Clinicopathologic features and risk factors for extrahepatic recurrences of hepatocellular carcinoma after curative resection

Prognostic comparison between pulmonary metastasectomy and combination immunotherapy with targeted molecular therapies for advanced hepatocellular carcinoma with pulmonary metastasis: A propensity score matching analysis

Background and aims

Advanced hepatocellular carcinoma (HCC) with pulmonary metastasis (PM) has a poor prognosis, and optimal treatment strategies remain controversial. This study aimed to compare the long-term outcomes of patients with advanced HCC with PM who were treated with resection of pulmonary metastases versus those treated with targeted therapies combined with immunotherapy.

Methods

A retrospective analysis was conducted on the medical records of HCC patients with PM who underwent either pulmonary metastasectomy or immunotherapy combined with targeted therapies at the Eastern Hepatobiliary Surgery Hospital, Changhai Hospital of Shanghai, Fujian Provincial Hospital, and West China Hospital of Sichuan University from September 2013 to October 2022. One-to-one propensity score matching (PSM) was employed to control the influence of potential confounders, and the survival outcomes were compared.

Results

A total of 119 HCC patients with PM were included in this study. The overall survival (OS) of patients who underwent pulmonary metastasectomy was significantly longer than that of patients who received immunotherapy targeted combinations (OS: 1-year, 80.0% vs. 59.3%; 2-year, 31.7% vs. 20.3%; 3-year, 20.0% vs. 0; P < 0.001). After PSM, the long-term prognosis of the pulmonary metastasectomy group remained significantly better than that of the immunotherapy combination group (OS: 1-year, 87.0% vs. 69.6%; 2-year, 34.8% vs. 30.4%; 3-year, 21.7% vs. 0; P = 0.005). Multivariate analysis revealed that treatment allocation (hazard ratio (HR) = 2.177, 95% confidence interval (CI) = 1.068-4.439) and hepatic tumor T stage (HR = 2.342, 95% CI = 1.209-4.538) were independent risk factors for OS.

Conclusions

Pulmonary metastasectomy was associated with improved survival compared to immunotherapy combined with targeted therapies and may represent an optimal treatment option for highly selected HCC patients with resectable PM.

Surgical resection of late extrahepatic metastasis of hepatocellular carcinoma 11 years after initial diagnosis: case report and literature review

Hepatocellular carcinoma (HCC) is the second most common cause of cancer mortality worldwide. Liver resection is considered the pillar of curative treatment, although it is usually reserved for early-stage localized disease since the presence of metastases carries a poor prognosis. Despite advances in imaging, surgical techniques, and systemic therapy, the recurrence rate after oncologic resection remains high, even with localized disease. In the setting of extrahepatic HCC recurrence, there is no consensus regarding the best treatment strategy. Nevertheless, while the development of metastasis can be considered an expression of systemic disease, surgical resection may prolong survival. We report the case of a patient with a history of an oncologic hepatic resection for HCC, successfully treated with resection of an isolated peritoneal cavity metastasis. This case demonstrates that an aggressive approach involving the resection of extrahepatic HCC metastasis should be considered in select patients with the intention of achieving prolonged survival.

Study on the expression and prognostic relationship of MYL6B in liver cancer based on bioinformatics

BACKGROUND

Primary liver cancer is a prevalent and deadly cancer type. Despite treatment advances, prognosis remains poor, with high recurrence rates. Early detection is crucial but challenging due to the disease's insidious nature. Myosin proteins play significant roles in cancer development, influencing cell migration, invasion, and tumor suppression. MYL6B, a myosin light chain, is involved in various cellular processes and has been associated with poor prognosis in colorectal adenocarcinoma and potential as a biomarker in breast cancer.

AIM

To investigate the expression of MYL6B in liver hepatocellular carcinoma (LIHC) and its impact on prognosis and potential mechanisms of action using bioinformatics methods.

METHODS

The expression of MYL6B in pan-cancer and normal tissues was analyzed using the gene expression profiling interactive analysis 2 and tumor immune estimation resource databases. The expression level of MYL6B in LIHC tissues and its relationship with prognosis were analyzed, immunohistochemical analysis of MYL6B and its effect on immune cell infiltration, and the protein network were further studied.

RESULTS

MYL6B was highly expressed in diffuse large b-cell lymphoma, LIHC, pancreatic adenocarcinoma, skin cutaneous melanoma, thymoma, uterine corpus endometrial carcinoma, uterine carcinosarcoma, and lowly expressed in kidney chromophobe, acute myeloid leukemia, testicular germ cell tumors. The expression level of MYL6B was significantly different between cancer and normal tissues. It had a significant impact on both overall survival and disease-free survival. MYL6B is highly expressed in hepatocellular carcinoma and its expression level increases with cancer progression. High MYL6B expression is associated with poor prognosis in terms of overall survival and recurrence-free survival. The immunohistochemical level of MYL6B is high in hepatocellular carcinoma tissues, and MYL6B has a high level of immune infiltration inflammation. In protein network analysis, MYL6B is correlated with MYL2, MYL6, MYL9, MYLK4, MYLK2, MYL12A, MYL12B, MYH11, MYH9 and MYH10.

CONCLUSION

The expression level of MYL6B in LIHC was significantly higher than in normal liver tissues, and it was correlated with the degree of differentiation survival rate, and immune infiltration. MYL6B is a potential target for LIHC treatment.

Patterns, Risk Factors, and Outcomes of Recurrence After Hepatectomy for Hepatocellular Carcinoma with and without Microvascular Invasion

Purpose

The patterns and risk factors of postsurgical recurrence of patient with hepatocellular carcinoma (HCC) with microvascular invasion (MVI) are not clarified. This study aimed to decipher and compare the postoperative recurrent patterns and the risk factors contributing to recurrence between MVI positive (MVI(+)) and MVI negative (MVI(-)) HCC after hepatectomy.

Patients and methods

Patients with HCC who underwent hepatectomy in three Chinese academic hospitals between January 1, 2009, and December 31, 2018, were enrolled. Recurrent patterns included early (≤2 years) or late (>2 years) recurrence, recurrent sites and number, and risk factors of recurrence were compared between the MVI(+)and MVI(-) groups by propensity score-matching (PSM).

Results

Of 1756 patients included, 581 (33.1%) were MVI(+), and 875 (49.8%) patients developed early recurrence. Compared with the MVI(-) group, the MVI(+) group had a higher 2-year recurrence rate in the PSM cohort (hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.59-2.10; P < 0.001), and more patients with multiple tumor recurrence. Patients with early recurrence in the MVI(+) group had a worse overall survival (OS) than those in the MVI(-) group (HR, 1.24; 95% CI, 1.02-1.50; P = 0.034). Resection margin (RM) ≤1.0 cm is a surgical predictor of early recurrence for the MVI(+) group (HR, 0.68; 95% CI, 0.54-0.87; P = 0.002), but not for the MVI(-) group.

Conclusion

Compared to MVI(-) HCC, MVI(+) HCC tends to be early, multiple recurrence and lung and lymph node metastasis after resection. RM ≤1.0 cm is a surgical risk factor of early recurrence for patient with MVI.

Macroscopic Characterization of Hepatocellular Carcinoma: An Underexploited Source of Prognostic Factors

The macroscopic appearance of a tumor such as hepatocellular carcinoma (HCC) may be defined as its phenotype which is de facto dictated by its genotype. Therefore, macroscopic characteristics of HCC are unlikely random but rather reflect genomic traits of cancer, presumably acting as a valuable source of information that can be retrieved and exploited to infer prognosis. This review aims to provide a comprehensive overview of the available data on the prognostic value of macroscopic characterization in HCC. A total of 57 studies meeting eligible criteria were identified, including patients undergoing liver resection (LR; 47 studies, 83%) or liver transplant (LT; 9 studies, 16%). The following macroscopic variables were investigated: tumor size (n = 42 studies), number of nodules (n = 28), vascular invasion (n = 24), bile duct invasion (n = 6), growth pattern (n = 15), resection margin (n = 11), tumor location (n = 6), capsule (n = 2) and satellite (n = 1). Although the selected studies provided insightful data with notable prognostic performances, a lack of standardization and substantial gaps were noted in the report and the analysis of gross findings. This topic remains incompletely covered. While the available studies underscored the value of macroscopic variables in HCC prognostication, important lacks were also observed. Macroscopic characterization of HCC is likely an underexploited source of prognostic factors that must be actively explored by future multidisciplinary research.

Nomograms for postsurgical extrahepatic recurrence prediction of hepatocellular carcinoma based on presurgical circulating tumor cell status and clinicopathological factors

BACKGROUND AND AIMS

Extrahepatic recurrence (EHR) is one of the major reasons for the poor prognosis of hepatocellular carcinoma (HCC). The present study aimed to develop and assess the performance of predictive models by using a combination of presurgical circulating tumor cell (CTCs) data and clinicopathological features to screen patients at high risk of EHR to achieve precise decision-making.

PATIENTS AND METHODS

A total of 227 patients with recurrent HCC and preoperative CTC data from January 2014 to August 2019 were enrolled. All patients were randomly assigned to one of two cohorts: development or validation. Two preoperative and postoperative nomogram models for EHR prediction were developed and multi-dimensionally validated.

RESULTS

Patients with EHR had generally lower recurrence-free survival (p < 0.001), and overall survival (p < 0.001), and significantly higher CTC counts (epithelial CTCs, epithelial/mesenchymal hybrid CTCs, and mesenchymal CTCs count, all p < 0.05) than those without EHR. Univariate and multivariate analyses revealed that EHR was associated with four risk factors in the development cohort: total CTC count (p = 0.014), tumor size (p = 0.028), node number (p = 0.045), and microvascular invasion (p = 0.035). These factors were incorporated into two nomogram models (preoperative and postoperative), which reliably predicted EHR through multidimensional verification (e.g., calibration plot, receiver operating characteristic analysis, decision curve analysis, and clinical impact curve analysis) in the development and validation cohorts, respectively. With threshold of scores of 100.3 and 176.8 before and after surgery respectively, both nomograms were able to stratify patients into two distinct prognostic subgroups (all p < 0.05).

CONCLUSION

The present study proposed two nomogram models integrating presurgical CTC counts and clinicopathological risks and showed relatively good predictive performance of EHR, which may be beneficial to the clinical practice of HCC recurrence. Further multicenter studies are needed to assess its general applicability.

Case Report: Complete response after tislelizumab treatment in a hepatocellular carcinoma patient with abdominal lymph node metastasis

Background

Abdominal lymph node (ALN) metastasis is associated with a poor prognosis in patients with hepatocellular carcinoma (HCC) because of the limited number of effective therapeutic options available. Immunotherapy with immune checkpoint inhibitors, such as those targeting programmed death receptor-1 (PD-1), have produced encouraging results in patients with advanced HCC. Here, we report a complete response (CR) in a patient with advanced HCC and ALN metastasis after combination treatment with tislelizumab (a PD-1 inhibitor) and locoregional therapy.

Case summary

A 58-year-old man with HCC experienced progressive disease with multiple ALN metastases after undergoing transcatheter arterial chemoembolization (TACE), radiofrequency ablation (RFA), and laparoscopic resection. Because the patient did not wish to receive systemic therapy, including chemotherapy and targeting therapy, we prescribed tislelizumab (as a single immunotherapeutic agent) together with RFA. After four tislelizumab treatment cycles, the patient achieved a CR without tumor recurrence for up to 15 months.

Conclusion

Tislelizumab monotherapy can be effectively used to treat advanced HCC with ALN metastasis. Moreover, the combination of locoregional therapy and tislelizumab is likely to further increase therapeutic efficacy.

Construction and validation of a prediction model of extrahepatic metastasis for hepatocellular carcinoma based on common clinically available data

OBJECTIVE

This study aimed to investigate the clinical characteristics and risk factors of patients with hepatocellular carcinoma (HCC) with extrahepatic metastases (EHM) and to establish an effective predictive nomogram.

METHODS

Clinical and pathological data from 607 patients with hepatocellular carcinoma admitted to the Affiliated Hospital of Qinghai University between 1 January 2015 and 31 May 2018 were documented, as well as demographics, clinical pathological characteristics, and tumor-related parameters to clarify clinical risk factors for HCC EHM. These risks were selected to build an R-based clinical prediction model. The predictive accuracy and discriminating ability of the model were determined by the concordance index (C-index) and the calibration curve. The results were validated with a bootstrap resample and 151 patients from 1 June 2018 to 31 December 2019 at the same facility.

RESULTS

In multivariate analysis, independent factors for EHM were neutrophils, prothrombin time, tumor number, and size, all of which were selected in the model. The C-index in the EHM prediction model was 0.672 and in the validation cohort was 0.694. In the training cohort and the validation cohort, the calibration curve for the probability of EHM showed good agreement between the nomogram prediction and the actual observation.

CONCLUSION

The extrahepatic metastasis prediction model of hepatocellular carcinoma constructed in this study has some evaluation capability.

Oncological outcomes of anatomic versus non-anatomic resections for small hepatocellular carcinoma: systematic review and meta-analysis of propensity-score matched studies

Background

Primary liver cancer is the second-most commonly occurring cancer and has resulted in numerous deaths worldwide. Hepatic resection is of two main types, i.e., anatomic resection (AR) and non-anatomic resection (NAR). The oncological outcomes of hepatocellular carcinoma (HCC) patients after AR and NAR are still considered controversial. Therefore, we aimed to compare the impact of AR and NAR on the oncological outcomes of HCC patients with tumor diameters ≤ 5 cm using the propensity score matching method and research-based evidence.

Method

A systematic literature search was conducted. The main outcomes were disease-free survival (DFS), overall survival (OS), intrahepatic recurrence rate, and extrahepatic metastasis rate. Relative risk (RR) was calculated from forest plots and outcomes using random-effects model (REM).

Result

AR significantly improved DFS at 1, 3. and 5 years after surgery, compared to NAR (RR = 1.09, 95% CI = 1.04–1.15, P = 0.0003; RR = 1.16, 95% CI = 1.07–1.27, P = 0.0005; RR = 1.29, 95% CI = 1.07–1.55, P = 0.008). However, both of the difference in DFS at 7 years and OS at 1 and 3 years after AR versus that after NAR were not statistically significant. Nevertheless, the long-term OS associated with AR (5, 7, and 10 years) was superior to that associated with NAR (RR = 1.12, 95% CI = 1.03–1.21, P = 0.01; RR = 1.19, 95% CI = 1.04–1.36, P = 0.01; RR = 1.18, 95% CI = 1.05–1.34, P = 0.008). The difference in the intrahepatic recurrence rate after AR versus that after NAR was not statistically significant, but the extrahepatic metastasis rate after AR was significantly lower than that observed after NAR (RR = 0.61, 95% CI = 0.40–0.94, P = 0.03).

Conclusion

Therefore, AR should be the preferred surgical approach for HCC patients with tumor diameters ≤ 5 cm.

Trial registration

PROSPERO registration number CRD42022330596.

Role of preoperative prediction of microvascular invasion in hepatocellular carcinoma based on the texture of FDG PET image: A comparison of quantitative metabolic parameters and MRI

Objective: To investigate the role of prediction microvascular invasion (mVI) in hepatocellular carcinoma (HCC) by ¹⁸F-FDG PET image texture analysis and hybrid criteria combining PET/CT and multi-parameter MRI.

Materials and methods: Ninety-seven patients with HCC who received the examinations of MRI and ¹⁸F-FDG PET/CT were retrospectively included in this study and were randomized into training and testing cohorts. The lesion image texture features of ¹⁸F-FDG PET were extracted using MaZda software. The optimal predictive texture features of mVI were selected, and the classification procedure was conducted. The predictive performance of mVI by radiomics classier in training and testing cohorts was respectively recorded. Next, the hybrid model was developed by integrating the ¹⁸F-FDG PET image texture, metabolic parameters, and MRI parameters to predict mVI through logistic regression. Furthermore, the diagnostic performance of each time was recorded.

Results: The ¹⁸F-FDG PET image radiomics classier showed good predicted performance in both training and testing cohorts to discriminate HCC with/without mVI, with an AUC of 0.917 (95% CI: 0.824–0.970) and 0.771 (95% CI: 0.578, 0.905). The hybrid model, which combines radiomics classier, SUVmax, ADC, hypovascular arterial phase enhancement pattern on contrast-enhanced MRI, and non-smooth tumor margin, also yielded better predictive performance with an AUC of 0.996 (95% CI: 0.939, 1.000) and 0.953 (95% CI: 0.883, 1.000). The differences in AUCs between radiomics classier and hybrid classier were significant in both training and testing cohorts (DeLong test, both p < 0.05).

Conclusion: The radiomics classier based on ¹⁸F-FDG PET image texture and the hybrid classier incorporating ¹⁸F-FDG PET/CT and MRI yielded good predictive performance, which might provide a precise prediction of HCC mVI preoperatively.

18F-FDG PET/CT radiomic analysis for classifying and predicting microvascular invasion in hepatocellular carcinoma and intrahepatic cholangiocarcinoma

Background

Microvascular invasion (MVI) is a critical risk factor for early recurrence of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). The aim of this study was to explore the contribution of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) radiomic features for the preoperative prediction of HCC and ICC classification and MVI.

Methods

In this retrospective study, 127 (HCC: ICC =76:51) patients with suspected MVI accompanied by either HCC or ICC were included (In HCC group, MVI positive: negative =46:30 in ICC group, MVI positive: negative =31:20). Results-driven feature engineering workflow was used to select the most predictive feature combinations. The prediction model was based on supervised machine learning classifier. Ten-fold cross validation on training cohort and independent test cohort were constructed to ensure stability and generalization ability of models.

Results

For HCC and ICC classification, radiomics predictors composed of two PET and one CT feature achieved area under the curve (AUC) of 0.86 (accuracy, sensitivity, specificity was 0.82, 0.78, 0.88, respectively) on test cohort. For MVI prediction, in HCC group, our MVI prediction model achieved AUC of 0.88 (accuracy, sensitivity, specificity was 0.78, 0.88, 0.60 respectively) with three PET features associated with tumor stage on test cohort. In ICC group, the phenotype composed of two PET features and carbohydrate antigen 19-9 (CA19-9) achieved AUC of 0.90 (accuracy, sensitivity, specificity was 0.77, 0.75, 0.80, respectively).

Conclusions

¹⁸F-FDG PET/CT radiomic features integrating clinical factors have potential in HCC and ICC classification and MVI prediction, while PET features have dominant predictive power in model performance. The prediction model has value in providing a non-invasive biomarker for an earlier indication and comprehensive quantification of primary liver cancers.

Complete response to local therapy for advanced hepatocellular carcinoma with lung metastasis: a case report

The concept of oligometastasis is widely accepted for various types of solid tumors; accordingly, better outcomes can be anticipated with aggressive local interventions. The treatment of advanced hepatocellular carcinoma (HCC) with extrahepatic metastasis is systemic therapy. However, treatment responses to systemic therapy are poor. Recently, a small number of metastatic cancers (oligometastasis) have been controlled by local therapy rather than systemic therapy. Our study reports a case of a 66-year-old male patient with advanced HCC with lung metastasis, which was treated with local therapy. There were less than four metastases in the lungs, which were treated with wedge resection, radiofrequency, and radiation therapy. He repeatedly underwent local therapy for lung oligometastasis and locoregional therapy for intrahepatic HCC rather than systemic therapy; control by local therapy was possible as his liver function was preserved with Child-Turcotte-Pugh class A.

CK19 Predicts Recurrence and Prognosis of HBV Positive HCC

BACKGROUND

Cytokeratin is associated with the recurrence and metastasis of some cancers and tends to increase the malignancy of the disease. It is getting more and more attention in cancer research. Abnormal expression of cytokeratin 19 (CK19) has been reported as an important prognostic factor in cancers. CK19 is a marker of bile duct cells, liver progenitor cells (HPCs), and early hepatoblasts, and its expression is associated with poor prognosis in patients diagnosed with hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the predictive value of CK19 for tumor recurrence after radical resection in patients with hepatitis B virus (HBV) positive HCC.

METHODS

This study was a retrospective study conducted in two institutions. A total of 674 patients with HBV positive HCC who underwent radical HCC resection from January 2010 to May 2020 were included in this study. Chi-square test or Fisher's exact test was used to compare the classification variables and continuous variables were compared by t-test or Wilcoxon rank sum test. Cox regression model was used for univariate and multi-variable survival analyses. Based on the results of the multi-variable analyses of Cox regression, the nomogram of 2-year recurrence-free survival (RFS) was plotted. The model was validated internally in the Hangzhou cohort (training set) and then externally in the Lanzhou cohort (test set) and the effectiveness of the model was tested.

RESULTS

For all 674 patients, 223 cases (33.1%) were positive and 451 cases (66.9%) were negative for CK19. The 2-year RFS rate was higher in patients with CK19 negative than in patients with CK19 positive. In the training set, correlation analysis showed that CK19 expression was correlated with preoperative potassium (P value(P) = 0.030), satellite nodules (P < 0.001) and microvascular invasion (P = 0.020). In the test set, CK19 expression was correlated with postoperative platelet (P = 0.038), satellite nodules (P = 0.003), microvascular invasion (P = 0.011), and maximum tumor size (P = 0.039). Univariate Cox regression correlation analyses showed that CK19 expression was correlated with preoperative potassium (P value(P) = 0.030), satellite nodules (P < 0.001), and microvascular invasion (P = 0.020). Training and test sets showed that postoperative platelet (> 300/L), CK19, satellite nodules in the training set, microvascular invasion, maximum tumor size, and tumor boundary were adverse factors for predicting RFS. Multi-variable analyses showed that in the training set, postoperative platelet > 300/L (hazard ratios (HR) = 2.753, 95% confidence interval (95%CI):1.234-6.142, P = 0.013), CK19 (HR = 1.410, 95%CI:1.006-1.976, P = 0.046), satellite nodule (HR = 1.476, 95%CI:1.026-2.120, P = 0.036), microvascular invasion (HR = 2.927, 95%CI:2.006-4.146, P < 0.001), incomplete tumor capsule (HR = 1.539, 95%CI:1.012-2.341, P = 0.044) were independent prognostic indicator of poor RFS. In the test set, postoperative platelet > 300/L (HR = 2.816, 95%CI:1.043-7.603, P = 0.041), CK19 (HR = 1.586, 95%CI:1.016-2.475, P = 0.042), satellite nodule (HR = 1.706, 95%CI:1.067-2.728, P = 0.026), microvascular invasion (HR = 1.611, 95%CI:1.034-2.510, P = 0.035), and tumor without capsule (HR = 1.870, 95%CI:1.120-3.120, P = 0.017) were independent prognostic indicators of poor RFS. The C-index for the nomogram was 0.698 (95%CI: 0.654-0.742) and the C-index for the test set was 0.670 (95%CI: 0.616-0.724). Both internal and external verification showed good results in identification and calibration.

CONCLUSION

CK19 plays a key role in tumor malignancy through overexpression and the expression of CK19 is an independent adverse factor affecting recurrence; therefore, CK19 can be used as a potential biomarker to predict adverse prognosis after surgery and adjuvant therapy in HCC patients.

The value of preoperative 18F-FDG PET metabolic and volumetric parameters in predicting microvascular invasion and postoperative recurrence of hepatocellular carcinoma

BACKGROUND

Microvascular invasion (MVI) is very important in the evaluation of hepatocellular carcinoma (HCC), but diagnosis is determined by postoperative pathology; thus, preoperative noninvasive methods will play an active role. The purpose of the study was to assess the performance of metabolic parameters of preoperative 18F-fluorodeoxyglucose PET/computerized tomography (18F-FDG PET/CT) in the prediction of MVI and postoperative recurrence in primary hepatocellular carcinoma.

METHODS

We retrospectively collected 72 patients with HCC who have performed 18F-FDG PET/CT scan before partial hepatectomy between 2016 and 2019. We used both normal liver tissue and inferior vena cava as the reference background and combined with clinicopathological features, 18F-FDG PET/CT metabolic and volumetric indices to predict MVI and postoperative recurrence of primary HCC before surgery.

RESULTS

Twenty-one of the 72 patients recurred, in recurrent cases showed higher maximum standard uptake value (SUVmax), TNR (ratio of tumor SUVmax to mean SUV [SUVmean] of the background tissue), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) than nonrecurrence cases (P < 0.001). All 18F-FDG PET metabolic and volumetric indices for predicting postoperative HCC recurrence were significant on receiver-operating-characteristic (ROC) curve analyses (P < 0.05). TNRIVC, TNRNL, MTVIVC, MTVNL TLGIVC and TLGNL were significant factors for predicting MVI in HCC (P < 0.05). On multivariate analyses, MVI, SUVmax, TNRIVC, TNRNL, MTVIVC, MTVNL, TLGIVC and TLGNL (P < 0.05) are independent risk factors for predicting postoperative HCC recurrence. TNRIVC is the most relevant PET/CT parameter for predicting MVI in HCC, and MTVIVC is the most valuable for predicting postoperative HCC recurrence. Moreover, the PET/CT parameters are more accurate for prognosis with inferior vena cava as a reference background than with normal liver tissue.

CONCLUSION

18F-FDG PET/CT metabolic and volumetric indices are effective predictors, and could noninvasively provide more comprehensive predictive information on MVI and postoperative recurrence of primary HCC before surgery.

Factors associated with liver cancer prognosis after hepatectomy: A retrospective cohort study

This article was to investigate risk factors influencing liver cancer prognosis after hepatectomy.Patients undergoing hepatectomy after being diagnosed with liver cancer in Zhongshan Hospital Affiliated to Xiamen University were collected in the retrospective cohort study between January 2012 and December 2017, and divided into disease progression and non-progression groups based on their prognostic status. Univariate analysis was performed on the patients' baseline and laboratory test data, with multivariate logistic regression further conducted to investigate the independent risk factors for liver cancer progression after hepatectomy.Among the 288 subjects, 159 had adverse outcomes (death or cancer recurrence). Hepatitis B and high levels of aspartate aminotransferase, gamma-glutamyltransferase, alkaline phosphatase (ALP), direct bilirubin, and total bilirubin as well as low level of lymphocyte (LYM) were found to be associated with disease progression in the univariate analysis, and were introduced into the multivariate logistic regression. The results indicated that patients with high ALP level (odds ratio [OR] = 1.004, 95%CI: 1.002-1.007, P = .003) and with a history of hepatitis B (OR = 2.182, 95%CI: 1.165-4.086, P = .015) had a higher risk of liver cancer progression compared with those of lower ALP level and those without hepatitis B respectively, whereas the elevated level of LYM (OR = 0.710, 95%CI: 0.516-0.978, P = .034) had favorable progression.The elevated ALP level and a history of hepatitis B may increase the risk of death or cancer recurrence, whereas high LYM level may decrease poor progression among liver cancer patients after hepatectomy. More importance should be attached to the improvement of the liver function and treatment of hepatitis B to enable a better outcome for the patients.

Circ_0072995 Promotes Proliferation and Invasion via Regulating miR-1253/EIF4A3 Signaling in HCC

Background

Hepatocellular carcinoma (HCC) is a major threat for human health. This work aimed to determine the potential function of circ_0072995 in HCC progression and its molecular mechanism.

Methods

qRT-PCR was conducted to analyze circ_0072995 expression. CCK8 and colony formation assays were utilized to detect cell proliferation. Transwell assay was performed to determine migration and invasion. Interactions among circ_0072995, miR-1253 and EIF4A3 (Eukaryotic Translation Initiation Factor 4A3) were predicted through bioinformatics methods and confirmed via luciferase reporter assay and RNA pulldown assay.

Results

circ_0072995 expression was upregulated in HCC tissues. Circ_0072995 high level was associated with poor prognosis. Circ_0072995 knockdown impaired proliferation, migration, invasion and survival. MiR-1253 was sponged by circ_0072995 and targeted EIF4A3 directly. Circ_0072995 inhibited miR-1253 to upregulate EIF4A3 level.

Conclusion

Circ_0072995 exerted tumorigenic roles to enhance HCC progression through activating EIF4A3 by sponging miR-1253.

Prognostic factors of patients after liver cancer surgery: Based on Surveillance, Epidemiology, and End Results database

This study aimed to investigate the prognostic factors of patients after liver cancer surgery and evaluate the predictive power of nomogram. Liver cancer patients with the history of surgery in the Surveillance, Epidemiology, and End Results database between 2000 and 2016 were preliminary retrieved. Patients were divided into the survival group (n = 2120, survival ≥5 years) and the death group (n = 2615, survival < 5 years). Single-factor and multi-factor Cox regression were used for analyzing the risk factors of death in patients with liver cancer after surgery. Compared with single patients, married status was the protective factor for death in patients undergoing liver cancer surgery (HR = 0.757, 95%CI: 0.685-0.837, P < .001); the risk of death in Afro-Americans (HR = 1.300, 95%CI: 1.166-1.449, P < .001) was higher than that in Caucasians, while the occurrence of death in Asians (HR = 0.821, 95%CI: 0.1754-0.895, P < .0012) was lower; female patients had a lower incidence of death (HR = 0.875, 95%CI: 0.809-0.947, P < .001); grade II (HR = 1.167, 95%CI: 1.080-1.262, P < .001), III (HR = 1.580, 95%CI: 1.433-1.744, P < .001), and IV (HR = 1.419, 95%CI: 1.145-1.758, P = 0.001) were the risk factors for death in patients with liver cancer. The prognostic factors of liver cancer patients after surgery include the marital status, race, gender, age, grade of cancer and tumor size. The nomogram with good predictive ability can provide the prediction of 5-year survival for clinical development.

Simple parameters predicting extrahepatic recurrence after curative hepatectomy for hepatocellular carcinoma

Extrahepatic recurrence (EHR) after curative hepatectomy for hepatocellular carcinoma (HCC) is associated with a poor prognosis. We investigated the features of EHR and identified its predictive factors. This retrospective study included 398 treatment-naive patients who underwent curative hepatectomy for HCC at two tertiary hospitals. Multivariate Cox-regression analysis was performed to identify the variables associated with EHR. EHR was diagnosed in 94 patients (23.6%) over a median follow-up period of 5.92 years, most commonly in the lungs (42.6%). The 5-/10-year cumulative rates of HCC recurrence and EHR were 63.0%/75.6% and 18.1%/35.0%, respectively. The median time to EHR was 2.06 years. Intrahepatic HCC recurrence was not observed in 38.3% of patients on EHR diagnosis. On multivariate analysis, pathologic modified Union for International Cancer Control stage (III, IVa), surgical margin involvement, tumor necrosis, sum of tumor size > 7 cm, and macrovascular invasion were predictive factors of EHR. Four risk levels and their respective EHR rates were defined as follows: very low risk, 1-/5-year, 3.1%/11.6%; low risk, 1-/5-year, 12.0%/27.7%; intermediate risk, 1-/5-year, 36.3%/60.9%; and high risk, 1-year, 100.0%. Our predictive model clarifies the clinical course of EHR and could improve the follow-up strategy to improve outcomes.

Multi-Institutional Development and External Validation of a Nomogram for Prediction of Extrahepatic Recurrence After Curative-Intent Resection for Hepatocellular Carcinoma

BACKGROUNDS

Extrahepatic recurrence of hepatocellular carcinoma (HCC) after surgical resection is associated with unfavorable prognosis. The objectives of the current study were to identify the risk factors and develop a nomogram for the prediction of extrahepatic recurrence after initial curative surgery.

METHODS

A total of 635 patients who underwent curative-intent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. The clinicopathological characteristics, risk factors, and long-term survival of patients with extrahepatic recurrence were analyzed. A nomogram for the prediction of extrahepatic recurrence was established and validated in 144 patients from an external cohort.

RESULTS

Among the 635 patients in the derivative cohort, 283 (44.6%) experienced recurrence. Among patients who recurred, 80 (28.3%) patients had extrahepatic ± intrahepatic recurrence, whereas 203 (71.7%) had intrahepatic recurrence only. Extrahepatic recurrence was associated with more advanced initial tumor characteristics, early recurrence, and worse prognosis versus non-extrahepatic recurrence. A nomogram for the prediction of extrahepatic recurrence was developed using the β-coefficients from the identified risk factors, including neutrophil-to-lymphocyte ratio, multiple lesions, tumor size, and microvascular invasion. The nomogram demonstrated good ability to predict extrahepatic recurrence (c-index: training cohort 0.786; validation cohort: 0.845). The calibration plots demonstrated good agreement between estimated and observed extrahepatic recurrence (p = 0.658).

CONCLUSIONS

An externally validated nomogram was developed with good accuracy to predict extrahepatic recurrence following curative-intent resection of HCC. This nomogram may help identify patients at high risk of extrahepatic recurrence and guide surveillance protocols as well as adjuvant treatments.

Risk factors and clinical outcomes of extrahepatic recurrence in patients with post-hepatectomy recurrent hepatocellular carcinoma

BACKGROUND

Extrahepatic recurrence remains a major obstacle to an improved prognosis in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy.

METHODS

From January 2001 to December 2014, we screened 1330 consecutive patients who underwent curative hepatectomy for HCC. Patients who experienced recurrence were enrolled in this study and divided into an extrahepatic recurrence (EHR) group and a pure intrahepatic recurrence (IHR) group. Clinical data and follow-up results were retrospectively collected and analysed.

RESULTS

A total of 556 patients were enrolled (EHR, 52; IHR, 504). In the EHR group, the lung was the most common site of extrahepatic recurrence (53.8%), among which 67.3% had associated intrahepatic lesions. Background Hepatitis B (HR 0.282; 95% CI 0.106-0.752; P = 0.011), tumour size ≥10 cm at initial diagnosis (HR 2.679; 95% CI 1.283-5.596; P = 0.009) and blood transfusion during initial surgery (HR 2.218; 95% CI 1.132-4.346; P = 0.020) were predictive of EHR. A multidisciplinary team treated recurrent HCC. After a median follow-up period of 46 months (range, 24-192 months), the 1-, 3- and 5-year overall survival rates in the EHR group were 60.7%, 8.9% and 0%, respectively, after recurrence, and 78.8%, 30.2% and 8.9%, respectively, after initial surgery, which were much lower than those in the IHR group.

CONCLUSION

Tumour size ≥10 cm and blood transfusion during initial surgery were predictive of extrahepatic recurrence in patients with post-hepatectomy recurrent HCC. Treatment options were limited, and long-term survival was unsatisfactory.

Prognostic Significance of Platelet-to-Lymphocyte Ratio (PLR) in Extrahepatic Metastasis of Hepatocellular Carcinoma After Curative Resection

Background

The prognosis for patients diagnosed of hepatocellular carcinoma (HCC) who have extrahepatic metastasis after liver resection is unsatisfactory. This study aimed to find out the relationship between the inflammation-related indexes and metastasis.

Methods

One thousand three hundred and sixty-six patients diagnosed of HCC who underwent curative resection were included in this study and divided into metastasis group (n=180) and non-metastasis group (n=1186). A receiver operating characteristic (ROC) curve was constructed to estimate the optimal cut-off value for inflammation-related indexes. Independent risk factors were identified by Cox regression analysis. The metastasis rate was analyzed by the Kaplan-Meier method, then the subgroup analyses were taken.

Results

The cut-off values of NLR, PLR, LMR, NγLR, PNLR, and PNI were 2.65, 107.67, 5.47, 134.52, 335.03, and 51.23, respectively. Multivariate Cox analysis revealed that elevated serum AFP level (P=0.004), tumor size more than 5cm (P<0.001), multiple tumors (P=0.040), and higher PLR (P=0.042) were independent risk factors associated with extrahepatic metastasis. The Kaplan-Meier method showed that the high PLR group has a higher extrahepatic metastasis rate than the low PLR group. Meanwhile, the results of subgroup analyses were consistent with the conclusion.

Conclusion

The PLR is an independent risk factor of extrahepatic metastasis after radical hepatectomy for HCC patients. The high PLR indicates a higher rate of extrahepatic metastasis.

Prognostic Nomograms for Patients with Hepatocellular Carcinoma After Curative Hepatectomy, with a Focus on Recurrence Timing and Post-Recurrence Management

Background

Prognoses of patients with hepatocellular carcinoma (HCC) after curative hepatectomy remain unsatisfactory because of the high incidence of postoperative recurrence. Published predictive systems focus on pre-resection oncological characteristics, ignoring post-recurrence factors.

Purpose

This study aimed to develop prognostic nomograms for 3- and 5-year overall survival (OS) of patients with HCC after curative hepatectomy, focusing on potentially influential post-recurrence factors.

Patients and Methods

Clinicopathological and postoperative follow-up data were extracted from 494 patients with HCC who underwent curative hepatectomy between January 2012 and June 2019. Early recurrence (ER) and late recurrence (LR) were defined as recurrence at ≤2 and >2 years, respectively, after curative hepatectomy. Nomograms for the prediction of 3- and 5-year OS were established based on multivariate analysis. The areas under time-dependent receiver operating characteristic curves (AUCs) for the nomograms were calculated independently to verify predictive accuracy. The nomograms were internally validated based on 2000 bootstrap resampling of 75% of the original data.

Results

In total, 494 patients with HCC who underwent curative hepatectomy met the eligibility criteria. Cox proportional hazard regression analysis identified factors potentially influencing 3- and 5-year OS. Multivariate analysis indicated that patient age, Hong Kong Liver Cancer stage, γ-glutamyl transferase (γ-GGT) level, METAVIR inflammation activity grade, ER and post-recurrence treatment modality were influencing factors for 3-year OS (AUC, 0.891; 95% CI, 0.8364-0.9447). γ-GGT > 60 U/L, hepatectomy extent, LR and post-recurrence treatment modality were influencing factors for 5-year OS (AUC, 0.864; 95% CI, 0.8041-0.9237). Calibration plots showed satisfactory concordance between the predicted and actual observation cohorts.

Conclusion

We propose new prognostic nomograms for OS prediction with a focus on the differentiation of recurrence timing and post-recurrence management. These nomograms overcome the shortcomings of previous predictive nomograms and significantly improve predictive accuracy.

Circular RNA MYLK Promotes Hepatocellular Carcinoma Progression Through the miR29a/KMT5C Signaling Pathway

Purpose

This study aimed to investigate the functions of the circular RNA circMYLK (hsa_circ_0002768) in the development of hepatocellular carcinoma (HCC) and to identify the underlying mechanisms of the circMYLK/miR29a/KMT5C axis.

Materials and Methods

Quantitative real-time polymerase chain reaction (qRT-PCR) was utilized to explore the expressions of circMYLK, miR-29a and KMT5C in HCC tissues and cells. A potential miRNA (miR-29a) regulated by circMYLK was also explored, and the target relationship between miR-29a and KMT5C was confirmed. FISH, qRT-PCR, Western blotting, and dual-luciferase reporter assays were used to examine the circMYLK/miR29a/KMT5C signaling pathways involved in HCC development. Additionally, HCC cells were implanted into nude mice subcutaneously to test the role of circMYLK in tumor growth.

Results

circMYLK was determined to be significantly upregulated in HCC tissues and cells. Suppression of circMYLK repressed HCC cell proliferation, migration, and invasion while increasing apoptosis. In addition, FISH, qRT-PCR, and Western blotting, as well as dual-luciferase reporter assays, revealed that circMYLK could bind to miR-29a. In rescue experiments, miR-29a had the potential to eliminate the inhibitory effect of circMYLK knockdown in HCC. Moreover, miR-29a was found to target the KMT5C gene, which was positively regulated by circMYLK. Finally, a nude mouse tumorigenicity assay showed that injection of circMYLK siRNA into nude mice drastically suppressed xenograft tumor formation in vivo.

Conclusion

Our current study demonstrated that circMYLK promotes HCC progression by acting as a competing endogenous RNA of miR-29a, which regulates the downstream oncogene KMT5C.

Postoperative circulating tumor cells: An early predictor of extrahepatic metastases in patients with hepatocellular carcinoma undergoing curative surgical resection

BACKGROUND

Postoperative extrahepatic metastases (EHM) contribute to a grim outcome in patients with hepatocellular carcinoma (HCC) who are undergoing curative surgical resection. The current study investigated the clinical value of circulating tumor cells (CTCs) in predicting EHM after curative surgery.

METHODS

A total of 197 patients with HCC who were undergoing curative surgical resection were assigned to a retrospective training cohort (144 patients) or a prospective validation cohort (53 patients). The CELLSEARCH system was used for the detection of CTCs prior to surgical resection and 1 month thereafter. The cutoff value of CTCs was estimated using receiver operating characteristic analysis. Bonferroni correction was applied for multiple testing in a Cox proportional hazards regression model.

RESULTS

In the training cohort, EHM was found to be associated with a higher postoperative CTC burden compared with no EHM (mean: 4.33 vs 0.52; P < .001). Receiver operating characteristic analysis demonstrated a postoperative CTC count ≥3 as the optimal cutoff value for the prediction of EHM. Patients with a postoperative CTC count ≥3 experienced a higher EHM risk (56.3% vs 5.5%) and a shorter median overall survival (31.25 months vs not reached) (all P < .001). The prognostic significance of a postoperative CTC count ≥3 also applied to patient subgroups with a low EHM risk, such as those with an α-fetoprotein level ≤400 ng/mL, absence of vascular invasion, well differentiation, and early tumor stage, and its predictive value was retained in patients with a continuous normal α-fetoprotein level during postoperative follow-up (all P < .05). The results were confirmed in the validation cohort.

CONCLUSIONS

A postoperative CTC count ≥3 appears to be a surrogate marker for the prediction of EHM after curative surgical resection of HCC. More careful surveillance should be recommended to patients with a high CTC load to ensure the greater possibility of early interventions for postoperative EHM.

Collagen 1A1 (COL1A1) Is a Reliable Biomarker and Putative Therapeutic Target for Hepatocellular Carcinogenesis and Metastasis

Increasing evidence shows that hepatocellular carcinoma (HCC) is a principal cause of cancer-related mortality globally, especially among Asian and African populations. Collagen type I α1 (COL1A1) is the major component of type I collagen. While aberrant expression of COL1A1 and COL1A2 is implicated in numerous cancers, the differential role of COL1A1 in malignant, premalignant and normal tissues remains unclear, and its clinical significance in HCC has not been elucidated. In this study, using bioinformatics analysis of publicly-available HCC microarray data from Gene Expression Omnibus (GEO) and RNAseq data from The Cancer Genome Atlas (TCGA) database, we determined that COL1A1 is significantly upregulated in HCC tumor tissues in comparison to normal tissues. Our analysis also revealed that COL1A1 confers survival advantage and enhanced oncogenicity on HCC cells. Interestingly, the siRNA-mediated silencing of COL1A1 expression (siCOLIA1) suppressed HCC cells clonogenicity, motility, invasiveness and tumorsphere formation. Concomitantly, siCOL1A1 abrogated Slug-dependent epithelial-to-mesenchymal transition (EMT) and HCC stemness gene-signature, by attenuating expression of stemness markers SOX2, OCT4 and CD133. The present study provides some mechanistic insight into COL1A1 activity in HCC and highlights its putative role as an important diagnostic biomarker and potential therapeutic target in early development and metastasis of HCC.

Long-Term Survival and Prognostic Factors of Pulmonary Metastasectomy in Liver Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Lung is the most common extrahepatic metastatic organ of liver cancer. Surgical resection is a common local treatment for pulmonary metastasis. But the long-term prognosis of pulmonary metastasectomy varies greatly due to the small sample size and different results of previous studies. Therefore, we conducted this meta-analysis to evaluate the combined 5-year overall survival (OS) rate and prognostic factors after pulmonary metastasectomy in liver cancer.

METHODS

Key words such as liver cancer pulmonary metastasis and metastasectomy were retrieved firstly in PubMed, Cochrane Library, Embase and Chinese Wanfang databases. Eligible studies were identified by manual searches. Each included study should report 5-year OS rate and/or prognostic factors of pulmonary metastasectomy. Newcastle-Ottawa Scale was used for quality assessment, and heterogeneity was estimated by I². We calculated the combined 5-year survival rates and determined the prognostic factors for OS by the hazard ratios (HR) and number of events.

RESULTS

Seventeen cohort studies with a total of 513 patients were included in this meta-analysis. The combined 5-year survival rates after pulmonary metastasectomy were 33% [95% confidence interval (95% CI) 29-37%]. The poor prognostic factors were disease-free interval (DFI) < 12 months (HR = 2.421 95% CI 1.384 4.236) and existence of cirrhosis (HR = 1.936 95% CI 1.031 3.636).

CONCLUSION

The 5-year OS rate of patients with pulmonary metastasectomy after resection of primary liver cancer is 33%. DFI < 12 months and existence of cirrhosis are probably poor prognostic factors.

miR‑29a suppresses the growth and metastasis of hepatocellular carcinoma through IFITM3

The interferon-induced transmembrane protein 3 (IFITM3, also called 1-8U) gene represents dysregulated expression in various tumors and is involved in tumorigenesis and progression. However, the role of IFITM3 and its underlying mechanism in hepatocellular carcinoma (HCC) are still far from elucidated. MicroRNAs (miRNAs), a class of endogenous (approximately 22 nucleotides) small noncoding RNAs, can post-transcriptionally regulate gene expression by repressing protein translation or silencing the expression of target genes that play critical roles in various cancers. miR-29a was identified as being aberrantly expressed in a significant proportion of HCC. However, the correlation between IFITM3 and miR-29a has not been reported to date. In this study, we investigated the expression of IFITM3 in HCC and its effect on the biological behavior of HCC cells as well as the association between IFITM3 and miR-29a. We determined that IFITM3 was upregulated and miR-29a downregulated in HCC tissues and that they were associated with HCC tumor size, tumor multifocal, and venous invasion. The expression of IFITM3 in HCC tissues was negatively correlated with miR-29a expression. Additionally, IFITM3 overexpression and miR-29a nonoverexpression were related to poor prognosis of HCC patients. Knockdown of IFITM3 inhibited migration, invasion, proliferation and promoted apoptosis of HCC cells, which are consistent with the effects of upregulated miR-29a. Additionally, after upregulation of IFITM3, the invasion, migration and proliferation abilities of HL-7702 cells were increased, but the apoptosis rate was decreased. Furthermore, using a Dual-Luciferase reporter gene assay, we identified IFITM3 as a new functional target gene of miR-29a. In conclusion, our findings demonstrated that the migration, invasion, proliferation and apoptosis features of HCC cells could be regulated by miR-29a via IFITM3. Thus, the present study indicated that miR-29a and IFITM3 play critical roles in the development and progression of HCC, revealing that miR-29a and IFITM3 may be novel potential therapeutic targets for patients with HCC.

Proposal of a New Preoperative Prognostic Model for Solitary Hepatocellular Carcinoma Incorporating 18F-FDG-PET Imaging with the ALBI Grade

BACKGROUND

Existing prognostic systems were not developed using only objective variables available preoperatively, and therefore do not provide ideal prognostication for patients undergoing hepatectomy for hepatocellular carcinoma (HCC). We aimed to develop a preoperative prognostic model using objective variables involving two parameters: ¹⁸F-fluorodeoxyglucose-positron emission tomography (¹⁸F-FDG-PET) and the albumin-bilirubin (ALBI) grade.

METHODS

This study included 207 consecutive patients with solitary HCC who underwent ¹⁸F-FDG-PET prior to hepatectomy. The tumor to non-tumor maximum standardized uptake value ratio (TNR) was used as an ¹⁸F-FDG PET imaging parameter.

RESULTS

The 5-year overall survival (OS) and disease-free survival (DFS) rates were 58.6% and 28.8%, respectively. Multivariate analysis of OS identified TNR ≥ 2 (hazard ratio [HR] 1.743, 95% confidence interval [CI] 1.114-2.648, p = 0.016) and ALBI grade 2 (HR 1.966, 95% CI 1.349-2.884, p < 0.001) as the only significant prognostic factors; tumor diameter and tumor markers were not significant. Patients were divided into low- (TNR < 2 and ALBI grade 1), intermediate- (TNR < 2 and ALBI grade 2, or TNR ≥ 2 and ALBI grade 1), and high-risk (TNR ≥ 2 and ALBI grade 2) groups, which differed significantly in terms of survival (5-year OS: 75.7, 49.6, and 27.3%, respectively, p < 0.001; 5-year DFS: 37.0, 24.9, and 13.6%, respectively, p < 0.001). Compared with other staging systems, our model had the best discriminatory ability (corrected Akaike information criteria 1054.8, p < 0.001) and homogeneity (likelihood ratio Chi square value 27.6, p < 0.001).

CONCLUSION

A preoperative prognostic model incorporating ¹⁸F-FDG-PET imaging with the ALBI grade may be useful for estimating the prognosis of selected patients with solitary HCC.

Extrahepatic metastasis of hepatocellular carcinoma arising from a hepatic adenoma without concurrent intrahepatic recurrence

Hepatocellular carcinoma (hcc) arising from a hepatic adenoma is a rare phenomenon accounting for fewer than 5% of hcc cases; it seldom recurs after resection of the primary tumour. We report a case of extrahepatic metastasis of hcc arising from a hepatic adenoma that presented as a solitary sternal metastasis without any evidence of intrahepatic recurrence. Our patient was initially treated with radiation therapy and bland embolization, without response. Subsequently, the patient developed progressive disease while taking sorafenib. He later received chemotherapy with docetaxel and gemcitabine, with the development of multiple pulmonary and splenic nodules. However, he remained free of intrahepatic recurrence. To the best of our knowledge, this is the first case of extrahepatic metastasis of hcc arising from a hepatic adenoma without evidence of intrahepatic recurrence.

Hepatocellular Carcinoma Extrahepatic Metastasis in Relation to Tumor Size and Alkaline Phosphatase Levels

BACKGROUND

Hepatocellular carcinoma (HCC) is known to metastasize. However, there are few reports on patients with metastasis at the time of HCC diagnosis.

AIMS

To evaluate the incidence and characteristics of extrahepatic metastasis patients presenting at baseline with noncurable, advanced HCC.

RESULTS

The total HCC cohort was initially dichotomized into 2 subcohorts, with (n = 214) and without (n = 719) extrahepatic metastasis ('metastasis'), and patient baseline characteristics were compared. The main findings for patients with metastasis (22.9% of total cohort) compared with other, nonmetastatic patients were: more advanced tumors, as judged by larger tumor diameters, more tumor multifocality and percent with portal vein thrombosis, higher blood α-fetoprotein and des x03B3;-carboxy prothrombin levels and alkaline phosphatase (ALKP), but not bilirubin levels, and a lower incidence of cirrhosis. There was a strong correlation between increases in tumor size and percent of patients with metastasis. A subset of patients with larger tumors was identified with low blood ALKP levels and better survival. Survival in the total metastasis cohort was lower than in the non-metastasis cohort, as expected, but only in patients with smaller tumors. In patients with larger tumors, survival with or without metastasis was similar and poor.

CONCLUSIONS

There was a lower incidence of cirrhosis in HCC patients with metastasis, and they had larger and more aggressive primary tumors. Patients with smaller, but not larger, tumors and metastasis had worse prognosis than patients without metastasis. A distinct subset of metastatic patients was identified that had better prognosis and low ALKP levels.

Factors affecting the recurrence and survival of hepatocellular carcinoma after hepatectomy: a retrospective study of 601 Chinese patients

OBJECTIVE

Indications for resection of hepatocellular carcinoma (HCC) remain controversial. This study aimed to identify prognostic factors that affect overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatectomy.

METHODS

From 2004 to 2010, 601 patients with HCC who underwent resection were enrolled. Factors stratified into the host, biochemical, surgical treatment and tumor-related features in terms of recurrence and overall survival were analyzed. Prognostic factors were evaluated by univariate and multivariate analyses, with Kaplan-Meier survival analyses and Cox proportional hazard model.

RESULTS

The overall survival rates of 1-, 3- and 5- year were 79, 62, and 54 %, and the corresponding DFS rates were 51, 38 and 31 %, respectively. In a multivariate analysis, Child-Pugh, serum AFP level, ALT level, time for hepatic resection, tumor differentiation, maximum size of tumors, local necrosis, portal vein tumor thrombus, and TNM Stage were correlated significantly with patients' OS. Gender (P = 0.046), cigarette smoking (P = 0.007), serum AFP level (P = 0.001), GGT level (P = 0.002), maximum size of tumors (P = 0.009), liver cirrhosis (P = 0.025), portal vein tumor thrombus (P = 0.022), microvascular tumor thrombus (P = 0.007) and TNM Stage (P = 0.001) were significantly affected DFS.

CONCLUSION

Preoperative AFP level, maximum size of tumors, portal vein tumor thrombus and TNM Stage were revealed as important prognostic factors for OS and DFS through follow-up of a relatively large cohort of Chinese HCC patients.

A long-term follow-up and comprehensive observation of risk and prognosis factors of recurrence and survival after resection of hepatocellular carcinoma

Although HBV, liver function and tumor characteristics were proven as hepatocellular carcinoma (HCC) prognosis-related, no large-scale and long-term follow-up studies have ever given robust evidence about prognosis predictive effect and contribution to different stage of postoperation. In this study, we evaluated the influence of above index on overall survival (OS) and disease-free survival (DFS) and other clinical data in a rather large population and long-term follow-up. Our study consisted of 1,326 HCC patients who underwent radical resection from 1996 to 2010. Epidemiology, clinical and prognosis data were analyzed. Risk factors of OS and DFS were explored. Cumulative survival comparison between groups was performed with log-rank. Multivariate analysis for independent prognostic factors was determined by Cox proportional hazards model. HBsAg status was a universal factor of HCC recurrence, while preoperational albumin (ALB) and portal vein tumor thrombus (PVTT) affected survival during the whole lifetime. Early stage recurrence was associated with capsule intact [OR (95 %) = 1.54,1.12-2.12, p = 0.009], preoperational alpha-fetoprotein (AFP), TNM and BCLC stages were the most important prognosis factors of recurrence in the early 5 years and PVTT affected the rest time. Survival was mainly associated with tumor characteristic and ALB. Short-time survival was affected with age and AFP, while BCLC was related with the long-time survival. We confirmed that during different periods after resection, factors affecting prognosis did not remain unchanged. Liver function and tumor characteristic affected DFS and OS the whole time, especially the early recurrence. However, HBV infection situation was associated with later recurrence. PVTT showed an opposite effect between early and later recurrence.

High level of serum protein DKK1 predicts poor prognosis for patients with hepatocellular carcinoma after hepatectomy

Aim

To evaluate prognostic significance of DKK1 for hepatocelluar carcinoma.

Materials & methods

We enrolled a test cohort consisting of 266 hepatitis virus B-related hepatocelluar carcinoma patients who had undergone hepatectomy and a validation cohort of 95. Associations of DKK1 with overall survival and time to recurrence were determined by Cox proportional hazards regression model.

Results

High levels of preoperative serum DKK1 were associated with poor overall survival and higher recurrence rate and DKK1 was an independent prognostic predictor. Moreover, DKK1 maintained ability to predict recurrence for patients with low recurrence risk. Double positives of DKK1 and AFP indicated the worst overall survival and the highest recurrence rate compared with either used alone. Patients with preoperatively and 1-day postoperatively positive DKK1 had higher recurrence rates than those whose values were both negative. Similar results were found in the validation cohort.

Conclusion

Serum DKK1 could predict prognosis of hepatocelluar carcinoma after hepatectomy.

Skin toxicity predicts efficacy to sorafenib in patients with advanced hepatocellular carcinoma

AIM

To study the relationship between adverse events (AEs), efficacy, and nursing intervention for sorafenib therapy in patients with hepatocellular carcinoma (HCC).

METHODS

We enrolled 37 consecutive patients with advanced HCC who received sorafenib therapy. Relationships among baseline characteristics as well as AE occurrence and tumor response, overall survival (OS), and treatment duration were analyzed. The nursing intervention program consisted of education regarding self-monitoring and AEs management, and telephone follow-up was provided once in 1-2 wk.

RESULTS

A total of 37 patients were enrolled in the study, comprising 30 males (81%) with a median age of 71 years. The disease control rate at 3 mo was 41%, and the median OS and treatment duration were 259 and 108 d, respectively. Nursing intervention was given to 24 patients (65%). Every patient exhibited some kinds of AEs, but no patients experienced G4 AEs. Frequently observed AEs > G2 included anorexia (57%), skin toxicity (57%), and fatigue (54%). Factors significantly associated with longer OS in multivariate analysis demonstrated that age ≤ 70 years, presence of > G2 skin toxicity, and absence of > G2 hypoalbuminemia. The disease control rate in patients with > G2 skin toxicity was 13/20 (65%), which was significantly higher compared with that in patients with no or G1 skin toxicity. Multivariate analysis revealed that nursing intervention and > G2 skin toxicity were independent significant predictors for longer treatment duration.

CONCLUSION

Skin toxicity was associated with favorable outcomes with sorafenib therapy for advanced HCC. Nursing intervention contributed to better adherence, which may improve the efficacy of sorafenib.

Surgical treatment of extrahepatic recurrence of hepatocellular carcinoma

PURPOSE

The purpose of this study was to clarify the clinicopathological features of extrahepatic hepatocellular carcinoma (HCC) recurrence after hepatectomy in order to schedule optimal treatment strategies for better long-term outcomes.

METHODS

A cohort of 206 patients who had undergone curative hepatectomy for HCC was analysed; 133 patients had developed relapse. Among them, 101 patients had intrahepatic recurrence only (IHR), and 32 patients had extrahepatic recurrence (EHR). Clinicopathological and survival data were compared between the two groups.

RESULTS

The overall survival rate after hepatectomy was better in the IHR than in the EHR group (p<0.0001). The recurrence-free interval after hepatectomy was significantly shorter in the EHR than in the IHR group (258 vs. 487 days, p<0.0043). Patients in the EHR group were more likely to have a high PIVKA II, a large tumour, and microscopic portal vein invasion when compared with patients in the IHR group. Microscopic portal vein invasion was the most important independent risk factor for EHR after hepatectomy (p=0.0295). Patients with more than two risk factors for EHR showed poor prognosis in comparison with patients without any risk factors (p<0.001). In the EHR group, patients who underwent repeated resection had significantly better survival than patients receiving only the best supportive care (539 vs. 133 days, p=0.0098). Furthermore, among EHR patients with concomitant IHR, patients with controllable IHR had significantly better survival than those with uncontrollable IHR (524 vs. 147 days, p=0.0131).

CONCLUSIONS

EHR of HCC was associated with early recurrence, and risk factors for the occurrence of EHR included the presence of high PIVKA II, large tumours, and microscopic portal vein invasion. Resection of recurrent tumour and local control of concomitant IHR may improve the prognosis of EHR patients.

Positive lymph node metastasis has a marked impact on the long-term survival of patients with hepatocellular carcinoma with extrahepatic metastasis

Background

The prognosis of hepatocellular carcinoma (HCC) patients with extrahepatic metastasis is extremely poor. However, what is the main risk factor for survival remains unclear for these patients. We aimed to find out the relative frequency, incidence and locations of extrahepatic metastases and the risk factors of long-term survival of the patients.

Methods

132 HCC patients with extrahepatic metastasis diagnosed by ¹⁸F-FDG PET/CT and conventional workup were enrolled into this study. The incidence and locations of extrahepatic metastases were summarized, and the related risk factors of overall survival were analyzed.

Results

The most frequent extrahepatic metastatic sites were lymph nodes in 72 (54.5%), bone in 33 (25.0%) and lung in 28 (21.2%) patients. On univariate analysis, prothrombin time, Child-Pugh grade, portal/hepatic vein invasion and lymph node metastasis were independent risk factors of overall survival. On multivariate analysis, lymph node metastasis was the only independent risk factor of overall survival. The cumulative survival rates at 1- and 3-years after diagnosis of extrahepatic metastasis of HCC were 34.4% and 9.3%, respectively. The median survival time was 7 months (range 1 ∼38 months). The median survival time for patients with or without lymph node metastasis were 5 months (range 1∼38 months) and 12 months (range 1∼30 months), respectively (P = 0.036).

Conclusions

This study showed lymph nodes to be the most frequent site of extrahepatic metastases for primary HCC. Lymph node metastasis was the main risk factor of overall survival in patients with HCC with extrahepatic metastasis.

Clinical characteristics and prognostic factors for advanced hepatocellular carcinoma with extrahepatic metastasis

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. The aim of this study was to evaluate whether there are differences in the clinical characteristics and survival between patients with advanced HCC with extrahepatic metastasis who received and those who did not receive previous treatment. Between April, 1998 and April, 2012, a total of 419 HCC patients with extrahepatic metastasis (81 previously untreated and 338 previously treated) were enrolled in this study. The differences in the clinical characteristics, including metastatic sites, were compared between the two groups. In addition, the prognostic predictors among all the patients and among the 81 previously untreated patients were analyzed. The distribution of the major metastatic sites was similar in the two groups; the most frequent site of extrahepatic metastasis was the lungs, followed by the bones, lymph nodes and adrenal glands. The median survival time (MST) among the 419 patients was 6.8 months. The 1-, 2-, 3- and 5-year survival rates were 31.6, 15.3, 9.5 and 2.3%, respectively. No significant differences in survival were observed between patients who received and those who did not receive previous treatment. The multivariate analysis revealed that the Child-Pugh classification, white blood cell count, neutrophil-lymphocyte ratio (NLR) and primary tumor stage were independent predictors of survival for all the patients and for the 81 previously untreated patients. Differences in the clinical characteristics of patients with advanced HCC with extrahepatic metastasis were identified between patients who received and those who did not receive previous treatment. Furthermore, intrahepatic tumor status, Child-Pugh classification, white blood cell count and NLR were demonstrated to be independent predictors of survival in HCC patients with extrahepatic metastasis.

Clinical utility and limitations of FDG PET in detecting recurrent hepatocellular carcinoma in postoperative patients

BACKGROUND

The clinical usefulness of positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) for the detection of recurrent hepatocellular carcinoma (HCC) is controversial because HCC displays varying FDG avidity. The purposes of this study were to re-evaluate the utility of FDG PET for the detection of recurrent HCC, and to assess its prognostic value in a large series of postoperative patients.

METHODS

We retrospectively reviewed 113 scans in 86 patients undergoing FDG PET after curative surgery for HCC. These scans were performed for suspected recurrence on radiologic imaging (group A: n = 44) because of an elevated tumor marker level with negative prior imaging results (group B: n = 32) or with no suspicion of recurrence (group C: n = 37). FDG PET's accuracy for recurrence detection and its value as a predictor of survival were assessed.

RESULTS

The sensitivity, specificity, and diagnostic accuracy were 53, 100, and 55 % for group A; 34, 100, and 41 % for group B; and 11, 100, and 78 % for group C, respectively. A change in therapy resulted from the scan results in 7, 9, and 8 % in groups A, B, and C, respectively. The combined sensitivities for intra- and extrahepatic recurrence were 30 and 42 %, respectively. Histopathological features at initial surgery did not affect the sensitivity. The overall survival of patients with positive scans was significantly poorer than that of patients with negative scans (P = 0.008).

CONCLUSIONS

The sensitivity of FDG PET for recurrent HCC was low, with little change in treatment resulting. However, it can predict prognosis in postoperative patients.