Pathogenesis and screening for hepatocellular carcinoma

MRI texture analysis for differentiation of malignant and benign hepatocellular tumors in the non-cirrhotic liver

Purpose

To find potentially diagnostic texture analysis (TA) features and to evaluate the diagnostic accuracy of two-dimensional (2D) magnetic resonance (MR) TA for differentiation between hepatocellular carcinoma (HCC) and benign hepatocellular tumors in the non-cirrhotic liver in an exploratory MR-study.

Materials and methods

108 non-cirrhotic patients (62 female; 41.5 ± 18.3 years) undergoing preoperative contrast-enhanced MRI were retrospectively included in this multi-center-study. TA including gray-level histogram, co-occurrence and run-length matrix features (total 19 features) was performed by two independent readers. Native fat-saturated-T1w and T2w as well as arterial and portal-venous post contrast-enhanced 2D-image-slices were assessed. Conventional reading was performed by two separate independent readers. Differences in TA features between HCC and benign lesions were investigated using independent sample t-tests. Logistic regression analysis was performed to obtain the optimal number/combination of TA-features and diagnostic accuracy of TA analysis. Sensitivity and specificity of the better performing radiologist were compared to TA analysis.

Results

The highest number of significantly differing TA-features (n = 5) was found using the arterial-phase images including one gray-level histogram (skewness, p = 0.018) and four run-length matrix features (all, p < 0.02). The optimal binary logistic regression model for TA-features of the arterial-phase images contained 13 parameters with an accuracy of 84.5% (sensitivity 84.1%, specificity 84.9%) and area-under-the-curve of 0.92 (95%-confidence-interval 0.85–0.98) for diagnosis of HCC. Conventional reading yielded a significantly lower sensitivity (63.6%, p = 0.027) and no significant difference in specificity (94.6%, p = 0.289) at best.

Conclusion

2D-TA of MR images is a feasible objective method that may help to distinguish HCC from benign hepatocellular tumors in the non-cirrhotic liver. Most promising results were found in TA features in the arterial phase images.

Hepatocellular carcinoma: early-stage management challenges

Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.

Symptom clusters in Chinese patients with primary liver cancer

PURPOSE/OBJECTIVES

To derive symptom clusters and their clinical meanings in Chinese patients with primary liver cancer (PLC), to examine the factors related to the identified symptom clusters, and to validate the impact of the identified symptom clusters on patients' quality of life (QOL).

DESIGN

Cross-sectional.

SETTING

Inpatient departments at a medical center for hepatobiliary disease in China.

SAMPLE

277 patients with PLC, aged 18-77 years.

METHODS

Data were collected from a number of measures, including demographic and disease characteristics, the MD Anderson Symptom Inventory, six additional symptom items specific to PLC, and the Functional Assessment of Cancer Therapy-Hepatobiliary questionnaire. Factor analysis was used to derive symptom clusters, independent-samples t test or one-way analysis of variance was performed to identify the factors related to each symptom cluster, and multivariate regression models were applied to examine the predictive impact of the identified symptom clusters on PLC.

MAIN RESEARCH VARIABLES

Demographic and medical variables, symptom clusters, and QOL.

FINDINGS

Three symptom clusters were identified: gastrointestinal sickness, neuropsychological, and liver dysfunction. Patients who received liver protection treatment, received more than one kind of treatment, and had poorer physical performance, worse liver function, and more advanced cancer scored higher in severity across all three symptom clusters. All of the symptom clusters explained 48% of the QOL variance, and the liver dysfunction symptom cluster (adjusted R2 = 0.425) showed a superior influence.

CONCLUSIONS

The liver dysfunction symptom cluster may be unique to Chinese patients with PLC. Patients with certain demographic and disease characteristics could be at risk for experiencing severe symptom clusters. In addition, a differential impact of the symptom clusters on QOL was noted in these patients.

IMPLICATIONS FOR NURSING

The factors related to severity should be considered when managing symptom clusters. Because the predictive impacts of the three individual symptom clusters on QOL were varied and ordered in magnitude, healthcare providers should first alleviate the primary symptom cluster. This approach could be cost-effective and improve QOL.

Human liver carboxylesterase 1 outperforms alpha-fetoprotein as biomarker to discriminate hepatocellular carcinoma from other liver diseases in Korean patients

Although alpha-fetoprotein (AFP) is currently the major serologic biomarker for hepatocellular carcinoma (HCC), it cannot efficiently distinguish this cancer from other forms of liver disease in early diagnosis due to its low sensitivity. The aim of this study is to compare sensitivity and specificity of human carboxylesterase 1 (hCE1) and AFP biomarker. Antibody-based assays for hCE1 and AFP were used to test both biomarkers with respect to diagnostic efficiency, Youden's index and the area under the curve (AUC) through receiver operating characteristic (ROC) analysis in plasma from 208 patients with HCC (n=57), liver cirrhosis (n=27), chronic hepatitis (n=37), cholangiocarcinoma (n=22), gastric cancer (n=31) and pancreatic cancer (n=34), along with 52 healthy donors (HDs). The levels of hCE1 were significantly higher in patients with HCC than HDs and the other diseases (p<0.005), further verified by AUC values and Youden's index. In the set of HCC versus liver cirrhosis the AUC values were 0.744 (AFP), 0.918 (hCE1) and 0.938 (combination of AFP and hCE1), respectively. These results indicate that hCE1 is not only a more potent and specific marker in distinguishing cancer from liver diseases, in particular cirrhosis, but the combination of hCE1 and AFP shows also synergistic potential for greater sensitivity and specificity in early diagnosis. Therefore the antibody-based hCE1 assay appears to have high diagnostic efficiency for discriminating HCC from other forms of liver disease. It is now feasible to further validate this novel plasma-based biomarker in the large cohort we assembled.

Pathology for the HPB Surgeon

Optimal care of a patient implies a good professional understanding between all the medical personnel involved in that patient's care. Similarly a basic understanding of the areas where surgery and pathology interact would go a long way, in clarifying the disease process in the patient. This review aims to cover a few topics in liver lesions, FNAC Vs core biopsy, IHC, Margin examination, and frozen sections, in order to improve the communication between these two specialities.

Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation

BACKGROUND

Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the B Positive pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.

METHODS

Estimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.

RESULTS

Assuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.

CONCLUSIONS

While the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.

Antiviral therapy for hepatitis B-related liver cancer prevention is more cost-effective than cancer screening

BACKGROUND/AIMS

In Australia, Asian-born populations are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. We therefore, modelled the consequences of different management strategies for chronic hepatitis B (CHB) in Asian-born adults aged > or = 35 years.

METHODS

A Markov model compared (1) enhanced surveillance for HCC alone (HCC surveillance), or (2) enhanced HCC surveillance coupled with CHB treatment (HCC prevention) to the current practice, of low CHB treatment uptake. Patients were stratified and managed according to risk categories, based upon hepatitis B virus (HBV) viral load and alanine aminotransferase (ALT) levels. We measured costs, health outcomes [cases of HCC and deaths averted, quality-adjusted life-years (QALYs) gained] and incremental cost-effectiveness ratios (ICERs).

RESULTS

HCC surveillance would cost on average AU$8479 per person, compared to AU$2632 with current clinical practice and result in a gain of 0.014 QALYs (AU$401,516/QALY gained). A HCC prevention strategy would cost on average AU$14,600 per person, result in 0.923 QALYs gained (AU$12,956/QALY gained), reduce cases of cirrhosis by 52%, HCC diagnoses by 47% and CHB-related deaths by 56%, compared to current practice.

CONCLUSIONS

HCC prevention appears to be a cost-effective public health strategy in at-risk populations in Australia and is preferable to HCC surveillance as a cancer control strategy.

Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis

OBJECTIVES

Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.

METHODS

A Markov decision model was developed that compared three management strategies - immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression - for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model's strength was assessed with sensitivity analyses.

RESULTS

In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.

CONCLUSIONS

The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.

Hepatocellular carcinoma: overcoming challenges in disease management

Hepatocellular carcinoma is the third most frequent cause of death from cancer and the eighth most commonly occurring cancer in the world. In the United States, hepatocellular carcinoma appears to be increasing along with evolution of chronic hepatitis infection, especially in the immigrant population, a major risk group. A disease of multifactorial etiology, hepatocellular carcinoma confers many management challenges. Hepatocarcinogenesis is a multistep process involving different genetic alterations that ultimately lead to malignant transformation of the hepatocyte. Early hepatocellular carcinoma is characteristically silent and slow growing with few symptoms until late in disease. Early and accurate diagnosis of hepatic tumors relies on clinical suspicion, screening protocols, serologic testing, radiologic imaging, and tissue confirmation. Lack of clinically validated biomarkers and clinical identification of hepatocellular carcinoma at advanced disease make diagnosis and treatment difficult. Advances in computed tomography and magnetic resonance imaging have markedly increased the sensitivity and specificity of testing, yet they are still flawed with a relatively high false-positive rate. Several surgical and nonsurgical therapies have been developed and used with varying degrees of success. Options include surgical resection, liver transplantation, local ablation therapies, and pharmaceutical interventions. At 5 years after resection, in those patients who are surgical candidates, the recurrence rate ranges between 30% and 60%. In patients with nonresectable disease, the prognosis is dismal, with a median survival of less than 12 months even with chemotherapy. The medical community faces numerous challenges in hepatocellular carcinoma and must work toward better management and multidisciplinary care of this complex disease.