Hepatocellular carcinoma without cirrhosis in the West: epidemiological factors and histopathology of the non-tumorous liver. Groupe d'Etude et de Traitement du Carcinome Hépatocellulaire

Portal vein thrombosis in a noncirrhotic patient after hemihepatectomy: A case report and review of literature

BACKGROUND

Portal vein thrombosis (PVT) is a condition caused by hemodynamic disorders. It may be noted in the portal vein system when there is an inflammatory stimulus in the abdominal cavity. However, PVT is rarely reported after hepatectomy. At present, related guidelines and major expert opinions tend to consider vitamin K antagonists or low-molecular weight heparin (LMWH) as the standard treatment. But based on research, direct oral anticoagulants may be more effective and safe for noncirrhotic PVT and are also beneficial by reducing the recurrence rate of PVT.

CASE SUMMARY

A 51-year-old woman without any history of disease felt discomfort in her right upper abdomen for 20 d, with worsening for 7 d. Contrast-enhanced computed tomography (CECT) of the upper abdomen showed right liver intrahepatic cholangiocarcinoma with multiple intrahepatic metastases but not to the left liver. Therefore, she underwent right hepatic and caudate lobectomy. One week after surgery, the patient underwent a CECT scan, due to nausea, vomiting, and abdominal distension. Thrombosis in the left branch and main trunk of the portal vein and near the confluence of the splenic vein was found. After using LMWH for 22 d, CECT showed no filling defect in the portal vein system.

CONCLUSION

Although PVT after hepatectomy is rare, it needs to be prevented during the perioperative period.

A Novel Method for Survival Prediction of Hepatocellular Carcinoma Using Feature-Selection Techniques

The World Health Organization (WHO) predicted that 10 million people would have died of cancer by 2020. According to recent studies, liver cancer is the most prevalent cancer worldwide. Hepatocellular carcinoma (HCC) is the leading cause of early-stage liver cancer. However, HCC occurs most frequently in patients with chronic liver conditions (such as cirrhosis). Therefore, it is important to predict liver cancer more explicitly by using machine learning. This study examines the survival prediction of a dataset of HCC based on three strategies. Originally, missing values are estimated using mean, mode, and k-Nearest Neighbor (k-NN). We then compare the different select features using the wrapper and embedded methods. The embedded method employs Least Absolute Shrinkage and Selection Operator (LASSO) and ridge regression in conjunction with Logistic Regression (LR). In the wrapper method, gradient boosting and random forests eliminate features recursively. Classification algorithms for predicting results include k-NN, Random Forest (RF), and Logistic Regression. The experimental results indicate that Recursive Feature Elimination with Gradient Boosting (RFE-GB) produces better results, with a 96.66% accuracy rate and a 95.66% F1-score.

Iron elevates mesenchymal and metastatic biomarkers in HepG2 cells

Liver iron excess is observed in several chronic liver diseases and is associated with the development of hepatocellular carcinoma (HCC). However, apart from oxidative stress, other cellular mechanisms by which excess iron may mediate/increase HCC predisposition/progression are not known. HCC pathology involves epithelial to mesenchymal transition (EMT), the basis of cancer phenotype acquisition. Here, the effect of excess iron (holo-transferrin 0–2 g/L for 24 and 48 h) on EMT biomarkers in the liver-derived HepG2 cells was investigated. Holo-transferrin substantially increased intracellular iron. Unexpectedly, mRNA and protein expression of the epithelial marker E-cadherin either remained unaltered or increased. The mRNA and protein levels of metastasis marker N-cadherin and mesenchymal marker vimentin increased significantly. While the mRNA expression of EMT transcription factors SNAI1 and SNAI2 increased and decreased, respectively after 24 h, both factors increased after 48 h. The mRNA expression of TGF-β (EMT-inducer) showed no significant alterations. In conclusion, data showed direct link between iron and EMT. Iron elevated mesenchymal and metastatic biomarkers in HepG2 cells without concomitant decrement in the epithelial marker E-cadherin and altered the expression of the key EMT-mediating transcription factors. Such studies can help identify molecular targets to devise iron-related adjunctive therapies to ameliorate HCC pathophysiology.

Hepatocellular Carcinoma With Tumor Thrombus to the Hepatic Veins and the Right Atrium: A Case Report and Review Exploring Various Presentations and Treatment Options

Hepatocellular carcinoma (HCC) is a leading cause of cancer and cancer-related deaths in the world. Some of the risk factors for the development of HCC include Hepatitis B virus (HBV), Hepatitis C virus (HCV), chronic alcoholism, autoimmune hepatitis, among others. One manifestation of HCC includes tumor thrombus (TT) to the right atrium (RA), which occurs in 0.67-4.1% of patients with HCC. Our case focuses on a unique presentation of HCC with RA TT with initial symptoms of nausea and vomiting without signs of cardiac decompensation or hemodynamic instability. Although there is no definitive treatment for TT to the RA, there are a variety of proven avenues of management of HCC TT to the RA, especially pertaining to patients with adequate liver function.

A 63-year old female with a past medical history of untreated HCV and alcohol abuse with no previously known liver disease or history of liver decompensation, presented with nausea, vomiting, and diarrhea. Initial labs revealed hypovolemic hyponatremia and transaminitis with negative ethanol levels. The model for end-stage liver disease (MELD-Na) score was calculated at 27, and she had a Child-Pugh class C score. Follow up labs were significant for elevated alpha-fetoprotein (AFP). Triple-phase CT of the liver revealed a large liver mass with extension into the RA with TT and necrosis of the liver. An echocardiogram revealed a RA mass versus thrombus. Throughout her hospitalization, she never admitted to cardiac symptoms, including shortness of breath, palpitations, or chest pain. No tachycardia was noted, and her blood pressure remained stable. She was not a candidate for surgery or chemotherapy. The patient declined any heroic measures, and palliative care was consulted for further management. She was transferred to hospice, where she died one week later. 

There are numerous etiologies and clinical presentations of HCC with TT to the RA. Its disease course is insidious and may not present as symptomatic until there is a sizable tumor burden. Therefore, treatment options for HCC with TT to the RA are reliant on HCC screening for at-risk populations, early diagnosis, and each individual patient’s baseline liver function.

Long-term impact of liver function on curative therapy for hepatocellular carcinoma: application of the ALBI grade

BACKGROUND

Application of curative therapy for hepatocellular carcinoma is crucially dependent on underlying liver function. Using the recently described ALBI grade we examined the long-term impact of liver dysfunction on survival of early-stage hepatocellular carcinoma (HCC) patients.

METHODS

This cohort study comprised 2559 HCC patients from different geographic regions, all treated with curative intent. We also examined the relation between indocyanine green (ICG) clearance and ALBI score. Survival was measured from the date of treatment to the date of death or last follow-up.

RESULTS

The ALBI score correlated well with ICG clearance. Among those undergoing surgical resection, patients with ALBI grade-1 (good liver function) survived approximately twice as long as those with ALBI grade-2 (less good liver function), although more than 90% of these patients were classified as Child-Pugh (C-P) grade A. In the cohort receiving ablative therapies, there was a similar difference in survival between ALBI grade-1 and grade-2. Cox regression analysis confirmed that the ALBI score along with age, gender, aetiology and tumour factors (AFP, tumour size/number and vascular invasion) independently influenced survival in HCC patients receiving curative treatments.

CONCLUSIONS

The ALBI score represents a simple approach to the assessment of liver function in patients with HCC. After potentially curative therapy, those with ALBI grade-1 survived approximately twice as long as those with ALBI grade-2. These data suggest that ALBI grade-1 patients are appropriately treated with surgical resection whereas ALBI grade-2 patients may, where the option exists, be more suitable for liver transplantation or the less invasive curative ablative therapies.

Surgical treatment of hepatocellular carcinoma in North America: can hepatic resection still be justified?

BACKGROUND

The incidence of hepatocellular cancer (HCC) is increasing dramatically worldwide. Optimal management remains undefined, especially for well-compensated cirrhosis and HCC.

STUDY DESIGN

This retrospective analysis included 5 US liver cancer centers. Patients with surgically treated HCC between 1990 and 2011 were analyzed; demographics, tumor characteristics, and survival rates were included.

RESULTS

There were 1,765 patients who underwent resection (n = 884, 50.1%) or transplantation (n = 881, 49.9%). Overall, 248 (28.1%) resected patients were transplant eligible (1 tumor <5 cm or 2 to 3 tumors all <3 cm, no major vascular invasion); these were compared with 496 transplant patients, matched based on year of transplantation and tumor status. Overall survivals at 5 and 10 years were significantly improved for transplantation patients (74.3% vs 52.8% and 53.7% vs 21.7% respectively, p < 0.001), with greater differences in disease-free survival (71.8% vs 30.1% at 5 years and 53.4% vs 11.7% at 10 years, p < 0.001). Ninety-seven of the 884 (11%) resected patients were within Milan criteria and had cirrhosis; these were compared with the 496 transplantation patients, with similar results to the overall group. On multivariate analysis, type of surgery was an independent variable affecting all survival outcomes.

CONCLUSIONS

The increasing incidence of HCC stresses limited resources. Although transplantation results in better long-term survival, limited donor availability precludes widespread application. Hepatic resection will likely remain a standard therapy in selected patients with HCC. In this large series, only about 10% of patients with cirrhosis were transplant-eligible based on tumor status. Although liver transplantation results are significantly improved compared with resection, transplantation is available only for a minority of patients with HCC.

Pathogenesis of hepatocellular carcinoma according to aetiology

Hepatocellular carcinoma is related to various etiologies including hepatitis B, hepatitis C, high alcohol intake, aflatoxin B1 and metabolic syndrome. Most of the time HCC developed on cirrhosis. Consequently, the mechanisms of carcinogenesis of these different risk factors are difficult to separate from the events leading to cirrhosis. In contrast, aflatoxin B1 and hepatitis B have a clear direct oncogenic role through point mutations in the TP53 tumour suppressor gene and insertional mutagenesis respectively. Finally, next-generation sequencing and transcriptome analysis will refine our knowledge of the relationship between aetiology and the genetic events that draw the mutational landscape of hepatocellular carcinoma.

Alcohol consumption and recurrence of non-B or non-C hepatocellular carcinoma after hepatectomy: a propensity score analysis

BACKGROUND

The aim of this study was to identify factors related to the recurrence of non-B or non-C (NBNC) hepatocellular carcinoma (HCC).

STUDY DESIGN

Between April 2000 and March 2012, out of 621 consecutive HCC patients at our institution, 543 who underwent initial hepatectomy and had no extrahepatic metastases were enrolled in the study. Multivariate analysis were performed to identify risk factors for poor disease-free survival (DFS).

RESULTS

The 5-year DFS rate of NBNC (34 %) was better than that of hepatitis virus B (30 %, P = 0.011) and hepatitis virus C (21 %, P < 0.0001), significantly. Multivariate analysis revealed NBNC [hazard ratio (HR), 0.5; 95 % CI, 0.4-0.8; P < 0.0001)] to be an independent factor for DFS rate. We constructed a propensity score matching model with the 543 patients, and the 5-year DFS rates with and without severe alcohol liver disease (ALD) were 31.6 and 47.5 %, respectively (P = 0.013). In the 163 NBNC patients, severe ALD, mild ALD, and no ALD were seen in 35, 56, and 72 patients, respectively. Multivariate analysis revealed a vascular invasion into the hepatic vein (HR, 3.3; 95 % CI, 1.7-6.3; P < 0.0001) and severe ALD (HR, 2.0; 95 % CI, 1.1-3.6; P = 0.020) to be independent risk factors for poor DFS. By propensity score matching between mild and severe ALD, the 5-year DFS rates with severe and mild ALD were 26 and 50 %, respectively (P = 0.035).

CONCLUSIONS

The prognoses of NBNC patients were better than those of patients with viral infections. Among the NBNC patients, preoperative excessive alcohol intake decreased DFS rate of HCC occurrence after surgery.

Resection for hepatocellular carcinoma

Hepatocellular Carcinoma (HCC) continues to present major challenges in management, which is further complicated by the presence of associated chronic liver disease. Key issues in surgical resection of HCC include the site, size, and number of lesions, the severity of the chronic liver disease, and the size of the functional liver remnant. De novo HCC in the absence of chronic liver disease can be treated by major liver resection with little risk of postoperative liver failure. Liver resection can also be used a bridge to liver transplantation as it affords the possibility of determining the pathologic grade of the tumortumor and its invasiveness, and thereby the prognosis. This review summarizes the current treatment approaches to surgical resection for HCC.

Hepatocellular carcinoma: a comprehensive overview of surgical therapy

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a rising incidence in the United States. The increase in medical and locally ablative therapies have improved prognosis, however surgery, either liver resection or transplantation, remains the mainstay of therapy. An increased understanding of liver anatomy, improved imaging modalities and refinements of surgical technique have all led to improved outcomes after surgery. Both resection and transplantation may be used in a complementary manner. Resection remains the treatment of choice for HCC when feasible. Liver transplantation, which removes both the tumor and the underlying diseased liver offers excellent outcomes in patients that meet the Milan criteria. While both these modalities have relatively well defined roles, the treatment of these patients must be tailored individually, using a multidisciplinary approach, to maximize survival, quality of life and allocation of scarce organs.

Iron, human growth, and the global epidemic of obesity

Iron is an essential nutrient utilized in almost every aspect of cell function and its availability has previously limited life. Those same properties which allow iron to function as a catalyst in the reactions of life also present a threat via generation of oxygen-based free radicals. Accordingly; life exists at the interface of iron-deficiency and iron-sufficiency. We propose that: (1) human life is no longer positioned at the limits of iron availability following several decades of fortification and supplementation and there is now an overabundance of the metal among individuals of many societies; (2) this increased iron availability exerts a positive effect on growth by targeting molecules critical in regulating the progression of the cell cycle; there is increased growth in humans provided greater amounts of this metal; and indices of obesity can positively correlate with body stores of iron; and (3) diseases of obesity reflect this over-abundance of iron. Testing potential associations between iron availability and both obesity and obesity-related diseases in populations will be difficult since fortification and supplementation is so extensively practiced.

[Prognosis assessment of alcoholic liver disease: how and why?]

Alcoholic liver disease (ALD) causes more than 5000 deaths per year in France. Most of those deaths could be prevented by an early diagnosis, which would give the patients the opportunity to modify their alcohol consumption while liver lesions are still reversible. Hepatic histology is the main parameter that predicts morbidity and mortality in patients with ALD. Non-invasive methods such as biomarker tests (e.g. FibroTest(®) or FibroMetre A(®)) or hepatic elastography (FibroScan(®)) may allow diagnosing alcohol-induced liver lesion without systematic biopsy. Despite promising preliminary results, those methods are not validated yet in ALD. A validation of non-invasive methods for ALD could allow a large screening of the severe forms of this pathology.

Roles of alcohol and tobacco exposure in the development of hepatocellular carcinoma

The purpose of this report is to summarize the roles of alcohol and tobacco exposure in the development of hepatocellular carcinoma (HCC). Chronic heavy alcohol exposure is a major risk factor for HCC, which is the most frequent type of liver cancer. Alcohol ingestion may initiate and or promote the development of HCC by: 1) acetaldehyde-DNA adduct formation; 2) cytochrome P4502E1-associated reactive oxygen species (ROS) generation , lipid peroxidation, p53 mutation, and conversion of pro-carcinogens to carcinogens; 3) iron accumulation that leads to ROS generation, lipid peroxidation, p53 mutation, and initiation of inflammatory cascade via nuclear factor-KappaB (NF-kB) activation; 4) glutathione depletion leading to oxidative stress; 5) s-adenosylmethionine (SAM) depletion and associated DNA hypomethylation of oncogenes ; 6) retinoic acid depletion and resultant hepatocyte proliferation via up-regulation of activator protein-1 (AP-1); 7) initiating an inflammatory cascade through increased transfer of endotoxin from intestine to liver, Kupffer cell activation via CD14/toll-like receptor-4 (TLR-4), oxidative stress, NF-kB or early growth response-1(Egr-1) activation, and generation of inflammatory cytokines and chemokines; 8) induction of liver fibrosis; and 9) decreasing the number and/or function of natural killer cells. Tobacco exposure is also a risk factor for HCC. It may contribute to the initiation and promotion of HCC due the presence of mutagenic and carcinogenic compounds as well as by causing oxidative stress due to generation of ROS and depletion of endogenous antioxidants. Simultaneous exposure to alcohol and tobacco is expected to promote the development of HCC in an additive and/or synergistic manner.

Peripheral intrahepatic cholangiocarcinoma occurring in patients without cirrhosis or chronic bile duct diseases: epidemiology and histopathology of distant nontumoral liver in 57 White patients

BACKGROUND/AIM

Peripheral intrahepatic cholangiocarcinoma (ICC) occurring mainly in the absence of cirrhosis represents an increasing subgroup of primary liver tumors in Western countries. Histopathologic changes in the non-neoplastic liver in this context are not well characterized.

PATIENTS AND METHODS

We assessed the clinical characteristics and histopathologic changes in the distant nontumoral liver of 57 consecutive White patients (34 men, mean age 59 years) referred to one medical and one surgical liver institution over a 16-year period who developed a peripheral ICC in the absence of cirrhosis or bile duct disease.

RESULTS

High alcohol consumption was observed in 11 patients (20%), 38 patients (66%) had a BMI of 25 kg/m or more, 22 patients (40%) had diabetes, two patients had hepatitis B virus infection, two others had hepatitis C virus infection, three patients had genetic hemochromatosis, and two patients had cutaneous porphyria tarda. The distant nontumoral liver was normal in 10 patients (18%). The two main histopathologic changes observed were macrovesicular steatosis (>10% of hepatocytes) in 38 patients (66%), including 11 patients (19%) with steatohepatitis, and moderate or intense hepatocyte iron overload in 22 patients (38%).

CONCLUSION

This study shows a high prevalence of macrovesicular steatosis associated or not with steatohepatitis and iron overload in patients who develop peripheral ICC in the absence of cirrhosis or bile duct disease.

Long-term results of liver resection for hepatocellular carcinoma in noncirrhotic liver

BACKGROUND

Hepatocellular carcinoma (HCC) is among the most common malignant neoplasms worldwide. Only few data on HCC in noncirrhotic livers without viral hepatitis in Western countries are available. The purpose of this study was to define the outcomes and potential prognostic factors associated with survival after hepatic resection in patients with HCC in the absence of liver cirrhosis and hepatitis B or C infection.

PATIENTS AND METHODS

From January 2000 to September 2010, 148 patients without liver cirrhosis and without extrahepatic metastases underwent curative hepatic resection for HCC at the Surgical Department of the Charité, Campus Virchow Klinikum. The outcomes of these patients were retrospectively reviewed. Patients with cirrhosis or severe fibrosis, fibrolamellar HCC, and those positive for hepatitis B or C were excluded.

RESULTS

The cumulative 1-, 3-, 5-, and 7-year survival rates were 75.4%, 54.7%, 38.9%, and 31.8%, respectively. The 1-, 3-, 5-, and 7-year disease-free survival rates were 60.3%, 38.0%, 29.1%, and 18.1%, respectively. In the multivariate analysis, cumulative survival was decreased by patient age, increased operative time, increased preoperative serum gamma-glutamyl transferase (GGT), and tumor stage. In the subgroup with unifocal neoplasms, N0 and R0 status, tumor size >10 cm, and tumor differentiation were highly predictive of lesser survival. Unfavorable survival was observed in patients with multifocal neoplasms, tumor size >10 cm, and/or poor tumor differentiation.

CONCLUSION

The current TNM staging system is stratified for survival and recurrence. Extension of the current TNM staging system by grading and more exact differentiation of tumor size may increase its prognostic accuracy for predicting outcome. Preoperative increased serum GGT level could be a new poor prognostic factor.

Roles of alcohol and tobacco exposure in the development of hepatocellular carcinoma

The purpose of this report is to summarize the roles of alcohol and tobacco exposure in the development of hepatocellular carcinoma (HCC). Chronic heavy alcohol exposure is a major risk factor for HCC, which is the most frequent type of liver cancer. Alcohol ingestion may initiate and or promote the development of HCC by: 1) acetaldehyde-DNA adduct formation; 2) cytochrome P4502E1-associated reactive oxygen species (ROS) generation , lipid peroxidation, p53 mutation, and conversion of pro-carcinogens to carcinogens; 3) iron accumulation that leads to ROS generation, lipid peroxidation, p53 mutation, and initiation of inflammatory cascade via nuclear factor-KappaB (NF-kB) activation; 4) glutathione depletion leading to oxidative stress; 5) s-adenosylmethionine (SAM) depletion and associated DNA hypomethylation of oncogenes ; 6) retinoic acid depletion and resultant hepatocyte proliferation via up-regulation of activator protein-1 (AP-1); 7) initiating an inflammatory cascade through increased transfer of endotoxin from intestine to liver, Kupffer cell activation via CD14/toll-like receptor-4 (TLR-4), oxidative stress, NF-kB or early growth response-1(Egr-1) activation, and generation of inflammatory cytokines and chemokines; 8) induction of liver fibrosis; and 9) decreasing the number and/or function of natural killer cells. Tobacco exposure is also a risk factor for HCC. It may contribute to the initiation and promotion of HCC due the presence of mutagenic and carcinogenic compounds as well as by causing oxidative stress due to generation of ROS and depletion of endogenous antioxidants. Simultaneous exposure to alcohol and tobacco is expected to promote the development of HCC in an additive and/or synergistic manner.

Hepatitis B vs. hepatitis C infection on viral hepatitis-associated hepatocellular carcinoma

BACKGROUND

To determine clinical-pathologic variables in patients with a new diagnosis of hepatocellular carcinoma (HCC) and underlying hepatitis B vs. C infection.

METHODS

Patients presenting to a single urban hospital with a new diagnosis of HCC were entered into a clinical database. Variables including number and size of tumors, presence of metastases, serum alpha-Fetoprotein, hepatitis serologies, severity of hepatic dysfunction, and presence of cirrhosis were evaluated in 127 patients.

RESULTS

Patients with hepatitis B (HBV) were more likely to develop HCC at a younger age than patients with hepatitis C (HCV) (HBV-26% under age 40, HCV-0% under age 40; p < 0.001), with greater serum alpha-Fetoprotein production (median level: HBV-1000 ng/ml vs. HCV-37 ng/ml; p = 0.002), with larger tumors (HBV-78% >5 cm, HCV-28% >5 cm; p < 0.001), in the absence of cirrhosis (HBV-40%, HCV-0%; p < 0.001), and a decreased eligibility for curative treatment (HBV-14%, HCV-34%; p < 0.05). Conversely, patients with HCV were more likely to develop HCC in association with multiple co-morbidities, cirrhosis, and older age.

CONCLUSIONS

Significant clinical-pathologic differences exist among HCC patients with underlying HBV vs. HCV. These differences impact eligibility for potentially-curative therapy and prognosis.

Prognostic factors and outcomes of patients with hepatocellular carcinoma in non-cirrhotic liver

OBJECTIVES

To report the outcome of patients with hepatocellular carcinoma (HCC) in non-cirrhotic liver depending on the mode of primary treatment and to define clinicopathological factors influencing patients' prognosis.

METHODS

A retrospective analysis of an unselected cohort of 105 patients was performed. Overall survival (OS) was estimated by the Kaplan-Meier method and potentially prognostic factors were analyzed in Cox regression models.

RESULTS

OS of the whole cohort at 1, 3, and 5 years was 66%, 47%, and 29%, respectively. Tobacco consumption, ECOG >0, macroscopic vascular invasion, continuous tumor diameter, and treatment other than resection were predictors of decreased OS in the whole cohort. Resection was performed in 64% of patients with 1-, 3-, and 5-year OS rates of 84%, 69%, and 42%, respectively. Siderosis and BCLC stage were associated with decreased OS after resection. Recurrence occurred in 57% of patients with 1-, 3-, and 5-year disease-free survival (DFS) rates of 63%, 39%, and 31%, respectively. Viral hepatitis and macroscopic vascular invasion were associated with decreased DFS. One-, 3-, and 5-year OS rates in patients with non-surgical approaches (transarterial chemoembolization, systemic therapy, best supportive care) were 38%, 11%, and 7%, respectively. Tobacco consumption and Okuda stage were associated with decreased OS in these patients.

CONCLUSIONS

OS and DFS of patients with HCC in non-cirrhotic liver depend most notably on tumor-related, demographic, and etiological factors. Features of the non-neoplastic liver tissue play only a minor role. Liver resection leads to a significantly better prognosis than non-surgical treatment approaches.

Hepatocellular carcinoma: management of an increasingly common problem

Hepatocellular carcinoma (HCC) is a common cancer that typically occurs in the setting of cirrhosis and chronic hepatitis virus infections. Hepatitis B and C account for approximately 80% of cases worldwide. HCC is currently the fifth most common malignancy in men and the eighth in women worldwide; its incidence is increasing dramatically in many parts of the world. Recognition of those at risk and early diagnosis by surveillance with imaging, with or without serologic testing, are extremely important. Many highly effective and even curative therapies are now available and include resection, liver transplantation, and local ablation. Appropriate application of these interventions offers hope of prolonged survival to many patients with this otherwise lethal complication of liver disease.

HCV genotype 3 is associated with a higher hepatocellular carcinoma incidence in patients with ongoing viral C cirrhosis

Liver steatosis is a main histopathological feature of Hepatitis C (HCV) infection because of genotype 3. Steatosis and/or mechanisms underlying steatogenesis can contribute to hepatocarcinogenesis. The aim of this retrospective study was to assess the impact of infection with HCV genotype 3 on hepatocellular carcinoma (HCC) occurrence in patients with ongoing HCV cirrhosis. Three hundred and fifty-three consecutive patients (193 men, mean age 58 ± 13 years), with histologically proven HCV cirrhosis and persistent viral replication prospectively followed and screened for HCC between 1994 and 2007. Log-rank test and Cox model were used to compare the actuarial incidence of HCC between genotype subgroups. The patients infected with a genotype 3 (n = 25) as compared with those infected with other genotypes (n = 328) had a lower prothrombin activity [78 (interquartile range 60-85) vs 84 (71-195) %, P = 0.03] and higher rate of alcohol abuse (48%vs 29%, P = 0.046). During a median follow-up of 5.54 years [2.9-8.6], 11/25 patients (44%) and 87/328 patients (26%) with a genotype 3 and non-3 genotype, respectively, develop a HCC. HCC incidences were significantly different among the genotype subgroups (P = 0.001). The 5-year occurrence rate of HCC was 34% (95% CI, 1.3-6.3) and 17% (95% CI, 5.7-9.2) in genotype 3 and non-3 genotype groups, respectively (P = 0.002). In multivariate analysis, infection with a genotype 3 was independently associated with an increased risk of HCC occurrence [hazard ratio 3.54 (95% CI, 1.84-6.81), P = 0.0002], even after adjustment for prothrombin activity and alcohol abuse [3.58 (1.80-7.13); P = 0.003]. For patients with HCV cirrhosis and ongoing infection, infection with genotype 3 is independently associated with an increased risk of HCC development.

Epidemiology of primary and secondary liver cancers

Primary liver cancer is the sixth most common cancer worldwide with a wide geographic distribution. The incidence of primary liver cancer is increasing and there is still a higher prevalence in developing countries. Early recognition remains an obstacle and lack of it results in poor outcomes for hepatocellular carcinoma (HCC), the most prevalent primary liver cancer, and cholangiocarcinoma. The most common risk factors associated with HCC are hepatitis B and chronic hepatitis C infections, alcohol use, smoking, and aflatoxin exposure. Emerging risk factors such as obesity might play an important role in the future because of the increasing prevalence of this condition.

Conventional Surgical Treatment of Hepatocellular Carcinoma

Liver resection remains the standard therapy for solitary hepatocellular carcinoma in patients with preserved hepatic function. In well-selected patients, 5-year survival rates are good and can approach that of liver transplantation for early-stage disease. Patient selection is critical to optimizing therapeutic benefit, and the health of the native liver must be considered in addition to tumor characteristics. Hepatic recurrence after resection is common. The difficulty lies in deciding which patients with chronic liver disease and small solitary tumors are best served by resection and which should proceed with transplant evaluation; this is the focus of this article.

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.

Hepatitis C prevalence in patients with hepatocellular carcinoma without cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) occurring in "noncirrhotic" hepatitis C virus (HCV)-infected patients has been reported; but the exact prevalence or incidence has not been described before.

METHODS

We conducted a systematic review of literature: Ovid was used to search the literature from January 1, 1990, to September 1, 2008. Articles containing "HCC" keywords (hepatocellular carcinoma, hepatoma, liver cancer) were combined with the word "cirrhosis" or "fibrosis" and with "absence" keywords [noncirrhotic, absence, without]. Two hundred articles were selected and screened according to predesigned exclusion and inclusion criteria.

RESULTS

Nineteen articles met the inclusion criteria. The estimated prevalence of noncirrhotic HCC ranged from 6.7% to 50.1%. The pooled prevalence estimates for HCV in noncirrhotic HCC ranged from 0% and 68.4% according to the geographic location. Reports from Japan had the highest estimated pooled prevalence of HCV (55.01%) followed by Italy (29.95%).

CONCLUSION

HCV can occur in patients with HCC without cirrhosis, but the true incidence and prevalence are very difficult to ascertain. Further studies are needed to define this group of patients.

[Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: presentation of 51 cases]

BACKGROUND

Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients.

OBJECTIVE

To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival.

MATERIAL AND METHODS

Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival.

RESULTS

Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis.

CONCLUSIONS

Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Liver stiffness measurement in patients with cirrhosis and hepatocellular carcinoma: a case-control study

OBJECTIVE

A wide range in values of liver stiffness measurement (LSM) is observed among cirrhotic patients. These variations reflect the extent of fibrosis and might influence the risk of hepatocellular carcinoma (HCC) occurrence.

METHODS

We compared LSM in 66 Child-Pugh A patients with HCC and alcoholic (n=23) or HCV-related cirrhosis (n=43) referred for radiofrequency ablation and in 199 Child-Pugh A with alcoholic (n=69) or HCV-related cirrhosis (n=130) without HCC.

RESULTS

Patients with HCC had higher LSM than patients without HCC [35.3 kPa (22.8-52.6) vs. 19.0 kPa (12.4-29.2), P<0.0001]. In multivariate analysis, HCC was associated with higher LSM [odds ratio=1.051 (1.030-1.072) (by 1 kPa increase), P<0.0001] and with age [odds ratio=1.075 (1.043-1.107) (by 1 year increase), P<0.0001]. In patients without HCC, LSM was not correlated with age but with decreased prothrombin activity, serum albumin, platelet count, and increased serum bilirubin level. Alcoholic patients had higher LSM compared with HCV-infected patients [22.1 kPa (14.0-36.5) vs. 15.9 kPa (10.8-21.9), P<0.0001] and LSM in the latter varied according to antiviral treatment response.

CONCLUSION

In patients with Child-Pugh A cirrhosis, a wide range of LSM is observed according to the cause underlying liver disease and the presence of HCC is associated with higher values in these patients.

Liver transplantation for hepatocellular carcinoma without preoperative tumor biopsy

BACKGROUND

Progress in liver imaging has made pretransplantation tumor biopsy no longer systematic in patients with hepatocellular carcinoma (HCC).

OBJECTIVES

Our aim was to evaluate the accuracy of a preoperative diagnosis of HCC based on clinical and radiological findings in 102 cirrhotics qualified for liver transplantation (LT) between January 1995 and August 2003 at our institution.

METHODS

The diagnostic accuracy of our policy was assessed by comparing pretransplant diagnosis with the pathologic report of explanted livers.

RESULTS

Sensitivity, specificity, positive, and negative predictive values for the preoperative clinical and radiological diagnosis of HCC were 89%, 94.3%, 77%, and 93.3%, respectively. A false-positive preoperative diagnosis was made in 20 of 102 patients (19.6%) (dysplastic nodules [n=9], regenerative nodules [n=5] cholangiocellular carcinoma [n=1], hemangioma [n=1], and no lesion [n=4]). All tumors larger than 3 cm were correctly diagnosed, irrespective of serum alpha-fetoprotein (sAFP) levels. The risk of overestimating the diagnosis of HCC in the subgroup of patients with tumors less than 3 cm was conversely correlated with preliver transplantation sAFP (sAFP<or=100 ng/L: 28%; sAFP>100: 11%; sAFP>200: 0%).

CONCLUSION

In cirrhotics with nodules larger than 3 cm irrespective of sAFP or nodules less than 3 cm with sAFP greater than 200 ng/L, the pretransplant diagnosis of HCC can be made without performing biopsy. In other cases (i.e., nodules less than 3 cm and sAFP lower than 200 ng/L), histologic confirmation of HCC or a close follow-up imaging should be considered.

Epidemiology of hepatocellular carcinoma in Finistère. Prospective study from June 2002 to May 2003

OBJECTIVES

The aims of this prospective study were to evaluate the incidence of hepatocellular carcinoma (HCC) in Finistère, an administrative district of western France, and to highlight epidemiological characteristics.

METHODS

From June 1st 2002 to May 31st 2003, all cases of HCC in Finistère were registered prospectively. Standardized incidence rates were calculated.

RESULTS

One hundred and six cases of HCC were registered. Standardized incidence rates were 13.8/100000 among men and 0.8/100000 among women. Among the incident cases of HCC, 52% were discovered in patients consulting for symptoms, and 28% in patients undergoing screening. The new non-invasive diagnostic criteria of HCC were used in 60% of cases. HCC was associated with cirrhosis in 89 patients (84%). Excessive alcohol intake was the main cause of cirrhosis. In all, 27 patients (25.5%) received potentially curative treatment.

CONCLUSION

Incidence of HCC is high in Finistère. The proportion of patients given potentially curative treatment is still low, illustrating how difficult screening can be when alcoholic cirrhosis predominates in the target population.

Hepatocellular carcinoma in patients with hepatitis C virus-related chronic liver disease

Hepatitis C virus (HCV) is a major cause of hepatocellular carcinoma (HCC) worldwide due to the high prevalence of HCV infection and the high rate of HCC occurrence in patients with HCV cirrhosis. A striking increase in HCC incidence has been observed during the past decades in most industrialized countries, partly related to the growing number of patients infected by HCV. HCC is currently the main cause of death in patients with HCV-related cirrhosis, a fact that justifies screening as far as curative treatments apply only in patients with small tumors. As a whole, treatment options are similar in patients with cirrhosis whatever the cause. Chemoprevention could be also helpful in the near future. It is strongly suggested that antiviral treatment of HCV infection could prevent HCC occurrence, even in cirrhotic patients, mainly when a sustained virological response is obtained.

Diabetes: one of few remarkable differences in clinicopathologic features between cirrhotic and noncirrhotic Swedes with hepatocellular carcinoma

The prognosis of hepatocellular carcinoma (HCC) is usually very poor, so increased knowledge of clinicopathologic characteristics and etiologic factors may improve the clinical handling. Because HCC in many patients is unrecognized before death, it is of particular interest to study cases from a period with a high autopsy frequency. The records and liver biopsies from all patients with a diagnosis of primary liver cancer in Göteborg, Sweden, during a 22-year period were scrutinized. Only patients with evaluable non-neoplastic liver tissue were included in the final analysis. The majority (95%) of 478 HCC cases were autopsied and cirrhosis of the liver could be established in 71%. At presentation, general paramalignant symptoms such as malaise, weight loss, anorexia, and hepatomegaly (84%) were common irrespective of cirrhosis. Alcoholism and diabetes mellitus were each significantly more common among cirrhotics (29% and 20%, respectively; P < .001), than among noncirrhotics, in which cholelithiasis was more common (54%; P < .001). The correlation between diabetes and cirrhosis was independent of reported alcoholism. In an unselected population in a low HCC incidence area, there are few differences in clinicopathologic features between cirrhotic and noncirrhotic patients. Diabetes mellitus seems to play an etiologic role in HCC in cirrhotics, and cholelithiasis in noncirrhotics.

[Non-surgical treatment of hepatocellular carcinoma. An overview]

Surgery is often not a treatment option in patients with hepatocellular carcinoma with the numerous limitations of liver transplantation or surgical resection due to coexisting cirrhosis in the later case. Non-surgical treatments deal with 3 types of methods: local ablation with curative purpose, transarterial treatments with many technical variants and systemic treatment. Local treatments rely on chemical or thermic agents to achieve ablation of liver lesions, which not exceed initially 3 cm in diameter. The use of radiofrequency ablation allows now larger limits. Intra-arterial treatment usually combines intra-arterial chemotherapy with embolisation of hepatic artery in a procedure called chemoembolisation. Its antitumoral effect mainly due to ischemia is well documented but the influence on survival remains controversial. Finally systemic treatments have yet to be demonstrated useful: new agents and new randomised trials are still needed.

The surveillance and diagnosis of hepatocellular carcinoma

The increasing incidence of hepatocellular carcinoma (HCC) is becoming a considerable problem in Europe. While no national surveillance programme exists, there is increasing evidence that surveillance programmes are efficacious and may be cost-effective. The prognosis of large, symptomatic HCC is poor and only palliative treatment is available. In contrast small tumours are now amenable to several modes of treatment including liver transplantation, surgical resection and loco-regional ablation with acceptable 5 year survival rates. Therefore, the identification of small lesions through screening should prolong survival. Consequently, the European Association for the Study of the Liver (EASL) has recommended surveillance with ultrasound scans and tests for alpha fetoprotein every 6 months. Screening is now routine clinical practice in many parts of the developed world.

Iron supplementation in athletes--first do no harm

Although it generally does not improve performance, iron is often used by elite athletes. The physiologic changes induced by exercise can mimic iron deficiency and decrease hemoglobin and ferritin concentrations. Determination of serum transferrin receptor concentrations may identify true iron deficiency, which occurs particularly in young athletes. In contrast, increased iron stores in the body are a frequent finding in elite athletes who have used long-term iron supplementation. Elite runners have increased intestinal blood loss, but this usually can be compensated by enhanced absorption of dietary iron. The combination of exercise-induced hemolysis with enhanced intestinal blood loss in various endurance sports leads to severe abnormalities of routine tests, and extreme physical activity may be responsible for positive fecal occult blood determinations. Indiscriminate iron supplementation carries the risk of inducing hemochromatosis in individuals homozygous for the widespread C282Y allele of the HFE gene. This polymorphism is common and can be found in about 1% of individuals of Northern European descent; moreover, iron supplementation can modify the presentation of important underlying diseases such as celiac disease or colon carcinoma. In conclusion, iron supplements should be prescribed for athletes with iron-deficiency anemia and carefully monitored if given for prophylaxis; unless a therapeutic response occurs, investigations to establish the cause of iron deficiency should be initiated.

Surgical treatment of hepatocellular carcinoma

Surgery for hepatocellular carcinoma (HCC) includes partial liver resection (LR) and liver transplantation (LT). Although LT represents the most efficient treatment in patients with small HCC, <30% of patients are eligible for LT because of restrictive criteria (one nodule <5 cm or two to three nodules <3 cm without macroscopic vascular invasion), graft unavailability and the high cost of the procedure. For large HCC, LR remains the only potential curative treatment. LR is now safer, with a low rate of mortality. Selective preoperative morphological assessment, preoperative use of portal vein embolization for increasing future remnant liver volume and the improvement of surgical techniques such as the use of intermittent clamping and anterior approach are factors that improve the safety and tolerance of LR. In patients with small HCCs and a preserved liver function (Child-Pugh grade A), good long-term survival can be achieved after anatomical resection that removes the tumor(s) and its portal vein territory. These good results of LR for small HCC and the increasing duration of the waiting list for candidates of LT have renewed the place of LR as a bridge treatment before LT.

Alcohol and hepatocellular carcinoma

More than 18 million adults in the United States abuse alcohol, a prevalence 5 times higher than that of hepatitis C. Chronic alcohol use of greater than 80 g/day for more than 10 years increases the risk for hepatocellular carcinoma (HCC) approximately 5-fold; alcohol use of less than 80 g/day is associated with a nonsignificant increased risk for HCC. The risk for HCC in decompensated alcohol induced cirrhosis approaches 1% per year. The risk does not decrease with abstinence, and HCC can occur in a noncirrhotic liver. Alcohol use in chronic hepatitis C doubles the risk for HCC as compared with the risk in hepatitis C alone. Furthermore, there may be synergism between alcohol and hepatitis C in the development of HCC, and in these patients HCC may occur at an earlier age and the HCC may be histologically more advanced. Studies in the United States and Italy suggest that alcohol is the most common cause of HCC (accounting for 32%-45% of HCC). The mechanisms by which alcohol causes HCC are incompletely understood, but may include chromosomal loss, oxidative stress, a decreased retinoic acid level in the liver, altered DNA methylation, and genetic susceptibility. Alcohol use is increasing in many countries, suggesting that alcohol will continue to be a common cause of HCC throughout the world.

Hepatocellular carcinoma in cirrhosis: incidence and risk factors

Emerging data indicate that the mortality rate of hepatocellular carcinoma (HCC) associated with cirrhosis is rising in some developed countries, whereas mortality from non-HCC complications of cirrhosis is decreasing or is stable. Cohort studies indicate that HCC is currently the major cause of liver-related death in patients with compensated cirrhosis. Hepatitis C virus (HCV) infection is associated with the highest HCC incidence in persons with cirrhosis, occurring twice as commonly in Japan than in the West (5-year cumulative incidence, 30% and 17%, respectively), followed by hereditary hemochromatosis (5-year cumulative incidence, 21%). In hepatitis B virus (HBV)-related cirrhosis, the 5-year cumulative HCC risk is 15% in high endemic areas and 10% in the West. In the absence of HCV and HBV infection, the HCC incidence is lower in alcoholic cirrhotics (5-year cumulative risk, 8%) and subjects with advanced biliary cirrhosis (5-year cumulative risk, 4%). There are limited data on HCC risk in cirrhosis of other causes. Older age, male sex, severity of compensated cirrhosis at presentation, and sustained activity of liver disease are important predictors of HCC, independent of etiology of cirrhosis. In viral-related cirrhosis, HBV/HCV and HBV/HDV coinfections increase the HCC risk (2- to 6-fold relative to each infection alone) as does alcohol abuse (2- to 4-fold relative to alcohol abstinence). Sustained reduction of HBV replication lowers the risk of HCC in HBV-related cirrhosis. Further studies are needed to investigate other viral factors (eg, HBV genotype/mutant, occult HBV, HIV coinfection) and preventable or treatable comorbidities (eg, obesity, diabetes) in the HCC risk in cirrhosis.

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Iron and liver cancer

Mechanisms whereby iron may act in carcinogenesis are induction of oxidative stress, facilitation of tumor growth, and modification of the immune system. Results of clinical and epidemiologic studies demonstrate a strong association between iron excess (even at mild levels) and the development of cancer at any site, but they do not indicate whether this reflects a causal link or an indirect association through other factors (i.e., aging, alcohol consumption, and insulin resistance). Findings obtained from experimental work are not conclusive with respect to a direct carcinogenic role of iron, but they support a carcinogenic or co-carcinogenic role of iron in chemically induced carcinogenesis.

Mutations of the HFE gene in patients with hepatocellular carcinoma

OBJECTIVE

Hepatocellular carcinoma (HCC) is a late consequence of severe liver disease. Patients with genetic hemochromatosis may be at risk for HCC, but limited information is available on the relationship of HCC and heterozygosity for the HFE gene mutations.

METHODS

HFE mutations (C282Y and H63D) were assessed in 162 consecutive patients (131 men/31 women) with HCC. A total of 159 patients had cirrhosis. The most common etiologies of cirrhosis were chronic viral hepatitis (hepatitis C 39%, hepatitis B 9%) and alcoholic liver disease (36%).

RESULTS

Five patients were C282Y homozygotes, four C282Y/H63D compound heterozygotes, and three H63D homozygotes. The C282Y and H63D allele frequencies in HCC were 8.3 (95% confidence limit = 5.3-11.3) and 11.1 (7.8-14.6), respectively, and not different from previously published data in healthy subjects or patients with chronic hepatitis C in Austria. Furthermore, there was no difference in the age at diagnosis in patients with or without HFE gene mutations. C282Y homozygotes had a 19-fold increased risk to develop HCC. In contrast, all other HFE allele constellations were not associated with such a risk.

CONCLUSIONS

Except for C282Y homozygotes, HFE gene mutations do not increase the risk to develop HCC in patients with cirrhosis.

Pathologic spectrum and prognostic significance of underlying liver disease in hepatocellular carcinoma

Although controversy persists about the influence of cirrhosis on the incidence of portal vein invasion and other prognostic indicators of recurrence and survival (e.g., histologic grade, mitotic activity, multiplicity), it is clear that the degree of cirrhosis is important for the long-term survival of patients with HCC. Multicentricity is especially important because it reflects the field carcinogenesis associated with viral hepatitis and particularly chronic HCV infection [59]. A better understanding of the different mechanisms linked to tumor recurrence will help select the best candidates for curative surgery and help tailor adjuvant therapy, such as interferon therapy, to each patient [60]. Finally, the importance of vascular invasion, number of tumors, and tumor size of HCCs in addition to the effect of fibrosis has led Vauthey et al [20] to propose a simplified staging of HCC with better prognostication of survival.

Hepatocellular carcinoma: the high-risk patient

Hepatocellular carcinoma (HCC) is the most common hepatic malignancy worldwide. The primary risk factor for the development of HCC is cirrhosis. Even patients without cirrhosis who develop HCC are typically found to have some underlying hepatic abnormality, such as steatohepatitis or chronic viral hepatitis. Although cirrhosis of any cause increases the risk of developing HCC, cirrhosis associated with chronic hepatitis B or C virus infection or hemochromatosis carries the greatest risk. Additional factors such as patient age and sex, duration and severity of liver disease, concurrent alcohol or aflatoxin exposure, liver histology, and alpha-fetoprotein levels also contribute to the relative risk of developing HCC. Vaccination programs aimed at preventing hepatitis B virus infection have been very successful in lowering the incidence of HCC in some areas of the world. Interferon-based therapy, which may control the inflammatory activity in chronic hepatitis C, also holds promise in preventing HCC. Other novel chemopreventative agents, such as glycyrrhizin and polyprenoic acid, may also have a role in preventing HCC, but they require further study before they can be recommended for widespread use.

Living related liver transplantation for recurrent hepatocellular carcinoma in a normal liver

The role of liver transplantation for hepatocellular carcinoma (HCC) is evolving. In patients with advanced liver disease and early stage HCC, transplantation offers the best hope for cure. A living donor offers the optimal approach to a timely transplant, before disease progression obviates the potential benefit. But extending the indications beyond those designated by the United Network for Organ Sharing (UNOS) for liver transplantation for HCC is controversial [Hepatology 2001: 33: 1073; Liver Transplant 2000: 6: S1]. Cadaver split techniques and use of living donors are potentially compelling ways to test the limitations of liver transplantation for HCC, without notably reducing the cadaver organ pool. Herein, we report a rare case of a patient who developed a well-differentiated HCC in a normal liver. After resection of the index lesion and, later, of a remote recurrent lesion, a living donor liver transplant was offered. The natural history of this lesion and the management of transplantation in this setting are discussed.