Surveillance for hepatocellular carcinoma in patients with chronic viral hepatitis in the United States of America

Dense-PSP-UNet: A neural network for fast inference liver ultrasound segmentation

Liver Ultrasound (US) or sonography is popularly used because of its real-time output, low-cost, ease-of-use, portability, and non-invasive nature. Segmentation of real-time liver US is essential for diagnosing and analyzing liver conditions (e.g., hepatocellular carcinoma (HCC)), assisting the surgeons/radiologists in therapeutic procedures. In this paper, we propose a method using a modified Pyramid Scene Parsing (PSP) module in tuned neural network backbones to achieve real-time segmentation without compromising the segmentation accuracy. Considering widespread noise in US data and its impact on outcomes, we study the impact of pre-processing and the influence of loss functions on segmentation performance. We have tested our method after annotating a publicly available US dataset containing 2400 images of 8 healthy volunteers (link to the annotated dataset is provided); the results show that the Dense-PSP-UNet model achieves a high Dice coefficient of 0.913±0.024 while delivering a real-time performance of 37 frames per second (FPS).

Comparison of a multitarget blood test to ultrasound and alpha-fetoprotein for hepatocellular carcinoma surveillance: Results of a network meta-analysis

Ultrasound‐based surveillance has suboptimal sensitivity for early detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. There are several emerging alternatives, including a novel multitarget HCC blood test (Mt‐HBT). We compared performance of mt‐HBT against ultrasound with or without alpha‐fetoprotein (AFP) for early HCC detection in patients with cirrhosis. Per the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines, two reviewers searched PubMed, Cochrane, Embase, and clinicaltrials.gov databases from January 1990 through December 2020 to identify studies reporting sensitivity and/or specificity of ultrasound and AFP for overall and early stage HCC detection in patients with cirrhosis. Mt‐HBT diagnostic performance was derived from a clinical validation study. A network meta‐analysis model was built for comparative assessment, and pooled estimates of sensitivity at a fixed specificity were estimated based on Bayesian binormal receiver operating characteristic models for each modality. Forty‐one studies (comprising 62,517 patients with cirrhosis) met inclusion criteria. Ultrasound‐alone sensitivity was 51.6% (95% credible interval [CrI], 43.3%–60.5%) for early stage HCC detection, which increased with the addition of AFP to 74.1% (95% CrI, 62.6%–82.4%); however, this was offset by decreased specificity (87.9% vs. 83.9%, respectively). With specificity fixed at 90%, mt‐HBT sensitivity for early stage HCC detection was higher than ultrasound alone (18.2%; 95% CrI, 0.2%–37.7%) and similar to ultrasound with AFP (−3.3%; 95% CrI, −22.3%–17.4%). Pairwise posterior probabilities suggested a preference for mt‐HBT over ultrasound alone in 97.4% of cases but only 36.3% of cases versus ultrasound with AFP. Conclusion: A blood‐based mt‐HBT has higher sensitivity than ultrasound alone for early stage HCC detection but similar sensitivity compared to ultrasound and AFP. Mt‐HBT could be a comparable alternative to existing methods for HCC surveillance in patients who are at risk.

Antioxidant and anti-apoptotic prophylactic effect of silymarin against lead-induced hepatorenal toxicity in rats

This study assessed prophylactic potentials of silymarin against lead-induced hepatorenal toxicity in rats with the respect to its antioxidant and anti-apoptotic activities. Forty male albino rats were distributed into four groups. Control group is provided with distilled water. Lead acetate group was given lead acetate (100 mg/kg bwt) orally for 10 weeks. The third and fourth groups administered silymarin at doses of 50 or 100 mg/kg bwt, respectively, 1 h before administration of lead acetate for 10 weeks. Lead acetate altered liver structure and function that represented by significant elevation of the activities of serum aspartate and alanine aminotransferases and serum levels of urea and creatinine. Hepatic and renal tissues' malondialdehyde concentrations were increased, while reduced glutathione content and superoxide dismutase and catalase activities were reduced in the lead acetate group. Also, lead acetate increased caspase-3 mRNA expression and inhibited alpha-fetoprotein mRNA expression in hepatic tissues, as well as it altered liver and kidney tissues' architectures. In contrast, silymarin ameliorated in a dose dependent mannar the toxic effects of lead acetate on the liver and kidneys through modulation of lead acetate which altered liver and kidney function and structures via reducing lipid oxidation and pathological changes of hepatic and renal tissue structure, improving antioxidant defense system of liver and kidneys, and decreasing pro-apoptotic gene expression in hepatic tissue. This study indicated that silymarin ameliorated lead acetate-induced hepatorenal toxicity via its antioxidant and cytoprotective potentials.

Long-term complete response to lenvatinib in a patient with unresectable hepatocellular carcinoma

A 36-year-old man had been diagnosed with a solitary hepatocellular carcinoma in the right lobe of the liver by computed tomography, and right hemihepatectomy was performed 16 years previously. Approximately 13 years later, he underwent partial hepatectomy because of intrahepatic recurrence in segment 4. Multinodular intrahepatic recurrences in the remnant liver were identified 19 months after repeat hepatectomy, and he underwent transcatheter arterial chemoembolization therapy. Ultimately, six transcatheter arterial chemoembolization therapies were required because of multiple repeat multinodular intrahepatic recurrences. The patient was refractory to transcatheter arterial chemoembolization, and therefore, he participated in a trial of lenvatinib monotherapy. At lenvatinib initiation, his liver function was Child-Pugh class A. Enhanced abdominal computed tomography detected four tumors in the remnant liver. Enhanced abdominal computed tomography findings at the first evaluation showed no residual contrast uptake on arterial phase images, corresponding to a complete response according to Response Evaluation Criteria in Solid Tumors at 4 months after initiation of lenvatinib. The patient was able to continue long-term lenvatinib therapy with well-controlled general health, and he maintained a complete response for two years and three months. Here, we describe his clinical course and radiological results during lenvatinib monotherapy.

The Impact of Sorafenib in Combination with Intermittent Hepatic Arterial Infusion Chemotherapy for Unresectable Hepatocellular Carcinoma with Major Vascular Invasion

The aim of the current study was to investigate the efficacy and safety of sorafenib and intermittent hepatic arterial infusion chemotherapy with cisplatin for unresectable hepatocellular carcinoma (HCC) with severe portal vein invasion. The antitumor effect was a complete response in 1 of 38 patients, a partial response in 12 patients, stable disease in 16 patients, and progressive disease in 9 patients, for a 34.2% response rate and a 76.3% disease control rate. This regimen had favorable efficacy and acceptable safety and may be feasible for unresectable HCC with severe portal vein invasion.

Comparison of unenhanced magnetic resonance imaging and ultrasound in detecting very small hepatocellular carcinoma

BACKGROUND

In hepatocellular carcinoma (HCC), detection and treatment prior to growth beyond 2 cm are important as a larger tumor size is more frequently associated with microvascular invasion and/or satellites. In the surveillance of very small HCC nodules (≤ 2 cm in maximum diameter, Barcelona clinical stage 0), we demonstrated that the tumor markers alpha-fetoprotein and PIVKA-Ⅱ are not so useful. Therefore, we must survey with imaging modalities. The superiority of magnetic resonance imaging (MRI) over ultrasound (US) to detect HCC was confirmed in many studies. Although enhanced MRI is now performed to accurately diagnose HCC, in conventional clinical practice for HCC surveillance in liver diseases, unenhanced MRI is widely performed throughout the world. While, MRI has made marked improvements in recent years.

AIM

To make a comparison of unenhanced MRI and US in detecting very small HCC that was examined in the last ten years in patients in whom MRI and US examinations were performed nearly simultaneously.

METHODS

In 394 patients with very small HCC nodules, those who underwent MRI and US at nearly the same time (on the same day whenever possible or at least within 14 days of one another) at the first diagnosis of HCC were selected. The detection rate of HCC with unenhanced MRI was investigated and compared with that of unenhanced US.

RESULTS

The sensitivity of unenhanced MRI for detecting very small HCC was 95.1% (97/102, 95% confidence interval: 90.9-99.3) and that of unenhanced US was 69.6% (71/102, 95% confidence interval: 60.7-78.5). The sensitivity of unenhanced MRI for detecting very small HCC was significantly higher than that of unenhanced US (P < 0.001). Regarding the location of HCC in the liver in patients in whom detection by US was unsuccessful, S_7-8 was identified in 51.7%.

CONCLUSION

Currently, unenhanced MRI is a very useful tool for the surveillance of very small HCC in conventional clinical follow-up practice.

Abdominal ultrasound and alpha-foetoprotein for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma (HCC) occurs mostly in people with chronic liver disease and ranks sixth in terms of global instances of cancer, and fourth in terms of cancer deaths for men. Despite that abdominal ultrasound (US) is used as an initial test to exclude the presence of focal liver lesions and serum alpha-foetoprotein (AFP) measurement may raise suspicion of HCC occurrence, further testing to confirm diagnosis as well as staging of HCC is required. Current guidelines recommend surveillance programme using US, with or without AFP, to detect HCC in high-risk populations despite the lack of clear benefits on overall survival. Assessing the diagnostic accuracy of US and AFP may clarify whether the absence of benefit in surveillance programmes could be related to under-diagnosis. Therefore, assessment of the accuracy of these two tests for diagnosing HCC in people with chronic liver disease, not included in surveillance programmes, is needed.

OBJECTIVES

Primary: the diagnostic accuracy of US and AFP, alone or in combination, for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of abdominal US and AFP, alone or in combination, for the diagnosis of resectable HCC; to compare the diagnostic accuracy of the individual tests versus the combination of both tests; to investigate sources of heterogeneity in the results.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic-Test-Accuracy Studies Register, Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, until 5 June 2020. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of US and AFP, independently or in combination, for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional and case-control designs, using one of the acceptable reference standards, such as pathology of the explanted liver, histology of resected or biopsied focal liver lesion, or typical characteristics on computed tomography, or magnetic resonance imaging, all with a six-months follow-up.

DATA COLLECTION AND ANALYSIS

We independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest-plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 373 studies. The index-test was AFP (326 studies, 144,570 participants); US (39 studies, 18,792 participants); and a combination of AFP and US (eight studies, 5454 participants). We judged at high-risk of bias all but one study. Most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Most studies with AFP had a case-control design. We also had major concerns for the applicability due to the characteristics of the participants. As the primary studies with AFP used different cut-offs, we performed a meta-analysis using the hierarchical-summary-receiver-operating-characteristic model, then we carried out two meta-analyses including only studies reporting the most used cut-offs: around 20 ng/mL or 200 ng/mL. AFP cut-off 20 ng/mL: for HCC (147 studies) sensitivity 60% (95% CI 58% to 62%), specificity 84% (95% CI 82% to 86%); for resectable HCC (six studies) sensitivity 65% (95% CI 62% to 68%), specificity 80% (95% CI 59% to 91%). AFP cut-off 200 ng/mL: for HCC (56 studies) sensitivity 36% (95% CI 31% to 41%), specificity 99% (95% CI 98% to 99%); for resectable HCC (two studies) one with sensitivity 4% (95% CI 0% to 19%), specificity 100% (95% CI 96% to 100%), and one with sensitivity 8% (95% CI 3% to 18%), specificity 100% (95% CI 97% to 100%). US: for HCC (39 studies) sensitivity 72% (95% CI 63% to 79%), specificity 94% (95% CI 91% to 96%); for resectable HCC (seven studies) sensitivity 53% (95% CI 38% to 67%), specificity 96% (95% CI 94% to 97%). Combination of AFP (cut-off of 20 ng/mL) and US: for HCC (six studies) sensitivity 96% (95% CI 88% to 98%), specificity 85% (95% CI 73% to 93%); for resectable HCC (two studies) one with sensitivity 89% (95% CI 73% to 97%), specificity of 83% (95% CI 76% to 88%), and one with sensitivity 79% (95% CI 54% to 94%), specificity 87% (95% CI 79% to 94%). The observed heterogeneity in the results remains mostly unexplained, and only in part referable to different cut-offs or settings (surveillance programme compared to clinical series). The sensitivity analyses, excluding studies published as abstracts, or with case-control design, showed no variation in the results. We compared the accuracy obtained from studies with AFP (cut-off around 20 ng/mL) and US: a direct comparison in 11 studies (6674 participants) showed a higher sensitivity of US (81%, 95% CI 66% to 90%) versus AFP (64%, 95% CI 56% to 71%) with similar specificity: US 92% (95% CI 83% to 97%) versus AFP 89% (95% CI 79% to 94%). A direct comparison of six studies (5044 participants) showed a higher sensitivity (96%, 95% CI 88% to 98%) of the combination of AFP and US versus US (76%, 95% CI 56% to 89%) with similar specificity: AFP and US 85% (95% CI 73% to 92%) versus US 93% (95% CI 80% to 98%).

AUTHORS' CONCLUSIONS

In the clinical pathway for the diagnosis of HCC in adults, AFP and US, singularly or in combination, have the role of triage-tests. We found that using AFP, with 20 ng/mL as a cut-off, about 40% of HCC occurrences would be missed, and with US alone, more than a quarter. The combination of the two tests showed the highest sensitivity and less than 5% of HCC occurrences would be missed with about 15% of false-positive results. The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

How frequently does hepatocellular carcinoma develop in at-risk patients with a negative liver MRI examination with intravenous Gadobenate dimeglumine?

OBJECTIVE

To determine the rate of development of clinically significant liver nodules (LR-4, LR-5, LR-M) after a negative MRI in an HCC screening population.

METHODS

This retrospective study included patients at risk of developing HCC requiring imaging surveillance who had undergone multiphase Gadobenate dimeglumine-enhanced MRI that was negative and had follow up LI-RADS compliant multiphase CTs or MRIs for at least 12 months or positive follow-up within 12 months. Follow-up examinations were classified as negative (no nodules or only LR-1 nodules) or positive (nodule other than LR-1). Time-to-first positive examination, types of nodules, and cumulative incidence of nodule development were recorded.

RESULTS

204 patients (mean age 58.9 ± 10.2 years, 128 women), including 172 with cirrhosis, were included. Based CT/MRI follow-up (median 35 months, range 12-80 months), the overall cumulative incidence of developing a nodule was 10.5%. Cumulative incidence of nodule development was: 0.5% at 6-9 months and 2.1% at 12 ± 3 months, including one LR-4 nodule, one LR-M nodule, and two LR-3 nodules. The cumulative incidence of clinically significant nodule development was 1.1% at 9-15 months. 70% (143/204) of patients also underwent at least one US follow-up, and no patient developed a positive US examination following index negative MRI.

CONCLUSION

Clinically significant liver nodules develop in 1.1% of at-risk patients in the first year following negative MRI. While ongoing surveillance is necessary for at-risk patients, our study suggests than longer surveillance intervals after a negative MRI may be reasonable and that further research is needed to explore this possibility.

The sensitivity and specificity of serum glycan-based biomarkers for cancer detection

Most of clinically used serum biomarkers for cancer detection were established in early 1980s when the Nobel Prize in physiology or medicine was awarded for the "discovery of the principle for the production of monoclonal antibodies." Using this "Nobel" technology, various monoclonal antibodies were obtained when different types of cancer cells were injected into mice and the ligands on the cancer cell surface were characterized. Both aberrant glycan structures and aberrant glycan-associated glycoproteins were revealed as a common feature of cancer cell surfaces through the specific interactions with the monoclonal antibodies. These results indicate that the biosynthesis of the environment-sensitive glycan structures goes awry in cancer cells, which is beyond genetic mutations. Later on, the glycan-related biomarkers were detected in the sera of cancer patients and then developed into serum biomarkers, such as CA125, CA153, CA195, CA199, CA242, CA27.29, CA50, and CA724, which are still in clinical use as of today. During the past 30 years, even with the advancement of different OMICS technologies not limited to genomics, epigenomics, proteomics, glycomics, lipidomics, and metabolomics, very few serum biomarkers have been introduced into clinical practice. The reason is that most of the newly discovered cancer biomarkers are inferior in terms of sensitivity and specificity to these biomarkers. We will summarize the reported sensitivity and specificity of currently used cancer biomarkers, especially the glycan-related biomarkers, in the forms of tables and radar plots and discuss the pros and cons of currently used cancer biomarkers.

Predictors of Ultrasound Failure to Detect Hepatocellular Carcinoma

Current guidelines recommend ultrasound (US) for hepatocellular carcinoma (HCC) surveillance in cirrhosis. We assess predictors of decreased US sensitivity for detecting HCC. At a single center in the United States, all HCC patients evaluated for liver transplantation (LT) received an abdominal US. From 2007-2015, consecutive patients presenting for untreated lesions found on computed tomography (CT) or magnetic resonance imaging (MRI) within 3 months of US were compared with US findings. Multivariate logistic regression models compared US sensitivities by patient characteristics. Of 1007 patients completing LT evaluation, 47.5% had indeterminate or previously treated nodules and were excluded; 10.4% had imaging that was too far apart or nondiagnostic. Median Model for End-Stage Liver Disease (MELD) of the cohort (n= 352) was 11 (interquartile range [IQR], 9-14), median body mass index (BMI) was 28 kg/m² (IQR, 25-32 kg/m² ), 39% had received locoregional therapy, and 10% had moderate/large ascites. Per-patient sensitivity of US compared with CT/MRI was 0.82 (95% confidence interval, 0.76-0.86). Patients with BMI ≥ 30 kg/m² had a US sensitivity of 0.76 versus 0.87 for BMI < 30 kg/m² (P = 0.01). MELD and ascites did not affect sensitivity. US sensitivity was decreased in patients with nonalcoholic steatohepatitis (NASH) versus other etiologies (0.59 versus 0.84; P = 0.02). Relative to CT/MRI, US is significantly less sensitive in patients with NASH or BMI ≥ 30 kg/m² . Further study is necessary to examine the added value of cross-sectional imaging for patients with NASH or obesity.

Role of Imaging in Surveillance and Diagnosis of Hepatocellular Carcinoma

The prognosis for hepatocellular carcinoma (HCC) is dependent on tumor stage at diagnosis, with curative treatment options more available to early-detected HCCs. Professional organizations have produced HCC screening guidelines in at-risk groups, with ultrasound the most commonly used screening tool and increased interest in MRI in specific populations. HCC may be diagnosed by imaging features alone and have been universally incorporated into management guidelines. The radiology community has standardized imaging criteria for HCC with the development of the Liver Imaging Reporting and Data System, which has expanded to incorporate computed tomography, MR, and contrast-enhanced ultrasound for diagnostic purposes.

Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis

BACKGROUND & AIMS

Society guidelines differ in their recommendations for surveillance to detect early-stage hepatocellular carcinoma (HCC) in patients with cirrhosis. We compared the performance of surveillance imaging, with or without alpha fetoprotein (AFP), for early detection of HCC in patients with cirrhosis.

METHODS

Two reviewers searched MEDLINE and SCOPUS from January 1990 through August 2016 to identify published sensitivity and specificity of surveillance strategies for overall and early detection of HCC. Pooled estimates were calculated and compared using the DerSimonian and Laird method for a random effects model. The study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

RESULTS

Thirty-two studies (comprising 13,367 patients) characterized sensitivity of imaging with or without AFP measurement for detection of HCC in patients with cirrhosis. Ultrasound detected any stage HCC with 84% sensitivity (95% confidence interval [CI] 76%-92%), but early-stage HCC with only 47% sensitivity (95% CI 33%-61%). In studies comparing ultrasound with vs without AFP measurement, ultrasound detected any stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (relative risk [RR] 0.88; 95% CI 0.83-0.93) and early-stage HCC with a lower level of sensitivity than ultrasound plus AFP measurement (RR 0.81; 95% CI 0.71-0.93). However, ultrasound alone detected HCC with a higher level of specificity than ultrasound plus AFP measurement (RR 1.08; 95% CI 1.05-1.09). Ultrasound with vs without AFP detected early-stage HCC with 63% sensitivity (95% CI 48%-75%) and 45% sensitivity (95% CI 30%-62%), respectively (P = .002). Only 4 studies evaluated computed tomography or magnetic resonance image-based surveillance, which detected HCC with 84% sensitivity (95% CI 70%-92%).

CONCLUSIONS

We found ultrasound alone has a low sensitivity to detect early stage HCC in patients with cirrhosis. Addition of AFP to ultrasound significantly increases sensitivity of early HCC detection in clinical practice.

Stratified alpha-fetoprotein pattern accurately predicts mortality in patients with acute-on-chronic hepatitis B liver failure

BACKGROUND

Alpha-fetoprotein (AFP) has been shown to predict the prognosis of liver disease in several studies. This study aimed to evaluate the prognostic value of stratified AFP in patients with acute-on-chronic hepatitis B liver failure (ACHBLF).

METHODS

A total of 192 patients were included and AFP were categorized into quartiles. The prognostic value was determined for overall survival (OS) and assessed by Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazard regression analyses studied the association of all independent parameters with disease prognosis.

RESULTS

The optimal cut-off points of AFP were: (Q1) 252.3-4800.0 ng/ml, (Q2) 76.0-252.2 ng/ml, (Q3) 18.6-75.9 ng/ml, and (Q4) 0.7-18.5 ng/ml. Based on the Kaplan-Meier analysis of the OS, each AFP quartile revealed a progressively worse OS and apparent separation (log-rank P = 0.006). The second-highest quartiles of AFP (Q2) always demonstrated an extremely favorable short-term survival. Combining the lowest AFP quartiles with a serum sodium < 131mmol/L or an INR ≥ 3.3 showed a poor outcome (90-days survival of 25.0% and 11.9% respectively).

CONCLUSIONS

Stratified AFP could strengthen the predictive power for short-term survival of patients with ACHBLF. Combining AFP quartiles with low serum sodium and high INR may better predict poor outcome in ACHBLF patients.

Coefficient of variation on Gd-EOB MR imaging: Correlation with the presence of early-stage hepatocellular carcinoma in patients with chronic hepatitis B

PURPOSE

To study whether the measurement of hepatic fibrosis on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) magnetic resonance (MR) imaging using the coefficient of variation (CV) might be correlated with the presence of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB).

MATERIALS AND METHODS

This study included 104 patients with and without CHB, who were divided into 4 groups: control group, CHB without liver cirrhosis (LC; Group I), CHB with LC (Group II), and CHB with LC and HCC (Group III). MR images were analyzed to measure the inhomogeneity of signal intensities calculated using the CV map of the liver parenchyma. Intergroup comparisons of CV values were performed using ANOVA. The diagnostic performance of the CV map and alpha-fetoprotein (AFP) for diagnosing HCC was evaluated using the receiver operating characteristic (ROC) curve.

RESULTS

On the hepatobiliary phase of Gd-EOB-DTPA-enhanced T1-weighted imaging, the mean CV values of the control group and Groups I, II, and III were 3.9 ± 0.99, 3.97 ± 1.09, 5.58 ± 2.05, and 6.80 ± 2.34, respectively (P = 0.000). On ROC analysis of the CV value for predicting HCC, the value of the area under the curve (AUC) on Gd-EOB-DTPA MR imaging was 0.788 (95% CI: 0.697-0.862). The sensitivity and specificity were 84.2% and 63.6%, respectively, at a CV cutoff value >4.75. The value of AUC determined using AFP was 0.766.

CONCLUSION

The CV value for hepatic fibrosis on Gd-EOB-DTPA MR imaging may be correlated with the presence of HCC in patients with CHB, and shows comparable diagnostic performance to AFP analysis.

Long noncoding RNAs in the initiation, progression, and metastasis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Despite awareness of risk factors for the development of HCC and advances in the diagnosis and clinical management of the disease, the molecular mechanisms underlying hepatocarcinogenesis remain poorly understood. Recent experimental studies provide strong evidence that long noncoding RNAs (lncRNAs), non-protein-coding transcripts with lengths >200 basepairs, contribute to the pathogenesis of numerous human diseases. Over the past decade, a role for lncRNAs in the initiation, progression, and metastasis of HCC has likewise emerged and developed into a highly active area of research. Although many lncRNAs appear to be dysregulated in HCC, extensive functional characterization has been performed on only a small proportion of these candidates to date. This review summarizes select lncRNAs that have been shown to wield functional relevance in the initiation, progression, or metastasis of HCC, focusing on the specific mechanisms by which lncRNA effects might be linked to clinical manifestations of the disease. In addition, an overview of circulating lncRNAs that have been identified as potential biomarkers for the diagnosis and prognosis of HCC is provided.

Screening and Surveillance of Hepatocellular Carcinoma: An Introduction to Ultrasound Liver Imaging Reporting and Data System

Given the high prevalence, increasing incidence, and significant morbidity and mortality related to hepatocellular carcinoma (HCC), a robust and cost-effective screening and surveillance program is needed. Most societies recommend ultrasound for HCC screening, despite lack of standardization in imaging acquisition, reporting content and language, and follow-up recommendations. The American College of Radiology Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) fills this unmet need by providing standardization in the use of US in at-risk patients. It is anticipated that US LI-RADS will improve the performance of ultrasound for HCC screening and surveillance and unify management recommendations.

NLRC and NLRX gene family mRNA expression and prognostic value in hepatocellular carcinoma

Nucleotide‐binding oligomerization domain (NOD)‐like receptor (NLR)C and NLRX family proteins play a key role in the innate immune response. The relationship between these proteins and hepatocellular carcinoma (HCC) remains unclear. This study investigated the prognostic significance of NLRC and NLRX family protein levels in HCC patients. Data from 360 HCC patients in The Cancer Genome Atlas database and 231 patients in the Gene Expression Omnibus database were analyzed. Kaplan–Meier analysis and a Cox regression model were used to determine median survival time (MST) and overall and recurrence‐free survival by calculating the hazard ratio (HR) and 95% confidence interval (CI). High NOD2 and low NLRX1 expression in tumor tissue was associated with short MST (P = 0.012 and 0.014, respectively). A joint‐effects analysis of NOD2 and NLRX1 combined revealed that groups III and IV had reduced risk of death from HCC as compared to group I (adjusted P = 0.001, adjusted HR = 0.31, 95% CI = 0.16–0.61 and adjusted P = 0.043, adjusted HR = 0.63, 95%CI = 0.41–0.99, respectively). NOD2 and NLRX1 expression levels are potential prognostic markers in HCC following hepatectomy.

Long-term survival after surveillance and treatment in patients with chronic viral hepatitis and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the main cause of mortality in patients with chronic viral hepatitis (CVH). We determined the impact of surveillance and treatments on long‐term outcomes in patients with CVH who developed HCC. Between 1984 and 2014, 333 patients with HCC and with hepatitis B or hepatitis C virus infection were evaluated. An adjusted lead time bias interval was added to patients with HCC who presented with HCC (no surveillance), and their survival was compared to patients whose HCC was detected by surveillance. After HCC treatments, survival rates within and beyond 3 years of follow‐up were compared. In 175 (53%) patients, HCC was detected through surveillance using alpha‐fetoprotein and abdominal ultrasound examinations. Compared to 158 (47%) patients with HCC who had no surveillance, more patients with HCC detected by surveillance received surgical and locoregional treatments (P <  0.0001 to P <  0.001), and their 1‐, 3‐, and 5‐year overall and disease‐free survival rates were significantly higher (P <  0.001 for both). During the first 3 years of follow‐up, patients with HCC receiving liver transplantation had similar survival rates as those with liver resection or radiofrequency ablation (RFA); however, due to HCC recurrence, survival in resection and RFA patients became significantly less when followed beyond 3 years (P =  0.001 to P =  0.04). Factors associated with mortality included tumors beyond University of California at San Francisco criteria (hazard ratio [HR] 2.02; P <  0.0001), Child‐Pugh class B and C (HR, 1.58‐2.26; P =  0.043 to P =  0.015, respectively), alpha‐fetoprotein per log ng/mL increase (HR, 1.30; P <  0.0001), previous antiviral therapy in hepatitis B virus patients (HR, 0.62; P =  0.032), and treatments other than liver transplantation (HR, 2.38‐6.45; P <  0.0001 to P < 0.003).

Conclusion. Patients with HCC detected by surveillance had prolonged survival. Due to HCC recurrence, survival rates after liver resection and RFA were lower when followed beyond 3 years after treatments. (Hepatology Communications 2017;1:595–608)

Should AFP (or any biomarkers) be used for HCC surveillance?

A PURPOSE OF REVIEW

To address the controversy around the use of biomarkers for hepatocellular carcinoma (HCC) surveillance in individuals with cirrhosis or chronic hepatitis B who are at risk for development of liver cancer.

B RECENT FINDINGS

Recent studies suggest that surveillance for hepatocellular carcinoma is beneficial, even after adjustment for lead time and other biases. Alpha fetoprotein (AFP) is complementary to ultrasound (US) in surveillance, particularly in obese patients and patients with infiltrative tumors. US and AFP are both associated with harms to patients from false positive over-diagnosis, with US appearing to cause greater harms. Including patient demographic characteristics and additional biomarkers into diagnostic models is beneficial. Recent studies emphasize the advantage of time trends in biomarkers over single cross-sectional measurements.

C SUMMARY

AFP and other biomarkers are complementary to US in surveillance for HCC, especially when applied in models including patient variables and incorporating time trends in biomarker levels. With advances in genetic and molecular analysis of tumors, we may be poised at the cusp of a revolution in HCC surveillance.

Hepatocellular carcinoma screening and surveillance in 2293 chronic hepatitis B patients in an endemic area

AIM

To determine the role of screening and surveillance of hepatocellular carcinoma (HCC) in treatment-naïve chronic hepatitis B (CHB) patients.

METHODS

We recruited 2293 CHB patients (both males and females; aged 20-65 years). All patients were screened and underwent surveillance using abdominal ultrasonography (AUS) and serum alpha-fetoprotein (AFP) assay every 6 mo. The diagnosis, staging and treatment of HCC followed the American Association for the Study of Liver Diseases practice guidelines and the Barcelona Clinic Liver Cancer guidelines. The exclusion criteria included: decompensated cirrhosis; a history of any cancer in the last 5 years; previous antiviral treatment for CHB; concurrent infection with hepatitis C virus or human immunodeficiency virus; a Karnofsky Performance Status score < 60%; or any medical condition preventing eligibility to complete the protocol. The prevalence and incidence rates of HCC were determined; survival rates were calculated at 3-year post HCC diagnosis. The sensitivity and specificity were calculated on a per-patient basis.

RESULTS

Among 2293 treatment-naïve CHB patients, seven cases had HCC at initial screening, giving a prevalence rate of 305 per 100000 persons; 3.3% were diagnosed with liver cirrhosis, all of which were Child-Pugh class A. With a median follow-up time of 42 (range, 3-48) mo, 10 additional cases were diagnosed with HCC, resulting in an incidence rate of 143 per 100000 persons per year. This burden was as high as that reported in other studies from East Asian countries. All HCC patients were aged ≥ 40 years. Most were at an early stage (Stage 0, A or B); 14/17 cases were successfully treated with surgical resection or radiofrequency ablation, with a high 3-year survival rate of 90%. Hemangioma was the most common focal liver lesion in CHB patients detected by AUS; the main causes of AFP elevation at the initial screening were cirrhosis, increased alanine aminotransferase level and HCC. AUS detected 16/17 HCC cases whereas AFP levels ≥ 20 μg/L at diagnosis were observed in only 7/17 patients, most with a tumor size > 5 cm. For HCC screening and surveillance, AUS had a sensitivity and specificity of 94% and 82%, respectively, whereas the sensitivity and specificity of AFP at a cut-off value of ≥ 20 μg/L were 41% and 98%, respectively. Combined use of AUS and AFP assay did not improve effectiveness.

CONCLUSION

Implementation of active screening and surveillance using AUS to detect early-stage HCC in naïve CHB patients aged ≥ 40 years in an endemic area is of benefit.

Diffusion-weighted MRI for hepatocellular carcinoma screening in chronic liver disease: Direct comparison with ultrasound screening

INTRODUCTION

Ultrasound is a widely utilized method of screening patients with chronic liver disease for hepatocellular carcinoma (HCC). However, the sensitivity of ultrasound for small tumours is limited. We have prospectively compared ultrasound screening with diffusion-weighted (DWI) MRI for detecting HCC.

METHODS

Patients with chronic liver disease referred for ultrasound screening underwent a liver ultrasound and a liver MRI comprising free breathing DWI. Each test was independently read to determine the accuracy of each modality for detecting HCC.

RESULTS

One hundred and ninety-two patients were recruited and HCC was diagnosed in six patients (3%); all of whom were detected at ultrasound screening, and five detected at MRI screening. Ultrasound had false-positive studies 20 times (10%) while DWI MRI had three false-positive examinations (2%) p≥0.05. The sensitivity, specificity, positive predictive value and negative predictive values for ultrasound are 100%, 90%, 23% and 100%, respectively, while for MRI are 83%, 98%, 63% and 99%.

CONCLUSION

In patients with chronic liver disease undergoing surveillance for hepatocellular carcinoma, DWI MRI screening shows similar sensitivity to screening ultrasound but with a significantly lower false-positive rate.

A simple diagnostic index comprising epithelial membrane antigen and fibronectin for hepatocellular carcinoma

Background and rationale for the study. Continuing search for suitable tumor-markers is of clinical value in managing patients with various malignancies. These markers may be presented as intracellular substances in tissues or may be released into the circulation and appear in serum. Therefore, this work is concerned with identification and quantitative determination of epithelial membrane antigen (EMA) and fibronectin and estimating their performances as surrogate markers for identifying hepatocellular carcinoma (HCC).

RESULTS

A total of 627 individuals constituted this study [fibrosis (F1-F3) = 217; cirrhosis = 191; HCC = 219]. Western-blot was used for identifying EMA and fibronectin in sera. As a result, a single immunoreactive band was shown at 130-kDa and 90-kDa corresponding to EMA and fibronectin, respectively. They were quantified using ELISA providing values in HCC higher than fibrosis or cirrhosis with a significant difference (P < 0.0001). For identifying HCC, EMA showed 0.82 area under receiver-operating characteristic curve (AUC) with sensitivity = 70% and specificity = 78% while fibronectin yielded AUC = 0.70 with sensitivity = 67% and specificity = 82%. FEBA-Test comprising fibronectin and EMA together with total-bilirubin and AFP was constructed yielding AUC = 0.92 for identifying HCC from cirrhosis with sensitivity = 89% and specificity = 85%. FEBA-Test was then tested for differentiating HCC from fibrosis showing AUC = 0.97 with sensitivity = 90% and specificity = 89%. FEBA-Test enabled the correct identification of HCC patients with CLIP 0-1 and size ≤ 3 cm with AUC = 0.80 and AUC = 0.84, respectively, indicating its ability in identifying early HCC.

CONCLUSIONS

A four-marker index may improve the early detection of HCC with a high degree of accuracy.

Evidence-Based Diagnosis, Staging, and Treatment of Patients With Hepatocellular Carcinoma

Evidence-based management of patients with hepatocellular carcinoma (HCC) is key to their optimal care. For individuals at risk for HCC, surveillance usually involves ultrasonography (there is controversy over use of biomarkers). A diagnosis of HCC is made based on findings from biopsy or imaging analyses. Molecular markers are not used in diagnosis or determination of prognosis and treatment for patients. The Barcelona Clinic Liver Cancer algorithm is the most widely used staging system. Patients with single liver tumors or as many as 3 nodules ≤3 cm are classified as having very early or early-stage cancer and benefit from resection, transplantation, or ablation. Those with a greater tumor burden, confined to the liver, and who are free of symptoms are considered to have intermediate-stage cancer and can benefit from chemoembolization if they still have preserved liver function. Those with symptoms of HCC and/or vascular invasion and/or extrahepatic cancer are considered to have advanced-stage cancer and could benefit from treatment with the kinase inhibitor sorafenib. Patients with end-stage HCC have advanced liver disease that is not suitable for transplantation and/or have intense symptoms. Studies now aim to identify molecular markers and imaging techniques that can detect patients with HCC at earlier stages and better predict their survival time and response to treatment.

Economic evaluation and budget impact analysis of the surveillance program for hepatocellular carcinoma in Thai chronic hepatitis B patients

BACKGROUND

The incidence rate and the treatment costs of hepatocellular carcinoma (HCC) are high, especially in Thailand. Previous studies indicated that early detection by a surveillance program could help by down-staging. This study aimed to compare the costs and health outcomes associated with the introduction of a HCC surveillance program with no program and to estimate the budget impact if the HCC surveillance program were implemented.

MATERIALS AND METHODS

A cost utility analysis using a decision tree and Markov models was used to compare costs and outcomes during the lifetime period based on a societal perspective between alternative HCC surveillance strategies with no program. Costs included direct medical, direct non-medical, and indirect costs. Health outcomes were measured as life years (LYs), and quality adjusted life years (QALYs). The results were presented in terms of the incremental cost-effectiveness ratio (ICER) in Thai THB per QALY gained. One- way and probabilistic sensitivity analyses were applied to investigate parameter uncertainties. Budget impact analysis (BIA) was performed based on the governmental perspective.

RESULTS

Semi-annual ultrasonography (US) and semi-annual ultrasonography plus alpha-fetoprotein (US plus AFP) as the first screening for HCC surveillance would be cost-effective options at the willingness to pay (WTP) threshold of 160,000 THB per QALY gained compared with no surveillance program (ICER=118,796 and ICER=123,451 THB/QALY), respectively. The semi-annual US plus AFP yielded more net monetary benefit, but caused a substantially higher budget (237 to 502 million THB) than semi-annual US (81 to 201 million THB) during the next ten fiscal years.

CONCLUSIONS

Our results suggested that a semi-annual US program should be used as the first screening for HCC surveillance and included in the benefit package of Thai health insurance schemes for both chronic hepatitis B males and females aged between 40-50 years. In addition, policy makers considered the program could be feasible, but additional evidence is needed to support the whole prevention system before the implementation of a strategic plan.

Surveillance for hepatocellular carcinoma in a mixed-aetiology UK cohort with cirrhosis: does α-fetoprotein still have a role?

Mortality from hepatocellular carcinoma (HCC) in people with cirrhosis is increasing whereas mortality from other causes is declining. Surveillance appears to reduce mortality but the optimal strategy is uncertain. Current guidelines differ by recommending ultrasonography alone or with α-fetoprotein (αFP). Records in three UK hospitals were analysed from 2006 to 2011. Of 111 HCC cases identified, 24 (47.1%) of those eligible were under surveillance: 21 (87.5%) were under combined ultrasonography-αFP, 2 (8.3%) ultrasonography-only and 1 (4.2%) αFP-only surveillance. αFP was elevated in 19 (86.4%), and αFP alone triggered a confirmatory study in 11 (9.9%) overall and 7 (29.1%) under surveillance. Surveillance, but not αFP, correlated with smaller tumours. Survival did not differ significantly between groups. Given that αFP use is associated with identifying smaller HCCs and that several diagnoses would have been delayed without αFP in this real-life cohort, these data support ongoing αFP use. However, further work is necessary with regard to whether αFP translates into improved clinical outcome and overall cost effects. In our area, stopping αFP use would also represent a significant change in practice.

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.

Large variations in risk of hepatocellular carcinoma and mortality in treatment naïve hepatitis B patients: systematic review with meta-analyses

BACKGROUND

The complications to chronic hepatitis B (HBV) include incidence of hepatocellular carcinoma (HCC) and mortality. The risk of these complications may vary in different patient groups.

AIM

To estimate the incidence and predictors of HCC and in untreated HBV patients.

METHODS

Systematic review with random effects meta-analyses of randomized controlled trials and observational studies. Results are expressed as annual incidence (events per 100 person-years) with 95% confidence intervals. Subgroup and sensitivity analyses of patient and study characteristics were performed to identify common risk factors.

RESULTS

We included 68 trials and studies with a total of 27,584 patients (264,919 person-years). In total, 1,285 of 26,687 (5%) patients developed HCC and 730 of 12,511 (6%) patients died. The annual incidence was 0.88 (95% CI, 0.76-0.99) for HCC and 1.26 (95% CI, 1.01-1.51) for mortality. Patients with cirrhosis had a higher risk of HCC (incidence 3.16; 95% CI, 2.58-3.74) than patients without cirrhosis (0.10; 95% CI, 0.02-0.18). The risk of dying was also higher for patients with than patients without cirrhosis (4.89; 95% CI, 3.16-6.63; and 0.11; 95% CI, 0.09-0.14). The risk of developing HCC increased with HCV coinfection, older age and inflammatory activity. The country of origin did not clearly predict HCC or mortality estimates.

CONCLUSIONS

Cirrhosis was the strongest predictor of HCC incidence and mortality. Patients with HBV cirrhosis have a 31-fold increased risk of HCC and a 44-fold increased mortality compared to non-cirrhotic patients. The low incidence rates should be taken into account when considering HCC screening in non-cirrhotic patients.

TRIAL REGISTRATION

Prospero CRD42013004764.

On-treatment alpha-fetoprotein is a specific tumor marker for hepatocellular carcinoma in patients with chronic hepatitis B receiving entecavir

Alpha-fetoprotein (AFP) is the most widely used biomarker for hepatocellular carcinoma (HCC) surveillance, which is criticized as neither sensitive nor specific in active hepatitis and liver cirrhosis. The aim of this study was to determine the performance of AFP as a tumor marker for HCC in entecavir-treated patients with chronic hepatitis B (CHB). This was a retrospective-prospective cohort study of 1,531 entecavir-treated patients under regular HCC surveillance with AFP and ultrasonography. Mean age was 52 ± 12 years; 1,099 (72%) patients were male and 332 (21.7%) had clinical evidence of cirrhosis. At a mean follow-up of 51 ± 13 months, 57 (2.9%) patients developed HCC (median size: 3.3 cm). AFP fluctuated with alanine aminotransferase (ALT) and peaked at the time of starting entecavir, then gradually decreased after. AFP started to increase 6 months before the diagnosis of HCC. The receiver operator characteristic curve (AUROC) of AFP was highest at the time of HCC diagnosis (0.85; 95% confidence interval [CI]: 0.73-0.98) and remained satisfactory at 3 (0.82; 95% CI: 0.73-0.91) and 6 months (0.79; 95% CI: 0.69-0.89) before the diagnosis. Using the conventional AFP cut-off (20 μg/L) at month 0, the sensitivity and specificity to diagnose HCC were 38.6% and 98.9%, respectively. Adopting the lower cut-off value (6 μg/L) of AFP level at month 0, sensitivity was increased to 80.7%, whereas specificity was decreased to 80.4%.

CONCLUSION

On-treatment AFP is a specific tumor marker for HCC in CHB patients receiving entecavir therapy. Adopting a lower cut-off value of AFP level at 6 μg/L would significantly increase the sensitivity for HCC detection.

Evaluation of alpha-fetoprotein in detecting hepatocellular carcinoma recurrence after radiofrequency ablation

BACKGROUND AND AIM

The performance of alpha-fetoprotein (AFP) in the detection of hepatocellular carcinoma (HCC) recurrence after radiofrequency ablation was analyzed.

METHODS

One hundred and forty-six solitary HCC lesions treated by radiofrequency ablation were evaluated. Using the AFP cutoff level at ≥ 20 ng/mL, tumors were categorized into AFP or non-AFP-producing HCC. Factors associated with true and false interpretations for cancer recurrence including analysis of elevated alanine aminotransferase (ALT) were evaluated. The performance of AFP using different cutoff levels adjusted for abnormal ALT was compared.

RESULTS

Of 146 HCCs, 103 demonstrated no HCC recurrence while 43 had local recurrence. In non-recurrence HCC cases, increased AFP levels (false positive) were associated with concomitant ALT elevations, while those with normal AFP (true negative) had correspondingly normal ALT values (P < 0.001). The AFP false positive rate in cases of elevated ALT was significantly higher than those with normal ALT levels (31.9% vs 5.4%, P = 0.001). Among all positive AFP tests, those with false positive values (non-recurrence) had a significantly lower AFP level than the true positive (recurrence) HCC cases (39.8 ng/mL vs 372 ng/mL, P < 0.001). At the 20 ng/mL cutoff level, the sensitivities of AFP for detecting recurrence in non-AFP-producing HCC and AFP-producing HCC were 12.0%, and 72.2%, respectively. Using a modified AFP criteria of ≥ 100 ng/mL for cases where ALT ≥ 40 U/L, the sensitivity and specificity in AFP-producing tumors increased from 72.2% and 56% to 100% and 85%, respectively.

CONCLUSION

Serum AFP is a useful test in the detection of HCC recurrence in AFP-producing HCC. The performance in AFP-producing HCC was significantly improved after adjusting for elevation of serum ALT.

Evaluation of individual and combined applications of serum biomarkers for diagnosis of hepatocellular carcinoma: a meta-analysis

The clinical value of Serum alpha-fetoprotein (AFP) to detect early hepatocellular carcinoma (HCC) has been questioned due to its low sensitivity and specificity found in recent years. Other than AFP, several new serum biomarkers including the circulating AFP isoform AFP-L3, des-gamma-carboxy prothrombin (DCP) and Golgi protein-73 (GP73) have been identified as useful HCC markers. In this investigation, we review the current knowledge about these HCC-related biomarkers, and sum up the results of our meta-analysis on studies that have addressed the utility of these biomarkers in early detection and prognostic prediction of HCC. A systematic search in PubMed, Web of Science, and the Cochrane Library was performed for articles published in English from 1999 to 2012, focusing on serum biomarkers for HCC detection. Data on sensitivity and specificity of tests were extracted from 40 articles that met the inclusion criteria, and the summary receiver operating characteristic curve (sROC) was obtained. A meta-analysis was carried out in which the area under the curve (AUC) for each biomarker or biomarker combinations (AFP, DCP, GP73, AFP-L3, AFP + DCP, AFP + AFP-L3, and AFP + GP73) was used to compare the diagnostic accuracy of different biomarker tests. The AUC of AFP, DCP, GP73, AFP-L3, AFP + DCP, AFP + AFP-L3, and AFP + GP73 are 0.835, 0.797, 0.914, 0.710, 0.874, 0.748, and 0.932 respectively. A combination of AFP + GP73 is superior to AFP in detecting HCC and differentiating HCC patients from non-HCC patients, and may prove to be a useful marker in the diagnosis and screening of HCC. In addition, the AUC of GP73, AFP + DCP and AFP + GP73 are better than that of AFP. The clinical value of GP73, AFP + DCP, or AFP + GP73 as serological markers for HCC diagnosis needs to be addressed further in future studies.

The detection of hepatocellular carcinoma using a prospectively developed and validated model based on serological biomarkers

BACKGROUND

Hepatocellular carcinoma is a common complication of chronic liver disease (CLD), and is conventionally diagnosed by radiological means. We aimed to build a statistical model that could determine the risk of hepatocellular carcinoma in individual patients with CLD using objective measures, particularly serological tumor markers.

METHODS

A total of 670 patients with either CLD alone or hepatocellular carcinoma were recruited from a single UK center into a case-control study. Sera were collected prospectively and specifically for this study. A logistic regression analysis was used to determine independent factors associated with hepatocellular carcinoma and a model built and assessed in terms of sensitivity, specificity, and proportion of correct diagnoses.

RESULTS

The final model involving gender, age, AFP-L3, α fetoprotein (AFP), and des-carboxy-prothrombin ("GALAD") was developed in a "discovery" data set and validated in independent data sets both from the same institution and from an external institution. When optimized for sensitivity and specificity, the model gave values of more than 0.88 irrespective of the disease stage.

CONCLUSIONS

The presence of hepatocellular carcinoma can be detected in patients with CLD on the basis of a model involving objective clinical and serological factors. It is now necessary to test the model's performance in a prospective manner and in a routine clinical practice setting, to determine if it may replace or, more likely, enhance current radiological approaches.

IMPACT

Our data provide evidence that an entirely objective serum biomarker-based model may facilitate the detection and diagnosis of hepatocellular carcinoma and form the basis for a prospective study comparing this approach with the standard radiological approaches.

Serologic autoantibodies as diagnostic cancer biomarkers--a review

Current diagnostic techniques used for the early detection of cancers are successful but subject to detection bias. A recent focus lies in the development of more accurate diagnostic tools. An increase in serologic autoantibody levels has been shown to precede the development of cancer disease symptoms. Therefore, autoantibody levels in patient blood serum have been proposed as diagnostic biomarkers for early-stage diagnosis of cancers. Their clinical application has, however, been hindered by low sensitivity, specificity, and low predictive value scores. These scores have been shown to improve when panels of multiple diagnostic autoantibody biomarkers are used. A five-marker biomarker panel has been shown to increase the sensitivity of prostate cancer diagnosis to 95% as compared with 12.2% for prostate-specific antigen alone. New potential biomarker panels were also discovered for lung, colon, and stomach cancer diagnosis with sensitivity of 76%, 65.4%, and 50.8%, respectively. Studies in breast and liver cancer, however, seem to favor single markers, namely α-2-HS-glycoprotein and des-γ-carboxyprothrombin with sensitivities of 79% and 89% for the early detection of the cancers. The aim of this review is to discuss the relevance of autoantibodies in cancer diagnosis and to outline the current methodologies used in the detection of autoantibodies. The review concludes with a discussion of the autoantibodies currently used in the diagnosis of cancers of the prostate, breast, lung, colon, stomach, and liver. A discussion of the potential future use of autoantibodies as diagnostic cancer biomarkers is also included in this review.

Clinical application of serum alpha-fetoprotein-IgM complexes on the diagnosis of primary hepatocellular carcinoma in Kazakh and Han populations

Aims and background

We detected serum AFP-IgM levels in patients with primary hepatocellular carcinoma in Kazakh and Han populations to investigate the clinical significance of AFP-IgM in the diagnosis of hepatocellular carcinoma.

Methods and study design

Serum AFP-IgM levels were examined in 28 cases of hepatocellular carcinoma and 164 controls in the Kazakh population and in 85 cases of hepatocellular carcinoma and 187 controls in the Han population. AFP-IgM was detected with the ELISA assay.

Results

In general, serum AFP-IgM levels of hepatocellular carcinoma patients in the Han population and hepatocellular carcinoma patients in the Kazakh population were statistically higher than those of controls, but there was no statistical significance between hepatocellular carcinoma patients in the Han and hepatocellular carcinoma patients in the Kazakh population.

Conclusions

AFP-IgM is an encouraging serological marker and may be useful in the diagnosis of hepatocellular carcinoma.

Frequent DNA methylation of MiR-129-2 and its potential clinical implication in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a highly malignant tumor with poor prognosis and high mortality due to a lack of effective medical treatment and apparent early stage symptoms. Understanding molecular mechanism of cancer development is crucial for HCC diagnosis, prognosis, and treatment. Recently, microRNAs have been shown to play an important role in carcinogenesis, being regulated by DNA methylation in several cases. In this study, a whole genome approach was used to identify methylation-regulated miRNAs in HCC, finally focusing on miR-129-2. MiR-129-2 methylation and reduced expression were observed in all examined HCC cell lines but not in normal liver cells and tissues. In 39 (93%) of 42 HCC, the methylation levels of miR-129-2 were significantly increased in tumor tissues compared with adjacent normal tissues. Furthermore, miR-129-2 methylation was detectable in plasma samples from HCC patients, but not in plasma samples from healthy individuals or patients with liver cirrhosis. At a cut-off value of -2.36 (log2 transformation of methylation level), it was possible to distinguish HCC from healthy and cirrhotic controls with sensitivity and specificity of 88% and 100%, respectively. This study indicates that miR-129-2 methylation is highly accurate in distinguishing HCC patients from cirrhosis patients and healthy individuals, implying its potential utility as an early diagnostic marker for HCC.

Controversies in surveillance and early diagnosis of hepatocellular carcinoma

The surveillance of hepatocellular carcinoma (HCC) is an established approach to detect early cancers in patients with defined risks. However, there are still varied controversies and issues to be addressed regarding the optimal surveillance methods and interval. Moreover, there are discrepancies in the opinion or practice of HCC surveillance between Eastern and Western countries. The Western strategy of ultrasound without a biomarker such as α-fetoprotein reflects the cost-effective utilization of limited resources. On the contrary, combined measurements of biomarkers in Eastern countries are based on the assumption that increased detection of early cancers could result in an overall survival benefit. To address this complicated issue, a prospective study comparing different surveillance tests might be required. More importantly, discovery of a novel biomarker with higher performance would be an alternative.

Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma

Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.

Novel Lens culinaris agglutinin-reactive fraction of α-fetoprotein: a biomarker of hepatocellular carcinoma recurrence in patients with low α-fetoprotein concentrations

BACKGROUND

Lens culinaris agglutinin-reactive fraction of α-fetoprotein (AFP-L3) is a specific marker used to detect hepatocellular carcinoma (HCC). However, its clinical utility is not sufficient in patients with low total AFP concentrations because of limitations in instrument sensitivity. Recent advances have led to the introduction of a highly sensitive AFP-L3% assay (sensitive AFP-L3%), provided by a novel on-chip, liquid-phase binding assay. This cross-sectional study was conducted to evaluate the clinical significance of the sensitive AFP-L3% in determining HCC recurrence in patients with low total AFP concentrations.

METHODS

A total of 370 consecutive patients with HCC were screened within 1-3 months of locoregional treatment, and 215 of the 370 patients showed serum AFP <20 ng/ml. Total AFP, sensitive AFP-L3%, and des-gamma-carboxy prothrombin (DCP) were measured in those 215 patients and HCC recurrence was evaluated by radiological findings. Optimal cutoff values of the markers for detecting HCC recurrence were obtained on the basis of receiver operating characteristic (ROC) curve.

RESULTS

The area under the ROC curve of the total AFP, sensitive AFP-L3%, and DCP in HCC patients with serum AFP <20 ng/ml were 0.638, 0.724, and 0.779, respectively. The diagnostic accuracies of the total AFP, sensitive AFP-L3%, and DCP were 60.9% (cutoff value 5 ng/ml), 67.7% (cutoff value 7%), and 64.6% (cutoff value 40 ng/ml), respectively.

CONCLUSIONS

The new sensitive AFP-L3% assay provides great utility in determining HCC recurrence in patients with low AFP concentrations. Further studies focusing on the combinatorial use of the markers (total AFP, sensitive AFP-L3%, and DCP) are required.

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.

Polyol profile as an early diagnostic and prognostic marker in natural product chemoprevention of hepatocellular carcinoma in diabetic rats

AIM

Diabetes mellitus (DM) is a risk factor for hepatocellular carcinoma (HCC). It directs glucose to sorbitol and fructose in polyol pathway (PP). To pursue contribution of PP in hepatocarcinogenesis.

METHODS

We utilized ascorbic acid (AA) and diallyl sulfide (DAS) in experimental DM and HCC against control. HCC was induced by diethyl nitrosamine (DENA, one intraperitoneal (IP) dose 125 mg/kg), DM, by streptozotocin (STZ, IP dose 65 mg/kg). AA was given as 7.4 g/kg/d, I.P., DAS 200mg/kg/d, orally. All animals were killed after 10 weeks.

RESULTS

DENA elevated serum AFP, erythrocyte sorbitol (ES), neoplastic changes in liver, lowered blood glucose, increased hepatocyte aldose reductase (AR) and sorbitol dehydrogenase (SDH), significantly alleviated by DAS/AA combination. DM elevated ES activating AR, inhibiting SDH, improved by DAS and AA.

CONCLUSION

Co-induction of DM and HCC increased liver tissue lesion, serum AFP, ES, liver AR and SDH. Co-administration of DAS/AA reduced ES, AR without changing SDH. DAS/AA co-therapy lowered ES by depressing AR without affecting SDH, meaning that AR is activated by cancer and DM in different ways. PP is early marker for HCC detection and response to chemoprevention. DAS/AA combination is promising cost effective chemopreventive and anti-diabetic combination.

Diagnostic sensitivity of hepatocellular carcinoma imaging and its application to non-cirrhotic patients

BACKGROUND AND AIMS

The American Association for the Study of Liver Disease issued guidelines that proposed that hepatocellular carcinoma (HCC) can be diagnosed if a mass is larger than 2 cm in a cirrhotic liver and shows typical features of HCC at triphasic liver computed tomography (CT) or dynamic magnetic resonance imaging (MRI). In non-cirrhotic livers, the criteria were not applicable. The aim of the present study was to retrospectively analyze the sensitivity of imaging by samples of definite HCC postoperatively and test their application to diagnose HCC in non-cirrhotic livers.

METHODS

From January 2006 to November 2008, a total of 343 pathologically-diagnosed HCC patients via surgical resection were reviewed. Among the 343 patients, 204 patients had undergone liver CT examination, and 80 patients underwent MRI examination; serum α-fetoprotein had been checked for all 343 patients prior to operation. The diagnostic sensitivity of HCC by imaging was evaluated and compared in patients with/without cirrhosis by ultrasound and histology.

RESULTS

The diagnostic sensitivity of HCC by single imaging was approximately 65-80% (liver CT or MRI). A higher sensitivity of HCC diagnosis was found in patients with ultrasound-diagnosed cirrhosis than non-cirrhosis, but the difference in sensitivity disappeared after histologically-cirrhotic validation. The results indicated that regardless of the presence or absence of cirrhosis (histology), a typical vascular pattern could diagnose HCC with equally high sensitivity.

CONCLUSIONS

We provide evidence that the sensitivity of HCC diagnosis by imaging is not influenced by the cirrhotic background. Further study is needed to validate the specificity and accuracy.

CT and MRI improve detection of hepatocellular carcinoma, compared with ultrasound alone, in patients with cirrhosis

BACKGROUND & AIMS

In patients with cirrhosis, hepatocellular carcinoma (HCC) is detected by ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI); US is recommended for screening and surveillance. We performed a retrospective analysis of the abilities of these cross-sectional imaging modalities to detect HCC.

METHODS

We analyzed data from 638 consecutive adult patients with cirrhosis who received liver transplants within 6 months of imaging at a tertiary care institution. Imaging reports and serum alpha-fetoprotein levels were compared with results from pathology analysis of explants as the reference standard. Sensitivities of US, CT, and MRI were calculated overall and in defined size categories. False-positive imaging results and patient-based specificities were evaluated.

RESULTS

Of the 638 patients, 225 (35%) had HCC, confirmed by pathology analysis of liver explants. In 23 cases, the lesions were infiltrative or extensively multifocal. In the remaining 202 explants (337 numerable, discrete nodules), respective lesion-based sensitivities of US, CT, and MRI were 46%, 65%, and 72% overall and 21%, 40%, and 47% for small (<2 cm) HCC. The sensitivity of US increased with the availability of CT or MRI data (P = .049); sensitivity values were 62% and 85% for lesions 2-4 and ≥ 4 cm, respectively. Patient-based specificities of US, CT, and MRI were 96%, 96%, and 87%, respectively.

CONCLUSIONS

US, CT, and MRI did not detect small HCC lesions with high levels of sensitivity, although CT and MRI provide substantial improvements over unenhanced US in patients with cirrhosis who received liver transplants.

Contrast-enhanced ultrasound for characterisation of hepatic lesions appearing non-hypervascular on CT in chronic liver diseases

OBJECTIVES

The purpose of this prospective study was to elucidate the efficacy of using contrast-enhanced ultrasound to characterise focal hepatic lesions appearing non-hypervascular on contrast-enhanced CT in chronic liver diseases.

METHODS

The study population included 22 patients with cirrhosis or chronic hepatitis, who between them had 27 focal hepatic lesions smaller than 20 mm (mean 13.9 ± 3.4) that appeared non-hypervascular on contrast-enhanced CT. Contrast-enhanced ultrasound with perflubutane microbubble agent (Sonazoid, 0.0075 ml kg(-1)) was performed prior to ultrasound-guided needle biopsy, and intensity analysis was done for hepatic lesions in the early phase (-60 s) and late phase (600 s post injection).

RESULTS

All seven early-phase hyperenhanced lesions were hepatocellular carcinoma (HCC). 20 lesions iso- or hypoenhanced during the early phase consisted of 11 regenerative nodules (RNs) and 9 HCCs. HCC was more frequent in early-phase hyperenhanced lesions than in iso- or hypoenhanced lesions (p=0.0108). Both late-phase hypoenhanced lesions were HCCs, whereas 25 late-phase isoenhanced lesions consisted of 11 RNs and 14 HCCs. The enhancement patterns of the 11 RNs included isoenhanced appearance in both the early and late phases in 8 lesions, and early-phase hypoenhancement combined with late-phase isoenhancement in the remaining 3. Both of these enhancement patterns (i.e. either iso-iso or hypo-iso) were found in 9 malignant lesions, 9 (75%) of the 12 well-differentiated HCCs.

CONCLUSION

Hypervascularity on contrast-enhanced ultrasound with Sonazoid strongly suggested HCC regardless of non-hypervascularity on CT, and late-phase hypoenhancement was another possible finding of HCC. However, characterisation of hepatic lesions with other enhancement patterns was difficult using our technique.