Characteristics of multicentric hepatocellular carcinomas: comparison with intrahepatic metastasis

Preoperative Predictors of Early Recurrence After Liver Resection for Multifocal Hepatocellular Carcinoma

BACKGROUND

Liver transplantation remains the optimal treatment for multifocal hepatocellular carcinoma (HCC). However, due to resource constrains, other therapeutic modalities such as liver resection (LR), are frequently utilized. LR, however, has to be balanced against potential morbidity and mortality along with the risks of early recurrence leading to futile surgery. In this study, we evaluated preoperative factors, including inflammatory indices, in predicting early (< 1 year) recurrence in patients who underwent LR for multifocal HCC.

METHODS

This was a post hoc analysis of 250 consecutive patients with multifocal HCC who underwent LR.

RESULTS

After exclusion of 10 patients with 30-day/in-hospital mortality, 240 were included of which 134 (55.8%) developed early recurrence. Hepatitis B/C aetiology, 3/ > more hepatic nodules and elevated alpha-fetoprotein (AFP) ≥ 200 ng/ml were significant independent preoperative predictors of early recurrence. The early recurrence rate was 72.1% when 2 out of 3 significant predictive factors were present. The conglomerate of all 3 factors predicted early recurrence of 100% with a statistically significant association between number of predictive factors and early recurrence (p < 0.001).

CONCLUSION

Better patient selection via the use of preoperative predictive factors of early recurrence such as hepatitis B/C aetiology, ≥ 3 nodules and elevated AFP ≥ 200 ng/ml may assist in identifying patients in whom LR is deemed futile and improve resource allocation.

Clinical utility of clonal origin determination in managing recurrent hepatocellular carcinoma

INTRODUCTION

Recurrence is the driving factor for reduced long-term survival in patients following resected hepatocellular carcinoma (HCC). Extensive research efforts have been conducted to understand the molecular processes precipitating disease recurrence. Modern genomic techniques have identified two distinct mechanisms for recurrent HCC (RHCC): Intrahepatic metastasis (IM-HCC); and multicentric origin (MO-HCC). Medline, EMBASE and Cochrane library were methodically searched for primary research articles in English with the aim of appraising existing literature on the identification of clonal origin of RHCC and its potential clinical utility.

AREAS COVERED

Molecular and next-generation sequencing techniques, when applied to clonal origin identification, yield superior accuracy than traditional clinicopathological criteria. Despite various treatment modalities, no optimal therapy has yet been identified for treating clonally differentiated RHCC. Patients with MO-HCC appear to experience improved long-term survival following re-treatment compared to their IM-HCC counterparts (91.7% vs 22.9% 5-year survival, p < 0.001). However, cautious interpretation is advised as heterogeneous classification criteria and small sample sizes restrict the generalizability of such findings.

EXPERT OPINION

Improved identification of clonal origin in RHCC may facilitate further research on RHCC treatment strategies and enable the development of novel therapeutic targets, potentially leading to individualized treatment approaches in the future.

Validation of ZMYND8 as a new treatment target in hepatocellular carcinoma

BACKGROUND

ZMYND8 (Zinc finger MYND (Myeloid, Nervy and DEAF-1)-type containing 8) has been known to play an important role in tumor regulation in various types of cancer. However, the results of ZMYND8 expression and their clinical significance in hepatocellular carcinoma (HCC) have not yet been published. In the present study, we investigate the expression of ZMYND8 protein and mRNA in HCC and elucidate its prognostic significance.

METHODS

ZMYND8 protein and mRNA expression in 283 and 234 HCCs were investigated using immunohistochemistry and microarray gene expression profiling data. The relationships between ZMYND8 expression with clinicopathologic features and prognosis of HCC patients were evaluated. Furthermore, we performed the invasion, migration, apoptosis, soft agar formation assay and sphere formation assay in HCC cell lines, and evaluated tumorigenicity in a nude mouse model, after ZMYND8 knockdown.

RESULTS

Overexpression of ZMYND8 protein and mRNA was observed in 20.5% and 26.9% of HCC cases, respectively. High ZMYND8 expression showed significant correlations with microvascular invasion, high Edmondson grade, advanced American Joint Committee on Cancer, and increased alpha-fetoprotein level. ZMYND8 mRNA overexpression was an independent prognostic factor for predicting early recurrence as well as short recurrence-free survival (RFS). Downregulation of ZMYND8 reduced migration and invasion of HCC cells, and promoted apoptosis of HCC cells in an in vitro model. In a xenograft nude mouse model, knockdown of ZMYND8 significantly reduced tumor growth.

CONCLUSION

ZMYND8 mRNA overexpression could be a prognostic marker of shorter RFS in HCC patients after curative resection. ZMYND8 might play an important role in the proliferation and progression of HCC and could be a promising candidate for targeted therapy.

Preoperative MR imaging for predicting early recurrence of solitary hepatocellular carcinoma without microvascular invasion

OBJECTIVES

This study aimed to identify preoperative MR imaging features for predicting early recurrence after curative resection of solitary hepatocellular carcinoma (HCC) without microvascular invasion (MVI).

METHODS

124 patients with MVI-negative HCC who underwent preoperative dynamic contrast-enhanced 1.5-T MR imaging before surgical resection were included. Liver Imaging Reporting and Data System (LI-RADS v2018) imaging features and three non-LI-RADS MR imaging features for predicting early recurrence (intrahepatic recurrence<2 years) were identified by univariable and multivariable analyses. A nomogram was constructed for individualized risk estimation, and its predictive accuracy and discriminative ability were identified by concordance index (C-index) and calibration curve.

RESULTS

In multivariable analysis, tumor size (p = 0.045), nonsmooth tumor margin (p = 0.013), and presence of mosaic architecture (p = 0.035) were independent significant variables associated with early recurrence. These were all incorporated to establish the nomogram. The C-index of the nomogram was 0.743 (95 % CI: 0.697-0.788).

CONCLUSION

At dynamic contrast-enhanced MR imaging, tumor size, nonsmooth tumor margin, and presence of mosaic architecture may be helpful to predict early recurrence of solitary HCC without MVI after curative resection.

Validation of ORAOV1 as a new treatment target in hepatocellular carcinoma

PURPOSE

Chromosome 11q13.2, which contains genes cyclin D1 (CCND1), fibroblast growth factor 19 (FGF19), and Oral Cancer Overexpressed 1 (ORAOV1), is the most highly amplified peak in hepatocellular carcinoma (HCC). CCND1 and FGF19 have been already suggested as therapeutic targets of HCC, but the role of ORAOV1 in carcinogenesis of HCCs has not been reported.

METHODS

This retrospective study investigated ORAOV1 expression using immunohistochemistry performed on tissue microarray blocks obtained from 259 HCC patients with curative resection, between 2000 and 2006. We assessed the prognostic significance of ORAOV1 expression by Kaplan-Meier method with log-rank test and Cox proportional hazards model. Also, we performed invasion, migration, apoptosis, and cell cycle assays in HCC cell lines, and evaluated the tumorigenicity of HCC xenografts in nude mice, after knockdown of ORAOV1.

RESULTS

High expression of ORAOV1 protein was observed in 80% of HCC tissues. The ORAOV1 high expression group showed shorter recurrence free survival (RFS) (p < 0.001) and shorter disease-specific survival (DSS) than the low expression group. It was an independent prognostic factor for predicting early recurrence [Odds ratio 2.74 (95% confidence interval (CI) 1.27-5.93), p = 0.01] as well as short RFS [hazard ratio 2.23 (95% CI 1.40-3.54), p = 0.001] and DSS [hazard ratio 2.30 (95% CI 1.27-4.17), p = 0.006]. Knockdown of ORAOV1 induced significant decreases in migration, invasion, and tumorigenicity of HCC cells in in-vitro model, and inhibited the growth of HCC xenografts in nude mice.

CONCLUSION

We demonstrated unfavorable prognostic effect of ORAOV1 expression with supporting experimental data in HCC. ORAOV1 may be used as a biomarker for predicting HCC prognosis and is a potential candidate for targeted therapy.

Prognostic significance of miR-122 expression after curative resection in patients with hepatocellular carcinoma

Downregulation of MicroRNA-122 (miR-122) and its association with cancer progression have been reported in hepatocellular carcinoma (HCC) cell line models and a limited number of HCC samples. Recently, restoration of miR-122 expression by direct delivery of miR-122 yielded promising results in HCCs. However, the prognostic effect of miR-122 expression in human HCC samples is not fully understood. We investigated the expression level of miR-122 by quantitative real-time polymerase chain reaction in 289 curatively resected HCC samples and 20 normal liver samples and evaluated the prognostic effect of miR-122 expression. The relative quantification value of miR-122 was much lower in HCC samples than in normal liver tissues. During a median 119 months of follow-up for survival, the low miR-122 expression group showed shorter recurrence-free survival (RFS) (p = 0.033) and intrahepatic recurrence-free survival (IHRFS) (p = 0.014), and a trend of short distant metastasis-free survival (DMFS) (p = 0.149) than high expression group. On multivariate analysis, miR-122 expression was an independent prognostic factor for RFS, IHRFS and DMFS. Downregulation of miR-122 expression, frequently found in HCC samples, was an independent prognostic factor for RFS after curative resection. Emerging therapeutic approaches targeting miR-122 could be applicable in patients with miR-122 downregulated hepatocellular carcinoma.

Preoperative lymphocyte-to-monocyte ratio is useful for stratifying the prognosis of hepatocellular carcinoma patients with a low Cancer of the Liver Italian Program score undergoing curative resection

BACKGROUND AND AIM

Although the Cancer of the Liver Italian Program (CLIP) score is useful for prognostication of patients with hepatocellular carcinoma (HCC), a previous study has reported that the CLIP score was unable to stratify the postoperative outcomes of HCC patients in whom the score was low (0-1). Recent studies have reported that the preoperative lymphocyte-to-monocyte ratio (LMR) is useful for prognostication of patients with various cancer.

METHODS

We reviewed 329 HCC patients with a low CLIP score (0-1) undergoing curative resection. This study had the approval of the Institutional Review Board (28068). Multivariate analyses were carried out to detect clinical factors correlating with overall survival (OS). Kaplan-Meier analysis and the log-rank test were used for comparison of OS.

RESULTS

Multivariate analysis showed that LMR (<4.35/≥4.35) was significantly associated with OS (hazard ratio [HR], 2.022; 95% CI, 1.141-3.583; P = 0.016) as well as portal vein invasion (HR, 2.410; 95%CI, 1.258-4.618; P = 0.008). Kaplan-Meier analysis and the log-rank test showed a significant difference in OS and relapse-free survival between patients with high LMR and those with low LMR.

CONCLUSION

Preoperative LMR is useful for stratifying the prognosis of HCC patients with a low CLIP score (0-1) undergoing curative resection.

Hepatectomy plus adjuvant transcatheter arterial chemoembolization improves the survival rate of patients with multicentric occurrence of hepatocellular carcinoma

The aim of the present study was to evaluate the role of hepatectomy plus adjuvant transcatheter arterial chemoembolization (TACE) in patients with multicentric occurrence (MO) or intrahepatic metastases (IM) of hepatocellular carcinoma (HCC). Patients with multifocal HCC who underwent hepatic resection only (HR) or HR plus adjuvant TACE (HRT) between January 2005 and December 2015 were divided into MO or IM groups. The patient characteristics and outcomes were retrospectively analyzed. A total of 103 patients (59 and 44 in the MO and IM groups, respectively) were included in the analysis. The 1-, 3- and 5-year overall survival (OS) rates were 92.7, 76.8 and 56.8% for the MO group, and 93.1, 41.6 and 18.5% for the IM group, respectively (OS, P=0.001), and the 1-, 3- and 5-year disease-free survival (DFS) rates were 84.1, 44.6 and 40.5% for the MO group and 51.7, 22.5 and 15.0% for the IM group, respectively (DFS, P<0.001). In the subgroup analysis, the overall survival were significantly better in the MO-HRT group compared with those in the MO-HR group (P=0.019), which was also observed between the IM-HRT and IM-HR groups (P=0.132). Furthermore, the 1-, 3- and 5-year OS demonstrated non-significant differences between patients with <3 and ≥3 tumors in the MO-HR group (P=0.300), but significantly reduced OS for patients with ≥3 tumors in the IM-HR group compared with that for patients with <3 tumors (P=0.132). In conclusion, surgical resection combined with adjuvant TACE may result in significantly increased survival rates of patients with MO-HCC. Tumor number should not be an absolute contradiction to hepatectomy in patients with MO-HCC.

ELTD1 Function in Hepatocellular Carcinoma is Carcinoma-Associated Fibroblast-Dependent

Introduction: EGF, latrophilin, and seven transmembrane domain containing 1 (ELTD1) constitutes an orphan G-protein-coupled receptor (GPCR) of the adhesion family. High expression of ELTD1 is correlated with favorable prognosis of hepatocellular carcinoma (HCC). After silencing ELTD1 expression, however, tumor invasiveness is drastically reduced. The underlying mechanism of this apparent contradictory phenomenon is unknown. Because adhesion GPCRs couple extracellular adhesion to intracellular signaling, as a member of this family, ELTD1 function may be related to its tumor microenvironment. We therefore investigated the interaction between ELTD1 and the HCC tumor microenvironment. Methods: ELTD1 expression was assessed by immunohistochemical analyses of tissue samples from two independent groups of 333 patients with HCC. Correlations between the ELTD1 expression and the clinicopathological values were examined. We also constructed ELTD1 overexpression and knockdown HCC cell lines and conducted a series of in vivo and in vitro ELTD1 functional assays. We further collected carcinoma associated fibroblast (CAF) culture supernatants to culture HCC cell lines and repeat the respective functional assays in comparison with the control group. Results: Clinicopathologic correlations and in vivo models indicated ELTD1 as a tumor suppressor gene, whereas in vitro experiments suggested that ELTD1 could promote malignancy in HCC cell lines. Immunohistochemical staining of the generated ELTD1 overexpression xenograft tumors demonstrated that the CAF markers vimentin and α-SMA were highly expressed compared to the control group. This suggests that ELTD1 expression is correlated to CAF distribution. In addition, culturing with CAF supernatants inhibited HCC cell proliferation and invasion rates, confirming the correlation between CAF and ELTD1. Conclusion: The results of this study indicated that ELTD1 regulation of HCC progression is CAF-dependent, suggesting that ELTD1 function is regulated by its tumor microenvironment. Further investigation is required to determine the underlying mechanisms.

Plasma Cell-Free DNA as a Predictive Marker after Radiotherapy for Hepatocellular Carcinoma

PURPOSE

Cell-free DNA (cfDNA) is gaining attention as a novel biomarker for oncologic outcomes. We investigated the clinical significance of cfDNA in hepatocellular carcinoma (HCC) patients treated with radiotherapy (RT).

MATERIALS AND METHODS

Fifty-five patients with HCC who received RT were recruited from two prospective study cohorts: one cohort of 34 patients who underwent conventionally fractionated RT and a second of 21 patients treated with stereotactic body radiation therapy. cfDNA was extracted and quantified.

RESULTS

In total, 30% of the patients had multiple tumors, 77% had tumors >2 cm, and 32% had portal vein tumor thrombus. Optimal cut-off values for cfDNA levels (33.65 ng/mL and 37.25 ng/mL, before and after RT) were used to divide patients into low-DNA (LDNA) and high-DNA (HDNA) groups. The pre-RT HDNA group tended to have more advanced disease and larger tumors (p=0.049 and p=0.017, respectively). Tumor response, intrahepatic failure-free rates, and local control (LC) rates were significantly better in the post-RT LDNA group (p=0.017, p=0.035, and p=0.006, respectively).

CONCLUSION

Quantitative analysis of cfDNA was feasible in our cohorts. Post-RT cfDNA levels were negatively correlated with treatment outcomes, indicating the potential for the use of post-RT cfDNA levels as an early predictor of treatment responses and LC after RT for HCC patients.

A systematic review and meta-analysis comparing the prognosis of multicentric occurrence and vs. intrahepatic metastasis in patients with recurrent hepatocellular carcinoma after hepatectomy

BACKGROUND

The aim of this meta-analysis was to evaluate the prognosis of patients with different types of hepatocellular cancer (HCC) recurrence following hepatectomy. Specifically, it evaluated overall survival and disease-free survival in HCC patients with multicentric occurrence (MO) or intrahepatic metastasis (IM).

METHODS

Medline, Cochrane, EMBASE, and Google Scholar were searched until August 22, 2016 using the following search terms: hepatocellular carcinoma, multicentric occurrence, intrahepatic metastasis, early recurrence, and late recurrence. Prospective, retrospective, and case control studies were included.

RESULTS

The pooled results showed that patients in the MO group had lower risk of death than the IM group (pooled HR = 0.495, 95% CI = 0.378 to 0.648, P < 0.001). The MO group also had significantly longer disease-free survival than the IM group (pooled HR = 0.774, 95% CI = 0.663 to 0.903, P = 0.001). Sensitivity analysis indicated that no one study dominated the findings and that the data are robust. Overall the included studies were of good quality.

CONCLUSION

This study found that MO patients have greater survival following surgery than IM patients, indicating the prognosis of MO patients is significantly better than that for IM patients.

Validated preoperative computed tomography risk estimation for postoperative hepatocellular carcinoma recurrence

AIM

To develop and validate a risk estimation of tumor recurrence following curative resection of operable hepatocellular carcinoma (HCC).

METHODS

Data for 128 patients with operable HCC (according to Barcelona Clinic Liver Cancer imaging criteria) who underwent preoperative computed tomography (CT) evaluation at our hospital from May 1, 2013 through May 30, 2014 were included in this study. Follow-up data were obtained from hospital medical records. Follow-up data through May 30, 2016 were used to retrospectively analyze preoperative multiphasic CT findings, surgical histopathology results, and serum α-fetoprotein and thymidine kinase-1 levels. The χ² test, independent t-test, and Mann-Whitney U test were used to analyze data. A P-value of < 0.05 was considered statistically significant.

RESULTS

During the follow-up period, 38 of 128 patients (29.7%) had a postoperative HCC recurrence. Microvascular invasion (MVI) was associated with HCC recurrence (χ² = 13.253, P < 0.001). Despite postoperative antiviral therapy and chemotherapy, 22 of 44 patients with MVI experienced recurrence after surgical resection. The presence of MVI was 57.9% sensitive, 75.6% specific and 70.3% accurate in predicting postoperative recurrence. Of 84 tumors without MVI, univariate analysis confirmed that tumor margins, tumor margin grade, and tumor capsule detection on multiphasic CT were associated with HCC recurrence (P < 0.05). Univariate analyses showed no difference between groups with respect to hepatic capsular invasion, Ki-67 proliferation marker value, Edmondson-Steiner grade, largest tumor diameter, necrosis, arterial phase enhanced ratio, portovenous phase enhanced ratio, peritumoral enhancement, or serum α-fetoprotein level.

CONCLUSION

Non-smooth tumor margins, incomplete tumor capsules and missing tumor capsules correlated with postoperative HCC recurrence. HCC recurrence following curative resection may be predicted using CT.

Epithelial-Mesenchymal Transition is Superior to Vessels-Encapsulate Tumor Cluster in Promoting Metastasis of Hepatocellular Carcinoma: a Morphological Evidence

Purpose Vessels-encapsulate tumor cluster (VETC) is a vascular pattern distinct from classical capillary-like pattern. It is reported that VETC structure is common in hepatocellular carcinoma (HCC) and can promote HCC metastasis in an epithelial-mesenchymal transition (EMT)-independent but VETC-dependent manner. However, the main metastatic manner of HCC containing both VETC and classical vascular structure (we called VETC±) is unknown. Methods Vascular pattern types and E-cadherin expression were evaluated by immunohistochemical staining in 168 HCC tissues, 50 pairs of primary HCC tissues and intrahepatic metastatic lesions, as well as 12 pairs of primary HCC tissues and major portal vein tumor thrombus. Survival and recurrence rates were evaluated using Kaplan-Meier analysis. The multivariate Cox proportional hazards model was used to determine the independent prognostic factors of HCC. Results VETC± cases were more common than VETC+ cases (HCC tissues with a VETC pattern fully distributed in the HCC section) in HCC. Statistical analysis showed that VETC± was an independent predictor of survival and recurrence. Furthermore, E-cadherin was positively correlated with the presence of VETC structure. In the case of HCCs with VETC±, their metastases (both intrahepatic and major vascular) were more likely to be VETC negative. Conclusions Our findings suggest that EMT may be superior to VETC in promoting HCC metastasis. Thus, both anti-EMT and anti-VETC agents should be considered in the case of HCC with VETC±.

Molecular alterations in the carcinogenesis and progression of hepatocellular carcinoma: Tumor factors and background liver factors

Although hepatocellular carcinoma (HCC) is associated with poor prognosis worldwide, the molecular mechanisms underlying the carcinogenesis and progression of this disease remain unclear. Several tumor characteristics have previously been demonstrated to be prognostic factors of survival following hepatic resection, or the recurrence of HCC or other types of cancer. Comparisons of normal tissues and HCC tumor tissues have revealed the presence of numerous molecular alterations in HCC, including genetic and epigenetic mechanisms, particularly mutations in certain genes and DNA methylation in the promoter regions of tumor-suppressor genes. A number of studies have previously used array analysis to detect variations in the expression levels of cancer-associated genes and microRNAs, and in DNA methylation. However, an investigation of HCC tumor tissues may not determine the effect of noncancerous liver tissues (background liver) in patients with HCC. As HCC may recur multicentrically following resection, a damaged or chronically diseased HCC background liver may be considered as a pre-cancerous organ. Therefore, the influence of the background liver on HCC requires further study. Detailed studies regarding the background liver may be essential for the improved understanding of the carcinogenesis and progression of this malignancy; however only a few studies have investigated the microenvironment of the HCC background liver. The present review discusses prior molecular studies of hepatocarcinogenesis that focus on HCC and background liver tissues.

The Prognostic Role of Mitotic Index in Hepatocellular Carcinoma Patients after Curative Hepatectomy

PURPOSE

High proliferation rate is a hallmark of cancer. The mitotic index is a useful and simple method for analysis of cell proliferation. However, the practical utility of mitotic index as a predictor of prognosis in patients with hepatocellular carcinoma (HCC) has not been determined. Therefore, we examined mitotic index as a prognostic marker in HCC patients.

MATERIALS AND METHODS

We counted the number of mitotic cells in 10 high-power fields of the tumor area on hematoxylin and eosin-stained slides representing 282 surgically resected HCCs. The highest number of mitotic cells was defined as the mitotic index.

RESULTS

High mitotic index was observed in 127 of 282 HCCs. High mitotic index showed significant association with younger age, larger tumor size, higher Edmondson grade, microvascular invasion, major portal vein invasion, intrahepatic metastasis, higher American Joint Committee on Cancer (AJCC) T-stage, higher Barcelona Clinic Liver Cancer (BCLC) stage, higher alpha-fetoprotein level, hepatitis B virus etiology, and liver cirrhosis. Patients with high mitotic index had shorter disease-specific survival (DSS) (p < 0.001) and tended to have shorter recurrence-free survival (p=0.112). In subgroup analysis among patients with a larger tumor size, microvascular invasion, intrahepatic metastasis, higher AJCC T-stage, and higher BLCL stage, high mitotic index showed unfavorable influences on DSS (p=0.001, p=0.008, p=0.003, p=0.012, and p < 0.001, respectively). In addition, high mitotic index was an independent predictor of shorter DSS (p=0.004).

CONCLUSION

High mitotic index may be a novel predictor of DSS in patients with HCC and may have utility as an auxiliary prognostic factor in HCC.

Long-term outcome of laparoscopic ablation therapies for unresectable hepatocellular carcinoma: a single European center experience of 426 patients

BACKGROUND

Radiofrequency ablation (RFA) is widely used as a first-line option in patients with hepatocellular carcinoma (HCC). However, since percutaneous approach of RFA may be, in some cases, unfeasible by the tumor size and its location, laparoscopic ablation therapies (LATs) were used as an alternative. Objective of the present study was to assess the efficacy of laparoscopic ultrasound examination in addition to LATs in the treatment of HCC in patients not eligible for percutaneous RFA or surgical resection.

METHODS

Four hundred and twenty-six patients who underwent LATs were analyzed. Laparoscopic approach was offered to patients fulfilling at least one of the following criteria: (a) patients with a single nodule or up to three nodules smaller than 3 cm not suitable for liver transplantation or not eligible for HR because of severe portal hypertension, impaired liver function, or coexistent comorbidities; (b) patients not suitable for percutaneous RFA because of inconvenient tumor location; and (c) short-term recurrence of HCC (<3 months).

RESULTS

Technical success was achieved in one session in 396 patients (93 %). One-month mortality and morbidity rates were 0.23 % (1 patient) and 25 % (106 patients), respectively. During a median follow-up of 37.2 months (range 2-193) in the remaining 425 patients, 276 (65 %) developed intra-hepatic recurrence: It appeared as a local tumor progression in 65 cases (15 %). Patients median survival was 39 months (95 % CI 34.8-47.2), while overall survivals at 1, 3, and 5 years were 88, 55, and 34 %, respectively.

CONCLUSIONS

In the treatment of HCC, LATs proved to be a safe and effective technique, as they permit to treat with low-morbidity-rate lesions not manageable by percutaneous approach. Moreover, they allow achieving a more accurate staging of the disease in one-fifth of patients, thus better redefining the prognosis of such individuals.

Expression of prothymosin alpha predicts early recurrence and poor prognosis of hepatocellular carcinoma

BACKGROUND

Prothymosin alpha (PTMA) is a nuclear oncoprotein-transcription factor essential for cell cycle progression and proliferation. PTMA was overexpressed in several human malignancies including hepatocellular carcinoma (HCC). However, the prognostic significance of PTMA protein expression in HCC remains unclear. In the present study, we evaluated PTMA protein expression by immunohistochemistry in order to elucidate the prognostic roles of PTMA in HCC patients.

METHODS

By immunohistochemistry, we investigated the expression of PTMA protein in tumor tissue from 226 HCC patients who underwent curative hepatectomy. Univariate and multivariate analyses were performed to evaluate its predictive value for tumor recurrence and survival of patients. The median follow-up period was 120 months.

RESULTS

PTMA expression was observed in 162 (71.7%) of the 226 HCC patients and was significantly associated with higher Edmondson grade, microvascular invasion, intrahepatic metastasis, higher American Joint Committee on Cancer (AJCC) T-stage, and lower albumin level. PTMA expression was an independent predictor of early recurrence (P=0.001). PTMA expression showed an unfavorable influence on recurrence-free survival (RFS) (P<0.001). Subgroup analysis showed that among patients with tumor size ≤5.0 cm (140 patients), patients at AJCC T-stage 1 (95 patients) and patients with alpha-fetoprotein ≤20 ng/mL (83 patients), the differences in RFS between PTMA-positive and PTMA-negative groups were also statistically significant (P=0.017, P=0.002 and P=0.002, respectively). In addition, PTMA expression was an independent predictor of shorter RFS (P=0.011). PTMA expression showed an unfavorable influence on overall survival (P=0.014), but was not an independent predictor of shorter overall survival (P=0.161).

CONCLUSIONS

PTMA protein expression might be a novel predictor of early recurrence and RFS in HCC patients, even those at early stage or with alpha-fetoprotein-negative after curative hepatectomy. PTMA could be used as an immunohistochemical biomarker to detect patients with a high risk of recurrence.

ATAD2 as a Poor Prognostic Marker for Hepatocellular Carcinoma after Curative Resection

Purpose

Cancer cells frequently express genes that are specifically or preferentially expressed in male germ cells under normal conditions. The ATPase family AAA domain-containing 2 (ATAD2) is one such and works as an important cofactor for MYC-dependent transcription. In hepatocellular carcinoma (HCC), ATAD2 has been identified as a candidate driver gene located within the amplified 8q24 locus. However, the prognostic significance of ATAD2 protein expression in HCC remains uncertain.

Materials and Methods

We investigated ATAD2 protein expression by immunohistochemistry in tumor tissue from 182 HCC patients who underwent curative resection. Associations of ATAD2 expression with clinicopathologic variables or prognosis of HCC patients were analyzed.

Results

ATAD2 expression was observed in 119 (65.4%) of the 182 HCCs and tended to be independent predictor of early recurrence (p=0.059). ATAD2 expression showed an unfavorable influence on recurrence-free survival (RFS) (p < 0.001). Subgroup analysis among patients with tumor size ≤ 5.0 cm (n=109), patients at Barcelona Clinic Liver Cancer stage 0 or A (n=92), and patients with α-fetoprotein ≤ 20 ng/mL (n=61), the ATAD2-positive groups unfavorably influenced RFS (p=0.008, p=0.009, and p=0.013, respectively). In addition, ATAD2 expression was an independent predictor of shorter RFS (p=0.002). ATAD2 expression showed an unfavorable influence on disease-specific survival (p=0.001), but was not an independent predictor of shorter disease-specific survival (p=0.109).

Conclusion

ATAD2 protein expression may be a potential predictor of RFS in HCC patients after curative resection and ATAD2 may have prognostic value in patients with early stage HCC or normal serum α-fetoprotein level.

Clinicopathological features and prognosis of combined hepatocellular carcinoma and cholangiocarcinoma after surgery

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is a rare subtype of primary liver cancer consisting of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). Because of the rarity of this tumor, its feature is poorly understood. The present study aimed to evaluate the clinicopathological features and long-term prognosis of patients with cHCC-CC after surgery and to compare with those of the patients with stage-matched HCC and CC.

METHODS

The clinicopathological features of the patients who underwent surgery for cHCC-CC at our center during the period of 2001-2010 were retrospectively analyzed and compared with those of stage-matched HCC and CC patients. Cancer staging was performed according to the AJCC Cancer Staging Manual (6th ed.). Overall survival and disease-free survival were compared among the groups and prognostic factors of cHCC-CC were evaluated.

RESULTS

Significant differences were observed in clinicopathological features among 42 patients with cHCC-CC, 90 patients with HCC and 45 patients with CC. Similar to HCC patients, cHCC-CC patients had frequent hepatitis B virus antigen positivity, microscopic vessel invasion, cirrhosis and high level of serum alpha-fetoprotein. Similar to CC patients, cHCC-CC patients showed increased bile duct invasion and decreased capsule. The 1-, 3-, and 5-year overall survival and disease-free survival of patients with cHCC-CC were not significantly different from those with stage-matched patients with CC; but significantly poorer than those with HCC. In subanalysis of patients with stage II, the overall survival in patients with cHCC-CC or CC was significantly poorer than that in patients with HCC. We did not find the difference in patients with other stages. Univariate analysis of overall and disease-free survival of patients with cHCC-CC showed that the vascular invasion and intrahepatic metastasis were the significant predictive factors.

CONCLUSION

Patients with cHCC-CC showed similar clinicopathological features as those with HCC or CC, and patients with cHCC-CC or CC had a poorer prognosis compared with those with HCC, especially at matched stage II.

High expression of ribonucleotide reductase subunit M2 correlates with poor prognosis of hepatocellular carcinoma

Background/Aims

Ribonucleotide reductase subunit M2 (RRM2) catalyzes the production of deoxynucleotide triphosphates, which are necessary for DNA synthesis. RRM2 has been reported to play an active role in tumor progression, and elevated RRM2 levels have been correlated with poor prognosis for colorectal cancer patients. This study aimed to elucidate the prognostic significance of RRM2 protein expression in hepatocellular carcinoma after surgery.

Methods

RRM2 protein expression was evaluated using immunohistochemistry in tumor tissues from 259 hepatocellular carcinoma patients who underwent curative hepatectomy.

Results

High RRM2 expression was observed in 210 of 259 patients (81.1%) with hepatocellular carcinomas. High RRM2 expression was significantly associated with viral etiology (p=0.035) and liver cirrhosis (p=0.036). High RRM2 expression was correlated with early recurrence (p=0.004) but not with late recurrence (p=0.144). Logistic regression analysis revealed that high RRM2 expression (p=0.040) and intrahepatic metastasis (p<0.001) were independent predictors of early recurrence. High RRM2 expression unfavorably influenced both shorter recurrence-free survival (p=0.011) and shorter disease-specific survival (p=0.002) and was an independent predictor of shorter disease-specific survival (p=0.008).

Conclusions

High RRM2 protein expression might be a useful marker for predicting early recurrence and may be a marker for poor prognosis of hepatocellular carcinoma after curative hepatectomy.

High expression of aldo-keto reductase 1B10 is an independent predictor of favorable prognosis in patients with hepatocellular carcinoma

BACKGROUND/AIMS

Upregulation of aldo-keto reductase 1B10 (AKR1B10) through the mitogenic activator protein-1 signaling pathway might promote hepatocarcinogenesis and tumor progression. The goal of this study was to evaluate the prognostic significance of AKR1B10 protein expression in patients with hepatocellular carcinoma after surgery.

METHODS

A tissue microarray was used to detect the expression level of AKR1B10 protein in tumors from 255 patients with hepatocellular carcinoma who underwent curative hepatectomy. The impact of AKR1B10 expression on the survival of patients was analyzed. The median follow-up period was 119.8 months.

RESULTS

High AKR1B10 protein expression was observed in 125 of the 255 patients with hepatocellular carcinoma (49.0%). High AKR1B10 expression was significantly associated with a lack of invasion of the major portal vein (p=0.022), a lack of intrahepatic metastasis (p=0.010), lower the American Joint Committee on Cancer T stage (p=0.016), lower the Barcelona Clinic Liver Cancer stage (p=0.006), and lower α-fetoprotein levels (p=0.020). High AKR1B10 expression was also correlated with a lack of early recurrence (p=0.022). Multivariate analyses of survival revealed that intrahepatic metastases and lower albumin levels were independent predictors of both shorter recurrence-free survival and shorter disease-specific survival. High AKR1B10 expression was an independent predictor of both longer recurrence-free survival (p=0.024) and longer disease-specific survival (p=0.046).

CONCLUSIONS

High AKR1B10 protein expression might be useful as a marker of a favorable prognosis in patients with hepatocellular carcinoma after curative hepatectomy.

Determination of clonal origin of recurrent hepatocellular carcinoma for personalized therapy and outcomes evaluation: a new strategy for hepatic surgery

BACKGROUND

Recurrent hepatocellular carcinoma (RHCC) after curative resection is a major challenge for hepatic surgeons. A better understanding of the clonal origin of RHCC will help clinicians design personalized therapy and assess postoperative outcomes. The current study was performed to determine the clonal origin of RHCC and its clinical significance.

STUDY DESIGN

Fifteen high-frequency of loss of heterozygosity of DNA microsatellites were determined on 100 tumor nodules in 60 matched pairs of RHCC from 40 patients who underwent liver re-resections. The relationships among the origin of clonal patterns of RHCC and the surgicopathologic features and clinical outcomes were analyzed.

RESULTS

Of 60 pairs of RHCC, there were 2 clonal patterns with 6 subclonal types. Pattern I was multicentric occurrence (MO type) in 14 pairs (23.3%) and pattern II was intrahepatic metastasis (IM type) in 46 pairs (76.7%). The clinicopathologic features, including recurrence time, tumor size, vascular invasion, histological grading, and associated chronic liver diseases in patients with the MO type of RHCC were significantly different from those with the IM type of RHCC (p < 0.05 to 0.001). Compared with patients in the IM group, patients in the MO group had significantly better overall survival (130.8 ± 8.5 months vs 80.8 ± 8.5 months; p < 0.05) and recurrence-free survival (33.8 ± 4.5 months vs 14.2 ± 2.5 months; p < 0.001).

CONCLUSIONS

The MO-type RHCC was closely associated with better postoperative outcomes when compared with the IM-type RHCC. Generally, we recommend liver re-resection for MO-type RHCC, and interventional therapy for IM-type RHCC. Microdissection-based microsatellite loss of heterozygosity protocol has advantages in assessing the clonal origin, modes of personalized treatment, and clinical outcomes of RHCC.

Contrast-enhanced intraoperative ultrasound for hepatocellular carcinoma: high sensitivity of diagnosis and therapeutic impact

BACKGROUND

Postoperative early recurrence is a crucial issue in the treatment of hepatocellular carcinoma (HCC) patients. Some early recurrences seem to occur from minute tumors which were overlooked during both preoperative and intraoperative investigations. Therefore, it is urgently necessary to increase detectability of minute HCCs during operation. If they could be detected and resected during surgery, the prognosis should be improved. The purpose of this study is to investigate the usefulness of contrast-enhanced intraoperative ultrasound (CEIOUS) for the diagnosis and treatment of HCC.

METHODS

Institutional ethics committee approval and informed consent were obtained. Fifty-two patients (mean age 65 years; 38 males and 14 females) who underwent liver resection with either preoperative computed tomography during angiography (CTA) or CEIOUS with Sonazoid (perflubutane microbubble contrast agent) were studied. We determined the presence of HCC on the basis of the histopathological findings of resected specimens.

RESULTS

The sensitivity of CEIOUS [97.6% (95% CI 91.8-99.4)] was higher than that of CTA [89.4% (95% CI 81.1-94.3)]. The positive predictive values of CEIOUS [91.2% (95% CI 83.6-95.5) and CTA [91.6% (95% CI 83.6-95.9)] were similar. Eight new HCCs from 7 patients, which accounted for 9.4% (8/85) of the total HCCs, were correctly detected and diagnosed by CEIOUS, and we performed an additional partial hepatectomy in 3 of these 7 patients.

CONCLUSIONS

CEIOUS with Sonazoid provided increased sensitivity of detection of small HCCs compared with preoperative CTA, thereby leading to a more appropriate surgical procedure and contributing to complete tumor removal.

Expression of fibroblast growth factor 19 is associated with recurrence and poor prognosis of hepatocellular carcinoma

BACKGROUND

Fibroblast growth factor 19 (FGF19)-mediated activation of mitogen-activated protein kinase and the β-catenin pathway may be involved in the development and progression of hepatocellular carcinoma. This study aimed to elucidate the prognostic significance of FGF19 protein expression in hepatocellular carcinoma patients.

METHODS

By immunohistochemistry, we investigated the expression of FGF19 protein in tumor tissue from 281 hepatocellular carcinoma patients who underwent curative hepatectomy. Univariate and multivariate analyses were performed to evaluate its predictive value for tumor recurrence and survival of patients. The median follow-up period was 75.6 months.

RESULTS

FGF19 protein expression was observed in 135 (48.0 %) of the 281 hepatocellular carcinomas. FGF19 expression was significantly associated with larger tumor size (P < 0.001), and higher BCLC stage (P = 0.001). FGF19 expression was correlated with the early recurrence (P < 0.001), but not with the late recurrence (P = 0.582). FGF19 expression (P = 0.002), viral etiology (P = 0.028), and intrahepatic metastasis (P < 0.001) were independent predictors of early recurrence. Multivariate analyses of survival revealed that FGF19 expression (P < 0.001), intrahepatic metastasis (P < 0.001), and liver cirrhosis (P = 0.019) were independent predictors of shorter disease-free survival. FGF19 expression (P = 0.005), larger tumor size (P = 0.038), major portal vein invasion (P = 0.048), intrahepatic metastasis (P < 0.001), lower albumin level (P = 0.024), and liver cirrhosis (P = 0.031) were independent predictors of shorter disease-specific survival.

CONCLUSIONS

FGF19 protein expression might be an effective predictor of early recurrence and a marker for poor prognosis of hepatocellular carcinoma after curative hepatectomy, indicating that FGF19 might be a potential preventive target in hepatocellular carcinoma patients.

Hepatic resection for hepatocellular carcinoma based on tumor hemodynamics

Survival or disease-free survival is not considered an appropriate surrogate outcome for the locoregional curability (i.e. surgical margin) of hepatectomy for hepatocellular carcinoma because these are greatly influenced by non-metastatic factors like multicentric carcinogenesis (MC) or liver function. Hepatocellular carcinoma metastasizes by hematogenous seeding; therefore, the tumor blood flow (TBF) drainage area is a high-risk area for intrahepatic metastasis, and can be identified by computed tomography under hepatic arteriography and completely resected as part of the surgical margin. The TBF pattern is classified into marginal, portal vein or hypovascular types. Partial hepatectomies were mostly performed in patients with marginal or hypovascular type, whereas anatomical surgery was frequently performed in those with portal vein type. Pathologically, nodules inside the TBF drainage area were moderately or poorly differentiated carcinomas, suggesting intrahepatic metastasis. In contrast, those outside the drainage area were frequently solitary and contained well-differentiated carcinoma, which is consistent with MC. The pattern of tumor recurrences after TBF-based hepatectomy is divided into two distinct groups - "a few nodules" and "many nodules in multiple segments or extrahepatic" - indicating that intrahepatic recurrences develop from MC and from circulating tumor cells in peripheral blood, respectively. Anatomical resection has not shown a survival benefit over that of TBF-based partial hepatectomy. TBF-based hepatectomy enables us to preserve liver function without compromising locoregional curability.

Beneficial effects of preoperative lipiodolization for resectable large hepatocellular carcinoma (≥ 5 cm in diameter)

BACKGROUND

The effects of preoperative lipiodolization (LPD) for large hepatocellular carcinoma (HCC) are controversial.

METHODS

A retrospective review was undertaken for 137 patients with initial solitary resectable HCC ≥ 5 cm who underwent hepatic resection between 1995 and 2008. Forty-two patients underwent preoperative LPD, and clinical data and prognosis were compared to those of patients without preoperative LPD (n=95).

RESULTS

Surgical results of the LPD group, such as surgical time, surgical blood loss, and the mortality and morbidity rate were statistically equal to those of the nonLPD group. The disease-free and overall survival of the LPD group were significantly better than those of the nonLPD group, and early tumor recurrence within 1-year of the LPD group was significantly lower than that of the nonLPD group. According to the multivariate analysis, the absence of preoperative LPD was an independent poor prognostic factor of patients with hepatic resection for HCC ≥ 5 cm.

CONCLUSION

Preoperative LPD suppressed early tumor recurrence and improved patient survival after hepatic resection for HCC ≥ 5 cm.

Multicentric occurrence of hepatocellular carcinoma with nonalcoholic steatohepatitis

AIM

To reveal the manner of hepatocellular carcinoma (HCC) development in patients with nonalcoholic steatohepatitis (NASH) focusing on multicentric occurrence (MO) of HCC.

METHODS

We compared clinicopathological characteristics between patients with and without MO of HCC arising from NASH background. The clinical features were implicated with reference to the literature available.

RESULTS

MO of HCC was identified with histological proof in 4 out of 12 patients with NASH-related HCC (2 males and 2 females). One patient had synchronous MO; an advanced HCC, two well-differentiated HCCs and a dysplastic nodule, followed by the development of metachronous MO of HCC. The other three patients had multiple advanced HCCs accompanied by a well-differentiated HCC or a dysplastic nodule. Of these three patients, one had synchronous MO, one had metachronous MO and the other had both synchronous and metachronous MO. There were no obvious differences between the patients with or without MO in terms of liver function tests, tumor markers and anatomical extent of HCC. On the other hand, all four patients with MO of HCC were older than 70 years old and had the comorbidities of obesity, type 2 diabetes mellitus (T2DM), hypertension and cirrhosis. Although these conditions were not limited to MO of HCC, all the conditions were met in only one of eight patients without MO of HCC. Thus, concurrence of these conditions may be a predisposing situation to synchronous MO of HCC. In particular, old age, T2DM and cirrhosis were suggested to be prerequisite for MO because these factors were depicted in common among two other cases with MO of HCC under NASH in the literature.

CONCLUSION

The putative predisposing factors and necessary preconditions for synchronous MO of HCC in NASH were suggested in this study. Further investigations are required to clarify the accurate prevalence and predictors of MO to establish better strategies for treatment and prevention leading to the prognostic improvement in NASH.

Early cancer-related death after resection of hepatocellular carcinoma

BACKGROUND

Surgeons have attempted to prevent early cancer-related death after resection of hepatocellular carcinoma to identify risk factors associated with early death from hepatocellular carcinoma recurrence after liver resection.

METHODS

The study group comprised 350 patients who had undergone liver resection for hepatocellular carcinoma between 1997 and 2007. The preoperative risk factors for early death from intrahepatic recurrence (within 1 year after resection) were evaluated.

RESULTS

Fourteen (4%) patients died of intrahepatic recurrence in the first year after resection. Multivariate analyses identified the following risk factors for early cancer-related death: multiple tumors (odds ratio 10.4; 95% confidence interval, 2.42-44.3; P = .002), vascular invasion (odds ratio 10.1; 95% confidence interval 2.07-50; P = .004), serum alpha-fetoprotein level >20 ng/mL (odds ratio 9.52; 95% confidence interval 1.0--84.2; P = .043), and tumor size ≥50 mm (odds ratio 4.80; 95% confidence interval 1.06-21.9; P = .042). Each of these factors was assigned a score of 1 point, and an algorithm was developed to predict the risk of early death. Outcomes did not differ significantly between patients with 3 or 4 points (P = .48) or between those with 1 or 2 points (P = .49). Patients who underwent liver resection could be stratified into the following distinct groups according to the point score and the associated 1-year survival rate and median survival (shown respectively): 0 points, 99%, and not yet; 1 or 2 points, 96%, and 68 months; and 3 or 4 points, 50%, and 12 months) (P < .0001).

CONCLUSION

Even if hepatocellular carcinoma is resectable, patients with a score of 3 or 4 points may not be good candidates for liver resection.

Osteopontin, a single marker for predicting the prognosis of patients with tumor-node-metastasis stage I hepatocellular carcinoma after surgical resection

BACKGROUND AND AIM

Osteopontin (OPN) has been linked to clinical outcomes in several solid tumors. However, it has not been fully evaluated whether OPN could be used as a single marker for the prognosis of patients with hepatocellular carcinoma (HCC), particularly in patients of the tumor-node-metastasis (TNM) stage I.

METHODS

A total of 151 patients with HCC who underwent surgical resection were enrolled, including 112 patients of the TNM stage I. OPN expression was evaluated using immunohistochemistry in the tissue microarrays derived from these patients. Immunoreactivity was classified according to the percentage and intensity of staining: negative (-), weak (+) and strong (++). The impact of OPN expression on survival of patients was analyzed.

RESULTS

In total, 65.6% (99 of 151) of HCC tissues expressed OPN. Overall survival in patients of OPN (-) group was significantly higher than those of OPN (+) or OPN (++) group (P = 0.049 and P = 0.001). Interestingly, in patients of the TNM stage I, OPN expression was correlated with the early recurrence after surgical resection (P = 0.001). Multivariate analysis showed that OPN expression was an independent prognostic factor for overall survival and disease-free survival in patients with the TNM stage I HCC (hazard ratio, 2.272, P = 0.014 and 1.982, P = 0.037).

CONCLUSIONS

These results suggest that OPN is commonly expressed in HCC and is a useful marker for predicting the prognosis of patients with the TNM stage I HCC, contributing to determining which individual patient needs adjuvant therapy to prevent the early recurrence after surgical resection.

The impact of anatomical resection for hepatocellular carcinoma that meets the Milan criteria

BACKGROUND

The aim of this study was to analyze the impact of anatomical resection for hepatocellular carcinoma (HCC) that meets the Milan criteria.

METHODS

Between 1990 and 2006, 322 consecutive patients with HCC who met the Milan criteria underwent curative resection (R0) and were classified into two groups: Group A (patients with a single HCC, with a tumor diameter of 5 cm or less) and Group B (patients with multiple tumors, no more than three tumor nodules, each with a diameter of 3 cm or less). Patient survival (PS), recurrence-free survival rates (RFS), and risk factors were analyzed.

RESULTS

Univariate analysis revealed that in Group A, anatomical resection was the significant factor related to PS, while anatomical resection was that related to RFS. Multivariate analysis showed that in Group A, anatomical resection was a significant favorite factor associated with PS and RFS. Univariate analysis for Group B revealed that anatomical resection was the significant factor related to PS, while that related to RFS was the anatomical resection. Multivariate analysis showed that anatomical resection was a significant favorite factor for only RFS in Group B.

CONCLUSION

Anatomical resection improved the surgical outcome of the patients with HCC which met the Milan criteria.

Elevated expression of DKK1 is associated with cytoplasmic/nuclear beta-catenin accumulation and poor prognosis in hepatocellular carcinomas

BACKGROUND/AIMS

To assess the value of Dickkopf-1 (DKK1) for predicting clinical outcome of human hepatocellular carcinoma (HCC) in patients with HCC.

METHODS

Expression of DKK1 and beta-catenin was investigated in HCC cell lines using qRT-PCR, Western blotting and immunofluorescence. Tissue microarrays representing 314 HCC patients were used to determine the expression patterns of DKK1 and beta-catenin by immunohistochemistry, and prognostic significance was assessed by using Kaplan-Meier survival estimates and log-rank tests.

RESULTS

The expression level of DKK1 was associated with the staining pattern of beta-catenin in HCC cell lines, and DKK1 overexpression correlated with beta-catenin cytoplasmic/nuclear accumulation in clinical HCC samples (P=0.011, correlation coefficient=0.144). High DKK1 expression predicted unfavorable prognosis in HCC patients, especially in early stage patients and those with normal AFP levels. In multivariate analyses, DKK1 was an independent predictor for overall survival (OS) (P=0.002) and disease-free survival (DFS) (P=0.002) of HCC patients. Furthermore, the HCC patients with high DKK1 expression and cytoplasmic/nuclear beta-catenin accumulation had very poor prognosis.

CONCLUSIONS

Elevated expression of DKK1 is a critical event in patients with HCC that indicates poor clinical outcome. DKK1, alone or combined with beta-catenin, is a novel prognostic predictor for HCC patients.

Clinicopathologic features between multicentric occurence and intrahepatic metastasis of multiple hepatocellular carcinomas related to HBV

AIMS

To clarify the incidence of multicentric occurrence (MO) and intrahepatic metastasis (IM) for hepatocellular carcinoma (HCC) related to hepatitis B virus (HBV) in China and to identify the differences between them.

PATIENTS AND METHODS

Histopathologic features of multiple tumors in 82 cases with HCC were analyzed. The two groups, the origin was determinable as of multicentric occurrence or as of intrahepatic metastasis, were analyzed for their survival rate, disease-free survival and clinicopathologic differences.

RESULTS

According to histological findings, 19.5% and 69.5% patients were considered to be MO and IM, respectively. In total 73 cases from the histopathological method were selected and divided into group MO (16 cases) and the group IM (57 cases). Analysis of stepwise regression identified that: Child's stage, cholinesterase (host factors), tumor size, histological grade and positive portal vein invasion (tumor factors) were the most important discriminating factors between MO and IM (p<0.05). As for their prognosis, Kaplan-Meier and Log rank test showed the survival rate in group MO was significantly better than that in the group IM (p=0.003). No statistical significance was found between the disease-free survival in group MO and that in group IM (p=0.141). The analysis of Cox's proportional hazards model showed that tumor type (MO or IM) and Child's stage were the important prognostic factors (p=0.002 and 0.014, respectively).

CONCLUSIONS

The incidence of MO in patients with multiple HCCs related to HBV is only about 20%, which is lower than that of Japan. Child's stage, cholinesterase (host factors), tumor size, histological grade and positive portal vein invasion (tumor factors) are the most important discriminating factors between MO and IM. The prognosis of patients with MO compared to IM is significantly better and tumor type (MO or IM) and Child's stage are important prognostic factors.

Comparison of surgical outcomes for small hepatocellular carcinoma in patients with hepatitis B versus hepatitis C: a Chinese experience

BACKGROUND

Although both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are well recognized risk factors for hepatocellular carcinoma (HCC), little is known with respect to how HBV and HCV infection affect HCC recurrence in postoperative HCC Chinese patients. The objective of this study was to determine if differences exist in preoperative characteristics and postoperative HCC recurrence in patients with different HBV and HCV infection status.

METHODS

The study population consisted of 413 patients undergoing a curative resection at Tianjin Cancer Hospital for small HCC (< or =3 cm) from January 1997 to December 2003. The patients were divided into four groups: HCV only (n = 75), HBV only (n = 251), HBV and HCV (n = 33), and neither HBV nor HCV (NBNC, n = 54). The preoperative status and postoperative HCC recurrence were recorded. Survival analyses were used to assess the impact of HBV/HCV status on HCC recurrence.

RESULTS

Patients with HCV had a significant association with older age, lower mean preoperative platelet counts and albumin levels, higher mean prothrombin time, alanine aminotransferase and total bilirubin levels and multinodular tumors during diagnosis. Patients with HCV also had significantly less differentiated tumors and a higher incidence of vascular invasion and cirrhosis when compared to the other groups. During the follow-up, the HCV group showed a higher incidence of intrahepatic recurrence and multiple recurrent lesions than the other patients.

CONCLUSIONS

Patients with HCV infection tended to be older, and were characterized by more severe cirrhosis and higher incidence of tumor multicentricity. The statistically significant determinants for reoccurrence in patients with small HCC were HCV infection, presence of vascular invasion and multiple tumors.

Longterm favorable results of limited hepatic resections for patients with hepatocellular carcinoma: 20 years of experience

BACKGROUND

Recently, anatomic resection has been, in theory, considered preferable for eradicating portal venous tumor extension and intrahepatic metastasis in hepatocellular carcinoma (HCC). We have reported the effectiveness of limited hepatic resection for cirrhotic patients with HCC.

STUDY DESIGN

A retrospective study was carried out in 321 patients who underwent curative hepatic resection (anatomic resection, n=201; limited resection, n=120) as the initial treatment for solitary HCC<5 cm in our institution in the period 1985 to 2004 (median followup period 5.1 years).

RESULTS

Anatomic resection did not influence overall and recurrence-free survival rates after hepatic resection. In the liver damage A group (n=215), both 5-year overall and recurrence-free survival rates in the anatomic resection group were considerably better than those in the limited resection group (87% versus 76%, p=0.02, and 63% versus 35%, p<0.01, respectively). In the liver damage B group (n=106), both 5-year overall and recurrence-free survival rates in the anatomic resection group were substantially worse than those in the limited resection group (48% versus 72%, p<0.01, and 28% versus 43%, p=0.01, respectively). The results of multivariate analysis revealed that anatomic resection was a notably poor factor in promoting recurrence-free survival in patients with liver damage B.

CONCLUSIONS

Anatomic resection should be recommended for noncirrhotic patients (liver damage A) with HCC. Longterm results of limited hepatic resection proved its validity for cirrhotic patients (liver damage B) with HCC.

Prognosis and postoperative lymphocyte count in patients with hepatocellular carcinoma who received intraoperative allogenic blood transfusion: a retrospective study

AIMS

The effect of perioperative blood transfusion on the survival of hepatocellular carcinoma (HCC) has not been fully investigated. To clarify the prognostic value of intraoperative allogenic blood transfusion, we conducted a comparative retrospective analysis of 224 patients with HCC who underwent hepatic resection.

METHODS

We compared clinicopathologic background and survival after hepatic resection between patients who received intraoperative blood transfusion (n=101) and those who did not (n=123).

RESULTS

Patients with blood transfusion had a larger tumor and more frequent vascular invasion than those without blood transfusion. The 5-year cancer-related survival rate after hepatic resection, but not the disease-free survival rate, was significantly lower in patients who underwent blood transfusion than in those who did not (38.3% vs. 66.7%, P<0.01). Multivariate analysis showed intraoperative blood transfusion (P=0.02), microscopic portal invasion (P<0.01), and preoperative serum alpha-fetoprotein elevation (P=0.03) to be independent risk factors for poor outcome after hepatic resection. The negative effect of blood transfusion on postoperative survival was observed only in patients with a tumor larger than 50mm in diameter. The absolute peripheral blood lymphocyte count on postoperative day 1 was significantly lower in patients who underwent blood transfusion (880/mm(3)) than in those who did not (1081/mm(3)) (P<0.01).

CONCLUSIONS

Our data suggest that intraoperative blood transfusion results in immunosuppression in the early postoperative period, allowing for progression of residual HCC after resection. Therefore, intraoperative allogenic blood transfusion should be avoided in patients with resectable HCC, particularly in those with a large tumor.

Prognosis in patients with hepatocellular carcinoma correlates to mutations of p53 and/or hMSH2 genes

Association of gene alterations and prognosis has not fully been elucidated in hepatocellular carcinoma (HCC). To clarify the relationship between p53 and hMSH2 mutations and prognosis, we analysed these mutations in 83 HCC cases and assessed their association with various clinicopathological factors. The 3-year disease-free survival (DFS) or overall survival (OS) rates in HCC patients with p53 mutation and p53 wild/hMSH2 mutation significantly decreased compared with those without these mutations (14.3% and 37.5% versus 67.5% for DFS; 35.7% and 50.0% versus 96.4% for OS, respectively). In the multivariate analysis, categories by p53 and hMSH2 mutation status, and liver cirrhosis demonstrated statistical significances for DFS and OS. Moreover, the frequency of patients with p53 and/or hMSH2 mutations in intrahepatic metastasis (75.0%) was significantly higher than that in multicentric occurrence (14.3%). Thus, p53 and hMSH2 mutations will be useful for identifying subsets of HCC patients with poor prognosis.

Clinical characteristics and surgical outcome in hepatocellular carcinoma without hepatitis B virus surface antigen or hepatitis C virus antibody

OBJECTIVE

We investigated clinical characteristics and surgical outcome of hepatocellular carcinoma in association with hepatitis viral status. No consensus exists concerning differences in surgical outcome in patients with hepatocellular carcinoma according to viral hepatitis status, especially those negative for hepatitis B virus surface antigen and antibody to hepatitis C virus.

METHODS

Clinicopathologic data were available for 39 hepatectomy patients with hepatocellular carcinoma who were negative for hepatitis B virus surface antigen and hepatitis C virus antibody. Clinical characteristics and surgical outcome were analyzed retrospectively and compared to those patients with positive hepatitis viral markers.

RESULTS

Patients negative for viral hepatitis markers were more likely to have large, advanced-stages tumors with relatively well-preserved liver function and had a lower incidence of intrahepatic recurrences (P = 0.009). The intrahepatic recurrence rate reached a plateau at approximately 3 years after resection in patients with negative viral markers, while it continued to increase steadily in patients positive for viral hepatitis markers. By multivariable analysis, the absence of viral hepatitis markers predicted a decreased rate of intrahepatic recurrence (relative risk, 0.222; P = 0.001).

CONCLUSIONS

Adequate surgical resection in hepatocellular carcinoma patients negative for viral markers offers a good survival benefit, regardless of the etiology of the hepatocellular carcinoma.

Molecular profiling of hepatocellular carcinomas by cDNA microarray

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. Conventional diagnosis and treatment of this malignancy have been dismal and should be complemented by novel tools. The development and progress of HCC are believed to be caused by the accumulation of genetic changes resulting in altered expression of thousands of cancer-related genes, which can be measured by globe genetic analysis. Gene expression profiling of HCC has been employed to elucidate hepatocarcinogenesis and disclose molecular mechanisms underlying complex clinical features. Identifying phenotype-associated genes/profiles has impacts on current diagnosis and management strategy of HCC. In spite of some pitfalls of this technology and challenges in improving the research process, scrutinous validation of profiling data of HCC combined with other approaches will eventually benefit the patients.

Detecting Postsurgical Recurrent Hepatocellular Carcinoma With Multiphasic Helical Computed Tomography

OBJECTIVE

The aim of this study was to assess the computed tomography (CT) patterns of postoperative recurrent hepatocellular carcinoma (HCC).

METHODS

Of 84 patients with histologically proven HCC by hepatectomies, multiphasic helical CT demonstrated 54 HCC lesions of intrahepatic recurrence in 31 (37%) patients. The initial and final appearances of HCC on hepatic arterial phase images were retrospectively determined by the serial CT scans, which were compared with appearances of primary HCC.

RESULTS

The initial appearances of 54 recurrent HCCs were identical to the appearances of primary HCC in 41 (76%) lesions. Serial changes from the initial appearance to the final appearance of recurrent HCC were observed in 10 (42%) of 24 lesions. The 13 discordant lesions and the 10 lesions with altered lesion vascularity in our series implied that at least 43% were of multicentric occurrence.

CONCLUSION

More than 40% of postoperative recurrent HCCs show intranodular hemodynamic changes. The incompatibility between CT findings of primary and recurrent HCCs implies that these tumors contain nodules of multicentric occurrence.

Pathological study on multicentric occurrence of hepatocellular carcinoma

Recently, it has been suggested that many of hepatocellular carcinoma (HCC) are of multicentric origin based on the clinicopathologic studies on small HCCs of the early stage and clinical follow-up studies after successful treatments of small HCCs. The author studied the multicentric occurrence of HCC from the point of view of pathomorphology in 168 HCCs less than 3 cm in diameter consecutively resected from 1999 to 2004 and 8 autopsy of liver cirrhosis of micronodular type from 1990 to 2004 at Kurume University Hospital from 1999 to 2004. The association of well-differentiated HCC ranging from 9 mm to 1.2 cm in diameter was found in the non-cancerous tissue of 9 cases (9.5%) among 94 cirrhotic livers. Adenomatous hyperplasia (AH) was found in 7 cases (7.4%). Accordingly, prevalence of synchronous and metachronous multicentric hepatocarcinogenesis was highly suggested in 9.5% and 7.4%, respectively. In 4 (50%) of the 8 autopsy cases of micronodular cirrhosis, however, the coexistence of 2 well-differentiated HCCs around 1.5 cm were found in the different segment. The prevalence of multicentric occurrence in the resected cases is the lowest estimation and true prevalence should be much more higher because HCC cases with multiple nodules are not sent to surgery and the observation is limited in a small area of the subsegmentectomized liver. Indeed, the result of autopsy cases reflects a true prevalence (50%) of synchronous occurrence of HCC.

Hepatitis viral status affects the pattern of intrahepatic recurrence after resection for hepatocellular carcinoma

AIM

To define whether the patterns of intrahepatic recurrence after resection for hepatocellular carcinoma differ according to hepatitis viral status.

METHODS

One hundred and eleven patients undergoing a curative resection for hepatocellular carcinoma were divided into three groups: the C-viral group (n=55), which tested positive for hepatitis C antibody; the B-viral group (n=32), which tested positive for hepatitis B surface antigen; and the non-B non-C (NBNC) group (n=24), which tested negative for both hepatitis B surface antigen and hepatitis C antibody. The long-term outcomes were analyzed retrospectively.

RESULTS

The pattern of development of intrahepatic recurrence differed between the NBNC group and the other groups: the cumulative probability of intrahepatic recurrence reached a plateau at 2.4 years after resection in the NBNC group, while it continued to increase steadily in the hepatitis viral groups. The C-viral group showed a higher incidence of intrahepatic recurrence than the other groups by univariate (P=0.0306) and multivariate (relative risk=1.69, P=0.0429) analyses. Multiple intrahepatic recurrent lesions were more common in the C-viral group (P=0.0457).

CONCLUSIONS

Multicentric carcinogenesis in the remnant liver was less common in the NBNC group than in hepatitis viral groups. Hepatitis C virus infection is a significant risk factor for intrahepatic recurrence after resection and is also associated with multiple intrahepatic recurrent lesions.