A comparison of surgical outcomes for noncirrhotic and cirrhotic hepatocellular carcinoma patients in a Western institution

Hepatocellular carcinoma in cirrhotic versus non-cirrhotic liver: Treatment and survival differences in a nationwide cohort

BACKGROUND AND AIMS

Numerous studies have reported superior outcome for patients with hepatocellular carcinoma (HCC) in non-cirrhotic compared to cirrhotic livers. This cohort study aims to describe the clinical presentation, disease course, treatment approaches, and survival differences in a population-based setting.

METHODS

Data on patients diagnosed with HCC in Sweden between 2008 and 2018 were identified and extracted from the Swedish Liver registry (SweLiv). Descriptive and survival statistics were applied.

RESULTS

Among the 4259 identified patients, 34% had HCC in a non-cirrhotic liver. Cirrhotic patients presented at a younger age (median = 64 vs 74 years, p < 0.001) and with a poorer performance status (Eastern Cooperative Oncology Group (ECOG) = 0-1: 64% vs 69%, p = 0.024). Underlying liver disease was more prevalent among cirrhotic patients (81% vs 19%, p < 0.001). Tumors in non-cirrhotic livers were diagnosed at a more advanced stage (T3-T4: 46% vs 31%) and more frequently with metastatic disease at diagnosis (22% vs 10%, p < 0.001). Tumors were significantly larger in non-cirrhotic livers (median size of largest tumor 7.5 cm) compared to cirrhotic livers (3.5 cm) (p < 0.001). Curative interventions were more commonly intended (45% vs 37%, p < 0.001) and performed (40% vs 31%, p < 0.001) in the cirrhotic vs non-cirrhotic patients. Median survival was 19 months (95% confidence interval (CI) = 18-21 months), in patients with cirrhosis as compared to 13 months in non-cirrhotic patients (95% CI = 11-15) (p < 0.001). In the multivariable Cox regression model, cirrhosis was not an independent predictor of survival, neither among curatively nor palliatively treated patients.

CONCLUSION

These population-based data show that patients with HCC in a cirrhotic liver receive curative treatment to a greater extent and benefit from superior survival compared to those with HCC in a non-cirrhotic liver. The differences in survival are more attributable to patient and tumor characteristics rather than the cirrhotic status itself.

CLINICAL TRIAL REGISTRATION

not applicable. Patient confidentially: not applicable.

Microwave ablation trocar for ablating cancerous tumors: a numerical analysis

Microwave ablation (MWA) is a newly developing minimally invasive thermal therapies technology. The ablation region obtained during MWA mainly depends on the type and efficiency of the trocar as well as the energy transfer from the generator to the biological tissue. In the present article, a novel trocar for MWA therapies has been proposed. A 3-dimensional tumor-embedded hepatic gland ablated with the novel MWA trocar has been numerically analyzed using finite element method-based software. The novel trocar consists of a flexible dual tine supplied with a microwave power of 15 W at 2.45/6 GHz for an ablation time of 10 min for all the cases. Various combinations of supplied energy and deploying lengths result in tumor ablations ranging from 2.7 to 4 cm in diameter. Supplying energy at high frequency (6 GHz) to the trocar results in ablating tumors (> 4 cm) with spherical ablation region. The novel trocar generated large ablation regions which are 2-3 times bigger than the tumors obtained using existing single-slot non-cooled trocars. This research on novel trocar may help clinicians in treating large size tumors of symmetric and asymmetric shapes by overcoming the problem associated with precise position of trocar into the tissue.

Preoperative inflammatory markers as prognostic predictors after hepatocellular carcinoma resection: data from a western referral center

Background

Recent studies from eastern centers have demonstrate an association between inflammatory response and long-term outcomes after hepatocellular carcinoma (HCC) resection. However, the prognostic impact of inflammatory markers in western patients, with distinct tumor and epidemiologic features, is still unknown.

Aim

To evaluate the prognostic impact of preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), as well as their impact according to tumor size (< 5 cm, 5–10 cm, > 10 cm) in patients undergoing HCC resection with curative intent.

Methods

Optimal cut-off values for NLR, PLR, and MLR were determined by plotting the receiver operator curves. Overall survival (OS) and disease-free survival (DFS) curves were calculated using the Kaplan–Meier method and compared using the log-rank test. The Cox method was used to identify independent predictors of OS and DFS.

Results

In total, 161 consecutive adult patients were included. A high NLR (> 1.715) was associated with worse OS (P = 0.018). High NLR (> 2.475; P = 0.047) and PLR (> 100.25; P = 0.028) were predictors of short DFS. In HCC < 5 cm, MLR (> 1.715) was associated with worse OS (P = 0.047). In the multivariate analysis, high PLR was an independent predictor of worse DFS [hazard ratio (HR) 3.029; 95%CI 1.499–6.121; P = 0.002].

Conclusion

Inflammatory markers are useful tools to predict long-term outcomes after liver resection in western patients, high NLR was able to stratify subgroups of patients with short OS and DFS, an increased PLR was an independent predictor of short DFS, while high MLR was associated with short OS in patients with early HCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01779-6.

Liver fibrosis promotes immunity escape but limits the size of liver tumor in a rat orthotopic transplantation model

Liver fibrosis plays a crucial role in promoting tumor immune escape and tumor aggressiveness for liver cancer. However, an interesting phenomenon is that the tumor size of liver cancer patients with liver fibrosis is smaller than that of patients without liver fibrosis. In this study, 16 SD rats were used to establish orthotopic liver tumor transplantation models with Walker-256 cell lines, respectively on the fibrotic liver (n = 8, LF group) and normal liver (n = 8, control group). MRI (magnetic resonance imaging) was used to monitor the size of the tumors. All rats were executed at the third week after modeling, and the immunohistochemical staining was used to reflect the changes in the tumor microenvironment. The results showed that, compared to the control group, the PD-L1 (programmed cell death protein receptor-L1) expression was higher, and the neutrophil infiltration increased while the effector (CD8+) T cell infiltration decreased in the LF group. Additionally, the expression of MMP-9 (matrix metalloproteinase-9) of tumor tissue in the LF group increased. Three weeks after modeling, the size of tumors in the LF group was significantly smaller than that in the control group (382.47 ± 195.06 mm3 vs. 1736.21 ± 657.25 mm3, P < 0.001). Taken together, we concluded that liver fibrosis facilitated tumor immunity escape but limited the expansion of tumor size.

Impact of diseased liver parenchyma on perioperative outcome among patients with hepatocellular carcinoma undergoing hepatectomy: Experience from a developing country

INTRODUCTION

Limited data can be found about surgical outcome of patients with hepatocellular carcinoma (HCC) arising in non-diseased liver. The study aim was to compare short- and long-term outcomes among HCC patients with normal and diseased liver parenchyma, undergoing potentially curative liver resection in a developing country.

MATERIALS AND METHODS

From November 2001 until January 2017, 228 patients with HCC underwent curative-intent hepatectomy at the University Clinic for Digestive Surgery. From that number, 190 patients were eligible for analysis. Diseased liver (DL) was present in 112 patients while 78 patients had HCC in non-diseased liver (NDL).

RESULTS

Median age, sex, ASA score, the presence of extrahepatic disease and lobar distribution of tumors were similar in both groups. The number of tumors was higher in DL group, while tumor diameter was higher in NDL group. Anatomic liver resection and major liver resections were performed more commonly in NDL than in DL group (66.7 vs 47.4%, p = 0.008; 33.3 vs. 15.2%, p = 0.003). Postoperative morbidity was significantly higher in DL group (p = 0.004). Overall survival was statistically longer in NDL group (p = 0.024). By univariate analysis potential prognostic factors for long-term survival were identified: presence of chronic HCV infection, presence of cirrhosis, Child-Pugh score B and operative time longer than 240 min. The last two were confirmed by multivariate analysis as independent negative prognostic factors for overall survival.

CONCLUSION

Liver resection in patients with HCC arising in non-diseased livers, despite of need for extended hepatectomies, provides favorable long-term prognosis.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

BACKGROUND AND AIMS

Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients.

METHODS

We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding.

RESULTS

We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23-1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99-1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21-3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31-2.00).

CONCLUSIONS

Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Comparison of survival outcomes of alcohol-related hepatocellular carcinoma with or without liver cirrhosis; a ten-year experience

We evaluated overall survivals (OSs) of alcohol-related hepatocellular carcinoma (HCC) patients without LC compared to those with LC.Between 2005 and 2015, 1343 patients were initially diagnosed as having HCC in our hospital. Of these, 186 alcohol-related HCC patients were enrolled in this study, and their medical records were retrospectively analyzed. Significant alcohol intake was defined as more than 210 grams/week for men and more than 140 grams/week for women.Non-cirrhotic HCC was observed in 37.1% of the 186 patients. Cumulative OS rates were significantly higher in non-cirrhotic patients (P = .006). For the 117 cirrhotic patients, cumulative OS rate was significantly higher in the CTP class A patients than in the CTP class B (P < .001) or CTP class C (P < .001) patients, respectively. In the 69 non-cirrhotic patients, cumulative OS rate was significantly higher in the CTP class A patients than in the CTP class C patients (P < .001), but, not than in the CTP class B patients (P = .157). Multivariate analyses revealed that CTP class B (P < .001), CTP class C (P < .001), and tumor size (P = .006) were significant predictors for OS in cirrhotic patients, and that CTP class C (P = .002) and tumor size (P = .023) were significant predictors for OS in non-cirrhotic patients.OS was found to be better for non-cirrhotic than cirrhotic patients with alcohol-related HCC. Survivals of alcohol-related HCC patients without cirrhosis were comparable between patients with CTP class A and B.

Surgical treatment results of hepatocellular carcinoma in non-cirrhotic liver in southern Chile: case series with follow-up

BACKGROUND

Hepatocellular carcinoma is the most frequent primary tumour of the liver. Although often associated with chronic liver disease, it can also occur in non-cirrhotic livers. The aim of this study was to describe post-operative morbidity (POM), and survival of patients with hepatocellular carcinoma in non-cirrhotic liver treated surgically, and to identify variables associated with prognosis.

METHODS

Case series of patients who underwent surgery for hepatocellular carcinoma in non-cirrhotic liver at Clínica RedSalud Mayor de Temuco, Chile (2001-2017), were studied. The minimum follow-up time considered was 12 months. Principal outcomes were development of POM and survival. Other variables of interest were age, sex, tumour diameter, surgical time, hospital stay, follow-up time, need for surgical re-intervention, mortality, vascular and lymph node invasion and staging. Descriptive and analytic statistics were calculated.

RESULTS

A total of 32 patients were studied. They were characterized by a mean age of 67.3 ± 7.2 years, 62.5% of whom were men. Averages of tumour diameter, surgical time and hospitalization were 12.0 ± 2.6 cm, 114.4 ± 32.3 min and 7.2 ± 2.9 days, respectively. POM was 31.3%. There was no mortality and there were no re-interventions. The overall actuarial survival at 1, 2 and 3 years was 96.8%, 73.4% and 17.3%, respectively. Lower survival was verified in patients with vascular invasion, lymph node infiltration and stages III and IVa.

CONCLUSION

Despite the tumour diameter and extent of the resections, POM in patients with hepatocellular carcinoma in non-cirrhotic liver is moderate. However, its prognosis is poor. Vascular invasion, lymph node invasion and advances stages were associated with worse survival.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Preoperative neutrophil-to-lymphocyte ratio as a prognostic predictor after curative-intent surgery for hepatocellular carcinoma: experience from a developing country

Purpose

The aim of the study was to evaluate a prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) on long-term survival of cirrhotic and noncirrhotic hepatocellular cancer (HCC) patients managed by a curative-intent liver surgery in a developing country.

Patients and methods

During the study period between November 1, 2001, and December 31, 2012, 109 patients underwent potentially curative hepatectomy for HCC. Data were retrospectively reviewed from the prospectively collected database. The median follow-up was 25 months. NLR was estimated by dividing an absolute neutrophil count by an absolute lymphocyte count from the differential blood count. Receiver operating characteristic curve was constructed to assess the ability of NLR to predict long-term outcomes and to determine an optimal cutoff value for all patients group, the subgroup with cirrhosis, and the subgroup without cirrhosis. The optimal cutoff values were 1.28, 1.28, and 2.09, respectively.

Results

The overall 3- and 5-year survival rates were 49% and 45%, respectively, for low NLR group and 38% and 26%, respectively, for high NLR group. The difference was statistically significant (p=0.015). Overall survival was similar between low and high NLR groups in patients with cirrhosis; no difference was found between the groups (p=0.124). In patients without cirrhosis, low NLR group had longer overall survival compared with high NLR group (p=0.015). Univariate analysis identified four factors as significant predictors of long-term survival: cirrhosis, Child-Pugh score, platelet count, and NLR. On multivariate analysis, only platelet count and NLR were independent prognostic factors of long-term survival.

Conclusion

Prognostic value of NLR was confirmed in noncirrhotic HCC patients who underwent curative-intent liver surgery. In HCC patients with cirrhosis, the prognostic role of NLR was not confirmed.

Survival following liver transplantation for liver-only colorectal metastases compared with hepatocellular carcinoma

Background

Liver transplantation is considered the standard of care for patients with hepatocellular carcinoma (HCC) within the Milan criteria. Liver transplantation in patients with unresectable colorectal cancer with liver-only disease has been shown to be associated with a 5-year overall survival rate of 56 per cent, compared with 9 per cent in patients receiving standard palliative chemotherapy. The aim of the present study was to compare disease-free (DFS) and overall (OS) survival after liver transplantation in patients with HCC and those with colorectal metastases.

Methods

Data were collected from the SEcondary CAncer (SECA) study database and an institutional (national) database of patients undergoing liver transplantation for HCC; all liver-transplanted patients were included. Patients with colorectal metastases treated by liver transplantation were divided into high- and low-risk groups for mortality based on carcinoembryonic antigen levels, response to chemotherapy, largest lesion at time of transplantation and time from primary surgery to transplantation.

Results

Patients with colorectal metastases had a median of 8 lesions, compared with 1 in patients with HCC within the Milan criteria. DFS was shorter in both the high-risk and the low-risk colorectal cancer groups compared with that in patients with HCC. The 5-year OS rate in the low-risk colorectal cancer group was 75 per cent, compared with 76 per cent in patients with HCC within the Milan criteria. The 5-year OS rate in patients with HCC beyond the Milan criteria was 56 per cent.

Conclusion

The low-risk group of patients with colorectal cancer and unresectable liver-only disease had a 5-year OS rate following liver transplantation similar to that of patients with HCC with lesions within the Milan criteria.

Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of “de principe liver transplant” (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Distinguished prognosis after hepatectomy of HBV-related hepatocellular carcinoma with or without cirrhosis: a long-term follow-up analysis

BACKGROUND

Conflicting results have often been observed for the prognosis of hepatocellular carcinoma (HCC) patients, but few studies have attempted to explore the reasons for the conflicting results. We aimed to distinguish the prognosis of patients with HCC with cirrhosis (HCC-C) and that of patients with HCC without cirrhosis (HCC-NC).

METHODS

Patients with hepatitis B virus (HBV)-associated HCC treated by curative liver resection at a single institution between 1995 and 2013 were retrospectively evaluated. Kaplan-Meier and multivariate analyses were performed to identify risk factors, including tumor-related factors, hypoxia-inducible factor 1α expression, HBV X protein (HBx) expression, and HBx double mutations for overall survival and recurrence-free survival in these patients.

RESULTS

The long-term prognosis of HCC-NC patients is better than that of HCC-C patients. Male sex, poor differentiation, preoperative serum alanine aminotransferase level greater than 80 IU/L, and α-fetoprotein level greater than 400 ng/mL were risk factors for overall survival among HCC-NC patients but not among HCC-C patients, and age greater than 50 years was associated with poor overall survival only in cirrhotic patients. HCC-C patients benefit more from antiviral therapy following curative hepatectomy than do HCC-NC patients. The clinical value of the biomarkers hypoxia-inducible factor 1α, HBx, and HBx double mutations for predicting HCC prognosis was significantly different between these two groups.

CONCLUSIONS

There were differences in tumor-related prognostic factors, effectiveness of the antiviral therapy after hepatectomy, and biomarkers between HCC-C and HCC-NC patients, indicating that subgroup analysis of the prognostic factors may result in better management of HCC and that HCC patients, especially those with liver cirrhosis, should be given antiviral therapy.

Risk Factors and Post-Resection Independent Predictive Score for the Recurrence of Hepatitis B-Related Hepatocellular Carcinoma

BACKGROUND

Independent risk factors associated with hepatitis B (HBV)-related hepatocellular carcinoma (HCC) after resection remains unknown. An accurate risk score for HCC recurrence is lacking.

METHODS

We prospectively followed up 200 patients who underwent liver resection for HBV-related HCC for at least 2 years. Demographic, biochemical, tumor, virological and anti-viral treatment factors were analyzed to identify independent risk factors associated with recurrence after resection and a risk score for HCC recurrence formulated.

RESULTS

Two hundred patients (80% male) who underwent liver resection for HBV-related HCC were recruited. The median time of recurrence was 184 weeks (IQR 52-207 weeks) for the entire cohort and 100 patients (50%) developed HCC recurrence. Stepwise Cox regression analysis identified that one-month post resection HBV DNA >20,000 IU/mL (p = 0.019; relative risk (RR) 1.67; 95% confidence interval (C.I.): 1.09-2.57), the presence of lymphovascular permeation (p<0.001; RR 2.69; 95% C.I.: 1.75-4.12), microsatellite lesions (p<0.001; RR 2.86; 95% C.I.: 1.82-4.51), and AFP >100ng/mL before resection (p = 0.021; RR 1.63; 95% C.I.: 1.08-2.47) were independently associated with HCC recurrence. Antiviral treatment before resection (p = 0.024; RR 0.1; 95% C.I.: 0.01-0.74) was independently associated with reduced risk of HCC recurrence. A post-resection independent predictive score (PRIPS) was derived and validated with sensitivity of 75.3% and 60.6% and specificity of 55.7% and 79.2%, to predict the 1- and 3-year risks for the HCC recurrence respectively with the hazard ratio of 2.71 (95% C.I.: 2.12-3.48; p<0.001). The AUC for the 1- and 3-year prediction were 0.675 (95% C.I.: 0.6-0.78) and 0.746 (95% C.I.: 0.69-0.82) respectively.

CONCLUSION

Several tumor, virological and biochemical factors were associated with a higher cumulative risk of HCC recurrence after resection. PRIPS was derived for more accurate risk assessment. Regardless of the HBV DNA level, antiviral treatment should be given to patients before resection to reduce the risk of recurrence.

Impact of age on the prognosis after liver transplantation for patients with hepatocellular carcinoma: a single-center experience

BACKGROUND

Liver transplantation (LT) offers the most effective treatment for hepatocellular carcinoma patients. Various preoperative variables are correlated with survival after LT, but the prognostic role of aging on LT remains controversial.

METHODS

Between January 2001 and December 2011, 290 consecutive transplants for patients with hepatocellular carcinoma performed in Shanghai First People's Hospital (People's Republic of China) were analyzed retrospectively. We compared patient characteristics and survival curves between a younger group (less than 49 years, n=135) and an aged group (50 years or older, n=155). We then performed Cox multivariate regression analysis of the risk factors for survival in aged and younger patients.

RESULTS

Younger age was associated with higher alpha-fetoprotein (P=0.014), larger tumor size (P=0.038), poorer differentiation (P=0.025), portal lymph node metastasis (P=0.001), and higher recurrence rate (P=0.038). Aged patients had significantly longer recurrence-free survival and overall survival (P=0.020 and P=0.014, respectively); however, there were no significant differences between the younger and aged patients who met the Milan criteria (P>0.05). The 1-, 3-, and 5-year recurrence-free survival rates were 59.7%, 44.5%, and 37.3%, respectively, in the younger group, and 67.9%, 55.3%, and 53.8%, respectively, in the aged group. The 1-, 3-, and 5-year overall survival rates were 68.4%, 45.5%, and 38.9%, respectively, in the younger group, and 76.1%, 59.7%, and 53.9%, respectively, in the aged group. Alpha-fetoprotein ≥400 ng/mL, microvascular invasion, and tumor size >5 cm were independent risk factors for prognosis in both groups.

CONCLUSION

Younger patients in our center tended to present with more aggressive tumors and have a higher risk of recurrence. Our single-center experience suggests that younger patients should be assessed more rigorously before LT, while aged patients should be actively considered for LT after appropriate selection.

AROS Is a Significant Biomarker for Tumor Aggressiveness in Non-cirrhotic Hepatocellular Carcinoma

Despite a low risk of liver failure and preserved liver function, non-cirrhotic hepatocellular carcinoma (HCC) has a poor prognosis. In the current study, we evaluated an active regulator of SIRT1 (AROS) as a prognostic biomarker in non-cirrhotic HCC. mRNA levels of AROS were measured in tumor and non-tumor tissues obtained from 283 non-cirrhotic HCC patients. AROS expression was exclusively up-regulated in recurrent tissues from the non-cirrhotic HCC patients (P = 0.015) and also in tumor tissues irrespective of tumor stage (P < 0.001) or BCLC stage (P < 0.001). High mRNA levels of AROS were statistically significantly associated with tumor stage (P < 0.001), BCLC stage (P = 0.007), alpha fetoprotein (AFP) level (P = 0.013), microvascular invasion (P = 0.001), tumor size (P = 0.036), and portal vein invasion (P = 0.005). Kaplan-Meir curve analysis demonstrated that HCC patients with higher AROS levels had shorter disease-free survival (DFS) in both the short-term (P < 0.001) and long-term (P = 0.005) compared to those with low AROS. Cox regression analysis demonstrated that AROS is a significant predictor for DFS along with large tumor size, tumor multiplicity, vascular invasion, and poor tumor differentiation, which are the known prognostic factors. In conclusion, AROS is a significant biomarker for tumor aggressiveness in non-cirrhotic hepatocellular carcinoma.

Transcatheter arterial chemoembolization combined with CT-guided percutaneous thermal ablation versus hepatectomy in the treatment of hepatocellular carcinoma

Introduction

Transcatheter arterial chemoembolization (TACE) plus thermal ablation has been widely used recently in the treatment of hepatocellular carcinoma (HCC). In this study, we aimed to compare results of the combination of TACE and percutaneous thermal ablation with those of hepatectomy in patients with HCC.

Methods

The clinical data of 137 HCC patients who sequentially received TACE and computed tomography (CT)-guided percutaneous thermal ablation as an initial curative treatment (combination group) and 148 matched HCC patients who received hepatectomy (surgery group) between 2004 and 2011 were collected and analyzed. After TACE, multiphase contrast-enhanced CT was performed to identify the total number of tumors as well as lipiodol deposition in the liver. Survival was calculated by using the Kaplan-Meier method and compared by using the log-rank test. The prognostic factors were assessed with multivariate Cox proportional hazards regression analysis.

Results

Of all 285 patients, 225 (79.0 %) had cancerous lesions ≤ 5 cm in diameter. In preoperative contrast-enhanced CT or magnetic resonance imaging, the number of tumors was 1–4 for each patient. The 1-, 3-, and 5-year overall survival rates were 95, 74 %, and 67 % in the combination group and 88, 66, and 47 % in the surgery group, respectively (P = 0.004); the corresponding recurrence-free survival rates for the two groups were 92, 69, and 61 % and 75, 58, and 44 %, respectively (P = 0.001). In the multivariate analysis, treatment allocation was an independent prognostic factor for survival. Only 60 patients in the combination group had sufficient imaging data, and 135 new lesions with lipiodol deposition were diagnosed as malignancies in 22 of 60 patients, whereas 20 new lesions were found in 11 of 148 patients in the surgery group.

Conclusion

The combination of TACE and CT-guided percutaneous thermal ablation for HCC improves survival of HCC patients compared with hepatectomy.

Unroofing hepatectomy: a facilitating approach for resection of deep-seated hepatocellular carcinoma adjacent to major intrahepatic vessels in cirrhotic patients

BACKGROUND AND OBJECTIVES

Unroofing hepatectomy, an alternative approach to remove a deep-seated hepatocellular carcinoma (HCC) adjacent to major intrahepatic vessels by peel-off technique after sacrificing the overlying noncancerous liver, may result in tumor exposure without resection margin. The aim of the study was to examine the value of this approach in cirrhotic patients.

METHODS

Between 1998 and 2012, 51 cirrhotic patients underwent unroofing hepatectomy for deep-seated newly-diagnosed HCC adjacent to major intrahepatic vessels (group A). Another 274 cirrhotic patients with similar tumor size and without gross major vessel involvement in the same period were selected as the control cohort (group B). The patients' clinicopathological characteristics, the early and long-term outcomes of the two groups were compared.

RESULTS

The HCCs in group A had a significantly higher rate of tumor encapsulation, smaller number of associated satellite nodules, and smaller amount of resected liver weight. Postoperative complication and 90-day mortality rates were similar, but group A patients had a significant better 5-year disease-free (56% vs. 32%, P = 0.011) and overall survival rates (82% vs. 53%, P = 0.008).

CONCLUSIONS

In selected cirrhotic patients, unroofing hepatectomy facilitates resection of deep-seated HCC adjacent to major intrahepatic vessels with acceptable early and long-term results.

Hepatocellular carcinoma review: current treatment, and evidence-based medicine

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Multiple treatment options are available for HCC including curative resection, liver transplantation, radiofrequency ablation, trans-arterial chemoembolization, radioembolization and systemic targeted agent like sorafenib. The treatment of HCC depends on the tumor stage, patient performance status and liver function reserve and requires a multidisciplinary approach. In the past few years with significant advances in surgical treatments and locoregional therapies, the short-term survival of HCC has improved but the recurrent disease remains a big problem. The pathogenesis of HCC is a multistep and complex process, wherein angiogenesis plays an important role. For patients with advanced disease, sorafenib is the only approved therapy, but novel systemic molecular targeted agents and their combinations are emerging. This article provides an overview of treatment of early and advanced stage HCC based on our extensive review of relevant literature.

The critical value of remnant liver volume-to-body weight ratio to estimate posthepatectomy liver failure in cirrhotic patients

BACKGROUND

The extensive use of major hepatectomy for liver malignancies with cirrhosis increases the risk of posthepatectomy liver failure (PHLF), which is associated with a high frequency of postoperative complications, mortality, and an increased length of hospital stay. Remnant liver volume-to-body weight ratio (RLV-BWR) is more specific than the ratio of RLV-to-total liver volume (RLV-TLV) in predicting postoperative course after major hepatectomy in normal liver. Patients having normal liver with an anticipated RLV-BWR ≤0.5% are at considerable risk for hepatic dysfunction and postoperative mortality. In the present study, the critical value of RLV-BWR after liver resection in cirrhotic liver was investigated.

PATIENTS AND METHODS

Thirty one patients who underwent hepatectomy for hepatocellular carcinoma in one medical treatment unit of West China Hospital from September 2012 to December 2012 were retrospectively enrolled in study. Volumetric measurements of TLV using computed tomography were obtained before hepatectomy. PHLF was diagnosed by the "50-50 criteria." The influence of RLV-TLV and RLV-BWR on the occurrence of PHLF was investigated, and the critical value of RLV-BWR was concluded.

RESULTS

According to the occurrence of PHLF, the patients were retrospectively divided into PHLF group and non-PHLF group. There were no statistical differences of preoperative indicators between the two groups. The intraoperative indicators including the resected liver volume, RLV-TLV, and RLV-BWR were statistically significant (P < 0.05) between the two groups. The postoperative indicators including total bilirubin (TBIL), international normalized ratio, and peritoneal drainage fluid at the third and the fifth day after surgery were statistically significant (P < 0.05) between the two groups. Area under the receiver operating characteristic curve (ROC curve) predicted by RLV-BWR to the incidence of PHLF was 0.864 (P = 0.019) with 95% confidence interval (95% CI = 0.608-0.819), and the sensitivity and specialty rate were 70% and 95%, which were more than 50% and 70%, respectively. It suggested that the critical value of RLV-BWR (1.4%) had a certain predictive value on PHLF. Area under the receiver operating characteristic curve predicted by RLV-TLV to the incidence of PHLF was 0.568 (P = 0.628) with 95% confidence interval (95% CI = 0.376-0.747), and the sensitivity and specialty rate were 42.9% and 82.6%, respectively. The sensitivity (42.9%) <50% suggested that the critical value of RLV-TLR (51%) had a poor predictive value on PHLF. According to the curve critical value 1.4% of RLV-BWR, the patients were divided into RLV-BWR ≥1.4% group and RLV-BWR <1.4% group, and the incidence of PHLF between the two groups was statistically significant (P = 0.006).

CONCLUSIONS

RLV-BWR was more specific than RLV-TLV in predicting PHLF after major hepatectomy of cirrhotic liver. Patients with an anticipated RLV-BWR <1.4% are at considerable risk for PHLF.