Results of resection and transplantation for hepatocellular carcinoma in cirrhosis and noncirrhosis

A new scoring system for predicting the outcome of hepatocellular carcinoma patients without microvascular invasion-a large-scale multicentre study

BACKGROUND

The prognosis of HCC patients without MVI (so called M0) is highly heterogeneous and the need for adjuvant therapy is still controversial.

METHODS

Patients with HCC with M0 who underwent liver resection (LR) or liver transplantation (LT) as an initial therapy were included. The Eastern Hepatobiliary Surgery Hospital (EHBH)-M0 score was developed from a retrospective cohort to form the training cohort. The classification which was developed using multivariate cox regression analysis was externally validated.

RESULTS

The score was developed using the following factors: α-fetoprotein level, tumour diameter, liver cirrhosis, total bilirubin, albumin and aspartate aminotransferase. The score differentiated two groups of M0 patients (≤3, >3 points) with distinct long-term prognoses outcomes (median overall survival (OS), 98.0 vs. 46.0 months; p < 0.001). The predictive accuracy of the score was greater than the other commonly used staging systems for HCC. And for M0 patients with a higher score underwent LR. Adjuvant transcatheter arterial chemoembolization (TACE) was effective to prolong OS.

CONCLUSIONS

The EHBH M0 scoring system was more accurate in predicting the prognosis of HCC patients with M0 after LR or LT. Adjuvant therapy is recommended for HCC patients who have a higher score.

Liver transplantation vs liver resection in HCC: promoting extensive collaborative research through a survival meta-analysis of meta-analyses

Background

HCC is a major global health concern, necessitating effective treatment strategies. This study conducts a meta-analysis of meta-analyses comparing liver resection (LR) and liver transplantation (LT) for HCC.

Methods

The systematic review included meta-analyses comparing liver resection vs. liver transplantation in HCC, following PRISMA guidelines. Primary outcomes included 5-year overall survival (OS) and disease-free survival (DFS). AMSTAR-2 assessed study quality. Citation matrix and hierarchical clustering validated the consistency of the included studies.

Results

A search identified 10 meta-analyses for inclusion. The median Pearson correlation coefficient for citations was 0.59 (IQR 0.41-0.65). LT showed better 5-year survival and disease-free survival in all HCC (OR): 0.79; 95% CI: 0.67-0.93, I^2:57% and OR: 0.44; 95% CI: 0.25-0.75, I^2:96%). Five-year survival in early HCC and ITT was 0.63 (95% CI: 0.50-0.78, I^2:0%) and 0.60 (95% CI: 0.39-0.92, I^2:0%). Salvage LT vs. Primary LT did not differ between 5-year survival and disease-free survival (OR: 0.62; 95% CI: 0.33-1.15, I^2:0% and 0.93; 95% CI: 0.82-1.04, I^2:0%).

Conclusion

Overall, the study underscores the superior survival outcomes associated with LT over LR in HCC treatment, supported by comprehensive meta-analysis and clustering analysis. There was no difference in survival or recurrence rate between salvage LT and primary LT. Therefore, considering the organ shortage, HCC can be resected and transplanted in case of recurrence.

Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time.

METHODS

We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis.

RESULTS

LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years.

CONCLUSION

LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.

Systematic review of outcomes and meta-analysis of risk factors for prognosis after liver resection for hepatocellular carcinoma without cirrhosis

Long-term overall survival (OS) after liver resection for non-cirrhotic hepatocellular carcinoma (NCHCC) has been reported recently. The aim of this study was to review outcomes systematically and analyze risk factors for survival after surgical resection for HCC without cirrhosis. A literature search was performed of the PubMed and Embase databases for papers published between January 1995 and October 2012, which focused on hepatic resection for HCC without underlying cirrhosis. Cochrane systematic review methodology was used for this review. Outcomes were OS, operative mortality and disease-free survival (DFS). Pooled hazard ratios (HR) were calculated using the random effects model for parameters considered as potential prognostic factors. Totally, 26 retrospective case series were eligible for inclusion. The 1-, 3- and 5-year OS rate after surgical resection of NCHCC ranged from 62% to 100%, 46.3%-78.0%, and 30%-64%, respectively. The corresponding DFS rates ranged from 48.7% to 84%, 31.0%-66.0%, and 24.0%-58.0%, respectively. Five variables were related to poor survival: multiple tumors (HR 1.68, 95%CI 1.25-2.11); larger tumor size (HR 2.66, 95%CI 1.69-3.63); non-clear resection margin (R0 resection) (HR 3.52, 95%CI 1.63-5.42); poor tumor stage (HR 2.61, 95%CI 1.64-3.58); and invasion of the lymphatic vessels (HR 4.85, 95%CI 2.67-7.02). In sum, hepatic resection provides excellent OS rates for patients with NCHCC, and results have tended to improve recently. Risk factors for poor prognosis comprise multiple tumors, lager tumor size, non-R0 resection and invasion of the lymphatic vessels.

Resection or Transplant in Early Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) has an incidence of 5-10 per 100 000 persons per year in the Western world. In 20% of cases, surgical liver resection (LR) or liver transplantation (LT) can be performed. LT results in longer survival, as it involves resection not only of the tumor, but of pre - cancerous tissue as well. The optimal allocation of donor organs depends on the identification of patients for whom LR is adequate treatment. In this meta-analysis, we compare LT and LR for patients with early HCC and wellcompensated cirrhosis.

METHODS

A systematic review of the pertinent literature was followed by a subgroup analysis of the studies in which patients with early HCC and wellcompensated cirrhosis were followed up after either LR or LT. Overall survival at 1, 3, and 5 years, as well as morbidity and mortality, were compared in a random effects meta-analysis.

RESULTS

54 studies with a total of 13 794 patients were included. Among patients with early HCC, the overall survival after LT became higher than the overall survival after LR 5 years after surgery (66.67% versus 60.35%, odds ratio 0.60 [0.45; 0.78], p <0.001); there was no significant difference 1 year or 3 years after surgery. Nor was there any significant difference in morbidity or mortality between the two types of treatment in this subgroup. These findings contrast with the results obtained in all of the studies, which documented significantly better survival 3 years after LT.

CONCLUSION

Three years after surgery, the survival rates and complication rates of patients with early HCC treated with either LR or LT are comparable. Resection should therefore be the preferred form of treatment if the prerequisites for it are met. In case of recurrent tumor, these patients can still be evaluated for liver transplantation. This strategy could improve the allocation of donor organs.

Brazilian society of hepatology recommendations for the diagnosis and treatment of hepatocellular carcinoma

Hepatocellular carcinoma is a malignancy of global importance and is associated with a high rate of mortality. Recent advances in the diagnosis and treatment of this disease make it imperative to update the recommendations on the management of the disease. In order to draw evidence-based recommendations concering the diagnosis and management of hepatocellular carcinoma, the Brazilian Society of Hepatology has sponsored a single-topic meeting in João Pessoa (PB). All the invited pannelists were asked to make a systematic review of the literature and to present topics related to the risk factors for its development, methods of screening, radiological diagnosis, staging systems, curative and palliative treatments and hepatocellular carcinoma in noncirrhotic liver. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript containing the recommendations of the Brazilian Society of Hepatology.

Tumour size and differentiation predict survival after liver resection for hepatocellular carcinoma arising from non-cirrhotic and non-fibrotic liver: a case-controlled study

AIMS

The aims of this study were to assess the outcomes of patients who underwent potentially curative hepatic resection for hepatocellular carcinoma (HCC) in a background of non-cirrhotic/non-fibrotic livers, and to determine prognostic factors that influenced survival.

METHODS

Over a 15-year period, all patients undergoing hepatectomy for HCC were identified. Collated data included demographics, laboratory analysis, operative findings and histo-pathological data. Survival differences between these factors following liver resection were determined.

RESULTS

57 patients were included with a median age of 70 years. The majority of patients underwent a hemi-hepatectomy or more radical resection (n = 37). Overall R0 resection rate was 90.4% (n = 51). The overall morbidity and mortality rates were 26.3% and 3.5%, respectively. The median follow-up period was 28 months. The 1-, 3- and 5- year disease-free survival was 65.4%, 41.8% and 39.1%, and the overall survival was 73.5%, 49.6% and 39.5%, respectively. AFP (p = 0.039) was the only predictor of poorer disease-free survival on univariate analysis. On multi-variable analysis, poorly differentiated tumour and large tumour size were independent predictors of overall survival.

CONCLUSIONS

Liver resection is a feasible treatment option for HCC in non-cirrhotic/non-fibrotic livers with good survival outcome. Tumour size and differentiation are adverse predictors of outcome in these patients.

Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000s using Child and MELD scores

INTRODUCTION

Despite of advances in modern surgical and intensive care treatment, perioperative mortality remains high in patients with liver cirrhosis undergoing nonhepatic general surgery. In the few existing articles, mortality was reported to be as high as 70% in patients with poor liver function (high Child or model for end-stage liver disease (MELD) score). Since data are limited, we analyzed our recent experience with cirrhotic patients undergoing emergent or elective nonhepatic general surgery at a German university hospital.

METHODS

Since 2000, 138 nonhepatic general surgical procedures (99 intra-abdominal, 39 abdominal wall) were performed in patients with liver cirrhosis. Liver cirrhosis was preoperatively classified according to the Child (41 Child A, 59 B, 38 C) and the MELD score (MELD median 13). Sixty-eight (49%) of the patients underwent emergent operations. Most abdominal wall operations were for hernias. Intra-abdominal operations consisted of GI tract procedures (n=53), cholecystectomies (n=15), and various others (n=31). Perioperative data were gained by retrospective analysis.

RESULTS

Overall perioperative mortality in all 138 cases was 28% (9% in elective surgery, 47% in emergent surgery; p<0.001). Perioperative mortality was higher after intra-abdominal than after abdominal wall operations (35% vs. 8%; p=0.001) or in patients requiring transfusions (43% vs. 5% without transfusions; p<0.001). Perioperative mortality increased with the Child score (10% Child A, 17% Child B, 63% Child C; p<0.01) and the MELD score (9% MELD <10, 19% MELD 10–15, 54% MELD >15; p<0.001). Univariately, further factors like American Society of Anesthesiologists (ASA) score and various preoperative laboratory values were also associated with perioperative mortality. By multivariate analysis of all 138 operations, the Child and ASA classifications, intraoperative transfusions, and a preoperative sodium <130 mmol/l, but not the MELD score, were independent prognostic factors. Analysis of elective operations revealed only a preoperatively increased creatinine as risk factor for perioperative mortality. In emergent operations again, Child class, blood transfusions, and low sodium level, but not the MELD score, predicted postoperative mortality.

CONCLUSIONS

Our results demonstrate that perioperative mortality remains high in patients with liver cirrhosisundergoing general surgery, especially in emergent situations. Patients with poor liver function and/or need for blood transfusions even had a very high mortality. In our experience, the Child score (together with other variables) independently correlates with perioperative mortality in emergent operations whereas the MELD score was inferior in predicting the outcome.

Hepatocellular carcinoma in non-cirrhotic liver: a reappraisal

Although not frequently, hepatocellular carcinoma (HCC) can ensue in a non-cirrhotic liver. As compared to cirrhotic HCC, this kind of tumour has some peculiarities, such as: (a) a lower male preponderance and a bimodal age distribution; (b) a lower prevalence of the three main risk factors (hepatitis B and C virus infections and alcohol abuse), with an increased prevalence of other etiologic factors, such as exposure to genotoxic substances and sex hormones, inherited diseases, genetic mutations; (c) a more advanced tumour stage at the time of diagnosis, as it is usually detected due to the occurrence of cancer-related symptoms, outside any scheduled surveillance program; (d) a much higher amenability to hepatic resection, due to the low risk of liver failure even after extended parenchymal mutilation; (e) overall and disease-free survivals after resection of non-advanced tumours (meeting the Milano criteria) comparable to that obtained with liver transplantation in cirrhotic patients carrying an early tumour; (f) overall survival strictly dependent on tumour burden (and its recurrence) and barely influenced by liver function.

Beyond Milan criteria--chances and risks of expanding transplantation criteria for HCC patients with liver cirrhosis

Orthotopic liver transplantation (OLT) is, apart from resection, one important curative treatment for hepatocellular carcinoma (HCC) in liver cirrhosis, and especially attractive because it eliminates both the tumor and the underlying liver disease. The application of restrictive inclusion criteria for OLT in HCC patients resulted in favorable long-term recurrence-free survival. These criteria, however, exclude a subgroup of patients which, despite advanced tumor size, demonstrate an acceptable outcome. As a consequence, expansion of the strict Milan criteria has been discussed. However, this will also deteriorate the average outcome of OLT in HCC patients. Considering that we run short of donor organs, more sophisticated prediction models for survival after OLT for HCC patients are needed to identify patients who benefit best from OLT. Neoadjuvant treatment that is frequently applied as a bridging technique for patients on the waiting list for OLT could provide useful information on tumor behavior to better predict the risk of post-OLT tumor recurrence. This might also allow expansion of the Milan criteria to patients with good response to downstaging methods without negatively affecting post-OLT survival. Furthermore, alternative scoring systems have been suggested to identify HCC patients that might still benefit from resection instead of OLT, and molecular tools are being explored to provide predictive information on HCC biology. This review discusses the advantages and risks of extended inclusion criteria for OLT and the currently available data on alternative prediction models and bridging methods in HCC patients.

Liver transplantation for unresectable hepatocellular carcinoma in patients without liver cirrhosis

Hepatocellular carcinoma (HCC) arising in noncirrhotic and nonfibrotic liver (NC-HCC) is a rare type of malignancy frequently found in healthy young individuals. Partial liver resection is the treatment of choice with expected 5-year survival rates between 40% and 70%. As a result of absence of any symptom, a considerable number of patients are diagnosed when the malignancy has progressed to an advanced stage and the tumor has turned already unresectable. Some other patients suffer from intrahepatic recurrence after previous liver resection that cannot be re-resected or locally ablated. In these situations, liver transplantation (LT) may be the only potentially curative treatment. The indication for LT in NC-HCC patients, however, is not well established. The preliminary results of recent analysis of the European Liver Transplant Registry (ELTR) together with a literature review identified over 150 patients transplanted for NC-HCC during the last 15 years. In contrast to the historical data, these studies showed 5-year survival rates at 50-70% in well-selected patients. Important determinants of poor outcome are macrovascular invasion, lymph node involvement, and time interval of <12 months when LT is used as rescue therapy for intrahepatic recurrence after a previous partial liver resection. Interestingly, outcomes after both liver resection and LT for NC-HCC are much less influenced by tumor size than is the case with cirrhotic HCC. A large tumor size per se should, therefore, not to be seen as a strict contraindication for performing LT in patients with NC-HCC.

Proteomic analysis of regenerating mouse liver following 50% partial hepatectomy

Background

Although 70% (or 2/3) partial hepatectomy (PH) is the most studied model for liver regeneration, the hepatic protein expression profile associated with lower volume liver resection (such as 50% PH) has not yet been reported. Therefore, the aim of this study was to determine the global protein expression profile of the regenerating mouse liver following 50% PH by differential proteomics, and thereby gaining some insights into the hepatic regeneration mechanism(s) under this milder but clinically more relevant condition.

Results

Proteins from sham-operated mouse livers and livers regenerating for 24 h after 50% PH were separated by SDS-PAGE and analyzed by nanoUPLC-Q-Tof mass spectrometry. Compared to sham-operated group, there were totally 87 differentially expressed proteins (with 50 up-regulated and 37 down-regulated ones) identified in the regenerating mouse livers, most of which have not been previously related to liver regeneration. Remarkably, over 25 differentially expressed proteins were located at mitochondria. Several of the mitochondria-resident proteins which play important roles in citric acid cycle, oxidative phosphorylation and ATP production were found to be down-regulated, consistent with the recently-proposed model in which the reduction of ATP content in the remnant liver gives rise to early stress signals that contribute to the onset of liver regeneration. Pathway analysis revealed a central role of c-Myc in the regulation of liver regeneration.

Conclusions

Our study provides novel evidence for mitochondria as a pivotal organelle that is connected to liver regeneration, and lays the foundation for further studies on key factors and pathways involved in liver regeneration following 50% PH, a condition frequently used for partial liver transplantation and conservative liver resection.

Treatment of ultrasound-guided radiofrequency ablation for primary hepatic carcinoma: an analysis of 46 cases

AIM: To compare and analyze the therapeutic efficacy of ultrasound-guided radiofrequency ablation (RFA) for the primary hepatic carcinoma.

METHODS: A total of 46 patients with 69 nodules of the primary hepatic carcinoma were treated at our hospital from March 2003 to July 2008. All patients were clinically diagnosed, treated with RFA and followed up. Patients' survival rates were analyzed using Kaplan-Meier model and Log-rank test, the complete ablation rate and the local recurrence rate were calculated using χ2 test.

RESULTS: After RFA treatment, the complete ablation rate, the local recurrence rate, the 1-, 2-, and 3-year survival rates were 93.61%, 6.82%, 87.10%, 80.13%, 61.92% respectively in the patients with the nodule < 3 cm, and were 68.18%, 27.27 %, 73.33%, 53.33%, 30.48% respectively in the patients with the nodule ≥ 3 cm; the complete ablation rate, the local recurrence rate, the 1- , 2-, and 3-year survival rates were 90.00%, 10.00%, 90.00%, 82.80% and 63.98% for the patients with the single nodule and were 82.05%, 15.38%, 68.75 %, 50.00 % and 28.57% respectively for those with multiple nodules; the complete ablation rate, the local recurrence rate, the 1- , 2-, and 3-year survival rates, were 87.93%, 13.21%, 86.40%, 75.25% and 54.99% respectively for the patients in Child-Pugh classification A, and 81.82%, 22.22%, 66.67%, 53.33%, 35.56 respectively for those in Child-Pugh classification B and C.

CONCLUSION: The complete ablation rate and the local recurrence rate of RFA treatment on PHC are related to the size of the nodules; the long-term survival rate is related to the number, size of the nodules and liver function.

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

BACKGROUND

The 6th edition tumor-node-metastasis (TNM) staging (TNM-6) for hepatocellular carcinoma (HCC) was recommended. Besides, Liver Cancer Study Group of Japan (LCSGJ)-T classification has been recently proposed. However, these newly established staging systems should be further verified in different subgroups of HCC patients. The current study mainly aimed to validate the predictive power of these novel criteria in a cohort of patients with hepatitis B virus-related HCC after radical hepatectomy. As a control, the 5th edition TNM staging (TNM-5) was also evaluated.

METHODS AND MATERIALS

Clinicopathological and follow-up data of consecutive 142 patients with HBV-related HCC undergoing radical hepatectomy were reviewed. The impact of variables on prognosis was determined by uni- and multivariate analyses.

RESULTS

By univariate analysis, LCSGJ-T classification, TNM-6, and TNM-5 were almost significantly prognostic, except for TNM-5 for disease-free survival. Meanwhile, tumor size>or=5 cm, alpha-fetoprotein>400 ng/mL, high Edmondson-Steiner grade, presence of microvascular invasion, portal vein tumor thrombosis, satellite nodule, and resection margin<or=1 cm were also associated with decreased overall or disease-free survival. Multivariate analysis, including aforementioned factors, suggested that Edmondson-Steiner grade was the sole independent prognosticator for both overall and disease-free survival, when LCSGJ-T classification, TNM-6, and TNM-5 were entered, respectively. However, all 3 staging systems lost their predictive potentials in multivariate analysis.

CONCLUSIONS

LCSGJ-T classification, TNM-6, and TNM-5 were not revealed to be independently prognostic in patients with HBV-related HCC after radical hepatectomy. Therefore, these staging criteria, especially the newly developed ones, call for more support in many subsets of HCC patients.