Microvascular Venous Invasion in Hepatocellular Carcinoma: Why Do Recurrences Occur?

Single-cell RNA sequencing reveals intratumoral heterogeneity and multicellular community in primary hepatocellular carcinoma underlying microvascular invasion

Background

Microvascular invasion (MVI) is associated with an unfavorable prognosis and early recurrence of hepatocellular carcinoma (HCC), which is the crucial pathological hallmark of immunotherapy. While microvascular invasion (MVI) in hepatocellular carcinoma (HCC) currently lacks a detailed single-cell analysis of the tumor microenvironment (TME), it holds significant promise for immunotherapy using immune checkpoint inhibitors (ICI).

Methods

We performed single-cell RNA sequencing (scRNA-seq) on 3 MVI positive (MVIP) and 14 MVI-negative (MVIN) tumor tissues, as well as their paired adjacent non-tumoral tissues.

Results

We identified SPP1+ macrophages and CD4+ proliferative T cells as intertumoral populations critical for the formation of cold tumors and immunosuppressive environments in MVI-positive patients and verified their prognostic value in correlation with MVIP HCC patients. Additionally, we identified SPP1+ dominated interactions between SPP1+ macrophages and the immunosuppressive T population as contributors to MVI destruction and tumorigenesis.

Conclusions

We provide a comprehensive single-cell atlas of HCC patients with MVI, shedding light on the immunosuppressive ecosystem and upregulated signaling associated with MVI. These findings demonstrate that intercellular mechanisms drive MVI and provide a potential immunotherapeutic target for HCC patients with HCC and underlying MVI.

Detecting microvascular invasion in hepatocellular carcinoma using the impeded diffusion fraction technique to sense macromolecular coordinated water

OBJECTIVES

Impeded diffusion fraction (IDF) is a novel and promising diffusion-weighted imaging (DWI) technique that allows for the detection of various diffusion compartments, including macromolecular coordinated water, free diffusion, perfusion, and cellular free water. This study aims to investigate the clinical potential of IDF-DWI in detecting microvascular invasion (MVI) in hepatocellular carcinoma (HCC).

METHODS

66 patients were prospectively included. Metrics derived from IDF-DWI and the apparent diffusion coefficient (ADC) were calculated. Multivariate logistic regression was employed to identify clinical risk factors. Diagnostic performance was evaluated using the area under the receiver operating characteristics curve (AUC-ROC), the area under the precision-recall curve (AUC-PR), and the calibration error (cal-error). Additionally, a power analysis was conducted to determine the required sample size.

RESULTS

The results suggested a significantly higher fraction of impeded diffusion (FID) originating from IDF-DWI in MVI-positive HCCs (p < 0.001). Moreover, the ADC was found to be significantly lower in MVI-positive HCCs (p = 0.019). Independent risk factors of MVI included larger tumor size and elevated alpha-fetoprotein (AFP) levels. The nomogram model incorporating ADC, FID, tumor size, and AFP level yielded the highest diagnostic accuracy for MVI (AUC-PR = 0.804, AUC-ROC = 0.783, cal-error = 0.044), followed by FID (AUC-PR = 0.693, AUC-ROC = 0.760, cal-error = 0.060) and ADC (AUC-PR = 0.570, AUC-ROC = 0.651, cal-error = 0.164).

CONCLUSION

IDF-DWI shows great potential in noninvasively, accurately, and preoperatively detecting MVI in HCC and may offer clinical benefits for prognostic prediction and determination of treatment strategy.

Effect of anatomical liver resection on early postoperative recurrence in patients with hepatocellular carcinoma assessed based on a nomogram: a single-center study in China

Introduction

We aimed to investigate risk factors for early postoperative recurrence in patients with hepatocellular carcinoma (HCC) and determine the effect of surgical methods on early recurrence to facilitate predicting the risk of early postoperative recurrence in such patients and the selection of appropriate treatment methods.

Methods

We retrospectively analyzed clinical data concerning 428 patients with HCC who had undergone radical surgery at Mianyang Central Hospital between January 2015 and August 2022. Relevant routine preoperative auxiliary examinations and regular postoperative telephone or outpatient follow-ups were performed to identify early postoperative recurrence. Risk factors were screened, and predictive models were constructed, including patients' preoperative ancillary tests, intra- and postoperative complications, and pathology tests in relation to early recurrence. The risk of recurrence was estimated for each patient based on a prediction model, and patients were categorized into low- and high-risk recurrence groups. The effect of anatomical liver resection (AR) on early postoperative recurrence in patients with HCC in the two groups was assessed using survival analysis.

Results

In total, 353 study patients were included. Multifactorial logistic regression analysis findings suggested that tumor diameter (≥5/<5 cm, odds ratio [OR] 2.357, 95% confidence interval [CI] 1.368-4.059; P = 0.002), alpha fetoprotein (≥400/<400 ng/L, OR 2.525, 95% CI 1.334-4.780; P = 0.004), tumor number (≥2/<2, OR 2.213, 95% CI 1.147-4.270; P = 0.018), microvascular invasion (positive/negative, OR 3.230, 95% CI 1.880-5.551; P < 0.001), vascular invasion (positive/negative, OR 4.472, 95% CI 1.395-14.332; P = 0.012), and alkaline phosphatase level (>125/≤125 U/L, OR 2.202, 95% CI 1.162-4.173; P = 0.016) were risk factors for early recurrence following radical HCC surgery. Model validation and evaluation showed that the area under the curve was 0.813. Hosmer-Lemeshow test results (X 2 = 1.225, P = 0.996 > 0.05), results from bootstrap self-replicated sampling of 1,000 samples, and decision curve analysis showed that the model also discriminated well, with potentially good clinical utility. Using this model, patients were stratified into low- and high-risk recurrence groups. One-year disease-free survival was compared between the two groups with different surgical approaches. Both groups benefited from AR in terms of prevention of early postoperative recurrence, with AR benefits being more pronounced and intraoperative bleeding less likely in the high-risk recurrence group.

Discussion

With appropriate surgical techniques and with tumors being realistically amenable to R0 resection, AR is a potentially useful surgical procedure for preventing early recurrence after radical surgery in patients with HCC.

Nomogram for Predicting Microvascular Invasion in Hepatocellular Carcinoma Using Gadoxetic Acid-Enhanced MRI and Intravoxel Incoherent Motion Imaging

RATIONALE AND OBJECTIVES

Microvascular invasion (MVI) is an important risk factor in hepatocellular carcinoma (HCC), but it can only be determined through histopathological results. The aim of this study was to develop and validate a nomogram for preoperative prediction MVI in HCC using gadoxetic acid-enhanced magnetic resonance imaging (MRI) and intravoxel incoherent motion imaging (IVIM).

MATERIALS AND METHODS

From July 2017 to September 2022, 148 patients with surgically resected HCC who underwent preoperative gadoxetic acid-enhanced MRI and IVIM were included in this retrospective study. Clinical indicators, imaging features, and diffusion parameters were compared between the MVI-positive and MVI-negative groups using the chi-square test, Mann-Whitney U test, and independent sample t test. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance in predicting MVI. Univariate and multivariate analyses were conducted to identify the significant clinical-radiological variables associated with MVI. Subsequently, a predictive nomogram that integrates clinical-radiological risk factors and diffusion parameters was developed and validated.

RESULTS

Serum alpha-fetoprotein level, tumor size, nonsmooth tumor margin, peritumoral hypo-intensity on hepatobiliary phase (HBP), apparent diffusion coefficient value and D value were statistically significant different between MVI-positive group and MVI-negative group. The results of multivariate analysis identified tumor size (odds ratio [OR], 0.786; 95% confidence interval [CI], 0.675-0.915; P < .01), nonsmooth tumor margin (OR, 2.299; 95% CI, 1.005-5.257; P < .05), peritumoral hypo-intensity on HBP (OR, 2.786; 95% CI, 1.141-6.802; P < .05) and D (OR, 0.293; 95% CI,0.089-0.964; P < .05) was the independent risk factor for the status of MVI. In ROC analysis, the combination of peritumoral hypo-intensity on HBP and D demonstrated the highest area under the curve value (0.902) in prediction MVI status, with sensitivity 92.8% and specificity 87.7%. The nomogram exhibited excellent predictive performance with C-index of 0.936 (95% CI 0.895-0.976) in the patient cohort, and had well-fitted calibration curve.

CONCLUSION

The nomogram incorporating clinical-radiological risk factors and diffusion parameters achieved satisfactory preoperative prediction of the individualized risk of MVI in patients with HCC.

A Grading System of Microvascular Invasion for Patients with Hepatocellular Carcinoma Undergoing Liver Resection with Curative Intent: A Multicenter Study

Background

Microvascular invasion (MVI) is closely correlated with poor clinical outcomes in patients with hepatocellular carcinoma (HCC). A grading system of MVI is needed to assist in the management of HCC patient.

Methods

Multicenter data of HCC patients who underwent liver resection with curative intent was analyzed. This grading system was established by detected number and distance from tumor boundary of MVI. Survival outcomes were compared among patients in each group. This system was verified by time-receiver operating characteristic curve, time-area under the curve, calibration curve, and decision curve analyses. Cox regression analysis was performed to study the associated factors of prognosis. Logistic analysis was used to study the predictive factors of MVI.

Results

All patients were classified into 4 groups: M0: no MVI; M1: 1~5 proximal MVIs (≤1 cm from tumor boundary); M2a: >5 proximal MVIs (≤1 cm from tumor boundary); M2b: ≥1 distal MVIs (>1 cm from tumor boundary). The recurrence-free survival (RFS), overall survival (OS), and early RFS rates among all the individual groups were significantly different. Based on the number of proximal MVI (0~5 vs >5), patients in the M2b group were further divided into two subgroups which also showed different prognosis. Multiple methods showed this grading system to be significantly better than the MVI two-tiered system in prognostic evaluation. Four multivariate models for RFS, OS, early RFS, late RFS, and a predictive model of MVI were then established and were shown to satisfactorily evaluate prognosis and have a great discriminatory power, respectively.

Conclusion

This MVI grading system could precisely evaluate prognosis of HCC patients after liver resection with curative intent and it could be employed in routine pathological reports. The severity of MVI from both adjacent and distant from tumor boundary should be stated. A hypothesis about two occurrence modes of distal MVI was proposed.

An Overview of Traditional Chinese Medicine in the Treatment After Radical Resection of Hepatocellular Carcinoma

According to the Barcelona Clinic Liver Cancer (BCLC) system, radical resection of early stage primary hepatocellular carcinoma (HCC) mainly includes liver transplantation, surgical resection, and radiofrequency ablation (RFA), which yield 5-year survival rates of about 70-79%, 41.3-69.5%, and 40-70%, respectively. The tumor-free 5-year rate for HCC patients undergoing radical resection only reach up to 13.7 months, so the prevention of recurrence after radical resection of HCC is very important for the prognosis of patients. The traditional Chinese medicine (TCM) takes the approach of multitarget and overall-regulation to treat tumors, it can also independently present the "component-target-pathway" related to a particular disease, and its systematic and holistic characteristics can provide a personalized therapy based on symptoms of the patient by treating the patient as a whole. TCM as postoperative adjuvant therapy after radical resection of HCC in Barcelona Clinic liver cancer A or B stages, and the numerous clinical trials confirmed that the efficacy of TCM in the field of HCC has a significant effect, not only improving the prognosis and quality of life but also enhancing patient survival rate. However, with the characteristics of multi-target, multi-component, and multi-pathway, the specific mechanism of Chinese medicine in the treatment of diseases is still unclear. Because of the positive pharmacological activities of TCM in combating anti-tumors, the mechanism studies of TCM have demonstrated beneficial effects on the regulation of immune function, chronic inflammation, the proliferation and metastasis of liver cancer cells, autophagy, and cell signaling pathways related to liver cancer. Therefore, this article reviews the mechanism of traditional Chinese medicine in reducing the recurrence rate of HCC after radical resection.

Roles and Molecular Mechanisms of Biomarkers in Hepatocellular Carcinoma with Microvascular Invasion: A Review

Hepatocellular carcinoma (HCC) being a leading cause of cancer-related death, has high associated mortality and recurrence rates. It has been of great necessity and urgency to find effective HCC diagnosis and treatment measures. Studies have shown that microvascular invasion (MVI) is an independent risk factor for poor prognosis after hepatectomy. The abnormal expression of biomacromolecules such as circ-RNAs, lncRNAs, STIP1, and PD-L1 in HCC patients is strongly correlated with MVI. Deregulation of several markers mentioned in this review affects the proliferation, invasion, metastasis, EMT, and anti-apoptotic processes of HCC cells through multiple complex mechanisms. Therefore, these biomarkers may have an important clinical role and serve as promising interventional targets for HCC. In this review, we provide a comprehensive overview on the functions and regulatory mechanisms of MVI-related biomarkers in HCC.

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Background

Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key Messages

The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

Construction of a ceRNA network to reveal a vascular invasion associated prognostic model in hepatocellular carcinoma

The aim of this study is to explore the prognostic value of vascular invasion (VI) in hepatocellular carcinoma (HCC) by searching for competing endogenous RNAs (ceRNA) network and constructing a new prognostic model for HCC. The differentially expressed genes (DEGs) between HCC and normal tissues were identified from GEO and TCGA. StarBase and miRanda prediction tools were applied to construct a circRNA-miRNA-mRNA network. The DEGs between HCC with and without VI were also identified. Then, the hub genes were screened to build a prognostic risk score model through the method of least absolute shrinkage and selection operator. The prognostic ability of the model was assessed using the Kaplan-Meier method and Cox regression analysis. In result, there were 221 up-regulated and 47 down-regulated differentially expressed circRNAs (DEcircRNAs) in HCC compared with normal tissue. A circRNA-related ceRNA network was established, containing 11 DEcircRNAs, 12 DEmiRNAs, and 161 DEmRNAs. Meanwhile, another DEG analysis revealed 625 up-regulated and 123 down-regulated DEGs between HCC with and without VI, and then a protein-protein interaction (PPI) network was built based on 122 VI-related DEGs. From the intersection of DEGs within the PPI and ceRNA networks, we obtained seven hub genes to build a novel prognostic risk score model. HCC patients with high-risk scores had shorter survival time and presented more advanced T/N/M stages as well as VI occurrence. In conclusion a novel prognostic model based on seven VI-associated DEGs within a circRNA-related ceRNA network was constructed in this study, with great ability to predict the outcome of HCC patients.

Prediction of Microvascular Invasion in Solitary AFP-Negative Hepatocellular Carcinoma ≤ 5 cm Using a Combination of Imaging Features and Quantitative Dual-Layer Spectral-Detector CT Parameters

RATIONALE AND OBJECTIVES

AFP-negative hepatocellular carcinoma (AFPN-HCC) within 5 cm is a special subgroup of HCC. This study aimed to investigate the value of dual-layer spectral-detector CT (DLCT) and construct a scoring model based on imaging features as well as DLCT for predicting microvascular invasion (MVI) in AFPN-HCC within 5 cm.

METHODS

This retrospective study enrolled 104 HCC patients who underwent multiphase contrast-enhanced DLCT studies preoperatively. Combined radiological features (CR) and combined DLCT quantitative parameter (CDLCT) were constructed to predict MVI. Multivariable logistic regression was applied to identify potential predictors of MVI. Based on the coefficient of the regression model, a scoring model was developed. The predictive efficacy was assessed through ROC analysis.

RESULTS

Microvascular invasion (MVI) was found in 28 (26.9%) AFPN-HCC patients. Among single parameters, the effective atomic number in arterial phase demonstrated the best predictive efficiency for MVI with an area under the curve (AUC) of 0.792. CR and CDLCT showed predictive performance with AUCs of 0.848 and 0.849, respectively. A risk score (RS) was calculated using the independent predictors of MVI as follows: RS = 2 × (mosaic architecture) + 2 × (corona enhancement) + 2 × (incomplete tumor capsule) + 2 × (2-trait predictor of venous invasion [TTPVI]) + 3 × (CDLCT > -1.229). Delong's test demonstrated this scoring system could significantly improve the AUC to 0.929 compared with CR (p = 0.016) and CDLCT (p = 0.034).

CONCLUSION

The scoring model combining radiological features with DLCT provides a promising tool for predicting MVI in solitary AFPN-HCC within 5 cm preoperatively.

Comparison of preoperative ultrasound and MRI in the diagnosis of microvascular invasion in hepatocellular carcinoma

Ultrasound has few reports on its application in prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC). The purpose of this study was to explore the diagnostic efficacies of preoperative ultrasound and magnetic resonance imaging (MRI) for HCC MVI and compare these two imaging methods for the diagnosis of this condition. The clinical and preoperative ultrasound and MR imaging data of 26 patients with newly diagnosed HCC were collected between October 2020 and October 2021. According to the gold standard (postoperative pathology), the patients were divided into MVI-positive and MVI-negative groups, and the efficacies of ultrasound and MRI in diagnosing HCC MVI and the consistency between the two imaging modalities were analyzed. For the preoperative diagnosis of MVI using ultrasound, the sensitivity was 93.33%, the specificity was 81.82%, and the accuracy was 88.46%. For preoperative MRI, the sensitivity was 66.67%, the specificity was 100%, and the accuracy was 80.77%. In diagnosing MVI, the two methods had significantly different efficacy (P = 0.031). Ultrasound and MRI have high diagnostic efficiency for MVI, but the accuracy of preoperative MRI was lower than that of preoperative ultrasound. These results indicate that ultrasound has a certain guiding significance in the diagnosis of HCC MVI.

Postoperative adjuvant therapy for hepatocellular carcinoma with microvascular invasion

Hepatocellular carcinoma (HCC) is one of the most lethal tumors in the world. Liver resection (LR) and liver transplantation (LT) are widely considered as radical treatments for early HCC. However, the recurrence rates after curative treatment are still high and overall survival is unsatisfactory. Microvascular invasion (MVI) is considered to be one of the important prognostic factors affecting postoperative recurrence and long-term survival. Unfortunately, whether HCC patients with MVI should receive postoperative adjuvant therapy remains unknown. In this review, we summarize the therapeutic effects of transcatheter arterial chemoembolization, hepatic arterial infusion chemotherapy, tyrosine protein kinase inhibitor-based targeted therapy, and immune checkpoint inhibitors in patients with MVI after LR or LT, aiming to provide a reference for the best adjuvant treatment strategy for HCC patients with MVI after LT or LR.

MVI-Mind: A Novel Deep-Learning Strategy Using Computed Tomography (CT)-Based Radiomics for End-to-End High Efficiency Prediction of Microvascular Invasion in Hepatocellular Carcinoma

Simple Summary

Microvascular invasion is an important indicator for reflecting the prognosis of hepatocellular carcinoma, but the traditional diagnosis requires a postoperative pathological examination. This study is the first to propose an end-to-end deep learning architecture for predicting microvascular invasion in hepatocellular carcinoma by collecting retrospective data. This method can achieve noninvasive, accurate and efficient preoperative prediction only through the patient’s radiomic data, which is very beneficial to doctors for clinical decision making in HCC patients.

Abstract

Microvascular invasion (MVI) in hepatocellular carcinoma (HCC) directly affects a patient’s prognosis. The development of preoperative noninvasive diagnostic methods is significant for guiding optimal treatment plans. In this study, we investigated 138 patients with HCC and presented a novel end-to-end deep learning strategy based on computed tomography (CT) radiomics (MVI-Mind), which integrates data preprocessing, automatic segmentation of lesions and other regions, automatic feature extraction, and MVI prediction. A lightweight transformer and a convolutional neural network (CNN) were proposed for the segmentation and prediction modules, respectively. To demonstrate the superiority of MVI-Mind, we compared the framework’s performance with that of current, mainstream segmentation, and classification models. The test results showed that MVI-Mind returned the best performance in both segmentation and prediction. The mean intersection over union (mIoU) of the segmentation module was 0.9006, and the area under the receiver operating characteristic curve (AUC) of the prediction module reached 0.9223. Additionally, it only took approximately 1 min to output a prediction for each patient, end-to-end using our computing device, which indicated that MVI-Mind could noninvasively, efficiently, and accurately predict the presence of MVI in HCC patients before surgery. This result will be helpful for doctors to make rational clinical decisions.

Methyl Gallate Suppresses the Migration, Invasion, and Epithelial-Mesenchymal Transition of Hepatocellular Carcinoma Cells via the AMPK/NF-κB Signaling Pathway in vitro and in vivo

Methyl gallate (MG), a polyphenolic compound found in plants, is widely used in traditional Chinese medicine. MG is known to alleviate several cancer symptoms. However, most studies that have reported the antitumor effects of MG have done so at the cellular level, and the inhibitory effect and therapeutic mechanism of MG in hepatocellular carcinoma (HCC) have not been extensively explored in vivo. We aimed to understand the therapeutic mechanism of MG in HCC in vitro and in vivo. MTT and colony formation assays were used to determine the impact of MG on the proliferation of a human HCC cell line, BEL-7402; wound healing and transwell assays were used to quantify the migration and invasion of HCC cells. Western blotting was used to quantify the expression of the AMPK/NF-κB signaling pathway proteins. In vivo tumor growth was measured in a xenograft tumor nude mouse model treated with MG, and hematoxylin–eosin staining and immunohistochemistry (IHC) were used to visualize the histological changes in the tumor tissue. We found that MG showed anti-proliferative effects both in vitro and in vivo. MG downregulated the protein expression of AMPK, NF-κB, p-NF-κB, and vimentin and upregulated the expression of E-cadherin in a dose-dependent manner. Additionally, MG inhibited the migration and invasion of HCC cells by decreasing MMP9 and MMP2 expression and increasing TIMP-2 expression. These were consistent with the results of IHC in vivo. MG inhibited the proliferation, migration, and invasion of HCC cells. This effect potentially involves the regulation of the AMPK/NF-κB pathway, which in turn impacts epithelial-mesenchymal transition and MMP expression.

The role of gadoxetic acid-enhanced MRI features for predicting microvascular invasion in patients with hepatocellular carcinoma

OBJECTIVE

To evaluate the predictive value of gadoxetic acid-enhanced MRI features (focused on Liver Imaging Reporting and Data System (LI-RADS) v2018 features and non-LI-RADS imaging features) for microvascular invasion (MVI) of hepatocellular carcinoma (HCC).

METHODS

From October 2018 to December 2020, 134 patients who underwent gadoxetic acid-enhanced MRI with a pathological diagnosis of HCC after hepatectomy were enrolled in this retrospective study. Two radiologists assessed the pre-hepatectomy LI-RADS v2018 imaging features and non-LI-RADS features to identify independent predictors of MVI of HCC with a logistic regression model.

RESULTS

Four MRI features were found to be independent predictors of MVI: corona enhancement [odds ratio (OR) 5.787; 95% confidence interval (CI) 1.180, 28.369; p = 0.030], mosaic architecture (OR 7.097; 95% CI 1.299, 38.783; p = 0.024), nonsmooth tumor margin (OR 13.131; 95% CI 3.950, 43.649; p < 0.001), and peritumoral hypointensity on hepatobiliary phase (HBP) (OR 33.123; 95% CI 2.897, 378.688; p = 0.005). When one of four imaging features was present, the sensitivity was 93.2% (41/44), and the specificity was 71.1% (64/90).

CONCLUSION

The four imaging features including corona enhancement, mosaic architecture, nonsmooth tumor margin, and peritumoral hypointensity on HBP can be used as preoperative imaging biomarkers for predicting MVI in patients at high risk for HCC. When one of the four imaging features is present, MVI can be predicted with a sensitivity > 90%.