Prognostic factors in patients with hepatocellular carcinoma receiving systemic chemotherapy

Exploring potential predictive biomarkers through historical perspectives on the evolution of systemic therapies into the emergence of neoadjuvant therapy for the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), a type of liver cancer, ranks as the sixth most prevalent cancer globally and represents the third leading cause of cancer-related deaths. Approximately half of HCC patients miss the opportunity for curative treatment and are then limited to undergoing systemic therapies. Currently, systemic therapy has entered the era of immunotherapy, particularly with the advent of immune-checkpoint inhibitors (ICIs), which have significantly enhanced outcomes for patients with advanced HCC. Neoadjuvant treatment for HCC has become a possibility-findings from the IMbrave 050 trial indicated that ICIs offer the benefit of recurrence-free survival for high-risk HCC patients post-resection or local ablation. However, only a small fraction of individuals benefit from systemic therapy. Consequently, there is an urgent need to identify predictive biomarkers for treatment response and outcome assessment. This study reviewed the historical progression of systemic therapy for HCC, highlighting notable therapeutic advancements. This study examined the development of systemic therapies involving conventional drugs and clinical trials utilized in HCC treatment, as well as potential predictive biomarkers for advanced and/or locally advanced HCC. Various studies have revealed potential biomarkers in the context of HCC treatment. These include the association of dendritic cells (DCs) with a favorable response to neoadjuvant therapy, the presence of enriched T effector cells and tertiary lymphoid structures, the identification of CD138+ plasma cells, and distinct spatial arrangements of B cells in close proximity to T cells among responders with locally advanced HCC receiving neoadjuvant cabozantinib and nivolumab treatment. Furthermore, pathological response has been associated with intratumoral cellular triads consisting of progenitor CD8+ T cells and CXCL13+ CD4+ T helper cells surrounding mature DCs in patients receiving neoadjuvant cemiplimab for resectable HCC. Despite no widely recognized predictive biomarkers for HCC individualized treatment, we believe neoadjuvant trials hold the most promise in identifying and validating them. This is because they can collect multiple samples from resectable HCC patients across stages, especially with multi-omics, bridging preclinical and clinical gaps.

Fufang Banmao Capsule, a Traditional Chinese Medicinal Formulation, Enhances the Survival of Patients with Hepatocellular Carcinoma and Vp3-4 Portal Vein Tumor Thrombosis Undergoing Supportive Treatment

Objectives: Fufang Banmao (FFBM) capsule, a type of Chinese medicinal formulation, has decades of history in treating hepatocellular carcinoma (HCC). This retrospective study aimed to observe the effect of FFBM capsules on the 6-month survival of patients with advanced HCC and Vp3-4 portal vein tumor thrombosis (PVTT) who received supportive therapy alone. Design: In total, 320 HCC/Vp3-4 PVTT patients underwent treatment with supportive therapy, of whom 95 took FFBM capsules and were treated with supportive therapy (FFBM group) and 225 received supportive therapy alone (control group). Comparisons of the 6-month overall survival (OS) rate of the two groups were performed. Propensity score matching (PSM) was used to match the characteristics between individuals in the two groups. A nomogram was built based on independent predictive factors for OS. Results: Cox multivariate analysis revealed that hepatic encephalopathy, aspartate transaminase (AST) and γ-glutamyl transpeptidase levels, Child-Pugh class, prothrombin time, α-fetoprotein level, largest tumor diameter, and use of FFBM capsules were independent predictive factors of OS. Variceal bleeding, alanine transaminase, AST, total bilirubin, and Barcelona Clinic for Liver Cancer stage were different at baseline in the FFBM and control groups. Analysis revealed no significant adverse effects or toxicities relevant to the medications. After PSM (1:1), 95 patient pairs were analyzed as FFBM versus control. The OS probability was remarkably higher for patients in the FFBM group than in those in the control group at 6 months (p < 0.0001). The median survival time was 4 months in the FFBM group and 2.2 months in the control group. Kaplan-Meier analysis showed significant statistical differences in the 6-month OS rates in the patients with total nomogram scores ≥84 (p < 0.0001). Conclusions: Given the satisfying survival outcomes, the results suggested that FFBM capsules should be administered to patients with HCC/Vp3-4 PVTT in the high-risk group (score ≥84). FFBM capsules have the potential for improving patient survival time in those with advanced HCC and Vp3-4 PVTT who receive supportive therapy alone, especially those in the high-risk group (score ≥84).

Treatment of hepatocellular carcinoma in patients with portal vein tumor thrombosis: Beyond the known frontiers

Hepatocellular carcinoma is one of the most frequent malignant tumors worldwide: Portal vein tumor thrombosis (PVTT) occurs in about 35%-50% of patients and represents a strong negative prognostic factor, due to the increased risk of tumor spread into the bloodstream, leading to a high recurrence risk. For this reason, it is a contraindication to liver transplantation and in several prognostic scores sorafenib represents its standard of care, due to its antiangiogenetic action, although it can grant only a poor prolongation of life expectancy. Recent scientific evidences lead to consider PVTT as a complex anatomical and clinical condition, including a wide range of patients with different prognosis and new treatment possibilities according to the degree of portal system involvement, tumor biological aggressiveness, complications caused by portal hypertension, patient's clinical features and tolerance to antineoplastic treatments. The median survival has been reported to range between 2.7 and 4 mo in absence of therapy, but it can vary from 5 mo to 5 years, thus depicting an extremely variable scenario. For this reason, it is extremely important to focus on the most adequate strategy to be applied to each group of PVTT patients.

Hypofractionated radiotherapy as a salvage treatment for recurrent hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: a multi-center analysis

Background

Recurrent hepatocellular carcinoma (HCC) with a tumor thrombus (TT) extending into the inferior vena cava (IVC)/right atrium (RA) is generally regarded as a terminal-stage condition and there is no worldwide consensus on the proper management of this situation. In the present study, we report the efficacy of hypofractionated radiotherapy (HFRT) as a salvage treatment for recurrent HCC with IVC/RA TT.

Methods

We retrospectively reviewed 75 HCC patients with an IVC/RA TT who were referred for HFRT at three institutions between 2008 and 2016. 57 cases had a TT located in the IVC (IVC group), and 18 cases had a TT located in the IVC and RA (IVC + RA group). HFRT was designed to focus on the TT with or without the primary intrahepatic tumors.

Results

In all cases, the TT completely disappeared (CR) in 17 patients (22.7%), 55 patients (73.3%) had a partial response (PR), and 3 patients (4.0%) had a stable disease (SD). There were no cases of progressive disease (PD). The 1-, 2-, and 3-year overall survival rates of the 75 patients were 38.7% (29/75), 13.3% (10/75) and 5.3% (4/75), respectively. The overall median survival time was 10 months. The mean survival times for the IVC group and IVC+ RA group were 13.8 ± 1.1 and 11.6 ± 2.5 months, respectively. There was no significant difference in survival between the two groups (p = 0.205). Log-rank test revealed that factors predicting poor survival were Child-Pugh B liver function classification, AFP ≥ 400 μg/L, intrahepatic multiple tumors, distant metastases, only the TT as the target, a biological effective dose (BED) < 55 Gy and no chance of further radiotherapy.

Conclusions

HFRT appears to be an effective and reasonable treatment option for recurrent HCC patients with IVC/RA TT. The location of the tumor thrombus, either in IVC or in IVC and RA, is not the factor that influences the efficacy of radiotherapy or survival.

Transarterial Ethanol Ablation Combined with Transarterial Chemoembolization for Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

BACKGROUND

The prognosis for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is extremely poor.

OBJECTIVES

This study aimed to evaluate the safety and effectiveness of transarterial ethanol ablation (TEA) for the treatment of HCC with PVTT.

METHODS

Patients were treated with TEA for PVTT under cone-beam computed tomography and traditional transarterial chemoembolization (TACE) with epirubicin for intrahepatic lesions.

RESULTS

Seventeen men were successfully treated with TACE plus TEA. The mean overall survival was 18.3 ± 9.0 months (95% CI: 13.7 - 3.0 months). The quality of life (QoL) score increased from 56.9 ± 15.7 before the procedure to 88.5 ± 11.7 at 4 weeks after the procedure. Lipiodol accumulation grades of 3, 2, 1, and 0 were obtained in 3 (17.6%), 8 (47.1%), 6 (35.3%), and 0 (0%) patients, respectively.

CONCLUSIONS

TEA is a safe and effective method for treating patients with PVTT, offering advantages for QoL, response rate after TEA, and OS.

The effect of using different embolic agents on survival in transarterial chemoembolization of hepatocellular carcinoma: gelfoam versus polyvinyl alcohol

PURPOSE

We aimed to compare the effect of using different embolic agents such as gelfoam and polyvinyl alcohol (PVA) on survival, tumor response, and complications in transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 38 inoperable HCC patients who underwent TACE between August 1998 and April 2007. A total of 50 TACE sessions were performed using PVA (n=18) or gelfoam particles (n=20), following the application of 60 mg doxorubicin with 10-20 mL lipiodol emulsion. The PVA and gelfoam groups were compared based on clinical, laboratory and demographic variables. Survival rates were calculated starting from the first TACE session using the Kaplan-Meier analysis.

RESULTS

There was no significant difference between the survival rates of PVA and gelfoam groups (P = 0.235). Overall survival rates at 12, 24, 36, 48, and 60 months were 55%, 36%, 15%, 7%, and 5%, respectively. Tumor response, age, lipiodol accumulation type, number of HCC foci, complications and serum alpha-fetoprotein level were significant factors for survival in all patients.

CONCLUSION

Use of gelfoam or PVA as the embolic agent did not have a significant impact on survival. Complete tumor response, intensive lipiodol accumulation in tumor, older age (<60 years), fewer (≤3) HCC foci, low serum alpha-fetoprotein level (≤400 ng/mL) were found to improve cumulative survival significantly.

Safety and efficacy of tigatuzumab plus sorafenib as first-line therapy in subjects with advanced hepatocellular carcinoma: A phase 2 randomized study

BACKGROUND & AIMS

Tigatuzumab is a humanized monoclonal antibody that acts as a death receptor-5 agonist and exerts tumour necrosis factor-related apoptosis-inducing ligand-like activity. In this phase II study, safety and tolerability of the combination of tigatuzumab and sorafenib was evaluated in patients with advanced hepatocellular carcinoma.

METHODS

Adults with advanced hepatocellular carcinoma, measurable disease, and an Eastern Cooperative Oncology Group performance score⩽1 were enrolled. Eligible subjects were randomly assigned 1:1:1 to tigatuzumab (6 mg/kg loading, 2 mg/kg/week maintenance) plus sorafenib 400 mg twice daily; tigatuzumab (6 mg/kg loading, 6 mg/kg/week maintenance) plus sorafenib 400 mg twice daily; or sorafenib 400 mg twice daily. The primary end point was time to progression. Secondary end points included overall survival and safety.

RESULTS

163 subjects were randomized to treatment. Median time to progression was 3.0 months in the tigatuzumab 6/2 mg/kg combination group (p=0.988 vs. sorafenib), 3.9 months in the tigatuzumab 6/6 mg/kg combination group (p=0.586 vs. sorafenib), and 2.8 months in the sorafenib alone group. Median overall survival was 12.2 months in the tigatuzumab 6/6 mg/kg combination group (p=0.659 vs. sorafenib), vs. 8.2 months in both other treatment groups (p=0.303, tigatuzumab 6/2 mg/kg combination vs. sorafenib). The most common treatment-emergent adverse events were palmar-plantar erythrodysesthesia syndrome, diarrhea, and decreased appetite.

CONCLUSIONS

Tigatuzumab combined with sorafenib vs. sorafenib alone in adults with advanced hepatocellular carcinoma did not meet its primary efficacy end point, although tigatuzumab plus sorafenib is well tolerated in hepatocellular carcinoma.

Surgical Strategy for Hepatocellular Carcinoma Patients with Portal/Hepatic Vein Tumor Thrombosis

Background

Portal/hepatic vein tumor thrombosis (PVTT/HVTT) in hepatocellular carcinoma (HCC) is a sign of advanced stage disease and is associated with poor prognosis. This study investigated the surgical outcomes of patients with HCC and PVTT/HVTT to determine the most appropriate surgical treatment strategy for these patients.

Materials and Methods

The study population included 77 HCC patients from January 2004 to June 2009 who underwent hepatectomy in our department and were diagnosed with PVTT/HVTT based on pathological examination. The patients were divided into two groups: in group 1, PVTT/HVTT was located in the hepatic resection area and removed with the tumor en bloc (38 cases); in group 2, PVTT/HVTT was beyond the resection line and removed by suction or thrombectomy (39 cases). Concerning the factor of surgical margins, the patients were further divided into four subgroups: group 1A: patients in group 1 with surgical margins ≤1 cm (28 cases); group 1B: patients in group 1 with surgical margins >1 cm (9 cases); group 2A: patients in group 2 with surgical margins ≤1 cm (28 cases); and group 2B: patients in group 2 with surgical margins >1 cm (9 cases).

Results

Most of the characteristics of groups 1 and 2 were similar. Patients in group 2 had significantly higher median blood loss (p=0.002) and higher blood transfusion rate (p=0.002) during the operation, which were not considered prognostic factors (p=0.323 and 0.571, respectively). The median overall survival (OS) duration in group 1 was significantly longer than that in group 2 (14.3 vs. 10.4 months, p=0.047). The median OS durations in groups 1A, 1B, 2A, and 2B were 14.3, 42.7, 7.5, and 18.0 months, respectively, which were significantly different(p=0.018).

Conclusions

When PVTT/HVTT is located in the hepatic resection area and removed with the tumor en bloc, the median OS duration is longer. Based on this finding, widening the surgical margins when technically possible may increase OS.

Post-hepatectomy survival in advanced hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To analyze hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) using the tumor-node-metastasis (TNM) staging system.

METHODS: We retrospectively analyzed 372 patients with HCC who underwent hepatectomy between 1980 and 2009. We studied the outcomes of HCC patients with PVTT to evaluate the American Joint Committee on Cancer TNM staging system (7^th edition) for stratifying and predicting the prognosis of a large cohort of HCC patients after hepatectomy in a single-center. Portal vein invasion (vp) 1 was defined as an invasion or tumor thrombus distal to the second branch of the portal vein, vp2 as an invasion or tumor thrombus in the second branch of the portal vein, vp3 as an invasion or tumor thrombus in the first branch of the portal vein, and vp4 as an invasion or tumor thrombus in the portal trunk or extending to a branch on the contralateral side.

RESULTS: The cumulative 5-year overall survival (5yrOS) and 5-year disease-free survival (5yrDFS) rates of the 372 patients were 58.3% and 31.3%, respectively. The 5yrDFS and 5yrOS of vp3-4 patients (n = 10) were 20.0%, and 30.0%, respectively, which was comparable with the corresponding survival rates of vp1-2 patients (P = 0.466 and 0.586, respectively). In the subgroup analysis of patients with macroscopic PVTT (vp2-4), the OS of the patients who underwent preoperative transarterial chemoembolization was comparable to that of patients who did not (P = 0.747). There was a significant difference in the DFS between patients with stage I HCC and those with stage II HCC (5yrDFS 39.2% vs 23.1%, P < 0.001); however, the DFS for stage II was similar to that for stage III (5yrDFS 23.1% vs 13.8%, P = 0.330). In the subgroup analysis of stage II-III HCC (n = 148), only alpha-fetoprotein (AFP) > 100 mg/dL was independently associated with DFS.

CONCLUSION: Hepatectomy for vp3-4 HCC results in a survival rate similar to hepatectomy for vp1-2. AFP stratified the stage II-III HCC patients according to prognosis.

Active treatments are a rational approach for hepatocellular carcinoma in elderly patients

AIM: To determine whether an active intervention is beneficial for the survival of elderly patients with hepatocellular carcinoma (HCC).

METHODS: The survival of 740 patients who received various treatments for HCC between 1983 and 2011 was compared among different age groups using Cox regression analysis. Therapeutic options were principally selected according to the clinical practice guidelines for HCC from the Japanese Society of Hepatology. The treatment most likely to achieve regional control capability was chosen, as far as possible, in the following order: resection, radiofrequency ablation, percutaneous ethanol injection, transcatheter arterial chemoembolization, transarterial oily chemoembolization, hepatic arterial infusion chemotherapy, systemic chemotherapy including molecular targeting, or best supportive care. Each treatment was used alone, or in combination, with a clinical goal of striking the best balance between functional hepatic reserve and the volume of the targeted area, irrespective of their age. The percent survival to life expectancy was calculated based on a Japanese national population survey.

RESULTS: The median ages of the subjects during each 5-year period from 1986 were 61, 64, 67, 68 and 71 years and increased significantly with time (P < 0.0001). The Child-Pugh score was comparable among younger (59 years of age or younger), middle-aged (60-79 years of age), and older (80 years of age or older) groups (P = 0.34), whereas the tumor-node-metastasis stage tended to be more advanced in the younger group (P = 0.060). Advanced disease was significantly more frequent in the younger group compared with the middle-aged group (P = 0.010), whereas there was no difference between the middle-aged and elderly groups (P = 0.75). The median survival times were 2593, 2011, 1643, 1278 and 1195 d for 49 years of age or younger, 50-59 years of age, 60-69 years of age, 70-79 years of age, or 80 years of age or older age groups, respectively, whereas the median percent survival to life expectancy were 13.9%, 21.9%, 24.7%, 25.7% and 37.6% for each group, respectively. The impact of age on actual survival time was significant (P = 0.020) with a hazard ratio of 1.021, suggesting that a 10-year-older patient has a 1.23-fold higher risk for death, and the overall survival was the worst in the oldest group. On the other hand, when the survival benefit was evaluated on the basis of percent survival to life expectancy, age was again found to be a significant explanatory factor (P = 0.022); however, the oldest group showed the best survival among the five different age groups. The youngest group revealed the worst outcomes in this analysis, and the hazard ratio of the oldest against the youngest was 0.35 for death. The survival trends did not differ substantially between the survival time and percent survival to life expectancy, when survival was compared overall or among various therapeutic interventions.

CONCLUSION: These results suggest that a therapeutic approach for HCC should not be restricted due to patient age.

Combination therapy of intra-arterial 5-fluorouracil and systemic pegylated interferon α-2b for advanced hepatocellular carcinoma

BACKGROUND

This study evaluated the efficacy of combined 5-fluorouracil (5-FU) and pegylated interferon (PEG-IFN) α-2b in patients with advanced hepatocellular carcinoma (HCC).

METHODS

Fifty patients with portal vein tumor thrombosis were enrolled. Of these, 21 patients were treated using subcutaneous administration of PEG-IFNα-2b and intra-arterial infusion of 5-FU (5-FU/PEG-IFN group), 12 patients were treated using intramuscular administration of IFNα-2b and intra-arterial infusion of 5-FU (5-FU/IFN group), and 17 patients received intra-arterial infusion chemotherapy with lipiodol-cisplatin (CDDP) suspension (CDDP group).

RESULTS

The objective early response rate was significantly higher in the 5-FU/PEG-IFN group than in the 5-FU/IFN or CDDP groups (71.4 vs. 8.3% and 17.6%, respectively; P < 0.0001). Cumulative survival rates at 6 and 12 months were 83.8 and 77.8% in the 5-FU/PEG-IFN group, 60.8 and 16.2% in the 5-FU/IFN group, and 58.4 and 12.5% in the CDDP group, respectively. The cumulative survival rate was significantly higher in the 5-FU/PEG-IFN group than in the other 2 groups (P = 0.0272). Serious complications and treatment-related deaths were not observed in any of the 3 groups.

CONCLUSION

Although a prospective randomized controlled trial using a larger population of patients with advanced HCC is needed to evaluate combination therapy with 5-FU and PEG-IFNα-2b, this new combination therapy may be useful for patients with advanced HCC.

Application of tumor-node-metastasis staging 2002 version in locally advanced hepatocellular carcinoma: is it predictive of surgical outcome?

BACKGROUND

Locally advanced (pT3-4N0M0) hepatocellular carcinoma (HCC) is a heterogeneous group of tumors, which consists of four different categories, including HCC with "multiple tumors more than 5 cm", "major vascular invasion", "invasion of adjacent organs", and "perforation of visceral peritoneum". The aim of our study was to verify whether the 2002 version of the Tumor-Node-Metastasis staging system could predict surgical outcomes in patients with locally advanced HCC.

METHODS

We retrospectively reviewed 298 patients with pT3-4N0M0 HCC who underwent hepatic resection from 1993 to 2000 in an academic tertiary hospital. Overall survival (OS) and cumulative recurrence rate (CRR) of the four categories of locally advanced HCC patients were compared.

RESULTS

In multivariate analysis, major vascular invasion was identified as the most significant factor (HR = 3.291, 95% CI 2.362-4.584, P < 0.001) followed by cirrhosis status on OS, and was found to be the only independent factor of CRR (HR = 2.242, 95% CI 1.811-3.358, P < 0.001) in patients with locally advanced HCC. Among the four categories of locally advanced HCC, OS was significantly worse, and CRR was significantly higher in patients with HCC with major vascular invasion (pT3) than with multiple tumors more than 5 cm (pT3); or tumor invasion of adjacent organs (pT4); or perforation of visceral peritoneum (pT4). No significant differences were observed in OS or CRR between the latter three groups of patients.

CONCLUSIONS

HCC with major vascular invasion, which are classified as pT3 under the current TNM staging, have the worst prognosis when compared with the other categories of pT3-4 disease. There is a need to redefine the T classification and to stratify locally advanced HCC.

Hepatic arterial infusion therapy with a fine powder formulation of cisplatin for advanced hepatocellular carcinoma with portal vein tumor thrombosis

OBJECTIVE

We retrospectively evaluated the antitumor effect, survival and toxicities of hepatic arterial infusion therapy using a fine powder formulation of cisplatin (cisplatin powder) in hepatocellular carcinoma patients with portal vein tumor thrombosis.

METHODS

Twenty-four patients classified as Child-Pugh class A or B underwent a single session of hepatic arterial infusion therapy using cisplatin powder. The treatment was repeated every 4-6 weeks in patients with no evidence of tumor progression or unacceptable toxicity. The treatment response was evaluated using contrast-enhanced computed tomography performed 1 month after each treatment. The survival rate was evaluated using the Kaplan-Meier method, and predictors of a better outcome were identified using univariate analysis.

RESULTS

The mean follow-up period was 11.2 months (range, 1.3-44.2 months). A total of 57 sessions of intra-arterial infusion (1-6 sessions per patient; mean, 2.4 sessions) with cisplatin powder were performed. A complete response and a partial response were obtained in one and four patients, respectively (objective response rate = 20.8%). The median survival time for all the patients was 7.0 months; the median survival times for the 5 responders and 19 non-responders were 37.3 and 5.6 months, respectively. The 1- and 2-year survival rates were 38% and 16%, respectively. Significant prognostic factors related to survival were the therapeutic effect, patient age and serum alanine aminotransferase level. Severe adverse reactions resulting in treatment discontinuation were not observed, and all the toxicities were successfully managed using conservative treatment.

CONCLUSIONS

Hepatic arterial infusion therapy with a fine powder formulation of cisplatin was safe, well-tolerated and might help to prolong the life span of advanced hepatocellular carcinoma patients with portal vein tumor thrombosis.

Treatment outcome of hepatocellular carcinoma patients with high-risk vascular invasion: a retrospective analysis

Background: Invasion of major hepatic vessels in hepatocellular carcinoma (HCC) generally prohibits the surgical treatment. Objective: Analyze outcomes of non-surgical approaches in this group of HCC. Methods: Retrospective review of medical records of 648 HCC admitted to King Chulalongkorn Memorial Hospital between January 2003 and December 2005 was carried out to select only patients who had unresectable HCC with vascular invasion and hepatic functions-Child-Pugh class-A. Vascular invasion was defined as involvement of portal vein, inferior vena cava (IVC), or their branches identified by imaging techniques. Non-surgical treatments were either transarterial chemoembolization (TACE) or systemic chemotherapy (SCT) in addition to general supportive care. Treatment outcomes of the patients were analyzed. Results: Out of 71 unresectable HCC patients enrolled, 57patients were treated with TACE, while 14 received SCT. In the TACE group, 39 (68%), 7 (12%) and 11 (19%) patients had portal vein, IVC, and both vessels invasion, respectively. In the SCT group; 11 (78%), 1 (7%) and 2 (14%) had invasion of portal vein, IVC, and both vessels, respectively. Median overall survival in both groups was 158 days. Univariate analysis demonstrated that AFP level <1000 ng/mL, tumor size <10 cm, and SCT treatment significantly influenced survival. Additional multivariate analysis confirmed that diameters of tumor, and SCT were independent prognostic factors for good survival. A survival analysis showed longer survival in the SCT group than that of TACE (210 vs. 149 days, p=0.03) group. Conclusion: Survival of HCC patients with major vessels invasion was better when treated with SCT compared to TACE. Future prospective study in larger populations to test the hypothesis is warranted.

An aggressive approach leads to improved survival in hepatocellular carcinoma patients with portal vein tumor thrombus

PURPOSE

Many physicians express a relatively nihilistic approach to the treatment of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Consensus among surgeons regarding the indications for an aggressive approach has not been reached. Current study was aimed to determine whether an aggressive approach, with an extended resection with thrombectomy and adjuvant therapy, would lead to an improved survival for HCC patients with PVTT.

METHODS

A retrospective review of 116 HCC patients with PVTT admitted from 1996 to 2006 was conducted. Patients were divided into 2 time-period (TP) cohorts, of them, 51 cases in the first 5 years (TP1) and 65 in the last 5 years (TP2).

RESULTS

Surgical operations were performed on 68 patients. Twenty-one surgical resections were performed in TP1 and forty-seven in TP2. The extent of liver resections, as well as the frequency of thrombectomy, was greater in TP2 (P = 0.039). During both time-periods, an aggressive therapy was associated with improved survival (P < 0.02 TP1, P < 0.001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.001), with a median survival of 15 months in TP2, whereas in TP1, the survival was only 9 months. The median 1-, 3-year survivals in TP2 (54 and 34%, respectively) were also greater than that in TP1 (31 and 7%, respectively). A multiple logistic regression analysis revealed that radical resection and adjuvant therapy were the independent predictors of overall survival.

CONCLUSIONS

An aggressive approach, combining extended liver resection with thrombectomy and adjuvant therapy, leads to an improved survival in the HCC patients with PVTT.

Cavo-atrial thrombectomy combined with left hemi-hepatectomy for vascular invasion from hepatocellular carcinoma on diseased liver under hypothermic cardio-circulatory arrest

Vascular invasion of supra-hepatic veins (SHV) is a major complication of primary liver tumours. The tumorous thrombus, when extended to the vena cava and right atrium, may produce occlusion of the tricuspid valve or pulmonary embolism with sudden cardiac death. The presence of macroscopic vascular infiltration represents an advanced stage of the tumour contraindicating liver transplantation, thus liver resection with thrombectomy is the only therapeutic option in this setting despite the concerns of postoperative liver failure and the dismal results at distance. A 45-year-old male with chronic active hepatitis/cirrhosis was referred to our department for a tumour in the left hemi-liver with infiltration of the left-middle hepatic veins and a tumour thrombus extension to the right atrium. We reported a successful cavo-atrial thrombectomy, along with left hemi-hepatectomy, under hypothermic cardio-circulatory arrest (HCA). To our knowledge, this technique has been used only once for primary liver cancer on chronic liver disease, this being the second case reported in literature. We conclude that this technique should be considered for atrial thrombi removal in patients affected by liver tumours in the presence of a healthy liver or of a well compensated liver cirrhosis in order to prolong the patient's life span.

Long-term outcome of cirrhotic patients with early hepatocellular carcinoma treated with ultrasound-guided percutaneous laser ablation: a retrospective analysis

PURPOSE

Percutaneous laser ablation (PLA) has been proposed as an active treatment in patients with hepatocellular carcinoma (HCC). However, large multicenter studies using this technique have not been reported.

PATIENTS AND METHODS

We retrospectively analyzed treatment and survival parameters of 432 cirrhotic patients with nonsurgical early HCC (single nodule < or = 4 cm or three nodules < or = 3 cm each) who had received PLA in nine Italian centers.

RESULTS

Single tumors were seen in 344 (80%) of 432 patients, and two to three nodules were seen in 88 patients (20%), for a total of 548 tumors. An initial complete response after PLA was observed in 338 patients (78%). Median overall survival time was 47 months (95% CI, 41 to 53 months). The 3- and 5-year cumulative survival rates were 61% and 34%, respectively. In multivariate analysis, independent predictors of survival were serum albumin levels more than 3.5 g/dL (P = .002; risk ratio [RR] = 0.580; 95% CI, 0.409 to 0.821), the achievement of a complete tumor ablation (P = .001; RR = 0.517; 95% CI, 0.346 to 0.771), and age less than 73 years (P < .001; RR = 0.466; 95% CI, 0.320 to 0.681). Child-Turcotte-Pugh class A patients had a 5-year cumulative survival rate of 41%; this figure increased up to 60% with a median survival time of 63 months (95% CI, 48 to 78 months) in patients with tumors < or = 2.0 cm.

CONCLUSION

This analysis confirms that a complete tumor ablation results in improved survival in patients with nonsurgical HCC. Ideal candidates for PLA are younger patients with normal serum albumin levels and tumor size < or = 2 cm.

Hepatocellular carcinoma associated with hemorrhaging from iatrogenic rupture of a rib metastasis

Detecting a rib metastasis as a first manifestation before identifying hepatocellular carcinoma (HCC) is rare. We report an HCC with massive bleeding from the biopsied rib tumor. A 68-year-old man was referred for right chest pain. Computed tomography showed a mass in the rib and two small masses in the liver. The biopsied rib continued to bleed, so we removed the entire tumor, including the rib. We histologically confirmed the diagnosis as rib metastasis from the HCC. The patient died 3 months after the onset. We caution against performing an incisional biopsy without due consideration.

Is there any difference in survival according to the portal tumor thrombectomy method in patients with hepatocellular carcinoma?

BACKGROUND

Although portal venous tumor thrombus (PVTT) is regarded as an ominous prognostic factor in patients with hepatocellular carcinoma (HCC), the optimal treatment method for maximizing both safety and long-term outcome has not yet been discussed. We describe a surgical technique in which the venous wall is peeled off from the PVTT.

METHODS

In the peeling off (PO) technique, the portal venotomy was placed after adequate vascular control of portal flow. The PVTT was dissected from the portal venous wall and removed through the opening. Macroscopically residual PVTTs intruding into tiny branches were meticulously extracted. This procedure was compared with the en bloc resection of PVTT. Between 1995 and 2006, 49 patients underwent curative hepatic resections for HCC with macroscopic PVTT; these patients were classified according to whether the PO technique (n = 20) or the en bloc technique (n = 29) had been utilized. Both the short- and long-term results were compared between the 2 groups.

RESULTS

No mortalities occurred in either group. Both the 5-year overall survival and the recurrence-free survival rates of the PO group were comparable with those of the en bloc group (39% vs 41% [P = .90] and 23% vs 18% [P = .89], respectively). No local recurrences or regrowth of the PVTT occurred in either group.

CONCLUSION

Our procedure is useful for removing PVTT extending beyond the bifurcation or into other sectors that should be preserved in terms of liver function and enables a more conservative resection than an en bloc technique without sacrificing curability.

Predictive factors of outcome and tumor response to systemic chemotherapy in patients with metastatic hepatocellular carcinoma

OBJECTIVE

Systemic chemotherapy is an important treatment modality for metastatic hepatocellular carcinoma (HCC); however, the predictive factors of outcome and tumor response have not been fully investigated. The aim of this study was to identify factors that could be used to predict outcome and tumor response to systemic chemotherapy in patients with metastatic HCC.

METHODS

We retrospectively examined 82 consecutive patients with metastatic HCC undergoing systemic chemotherapy to investigate factors associated with outcome and tumor response. The patients underwent 5-fluorouracil, mitoxantrone and cisplatin (FMP) therapy.

RESULTS

The overall objective response rate was 22% (95% confidence interval, 14-32), and the median survival time and 1-year survival for all patients were 11.2 months and 43.5%, respectively. Multivariate analysis demonstrated that the absence of radiologically active intrahepatic disease (P = 0.02) and ascites (P = 0.002) was independent favorable prognostic factors. Although multivariate analysis revealed no significant predictive factors of tumor response, the response rates in patients without radiologically active intrahepatic disease (response rate, 46%) tended to be higher than those in patients with active intrahepatic disease (response rate, 17%) (P = 0.05).

CONCLUSION

Patients with metastatic HCC, who had sufficient hepatic function and no radiologically active intrahepatic disease, might be good candidates for systemic chemotherapy.

Adjuvant intraportal venous chemotherapy for patients with hepatocellular carcinoma and portal vein tumor thrombi following hepatectomy plus portal thrombectomy

BACKGROUND

The aim of this study was to evaluate the clinical value of adjuvant chemobiotherapy via portal vein for patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombi (PVTT) following hepatectomy plus thrombectomy.

METHODS

Eighty-six HCC patients with tumor thrombi in the portal trunk and/or the first-order branch were divided into groups A (n = 33) and B (n = 53). Patients in group A were treated with hepatectomy plus portal thrombectomy in combination with postoperative adjuvant chemobiotherapy administered via portal vein. The chemobiotherapy regimen consisted of 5-FU, adriamycin, cisplatin, and IFNalpha. Patients in Group B were subjected to hepatectomy plus thrombectomy alone. Survival rates of the two groups were compared and prognostic factors were identified using Cox proportional hazards model.

RESULTS

Group A had a significantly longer median tumor-free survival time and median survival time compared with group B, i.e., 5.1 vs. 2.5 months (p = 0.017) and 11.5 vs. 6.2 months (p = 0.007), respectively. One-, two-, and three-year tumor-free survival rates were remarkably higher in group A than in group B, i.e., 18.4% vs. 8.4%, 13.8% vs. 4.2%, and 9.2% vs. 4.2%, respectively. One-, two-, and three-year survival rates were markedly greater in group A than in group B, i.e., 46.8% vs. 23.4%, 14.4% vs. 5.8%, and 9.6% vs. 5.8%, respectively. Multivariate analysis using the Cox proportional hazards model revealed that adjuvant chemobiotherapy, pathologic grading, and tumor size were independent prognostic factors for survival time (p = 0.000, 0.001, and 0.013, respectively), and chemobiotherapy and pathologic grading were independent prognostic factors for tumor-free survival time (p = 0.002 and 0.003, respectively).

CONCLUSIONS

Surgical resection combined with adjuvant chemobiotherapy via portal vein is an effective and safe treatment modality for hepatocellular carcinoma with major portal vein thrombus.

A comparison of chemoembolization endpoints using angiographic versus transcatheter intraarterial perfusion/MR imaging monitoring

PURPOSE

Transcatheter arterial chemoembolization (TACE) is an established treatment for unresectable liver cancer. This study was conducted to test the hypothesis that angiographic endpoints during TACE are measurable and reproducible by comparing subjective angiographic versus objective magnetic resonance (MR) endpoints of TACE.

MATERIALS AND METHODS

The study included 12 consecutive patients who presented for TACE for surgically unresectable HCC or progressive hepatic metastases despite chemotherapy. All procedures were performed with a dedicated imaging system. Angiographic series before and after TACE were reviewed independently by three board-certified interventional radiologists. A subjective angiographic chemoembolization endpoint (SACE) classification scheme, modified from an established angiographic grading system in the cardiology literature, was designed to assist in reproducibly classifying angiographic endpoints. Reproducibility in SACE classification level was compared among operators, and MR imaging perfusion reduction was compared with SACE levels for each observer.

RESULTS

Twelve patients successfully underwent 15 separate TACE sessions. SACE levels ranged from I through IV. There was moderate agreement in SACE classification (kappa = 0.46 +/- 0.12). There was no correlation between SACE level and MR perfusion reduction (r = 0.16 for one operator and 0.02 for the other two).

CONCLUSIONS

Angiographic endpoints during TACE vary widely, have moderate reproducibility among operators, and do not correlate with functional MR imaging perfusion endpoints. Future research should aim to determine ideal angiographic and functional MR imaging endpoints for TACE according to outcome measures such as imaging response, pathologic response, and survival.

Efficacy of preoperative radiotherapy to portal vein tumor thrombus in the main trunk or first branch in patients with hepatocellular carcinoma

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) in the main trunk or the first branch is very poor.

METHODS

Radiotherapy (RT) to PVTT was followed by hepatectomy within 2 weeks. The dose used was 30-36 Gy, in 10-12 fractions, for 15-20 days. The efficacy of preoperative RT to PVTT in the main trunk or first branch was evaluated by comparing results in patients who underwent hepatectomy (group R; n = 15) with preoperative RT and those without preoperative RT (group N; n = 28).

RESULTS

The 1-, 3-, and 5-year survival rates in group R were 86.2%, 43.5%, and 34.8%, respectively, while these values in group N were 39.0%, 13.1%, and 13.1%, respectively. The survival curve of group R was significantly better than that of group N (P = 0.0359). In group R, five (83.3%) of six patients whose tumor thrombus was completely necrosed (based on pathological examination) and whose follow-up period was over 2 years survived for more than 2 years. Female sex (P = 0.0066), multiple tumors (P = 0.0369), and absence of preoperative RT (P = 0.0359) were ranked as significant factors for a poor prognosis by univariate analysis. Multivariate analysis revealed absence of preoperative RT and female sex to be significant factors for a poor prognosis.

CONCLUSION

Preoperative RT to PVTT in the main trunk or first branch improved the prognosis of patients with HCC with PVTT, and could be a promising new modality in the treatment of these patients.

Do young hepatocellular carcinoma patients with relatively good liver function have poorer outcomes than elderly patients?

BACKGROUND AND AIM

The risk of hepatocellular carcinoma (HCC) is known to be age dependent; the influence of age on prognosis is, however, controversial. The aim of this study was to compare the tumor characteristics and survival rates of young and old HCC patients, with respect to tumor stage.

METHODS

We reviewed the clinical data and survival times of 71 young HCC patients from 1987 to 2003 and compared these with those of their older counterparts (n = 239). Patients were categorized into three age groups: group A, age <30 years (n = 71); group B, age >/=30 to <61 years (n = 168); and group C, age >/=61 years (n = 81). Kaplan-Meier methods and Cox proportional hazards regression were used to analyze survival.

RESULTS

The overall survival time of group A was shorter than groups B or C (P = 0.0071). Survival was not different in the three groups in subgroup analysis according to several tumor staging systems (e.g. Japan Integrated Staging score, Cancer of the Liver Italian Program scoring system and Barcelona Clinic Liver Cancer staging classification). The multivariate hazard ratio of group B was 0.840 (95% confidence interval [CI] 0.490-1.440) and that of group C was 0.770 (95% CI 0.410-1.446) in reference to group A.

CONCLUSIONS

Young HCC patients showed a poorer prognosis than older HCC patients because they have a more advanced tumor stage at diagnosis. However, age was not an independent prognostic factor when stages were matched. Therefore, we suggest that periodic surveillance in young chronic hepatitis B virus carriers would improve outcomes.

Complete remission of hepatocellular carcinoma with portal vein tumor thrombus and lymph node metastases by arterial infusion of 5-fluorouracil and interferon-alpha combination therapy following hepatic resection

We report two cases of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) and lymph node (LN) metastases successfully treated by hepatic arterial infusion of 5-fluorouracil (5-FU) combined with systemic injection of interferon (IFN)-alpha following hepatic resection for the liver tumor. Complete remission was obtained. Case 1 was a 51-year-old man who had HCC in the right lobe of the liver with PVTT and multiple intrahepatic metastases. He also had abdominal and mediastinal LN metastases. Case 2 was a 53-year-old man who had diffuse-type HCC in the right lobe of the liver with PVTT and intrahepatic metastases. A chest computed tomography scan revealed lymph nodes enlarged to 1.0 cm from the mediastinum to the left supraclavicular space. Both patients underwent the hepatectomy to reduce the tumor volumes and remove the PVTT to relieve portal vein obstruction. Following the surgery, the patients underwent IFN-alpha/5-FU combination therapy. Three months after this combined therapy, tumor markers (both alpha-fetoprotein and protein induced by vitamin K absence or antagonist II) returned to the normal range and residual tumors in the liver disappeared. The patients are alive without any recurrence more than 1 year after initial treatment. IFN-alpha/5-FU combined therapy following hepatic resection is a promising modality for the treatment of advanced HCC with LN metastasis.

Treatment of hepatocellular carcinoma accompanied by portal vein tumor thrombus

The prognosis of patients with hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombus (PVTT) is generally poor if left untreated: a median survival time of 2.7-4.0 mo has been reported. Furthermore, while transcatheter arterial chemoembolization (TACE) has been shown to be safe in selected patients, the median survival time with this treatment is still only 3.8-9.5 mo. Systemic single-agent chemotherapy for HCC with PVTT has failed to improve the prognosis, and the response rates have been less than 20%. While regional chemotherapy with low-dose cisplatin and 5-fluorouracil or interferon and 5-fluorouracil via hepatic arterial infusion has increased the response rate, the median survival time has not exceeded 12 (range 4.5-11.8) mo. Combined treatment consisting of radiation for PVTT and TACE for liver tumor has achieved a high response rate, but the median survival rates have still been only 3.8-10.7 mo. With hepatic resection as monotherapy, the 5-year survival rate and median survival time were reportedly 4%-28.5% and 6-14 mo. The most promising results were reported for combined treatments consisting of hepatectomy and TACE, chemotherapy, or internal radiation. The reported 5-year survival rates and median survival times were 42% and 31 mo for TACE followed by hepatectomy; 36.3% and 22.1 mo for hepatectomy followed by hepatic arterial infusion chemotherapy; and 56% for chemotherapy or internal radiation followed by hepatectomy.

Transplantation for hepatocellular carcinoma: The Milan criteria and beyond

1. Liver transplantation offers excellent results for selected candidates with hepatocellular carcinoma (HCC). 2. Selection strategies have evolved but are mainly based on size and number of tumors, which are surrogates for vascular invasion. Newer techniques show promise for identifying patients at high risk for recurrence and selecting those with low risk, even though they may exceed currently established tumor size criteria. 3. Evaluation of the effectiveness of liver transplantation for HCC requires an intent-to-treat approach that must include an accounting of the dropout rate of patients while waiting. 4. Locoregional pretransplantation adjuvant treatments may have some role for downstaging and/or reducing the dropout rate before transplantation, but their posttransplantation effect on outcome remains undetermined. 5. Liver allocation for HCC candidates in the context of increasing HCC prevalence requires better and evidence-based prioritization policies.

Resection of hepatocellular carcinoma with tumor thrombus in the major vasculature. A European case-control series

Tumor thrombus in major vasculature is a frequent finding with a poor long-term prognosis in patients with hepatocellular carcinoma (HCC). The utility of surgical resection is still controversial. This study compared morbidity and survival after resection for HCC with and without tumor thrombus. Data of 108 patients who underwent major hepatic resection for HCC were prospectively recorded. Patients were divided into two groups. The venous thrombectomy (VT) group included 26 patients who had HCC with tumor thrombus in the portal or hepatic veins. The matched control group included 82 patients who had HCC without tumor thrombus. Surgical technique, early outcome, and late survival were analyzed in each group. Multivariate analysis was performed to assess the prognostic value of this feature. Surgical technique was comparable in the VT and control group with regard to extent of hepatectomy, procedure duration, and transfusion requirements. Early postoperative outcome was also comparable. Actuarial survival at 1, 3, and 5 years was 38%, 20%, and 13%, respectively, in the VT group (median: 9 months) versus 74%, 56%, and 33%, respectively, in the control group (median: 41 months). In the subgroup of patients with tumor thrombus limited to the portal vein, actuarial survival at 1, 3, and 5 years was 50%, 26%, and 17%, respectively, (median: 12 months) and two patients lived longer than 5 years. Multivariate analysis showed that incomplete resection, alphafetoprotein level greater than 100 N, more than two tumor nodules, and tumor thrombus in major vasculature were independent factors of poor prognosis. Survival after resection for HCC with tumor thrombus in the major vasculature is poorer than after resection for HCC without tumor thrombus. However, an aggressive surgical strategy can provide significant survival with comparable morbidity in selected cases, that is, tumor thrombus located in the portal vein only and expected complete resection of the lesions.

Prognostic index for patients with hepatocellular carcinoma combined with tumor thrombosis in the major portal vein

BACKGROUND

This study sought to analyze prognostic factors in patients with hepatocellular carcinoma and tumor thrombosis in the first branch or trunk of the portal vein, and to provide a prognostic index.

STUDY DESIGN

We performed a retrospective cohort study of 78 consecutive patients with hepatocellular carcinoma and tumor thrombosis in the first branch or trunk of the portal vein who underwent liver resection. Multivariate analysis of survival used the Cox's proportional hazard model.

RESULTS

Median survival time and 3-year survival rate were 0.74 years and 21.7%, respectively. Six factors, ie, absence of ascites, average elimination rate constant of indocyanine green, prothrombin activity, serum albumin level, maximal tumor diameter, and blood loss at operation were univariately related to survival time. By multivariate analysis, absence of ascites (hazard ratio, 2.23; 95% confidence interval, 1.10 to 4.52; p = 0.027), prothrombin activity > or = 75% (hazard ratio, 2.37; confidence interval, 1.30 to 4.32; p = 0.005), and maximal tumor diameter < 5 cm (hazard ratio, 2.37; confidence interval, 1.14 to 4.94; p = 0.021) were independent prognostic factors with similar hazard ratios. We calculated a prognostic index from these factors as follows: (ascites: absent = 0, present = 1) + (prothrombin activity: > or = 75% = 0, < 75% = 1) + (maximal tumor diameter: < 5 cm = 0, > or = 5 cm = 1). This index provided good stratification ability (log-rank, p < 0.001). Median survival times for patients with prognostic index 0, 1, 2, and 3 were 5.6, 1.6, 0.5, and 0.1 years, respectively.

CONCLUSION

This prognostic index is a useful for making appropriate treatment strategy decisions for patients with hepatocellular carcinoma and tumor thrombosis in the major portal vein.

Thalidomide in advanced hepatocellular carcinoma with optional low-dose interferon-alpha2a upon progression

PURPOSE

To evaluate thalidomide in advanced hepatocellular carcinoma (HCC) and to evaluate combined thalidomide and low-dose interferon-alpha2a (IFN-alpha2a) after tumor progression on thalidomide. Systemic therapy is minimally effective in HCC and tumor angiogenesis is a potential therapeutic target.

PATIENTS AND METHODS

Patients with unresectable HCC were eligible if they had preserved hepatic and renal function. The initial thalidomide dosage was 200 mg daily and was adjusted for toxicity. Upon progression, patients could continue thalidomide with additional low-dosage (one million units twice daily) IFN-alpha2a.

RESULTS

Thirty-eight enrolled patients were predominantly hepatitis C virus infected (53%), Child-Pugh class A (79%), and Eastern Cooperative Oncology Group performance status 0-1 (92%); 60% had extrahepatic metastasis. Confirmed disease control was seen in seven patients (18%) and included one complete and one partial response (5% response rate). The median progression-free survival was 2.1 months, and median overall survival was 5.5 months. Tumor invasion of the portal vein or vena cava, large (>10 cm) tumor, and younger age were associated with shorter overall survival. Toxicity included fatigue in 74% of patients. Six patients stopped therapy because of side effects, including two patients (5%) with grade 4 arteriothrombotic events. Five patients continued thalidomide upon progression with the addition of IFN-alpha2a; there was no disease control and 80% had grade 3 toxicity.

CONCLUSIONS

Thalidomide is not well tolerated and confers limited disease control in advanced HCC. Combination thalidomide and low-dose IFN-alpha2a is neither safe nor efficacious in this population.

Hepatectomy for hepatocellular carcinoma with major portal or hepatic vein invasion: results of a multicenter study

BACKGROUND

The role of hepatic resection in patients with hepatocellular carcinoma (HCC) and invasion of a main portal or hepatic vein branch is controversial. We evaluated the efficacy of hepatic resection and the factors affecting survival after resection in such patients.

METHODS

The records of 102 patients who underwent resection for HCC with major vascular invasion between 1984 and 1999 were reviewed. Prognostic factors were evaluated by univariate and multivariate analysis.

RESULTS

The study included 87 men and 15 women. The median age was 59 years. The perioperative mortality rate was 5.9%. Median survival was 11 months (median follow-up, 93 months). The 1-, 3-, and 5-year survival rates were 45%, 17%, and 10%; the longest-living survivor was still alive at 14.8 years. Absence of moderate to severe fibrosis and absence of high nuclear grade were associated with a better 5-year survival rate (23% vs 5%; P = .001 and 21% vs 9%; P = .04, respectively). On multivariate analysis, moderate to severe fibrosis remained a significant predictor of both short-term (< or = 6 months) and long-term (>6 months) survival ( P < .03 and P < .01, respectively).

CONCLUSIONS

Hepatic resection for HCC with major vascular invasion is associated with median survival exceeding historical survival in patients not treated surgically. Patients with HCC and major vascular invasion who derive long-term benefit from resection have no or minimal underlying fibrosis.

Transcatheter hepatic arterial chemoembolization for hepatocellular carcinoma invading the portal veins: therapeutic effects and prognostic factors

PURPOSE

This retrospective study was undertaken to evaluate the therapeutic effects of transcatheter hepatic arterial chemoembolization on hepatocellular carcinoma (HCC) invading the portal veins and to identify prognostic factors.

MATERIALS AND METHODS

Sixty-one patients underwent chemoembolization. The HCC had invaded the main portal vein in 23 patients, a first-order branch in 25 patients and a second-order branch in 13 patients. The hepatic arteries feeding the tumors were embolized with gelatin sponge after a mixture of iodized oil and anticancer drugs was injected via these vessels. Tumor response was evaluated by measuring tumor sizes on CT images. A reduction in maximum diameter of 25% or more was considered to indicate response to chemoembolization. Significant prognostic factors were identified by univariate and multivariate analyses.

RESULTS

Tumor size was reduced by 25% or more in 26 patients (43%). The 1-, 3- and 5-year survival rates were 42, 11 and 3%, respectively, with mean survival of 15 months in all patients. In the univariate analysis, the following six variables were significantly associated with prognosis: (i) tumor response; (ii) ascites; (iii) accumulation of iodized oil in tumor thrombi; (iv) in main tumors; (v) Okuda classification; and (vi) tumor size. In the multivariate analysis, the first three of these factors showed significantly independent values for patient prognosis.

CONCLUSION

Chemoembolization appears to be an effective treatment for HCCs invading the portal venous system. The prognostic factors identified here are expected to be helpful in classifying patients with HCCs invading the portal veins and should serve as useful guidelines for chemoembolization in clinical practice.

A phase II trial of continuous infusion of 5-fluorouracil, mitoxantrone, and cisplatin for metastatic hepatocellular carcinoma

BACKGROUND

The aim of the current study was to evaluate the antitumor activity and toxicity of continuous infusion of 5-fluorouracil, mitoxantrone, and cisplatin (FMP therapy) in chemotherapy-naive patients with metastatic hepatocellular carcinoma (HCC).

METHODS

Fifty-one patients with metastatic HCC who had not undergone previous systemic chemotherapy were enrolled. The therapy consisted of intravenous administration of 80 mg/m2 cisplatin and 6 mg/m2 mitoxantrone on Day 1 and continuous intravenous infusion of 450 mg/m2 5-fluorouracil per day on Days 1-5. The treatment was repeated every 4 weeks for a maximum of 6 courses with dose adjustments based on the observed toxic effects if there was no evidence of tumor progression or unacceptable toxicity.

RESULTS

Of the 51 enrolled patients, 14 (27%) achieved a partial response (95% confidence interval, 16-42%) with a median duration of 7.6 months (range, 2.3-18.4 months). Twenty-seven patients (53%) showed no change and 9 (18%) had progressive disease. The median survival time, 1-year survival rate, and median progression-free survival time for all patients were 11.6 months, 44.3%, and 4.0 months, respectively. The main Grade 3 and 4 toxicities were leukocytopenia (67%), neutropenia (71%), thrombocytopenia (27%), and elevated levels of aspartate aminotransferase (37%) and alanine aminotransferase (41%). These symptoms were generally brief and reversible, with the exception of one treatment-related death due to acute hepatic failure.

CONCLUSIONS

FMP therapy had significant antitumor activity with acceptable toxicity in patients with metastatic HCC.

Optimal treatment strategy for elderly patients with hepatocellular carcinoma

BACKGROUND AND AIMS

The age distribution of patients with hepatocellular carcinoma (HCC) now peaks at nearly 70 years in Japan and this is continually increasing. Whether such elderly patients with HCC aged 80 years or older should be treated, and if so, how they should be selected for treatment remains uncertain. The present study was undertaken to determine any differences in the clinical characteristics and prognostic features between patients with HCC aged 80 years or older and those younger than 80 years of age. We also aimed to identify any significant variables in the prognosis of elderly patients with HCC aged 80 years or older.

METHODS

Seven hundred and four patients with HCC, diagnosed during a 12-year period from January 1989 to December 2000, were categorized into two groups as follows: (i) 36 patients aged 80 years or older at the detection of HCC were defined as the elderly group and; (ii) 668 patients younger than 80 years of age were placed in the non-elderly group. Clinical variables were analyzed and compared between the two groups, and any significant variables in the prognosis were simultaneously determined.

RESULTS

Regarding sex, viral markers, concentration of serum alpha-fetoprotein, diameter and number of tumors, Child's grade, presence of portal thrombosis, histology grade of HCC and any types of treatment, no significant difference was found between the two groups. The 1-year and 3-year survival rates in the elderly group (54.1 and 28.1%, respectively) were not significantly different from those in the non-elderly group (69.9 and 43.2%, respectively; P = 0.1053). The only significant factor in the prognosis in the elderly group was the presence of portal thrombosis, although a Child's grade of B or C was almost a significant factor with a P-value of 0.063. Tumor size measuring more than 3 cm in the greatest dimension, non-solitary tumor, Child's grade of B or C, and the presence of portal thrombosis were all found to be prognostic factors in the non-elderly group using a multivariate analysis.

CONCLUSIONS

An advanced stage of HCC, not advanced age, influenced the survival rate in these elderly patients. Therefore, an optimal treatment strategy should be applied for elderly patients with HCC who demonstrate less prognostic factors in the same manner as that for non-elderly patients.

Systemic treatment and liver transplantation for hepatocellular carcinoma: two ends of the therapeutic spectrum

Hepatocellular carcinoma is the fifth most common malignant disorder and causes nearly 1 million deaths a year worldwide. A background of cirrhosis is the major risk factor, and in Asia and subSaharan Africa, cirrhosis is attributable mainly to endemic hepatitis B infection. In Europe and the USA the incidence of hepatocellular carcinoma is increasing as a result of the high prevalence of hepatitis C. The only curative treatments are surgical resection or liver transplantation, but only a few patients are eligible for these procedures. Local ablative treatments such as ethanol injection can lengthen survival in selected patients, and radiofrequency ablation also shows promise. Unfortunately, most patients are suitable only for palliative treatment because of the extent of their tumour or background liver disease or both. For these patients, a wide range of therapeutic interventions have been assessed, including transarterial embolisation (with or without chemotherapy), hormone therapy with antioestrogens and androgens, octreotide, interferon, and both arterial and systemic chemotherapy, of which only chemoembolisation improves survival over symptomatic care. Tamoxifen is ineffective, and there are insufficient randomised data to show the benefit of any other intervention. In this review, we focus on two ends of the therapeutic spectrum--transplantation, which is highly effective but applicable to only a few patients, and systemic chemotherapy, which is of uncertain benefit but widely applicable.

Percutaneous radiofrequency ablation of hepatocellular carcinoma in the presence of portal vein thrombosis

Portal vein thrombosis (PVT) may not be an absolute contraindication for hepatic radiofrequency ablation (RFA). Although the data are sparse, PVT is commonly considered a contraindication to RFA. PVT has actually been described as a complication following RFA. RFA was used to treat a 3.9 x 2.9 cm primary hepatocellular carcinoma (HCC) in a patient with concomitant PVT without complication. RFA can be safely performed in this setting but further studies could clarify this issue.

MR-guided laser thermal ablation of primary and secondary liver tumours

AIM

To test the hypothesis that magnetic resonance (MR)-guided hepatic tumour ablation is (i) safe and feasible, (ii) is associated with favourable patient survival, and (iii) decreases viable tumour.

MATERIALS AND METHODS

One hundred and twenty-five MR-guided laser thermal ablations (LTA) were performed on 35 patients with hepatocellular carcinoma (HCC, n=19), hepatic metastases (n=11, mainly colorectal) and carcinoid liver tumours (n=5).

RESULTS

Mean overall survival was 14.8 months (HCCs 14.6 months, metastases 15.2 months). Near real-time T1-weighted colourized thermal maps correlated moderately with follow-up gadolinium-enhanced MR imaging in predicting ablated tumour area (Pearson correlation coefficient=0.5). There was a significant difference in percentage enhancing pre- and post-LTA (Wilcoxon signed ranks test=0.0001). An average of 50.7% of tumour was ablated by each treatment. In patients with multiple liver tumours ablated tumours grew significantly less than untreated tumours (108%compared with 196% growth, follow-up period 5.8 months, WSRTp=0.07).

CONCLUSION

MR- guided LTA of primary and secondary liver tumours is safe, feasible, and significantly decreased amount of enhancing or viable tumour. MR-guided LTA produces a better survival in patients with HCC than would be expected in untreated patients, and has a mean survival in patients with metastases at least equal to the longest median survival in untreated patients.

Results of hepatic resection for hepatocellular carcinoma invading major portal and/or hepatic veins

Nonsurgical therapy for patients with advanced hepatocellular carcinoma (HCC) has yielded poor long-term survival. This study evaluates the effects of surgical treatments for patients with HCC invading major portal and/or hepatic veins. The surgical results of 112 patients with HCC invading major portal and/or hepatic veins who underwent hepatic resection between 1985 and 2001 were studied to evaluate the feasibility of hepatic resection as a local treatment.

Hepatorenal syndrome: diagnostic accuracy, clinical features, and outcome in a tertiary care center

OBJECTIVES

Hepatorenal syndrome (HRS) is a common and life-threatening entity that is associated with advanced liver disease. There are limited data on predisposing or precipitating factors related to the development of this syndrome. The aims of this study were: 1) to determine the accuracy of the diagnosis of HRS in an urban tertiary care center; 2) to compare features of HRS with those of non-HRS renal failure; and 3) to document the precipitating factors for HRS in this setting.

METHODS

We conducted a retrospective chart review of 46 patients at the Health Sciences Center in Winnipeg, Manitoba, who were diagnosed with HRS within the last 10 yr. In addition to assessing the accuracy of the diagnosis of HRS (as defined by the International Ascites Club), we also developed a database that included clinical and biochemical features of these patients' liver disease, possible predisposing factors, precipitating events, etiology of cirrhosis, and mortality rates. A cohort of 19 patients with advanced liver disease and renal failure not ascribed to HRS (non-HRS) served as controls.

RESULTS

A total of 46 patients were labeled as having HRS during their hospital stay, of whom 27 (59%) fulfilled International Ascites Club criteria. Their mean age was 51.8 +/- 12.1 yr, and 67% were male. Demographic and biochemical findings in the HRS patients were similar to those of the non-HRS patients. Hepatic encephalopathy (p < 0.03) and jaundice (p < 0.01) more commonly preceeded renal failure in the HRS group than in the controls. The most common predisposing factor for HRS was alcohol abuse. Precipitating factors for HRS included infection in 48% patients, GI bleeding in 33%, and over paracentesis in 27%. Drug-induced renal disease was significantly more common in patients with non-HRS renal failure. Contrary to previous reports, nonsteroidal anti-inflammatory drugs were not common precipitating factors of HRS. Alcohol-related liver disease was the most common underlying etiology of liver disease in all patients who developed renal failure but was proportionally higher in the HRS group. Mortality was almost universal in both groups, regardless of the cause of renal failure.

CONCLUSIONS

The diagnostic accuracy (or lack thereof) of HRS highlights the importance of ensuring that diagnostic criteria are met in studies describing the natural history and/or the results of therapeutic intervention in HRS. Alcohol abuse is a common predisposing factor for the development of HRS. Infection, GI bleed, and aggressive paracentesis were the most common precipitating factors for HRS.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis: analysis of 48 cases

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is extremely poor. The aim of this study was to elucidate the efficacy of hepatic arterial infusion chemotherapy (HAIC) for patients with advanced HCCs.

METHODS

Forty-eight HCC patients with PVTT were treated by HAIC via a subcutaneously implanted injection port. Of these, 14 had PVTT in the second portal branch and 34 patients had PVTT in the first portal branch or in the main portal trunk. One course of chemotherapy consisted of daily cisplatin (7 mg/m(2) for 1 hour on Days 1-5) followed by 5-fluorouracil (170 mg/m(2) for 5 hours on Days 1-5). Patients were scheduled to receive four serial courses of HAIC. Responders were defined as having either a complete response (CR) or partial response (PR) and nonresponders were defined as exhibiting stable disease or progressive disease. The prognosis after HAIC and factors related to survival were analyzed.

RESULTS

Following HAIC, 4 and 19 patients exhibited a CR and PR, respectively (response rate = 48%). The 1, 2, 3, and 5-year cumulative survival rates of 48 patients treated with HAIC were 45%, 31%, 25%, and 11%, respectively. Median survival periods for 23 responders and 25 nonresponders were 31.6 (range, 8.3-76.9) months and 5.4 (1.9-29.0) months, respectively. Therapeutic effect (P < 0.001) and hepatic reserve capacity (P = 0.021) were identified as significant prognostic factors by univariate analysis. Multivariate analysis identified only therapeutic effect as being significantly related to survival.

CONCLUSIONS

HAIC using low-dose cisplatin and 5-fluorouracil may be a useful therapeutic option for patients with advanced HCC with PVTT. HCC patients with PVTT who respond to HAIC could certainly have survival benefits.

Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus

OBJECTIVE

To examine the usefulness of the authors' method involving preoperative transcatheter arterial chemoembolization followed by hepatectomy.

SUMMARY BACKGROUND DATA

The presence of portal vein tumor thrombus in a patient with hepatocellular carcinoma is one of the most significant factors for a poor prognosis. No standard therapy has been established.

METHODS

Forty-five of 455 patients with hepatocellular carcinoma (10%) from 1989 to 1998 were included in this study. These patients had gross portal vein tumor thrombus but no distant metastases. The 23 patients (50%) who had indications for surgery received preoperative transcatheter arterial chemoembolization: 18 underwent hepatic resection and 5 underwent ligation of the hepatic artery or portal vein on laparotomy. Among the remaining 22 patients who did not have indications for hepatectomy, 10 received regional chemotherapy and 12 underwent transcatheter arterial chemoembolization.

RESULTS

The mean duration of survival was 3.4 +/- 2.7 years in the 18 patients who received transcatheter arterial chemoembolization and hepatectomy and 0.36 +/- 0.26 years in the 27 patients who did not receive hepatectomy. The survival rate of the 18 patients who received hepatic resection with preoperative transcatheter arterial chemoembolization was 82% at 1 year, 42% at 3 years, and 42% at 5 years. Portal trunk occlusion by tumor thrombus, three or more primary nodules, an indocyanine green retention rate at 15 minutes of 20% or worse, and therapeutic choice other than hepatectomy were significant predictors of a poor prognosis on univariate analysis. Hepatectomy was the only factor that was significant on multivariate analysis.

CONCLUSIONS

Patients may enjoy long-term survival if they receive hepatectomy with preoperative transcatheter arterial chemoembolization, when the number of primary nodules is no more than two, the portal trunk is not occluded by tumor thrombus, and the indocyanine green retention rate at 15 minutes is better than 20%.

Review of 336 patients with hepatocellular carcinoma at Songklanagarind Hospital

AIM: To determine the clinical presentations, survival and prognostic factors of hepatocellular carcinoma (HCC) in Southern Thailand.

METHODS: Retrospective analysis was performed on the 336 hepatocellular carcinoma patients treated at Songklanagarind hospital between 1 January 1991 and 31 January 1999.

RESULTS: Of these 336 patients, 276 were males and 60 were females. The mean age was 54.4 years. The common symptoms and signs were abdominal pain and hepatomegaly. The most common presentation of tumor was a dominant mass with daughter nodules. Portal vein involvement was found in 50% of total. Extra hepatic metastasis was found in 13%, and the lung was the most common site. There were 65.4% with evidence of cirrhosis and half of them were in Child's class B. HBsAg was positive in 72.6%. Regarding Okuda's tumor staging, 15%, 61% and 24% were stage I, II and III, respectively. Overall median survival was 2.1 months (11.5, 2.6 and 0.7 months for stage I, II and III respectively). Treatments of HCC improved patient survival (5.5 months vs 1.6 months for untreated patients). Most common causes of death were hepatic failure. Using multivariate analysis, the prognostic factors identified were tumor staging, alpha-fetoprotein level above 10000 μg·L^-1, extrahepatic metastasis, portal vein thrombosis and treatment.

CONCLUSION: HCC in Thailand is a fatal disease with poor outcome due to late presentation and high prevalence of liver cirrhosis. Early detection and proper management may improve outcome.

A prognostic index of the survival of patients with unresectable hepatocellular carcinoma after transcatheter arterial chemoembolization

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been used as a palliative treatment for patients with unresectable hepatocellular carcinoma (HCC), but its prognostic usefulness has not previously been clarified.

METHODS

The authors reviewed all patients treated at their institution with TACE for unresectable HCC in order to analyze prognostic factors and to determine which patients might benefit from this treatment. One hundred forty-three patients were retrospectively studied. Pretreatment, treatment, and follow-up variables with possible prognostic significance were analyzed. A stepwise multivariate analysis was performed using the Cox regression model, and a prognostic index was obtained.

RESULTS

According to univariate analysis, variables significantly associated with survival were alpha-fetoprotein (>400 U/L), tumor size (>50%), ascites, albumin (<30 g/L), Child-Pugh grade (Child C), Okuda stage (Okuda III), portal vein thrombosis, tumor greatest dimension larger than 5 cm, more than 3 nodules, bilobular involvement, and pattern of iodized oil uptake, tumor size reduction, and radiologic T classification on computed tomography scan performed 7 and 30 days after TACE. However, only ascites, alpha-fetoprotein (>400 U/L), tumor size (>50%), Child-Pugh grade (Child C), pattern of iodized oil uptake, and portal vein thrombosis were independent factors in multivariate analysis. Using the beta-coefficients of alpha-fetoprotein (>400 U/L), tumor size (>50%) and Child-Pugh score, a prognostic index was calculated, and according to this index patients were classified into 3 categories with different prognoses. Ascites was excluded from the analysis because it is included in Child-Pugh grade, and iodized oil uptake was excluded because it cannot be evaluated before treatment.

CONCLUSIONS

This simple prognostic index can predict the survival of patients treated with TACE and can therefore be used to decide which patients with unresectable HCC should receive this therapy. TACE should not be administered to patients with one or more positive prognostic factors.

A prognostic index of the survival of patients with unresectable hepatocellular carcinoma after transcatheter arterial chemoembolization

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been used as a palliative treatment for patients with unresectable hepatocellular carcinoma (HCC), but its prognostic usefulness has not previously been clarified.

METHODS

The authors reviewed all patients treated at their institution with TACE for unresectable HCC in order to analyze prognostic factors and to determine which patients might benefit from this treatment. One hundred forty-three patients were retrospectively studied. Pretreatment, treatment, and follow-up variables with possible prognostic significance were analyzed. A stepwise multivariate analysis was performed using the Cox regression model, and a prognostic index was obtained.

RESULTS

According to univariate analysis, variables significantly associated with survival were alpha-fetoprotein (>400 U/L), tumor size (>50%), ascites, albumin (<30 g/L), Child-Pugh grade (Child C), Okuda stage (Okuda III), portal vein thrombosis, tumor greatest dimension larger than 5 cm, more than 3 nodules, bilobular involvement, and pattern of iodized oil uptake, tumor size reduction, and radiologic T classification on computed tomography scan performed 7 and 30 days after TACE. However, only ascites, alpha-fetoprotein (>400 U/L), tumor size (>50%), Child-Pugh grade (Child C), pattern of iodized oil uptake, and portal vein thrombosis were independent factors in multivariate analysis. Using the beta-coefficients of alpha-fetoprotein (>400 U/L), tumor size (>50%) and Child-Pugh score, a prognostic index was calculated, and according to this index patients were classified into 3 categories with different prognoses. Ascites was excluded from the analysis because it is included in Child-Pugh grade, and iodized oil uptake was excluded because it cannot be evaluated before treatment.

CONCLUSIONS

This simple prognostic index can predict the survival of patients treated with TACE and can therefore be used to decide which patients with unresectable HCC should receive this therapy. TACE should not be administered to patients with one or more positive prognostic factors.