Predictors of Macrovascular Invasion and Extrahepatic Metastasis in Treatment Naive Hepatocellular Carcinoma: When Is [18F] FDG PET/CT Relevant?

Changing Etiological Spectrum of Hepatocellular Carcinoma in India-A Systematic Review and Meta-analysis

Background

Recent studies from both India and outside India have shown a change in the etiological profile of hepatocellular carcinoma (HCC). We aimed to analyze the etiological spectrum and changing trends of HCC etiology in India using a systematic review of current literature and meta-analysis.

Methods

Electronic databases of PubMed/Medline, Scopus, and Embase were searched from inception to July 2023 for studies reporting the data on the etiology of HCC from India. The pooled proportions with 95% confidence interval were calculated using summative statistics.

Results

A total of 60 studies (n = 12,327) were included in the final analysis. The pooled proportions of HCC cases with at least one positive and negative viral marker were 56.0 (49.5-62.6) and 43.1% (36.5-49.8), respectively. The pooled proportion of HCC cases with positive hepatitis B virus (HBV) markers was 41.0 (35.8-46.1), while those with positive markers for hepatitis C virus were 20.3 (17.0-23.6). The pooled proportion of cases with HCC with significant alcohol intake was 19.0% (15.6-22.4), and those related to nonalcoholic fatty liver disease (NAFLD) were 16.9% (12.1-21.7). Around 7.9% (5.8-10.0) of the cases had HCC with multiple etiologies. Subgroup analysis showed a significant variation with the location of the study based on zone. Meta-regression analysis based on publication year (1990-2023) showed a significant reduction in the proportion of cases with HBV and an increase in cases with NAFLD. In contrast, the proportion of cases with hepatitis C virus and alcohol did not change significantly.

Conclusion

Viral hepatitis is the most common etiology of HCC in India, predominantly HBV. The proportions of cases with HCC related to NAFLD are increasing, and those related to HBV are declining.

Radiomics and machine learning based on preoperative MRI for predicting extrahepatic metastasis in hepatocellular carcinoma patients treated with transarterial chemoembolization

Purpose

To develop and validate a radiomics machine learning (Rad-ML) model based on preoperative MRI to predict extrahepatic metastasis (EHM) in hepatocellular carcinoma (HCC) patients receiving transarterial chemoembolization (TACE) treatment.

Methods

A total of 355 HCC patients who received multiple TACE procedures were split at random into a training set and a test set at a 7:3 ratio. Radiomic features were calculated from tumor and peritumor in arterial phase and portal venous phase, and were identified using intraclass correlation coefficient, maximal relevance and minimum redundancy, and least absolute shrinkage and selection operator techniques. Cox regression analysis was employed to determine the clinical model. The best-performing algorithm among eight machine learning methods was used to construct the Rad-ML model. A nomogram combining clinical and Rad-ML parameters was used to develop a combined model. Model performance was evaluated using C-index, decision curve analysis, calibration plot, and survival analysis.

Results

In clinical model, elevated neutrophil to lymphocyte ratio and alpha-fetoprotein were associated with faster EHM. The XGBoost-based Rad-ML model demonstrated the best predictive performance for EHM. When compared to the clinical model, both the Rad-ML model and the combination model performed better (C-indexes of 0.61, 0.85, and 0.86 in the training set, and 0.62, 0.82, and 0.83 in the test set, respectively). However, the combined model's and the Rad-ML model's prediction performance did not differ significantly. The most influential feature was peritumoral waveletHLL_firstorder_Minimum in AP, which exhibited an inverse relationship with EHM risk.

Conclusions

Our study suggests that the preoperative MRI-based Rad-ML model is a valuable tool to predict EHM in HCC patients treated with TACE.

2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations

Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.