Clinical utility of des-γ-carboxyprothrombin kinetics as a complement to radiologic response in patients with hepatocellular carcinoma undergoing transarterial chemoembolization

Evaluating treatment response following locoregional therapy for hepatocellular carcinoma: A review of the available serological and radiological tools for assessment

Hepatocellular carcinoma (HCC) is an aggressive primary malignancy of the liver and is the third most common cause of cancer-related global mortality. There has been a steady increase in treatment options for HCC in recent years, including innovations in both curative and non-curative therapies. These advances have brought new challenges and necessary improvements in strategies of disease monitoring, to allow early detection of HCC recurrence. Current serological and radiological strategies for post-treatment monitoring and prognostication and their limitations will be discussed and evaluated in this review.

Risk stratification of patients with hepatocellular carcinoma undergoing trans arterial chemoembolization using an alpha-fetoprotein model

Background

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. There are multiple factors that could affect the malignancy and progression of HCC including tumor number, size, and macrovascular invasion. The alpha-fetoprotein (AFP) model was validated as a predictor for HCC recurrence post-liver transplantation, especially in France. However, the AFP model has not been studied on patients with HCC undergoing locoregional treatment. This study aimed to assess the prognostic value of the AFP model in patients with HCC undergoing trans arterial chemoembolization (TACE). This cohort study was conducted at Ain Shams University Hospitals, Cairo, Egypt. We included all newly diagnosed patients with HCC who were fit for TACE from January 2012 to January 2017. The AFP model was calculated for each patient before TACE. Subsequently, we classified them into low- and high-risk groups for TACE. The patients were followed up by AFP level and triphasic spiral CT performed 1 month after TACE to evaluate the response then at 4 months and 7 months post TACE to evaluate the local and distant recurrence.

Results

One hundred and thirty-two patients were included in the study. Complete response (CR) was achieved nonsignificantly at a higher percentage in the low-risk group in comparison with the high-risk group. One- and three-year recurrence-free survivals (RFS) were longer in the low-risk group in comparison with the high-risk group (50% and 24.1% vs. 29.1% and 16.2%, respectively). One- and three-year overall survival (OS) rates were 97% and 37.3% in the low-risk group vs. 98.1% and 11.6% in the high-risk group, respectively, without statistical significance. On classifying patients with AFP levels < 100 IU/mL into low- and high-risk patients, CR was achieved in a significantly higher percentage in the low-risk group in comparison with the high-risk group(P < 0.05). Recurrence occurred nonsignificantly in a less percentage in low than high-risk group. The median OS was significantly higher in the low-risk group in comparison with that in the high-risk group (18 vs. 16 months respectively) (P < 0.01).

Conclusion

The AFP model may have a prognostic value for patients with HCC undergoing TACE especially in patients with an AFP level < 100 IU/mL.

The potential of PIVKA-II as a treatment response biomarker in hepatocellular carcinoma: a prospective United Kingdom cohort study

Prothrombin induced by vitamin K absence II (PIVKA-II) has recently been validated internationally as a diagnostic biomarker for hepatocellular carcinoma (HCC), as part of the GALAD model. However, its role as a treatment response biomarker has been less well explored. We, therefore, undertook a prospective study at a tertiary centre in the UK to evaluate the role of PIVKA-II as a treatment response biomarker in patients with early, intermediate and advanced stage HCC. In a cohort of 141 patients, we found that PIVKA-II levels tracked concordantly with treatment response in the majority of patients, across a range of different treatment modalities. We also found that rises in PIVKA-II levels almost always predated radiological progression. Among AFP non-secretors, PIVKA-II was found to be informative in 60% of cases. In a small cohort of patients undergoing liver transplantation, pre-transplant PIVKA-II levels predicted for microvascular invasion and poorer differentiation. Our results demonstrate the potential utility of PIVKA-II as a treatment response biomarker and in predicting microvascular invasion, in a Western population. PIVKA-II demonstrated improved performance over AFP but, as a single biomarker, its performance was still limited. Further larger prospective studies are recommended to evaluate PIVKA-II as a treatment response biomarker, within the GALAD model.

Tumor Biomarkers and Interventional Oncology: Impact on Local Outcomes for Liver and Lung Malignancy

PURPOSE OF REVIEW

Interventional oncology (IO) loco-regional treatments are widely utilized in clinical practice. However, local tumor control rates are still widely variable. There is a need to identify and develop novel biomarkers prognosticators following IO therapies. Here, we review the current literature on molecular tumor biomarkers in IO, mainly focusing on patients with liver and lung cancers.

RECENT FINDINGS

RAS mutation is a prognosticator for patients with colorectal liver metastases. Several promising serum metabolites, gene signatures, circulating tumor nucleotides, and peptides are being evaluated for patients with hepatocellular carcinoma. Ki-67 and RAS mutation are independent risk factors for local tumor progression in the ablation of lung cancer. The relevant interplay between specific tumor biomarkers and IO loco-regional therapies outcomes has brought a new vision in the management of cancer. Further evolution of personalized interventional oncology accordingly to tumor biomarkers should improve oncologic outcomes for patients receiving IO therapies.

Biological response under treatment and prognostic value of protein induced by vitamin K absence or antagonist-II in a French cohort of patients with hepatocellular carcinoma

OBJECTIVES

We have confirmed the diagnostic value of protein induced by vitamin K absence or antagonist-II (PIVKA-II) in a French cohort of patients with hepatocellular carcinoma (HCC). Herein, we aim to study the biological response under treatment and the prognostic value of PIVKA-II serum level in patients treated for HCC.

METHODS

Patients with primary HCC developed chronic liver disease with serum PIVKA-II, and alpha-fetoprotein (AFP) levels available at baseline and after first HCC treatment [within 3 months (M1-M3) and/or within 6-9 months (M6-M9)] were included.

RESULTS

A total of 94 patients were included. Median follow-up was 23 months (range 11-31 months). PIVKA-II levels significantly decreased from baseline to M1-M3 (P = 0.002) and to M6-M9 (P = 0.035). By multivariate analysis, biological response (M1-M3/baseline PIVKA-II ratio) independently and significantly predicted overall survival (OS). A ratio below 0.73 was able to identify patients with the better prognosis in the total population [OS: 27 months (range 17-31) vs. 17 (range 9-25); P = 0.008] and in patients who had transarterial chemoembolization or selective internal radiation therapy as first treatment approach [OS: 26 months (range 14-31) vs. 16 (range 9-25); P = 0.002 and 2-year OS of 73% vs. 30%; P = 0.009]. PIVKA-II serum levels at baseline and PIVKA-II biological response were significantly associated with radiological response.

CONCLUSION

PIVKA-II serum level seems to be a good prognostic and promising biomarker for early monitoring treatment outcomes for patients with HCC.

Prognostic value of des-γ-carboxy prothrombin in patients with hepatocellular carcinoma treated with transarterial chemotherapy: A systematic review and meta-analysis

BACKGROUND

Serum des-γ-carboxy prothrombin (DCP) is a hepatocellular carcinoma (HCC) tumor marker that can be used to assess patient prognosis. Since the value of DCP in predicting the prognosis of hepatocellular carcinoma patients treated with transarterial chemotherapy remains controversial, we performed a meta-analysis of previous clinical studies.

METHODS

A systematic literature search was performed using PubMed, the MEDLINE database, EMBASE, and the Cochrane Library in accordance with the PRISMA guidelines. The hazard ratio (HR) with 95% confidence interval (CI) was used to estimate the effect size.

RESULTS

Six respective cohort studies including a total of 943 cases were identified. The pooled results showed that low DCP was associated with a favorable overall survival (OS)(HR 0.653, 95% CI 0.444-0.960), and DCP response was associated with increased OS (HR 0.387,95% CI 0.215-0.697) and progression-free survival (PFS) (HR 0.42,95% CI 0.23-0.74) in HCC patients treated with transarterial chemotherapy.

CONCLUSIONS

DCP values in HCC patients undergoing hepatic arterial chemotherapy seem to be associated with OS and PFS. Thus, monitoring DCP values and observing the DCP response should be part of the management of patients undergoing transarterial chemotherapy.

The status of transarterial chemoembolization treatment in the era of precision oncology

Transarterial chemoembolization (TACE) is the gold standard of therapy for patients with unresectable intermediate stage hepatocellular carcinoma (HCC), and is also commonly used as postresection adjuvant therapy in Asia. The delivery of TACE is highly variable from center to center, and clinical decision making for patients is based primarily on tumor staging guidelines, with very little focus on individualized tumor features. This review will discuss recent efforts for improving patient outcomes with TACE treatment through personalized medicine advances, including ongoing clinical trials investigating the combination of targeted therapy with TACE and the discovery of prognostic biomarkers for predicting TACE response.

Early Prediction of the Outcome Using Tumor Markers and mRECIST in Unresectable Hepatocellular Carcinoma Patients Who Underwent Transarterial Chemoembolization

OBJECTIVE

We examined early predictors of the outcome in hepatocellular carcinoma (HCC) patients after transarterial chemoembolization (TACE).

METHODS

We analyzed 116 patients with unresectable HCC treated with initial TACE. α-Fetoprotein (AFP) or des-γ-carboxy prothrombin (DCP) response was assessed in patients who had baseline AFP levels ≥200 ng/ml or DCP ≥60 mAU/ml; a positive response was defined as a reduction of >50% compared to baseline 1 month after TACE.

RESULTS

A baseline AFP level ≥200 ng/ml was associated with a poor overall survival (OS) (29.4 vs. 6.1 months; p <0.0001). AFP response had no significantly prognostic effects on the OS. Conversely, although the baseline DCP did not influence the OS, DCP responders showed a significantly better OS than nonresponders (67.0 vs. 19.8 months, p = 0.020). The baseline AFP (p = 0.004) and initial tumor response evaluated by the modified Response Evaluation Criteria in Solid Tumors (mRECIST) (p = 0.012) were found to be independent predictors of the OS. The combination of the baseline AFP and initial assessment by mRECIST allowed stratification of the OS.

CONCLUSIONS

The combination of the baseline AFP level and mRECIST is useful for the early prediction of the OS in HCC patients who underwent TACE.

Hepatocellular carcinoma

Liver cancer is the second leading cause of cancer-related deaths globally and has an incidence of approximately 850,000 new cases per year. Hepatocellular carcinoma (HCC) represents approximately 90% of all cases of primary liver cancer. The main risk factors for developing HCC are well known and include hepatitis B and C virus infection, alcohol intake and ingestion of the fungal metabolite aflatoxin B1. Additional risk factors such as non-alcoholic steatohepatitis are also emerging. Advances in the understanding of the molecular pathogenesis of HCC have led to identification of critical driver mutations; however, the most prevalent of these are not yet druggable targets. The molecular classification of HCC is not established, and the Barcelona Clinic Liver Cancer staging classification is the main clinical algorithm for the stratification of patients according to prognosis and treatment allocation. Surveillance programmes enable the detection of early-stage tumours that are amenable to curative therapies - resection, liver transplantation or local ablation. At more developed stages, only chemoembolization (for intermediate HCC) and sorafenib (for advanced HCC) have shown survival benefits. There are major unmet needs in HCC management that might be addressed through the discovery of new therapies and their combinations for use in the adjuvant setting and for intermediate- and advanced-stage disease. Moreover, biomarkers for therapy stratification, patient-tailored strategies targeting driver mutations and/or activating signalling cascades, and validated measurements of quality of life are needed. Recent failures in the testing of systemic drugs for intermediate and advanced stages have indicated a need to refine trial designs and to define novel approaches.

Early Decreases in α-Fetoprotein and Des-γ-carboxy Prothrombin Predict the Antitumor Effects of Hepatic Transarterial Infusion Chemotherapy with Cisplatin (CDDP) Powder in Patients with Advanced Hepatocellular Carcinoma

Objective We retrospectively investigated the relationship between the tumor response and serial changes in α-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP) during hepatic arterial infusion of a cisplatin powder formulation (CDDP powder) in patients with advanced hepatocellular carcinoma (HCC). Methods Seventy-six advanced HCC patients were analyzed. All HCC patients received high-concentration cisplatin (1.43 mg/mL) via the haptic artery at a dose of 65 mg/m(2). AFP and DCP were measured at baseline and four to eight weeks after treatment, and the antitumor responses were evaluated according to the response evaluation criteria in solid tumours (RECIST) criteria after one or two courses of treatment. The patients were classified into two groups, a decreased group and a non-decreased group, according to the change in the serum levels of AFP and DCP at four to eight weeks compared to baseline. Results The response to treatment of the decreased group (n=16) and non-decreased group (n=60) was complete response/partial response/stable disease/progressive disease (CR/PR/SD/PD) in 4/4/5/3 and 1/11/8/40 patients, respectively. The response rate and disease control rate of the decreased group were significantly higher than those of the non-decreased group (p=0.016 and p<0.001, respectively). The median survival time (MST) of the decreased/non-decreased groups were 25.9/10.6 months, respectively. The cumulative survival rates for the decreased group were significantly higher than those of the non-decreased group (p=0.042). In the multivariate analysis, vascular invasion and the decreased group were significant factors that affected the therapeutic efficacy. Conclusion A decrease in the levels of AFP and DCP after the first treatment with CDDP powder is a good predictor for the antitumor effect and the prognosis.

Circulating biomarkers of hepatocellular carcinoma response after locoregional treatments: New insights

Hepatocellular cancer is the 5^th most common cancer in the world and the third cause of death by malignant disease. Locoregional therapies are the most usual treatment of choice for patients with early or intermediate stage of disease. The main diagnostic tools for the detection of recurrence are the radiological techniques such as 4-phase computed tomography or dynamic contrast enhanced magnetic resonance imaging. However, in order to achieve best evaluation of treatment outcome and recurrence rates, there is a great need for the identification of specific and easily measured circulating biomarkers. The aim of this review is to analyze the existing data considering the prognostic significance of changes of serum diagnostic markers such as alpha-fetoprotein, des-gamma-carboxy prothrombin, alpha-fetoprotein-L3, angiogenetic factors (vascular endothelial growth factor, hypoxia inducible factor-1a) and immune parameters before and after radiofrequency ablation or transarterial chemoembolization.

Clinical significance of AFP and PIVKA-II responses for monitoring treatment outcomes and predicting prognosis in patients with hepatocellular carcinoma

Aim. Recently, the utility of tumor markers in the hepatocellular carcinoma (HCC) field has received a good deal of attention. Here, we review and summarize the results of studies on the roles played by the α-fetoprotein (AFP) and prothrombin induced by the absence of vitamin K or antagonist-II (PIVKA-II) responses in terms of the monitoring of outcomes and prediction of prognosis after various HCC treatments. Methods. Studies lodged in PUBMED and that satisfied our inclusion criteria were reviewed. Results. We reviewed 12 studies measuring both AFP and PIVKA-II responses in HCC patients treated in various ways. The results are presented by treatment modality. Conclusion. Measurement of AFP and PIVKA II marker levels before and after HCC treatment is clinically useful in monitoring of treatment outcomes and prognosis and in predicting recurrence and survival.

Hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the prognostic factors and efficacy of hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein tumor thrombosis.

METHODS: Fifty hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) were treated using hepatic arterial infusion chemotherapy (HAIC) via a subcutaneously implanted port. The epirubicin-cisplatin-5-fluorouracil (ECF) chemotherapeutic regimen consisted of 35 mg/m² epirubicin on day 1, 60 mg/m² cisplatin for 2 h on day 2, and 500 mg/m² 5-fluorouracil for 5 h on days 1-3. The treatments were repeated every 3 or 4 wk.

RESULTS: Three (6%) of the 50 patients achieved a complete response (CR), 13 (26%) showed partial responses (PR), and 22 (44%) had stable disease (SD). The median survival and time to progression were 7 and 2 mo, respectively. After 2 cycles of HAIC, CR was achieved in 1 patient (2%), PR in 10 patients (20%) and SD in 26 patients (52%). Significant pre-treatment prognostic factors were a tumor volume of < 400 cm³ (P = 0.01) and normal levels of protein induced by vitamin K absence or antagonist (PIVKA)-II (P = 0.022). After 2 cycles of treatment, disease control (CR + PR + SD) (P = 0.001), PVTT response (P = 0.003) and α-fetoprotein reduction of over 50% (P = 0.02) were independent factors for survival. Objective response (CR + PR), disease control, PVTT response, and combination therapy during the HAIC were also significant prognostic factors. Adverse events were tolerable and successfully managed.

CONCLUSION: HAIC may be an effective treatment modality for advanced HCC with PVTT in patients with tumors < 400 cm³ and good prognostic factors.

Computed tomography follow-up for the detection of hepatocellular carcinoma recurrence after initial radiofrequency ablation: a single-center experience

PURPOSE

Recurrence of hepatocellular carcinoma (HCC) is very common even after curative resection or ablation. This retrospective study compared the radiologic features of recurrent HCC seen by computed tomography (CT) to evaluate our empirical protocol of CT surveillance using 4-month intervals.

MATERIALS AND METHODS

A total of 113 patients who were diagnosed with a first HCC recurrence after radiofrequency (RF) ablation between January 2005 and December 2006 were enrolled at a single center. Definite HCC was defined as hyperattenuation in the arterial phase with washout in the portal venous phase, and a diagnosis of naive and recurrent HCC was based on dynamic CT findings. Recurrent nodules were classified according to the enhancement patterns of previous CT images. The treatment modality for recurrent HCC and survival were evaluated.

RESULTS

One hundred seventy-seven nodules were diagnosed as recurrent HCC: 31 (17.5%) had already been diagnosed on previous CT images as typical HCC, 72 (40.6%) had arterial hypervascularity without washout in the portal venous phase, 21 (11.9%) showed portal venous phase washout without arterial hypervascularity, and no lesions were noted in the remaining 49 (27.7%). Tumor size at recurrence was smaller than 2 cm in diameter in 98 (86.7%) cases. One hundred four patients were treated for recurrent HCC with RF ablation. The 5-year survival rate after recurrence was 49.8%. There was no significant difference in survival among groups divided by the enhancement pattern on the previous CT examination.

CONCLUSIONS

Dynamic CT in 4-month intervals is an acceptable recurrence-monitoring strategy because it detects most recurrent nodules at a stage at which RF ablation is still feasible.