A novel and validated prognostic index in hepatocellular carcinoma: the inflammation based index (IBI)

Tumor Growth Pattern and Intra- and Peritumoral Radiomics Combined for Prediction of Initial TACE Outcome in Patients with Primary Hepatocellular Carcinoma

Purpose

Non-invasive methods are urgently needed to assess the efficacy of transarterial chemoembolization (TACE) and to identify patients with hepatocellular carcinoma (HCC) who may benefit from this procedure. This study, therefore, aimed to investigate the predictive ability of tumor growth patterns and radiomics features from contrast-enhanced magnetic resonance imaging (CE-MRI) in predicting tumor response to TACE among patients with HCC.

Patients and Methods

A retrospective study was conducted on 133 patients with HCC who underwent TACE at three centers between January 2015 and April 2023. Enrolled patients were divided into training, testing, and validation cohorts. Rim arterial phase hyperenhancement (Rim APHE), tumor growth patterns, nonperipheral washout, markedly low apparent diffusion coefficient (ADC) value, intratumoral arteries, and clinical baseline features were documented for all patients. Radiomics features were extracted from the intratumoral and peritumoral regions across the three phases of CE-MRI. Seven prediction models were developed, and their performances were evaluated using receiver operating characteristic (ROC) and decision curve analysis (DCA).

Results

Tumor growth patterns and albumin-bilirubin (ALBI) score were significantly correlated with tumor response. Tumor growth patterns also showed a positive correlation with tumor burden (r = 0.634, P = 0.000). The Peritumor (AUC = 0.85, 0.71, and 0.77), Clinics_Peritumor (AUC = 0.86, 0.77, and 0.81), and Tumor_Peritumor (AUC = 0.87, 0.77, and 0.80) models significantly outperformed the Clinics and Tumor models (P < 0.05), while the Clinics_Tumor_Peritumor model (AUC = 0.88, 0.81, and 0.81) outperformed the Clinics (AUC = 0.67, 0.77, and 0.75), Tumor (AUC = 0.78, 0.72, and 0.68), and Clinics_Tumor (AUC = 0.82, 0.83, and 0.78) models (P < 0.05 or 0.053, respectively). The DCA curve demonstrated better predictive performance within a specific threshold probability range for Clinics_Tumor_Peritumor.

Conclusion

Combining tumor growth patterns, intra- and peri-tumoral radiomics features, and ALBI score could be a robust tool for non-invasive and personalized prediction of treatment response to TACE in patients with HCC.

Predictive value of platelet-to-lymphocyte and neutrophil-to-lymphocyte ratio in HCC treated with sorafenib and radioembolization

Background & Aims

Herein we used data derived from the SORAMIC trial to explore the predictive value of systemic inflammatory markers (neutrophil-to-lymphocyte ratio [NLR] and platelet-to-lymphocyte ratio [PLR]) in patients with advanced hepatocellular carcinoma (HCC) treated with sorafenib monotherapy or the combination of selective internal radiation therapy (SIRT)/sorafenib.

Methods

Patients randomized to sorafenib monotherapy or SIRT/sorafenib within the per-protocol population of the SORAMIC trial were evaluated in this exploratory post hoc analysis. The median baseline values of NLR and PLR were used as cut-off values to describe subgroups. Kaplan-Meier curves with log-rank tests were used to evaluate median survival in the sorafenib and SIRT/sorafenib arms in each subgroup. Multivariable Cox regression analysis was applied to eliminate the effect of confounding factors.

Results

A total of 275 patients with a median overall survival of 12.4 months were included in this analysis. The median NLR value of the cohort was 2.77 and the median PLR was 26.5. There was no significant difference in overall survival between the sorafenib and SIRT/sorafenib arms in patients with low NLR (p = 0.72) and PLR (p = 0.35) values. In patients with high NLR values, there was no statistically significant difference in median overall survival between SIRT/sorafenib and sorafenib cohorts (12.1 vs. 9.2 months, p = 0.21). In patients with high PLR values, overall survival in the SIRT/sorafenib arm was significantly longer than in the sorafenib arm (15.9 vs. 11.0 months, p = 0.029). This significant difference was preserved in the multivariable analysis (SIRT/sorafenib arm: hazard ratio 0.65, 95% CI 0.44-0.96, p = 0.03) incorporating age, Child-Pugh grade, and alpha-fetoprotein levels.

Conclusions

PLR is a potential predictive factor of benefit from additional SIRT in patients with HCC receiving sorafenib therapy. The potential predictive value of PLR should be further evaluated in future trials.

Impact and implications

Systemic therapies are the mainstay of treatment in patients with hepatocellular carcinoma at advanced stages. However, not all patients respond well to these treatments. In our analysis, using blood test parameters showing systemic inflammation status, we were able to identify patients who would benefit more from combined treatment with a locoregional treatment of radioembolization (or selective internal radiation therapy).

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Prognostic value of the systemic immune-inflammation index, systemic inflammation response index, and prognostic nutritional index in head and neck cancer

PURPOSE

This study sought to investigate the prognostic value of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and prognostic nutritional index (PNI) in patients with head and neck cancer.

METHODS

The data of 310 patients with head and neck cancer who were referred to the Radiation Oncology Clinic of Sivas Cumhuriyet University Faculty of Medicine (n = 271, 87%) and to S.B.U. Dr. Abdurrahman Yurtaslan Ankara Oncology Health Practice and Research Centre (n = 39, 13%) between January 2009 and March 2020 were retrospectively analysed. At the time of diagnosis, patients' neutrophil, lymphocyte, monocyte, platelet and albumin levels were used to calculate their SII, SIRI and PNI indices.

RESULTS

Multivariate analysis found the after variables to be independent prognostic factors for overall survival (OS): SII [hazard ratio (HR) 1.71, 95% confidence interval (CI) 1.18-2.47; p = 0.002] and PNI (HR 0.66, 95% CI 0.43-0.97; p = 0.038), stage (HR 2.11, 95% CI 1.07-4.16; p = 0.030), fraction technique (HR 0.49, 95% CI 0.28-0.85; p = 0.011) and age (HR 2.51, 95% CI 1.77-3.57; p = 0.001).The following variables were found to be independent prognostic factors for disease-free survival (DFS) in multivariate analysis: SII (HR 2.16, 95% CI 1.22-3.83; p = 0.008), fractionation technique (HR 0.17, 95% CI 0.004-0.64; p = 0.017) and age (HR 2.11, 95% CI 1.13-3.93; p = 0.019).

CONCLUSION

This study found a high SII to be an independent poor prognostic factor for both OS and DFS, while a low PNI was found to be an independent poor prognostic factor only for OS.

Machine learning prediction model for post- hepatectomy liver failure in hepatocellular carcinoma: A multicenter study

Introduction

Post-hepatectomy liver failure (PHLF) is one of the most serious complications and causes of death in patients with hepatocellular carcinoma (HCC) after hepatectomy. This study aimed to develop a novel machine learning (ML) model based on the light gradient boosting machines (LightGBM) algorithm for predicting PHLF.

Methods

A total of 875 patients with HCC who underwent hepatectomy were randomized into a training cohort (n=612), a validation cohort (n=88), and a testing cohort (n=175). Shapley additive explanation (SHAP) was performed to determine the importance of individual variables. By combining these independent risk factors, an ML model for predicting PHLF was established. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value, and decision curve analyses (DCA) were used to evaluate the accuracy of the ML model and compare it to that of other noninvasive models.

Results

The AUCs of the ML model for predicting PHLF in the training cohort, validation cohort, and testing cohort were 0.944, 0.870, and 0.822, respectively. The ML model had a higher AUC for predicting PHLF than did other non-invasive models. The ML model for predicting PHLF was found to be more valuable than other noninvasive models.

Conclusion

A novel ML model for the prediction of PHLF using common clinical parameters was constructed and validated. The novel ML model performed better than did existing noninvasive models for the prediction of PHLF.

Can alternative liver function scores facilitate the establishment of an indication for radioablative therapy in patients with hepatocellular carcinoma?

Background and purpose

ALBI and IBI are new scores to evaluate the liver function in patients with hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the prognostic abilities of those scores in patients treated with interstitial brachytherapy (iBT).

Materials and methods

190 patients treated with iBT between 01.01.2006 and 01.01.2018 were included in this study. The clinical target dose was 15 Gy. The patients were all in Child–Pugh stadium A or B and across the Barcelona Clinic Liver Cancer (BCLC) Stages 0–C. Retrospectively ALBI and IBI were calculated pre- and post-therapeutic until 6 months after iBT. Hazards ratios were calculated, and p values corrected using the false discovery rate according to Benjamini and Hochberg.

Results

The median overall survival was 23.5 months (CI 19–28.5 months), and the median progression-free survival was 7.5 months (CI 6–9 months). Elevated ALBI showed a significantly higher risk to die with a hazard ratio (HR) of 2.010 (ALBI 2 vs. 1) and 4082 (ALBI 3 vs. 1), respectively. The IBI did also show a higher risk with an HR of 1.816 (IBI 1 vs. 0) and 4608 (IBI 2 vs. 0), respectively. Even 3 months after therapy elevated ALBI and IBI showed poor overall survival. Concerning progression-free survival, ALBI and IBI could not provide any relevant additional information.

Conclusion

ALBI and IBI are useful tools to predict the overall survival in patients treated with iBT and might be helpful to assign the patients to the appropriate therapy.

Role of lymphocyte-related immune-inflammatory biomarkers in detecting early progression of Guillain-Barré syndrome

OBJECTIVES

This study aimed to investigate the role of peripheral neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelet to lymphocyte ratio (PLR) in the progression and severity of the Guillain-Barré syndrome (GBS).

METHODS

47 GBS patients and 50 age and sex-matched healthy controls (HC) were retrospectively included. Demographic and clinical assessment data were reviewed and abstracted. NLR, MLR, and PLR were calculated based on the peripheral blood tests by reviewing clinical data. The relationship between the Hughes' score and NLR, MLR, PLR levels was investigated.

RESULTS

The GBS patients had higher NLR levels (P < 0.001), MLR levels (P = 0.001) and PLR levels (P < 0.001) than those in HC. And patients with severe disability score (Hughes' score ≥ 3) had significantly higher NLR (P = 0.007), MLR (P = 0.04), PLR (P = 0.013). Spearman correlation analysis indicated that NLR was positively associated with the Hughes' score (r = 0.331, P = 0.023). In the patients with acute inflammatory demyelinating polyneuropathy (AIDP), Spearman correlation analysis indicated that NLR, MLR and PLR were positively associated to the Hughes' score (r = 0.825, P = 0.001 for NLR, r = 0.727, P = 0.005 for MLR, and r = 0.723, P = 0.005 for PLR).

CONCLUSIONS

NLR, MLR, and PLR may be indicators of disease activity in patients with GBS or AIDP. These parameters may benefit the active treatment of GBS patients with a high degree of disability.

Glasgow prognostic score predicts survival in patients with unresectable hepatocellular carcinoma treated with lenvatinib: a multicenter analysis

OBJECTIVE

The use of Glasgow prognostic score (GPS), calculated using the serum C-reactive protein and albumin levels, to predict the outcomes of patients with unresectable hepatocellular carcinoma (HCC) treated with lenvatinib was investigated in this study.

METHODS

A total of 508 patients with Child-Pugh class A HCC treated with lenvatinib were included in this study.

RESULTS

The median overall and progression-free survivals were 20.4 months [95% confidence interval (CI), 17.7-23.2 months] and 7.5 months (95% CI, 6.8-8.5 months), respectively. The median overall survivals of patients with a GPS of 0, 1, and 2 were 28.5, 16.0, and 9.1 months, respectively (P < 0.001). When adjusted for age, sex, performance status, etiology, α-fetoprotein, macroscopic vascular invasion, extrahepatic spread, history of sorafenib therapy, and GPS, a GPS of 1 [hazard ratio (HR), 1.664; 95% CI, 1.258-2.201; P < 0.001] and a GPS of 2 (HR, 2.664; 95% CI, 1.861-3.813; P < 0.001) were found to be independently associated with overall survival. The median progression-free survivals of patients with a GPS of 0, 1, and 2 were 8.8, 6.8, and 3.8 months, respectively (P < 0.001). When adjusted for the same factors of overall survival, a GPS of 2 (HR, 2.010; 95% CI, 1.452-2.784; P < 0.001) was found to be independently associated with progression-free survival. As the albumin-bilirubin with tumor node metastasis score increased, the proportion of patients with a GPS of 1 or 2 increased (P < 0.001).

CONCLUSIONS

GPS can be used to predict survival in patients with unresectable HCC who were treated with lenvatinib.

Prognostic and Predictive Factors in Patients with Advanced HCC and Elevated Alpha-Fetoprotein Treated with Ramucirumab in Two Randomized Phase III Trials

PURPOSE

Ramucirumab is an effective treatment for patients with advanced hepatocellular carcinoma (aHCC) and baseline alpha-fetoprotein (AFP) ≥400 ng/mL. We aimed to identify prognostic and predictive factors of response to ramucirumab in patients with aHCC with AFP ≥400 ng/mL from the phase III REACH and REACH-2 randomized trials.

PATIENTS AND METHODS

Patients with aHCC, Child-Pugh class A with prior sorafenib treatment were randomized in REACH and REACH-2 (ramucirumab 8 mg/kg or placebo, biweekly). Meta-analysis of individual patient-level data (pooled population) from REACH (AFP ≥400 ng/mL) and REACH-2 was performed. A drug exposure analysis was conducted for those with evaluable pharmacokinetic data. To identify potential prognostic factors for overall survival (OS), multivariate analyses were performed using a Cox proportional hazards regression model. To define predictors of ramucirumab benefit, subgroup-by-treatment interaction terms were evaluated.

RESULTS

Of 542 patients (316 ramucirumab, 226 placebo) analyzed, eight variables had independent prognostic value associated with poor outcome (geographical region, Eastern Cooperative Oncology Group performance score ≥1, AFP >1,000 ng/mL, Child-Pugh >A5, extrahepatic spread, high neutrophil-to-lymphocyte ratio, high alkaline phosphatase and aspartate aminotransferase). Ramucirumab survival benefit was present across all subgroups, including patients with very aggressive HCC [above median AFP; HR: 0.64; 95% confidence interval (CI): 0.49-0.84] and nonviral aHCC (HR: 0.56; 95% CI: 0.40-0.79). While no baseline factor was predictive of a differential OS benefit with ramucirumab, analyses demonstrated an association between high drug exposure, treatment-emergent hypertension (grade ≥3), and increased ramucirumab benefit.

CONCLUSIONS

Ramucirumab provided a survival benefit irrespective of baseline prognostic covariates, and this benefit was greatest in patients with high ramucirumab drug exposure and/or those with treatment-related hypertension.

C-reactive protein to albumin ratio predicts survival in patients with unresectable hepatocellular carcinoma treated with lenvatinib

We investigated the impact of C-reactive protein to albumin ratio (CAR) on predicting outcomes in 522 patients with unresectable hepatocellular carcinoma (HCC) treated with lenvatinib. We determined the optimal CAR cutoff value with time-dependent receiver operating characteristic curve analysis. Additionally, we clarified the relationship between CAR and liver function or HCC progression. Median overall survival was 20.0 (95% confidence interval (CI), 17.2-22.6) months. The optimal CAR cutoff value was determined to be 0.108. Multivariate analysis showed that high CAR (≥ 0.108) (hazard ratio (HR), 1.915; 95% CI, 1.495-2.452), Eastern Cooperative Oncology Group performance status ≥ 1 (HR, 1.429), and α-fetoprotein ≥ 400 ng/mL (HR, 1.604) were independently associated with overall survival. Cumulative overall survival differed significantly between patients with low versus high CAR (p < 0.001). Median progression-free survival was 7.5 (95% CI, 6.7-8.1) months. Multivariate analysis showed that age, CAR ≥ 0.108 (HR, 1.644; 95% CI, 1.324-2.043), and non-hepatitis B, non-hepatitis C etiology (HR, 0.726) were independently associated with progression-free survival. Cumulative progression-free survival differed significantly between patients with low versus high CAR (p < 0.001). CAR values were significantly higher as Japan Integrated Staging score increased (p < 0.001). In conclusion, CAR can predict outcomes in patients with unresectable HCC treated with lenvatinib.

Using Systemic Inflammatory Markers to Predict Microvascular Invasion Before Surgery in Patients With Hepatocellular Carcinoma

Background

Mounting studies reveal the relationship between inflammatory markers and post-therapy prognosis. Yet, the role of the systemic inflammatory indices in preoperative microvascular invasion (MVI) prediction for hepatocellular carcinoma (HCC) remains unclear.

Patients and Methods

In this study, data of 1,058 cases of patients with HCC treated in the First Affiliated Hospital of Sun Yat-sen University from February 2002 to May 2018 were collected. Inflammatory factors related to MVI diagnosis in patients with HCC were selected by least absolute shrinkage and selection operator (LASSO) regression analysis and were integrated into an “Inflammatory Score.” A prognostic nomogram model was established by combining the inflammatory score and other independent factors determined by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were used to evaluate the predictive efficacy of the model.

Results

Sixteen inflammatory factors, including neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, etc., were selected by LASSO regression analysis to establish an inflammatory score. Multivariate logistic regression analysis showed that inflammatory score (OR = 2.14, 95% CI: 1.63–2.88, p < 0.001), alpha fetoprotein (OR = 2.02, 95% CI: 1.46–2.82, p < 0.001), and tumor size (OR = 2.37, 95% CI: 1.70–3.30, p < 0.001) were independent factors for MVI. These three factors were then used to establish a nomogram for MVI prediction. The AUC for the training and validation group was 0.72 (95% CI: 0.68–0.76) and 0.72 (95% CI: 0.66–0.78), respectively.

Conclusion

These findings indicated that the model drawn in this study has a high predictive value which is capable to assist the diagnosis of MVI in patients with HCC.

Prognostic utility of systemic inflammatory markers and chronic hepatitis C virus infection status in hepatocellular carcinoma patients treated with local ablation

Background

Hepatocellular carcinoma (HCC) has high incidence and mortality worldwide. Local ablation using radiofrequency ablation (RFA) or microwave ablation (MWA) is potentially curative for early-stage HCC with outcomes comparable to surgical resection. We explored the influence of demographic, clinical, and laboratory factors on outcomes of HCC patients receiving ablation.

Methods

This retrospective cohort study included 221 HCC patients receiving local ablation at Mayo Clinic between January 2000 and October 2018, comprising 140 RFA and 81 MWA. Prognostic factors determining overall survival (OS) and disease-free survival (DFS) were identified using multivariate analysis.

Results

There was no clinically significant difference in OS or DFS between RFA and MWA. In multivariate analysis of OS, pre-ablation lymphocyte-monocyte ratio [Hazard ratio (HR) 0.7, 95% confidence interval (CI) 0.58–0.84, P = 0.0001], MELD score [HR 1.12, 95%CI 1.068–1.17, P <  0.0001], tumor number [HR 1.23, 95%CI 1.041–1.46, P = 0.015] and tumor size [HR 1.18, 95%CI 1.015–1.37, P = 0.031] were clinically-significant prognostic factors. Among HCC patients with chronic hepatitis C (HCV) infection, positive HCV PCR at HCC diagnosis was associated with 1.4-fold higher hazard of death, with 5-year survival of 32.8% vs 53.6% in HCV PCR-negative patients. Regarding DFS, pre-ablation lymphocyte-monocyte ratio [HR 0.77, 95%CI 0.66–0.9, P = 0.001], MELD score [HR 1.06, 95%CI 1.022–1.11, P = 0.002], Log² AFP [HR 1.11, 95%CI 1.033–1.2, P = 0.005], tumor number [HR 1.29, 95%CI 1.078–1.53, P = 0.005] and tumor size [HR 1.25, 95%CI 1.043–1.51 P = 0.016] were independently prognostic.

Conclusions

Pre-ablation systemic inflammation represented by lymphocyte-monocyte ratio is significantly associated with OS and DFS in HCC patients treated with local ablation. HCV viremia is associated with poor OS. Tumor biology represented by tumor number and size are strongly prognostic for OS and DFS while AFP is significantly associated with DFS only.

Inflammatory markers and long term hematotoxicity of holmium-166-radioembolization in liver-dominant metastatic neuroendocrine tumors after initial peptide receptor radionuclide therapy

PURPOSE

In patients with neuroendocrine tumor liver metastases, additional tumor reduction can be achieved by sequential treatment with [166Ho]-radioembolization after peptide receptor radionuclide therapy (PRRT). The aim of this study was to analyze hematotoxicity profiles, (i.e. lymphocyte and neutrophile toxicity) and the prognostic value of neutrophil-to-lymphocyte ratio (NLR) and thrombocyte-to-lymphocyte ratio (TLR).

METHODS

All patients included in the prospective HEPAR PLuS study were included in this study. Blood testing was performed at baseline (before radioembolization) and at regular intervals during 1-year follow-up. Radiological response was assessed at 3, 6, 9, and 12 months according to RECIST 1.1. Logistic regression was used to analyze the prognostic value of NLR and TLR on response.

RESULTS

Thirty-one patients were included in the toxicity analysis; thirty were included in the response analysis. Three weeks after radioembolization, a significant decrease in lymphocyte count (mean change - 0.26 × 109/L) was observed. Ten patients (32.2%) experienced grade 3-4 lymphocyte toxicity. This normalized at 6 weeks and 3 months after treatment, while after 6 months a significant increase in lymphocyte count was observed. An increase in NLR and TLR at 3 weeks, compared to baseline, significantly predicted response at 3 months (AUC = 0.841 and AUC = 0.839, respectively) and at 6 months (AUC = 0.779 and AUC = 0.765). No significant relation with survival was found.

CONCLUSIONS

Toxicity after sequential treatment with PRRT and [166Ho]-radioembolization is limited and temporary, while significant additional benefit can be expected. Change in NLR and TLR at 3-weeks follow-up may be valuable early predictors of response. Trial registration ClinicalTrials.gov, NCT02067988. Registered 20 February 2014, https://clinicaltrials.gov/ct2/show/record/NCT02067988 .

Prognosis of patients with hepatocellular carcinoma treated with immunotherapy - development and validation of the CRAFITY score

BACKGROUND & AIMS

Immunotherapy with atezolizumab plus bevacizumab represents the new standard of care in systemic front-line treatment of hepatocellular carcinoma (HCC). However, biomarkers that predict treatment success and survival remain an unmet need.

METHODS

Patients with HCC put on PD-(L)1-based immunotherapy were included in a training set (n = 190; 6 European centers) and a validation set (n = 102; 8 European centers). We investigated the prognostic value of baseline variables on overall survival using a Cox model in the training set and developed the easily applicable CRAFITY (CRP and AFP in ImmunoTherapY) score. The score was validated in the independent, external cohort, and evaluated in a cohort of patients treated with sorafenib (n = 204).

RESULTS

Baseline serum alpha-fetoprotein ≥100 ng/ml (hazard ratio [HR] 1.7; p = 0.007) and C-reactive protein ≥1 mg/dl (HR, 1.7; p = 0.007) were identified as independent prognostic factors in multivariable analysis and were used to develop the CRAFITY score. Patients who fulfilled no criterion (0 points; CRAFITY-low) had the longest median overall survival (27.6 (95% CI 19.5-35.8) months), followed by those fulfilling 1 criterion (1 point; CRAFITY-intermediate; 11.3 (95% CI 8.0-14.6) months), and patients meeting both criteria (2 points; CRAFITY-high; 6.4 (95% CI 4.8-8.1) months; p <0.001). Additionally, best radiological response (complete response/partial response/stable disease/progressive disease) was significantly better in patients with lower CRAFITY score (CRAFITY-low: 9%/20%/52%/20% vs. CRAFITY-intermediate: 3%/25%/36%/36% vs. CRAFITY-high: 2%/15%/22%/61%; p = 0.003). These results were confirmed in the independent validation set and in different subgroups, including Child-Pugh A and B, performance status 0 and ≥1, and first-line and later lines. In the sorafenib cohort, CRAFITY was associated with survival, but not radiological response.

CONCLUSIONS

The CRAFITY score is associated with survival and radiological response in patients receiving PD-(L)1 immunotherapy. The score may help with patient counseling but requires prospective validation.

LAY SUMMARY

The immunotherapy-based regimen of atezolizumab plus bevacizumab represents the new standard of care in systemic first-line therapy of hepatocellular carcinoma (HCC). Biomarkers to predict treatment outcome are an unmet need in patients undergoing immunotherapy for HCC. We developed and externally validated a score that predicts outcome in patients with HCC undergoing immunotherapy with immune checkpoint blockers.

Superiority of CRP-albumin-lymphocyte index (CALLY index) as a non-invasive prognostic biomarker after hepatectomy for hepatocellular carcinoma

BACKGROUND

We aimed to investigate whether a novel biomarker incorporating albumin, lymphocytes, and CRP can predict the prognosis for hepatocellular carcinoma (HCC) after hepatectomy.

METHODS

Between January 2011 and December 2013, 384 patients who underwent hepatectomy in four university hospitals in Japan were investigated as a discovery cohort. The CRP-Albumin-Lymphocyte (CALLY index) was defined as (Albumin × Lymphocyte)/(CRP × 10⁴). Patients with a CALLY index ≥5 (n = 200) were compared to those with an index <5 (n = 184). Next, validation was performed using 267 patients from three other university hospitals (external validation cohort).

RESULTS

The number of TNM Stage III and IV patients was significantly higher in the CALLY <5 group than the ≥5 group (p = 0.003). There was a significant difference in the 5-year survival rate (CALLY ≥5: 71% vs. <5: 46%; p < 0.001). Multivariate analysis identified the CALLY index as an independent factor of overall survival. Similarly, there was a significant difference in the 5-year survival rate between the CALLY ≥5 (73%) and <5 (48%) groups (p < 0.001), and the CALLY index was identified as an independent prognostic factor in the external validation cohort.

CONCLUSION

The CALLY index derived from CRP, albumin, and lymphocyte values is a promising predictive biomarker for postoperative prognosis of patients with HCC.

The Systemic Inflammatory Response Identifies Patients with Adverse Clinical Outcome from Immunotherapy in Hepatocellular Carcinoma

Systemic inflammation is a hallmark of cancer, and it has a pivotal role in hepatocellular carcinoma (HCC) development and progression. We conducted a retrospective study including 362 patients receiving immune check-point inhibitors (ICIs) across three continents, evaluating the influence of neutrophiles to lymphocytes ratio (NLR), platelets to lymphocytes ratio (PLR), and prognostic nutritional index (PNI) on overall (OS), progression free survival (PFS), and radiologic responses. In our 362 patients treated with immunotherapy, median OS and PFS were 9 and 3.5 months, respectively. Amongst tested inflammatory biomarkers, patients with NLR ≥ 5 had shorter OS (7.7 vs. 17.6 months, p < 0.0001), PFS (2.1 vs. 3.8 months, p = 0.025), and lower objective response rate (ORR) (12% vs. 22%, p = 0.034); similarly, patients with PLR ≥ 300 reported shorter OS (6.4 vs. 16.5 months, p < 0.0001) and PFS (1.8 vs. 3.7 months, p = 0.0006). NLR emerged as independent prognostic factors for OS in univariate and multivariate analysis (HR 1.95, 95%CI 1.45-2.64, p < 0.001; HR 1.73, 95%CI 1.23-2.42, p = 0.002) and PLR remained an independent prognostic factor for both OS and PFS in multivariate analysis (HR 1.60, 95%CI 1.6-2.40, p = 0.020; HR 1.99, 95%CI 1.11-3.49, p = 0.021). Systemic inflammation measured by NLR and PLR is an independent negative prognostic factor in HCC patients undergoing ICI therapy. Further studies are required to understand the biological mechanisms underlying this association and to investigate the predictive significance of circulating inflammatory biomarkers in HCC patients treated with ICIs.

Usefulness of neutrophil-to-lymphocyte ratio (NLR) as a prognostic predictor after treatment of hepatocellular carcinoma." Review article

The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker which has been investigated as a prognostic indicator in post-therapeutic recurrence and survival of patients with HCC. Our aim was to review all studies that assessed the prognostic value of pre-treatment NLR in predicting patient survival, cancer recurrence, and graft survival in patients undergoing various therapies for HCC. We searched the database of PubMed and Google Scholar to review all studies that have the word "NLR" and the word "HCC." We included all studies that assessed pre-treatment NLR as a prognostic factor in predicting outcomes in HCC patients. We excluded studies that assessed the correlation between post-treatment NLR or dynamic changes in NLR after treatment and HCC outcomes in an effort to minimize the confounding effect of each treatment on NLR. We reviewed 123 studies that studied the correlation between pre-treatment NLR and patient survival, 72 studies that evaluated the correlation between pre-treatment NLR and tumor recurrence, 21 studies that evaluated the correlation between NLR and tumor behavior, and 4 studies that assessed the correlation between NLR and graft survival. We found a remarkable heterogeneity between the methods of the studies, which is likely responsible for the differences in outcomes. The majority of the studies suggested a correlation between higher levels of pre-treatment NLR and poor outcomes. We concluded that NLR is a reliable and inexpensive biomarker and should be incorporated into other prognostic models to help determine outcomes following HCC treatment.

Artificial Intelligent Multi-Modal Point-of-Care System for Predicting Response of Transarterial Chemoembolization in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) ranks the second most lethal tumor globally and is the fourth leading cause of cancer-related death worldwide. Unfortunately, HCC is commonly at intermediate tumor stage or advanced tumor stage, in which only some palliative treatment can be used to offer a limited overall survival. Due to the high heterogeneity of the genetic, molecular, and histological levels, HCC makes the prediction of preoperative transarterial chemoembolization (TACE) efficacy and the development of personalized regimens challenging. In this study, a new multi-modal point-of-care system is employed to predict the response of TACE in HCC by a concept of integrating multi-modal large-scale data of clinical index and computed tomography (CT) images. This multi-modal point-of-care predicting system opens new possibilities for predicting the response of TACE treatment and can help clinicians select the optimal patients with HCC who can benefit from the interventional therapy.

Role of inflammatory markers in predicting hepatocellular carcinoma recurrence after liver transplantation

Background

Liver transplantation (LT) is the best treatment for selected patients with cirrhosis and small hepatocellular carcinoma (HCC) who are not candidates for resection. The proinflammatory effects of systemic inflammatory response have been linked with HCC. Therefore, the measurement of inflammatory markers represents a significant tool to limit recurrence after LT.

Results

There are eleven patients with HCC recurrence post-transplantation. Pre-transplantation AFP can predict HCC recurrence with the best cutoff value of > 17.8 ng/ml with a sensitivity of 82% and specificity of 70%. Post-transplantation CRP can predict HCC recurrence with the best cutoff value of > 0.85 (mg/dl) with a sensitivity of 73% and specificity of 71%. Other inflammatory markers NLR and PLR were not significant in predicting HCC recurrence. Moreover, HCC recurrence significantly affects the outcome of patients undergoing LT (p value < 0.001) with a worse prognosis.

Conclusion

Our results showed additional benefits of inflammatory markers as CRP to standard parameters in predicting HCC recurrence to refine recipient selection and achieve better survival outcomes post-LT.

Glasgow Prognostic Score and modified Glasgow Prognostic Score and survival in patients with hepatocellular carcinoma: a meta-analysis

Objective

To evaluate the association between inflammation-related markers, modified Glasgow Prognostic Score (mGPS) and Glasgow Prognostic Score (GPS), and survival outcome and recurrence risk in patients with hepatocellular carcinoma (HCC) after treatment.

Design

Systematic reviews and meta-analysis of cohort studies.

Date sources

Embase, Scopus, Web of Science and PubMed were searched through 10 March 2021.

Eligibility criteria

We included cohort studies that assessed the effect of pretreatment mGPS/GPS levels on survival outcomes in patients with HCC.

Data extraction and synthesis

Two researchers independently selected the data and reached a consensus. In case of disagreement, a third researcher was required to assist. The HRs and 95% CIs were used as the effect size indexes. Newcastle-Ottawa Scale was used to assess risk of bias and quality assessment of the included studies.

Results

The meta-analysis included 23 studies, most of which were retrospective. Participants were grouped according to the score of mGPS/GPS. When analysed into two groups (1/2 vs 0), the results showed that patients with a mGPS/GPS of 1 or 2 had poorer overall survival (OS) than those with a score of 0 (both p<0.001). When analysed into three groups (1 vs 0 and 2 vs 0), the results revealed that an mGPS/GPS of 2 is related to poorer OS in patients with HCC (HR=2.46, 95% CI 2.06 to 2.95, and HR=3.45, 95% CI 1.68 to 7.10, respectively). However, a GPS of 1 (p=0.005) but not an mGPS of 1 (p=0.177) had a significant association with OS. No association was found between mGPS/GPS and disease-free survival or recurrence-free survival.

Conclusion

GPS was more closely associated the survival in patients with HCC than mGPS. A higher GPS has an association with poorer survival. It can be combined with tumour staging to assess the OS of HCC more accurately.

PROSPERO registration number

CRD42021242049.

A combined prediction model for biliary tract cancer using the prognostic nutritional index and pathological findings: a single-center retrospective study

Background

The prognostic nutritional index, a marker of nutritional status and systemic inflammation, is a known biomarker for various cancers. However, few studies have evaluated the predictive value of the prognostic nutritional index in patients with biliary tract cancer. Therefore, we investigated the prognostic significance of the prognostic nutritional index, and developed a risk-stratification system to identify prognostic factors in patients with biliary tract cancer.

Methods

Between July 2010 and March 2021, 117 patients with biliary tract cancer were recruited to this single-center, retrospective study. The relationship between clinicopathological variables, including the prognostic nutritional index, and overall survival was analyzed using univariate and multivariate analyses. A P < 0.05 was considered statistically significant.

Results

The median age was 75 (range 38–92) years. Thirty patients had intrahepatic cholangiocarcinoma; 29, gallbladder carcinoma; 27, distal cholangiocarcinoma; 17, ampullary carcinoma; and 13, perihilar cholangiocarcinoma. Curative (R0) resection was achieved in 99 patients. In univariate analysis, the prognostic nutritional index (< 42), lymph node metastasis, carbohydrate antigen 19-9 level (> 20 U/mL), preoperative cholangitis, tumor differentiation, operation time (≥ 360 min), and R1–2 resection were significant risk factors for overall survival. The prognostic nutritional index (P = 0.027), lymph node metastasis (P = 0.040), and tumor differentiation (P = 0.006) were independent prognostic factors in multivariate analysis. A combined score of the prognostic nutritional index and pathological findings outperformed each marker alone, in terms of discriminatory power.

Conclusions

The prognostic nutritional index, lymph node metastasis, and tumor differentiation were independent prognostic factors after surgical resection in patients with biliary tract cancer. A combined prediction model using the prognostic nutritional index and pathological findings accurately predicted prognosis, and can be used as a novel prognostic factor in patients with biliary tract cancer.

Changes of immune cells in patients with hepatocellular carcinoma treated by radiofrequency ablation and hepatectomy, a pilot study

In this pilot study, we compared the dynamic changes of circulating immune cells between patients with hepatocellular carcinoma (HCC) who underwent radiofrequency ablation (RFA) and hepatectomy. Seventy-three patients were enrolled in this study. Flow cytometry assay was performed to determine the immune cells in the peripheral blood mononuclear cells (PBMCs) before treatment and on days 7, 14, and 28 after treatment. We found that in the RFA group, the circulating cluster of differentiation (CD)4+ cells, the CD4+/CD8+ ratio, and natural killer (NK) cells continued to increase, and the circulating CD8+ cells continued to decrease after the treatment. In contrast, in the surgery group, the circulating CD4+ cells and CD4+/CD8+ ratio decreased over the first seven postoperative days and then began to increase, and CD8+ cells decreased on the first 7 postoperative days and began to increase thereafter. The changes of immune cells in tumor tissues consisted of an increase in the number of CD4+ cells, CD8+ cells, CD3+ cells, and NK cells immediately after RFA. Our results show that postoperative immune function continued to improve after RFA, but after surgery, it decreased in the first week and started to improve thereafter. These findings are important for clinicians when selecting the appropriate therapy for HCC.

A comparison of prognostic performance of perioperative inflammation markers in surgical resection for hepatocellular carcinoma

BACKGROUND

Systemic inflammation correlates closely with tumor invasion and may predict survival in cancer patients. We aimed to compare the prognostic value of various inflammation-based markers in patients with hepatocellular carcinoma.

METHODS

We consecutively enrolled 1450 patients with primary hepatocellular carcinoma undergoing surgical resection at the medical center between 2005 and 2016 and assessed them through September 2018. Prognostic nutritional index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio along with their perioperative dynamic changes were analyzed regarding their predictive ability of postoperative disease-free survival and overall survival. We calculated the adjusted hazard ratio (HR) and 95% CI of the association between inflammation-based markers and survival using multiple Cox proportional hazards models. Youden's index of receiver operating characteristics curves was used to determine optimal cut-off points.

RESULTS

Prognostic nutritional index was an independent predictor for both disease-free survival (<50.87 vs ≥50.87, HR: 1.274, 95% CI, 1.071-1.517, p = 0.007) and overall survival (<46.65 vs ≥46.65, HR: 1.420, 95% CI, 1.096-1.842, p = 0.008). Besides, the relative change of neutrophil-to-lymphocyte ratio predicted overall survival (<277% vs ≥277%, HR: 1.634, 95% CI, 1.266-2.110, p < 0.001). Combination of both markers offered better prognostic performance for overall survival than either alone. Body mass index, liver cirrhosis, chronic kidney disease, and tumor diameter were significantly associated with both markers.

CONCLUSION

Prognostic nutritional index and perioperative relative change of neutrophil-to-lymphocyte ratio independently predict postoperative survival in patients undergoing surgical resection of hepatocellular carcinoma. These results provided important evidence for risk stratification and individualized anti-cancer therapy.

Predictive impact of prognostic nutritional index in early-stage hepatocellular carcinoma after operative microwave ablation

BACKGROUND

The prognostic nutritional index (PNI) is used to assess immune and nutritional status, and is a prognostic factor for several malignant tumors. However, little evidence exists regarding the predictive impact of prognostic nutritional index (PNI) after local ablation therapy for hepatocellular carcinoma (HCC). The aim of this study was to evaluate the value of PNI to predict recurrence and survival after operative microwave ablation in patients with early-stage HCC.

METHODS

This retrospective study included 341 patients who underwent operative microwave ablation for HCC in Barcelona Clinic Liver Cancer (BCLC) stage 0-A at our institute between 2007 and 2015. We analyzed overall survival (OS) and recurrence-free survival (RFS), and evaluated factors related to prognosis in multivariate Cox regression analyses.

RESULTS

The OS rates at 1, 3, 5, and 10 years after microwave ablation were 100%, 92.7%, 85.1%, and 57.5% in patients with high-PNI levels, and 96.5%, 78.2%, 59.7%, and 20.7% in patients with low-PNI levels, respectively (P < 0.001). The RFS rates at 1, 3, 5, and 10 years after microwave ablation were 96.3%, 75.2%, 55.4%, and 30.4% in patients with high-PNI levels, and 94.4%, 48.8%, 36.4%, and 13.1% in patients with low-PNI levels, respectively (P < 0.001). In multivariate analyses, preoperative PNI level was an independent prognostic factor for both OS and RFS.

CONCLUSION

Our results revealed the preoperative PNI level was a simple and novel predictive marker of survival and recurrence after microwave ablation in patients with early-stage HCC.

The population characteristics of the main leukocyte subsets and their association with chronic diseases in a community-dwelling population: a cross-sectional study

Aim:

To analyse the characteristics of the main leukocyte subsets and elucidate their distributions amongst the natural population. We wanted to determine whether leukocyte subsets are potential biomarkers to evaluate the risk of common chronic diseases.

Background:

The peripheral blood leukocyte count is a routine exam performed to detect pathogen infections. Recently, subsets of white blood cells and their homeostasis have shown strong associations with some chronic diseases. Therefore, studies aiming to discover whether the distribution of leukocyte counts and its subsets are useful for predicting health conditions are worthwhile.

Methods:

This cross-sectional study analysed 10 564 residents from the basic public health service project of the Health Checkup Program performed by the BaiYun Community Health Service Center. Data on demographic information, physical measurements, medical history, and routine blood examination parameters were collected using questionnaires and health check-ups. Restricted cubic spline incorporated into logistic regression analysis was performed to evaluate the association between subsets of leukocytes and common chronic diseases.

Findings:

The counts of leukocytes and their subsets in males were higher than those in females amongst all age groups, yet the percentages of lymphocytes and neutrophils did not present sex-specific differences. A low lymphocyte count and percentage were associated with old age. The neutrophil-to-lymphocyte ratio (NLR) in patients with hypertension was higher than that in the non-hypertensive population. The risk of NLR in the top quartiles was 1.17-fold higher than that in people in the lowest quartiles.

Conclusions:

The distributions of the white blood cell count and percentage were associated with age, sex, and body mass index (BMI). In addition to the immune barrier for pathogens, the NLR or monocyte-to-lymphocyte ratio (MLR) may be potentially used to indicate the risk of some chronic non-communicable diseases. Homeostasis of subsets of leukocytes may be an important biomarker for body health conditions.

Validation of the conventional Glasgow Prognostic Score and development of the improved Glasgow Prognostic Score in patients with stage 0-III colorectal cancer after curative resection

AIM

Many inflammation-nutrition scores, including the Glasgow Prognostic Score (GPS), have been reported as prognostic biomarkers in patients with colorectal cancer (CRC). We aimed to examine the predictive ability of the GPS and to improve the GPS.

METHODS

We included a total of 438 patients with stage 0-III CRC who underwent curative surgery from 2010 to 2013. They were divided into a training set comprising 221 patients and a validation set comprising 227 patients, according to the date of surgery. In the training set, the GPS was verified using a Cox regression model, and cut-off values for C-reactive protein (CRP) and albumin for relapse-free survival (RFS) were calculated using receiver operating characteristics (ROC) curves. The improved GPS (iGPS) was developed with additional optimal cut-off values. We also compared the iGPS with the conventional GPS in the validation set.

RESULTS

The high GPS (GPS: 1-2) was correlated with RFS and overall survival (OS) in the training set. Cut-off values of CRP and albumin for RFS were 1.6 and 3.9, and we modified the GPS accordingly, adding the cut-off values of 2 and 3.9 to CRP and albumin, respectively. In the validation set, a high iGPS was an independent prognostic factor for RFS (hazard ratio [HR]: 2.273; 95% confidence interval [CI]: 1.212-4.364; P = .011), although the conventional GPS was not.

CONCLUSION

The iGPS was a more accurate prognostic predictor for patients with stage 0-III CRC.

Prognostic value and association of sarcopenic obesity and systemic inflammatory indexes in patients with hepatocellular carcinoma following hepatectomy and the establishment of novel predictive nomograms

Background

The specific impacts of sarcopenic obesity (SO) on hepatocellular carcinoma (HCC) and the association between SO and systemic inflammation remain unclear. This study aimed to investigate the prognostic value and association of SO and systemic inflammation with outcomes after hepatectomy for HCC and develop novel nomograms based on SO and inflammatory indexes for survival prediction.

Methods

We retrospectively enrolled 452 patients with HCC who underwent radical hepatectomy between January 2012 and March 2015 in Fujian Provincial Hospital as the training cohort. In addition, 275 patients during the same period were enrolled as the external validation cohort. Patients were classified into different groups according to the presence of sarcopenia and obesity. Different inflammation indexes were evaluated to select the best predictor of overall survival (OS) and recurrence-free survival (RFS). Univariate and multivariate logistic regression were performed to investigate the associations between inflammatory indexes and SO. The inflammatory indexes with the highest predictive values and SO were selected for subgroup analyses to establish a novel classification system: the SOLMR grade. SOLMR grades identified in the multivariate Cox analysis were selected to construct novel nomograms for OS and RFS.

Results

SO (P<0.001) was an independent risk factor for OS and RFS. The lymphocyte-monocyte ratio (LMR) had the highest areas under the receiver operating characteristic (ROC) curves (AUCs) for OS (P<0.001) and RFS (P<0.001) and was identified as an independent factor of SO (P=0.001). SO and the LMR were selected to establish the SOLMR grade. Multivariate Cox analysis revealed that SOLMR grade was a significant independent predictor of OS (P<0.001) and RFS (P<0.001). Nomograms based on SOLMR grades were generated and accurately predicted 1-, 3- and 5-year OS and RFS in HCC patients. The C-index of the novel nomograms was higher than those of the other conventional staging systems (P<0.001).

Conclusions

Both SO and the LMR were independent risk factors for OS and RFS in HCC patients after hepatectomy. The LMR was an independent factor of SO. The novel nomograms developed from the SOLMR grading system combining SO with the LMR provide good prognostic estimates of the outcomes of HCC patients.

Changes in hepatocellular carcinoma aggressiveness characteristics with an increase in tumor diameter

BACKGROUND

Hepatocellular carcinoma prognosis depends on both liver and tumor determinants, especially on maximum tumor diameter, multifocality, and presence of portal vein thrombosis, despite apparently complete tumor removal by resection or liver transplantation.

AIMS

To examine parameters of hepatocellular carcinoma aggressiveness as tumor size increases.

METHODS

A large hepatocellular carcinoma database was examined for trends in serum alpha-fetoprotein and the percentage of patients with macroscopic portal vein thrombosis or tumor multifocality.

RESULTS

A total of 13,016 hepatocellular carcinoma patients were identified having full tumor and survival data. Of these, 76.56% were male and 23.44% were female, with a median age of 64.4 years. We found that as the maximum tumor diameter increased, there was a significant trend for increased alpha-fetoprotein levels (P<0.001) and an increased percentage of patients with either portal vein thrombosis or tumor multifocality, each P<0.0001. Furthermore, the increases of both alpha-fetoprotein and portal vein thrombosis were proportionately greater than the related maximum tumor diameter increases. These trends of increased alpha-fetoprotein, portal vein thrombosis, and multifocality with increasing maximum tumor diameter had non-linear patterns. Within alpha-fetoprotein and multifocality trends, there were identifiable sub-trends associated with specific maximum tumor diameter ranges.

CONCLUSIONS

The greater fold-increases in alpha-fetoprotein and portal vein thrombosis compared with increases in maximum tumor diameter imply that hepatocellular carcinoma characteristics may change with increasing size to a more aggressive phenotype, suggesting that follow-up tumor sampling might be useful, in addition to baseline tumor sampling, for optimal therapeutic choices to be made.

Multi-institutional validation of novel models for predicting the prognosis of patients with huge hepatocellular carcinoma

The population of patients with huge hepatocellular carcinoma (H-HCC diameter > 10.0 cm) is an odd group that is not well adjudicated in the current staging systems, whose prognosis after curative resection varies. We aimed to develop novel models to predict the long-term outcomes of patients with H-HCC without portal vein tumor thrombus after hepatectomy. There were 1076 H-HCC patients enrolled who underwent curative liver resection in five institutions in China. In total, 670 patients were recruited from our center and randomly divided into the training cohort (n = 502) and internal validation (n = 168) cohorts. Additionally, 406 patients selected from other four centers as the external validation cohort. Novel models were constructed based on independent preoperative and postoperative predictors of postsurgical recurrence (PSR) and postsurgical mortality (PSM) determined in multivariable cox regression analysis. The predictive accuracy and discriminative ability of the model were measured using Harrell's concordance index (C index) and calibration curve and compared with five conventional HCC staging systems. PSR model and PSM model were constructed based on tumor number, microscopic vascular invasion, tumor differentiation, preoperative alpha-fetoprotein level, albumin-bilirubin grade, liver segment invasion, neutrophil-to-lymphocyte ratio or platelet-to-neutrophil ratio, and surgical margin or intraoperative blood transfusion. The C-indexes were 0.84 (95% CI, 0.78-0.90) and 0.85 (95% CI, 0.78-0.91) for the PSR and PSM models, respectively, which were substantially higher than those of the five conventional HCC staging systems (0.63-0.75 for PSR; 0.66-0.77 for PSM). The two novel models achieved more accurate prognostic predictions of PSR and PSM for H-HCC patients after curative liver resection.

Platelet-lymphocyte ratio predicts survival in patients with hepatocellular carcinoma who receive lenvatinib: an inverse probability weighting analysis

OBJECTIVE

Lenvatinib, a newly developed molecularly targeted agent, has become available as a first-line therapy in patients with unresectable hepatocellular carcinoma (HCC). The platelet-to-lymphocyte ratio (PLR) has been associated with poor outcome in various malignancies, including HCC. In this study, we investigated the ability of PLR to predict outcomes in patients with unresectable HCC who received lenvatinib.

METHODS

Multivariate survival analysis was performed in 283 patients with unresectable HCC who received lenvatinib. In addition, the utility of PLR for predicting survival was clarified using an inverse probability weighting (IPW) analysis.

RESULTS

Cumulative overall survival at 100, 200, 300, 400, and 500 days was 95.2, 83.8, 68.3, 60.3, and 49.9%, respectively. Multivariate analysis with Cox proportional hazards modeling showed that PLR (≥150) [hazard ratio, 1.588; 95% confidence interval (CI), 1.039-2.428; P = 0.033], α-fetoprotein level, and Barcelona clinic liver cancer stage were independently associated with overall survival. Cumulative overall survival differed significantly between patients with low versus high PLR (P = 0.029). In addition, univariate analysis with Cox proportional hazards modeling adjusted by IPW showed that PLR (≥150) (hazard ratio, 1.396; 95% CI, 1.051-1.855; P = 0.021) was significantly associated with overall survival. Conversely, univariate analysis with Cox proportional hazards modeling adjusted only by IPW showed that PLR (≥150) (hazard ratio, 1.254; 95% CI, 1.016-1.549; P = 0.035) was significantly associated with progression-free survival. PLR values were not independently associated with therapeutic responses before or after IPW-adjusted logistic regression analysis.

CONCLUSIONS

PLR predicted overall survival in patients with unresectable HCC who received lenvatinib.

Serum levels of inflammatory markers CRP, ESR and albumin in relation to survival for patients with hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma is associated with several chronic inflammatory conditions. It is increasingly understood that the inflammation may be part of the carcinogenic process and prognostically important.

OBJECTIVE

To evaluate the serum levels of three inflammation markers in relation to survival in HCC patients.

METHODS

We retrospectively examined the serum levels of CRP, albumin and ESR, both singly and in combination, in relation to patient survival.

RESULTS

Survival worsened with increase in CRP or ESR or decrease in albumin levels. Combinations of CRP plus albumin or CRP plus ESR were associated with an even greater range of survival (3-fold), together with significant differences in maximum tumor diameter (PVT) and percent of patients with portal vein thrombosis (PVT). The triplet of CRP plus albumin plus ESR was associated with a sevenfold difference in survival, comparing low vs high parameter levels. These significant differences were found in patients with small or large tumors.

CONCLUSIONS

Combinations of CRP with albumin or ESR or all three parameters together significantly related to differences in survival and to differences in MTD and percent PVT, in patients with both small and large size HCCs.

Neutrophil-to-Lymphocyte Ratio on Admission is an Independent Risk Factor for the Severity of Neurological Impairment at Disease Onset in Patients with a First Episode of Neuromyelitis Optica Spectrum Disorder

PURPOSE

To investigate the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the severity of neurological impairment at disease onset in patients with a first episode of neuromyelitis optica spectrum disorder (NMOSD).

PATIENTS AND METHODS

This retrospective study included 259 patients with newly diagnosed NMOSD who were hospitalized at our institution between January 2013 and January 2020 (NMOSD group) and 169 healthy control subjects who underwent a physical examination at our hospital during the same period (control group). The clinical data collected included general information, past medical history, biochemical test results, imaging findings, NLR, AQP-4 antibody status, and initial Expanded Disability Status Scale score. A logistic regression model was used to analyze NLR as an independent risk factor for the severity of neurological impairment at disease onset in the NMOSD group. Receiver-operating characteristic curve analysis was used to evaluate the ability of the NLR to predict the severity of neurological impairment at disease onset in the NMOSD group and to determine its critical value.

RESULTS

The NLR was significantly higher in the NMOSD group than in the control group (P<0.001). In the NMOSD group, neurological impairment at disease onset was more severe in those with a high NLR than in those with a low NLR (P<0.001). At onset of disease, patients with severe neurological impairment had a more significant increase in NLR than those with mild-to-moderate neurological impairment (P<0.001). Both univariate (OR 1.180, 95% CI 1.046-1.331, P=0.007) and multivariate (OR 1.146, 95% CI 1.003-1.308, P=0.044) logistic regression analyses showed that the NLR was positively correlated with the severity of neurological impairment at onset of disease in the NMOSD group. The area under the receiver-operating characteristic curve was 0.687.

CONCLUSION

The NLR is an independent risk factor for the severity of neurological impairment at disease onset in patients with a first episode of NMOSD.

Association between platelet count and hepatocellular carcinoma overall survival: a large retrospective cohort study

OBJECTIVES

To explore the non-linear relationship between platelet count (PLT) and hepatocellular carcinoma (HCC) overall survival (OS).

SETTING

The study was done in Sun Yat-sen University Cancer Center (SYSUCC) from January 2007 to May 2012, a total of 5005 consecutive participants at SYSUCC were retrospectively reviewed, and 979 patients with Barcelona clinic liver cancer (BCLC) stage B were selected for the final analysis.

PARTICIPANTS

A total of 979 newly diagnosed patients with HCC with BCLC stage B were identified for the secondary analysis. Eight cases were excluded for missing data of PLT.

MAIN OUTCOME MEASURES

Cox proportional hazard regression models were used to calculate multivariable-adjusted HRs and 95% CIs for HCC. The non-linear relationship was estimated through a restricted cubic spline regression, and a two-piecewise Cox proportional hazards model was further performed to calculate the threshold effect. We used multiple imputation to deal with the missing data.

RESULTS

In the multivariate analysis, Log PLT was associated with a 91% risk increase in death (HR 1.91; 1.28 to 2.85) with adjustment for gender, Child-Pugh class, age × diameter of main tumour, both lobe with lesions × number of the intrahepatic lesions, alpha-fetoprotein (<25, ≥25) and lactic dehydrogenase (<245, ≥245). We also found a U-shape relationship between PLT and HCC OS at the inflexion point of 67.6×10⁹/L. The HR was 0.12 (95% CI 0.03 to 0.52) for Log PLT≤10.83 and 3.07 (CI 1.91 to 4.92) for Log PLT>10.83 after adjusting for potential confounders. The core results were consistent with those from the sensitivity analysis. Besides, a significantly higher hazard risk was found in the patients with age <55, both lobes with lesions, tumour diameter >50, haemoglobin ≥120 and C reactive protein >10.

CONCLUSION

PLT was nonlinearly associated with HCC OS.

Novel inflammation-based prognostic nomograms for individualized prediction in hepatocellular carcinoma after radical resection

Background

The prognosis for patients with hepatocellular carcinoma (HCC) after liver resection ranges widely and is unsatisfactory. This study aimed to develop two novel nomograms that combined tumor characteristics and inflammation-related indexes to predict overall survival (OS) and recurrence-free survival (RFS).

Methods

In total, 3,071 patients who underwent radical resection were recruited. Independent risk factors were identified by Cox regression analysis and used to conduct prognostic nomograms. The C-index, time-dependent areas under the receiver operating characteristic curve (time-dependent AUC), decision curve analysis (DCA), and calibration curves were used to assess the performance of the nomograms.

Results

Multivariate analysis revealed that alpha-fetoprotein (AFP), resection margin, neutrophil times γ-glutamyl transpeptidase-to-lymphocyte ratio (NrLR), platelet-to-lymphocyte ratio (PLR), γ-glutamyl transpeptidase-to-platelet ratio (GPR), tumor size, tumor number, microvascular invasion, and Edmondson-Steiner grade were the independent risk factors associated with OS. The independent risk factors associated with RFS were hepatitis, AFP, albumin-bilirubin (ALBI), NrLR, PLR, PNI, GPR, tumor size, tumor number, microvascular invasion, and Edmondson-Steiner grade. The C-index of the nomograms in the training and validation cohort were 0.71 [95% confidence interval (CI): 0.70–0.73] and 0.71 (95% CI: 0.69–0.74) for the OS, and 0.71 (95% CI: 0.70–0.73) and 0.74 (95% CI: 0.72–0.76) for RFS, respectively. The C-index, time-dependent AUC, and DCA of the nomograms showed significantly better predictive performances than those of commonly used staging systems. The models could stratify patients into three different risk groups. The web-based tools are convenient for clinical practice.

Conclusions

Two novel nomograms in which integrated inflammation-related indexes and accessible clinical parameters were developed to predict OS and RFS in HCC patients who underwent radical resection. Such models will help guide postoperative individualized follow-up and adjuvant therapy.

Clinicopathological and prognostic significance of platelet-lymphocyte ratio (PLR) in gastric cancer: an updated meta-analysis

BACKGROUND

Pre-treatment PLR (platelet-lymphocyte ratio) was reported to be associated with the prognosis in gastric cancer (GC), but the results remain inconclusive. This meta-analysis aimed to investigate the prognostic potential of the pre-treatment PLR in gastric cancer.

METHODS

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library to identify eligible publications. The hazard ratio (HR)/odds ratio (OR) and its 95% confidence (CI) of survival outcomes and clinicopathological parameters were calculated.

RESULTS

A total of 49 studies (51 cohorts), collecting data from 28,929 GC patients, were included in the final analysis. The pooled results demonstrated that the elevated pre-treatment PLR was significantly associated with poor overall survival (OS) (HR 1.37, 95% CI 1.26-1.49, p < 0.001; I² = 79.90%, P_h < 0.001) and disease-free survival (DFS) (HR 1.52, 95% CI 1.22-1.90, p < 0.001, I² = 88.6%, P_h < 0.001). Furthermore, the patients with the elevated PLR had a higher risk of lymph node metastasis (OR = 1.17, 95% CI 1.02-1.33, p = 0.023), serosal invasion (T3+T4) (OR = 1.34, 95% CI 1.10-1.64, p = 0.003), and increased advanced stage (III+IV) (OR = 1.20, 95% CI 1.06-1.37, p = 0.004).

CONCLUSIONS

An elevated pre-treatment PLR was a prognostic factor for poor OS and DFS and associated with poor clinicopathological parameters in GC patients.

Tumor aggression among hepatitis-C related hepatocellular carcinoma patients: an observational study regarding the impact of anti-HCV therapy

BACKGROUND

Hepatitis C virus (HCV) represents a major risk factor for hepatocellular carcinoma (HCC) development and anti-HCV therapy is a significant measure to reduce the incidence of HCC, however development of HCC in HCV treated patients is an emerging clinical problem which needs to be investigated. In this study we aim to analyze association between anti-HCV therapy and tumor pattern of HCV related HCC patients.

METHODS

Hepatocellular Carcinoma (HCC) patients with seropositivity for hepatitis C virus (HCV) antibodies, registered at three tertiary care hospitals of Rawalpindi and Islamabad, Pakistan during August 2017 to July 2018 were enrolled. Selected patients were then segregated in two groups on the basis of their HCV treatment history i.e., "TN" (HCV Treatment Naïve i.e. having no history/medical record for treatment prior to HCC diagnosis) and "TH" (Treated for HCV infection). Aggressiveness index (AgI) scoring system was applied to determine the tumor pattern. Univariate and multivariate analysis was carried out to analyze the independent effect of anti-HCV therapy on tumor pattern.

RESULTS

Out of 234 consecutive HCC patients, 171 HCV-related HCC patients were enrolled in final analysis and labeled as "TN" (n = 120) and "TH" (n = 51). Tumor pattern was found to be significantly aggressive (P = 0.02) in the treated cohort with an adjusted odds of 2.47 for aggressive and 6.92 for highly aggressive tumor. Neutrophil to lymphocyte ratio (NLR) was strongly associated with highly aggressive tumor pattern (P = 0.012). Patients in TN group were found to be marginally older than those in the TH group (59.5 vs. 55 years) where mean age of the patients treated with direct acting anti-viral agents was found to be visibly lower than mean age of patients who received interferon based treatment (53.5 vs. 57 years) with significant masculine predominance (62.1 vs. 37.9%, P = 0.049).

CONCLUSION

We observed raised neutrophil to lymphocyte ratio and prominence of younger age with aggressive tumor biology in HCV treated HCC patients. These observations highlight the need for a longitudinal prospective study on HCV positive subjects treated with antivirals, irrespective of treatment response.

Development of a Novel Inflammation-Based Index for Hepatocellular Carcinoma

BACKGROUND

The aim of current study was to (1) construct and validate a novel hepatocellular carcinoma (HCC)-specific inflammatory index; (2) compare the performances of the Integrated Liver Inflammatory Score (ILIS) to existing 4 inflammatory indices in HCC; (3) explore the association between the inflammatory indices and systemic/intratumoral inflammatory markers.

METHODS

Two cohorts from Hong Kong (HK; n = 1,315) and Newcastle (n = 574) were studied. A novel index was constructed from the HK training set (n = 627). The index was constructed from the training set by combing independent prognostic circulating parameters, followed by validating in the validation set of HK cohort (n = 688) and the Newcastle cohort. Its prognostic performance was compared to 4 inflammatory indices, namely, the neutrophil to lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutrition index, and systemic immune-inflammation index, were compared in the HK cohort. Circulating cytokines and intratumoral gene expression were analyzed in a subset of patients with available samples and correlated with the inflammatory indices.

RESULTS

In the training set of the HK cohort, the ILIS, was generated: -0.057 × albumin (g/L) + 0.978 × log (Bilirubin, µmol/L) + 1.341 × log (alkaline phosphatase, IU/L) + 0.086 × Neutrophil (10⁹/L) + 0.301 × log (alpha-fetoprotein, µg/L). With cutoff of 2.60 and 3.87, the ILIS could categorize patients into 3 risk groups in the both validation cohorts. ILIS outperforms other inflammatory indices and remains an independent prognosticator for overall survival after adjustment with Barcelona Clinic Liver Cancer (hazard ratio 31.90, p < 0.001). The ILIS had the best prognostic performances as compared to other inflammatory indices. In exploratory analyses, the ILIS correlated with circulating inflammatory cytokines (e.g., IL-8) but not with any intratumoral inflammatory gene expression.

CONCLUSIONS

ILIS is an HCC-specific prognostic index built on 5 readily available blood parameters. Its versatility is validated both Eastern and Western population of HCC. The score is correlated with levels of circulating cytokines.

Combination of inflammatory score/liver function and AFP improves the diagnostic accuracy of HBV-related hepatocellular carcinoma

Background

Alpha‐fetoprotein (AFP), routinely used for diagnosis of hepatocellular carcinoma (HCC), is limited with relatively low sensitivity and high false positivity in HBV‐related HCC (HBV‐HCC). Thus, an alternative approach was explored to improve specificity/sensitivity for diagnosis of HBV‐HCC, using the combination of AFP, inflammatory score, and liver function.

Methods

Chronic hepatitis B (CHB) (n = 510) and HBV‐HCC (n = 473) patients were identified retrospectively for this study. The diagnostic value of single vs combined biomarkers for HBV‐HCC was analyzed, using ROC curve.

Results

It was observed that elderliness, male sex, cirrhosis, HBeAg⁺ or no‐antiviral therapy, and elevation of ALT, AST, neutrophil‐lymphocyte ratio (NLR), and AFP were associated with developing HBV‐HCC. However, the cut‐off ALT defined by Chinese standard, but not by AASLD, was a risk factor. Interestingly, AFP of HBeAg^‐ HBV‐HCC patients without cirrhosis was significantly higher than that of the HBeAg⁺ patients. AUC values for AFP, ALT, AST, or NLR were 0.84 (95% CI: 0.815‐0.862), 0.533 (95% CI: 0.501‐0.565), 0.696 (95% CI: 0.666‐0.725), or 0.684 (95% CI: 0.654‐0.713) with optimal cut‐off at 7.21 ng/mL, 43 IU/mL, 38 IU/mL, or 2.61, respectively. Combination of AFP with ALT, AST, and NLR improved the diagnostic performance for HBV‐HCC, compared to any of the single biomarkers or any other combinations among these patients (except no‐cirrhosis).

Conclusions

Elderliness, male sex, elevated ALT, AST, NLR, AFP, cirrhosis, HBeAg⁺, and no‐antiviral treatment were independent risk factors for HBV‐HCC. AASLD standard of ALT cut‐off value may not be suitable for the Chinese population. Regular monitoring of HCC among HBeAg^‐ patients with abnormal AFP may improve the management of HBV‐HCC. The diagnostic performance of AFP combined with ALT, AST, and NLR for HBV‐HCC was superior to single biomarker or any other combinations among these patients, and its diagnostic equation can be used as useful tool for differentiation of HBV‐HCC from CHB.

Nomogram based on inflammatory indices for differentiating intrahepatic cholangiocarcinoma from hepatocellular carcinoma

Objective

To establish nomogram based on inflammatory indices for differentiating intrahepatic cholangiocarcinoma (ICC) from hepatocellular carcinoma (HCC).

Methods

A cohort of 422 patients with HCC or ICC hospitalized at Xiangya Hospital between January 2014 and December 2018 was included in the study. Univariate and multivariate analysis was performed to identify the independent differential factors. Through combining these independent differential factors, a nomogram was established for differential diagnosis between ICC and HCC. The accuracy of nomogram was evaluated by using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). The results were validated using a prospective study on 98 consecutive patients operated on from January 2019 to November 2019 at the same institution.

Results

Sex (OR = 9.001, 95% CI: 3.268‐24.792, P < .001), hepatitis (OR = 0.323, 95% CI: 0.121‐0.860, P = .024), alpha‐fetoprotein (AFP) (OR = 0.997, 95% CI: 0.995‐1.000, P = .046), carbohydrate antigen 19‐9 (CA199) (OR = 1.016, 95% CI: 1.007‐1.025, P < .001), and aspartate transaminase‐to‐neutrophil ratio index (ANRI) (OR = 0.904, 95% CI: 0.843‐0.969, P = .004) were the independent differential factors for ICC. Nomogram was established with well‐fitted calibration curves through incorporating these 5 factors. Comparing model 1 including gender, hepatitis, AFP, and CA199 (C index = 0.903, 95% CI: 0.849‐0.957) and model 2 enrolling AFP and CA199 (C index = 0.850, 95% CI: 0.791‐0.908), the nomogram showed a better discrimination between ICC and HCC, with a C index of 0.920 (95% CI, 0.872‐0.968). The results were consistent in the validation cohort. DCA also confirmed the conclusion.

Conclusion

A nomogram was established for the differential diagnosis between ICC and HCC preoperatively, and better therapeutic choice would be made if it was applied in clinical practice.

Inflammation-Based Index and 68Ga-DOTATOC PET-Derived Uptake and Volumetric Parameters Predict Outcome in Neuroendocrine Tumor Patients Treated with 90Y-DOTATOC

We performed post hoc analyses on the utility of pretherapeutic and early interim ⁶⁸Ga-DOTATOC PET tumor uptake and volumetric parameters and a recently proposed biomarker, the inflammation-based index (IBI), for peptide receptor radionuclide therapy (PRRT) in neuroendocrine tumor (NET) patients treated with ⁹⁰Y-DOTATOC in the setting of a prospective phase II trial. Methods: Forty-three NET patients received up to 4 cycles of ⁹⁰Y-DOTATOC at 1.85 GBq/m²/cycle with a maximal kidney biologic effective dose of 37 Gy. All patients underwent ⁶⁸Ga-DOTATOC PET/CT at baseline and 7 wk after the first PRRT cycle. ⁶⁸Ga-DOTATOC-avid tumor lesions were semiautomatically delineated using a customized SUV threshold-based approach. PRRT response was assessed on CT using RECIST 1.1. Results: Median progression-free survival and overall survival (OS) were 13.9 and 22.3 mo, respectively. An SUV_mean higher than 13.7 (75th percentile) was associated with better survival (hazard ratio [HR], 0.45; P = 0.024), whereas a ⁶⁸Ga-DOTATOC-avid tumor volume higher than 578 cm³ (75th percentile) was associated with worse OS (HR, 2.18; P = 0.037). Elevated baseline IBI was associated with worse OS (HR, 3.90; P = 0.001). Multivariate analysis corroborated independent associations between OS and SUV_mean (P = 0.016) and IBI (P = 0.015). No significant correlations with progression-free survival were found. A composite score based on SUV_mean and IBI allowed us to further stratify patients into 3 categories with significantly different survival. On early interim PET, a decrease in SUV_mean of more than 17% (75th percentile) was associated with worse survival (HR, 2.29; P = 0.024). Conclusion: Normal baseline IBI and high ⁶⁸Ga-DOTATOC tumor uptake predict better outcome in NET patients treated with ⁹⁰Y-DOTATOC. This method can be used for treatment personalization. Interim ⁶⁸Ga-DOTATOC PET does not provide information for treatment personalization.

Hepatocellular carcinoma recurrence after acute liver allograft rejection treatment: A multicenter European experience

BACKGROUND

During the last decades, several risk factors for the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) have been investigated. However, the impact of two important drivers of oncogenesis, namely the immunosuppression and the treatment of acute cellular rejection (ACR) have been marginally addressed. This study aimed at investigating the impact of ACR treatment on the incidence of tumor recurrence in a large European HCC-LT population.

METHODS

Seven hundred and eighty-one adult patients transplanted between February 1, 1985 and June 30, 2016 were retrospectively analyzed. After propensity score match, 116 patients treated for ACR using steroid boluses were compared with 115 patients who did not present any ACR or a histologic but clinical irrelevant ACR.

RESULTS

Steroid boluses treated patients had a 18-fold higher overall incidence of HCC recurrence than those non-treated patients (16.4% vs. 0.9%; P<0.0001). At multivariate Cox regression analysis, steroid boluses used to treat ACR were an independent risk factor for HCC recurrence (HR=14.2; 95% CI: 1.8-110.4; P = 0.010).

CONCLUSIONS

The decision to treat ACR as well as to reinforce immunosuppression load should be cautiously taken in view of the presented results. Prospective studies are needed to further elucidate the clinical impact of immunosuppression on HCC recurrence after transplantation.

A novel prognostic score model based on combining systemic and hepatic inflammation markers in the prognosis of HBV-associated hepatocellular carcinoma patients

Objectives: The study aimed to evaluate the prognostic value of systemic inflammation markers [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), Prognostic Nutritional Index (PNI)] and hepatic inflammation markers [aspartate aminotransferase-to-platelet ratio index (APRI), γ-glutamyl transferase (γ-GT)/alanine aminotransferase (ALT)] in patients with hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and further to develop a novel prognostic score model. Methods: A total of 401 cases with HBV-associated HCC who underwent hepatectomy as initial therapy were included in the analysis. Kaplan-Meier was performed to construct survival curves and receiver operating characteristic (ROC) analysis was used to detect the optimal cut-off value of markers. The prognostic score model was constructed using significant inflammation markers in the Cox model. Each factor was given a score of 1 and patients were stratified according to the scores. Results: In the Cox model, α-fetoprotein (AFP), ALT, tumour differentiation, maximum size of tumours, TNM stage, PNI and γ-GT/ALT were independently prognostic factors. We established a preoperative inflammation-based prognostic scoring model combining PNI and γ-GT/ALT. The novel preoperative inflammation-based prognostic score was superior (area under the curve [AUC], 0.659) to 7^th tumour-node-metastasis (TNM) stage (AUC, 0.600) despite no statistical significance (p = .1036). Conclusion: PNI and γ-GT/ALT are independent predictors for prognosis. The novel prognostic score model based on systemic and hepatic inflammation markers is suitable for the prognosis evaluation in patients with HBV-associated HCC.

The systemic inflammatory response as a source of biomarkers and therapeutic targets in hepatocellular carcinoma

The pathogenesis of hepatocellular carcinoma (HCC) strongly relates to inflammation, with chronic up-regulation of pro-inflammatory mediators standing as a potential unifying mechanism that underscores the origin and progression of HCC independent of aetiology. Activation of the diverse pro-inflammatory mediators either within the tumour or its microenvironment is part of an active cross-talk between the progressive HCC and the host, which is known to influence clinical outcomes including recurrence after radical treatments and long-term survival. A number of clinical biomarkers to measure the severity of cancer-related inflammation are now available, most of which emerge from routine blood parameters including neutrophil, lymphocyte, platelet counts, as well as albuminaemia and C-reactive protein levels. In this review, we summarise the body of evidence supporting the biologic qualification of inflammation-based scores in HCC and review their potential in facilitating the prognostic assessment and treatment allocation in the individual patient. We also discuss the evidence to suggest modulation of tumour-promoting inflammation may act as a source of novel therapeutic strategies in liver cancer.

Comparative performance of inflammation-based prognostic scores in patients operated for intrahepatic cholangiocarcinoma

Objective

Prognostic performance of inflammation-based prognostic scores, including the Glasgow Prognostic Score (GPS), modified Glasgow Prognostic Score (mGPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), Prognostic Index (PI) and Prognostic Nutritional Index (PNI) has been explored in patients with varied types of cancer, though little data is available in intrahepatic cholangiocarcinoma (ICC). This study sought to evaluate the impact of systemic inflammation on the overall survival (OS) of ICC patients, and to identify more optimal prognostic indices.

Patients and methods

The prognostic power of all the scores mentioned above was compared in 123 patients underwent curative surgery for ICC using Kaplan–Meier curves, COX regression models and the receiver operating characteristics (ROC) curves. The results were validated in a cohort of 95 ICC patients.

Results

Multivariate analysis identified LMR as the only independent inflammation-based predictor for OS in the training cohort (P=0.007, HR 2.082, 95% CI 1.218–3.558). More importantly, the combined score of LMR and pTNM designated the inflammation-based pathological stage (IPS) outperformed other established scores in terms of discriminatory ability, monotonicity and homogeneity in the training and validation cohorts.

Conclusion

This study reveals that preoperative LMR is an independent predictor of OS in ICC patients after hepatectomy, and the IPS can be applied as a novel prognostic indicator in these patients.

Comparison of Platelet to Lymphocyte Ratio between Degrees of the Barcelona Clinic Liver Cancer on Hepatocellular Carcinoma Patients at Haji Adam Malik General Hospital

BACKGROUND:

Hepatocellular carcinoma (HCC) is the fifth most common malignancy. The Barcelona Clinical Liver Cancer System (BCLC), guides the treatment of patients with HCC. Platelet to lymphocyte ratio (PLR) is an inflammatory marker used as a prognostic factor disease of HCC. An increase in PLR indicates higher host’s inflammatory response and is associated with aggressive HCC behaviour, according to BCLC.

AIM:

This study aims to determine the PLRs between among the degrees of BCLC (The Barcelona Clinic Liver Cancer) in HCC patients at Haji Adam Malik General Hospital in Medan during 2015-2016.

METHODS:

This retrospective study involved 166 patients with HCC who were then classified by the BCLC guidelines. PLRs among the patient’s degrees of BCLC were compared using Kruskal Wallis test.

RESULTS:

A total of 166 HCC patients, 129 (77.7%) were men and 37 (22.3%) were women. The PLR value has a median value of 17841with the lowest value of 1776 and the highest value of 223684. There were differences in PLR levels with various BCLC stages in patients with HCC at Haji Adam Malik Hospital during 2015-2016 (p = 0.026).

CONCLUSION:

There were differences in PLR levels with various BCLC stages in patients with HCC at Haji Adam Malik Hospital during 2015-2016.

Predictive Effects of Inflammatory Scores in Patients with BCLC 0-A Hepatocellular Carcinoma after Hepatectomy

Background: Inflammatory markers are regarded as prognostic factors of the outcomes of hepatocellular carcinoma (HCC). Examples include the neutrophil-to-lymphocyte ratio (NLR); platelet to lymphocyte ratio (PLR); the albumin and lymphocyte counts used in the prognostic nutritional index (PNI); and the neutrophil, lymphocyte, and platelet counts used in the systemic immune-inflammation index (SII). This study evaluates the effects of PNI, NLR, PLR, and SII to predict recurrence and survival in patients with Barcelona Clinic Liver Cancer (BCLC) stages 0-A of HCC after hepatectomy. Methods: This retrospective study was conducted at Kaohsiung Chung-Gung Memorial Hospital, Taiwan. The study enrolled 891 patients (77.9% males; mean age 58.53 ± 11.60 years) with BCLC stage 0/A HCC undergoing hepatectomy between 2001 and 2016. PNI, NLR, PLR and SII were measured before hepatectomy. Results: High NLR (>1.8) was adversely associated with overall survival (p = 0.032). Low PNI (≤45) was adversely associated with overall survival and disease-free survival (p < 0.001). Low SII (≤45) also had an adverse association with overall survival (p = 0.008) and disease-free survival (p < 0.001). Diabetes mellitus, cirrhosis, microvascular invasion, low PNI (≤45), and low SII (≤160) were independently associated with poor overall survival in a multivariate analysis. HCV infection, diabetes mellitus, cirrhosis, microvascular invasion, low PNI, and low SII were independent prognostic factors of recurrent HCC. The combined use of PNI and SII provided improved prognostic information. Conclusions: Low PNI and low SII are significantly poor prognostic factors for overall survival and recurrence in patients with BCLC 0-A hepatocellular carcinoma after hepatectomy.

Improved Prediction of Survival by a Risk Factor-Integrating Inflammatory Score in Sorafenib-Treated Hepatocellular Carcinoma

BACKGROUND AND AIMS

Inflammation affects progression of hepatocellular carcinoma (HCC). We therefore postulate that systemic inflammatory markers could help to predict prognosis in HCC patients receiving sorafenib therapy.

METHODS

Overall survival (OS) of HCC patients receiving palliative sorafenib treatment was correlated with the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS) and the modified GPS (mGPS) along with clinicopathological parameters. Predictors of OS were assessed by multivariable Cox regression and receiver operating characteristics and area under the curve (ROC-AUC) analyses.

RESULTS

Patients receiving sorafenib (n = 120) for advanced HCC (Barcelona Clinic Liver Cancer stage C) were explored by retrospective analysis. Findings were subsequently validated by a second HCC cohort (n = 113) receiving sorafenib at two independent treatment centers. Multivariable assessment across these HCC cohorts confirmed a stable association of CAR (p ≤ 0.001), GPS (p ≤ 0.01) and mGPS (p ≤ 0.004) with OS. This study also identified Eastern Cooperative Oncology Group (ECOG) performance score (p < 0.001) and portal thrombosis (p = 0.002) as prognostic factors and uncovered an inconsistent OS association of NLR and PLR in HCC patients. Additional combined analysis of ECOG, portal thrombosis and GPS within an extended score (GPS-EP) was associated with OS (p = 0.021), which was confirmed within the validation cohort (p = 0.001). In sorafenib-treated HCC, the ROC-AUC value for the prediction of 12-month survival was 0.761 (CAR >/≤0.37 cut-off, p < 0.001), 0.766 (GPS, p < 0.001) and 0.754 (mGPS, p < 0.001), respectively. In comparison to this, GPS-EP achieved a higher AUC of 0.826 (0.746-0.907) for the 12-month survival prediction, resulting in a 64.4% sensitivity and 83.3% specificity at a > 2 point cut-off.

CONCLUSIONS

Inflammatory scores obtained before sorafenib treatment initiation are associated with OS in advanced HCC. Their combination with other risk factors improves prediction of 3- and 12-month survival, which could guide treatment decisions in selected patient subgroups.

Risk Factors and Outcomes of Early Relapse After Curative Resection of Intrahepatic Cholangiocarcinoma

Early relapse after hepatectomy for intrahepatic cholangiocarcinoma (ICC) has a tremendous influence on the long-term survival outcomes of ICC patients. The purpose of our study was to investigate risk factors for early tumor relapse and confirm whether early relapse was correlated with ICC patients' long-term survival outcomes. Three hundred and twenty-two consecutive ICC patients undergoing partial hepatectomy at Liver Surgery Department of Zhongshan Hospital (Fudan University, Shanghai, China) between January 2005 and December 2011 were included in this retrospectively study. The definition of early relapse had been described as tumor relapse within 24 months after hepatectomy in ICC patients. We identified a total of 168 ICC patients with early relapse and 23 ICC patients with late relapse after hepatectomy. From the time of relapse, the long-term survival outcomes were worse among patients who had early vs. late relapse (median OS 16.5 vs. 44.7 months, respectively; P < 0.0001). The overall survival of the early relapse group was lower than that of the late relapse group (P < 0.0001). Multivariate Cox regression analysis indicated that multiple tumors (hazard ratio [HR], 1.951; 95% CI, 1.382-2.755; P < 0.001), lymphonodus metastasis (HR, 1.517; 95% CI, 1.061-2.168; P = 0.022), and higher serum CA19-9 levels (HR, 1.495; 95% CI, 1.095-2.039; P = 0.011) were independent risk factors of early relapse. Moreover, multiple tumors (HR, 1.641; 95% CI, 1.120-2.406; P = 0.011), lymphonodus metastasis (HR, 2.008; 95% CI, 1.367-2.949; P < 0.001), elevated NLR (HR, 1.921; 95% CI, 1.331-2.774; P < 0.001) and higher serum CA19-9 levels (HR, 1.990; 95% CI, 1.409-2.812; P < 0.001) were independent predictors of overall survival for ICC patients with early relapse. Collectively, our findings demonstrated that multiple tumors, lymphonodus metastasis, and higher serum CA19-9 levels were associated with the increased risks of early relapse and worse prognoses of ICC after curative-intent resection.

Clinical and prognostic implications of pretreatment albumin to C-reactive protein ratio in patients with hepatocellular carcinoma

BACKGROUND

Despite recent advances in the treatments of hepatocellular carcinoma (HCC), the prognosis of HCC patients remains controversial. The purpose of this study was to investigate the prognostic performance of pretreatment albumin to C-reactive protein ratio (ACR) in patients with HCC.

METHODS

This study included 409 initially diagnosed HCC patients retrospectively. The optimal cut-off points for distinguishing high and low ACR value was determined by the X-tile software. The chi-squared test was used for comparing the baseline clinicopathologic parameters in different groups and subgroups. The Cox regression with log-rank tests was used to analyze OS and DFS, and Kaplan-Meier curves was used to estimate the prognosis of HCC patients.

RESULTS

Patients with lower ACR were significantly correlated with advanced clinical parameters, using a cut-off points of 5.4 (high ACR, n = 236 vs. low ACR, n = 173). Multivariate analysis demonstrated that ACR was associated with OS (HR = 0.544, 95% CI: 0.385-0.769, p = 0.001), with DFS (HR = 0.550, 95% CI: 0.392-0.772, p = 0.001). Treatment exposure (HR = 2.191; 95% CI: 1.533-3.132; p <  0.001), tumor size (HR = 1.973; 95% CI: 1.230-3.164; p = 0.005), serum AFP level (HR = 1.752; 95% CI: 1.277-2.403; p = 0.001), and TNM stage (HR = 0.470; 95% CI: 0.319-2.504; p <  0.001), were independent factors for OS in HCC patients. Treatment exposure (HR = 2.244; 95% CI: 1.590-3.166; p <  0.001), TNM stage (HR = 2.075; 95% CI: 1.436-3.000; p <  0.001), serum AFP level (HR = 1.819; 95% CI: 1.340-2.469; p = 0.001), tumor size (HR = 1.730; 95% CI: 1.113-2.689; p = 0.015), and ACR (HR = 0.550; 95% CI: 0.392-0.772; p = 0.001) were independent factors for DFS in HCC patients.

CONCLUSIONS

Pretreatment ACR is a convenient and useful parameter for HCC patients predicting OS and DFS. Lower ACR was associated with advanced TNM stage, larger tumor size, and a high concentration of AFP. These results may help to design strategies to personalize management approaches among HCC patients.

Immune inflammation indicators and ALBI score to predict liver cancer in HCV-patients treated with direct-acting antivirals

BACKGROUND

Unexpectedly high occurrence or recurrence rate of hepatocellular carcinoma (HCC) has been observed in patients with chronic hepatitis C receiving direct-acting antivirals (DAAs) therapy.

AIMS

We evaluated the predictive value of albumin-bilirubin (ALBI) score and immune-inflammation indicators to identify the risk of occurrence or recurrence of HCC in patients treated with DAAs in a real life setting.

METHODS

In this retrospective cohort study, we analysed data from 514 patients with cirrhosis who were prospectively enrolled for treatment with DAAs. We assessed baseline neutrophil to lymphocyte ratio (NLR), systemic immune-inflammation index (SII), platelet to lymphocyte ratio (PLR), aspartate aminotransferase-lymphocyte ratio (ALRI) index and ALBI score.

RESULTS

In patients with no history of HCC (N = 416), increased AST, bilirubin, ALRI, and ALBI score, and decreased albumin and platelets were significantly associated with an increased risk of HCC development, at univariate analysis. At multivariate analysis, increase in ALBI grade (p = 0.038, HR: 2.35, 95% CI: 1.05-5.25) and decrease in platelets (p = 0.048, HR: 0.92, 95% CI: 0.85-1.0) were independently associated with HCC development. In patients with previous HCC (N = 98), adjusting for the time from HCC treatment, increased ALRI (p = 0.008, HR: 1.05, 95% CI: 1.01-1.09) was significantly associated with a risk of recurrence.

CONCLUSION

ALBI score, platelet count and ALRI are promising, easy to perform and inexpensive tools for identifying patients with higher risk of HCC after treatment with DAAs.