Long-term prognostic factors of patients with hepatocellular carcinoma who survive over 10 years after hepatectomy

Predicting symptomatic post-hepatectomy liver failure in patients with hepatocellular carcinoma: development and validation of a preoperative nomogram

OBJECTIVE

To develop and validate a nomogram based on liver stiffness (LS) for predicting symptomatic post-hepatectomy (PHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 266 patients with HCC were enrolled prospectively from three tertiary referral hospitals from August 2018 to April 2021. All patients underwent preoperative laboratory examination to obtain parameters of liver function. Two-dimensional shear wave elastography (2D-SWE) was performed to measure LS. Three-dimensional virtual resection obtained the different volumes including future liver remnant (FLR). A nomogram was developed by using logistic regression and determined by receiver operating characteristic (ROC) curve analysis and calibration curve analysis, which was validated internally and externally.

RESULTS

A nomogram was constructed with the following variables: FLR ratio (FLR of total liver volume), LS greater than 9.5 kPa, Child-Pugh grade, and the presence of clinically significant portal hypertension (CSPH). This nomogram enabled differentiation of symptomatic PHLF in the derivation cohort (area under curve [AUC], 0.915), internal fivefold cross-validation (mean AUC, 0.918), internal validation cohort (AUC, 0.876) and external validation cohort (AUC, 0.845). The nomogram also showed good calibration in the derivation, internal validation, and external validation cohorts (Hosmer-Lemeshow goodness-of-fit test, p = 0.641, p = 0.06, and p = 0.127, respectively). Accordingly, the safe limit of the FLR ratio was stratified using the nomogram.

CONCLUSION

An elevated level of LS was associated with the occurrence of symptomatic PHLF in HCC. A preoperative nomogram integrating LS, clinical and volumetric features was useful in predicting postoperative outcomes in patients with HCC, which might help surgeons in the management of HCC resection.

CLINICAL RELEVANCE STATEMENT

A serial of the safe limit of the future liver remnant was proposed by a preoperative nomogram for hepatocellular carcinoma, which might help surgeons in 'how much remnant is enough in liver resection'.

KEY POINTS

• An elevated liver stiffness with the best cutoff value of 9.5 kPa was associated with the occurrence of symptomatic post-hepatectomy liver failure in hepatocellular carcinoma. • A nomogram based on both quality (Child-Pugh grade, liver stiffness, and portal hypertension) and quantity of future liver remnant was developed to predict symptomatic post-hepatectomy liver failure for HCC, which enabled good discrimination and calibration in both derivation and validation cohorts. • The safe limit of future liver remnant volume was stratified using the proposed nomogram, which might help surgeons in the management of HCC resection.

Systemic immune-inflammation index and the survival of hepatocellular carcinoma patients after transarterial chemoembolization: a meta-analysis

The systemic immune-inflammation index (SII), derived from neutrophil, platelet, and lymphocyte counts, has been associated with prognosis of patients with cancer. We performed a meta-analysis to evaluate the association between pretreatment SII and survival of patients with hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE). Cohort studies were identified by search of PubMed, Embase, Web of Science, CNKI, and Wanfang databases. Pooling the results was achieved with a random-effect model that incorporates potential heterogeneity between studies. Nine studies including 3557 patients with HCC contributed to the meta-analysis. Compared to patients with a lower SII, HCC patients with a higher pretreatment SII had poor overall survival (OS, hazard ratio [HR] 1.66, 95% confidence interval [CI] 1.25-2.21, p < 0.001; I2 = 80%) and poor progression-free survival (PFS, HR 1.28, 95% CI 1.05-1.56, p = 0.01; I2 = 0%) after TACE treatment. Further subgroup analyses confirmed a significant association between a high pretreatment SII and poor OS after TACE, which was not significantly affected by study country, sample size, age of the patients, cutoff values for SII, and adjustment of Child-Pugh score or alpha fetoprotein (p for subgroup effect all < 0.05). However, a higher SII was associated with poor OS in studies with follow-up duration ≤ 24 months (HR 1.94, 95% CI 1.39-2.72, p < 0.001), but the association was not statistically significant in studies with follow-up duration > 24 months (HR 1.27, 95% CI: 0.96-1.68, p = 0.09). A higher pretreatment SII was correlated with poor survival of HCC patients after TACE. A preliminary measurement of SII may be valuable for the prediction of the prognosis in HCC patients after TACE.

Prediction of early recurrence of hepatocellular carcinoma after resection based on Gd-EOB-DTPA enhanced magnetic resonance imaging: a preliminary study

BACKGROUND

Early recurrence (ER) after radical resection of hepatocellular carcinoma (HCC) affects the prognosis of patients. Gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) can improve the detection rate of small HCC. This study innovatively introduces a new quantitative index combined with qualitative index to compare the differences in clinical and imaging characteristics between ER and non-ER groups and evaluate the feasibility of Gd-EOB-DTPA-enhanced MRI in predicting ER.

METHODS

A total of 68 patients with HCC confirmed by operation and pathology in the Shandong Cancer Hospital and Institute were included retrospectively. All participants were examined by Gd-EOB-DTPA-enhanced MRI within 3 weeks before surgery. Regular follow-up was performed every 2 months within 1 year after operation. Among them, 18 cases with new lesions were in ER group, and 50 cases without new lesions were in non-ER group. The clinical and imaging data of the 2 groups were collected, and the differences of clinical data and preoperative MRI signs between the ER group and non-ER group were compared. The predictive factors of ER after HCC were analyzed by multivariate logistic regression.

RESULTS

The quantitative parameter lesion-to-liver contrast enhancement ratio (LLCER) can predict the pathological grade of HCC (P=0.023). The results of univariate analysis between the ER group and non-ER group showed that there were significant differences in pathological grade (P=0.008), lesion morphology (P=0.011), peritumoral low signal intensity in hepatobiliary phase (HBP) (P<0.001), satellite nodules (P<0.001), and LLCER (P<0.001) between the 2 groups. Multivariate logistic regression analysis showed that HBP peritumoral low signal intensity [odds ratio (OR) =7.214, 95% confidence interval (CI): 1.230-42.312, P=0.029], satellite nodules (OR =9.198, 95% CI: 1.402-60.339, P=0.021), and parameter LLCER value (OR =0.906, 95% CI: 0.826-0.995, P=0.039) were independent predictors of ER of HCC after resection.

CONCLUSIONS

Preoperative Gd-EOB-DTPA enhanced MRI has important predictive value for early recurrence after radical resection of hepatocellular carcinoma.

Liver Stiffness Measured by Two-Dimensional Shear Wave Elastography for Predicting Symptomatic Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

OBJECTIVES

To evaluate the ability of liver stiffness (LS) measured by two-dimensional shear wave elastography (2D SWE) to predict symptomatic post-hepatectomy liver failure (SPHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 119 patients who underwent hepatectomy for HCC between August 2018 and July 2019 were enrolled. Preoperative assessments for LS and other clinicopathological tests were performed in all patients. Univariate and multivariate analyses were conducted for the risk factors of SPHLF. Further subgroup analysis was performed according to multivariate analysis results.

RESULTS

SPHLF occurred in 38 patients (31.9%). The best cutoff value of LS for predicting SPHLF was 9.5 kPa. Multivariate analysis identified LS ≥ 9.5 kPa, greater Child-Turcotte-Pugh (CTP) grade, and major hepatectomy as independent predictors of SPHLF. Based on the extent of hepatectomy, CTP grade could stratify the risk of SPHLF in the minor hepatectomy group (12.2% vs. 100.0%, p = 0.001), whereas LS was superior in predicting SPHLF in the major hepatectomy group (18.9% vs. 72.4%, p < 0.001). In patients with CTP grade A, LS could further stratify the risks of SPHLF in both the minor and major hepatectomy groups (3.7% vs. 22.7%, p = 0.043; 17.6% vs. 70.4%, p < 0.001, respectively).

CONCLUSIONS

LS measured using 2D SWE could predict SPHLF using the best cutoff value of 9.5 kPa. CTP grade was a stronger indicator of SPHLF in minor hepatectomy, whereas LS was more effective in selecting candidates for major hepatectomy. LS could further stratify the risk of SPHLF in CTP grade A patients, regardless of the extent of hepatectomy.

Update on Hepatocellular Carcinoma: a Brief Review from Pathologist Standpoint

Hepatocellular carcinoma is one of the most common cancers and an important health problem all over the world. Its prognosis is poor. For better patient care, early diagnosis is essential. Although new imaging techniques have a big impact on hepatocellular carcinoma diagnosis, histopathological examination is still the gold standard for precise diagnosis. Histopathological evaluation gives exact diagnosis in the meaning of tumor size, histological subtypes, grading, and differential diagnosis from metastasis and other tumors. Immunohistochemistry as a part of diagnostic histopathological technique plays an important role in routine practice. Immunohistochemistry is useful for confirming of hepatocytic origin, supporting hepatocellular malignancy, and differential diagnosis. It also gives prognostic information. There are growing attempts to classify tumors by their molecular genetic signatures. This is also actual for hepatocellular carcinoma. This mini review focuses on the histopathology of hepatocellular carcinoma including subtypes; differential diagnosis and immunohistochemistry as an ancillary diagnostic tool, updated or added entities, i.e., combined hepatocellular-cholangiocarcinoma; small hepatocellular carcinoma; correlation with molecular studies; and future perspectives.