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Maher AM, Shanker M, Liu HYH, Lee Y, Leggett D, Hodgkinson P, Pryor D, Stuart KA. Comparison of outcomes following surgical resection, percutaneous ablation or stereotactic body radiation therapy in early-stage, solitary and small (≤3 cm) treatment-naïve hepatocellular carcinoma. Cancer Med 2024; 13:e6978. [PMID: 38400681 PMCID: PMC10891469 DOI: 10.1002/cam4.6978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/03/2023] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Stereotactic body radiation therapy (SBRT) is associated with high local control rates in hepatocellular carcinoma (HCC). This study reports the outcomes of SBRT compared to surgical resection (SR) and percutaneous ablation (PA) for treatment-naïve, solitary HCCs ≤3 cm. METHODS This was a retrospective study of patients with BCLC stage 0/A HCC with a single ≤3 cm lesion, treated with curative intent between 2016 and 2020. SBRT was used for patients considered unsuitable for SR or PA. The co-primary endpoints were progression-free survival (PFS) and overall survival (OS). The secondary endpoints were treatment-related clinical toxicity rates and local control (LC) rates. RESULTS There were 112 patients included in this study. SBRT was delivered in 36 patients (32.1%), 51 had PA (45.5%) and 25 underwent SR (22.3%). Median follow-up was 23 months (range, 3-60 months) from diagnosis. The 3-year PFS and OS were 67% and 69% following SBRT, 55% and 80% following PA, and 85% and 100% following SR, respectively. Patients in the SR cohort had significantly better 3-year PFS and OS compared to SBRT and PA groups (p = 0.03 and p = 0.04, respectively). There was no significant difference in PFS (p = 0.15) or OS (p = 0.23) between SBRT and PA treated patients. The 3-year LC rate for the entire cohort was 98%. CONCLUSIONS In patients with treatment-naïve, early-stage solitary HCCs ≤3 cm, SBRT was associated with comparable PFS, OS and LC outcomes to PA. SBRT should be considered as a curative intent therapy to avoid treatment stage migration in this favourable prognostic cohort of patients.
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Affiliation(s)
- A. M. Maher
- Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - M. Shanker
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - H. Y. H. Liu
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Y. Lee
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - D. Leggett
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Department of Medical ImagingPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - P. Hodgkinson
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Department of Hepatobiliary and Pancreatic SurgeryPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Queensland Liver Transplant ServiceBrisbaneQueenslandAustralia
| | - D. Pryor
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - K. A. Stuart
- Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Queensland Liver Transplant ServiceBrisbaneQueenslandAustralia
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2
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Liu HYH, Lee YYD, Sridharan S, Wang W, Khor R, Chu J, Oar A, Choong ES, Le H, Shanker M, Wigg A, Stuart K, Pryor D. Definitive Stereotactic Body Radiation Therapy in Early-Stage Solitary Hepatocellular Carcinoma: An Australian Multi-Institutional Review of Outcomes. Clin Oncol (R Coll Radiol) 2023; 35:787-793. [PMID: 37709623 DOI: 10.1016/j.clon.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/08/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023]
Abstract
AIMS Standard curative options for early-stage, solitary hepatocellular carcinoma (HCC) are often unsuitable due to liver dysfunction, comorbidities and/or tumour location. Stereotactic body radiation therapy (SBRT) has shown high rates of local control in HCC; however, limited data exist in the treatment-naïve, curative-intent setting. We report the outcomes of patients with solitary early-stage HCC treated with SBRT as first-line curative-intent therapy. MATERIALS AND METHODS A multi-institutional retrospective study of treatment-naïve patients with Barcelona Clinic Liver Cancer stage 0/A, solitary ≤5 cm HCC, Child-Pugh score (CPS) A liver function who underwent SBRT between 2010 and 2019 as definitive therapy. The primary end point was freedom from local progression. Secondary end points were progression-free survival, overall survival, rate of treatment-related clinical toxicities and change in CPS >1. RESULTS In total, 68 patients were evaluated, with a median follow-up of 20 months (range 3-58). The median age was 68 years (range 50-86); 54 (79%) were men, 62 (91%) had cirrhosis and 50 (74%) were Eastern Cooperative Oncology Group 0. The median HCC diameter was 2.5 cm (range 1.3-5) and the median prescription biologically effective dose with a tumour a/b ratio of 10 Gy (BED10) was 93 Gy (interquartile range 72-100 Gy). Two-year freedom from local progression, progression-free survival and overall survival were 94.3% (95% confidence interval 86.6-100%), 59.5% (95% confidence interval 46.3-76.4%) and 88% (95% confidence interval 79.2-97.6%), respectively. Nine patients (13.2%) experienced grade ≥2 treatment-related clinical toxicities. A rise >1 in CPS was observed in six cirrhotic patients (9.6%). CONCLUSION SBRT is an effective and well-tolerated option to consider in patients with solitary, early-stage HCC. Prospective, randomised comparative studies are warranted to further refine its role as a first-line curative-intent therapy.
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Affiliation(s)
- H Y-H Liu
- Department of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia.
| | - Y-Y D Lee
- Department of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
| | - S Sridharan
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, New South Wales, Australia
| | - W Wang
- Department of Radiation Oncology, The Crown Princess Mary Cancer Centre, Westmead, New South Wales, Australia; Department of Radiation Oncology, Nepean Cancer Care Centre, Kingswood, New South Wales, Australia
| | - R Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - J Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Oar
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - E S Choong
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - H Le
- Department of Radiation Oncology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - M Shanker
- Department of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
| | - A Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - K Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - D Pryor
- Department of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
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3
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Hendriks P, Boel F, Oosterveer TTM, Broersen A, de Geus-Oei LF, Dijkstra J, Burgmans MC. Ablation margin quantification after thermal ablation of malignant liver tumors: How to optimize the procedure? A systematic review of the available evidence. Eur J Radiol Open 2023; 11:100501. [PMID: 37405153 PMCID: PMC10316004 DOI: 10.1016/j.ejro.2023.100501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction To minimize the risk of local tumor progression after thermal ablation of liver malignancies, complete tumor ablation with sufficient ablation margins is a prerequisite. This has resulted in ablation margin quantification to become a rapidly evolving field. The aim of this systematic review is to give an overview of the available literature with respect to clinical studies and technical aspects potentially influencing the interpretation and evaluation of ablation margins. Methods The Medline database was reviewed for studies on radiofrequency and microwave ablation of liver cancer, ablation margins, image processing and tissue shrinkage. Studies included in this systematic review were analyzed for qualitative and quantitative assessment methods of ablation margins, segmentation and co-registration methods, and the potential influence of tissue shrinkage occurring during thermal ablation. Results 75 articles were included of which 58 were clinical studies. In most clinical studies the aimed minimal ablation margin (MAM) was ≥ 5 mm. In 10/31 studies, MAM quantification was performed in 3D rather than in three orthogonal image planes. Segmentations were performed either semi-automatically or manually. Rigid and non-rigid co-registration algorithms were used about as often. Tissue shrinkage rates ranged from 7% to 74%. Conclusions There is a high variability in ablation margin quantification methods. Prospectively obtained data and a validated robust workflow are needed to better understand the clinical value. Interpretation of quantified ablation margins may be influenced by tissue shrinkage, as this may cause underestimation.
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Affiliation(s)
- Pim Hendriks
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur Boel
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Timo TM Oosterveer
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander Broersen
- LKEB Laboratory of Clinical and Experimental Imaging, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
- Biomedical Photonic Imaging Group, University of Twente, the Netherlands
| | - Jouke Dijkstra
- LKEB Laboratory of Clinical and Experimental Imaging, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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4
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Cox DRA, Chung W, Grace J, Wong D, Kutaiba N, Ranatunga D, Khor R, Perini MV, Fink M, Jones R, Goodwin M, Dobrovic A, Testro A, Muralidharan V. Evaluating treatment response following locoregional therapy for hepatocellular carcinoma: A review of the available serological and radiological tools for assessment. JGH OPEN 2023; 7:249-260. [PMID: 37125252 PMCID: PMC10134770 DOI: 10.1002/jgh3.12879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 04/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is an aggressive primary malignancy of the liver and is the third most common cause of cancer-related global mortality. There has been a steady increase in treatment options for HCC in recent years, including innovations in both curative and non-curative therapies. These advances have brought new challenges and necessary improvements in strategies of disease monitoring, to allow early detection of HCC recurrence. Current serological and radiological strategies for post-treatment monitoring and prognostication and their limitations will be discussed and evaluated in this review.
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Affiliation(s)
- Daniel R A Cox
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Hepatopancreatobiliary and Liver Transplant Surgery Unit Austin Health Melbourne Victoria Australia
| | - William Chung
- Department of Medicine (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Liver Transplant Unit, Department of Gastroenterology and Hepatology Austin Health Melbourne Victoria Australia
| | - Josephine Grace
- Department of Medicine (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Liver Transplant Unit, Department of Gastroenterology and Hepatology Austin Health Melbourne Victoria Australia
| | - Darren Wong
- Department of Medicine (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Liver Transplant Unit, Department of Gastroenterology and Hepatology Austin Health Melbourne Victoria Australia
| | - Numan Kutaiba
- Department of Radiology Austin Health Melbourne Victoria Australia
| | - Dinesh Ranatunga
- Department of Radiology Austin Health Melbourne Victoria Australia
| | - Richard Khor
- Department of Radiation Oncology Austin Health Melbourne Victoria Australia
- School of Molecular Sciences, La Trobe University Melbourne Victoria Australia
- Department of Medical Imaging and Radiation Sciences Monash University Melbourne Victoria Australia
| | - Marcos V Perini
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Hepatopancreatobiliary and Liver Transplant Surgery Unit Austin Health Melbourne Victoria Australia
| | - Michael Fink
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Hepatopancreatobiliary and Liver Transplant Surgery Unit Austin Health Melbourne Victoria Australia
| | - Robert Jones
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Hepatopancreatobiliary and Liver Transplant Surgery Unit Austin Health Melbourne Victoria Australia
- Liver Transplant Unit, Department of Gastroenterology and Hepatology Austin Health Melbourne Victoria Australia
| | - Mark Goodwin
- Department of Radiology Austin Health Melbourne Victoria Australia
| | - Alex Dobrovic
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
| | - Adam Testro
- Department of Medicine (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Liver Transplant Unit, Department of Gastroenterology and Hepatology Austin Health Melbourne Victoria Australia
| | - Vijayaragavan Muralidharan
- Department of Surgery (Austin Precinct) The University of Melbourne Melbourne Victoria Australia
- Hepatopancreatobiliary and Liver Transplant Surgery Unit Austin Health Melbourne Victoria Australia
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5
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Loo KF, Woodman RJ, Bogatic D, Chandran V, Muller K, Chinnaratha MA, Bate J, Campbell K, Maddison M, Narayana S, Le H, Pryor D, Wigg A. High rates of treatment stage migration for early hepatocellular carcinoma and association with adverse outcomes: An Australian multicenter study. JGH Open 2022; 6:599-606. [PMID: 36091321 PMCID: PMC9446396 DOI: 10.1002/jgh3.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Kee Fong Loo
- Hepatology and Liver Transplant Medicine Unit Southern Adelaide Local Health Network Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Richard J Woodman
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Damjana Bogatic
- Department of Medicine Royal Adelaide Hospital Adelaide South Australia Australia
| | - Vidyaleha Chandran
- Department of Gastroenterology and Hepatology Lyell McEwin Hospital Adelaide South Australia Australia
| | - Kate Muller
- Hepatology and Liver Transplant Medicine Unit Southern Adelaide Local Health Network Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Mohamed Asif Chinnaratha
- Department of Gastroenterology and Hepatology Lyell McEwin Hospital Adelaide South Australia Australia
- Faculty of Health and Medical Sciences The University of Adelaide Adelaide South Australia Australia
| | - John Bate
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Kirsty Campbell
- Department of Gastroenterology and Hepatology Royal Darwin Hospital Darwin Northern Territory Australia
| | - Matthew Maddison
- Department of Gastroenterology and Hepatology Royal Darwin Hospital Darwin Northern Territory Australia
| | - Sumudu Narayana
- Hepatology and Liver Transplant Medicine Unit Southern Adelaide Local Health Network Adelaide South Australia Australia
| | - Hien Le
- Department of Radiation Oncology Royal Adelaide Hospital Adelaide South Australia Australia
- The University of South Australia Adelaide South Australia Australia
| | - David Pryor
- Department of Radiation Oncology Princess Alexandra Hospital Brisbane Queensland Australia
- Queensland University of Technology Brisbane Queensland Australia
| | - Alan Wigg
- Hepatology and Liver Transplant Medicine Unit Southern Adelaide Local Health Network Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
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6
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Impact of Extended Use of Ablation Techniques in Cirrhotic Patients with Hepatocellular Carcinoma: A Cost-Effectiveness Analysis. Cancers (Basel) 2022; 14:cancers14112634. [PMID: 35681618 PMCID: PMC9179352 DOI: 10.3390/cancers14112634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/22/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The optimal management of non-metastatic hepatocellular carcinoma (HCC) remains debated. The association between HCC and cirrhosis influences prognosis and therapeutic choices between curative and palliative treatments. The goal of our retrospective study was to evaluate the cost-effectiveness of the extended use of ablation for the treatment of HCC with cirrhosis in an expert ablation center when compared to the non-extended use of ablation in equivalent tertiary care centers. In a propensity-score matched cohort of 532 patients with naïve HCC, the extended use of ablation led to better compliance with the Barcelona Clinic Liver Classification (BCLC) guidelines (80% vs. 67%) and was more effective and less expensive than the non-extended use of ablation strategy, particularly at an earlier stage of the disease. The shift from curative to palliative treatments was noted in a considerable percentage of patients; therefore, this needs to be redefined as the wide choice of ablation techniques and technical advances in imaging guidance increase the curative options available to treat a maximum of patients with HCC. Abstract Background: To evaluate the cost-effectiveness of the extended use of ablation for the treatment of hepatocellular carcinoma (HCC) with cirrhosis in an expert ablation center when compared to the non-extended use of ablation in equivalent tertiary care centers. Methods: Consecutive cirrhotic patients with non-metastatic HCC, no prior treatment, and referred to three tertiary care centers between 2012 and 2016 were retrospectively identified. The Bondy group, including all of the patients treated at Jean Verdier Hospital, where the extended use of ablation is routinely performed, was compared to the standard of care (SOC) group, including all of the patients treated at the Beaujon and Mondor Hospitals, using propensity score matching. A cost-effectiveness analysis was carried out from the perspective of French health insurance using a Markov model on a lifetime horizon. Results: 532 patients were matched. The Bondy group led to incremental discounted lifetime effects of 0.8 life-years gained (LYG) (95% confidence interval: 0.4, 1.3) and a decrease in lifetime costs of EUR 7288 (USD 8016) (95% confidence interval: EUR 5730 [USD 6303], EUR 10,620 [USD 11,682]) per patient, compared with the SOC group, resulting in a dominant mean incremental cost-effectiveness ratio (ICER). A compliance with the Barcelona Clinic Liver Classification (BCLC) guidelines for earlier stage contributed to the greater part of the ICER. Conclusion: The extended use of ablation in cirrhotic patients with HCC was more effective and less expensive than the non-extended use of the ablation strategy.
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7
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Christou CD, Tsoulfas G. Role of three-dimensional printing and artificial intelligence in the management of hepatocellular carcinoma: Challenges and opportunities. World J Gastrointest Oncol 2022; 14:765-793. [PMID: 35582107 PMCID: PMC9048537 DOI: 10.4251/wjgo.v14.i4.765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/24/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) constitutes the fifth most frequent malignancy worldwide and the third most frequent cause of cancer-related deaths. Currently, treatment selection is based on the stage of the disease. Emerging fields such as three-dimensional (3D) printing, 3D bioprinting, artificial intelligence (AI), and machine learning (ML) could lead to evidence-based, individualized management of HCC. In this review, we comprehensively report the current applications of 3D printing, 3D bioprinting, and AI/ML-based models in HCC management; we outline the significant challenges to the broad use of these novel technologies in the clinical setting with the goal of identifying means to overcome them, and finally, we discuss the opportunities that arise from these applications. Notably, regarding 3D printing and bioprinting-related challenges, we elaborate on cost and cost-effectiveness, cell sourcing, cell viability, safety, accessibility, regulation, and legal and ethical concerns. Similarly, regarding AI/ML-related challenges, we elaborate on intellectual property, liability, intrinsic biases, data protection, cybersecurity, ethical challenges, and transparency. Our findings show that AI and 3D printing applications in HCC management and healthcare, in general, are steadily expanding; thus, these technologies will be integrated into the clinical setting sooner or later. Therefore, we believe that physicians need to become familiar with these technologies and prepare to engage with them constructively.
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Affiliation(s)
- Chrysanthos D Christou
- Department of Transplantation Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
| | - Georgios Tsoulfas
- Department of Transplantation Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
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8
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Lockart I, Hajarizadeh B, Buckley N, Davison S, Prakoso E, Levy MT, George J, Dore GJ, Danta M. All-cause hepatocellular carcinoma survival in the era of direct-acting antiviral therapy. J Gastroenterol Hepatol 2021; 36:3515-3523. [PMID: 34520088 DOI: 10.1111/jgh.15687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/20/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Hepatitis C virus (HCV) cure with direct-acting antiviral (DAA) therapy improves survival in patients with HCV-related hepatocellular carcinoma (HCC). We hypothesized that HCV-HCC survival has increased in the DAA era, more than other aetiologies of HCC. We aimed to evaluate survival following HCC diagnosis in the pre-DAA and DAA eras, across each aetiology of HCC. METHODS Patients with HCC at three tertiary referral hospitals were included retrospectively (January 2008 to December 2019). Patients were categorized as HCV-HCC, hepatitis B virus (HBV)-HCC, or non-viral HCC. For each aetiology, the risk of death following incident HCC among patients diagnosed in the DAA era (2015-2019) was compared with patients diagnosed in the pre-DAA era (2008-2014). RESULTS Among 1161 patients, there were 422 (36%) patients with HCV-HCC, 227 (20%) with HBV-HCC, and 512 (44%) with non-viral HCC. In adjusted analysis, the risk of death was lower in patients with HCV-HCC diagnosed in 2015-2019, compared with patients diagnosed in 2008-2014 (adjusted hazard ratio [aHR]: 0.68; 95% confidence interval [CI]: 0.52-0.89; P = 0.005). In contrast, there was no difference in the risk of death between time periods for patients with HBV-HCC (HR: 0.91; 95% CI: 0.64-1.29; P = 0.602) or non-viral HCC on adjusted analysis (aHR: 0.92; 95% CI: 0.74-1.15; P = 0.476). Although patients with HBV-HCC had better survival compared with patients with HCV-HCC in 2008-2014 (aHR: 0.74; 95% CI: 0.55-0.98; P = 0.037), this difference disappeared in 2015-2019 (aHR: 1.26; 95% CI: 0.90-1.77; P = 0.175). CONCLUSIONS Hepatitis C virus-related HCC survival has increased in the DAA era, whereas adjusted survival remained stable for HBV-HCC and non-viral HCC.
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Affiliation(s)
- Ian Lockart
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,St Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Niamh Buckley
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Scott Davison
- Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Emilia Prakoso
- Liverpool Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Miriam T Levy
- Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney and Westmead Hospital, Sydney, New South Wales, Australia
| | - Gregory J Dore
- St Vincent's Hospital, Sydney, New South Wales, Australia.,The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,St Vincent's Hospital, Sydney, New South Wales, Australia
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9
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Mospan AR, Morris HL, Fried MW. Real-world evidence in hepatocellular carcinoma. Liver Int 2021; 41 Suppl 1:61-67. [PMID: 34155788 DOI: 10.1111/liv.14864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
Real-world evidence includes all health-related information, such as electronic health records, insurance claims, pharmacy records and wearables that are obtained outside of clinical trials. These data can provide critical insights into the natural history of disease and evaluate the safety and effectiveness of treatment regimens used in clinical practice. Real-world data have been applied to varying degrees by global regulatory agencies to inform and expedite many phases of drug development and help refine the use of therapeutic regimens after marketing, especially in populations that are under-represented in registration trials. For the management of hepatocellular carcinoma, early detection provides the best chance for curative therapies, whose success has been evaluated in numerous cohorts. The availability of novel systemic therapies, including kinase inhibitors and immunotherapies, has provided new treatment options and improved survival in patients with advanced stage hepatocellular carcinoma. Real-world longitudinal observational studies can help understand the long-term safety and effectiveness of these agents.
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Affiliation(s)
| | | | - Michael W Fried
- Target RWE, Durham, NC, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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10
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Lubel JS, Roberts SK, Strasser SI, Thompson AJ, Philip J, Goodwin M, Clarke S, Crawford DH, Levy MT, Shackel N. Australian recommendations for the management of hepatocellular carcinoma: a consensus statement. Med J Aust 2020; 214:475-483. [PMID: 33314233 DOI: 10.5694/mja2.50885] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at-risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators. METHODS AND RECOMMENDATIONS This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.
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Affiliation(s)
- John S Lubel
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW.,University of Sydney, Sydney, NSW
| | | | - Jennifer Philip
- University of Melbourne, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
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Kuo TM, Chang KM, Kao KJ. Why Cannot BCLC 0- or A-Stage Patients Receive Curative Treatment? Gastrointest Tumors 2020; 7:125-133. [PMID: 33173776 DOI: 10.1159/000509824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Barcelona Clinic Liver Cancer (BCLC) staging has been an important clinical guideline for the management of hepatocellular carcinoma (HCC). BCLC 0 and A stages (BCLC 0/A) have been designated as the early-stage HCC, and the curative treatment is recommended as the primary therapeutic modality. However, a recent study indicated that a significant number of BCLC 0/A patients were not initially managed with the curative treatment without knowing why. Methods We, therefore, conducted a study on BCLC 0/A patients who had and had not received initial curative treatment cared at our cancer center from January 2011 to December 2015 and analyzed causes contributing to not having the initial curative treatment. Results One hundred and sixty-nine BCLC 0/A patients were identified and included in the study. Seventy two patients (43%) received the initial curative treatment and 97 patients (57%) did not. After careful review of medical records, all 97 patients without the initial curative treatment had identifiable reasons for not having the initial curative treatment. Two main reasons for not having the initial curative treatment were "probable presence of additional HCC and requiring diagnostic angiography" (28%) and "difficult or complicating anatomical location of tumors" (17%). When the relevant clinical parameters were compared between the 2 groups of patients, it was found that patients without the initial curative treatment had more serious clinical conditions and worse overall and recurrence-free survival outcomes compared with those who had the initial curative treatment. Discussion/Conclusion Our finding indicates that a significant fraction of the BCLC 0/A HCC patients is unable to have initial curative treatment as recommended by BCLC guidelines. These early stages of HCC patients represent a distinctive subpopulation and are in need of further investigation to improve their survival outcomes.
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Affiliation(s)
- Tse-Ming Kuo
- Division of Gastroenterology and Hepatobiliary Disease, Department of Internal Medicine, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Kai-Ming Chang
- Department of Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Kuo-Jang Kao
- Department of Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
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Management of Hepatocellular Carcinoma in the Era of Individualized Therapy: The Experience of a Greek Tertiary Center. Ochsner J 2020; 20:272-278. [PMID: 33071659 PMCID: PMC7529125 DOI: 10.31486/toj.19.0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: The treatment of hepatocellular carcinoma (HCC) in the era of individualized therapy mandates a multidisciplinary approach and therefore the cooperation of physicians from multiple medical specialties. Treatment selection is based on the stage of the disease. The most prominent staging system is the Barcelona Clinic Liver Cancer (BCLC) classification system. Methods: We conducted a retrospective cohort study of patients with HCC treated in our department. Patients were originally staged based on the BCLC classification system. However, a multidisciplinary team refined the BCLC classes, using clinical data and biomarkers to tailor an individualized course of treatment. Results: The study population was 63 patients who were BCLC staged at diagnosis as follows: very early (5 patients, 7.9%), early (38 patients, 60.3%), intermediate (14 patients, 22.2%), and advanced (6 patients, 9.5%). Thirty-two patients (50.8%) were treated with surgery and 31 patients (49.2%) with locoregional treatments. The 1-year, 3-year, and 5-year survival rates in the surgery group were 81.3%, 52.9%, and 18.9%, respectively, whereas in the locoregional treatment group, the 1-year, 3-year, and 5-year survival rates were 71.0%, 38.7%, and 19.0%, respectively. The mean overall survival was 35.42 ± 23.54 months for the surgery group and 28.42 ± 23.0 months for the locoregional treatment group. In the surgery group, the mean overall survival of the patients treated with surgery alone was 26.68 ± 21.97 months compared to 48.18 ± 20.26 months for the patients treated with surgery followed by locoregional treatment for recurrence. Conclusion: In this study, patients treated with hepatic resection had higher survival rates than patients treated with locoregional treatments. However, this superiority did not reach statistical significance (P=0.426). Thus, locoregional treatments are highlighted as a valuable alternative to surgery, particularly when hepatic resection is not feasible. Finally, patients who received locoregional treatment following surgery had significantly higher survival compared to patients treated with surgery alone (P=0.038).
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Mishra G, Dev A, Paul E, Cheung W, Koukounaras J, Jhamb A, Marginson B, Lim BG, Simkin P, Borsaru A, Burnes J, Goodwin M, Ramachandra V, Spanger M, Lubel J, Gow P, Sood S, Thompson A, Ryan M, Nicoll A, Bell S, Majeed A, Kemp W, Roberts SK. Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation. BMC Cancer 2020; 20:483. [PMID: 32471447 PMCID: PMC7257176 DOI: 10.1186/s12885-020-06806-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion. METHOD Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival. RESULTS Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively. CONCLUSION Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.
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Affiliation(s)
- Gauri Mishra
- Gastroenterology, Monash Health, Melbourne, Australia
| | - Anouk Dev
- Gastroenterology, Monash Health, Melbourne, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Wa Cheung
- Radiology, Alfred Health, Melbourne, Australia
| | | | - Ashu Jhamb
- Radiology, St. Vincent's Hospital, Melbourne, Australia
| | - Ben Marginson
- Radiology, St. Vincent's Hospital, Melbourne, Australia
| | - Beng Ghee Lim
- Radiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Paul Simkin
- Radiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Adina Borsaru
- Radiology, Monash Health Eastern Health, Melbourne, Australia
| | - James Burnes
- Radiology, Monash Health Eastern Health, Melbourne, Australia
| | | | | | | | - John Lubel
- Department of Gastroenterology, The Alfred Hospital, 55 Commercial Rd, Melbourne, 3004, Australia
| | - Paul Gow
- Gastroenterology, Austin Health, Melbourne, Australia
| | - Siddharth Sood
- Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Marno Ryan
- Gastroenterology, St. Vincent's Hospital, Melbourne, Australia
| | - Amanda Nicoll
- Gastroenterology, Eastern Health, Melbourne, Australia
| | - Sally Bell
- Gastroenterology, Monash Health, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology, The Alfred Hospital, 55 Commercial Rd, Melbourne, 3004, Australia
| | - William Kemp
- Department of Gastroenterology, The Alfred Hospital, 55 Commercial Rd, Melbourne, 3004, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, The Alfred Hospital, 55 Commercial Rd, Melbourne, 3004, Australia.
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Pinato DJ. Therapeutic hierarchy in hepatocellular carcinoma: A dispute of evidence versus practice. Liver Int 2019; 39:1622-1623. [PMID: 31503411 DOI: 10.1111/liv.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 12/19/2022]
Affiliation(s)
- David J Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
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