LCSGJ-T classification, 6th or 5th edition TNM staging did not independently predict the long-term prognosis of HBV-related hepatocellular carcinoma after radical hepatectomy

Optimizing hepatocellular carcinoma disease staging systems by incorporating tumor micronecrosis: A multi-institutional retrospective study

Tumor micronecrosis is a pathological feature that reflects malignant biological behavior in hepatocellular carcinoma (HCC). However, whether micronecrosis can optimize HCC staging systems remains unilluminated. A total of 1632 HCC patients who underwent curative hepatectomy in four institutions from January 2014 to December 2021 were enrolled in this study. Independent prognostic factors were identified, and optimized staging models were established using a training cohort (n = 934). The performance of optimized staging models was validated using an external cohort consisting of cases from three other institutions (n = 232). In addition, patients from our prospectively collected database (n = 379) tested the application effectiveness of the models. Harrel's c-statistics and the corrected Akaike information criterion (AICc) were used to assess the performance of staging models. In most of Barcelona Clinic Liver Cancer (BCLC) and tumor (T) stages, HCC patients with tumor micronecrosis showed poorer prognosis than those without. Tumor micronecrosis, microvascular invasion, multiple tumors and tumor size >2 cm were independent prognostic-related factors. The BCLC and T staging models incorporating tumor micronecrosis showed better performance than the original systems (c-statistic, 0.712 and 0.711 vs. 0.664 and 0.679; AICc, 2314.8 and 2322.3 vs. 2338.2 and 2338.1; respectively). Furthermore, the external validation cohort confirmed that the optimized staging models had improved efficiency compared with the original ones. Moreover, the prospective cohort demonstrated the applicability of the optimized staging systems. Tumor micronecrosis plays a stage-ascending role in HCC patients. The BCLC and T staging systems incorporating tumor micronecrosis can improve the prognosis stratification efficiency of patients.

Non-invasive preoperative prediction of Edmondson-Steiner grade of hepatocellular carcinoma based on contrast-enhanced ultrasound using ensemble learning

Purpose

This study aimed to explore the clinical value of non-invasive preoperative Edmondson-Steiner grade of hepatocellular carcinoma (HCC) using contrast-enhanced ultrasound (CEUS).

Methods

212 cases of HCCs were retrospectively included, including 83 cases of high-grade HCCs and 129 cases of low-grade HCCs. Three representative CEUS images were selected from the arterial phase, portal vein phase, and delayed phase and stored in a 3-dimensional array. ITK-SNAP was used to segment the tumor lesions manually. The Radiomics method was conducted to extract high-dimensional features on these contrast-enhanced ultrasound images. Then the independent sample T-test and the Least Absolute Shrinkage and Selection Operator (LASSO) were employed to reduce the feature dimensions. The optimized features were modeled by a classifier based on ensemble learning, and the Edmondson Steiner grading was predicted in an independent testing set using this model.

Results

A total of 1338 features were extracted from the 3D images. After the dimension reduction, 10 features were finally selected to establish the model. In the independent testing set, the integrated model performed best, with an AUC of 0.931.

Conclusion

This study proposed an Edmondson-Steiner grading method for HCC with CEUS. The method has good classification performance on independent testing sets, which can provide quantitative analysis support for clinical decision-making.

Development of a prognostic gene signature for hepatocellular carcinoma

Accurate prediction of overall survival is important for prognosis and the assignment of appropriate personalized clinical treatment in hepatocellular carcinoma (HCC) patients. The aim of the present study was to establish an optimal gene model for the independent prediction of prognosis associated with common clinical patterns. Gene expression profiles and the corresponding clinical information of the LIHC cohort were obtained from The Cancer Genome Atlas. Differentially expressed genes were found using the R package "limma". Subsequently, a prognostic gene signature was developed using the LASSO Cox regression model. Kaplan-Meier, log-rank, and receiver operating characteristic (ROC) analyses were performed to verify the predictive accuracy of the prognostic model. Finally, a nomogram and calibration plot were created using the "rms" package. Differentially expressed genes were screened with threshold criteria (FDR < 0.01 and |log FC|>3) and 563 differentially expressed genes were obtained, including 448 downregulated and 115 upregulated genes. Using the LASSO Cox regression model, a prognostic gene signature was developed based on nine genes, IQGAP3, BIRC5, PTTG1, STC2, CDKN3, PBK, EXO1, NEIL3, and HOXD9, the expression levels of which were quantitated using RT-qPCR. According to the risk scores, patients were separated into high-risk and low-risk groups. In conclusion, the prognostic gene signature can be used as a combined biomarker for the independent prediction of overall survival in HCC patients. Moreover, we created a nomogram that can be used to infer prognosis and aid individualized decisions regarding treatment and surveillance.

Comparison of prognostic value of three objective nutritional indicators in patients with hepatocellular carcinoma before radical resection

BACKGROUND

Various nutrition-based prognostic scores, including control of nutritional status (CONUT) score, nutritional risk index (NRI), and prognostic nutritional index (PNI), are associated with survival rates in patients with various types of cancer.

AIM

To compare the prognostic value of the above-mentioned scores in patients with hepatocellular carcinoma (HCC) before radical resection.

METHODS

A retrospective analysis of 470 patients who underwent radical resection for HCC at the Yiwu Central Hospital from January 2007 to June 2016 was performed. Clinical pathological parameters, CONUT score, NRI, and PNI were collected and compared. The area under the receiver operating characteristic curve (AUC) was calculated to compare the predictive power of each scoring system. Univariate and multivariate analyses were performed using the COX proportional hazards model to identify risk factors associated with overall survival (OS).

RESULTS

In the univariate analysis, albumin, PNI, NRI, CONUT score, and histology were significantly associated with OS in patients with HCC. PNI, NRI, and CONUT score were significantly associated with 1-year, 3-year, and 5-year HCC survival rates. NRI always had a higher AUC value than other nutrition-based prognostic scores. In the multivariate analysis, AST (hazard ratio [HR] = 1.503, P = 0.031), FIB status (HR = 1.981, P = 0.001), and NRI (HR = 1.584, P = 0.014) were independent risk factors for prognosis in patients with HCC.

CONCLUSION

Our study suggests that NRI is superior to other nutrition-based prognostic scores in predicting overall survival in patients undergoing radical surgery for HCC.

Identification of a novel DNA repair-related prognostic signature predicting survival of patients with hepatocellular carcinoma

Purpose

Hepatocellular carcinoma (HCC) is the sixth most lethal neoplasm worldwide. Traditional biomarkers often exploit the relationship between a certain gene and cancer progression, but they cannot predict patient survival or prognosis accurately. We aim to construct a new DNA repair-related gene signature that combines several genes to improve prognosis prediction in HCC.

Methods

We selected an HCC mRNA sequencing (mRNA-seq) dataset (n=365) from The Cancer Genome Atlas (TCGA), and gene set enrichment analysis (GSEA) was used to explore bioinformatics information and further screen genes. We then built a gene signature based on the Cox proportional hazards regression model.

Results

GSEA revealed that the hallmark DNA repair gene set was significantly upregulated in the tumor phenotype. A set of seven genes, namely, ADA, FEN1, POLR2G, SAC3D1, SEC61A1, SF3A3, and UPF3B, were significantly a ssociated with overall survival (OS) and used to form a gene signature. The signature risk score was calculated and used to divide patients into high‐ and low‐risk groups. The high-risk group showed worse prognosis (log-rank test p<0.0001). Univariate and multivariate Cox regression analysis showed that the prognostic performance of this risk score signature was robust in different subgroups based on clinicopathological features, with p-values <0.05 (HR=2.38, 95% CI (confidence interval) =1.355–4.184), indicating that it can serve as an independent prognostic indicator.

Conclusion

We developed and identified a seven‐gene signature related to the DNA repair process that can predict survival in HCC. It can be used as an effective classification tool and to guide clinical treatment.

The optimal cut-off value of the preoperative prognostic nutritional index for the survival differs according to the TNM stage in hepatocellular carcinoma

PURPOSE

To establish the optimal cut-off value of the preoperative prognostic nutritional index (PNI) for prognosis according to the Tumor Node Metastasis (TNM) stage of hepatocellular carcinoma (HCC) after curative resection.

METHODS

This retrospective study reviewed the records of 375 patients. The optimal cut-off value of the PNI was established according to the TNM stage, and overall survival was compared between the low and high PNI groups.

RESULTS

The optimal cut-off value of the PNI decreased with increasing TNM stage, with 52, 47, and 43 patients having stage I, II, and III HCC, respectively. A low preoperative PNI predicted a poorer overall survival than did a high PNI for stage I (P < 0.001) and II (P = 0.002), but not stage III disease (P = 0.052). Multivariate analysis revealed that the preoperative PNI was an independent predictor of overall survival for stage I and II HCC (hazard ratios: 6.96 and 3.57, P = 0.001 and P = 0.001, respectively).

CONCLUSIONS

The findings of this study show that the optimal cut-off value for the PNI for prognosis differs among the TNM stages and that the preoperative PNI is a favorable prognostic factor for stage I HCC.

Nomogram prediction of individual prognosis of patients with hepatocellular carcinoma

Background

The purpose of this study was to develop an effective nomogram capable of estimating the individual survival outcomes of patients with hepatocellular carcinoma (HCC), and compare the predictive accuracy and discriminative ability with other staging systems.

Methods

The nomogram was established based on a retrospective study of 661 patients newly diagnosed with HCC at the Beijing Ditan Hospital (Beijing, China), Capital Medical University, between October 2008 and July 2012. The predictive accuracy and discriminative ability of the previously developed nomogram were assessed by C-index and calibration curves, and were compared to seven current commonly used staging systems. The results were validated, using a bootstrap approach to correct for bias, in a prospective study of 220 patients consecutively enrolled between August 2012 and March 2013.

Results

Multivariate analysis of the primary cohort for survival analysis identified the independent factors to be aspartate aminotransferase, ɣ-glutamyl transpeptidase, white blood cell count, neutrophil-to-lymphocyte ratio, prothrombin activity, α-fetoprotein, tumor number and size, lymph node metastasis, and portal vein involvement, which were all included to build the nomogram. The calibration curve for predicting the probability of survival showed consistency between the nomogram and the actual observation. The C-index of the nomogram was 0.81 (95% confidence interval, 0.79–0.82), which was statistically better than that of the Tumor, Node, Metastasis staging (0.71), Barcelona Clinic Liver Cancer staging (0.77), Okuda (0.62), Japan Integrated Staging (0.73), Cancer of the Liver Italian Program score (0.76), Chinese University Prognostic Index (0.68), and the Groupe d’ Etude et de Traitement du Carcinome Hepatocellulaire Prognostic classification (0.65) (p < 0.001 for all). The results were validated in the prospective validation cohort.

Conclusions

The prognostic nomogram resulted in more accurate individualized risk estimates for overall survival in HCC patients.

Neutrophil to lymphocyte ratio as an indicator of the malignant behaviour of hepatocellular carcinoma

Background

The preoperative serum neutrophil to lymphocyte ratio (NLR) has been associated with survival in patients with hepatocellular carcinoma (HCC). However, it is still unclear what the NLR reflects precisely. This study aimed to elucidate the relationship between the NLR and TNM stage, and the role of NLR as a prognostic factor after liver resection for HCC.

Methods

This retrospective study enrolled patients who underwent liver resection as initial treatment for HCC. The best cut-off value of serum NLR was determined, and overall survival was compared among patients grouped according to TNM stage (I, II and III).

Results

The best cut-off value for NLR was 2·8. A high preoperative NLR was more frequently associated with poor overall survival than a low preoperative NLR after resection for TNM stage I tumours (5-year survival 45·0 versus 76·4 per cent, P &lt; 0·001), but not stage II (P = 0·283) or stage III (P = 0·155) tumours. Among patients with TNM stage I disease, the proportion of patients with extrahepatic recurrence was greater in the group with a high preoperative NLR than in the low-NLR group (P = 0·006). In multivariable analysis, preoperative NLR was the strongest independent prognostic risk factor for overall survival in TNM stage I (hazard ratio 2·69, 95 per cent c.i. 1·57 to 4·59; P &lt; 0·001).

Conclusion

Preoperative NLR was an important prognostic factor for TNM stage I HCC after liver resection with curative intent. These results suggest that the NLR may reflect the malignant potential of HCC.

A Novel and Validated Inflammation-Based Score (IBS) Predicts Survival in Patients With Hepatocellular Carcinoma Following Curative Surgical Resection: A STROBE-Compliant Article

As chronic inflammation is involved in the pathogenesis and progression of hepatocellular carcinoma (HCC), we investigated the prognostic accuracy of a cluster of inflammatory scores, including the Glasgow Prognostic Score, modified Glasgow Prognostic Score, platelet to lymphocyte ratio, Prognostic Nutritional Index, Prognostic Index, and a novel Inflammation-Based Score (IBS) integrated preoperative and postoperative neutrophil to lymphocyte ratio in 2 independent cohorts. Further, we aimed to formulate an effective prognostic nomogram for HCC after hepatectomy.Prognostic value of inflammatory scores and Barcelona Clinic Liver Cancer (BCLC) stage were studied in a training cohort of 772 patients with HCC underwent hepatectomy. Independent predictors of survival identified in multivariate analysis were validated in an independent set of 349 patients with an overall similar clinical feature.In both training and validation cohorts, IBS, microscopic vascular invasion, and BCLC stage emerged as independent factors of overall survival (OS) and recurrence-free survival (RFS). The predictive capacity of the IBS in both OS and RFS appeared superior to that of the other inflammatory scores in terms of C-index. Additionally, the formulated nomogram comprised IBS resulted in more accurate prognostic prediction compared with BCLC stage alone.IBS is a novel and validated prognostic indicator of HCC after curative resection, and a robust HCC nomogram including IBS was developed to predict survival for patients after hepatectomy.

Role of ¹⁸F-FDG PET CT as an independent prognostic indicator in patients with hepatocellular carcinoma

OBJECTIVES

The aim of the study was to evaluate the role of F-fluorodeoxyglucose PET computed tomography (F-FDG PET CT) as an independent prognostic indicator in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

PET contrast-enhanced CT scans of 100 consecutive patients with HCC were reviewed retrospectively. Patients were asked to fast for 6 h before the study and blood glucose levels were monitored and ensured to be less than 200 mg/dl before injection of F-FDG. After administering the F-FDG injection (370-550 MBq) patients were instructed to rest comfortably for 45-60 min. All images were acquired using a dedicated GE Discovery PET/CT scanner. The PET CT scans of all the patients were reported separately by two nuclear medicine physicians. A stage-wise analysis of the compiled data was carried out. Lesions that showed standardized uptake values greater than background activity (activity in adjacent normal liver tissue) were defined as having increased F-FDG uptake. Pearson's χ -test or the Kruskal-Wallis test was used to assess statistical significance. A P value less than 0.05 was taken as significant.

RESULTS

In this retrospective study of 100 HCC patients, a radiologically higher-stage disease was found more commonly in patients with F-FDG-avid primary tumors (P<0.001), whereas a lower-stage disease was found in patients with non-F-FDG-avid primary tumors. The non-F-FDG-avid tumors also showed lower incidence of metastatic disease and portal vein thrombosis (P<0.001). The histopathological findings of the patients who underwent liver transplantation demonstrated that a higher-grade tumor was more common in the F-FDG-avid tumor group than in the non-F-FDG-avid tumor group (P<0.05).

CONCLUSION

An F-FDG PET CT scan can be used not only for staging but also as a tool for preoperative prediction of cellular differentiation in patients with HCC. The F-FDG uptake seen on a PET scan can serve as a molecular signature for management decisions and can be used as an independent and significant prognostic factor in patients with HCC.

Prediction of the postoperative prognosis of intrahepatic cholangiocarcinoma (ICC): importance of preoperatively- determined anatomic invasion level and number of tumors

BACKGROUND

Preoperative prediction of the prognosis of patients with intrahepatic cholangiocarcinoma (ICC) following surgical treatment remains quite difficult and controversial. We attempted to identify the preoperative and postoperative predictors of the overall survival rates inpatients with ICC in order to clarify the appropriate indications for surgical resection of ICC.

PATIENTS AND METHODS

We retrospectively investigated the clinicopathological features of ICC and outcome of surgical resection in 111 consecutive patients who underwent surgical treatment at our hospital between 1980 and March 2012. Both preoperative factors and operatively confirmed factors were evaluated as potential risk factors for determination of the post-surgical prognosis.

RESULTS

Curative resection (R0) was performed in 72 patients (64.9 %). The 1- and 3-year overall survival rates were 85.0 and 59.7 % in the R0 group. Two preoperative factors [hilar invasion as recognized by computed tomography(HR 3.16, P = 0.020) and multiple intrahepatic tumors (HR 7.09, P = 0.0002)] and two operatively confirmed factors [multiple intrahepatic tumors (HR 9.17,P = 0.0009) and lymph node metastasis as confirmed by final histology (HR 6.41, P = 0.003)] were identified as significant risk factors adversely influencing the overall survival rate after surgery. Furthermore, solitary, small(\5 cm) and peripheral ICCs were associated with a very low probability of lymph node metastasis.

CONCLUSIONS

Preoperatively diagnosed hilar invasion,multiple intrahepatic tumors and histologically confirmed lymph node metastasis were the main determinants of an adverse postoperative prognosis in patients with ICC.Lymph node dissection could be omitted for patients with solitary, small and peripheral ICCs.

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

BACKGROUND & AIMS

Outcome prediction is uniquely different in hepatocellular carcinoma (HCC) as the progressive functional impairment of the liver impacts patient survival independently of tumour stage. As chronic inflammation is associated with the pathogenesis of HCC, we explored the prognostic impact of a panel of inflammatory based scores, including the modified Glasgow Prognostic Score (mGPS), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR), in independent cohorts.

METHODS

Inflammatory markers, Barcelona Clinic Liver Cancer (BCLC) and Cancer of the Liver Italian Program (CLIP) scores were studied in a training set of 112 patients with predominantly unresectable HCC (75%). Independent predictors of survival identified in multivariate analysis were validated in an independent cohort of 466 patients with an overall lower tumour burden (BCLC-A, 56%).

RESULTS

In both training and validation sets, mGPS and CLIP scores emerged as independent predictors of overall survival. The predictive accuracy of the combined mGPS and CLIP score (c score 0.7, 95% CI 0.6-0.8) appeared superior to that of the CLIP score alone (c score 0.6, 95% CI 0.5-0.7).

CONCLUSIONS

Systemic inflammation as measured by the mGPS, independently predicts overall survival in HCC. We have validated a novel, easy to use inflammatory score that can be used to stratify individuals. These data enable formulation of a new prognostic system, the inflammation based index in HCC (IBI). Further validation of the IBI considering treatment allocation and survival is warranted in an independent patient cohort.

Comparison of staging systems of hepatocellular carcinoma

Many staging systems of hepatocellular carcinoma (HCC) were established; however, there is no consensus on which is proper in predicting prognosis. This study aims to evaluate various commonly used staging systems of HCC. Patients who underwent surgery during 2001-2007 were included. All patient data were retrospectively staged using six staging systems, that are American Joint Committee on Cancer (AJCC) Tumour-Node-Metastasis (TNM), Okuda staging, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Chinese University Prognostic Index (CUPI), and Japan Integrated Staging (JIS). Child-Pugh classification was also evaluated. The staging systems were compared by mean of overall and disease-free survival. Total of 99 patient data were enrolled in the analyses. All staging systems except Okuda were significant in determining overall survival in univariate analyses. In multivariate analyses, TNM and Child-Pugh demonstrated better predictive power for overall survival. In terms of disease-free survival, univariate analyses revealed that TNM, CLIP, BCLC, CUPI, and JIS were significant, and TNM was the best predictive staging system in multivariate analyses. In our study, TNM and Child-Pugh are the representative systems in predicting survival of HCC patients who undergo surgical resection. Moreover, they are practical and easily assessable in clinical practice.

Glypican-3, a novel prognostic marker of hepatocellular cancer, is related with postoperative metastasis and recurrence in hepatocellular cancer patients

Metastasis/recurrence has been the most fundamental characteristic of hepatocellular cancer (HCC) and the ultimate cause of most HCC-related deaths. However, there are still a limited number of reliable tumor markers that can be used to predict the possibility of metastasis/recurrence in an HCC patient after operation. Recently, much evidence has shown that glypican-3 (GPC3) can be a useful tool to identify the early development of HCC, but little research has been done to test its usefulness as a prognostic marker related to post-operative metastasis/recurrence in HCC patients. In this study, the expression of GPC3 and its relationship with clinicopathological factors were determined by immunohistochemical analysis in 61 primary HCC patients. The potential prognostic value of GPC3 was investigated by comparing the survival time between HCC patients with high and low GPC3 expression. The results demonstrated that GPC3 expression was closely related with metastasis/recurrence in an HCC patient who can receive the operation. The risk of metastasis/recurrence after surgery in an HCC patient with high GPC3 expression was increased to 3.214 as compared to that of an HCC patient with low GPC3 expression. Survival analysis showed that HCC patients with high GPC3 expression had a significantly shorter overall survival time than HCC patients with low GPC3 expression (P=0.003). Further, multivariate analysis showed that GPC3 expression was a significant, independent prognostic parameter (P=0.030) for HCC patients. Overall, the study indicates that GPC3 might be a valuable marker closely related with prognosis and post-operative metastasis/recurrence in HCC patients.

Characterisation of a novel cell line (CSQT-2) with high metastatic activity derived from portal vein tumour thrombus of hepatocellular carcinoma

BACKGROUND

Portal vein tumour thrombus (PVTT) is highly associated with the progression and metastasis of hepatocellular carcinoma (HCC). However, there are no appropriate cell models of PVTT with which to study the biological and physiological characteristics of PVTT.

METHODS

Primary cell culture was performed by the use of a successive xenograft line called PVTT-#1, which was obtained from a 60-year-old male HCC patient accompanied by PVTT.

RESULTS

A successive cell line named CSQT-2 was established. The cell line showed aggressive phenotypes in terms of cell growth, survival, migration, xenograft and metastasis. Moreover, an orthotopic transplantation assay showed that PVTT can be generated in nude mice when CSQT-2 cells were inoculated in the liver and that it shows a typical migratory tendency in the vascular branches of portal vein. Moreover, the established CSQT-2 cells also showed varied expression of tumour-initiating cell (TIC) markers such as CD133, CD90 and EpCAM.

CONCLUSION

Establishment of CSQT-2 may provide a suitable model with which to investigate the molecular mechanisms of PVTT-related HCC.