Screening and detection of hepatocellular carcinoma

Update on PET Radiopharmaceuticals for Imaging Hepatocellular Carcinoma

Numerous positron emission tomography (PET) targets for detection and staging of hepatocellular cancer have been developed in recent years. Hepatocellular carcinomas (HCCs) are clinically and pathologically heterogeneous tumours with a high tendency to be aggressive and unresponsive to chemotherapy. Early detection is essential, and the need for an adequate imaging biomarker, which can overcome some of the limitations of conventional radiological imaging, is persistent. Flourine-18 (18F) flourodeoxyglucose (FDG), the most widely used PET radiopharmaceutical, has proven disappointing as a possible staple in the evaluation of HCC. This disappointment had led to experimentation with carious radiotracers, such as the choline derivatives, acetate, and prostate-specific membrane antigen, which appear to complement and/or enhance the role of FDG. In this study, we look at the various PET radiopharmaceuticals that have been used for imaging HCC and the particular pathways that they target in HCC and liver cancers.

Non-invasive evaluation of vascular architecture of focal liver lesions by micro vascular imaging

OBJECTIVE

To explore the value of vascular architecture detected by micro vascular imaging (MVI) in preoperative diagnosis of focal liver lesions (FLLs).

METHODS

In this retrospective study, patients with surgery and histopathologically proved or radiologically confirmed FLLs were included. Vascular architecture of FLLs were acquired by color Doppler flow imaging (CDFI) and MVI on LOGIQ™ E20 ultrasound machine (C1-6 convex array probes). Alder semiquantitative analysis (grade 0-3) and morphologic features of blood vessels (pattern a-f) were used to assess the blood flow within the FLLs. Interobserver agreement for evaluating blood flow of FLLs was analyzed. Using Adler's grading or morphologic patterns as diagnostic criteria for malignant FLLs, the diagnostic efficiency was analyzed and compared.

RESULTS

From October 2021 and February 2022, 50 patients diagnosed with 40 malignant FLLs and 10 benign FLLs were finally included. The Kappa value within two observers for evaluating the blood flow of FLLs was 0.78 for MVI and 0.55 for CDFI. According to Alder semiquantitative analysis, more high-level blood flow signals (grade 2-3) were detected by MVI than CDFI (P <  0.05). Based on high-level blood flow signals (grade 2-3) and hypervascular supply patterns (pattern e and f), the diagnostic accuracy for malignant FLLs were 76% and 68% for MVI, 56% and 38% for CDFI, respectively.

CONCLUSION

MVI is superior to CDFI in evaluating vascular architecture of FLLs. The high-level flow signals and hypervascular pattern detected by MVI have a useful and complementary value in preoperative non-invasive identification of malignant FLLs.

Rate of Nonsurveillance and Advanced Hepatocellular Carcinoma at Diagnosis in Chronic Liver Disease

AIMS

Ultrasound surveillance for hepatocellular carcinoma (HCC) is recommended in cirrhotic patients to allow early diagnosis. This study investigated risk factors for nonsurveillance and advanced HCC at diagnosis and their effect on survival.

MATERIALS AND METHODS

Two hundred seventy HCC patients were included. Clinical data were collected from hospital databases.

RESULTS

One hundred twenty-eight (47.1%) patients had 6-monthly ultrasound surveillance before HCC diagnosis. Ninety-two (34.1%) patients had advanced HCC (multifocal or total diameter ≥6 cm) at diagnosis. The nonsurveillance rate was significantly higher in nonalcoholic fatty liver disease (NAFLD) (79%) compared with other causes of chronic liver disease (31.6% to 58.1%, P<0.001). Nonrecognition of NAFLD was significantly higher (68.4%) compared with other causes of chronic liver disease (0% to 23.2%, P<0.001). In NAFLD HCC patients, 23.7% were noncirrhotic and smoking was significantly associated HCC in this noncirrhotic group (P=0.041). No-surveillance for HCC was significantly associated with advanced HCC at diagnosis with an odds ratio (OR) of 8.1. Compared with nondrinkers, heavy alcohol consumption was significantly associated with advanced HCC (OR=7.6). In the surveillance group, diagnosis using computed tomography rather than magnetic resonance imaging was significantly associated with advanced HCC (OR=3.36). Patients without HCC surveillance had a significantly shorter median survival compared with those who had HCC surveillance (27.4 vs. 52.0 mo, P=0.0006).

CONCLUSIONS

The lack of HCC surveillance is associated with advanced HCC at diagnosis and decreased survival. NAFLD patients with HCC have a significantly lower rate of diagnosis of chronic liver disease and HCC surveillance compared with the other causes of chronic liver disease.

Variations in the AURKA Gene: Biomarkers for the Development and Progression of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a liver malignancy and a major cause of cancer mortality worldwide. AURKA (aurora kinase A) is a mitotic serine/threonine kinase that functions as an oncogene and plays a critical role in hepatocarcinogenesis. We report on the association between 4 single nucleotide polymorphisms (SNPs) of the AURKA gene (rs1047972, rs2273535, rs2064836, and rs6024836) and HCC susceptibility as well as clinical outcomes in 312 patients with HCC and in 624 cancer-free controls. We found that carriers of the TT allele of the variant rs1047972 were at greater risk of HCC compared with wild-type (CC) carriers. Moreover, carriers of at least one A allele in rs2273535 were less likely to progress to stage III/IV disease, develop large tumors or be classified into Child-Pugh class B or C. Individuals with at least one G allele at AURKA SNP rs2064863 were at lower risk of developing large tumors or progressing to Child-Pugh grade B or C. Our results indicate that genetic variations in the AURKA gene may serve as an important predictor of early-stage HCC and be a reliable biomarker for the development of HCC.

Impact of matrix metalloproteinase-11 gene polymorphisms upon the development and progression of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a liver malignancy and a major cause of cancer mortality worldwide. Matrix metalloproteinase-11 (MMP-11), also known as stromelysin-3, plays a critical role during tumor migration, invasion and metastasis. Here, we report on the association between five single nucleotide polymorphisms (SNPs) - rs738791, rs2267029, rs738792, rs28382575, and rs131451 - of the MMP-11 gene and HCC susceptibility, as well as clinical outcomes, in 293 patients with HCC and in 586 cancer-free controls. We found that carriers of the CT+TT allele of the rs738791 variant were at greater risk of HCC compared with wild-type (CC) carriers. Moreover, carriers of at least one C allele (C/T+C/C genotype) at the MMP-11 SNP rs738792 were likely to progress to Child-Pugh B or C grade, while individuals with at least one C allele (C/T+C/C genotype) at the MMP-11 SNP rs28382575 were at higher risk of developing stage III/IV disease, large tumors or lymph node metastasis. We believe that genetic variations in the MMP-11 gene may help to predict early-stage HCC and act as reliable biomarkers for HCC progression.

Diagnostic Imaging of Hepatocellular Carcinoma - A Pictorial Essay

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, which develops mostly in the setting of chronic liver disease. European Association for the Study of the Liver (EASL) and European Organization for Research and Treatment of Cancer (EORTC) prepared guidelines for screening, follow-up and diagnosis of HCC to facilitate decision making and optimize both diagnostic and therapeutic protocols. The review briefly describes etiology, epidemiology and histopathology of HCC and presents EASL-EORTC guidelines for surveillance and diagnosis of HCC. Target population and screening algorithm is presented in the surveillance section. Ultrasound imaging of HCC and the role of contrast enhanced ultrasound are described as well as the value of laboratory tests in screening. Further, radiological features of HCC in multiphase CT and dynamic contrast enhanced MRI and diagnostic criteria are presented. Additionally, the advantages of advanced techniques in MRI such as diffusion weighed imaging and the use of hepatocyte-specific contrast agents are discussed. Lastly, the EASL-EORTC guidelines are compared with the guidelines of the American Association for the Study of Liver Diseases and the Japan Society of Hepatology. Also LI-RADS and the Barcelona Clinic Liver Cancer classification are mentioned. In the near future, due to the ongoing advances in imaging a revision of the guidelines may be expected.

Impacts of CCL4 gene polymorphisms on hepatocellular carcinoma susceptibility and development

Hepatocellular carcinoma (HCC) is the sixth most common cancer globally and the third most common cause of cancer mortality. In Taiwan, HCC is the second leading cause of cancer death. CCL4 (C-C chemokine ligand 4), is a macrophage inflammatory protein with a chief effect in inflammation and immune-regulation, and was documented in cancer progression by promoting instability in the tumor environment. Polymorphisms in chemokine genes help to determine host-pathogen interactions that influence chemokine levels. We investigated the effects of CCL4 gene polymorphisms on the risk of hepatocellular carcinoma (HCC) disease progression in a cohort of Taiwanese patients. We recruited total of 1,546 participants in current study, including 1,200 healthy control and 346 patients with HCC. Three single-nucleotide polymorphisms (SNPs) of the CCL4 gene were examined by a real-time PCR. We found that the A/G homozygotes of CCL4 rs10491121 polymorphism reduced the risks for HCC. On the other hand, AG and GA haplotypes of 2 CCL4 SNPs (rs1049112 and rs171915) also reduced the risks for HCC by 0.025 and 0.515 fold, respectively. The present report is the first time to examine the risk factors associated with CCL4 SNPs in HCC progression in Taiwan.

International trends in liver cancer incidence, overall and by histologic subtype, 1978-2007

Primary liver cancer, the most common histologic types of which are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), is the second leading cause of cancer death worldwide. While rising incidence of liver cancer in low-risk areas and decreasing incidence in some high-risk areas has been reported, trends have not been thoroughly explored by country or by histologic type. We examined liver cancer incidence overall and by histology by calendar time and birth cohort for selected countries between 1978 and 2007. For each successive 5-year period, age-standardized incidence rates were calculated from volumes V-IX of the Cancer Incidence in Five Continents electronic database (CI5plus) and the newly released CI5X (volume X) database. Wide global variations persist in liver cancer incidence. Rates of liver cancer remain highest in Asian countries, specifically Eastern and South-Eastern Asian countries. While rates in most of these high-risk countries have been decreasing in recent years, rates in India and several low-risk countries of Africa, Europe, the Americas, and Oceania have been on the rise. Liver cancer rates by histologic type tend to convey a similar temporal profile. However, in Thailand, France, and Italy, ICC rates have increased while HCC rates have declined. We expect rates in high-risk countries to continue to decrease, as the population seroprevalence of hepatitis B virus (HBV) continues to decline. In low-risk countries, targeted screening and treatment of the hepatitis C virus (HCV), treatment of diabetes and primary prevention of obesity, will be key in reducing future liver cancer incidence.

Changes in Doppler parameters of portal pressure after interventional management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has many options for management; some of them are complicated by development of portal hypertension (PHT). Doppler ultrasound is an effective method to diagnose and monitor PHT changes after HCC ablation procedures. The aim of this study is to investigate changes in portal pressure hemodynamics of HCC patients following treatment with different interventional strategies: radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). A total of 60 patients with HCC were divided into three main groups, and each group received a different type of therapy (RFA, MWA, and TACE). Full medical record and basic investigations were performed including Doppler ultrasound and upper GIT endoscopy for evaluation of PHT parameters, and then repeated after three months of ablation. RFA is associated with the increased splenic artery resistive index, while MWA has no significant impact on PHT indices. TACE has led to a marked increase in liver vascular index with significant decrease in hepatic artery resistive index and PHI after treatment. No significant changes in esophageal varices were observed by upper GIT endoscopy following all ablation methods. RFA is quite safe but associated with degree of PHT. On the contrary, TACE is associated with improved PHT parameters. MWA has no significant association to development of PHT following the technique. Doppler ultrasound could be used as a reliable and effective method of evaluation of PHT post ablation for HCC.

Surveillance of Hepatocellular Carcinoma and Diagnostic Algorithms in Patients with Liver Cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) is the most deadly complication of all major chronic liver diseases. Since early detection is the most significant determinant of overall survival, intense screening is of major importance.

METHODS

This overview is based on a systematic review of the available literature on HCC screening and surveillance in the PubMed database.

RESULTS

Over the last decades, major etiological risk factors were identified and the population at highest risk for the development of HCC was clearly defined. Screening in these patients has been repeatedly demonstrated to detect early tumor stages and to be cost-effective. Therefore, screening is recommended by all current guidelines and usually comprises a bi-annual ultrasound examination in Western countries. In some Asian countries biomarkers are also used; however, their efficiency for Western HCCs remains to be determined. The detection of lesions >1 cm during routine screening requires subsequent confirmation of HCC. The diagnosis can be accurately established by modern imaging techniques, i.e. computed tomography or magnetic resonance imaging, in the majority of patients. In ambiguous cases and if radiological criteria are not met by two imaging techniques, biopsies remain the gold standard for diagnosis. Furthermore, histology is of key importance for the development of new diagnostic and predictive biomarkers.

CONCLUSION

Screening and detection algorithms for patients at risk for HCC are effective and should be rigorously implemented in clinical routine.

Effects of HMGB1 Polymorphisms on the Susceptibility and Progression of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a malignancy of liver and a leading cause of cancer mortality worldwide. Its management is compounded by biological and clinical heterogeneity. These interindividual genetic variations can modulate the effects of HCC treatment. High-mobility group box protein 1 (HMGB1) is a well investigated, ubiquitous nuclear protein found in eukaryotic cells that plays a multiple biological roles such as DNA stability, program cell death, immune response, and furthermore in cancer progression. In this report, we examined HMGB1 single nucleotide polymorphisms (SNPs) with multiple risk factors related to HCC susceptibility and clinicopathological characteristics. Four HMGB1 SNPs (rs1412125, rs2249825, rs1045411, and rs1360485) were assessed by using a TaqMan SNPs Genotyping in 324 patients with HCC and in 695 cancer-free controls. The results showed that HMGB1 SNP rs1045411 with CT or at least one T alleles has lower risk of HCC than wild-type (CC) carriers. Moreover, HMGB1 SNP rs1412125 with TT allele has a higher risk of distant metastasis compared with patients carrying at least one C allele. The present study is the first report to discuss the risk factors associated with HMGB1 SNPs in HCC progression in Taiwan.