Clinical features of small hepatocellular carcinomas as assessed by histologic grades

Recurrence of hepatocellular carcinoma after liver transplantation: an update

Liver transplantation is the only curative alternative for selected patients with hepatocellular carcinoma (HCC) who are not eligible for resection and/or with decompensated cirrhosis. According to Milan criteria the 5-year survival rate is 70-85%, with a recurrence-free survival of 75%. However, HCC recurrence rate after liver transplantation remains a significant problem in the clinical practice. The prognosis in patients with HCC recurrence is poor. The treatment of choice for HCC recurrence is surgery, but it seems that a systemic treatment based on combination of an mTOR inhibitor with sorafenib can be used. Data on safety and efficacy are limited, clinical monitoring is necessary. The aim of this review is to underline the main concerns, pitfalls and warnings for these patients.

Histologic Grade and Mitotic Index as Predictors of Microvascular Invasion in Hepatocellular Carcinoma

OBJECTIVES

Microvascular invasion is a well-known risk factor for hepatocellular carcinoma recurrence and mortality after hepatic resection and liver transplant. We sought to determine the clinico-pathological predictive factors associated with microvascular invasion.

MATERIALS AND METHODS

We studied all patients who had undergone liver transplant because of hepatocellular carcinoma between July 2001 and December 2010 at our institution. Laboratory tests, clinical, and demographic data were obtained. Histopathological hematoxylin and eosin specimens were performed by a single liver pathologist.

RESULTS

During the study, 107 patients had LT because of HCC and they were selected for this investigation: 76 were men (71%) and 31 women (29%) (mean age, 56.8 ± 8.7 y). It was not possible to retrieve histologic samples from 5 patients; therefore, the final studied analysis was 102 individuals. Tumor recurrence rate was 12.9%. One-, three- and five-year overall survivals were 75.0%, 71.4%, and 67.5%. Mitotic index, histologic grade, tumor architecture, alpha-fetoprotein, and tumor fibrosis were associated with microvascular invasion on univariate analysis. Significant independent predictors of microvascular invasion on logistic regression analysis were histologic grade and mitotic index (P < .001; odds ratio, 3.16; 95% confidence interval, 1.525-4.156, and P = .046; odds ratio, 2.56; 95% confidence interval, 1.061-6.451).

CONCLUSIONS

Mitotic index and histologic grade are significant predictors of microvascular invasion. No other risk factor was identified in the logistic regression. As both pathological characteristics may be assessed by liver biopsy, these results highlight the importance of discussing pretransplant liver biopsy to access prognosis and define treatment modalities in the setting of liver transplant.

The risk factors of early recurrence after hepatectomy in hepatocellular carcinoma

Purpose

Early recurrence after hepatectomy is a well-known poor prognostic factor in patients with hepatocellular carcinoma. This study was undertaken to identify the risk factors of early recurrence in patients with hepatocellular carcinoma after hepatectomy.

Methods

One hundred and sixty-seven patients that underwent hepatectomy for hepatocellular carcinoma from January 2005 to December 2010 were enrolled. The numbers of patients with or without early recurrence group were 40 and 127, respectively. Clinico-pathologic factors were retrospectively analyzed.

Results

Potential risk factors were classified as host, tumor, or surgical factors. Of the host factors examined, lobular hepatitis activity was found to be a significant risk factor of early recurrence, and of the tumor factors, infiltrative type of gross appearance, level of preoperative AFP and worst Edmondson-Steiner grade were significant.

Conclusion

The present study shows that an infiltrative gross appearance, a high preoperative AFP level, high lobular hepatitis activity, and a poor Edmondson-Steiner grade are independent risk factors of early recurrence. Accordingly, patients with these risk factors should be followed closely after hepatectomy.

Prediction of poorly differentiated hepatocellular carcinoma using contrast computed tomography

BACKGROUND

Percutaneous radiofrequency ablation (RFA) is a well-established local treatment for small hepatocellular carcinoma (HCC). However, poor differentiation is a risk factor for tumor seeding or intrahepatic dissemination after RFA for HCC. The present study aimed to develop a method for predicting poorly differentiated HCC using contrast computed tomography (CT) for safe and effective RFA.

METHODS

Of HCCs diagnosed histologically, 223 patients with 226 HCCs showing tumor enhancement on contrast CT were analyzed. The tumor enhancement pattern was classified into two categories, with and without non-enhanced areas, and tumor stain that disappeared during the venous or equilibrium phase with the tumor becoming hypodense was categorized as positive for washout.

RESULTS

The 226 HCCs were evaluated as well differentiated (w-) in 56, moderately differentiated (m-) in 137, and poorly differentiated (p-) in 33. The proportions of small HCCs (3 cm or less) in w-HCCs, m-HCCs, and p-HCCs were 86% (48/56), 59% (81/137), and 48% (16/33), respectively. The percentage with heterogeneous enhancement in all HCCs was 13% in w-HCCs, 29% in m-HCCs, and 85% in p-HCCs. The percentage with tumor stain washout in the venous phase was 29% in w-HCCs, 63% in m-HCCs, and 94% in p-HCCs. The percentage with heterogeneous enhancement in small HCCs was 10% in w-HCCs, 10% in m-HCCs, and 75% in p-HCCs. The percentage with tumor stain washout in the venous phase in small HCCs was 23% in w-HCCs, 58% in m-HCCs, and 100% in p-HCCs. Significant correlations were seen for each factor (p < 0.001 each). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for prediction of poor differentiation in small HCCs by tumor enhancement with non-enhanced areas were 75%, 90%, 48%, 97%, and 88%, respectively; for tumor stain washout in the venous phase, these were 100%, 55%, 22%, 100%, and 60%, respectively.

CONCLUSIONS

Tumor enhancement patterns were associated with poor histological differentiation even in small HCCs. Tumor enhancement with non-enhanced areas was valuable for predicting poorly differentiated HCC.

Serological and histological indices of hepatocellular carcinoma and tumor volume doubling time

Hepatocellular carcinoma (HCC) frequently develops in cirrhotic liver and is one of the most common malignancies worldwide. The tumor volume doubling time (TVDT) reflects the natural tumor growth rate and is an indicator of the biological malignant potential of a tumor. The present study aimed to elucidate the association between the serological and histological indices of HCC and TVDT. TVDT was analyzed for 53 HCCs by measuring the enlargement of the tumor diameter on dynamic computed tomography. Differences in TVDT were compared among histological grades of HCC differentiation. The α-fetoprotein (AFP) doubling time (T2AFP) for 44 HCCs with AFP levels >200 ng/ml was calculated and the differences in T2AFP were compared according to the histological grade of HCC differentiation and positivity for Lens culinaris agglutinin-reactive fraction of α-fetoprotein (AFP-L3). Among these 44 HCCs, the correlation between T2AFP and TVDT was analyzed for the 27 tumors for which TVDT could be calculated. The mean ± standard deviation (SD) TVDT in Edmondson grade 1 (Ed1), Ed2 and Ed3 HCC was 138.3±110.3, 94.9±91.5 and 32.2±20.8 days, respectively (P<0.05). The mean ± SD T2AFP in Ed2 and Ed3 HCC was 121.0±167.5 and 37.3±24.6 days, respectively (P<0.01). TVDT and T2AFP decreased with histological dedifferentiation of HCC. The mean ± SD T2AFP in the AFP-L3-positive and -negative groups was 63.2±101.2 and 191.9±209.9 days, respectively, with a statistically significant difference between the groups (P<0.01). A significant correlation was observed between T2AFP and TVDT (correlation coefficient, 0.70; P<0.01). A significant correlation was also observed among TVDT, serological indices and histological grades of HCC differentiation. A short T2AFP and/or AFP-L3-positivity were shown to reflect a poorly differentiated HCC histopathology and a higher malignant potential.

Small hepatocellular carcinoma: current and future approaches

Over 3 decades have passed since the first report of small hepatocellular carcinoma (SHCC), which has been confirmed as one of the most significant prognostic factors. Obviously, it is indeed very important to know when an early SHCC will become more aggressive and lead to worse clinical outcome once it grows beyond a critical size. However, so far, no consensus has been achieved on the size criterion for SHCC among different authors or different clinical practice guidelines that have been used worldwide, although there are currently numerous cutoff values for tumor size used to define SHCC, including 5, 3 and 2 cm in diameter, etc. Herein, based on our current understanding concerning the pathobiological features of SHCC, we briefly review the history of SHCC study, analyze the advantages and limitations of the above criteria for SHCC, and discuss the pathobiological characteristics as well as the clinical significance of SHCC.

Long-term outcome of percutaneous ablation in very early-stage hepatocellular carcinoma

PURPOSE

The aim of this study was to investigate the long-term outcomes of percutaneous ablation (PA) of very early-stage hepatocellulcar carcinoma (HCC) with a multimodal strategy.

METHODS

Written informed consent was obtained from all patients before treatment. Percutaneous ethanol injection (PEI) was performed for tumors in unfavorable locations; microwave ablation (MWA) was performed for tumors in favorable positions without a capsule; and radiofrequency ablation (RFA) was carried out in favorable tumors with a capsule. Since 2003, these advanced PA techniques have been used.

RESULTS

Eighty-three patients with very early HCC were treated with PA, including 33 with PEI, 19 with MWA, and 31 with RFA. Initial complete response (CR) was achieved in 79 patients (95%). The mean follow-up period was 45 ± 27 months (range, 24-155 months). Late treatment failure was observed in eight patients (10%), which was significantly associated with tumor size (P = 0.046) and technique advancements (P = 0.009). Sustained CR was achieved in 51 patients (61%) at the end of follow-up. Major complications occurred in two patients (2%). The 1-, 3-, 5-, and 6-year disease-free survival rates were 87%, 69%, 62%, and 59%, respectively. The 1-, 3-, 5-, and 7-year overall survival rates were 94%, 88%, 78%, and 74%, respectively.

CONCLUSIONS

Treatment of very early-stage HCC using a multimodal strategy tailored to tumor characteristics achieves equivalent initial CR rates and long-term survival rates compared to surgical resection.

Radiofrequency ablation of hepatocellular carcinoma

Radiofrequency ablation (RFA), usually performed under percutaneous ultrasound guidance, is considered the gold standard among minimally invasive therapies. On the strength of some recent randomized trials, its indications include operable patients with small hepatocellular carcinoma and inoperable patients with more advanced disease also in combination with other therapies. RFA has lower complication rates and costs less than surgery.

Critical review of controversial issues in the management of advanced pediatric liver tumors

Hepatocellular carcinoma (HCC) and hepatoblastoma (HB) are the most common primary tumors of liver in children. The management of patients with locally advanced, unresectable disease or those with extra-hepatic distant metastases provides substantial challenges to pediatric oncologists, hepatologists, and surgeons. Herein, we critically debate the two sides of three specific controversies: (1) the role of chemotherapy in the treatment of advanced pediatric HCC; (2) the indications for liver transplantation in children with HCC, specifically, the appropriateness of using adult Milan criteria; and (3) the role of liver trasplantation in children with unresectable HB that present with metastatic disease. Pediatr Blood Cancer 2011;56:1013-1018. © 2010 Wiley-Liss, Inc.

Treatment options in hepatocellular carcinoma today

Hepatocellular carcinoma (HCC) is the third most common cause of cancer related death worldwide. As over 90% of HCCs arise in cirrhotic livers preventive methods and surveillance policies have been adopted in most countries with high prevalence of hepatitis B or C infected people. Poor prognosis of HCC has shown some improvement during the last years. Targeted therapy with radiofrequency ablation (RFA), hepatic resection (HR), liver transplantation (LT), and transcatheter arterial chemoembolisation (TACE) seems to have an influence on this development. The heterogeneity of cirrhotic patients with HCC is still a big challenge. A patient with a small tumour in a cirrhotic liver may have a worse prognosis than a patient with a large tumor in a relatively preserved liver after "curative" HR. The choice of the treatment modality depends on the size and the number of tumours, the stage and the cause of cirrhosis and finally on the availability of various modalities in each centre.

Assessment of hepatocellular carcinomas using conventional magnetic resonance imaging correlated with histological differentiation and a serum marker of poor prognosis

PURPOSE

To establish a method of assessing the malignant potential of hepatocellular carcinoma (HCC) using magnetic resonance imaging (MRI).

METHODS

For 69 nodules [12 Edmondson (Ed)-I, 48 Ed-II, 9 Ed-III] in 54 HCC patients, signal intensity patterns and enhancement patterns of gadopentate dimeglumine (Gd-DTPA) dynamic studies were correlated with histological differentiation and serum lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3) level, which is an indicator of poor prognosis.

RESULTS

Hypointensity on T1-weighted imaging was seen in 17, 72, and 89% of Ed-I, Ed-II, and Ed-III HCCs, respectively (P < 0.001). Meanwhile, hyperintensity on T2-weighted imaging was seen in 42, 88, and 89% (P < 0.005). Tumor stain during the arterial phase of Gd dynamic MRI was seen in 75, 86, and 89%. Tumor stain washout during the portal phase was seen in 43% of Ed-II and 100% of Ed-III HCCs (P < 0.005). In the Ed-II and Ed-III HCCs, hypointensity on T1-weighted imaging was seen in 65% of AFP-L3-negative HCCs and 90% of AFP-L3-positive HCCs (P = 0.071). Washout of tumor stain during the portal phase was seen in 39% of AFP-L3-negative HCCs and 75% of AFP-L3-positive HCCs (P < 0.05).

CONCLUSIONS

Although hyperintensity of tumor on T2-weighted imaging and arterial hypervascularity of tumor are considered to be useful for differential diagnosis between well differentiated HCCs and moderately/poorly differentiated HCCs, hypointensity of tumor on T1-weighted imaging and tumor stain washout during the portal phase of Gd-DTPA dynamic MRI reflected poorer histological differentiation of HCCs and correlated with AFP-L3 levels.

Is it time to reconsider the BCLC/AASLD therapeutic flow-chart?

PURPOSE

Recommendations of the Barcelona Clinic Liver Cancer (BCLC) therapeutic flow-chart, endorsed by the American Association for the Study of Liver Diseases (AASLD), are the most applied worldwide. Over recent years, however, several referral centers have questioned some of the BCLC treatment allocations and proposed alternative strategies. The present study plans to review and discuss these suggestions, with the aim to evaluate whether there are well-grounded reasons to reconsider some of the BCLC/AASLD recommendations.

METHODS

A search was made into the MEDLINE database, focusing on randomized controlled trials, meta-analysis reviews, case-control studies, concordant clinical trials on novel therapies and studies reporting the opinion of respected experts. Their results and conclusions were compared stage by stage with BCLC/AASLD recommendations.

RESULTS

In stage 0 (very early, or single <2  cm, or carcinoma in situ, Child A) radiofrequency should replace resection. In stage A (early, or single or three nodules up to 3  cm, Child A-B) radiofrequency and resection should expand their indications. In stage B (intermediate, or multinodular, Child A-B) resection and transplantation should expand their indications, while intra-arterial therapies are changing from conventional to selective treatments. In stage C (advanced, portal invasion or extrahepatic disease, Child A-B) systemic therapies should offer previously unknown promising options.

CONCLUSION

In our opinion, so much evidence leads to suggest it is time to reconsider several BCLC/AASLD recommendations. Some treatments are comparable in results but vary in costs, local availability, or complication rates.

Evaluation of metabolic characteristics and viability of lipiodolized hepatocellular carcinomas using 18F-FDG PET/CT

This study aimed to evaluate the metabolic characteristics of lipiodolized hepatocellular carcinomas (HCCs) and the diagnostic accuracy of (18)F-FDG PET/CT in assessing the viability of lipiodolized HCCs.

METHODS

Thirty-six patients (age range, 32-73 y) with 38 lipiodolized HCCs who had undergone transcatheter arterial chemoembolization (TACE) with lipiodol before (18)F-FDG PET/CT (2-434 d) and 55 patients (age range, 36-77 y) with 57 treatment-naïve HCCs who had not been treated with TACE were retrospectively studied. All patients underwent hepatic lobectomy or transplantation within 1 mo after PET/CT and multiphasic contrast-enhanced CT. (18)F-FDG uptake by lipiodolized and naïve HCCs was compared and correlated with tumor size, pathologic grade, serum α-fetoprotein (AFP) concentration, and time interval between TACE and PET/CT. The diagnostic accuracy of PET/CT and contrast-enhanced CT in evaluating the viability of lipiodolized HCC was compared.

RESULTS

Histologic examination showed 30 viable and 8 nonviable lipiodolized HCCs. Of the 30 viable tumors, 19 showed increased, 10 similar, and 1 decreased (18)F-FDG uptake. Of the 8 nonviable HCCs, 3 showed increased and 5 decreased (18)F-FDG uptake. Uptake by viable lipiodolized HCCs was correlated with tumor size (P < 0.05) but not correlated with pathologic grade, AFP concentration, or interval between TACE and PET/CT. In contrast, (18)F-FDG uptake by naïve HCCs was significantly correlated with tumor size and pathologic grade (P < 0.05 for each comparison). When lipiodolized HCCs with (18)F-FDG uptake that was greater than or similar to that in the surrounding normal liver were considered viable, the diagnostic sensitivity of PET/CT and contrast-enhanced CT in the early postembolic period (<3 mo) was 100% and 94%, respectively, and that in the late postembolic period was 93% and 79%, respectively. The specificity of (18)F-FDG PET/CT and contrast-enhanced CT was 63% and 100%, respectively, in the acute period. Three viable lipiodolized HCCs with high AFP concentration were true-positives on PET/CT but false-negatives on contrast-enhanced CT images.

CONCLUSION

After TACE, (18)F-FDG uptake in lipiodolized HCCs was not correlated with pathologic grade, in contrast to uptake in treatment-naïve HCCs. (18)F-FDG PET/CT showed a high diagnostic sensitivity in assessing the viability of lipiodolized HCCs, with moderate specificity. This method may be useful in determining the viability of lipiodolized HCCs in patients with increased serum AFP concentration or normal results on contrast-enhanced CT images.

The genotypes of IL-1 beta and MMP-3 are associated with the prognosis of HCV-related hepatocellular carcinoma

BACKGROUND AND AIM

Cytokines and matrix metalloproteinases (MMPs) are involved in tumor growth, invasion, and remote metastasis in various cancers. Recently, functional gene polymorphisms in these cytokines and MMPs have been found, and some reports have revealed an association between these polymorphisms and the prognosis of various cancers. In this study, we examined the relationship between the gene polymorphisms of interleukin 1 beta (IL-1b), IL-1 receptor antagonist (IL-1 RN), transforming growth factor beta 1 (TGF-b1), MMP-1, MMP-3, and MMP-9 and the prognosis of hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC).

METHODS

We enrolled 92 HCV-related HCC patients in the study, and gene polymorphisms of IL-1b -31 C/T, IL-1 RN variable number of tandem repeats (VNTR), TGF-b1 +869 C/T, MMP-1 -1,607 1G/2G, MMP-3 -1,171 5A/6A, and MMP-9 -1,562 C/T were analyzed.

RESULTS

In HCC clinical features, TGF-b1 C carriers and MMP-3 5A carriers had significantly larger HCC diameters than TGF-b1 T and MMP-3 6A homozygotes. In HCC prognosis, IL-1b T homozygotes and MMP-3 5A carriers had a significantly poorer prognosis than IL-1b C carriers and MMP-3 6A homozygotes. Those with a combination of IL-1b T homozygosity and MMP-3 5A had synergistically poorer HCC prognosis.

CONCLUSION

The IL-1b -31 T allele and MMP-3 5A allele are cooperative risk factors for poor prognosis in HCC patients, suggesting that these gene polymorphisms might be potential markers for predicting the prognosis of HCC patients.

Single HCC smaller than 2 cm: surgery or ablation: interventional oncologist's perspective

In the EASL and AASLD guidelines, hepatic resection (HR) is considered the first option for patients in stage 0 (very early HCC). This statement was not based on randomized controlled trials (RCTs) versus other therapies, but on the oncological assumption that HR is the better procedure for obtaining complete tumor ablation including a safety margin. Subsequently, three RCTs compared percutaneous radiofrequency ablation (RFA) versus HR in patients with early HCC. All failed to demonstrate better survival in favor of HR, even though the larger size of the early stage needs a larger area of necrosis. A recent study focused on stage 0 demonstrated a sustained local complete response after RFA comparable with that of HR. All these trials established that RFA is less invasive and associated with lower complication rates and lower costs. These data suggest that RFA can be considered the first option for operable patients with very early HCC. Other options (HR, PEI, selective TAE/TACE) can be used as salvage therapy for the few cases in which RFA is unsuccessful or unfeasible.

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice?

If liver transplantation is not feasible, partial resection is considered the treatment of choice for hepatocellular carcinoma (HCC) in patients with cirrhosis. However, in some centers the first-line treatment for small, single, operable HCC is now radiofrequency ablation (RFA). In the current study, 218 patients with single HCC <or= 2.0 cm (very early or T1 stage) underwent RFA. We assessed 2 primary end points that could be easily compared with those reported for resective surgery: (1) the rate of sustained, local, complete response and (2) the rate of treatment-related complications. The secondary end point was 5-year survival in the 100 patients whose tumors had been considered potentially operable. After a median follow-up of 31 months, sustained complete response was observed in 216 patients (97.2%). In the remaining 6, percutaneous ethanol injection, selective intraarterial chemoembolization, or resection were used as salvage therapy. Perioperative mortality, major complication, and 5-year survival rates were 0%, 1.8%, and 68.5%, respectively.

CONCLUSION

Compared with resection, RFA is less invasive and associated with lower complication rate and lower costs. RFA is also just as effective for ensuring local control of stage T1 HCC, and it is associated with similar survival rates (as recently demonstrated by 2 randomized trials). These data indicate that RFA can be considered the treatment of choice for patients with single HCC <or= 2.0 cm, even when surgical resection is possible. Other approaches can be used as salvage therapy for the few cases in which RFA is unsuccessful or unfeasible.

Primary pleural thymoma with coexistent incidental small hepatocellular carcinoma – An autopsy case report with brief review of literature

Primary pleural thymomas are rare tumors often mistaken for malignant mesothelioma clinically and radiologically. An autopsy case report of primary pleural thymoma associated with a coincidental small hepatocellular carcinoma is presented. This case is reported because of the rarity of pleural thymoma and the coincidental finding of a small hepatocellular carcinoma in a non-cirrhotic background. The literature on these two tumors has been reviewed.

Tumor size predicts vascular invasion and histologic grade: Implications for selection of surgical treatment for hepatocellular carcinoma

Vascular invasion and high histologic grade predict poor outcome after surgical resection or liver transplantation for hepatocellular carcinoma (HCC). Despite the known association between tumor size and vascular invasion, a proportion of patients with large tumors can be treated surgically with excellent outcomes. Clarification of the association between tumor size, histologic grade, and vascular invasion has implications for patient selection for resection and transplantation. The objective of this study was to examine the relationship between HCC tumor size and microscopic (occult) vascular invasion and histologic grade in a multicenter international database of 1,073 patients who underwent resection of HCC. The incidence of microscopic vascular invasion increased with tumor size (< or =3 cm, 25%; 3.1-5 cm, 40%; 5.1-6.5 cm, 55%; >6.5 cm, 63%) (P < 0.005). Both size and number of tumors were important factors predicting vascular invasion. Among all patients with tumors 5.1 to 6.5 cm, microscopic vascular invasion was present in 55% compared with 31% for all patients with tumors 5 cm or smaller (P < 0.001). Among patients with solitary tumors only, microscopic vascular invasion was significantly more common in tumors measuring 5.1 to 6.5 cm (41%) compared with 27% of tumors 5 cm or smaller (P < 0.003). Tumor size also predicted histologic grade: 36% of tumors 5 cm or smaller were high grade, compared with 54% of lesions 5.1 to 6.5 cm (P = 0.01). High histologic grade, an alpha-fetoprotein level of at least 1000 ng/mL, and multiple tumor nodules each predicted occult vascular invasion in tumors larger than 5 cm. The high incidence of occult vascular invasion and advanced histologic grade in HCC tumors larger than 5 cm, as well as biologic predictors of poor prognosis, should be considered before criteria for transplantation are expanded to include these patients.

Expression of lysosome-associated protein transmembrane 4B-35 in cancer and its correlation with the differentiation status of hepatocellular carcinoma

AIM: To produce high-quality polyclonal antibody to lysosome-associated protein transmembrane 4B-35 and to identify LAPTM4B-35 expression in cancer tissues and its correlation with differentiation status of hepatocellular carcinoma (HCC).

METHODS: The 297 bp 5’ end of LAPTM4B cDNA was obtained by PCR and inserted into prokaryotic expression vector pGEX-KG. Then the recombinant pGEX-KG-N_1-99 was transformed into E.coli JM109 to express GST-fusion protein. The fusion protein was purified by glutathione sepharoseTM 4B agarose. The purified GST-LAPTM4B-N_1-99 was characterized by SDS-PAGE, and used to immunize rabbits. The titer and specificity of antisera were detected by ELISA and Western blot, respectively. The correlation between the expression levels of LAPTM4B-35 and the differentiation status of HCC was analyzed via Western blot. The expression of LAPTM4B-35 in HCC and other six cancer tissues was investigated via tissue chip and immunohistochemical analysis.

RESULTS: About 6.2 mg of pure GST-LAPTM4B-N_1-99 was isolated from 1 L of bacteria. The GST-LAPTM4B-N_1-99 produced high titer antisera in rabbits and showed good immunity. Western blot showed specific reactions for the antibody to the LAPTM4B-35 in the total proteins from HCC tissues and BEL-7402 cells, also to the fusion protein purified or in the transformed bacteria. LAPTM4B-35 was remarkably expressed in several cancers, such as HCC, breast cancer, gastric carcinoma, lung cancer, and colon carcinoma, but not commonly expressed in esophageal cancer and rectum carcinoma. Notably, the expression levels of LAPTM4B-35 were significantly and inversely correlated to the differentiation of HCCs in a 20 case analysis.

CONCLUSION: Specific polyclonal antibody (LAPTM4B-N_1-99-pAb) to LAPTM4B-35 was produced. It identified the expression of LAPTM4B-35 in some cancer tissues originated from single layer cuboidal and columnar epithelial cells and firmly demonstrated that the expression of LAPTM4B-35 in HCC was inversely correlated with the differentiation of HCC.

Role of Expression of Focal Adhesion Kinase in Progression of Hepatocellular Carcinoma

PURPOSE

Although hepatocellular carcinoma (HCC) is the most common cancer of the human liver, the mechanisms that regulate HCC development and progression remain unclear. The aim of this study was to investigate whether focal adhesion kinase (FAK) is involved in the progression of human HCC.

EXPERIMENTAL DESIGN

Western blot analysis for FAK was performed on three HCC cell lines. We reviewed 64 consecutive patients who had undergone initial liver resection for HCC without preoperative treatment. Immunohistochemistry analysis for FAK was performed on paraffin-embedded tissues. FAK expression was confirmed by Western blot analysis in several clinical samples. We investigated the correlation between FAK expression and clinical outcome.

RESULTS

FAK proteins were detected in all HCC cell lines. Hepatocytes in the normal liver and chronic hepatitis with or without cirrhosis were negative for immunohistochemical staining for FAK expression. Cytoplasmic FAK expression was observed in 18 of 64 patients (28.1%), and this positive staining was correlated with gender (P < 0.05), a lower level of serum albumin (P < 0.05), and portal venous invasion (P < 0.01). Positive staining for FAK was associated with significantly poorer survival (P < 0.05). In multivariate analysis, FAK overexpression was an independent factor in determining the prognosis of patients.

CONCLUSIONS

These data suggest that FAK plays an important role in promoting tumor progression, especially vascular invasion, in HCC. FAK could play an important role in HCC progression and would be a novel target for HCC therapeutics as well as a prognostic marker.

Liver transplantation for the treatment of moderately or well-differentiated hepatocellular carcinoma

OBJECTIVE

To determine the long-term results of liver transplantation for well- or moderately differentiated hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

HCC patient selection for liver transplantation remains controversial, and deciding exclusively on the strength of criteria such as number and size of nodules appears prognostically inaccurate.

METHODS

Since 1991, preoperative tumor grading has been used at our center to establish whether a patient with HCC is fit for transplantation. Poorly differentiated HCC cases were excluded, while size and number of nodules were not considered as absolute selection criteria. Thirty-three patients with moderately or well-differentiated HCC were prospectively studied after liver transplantation. A group of 15 patients with incidental HCC transplanted during the same period were also evaluated and compared with the 33 patients with preoperatively diagnosed HCC.

RESULTS

On histologic examination, 38% of the entire group of 48 patients did not meet the "Milan criteria" and 42% were pTNM stages III and IV. The median follow-up was 44 months. The 5-year actuarial survival rate was 75% and recurrence-free survival was 92%. HCC recurred in only 3 patients (6%). The only histomorphologic variable differing significantly between incidental and nonincidental HCC was nodule size. The timing of diagnosis (incidental vs. nonincidental HCC), the Milan criteria, and the TNM stage revealed no statistically significant impact on overall and recurrence-free survival rates.

CONCLUSIONS

The routine pre-orthotopic liver transplantation tumor grading may represent a valid tool in the selection of unresectable HCC patients for transplantation.

A mechanical model of tumor encapsulation and transcapsular spread

In this paper, a mathematical modeling framework is presented which describes the growth, encapsulation, and transcapsular spread of solid tumors. The model is based on the physical forces and cellular interactions involved in tumorigenesis and is used to test and compare the active (foreign body hypothesis) and passive (expansive growth hypothesis) hypotheses of capsule formation, such investigations being ideally suited to our mechanical model. The model simulations lead us to predict that, although an active response can successfully control tumor growth via the deposition of large amounts of collagen, this alone is insufficient for capsule formation. In contrast, a solely passive responsive is capable of producing an encapsulated tumor with minimal accumulation of connective tissue within the tumor. When both responses are active, a denser capsule forms and there is a significant increase in connective tissue within the tumor. Using a modified version of the model, in which tumor cells are assumed to produce degradative proteases at a rate which depends on the pressure they experience, it is also possible to show that transcapsular spread or invasion of the tumor may be due to the production by the tumor cells of proteases and their subsequent action.

Expression of smooth muscle calponin in tumor vessels of human hepatocellular carcinoma and its possible association with prognosis

BACKGROUND

Hepatocellular carcinoma (HCC) is a vascular-rich tumor. The tumor vessels in HCC were demonstrated to have alpha-smooth muscle actin positive smooth muscle cells (SMCs). However, it is unclear whether the SMCs in the wall of the tumor vessels are differentiated or undifferentiated. Basic calponin is an actin-, tropomyosin-, and calmodulin-binding protein, and expression of the calponin gene in SMCs has been recognized as one of the late stage differentiation markers of SMCs. The authors investigated the differentiation state of SMCs in tumor vessels by immunohistochemical examination of calponin in patients with HCC, and whether it is associated with the patients' prognosis.

METHODS

Tumor and nontumor tissues were obtained from 75 patients with HCC who underwent radical hepatic resection. The differentiation state of the smooth muscle cells were evaluated based on the expression level of calponin, an actin-binding protein, using immunohistochemistry and reverse transcription-polymerase chain reaction analysis. The disease free survival (DFS) rates were estimated according to the Kaplan-Meier method comparing groups of patients with calponin positive and negative tumor vessels. A multivariate analysis based on the Cox proportional hazards regression model was performed to estimate whether the expression of calponin is an independent prognostic factor.

RESULTS

In the 75 patients with HCC examined, 36 patients (48%) possessed calponin positive SMCs, and the remaining 39 (52%) did not. There were no significant differences in either clinical or pathologic factors between the two groups of patients. The 5- and 8-year DFS rate of the patients with calponin positive vessels were 37% and 26%, respectively. These values were significantly higher (11% and 5%) than those of patients with calponin negative vessels. Gender, TNM classification, perioperative transfusion, and calponin expression were found to be independent prognostic factors for DFS.

CONCLUSIONS

Immunohistochemical examination of the calponin expression in the tumor vessels is a new and useful means to predict the prognosis of HCC patients after hepatic resection.

Fluorine-18 FDG positron emission tomography for imaging of hepatocellular carcinoma

OBJECTIVE

The detection of increased fluorine-18 fluorodeoxyglucose (18F-FDG) uptake by positron emission tomography (PET) is based on the enhanced glucose metabolism of tumor cells. Because the detection and staging of hepatocellular carcinoma (HCC) in patients with liver cirrhosis can be difficult, we prospectively evaluated the sensitivity of 18F-FDG PET in 14 consecutive patients with HCC.

METHODS

Whole body and regional 18F-FDG PET of the liver were obtained. The results were compared with ultrasonography, contrast-enhanced, helical CT, histological grading, p53 protein expression of HCC, and serum alpha-fetoprotein (AFP) level.

RESULTS

In 7 patients PET demonstrated increased tumor 18F-FDG uptake, whereas HCC was not distinguishable from nonmalignant liver tissue in 7 other patients. Hepatic lesions were detected by ultrasonography in all patients, whereas only 11 of 14 HCCs could be identified by CT. In 3 patients extrahepatic spread was demonstrated by 18F-FDG PET. Patients with increased tumor 18F-FDG uptake had significantly larger hepatic lesions and higher serum AFP levels than those with normal 18F-FDG uptake. Lesions could be visualized by 18F-FDG PET in 7 of 8 patients with moderately or poorly differentiated HCC, whereas none of the six well-differentiated tumors was detected. Two patients with strong p53 expression demonstrated increased tumor 18F-FDG uptake and extrahepatic metastases.

CONCLUSIONS

The sensitivity of 18F-FDG PET for the imaging of HCC is low. Nevertheless, in patients with moderately or poorly differentiated HCC, tumors >5 cm, or with markedly elevated AFP levels 18F-FDG PET may contribute to an effective noninvasive staging.

Assessment of genetic changes in hepatocellular carcinoma by comparative genomic hybridization analysis: relationship to disease stage, tumor size, and cirrhosis

Hepatocellular carcinoma (HCC) is a common and highly malignant tumor that is prevalent in Southeast Asia. Although the etiological factors associated are now well recognized, the interactions between individual factors and the molecular mechanisms by which they lead to cancer remain unclear. Cytogenetic analysis on HCC has been limited because of poor hepatocyte growth in vitro. The recently developed technique of comparative genomic hybridization (CGH), however, permits screening of the entire genome without the need of cell culture. CGH was applied to the study of genomic aberrations in 67 surgically resected samples of HCC, 3 of adenomatous hyperplasia (AH), and 12 of nontumorous cirrhotic liver surrounding the tumors. All samples were from patients of a racially and etiologically homogeneous population in Southern China, where chronic hepatitis B virus infection is the main etiological factor. CGH analysis of the HCC samples revealed frequent copy number gain of 1q (48/67 cases, 72%), 8q (32/67 cases, 48%), 17q (20/67 cases, 30%), and 20q (25/67 cases, 37%) and common losses on 4q (29/67 cases, 43%), 8p (25/67 cases, 37%), 13q (25/67 cases, 37%), and 16q (20/67 cases, 30%). Our finding of a high incidence of 1q gain strongly suggested this aberration was associated with the development of HCC. Genomic abnormalities were detected in 1 of the 3 AH specimens but absent in all 12 cirrhotic tissues surrounding the tumor. Clinical staging classified 3/67 HCC cases as T1, 53 cases as T2, and 11 cases as T3. No significant difference in the pattern of genomic imbalances was detected between stages T2 and T3. A significant copy number loss of 4q11-q23 was, however, identified in those tumors larger than 3 cm in diameter. Of particular interest was the identification of 8q copy number gain in all 12 cases of HCC that arose in a noncirrhotic liver, compared with only 20/55 cases in HCC arising in a cirrhotic liver. We suggest that 8q over-representation is likely associated with a growth advantage and proliferative stimulation that have encouraged malignant changes in the noncirrhotic human liver.