Cancer of the Liver Italian Program (CLIP)

PURPOSE

To describe the characteristics at presentation and the outcome of elderly patients (> or =70 years old) with HCC, a retrospective analysis using a CLIP database was performed.

PATIENTS AND METHODS

The database included 650 patients. Chi2-test, logistic and Cox model were applied.

RESULTS

Baseline characteristics and stage were similarly among elderly (n=158) and non-elderly (n=492) patients. More elderly patients did not receive any local treatment (56% versus 38%, p<0.0001). Age and CLIP score were independently predictive of the odds of locoregional treatment. Prognosis was worse for elderly patients with a hazard ratio of death of 1.49 (95% CI 1.20-1.86) at multivariable analysis. The survival difference disappeared when patients were compared within each treatment group, suggesting a close link between undertreatment and shorter survival.

CONCLUSION

Elderly patients with HCC have a worse prognosis compared to non-elderly ones. Such difference seems the consequence of undertreatment.

Radiofrequency ablation for hepatocellular carcinoma in so-called high-risk locations

We evaluated the efficacy and safety of radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) in presumably high-risk locations. Between February 1999 and December 2001, we performed RF ablation on 1419 nodules in 636 consecutive HCC patients, of which 231 nodules in 207 patients were in high-risk locations, defined as less than 5 mm from a large vessel or an extrahepatic organ. Eighty-one patients had a nodule adjacent to a large vessel, 145 patients had a nodule adjacent to an extrahepatic organ, of whom 19 also had one adjacent to a large vessel. Early complications and local tumor progression were analyzed with regard to the location of each nodule. The mean nodule diameter and average number per patient were 27 mm and 2.3, respectively. Early complications, within 30 days after ablation, occurred in 12 of 207 patients (5.8%) with a nodule in a high-risk location and in 15 of 429 patients (3.5%) without (P = .1776). There was no significant difference in local tumor progression rate between nodules in high-risk locations (1 year: 2.1%, 2 years: 3.1%, 3 years: 3.1%) and those elsewhere (1 year: 0.6%, 2 years: 1.7%, 3 years: 2.5%) (P = .2745). In conclusion, HCC nodules adjacent to a large vessel or extrahepatic organ were treated with RF ablation without compromising the efficacy of the procedure. However, even though without significant difference, some complications occurred at risky locations and need to be carefully considered.

Impact of age on screening and surveillance for primary liver cancer

OBJECTIVES

Although screening and surveillance for liver cancers have become established practices, the impact of age on these practices is unknown. The age at which these could be stopped, if any, is unclear. Our aims were to assess the impact of age on developing or dying from liver cancer, and to define the relative impact of prematurely stopping screening.

METHODS

Actuarial life-table analyses were performed using age-stratified mortality rates for primary liver cancers, and for all other causes combined, obtained from population-based databases from the United States. The impact of prematurely stopping screening at a given age was expressed as days of life lost compared to the maximal benefit expected from lifelong screening.

RESULTS

Mortality from primary liver cancers increases with age and peaks at 37 per 100,000 persons at ages 85-90 yr. However, mortality from other causes increases even more with age. Consequently, the relative proportion of deaths from primary liver cancer is maximal at 1.34% of all deaths at age 50 yr, and gradually decreases thereafter. Eighty percent of the maximal potential benefit of lifetime screening from age 45 yr is achieved by age 77 yr, and 90% by age 82 yr.

CONCLUSIONS

The relative benefits from screening for primary liver cancer are reduced in the elderly due to competing risks for death despite an increasing incidence of primary liver cancer with age. The majority of societal benefit is gained from screening at younger ages, when the relative proportions of death attributable to liver cancer are the greatest.

Baseline characterization of patients aged 70 years and above with hepatocellular carcinoma

AIM

To characterize the baseline profiles of patients aged 70 years and above with hepatocellular carcinoma (HCC).

METHODS

A series of 127 consecutive patients with HCC were enrolled between 2000 and 2004, and none of them had been diagnosed as having HCC previously. Baseline profiles, including parameters of hepatic function such as serum transaminase and prothrombin time [PT (% activity)] were compared between patients aged > or = 70 and < 70 years.

RESULTS

Patients > or = 70 years old showed significantly lower levels of aspartate aminotransferase (P = 0.04) and alanine aminotransferase (P = 0.01), and significantly higher PTs (P = 0.04) and platelet counts (P = 0.02). Concomitantly, among > or = 70-year-old patients, HCC was more common in non-cirrhotics, whereas among patients < 70 years old, HCC was more common in cirrhotics. There was no significant difference between the groups in the number or size of tumors.

CONCLUSION

Older HCC patients showed less inflammation and better preservation of hepatic function, indicating that not only cirrhotic patients but also non-cirrhotic patients should be considered as a high-risk group among the elderly.

Hepatocellular carcinoma in Egypt: A single center study over a decade

AIM: To identify the trend, possible risk factors and any pattern change of hepatocellular carcinoma (HCC) in Egypt over a decade.

METHODS: All HCC patients attending Cairo Liver Center between January 1993 and December 2002, were enrolled in the study. Diagnosis of HCC was based on histopathological examination and/or detection of hepatic focal lesions by two imaging techniques plus α-fetoprotein level above 200 ng/mL. The duration of the study was divided into two periods of 5 years each; period I (1993-1997) and period II (1998-2002). Trend, demographic features of patients (age, gender, and residence), risk factors (HBsAg, HCV-Ab, schistosomiasis and others) and pattern of the focal lesions were compared between the two periods. Logistic regression model was fitted to calculate the adjusted odds ratios for the potential risk factors. The population attributable risk percentage was calculated to estimate the proportion of HCC attributed to hepatitis B and C viral infections.

RESULTS: Over a decade, 1 328 HCC patients out of 22 450 chronic liver disease (CLD) patients were diagnosed with an overall proportion of 5.9%. The annual proportion of HCC showed a significant rising trend from 4.0% in 1993 to 7.2% in 2002 (P = 0.000). A significant increase in male proportion from 82.5% to 87.6% (P = 0.009); M/F from 5:1 to 7:1 and a slight increase of the predominant age group (40-59 years) from 62.6% to 66.8% (P = 0.387) in periods I and II respectively, reflecting a shift to younger age group. In the bivariate analysis, HCC was significantly higher in rural residents, patients with history of schistoso-miasis and/or blood transfusion. Yet, after adjustment, these variables did not have a significant risk for development of HCC. There was a significant decline of HBsAg from 38.6% to 20.5% (P = 0.000), and a slight increase of HCV-Ab from 85.6% to 87.9% in periods I and II respectively. HBV conferred a higher risk to develop HCC more than HCV in period I (OR 1.9 vs 1.6) and period II (OR 2.7 vs 2.0), but the relative contribution of HBV for development of HCC declined in period II compared to period I (PAR% 4.2%, 21.32%). At presentation, diagnostic α-fetoprotein level (≥200 ng/mL) was demonstrated in 15.6% vs 28.9% and small HCC (≤3 cm) represented 14.9% vs 22.7% (P = 0.0002) in periods I and II respectively.

CONCLUSION: Over a decade, there was nearly a twofold increase of the proportion of HCC among CLD patients in Egypt with a significant decline of HBV and slight increase of HCV as risk factors. α-Fetoprotein played a limited role in diagnosis of HCC, compared to imaging techniques. Increased detection of small lesions at presentation reflects increased awareness of the condition.

A critical appraisal of the literature on local ablative therapies for hepatocellular carcinoma

Image-guided percutaneous ablation is currently accepted as the best therapeutic option for nonsurgical patients with early-stage hepatocellular carcinoma. Ethanol injection is the seminal technique for local tumor treatment, and may achieve 50% 5-year survival in selected Child A patients. Radiofrequency ablation constitutes the most assessed alternative technique. On the basis of the identified evidence, radiofrequency ablation seems to reach higher recurrence-free survival rates compared with ethanol injection. Further randomized trials are needed to establish the clinical efficacy of radiofrequency ablation with respect to other percutaneous treatments and to devise an unbiased therapeutic strategy.

Prognosis of Hepatocellular Carcinoma after Hepatectomy in Patients with Renal Dysfunction

We evaluated the effect of renal dysfunction on the prognosis of hepatocellular carcinoma in 224 patients who underwent hepatic resection. Survival was compared between patients with (57 patients) and without renal dysfunction (116 patients), using a creatinine clearance </=70 ml/min as the cut-off value. There were no significant differences with respect to other preoperative characteristics, operative findings, or histology between the two groups. There was also no difference in survival between the two groups after hepatic resection. However, among 132 patients with a solitary tumor measuring </=5 cm in greatest dimension, the disease-free and overall survival rates of 36 patients with renal dysfunction were significantly worse after resection than those of the patients without renal dysfunction (p = 0.04 and p = 0.0003, respectively). By multivariate analysis, renal dysfunction was an independent factor indicating a poor prognosis for disease-free and overall survival after resection of small solitary tumors (p = 0.0401 and p = 0.0031, respectively). Renal dysfunction did not affect the overall prognosis after resection of hepatocellular carcinoma, but it worsened the prognosis of patients with small solitary lesions.

Evaluation of transcatheter arterial embolization prior to percutaneous tumor ablation in patients with hepatocellular carcinoma: a randomized controlled trial

BACKGROUND

Transcatheter arterial embolization (TAE) may reduce the risk of hepatocellular carcinoma (HCC) recurrence when performed before percutaneous tumor ablation (PTA), either percutaneous ethanol injection therapy (PEIT) or radiofrequency ablation (RFA). We conducted a randomized, controlled trial comparing the use of TAE combined with percutaneous ethanol injection therapy (TAE/PEIT) to the use of PEIT only to assess the effects on HCC recurrence and survival. We continued the study after the introduction of RFA and compared TAE combined with RFA (TAE/RFA) with RFA only.

METHODS

Between March 1997 and April 2001, 42 HCC patients were enrolled who satisfied the following inclusion criteria: (1) uninodular HCC as determined by angiography under computed tomography, (2) arterial hypervascularity, and (3) no prior history of HCC treatment. Twenty-two patients were treated with TAE/PTA (PEIT, 12; RFA, 10) and 20 patients with PTA only (PEIT, 14; RFA, 6).

RESULTS

There were four cases of local recurrence in the PTA-only group and none in the TAE/PTA group (P=0.043). The four patients with local recurrence were treated with PEIT. None of the patients treated with RFA showed local recurrence. The effect of TAE on overall recurrence was not significant (P=0.4179). In the multivariate analysis, prior TAE was not significant for survival (P=0.514).

CONCLUSIONS

TAE has a limited use in suppressing local recurrence when performed before PEIT but not before RFA.

Surveillance for hepatocellular carcinoma in elderly Italian patients with cirrhosis: effects on cancer staging and patient survival

OBJECTIVES

Surveillance of cirrhotic individuals for early detection of HCC, based on ultrasonography (US) and alpha1-fetoprotein (AFP) determination, is a recommended practice currently applied also to elderly patients. However, several age-related factors may jeopardize the results of surveillance in these patients. Aim of the study was to evaluate the benefit of surveillance for HCC in elderly individuals.

METHODS

Multicenter retrospective study on 1,277 consecutive patients with HCC. The inclusion criteria were: underlying chronic liver disease, description of cancer stage, and modalities of its diagnosis. Among the 1,037 patients fulfilling these criteria, 363 aged > or = 70 yr were considered.

RESULTS

The tumor was detected during surveillance, based on US and AFP performed every 6-12 months, in 158 individuals (group 1), incidentally in 138 (group 2) and because of symptoms in 67 (group 3). Surveillance reduced the risk of dealing with an advanced cancer (odds ratio (95% Confidence Interval): 0.18 (0.09-0.37) vs group 3, and 0.29 (0.17-0.49) vs group 2). The frequency of effective treatments decreased from group 1 to group 3 (73%, 57%, and 31%, respectively). The main cause of death was HCC progression. The survival corrected for the lead time of group 1 (median: 24 months) was significantly better than the crude survival of group 3 (7 months; p= 0.003) and barely better than that of group 2 (21 months). The latter also showed a better prognosis with respect to group 3 (p= 0.018).

CONCLUSIONS

Surveillance for HCC improves the survival of elderly cirrhotic patients by expanding the percentage of cancers amenable to effective treatments.

Dosimetric study of boron neutron capture therapy with borocaptate sodium (BSH)/lipiodol emulsion (BSH/lipiodol-BNCT) for treatment of multiple liver tumors

PURPOSE

We performed a computational study to investigate the feasibility of borocaptate sodium (BSH)/lipiodol-boron neutron capture therapy (BSH/lipiodol-BNCT) for multiple liver tumors using Simulation Environment for Radiotherapy Applications (SERA), a currently available BNCT treatment planning system.

METHODS AND MATERIALS

Three treatment plans for BSH/lipiodol-BNCT using two or three epithermal neutron beams in one fraction were generated for 4 patients with multiple liver tumors using the SERA system. The (10)B concentrations in the tumor and the liver assumed in the study were 197.3 and 15.3 ppm, respectively; and were obtained from experimental studies in animals. The therapeutic gain factors for the liver tumors, defined as the minimum dose to the tumor/maximum dose to the liver, and the inhomogeneity index of the thermal neutron fluence for the whole of the liver, defined as the maximum neutron fluence - minimum neutron fluence/mean neutron fluence, were evaluated in each plan.

RESULTS

Three epithermal neutron beams incident on the anterior, posterior, and right side of the patient can deliver the most homogeneous distribution of thermal neutron fluence to the whole of the liver and provide the greatest therapeutic gain factors for tumors in the right lobe and approximately equal therapeutic gain factors for tumors in the left lobe, compared with the two opposed (anterior-posterior) and two orthogonal (anterior-right) beams.

CONCLUSIONS

From a dosimetric viewpoint, the BSH/lipiodol-BNCT treatment plan using three epithermal neutron beams is the most suitable for the treatment of multiple liver tumors.

Combined transarterial chemoembolization and arterial administration of Bletilla striata in treatment of liver tumor in rats

AIM: To evaluate and compare the effect of combined transarterial chemoembolization (TACE) and arterial administration of Bletilla striata (a Chinese traditional medicine against liver tumor) versus TACE alone for the treatment of hepatocellular carcinoma (HCC) in ACI rats.

METHODS: Subcapsular implantation of a solid Morris hepatoma 3924A (2 mm³) in the liver was carried out in 30 male ACI rats. Tumor volume (V1) was measured by magnetic resonance imaging (MRI) on day 13 after implantation. The following different agents of interventional treatment were injected after retrograde catheterization via gastroduodenal artery (on day 14), namely, (A) TACE (0.1 mg mitomycin + 0.1 ml Lipiodol) + Bletilla striata (1.0 mg) (n = 10); (B) TACE + Bletilla striata (1.0 mg) + ligation of hepatic artery (n = 10), (C) TACE alone (control group, n = 10). Tumor volume (V2) was assessed by MRI (on day 13 after treatment) and the tumor growth ratio (V2/V1) was calculated.

RESULTS: The mean tumor volume before (V1) and after (V2) treatment was 0.0355 cm³ and 0.2248 cm³ in group A, 0.0374 cm³ and 0.0573 cm³ in group B, 0.0380 cm³ and 0.3674 cm³ in group C, respectively. The mean ratio (V2/V1) was 6.2791 in group A, 1.5324 in group B and 9.1382 in group C. Compared with the control group (group C), group B showed significant inhibition of tumor growth (P < 0.01), while group A did not (P > 0.05). None of the animals died during implantation or in the postoperative period.

CONCLUSION: Combination of TACE and arterial administration of Bletilla striata plus ligation of hepatic artery is more effective than TACE alone in the treatment of HCC in rats.

Combined interventional therapies of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world, responsible for an estimated one million deaths annually. It has a poor prognosis due to its rapid infiltrating growth and complicating liver cirrhosis. Surgical resection, liver transplantation and cryosurgery are considered the best curative options, achieving a high rate of complete response, especially in patients with small HCC and good residual liver function. In nonsurgery, regional interventional therapies have led to a major breakthrough in the management of unresectable HCC, which include transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave coagulation therapy (MCT), laser-induced thermotherapy (LITT), etc. As a result of the technical development of locoregional approaches for HCC during the recent decades, the range of combined interventional therapies has been continuously extended. Most combined multimodal interventional therapies reveal their enormous advantages as compared with any single therapeutic regimen alone, and play more important roles in treating unresectable HCC.

Hepatocellular carcinoma screening in patients waiting for liver transplantation: a decision analytic model

De novo hepatocellular carcinoma (HCC) may have a large impact on patients waiting for liver transplantation. The presence of HCC can lead to a status upgrade or removal from the waitlist. Our aim is to compare costs and outcomes of different liver cancer surveillance strategies. A Markov-based decision analytic model is created to simulate costs and health outcomes for a hypothetical cohort awaiting liver transplantation undergoing HCC screening. Three strategies of HCC screening are compared with the referent strategy of using alphafetaprotein (AFP) level alone: (1) ultrasound (U/S), (2) AFP plus U/S, and (3) computed tomography (CT). Screening is performed for all strategies at 6-month intervals. Selected tumors are treated locally. Costs and clinical outcomes are discounted. Using baseline assumptions, incremental cost-effectiveness ratios (ICERs) for U/S, U/S plus AFP, and CT are $60,300/life-year saved (LY), $74,000/LY, and $101,100/LY, respectively. The most cost-effective strategy was dependent on the relative costs of each screening modality. U/S screening becomes the dominant strategy when the cost of an AFP test is decreased. Our results show that screening with CT is associated the greatest gain in life expectancy and greatest costs. U/S screening strategy is the preferred screening strategy based on the lowest ICER. Ultimately, costs of the screening modalities determine the most cost-effective strategy.