Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma - A meta-analysis

Comparing transarterial chemoembolization alone to combined transarterial chemoembolization and radiofrequency ablation in primary hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Transarterial chemoembolization (TACE) combined with percutaneous radiofrequency ablation (RFA) has emerged as a promising treatment strategy for patients with unresectable HCC.

AIM

To evaluate the effectiveness and safety of TACE combined with RFA compared to TACE alone in the management of primary HCC.

METHODS

A comprehensive retrospective analysis was conducted at our institution from January 2020 to January 2024, involving 106 patients diagnosed with intermediate to advanced-stage HCC. Patients were divided into two groups: Those receiving TACE alone (n = 56) and those undergoing combined TACE and RFA therapy (n = 50). Treatment efficacy was assessed based on tumor response rates, serum alpha-fetoprotein (AFP) levels, and survival outcomes. Statistical analyses, including χ² tests and Kaplan-Meier survival analysis, were performed to compare the outcomes between the two groups.

RESULTS

The TACE + RFA group demonstrated significantly higher rates of complete response (15 vs 4, P < 0.01) and partial response (23 vs 15, P = 0.046) compared to the TACE group. Conversely, the TACE group exhibited higher rates of stable disease (25 vs 7, P < 0.01) and progressive disease (12 vs 5, P < 0.01). Serum AFP levels decreased over time in the TACE + RFA group, while they increased in the TACE group. Survival analysis revealed superior survival outcomes in the TACE + RFA group, with higher survival rates and a prolonged median survival time compared to the TACE group.

CONCLUSION

The combination of RFA with TACE could offer enhanced treatment response and prolonged survival in patients with primary HCC compared to TACE alone. These findings might support the adoption of multimodal therapeutic approaches, emphasizing the importance of personalized treatment strategies in the management of HCC.

Dynamic ALBI score and FIB-4 index trends to predict complications after resection of hepatocellular carcinoma: A K-means clustering approach

BACKGROUND

Severe postoperative complications still occur following hepatectomy among patients with hepatocellular carcinoma (HCC). There is a need to identify high-risk patients for severe complications to enhance patient safety. We sought to evaluate the combined impact of pre- and postoperative albumin-bilirubin (ALBI) score and Fibrosis-4 (FIB-4) index trends to predict severe complications after HCC resection.

METHOD

Patients with HCC undergoing curative-intent hepatectomy (2000-2023) were identified from an international, multi-institutional database. The cohort was divided into training (n = 439) and testing (n = 651) sets. ALBI score and FIB-4 index trends from preoperative to postoperative days 1, 3, and 5 were used for K-means clustering (K = 3). A logistic regression model was developed using the training set, and its performance was evaluated using the area under the receiver operating characteristic curve (AUC) in both cohorts.

RESULTS

Severe complications (Clavien-Dindo Grade ≥ IIIa) occurred in 118 patients (10.8 %); 43 (9.8 %) in training and 75 (11.5 %) in testing set (p = 0.42). K-means clustering identified three groups: Cluster1 (low), Cluster2 (intermediate), and Cluster3 (high), which was associated with a progressively increasing risk of complications (p < 0.01). On multivariable logistic regression, patients in ALBI Cluster1 had 76 % decreased odds (odds ratio[OR] 0.24, 95 % CI 0.07-0.83, p = 0.02) of postoperative complications relative to Cluster3 patients. Individuals categorized into FIB-4 Cluster1 had 85 % decreased odds (OR 0.15, 95 % CI 0.02-1.24, p = 0.07) versus patients in FIB-4 Cluster3. A new prediction model incorporating ALBI and FIB-4 index clusters achieved an AUC of 0.71, outperforming models based on preoperative data. A tool was made available at https://nm49jf-miho-akabane.shinyapps.io/HCC_ALBI/.

CONCLUSION

A dynamic ALBI score and FIB-4 index trend tool improved risk stratification of patients undergoing resection of HCC relative to severe complications.

Conventional transarterial chemoembolization followed by irreversible electroporation for hepatocellular carcinoma

OBJECTIVES

This study aimed to assess the effectiveness and safety of conventional transarterial chemoembolization (c-TACE) followed by irreversible electroporation (IRE) for the treatment of hepatocellular carcinoma (HCC).

METHODS

From January 2019 to September 2019, 12 patients with HCC who received c-TACE followed by IRE comprised the study group. The control group comprised 15 patients who received c-TACE followed by radiofrequency ablation (RFA). The 1-month, 3-month, 6-month, and 12-month local control rates and median progression-free survival (PFS) were compared between the two groups. Additionally, postoperative complications were assessed.

RESULTS

The study group comprised 12 patients (median age: 57.5 years; range: 46-68 years), while the control group consisted of 15 patients (median age: 56 years; range: 31-69 years). Local control rates at 1, 3, 6, and 12 months were 91.7%, 91.7%, 83.3%, and 33.3%, respectively, for the study group, and 73.3%, 66.7%, 66.7%, and 20.0% for the control group. Statistical analysis revealed no significant differences between the two groups. In terms of survival, 9 patients (75%) in the study group and 11 patients (73.3%) in the control group were still alive at the last follow-up. The median PFS was 8 months in the study group and 7 months in the control group, with no significant difference between the two groups (p = 0.96). Notably, no severe surgery-related side effects were observed in either group, and also no significant differences were found in postoperative complications between the two groups (p = 0.64).

CONCLUSIONS

The long-term therapeutic outcomes of c-TACE followed by IRE were found to be similar to those of c-TACE followed by RFA in the study. The research suggests that c-TACE followed by IRE offered an effective and safe treatment option for HCC.

Therapeutic outcomes of thermal ablation versus repeated hepatic resection for recurrent hepatocellular carcinoma by using propensity score analysis: a multicenter real-world study

BACKGROUND

The therapeutic value of thermal ablation (TA) versus repeat hepatic resection (RHR) for recurrent hepatocellular carcinoma (rHCC) after initial hepatic resection is uncertain. This study aimed to investigate the prognosis of TA and RHR.

MATERIALS AND METHODS

In this multicenter real-world retrospective study, 473 patients were enrolled between January 2015 and August 2023, with 340 in the TA group and 133 in the RHR group. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to reduce selection bias. Local tumor progression (LTP), recurrence-free survival (RFS), and post-recurrence survival (PRS) were compared before and after PSM and IPTW.

RESULTS

A total of 473 patients (231 aged ≥ 60 years; 393 men) were evaluated. LTP, RFS, and PRS rates did not differ significantly between groups before (P = 0.940, P = 0.180, and P = 0.700) and after matching (P = 0.420, P = 0.680, and P = 0.810) and weighting (P = 0.940, P = 0.180, and P = 0.700). Multivariable Cox analysis identified tumor number (HR: 2.28; P < 0.001) and PLT (HR: 0.73; P = 0.038) as independent prognostic factors for RFS in the entire rHCC cohort. And tumor location, size, number, ascites, AST, and AFP (HR: 0.55-2.18; P = 0.004-0.046) were independent prognostic factors for PRS. Subgroup analysis showed both TA and RHR were effective treatments for rHCC, regardless of tumor size, number, subcapsular, or perivascular lesions.

CONCLUSIONS

The cumulative LTP, RFS, and PRS were not significantly different between TA and RHR for rHCC within the Milan criteria. TA may be a viable curative option for early-stage rHCC patients.

Advancements in locoregional therapy for advanced hepatocellular carcinoma: Emerging perspectives on combined treatment strategies

Hepatocellular carcinoma (HCC) persists as a leading cause of cancer-related mortality, often diagnosed at advanced stages with limited treatment options. Locoregional therapies (LRTs) are crucial in HCC management, playing significant roles in neoadjuvant and palliative treatments, among others. However, the unique disease background of HCC necessitates multidisciplinary and integrated treatment strategies. The therapeutic landscape for advanced HCC has been significantly broadened by the advent of combined therapies, presenting multiple approaches aimed at improving long-term survival, which remains a critical challenge. This review offers a comprehensive overview of major LRTs for HCC, highlighting recent technological advancements and exploring the challenges and limitations in their application, and presents the latest developments in combination therapies, including combinations between different LRTs and their integration with systemic treatments. Additionally, we outline future directions for the development of integrated treatment modalities for advanced HCC.

Multicenter Study on Transarterial Chemoembolization Combined with Radiofrequency Ablation for Early-Stage Hepatocellular Carcinoma: Primary versus Recurrent HCC

Purpose

To evaluate the efficacy of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) for both primary and recurrent early-stage hepatocellular carcinoma (HCC) and to analyze the significant prognostic factors.

Patients and Methods

Data from patients with early-stage primary or recurrent HCC who underwent TACE plus RFA between August 2019 and May 2024 were collected from three major general hospitals. 158 patients were divided into a primary group and a recurrent group on the basis of their baseline characteristics. Compared the objective response rate (ORR), 1-, 3-, and 5-year progression-free survival (PFS) rates, 1-, 3-, and 5-year overall survival (OS) rates, and complication rate between the two groups. Multivariate analyses were used to evaluate the factors influencing PFS and OS.

Results

One hundred fifty-eight patients were enrolled. The ORRs of the primary and recurrent groups were 98.2% and 95.1%, respectively, with no statistically significant difference (χ2= 2.032, Ρ = 0.362). The primary group having a significantly longer PFS time than the recurrent group (Ρ < 0.001). However, there was no significant difference in the 1-, 3-, and 5-year OS rates between the two groups (Ρ = 0.218). Multivariate analysis revealed that primary or recurrent HCC and the Child‒Pugh score were significant prognostic factors for PFS, whereas the serum albumin level was a significant prognostic factor for OS.

Conclusion

TACE plus RFA has similar clinical efficacy and safety for both primary and recurrent early HCC. Compared with patients with primary HCC, those with recurrent disease had significantly shorter PFS times.

Machine learning models including preoperative and postoperative albumin-bilirubin score: short-term outcomes among patients with hepatocellular carcinoma

BACKGROUND

We sought to assess the impact of various perioperative factors on the risk of severe complications and post-surgical mortality using a novel maching learning technique.

METHODS

Data on patients undergoing resection for HCC were obtained from an international, multi-institutional database between 2000 and 2020. Gradient boosted trees were utilized to construct predictive models.

RESULTS

Among 962 patients who underwent HCC resection, the incidence of severe postoperative complications was 12.7% (n = 122); in-hospital mortality was 2.9% (n = 28). Models that exclusively used preoperative data achieved AUC values of 0.89 (95%CI 0.85 to 0.92) and 0.90 (95%CI 0.84 to 0.96) to predict severe complications and mortality, respectively. Models that combined preoperative and postoperative data achieved AUC values of 0.93 (95%CI 0.91 to 0.96) and 0.92 (95%CI 0.86 to 0.97) for severe morbidity and mortality, respectively. The SHAP algorithm demonstrated that the factor most strongly predictive of severe morbidity and mortality was postoperative day 1 and 3 albumin-bilirubin (ALBI) scores.

CONCLUSION

Incorporation of perioperative data including ALBI scores using ML techniques can help risk-stratify patients undergoing resection of HCC.

Improving clinical outcomes of patients with hepatocellular carcinoma: Role of antiviral therapy, conversion therapy, and palliative therapy

In this editorial, I comment on three articles published in the recent issue of the World Journal of Gastrointestinal Oncology. Hepatocellular carcinoma (HCC) is an important public health concern, and there are three articles on the theme of HCC in this issue. I focus on the articles by Mu et al, Chu et al, and Ma et al for this editorial. While these articles may be considered as low-quality evidence, and the results cannot be generalized to non-hepatitis-B or C virus patients, the discussion of the results is important. In addition, though all the articles are from China, the relevance of the results is not minuscule. As resection is the main form of curative treatment modality owing to a donor liver shortage, surgeons need to be aware that preoperative long-course antiviral therapy can improve clinical outcomes by reducing postoperative liver dysfunction and recurrence of HCC following resection. Similarly, patients with super-giant HCC (defined as ≥ 15 cm diameter) should also be carefully considered for liver resection, and if it is unresectable upfront, then a combination of liver-directed therapy and systemic therapy may downstage HCC. If, following downstaging, the patient qualifies for liver resection based on locally prevalent resectability criteria, then such therapy is labelled as conversion (from unresectable to resectable) therapy. In unresectable patients treated by a combination of treatment options, serological markers like neutrophil-to-lymphocyte ratio and alpha-fetoprotein are reported to predict treatment responses, thus enabling personalized medicine.

Comprehensive review of hepatocellular carcinoma with portal vein tumor thrombus: State of art and future perspectives

BACKGROUND

Despite advances in the diagnosis of patients with hepatocellular carcinoma (HCC), 70%-80% of patients are diagnosed with advanced stage disease. Portal vein tumor thrombus (PVTT) is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.

DATA SOURCES

A systematic search of MEDLINE (PubMed), Embase, Cochrane Library and Database for Systematic Reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases until December 2022 was conducted using free text and MeSH terms: hepatocellular carcinoma, portal vein tumor thrombus, portal vein thrombosis, vascular invasion, liver and/or hepatic resection, liver transplantation, and systematic review.

RESULTS

Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy. Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus, accurate identification of the subgroups of patients who may benefit from resection, as well as meticulous surgical technique. This review addressed five specific areas: (a) formation of PVTT; (b) classifications of PVTT; (c) controversies related to clinical guidelines; (d) surgical treatments versus non-surgical approaches; and (e) characterization of surgical techniques correlated with classifications of PVTT.

CONCLUSIONS

Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.

TACE-assisted multi-image guided radiofrequency ablation for the treatment of single hepatocellular carcinoma ≤ 5 cm: a retrospective study

Background/Objective

Treatment of hepatocellular carcinoma (HCC) with ablation alone often results in high rates of recurrence and metastasis, reaching up to 25.9% within two years. Therefore, this study aimed to examine the efficacy and safety of transarterial chemoembolization (TACE)-assisted multi-image guided radiofrequency ablation (RFA) for the treatment of stage Ia HCC according to the China liver cancer staging (CNLC).

Methods

This study enrolled and analyzed a total of 118 patients diagnosed with HCC, each with a single nodular lesion no larger than 5 cm, who received TACE-RFA as first-line therapy between February 1, 2014, and December 31, 2021. The median/mean follow-up period was 29.0 months [95% confidence interval (CI): 21.8-36.2 months] and 31.8 months (95% CI: 27.5-36.0 months), respectively. We assessed the treatment's effectiveness, potential complications, and survival rate.

Results

The technical success rate was 100% (118/118) after the initial treatment. Out of the total, 3 out of 118 patients (2.5%) developed local tumor progression (LTP) during the follow-up period. The median time for LTP was 29.0 months (95%CI: 21.9-36.1 months; mean: 31.5 months; range 1-92 months). At 1, 3, 5, and 7 years after treatment, the cumulative LTP rates were 0%, 4.6%, 4.6%, and 4.6%, respectively. The overall survival rates at 1, 3, 5, and 7 years were 100%, 95.2%, 95.2%, and 95.2%, respectively. In total, 28 patients experienced minor Grade B complications, and no major complications or treatment-related mortality occurred.

Conclusion

The treatment of CNLC stage Ia HCC using TACE-assisted multi-image-guided RFA was found to be both safe and feasible.

Can propensity score matching replace randomized controlled trials?

Randomized controlled trials (RCTs) have long been recognized as the gold standard for establishing causal relationships in clinical research. Despite that, various limitations of RCTs prevent its widespread implementation, ranging from the ethicality of withholding potentially-lifesaving treatment from a group to relatively poor external validity due to stringent inclusion criteria, amongst others. However, with the introduction of propensity score matching (PSM) as a retrospective statistical tool, new frontiers in establishing causation in clinical research were opened up. PSM predicts treatment effects using observational data from existing sources such as registries or electronic health records, to create a matched sample of participants who received or did not receive the intervention based on their propensity scores, which takes into account characteristics such as age, gender and comorbidities. Given its retrospective nature and its use of observational data from existing sources, PSM circumvents the aforementioned ethical issues faced by RCTs. Majority of RCTs exclude elderly, pregnant women and young children; thus, evidence of therapy efficacy is rarely proven by robust clinical research for this population. On the other hand, by matching study patient characteristics to that of the population of interest, including the elderly, pregnant women and young children, PSM allows for generalization of results to the wider population and hence greatly increases the external validity. Instead of replacing RCTs with PSM, the synergistic integration of PSM into RCTs stands to provide better research outcomes with both methods complementing each other. For example, in an RCT investigating the impact of mannitol on outcomes among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial, the baseline characteristics of comorbidities and current medications between treatment and control arms were significantly different despite the randomization protocol. Therefore, PSM was incorporated in its analysis to create samples from the treatment and control arms that were matched in terms of these baseline characteristics, thus providing a fairer comparison for the impact of mannitol. This literature review reports the applications, advantages, and considerations of using PSM with RCTs, illustrating its utility in refining randomization, improving external validity, and accounting for non-compliance to protocol. Future research should consider integrating the use of PSM in RCTs to better generalize outcomes to target populations for clinical practice and thereby benefit a wider range of patients, while maintaining the robustness of randomization offered by RCTs.

Establishment and Internal Validation of a Prognostic Score for Post-hepatectomy Liver Failure Based on Functional Liver Parameters Estimated via TC-99m GSA

Background The 99mTc-galactosyl human serum albumin (Tc-99m GSA) scintigraphy evaluates the future remnant liver function, which is an important prognostic factor for post-hepatectomy liver failure (PHLF). This study aimed to establish a new prognostic score for PHLF, including the functional liver parameters evaluated by Tc-99m GSA scintigraphy. Materials and methods This study reviewed a single-center, retrospective 368-patient database of those who underwent open and laparoscopic hepatectomy in Meiwa Hospital from January 2016 to October 2021. Moreover, 102 patients who underwent Tc-99m GSA scintigraphy following hepatectomy were analyzed. The index of blood clearance of the tracer was calculated from the uptake ratio of heart at 15 minutes to that at 3 minutes (HH15) and the index of hepatic accumulation was calculated from the uptake ratio of liver to liver plus heart at 15 minutes after the injection (LHL15) were calculated for the general functional parameters. The maximal removal rate of Tc-99m GSA (GSARmax) was also calculated, then the GSARmax of the remnant liver (GSARmax-RL) was estimated as the future remnant liver function depending on the hepatectomy. Multivariate analysis was conducted to identify the PHLF predictor, and then a risk-scoring system was established with the 1,000-times bootstrapped validation. Results PHLF (grade ≥ B) was observed in 13 of 102 patients. Multivariate analysis revealed that PHLF was independently predicted by GSARmax-RL (<0.26 mg/min) and LHL15 (<0.89). The risk score was assigned to each item and then classified into four subgroups, with a predicted PHLF of 3.7%, 14.4%, 42.8%, and 76.8%. Receiver operating characteristic (ROC) curve analysis demonstrated good discrimination (adjusted area under the curve (AUC) after bootstrapped validation, 0.779). The ROC curve analysis compared with other prognostic scores showed that the new model had the highest AUC values for accuracy. Conclusions The new prognostic score based on Tc-99m GSA scintigraphy could recognize patients with a high risk of progressing to PHLF and be helpful in planning therapeutic strategies.

A deep learning model for prediction of post hepatectomy liver failure after hemihepatectomy using preoperative contrast-enhanced computed tomography: a retrospective study

Objective

Post-hepatectomy liver failure (PHLF) remains clinical challenges after major hepatectomy. The aim of this study was to establish and validate a deep learning model to predict PHLF after hemihepatectomy using preoperative contrast-enhancedcomputed tomography with three phases (Non-contrast, arterial phase and venous phase).

Methods

265 patients undergoing hemihepatectomy in Sir Run Run Shaw Hospital were enrolled in this study. The primary endpoint was PHLF, according to the International Study Group of Liver Surgery's definition. In this study, to evaluate the proposed method, 5-fold cross-validation technique was used. The dataset was split into 5 folds of equal size, and each fold was used as a test set once, while the other folds were temporarily combined to form a training set. Performance metrics on the test set were then calculated and stored. At the end of the 5-fold cross-validation run, the accuracy, precision, sensitivity and specificity for predicting PHLF with the deep learning model and the area under receiver operating characteristic curve (AUC) were calculated.

Results

Of the 265 patients, 170 patients with left liver resection and 95 patients with right liver resection. The diagnosis had 6 types: hepatocellular carcinoma, intrahepatic cholangiocarcinoma, liver metastases, benign tumor, hepatolithiasis, and other liver diseases. Laparoscopic liver resection was performed in 187 patients. The accuracy of prediction was 84.15%. The AUC was 0.7927. In 170 left hemihepatectomy cases, the accuracy was 89.41% (152/170), and the AUC was 82.72%. The accuracy was 77.47% (141/182) with liver mass, 78.33% (47/60) with liver cirrhosis and 80.46% (70/87) with viral hepatitis.

Conclusion

The deep learning model showed excellent performance in prediction of PHLF and could be useful for identifying high-risk patients to modify the treatment planning.

Recent Advances in Locoregional Therapy of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is responsible for 90% of primary hepatic cancer cases, and its incidence with associated morbidity and mortality is growing worldwide. In recent decades, there has been a revolution in HCC treatment. There are three main types of locoregional therapy: radiofrequency ablation, transarterial chemoembolisation, and transarterial radioembolisation. This article summarises recent advances in locoregional methods.

Role of Transarterial Chemoembolization in the Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, transarterial chemoembolization (TACE) is the first-line recommendation for intermediate-stage HCC. In real-world clinical practice, TACE also plays an important role in early- and advanced-stage HCC. This review article by the experts from Chinese Liver Cancer Clinical Study Alliance (CHANCE) summarizes the available clinical evidence pertaining to the current application of TACE in patients with early-, intermediate-, and advanced-stage HCC. In addition, combination of TACE with other treatment modalities, especially immunotherapy, is reviewed.

The prognostic role of the AST/ALT ratio in hepatocellular carcinoma patients receiving thermal ablation combined with simultaneous TACE

BACKGROUND

To evaluate the prognostic value of the pre-treatment aspartate transaminase (AST)/alanine transaminase (ALT) ratio in hepatocellular carcinoma (HCC) patients receiving radiofrequency ablation (RFA)/microwave ablation (MWA) combined with simultaneous TACE.

METHODS

The data for 117 patients were retrospectively analyzed in this study. The endpoint of prognosis was overall survival (OS). The Youden index was used to choose the optimal cut-off value of the pre-treatment AST/ALT ratio for OS prediction. Univariate and multivariate analyses were used to identify independent risk factors, then integrated to establish the nomogram.

RESULTS

The AST/ALT ratio cut-off value for OS prediction was 0.89, and patients with a higher AST/ALT ratio had poorer OS. The median OS for the high-value AST/ALT group was not reached, while the median OS for the low-value AST/ALT group was 48.5 months (P = 0.0047). The univariate and multivariate analysis showed that AST/ALT ratio, AFP, and tumor numbers were independent prognostic indicators for OS. The integrated nomogram showed higher predictive accuracy for OS (C-index 0.674, 95%CI: 0.600-0.748).

CONCLUSIONS

The preoperative AST/ALT ratio could be a prognostic indicator for HCC patients receiving thermal ablation combined with simultaneous TACE.

Does size matter for resection of giant versus non-giant hepatocellular carcinoma? A meta-analysis

BACKGROUND

Research on long-term survival after resection of giant (≥ 10 cm) and non-giant hepatocellular carcinoma (HCC) (< 10 cm) has produced conflicting results.

AIM

This study aimed to investigate whether oncological outcomes and safety profiles of resection differ between giant and non-giant HCC.

METHODS

PubMed, MEDLINE, EMBASE, and Cochrane databases were searched. Studies designed to investigate the outcomes of giant vs non-giant HCC were included. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were postoperative complications and mortality rates. All studies were assessed for bias using the Newcastle–Ottawa Scale.

RESULTS

24 retrospective cohort studies involving 23747 patients (giant = 3326; non-giant = 20421) who underwent HCC resection were included. OS was reported in 24 studies, DFS in 17 studies, 30-d mortality rate in 18 studies, postoperative complications in 15 studies, and post-hepatectomy liver failure (PHLF) in six studies. The HR was significantly lower for non-giant HCC in both OS (HR 0.53, 95%CI: 0.50-0.55, P < 0.001) and DFS (HR 0.62, 95%CI: 0.58-0.84, P < 0.001). No significant difference was found for 30-d mortality rate (OR 0.73, 95%CI: 0.50-1.08, P = 0.116), postoperative complications (OR 0.81, 95%CI: 0.62-1.06, P = 0.140), and PHLF (OR 0.81, 95%CI: 0.62-1.06, P = 0.140).

CONCLUSION

Resection of giant HCC is associated with poorer long-term outcomes. The safety profile of resection was similar in both groups; however, this may have been confounded by reporting bias. HCC staging systems should account for the size differences.

Gadoxetic acid-enhanced MRI with a focus on LI-RADS v2018 imaging features predicts the prognosis after radiofrequency ablation in small hepatocellular carcinoma

Introduction

Gadoxetic acid-enhanced magnetic resonance imaging (MRI) contributes to evaluating the prognosis of small hepatocellular carcinoma (sHCC) following treatment. We have investigated the potential role of gadoxetic acid-enhanced MRI based on LI-RADS (Liver Imaging Reporting and Data System) v2018 imaging features in the prognosis prediction of patients with sHCC treated with radiofrequency ablation (RFA) as the first-line treatment and formulated a predictive nomogram.

Methods

A total of 204 patients with sHCC who all received RFA as the first-line therapy were enrolled. All patients had undergone gadoxetic acid-enhanced MRI examinations before RFA. Uni- and multivariable analyses for RFS were assessing using a Cox proportional hazards model. A novel nomogram was further constructed for predicting RFS. The clinical capacity of the model was validated according to calibration curves, the concordance index (C-index), and decision curve analyses.

Results

Alpha fetoprotein (AFP) > 100 ng/ml (HR, 2.006; 95% CI, 1.111-3.621; P = 0.021), rim arterial phase hyperenhancement (APHE) (HR, 2.751; 95% CI, 1.511-5.011; P = 0.001), and targetoid restriction on diffusion-weighted imaging (DWI) (HR, 3.289; 95% CI, 1.832-5.906; P < 0.001) were considered as the independent risk features for recurrence in patients with sHCC treated with RFA. The calibration curves and C-indexes (C-index values of 0.758 and 0.807) showed the superior predictive performance of the integrated nomogram in both the training and validation groups.

Discussion

The gadoxetic acid-enhanced MRI features based on LI-RADS v2018, including rim APHE, targetoid restriction on DWI, and the AFP level, are the independent risk factors of recurrence in patients with sHCC treated with RFA as the first-line therapy. The predictive clinical-radiological nomogram model was constructed for clinicians to develop individualized treatment and surveillance strategies.

External validation and improvement of the scoring system for predicting the prognosis in hepatocellular carcinoma after interventional therapy

Background

Currently, locoregional therapies, such as transarterial chemoembolization (TACE) and ablation, play an important role in the treatment of Hepatocellular carcinoma (HCC). However, an easy-to-use scoring system that predicts recurrence to guide individualized management of HCC with varying risks of recurrence remains an unmet need.

Methods

A total of 483 eligible HCC patients treated by TACE combined with ablation from January 1, 2017, to December 31, 2019, were included in the temporal external validation cohort and then used to explore possibilities for refinement of the original scoring system. We investigated the prognostic value of baseline variables on recurrence-free survival (RFS) using a Cox model and developed the easily applicable YA score. The performances of the original scoring system and YA score were assessed according to discrimination (area under the receiver operating curve [AUROC] and Harrell's concordance index [C-statistic]), calibration (calibration curves), and clinical utility [decision curve analysis (DCA) curves]. Finally, improvement in the ability to predict in the different scoring systems was assessed using the Net Reclassification Index (NRI). The YA score was lastly compared with other prognostic scores.

Results

During the median follow-up period of 35.6 months, 292 patients experienced recurrence. In the validation cohort, the original scoring system exhibited high discrimination (C-statistic: 0.695) and calibration for predicting the prognosis in HCC. To improve the prediction performance, the independent predictors of RFS, including gender, alpha-fetoprotein (AFP) and des-γ-carboxyprothrombin (DCP), tumor number, tumor size, albumin-to-prealbumin ratio (APR), and fibrinogen, were incorporated into the YA score, an improved score. Compared to the original scoring system, the YA score has better discrimination (c-statistic: 0.712VS0.695), with outstanding calibration and the clinical net benefit, both in the training and validation cohorts. Moreover, the YA score accurately stratified patients with HCC into low-, intermediate- and high-risk groups of recurrence and mortality and outperformed other prognostic scores.

Conclusion

YA score is associated with recurrence and survival in early- and middle-stage HCC patients receiving local treatment. Such score would be valuable in guiding the monitoring of follow-up and the design of adjuvant treatment trials, providing highly informative data for clinical management decisions.

Comparison of the Efficacy and Safety of Transarterial Chemoembolization Plus Microwave Ablation versus Surgical Resection in Patients with Solitary Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

Background

The liver resection for solitary large hepatocellular carcinoma (SLHCC) remains controversial due to the high risk of complications and recurrence after resection. This study aimed to compare the efficacy and safety of transcatheter arterial chemoembolization (TACE) plus microwave ablation (MWA) with resection for SLHCC.

Methods

We retrospectively analyzed a total of 148 patients who were treated with either TACE-MWA (n = 94) or resection (n = 54) for SLHCC (≥5 cm). A matched cohort composed of 86 patients was included after propensity score matching (PSM). The primary endpoint was overall survival (OS), and the secondary endpoints were progression-free survival (PFS) and safety.

Results

The TACE-MWA group was older with higher ALT and AST (all P < 0.05). After PSM, the 1-, 3-, and 5-year OS were 100%, 80.3%, and 51.0% in the TACE-MWA group, and 88.3%, 66.7%, and 39.4% in the liver resection group, respectively. The 1-, 3-, and 5-year PFS were 76.7%, 48.8%, and 19.6% in the TACE-MWA group, and 72%, 40.2%, and 22.6% in the liver resection group, respectively. There was no significant difference in OS and PFS between the two groups (all P > 0.05). For SLHCC patients with tumor size ≥7cm, TACE-MWA showed favorable OS than liver resection. The TACE-MWA group exhibited a lower rate of major complications and shorter hospital stay than the resection group.

Conclusion

TACE-MWA showed comparable efficacy to liver resection in patients with SLHCC, but better safety and shorter hospital stay. TACE-MWA might provide a longer OS than liver resection for SLHCC patients with tumor size ≥7cm.

Long‐term efficacy of no‐touch radiofrequency ablation in the treatment of single small hepatocellular carcinoma: A single center long‐term follow‐up study

OBJECTIVE

To evaluate the long-term efficacy of no-touch radiofrequency ablation (NT-RFA) for treating single hepatocellular carcinoma (HCC) less than 3 cm.

METHODS

A total of 331 patients with HCC less than 3 cm undergoing RFA in Southwest Hospital from 2015 to 2020 were analyzed retrospectively. All patients were divided into NT-RFA group (n = 113) and conventional RFA (C-RFA) group (n = 218). The survival rate, local tumor progression (LTP) and intrahepatic distant recurrence (IDR) of the two groups were calculated and compared.

RESULTS

A significant difference was observed in ablation range (p = 0.000) and safety margin (p = 0.000) between the two groups. The 1-, 2-, 3-, 4-and 5-year overall survival (OS) rates in NT-RFA and C-RFA group were 99.12%, 93.73%, 76.18%, 57.00%, 45.17% and 99.08%, 89.91%, 71.26%, 54.28%, 41.77%, respectively. There was no significant difference between the two groups (p = 0.281). The 1-, 2-, 3-, 4-and 5-year recurrence-free survival (RFS) rates in NT-RFA and C-RFA group were 78.51%, 52.59%, 41.02%, 34.36%, 30.92% and 68.81%, 44.95%, 30.88%, 23.73%, 22.88%, respectively. The two groups differed significantly (p = 0.044). The 1-, 3-and 5-year LTP-free survival rates in NT-RFA and C-RFA group were 87.12%, 74.99%, 72.32% and 75.75%, 65.52%, 65.52%, respectively. The two groups also differed significantly (p = 0.024). Furthermore, the RFS rates of D ≤ 2 cm subgroups in NT-RFA and C-RFA groups differed significantly (p = 0.037), while the RFS rates of 2 cm < D ≤ 3 cm subgroups in two groups showed no significant difference (p = 0.578).

CONCLUSIONS

The RFS rates of single HCC less than 3 cm treated by NT-RFA was significantly higher than that of C-RFA. Due to a larger ablation range and safety margin, NT-RFA could significantly reduce LTP and improve RFS. Dual-electrode NT-RFA can significantly improve the RFS rate of patients with HCC less than 2 cm, but there is no obvious advantage compared with C-RFA in the treatment of HCC over 2 cm.

Efficacy of texture analysis of pre-operative magnetic resonance imaging in predicting microvascular invasion in hepatocellular carcinoma

BACKGROUND

Presence of microvascular invasion (MVI) indicates poorer prognosis post-curative resection of hepatocellular carcinoma (HCC), with an increased chance of tumour recurrence. By present standards, MVI can only be diagnosed post-operatively on histopathology. Texture analysis potentially allows identification of patients who are considered ‘high risk’ through analysis of pre-operative magnetic resonance imaging (MRI) studies. This will allow for better patient selection, improved individualised therapy (such as extended surgical margins or adjuvant therapy) and pre-operative prognostication.

AIM

This study aims to evaluate the accuracy of texture analysis on pre-operative MRI in predicting MVI in HCC.

METHODS

Retrospective review of patients with new cases of HCC who underwent hepatectomy between 2007 and 2015 was performed. Exclusion criteria: No pre-operative MRI, significant movement artefacts, loss-to-follow-up, ruptured HCCs, previous hepatectomy and adjuvant therapy. Fifty patients were divided into MVI (n = 15) and non-MVI (n = 35) groups based on tumour histology. Selected images of the tumour on post-contrast-enhanced T1-weighted MRI were analysed. Both qualitative (performed by radiologists) and quantitative data (performed by software) were obtained. Radiomics texture parameters were extracted based on the largest cross-sectional area of each tumor and analysed using MaZda software. Five separate methods were performed. Methods 1, 2 and 3 exclusively made use of features derived from arterial, portovenous and equilibrium phases respectively. Methods 4 and 5 made use of the comparatively significant features to attain optimal performance.

RESULTS

Method 5 achieved the highest accuracy of 87.8% with sensitivity of 73% and specificity of 94%.

CONCLUSION

Texture analysis of tumours on pre-operative MRI can predict presence of MVI in HCC with accuracies of up to 87.8% and can potentially impact clinical management.

Role of interventional oncology in hepatocellular carcinoma: Future best practice beyond current guidelines

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths globally. Liver transplant remains the goal of curative treatment, but limited supply of organs decreases accessibility and prolongs waiting time to transplantation. Therefore, interventional oncology therapies have been used to treat the majority of HCC patients, including those awaiting transplant. The Barcelona Clinic Liver Cancer (BCLC) classification is the most widely used staging system in management of HCC that helps allocate treatments. Since its inception in 1999, it was updated for the fifth time in November 2021 and for the first time shaped by expert opinions outside the core BCLC group. The most recent version includes additional options for early-stage disease, substratifies intermediate disease into three groups, and lists alternates to Sorafenib that can double the expected survival of advanced-stage disease. The group also proposed a new BCLC staging schema for disease progression, and endorsed treatment stage migration (TSM) directly into the main staging and treatment algorithm. This article reviews the recent developments underlying the current BCLC guidelines and highlights ongoing research, particularly involving radioembolization, that will shape future best practice.

Effect of Transarterial Chemoembolization Plus Percutaneous Ethanol Injection or Radiofrequency Ablation for Liver Tumors

Background

The efficacy of the transarterial chemoembolization (TACE) process combined with percutaneous ethanol injection (PEI, TACE-P) or the radiofrequency ablation (RFA, TACE-R) process was found to be good when used for the treatment of patients suffering from early or intermediate hepatocellular carcinoma (eiHCC). The study was conducted to compare the efficacy and safety of the TACE-P with TACE-A processes followed during the treatment of patients with eiHCC.

Methods

A total of 241 patients suffering from eiHCC, subjected to TACE-P (147 patients) or TACE-R (94 patients) processes from January 1, 2014, to December 31, 2018, were retrospectively reviewed and included. The propensity score matching (PSM) method was used to reduce selection bias.

Results

The median overall survival (mOS) and progression-free survival (mPFS) of the TACE-P group were similar to those recorded for the TACE-R group (P>0.05) before using the PSM technique. Similar results were obtained post the use of the PSM technique. In the subgroup analysis after PSM, patients with single tumor (dimension: ≤5 cm), who were subjected to TACE-P-based treatment methods, exhibited worse tumor response than patients subjected to TACE-R-based methods (HR: 1.804, 95% CI: 1.083–3.005, P=0.023). Seven adverse events were reported. A statistically significant difference for all grades of adverse events (and grade III or IV adverse events) between the two groups (all P>0.05) was not reported.

Conclusion

The benefits and advantages of using the TACE-P based method was similar was those obtained using the TACE-R in patients with eiHCC, especially for patients with a single large tumor or multiple tumors.

Radiofrequency Hyperthermia Enhances Locally Delivered Oncolytic Immuno-Virotherapy for Pancreatic Adenocarcinoma

PURPOSE

To investigate the effect of radiofrequency hyperthermia (RFH)-enhanced oncolytic immuno-virotherapy on in vitro pancreatic adenocarcinoma cell line and in vivo rat pancreatic cancer model.

MATERIALS AND METHODS

Rat pancreatic adenocarcinoma cell line and 24 Lewis rats with orthotopic pancreatic adenocarcinomas underwent treatment with either (1) oncolytic virotherapy (talimogene laherparepvec [T-VEC]) plus RFH at 42 °C for 30 min; (2) oncolytic virotherapy-only; (3) RFH-only; or (4) saline (control). MTS assays and flow cytometry were used to analyze tumor cell viability and apoptosis levels 24 h after treatment. In the in vivo studies, bioluminescence optical/x-ray imaging and ultrasound imaging was used to assess tumor viability and size 7 and 14 days after treatment. Histopathologic analysis was performed after hematoxylin and eosin staining, TUNEL, Ki-67, and immunohistochemical staining with CD8 and ANK61.

RESULTS

Combination therapy (T-VEC + RFH) induced decreased cell viability and increased cell apoptosis compared to T-VEC alone, RFH alone, or control. Optical/x-ray imaging and ultrasound imaging demonstrated decreased tumor bioluminescent signal and tumor volume relative to baseline after combination therapy compared to T-VEC alone, RFH alone, or control. Histopathology demonstrated decreased tumor volume and cell proliferation, increased CD8⁺ T cell and NK cell infiltration in tumors treated with the combination therapy compared to other three groups.

CONCLUSION

RFH enhances locally delivered oncolytic immuno-virotherapy for pancreatic adenocarcinoma, with decreased cell viability and increased apoptosis observed after combination therapy in vitro, and decreased cell viability and tumor volume and increased immune cell infiltrate observed after combination therapy in vivo.

A Novel Nomogram Model to Predict the Recurrence-Free Survival and Overall Survival of Hepatocellular Carcinoma

Background

Treatments for patients with early‐stage hepatocellular carcinoma (HCC) include liver transplantation (LT), liver resection (LR), radiofrequency ablation (RFA), and microwave ablation (MWA), are critical for their long-term survival. However, a computational model predicting treatment-independent prognosis of patients with HCC, such as overall survival (OS) and recurrence-free survival (RFS), is yet to be developed, to our best knowledge. The goal of this study is to identify prognostic factors associated with OS and RFS in patients with HCC and develop nomograms to predict them, respectively.

Methods

We retrospectively retrieved 730 patients with HCC from three hospitals in China and followed them up for 3 and 5 years after invasive treatment. All enrolled patients were randomly divided into the training cohort and the validation cohort with a 7:3 ratio, respectively. Independent prognostic factors associated with OS and RFS were determined by the multivariate Cox regression analysis. Two nomogram prognostic models were built and evaluated by concordance index (C-index), calibration curves, area under the receiver operating characteristics (ROC) curve, time-dependent area under the ROC curve (AUC), the Kaplan–Meier survival curve, and decision curve analyses (DCAs), respectively.

Results

Prognostic factors for OS and RFS were identified, and nomograms were successfully built. Calibration discrimination was good for both the OS and RFS nomogram prediction models (C-index: 0.750 and 0.746, respectively). For both nomograms, the AUC demonstrated outstanding predictive performance; the DCA shows that the model has good decision ability; and the calibration curve demonstrated strong predictive power. The nomograms successfully discriminated high-risk and low-risk patients with HCC associated with OS and RFS.

Conclusions

We developed nomogram survival prediction models to predict the prognosis of HCC after invasive treatment with acceptable accuracies in both training and independent testing cohorts. The models may have clinical values in guiding the selection of clinical treatment strategies.

Transarterial Chemoembolization Combined With Radiofrequency Ablation Versus Hepatectomy for Hepatocellular Carcinoma: A Meta-Analysis

Background

Although many studies reported the effectiveness of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or surgical resection (SR) in the treatment of hepatocellular carcinoma (HCC), the efficacy of these two strategies remains controversial. Therefore, this meta-analysis aimed to evaluate and compare the efficacy of sequential use of TACE plus RFA (TACE + RFA) and SR alone in treating HCC.

Methods

Relevant studies with unmatched and propensity score-matched patients were identified by comprehensive search of MEDLINE, PubMed, EMBASE, Web of Science, and Cochrane electronic databases. Meta-analysis was conducted using Review Manager (RevMan) software version 5.4.1. Finally, 12 eligible studies were included in this study, including 11 case–control studies and 1 randomized controlled trial. The primary outcome of interest for this study was to compare the 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS), major complications, 5-year OS in different tumor diameters between the two treatment strategies, and hospital stay time.

Results

HCC patients who received TACE + RFA had a lower incidence of complication rates and shorter hospital stay time than those who received SR alone. Among these studies using propensity score-matched cohorts, SR had better 3- and 5-year OS than TACE + RFA, whereas there were no significant differences between TACE + RFA and SR regarding the 1-, 3-, and 5-year DFS. When the tumor diameter is longer than 3 cm, the 5-year OS rate is better when SR is selected.

Conclusion

There was no significant difference in the short-term survival outcomes between TACE + RFA and SR in HCC patients. Moreover, SR is superior to TACE + RFA in terms of long-term beneficial effects but may result in a higher risk of major complications and a longer hospital stay time.

Outcomes after primary and repeat thermal ablation of hepatocellular carcinoma with or without liver transplantation

OBJECTIVES

Thermal ablation (TA) is an established treatment for early HCC. There is a lack of data on the efficacy of repeated TA for recurrent HCC, resulting in uncertainty whether good oncologic outcomes can be obtained without performing orthotopic liver transplantation (OLTx). This study analyses outcomes after TA, with a special focus on repeat TA for recurrent HCC, either as a stand-alone therapy, or in relationship with OLTx.

METHODS

Data from a prospectively registered database on interventions for HCC in a tertiary hepatobiliary centre was completed with follow-up until December 2020. Outcomes studied were rate of recurrence after primary TA and after its repeat interventions, the occurrence of untreatable recurrence, OS and DSS after primary and repeat TA, and complications after TA. In cohorts matched for confounders, OSS and DSS were compared after TA with and without the intention to perform OLTx.

RESULTS

After TA, 100 patients (56·8%) developed recurrent HCC, of whom 76 (76·0%) underwent up to four repeat interventions. During follow-up, 76·7% of patients never developed a recurrence unamenable to repeat TA or OLTx. OS was comparable after primary TA and repeat TA. In matched cohorts, OS and DSS were comparable after TA with and without the intention to perform OLTx.

CONCLUSIONS

We found TA to be an effective and repeatable therapy for primary and recurrent HCC. Most recurrences can be treated with curative intent. There are patients who do well with TA alone without ever undergoing OLTx.

KEY POINTS

• Recurrent HCC after primary TA can often be treated effectively with repeat TA. Survival after repeat TA is comparable to primary TA. • In matched cohorts, outcomes after TA with and without subsequent waitlisting for OLTx are comparable. • There are patients who do well for many years with primary and repeat TA alone; some despite multiple recurrences.

Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma

BACKGROUND

 Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies.

MATERIALS AND METHODS

 The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years.

RESULTS AND CONCLUSIONS

 Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years.

KEY POINTS

· RFA and MWA are considered equal to surgical resection as a first-line therapy for the curative treatment of stage BCLC 0 and A HCCs with a diameter of up to 3 cm.. · For HCCs with a diameter between 3 and 5 cm, a combination of TACE and RFA or MWA is recommended. This combination therapy yields results comparable to those of surgical resection in terms of overall survival.. · Due to insufficient evidence, alternative ablation methods have only been used in individual cases and within the framework of studies. However, nonthermal methods, such as IRE, IBT, and, most recently, ECT, are a reasonable alternative for ablation of HCCs adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods..

CITATION FORMAT

· Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1768-0954.

Alpha-Fetoprotein+Alkaline Phosphatase (A-A) Score Can Predict the Prognosis of Patients with Ruptured Hepatocellular Carcinoma Underwent Hepatectomy

Background

This research is aimed at establishing a scoring system alpha-fetoprotein+alkaline phosphatase (A-A score) based on preoperative serum alpha-fetoprotein (AFP) and alkaline phosphatase (ALP) levels and to investigate its clinical significance in patients with ruptured hepatocellular carcinoma (rHCC) after hepatectomy.

Methods

175 ruptured hepatocellular carcinoma (HCC) patients treated with hepatectomy were included. Survival analysis was assessed by the Kaplan-Meier method. Prognostic factors were analyzed in a multivariate model. Preoperative serum AFP and ALP values are assigned a score of 1 if they exceed the threshold value and 0 if they are below the threshold value, A-A score is obtained by summing the scores of two variables (AFP, ALP), and the predictive values of AFP, ALP, and A-A score were compared by receiver operating characteristic curve (ROC) analysis, and subgroup analyses were performed to further evaluate the power of A-A scores.

Results

Of the 175 patients, 67 (38.3%) had an A-A score of 0, 72 (41.1%) had an A-A score of 1, and 36 (20.6%) had an A-A score of 2. In multivariate analysis, the A-A score, the BCLC stage, and the extent of resection were independent predictors of OS in patients with rHCC. The 1-, 3-, and 5-year OS and RFS in patients with an A-A score of 1 were better than those with an A-A score of 0 and worse than those with an A-A score of 1 (all p < 0.05). Based on the results of ROC analysis, the A-A score is superior to AFP or ALP alone in predicting the prognosis of patients with ruptured HCC. In subgroup analysis, A-A score could accurately predict the prognosis of patients with or without microvascular invasion (MVI) and with different Child-Pugh grades or gender.

Conclusions

The A-A score can effectively predict the prognosis of patients after hepatectomy of ruptured hepatocellular carcinoma. At the same time, it also has good evaluation ability in different subgroups.

Predictive Value of Preoperative Neutrophil-to-Lymphocyte Ratio in Patients with Hepatocellular Carcinoma after Transarterial Chemoembolization Combined with Radiofrequency Ablation

PURPOSE

To determine the predictive value of preoperative inflammatory markers in hepatocellular carcinoma (HCC) prognosis after transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA).

MATERIALS AND METHODS

A total of 161 patients with HCC who underwent TACE combined with RFA were enrolled in this retrospective study. Receiver operating characteristic (ROC) curve analysis was used to decide the cutoff value of the neutrophil-to-lymphocyte ratio (NLR), the lymphocyte-to-monocyte ratio (LMR), the platelet-to-lymphocyte ratio (PLR), and the prognostic nutritional index (PNI). The relationship between preoperative NLR, LMR, PLR, PNI, and survival outcomes was analyzed using Kaplan-Meier curves and multivariate Cox regression analyses.

RESULTS

The cutoff value of NLR for the best discrimination of HCC prognosis was 2.95. The median recurrence-free survival (RFS) of the low NLR (≤ 2.95) group was longer than that of the high NLR (>2.95) group (29 months vs. 20 months, P = 0.013). The median overall survival (OS) of the low NLR group was longer than that of the high NLR group (60 months vs. 38 months, P = 0.006). Multivariate analysis showed that the tumor size (≤ 3cm vs. >3cm), tumor number (single vs. multiple), and NLR (≤2.95 vs. >2.95) were independent predictors of the PFS and OS. LMR, PLR, and PNI did not have any prognostic significance.

CONCLUSION

NLR was confirmed as an independent predictive biomarker for hepatocellular carcinoma prognosis after TACE combined with RFA.

Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma

BACKGROUND

Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC.

METHODS

An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained.

RESULTS

Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality.

CONCLUSION

One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.

Efficacy and safety of various primary treatment strategies for very early and early hepatocellular carcinoma: a network meta-analysis

BACKGROUND

Several treatments are available for treatment of early and very early-stage Hepatocellular Carcinoma, also known as small Hepatocellular Carcinoma (SHCC). However, there is no consensus with regards to the efficacies of these methods. We aimed at identifying the most effective initial treatment strategy for SHCC through Bayesian network meta-analyses.

METHODS

Studies published between January, 2010, and February, 2021 were searched in EMBASE, Cochrane Library, PubMed and Web of science databases, and conference proceedings for trials. The included studies reported the survival outcomes of very early and early Hepatocellular Carcinoma patients subjected to radiofrequency ablation (RFA), microwave ablation (MWA), surgical resection (SR), transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), minimally invasive liver surgery (MIS), stereotactic body radiotherapy (SBRT) and cryoablation (CA). Then, data were extracted from studies that met the inclusion criteria. Patient survival data were retrieved from the published Kaplan-Meier curves and pooled. A Bayesian random-effects model was used to combine direct and indirect evidence.

RESULTS

A total of 2058 articles were retrieved and screened, from which 45 studies assessing the efficacies of 8 different treatments in 11,364 patients were selected. The included studies had high methodological quality. Recurrence free survival* (progression/recurrence/relapse/disease/tumor-free survival were combined and redefined as RFS*) and overall survival (OS) outcomes were highest in MIS-treated patients (HR 0·57, 95% confidence intervals [CI] 0·38-0·85; HR 0.48,95% CI 0.36-0.64, respectively), followed by SR-treated patients (HR 0.60, 95% CI 0.50-0.74; HR 0.62, 95% CI 0.55-0.72, respectively). TACE was highly efficacious (58.9%) at decreasing the rates of major complications. Similar findings were obtained through sensitivity analysis, and in most of the prognostic subgroups.

CONCLUSIONS

MIS and SR exhibited the highest clinical efficacies, however, they were associated with higher rates of complications. Ablation is effective in small tumors, whereas SBRT is a relatively promising treatment option for SHCC. More well-designed, large-scale randomized controlled trials should be performed to validate our findings.

Combined treatments in hepatocellular carcinoma: Time to put them in the guidelines?

The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma (HCC) we do have a far-reaching arsenal. Moreover, because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options. The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies, discussing their advantages and flaws in comparison to the current standard of care. One particular combination therapy seems to be in the forefront: Transarterial chemoembolization plus ablation for medium-size non-resectable HCC (3-5 cm), which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B. Not only does it improve the outcome in contrast to each individual therapy, but it also seems to have similar results to surgery. Also, the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC. Although the path of combination therapies in HCC is still filled with uncertainty and caveats, in the following years the hepatology and oncology fields could witness an HCC guideline revolution.

Hyperthermia ablation combined with transarterial chemoembolization versus monotherapy for hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND AIMS

The existing evidence has indicated that hyperthermia ablation (HA) and HA combined with transarterial chemoembolization (HATACE) are the optimal alternative to surgical resection for patients with hepatocellular carcinoma (HCC) in the COVID-19 crisis. However, the evidence for decision-making is lacking in terms of comparison between HA and HATACE. Herein, a comprehensive evaluation was performed to compare the efficacy and safety of HATACE with monotherapy.

MATERIALS AND METHODS

Worldwide studies were collected to evaluate the HATACE regimen for HCC due to the practical need for global extrapolation of applicative population. Meta-analyses were performed using the RevMan 5.3 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Thirty-six studies involving a large sample of 5036 patients were included finally. Compared with HA alone, HATACE produced the advantage of 5-year overall survival (OS) rate (OR:1.90; 95%CI:1.46,2.46; p < 0.05) without increasing toxicity (p ≥ 0.05). Compared with TACE alone, HATACE was associated with superior 5-year OS rate (OR:3.54; 95%CI:1.96,6.37; p < 0.05) and significantly reduced the incidences of severe liver damage (OR:0.32; 95%CI:0.11,0.96; p < 0.05) and ascites (OR:0.42; 95%CI:0.20,0.88; p < 0.05). Subgroup analysis results of small (≤3 cm) HCC revealed that there were no significant differences between the HATACE group and HA monotherapy group in regard to the OS rates (p ≥ 0.05).

CONCLUSIONS

Compared with TACE alone, HATACE was more effective and safe for HCC. Compared with HA alone, HATACE was more effective for non-small-sized (>3 cm) HCC with comparable safety. However, the survival benefit of adjuvant TACE in HATACE regimen was not found for the patients with small (≤3 cm) HCC.

Clinical practice of transarterial chemoembolization for hepatocellular carcinoma: consensus statement from an international expert panel of International Society of Multidisciplinary Interventional Oncology (ISMIO)

Importance

Transarterial chemoembolization (TACE) has been associated with a wide range of practice variations for hepatocellular carcinoma (HCC) between the East and the West. This considerable ambiguity may lead to the heterogeneous quality in treatment and have a negative impact on the role of TACE in the overall multidisciplinary HCC treatment system.

Objective

It may be a good start to establish a guideline worldwide to have this consensus from experts who represent east and west, although it does not cover all aspects of TACE.

Evidence Review

An international expert panel on TACE is convened to cluster the expert's opinions and summary a standard consensus. This panel committee consist of leading physicians in TACE on HCC from USA, France, Japan, Singapore, Korea, China, and so on. The first-round face-to-face consensus meeting was held during in Nanjing, China in October 2019. The second-round conference for revision of the consensus was held during the Annual Meeting of Chinese College of Interventionalists in August 2020 by a hybrid format of a Webinar and roundtable meeting. After several on-line revisions, the final manuscript was approved by all members of the panel in June 2021.

Findings

The consensus statements were organized into the following categories: patients' selection, performing the procedure, TACE outcomes, repeat TACE, TACE failure/refractory, and TACE-based combination treatments.

Conclusions and Relevance for Reviews

More and more evidences have showed the better outcomes with strategy of combined TACE with other local therapies such as ablations. The most-recently developing strategy of combined TACE with PD-1/PD-L1 plus tyrosine kinase inhibitor (TKI) agents has shined a light to the HCC patients, especially to those with high risk of tumor recurrence after treatment or TACE failure/refractory.

Chemoembolization Plus Microwave Ablation vs Chemoembolization Alone in Unresectable Hepatocellular Carcinoma Beyond the Milan Criteria: A Propensity Scoring Matching Study

Purpose

Transarterial chemoembolization (TACE) is recommended in patients with unresectable HCC beyond the Milan criteria (MC). However, the long-term efficacy of TACE remains unsatisfactory. Percutaneous microwave ablation (MWA) is a curative therapy for early-stage HCC that provides better local tumor control than TACE; however, MWA is limited for large or multifocal lesions. We aimed to compare treatment efficacy and downstaging rate following combined TACE-MWA and TACE alone in patients with unresectable HCC beyond the MC.

Patients and Methods

Patients with unresectable HCC beyond the MC who underwent either TACE-MWA (n=91) or TACE alone (n=140) at four medical institutions were included. Potential influencing factors on overall survival (OS) and progression-free survival (PFS) were included in the Cox regression analysis. Propensity-score matching of patients treated with TACE-MWA and TACE alone was performed. Differences in OS and PFS were compared with the Log rank test. Patients who met the University of California, San Francisco criteria were eligible for assessment of the probability of downstaging within the MC. Downstaging rate was compared between the two groups.

Results

In multivariate analysis, treatment with TACE alone was an independent predictor of poor PFS (P=0.011) and OS (P<0.001). Both PFS (P=0.043) and OS (P=0.002) were significantly higher in patients treated with TACE-MWA than those treated with TACE alone. The downstaging rate was higher in patients treated with TACE-MWA than those treated with TACE alone (P=0.039).

Conclusion

Compared with TACE alone, TACE-MWA may offer a survival benefit in terms of OS and PFS in HCC patients beyond the MC. Additionally, TACE-MWA may provide higher probability of downstaging within the MC than TACE alone, thereby increasing the possibility of liver transplantation.

Thermal ablation and immunotherapy for hepatocellular carcinoma: Recent advances and future directions

Hepatocellular carcinoma (HCC) is one of most common cancers that cause death in the world. Thermal ablation (TA) is an important alternative treatment method for HCC patients who are not appropriate for surgery or liver transplantation. Particularly for small and early HCCs, TA can be considered as the first-line curative treatment. However, local and distant recurrence rates are still high even though the TA equipment and technology develop rapidly. Immunotherapy is a novel systemic treatment method to enhance the anti-tumor immune response of HCC patients, which has the potential to reduce the tumor recurrence and metastasis. The combination of local TA and systemic immunotherapy for HCCs may be an ideal treatment for enhancing the efficacy of TA and controlling the recurrence. Herein we summarize the latest progress in TA, immunotherapy, and their combination for the treatment of patients with HCC and discuss the limitations and future research directions of the combined therapy.

In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

Conventional transarterial embolization (cTACE) has been proven to be effective for intermediate stage hepatocellular carcinoma (HCC), with a recent systematic review showing an overall survival (OS) of 19.4 months. Nevertheless, due to the rapid development of the systemic therapeutic landscape, the place of TACE is becoming questionable. Is there still a niche for TACE in the era of immunotherapy and combination treatments such as atezolizumab-bevacizumab, which has shown an OS of 19.2 months with excellent tolerance? The development of drug-eluting microspheres (DEMs) has led to the standardization of the technique, and along with adequate selection, it showed an OS of 48 months in a retrospective study. In order to increase treatment selectivity, new catheters have also been added to the TACE arsenal as well as the use of cone-beam CT (CBCT), which provides three-dimensional volumetric images and guidance during procedures. Moreover, the TACE indications have also widened. It may serve as a "bridging therapy" for liver transplantation candidates while they are on the waiting list, and it represents a valuable downstaging tool to transplantation criteria. The aim of this review is to explore the current data on the advancements of TACE and its future place amongst the growing panel of treatments.

Long-term Outcomes of Transcatheter Arterial Chemoembolization Combined With Radiofrequency Ablation as an Initial Treatment for Early-Stage Hepatocellular Carcinoma

IMPORTANCE

The long-term outcomes of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) are not determined.

OBJECTIVE

To report the long-term outcomes of TACE-RFA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed long-term follow-up data from a phase 3 randomized clinical trial of adults with early HCC conducted from October 2006 to June 2009. Participants were randomly assigned to the TACE-RFA group or the RFA group in a 1:1 ratio and followed up approximately 6 years after the trial was closed. Data analysis was performed March 2020.

EXPOSURE

In the TACE-RFA group, TACE was performed first, and RFA was done 2 weeks later.

MAIN OUTCOMES AND MEASURES

Overall survival (OS) and recurrence-free survival (RFS).

RESULTS

Of 189 patients who were included (mean [SD] age, 54.3 [12.0] years; 146 [77.2%] men), 94 and 95 patients were assigned to the TACE-RFA group and RFA group, respectively, with their baseline characteristics well matched. Three patients in each group were lost to follow-up. The 5-year and 7-year OS rates for the TACE-RFA group vs the RFA group were 52.0% and 36.4% vs 43.2% and 19.4%, respectively (hazard ratio [HR], 0.55; 95% CI, 0.39-0.78; P = .001). The 5-year and 7-year RFS rates for the TACE-RFA group vs the RFA group were 41.4% and 34.5% vs 27.4% and 18.1%, respectively (HR, 0.66; 95% CI, 0.49-0.89; P = .007). On subgroup analysis comparing patients who had tumors larger than 3 cm with those who had tumors 3 cm or smaller, the OS and RFS survival rates in the TACE-RFA group (HR, 3.20; 95% CI, 1.91-5.35, P < .001) were significantly better than those in the RFA group (HR, 2.03; 95% CI, 1.30-3.17; P = .002).

CONCLUSIONS AND RELEVANCE

In this cohort study, combined RFA and TACE was associated with better survival than RFA alone on long-term follow-up. Patients with tumors 3 cm or smaller did not benefit as well as patients with tumors larger than 3 cm from the combined treatment.

Efficacy of microwave ablation versus radiofrequency ablation for hepatocellular carcinoma: a propensity score analysis

Purpose

To evaluate the efficacy and safety of radiofrequency ablation (RFA) and new-generation microwave ablation (MWA) for the treatment of hepatocellular carcinoma (HCC).

Methods

The propensity score matching method was applied to patients with HCC treated with MWA (93 patients) or RFA (156 patients) at a single institution from January 2014 to April 2020. The local tumor progression (LTP), intrahepatic distant recurrence (IDR), and recurrence-free survival (RFS) of the two matched therapies were analyzed using the Kaplan–Meier method. Cox proportional hazard models were used to identify risk factors for LTP and RFS. The therapeutic effects and complications of the two treatments were also compared.

Results

The LTP, IDR, and RFS of MWA and RFA were equivalent (LTP: hazard ratio [HR] = 0.87; 95% confidence interval [95% CI] 0.36- 2.07; P = 0.746, IDR: HR = 1.03; 95% CI 0.61–1.73; P = 0.890, RFS: HR = 1.15; 95% CI 0.69–1.91; P = 0.566). Para-vessel lesions was the only risk factor for LTP, whereas age, previous treatment, Albumin-Bilirubin score, and tumor diameter were risk factors for RFS. On the other hand, the ablation time per nodule (6.79 ± 2.73 and 9.21 ± 4.90 min; P = 0.008) and number of sessions per nodule required to achieve technical success (1.16 ± 0.39 and 1.34 ± 0.57; P = 0.009) were significantly lower in MWA than in RFA. The major complication rate of MWA and RFA was also equivalent.

Conclusion

MWA and RFA have similar therapeutic effects and safety, although MWA has advantages over RFA regarding efficacy, including shorter ablation time and fewer sessions required.

Radiofrequency ablation of hepatocellular carcinoma: Prognostic factors and recent advances

With the improvement of technology and diagnostic level, radiofrequency ablation (RFA) has made rapid progress in the treatment of primary hepatocellular carcinoma (HCC) in the past two decades. Especially, the overall survival after the treatment of small HCCs by RFA can be comparable to that achieved by hepatic resection. The 10-year survival rates of RFA for HCC were 27.3%-46.1%, and for solitary HCC less than 3 cm, the 10-year survival rate is about 74.0%. RFA combined with other therapies can expand the indications of RFA treatment and benefit the survival of patients with HCC. The prognostic model of RFA for HCC provides a powerful tool for individualized clinical diagnosis and treatment.

A Comparison of Adverse Events Among Radiofrequency Ablation, Conventional Transarterial Chemoembolization (TACE) and Drug-Eluting Bead TACE in Treating Hepatocellular Carcinoma Patients

Background

There has been very limited investigation regarding the comparison of adverse events (AEs) among radiofrequency ablation (RFA), conventional transarterial chemoembolization (cTACE), and drug-eluting bead TACE (DEB-TACE) in treating HCC patients; therefore, the present study aimed to resolve this issue.

Methods

Two-hundred and forty-six HCC patients (with a total of 267 procedures [treatment times]) treated with RFA (73 patients with 79 procedures), cTACE (86 patients with 94 procedures), or DEB-TACE (87 patients with 94 procedures) were included. Demographic and clinical data were collected. The information on AEs was also retrieved and analyzed.

Results

Total AEs incidence was notably different among the RFA group, cTACE group, and DEB-TACE group and was the highest in cTACE group (86.2%), then in DEB-TACE group (76.6%), and the lowest in RFA group (63.3%). Regarding specific AEs incidence, the incidences of fever, fatigue, and nausea were distinctive among the three groups, while no distinctiveness was found in incidence of other AEs. Furthermore, multivariate logistic regression revealed that cTACE (versus RFA) was independently correlated with increased risk of total AEs, fatigue, and nausea/vomiting; however, the interventional therapies were not independently correlated with the risk of pain, fever or constipation. Other independent predictive factors for total AEs risk were male gender, bronchial asthma, and disease duration.

Conclusion

cTACE resulted in the highest AEs incidence compared with RFA and DEB-TACE in treating HCC patients.

Prognostic Values of Alpha-Fetoprotein and Des-Gamma-Carboxyprothrombin in Hepatocellular Carcinoma in China: An Analysis of 4792 Patients

Background

The importance of alpha-fetoprotein (AFP) and des-gamma-carboxyprothrombin (DCP) in hepatocellular carcinoma (HCC) has been studied extensively in Japan, where hepatitis C virus is the predominant aetiology of HCC. The clinical profiles of HCC regarding the state of AFP and DCP in a hepatitis B virus epidemic area have not been comprehensively investigated, and the value of these tumour markers in evaluating the response to treatment and the detection of recurrence has yet to be determined.

Patients and Methods

A total of 4792 patients treated in our centre were continuously analysed regarding accessible AFP and DCP data pre- and posttreatment. Baseline characteristics were summarized, and comparisons of progression-free survival (PFS) and overall survival (OS) rates were made independently. The prognostic significance of each factor was tested with the Cox proportional hazards model. Patients who had AFP and DCP data pretreatment, pre- and posttreatment, and those who were continuously monitored more than twice were analysed separately.

Results

A total of 2600 patients (53.4%) were positive for AFP and DCP; 362 (7.6%) and 1211 (25.3%) patients were AFP- or DCP-positive, respectively, and 619 patients (12.9%) were negative for both AFP and DCP. Patients in the AFP single-positive or double-negative groups had the best OS (P<0.001). Patients with less than 50% responses in AFP and DCP after treatments suffered from worse prognostic survival (P<0.001). In the multivariate analysis, elevated AFP and DCP were identified as independent prognostic factors of PFS and OS. In addition, different tumour markers were related to different clinical and pathological traits.

Conclusion

The present study comprehensively explored the clinical value of classical tumour markers for HCC using the “point-to-line” method. Positivity of pretreatment AFP and DCP or less than 50% treatment response rates exhibited more aggressive HCC, resulting in poor PFS and OS in HCC patients.

Liver stiffness measured by magnetic resonance elastography in early recurrence of hepatocellular carcinoma after treatment: A protocol for systematic review and meta analysis

BACKGROUND

With high diagnostic accuracy, magnetic resonance elastography (MRE) is a noninvasive tool and can be adopted to measure liver stiffness (LS). In this study, meta-analysis was carried out to further evaluate whether LS measured by MRE can predict early recurrence in patients with hepatocellular carcinoma (HCC).

METHODS

PUBMED, EMBASE, Web of Science, China National Knowledge Infrastructure, and Cochrane Library database were searched for studies related to LS measured by MRE in the prediction of recurrence in patients with HCC. Survival outcome was estimated by hazard ratios and 95% confidence intervals. Meta-analysis was conducted with the Stata 16.0.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide evidence support for LS measured by MRE in predicting the recurrence of HCC.

ETHICS AND DISSEMINATION

The private information from individuals will not be published. This systematic review also should not damage participants' rights. Ethical approval is not available. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/ OSF.IO / SURH3.

Prognostic Value of the Preoperative Lymphocyte-C-Reactive Protein Ratio in Hepatocellular Carcinoma Patients Treated with Curative Intent: A Large-Scale Multicentre Study

Purpose

This study aimed to evaluate the prognostic value of the lymphocyte-C-reactive protein ratio (LCR) score, a novel inflammation-based score based on lymphocytes and C-reactive protein, in hepatocellular carcinoma (HCC) patients treated with curative intent.

Patients and Methods

A total of 1158 HCC patients undergoing surgical resection or radiofrequency ablation with curative intent were recruited from 3 different centres and divided into a primary cohort (n=716) and a validation cohort (n=442). Univariate and multivariate analyses were performed to identify variables associated with overall survival (OS). The discriminatory accuracy of seven inflammation-based scores was compared by using the concordance index (C-index).

Results

The LCR score differentiated HCC patients into two groups with distinct prognoses (1-, 3-, and 5-year OS rates and median OS: 92.9%, 81.9%, 73.3% and 99.2 months and 79.8%, 56.6%, 49.7% and 69.1 months; P<0.001). Multivariate analysis showed that LCR score, AFP, ALBI score, tumour size, and TNM stage were independently associated with OS. When patients were stratified according to different disease states, the LCR score could still differentiate HCC patients into two groups with distinct prognoses (all P<0.005). The LCR score demonstrated a markedly superior C-index of 0.621 compared with the other inflammation-based scores (0.503–0.590). These findings were supported by the validation cohort.

Conclusion

The preoperative LCR score is a novel, stable, and clinically feasible prognostic marker for patients with HCC, independent of liver function, tumour characteristics, and treatment allocation and is superior to other inflammation-based scores in terms of its prognostic ability.

The Short-Term Efficacy of Novel No-Touch Combined Directional Perfusion Radiofrequency Ablation in the Treatment of Small Hepatocellular Carcinoma with Cirrhosis

BACKGROUND

No-touch combined directed perfusion radiofrequency ablation (NTDP-RFA) is a new technique for the treatment of hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the short-term efficacy of this new technique for the treatment of small HCC with cirrhosis.

METHODS

From January 2017 to March 2018, 56 consecutive patients treated with NTDP-RFA at our center were enrolled in this retrospective study. All NTDP-RFA procedures involved the use of internally cooled wet electrodes with a directional injection function, which can perform both intraelectrode cooling and extraelectrode saline perfusion. Survival curves were analyzed using Kaplan-Meier methods, and Cox proportional hazards regression analyses were used to assess predictors of tumor progression and overall survival. Operative characteristics and complications were also assessed.

RESULTS

No technical failure occurred, and the complete ablation rate after single NTDP-RFA treatment was 98.2%. The median tumor diameter and ablation time were 26 (18.0 - 28.0) mm and 8 (6 - 8) min, respectively. Mild complications occurred in five patients (8.9%) postoperatively, and the median hospital stay was 4 (4 - 5) days. In the 18 patients (32.1%) with poor liver function reserve (indocyanine green retention rate at 15 min > 15%, their liver function returned to normal on the third day after the postoperation. The 1- and 2-year local and distant progression rates were 1.7%, 7.1%, 3.5% and 10.7%, respectively.

CONCLUSIONS

NTDP-RFA in the treatment of small HCC with cirrhosis has a low incidence of complications and provides a high survival rate without local tumor progression.

Efficacy and Safety of Transarterial Chemoembolization for the Treatment of Unresectable Hepatocellular Carcinoma Associated with Bile Duct Tumor Thrombus: A Real-World Retrospective Cohort Study

Background

The occurrence of hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is rare. The aim of the study was to evaluate the effectiveness and safety of transarterial chemoembolization (TACE) for patients with unresectable HCC with BDTT.

Methods

This retrospective study was conducted on newly diagnosed HCC and BDTT patients who were initially treated with TACE or conservative management (CM) from 2009 to 2018. Survival outcomes of patients treated with TACE were compared with those of patients given CM. Multivariate analyses were performed to identify independent prognostic factors related to survival.

Results

Out of 100 patients included in this study, 40 patients underwent TACE, while the remaining 60 received CM. The median survival time of the TACE group was 8.0 months longer than that of the CM group (13.0 versus 5.0 months, P < 0.001). The 6-, 12-, 18-, 24-month overall survival (OS) rates were 90.0%, 52.5%, 22.5%, and 12.5%, respectively, for the TACE group compared with 26.7%, 8.3%, 5.0%, and 3.3%, respectively, for the CM group. Multivariate analyses showed that treatment allocation (hazard ratio [HR], 0.421; 95% confidence interval [CI], 0.243–0.730; P = 0.002), Child–Pugh status (HR, 2.529; 95% CI, 1.300–4.920; P = 0.006) and total bilirubin level (HR, 1.007; 95% CI, 1.004–1.009; P < 0.001) on first admission were independent predictors of OS. There was no procedure-related mortality within one month after TACE treatment.

Conclusion

TACE is a safe and effective treatment method that may improve the OS of patients with unresectable HCC with BDTT.