Postoperative recurrence of hepatocellular carcinoma

Mixed Hepatocellular Cholangiocarcinoma: A Comparison of Survival between Mixed Tumors, Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma from a Single Center

BACKGROUND

Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy, followed by intrahepatic cholangiocarcinoma (ICC). In addition, there is a mixed form for which only limited data are available. The aim of this study was to compare recurrence and survival of the mixed form within the cohorts of patients with HCC and ICC from a single center.

METHODS

Between January 2008 and December 2020, all patients who underwent surgical exploration for ICC, HCC, or mixed hepatocellular cholangiocarcinoma (mHC-CC) were included in this retrospective analysis. The data were analyzed, focusing on preoperative and operative details, histological outcome, and tumor recurrence, as well as overall and recurrence-free survival.

RESULTS

A total of 673 surgical explorations were performed, resulting in 202 resections for ICC, 344 for HCC (225 non-cirrhotic HCC, ncHCC; 119 cirrhotic HCC, cHCC), and 14 for mHC-CC. In addition, six patients underwent orthotopic liver transplant (OLT) in the belief of dealing with HCC. In 107 patients, tumors were irresectable (resection rate of 84%). Except for the cHCC group, major or even extended liver resections were required. Vascular or visceral extensions were performed regularly. Overall survival (OS) was highly variable, with a median OS of 17.6 months for ICC, 26 months for mHC-CC, 31.8 months for cHCC, and 37.2 months for ncHCC. Tumor recurrence was common, with a rate of 45% for mHC-CC, 48.9% for ncHCC, 60.4% for ICC, and 67.2% for cHCC. The median recurrence-free survival was 7.3 months for ICC, 14.4 months for cHCC, 16 months for mHC-CC, and 17 months for ncHCC. The patients who underwent OLT for mHC-CC showed a median OS of 57.5 and RFS of 56.5 months.

CONCLUSIONS

mHC-CC has a comparable course and outcome to ICC. The cholangiocarcinoma component seems to be the dominant one and, therefore, may be responsible for the prognosis. 'Accidental' liver transplant for mHC-CC within the Milan criteria offers a good long-term outcome. This might be an option in countries with no or minor organ shortage.

Empirical 188Re-HDD/lipiodol intra-arterial therapy based on tumor volume, in patients with solitary inoperable hepatocellular carcinoma

OBJECTIVE

This study aimed to assess the potential benefits and tolerability of an empirical dose of approximately 0.8-1.2 mCi (29.6-44.4 MBq) of Re-4-hexadecyl-1-2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol/lipiodol (Re-HDD/lipiodol) per milliliter of tumor volume, administered after super-selection of the tumor feeding branches of hepatic artery for treatment of inoperable hepatocellular carcinoma (HCC).

METHODS

Patients with advanced HCC or classified as inoperable, with no demonstrated extrahepatic disease and no significant comorbidities were eligible. The patients selected for this study had a single tumoral lesion, measuring less than 150 cc. The range of total activity administered was between 30 and 100 mCi (1.2-3.7) GBq Re-HDD/lipiodol, administered in the super selected branches of the hepatic artery supplying the tumor in 42 Patients. Whole-body scintigraphies and single-photon emission computed tomography-computed tomography (SPECT-CT) of the liver including tumor were performed at four-time points after injection. Absorbed doses to the various organs were calculated according to the Medical Internal Radiation Dose formalism. Blood and urine samples were collected at multiple time points until 72 h after injection. Hematological, hepatic and pulmonary toxicity was assessed until 12 weeks after administration using the Common Toxicity Criteria for Adverse Events (version 3.0) scale. Responses were evaluated on contrast enhanced computed tomography (CECT) and by alfa-fetoprotein (AFP) level monitoring.

RESULTS

About 40.6 ± 4.8% of the injected activity was excreted in the urine by 72 h after injection. The mean absorbed dose to the liver, lungs, stomach, kidney and intestine was 14.4 ± 1.8, 4.8 ± 0.6, 5.5 ± 1.1, 5.1 ± 0.7, and 6.5 ± 1.0 Gy (mean ± SD), respectively. Up to 6 days after administration, 26 of 44 patients had adverse events consisting of aggravations of preexisting laboratory changes (24 patients), fatigue (5 patients), vomiting (6 patients), fever (2 patients), right hypochondrial pain (8 patients), and pain at site of femoral catheter insertion (8 patients). Toxicity assessment at weeks 6 and 12 revealed two cases of mild worsening of liver function tests and no lung or hematological toxicity noted. Two patients were lost to follow-up after the 6-week visit. The response was assessed on CECT in all the remaining patients and the classification of results was more standardized when using European Association for the Study of the Liver (EASL) criteria rather than response evaluation criteria in solid tumors (RECIST) criteria. According to EASL criteria, 8 patients had a partial response, 28 patients had a complete response, 4 patients had progressive disease and 4 patients with stable disease were reported. Thirty-six patients had a baseline elevated AFP and on follow-up at 6 weeks, 6 of these patients showed stable AFP, progression in 4 patients and 26 showed a reduction.

CONCLUSION

After the administration of 1.2-3.7 GBq Re-HDD/lipiodol based on empirical activity calculation of 0.8-1.2 mCi/mL of tumor volume, more than half of the patients in the present study had an objective response on imaging and biochemically. No significant adverse side effects were noted and most of the laboratory markers as well as symptoms returned to normal after 48-72 h post-administration. Selective administration of the radiopharmaceutical into the tumor feeding arteries gives a good anti-tumoral effect with minimal side effects and damage to surrounding normal liver tissue.

Novel Prognostic Nomograms for Hepatocellular Carcinoma Patients with Microvascular Invasion: Experience from a Single Center

Background/Aims

Microvascular invasion (MVI) is an established risk factor for hepatocellular carcinoma (HCC). However, prediction models that specifically focus on the individual prognoses of HCC patients with MVI is lacking.

Methods

A total of 385 HCC patients with MVI were randomly assigned to training and validation cohorts in a 2:1 ratio. The outcomes were disease-free survival (DFS) and overall survival (OS). Prognostic nomograms were established based on the results of multivariate analyses. The concordance index (C-index), calibration plots and Kaplan-Meier curves were employed to evaluate the accuracy, calibration and discriminatory ability of the models.

Results

The independent risk factors for both DFS and OS included age, tumor size, tumor number, the presence of gross vascular invasion, and the presence of Glisson’s capsule invasion. The platelet-to-lymphocyte ratio was another risk factor for OS. On the basis of these predictors, two nomograms for DFS and OS were constructed. The C-index values of the nomograms for DFS and OS were 0.712 (95% confidence interval [CI], 0.679 to 0.745; p<0.001) and 0.698 (95% CI, 0.657 to 0.739; p<0.001), respectively, in the training cohort and 0.704 (95% CI, 0.650 to 0.708; p<0.001) and 0.673 (95% CI, 0.607 to 0.739; p<0.001), respectively, in the validation cohort. The calibration curves showed optimal agreement between the predicted and observed survival rates. The Kaplan-Meier curves suggested that these two nomograms had satisfactory discriminatory abilities.

Conclusions

These novel predictive models have satisfactory accuracy and discriminatory abilities in predicting the prognosis of HCC patients with MVI after hepatectomy.

Near-IR emissive rare-earth nanoparticles for guided surgery

Intraoperative image-guided surgery (IGS) has attracted extensive research interests in determination of tumor margins from surrounding normal tissues. Introduction of near infrared (NIR) fluorophores into IGS could significantly improve the in vivo imaging quality thus benefit IGS. Among the reported NIR fluorophores, rare-earth nanoparticles exhibit unparalleled advantages in disease theranostics by taking advantages such as large Stokes shift, sharp emission spectra, and high chemical/photochemical stability. The recent advances in elements doping and morphologies controlling endow the rare-earth nanoparticles with intriguing optical properties, including emission span to NIR-II region and long life-time photoluminescence. Particularly, NIR emissive rare earth nanoparticles hold advantages in reduction of light scattering, photon absorption and autofluorescence, largely improve the performance of nanoparticles in biological and pre-clinical applications. In this review, we systematically compared the benefits of RE nanoparticles with other NIR probes, and summarized the recent advances of NIR emissive RE nanoparticles in bioimaging, photodynamic therapy, drug delivery and NIR fluorescent IGS. The future challenges and promises of NIR emissive RE nanoparticles for IGS were also discussed.

Application of CT radiomics in prediction of early recurrence in hepatocellular carcinoma

PURPOSE

To appraise the ability of the computed tomography (CT) radiomics signature for prediction of early recurrence (ER) in patients with hepatocellular carcinoma (HCC).

METHODS

A set of 325 HCC patients were enrolled in this retrospective study and the whole dataset was divided into 2 cohorts, including "training set" (225 patients) and "test set" (100 patients). All patients who underwent partial hepatectomy were followed up at least within 1 year. 656 Radiomics features were extracted from arterial-phase and portal venous-phase CT images. Lasso regression model was used for data dimension reduction, feature selection, and radiomics signature building. Univariate analysis was used to identify clinical and radiomics significant features. Models (radiomics signature, clinical model, and combined model) were evaluated by area under the curve (AUC) of receiver operating characteristic curve. The models' performances for prediction of ER were assessed.

RESULTS

The radiomics signature was built by 14 selected radiomics features and was significantly associated with ER (P < 0.001); the AUCs of the "train set" and the "test set" were 0.818 (95% CI 0.760-0.865) and 0.719 (95% CI 0.621-0.805), respectively. The tumor size, tumor capsule, and γ-glutamyl transferase (GGT) were significantly associated with ER in the clinical model (P < 0.05). The combined model showed incremental prognostic value, with the AUCs of "training dataset" and "test dataset" were 0.846 (95% CI 0.792-0.890) and 0.737 (95% CI 0.640-0.820), respectively. The radiomics signature, tumor size, and the level of GGT were independent predictors of ER (P < 0.05).

CONCLUSIONS

The CT radiomics signature can be conveniently used to predict the ER in patient with HCC. The combined model performed better for prediction of ER than radiomics signature or clinical model.

Predicting hepatocellular carcinoma recurrences: A data-driven multiclass classification method incorporating latent variables

Hepatocellular carcinoma (HCC), a malignant form of cancer, is frequently treated with surgical resections, which have relatively high recurrence rates. Effective recurrence predictions enable physicians' timely detections and adequate therapeutic measures that can greatly improve patient care and outcomes. Toward that end, predictions of early versus late HCC recurrences should be considered separately to reflect their distinct onset time horizons, clinical causes, underlying clinical etiology, and pathogenesis. We propose a novel Bayesian network-based method to predict different HCC recurrence outcomes by considering the respective recurrence evolution paths. Typical patient information obtained in early stages is insufficiently informative to predict recurrence outcomes accurately, due to the lack of subsequent patient progression information. Our method alleviates such information deficiency constraints by incorporating an independent latent variable, dominant recurrence type, to regulate recurrence outcome predictions (early, late, or no recurrence). We use a real-world HCC data set to evaluate the proposed method, relative to three prevalent benchmark techniques. Overall, the results show that our method consistently and significantly outperforms all the benchmark techniques in terms of accuracy, precision, recall, and F-measures. For increased robustness, we use another data set to perform an out-of-sample evaluation and obtain similar results. This study thus contributes to HCC recurrence research and offers several implications for clinical practice.

Radiation improves antitumor effect of immune checkpoint inhibitor in murine hepatocellular carcinoma model

Background & aims

Although immunotherapy has emerged as an attractive therapy for refractory cancers, its limited efficacy in hepatocellular carcinoma (HCC) suggests the need for a combination strategy that can either enhance or complement therapeutic effect. We investigated whether combination of immune checkpoint blockade (ICB) and radiation could enhance antitumor effect in a murine HCC model.

Methods

Using murine HCC, HCa-1, the effect of radiation on programmed death-ligand1 (PD-L1) expression was determined by real-time PCR, flow cytometry, and western blotting. Signaling pathways involved in altered PD-L1 expression were examined. Tumor growth and survival rate were evaluated for a combination of anti-PD-L1 and radiation. Immunological parameters in the tumor were assessed using flow cytometry and histological study.

Results

Radiation upregulated PD-L1 expression in tumor cells through IFN-γ/STAT3 signaling, which could facilitate therapeutic action of anti-PD-L1. Combination of anti-PD-L1 and radiation significantly suppressed tumor growth compared to treatment with anti-PD-L1 alone or radiation alone group (P<0.01). Survival was significantly improved in the combination group compared to anti-PD-L1 alone or radiation alone group (7-week survival rate; 90% vs. 0% or 30%, respectively, P<0.001). The underlying mechanism involved increasing apoptosis, decreasing tumor cell proliferation, as well as restoration of CD8⁺ T cell functions.

Conclusions

The combination of anti-PD-L1 and radiation significantly improved the antitumor effect shown in tumor growth delay as well as in survival, supporting a novel combination strategy of immunoradiotherapy in HCC.

MicroRNA-125b expression and intrahepatic metastasis are predictors for early recurrence after hepatocellular carcinoma resection

AIM

Early hepatocellular carcinoma (HCC) recurrence after curative resection is a known poor prognostic factor. We aimed to identify microRNAs associated with recurrence after curative HCC resection.

METHODS

To identify risk factors for early recurrence and metastasis, 694 patients who underwent primary curative HCC resection were analyzed. We evaluated microRNA expression in cancerous and non-cancerous tissues by microarray and quantitative PCR analyses using 16 HCC samples. We defined patients who had a recurrence within 1 year of resection as the early recurrence (ER) group, patients who had a recurrence within 1-5 years as the late recurrence (LR) group, and patients who did not recur during the 5-year observation period as the no recurrence (NR) group. We examined the relationship between microRNA expression and clinical features.

RESULTS

Multivariate analysis revealed that α-fetoprotein >31 ng/mL, tumor size >4 cm, and intrahepatic metastasis (IM) were significant factors. Afterwards, microarray analyses revealed that microRNA (miR)-125b-5p and miR-148a-3p were significantly downregulated in recurrent cases. The ratio of miR-125b-5p expression in cancerous versus non-cancerous tissue (miR-125b ratio), but not miR-148a-3p, was significantly lower in the ER group. Early recurrence was associated with reduced overall survival compared with the LR and NR group. The miR-125b ratio was significantly lower in the ER group than in the LR and NR groups. Multivariate analysis showed that a low miR-125b ratio and IM were independently associated with ER and disease-free survival.

CONCLUSIONS

Assessing tissue miR-125b-5p expression and IM is useful for stratifying patients at risk of early HCC recurrence after curative resection.

Clinicopathological Characteristics of Hepatocellular Carcinoma with Microscopic Portal Venous Invasion and the Role of Anatomical Liver Resection in These Cases

BACKGROUND

The aims of this study were to investigate predictive factors for microscopic portal venous invasion (mPVI) in hepatocellular carcinoma (HCC) and whether anatomical liver resection (ALR) was useful in such cases.

METHODS

We analyzed 852 patients with HCC without macroscopic portal venous invasion who were treated at our hospital between January 1990 and May 2014. These patients were stratified into a microscopic portal venous invasion group (mPVI group; n = 153) and non-microscopic portal venous invasion group (NmPVI group; n = 699).

RESULTS

PIVKA-II ≥100 mAU/ml, a tumor size ≥5 cm, a confluent lesion, and poor differentiation were found to be independent risk factors for mPVI. Among the mPVI group who had single HCC under 5 cm, serum albumin level <4.0 g/dl, PIVKA-II ≥100 mAU/ml, a positive surgical margin, and non-ALR (NALR) were independent unfavorable prognostic factors for overall survival (OS). PIVKA-II ≥100 mAU/ml, a positive surgical margin and NALR were independent unfavorable prognostic factors for relapse-free survival (RFS). ALR was significantly favorable factor for both OS and RFS of the mPVI group who had single HCC under 5 cm.

CONCLUSIONS

Even if no portal venous invasion is detectable in HCC patients preoperatively, a PIVKA-II ≥100 mAU/ml, tumor size ≥5 cm, and a confluent lesion indicate a high risk of mPVI. ALR should be considered for the patients with these characteristics because it is a favorable prognostic factor in these cases with mPVI.

Preoperative maximal removal rate of technetium-99m-galactosyl-human serum albumin of the remnant liver is associated with postoperative tumor relapse in hepatitis C virus-related hepatocellular carcinoma

BACKGROUND

Prognosis in patients with hepatocellular carcinoma (HCC) is not only influenced by tumor-related factors but also by the background liver functions. The maximal removal rate of technetium-99m-galactosyl human serum albumin (GSA-Rmax) of the remnant liver (rGSA-Rmax) is a useful candidate for predicting the liver function and clarifying the relationship between the remnant liver functional reserve and tumor-free survival in patients who have undergone hepatectomy.

PATIENTS AND METHODS

One hundred and sixty-five patients with HCC who underwent curative hepatectomy were divided into three groups of hepatitis B virus (B-HCC; n=42), hepatitis C virus (C-HCC, n=58), and non-B, non-C (NBNC-HCC, n=65). The relationship between rGSA-Rmax and survival was examined by univariate and multivariate analyses.

RESULTS

In the C-HCC group, the albumin, or LHL15, level was significantly lower, and alanine aminotransferase, ICGR15, and the prevalence of grade B liver damage were significantly higher than other two groups (P<0.05). GSA-Rmax or rGSA-Rmax was not different between the three groups. Lower GSA-Rmax and rGSA-Rmax were only significantly associated with lower tumor-free survival in the C-HCC group by the univariate analysis (P<0.05) but not significantly by the multivariate analysis.

CONCLUSION

GSA-Rmax and rGSA-Rmax reflect the severity of liver dysfunction and furthermore, the lower rGSA-Rmax is useful as a complementary factor to predict the early HCC recurrence after hepatectomy.

Impact of intraoperative vascular occlusion during liver surgery on long-term outcomes: A systematic review and meta-analysis

OBJECTIVE

To determine the impact of intraoperative vascular occlusion during liver surgery on postoperative long-term outcomes for hepatocellular carcinoma (HCC) patients using a meta-analysis.

METHODS

A systematic literature search of PubMed, EMBASE, and Cochrane Central was conducted to discover relevant randomized controlled trials (RCTs) and observational studies. Studies that reported postoperative long-term outcomes; 1-, 3-, and 5-year overall survival (OS); and/or 1-, 3-, and 5-year recurrence-free survival (RFS) for both an observation group (vascular occlusion) and a control group (vascular non-occlusion) were included. Forest plots were performed to calculate the difference between the 2 groups. The Q statistic and the I² index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test.

RESULTS

Four observational studies containing 2917 patients were included in this meta-analysis. The pooled estimation results indicated that intraoperative vascular occlusion would not shorten the postoperative OS (RR = 1.01; 95%CI: 0.98-1.03; P = 0.763) and would not increase the risk of HCC recurrence (RR = 0.99; 95%CI: 0.97-1.02; P = 0.320) with low heterogeneity (I² = 0.0% and 12.7%, respectively). Furthermore, Egger's test did not reveal any publication bias (P = 0.405 and P = 0.269, respectively) in this research.

CONCLUSIONS

Intraoperative vascular occlusion during liver surgery is safe for HCC patients. It does not affect the postoperative overall survival or increase the risk of HCC recurrence.

Biosynthesized Protein-Capped Silver Nanoparticles Induce ROS-Dependent Proapoptotic Signals and Prosurvival Autophagy in Cancer Cells

In recent years, the use of silver nanoparticles (AgNPs) in biomedical applications has shown an unprecedented boost along with simultaneous expansion of rapid, high-yielding, and sustainable AgNP synthesis methods that can deliver particles with well-defined characteristics. The present study demonstrates the potential of metal-tolerant soil fungal isolate Penicillium shearii AJP05 for the synthesis of protein-capped AgNPs. The particles were characterized using standard techniques, namely, UV-visible spectroscopy, transmission electron microscopy, X-ray diffraction, and Fourier transform infrared spectroscopy. The anticancer activity of the biosynthesized AgNPs was analyzed in two different cell types with varied origin, for example, epithelial (hepatoma) and mesenchymal (osteosarcoma). The biological NPs (bAgNPs) with fungal-derived outer protein coat were found to be more cytotoxic than bare bAgNPs or chemically synthesized AgNPs (cAgNPs). Elucidation of the molecular mechanism revealed that bAgNPs induce cytotoxicity through elevation of reactive oxygen species (ROS) levels and induction of apoptosis. Upregulation of autophagy and activation of JNK signaling were found to act as a prosurvival strategy upon bAgNP treatment, whereas ERK signaling served as a prodeath signal. Interestingly, inhibition of autophagy increased the production of ROS, resulting in enhanced cell death. Finally, bAgNPs were also found to sensitize cells with acquired resistance to cisplatin, providing valuable insights into the therapeutic potential of bAgNPs. To the best of our knowledge, this is the first study that provides a holistic idea about the molecular mechanisms behind the cytotoxic activity of protein-capped AgNPs synthesized using a metal-tolerant soil fungus.

Prediction of Recurrence after HCC Resection

In trying to clarify the high recurrence rate after removal of small hepatocellular carcinoma (HCC), we assessed the postoperative evolution of minute hepatic Lipiodol deposits which had been diagnosed as artifacts on the preoperative Lipiodol-CT. Of 27 patients with solitary HCC less than 5 cm in diameter, 14 had such Lipiodol deposits in the preoperative CT and 9 of them (64%) developed recurrent tumors. On the other hand, 6 of the 13 patients without deposits (46%) suffered recurrence, but in 5 of these 6 patients the HCC was metachronous multicentric. The cumulative survival rate of the non-deposit group was better than that of the deposit group (p < 0.1). The present study suggested that, even in patients with small HCC, minute concomitant tumors invisible by conventional imaging techniques may exist at the time of surgery. Some of these lesions without sufficient tumor vasculature showing a hypervascular blush on angiography appear to retain small, vague Lipiodol deposits.

Multicarotenoids at Physiological Levels Inhibit Metastasis in Human Hepatocarcinoma SK-Hep-1 Cells

Several studies have demonstrated that single carotenoid, including lycopene, β-carotene, and α-carotene, exhibits antimetastatic effects; however, little is known whether multicarotenoids have similar effects. Herein, we investigated the antimetastatic effect of multicarotenoids at physiological serum levels in Taiwanese (MCT at 1.4 μM) and American (MCA at 1.8 μM) populations using human hepatocarcinoma SK-Hep-1 cells in comparison with single carotenoid, such as lycopene (0.3 or 0.6 μM, respectively), α-carotene (0.1 μM), β-carotene (0.4 μM), lutein (0.4 or 0.5 μM, respectively), and β-cryptoxanthin (0.2 μM). Results reveal that MCA treatment exhibited an additive inhibition on invasion, migration and adhesion at 24 and 48 h of incubation, whereas MCT treatment possessed additive inhibition at 48 h of incubation. The antimetastatic action of MCT and MCA involved additive reduction on activities of matrix metalloproteinase (MMP)-2, -9, and protein expression of Rho and Rac 1 but additive promotion on protein expression of tissue inhibitor of MMP (TIMP)-1 and -2. All of these effects were stronger in MCA than in MCT at 24 and 48 h of incubation. These results demonstrate that multi-carotenoids effectively inhibit metastasis of human hepatocarcinoma SK-Hep-1 cells. More in vivo studies are needed to confirm these findings.

Clinicopathological significance of S100A4 expression in human hepatocellular carcinoma

OBJECTIVE

Prognostic markers for hepatocellular carcinoma (HCC) could help in the clinical management and understanding of its poor prognosis. S100 calcium binding protein A4 (S100A4) is directly involved in tumour metastasis. This study evaluated S100A4 gene expression in human HCC, to identify its role in tumour progression.

METHODS

In this retrospective study, S100A4 protein levels in HCC samples from Chinese patients were evaluated using immunohistochemistry and compared with paired normal tumour-adjacent tissue samples (controls). All patients were evaluated for HCC recurrence.

RESULTS

S100A4 levels were significantly increased in HCC samples compared with controls (n = 72, each sample type). Moderately or poorly differentiated tumours had significantly higher levels of S100A4 protein than well-differentiated tumours, and those with tumour vascular invasion showed significantly higher S100A4 levels than those without invasion. Risk of recurrence increased in patients positive for S100A4, and S100A4 positivity correlated with a shorter overall survival time.

CONCLUSION

This pilot study suggests S100A4 as a likely tumour marker for HCC that correlates with tumour differentiation, invasion, recurrence and overall survival. S100A4 could be a useful marker of tumour aggressiveness and prognosis.

Significant impact of patient age on outcome after liver resection for HCC in cirrhosis

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The majority of patients with HCC have cirrhosis. Beside liver transplantation the resection is an established curative treatment option for patients with HCC in cirrhosis. However, the long term success is limited by a high tumor recurrence rate. Furthermore, by many patients surgical resection is restricted by poor liver function. The purpose of this study was to investigate the influence of patient age on long term outcome after liver resection in patients with HCC in cirrhotic liver. Further purpose was to define the potential prognostic factors.

PATIENTS AND METHODS

The outcome of 141 patients with liver cirrhosis after curative resection was analyzed using a prospective database. Only patients with postoperative histological assurance of HCC were included in the database. Patients with fibrolamellar HCC were excluded.

RESULTS

By patients below 70 years of age the 1-, 3- and 5-year survival rates were 78.5%, 56.5% and 47.1%. By patients over 70 years the 1-, 3- and 5-year survival rates were 59.9%, 40.3% and 6.7%. Cumulative survival of the total collective was significant influenced by patient age, Clavien grade, positive lymph vessels, mechanical ventilation and BMI. The overall postoperative morbidity was 44.7%. No intraoperative deaths were observed, but 11 patients (8 older than 70 and 3 younger than 70 years) died during the hospital stay. Clavien grade correlated with preoperative increased GGT, need for intraoperative blood and fresh frozen plasma transfusion.

CONCLUSIONS

Patient age and postoperative complications are more relevant for the outcome than many tumor factors, especially by patients over 70 years of age. In contrast, the prognosis of patients below 70 years of age is significantly better and a 5 year survival rate above 50% could be shown in our patients. However, by carefully selected elderly patients with HCC in cirrhosis an acceptable long term survival is reachable.

A survival benefit of major hepatectomy for hepatocellular carcinoma identified by preoperative [18F] fluorodeoxyglucose positron emission tomography in patients with well-preserved hepatic function

AIMS

Hepatic resection can cure hepatocellular carcinoma (HCC). However, the optimal extent of resection remains controversial. Major hepatectomy could minimize a tumor recurrence, but it is harmful due to decreased hepatic functional reserve. [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scans are known as their reflection tumor differentiation and biological activity in HCC. To evaluate a benefit of major hepatectomy for HCC, we performed this retrospective analysis in patients with well-preserved hepatic function, and further analyzed in the subset identified by preoperative FDG-PET.

METHODS

We reviewed the medical records of 189 patients with HCC who underwent curative resection between August 2004 and December 2010 at two institutes. All patients underwent anatomical resection, either by major or minor hepatectomy.

RESULTS

Median overall survival did not differ significantly between the major and minor hepatectomy groups (29.4 versus 26.3 months, p = 0.269). However, the major hepatectomy group had a better recurrence-free survival (24.5 versus 19.9 months, p = 0.004). On multivariate analysis, the presence of intrahepatic metastasis independently predicted overall survival (p = 0.009), but other examined variables did not. Overall survival and recurrence-free survival were significantly better following major hepatectomy rather than minor hepatectomy in patients whose preoperative FDG-PET indicated that the maximum standardized uptake value of the tumor (SUVtumor) was ≥4 and the tumor-to-nontumor SUV ratio (TNR) was ≥1.5.

CONCLUSIONS

Our findings suggest that preoperative FDG-PET may be useful in identifying patients with favorable hepatic reserve who are most likely to benefit from major rather than minor hepatectomy.

Cortactin is a sensitive biomarker relative to the poor prognosis of human hepatocellular carcinoma

BACKGROUND

Cortactin is an important regulator involved in invasion and migration of hepatocellular carcinoma (HCC). The aim of this study was to elucidate the forecasting role of cortactin in resectable HCCs.

METHODS

We compared the invasiveness and motility among liver epithelial cell line and HCC cell lines by using Transwell assay and wound healing assay. We further investigated the CTTN mRNA expression by real-time PCR. Next, 91 HCC and 20 normal liver tissue samples were detected by IHC and real-time PCR. Finally, we analyzed the clinicopathologic features and survival time of the HCC cases.

RESULTS

We identified that HepG2, LM3, and SK-Hep-1 had more invasiveness and motility (P <0.05). Compared with liver epithelial cell line, CTTN expression was higher in LM3, HepG2, and MHCC97-L (P <0.01) and lower in SK-Hep-1 (P <0.05). IHC examination showed cortactin expression was closely relative to TNM stage (AJCC/UICC), cancer embolus, and metastasis (P <0.01). Cortactin overexpression indicated a longer survival time of 52 ± 8.62 months and low expression of a shorter survival time of 20 ± 4.95 months (P <0.01). Cortactin examination has more predictive power in patients with Child-Pugh grade A and BCLC stage 0-B.

CONCLUSIONS

Overexpression of cortactin is closely associated with poor human HCCs prognosis that caused by cancer embolus and metastasis. Cortactin and CTTN should be used for differentiating varieties of survival for patients after HCC resection.

Solitary mediastinal metastasis of hepatocellular carcinoma treated by video-assisted thoracic surgery: report of a case

Solitary mediastinal metastasis of hepatocellular carcinoma (HCC) is extremely rare. We report a case of solitary mediastinal metastasis arising from HCC treated by video-assisted thoracic surgery (VATS). A 75-year-old man underwent hepatic resection and transcatheter arterial embolization for HCC. The level of protein induced by vitamin K antagonist was subsequently found to be elevated. Computed tomography showed a 2-cm mediastinal tumor. (18)F-fluorodeoxy-glucose positron emission tomography revealed slight uptake by the tumor. VATS was performed. The histopathological diagnosis was metastatic HCC of the lymph nodes. The postoperative course was uneventful, with a postoperative hospital stay of 6 days. There has been no recurrence at 4 months after surgery. VATS is a minimally invasive and useful treatment for solitary mediastinal metastasis of HCC.

Antisense oligonucleotide against clusterin regulates human hepatocellular carcinoma invasion through transcriptional regulation of matrix metalloproteinase-2 and E-cadherin

Secreted clusterin (sCLU) has been shown to be overexpressed in metastatic hepatocellular carcinoma (HCC) tissue, and its overexpression in HCC cells increases cell migration and the formation of liver metastatic tumor nodules in vivo. In this study, we tested the hypothesis that sCLU plays a role in the invasiveness of human HCC and may be associated with its metastatic spread. HCCLM3, a human hepatocellular carcinoma cell line, was transiently transfected with an antisense oligonucleotide (ASO) against sCLU (OGX-011). HepG2 liver hepatocellular cells were transiently transfected with the pc.DNA3.1-sCLU plasmid to overexpress sCLU, and subsequently evaluated for effects on invasion and the expression of molecules involved in invasion. We observed that suppression of the sCLU gene significantly reduced the invasive capability of the highly invasive HCCLM3 cells, and vice versa in the low invasive HepG2 cell line. The results revealed that knockdown of sCLU by OGX-011 resulted in a significant increase in the expression of E-cadherin and a decrease in matrix metalloproteinase-2 (MMP-2) gene transcription. Overexpression of sCLU by transfection with pc.DNA3.1-sCLU significantly decreased the expression of E-cadherin and increased MMP-2 gene transcription. These data were further verified by reverse transcription-PCR and Western blot analysis. A significant reduction in MMP-2 expression and an increase in E-cadherin expression in sCLU-knockdown HCCLM3 cells were observed, as well as a significant increase in MMP-2 expression and a decrease in E-cadherin expression in HepG2 cells overexpressing sCLU. These data indicate a role for sCLU in augmenting MMP-2 transcription and decreasing E-cadherin expression. Our data show the involvement of sCLU in human HCC invasion, and demonstrate that silencing sCLU gene expression inhibits the invasion of human HCC cells by inhibiting MMP-2 expression and promoting E-cadherin expression. Thus, OGX-011 could be an effective therapeutic agent for HCC.

The scent fingerprint of hepatocarcinoma: in-vitro metastasis prediction with volatile organic compounds (VOCs)

BACKGROUND

Hepatocellular carcinoma (HCC) is a common and aggressive form of cancer. Due to a high rate of postoperative recurrence, the prognosis for HCC is poor. Subclinical metastasis is the major cause of tumor recurrence and patient mortality. Currently, there is no reliable prognostic method of invasion.

AIM

To investigate the feasibility of fingerprints of volatile organic compounds (VOCs) for the in-vitro prediction of metastasis.

METHODS

Headspace gases were collected from 36 cell cultures (HCC with high and low metastatic potential and normal cells) and analyzed using nanomaterial-based sensors. Predictive models were built by employing discriminant factor analysis pattern recognition, and the classification success was determined using leave-one-out cross-validation. The chemical composition of each headspace sample was studied using gas chromatography coupled with mass spectrometry (GC-MS).

RESULTS

Excellent discrimination was achieved using the nanomaterial-based sensors between (i) all HCC and normal controls; (ii) low metastatic HCC and normal controls; (iii) high metastatic HCC and normal controls; and (iv) high and low HCC. Several HCC-related VOCs that could be associated with biochemical cellular processes were identified through GC-MS analysis.

CONCLUSION

The presented results constitute a proof-of-concept for the in-vitro prediction of the metastatic potential of HCC from VOC fingerprints using nanotechnology. Further studies on a larger number of more diverse cell cultures are needed to evaluate the robustness of the VOC patterns. These findings could benefit the development of a fast and potentially inexpensive laboratory test for subclinical HCC metastasis.

The role of preoperative [18F]fluorodeoxyglucose positron emission tomography in predicting early recurrence after curative resection of hepatocellular carcinomas

PURPOSE

(18)F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) scan reflects tumor differentiation and predicts clinical outcome in patients with hepatocellular carcinoma (HCC). We investigated the correlation of PET scans with tumor differentiation and early tumor recurrence (time-to-recurrence <1 year).

METHODS

We reviewed the medical records of 93 patients with HCC who underwent curative resection at our hospital from August 2004 through December 2008. PET scans were performed preoperatively, and the maximum standardized uptake value of the tumor (SUV(tumor)) and the tumor-to-non-tumor SUV ratio (TNR) were calculated from FDG uptake.

RESULTS

Twenty-six (27.9%) had recurrences and 12 of them (46.2%) had early recurrences. SUV(tumor) and TNR correlated strongly with tumor differentiation (p < 0.001). Early recurrence-free and the overall survival rates in the low TNR group (TNR <2.0) were higher than in the high TNR group (TNR ≥2.0) (p = 0.015, p = 0.013). According to univariate analysis, predictors of early tumor recurrence were large tumor size (≥5 cm), high TNR (≥2), high SUV(tumor) (≥4), and high Edmoson-Steiner grade. However, on multivariate analysis, none of the examined factors were statistically significant independent predictor.

CONCLUSION

PET scans reflect tumor differentiation in HCCs. Because high TNR (TNR ≥2) and SUV(tumor) (SUV ≥4) were these cutoff point significant predictors in univariate analysis, future studies with more statistical power are needed to assess the significance.

Hepatitis B virus infection: A favorable prognostic factor for intrahepatic cholangiocarcinoma after resection

AIM: To study the prognostic factors for intrahepatic cholangiocarcinoma (ICC) and evaluate the impact of chronic hepatitis B virus (HBV) infection on survival rate of ICC patients.

METHODS: A total of 155 ICC patients who underwent macroscopic curative resections (R0 and R1) were enrolled in this retrospective study and divided into group A with HBV infection and group B without HBV infection according to their chronic HBV infection, represented by positive hepatitis B surface antigen (HBsAg) in serum or in liver tissue. Clinicopathological characteristics and survival rate of the patients were evaluated.

RESULTS: All patients underwent anatomical resection. Their 1- and 3-year survival rates were 60.6% and 32.1%, respectively. Multivariate analyses revealed that HBV infection, hepatolithiasis, microscopic satellite lesion, and lymphatic metastasis were the independent prognostic factors for the survival rate of ICC patients. The median disease-free survival time of the patients was 5.0 mo. The number of tumors, microscopic satellite lesion, and vascular invasion were the independent prognostic factors for the disease-free survival rate of the patients. The prognostic factors affecting the survival rate of ICC patients with HBV infection and those without HBV infection were not completely consistent. Alkaline phosphatase > 119 U/L, microscopic satellite lesion, vascular invasion, and lymphatic metastasis were the independent factors for the patients with HBV infection, while r-glutamyltransferase > 64 U/L, microscopic satellite lesion, and poor tumor differentiation were the independent factors for the patients without HBV infection.

CONCLUSION: HBV infection is a valuable clinical factor for predicting tumor invasiveness and clinical outcome of ICC patients. ICC patients with HBV infection should be distinguished from those without HBV infection because they have different clinicopathological characteristics, prognostic factors and outcomes after surgical resection.

Clinicopathological significance of nuclear factor-κB activation in hepatocellular carcinoma

AIM

  Nuclear factor-κB (NF-κB) is a critical signaling mediator in inflammation, apoptosis resistance and oncogenesis. It has been reported that NF-κB is activated in several cancers, including hepatocellular carcinoma (HCC). Studies of genetic disruptions in mice also suggest that NF-κB plays critical roles in hepatocarcinogenesis. The aim of the present study is to characterize NF-κB activation and correlate it with the degree of malignancy in HCC.

METHODS

  To examine the correlation between the positivity of the nuclear p50 subunit and HCC recurrence, we analyzed immunostaining of the NF-κB p50 subunit in two groups of HCC samples with known prognosis and Akt phosphorylation status: 49 patients showing early recurrence within 6 months (group A) and 50 patients who were recurrence-free for at least for 3 years (group B).

RESULTS

  In group A, positive nuclear staining of p50 was shown in 18 cases (36.7%), whereas only one case (2.0%) in group B had positive nuclear staining of p50 (P = 2.48839 × 10(-5) ). This suggests a positive relationship between nuclear p50 and early recurrence and advanced HCC in humans. The presence of phosphorylated Akt correlated with nuclear staining of p50 in HCCs in group A (R(2)  = 0.213, P < 0.001).

CONCLUSION

  Our results indicate that nuclear staining of p50 was clearly associated with early recurrent HCC, and the Akt pathway might play a role in NF-κB activation in a subset of early recurrent HCC.

Risk factors, prognosis, and management of early and late intrahepatic recurrence after resection of primary clear cell carcinoma of the liver

BACKGROUND

Primary clear cell carcinoma of the liver (PCCCL) is an uncommon variant of hepatocellular carcinoma (HCC). The prognostic factors influencing its recurrence and survival are not clarified. This study is to evaluate the predictive factors, the therapy, and prognosis of intrahepatic recurrences after resection of PCCCL.

METHODS

A total of 214 PCCCL patients treated by curative resection from January 1996 to March 2006 were retrospectively analyzed. Intrahepatic recurrences were classified into early (≤1 year) and late (>1 year) recurrences.

RESULTS

The 1-, 3-, and 5-year overall survival (OS) rates for PCCCL patients were significantly better than those of HCC patients (P = .001). Serum a-fetoprotein (AFP) level, tumor size, liver cirrhosis, and vascular invasion were independent risk factors for both OS and disease-free survival (DFS) of PCCCL. Early and late intrahepatic recurrences developed in 28 patients and 71 patients, respectively. In multivariate analysis, ALT level and vascular invasion were independent risk factors for early recurrence, whereas age was the only significant risk factor for late recurrence. OS of late-recurrence group was significantly better than that of early-recurrence group (P = .001), and re-resection rate was higher in late than in early-recurrence group (P = .04). The 1-, 3-, and 5-year OS of patients with recurrence who received curative treatment was comparable to those who never had tumor recur (P = .71).

CONCLUSION

PCCCL has a better prognosis and tends to recur later than HCC. Early and late recurrences of PCCCL are linked to different predictive factors. The time to recurrence and feasibility of curative treatment are the best determinants for the prognosis.

Osteopontin expression predicts overall survival after liver transplantation for hepatocellular carcinoma in patients beyond the Milan criteria

BACKGROUND & AIMS

Microarray data showed that osteopontin overexpression predicts early HCC-recurrence after liver resection. Osteopontin (OPN) expression could serve as a predictor of HCC-recurrence after OLT.

METHODS

Osteopontin expression was investigated immunohistochemically in a unique population of 125 HCC-patients undergoing OLT between 1982 and 2002, including 81 patients (65%) outside the Milan criteria. Multivariate analysis of factors associated with median overall survival (OS) and time to recurrence (TTR) was performed.

RESULTS

Osteopontin was expressed in 40/125 (32%) of the HCCs. Overall survival post-OLT at 1, 2, 3, 5 years was 77%, 62%, 52%, and 43% (median survival 37 months). Overall survival was significantly longer without expression of OPN (p < 0.05; (median OS: 56 vs. 23 months). The same was true for median TTR (p = 0.008). Outside Milan criteria, patients without OPN-expression had better prognosis (median OS: 37.8 vs. 19.2 months, p = 0.003). Tumor recurrence in patients transplanted outside Milan criteria occurred in 43% (23 of 54) of patients without and 70% (19 of 27, p = 0.018) of patients with OPN-expression after a median TTR of 83.5 vs. 13.9 months. On multivariate analysis, vascular invasion and OPN-expression were independently associated with OS and TTR in HCC-patients after OLT.

CONCLUSIONS

Immunohistochemically detectable Osteopontin in HCC is an independent predictor of tumor recurrence and survival in patients beyond Milan criteria undergoing OLT.

High expression of H3K27me3 in human hepatocellular carcinomas correlates closely with vascular invasion and predicts worse prognosis in patients

It has been suggested that trimethylation of lysine 27 on histone H3 (H3K27me3) is a crucial epigenetic process in tumorigenesis. However, the expression dynamics of H3K27me3 and its clinicopathological/prognostic significance in hepatocellular carcinoma (HCC) are unclear. In this study, immunohistochemical analysis (IHC) was used to examine protein expression of H3K27me3 in HCC tissues from two independent cohorts and corresponding nontumorous hepatocellular tissues by tissue microarray. The optimal cutpoint of H3K27me3 expression was assessed by the X-tile program. Our results showed that the cutpoint for high expression of H3K27me3 in HCCs was determined when more than 70% of the tumor cells showed positive staining. High expression of H3K27me3 was observed in 134 of 212 (63.2%) and 76 of 126 (60.4%) of HCCs in the testing and validation cohorts, respectively. Correlation analysis demonstrated that high expression of H3K27me3 in HCCs was significantly correlated with large tumor size, multiplicity, poor differentiation, advanced clinical stage and vascular invasion (P < 0.05). In addition, high expression of H3K27me3 in HCC patients was associated closely with shortened survival time, independent of serum α-fetoprotein levels, tumor size and multiplicity, clinical stage, vascular invasion and relapse as evidenced by univariate and multivariate analysis in both cohorts (P < 0.05). In different subsets of HCC patients, H3K27me3 expression was also a prognostic indicator in patients with stage II tumors (P < 0.05). Thus, these findings provide evidence that a high expression of H3K27me3, as detected by IHC, correlates closely with vascular invasion of HCCs and is an independent molecular marker for poor prognosis in patients with HCC.

Reduced transforming growth factor-beta receptor II expression in hepatocellular carcinoma correlates with intrahepatic metastasis

Hepatocellular carcinoma (HCC) occurs mainly in the liver associated with chronic hepatitis and hepatic cirrhosis as a result of prolonged viral infection. Transforming growth factor-beta (TGF-beta) induces the fibrosis in hepatic cirrhosis, although it is also an inhibitor of hepatocyte proliferation. To understand the role of TGF-beta signaling in HCC progression, we analyzed gene expression in HCC cells in relation to TGF-beta signaling using a two-way clustering algorithm. By the analysis, five HCC cell lines were classified into two groups according to their metastatic capacity. TGF-beta receptor II (TGFBR2) was downregulated in metastatic cells, which did not show a response to TGF-beta. Immunohistochemistry demonstrated clear membrane distribution of TGFBR2 in noncancerous hepatocytes, whereas reduced TGFBR2 expression was observed in 34 of 136 HCCs. In clinical cases, reduced TGFBR2 expression correlated with larger tumor size (P<0.001), poor differentiation (P<0.001), portal vein invasion (P=0.002), intrahepatic metastasis (IM) (P<0.001), and shorter recurrence-free survival (P=0.022). In conclusion, reduced TGFBR2 expression was associated with aggressive features of HCC such as IM, and may represent an immunohistochemical biomarker to detect aggressive HCC.

Keratin 19 marks poor differentiation and a more aggressive behaviour in canine and human hepatocellular tumours

Background

The expression of Keratin 19 (K19) was reported in a subset of hepatocellular carcinomas (HCCs). K19 positive HCCs are associated with an increased malignancy compared to K19 negative HCCs. No suitable mouse models exist for this subtype of HCC, nor is the incidence of K19 expression in hepatocellular neoplasia in model animals known. Therefore, we compared the occurrence and tumour behaviour of K19 positive hepatocellular neoplasias in dog and man.

Results

The expression of hepatocellular differentiation (HepPar-1), biliary/progenitor cell (K7, K19), and malignancy (glypican-3) markers was semi-quantitatively assessed by immunohistochemistry. The histological grade of tumour differentiation was determined according to a modified classification of Edmondson and Steiner; the staging included intrahepatic, lymph node or distant metastases. Four of the 34 canine hepatocellular neoplasias showed K19 positivity (12%), of which two co-expressed K7. K19 positive tumours did not express HepPar-1, despite the histological evidence of a hepatocellular origin. Like in human HCC, all K19 positive hepatocellular neoplasias were glypican-3 positive and histologically poorly differentiated and revealed intra- or extrahepatic metastases whereas K19 negative hepatocellular neoplasias did not.

Conclusions

K19 positive hepatocellular neoplasias are highly comparable to man and occur in 12% of canine hepatocellular tumours and are associated with a poorly differentiated histology and aggressive tumour behaviour.

Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection

BACKGROUND

In perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma.

METHODS

The subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival.

RESULTS

In multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death.

CONCLUSION

Transfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.

Role of overexpression of CD151 and/or c-Met in predicting prognosis of hepatocellular carcinoma

It has been reported that tetraspanin CD151 acts as a promoter of metastasis in several tumors and plays an important role in c-Met/hepatocyte growth factor signaling. However, the role of CD151 alone and coexpression of CD151/c-Met in hepatocellular carcinoma (HCC) remains unclear. We found that expression of CD151 was positively related to metastatic potential of HCC cell lines, and modified cells with CD151(high) showed higher secretion of matrix metalloproteinase 9 and aggressiveness in vitro and higher metastatic ability in vivo. Furthermore, HCC patients with vascular invasion, large tumors, multiple tumors, high tumor-node-metastasis stage, and undifferentiated tumor were prone to have higher CD151 expression. The postoperative 3-, 5-, and 7-year overall survival (OS) of patients in HCCs with CD151(high) were significantly lower than those in the CD151(low) group, and correspondingly cumulative recurrence rates in HCCs with CD151(high) were significantly higher than those in the CD151(low) group. Both CD151 and c-Met were remarkably overexpressed in HCCs, compared with adjacent nontumorous and normal liver tissues. Pearson correlation analysis showed a slight correlation between CD151 and c-Met in HCCs. Importantly, the 5- and 7-year OS rates in CD151(high)/c-Met(high) patients were 50.5% and 37.8%, respectively, significantly lower than those of CD151(low)/c-Met(low) patients (63.9% and 54.6%, respectively). Five- and 7-year cumulative recurrence rates in CD151(high)/c-Met(high) patients were 53.3% and 71.9%, respectively, markedly higher than those of CD151(low)/c-Met(low) patients (39.0% and 52.5%, respectively). Multivariate analysis revealed that CD151 and combination of CD151/c-Met were independent prognostic indicators for OS and cumulative recurrence.

CONCLUSION

CD151 is positively associated with invasiveness of HCC, and CD151 or combination of CD151/c-Met is a novel marker in predicting the prognosis of HCC and a potential therapeutic target.

Risk factors and outcome of early recurrence after resection of small hepatocellular carcinomas

BACKGROUND

This study aimed to clarify risk factors for early recurrence and examine the subsequent outcome in patients undergoing potentially R0 resection of small hepatocellular carcinomas (HCCs) (<or=2 cm in greatest dimension).

METHODS

Eighty-nine patients were divided into 2 groups as follows: 26 patients suffering from recurrence within 2 years of surgery (early recurrence group) and 63 patients who were disease-free for at least 2 years (disease-free 2Y group).

RESULTS

Only 7 of 63 patients (11%) from the group that was disease-free for at least 2 years died during the 5-year period after surgery, whereas 13 of 26 patients (50%) from the early recurrence group died. Multivariate analysis showed that the preoperative maximum removal rate of technetium-99m-diethylenetriamine pentaacetic acid-galactosyl human serum albumin and microscopic vascular invasion were independent predictors of the early recurrence of small HCC.

CONCLUSIONS

Early recurrence of small HCC is the leading cause of death within 5 years after R0 resection. The preoperative hepatic functional reserve influences early recurrence, even in patients with small tumors.

Response to interferon therapy affects risk factors for postoperative recurrence of hepatitis C virus-related hepatocellular carcinoma

BACKGROUND

Interferon therapy might reduce recurrence after resection of hepatitis C virus-related hepatocellular carcinoma, especially among sustained virologic or biochemical responders.

METHODS

Of 209 patients who underwent curative resection for early-stage hepatitis C virus related hepatocellular carcinoma, 70 patients underwent interferon therapy. A sustained virologic or biochemical response was achieved in 40 patients (SVR/BR group). Thirty no responders and 139 patients who had not received interferon therapy were classified as the NR/non-IFN group. Risk factors for postoperative recurrence in each group were analyzed.

RESULTS

The tumor-free survival rates in the SVR/BR group were significantly higher than those in the NR/non-IFN group. By multivariate analysis, the presence of multiple tumors was independently associated with recurrence after resection in both groups, while histologic evidence of cirrhosis was another independent risk factor for postoperative recurrence in the NR/non-IFN group.

CONCLUSIONS

Newly multicentric carcinogenesis after resection could be suppressed when active hepatitis is controlled by interferon therapy. Patients with single hepatitis C virus related hepatocellular carcinoma detected after successful interferon therapy are good candidates for surgical resection. Adjuvant interferon therapy might be indicated for patients who undergo curative resection for single hepatocellular carcinoma associated with hepatitis C.

Orthotopic liver transplantation as a rescue operation for recurrent hepatocellular carcinoma after partial hepatectomy

AIM

To compare post-orthotopic liver transplantation (OLT) survival between patients with recurrent hepatocellular carcinoma (HCC) after partial hepatectomy and those who received de novo OLT for HCC and to assess the risk factors associated with post-OLT mortality.

METHODS

From July 2003 to August 2005, 77 consecutive HCC patients underwent OLT, including 15 patients with recurrent HCC after partial hepatectomy for tumor resection (the rescue OLT group) and 62 patients with de novo OLT for HCC (the de novo OLT group). Thirty-three demographic, clinical, histological, laboratory, intra-operative and post-operative variables were analyzed. Survival was calculated by the Kaplan-Meier method. Univariable and multivariable analyses were also performed.

RESULTS

The median age of the patients was 49.0 years. The median follow-up was 20 mo. Three patients (20.0%) in the rescue OLT group and 15 patients (24.2%) in the de novo OLT group died during the follow-up period (P = 0.73). The 30-day mortality of OLT was 6.7% for the rescue OLT group vs 1.6% for the de novo OLT group (P = 0.27). Cox proportional hazards model showed that pre-OLT hyperbilirubinemia, the requirement of post-OLT transfusion, the size of the tumor, and family history of HCC were significantly associated with a higher hazard for mortality.

CONCLUSION

There are no significant differences in survival/mortality rates between OLT as de novo therapy and OLT as a rescue therapy for patients with hcc. Pre-OLT hyperbilirubinemia, post-OLT requirement of transfusion, large tumor size and family history of HCC are associated with a poor survival outcome.

Laparoscopy-assisted hepatectomy for giant hepatocellular carcinoma

The indications for laparoscopic hepatectomy were limited; generally, tumors smaller than 5 cm serve as proper indications. Here, we initially report on a patient with huge hepatocellular carcinoma (HCC) sized 15 cm in the left lateral segment who was treated by laparoscopy-assisted technique.

SURGICAL TECHNIQUE

3 trocars were inserted under pneumoperitoneum. The attached ligament was divided and mobilization of the liver could be performed with laparoscopic coagulating system. In accomplishing this maneuver, upper median skin incision of 7 cm was made. The left lateral segment was exposed to be lifted up the tape around the liver. Dissecting sealer (DS30) was used for transection of the liver parenchyma. The relatively large branched vessels and ducts were ligated and transected by direct view from upper median 7-cm incision. Segment 2 and 3 Glisson's sheaths and left hepatic vein were divided using an endolinear stapler. A Hand Port system laparotomy device was installed under pneumoperitoneum, the resected liver maneuvered into a suitable sized plastic bag by endoscopic view. Extraction of the undivided specimen was performed, thus enabling histologic review. Operation time was 170 minutes and operative blood loss was 100 g. The tumor was a 15x12x9 cm in size. Oral intake and ambulation was on the first day; 7 days after the surgery patient was discharged with an uneventful postoperative course. Because of the specific characteristics of HCCs such as their high recurrence rate, the most important goals in HCC treatment are curability and minimal invasiveness. Laparoscopic hepatectomy in this case is beneficial for the patients' quality of life as a minimally invasive operation.

Clinicopathologic features of hepatocellular carcinoma patients with compensated cirrhosis surviving more than 10 years after curative hepatectomy

BACKGROUND

The aim of this study was to clarify the clinicopathologic features of hepatocellular carcinoma (HCC) patients with compensated cirrhosis surviving more than 10 years after initial hepatectomy.

STUDY DESIGN

Among 250 patients who underwent hepatectomy for HCC between 1987 and 1994 at our institute, 145 patients who had Child-Pugh class A liver function and who underwent curative resection were included in this study. Clinicopathologic factors in 10-year survivors and patients who died within 10 years (nonsurvivors) were compared, and the prognostic factors affecting survival were identified.

RESULTS

There were 29 patients who survived for more than 10 years after initial hepatectomy, and 9 of those patients survived without cancer recurrence. The 3-, 5-, and 10-year survival rates were 76.2%, 53.0%, and 26.9% respectively. The corresponding disease-free survival rates were 43.1%, 25.7%, and 9.9% respectively. In multivariate analysis, liver fibrosis grade F0-2, female gender, ICG-R15 value of less than 15%, and absence of microscopic vascular invasion were favorable independent factors associated with 10-year survival. Disease-free interval after initial hepatectomy in 10-year survivors with recurrence was significantly longer than that in nonsurvivors with recurrence, 5.1 and 1.9 years respectively (P = 0.0004). The number of intrahepatic recurrent nodules in 10-year survivors tended to be fewer than that in nonsurvivors.

CONCLUSIONS

Based on the results of our study, liver fibrosis grade F0-2, female gender, ICG-R15 value of less than 15% and absence of microscopic vascular invasion at initial hepatectomy might be biologically favorable conditions for long-term survival. Close follow-up as well as multimodal treatment could contribute to prolongation of survival in such patients, even if HCC recurrence develops.

Protein expression associated with early intrahepatic recurrence of hepatocellular carcinoma after curative surgery

The poor prognosis of patients with hepatocellular carcinoma (HCC) is attributed to intrahepatic recurrence. To understand the molecular background of early intrahepatic recurrence, we conducted a global protein expression study. We compared the protein expression profiles of the primary HCC tissues of 12 patients who showed intrahepatic recurrence within 6 months post surgery with those of 15 patients who had no recurrence 2 years post surgery. Two-dimensional difference gel electrophoresis identified 23 protein spots, the intensity of which was highly associated with early intrahepatic recurrence. To validate the prediction performance of the identified proteins, we examined additional HCC tissues from 13 HCC patients; six with early intrahepatic recurrence and seven without recurrence. We found that all but one of the 13 patients were grouped according to their recurrence status based on the intensity of the 23 protein spots. Mass spectrometry identified 23 proteins corresponding to the spots. Although 13 of 23 have been previously reported to be correlated with HCC, their association with early intrahepatic recurrence had not been established. The identified proteins are involved in signal transduction pathways, glucose metabolism, cytoskeletal structure, cell adhesion, or function as antioxidants and chaperones. The identified proteins may be candidates for prognostic markers and contribute to the improvement of existing therapeutic strategies.

Anatomic wide hepatectomy for treatment of hepatocellular carcinoma

PURPOSE

We aimed to clarify the prognostic impact of the anatomic extent of hepatic resection (Hr) related to the tumor hepatic involvement (H) on patients' survival in the treatment of hepatocellular carcinoma (HCC).

METHOD

The 305 patients with HCC who had undergone hepatectomy were analyzed retrospectively. The patients were classified into the anatomic wide hepatectomy (Hr > H hepatectomy, i.e. Hr was larger than H, n = 93) group and the other hepatectomies (Hr < or = H hepatectomy, i.e. Hr was equal to or smaller than H, n = 212) group. We compared the clinico-pathologic features between the two hepatectomy groups and the prognostic factors associated with postoperative HCC recurrence by using the Cox's proportional hazard model.

RESULTS

After median follow-up duration of 50 months (range 1-223 months), in Hr > H and Hr < or = H hepatectomy groups, the cumulative 3, 5, 10 year disease-free survival rates were 58.1, 44.6, 27.1% and 49.2, 33.0, 14.6%, respectively (P = 0.043). The overall survival was not significantly different between the groups (P = 0.401). Multivariate analysis revealed that Hr > H hepatectomy was an independent favorable factor for disease-free survival: the relative risk was 0.64 (95% confidence interval, 0.43-0.95; P = 0.026).

CONCLUSION

Anatomic wide (Hr > H) hepatectomy is a favorable procedure of choice in HCC for possibly reducing the risk of postoperative recurrence.

Loss of claudin-1 expression correlates with malignancy of hepatocellular carcinoma

BACKGROUND

The prognosis for the hepatocellular carcinoma (HCC) patient is affected by invasion and metastases. The attenuated expression of adherens junction protein epithelial-cadherin (E-cad) correlates with a more malignant potential in HCC. However, the potential of the claudin (CL) family of tight junctional proteins for HCC prognosis has remained unrecognized.

MATERIALS AND METHODS

We immunohistochemically examined the expression of CL-1 and E-cad in resected specimens from 55 HCC cases. The percentage of CL-1- or E-cad-positive cells was counted in HCC cells and the surrounding hepatocytes and scored as 0 (0%), 1 (1-33%), 2 (34-66%), and 3 (67-100%). The expression of CL-1 or E-cad was considered "preserved" if the score in HCC was equal to or more than that in the surrounding hepatocytes, and "attenuated" if not so.

RESULTS

In nontumorous tissue, CL-1 and E-cad were observed at the lateral surface of hepatocytes and biliary epithelial cells. In well-differentiated HCCs, the expression of CL-1 and E-cad was preserved in 12 of 14 cases. In poorly differentiated HCCs, E-cad expression was preserved in 9 of 18 cases, while CL-1 expression was preserved in only 4 cases (P<0.01 versus well-differentiated HCCs). HCCs with portal invasion showed significantly attenuated CL-1 expression than those without portal invasion (P<0.05). The survival rate after hepatectomy for HCC with attenuated CL-1 expression was significantly lower than that for HCC with preserved CL-1 expression.

CONCLUSIONS

Attenuated expression of CL-1 closely correlates with the dedifferentiation and portal invasion of HCC. Down-regulated CL-1 expression may serve as a potential marker for a poor prognosis in HCC.

Analysis of risk factors associated with early multinodular recurrences after hepatic resection for hepatocellular carcinoma

BACKGROUND

Sometimes patients experience an unexpected fulminant recurrence after partial hepatic resection for the treatment of hepatocellular carcinoma, and this carries a dismal prognosis. We conducted this retrospective study to investigate the risk factors of early multinodular (ie, 10 nodules within 6 months of surgery) recurrence in hepatocellular carcinoma.

METHODS

The study population consisted of 409 patients who underwent curative hepatic resection between January 2000 and April 2003. Patients were divided into 3 groups: nodular (<10 nodules) recurrence, multinodular (> or =10 nodules) recurrence, and no recurrence within the 6-month postoperative period. Twenty-six clinicopathologic and surgical variables were subject to univariate and multivariate analysis.

RESULTS

According to univariate analysis, the risk factors for early multinodular recurrence in HCC were microvascular tumor emboli, portal vein tumor thrombi, intrahepatic metastases, high Edmonson-Steiner classification, lack of tumor capsule formation, increased alpha-fetoprotein concentration, and tumor size. Of these factors, intrahepatic metastases and portal vein thrombi proved to be significant predictive factors of multinodular recurrence by multivariate analysis.

COMMENTS

Postoperative early multinodular recurrence was found to be related to portal vein tumor thrombi and intrahepatic metastases. Accordingly, an effective adjuvant therapeutic modality should be made available for patients with these risk factors.

Laparoscopic hepatectomy: indications and outcomes

We outline the indications, evaluate the degree of invasiveness, and analyze the outcomes of laparoscopic hepatectomy, mainly in the treatment of hepatocellular carcinoma (HCC). The important considerations in determining indications for laparoscopic hepatectomy include tumor size, type, and location. Nodular tumors smaller than 4 cm or pedunculated tumors smaller than 6 cm are suitable candidates. Concerning location, tumors in the lower segment or the left lateral segment are suitable. Regarding operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral segmentectomy is a feasible, less invasive procedure. Operative time in our recent laparoscopic hepatectomy patients has decreased, with less bleeding. Furthermore, laparoscopic hepatectomy is less invasive than conventional hepatectomy on evaluation by the Estimation of Physiolic Ability and Surgical Stress (E-PASS) scoring system. Patients recovered more quickly after laparoscopic hepatectomy, which allowed shorter hospitalization. Both the 5-year survival rate for HCC and the survival rate without recurrence were nearly identical to those of open conventional hepatectomy, although further analysis will be necessary to reach definitive conclusions. In conclusion, laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy in properly selected patients and is beneficial for patient quality of life, because it is a minimally invasive procedure when indications are strictly followed.

MEK/ERK signaling is a critical mediator for integrin-induced cell scattering in highly metastatic hepatocellular carcinoma cells

The human hepatocellular carcinoma (HCC)-derived cell line KYN-2 is thought to provide a good model for studying the molecular basis of invasion and metastasis of human HCC, because it often shows cell scattering in vitro and intrahepatic metastasis in vivo. We previously found that integrin-mediated extracellular signals inactivated E-cadherin in KYN-2, and caused loss of cell-cell contact with gain of cell motility, which is considered to be a critical step in the process of cancer cell invasion and metastasis. To further understand molecular mechanisms involved in biological aggressiveness of HCC, we investigated intracellular signaling involved in integrin-mediated scattering of KYN-2 cells. Cultured KYN-2 cells formed trabecular aggregates in suspension, but when adhering to integrin-stimulating substrata, they scattered according to phosphorylation of extracellular signal-regulated kinase (ERK). Upon treatment with ERK kinase (MEK) inhibitor PD98059, adhered KYN-2 cell scattering was inhibited, tight cell-to-cell contact was recovered, and both E-cadherin and actin filaments accumulated in the area of intercellular contact zone. In contrast, constitutively active MEK1-transfected KYN-2 cells showed reduced E-cadherin and actin filaments in the intercellular contact zone, showing a flattened phenotype with broad lamellipodia. Enforced signaling of MEK-ERK pathway in KYN-2 cells suppressed cadherin-mediated homotypic adhesion and increased the potential of cell motility. An antibody-based protein microarray analysis revealed that the cytoplasmic protein c-Cbl was significantly downregulated in MEK1-transfected KYN-2 cells, suggesting that c-Cbl might be a candidate downstream mediator of integrin/MEK/ERK-mediated cell scattering. In conclusion, cell scattering of the highly metastatic cell line KYN-2 is regulated through the integrin-MEK-ERK signaling cascade, suggesting that this molecular pathway may be critical in intrahepatic metastasis of human HCC.

Clusterin plays an important role in hepatocellular carcinoma metastasis

To identify genes associated with tumor metastasis in hepatocellular carcinoma (HCC), gene expression profiles between a pair of primary HCC (H2-P) and their matched metastatic HCC (H2-M) were compared. Overexpression of clusterin (CLU) was found in H2-M cells. To determine the roles CLU played in HCC metastasis, CLU was transfected into H2-P cells. Overexpression of CLU in H2-P cells increased cell migration by twofold in vitro and formation of metastatic tumor nodules in liver by eightfold in vivo. To evaluate the correlation of CLU expression with HCC metastasis, the expression levels of CLU in HCCs were investigated using a tissue microarray (TMA) containing 104 pairs of primary HCCs and their matched metastases. The frequency of CLU overexpression increased significantly in metastatic HCCs (59.1%) compared with that in primary tumors (32.6%, P<0.001). To gain additional insight into the function of CLU, the expression profile of H2P-CLU was compared with vector-transfected H2-P cells by cDNA microarray. A total of 35 upregulated and 14 downregulated genes were detected in H2P-CLU. One of the upregulated genes known as YKL-40, which is implicated in matrix-remodeling and metastasis, was further studied using TMA. A significant correlation (P<0.001) between the expression levels of YKL-40 and CLU was observed, implying that the CLU-YKL-40 pathway may play an important role in HCC metastasis.

Encapsulated hepatocellular carcinoma: CT-pathologic correlations

This study is a retrospective evaluation of the correlations between the presence and integrity of the capsule of nodular hepatocellular carcinomas (HCC) by dynamic CT and histopathology, with histopathologic evidence of tumor propagation to surrounding hepatic parenchyma. Dynamic CT scans of 75 nodular HCCs in 73 patients (61 men, 12 women; age range, 32-81; mean, 53) were evaluated regarding capsule visualization and integrity. Histopathologic findings of HCCs in resected specimens were correlated with the presence of a capsule, tumor invasion onto the capsule, and with the presence of microvascular emboli in the surrounding liver parenchyma. On histopathologic examination, capsules were present in 57 of 75 nodular HCCs; the capsules were invaded by tumor in 18 nodules and there were microvascular emboli around the nodular HCC in 49 cases. Capsule visualization by CT was correlated with the presence of capsule by histopathology (P<0.001). Disruption of capsule by CT was correlated with tumor invasion by histopathology (P=0.003) and with microvascular tumor emboli (P<0.001). The presence and structural integrity of HCC capsules on CT was closely correlated with the presence of capsule on histopathology and the absence of microvascular tumor emboli.

Factors associated with early recurrence after resection for hepatocellular carcinoma and outcomes

BACKGROUND

Early recurrence (ER) (<1 year) after liver resection is one of the most important factors that impact the prognosis of patients with hepatocellular carcinoma (HCC). We sought to determine factors associated with ER of HCC and examine the outcomes thereafter.

STUDY DESIGN

From March 2001 to June 2003, 56 patients underwent hepatic resection for HCC at University of Toronto and were prospectively followed with median followup of 24 months. Patients with ER were compared with those who remained disease free for more than 1 year. Patient characteristics, tumor stage, and operative procedures were evaluated for their prognostic significance by univariate and multivariable analysis. Time to recurrence and time to death were analyzed using Kaplan-Meier survival curves and compared using log-rank analysis.

RESULTS

The initial procedure in all patients was surgical hepatectomy. ER occurred in 21 patients (38%), 31 (55%) remained disease free for more than 1 year, and 4 (7%) were omitted from evaluation because of early (<30 days) death. Median survival after initial hepatic resection for those with ER was 27 months, and 2-year survival was 54%. There were no deaths in the group that remained disease free for more than 1 year (100% 2-year survival, p < 0.05). By multivariate analysis, vascular invasion and positive microscopic margins were significant predictors when all 4 variables were considered in the model (p < 0.05). After ER, 11 of 21 patients (52%) underwent additional therapy with significant improvement in median survival (33 months) compared with those not eligible for conventional therapy (18 months, p = 0.05).

CONCLUSIONS

ER after liver resection for HCC is the leading cause of death during the first 2 years after potentially curative resection. ER will develop in approximately 75% of patients with either vascular invasion or positive margins. For patients with these predictive factors additional treatment might be advised.

Prognostic Evaluation of the New American Joint Committee on Cancer/International Union Against Cancer Staging System for Hepatocellular Carcinoma: Analysis of 112 Cirrhotic Patients Resected for Hepatocellular Carcinoma

BACKGROUND

In 2002, the American Joint Committee on Cancer and the International Union Against Cancer redefined the T-classification for hepatocellular carcinoma, shifting the cutoff value for tumor size from 2 to 5 cm and giving more emphasis to vascular invasion.

METHODS

A retrospective cohort study was conducted on 223 consecutive patients with hepatocellular carcinoma observed between 1990 and 2002. One hundred twelve were resected and considered for retrospective analysis. Univariate and multivariate analyses were performed on several clinicopathologic variables. After classification according to each staging system, the long-term survival of different stages was compared. The prognostic value of each staging system was further evaluated by entering each stage, in turn, into the Cox regression model with other clinicopathologic variables. The median follow-up was 19 months.

RESULTS

On multivariate analysis, the viral etiology of cirrhosis and the presence of multiple nodules were independent prognostic factors. When the new staging system was entered into the multivariate analysis, it was the only independent factor (P = .02). When stratified according to the old tumor-node-metastasis system, there were no significant differences in the survival between stage I and II (P = .14) or between stage IIIA and IVA (P = .33); only the survival of stage II and IIIA was different (P < .01). When stratified according to the new tumor-node-metastasis system, there were significant differences between stage I and II (71.7% vs. 54.7%; P = .02).

CONCLUSIONS

The new staging system is a more reliable and objective method for T classification. It is easy to use in clinical practice and is better at stratifying curatively resected patients with respect to prognosis.