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

Construction of a Nomogram to Predict Overall Survival in Patients with Early-Onset Hepatocellular Carcinoma: A Retrospective Cohort Study

Hepatocellular carcinoma (HCC) is a widespread and impactful cancer which has pertinent implications worldwide. Although most cases of HCC are typically diagnosed in individuals aged ≥60 years, there has been a notable rise in the occurrence of HCC among younger patients. However, there is a scarcity of precise prognostic models available for predicting outcomes in these younger patients. A retrospective analysis was conducted to investigate early-onset hepatocellular carcinoma (EO-LIHC) using data from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2018. The analysis included 1392 patients from the SEER database and our hospital. Among them, 1287 patients from the SEER database were assigned to the training cohort (n = 899) and validation cohort 1 (n = 388), while 105 patients from our hospital were assigned to validation cohort 2. A Cox regression analysis showed that age, sex, AFP, grade, stage, tumor size, surgery, and chemotherapy were independent risk factors. The nomogram developed in this study demonstrated its discriminatory ability to predict the 1-, 3-, and 5-year overall survival (OS) rates in EO-LIHC patients based on individual characteristics. Additionally, a web-based OS prediction model specifically tailored for EO-LIHC patients was created and validated. Overall, these advancements contribute to improved decision-making and personalized care for individuals with EO-LIHC.

Survival benefit of perioperative locoregional adjuvant treatment for hepatocellular carcinoma with portal vein tumor thrombosis: A systematic review and Bayesian network meta-analysis

BACKGROUND

To identify the optimal strategy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) by comparing the oncological prognosis of different perioperative locoregional adjuvant treatments.

METHODS

Electronic database were searched for relevant studies. Overall survival (OS) and recurrence-free survival (RFS) were pooled by pairwise and network meta-analysis.

RESULTS

Fourteen eligible trials with 1927 patients and covering four adjuvant treatments were included. All adjuvant therapies in combination with surgery were shown to be superior to surgery alone. Adjuvant therapy with radiotherapy had the lowest hazard ratio (HR) for both OS (HR: 0.38, 95% CrI: 0.25-0.57) and RFS (HR: 0.27, 95% CrI: 0.11-0.65) compared with other combination treatments, with estimated surface under the cumulative ranking of 93.2% and 82.7%, respectively.

CONCLUSIONS

Perioperative locoregional adjuvant therapy provides OS benefits and reduces the risk of recurrence for patients suffering from HCC with PVTT. Radiotherapy is likely to be the most effective adjuvant regimen.

A web-based nomogram model for predicting the overall survival of hepatocellular carcinoma patients with external beam radiation therapy: A population study based on SEER database and a Chinese cohort

BACKGROUND

External beam radiation therapy (EBRT) for hepatocellular carcinoma (HCC) is rarely used in clinical practice. This study aims to develop and validate a prognostic nomogram model to predict overall survival (OS) in HCC patients treated with EBRT.

METHOD

We extracted eligible data of HCC patients between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Those patients were randomly divided into a training cohort (n=1004) and an internal validation cohort (n=429), and an external validation cohort composed of a Chinese cohort (n=95). A nomogram was established based on the independent prognostic variables identified from univariate and multivariate Cox regression analyses. The effective performance of the nomogram was evaluated using the concordance index (C-index), receiver operating characteristic curve (ROC), and calibration curves. The clinical practicability was evaluated using decision curve analysis (DCA).

RESULTS

T stage, N stage, M stage, AFP, tumor size, surgery, and chemotherapy were independent prognostic risk factors that were all included in the nomogram to predict OS in HCC patients with EBRT. In the training cohort, internal validation cohort, and external validation cohort, the C-index of the prediction model was 0.728 (95% confidence interval (CI): 0.716-0.740), 0.725 (95% CI:0.701-0.750), and 0.696 (95% CI:0.629-0.763), respectively. The 6-, 12-,18- and 24- month areas under the curves (AUC) of ROC in the training cohort were 0.835 、0.823 、0.810, and 0.801, respectively; and 0.821 、0.809 、0.813 and 0.804 in the internal validation cohort, respectively; and 0.749 、0.754 、0.791 and 0.798 in the external validation cohort, respectively. The calibration curves indicated that the predicted value of the prediction model performed well. The DCA curves showed better clinical practicability. In addition, based on the nomogram, we established a web-based nomogram to predict the OS of these patients visually.

CONCLUSION

Based on the SEER database and an independent external cohort from China, we established and validated a nomogram to predict OS in HCC patients treated with EBRT. In addition, for the first time, a web-based nomogram model can help clinicians judge the prognoses of these patients and make better clinical decisions.

Association between chemotherapy and prognostic factors of survival in hepatocellular carcinoma: a SEER population-based cohort study

Hepatectomy and transplantation are the main surgical therapies for HCC patients, and radiotherapy or chemotherapy is often used as adjuvant treatment. Researches have evaluated the independent predictors of HCC, but evidence for factors predicting the efficacy of chemotherapy is rare. Patients diagnosed with HCC between 2010 and 2015 from the SEER database were included and randomly divided into non-chemotherapy and chemotherapy groups. The predictors of CSS and OS were analyzed with the Cox proportional-hazards regression model and Fine and Gray’s competing risk model. Although there was no significant difference in survival analysis between the chemotherapy and non-chemotherapy groups, the cumulative cancer-specific mortality of most HCC patients was decreased in the chemotherapy group. AJCC stage, tumor size, grade, surgery and radiotherapy were predictors of OS and CSS in the non-chemotherapy group, while AJCC stage, tumor size, AFP, grade and surgery in the chemotherapy group. Surgery combined with chemotherapy was applicable to all AJCC stage patients. Surgery was the major treatment option for patients in AJCC I and AJCC II stage, and chemotherapy in AJCC III and AJCC IV stage. In conclusion, the study provided population-based estimates of the prognostic factors in HCC patients with or without chemotherapy.

Locoregional Therapies for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Hepatocellular carcinoma is the fourth leading cause of cancer worldwide, and the fastest increasing cause of cancer mortality in the United States. Its propensity for vascular invasion leads to the presence of portal vein tumor thrombus in up to half of patients. PVTT results in a classification of advanced disease, given the risk recurrence secondary to intravascular spread, and formal guidelines recommend systemic therapy in these patients. However, recent advances in locoregional therapies including TACE, TARE, and ablation have demonstrated the potential to drastically improve overall survival in patients with HCC complicated by PVTT.

Outcomes of Hepatic Resection for Hepatocellular Carcinoma Associated with Portal Vein Invasion

BACKGROUND

To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI).

METHODS

Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM).

RESULTS

Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172).

CONCLUSION

Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

Chemotherapeutic perfusion of portal vein after tumor thrombectomy and hepatectomy benefits patients with advanced hepatocellular carcinoma: A propensity score-matched survival analysis

BACKGROUND

Portal vein tumor thrombus (PVTT) is a common complication in hepatocellular carcinoma (HCC), signaling dismal outcomes. This study was conducted to evaluate the survival benefit of postoperative portal vein perfusion chemotherapy (PVC) in patients with HCC and PVTT.

METHODS

A retrospective review was conducted in 401 consecutive patients with HCC and PVTT who underwent hepatic resection between January 2009 and December 2015 and 67 patients received adjuvant postoperative PVC. A propensity score matching (PSM) was used to match patients with and without PVC at a ratio of 1:1.

RESULTS

After PSM, the median time to recurrence (TTR) and overall survival (OS) were significantly longer in PVC group compared with control group (12.3 vs 5.8 months, P = .001; 19.0 vs 13.4 months, P = .037; respectively). At 1, 2, 3, and 5 years, the cumulative recurrence rates in PVC group were 48.1%, 86.5%, 92.3% ,96.2%, respectively, with OS rates of 63.8%, 37.9%, 24.4%, 18.3%, respectively; whereas cumulative recurrence rates of 76.6%, 91.5%, 94.3%, and 97.2%, respectively and OS rates of 55.4%, 23.0%, 12.4%, and 12.4%, respectively were recorded for the control group. In multivariate analysis, postoperative PVC emerged as a significant predictor for TTR (hazard ratio [HR], 0.523; P = .001) and OS (HR, 0.591; P = .010). PVC could reduce early recurrence (≤1 year) rate after surgical resection (40.3% vs 64.2%, P = .006) and clinical outcomes were further enhanced by adding sorafenib to postoperative PVC.

CONCLUSIONS

Compared with surgical resection alone, postoperative adjuvant PVC treatment boosts survival and reduces early tumor recurrences in patients surgically treated for HCC and PVTT.

Determination of portal vein tumor thrombus blood supply using in vivo cellular magnetic resonance imaging in a rabbit model

Objective: This study aimed to investigate the anatomic configuration of the blood vessels that contribute to portal vein tumor thrombus (PVTT), a common complication of hepatocellular carcinoma, in VX2 rabbits.

Materials and methods: Peripheral blood mononuclear cells (MNCs) were isolated and labeled using superparamagnetic iron oxide particles in vitro. Twenty-four rabbits were injected with the VX2 tumor via the portal vein to establish the PVTT model. The rabbits (n=6/treatment group) were randomly assigned into four groups. Rabbits of groups A, B and C received an infusion of iron-labeled MNCs via the hepatic artery, the portal vein or the auricular vein, respectively, whereas rabbits of group D received an injection of normal saline via the auricular vein 7 days after the injection of VX2 tumors. MRI was performed, and the signal intensity (SI) of the PVTTs was measured on T2-weighted images (T2WIs) 1 day after the transfusion of iron-labeled cells.

Results: The SI of PVTTs, as measured on T2WIs, in rabbits of groups A, B, C and D was 241.400 (172.350, 364.825), 221.150 (203.775, 318.225), 590.200 (363.325, 728.875) and 568.050 (474.725, 705.150), respectively. Our data showed a significant decrease in the SI of PVTTs in rabbits of groups A and B compared with rabbits of groups C and D (group A vs group C, U=4.000, p=0.025; group A vs group D, U=2.000, p=0.010; group B vs group C, U=4.000, p=0.025; group B vs group D, U=1.000, p=0.006). There was no significant difference in the SI of PVTTs in rabbits of group A and B.

Conclusion: Our results indicated that the portal vein and the hepatic artery supplied blood flow to the PVTT in rabbits.

Resection for hepatocellular cancer: overpassing old barriers

Several recent studies have shown that the selection limits commonly used for patients with hepatocellular cancer (HCC) potentially requiring a liver resection (LR) are too restrictive. The present review aims at investigating the studies showing that LR is no longer a treatment suitable only for highly selected patients, but also for patients selectively presenting one-to-more negative factors. Several specific variables have been investigated, none of them showing to be an absolute contraindication for LR: age; single vs. multiple diseases; the dimension of the nodule; hyperbilirubinemia; clinically relevant portal hypertension; Child-Pugh status; macrovascular invasion. As a consequence, LR for the treatment of HCC-on-cirrhosis is a safe and effective procedure not only in "ideal cases", but also for selected patients presenting risk factors. The presence of only one of these factors does not represent an absolute contraindication for LR. On the opposite, the contemporaneous presence of risk factors should contraindicate the procedure. Further studies investigating the "borderline" cases are required, mainly looking at the possible decisive role of laparoscopy in this setting.

Postoperative adjuvant chemo (embolization) therapy for hepatocellular carcinoma with portal vein tumor thrombosis

Background

The present meta-analysis was aimed to evaluate the effects of postoperative adjuvant chemotherapy/transarterial chemoembolization (TACE) on the survival/disease-free survival (DFS) rate in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT).

Methods

The relevant trials were collected using a database search of MEDLINE, Embase, Cochrane Library, Web of Science, ScienceDirect, the China Journal Full-text Database, and the National Institute of Health Clinical Trials Database. The 1-, 3-, and 5-year survival/DFS rates were considered to be the primary end points. A sensitivity analysis was conducted by reanalyzing the data using different statistical approaches.

Results

Eight studies met the inclusion criteria. When compared with surgery alone, the pooled OR showed that the postoperative adjuvant therapy significantly increased the 1-, 3-, and 5-year survival rates for HCC patients with PVTT (the pooled OR and 95% CI of the 1-, 3-, and 5-year survival rates, respectively, were as follows: 2.72, 1.98-3.74; 1.62, 1.13-2.33; 1.99, 1.20-3.29). In addition, when compared with surgery alone, subgroup analysis showed that the postoperative chemotherapy improved the 1-, 3-, and 5-year survival rates of HCC patients with PVTT.

Conclusion

Compared with surgery alone, postoperative adjuvant chemotherapy can improve the 1-, 3- and 5-year survival rates of HCC patients with PVTT. However, postoperative TACE can only increase the 1-year survival rate. However, due to the limitations of this meta-analysis, additional relevant trials are required to confirm these findings.

Systematic review of the outcomes of surgical resection for intermediate and advanced Barcelona Clinic Liver Cancer stage hepatocellular carcinoma: A critical appraisal of the evidence

AIM

To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas (HCC).

METHODS

A systematic review of the published literature was performed using the PubMed database from 1^st January 1999 to 31^st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer (BCLC) stage B or C HCC. The primary end point was to determine the overall survival (OS) and disease free survival (DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve (i.e., Child’s A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC (defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.

RESULTS

We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to (1) BCLC stage B or C HCC, (2) Size of HCC and (3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7% (range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0% (range 0.0-42.0). The collective median 5-year OS of both stages was 27.9% (0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR (95%CI) = 1.00 (0.76-1.31)] and mortality [RR (95%CI) = 1.15 (0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.

CONCLUSION

Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.

Hepatectomy for hepatocellular carcinoma with portal vein tumor thrombus

Despite surgical removal of tumors with portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) patients, early recurrence tends to occur, and overall survival (OS) periods remain extremely short. The role that hepatectomy may play in long-term survival for HCC with PVTT has not been established. The operative mortality of hepatectomy for HCC with PVTT has also not been reviewed. Hence, we reviewed recent literature to assess these parameters. The OS of patients who received hepatectomy in conjunction with multidisciplinary treatment tended to be superior to that of patients who did not. Multidisciplinary treatments included the following: preoperative radiotherapy on PVTT; preoperative transarterial chemoembolization (TACE); subcutaneous administration of interferon-alpha (IFN-α) and intra-arterial infusion of 5-fluorouracil (5-FU) with infusion chemotherapy in the affected hepatic artery; cisplatin, doxorubicin and 5-FU locally administered in the portal vein; and subcutaneous injection of IFN-α, adjuvant chemotherapy (5-FU + Adriamycin) administration via the portal vein with postoperative TACE, percutaneous isolated hepatic perfusion and hepatic artery infusion and/or portal vein chemotherapy. The highest reported rate of operative mortality was 9.3%. In conclusion, hepatectomy for patients affected by HCC with PVTT is safe, has low mortality and might prolong survival in conjunction with multidisciplinary treatment.

Surgical treatment for advanced hepatocellular carcinoma with portal vein tumor thrombus

The Barcelona Clinic Liver Cancer staging system recommends a tyrosine kinase inhibitor (sorafenib) as standard therapy in advanced hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). Sorafenib has been shown to prolong median overall survival (OS) by approximately 3 months in advanced HCC patients with PVTT (8.1 vs. 4.9 months). However, its clinical effectiveness is still controversial and standard treatment with sorafenib is not established in Japan. Surgical resection is considered a potentially curative treatment and provides an acceptable outcome for carefully selected patients. The surgical mortality rate in patients with PVTT who receive surgical resection ranges from 0% to 10%. The median survival time and 1-year OS rate in HCC patients with PVTT who undergo surgical resection have been found to range from 8 to 22 months and 21.7% to 69.6%, respectively. But improvement in therapeutic outcome is difficult with surgical treatment alone. Combination treatment in conjunction with such methods as transarterial chemoembolization, hepatic artery infusion chemotherapy, and radiotherapy has been found to improve the prognosis (median survival time, 11.5-37 months; 1-year OS rate, 46.8-100%). Yet, many problems remain, such as surgical indications and surgical techniques. After resolving these points, a multidisciplinary strategy based on surgical treatment should be established for advanced HCC with PVTT.

Surgical resection for hepatocellular carcinoma with portal vein tumor thrombus in the Asia-Pacific region beyond the Barcelona Clinic Liver Cancer treatment algorithms: a review and update

Portal vein tumor thrombus (PVTT) usually worsens prognosis of hepatocellular carcinoma (HCC), as characterized by aggressive disease progression, impaired liver function and tolerance to treatment. Conventionally, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) accepted the Barcelona Clinical Liver Cancer (BCLC) treatment algorithms, identifying PVTT as an absolute contra-indication of surgical resection for HCC. HCC-PVTT patients are offered sorafenib as the standard treatment. Evidently, SHARP and Asia-Pacific trials demonstrated that sorafenib only improves overall survival by approximately 3 months in patients with advanced HCC. Besides, BCLC treatment algorithm does not provide different therapeutic recommendations for different degree of PVTT, and only supports single treatment option for each stage of HCC rather than a combination of comprehensive treatments, which limited individual and best care for every HCC-PVTT patients. In the past few years, many surgeons do not restrict surgical resection to HCC with PVTT. There have been new reports demonstrated that surgical treatment is feasible for selected HCC-PVTT patients with resectable tumor and moderate liver function to prolong survival period and elevate life quality as long as PVTT limited to the first-order branch, whereas non-surgical treatments fail to provide comparable therapeutic effects. At present, guidelines on HCC management from mainland China, Japan, and Hong Kong have been updated and a consensus of Asia-Pacific experts has established that portal venous invasion is not an absolute contradiction of surgical resection for HCC. This review summarized the emerging data on surgical resection for HCC-PVTT patients beyond the BCLC treatment algorithms and discussed recent therapeutic conceptualchanges in the Asia-Pacific region.

Viral hepatitis and hepatocellular carcinoma: etiology and management

Chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) are associated with hepatic fibrosis and development of hepatocellular carcinoma (HCC). There are differences and variation with the incidence of HCC worldwide. Additionally, HCC develops via different pathways with these viral hepatitides. This review outlines the various mechanisms and pathophysiology that contributes to this process. There will also be a review on the recommended screening for HCC. Treatment considerations, which are different for these viruses, will be outlined in this review.

Living Donor Liver Transplantation for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis after Concurrent Chemoradiation Therapy

Locally advanced hepatocellular carcinoma (HCC) with portal vein thrombosis carries a 1-year survival rate <10%. Localized concurrent chemoradiotherapy (CCRT), followed by hepatic arterial infusion chemotherapy (HAIC), was recently introduced in this setting. Here, we report our early experience with living donor liver transplantation (LDLT) in such patients after successful down-staging of HCC through CCRT and HAIC. Between December 2011 and September 2012, eight patients with locally advanced HCC at initial diagnosis were given CCRT, followed by HAIC, and underwent LDLT at the Severance Hospital, Seoul, Korea. CCRT [45 Gy over 5 weeks with 5-fluorouracil (5-FU) as HAIC] was followed by HAIC (5-FU/cisplatin combination every 4 weeks for 3-12 months), adjusted for tumor response. Down-staging succeeded in all eight patients, leaving no viable tumor thrombi in major vessels, although three patients first underwent hepatic resections. Due to deteriorating liver function, transplantation was the sole therapeutic option and offered a chance for cure. The 1-year disease-free survival rate was 87.5%. There were three instances of post-transplantation tumor recurrence during follow-up monitoring (median, 17 months; range, 10-22 months), but no deaths occurred. Median survival time from initial diagnosis was 33 months. Four postoperative complications recorded in three patients (anastomotic strictures: portal vein, 2; bile duct, 2) were resolved through radiologic interventions. Using an intensive tumor down-staging protocol of CCRT followed by HAIC, LDLT may be a therapeutic option for selected patients with locally advanced HCC and portal vein tumor thrombosis.

The strategies for treating primary hepatocellular carcinoma with portal vein tumor thrombus

PURPOSE

To further improve the effectiveness and prognosis of primary hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), the current status of treatment for HCC with PVTT was reviewed.

METHODS

A Medline search was undertaken to identify articles using the keywords "HCC", "PVTT" and "therapy". Additional papers were identified by a manual search of the references from the key articles.

RESULTS

PVTT, as a common complication of HCC, was divided into type I ∼ IV. The therapeutic approach is mainly composed of five types: surgical resection, regional interventional therapy, radiotherapy, combination therapy, targeted therapy. All of these therapeutic approaches were separately evaluated in detail.

CONCLUSIONS

For those resectable tumors, the better choice for treatment of HCC with PVTT should be hepatectomy and removal of PVTT. For those unresectable tumors, TACE (especially the super-selective TACE) has been the preferred palliative treatment, the other regional interventional therapy and/or radiotherapy could improve the therapeutic effects. The multidisciplinary treatments may further improve the quality of life and prolong the survival period for the HCC patients associated with PVTT.

Hepatic resection as a safe and effective treatment for hepatocellular carcinoma involving a single large tumor, multiple tumors, or macrovascular invasion

This systematic review examined whether the available evidence justifies using hepatic resection (HR) during later stages of hepatocellular carcinoma (HCC), which contravenes treatment guidelines but is current practice at many medical centers.Official guidelines and retrospective studies recommend different roles for HR for patients with large/multinodular HCC or with HCC involving macrovascular invasion (MVI).Several databases were systematically searched for studies examining the safety and efficacy of HR for treating HCC involving a single large tumor (>5 cm) or multiple tumors, or for treating HCC involving MVI.We identified 50 studies involving 14, 808 patients that investigated the use of HR to treat large/multinodular HCC, and 24 studies with 4389 patients that investigated HR to treat HCC with MVI. Median in-hospital mortality for patients with either type of HCC was significantly lower in Asian studies (2.7%) than in non-Asian studies (7.3%, P < 0.001). Median overall survival (OS) was significantly higher for all Asian patients with large/multinodular HCC than for all non-Asian patients at both 1 year (81% vs 65%, P < 0.001) and 5 years (42% vs 32%, P < 0.001). Similar results were obtained for median disease-free survival at 1 year (61% vs 50%, P < 0.001) and 5 years (26% vs 24%, P < 0.001). However, median OS was similar for Asian and non-Asian patients with HCC involving MVI at 1 year (50% vs 52%, P = 0.45) and 5 years (18% vs 14%, P = 0.94). There was an upward trend in 5-year OS in patients with either type of HCC.HR is reasonably safe and effective at treating large/multinodular HCC and HCC with MVI. The available evidence argues for expanding the indications for HR in official treatment guidelines.

Elevated preoperative peripheral blood monocyte count predicts poor prognosis for hepatocellular carcinoma after curative resection

BACKGROUND

Peripheral blood monocyte count is an easily assessable parameter of systemic inflammatory response. The aim of this study was to determine whether monocyte count was prognostic in hepatocellular carcinoma (HCC) following hepatic resection.

METHODS

We retrospectively reviewed 351 patients with HCC treated with hepatic resection from 2006 to 2009. Preoperative absolute peripheral monocyte count, demographics, and clinical and pathological data were analyzed.

RESULTS

On univariate and multivariate analysis, elevated monocyte counts (≥ 545/mm(3)), tumor size ≥ 5 cm, non-capsulation, and multiple tumors were associated with poor disease-free survival (DFS) and overall survival (OS). The 1-, 3- and 5-year DFS rates were 58%, 41% and 35%, respectively, for patients with monocyte counts <545/mm(3), and 36%, 23% and 21% for patients with monocyte counts ≥ 545/mm(3). Correspondingly, the 1-, 3- and 5-year OS rates were 79%, 53% and 46% for monocyte counts <545/mm(3), and 64%, 36% and 29% for monocyte counts ≥ 545/mm(3). Subgroup analysis indicated that DFS after hepatic resection in hepatitis B virus (HBV)-infected patients was significantly better in those with a peripheral blood monocyte counts <545/mm(3), but it did not differ between patients without HBV infection. In addition, DFS was significantly better for patients with a peripheral blood monocyte count <545/mm(3), whether or not cirrhosis was present. Patients with elevated monocyte counts tended to have larger tumors.

CONCLUSIONS

Elevated preoperative monocyte count is an independent predictor of worse prognosis for patients with HCC after hepatic resection, especially for those with HBV infection. Postoperative adjuvant treatment might be considered for patients with elevated preoperative monocyte counts.

Resection of hepatocellular carcinoma with macroscopic vascular invasion

BACKGROUND

Survival for Child's A patients with hepatocellular cancer (HCC) and macroscopic vascular invasion (MVI) has been reported as approximately 8.1 months with sorafenib. The role of surgery for these patients remains controversial.

METHODS

The records of all patients undergoing resection of HCC at a single center were reviewed. Only patients with pathologically proven MVI were included. Inclusion criteria for resection required Child's A liver disease, no clinical portal hypertension (after 2002), and no extrahepatic disease. The superior mesenteric vein and portal vein branch to the remaining lobe had to be patent.

RESULTS

We identified 165 patients with MVI treated with hepatic resection between June 1992 and March 2010. Median follow-up was 11.9 months with 127 deaths, including 12 (7.3%) perioperative mortalities. Median and 5-year survivals were 13.1 months and 14%. Multivariate analysis found α-fetoprotein (AFP) >30 ng/ml (hazard ratio 2.07), tumor size >7 cm (hazard ratio 1.59), and extent of vascular invasion (hazard ratio 1.74) to be independently associated with survival. Those with invasion of hepatic veins or vena cava had a median survival of only 4.7 months.

CONCLUSIONS

The results for resection of HCC with MVI remain somewhat disappointing but are better than what is reported with medical therapy in similar patients. Tumor size, AFP, and extent of vascular invasion can help select those that will benefit most from hepatic resection. Resection of patients with hepatic vein or vena cava involvement may not be justified, given such poor results.

Treatment strategy for hepatocellular carcinoma with major portal vein or inferior vena cava invasion: a single institution experience

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) invading the main trunk of the portal vein and the inferior vena cava is dismal. The best strategy for treatment is not well known.

STUDY DESIGN

We retrospectively reviewed the medical records of 641 patients treated for HCC between 1990 and June 2009. Eighty-four (13%) of these patients had HCC, with a tumor thrombus invading the main trunk or the first-order branch of the portal vein, or the inferior vena cava. Thirty-four patients underwent hepatectomy and 50 patients underwent transcatheter arterial chemoembolization (TACE). We specifically focused on these 34 patients to describe our results of surgical treatment for advanced HCC.

RESULTS

Among the 34 patients who underwent hepatectomy, preoperative TACE was performed in 15 patients. Six patients were identified as having a tumor size reduction or necrosis of 50% or higher (TE3) by TACE. The median operative duration was 355 minutes. Postoperative morbidity and mortality rates were 44% and 2.9%, respectively. The 5-year survival rate after hepatectomy was 20%, which was better than that of patients after TACE alone. The response after preoperative TACE (hazard ratio 4.65; 95% CI, 1.39 to 15.5) and tumor diameter (hazard ratio 2.78; 95% CI, 1.16 to 6.64) were identified as significant favorable preoperative prognostic factors for survival using the multivariable Cox model. Patients with tumors smaller than 10 cm and TE3 effect had a more favorable survival than patients with tumors 10 cm or larger and who did not have a good TACE outcome.

CONCLUSIONS

A combination of aggressive surgical treatment and effective preoperative TACE treatment for HCC with major vascular invasion may be beneficial for selected patients.

Foxp3+ regulatory T cells and the formation of portal vein tumour thrombus in patients with hepatocellular carcinoma

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) have advanced-stage disease at diagnosis. The prognosis for patients with HCC is very poor, especially for those with portal vein tumour thrombi (PVTT). The purpose of our study was to observe the prognostic value of PVTT and tumour-infiltrating regulatory T cells (Tregs) and the correlation between them.

METHODS

We examined 76 HCC specimens by immunohistochemistry for CD4+, CD8+ T cells and Foxp3+ Tregs. The survival of patients was prospectively followed up. Patients with HCC were grouped according to the formation of PVTT or Treg infiltration status. We performed a Kaplan-Meier survival analysis to observe the difference in prognosis between the groups. We analyzed the correlation of Treg expression with clinical and pathologic features.

RESULTS

Survival analysis revealed that both the disease-free survival rate and total survival rate after hepatic resection were significantly lower in patients in the PVTT group than those in the non-PVTT group (p=0.026 and p=0.022, respectively). Likewise, both the disease-free survival rate and the total survival rate were significantly lower in patients in the high Treg group than those in the low Treg group (p=0.012 and p=0.023, respectively). We found that intratumoural Tregs were associated with PVTT formation (p=0.001) and that patients with high Treg infiltration had a higher percentage of PVTT formation.

CONCLUSION

Patients with PVTT formation or high intratumoural Treg infiltration tended to have a poor prognosis. Intratumoural Treg was associated with formation of PVTT in patients with HCC.

Clinicopathologic characteristics and surgical outcomes of hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

Hepatocellular carcinoma (HCC) has a high predilection for portal vein invasion. Furthermore, the treatment of HCC with portal vein tumor thrombosis (PVTT) is controversial. The objective of this study was to investigate clinicopathologic characteristics and surgical outcomes of HCC patients with PVTT.

METHODS

The clinicopathologic data and surgical outcomes of 88 patients HCC with PVTT and 211 patients without PVTT who underwent surgery were retrospectively reviewed. The risk factors and the prognosis of HCC patients with PVTT were determined.

RESULTS

Cirrhosis, serum alkaline phosphatase (ALP) > 100 IU/L, tumor size > 8 cm, incomplete tumor capsule, and adjacent organ invasion were risk factors for PVTT in HCC on multivariate analysis. Furthermore, HCC patients with PVTT received more major hepatectomies, had more intraoperative blood loss and greater blood transfusion requirements, and higher incidence of postoperative mortality compared with HCC patients without PVTT. The median overall survival of HCC patients with PVTT after surgery was 9 mo, with the 1-, 2-, and 3-y overall survival rates of 31.1%, 18.3%, and 15.2 %, respectively. AFP level, adjacent organ invasion, and PVTT location predicted overall survival of HCC patients with PVTT.

CONCLUSIONS

High serum ALP level, cirrhosis, large tumor, incomplete tumor capsule and adjacent organ invasion are predictors of PVTT in HCC. Surgery is a valid therapy for selected HCC patients with PVTT.

Characterisation of a novel cell line (CSQT-2) with high metastatic activity derived from portal vein tumour thrombus of hepatocellular carcinoma

BACKGROUND

Portal vein tumour thrombus (PVTT) is highly associated with the progression and metastasis of hepatocellular carcinoma (HCC). However, there are no appropriate cell models of PVTT with which to study the biological and physiological characteristics of PVTT.

METHODS

Primary cell culture was performed by the use of a successive xenograft line called PVTT-#1, which was obtained from a 60-year-old male HCC patient accompanied by PVTT.

RESULTS

A successive cell line named CSQT-2 was established. The cell line showed aggressive phenotypes in terms of cell growth, survival, migration, xenograft and metastasis. Moreover, an orthotopic transplantation assay showed that PVTT can be generated in nude mice when CSQT-2 cells were inoculated in the liver and that it shows a typical migratory tendency in the vascular branches of portal vein. Moreover, the established CSQT-2 cells also showed varied expression of tumour-initiating cell (TIC) markers such as CD133, CD90 and EpCAM.

CONCLUSION

Establishment of CSQT-2 may provide a suitable model with which to investigate the molecular mechanisms of PVTT-related HCC.

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.

Efficacy of a hepatectomy and a tumor thrombectomy for hepatocellular carcinoma with tumor thrombus extending to the main portal vein

INTRODUCTION

Hepatocellular carcinoma (HCC) with major portal tumor thrombus has been considered to be a fatal disease. A thrombectomy remains the only therapeutic option that offer a chance of complete tumor removal avoiding acute portal vein obstruction. However, the efficacy of tumor thrombectomy in addition to hepatectomy has not been well evaluated.

METHODS

Of 979 patients who consecutively underwent initial HCC resection, 45 (4.6%) HCC patients with tumor invasion of the first branch of the portal vein (vp3) and tumor in the main portal trunk or the opposite-side portal branch (vp4) were retrospectively analyzed to evaluate the efficacy of hepatectomy and tumor thrombectomy.

RESULTS

Alpha-fetoprotein, serosal invasion, and intrahepatic metastases were independently significant prognostic factors in all the 45 patients with vp3 or vp4 HCC. The 3- and 5-year survival rates in vp3 and vp4 group were 35.3% and 41.8%, and 21.2% and 20.9%, respectively. There were longer operative times and more intraoperative bleeding in patients with vp4, but no significant difference in mortality, morbidity, and survival between patients with vp3 and vp4.

CONCLUSION

Hepatectomy and thrombectomy for vp4 could not only avoid acute portal occlusion due to tumor thrombus but provide a comparable survival benefit with hepatectomy for vp3.

Prognosis of hepatocellular carcinoma accompanied by microscopic portal vein invasion

AIM: To investigate the prognostic factors in patients with hepatocellular carcinoma (HCC) accompanied by microscopic portal vein invasion (PVI).

METHODS: Of the 267 patients with HCC undergoing hepatic resection at Aso Iizuka Hospital, 71 had PVI. After excluding 16 patients with HCC that invaded the main trunk and the first and second branches of the portal vein, 55 patients with microscopic PVI were enrolled.

RESULTS: The patients with HCC accompanied by microscopic invasion were divided into two groups: solitary PVI (PVI-S: n = 44), and multiple PVIs (PVI-M: n = 11). The number of portal vein branches invaded by tumor thrombi was 5.4 ± 3.8 (2-16) in patients with PVI-M. In cumulative survival, PVI-M was found to be a significantly poor prognostic factor (P = 0.0019); while PVI-M and non-anatomical resection were significantly poor prognostic factors in disease-free survival (P = 0.0213, and 0.0115, respectively). In patients with PVI-M, multiple intrahepatic recurrence was more common than in the patients with PVI-S (P = 0.0049). In patients with PVI-S, non-anatomical resection was a significantly poor prognostic factor in disease-free survival (P = 0.0370). Operative procedure was not a significant prognostic factor in patients with PVI-M.

CONCLUSION: The presence of PVI-M was a poor prognostic factor in patients with HCC, accompanied by microscopic PVI. Anatomical resection is recommended in these patients with HCC. Patients with HCC and PVI-M may also be good candidates for adjuvant chemotherapy.

Surgical strategy for hepatocellular carcinoma patients with portal vein tumor thrombus based on prognostic factors

RATIONALE

Surgical strategy for patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT) remains to be established.

METHODS

From 1990 to 2008, 48 hepatocellular carcinoma patients with PVTT detected by preoperative imaging underwent hepatic resection, and their clinical data were retrospectively analyzed. Possible prognostic factors for survival were analyzed with postoperative survival curves, and significant factors were determined by univariate and multivariate analysis. The frequency of postoperative severe complications was investigated for each prognostic factor.

RESULTS

Significant prognostic factors included patient age <60 years, serum total bilirubin (T-Bil) >0.8 mg/dl, serum aspartate aminotransferase >30 IU/L, serum alkaline phosphatase (ALP) >300 IU/L, tumor size >4 cm, PVTT in the main trunk (Vp4), and a surgical margin <1 mm by univariate analysis, and independent prognostic factors were serum T-Bil, ALP, and Vp4. No patient with Vp4 survived for more than 400 days after surgery, and frequency of postoperative severe complications in these Vp4 patients was significantly higher than in other Vp1-3 patients.

CONCLUSION

Hepatic resection as a first-choice treatment should be carefully selected in patients with Vp4 unless emergent removal of the PVTT is required.