Risk factors for intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

Contrastive Learning for Preoperative Early Recurrence Prediction of Hepatocellular Carcinoma with Liver CT Image and Tumor Mask

High early recurrence (ER) rate is the main factor leading to the poor outcome of patients with hepatocellular carcinoma (HCC). Accurate preoperative prediction of ER is thus highly desired for HCC treatment. Many radiomics solutions have been proposed for the preoperative prediction of HCC using CT images based on machine learning and deep learning methods. Nevertheless, most current radiomics approaches extract features only from segmented tumor regions that neglect the liver tissue information which is useful for HCC prognosis. In this work, we propose a deep prediction network based on CT images of full liver combined with tumor mask that provides tumor location information for better feature extraction to predict the ER of HCC. While, due to the complex imaging characteristics of HCC, the image-based ER prediction methods suffer from limited capability. Therefore, on the one hand, we propose to employ supervised contrastive loss to jointly train the deep prediction model with cross-entropy loss to alleviate the problem of intra-class variation and inter-class similarity of HCC. On the other hand, we incorporate the clinical data to further improve the prediction ability of the model. Experiments are extensively conducted to verify the effectiveness of our proposed deep prediction model and the contribution of liver tissue for prognosis assessment of HCC.

Phase Attention Model for Prediction of Early Recurrence of Hepatocellular Carcinoma With Multi-Phase CT Images and Clinical Data

Hepatocellular carcinoma (HCC) is a primary liver cancer that produces a high mortality rate. It is one of the most common malignancies worldwide, especially in Asia, Africa, and southern Europe. Although surgical resection is an effective treatment, patients with HCC are at risk of recurrence after surgery. Preoperative early recurrence prediction for patients with liver cancer can help physicians develop treatment plans and will enable physicians to guide patients in postoperative follow-up. However, the conventional clinical data based methods ignore the imaging information of patients. Certain studies have used radiomic models for early recurrence prediction in HCC patients with good results, and the medical images of patients have been shown to be effective in predicting the recurrence of HCC. In recent years, deep learning models have demonstrated the potential to outperform the radiomics-based models. In this paper, we propose a prediction model based on deep learning that contains intra-phase attention and inter-phase attention. Intra-phase attention focuses on important information of different channels and space in the same phase, whereas inter-phase attention focuses on important information between different phases. We also propose a fusion model to combine the image features with clinical data. Our experiment results prove that our fusion model has superior performance over the models that use clinical data only or the CT image only. Our model achieved a prediction accuracy of 81.2%, and the area under the curve was 0.869.

Inflammatory indexes in preoperative blood routine to predict early recurrence of hepatocellular carcinoma after curative hepatectomy

Background

The inflammation indexes in blood routine play an essential role in evaluating the prognosis of patients with hepatocellular carcinoma, but the effect on early recurrence has not been clarified. The study aimed to investigate the risk factors of early recurrence (within 2 years) and recurrence-free survival after curative hepatectomy and explore the role of inflammatory indexes in predicting early recurrence.

Methods

The baseline data of 161 patients with hepatocellular carcinoma were analyzed retrospectively. The optimal cut-off value of the inflammatory index was determined according to the Youden index. Its predictive performance was compared by the area under the receiver operating characteristic curve. Logistic and Cox regression analyses were used to determine the risk factors of early recurrence and recurrence-free survival.

Results

The area under the curve of monocyte to lymphocyte ratio (MLR) for predicting early recurrence was 0.700, which was better than systemic inflammatory response index (SIRI), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and systemic immune-inflammatory index (SII). MLR, tumour size, tumour differentiation and BCLC stage are all risk factors for early recurrence and recurrence-free survival of HCC. Combining the above four risk factors to construct a joint index, the area under the curve for predicting early recurrence was 0.829, which was better than single MLR, tumour size, tumour differentiation and BCLC stage. Furthermore, with the increase of risk factors, the recurrence-free survival of patients is worse.

Conclusion

The combination of MLR and clinical risk factors is helpful for clinicians to identify high-risk patients with early recurrence and carry out active postoperative adjuvant therapy to improve the prognosis of patients.

Role of selected criteria and preventive chemotherapy in tumor recurrence after liver transplantation

BACKGROUND

Long-term survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) patients remains poor because of tumor recurrence. To improve the prognosis of HCC patients after LT, we aimed to identify different transplantation criteria and risk factors related to tumor recurrence and evaluate the effect of preventive chemotherapy in a single center.

METHODS

In total, data on 20 variables and the survival of 199 patients with primary HCC who underwent LT between 2005 and 2015 were included for analysis. The patients were divided into the following three groups: Group 1, within the Milan and Hangzhou criteria (n = 51); Group 2, beyond the Milan but within the Hangzhou criteria (n = 36); and Group 3, beyond the Milan and Hangzhou criteria (n = 112). Survival probabilities for the three groups were calculated using multivariate Cox regression analysis. The association between preventive therapy and HCC-recurrence after LT was analyzed by multiple logistic regression analysis.

RESULTS

Child-Pugh stage C and hepatitis B virus (HBV) infection were independent risk factors for patients with tumor recurrence who did not meet the Milan criteria. The overall survival rates of the 199 patients showed statistically significant differences among the three groups (P < 0.001). Moreover, no significant difference was noted in the survival rate between Group 1 and Group 2 (P > 0.05). Multivariate logistic regression analysis showed that postoperative prophylactic chemotherapy reduced the risk of tumor recurrence in patients who did not meet the Hangzhou and Milan criteria (OR = 0.478; 95% CI: 0.308-0.741; P = 0.001).

CONCLUSIONS

Child-Pugh classification and HBV infection were the independent risk factors of tumor recurrence in HCC patients with LT. The Hangzhou criteria were effective and analogous compared with the Milan criteria. Preventive chemotherapy significantly reduced the risk of recurrence and prolonged the survival time for HCC patients beyond the Milan and Hangzhou criteria after LT.

Deep Learning-Based Radiomics Models for Early Recurrence Prediction of Hepatocellular Carcinoma with Multi-phase CT Images and Clinical Data

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world and the second most common cause of cancer-related death. By surgically removing hepatocellular carcinoma, the patients may have the early recurrence within one year. Recently, CT radiomics signatures have been demonstrated to be effective on predicting early recurrence of HCC. However, the radiomics signatures are based on hand-crafted low-level features, such as density and texture. In this paper, we propose a deep learning-based radiomics approach for predicting early recurrence of hepatocellular carcinoma with multi-phase computed tomography (CT) images. We also propose several models to combine the high-level radiomics features with clinical data to improve the prediction accuracy. The area under the curve (AUC) of receiver operating characteristic curve (ROC) is 0.825.

Serum metabolites may be useful markers to assess vascular invasion and identify normal alpha-fetoprotein in hepatocellular carcinoma undergoing liver resection: a pilot study

Purpose

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver with a dismal prognosis. Vascular invasion, among others, is the most robust indicator of postoperative recurrence and overall survival after liver resection for HCC. Few studies to date have attempted to search for effective markers to predict vascular invasion before the operation. The current study would examine the plasma metabolic profiling via ¹H-NMR of HCC patients undergoing liver resection and aim to search for potential biomarkers in the early detection of HCC with normal alpha-fetoprotein (AFP) and the diagnosis of vascular invasion preoperatively.

Materials and methods

HCC patients scheduled to receive liver resections for their HCC were recruited and divided into two separate groups, investigation cohort and validation cohort. Their preoperative blood samples were collected and subjected to a comprehensive metabolomic profiling using ¹H-nuclear magnetic resonance spectroscopy (NMR).

Results

There were 35 HCC patients in the investigation group and 22 patients in the validation group. Chronic hepatitis B remained the most common etiology of HCC, followed by chronic HCV infection. The two study cohorts were essentially comparable in terms of major clinicopathological variables. After ¹H-nuclear NMR analysis, we found in the investigation cohort that HCC with normal alpha-fetoprotein (AFP < 15 ng/mL) had significantly higher serum level of O-acetylcarnitine than those with higher AFP (AFP ≥ 15 ng/mL, P = 0.025). In addition, HCC with microscopic vascular invasion (VI) had significantly higher preoperative serum level of formate than HCC without microscopic VI (P = 0.023). These findings were similar in the validation cohort.

Conclusion

A comprehensive metabolomic profiling of HCC demonstrated that serum metabolites may be utilized to assist the early diagnosis of AFP-negative HCC patients and recognition of microvascular invasion in order to facilitate preoperative surgical planning and postoperative follow-up. Further, larger scale prospective studies are warranted to consolidate our findings.

Long non-coding RNA expression profile can predict early recurrence in hepatocellular carcinoma after curative resection

AIM

The aim of this study was to develop a novel long non-coding RNA (lncRNA) expression signature to accurately predict early recurrence for patients with hepatocellular carcinoma (HCC) after curative resection.

METHODS

Using expression profiles downloaded from The Cancer Genome Atlas database, we identified multiple lncRNAs with differential expression between early recurrence (ER) and non-early recurrence (non-ER) groups of patients with HCC. Least absolute shrinkage and selection operator for logistic regression models were used to develop an lncRNA-based classifier for predicting ER in the training set. An independent test set was used to validate the predictive value of this classifier. Furthermore, a co-expression network based on these lncRNAs and its highly related genes was constructed and Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses of genes in the network were carried out.

RESULTS

We identified 10 differentially expressed lncRNAs, including three that were upregulated and seven that were downregulated in the ER group. The lncRNA-based classifier was constructed based on seven lncRNAs (AL035661.1, PART1, AC011632.1, AC109588.1, AL365361.1, LINC00861, and LINC02084), and its accuracy was 0.83 in the training set, 0.87 in the test set, and 0.84 in the total set. Receiver operating characteristic curve analysis showed the area under the curve was 0.741 in the training set, 0.824 in the test set, and 0.765 in the total set. A functional enrichment analysis suggested that the genes highly related to four lncRNAs are involved in the immune system.

CONCLUSION

The expression profile of seven lncRNAs can effectively predict ER after surgical resection for HCC.

Pattern of disease recurrence and its implications for postoperative surveillance after curative hepatectomy for hepatocellular carcinoma: experience from a single center

Background

Hepatectomy is a widely accepted curative treatment for hepatocellular carcinoma (HCC). However, the disease frequently recurs after a curative hepatectomy. The objective of this study is to provide a better understanding of the pattern of disease recurrence and the risk factors involved so as to improve the postoperative surveillance.

Methods

A retrospective study for all patients receiving hepatectomy for HCC between 2003 and 2014 was performed. Emphasis was made on the timing and pattern of recurrent disease, and type of treatment given.

Results

There were 506 patients in the study. Median follow-up was 43.7 months. The 1-, 3-, 5-, 10-year overall and disease free survival were 89.5%, 74.1%, 63.9%, 49.0% and 69.5%, 54.3%, 43.4%, 30.9% respectively. Recurrent disease occurred in 267 patients, 47.2% occurred within 9 months of hepatectomy and 80.1% recurred only in liver. Median survival was shorter for recurrence occurring within 9 months compared with those occurring between 10 months and 2 years postoperatively (36.2 vs. 65.7 months, P<0.01) whilst less curative treatment was offered for patients with early (within 9 months) intrahepatic alone recurrence (22.2% vs. 51.7%, P<0.01). Multivariate analysis revealed tumor size >3.5 cm and history of rupture were risk factors for recurrence within 9 months.

Conclusions

These findings suggest that recurrent diseases are common after curative hepatectomy for HCC and most recurrences occur in the remnant liver. Since almost half of recurrences occurred within first 9 months after hepatectomy, a more stringent postoperative surveillance with target imaging of liver in this period is needed. Early diagnosis of recurrent disease and curative retreatment hopefully can bring about a longer survival.

Detection of recurrent hepatocellular carcinoma after surgical resection: Non-contrast liver MR imaging with diffusion-weighted imaging versus gadoxetic acid-enhanced MR imaging

OBJECTIVE:

To compare the diagnostic performance of non-contrast liver MRI to whole MRI using gadoxetic acid for detection of recurrent hepatocellular carcinoma (HCC) after hepatectomy.

METHODS:

This retrospective study analyzed 483 patients who underwent surveillance with liver MRI after hepatectomy for HCC (median time interval, 7.7 months). Non-contrast MRI set (T₁- and T₂ weighted and diffusion-weighted images) and whole MRI set (gadoxetic acid-enhanced and non-contrast MRI) were analyzed independently by two observers. Receiver operating characteristic analysis was used (with the observers' individual observations and consensus) to detect recurrent HCC. The accuracy, sensitivity, and specificity were calculated.

RESULTS:

A total of 113 patients had 197 recurrent HCCs on first follow-up MRI. Although non-contrast MRI had fairly high sensitivity for recurrent HCC, there were significant differences in sensitivity (94.7% vs 99.1%, p = 0.025) and accuracy (97.5% vs 99.2%, p = 0.021) between the two image sets (per-patients base analysis). However, in patients followed for ≥1 year after surgery, the diagnostic performance of non-contrast MRI and whole MRI were not significantly different (p > 0.05).

CONCLUSION:

Non-contrast MRI may serve as an alternative follow-up method which can potentially replace whole MRI at least in selected patients followed up ≥1 year after surgery who have relatively lower risk of HCC recurrence.

ADVANCES IN KNOWLEDGE:

There is no consensus regarding the ideal imaging modality or follow-up interval after resection of HCC. Non-contrast MRI had comparable performance to that of gadoxetic acid-enhanced MRI in the detection of HCC recurrence during surveillance ≥1 year after surgery.

Circulating cell-free DNA of methylated insulin-like growth factor-binding protein 7 predicts a poor prognosis in hepatitis B virus-associated hepatocellular carcinoma after hepatectomy

The initiation and progression of hepatocellular carcinoma (HCC) is a multistage process involving a variety of changes at the gene level. Methylation of insulin-like growth factor-binding protein 7 (IGFBP7) plays a crucial role in HCC development. The main purpose of this study was to investigate the relationship between oxidative stress, DNA methyltransferases (DNMTs) expression, and IGFBP7 methylation, and to evaluate the prognostic value of serum IGFBP7 methylation status in patients with HCC after hepatectomy. We enrolled 155 patients with HCC undergoing surgical resection. The IGFBP7 methylation status, DNMTs mRNA levels and malondialdehyde (MDA), xanthine oxidase (XOD), reduced glutathione hormone (GSH), and glutathione-S-transferases (GST) levels were detected. MDA and XOD levels were significantly higher in IGFBP7 methylated group than unmethylated group, while GSH level was lower in methylated group than unmethylated group. The DNMT1 and DNMT3a mRNA levels were higher in IGFBP7 methylated group than unmethylated group. Kaplan-Meier curve analysis revealed that IGFBP7 promoter methylation was significantly correlated with overall survival (OS) (p < .001). Moreover, IGFBP7 methylation was an independent prognostic predictor for OS (p = .000) and early tumour recurrence (ETR) (p = .008) in HCC after hepatectomy. Our results indicated that IGFBP7 promoter methylation was associated with oxidative stress and DNMTs expression. Meanwhile, IGFBP7 promoter methylation was associated with OS and ETR, indicating that it might serve as a potentially independent prognostic factor in patients with HCC after hepatectomy.

The utility of gadoxetic acid-enhanced magnetic resonance imaging in the surveillance for postoperative recurrence of hepatocellular carcinoma

This study aimed to investigate the utility of gadoxetic acid-enhanced magnetic resonance imaging (Gd-MRI) in surveillance for recurrent hepatocellular carcinoma (HCC) after hepatectomy.This retrospective study analyzed 147 patients who underwent surveillance with alternating multidetector computed tomography (MDCT) and Gd-MRI after hepatectomy for HCC. The patients were followed-up every 3 months during the first 2 years, and every 6 months thereafter. At each visit, MDCT was performed but once a year (every 12 months), Gd-MRI was performed instead of MDCT. Each HCC recurrence detection rate of MDCT and Gd-MRI was evaluated, and recurrent HCC characteristics were compared according to the detection test.A total of 63 patients had recurrent HCC. Among them, 9 were detected with Gd-MRI and 29 with MDCT. The baseline characteristics of patients with recurrent HCC showed no significant differences according to the detection test. The HCC recurrence detection rate of Gd-MRI and MDCT was 4.8% (9/180) and 4.3% (29/580), respectively, on the per test basis (P = 0.764). However, in the population with a follow-up period of ≥12 months, the detection rate of Gd-MRI and MDCT was 4.3% (7/150) and 1.5% (19/400), respectively (P = 0.035). Recurrent HCCs detected with Gd-MRI were smaller than those detected with MDCT (tumor size < 2 cm, 100% vs 65.5%, P = 0.040).Our data suggest that Gd-MRI has advantages in detecting recurrent HCC after hepatectomy. Surveillance with alternating MDCT and Gd-MRI may identify more recurrent HCC in an early stage than with MDCT alone in patients who received hepatectomy for HCC.

Effect of adjuvant interferon therapy on hepatitis B virus-related hepatocellular carcinoma: a systematic review

Objective

The objective of this study is to evaluate the efficacy of adjuvant interferon therapy for hepatitis B virus-related hepatocellular carcinoma (HCC) after different previous therapy.

Methods

An electronic search for articles about adjuvant treatment with IFN for patients with HCC published between 2000 and 2015 was conducted in MEDLINE, PubMed, Cochrane Library, and EMBASE databases. All data was tested with Stata12.0 software.

Results

Six trials with a total of 1054 subjects were screened according to inclusion and exclusion standards. Five hundred and seventeen HCC patients were treated with adjuvant treatment with IFN and 537 patients with placebo. Compared to the control group, both the recurrence rate and death rate of HCC in IFN group were statistically lower, especially after transhepatic arterial chemotherapy and embolization (TACE) treatment and both TACE and resection according to subgroup analysis.

There is no statistical significance on the both recurrence and death rate of HBV-related hepatocellular carcinoma after surgical resection treatment (RR = 0.96, 95 % CI, 0.84 to 1.1, p = 0.59 for recurrence and RR = 0.78, 95 % CI, 0.60 to 1.04, p = 0.09 for death rates).

Conclusions

Adjuvant IFN therapy may significantly reduced mortality as well as recurrence rate of patients with HBV-related HCC after no matter what the previous treatment. On the other hand, there is no statistical significance on the recurrence rate and mortality after surgical resection only. More research is needed into the relationship between effect of adjuvant interferon therapy and previous therapy, especially TACE.

Optimal duration of the early and late recurrence of hepatocellular carcinoma after hepatectomy

AIM: To determine the best cut-off value between the early and late recurrence periods after the initial recurrence of hepatocellular carcinoma (HCC).

METHODS: The clinical records of 404 patients who underwent macroscopic curative hepatectomy for HCC between 1980 and 2010 were retrospectively examined. We divided the 252 patients experienced a recurrence of HCC into two groups, the early and late recurrence groups using the “minimum P-value” approach. Factors for early recurrence were investigated using all 404 patients, and factors related to late recurrence were investigated in the patients who were confirmed to be recurrence free at the end of the early recurrence period.

RESULTS: For the 252 patients who experienced a recurrence, the optimal cut-off value for differentiating early and late recurrence based on the overall survival after initial recurrence was 17 mo (5-year overall survival after initial recurrence: 15.4% vs 36.3%, P = 0.000018). Cox proportional hazard analysis identified early recurrence (P = 0.003) as one of the independent prognostic factors associated with overall survival after initial recurrence. A logistic regression model showed that an alpha-fetoprotein level > 100 ng/mL (P < 0.001), multiple HCC (P < 0.001), serosal invasion (P = 0.031), and microvascular invasion (P = 0.012) were independent factors associated with early recurrence, whereas the only independent factor related to late recurrence was liver cirrhosis (P = 0.002).

CONCLUSION: Seventeen months after hepatectomy is a useful cut-off value between early and late recurrence of HCC based on the prognosis and different etiologies.

Comparison of survival of patients with BCLC stage A hepatocellular carcinoma after hepatic resection or transarterial chemoembolization: a propensity score-based analysis

BACKGROUND

It is unclear whether hepatic resection (HR) or transarterial chemoembolization (TACE) is associated with better outcomes for patients with hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage A. The present study compared survival for patients with BCLC stage A HCC treated by HR or TACE.

METHODS

Our study examined 360 patients treated by HR and 221 treated by TACE. To reduce bias in patient selection, 152 pairs of propensity-score-matched patients were generated, and their long-term survival was compared using the Kaplan-Meier method. Independent predictors of survival were identified using the Cox proportional hazards model.

RESULTS

Among propensity-score-matched pairs of patients with Child-Pugh A liver function who were treated by HR or TACE, the 1-, 3-, and 5-year overall survival rates were 75.5, 44.8, and 30.2 % after HR and 64.5, 24.1, and 13.7 % after TACE (P < 0.001). Serum AST level, serum AFP level, tumor size, and TACE independently predicted survival in Cox regression analysis.

CONCLUSIONS

Our propensity-score-matched study confirmed that HR was associated with higher survival rates than was TACE in patients with BCLC stage A HCC.

Early viral suppression predicts good postoperative survivals in patients with hepatocellular carcinoma with a high baseline HBV-DNA load

PURPOSE

To correlate early HBV-DNA suppression by antiviral treatment with posthepatectomy long-term survivals in patients with HBV-related hepatocellular carcinoma (HCC).

METHODS

A retrospective study was conducted on patients with a baseline HBV-DNA load of >2,000 IU/ml. The cumulative rates of HBV-DNA undetectability at weeks 24 and 48, as well as long-term tumor recurrence and overall survivals were determined.

RESULTS

Of 1,040 patients with a high baseline HBV-DNA load, 865 patients received antiviral treatment. At a median follow-up of 42 months, 616 patients (59.2 %) had developed HCC recurrence and 482 patients (46.3 %) had died. The median time to recurrence was 25 months. In patients who received antiviral treatment, the cumulative rates of HBV-DNA undetectability (<200 IU/ml) were 54.3 and 88.1 % at weeks 24 and 48, respectively. There was no significant difference between the two groups of patients who received antiviral treatment or not for disease-free survival. On multivariate analyses, tumor size >5 cm, blood transfusion, surgical margin <1 cm, presence of satellite nodules, presence of portal vein tumor thrombus and high Ishak inflammation score were significant risk factors of HCC recurrence. Also, tumor size >5 cm, surgical margin <1 cm, presence of satellite nodules, presence of portal vein tumor thrombus and high Ishak fibrosis score were significant factors associated with poor postoperative overall survival. On the other hand, an undetectable HBV-DNA level before week 24 was a significant protective factor of disease-free survival and overall survival.

CONCLUSIONS

Early HBV-DNA suppression with antiviral treatment improved prognosis of patients with HBV-related HCC.

Long-term survival after resection of hepatocellular carcinoma

BACKGROUNDS/AIMS

Although recent advances in surgical techniques and alternative treatment, the long-term survival >5 years after liver resection for hepatocellular carcinoma (HCC) is still unsatisfactory due to the high recurrence rate compared with other solid organ cancers. This study was conducted to analyze long-term survival after HCC resection and to develop an optimal strategy to achieve long-term survival.

METHODS

A retrospective review was performed for HCC patients who underwent liver resection between 1996 and 2006. The survival rates and prognostic factors were assessed. The clinical and pathological factors of patients who survived more than 5 years were compared with those of patients whose survival was less than 5 years. The clinicopathological features characterizing long-term survivors were also reviewed.

RESULTS

The overall and disease-free 5-year survival rates of 87 cases were 38.5% and 29.4%, respectively. Twenty-seven of 87 patients survived longer than 5 years after liver resection. The univariate analysis revealed that hepatitis C, the serum aspartate sminotransferase (AST) level, liver cirrhosis, Edmondson-Steiner grade, AJCC stage, and vascular invasion were significant factors for overall survival, and serum AST level, liver cirrhosis, Edmondson-Steiner grade, AJCC stage, and vascular invasion were the affecting factors for disease-free survival. In multivariate analysis, serum AST level, hepatitis C and vascular invasion were related with the overall survival, liver cirrhosis and vascular invasion which were associated with disease-free survival. Vascular invasion, AJCC stage, and the Edmondson-Steiner grade were significant factors in long-term survivors.

CONCLUSIONS

Patients without liver cirrhosis, vascular invasion and normal liver function, good differentiation and an early stage may be expected to have a long-term survival.

High HBV-DNA titer in surrounding liver rather than in hepatocellular carcinoma tissue predisposes to recurrence after curative surgical resection

GOALS

In this study the authors intended to investigate the relationship between intrahepatic hepatitis B virus (HBV)-DNA concentrations and posthepatectomy recurrence of HBV-associated hepatocellular carcinoma (HCC).

BACKGROUND

High HBV-DNA level is strongly associated with HCC development in chronic HBV infection and considered to be a risk factor of HCC recurrence.

STUDY

A total of 109 patients with HBV-associated HCC who underwent curative surgical resection were followed up every 3 to 6 months for a median of 82 months. Intrahepatic total HBV-DNA titer was measured in HCC and surrounding liver tissues using a TaqMan probe-based real-time polymerase chain reaction method. HBV-DNA titers in HCC and surrounding liver were compared in accordance with patients' clinical, radiologic, and histopathological characteristics. The relationships between HBV-DNA titers in HCC or surrounding liver tissues and cumulative HCC recurrence rates were determined.

RESULTS

Of the 109 patients, 67 (62%) showed posthepatectomy recurrence of HCC. In all patients, total HBV-DNA titers were significantly higher in HCCs than in surrounding liver tissues (P=0.019). HCC recurred more frequently in patients with higher than those with lower HBV-DNA titers in surrounding liver tissues (P=0.009). In contrast, the HCC recurrence rates were similar in patients with higher and those with lower HBV-DNA titers in HCC specimens (P=0.301). Multivariate analysis showed that tumor size >5 cm (P=0.008), the presence of portal vein thrombus (P=0.001), and high HBV-DNA titer in surrounding liver tissues (P=0.002) were independent risk factors for posthepatectomy HCC recurrence in patients with HBV-associated HCC.

CONCLUSIONS

In patients with HBV-associated HCC, high HBV-DNA titer in surrounding liver rather than in the HCC itself is associated with posthepatectomy HCC recurrence after curative surgical resection.

MRI features of hepatocellular carcinoma expressing progenitor cell markers

BACKGROUND & AIMS

To determine whether magnetic resonance (MR) imaging features differ between hepatocellular carcinomas (HCCs) with and without expression of progenitor cell markers, such as cytokeratin (CK) 19 and epithelial cell adhesion molecule (EpCAM).

METHODS

Sixty-three patients with 71 HCCs who underwent surgery after preoperative gadoxetic acid-enhanced MR imaging were evaluated. HCCs expressing progenitor cell markers were defined as showing CK19 or EpCAM expression. MR imaging features, including the fat component, arterial enhancement (global vs. peripheral), dynamic enhancement (washout vs. progressive or persistent), nodule-in-nodule appearance and MR gross morphology (expanding vs. non-expanding), were compared between HCCs with and without progenitor cell markers expression. Lesion-to-liver signal intensity ratio (SIR) and apparent diffusion coefficient values were compared using an independent samples t-test. Early recurrence rates were also compared.

RESULTS

HCCs expressing progenitor cell markers were more commonly of the non-expanding type (P = 0.016), more frequently had a progressive or persistent dynamic enhancement pattern (P = 0.008) and less frequently demonstrated a nodule-in-nodule appearance (P = 0.009). HCCs expressing progenitor cell markers had significantly higher SIRs on diffusion-weighted images (DWIs) (b = 50 and 800, P < 0.001; b = 400, P = 0.001) and a significantly lower SIR on hepatobiliary phase images (P = 0.024). The early recurrence rate was significantly higher in patients with prior HCCs that expressed progenitor cell markers (P = 0.045).

CONCLUSIONS

HCCs expressing progenitor cell markers can be characterized according to their non-expanding MR gross morphology, persistent or progressive dynamic enhancement patterns, higher SIRs on DWIs, lower SIRs on hepatobiliary phase images and less frequent nodule-in-nodule appearance.

Effect of vitamin K2 on the recurrence of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative treatment. Vitamin K2, which has been reported to reduce HCC development, may be effective in preventing HCC recurrence. Patients who underwent curative ablation or resection of HCC were randomly assigned to receive placebo, 45 mg/day, or 90 mg/day vitamin K2 in double-blind fashion. HCC recurrence was surveyed every 12 weeks with dynamic computed tomography/magnetic resonance imaging, with HCC-specific tumor markers monitored every 4 weeks. The primary aim was to confirm the superiority of active drug to placebo concerning disease-free survival (DFS), and the secondary aim was to evaluate dose-response relationship. Disease occurrence and death from any cause were treated as events. Hazard ratios (HRs) for disease occurrence and death were calculated using a Cox proportional hazards model. Enrollment was commenced in March 2004. DFS was assessed in 548 patients, including 181 in the placebo group, 182 in the 45-mg/day group, and 185 in the 90-mg/day group. Disease occurrence or death was diagnosed in 58, 52, and 76 patients in the respective groups. The second interim analysis indicated that vitamin K2 did not prevent disease occurrence or death, with an HR of 1.150 (95% confidence interval: 0.843-1.570, one-sided; P=0.811) between the placebo and combined active-drug groups, and the study was discontinued in March 2007.

CONCLUSION

Efficacy of vitamin K2 in suppressing HCC recurrence was not confirmed in this double-blind, randomized, placebo-controlled study.

Risk Factors for Intrahepatic Recurrence after Resection of Hepatocellular Carcinomas in Patients with Hepatitis B Virus Infection

PURPOSE

Although surgical resection offers patients with HCC the chance of a cure, the post-resection tumor recurrence rate is high, with reported cumulative 5-year tumor recurrence rates ranging from 40 to 70%. The objective of this study was to investigate risk factors for intrahepatic recurrence after resection of hepatocellular carcinoma, especially in patients with hepatitis B virus infection.

METHODS

Between January 1999 and December 2003, 59 patients in our Hospital with hepatitis B virus infection underwent liver resection for hepatocellular carcinoma. Clinical, biological, and histopathological characteristics of these patients were collected and tested for their prognostic significance using a Chi-square test and a Student's t-test. Time to recurrence and survival rate were analyzed by the Kaplan-Meier method.

RESULTS

Of the 59 patients who underwent liver resection, 24 (41%) experienced intrahepatic recurrence. The 1-, 3-, and 5-year overall survival rates of total enrolled patients were 83%, 63%, and 42%, respectively. The 1-, 3-, and 5-year overall survival rates after recurrence were 87%, 52%, and 20%, respectively. The risk factors for early recurrence were elevated serum aspartate aminotransferase (AST) level (p=0.044) and larger tumor size (p=0.049). For late recurrence, greater tumor size (p=0.039) was the only risk factor.

CONCLUSION

Tumor size and serum aspartate aminotransferase are risk factors of intrahepatic recurrence after resection of HCC in patients with chronic hepatitis B virus infection. This finding indicates that patients who have these risk factors should be under more careful supervision and have more aggressive follow-up.

Risk factors of recurrence after curative resection of hepatocellular carcinoma in Taiwan

INTRODUCTION

The purpose of this study was to explore the potential risk factors of hepatocellular carcinoma (HCC) recurrence after curative resection of primary HCC.

METHODS

This was a hospital-based retrospective cohort study. The authors analyzed the medical records of all the subjects with HCC initially treated by hepatic resection at a medical center in Taiwan from 1995 to 2006. In all, 222 subjects were enrolled in this study. The total observational period was 3 years.

RESULTS

There were 172 men (77.5%) and 50 women (22.5%). The mean age was 57.0 ± 13.7 years (range, 15-79 years). Among 222 subjects, the overall recurrence rates were 28.8% (64/222), 42.3% (94/222) and 47.7% (106/222) at 1, 2 and 3 years, respectively. Multivariate logistic regression analysis exhibited that tumor size ≥ 5 cm [odds ratio (OR) = 2.31, 95% confidence interval (CI) = 1.27-4.17], liver cirrhosis (OR = 2.11, 95% CI = 1.18-3.79) and preoperative aspartate aminotransferase level ≥ 34 IU/L (OR = 2.02, 95% CI = 1.01-4.04) were independent risk factors of HCC recurrence.

CONCLUSION

Patients who have larger tumor size, liver cirrhosis and higher preoperative aspartate aminotransferase level should be carefully followed up because they are at high risk of HCC recurrence postoperatively.

Overexpression of engulfment and cell motility 1 promotes cell invasion and migration of hepatocellular carcinoma

Engulfment and cell motility 1 (Elmo1) has been linked to the invasive phenotype of glioma cells. The use of Elmo1 inhibitors is currently being evaluated in hepato-cellular carcinoma (HCC), but the molecular mechanisms of their therapeutic effect have yet to be determined. Elmo1 expression in HCC tissue samples from 131 cases and in 5 HCC cell lines was determined by immunohistochemistry, quantitative RT-PCR and Western blotting. To functionally characterize Elmo1 in HCC, Elmo1 expression in the HCCLM3 cell line was blocked by siRNA. Cell migration was measured by wound healing and transwell migration assays in vitro. Elmo1 overexpression was significantly correlated with cell invasion and the poor prognosis of HCC. Elmo1-siRNA-treated HCCLM3 cells demonstrated a reduction in cell migration. The present study demonstrated for the first time that the suppression of Elmo1 expression inhibits cell invasion in HCC.

Intraoperative ultrasound score to predict recurrent hepatocellular carcinoma after radical treatments

Despite the high complete necrosis rate of radio-frequency ablation (RFA) or the complete removal following curative hepatic resection (HR), recurrent hepatocellular carcinoma (HCC) remains a significant problem. The aim of the study is to identify some intraoperative ultrasound (IOUS) patterns, predicting intrahepatic recurrences. From January 1997 to July 2009, 410 patients with HCC were treated (162 HR and 248 RFA through a surgical access). All patients were submitted to IOUS examination: 148 IOUS were performed during the laparotomic access while 262 IOUS were performed during the laparoscopic access. Primary HCC was classified according to diameter, HCC pattern (nodular or infiltrative), echogenicity (hyper- or hypo-echoic), echotexture (homogeneous or inhomogeneous), capsular invasion, mosaic pattern, nodule in nodule aspect and infiltration of portal vessels. Number of HCC nodules was also considered. Multivariate analysis (Cox model) was performed to determine features associated with recurrent HCC using IOUS patterns that independently predicted recurrent HCC, a IOUS score was developed. The patients were followed for 3-127 months, (median follow-up: 21.5 months). In 220 patients (54%), intrahepatic recurrences occurred. In 155 patients (38%), distant intrahepatic recurrences arose in different segments at the primary tumor site. In 65 HCC cases (16%), local recurrences were found. At multivariate analysis, multiple nodules, HCC diameter (>20 mm), HCC pattern (infiltrative), hyperechoic nodule and portal infiltration were statistically significant for risk factor of intrahepatic recurrences. Therefore, a IOUS scoring system was calculated on the basis of multivariate analysis and identified three risk categories of patients: in group 1 recurrences occurred in 37%, group 2 in 46% and group 3 in 66% (p = 0.0001). IOUS is an accurate staging tool during "surgical" procedures. This study showed an added value of IOUS: it permitted to identify ultrasound patterns, which can predict the risk of HCC recurrences. The calculated IOUS score permits to intraoperatively evaluate the actual surgical choice and to program the best treatment strategies during the follow-up period.

Intraoperative ultrasound patterns predict recurrences after surgical treatments for hepatocellular carcinoma()

INTRODUCTION

Hepatocellular carcinoma (HCC) is associated with a high incidence of postoperative recurrence, despite high rates of complete necrosis with radiofrequency ablation (RFA) and curative hepatic resections (HR). The aim of this study was to identify intraoperative ultrasound patterns observed during HR or RFA that predicting intrahepatic HCC recurrence.

MATERIALS AND METHODS

From January 1997 through August 2008, we treated 377 patients with HCC (158 with HR and 219 with surgical RFA). All patients underwent intraoperative ultrasound (IOUS) examination. Primary HCCs was classified according to diameter, HCC pattern (nodular or infiltrative), echogenicity (hyper- or hypo-), echotexture (homogeneous or inhomogeneous), capsular invasion, mosaic pattern, nodule-in-nodule appearance, and infiltration of portal vessels. Number of HCC nodules was also considered. Comparisons between the groups of possible factors for intrahepatic recurrence of treated tumors were performed using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Patients were followed for 9-127 months (median: 18.6 months), and intrahepatic recurrence was observed in 198 (52.5%). In 138 patients (36.5%), recurrences were located in different segments with respect to the primary tumor. In 60 HCC tumors (16%), local recurrences were found in the same segment as the primary tumor. At univariate analysis, primary HCC echogenicity and mosaic pattern were the only factors not significant associated with intrahepatic recurrences.

CONCLUSION

IOUS is an accurate staging tool for use during "surgical" resection or RFA. This study shows that IOUS patterns can also be used to estimate the risk of post-treatment HCC recurrence. In patients at high risk for this outcome, closer follow-up and use of adjuvant therapies could be useful.

Prognostic factors affecting survival and recurrence after hepatic resection for hepatocellular carcinoma in cirrhotic liver

AIM

Hepatic resections for hepatocellular carcinoma (HCC) in cirrhotic liver are characterized by early recurrence and poor survival. In this study, we analyzed several factors affecting both survival and recurrence after hepatic resection.

PATIENTS AND METHODS

From October 1995 to April 2007, 550 patients underwent hepatic resections, of which, 175 patients had HCC in cirrhotic liver in Gastroenterology Surgical Center, Mansoura University, Egypt. There were 131 males (74.9%) and 44 females (25.1%) with a mean age of 54.8 +/- 9.2 years (ranges from 26 to 75 years).

RESULTS

Most of our patients were in Child's Pugh class A (86.9%). Major hepatic resection was done for 65 patients (37.1%), segmentectomy was done for 62 patients (35.4%), and localized resection was done for 48 patients (27.4%). Hospital mortality occurred in 16 (9.1%) patients, while hospital morbidity occurred in 40% of patients. The 1, 3, and 5 years survival were 68.6%, 29.6%, and 10.7%, respectively. The prognostic factors affecting recurrence were multifactorial, and the univariate analysis showed that multifocality of the tumor (p = 0.006), capsule (p = 0.001), staging (p = 0.001), blood transfusion (p = 0.02), infiltration of the cut margin (p = 0.001), vascular invasion (p = 0.006), and lymph nodes infiltration (p = 0.014) affect the recurrence rate, while with multivariate analysis, only cut margin was significantly affecting the recurrence (p = 0.026). Also, factors that significantly predicted survival were preoperative serum albumin (p = 0.005), tumor differentiation (p = 0.008), staging (p = 0.001), tumor's capsule (p = 0.001), cut margin (p = 0.031), vascular invasion (p = 0.049), and operative blood transfusion (p = 0.001). However, tumor differentiation (p = 0.048) was the only independent factor on multivariate analysis affecting long-term survival.

CONCLUSION

In our experience, the prognostic factors after resection for recurrence and survival are different and multifactorial. However, resection of HCC in cirrhotic liver with preserved liver function is the treatment of choice in the present time and can be done with favorable results.

Clinicopathological and prognostic analysis of 429 patients with intrahepatic cholangiocarcinoma

AIM: To understand the clinicopathological characteristics and treatment selections and improve survival and provide valuable information for patients with intrahepatic cholangiocarcinoma (ICC).

METHODS: We retrospectively evaluated 5311 liver cancer patients who received resection between October 1999 and December 2003. Of these, 429 (8.1%) patients were diagnosed with ICC, and their clinicopathological, surgical, and survival characteristics were analyzed.

RESULTS: Upper abdominal discomfort or pain (65.0%), no symptoms (12.1%), and hypodynamia (8.2%) were the major causes for medical attention. Laboratory tests showed 198 (46.4%) patients were HBsAg positive, 90 (21.3%) had α-fetoprotein > 20 μg/L, 50 (11.9%) carcinoembryonic antigen > 10 μg/L, and 242 (57.5%) carbohydrate antigen 19-9 (CA19-9) > 37 U/mL. Survival data was available for 329 (76.7%) patients and their mean survival time was 12.4 mo. The overall survival of the patients with R0, R1 resection and punching exploration were 18.3, 6.6 and 5.6 mo, respectively. Additionally, CA19-9 > 37 U/mL was associated with lymph node metastases, but inversely associated with cirrhosis. Multivariate analysis indicated that radical resection, lymph node metastases, macroscopic tumor thrombi and size, and CA19-9 were associated with prognosis.

CONCLUSION: Surgical radical resection is still the most effective means to cure ICC. Certain laboratory tests (such as CA19-9) can effectively predict the survival of the patients with ICC.

A prospective clinical study on early recurrence of hepatocellular carcinoma after hepatectomy

BACKGROUND

To determine more precisely time interval from resection to recurrence of hepatocellular carcinoma (HCC) and to identify the risk factors associated with postoperative recurrence.

METHODS

From January 2004 to December 2007, 178 patients who underwent resection of HCC were followed prospectively for at least 12 months. Recurrence was identified by the digital subtraction angiography (DSA). Demographic, tumor, and disease characteristics were compared between patients with recurrence within 6 months and between 7 and 12 months, and those without recurrence to evaluate for their prognostic significance. Patients with intrahepatic recurrence were treated with trans-arterial chemoembolization (TACE) and re-assessed by CT scans, contrast-enhanced ultrasound, or MRI.

RESULTS

Recurrence developed in 52 patients between 1 and 6 months, 11 patients between 7 and 12 months, and 115 patients remained disease free for at least 1 year. The recurrence rates of 6 months and 1 year were 29.2% and 35.4%, respectively. No statistically significant difference between was observed. Fourteen (22.2%) patients with recurrence and 11 (9.6%) patients without recurrence had previously presented as multifocal HCC, and the difference is of statistical significance (P = 0.025). The diagnostic accuracy of DSA as validated by other diagnostic methods was 81.8%.

CONCLUSIONS

Recurrences are more likely to develop within the first 6 months after resection for HCC. Multifocal HCC is an important risk factor associated with early recurrence of advanced HCC after hepatectomy. DSA may serve as an important surveillance for early detection of intrahepatic recurrence after surgery.

Glypican-3 expression is correlated with poor prognosis in hepatocellular carcinoma

The relationship between overexpression of glypican (GPC)-3 that is specific for hepatocellular carcinoma (HCC) and the prognosis has not yet been clarified. We attempted to determine the expression profile of GPC3 in association with the clinicopathological factors by immunohistochemical analysis in HCC patients and investigated the potential prognostic value of GPC3 by comparing the survival rate between the GPC3-positive and GPC3-negative HCC patients. Primary HCC tissue samples (n = 107) obtained from patients who had undergone hepatectomy between 2000 and 2001 were analyzed. GPC3 expression was less frequently observed in well-differentiated HCC than in moderately and poorly differentiated HCC, the difference in the frequency being statistically significant. GPC3-positive HCC patients had a significantly lower 5-year survival rate than the GPC3-negative HCC patients (54.5 vs 87.7%, P = 0.031). Among 80 of the 107 (74.6%) patients with initial treatment who underwent hepatectomy, none of GPC3-negative HCC patients (n = 16, 20.0%) died during the follow-up period. No deaths were noted in the GPC3-negative HCC patients among the 71 (88.7%) patients with moderately and poorly differentiated HCC. Multivariate analysis identified GPC3 expression (P = 0.034) as an independent prognostic factor for the overall survival. We showed that GPC3 expression is correlated with a poor prognosis in HCC patients.

Endocan expression correlated with poor survival in human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second leading cause of cancer death in China. We aimed to first present the expression of endocan in HCC tissue and its correlation with the clinicopathological features and overall survival of patients with HCC after curative hepatectomy. Immunohistochemical detection of endocan, CD34, and vascular endothelial growth factor (VEGF) were performed on samples from 100 patients with HCC. Endocan protein was expressed in endothelium of HCC tissue in all specimens, but was not expressed in endothelium of pericarcinomatous liver tissue and normal liver tissue. Microvessel density (MVD) denoted by endocan (endocan-MVD) in HCC was correlated with microscopic venous invasion and VEGF expression (P < 0.05). Survival analysis showed that overall survival of patients was inversely associated with endocan-MVD (P < 0.01). Multivariate analysis showed that endocan-MVD was an independent prognostic marker for overall survival of HCC (P < 0.01). In conclusion, endocan-MVD was a significant factor to predict the prognosis of HCC patients after curative hepatectomy.