Evaluating the risk of hepatocellular carcinoma in patients with prominently elevated liver stiffness measurements by FibroScan: a multicentre study

Stromal inflammation, fibrosis and cancer: An old intuition with promising potential

It is now well established that the biology of cancer is influenced by not only malignant cells but also other components of the tumour microenvironment. Chronic inflammation and fibrosis have long been postulated to be involved in carcinogenesis. Chronic inflammation can promote tumorigenesis via growth factor/cytokine-mediated cellular proliferation, apoptotic resistance, immunosuppression; and free-radical-induced oxidative deoxyribonucleic acid damage. Fibrosis could cause a perturbation in the dynamics of the tumour microenvironment, potentially damaging the genome surveillance machinery of normal epithelial cells. In this review, we will provide an in-depth discussion of various diseases characterised by inflammation and fibrosis that have been associated with an increased risk of malignancy. In particular, we will present a comprehensive overview of the impact of alterations in stromal composition on tumorigenesis, induced as a consequence of inflammation and/or fibrosis. Strategies including the application of various therapeutic agents with stromal manipulation potential and targeted cancer screening for certain inflammatory diseases which can reduce the risk of cancer will also be discussed.

Computed Tomography-Measured Liver Volume Predicts the Risk of Hepatocellular Carcinoma Development in Chronic Hepatitis C Patients

AIM

In this retrospective cohort study, we evaluated the significance of liver volume in the prediction of hepatocellular carcinoma (HCC) in 277 chronic hepatitis C (CHC) patients who received dynamic computed tomography (CT) during surveillance.

METHODS

Liver volumes were measured on portal venous phase of CT images by using ImageJ software. Liver volume index, a ratio of the standard liver volume expected by weight and height to the measured liver volume, was calculated to adjust for normal variations. The cohort was randomly divided to derivation (n = 100) and validation sets (n = 177) for the generation of a liver volume-based Cox prediction model and validation of a liver volume-based nomogram, respectively.

RESULTS

The liver volume index was independent of weight or height, and it predicted further development of HCC (hazard ratio [HR] 16.30, 95% CI 6.70-39.62; p < 0.001). Liver cirrhosis, gamma-glutamyl transferase, and liver volume index were independent predictors of HCC, and nomogram-based prediction score from these three parameters identified high-risk patients at the cutoff of 110 in both derivation (p < 0.001) and validation cohort (p < 0.001).

CONCLUSION

Liver volume-based prediction model stratifies the risk of developing HCC in CHC patients whose initial dynamic CT study gave negative results.

Differential Imaging of Liver Tumors before and after Microwave Ablation with Electrode Displacement Elastography

Liver cancer is a leading cause of cancer-related deaths; however, primary treatment options such as surgical resection and liver transplant may not be viable for many patients. Minimally invasive image-guided microwave ablation (MWA) provides a locally effective treatment option for these patients with an impact comparable to that of surgery for both cancer-specific and overall survival. MWA efficacy is correlated with accurate image guidance; however, conventional modalities such as B-mode ultrasound and computed tomography have limitations. Alternatively, ultrasound elastography has been used to demarcate post-ablation zones, yet has limitations for pre-ablation visualization because of variability in strain contrast between cancer types. This study attempted to characterize both pre-ablation tumors and post-ablation zones using electrode displacement elastography (EDE) for 13 patients with hepatocellular carcinoma or liver metastasis. Typically, MWA ablation margins of 0.5-1.0 cm are desired, which are strongly correlated with treatment efficacy. Our results revealed an average estimated ablation margin inner quartile range of 0.54-1.21 cm with a median value of 0.84 cm. These treatment margins lie within or above the targeted ablative margin, indicating the potential to use EDE for differentiating index tumors and ablated zones during clinical ablations. We also obtained a high correlation between corresponding segmented cross-sectional areas from contrast-enhanced computed tomography, the current clinical gold standard, when compared with EDE strain images, with r2 values of 0.97 and 0.98 for pre- and post-ablation regions.

Viral Biomarkers for Hepatitis B Virus-Related Hepatocellular Carcinoma Occurrence and Recurrence

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the fourth leading cause of cancer-related death. The most common risk factor for developing HCC is chronic infection with hepatitis B virus (HBV). Early stages of HBV-related HCC (HBV-HCC) are generally asymptomatic. Moreover, while serum alpha-fetoprotein (AFP) and abdominal ultrasound are widely used to screen for HCC, they have poor sensitivity. Thus, HBV-HCC is frequently diagnosed at an advanced stage, in which there are limited treatment options and high mortality rates. Serum biomarkers with high sensitivity and specificity are crucial for earlier diagnosis of HCC and improving survival rates. As viral-host interactions are key determinants of pathogenesis, viral biomarkers may add greater diagnostic power for HCC than host biomarkers alone. In this review, we summarize recent research on using virus-derived biomarkers for predicting HCC occurrence and recurrence; including circulating viral DNA, RNA transcripts, and viral proteins. Combining these viral biomarkers with AFP and abdominal ultrasound could improve sensitivity and specificity of early diagnosis, increasing the survival of patients with HBV-HCC. In the future, as the mechanisms that drive HBV-HCC to become clearer, new biomarkers may be identified which can further improve early diagnosis of HBV-HCC.

Systematic review: Investigating the prognostic performance of four non-invasive tests in alcohol-related liver disease

BACKGROUND AND AIM

Mortality of alcohol-related liver disease (ArLD) is increasing, and liver fibrosis stage is the best mortality predictor. Non-invasive tests (NITs) are increasingly used to detect fibrosis, but their value as prognostic tests in chronic liver disease, and in particular in ArLD, is less well recognized. We aimed to describe the prognostic performance of four widely used NITs (Fibrosis 4 test [FIB4], Enhanced Liver Fibrosis [ELF] test, FibroScan, and FibroTest) in ArLD.

METHODS

Applying systematic review methodology, we searched four databases from inception to May 2020. Inclusion/exclusion criteria were applied to search using Medical Subject Heading terms and keywords. The first and second reviewers independently screened results, extracted data, and performed risk-of-bias assessment using Quality in Prognosis Studies tool.

RESULTS

Searches produced 25 088 articles. After initial screening, 1020 articles were reviewed independently by both reviewers. Eleven articles remained after screening for eligibility: one on ELF, four on FibroScan, four on FIB4, one on FIB4 + FibroScan, and one on FibroTest + FIB4. Area under the receiver operating characteristic curves for outcome prediction ranged from 0.65 to 0.76 for FibroScan, 0.64 to 0.83 for FIB4, 0.69 to 0.79 for FibroTest, and 0.72 to 0.85 for ELF. Studies scored low-moderate risk of bias for most domains but high risk in confounding/statistical reporting domains. The results were heterogeneous for outcomes and reporting, making pooling of data unfeasible.

CONCLUSIONS

This systematic review returned 11 papers, six of which were conference abstracts and one unpublished manuscript. While the heterogeneity of studies precluded direct comparisons of NITs, each NIT performed well in individual studies in predicting prognosis in ArLD (area under the receiver operating characteristic curves >0.7 in each NIT category) and may add value to prognostication in clinical practice.

Prognostic value of postoperative change in liver stiffness in patients with HBV-related hepatocellular carcinoma

Objective

To investigate the prognostic value of change in liver stiffness following surgery, in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC).

Methods

Patients with HBV-related HCC were included. Preoperative (baseline) liver stiffness and postoperative dynamic change in liver stiffness was evaluated.

Results

Out of 158 patients in total, postoperative liver stiffness was increased in 98 patients and decreased in 60 patients compared with baseline values. Kaplan-Meier analysis revealed that patients with elevated liver stiffness had significantly worse overall survival outcomes than those with decreased liver stiffness. Similar trends were observed for diseases-free survival and recurrence outcomes. Multivariate analyses showed that Child–Turcotte–Pugh score (hazard ratio [HR] 1.209) and liver stiffness changes (HR 1.891) were independent factors associated with overall survival. Liver stiffness changes (HR 1.521) and α-fetoprotein level (HR 1.210) were found to be independent factors for disease-free survival in patients with HCC.

Conclusion

Increased postoperative liver stiffness may be an independent risk factor of HCC prognosis. Patients with increased liver stiffness following surgery should undergo additional examinations during follow-up.

Proteoglycans as Mediators of Cancer Tissue Mechanics

Proteoglycans are a diverse group of molecules which are characterized by a central protein backbone that is decorated with a variety of linear sulfated glycosaminoglycan side chains. Proteoglycans contribute significantly to the biochemical and mechanical properties of the interstitial extracellular matrix where they modulate cellular behavior by engaging transmembrane receptors. Proteoglycans also comprise a major component of the cellular glycocalyx to influence transmembrane receptor structure/function and mechanosignaling. Through their ability to initiate biochemical and mechanosignaling in cells, proteoglycans elicit profound effects on proliferation, adhesion and migration. Pathologies including cancer and cardiovascular disease are characterized by perturbed expression of proteoglycans where they compromise cell and tissue behavior by stiffening the extracellular matrix and increasing the bulkiness of the glycocalyx. Increasing evidence indicates that a bulky glycocalyx and proteoglycan-enriched extracellular matrix promote malignant transformation, increase cancer aggression and alter anti-tumor therapy response. In this review, we focus on the contribution of proteoglycans to mechanobiology in the context of normal and transformed tissues. We discuss the significance of proteoglycans for therapy response, and the current experimental strategies that target proteoglycans to sensitize cancer cells to treatment.

Role of Fibroscan for early detection of hepatocellular carcinoma (HCC) in hepatitis C cirrhotic patients

Background

Liver cancer (HCC) ranks as the fifth most prevalent cancer worldwide and is ranked third as a common cause of death due to cancer. The benefit of Fibroscan in assessing the risk of developing liver cancer that was evaluated in this work was not fully demonstrated. The aim of this work was to study the role and clinical significance of Fibroscan for early detection of liver cancer in hepatitis C patients with cirrhosis.

Results

As regards binary logistic regression for predictors of HCC, it was found that Child C, AST, Fibroscan, and AFP were predictors for developing HCC. Liver stiffness values were significantly high in all groups, and the specific cutoff value for hepatocellular carcinoma detection was above 24 kPa in hepatitis C virus patients. Therefore, liver stiffness of more than 24 kPa can be considered as an independent risk factor for the development of liver cancer in HCV patients.

Conclusion

Liver stiffness of more than 24 kPa was an independent risk factor for developing new liver cancer in HCV patients.

Lipid droplets disrupt mechanosensing in human hepatocytes

Hepatocellular carcinoma (HCC) is the fourth-leading cause of cancer death in the world. Although most cases occur in stiff, cirrhotic livers, and stiffness is a significant risk factor, HCC can also arise in noncirrhotic livers in the setting of nonalcoholic fatty liver disease (NAFLD). We hypothesized that lipid droplets in NAFLD might apply mechanical forces to the nucleus, functioning as mechanical stressors akin to stiffness. We investigated the effect of lipid droplets on cellular mechanosensing and found that primary human hepatocytes loaded with the fatty acids oleate and linoleate exhibited decreased stiffness-induced cell spreading and disrupted focal adhesions and stress fibers. The presence of large lipid droplets in hepatocytes resulted in increased nuclear localization of the mechano-sensor Yes-associated protein (YAP). In cirrhotic livers from patients with NAFLD, hepatocytes filled with large lipid droplets showed significantly higher nuclear localization of YAP as compared with cells with small lipid droplets. This work suggests that lipid droplets induce a mechanical signal that disrupts the ability of the hepatocyte to sense its underlying matrix stiffness and that the presence of lipid droplets can induce intracellular mechanical stresses.NEW & NOTEWORTHY This work examines the impact of lipid loading on mechanosensing by human hepatocytes. In cirrhotic livers, the presence of large (although not small) lipid droplets increased nuclear localization of the mechanotransducer YAP. In primary hepatocytes in culture, lipid droplets led to decreased stiffness-induced cell spreading and disrupted focal adhesions and stress fibers; the presence of large lipid droplets resulted in increased YAP nuclear localization. Collectively, the data suggest that lipid droplets induce intracellular mechanical stress.

Non-invasive tests for the prediction of primary hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world and it is one of the main complications of cirrhosis and portal hypertension. Even in the presence of a well-established follow-up protocol for cirrhotic patients, to date poor data are available on predictive markers for primary HCC occurrence in the setting of compensated advanced chronic liver disease patients (cACLD). The gold standard method to evaluate the prognosis of patients with cACLD, beyond liver fibrosis assessed with histology, is the measurement of the hepatic venous pressure gradient (HVPG). An HVPG ≥10 mmHg has been related to an increased risk of HCC in cACLD patients. However, these methods are burdened by additional costs and risks for patients and are mostly available only in referral centers. In the last decade increasing research has focused on the evaluation of several, simple, non-invasive tests (NITs) as predictors of HCC development. We reviewed the currently available literature on biochemical and ultrasound-based scores developed for the non-invasive evaluation of liver fibrosis and portal hypertension in predicting primary HCC. We found that the most reliable methods to assess HCC risk were the liver stiffness measurement, the aspartate aminotransferase to platelet ratio index score and the fibrosis-4 index. Other promising NITs need further investigations and validation for different liver disease aetiologies.

Role of Liver Stiffness Measurement in Predicting HCC Occurrence in Direct-Acting Antivirals Setting: A Real-Life Experience

PURPOSE

The aim of this study was to evaluate the relationship between the liver stiffness measurement and the risk of developing hepatocellular carcinoma (HCC) in HCV cirrhotic patients undergoing new direct-acting antivirals.

METHODS

From April 2015 to April 2017, all consecutive HCV cirrhotic patients treated by direct-acting antivirals were enrolled. A liver stiffness measurement was computed at baseline, and an ultrasound evaluation was provided for all patients at baseline and every 6 months until 1 year after the stopping of the antiviral therapy. The diagnosis of HCC was performed according to international guidelines by imaging technique workup.

RESULTS

Two hundred and fifty-eight HCV patients with a diagnosis of cirrhosis were identified. The median liver stiffness was 25.5 kPa. Thirty-five patients developed HCC. Patients were divided into three groups, based on their liver stiffness: < 20 kPa (n = 72), between 20 and 30 kPa (n = 92) and > 30 kPa (n = 94). Compared to the < 20 kPa and 20-30 kPa groups, the > 30 kPa group showed a statistically significant increased risk of HCC (p = 0.019; HR 0.329; 95% CI 0.131-0.830). A ROC curve analysis to assess the overall predictive performance of liver stiffness measurement on the HCC risk was performed. The results allow us to identify a cutoff value of liver stiffness measurement equal to 27.8 kPa, which guarantees the highest sensitivity and specificity (respectively, 72% and 65%).

CONCLUSIONS

The data underline that the baseline liver stiffness measurement and ultrasound surveillance is a valuable tool for assessing the risk of HCC in cirrhotic patients undergoing the direct-acting antivirals treatment.

Liver stiffness measurement at complete virological response in hepatoma prediction for HBV-related cirrhosis patient with potent antiviral agent

Hepatocellular carcinoma (HCC) development is ameliorated with nucleos(t)ide agent (NA) therapy for hepatitis B virus (HBV)-related cirrhosis patients. This study investigates whether liver stiffness (LS) measurement at complete virological response (CVR) was useful in predicting HCC development. Between July 2006 and August 2016, HBV-related cirrhosis patients with potent NA (entecavir/tenofovir) with the first LS measurement during CVR and with serial LS were enrolled. Patients developing HCC 6 months after potent NA or before the first LS measurement were excluded. Three hundred and seventy-one patients were enrolled. The median follow-up was 5.6 and 3.8 years from potent NA treatment and the first LS measurement respectively. Twenty-seven patients developed HCC. The 1-, 3-, 5- and 7-year cumulated incidences of HCC occurrence were 0%, 2.8%, 5.8% and 9%, respectively. In addition to age > 57 years, LS > =21.5 kPa (HR: 3.86, 95%CI: 1.67-8.94) was an independent factor associated with HCC occurrence in multivariate analysis. However, the magnitude of change in LS was not associated with HCC development. For the first LS in HCC prediction, the performance was 0.636. There were two to thirteen LS measurements during CVR. The change in LS was classified into four patterns stratified by the first and serial LS. Compared with those with serial LS < 21.5 kPa, patients with LS > =21.5 kPa tend to have higher HCC occurrence (P = .062). In summary, LS at CVR was an independent factor associated with HCC development for HBV-related cirrhosis patients with potent NA. However, LS was not satisfactory in the prediction performance of HCC development.

Decreased liver stiffness by transient elastography indicates lower incidence of hepatocellular carcinoma in patients with chronic hepatitis B

The prognositc value of dynamic liver stiffness (LS) variation on hepatocellular carcinoma (HCC) incidence in patients with chronic hepatitis B (CHB) remains to be explored. We aim to compare HCC incidence in patients with compensated CHB-related cirrhosis with increased and decreased LS after nucleos(t)ide analog (NA) regimens.A total of 168 patients with CHB-related compensated cirrhosis were divided into groups according to LS variation post to NA treatment. The laboratory results of 2 groups were reviewed and investigated. The probability of HCC development among each group was analyzed and compared.A total of 168 patients with CHB with compensated cirrhosis received NA treatment and Fibroscan. Child-Pugh score, alanine aminotransferase, total bilirubin level, status of hepatitis B e antigen, and serum hepatitis B virus DNA level were compared between groups. The cumulative probability of HCC development in patients with decreased LS was significantly lower than in patients with increased LS (P < .05). Multi-variant analysis indicated that decreased LS was significantly associated with lower probability of HCC development (hazard ratio, 0.65; 95% confidence interval range, 0.33-0.84, P < .05).Decreased LS after NA treatment indicates a lower HCC incidence in patients with CHB with compensated cirrhosis.

Clinical significance of preoperative liver stiffness measurements in primary HBV-positive hepatocellular carcinoma

AIM

To analyze clinical significance of preoperative liver stiffness measurement (LSM) by FibroScan in postcurative resection hepatitis B virus (HBV) related hepatocellular carcinoma (HCC).

PATIENTS & METHODS

A total of 263 patients underwent preoperative LSM and curative operation for primary HBV-positive HCC were enrolled. The correlation between preoperative LSM and survival was analyzed.

RESULTS

All patients were stratified into two groups using the optimal cut-off value (13.2 kPa) of LSM using the receiver-operating characteristic. Patients with an LSM ≥13.2 kPa had poorer overall survival (median, 61.3 vs 48.2 months, hazard ratio: 0.15; p = 0.009) and recurrence-free survival (median, 60.4 vs 47.0 months; hazard ratio: 0.32; p = 0.011) than patients with an LSM <13.2 kPa and LSM also have been confirmed as independent predictor for survival for HCC.

DISCUSSION

This could potentially guide patient stratification and individualized treatment.

CONCLUSION

Preoperative LSM can be considered as an independent prognostic factor for HBV-positive HCC after curative resection.