Prognosis of hepatocellular carcinoma in relation to treatment: A multivariate analysis of 178 patients from a single European institution

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.

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.

The dual-inhibitory effect of miR-338-5p on the multidrug resistance and cell growth of hepatocellular carcinoma

Chemotherapeutic treatments against hepatocellular carcinoma (HCC) are necessary for both inoperable patients to improve prospects for survival and surgery patients to improve the outcome after surgical resection. However, multidrug resistance (MDR) is a major obstacle to obtaining desirable results. Currently, increasing the chemotherapy sensitivity of tumor cells or discovering novel tumor inhibitors is an effective therapeutic strategy to solve this issue. In the present study, we uncovered the dual-inhibitory effect of miR-338-5p: on the one hand, it could downregulate ABCB1 expression and sensitize HCC cells to doxorubicin and vinblastine by directly targeting the 3′-untranslated region (3′-UTR) of ABCB1, while, on the other hand, it could suppress the proliferation of HCC cells by directly targeting the 3′-UTR of EGFR and reducing EGFR expression. Since EGFR regulates ABCB1 levels, the indirect action of miR-338-5p in ABCB1 modulation was revealed, in which miR-338-5p inhibits ABCB1 expression by targeting the EGFR/ERK1/2 signaling pathway. These data indicate that the miR-338-5p/EGFR/ABCB1 regulatory loop plays a critical role in HCC, and a negative correlation between miR-338-5p and EGFR or ABCB1 was also detected in HCC clinical samples. In conclusion, these findings reveal a critical role for miR-338-5p in the regulation of MDR and proliferation of HCC, suggesting the potential therapeutic implications of miR-338-5p in HCC treatment.

A small RNA molecule inhibits the growth of liver cancer cells while also making the cells sensitive to the anti-cancer drugs. These twin effects of the natural microRNA miR-338-5p were discovered by researchers in China, led by Chunzhu Li and Jin Ren at the Center for Drug Safety Evaluation and Research in Shanghai. MicroRNAs control gene activity by interacting with the messenger RNA copies of genes that guide synthesis of the proteins the genes encode. The research identified a gene whose expression miR-338-5p inhibits to restrict the growth of hepatocellular carcinoma – the most common form of liver cancer. This is also one of the most drug-resistant forms of liver cancer. A different gene whose activity miR-338-5p controls to sensitize cells to chemotherapeutic drugs was also identified. Using miR-338-5p to treat liver cancer warrants further investigation.

Survival analysis of patients with stage I and II hepatocellular carcinoma after a liver transplantation or liver resection

INTRODUCTION

Liver transplantation (LT) is a treatment option in select patients with hepatocellular carcinoma (HCC). The aim of the present study was to compare survival in Stage I or II HCC patients undergoing either liver transplant (LT) or a liver resection (LR).

METHOD

The study is a retrospective analysis of the National Cancer Data Base (1998-2011). In total, 148,882 patients with liver cancer were identified, of which 5-year survival data (1998-2006) were available for 64,227 patients. Patients were stratified by the American Joint Committee on Cancer (AJCC) clinical stage I and II. Kaplan-Meier curves and log-rank tests were used for statistical analysis.

RESULTS

3340 HCC patients met analysis criteria. Among stage I HCC, 860 had LT and 871 had LR. Among stage II HCC, 833 had LT and 776 LR. In stage I patients the median survival for LT and LR were 127.9 and 56.7 months, respectively, (P < 0.0001) and in stage II patients the median survival was 110.8 and 42.8 months (P < 0.0001). Unlike LT patients, LR patients with Stage I HCC had a longer median survival compared with Stage II patients (P = 0.0002).

CONCLUSION

Liver transplantation offers a survival advantage compared with a liver resection among patients with Stage I and II HCC. LT is the best surgical treatment for early stage (I/II) HCC in patients with advanced fibrosis or cirrhosis, whereas LR provides equivalent outcomes to LT in patients without advanced fibrosis and should be considered as the first surgical option.

Clinical characteristics, outcome, and risk factors for early and late intrahepatic recurrence of female patients after curative resection of hepatocellular carcinoma

BACKGROUND

There have been progressive increases in both the incidence and death rates of female patients with hepatocellular carcinoma (HCC). Our objective was to investigate the clinicopathologic characteristics and prognostic factors influencing the recurrence and survival of female patients with HCC.

METHODS

We performed a retrospective analysis of 459 consecutive female and 2,936 male patients with HCC who underwent curative resection. Multivariate competing risks analyses with Bonferroni correction were used to evaluate independent prognostic factors.

RESULTS

Female patients had a better overall survival rate (P = .001) than male patients, but a survival benefit was only observed in female patients with tumor-node-metastasis stage I diseases compared with male patients of the same stage (P = .023). Female patients less often had multiple tumors, vascular invasion, and larger tumors. Although female patients had a greater prevalence of increased serum alpha-fetoprotein (AFP), AFP and tumor number had prognostic significance only for male but not for female patients. The incidence of recurrence in female patients was not different than male patients (P = .130). Vascular invasion and serum γ-glutamyl transpeptidase level were independent risk factors for early recurrence of female patients, whereas AFP and γ-glutamyl transpeptidase level were independent risk factors for late recurrence. After curative treatment for recurrence, female patients still had a better overall survival than male patients (P = .025).

CONCLUSION

Female patients had a less invasive tumor phenotype and different prognostic factors from male patients. AFP had no prognostic value in female patients. Estrogen may have a protective effect against early- but not late-stage HCC. Female patients have a better outcome after curative resection of recurrent HCC.

Liver transplantation versus liver resection in the treatment of hepatocellular carcinoma: a meta-analysis of observational studies

BACKGROUND

A number of cohort studies have compared the outcomes of liver transplantation (LT) and liver resection (LR) in hepatocellular carcinoma (HCC) patients. However, the effects of LT versus LR remain unclear. We searched electronic databases and reference lists for relevant articles published before February 2013.

METHODS

The primary endpoints were pooled using random-effects models to model potential heterogeneity, including overall survival (OS), disease-free survival, and recurrence rate.

RESULTS

We found similar 1-year OS (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81-1.43; P=0.61) yet significantly better 3-year OS (OR, 1.47; 95% CI, 1.18-1.84; P<0.001) and 5-year OS (OR, 1.77; 95% CI, 1.45-2.16; P<0.001) after LT compared with LR with relative risk differences of 9% (P<0.001) and 14% (P<0.001), respectively. The 1-, 3-, and 5-year difference-free survival were 13%, 29%, and 39% higher (P<0.001 in all) in LT recipients than LR patients. Additionally, recurrence rate was 30% less (P<0.001) in LT than LR. Furthermore, better 5-year difference-free survival (P<0.001) and recurrence rates (P<0.05) were yielded after LT when patients from the entire HCC population were included.

CONCLUSIONS

When including all the 62 previous studies comparing LT and resection, LT provides increased survival and lower recurrence rates than LR for HCC patients. These results of disease-free survival and recurrence rate are similar among early HCC patients with Child-Turcotte-Pugh class A cirrhosis. However, summary ORs and risk differences cannot be interpreted as causal effects of LT versus LR.

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function

PURPOSE

In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function.

METHODS

In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Cox's model.

RESULTS

The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence.

CONCLUSION

TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

Radioembolization using 90Y-resin microspheres for patients with advanced hepatocellular carcinoma

PURPOSE

To investigate the antitumor effect of resin microspheres loaded with 90-yttrium against hepatocellular carcinoma and their safety in the setting of liver cirrhosis.

PATIENTS AND METHODS

Data from 24 consecutive patients with hepatocellular carcinoma (HCC) treated by radioembolization in the period from September 2003 to February 2005 were reviewed. Patients received no further antineoplastic therapy. A comprehensive evaluation was performed to prevent the risk of damage due to microsphere misplacing. Patients were discharged the day after microspheres injection.

RESULTS

Serious liver toxicity observed among cirrhotic patients in a first period was subsequently prevented by modifying the selection criteria and the method for calculating the activity to be administered. Among 21 patients evaluable for response using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, a reduction in size of target lesions was observed in all but 1 patient. When considering only target lesions, disease control rate and response rate were 100% and 23.8%, respectively. However, 43% of patients progressed in the liver in the form of new lesions appearing a median time of 3 months after radioembolization.

CONCLUSION

Our experience in these series of patients indicates that radioembolization using resin microspheres has a significant antitumor effect against HCC and that using stringent selection criteria and conservative models for calculating the radiation activity to be administered, radioembolization can be performed safely even in cirrhotic patients.

New therapies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC), one of the most common cancers worldwide, is often diagnosed at an advanced stage when most potentially curative therapies such as resection, transplantation or percutaneous and transarterial interventions are of limited efficacy. The fact that HCC is resistant to conventional chemotherapy, and is rarely amenable to radiotherapy, leaves this disease with no effective therapeutic options and a very poor prognosis. Therefore, the development of more effective therapeutic tools and strategies is much needed. HCCs are phenotypically and genetically heterogeneous tumors that commonly emerge on a background of chronic liver disease. However, in spite of this heterogeneity recent insights into the biology of HCC suggest that certain signaling pathways and molecular alterations are likely to play essential roles in HCC development by promoting cell growth and survival. The identification of such mechanisms may open new avenues for the prevention and treatment of HCC through the development of targeted therapies. In this review we will describe the new potential therapeutic targets and clinical developments that have emerged from progress in the knowledge of HCC biology, In addition, recent advances in gene therapy and combined cell and gene therapy, together with new radiotherapy techniques and immunotherapy in patients with HCC will be discussed.

Hepatocellular carcinoma in Lebanon: Etiology and prognostic factors associated with short-term survival

AIM: To study the epidemiology of HCC in Lebanon and prognostic factors predictive of early mortality.

METHODS: An observational follow-up cohort study of HCC cases diagnosed over a five-year period was carried out. Multivariate analysis was conducted to identify prognostic factors in comparison to Cancer of the Liver Italian Program (CLIP) score. Multiple variables including the etiology of underlying liver disease, the demographic characteristics of patients, and the severity of liver disease evaluated by the Child-Pugh score were studied. Tumor parameters included the time of diagnosis of HCC, alpha-fetoprotein level, number and size of nodules, presence of portal vein thrombosis, and treatment modalities. Death or loss of follow-up was considered as an end-point event.

RESULTS: Ninety-two patients (mean 60.5 ± 22.3 years) were included. Etiology of underlying disease was hepatitis B, C, and alcohol in 67%, 20%, and 23.5% respectively. Child-Pugh class at diagnosis was A, B, and C in 34.8%, 39.3% and 25.8% respectively. Overall survival was 44.8%, 32.8% and 17.6% at 1, 2 and 3 years respectively (mean F/U 40.2 ± 23.5 mo). Multivariate analysis identified three predictors of early mortality (< 6 mo): bilirubin > 3.2 mg/dL (P < 0.01), HCC as first presentation of liver disease (P = 0.035), and creatinine > 1 mg/dL (P = 0.017). A score based on these variables outperformed the CLIP score by Cox proportional hazard. ROC curve showed both models to be equivalent and moderately accurate.

CONCLUSION: HBV is the leading cause of HCC in Lebanon. Independent predictors of early mortality are elevated bilirubin, creatinine and HCC as first manifestation of disease. Prospective validation of a score based on these clinical parameters in predicting short-term survival is needed.

New Indication for Reduction Surgery in Patients with Advanced Hepatocellular Carcinoma with Major Vascular Involvement

BACKGROUND

The prognosis of advanced hepatocellular carcinoma (HCC) remains poor, particularly in patients with tumor thrombi (TT) in the major vessels.

PATIENTS AND METHODS

From July 1992 to October 2004, 161 patients diagnosed as having advanced HCC with major vascular involvement were seen consecutively at our hospital. Among these patients, 32 (20%) underwent surgical resection [16 complete resection (CR), 16 reductive resection (RR)]. Eighteen patients (11%) received radiotherapy (RT), 73 (45%) underwent transcatheter arterial chemoembolization (TACE) or transcatheter arterial infusion chemotherapy (TAI), 8 (5%) with distant metastases received systemic chemotherapy, and 30 (19%) received palliative therapy.

RESULTS

Excluding the CR group, the patients in the RR group had a higher 1-year survival rate than the other treatment groups. However, there was no significant difference in the overall survival rates of the RR, RT, and TACE/TAI groups. When we evaluated prognostic factors to clarify the indications for RR in the multidisciplinary treatment of patients with advanced HCC with TT, prothrombin activity (PA) was identified as a significant independent preoperative factor for overall survival in the RR group. The survival rate in patients with PA of < or = 78% was significantly lower than that of patients with PA of > 78% (P = 0.0004). The median survival time of patients with serum PA of > 78% who underwent RR was 13.9 months and that of patients who underwent CR was 9.1 months, with no survival difference between the groups.

CONCLUSION

In advanced HCC with major vascular involvement, patients who had RR with PA of greater 78% achieved a similar survival to those who had CR. The surgeon should still proceed with RR in those patients with serum PA of > 78% if CR does not seem feasible on preoperative evaluation.

Glutathione S-transferase M1 and T1 genetic polymorphisms are not related to the risk of hepatocellular carcinoma: a study in the Spanish population

Glutathione S-transferases constitute a superfamily of enzymes that catalyse the inactivating conjugation of endogenous and environmental substrates involved in the pathogenesis of hepatocellular carcinoma (HCC) and glutathione. Genes encoding either glutathione S-transferase Mu-1 or Theta-1 (GSTM1 and GSTT1, respectively) isoforms are polymorphic. Homozygotes for the mutated inactive alleles of each gene are devoid of any specific enzymatic activity (null genotypes). Our aim was to investigate whether individuals with null GST genotypes have a higher risk of developing HCC. A total of 184 Caucasian Spanish patients with a diagnosis of HCC and 329 healthy controls of the same ethnic origin were included. Polymorphisms in GSTM1 and GSTT1 genes were identified through multiplex polymerase chain reactions, and the dihydrofolate reductase (DHFR) gene was used as internal control. No differences were found between the frequencies of GSTM1 (47.8% versus 45.3%) and GSTT1 (28.8% versus 23.1%) null genotypes in cases and controls, respectively, nor in the proportion of carriers of two, one or no active genotypes. Gender, age at diagnosis, tobacco use, chronic infection with hepatitis B or C virus and alcohol abuse did not influence these results. In conclusion, polymorphisms in GSTM1 and GSTT1 genes are not related to the incidence of HCC in a high-risk Spanish population.

Rapid inhibition of MAPK signaling and anti-proliferation effect via JAK/STAT signaling by interferon-α in hepatocellular carcinoma cell lines

The potential anti-proliferation effect of interferon-alpha (IFN-alpha) against hepatocellular carcinoma (HCC) and its growth inhibitory mechanisms remain unclear. We examined four human HCC cell lines and every cell line had the anti-proliferative effect of IFN-alpha. The PLC/PRF/5 cell line, which expressed the IFN receptor most abundantly, responded most effectively to IFN-alpha stimulation. Here, we delineate the anti-proliferative effect of IFN-alpha via the MAPK pathway in human HCC cell lines. IFN-alpha retarded G1/S transition with no evidence of apoptosis and inhibited cell proliferation. IFN-alpha diminished the phosphorylation of both extracellular signal-regulated kinase (ERK) and mitogen-activated ERK-regulating kinase (MEK), but not Raf, within 5 min. Knockdown of signal transducers of activation and transcription1 (STAT1) or Janus kinase1 (JAK1) suppressed the reduction of phosphorylation both of ERK and MEK and diminished the growth inhibition by IFN-alpha. These results suggest that IFN-alpha induces anti-proliferative signaling via the JAK/STAT pathway downstream of IFN-alpha receptors and may reduce the growth stimulation signaling by cross-talk with the MEK/ERK pathway without IFN-alpha-induced transcription.

Future therapies for hepatocellular carcinoma

A large proportion of patients with advanced hepatocellular carcinoma (HCC) lack effective therapy. Due to chemoresistance, hope has focused on other approaches including targeted therapies, immune stimulants, and the emerging area of gene therapy. Increasing efforts in basic and clinical development of these approaches will hopefully result in more efficient therapies against HCC.

Therapeutic efficacy of 5-FU bletilla striata microspheres infused through hepatic artery against rabbit VX2 transplanted hepatoma

AIM

To observe the therapeutic efficacy of 5-FU bletilla striata microspheres inFUsed through hepatic artery against rabbit VX2 transplanted hepatoma.

METHODS

Fifty rabbits bearing VX2 transplanted hepatoma were randomly divided into five groups (n =10). Normal saline 1 mL, 5-Fu solutions 1 mL, ultr-liquor-lipiodol 0.3-0.4 mL and 5-Fu solutions 1 mL, 100 g/L Bletillaolloid 0.4 mL and 5-Fu solutions 1 mL, 5 FU-bletilla striate microspheres 10 mg/kg were infused though hepatic artery respectively. The tumor growth rates, necrosis rates and hepatic function were compared among the 5 groups.

RESULTS

5-FU bletilla striata microspheres had a very good vessel embolization function. In 5FU-bletilla striata microspheres group, the tumor was significantly inhibited, tumor growth rate was lower than tant in the control group (P <0.01) and the lipiodol group (P <0.05). Tumor necrosis grades were also more higher compared with to the other 4 groups. Complete necrosis was found in 2 of 10 rabbits in 5FU-bletilla striata microspheres group, which was more severe than that in the lipiodol group and bletillaolloid group. But the damage of normal liver tissues was also more serious.

CONCLUSION

5-FU bletilla striata microsphere is a safe and effective peripheral embolization agent.

New considerations for an overall approach to treat hepatocellular carcinoma in cirrhotic patients

BACKGROUND

Increasing numbers of cases and organ shortage justify reconsidering the global therapeutic approach for hepatocelluar carcinoma in cirrhotic patients.

METHODS

Recent literature was reviewed, focused on new therapeutic technologies such as radiofrequency.

RESULTS

For small tumors, liver transplantation offers theoretically the best chance for cure. However, organ shortage may eliminate this advantage, because of tumor progression while waiting for a graft. For small tumors, arising on compensated cirrhosis, resection or radiofrequency ablation may provide efficient local tumor control without precluding subsequent transplantation in case of tumor recurrence and/or cirrhosis decompensation.

CONCLUSIONS

For small tumors and compensated cirrhosis, resection or radiofrequency could represent acceptable first line treatments. In addition to permit safe and immediate tumor control, this strategy would allow a preferential redistribution of grafts to patients with decompensated cirrhosis in whom transplantation is the only possibility.

Surgical treatment of hepatocellular cancer in the era of hepatic transplantation

BACKGROUND

This study compares liver resection (LR) or transplantation (LTx) in an attempt to reevaluate the indications for treatment.

STUDY DESIGN

One hundred fifty-four LRs and 121 LTxs performed from 1985 to 1999 were considered. Survival and recurrence rate, together with age, gender, liver disease, Child-Pugh classification, alpha-fetoprotein (AFP), tumor capsule, vascular invasion, size, number of nodules, histologic grade, and pTNM were considered. Followup was completed in all cases (mean +/- SD = 3.2 +/- 2.9 years).

RESULTS

The 5- and 10-year actuarial survival rates were 61.7% and 59.8% in LTx and 46.9% and 28.0% in LR (p = 0.08). Recurrence-free survival was 85.9% and 85.9%, respectively, in LTx and 42.8% and 30.7% in LR (p < 0.0001). In both groups, size, capsule, AFP, vascular invasion, grade, pTNM, Child-Pugh classification, and age were all significantly related to survival and cancer recurrence. pTNM, AFP, Child-Pugh classification, and age, in LR, and capsule, AFP, and viral cirrhosis, in LTx, were significant independent variables in Cox's regression model for survival. Only AFP, vascular invasion, and grade were significant in both groups for recurrence.

CONCLUSIONS

LTx offers better recurrence freedom than LR, but longterm survival is not significantly different in the two series. A strict selection should be made to optimize graft allocation. Size and multifocality should not be considered absolute contraindications for LTx. AFP, vascular invasion, and grade are more likely to reflect the risk of recurrence of the disease. LR should be considered in patients who do not fulfill transplant criteria and also in some categories of patients with certain tumor characteristics (small resectable tumors in well-compensated cirrhosis).

An implantable rat liver tumor model for experimental transarterial chemoembolization therapy and its imaging features

AIM: To establish an ideal implantable rat liver tumor model for interventional therapy study and examine its angiographic signs and MRI, CT features before and after embolization.

METHODS: Forty male Wistar rats were implanted with Walker-256 tumor in the left lateral lobe of liver. Digital subtraction angiography (DSA) and transarterial chemoembolization were performed on day 14 after implantation. Native computer tomography (CT, n = 8) and native magnetic resonance (MR, n = 40) were performed between the day 8 and day 21 after implantation. The radiological morphological characteristics were correlated with histological findings.

RESULTS: Successful implantation was achieved in all forty rats, which was confirmed by CT and MRI. MR allowed tumor visualization from day 8 while CT from day 11 after implantation. The tumors were hypodensity on CT, hypointense on MR T1-weighted and hyperintense on T2-weighted. The model closely resembled human hepatocarcinoma in growth pattern and the lesions were rich in vasculature on angiography and got its filling mainly from the hepatic artery. Before therapy, tumor size was 211.9 ± 48.7 mm³. No ascites, satellite liver nodules or lung metastasis were found. One week after therapy, tumor size was 963.6 ± 214.8 mm³ in the control group and 356.5 ± 78.4 mm³ in TACE group. Ascites (4/40), satellite liver nodules (7/40) or lung metastasis (3/40) could be seen on day 21.

CONCLUSION: Walker-256 tumor rat model is suitable for the interventional experiment. CT and MRI are helpful in animal optioning and evaluating experimental results.

Chemoembolization of hepatocellular carcinoma--what to tell the skeptics: review and meta-analysis

Transcatheter arterial chemoembolization (TACE) has become the standard treatment for patients with unresectable hepatocellular carcinoma (HCC). When untreated, patients with inoperable HCC have a median survival of three months. Given the widespread use of chemoembolization, accurate evidence of the impact of TACE on patient survival is critical. Several review articles have examined randomized controlled trials (RCTs) of TACE; however, these analyses are inherently flawed by including trials in which control groups were treated. There have been only four RCTs comparing TACE to untreated controls to date. None has demonstrated a significant impact of TACE on patient survival. However, in addition to severe methodological flaws, these RCTs were limited by low patient enrollment, precluding any meaningful conclusions. In contrast, several non-randomized trials have clearly demonstrated a significant benefit of TACE on patient survival. New RCTs examining the impact of chemoembolization on survival are urgently needed to provide definitive evidence for the increasing number of patients treated with TACE. A new, well-designed RCT would provide significant insight on the impact of chemoembolization on patient survival.

Chemoembolization of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for patients with unresectable hepatocellular carcinoma (HCC). Chemoembolization involves delivery of some type of chemotherapy combined with some type of arterial embolization to destroy tumor cells. Whereas diffuse tumors may require lobar embolization, smaller tumors may be treated selectively. The goal of TACE is to cause tumor necrosis and control tumor growth while preserving as much functional liver tissue as possible. The ultimate purpose, however, is to prolong life. Several different TACE protocols have been developed, with no consensus as to the most effective techniques. The effect of TACE on patient survival remains unclear. Several nonrandomized studies have demonstrated a beneficial effect of TACE on survival. This result has not been confirmed with randomized trials. It is clear, however, that TACE is a palliative procedure that has been unable to provide a cure for HCC. When combined with other procedures such as percutaneous ethanol injection, TACE has been more successful at achieving survival rates matching those obtained after surgical resection in similar patient populations. Finally, TACE may also be useful as a neoadjuvant therapy by improving the outcomes of potentially curative therapies and as a bridge to liver transplantation.

Preoperative portal vein embolisation for primary and metastatic liver tumours: volume effects, efficacy, complications and short-term outcome

BACKGROUND

The aim of portal vein embolisation is to induce hyperplasia of normal tissue when resection of a cancerous portion of the liver is contraindicated only by the volume of liver that would remain following operation.

METHODS

Eight patients with inoperable liver tumours (3 women and 5 men, median age 69.5 years, 3 colorectal hepatic metastasts, 2 choloangiocarcinomas and 3 hepatocellular cancers) were selected for portal vein embolisation. Selected portal branches were occluded with microparticles and coils. Liver volumes were determined by magnetic resonance imaging (MRI) before embolisation and again before operation.

RESULTS

Embolisation was successfully performed in all 8 patients, 7 by the percutaneous-transhepatic route, while one patient required open cannulation of a mesenteric vein. Management was altered in 6 patients who proceded to 'curative' resection; projected remaining liver volumes increased (Wilcoxon's matched pairs test p=0.02) from a median of 361 cc to a median of 550 cc; two patients had disease progression such that operation was no longer indicated. In one patient a misplaced coil unintentionally occluded a portal branch to normal liver.

CONCLUSIONS

Portal vein embolisation produced appreciable hyperplasia of the normal liver and extended the option of 'curative' operation to 6 out of the 8 cases attempted. Complications can occur. The long-term results following operation are unknown.

Pegylated liposomal doxorubicin in combination with hyperthermia in the treatment of a case of advanced hepatocellular carcinoma

BACKGROUND

Currently, there is no standard treatment of inoperable advanced hepatocellular carcinoma.

STUDY

A patient with advanced hepatocellular carcinoma was treated with intravenous infusion of pegylated liposomal doxorubicin (PLD, Caelyx) in combination with ultrasound hyperthermia of the liver. Each cycle consisted of infusion of 60 mg of PLD followed by two fractions of hyperthermia 41 degrees C to 43 degrees C for 45 minutes 1 and 48 hours after infusion, respectively.

RESULTS

A substantial regression of the tumor was observed on computed tomography scans. No toxicity of combined treatment was noted.

CONCLUSIONS

This may be the first report of the combination of PLD and hyperthermia in the treatment of advanced hepatocellular carcinoma. Our observation suggests that the combination of PLD with hyperthermia is technically feasible, well tolerated, and could have synergistic potential.

Multidrug resistance gene (MDR-1) expression as a useful prognostic factor in patients with human hepatocellular carcinoma after surgical resection

BACKGROUND

Multidrug resistance gene (MDR-1) overexpression has been correlated with tumor aggressiveness and worse prognosis in some human neoplasms. The aim of this study is to evaluate the clinical value of MDR-1 mRNA expression as a prognostic factor after surgical resection in human hepatocellular carcinoma (HCC).

METHODS

MDR-1 mRNA levels in tissue samples from 34 patients with HCC, who underwent surgical resection, were measured by quantitative northern blot analysis. We stratified these patients into two groups according to a ratio of MDR-1 mRNA levels of HCC to nontumorous tissue; MDR-1 mRNA ratio > or = 1.0 and < 1.0. The overall and disease-free survival rates were analyzed using multivariate regression analysis.

RESULTS

The median survival periods were 10.3 and 35.8 months for patients with the MDR-1 mRNA ratio > or = 1.0 and < 1.0, respectively, and the corresponding 5-year survival rates were 33 and 54%, respectively, P < 0.05. The multivariate analysis revealed that TNM stage and MDR-1 mRNA ratio were independent factors for predicting overall survival after surgical resection.

CONCLUSION

This study suggested that the measurement of the MDR-1 mRNA levels in HCC and nontumorous liver tissue might be a useful prognostic factor after surgical resection in patients with HCC.

Clinical characteristics and outcome of a cohort of 101 patients with hepatocellular carcinoma

AIM: To conduct a cohort study of 101 patients with hepatocellular carcinoma (HCC) presenting to a tertiary care medical referral center in Germany between 1997 and 1999.

METHODS AND RESULTS: Data were retrospectively analyzed by chart review. In 95 cases (72 males and 23 females) sufficient data were available for analysis. Twenty five (29%) of 85 patients were HBsAg or anti HBc positive, 21/85 (25%) were anti HCV positive, and 6/ 85 (7%) were positive for both HBV and HCV-markers. Age was significantly lower in HBV positive patients than in the other two groups. Thirty one (34%) of 90 patients had histories of alcohol abuse. In 79/94 (84%) patients, cirrhosis was diagnosed. Of these cirrhotic patients, 29/79 (37%) belonged to Child Pugh’s group (CHILD) A, 32/79 (40%) to CHILD B, and 18/79 (23%) to CHILD C. AFP was elevated in 61/91 (67%) patients. A single tumor nodule was found in 38/94 (40%), more than one nodule in 31/94 (34%), and 25/94 (26%) had a diffusely infiltrating tumor, i.e. the tumor margins could not be seen on imaging procedures. Portal vein thrombosis was present in 19/94 (20%). Imaging data consistent with lymph node metastases were found in 10/92 (11%), while distant metastases were found in 8/93 (9%). According to Okuda 28/94 (30%) were grouped to stage I, 53/94 (56%) were grouped to stage II, and 13/94 (14%) were grouped to stage III. Survival data were available for 83 patients. The Kaplan-Meier estimate for median survival was 84 months. Factors influencing survival were the Okuda score, the presence of portal vein thrombosis, and the presence of ascites. The presence of non complicated liver cirrhosis by itself, distant metastases, or infection with hepatitis viruses did not influence survival. AFP positivity by itself did not influence survival, though patients with an AFP value greater than 100 μg/L did experience shortened survival. Treatment besides tamoxifen or supportive care was associated with prolonged survival. The influence of therapy on survival was most pronounced in Okuda stage II patients. There was longer survival in those Okuda stage II patients who were treated with percutaneous ethanol injection.

CONCLUSION: Even in a low incidence area such as Germany, the majority of HCC is caused by viral hepatitis and therefore potentially preventable. Reflecting the high proportion of advanced stage tumors in our patients, the median survival was poor. Patients who received active therapy had a longer survival.

Hepatic malignancies

The battle against malignancies of the liver is far from over, although tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. Even after the best attempts at curative treatment, recurrence of primary and secondary malignancies of the liver continues to be the cause of demise for more than 70% of treated patients. The battle continues in the laboratories, where investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. The new millennium holds promise for formulating therapies that may improve disease-free survival for patients with malignancies of the liver.

Hepatic artery embolization: factors predisposing to postembolization pain and nausea

PURPOSE

Analysis of preprocedural factors that may be helpful in predicting the severity of pain and nausea after hepatic arterial embolization (HAE) for liver neoplasms.

MATERIALS AND METHODS

During a 2-year period, 62 patients (33 men, 29 women) underwent 130 palliative lobar HAEs for unresectable liver neoplasms. The hepatic lobe was embolized with 150-250-microm polyvinyl alcohol particulates with or without lipiodol and/or chemotherapeutic agents. Postembolization pain was rated at rest and during movement with use of an 11-point verbal pain scale, and postembolization nausea was assessed with use of a four-point verbal scale, each at two separate time periods. Daily morphine use was also recorded. Primary analysis was made using the first embolization procedure. One-way analysis of variance and Spearman correlation coefficients were used to identify associated predictors. Plots of the outcomes versus the pre-embolization liver function tests and sensitivities and specificities were used to identify the strength of the associations for prediction purposes. A secondary analysis was performed in patients who underwent multiple embolizations.

RESULTS

No strong categorical predictors were found from the ANOVA on the severity of postembolization pain or nausea. There were significant (P < .05) associations between the pre-embolization liver function tests and the pain outcomes only. However, while these laboratory values demonstrate strong associations with resultant pain, they are not strong predictors of pain and morphine requirements for any individual patient. The morphine requirements were highly associated (P < .0001) with the pain scores at rest and with movement. The authors did not find significant differences on any of the pain outcomes or morphine requirements between the first and second embolizations.

CONCLUSION

Laboratory values and patient age are not predictors for the severity of postembolization pain and nausea. Postembolization pain is a significant complication and poses a continuing challenge to the physician with regards to patient management.