Clinical management of recurrent hepatocellular carcinoma

A Prognostic Model To Predict Survival After Recurrence Among Patients With Recurrent Hepatocellular Carcinoma

OBJECTIVE

We sought to develop and validate a preoperative model to predict survival after recurrence (SAR) in hepatocellular carcinoma (HCC).

BACKGROUND

Although HCC is characterized by recurrence as high as 60%, models to predict outcomes after recurrence remain relatively unexplored.

METHODS

Patients who developed recurrent HCC between 2000 and 2020 were identified from an international multi-institutional database. Clinicopathologic data on primary disease and laboratory and radiologic imaging data on recurrent disease were collected. Multivariable Cox regression analysis and internal bootstrap validation (5000 repetitions) were used to develop and validate the SARScore. Optimal Survival Tree analysis was used to characterize SAR among patients treated with various treatment modalities.

RESULTS

Among 497 patients who developed recurrent HCC, median SAR was 41.2 months (95% CI 38.1-52.0). The presence of cirrhosis, number of primary tumors, primary macrovascular invasion, primary R1 resection margin, AFP>400 ng/mL on the diagnosis of recurrent disease, radiologic extrahepatic recurrence, radiologic size and number of recurrent lesions, radiologic recurrent bilobar disease, and early recurrence (≤24 months) were included in the model. The SARScore successfully stratified 1-, 3- and 5-year SAR and demonstrated strong discriminatory ability (3-year AUC: 0.75, 95% CI 0.70-0.79). While a subset of patients benefitted from resection/ablation, Optimal Survival Tree analysis revealed that patients with high SARScore disease had the worst outcomes (5-year AUC; training: 0.79 vs. testing: 0.71). The SARScore model was made available online for ease of use and clinical applicability ( https://yutaka-endo.shinyapps.io/SARScore/ ).

CONCLUSION

The SARScore demonstrated strong discriminatory ability and may be a clinically useful tool to help stratify risk and guide treatment for patients with recurrent HCC.

Development and Validation of an α-Fetoprotein Tumor Burden Score Model to Predict Postrecurrence Survival among Patients with Hepatocellular Carcinoma

BACKGROUND

The purpose of this study is to establish a prognostic model to predict postrecurrence survival (PRS) probability after initial resection of hepatocellular carcinoma (HCC).

STUDY DESIGN

Patients with recurrent HCC after curative resection were identified through a multicenter consortium (training cohort, TC); data were from a separate institution were used as validation cohort (VC). The α-fetoprotein (AFP) tumor burden score (ATS) was defined as the distance from the origin on a 3-dimensional Cartesian coordinate system that incorporated 3 variables: largest tumor diameter ( x axis), number of tumors ( y axis), and ln AFP ( z axis). ATS was calculated using the Pythagorean theorem: ATS 2 = (largest tumor diameter) 2 + (number of tumors) 2 + (ln AFP) 2 , where ATS d and ATS r represent ATS at the time of initial diagnosis and at the time of recurrence, respectively. The final model was ATS m = ATS d + 4 × ATS r . Predictive performance and discrimination of the ATS model were evaluated and compared with traditional staging systems.

RESULTS

The ATS model demonstrated strong predictive performance of PRS in both the TC (area under the curve [AUC] 0.70) and VC (AUC 0.71). An ATS-based nomogram was able to stratify patients accurately into low- and high-risk categories relative to PRS (TC: ATS m ≤ 27, 74.9 months vs. ATS m ≥ 28, 23.3 months; VC: ATS m ≤ 27, 59.4 months vs. ATS m ≥ 28, 15.1 months; both p < 0.001). The ATS model predicted PRS among patients undergoing curative or noncurative treatment of HCC recurrence (both p < 0.05). Of note, the ATS model outperformed the Barcelona Clinic Liver Cancer (BCLC), China Liver Cancer (CNLC), and American Joint Committee on Cancer (AJCC) staging systems relative to 1-, 2-, 3-, 4- and 5-year PRS (AUC 0.70, vs. BCLC, AUC 0.50, vs. CNLC, AUC 0.54, vs. AJCC, AUC 0.51).

CONCLUSIONS

The ATS model had excellent prognostic discriminatory power to stratify patients relative to PRS.

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.

Transarterial Chemoembolization Combined With Radiofrequency Ablation Versus Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma After Curative Resection: A 10-Year Single-Center Comparative Study

Background

The purpose of this study was to compare the efficacy and safety of transarterial chemoembolization (TACE) in combination with radiofrequency ablation (RFA) (TACE-RFA) and repeat hepatectomy in the treatment of recurrent hepatocellular carcinoma (HCC) after curative resection.

Methods

This retrospective study evaluated consecutive medical records of patients who received either TACE-RFA or repeat hepatectomy between January 2010 and May 2021. Overall survival (OS), progression-free survival (PFS), and complications were compared.

Results

Of the 2672 patients who received either TACE-RFA or repeat hepatectomy, 111 eligible patients were included in our study, 63 in the TACE-RFA group and 48 in the repeat hepatectomy group. The median OS was 38 months in the TACE-RFA group and 42 months in the repeat hepatectomy group, with no statistically difference between the two groups (P=0.45). Meanwhile, there was also no statistically significant difference in PFS between the two groups (P=0.634). Although both groups achieved similar outcomes, the rate of major complications was significantly higher in the repeat hepatectomy group (P=0.003).

Conclusions

Patients with recurrent HCC in the TACE-RFA group and the repeat hepatectomy group had similar OS and PFS regardless of the patient’s tumor diameter, but the TACE-RFA group was safer and more minimally invasive.

Knockdown of THOC1 reduces the proliferation of hepatocellular carcinoma and increases the sensitivity to cisplatin

Background

Hepatocellular carcinoma (HCC) is one of the most common malignant cancers with poor prognosis and high incidence. The clinical data analysis of liver hepatocellular carcinoma samples downloaded from The Cancer Genome Atlas reveals that the THO Complex 1 (THOC1) is remarkable upregulated in HCC and associated with poor prognosis. However, the underlying mechanism remains to be elucidated. We hypothesize that THOC1 can promote the proliferation of HCC. The present study aims to identify THOC1 as the target for HCC treatment and broaden our sights into therapeutic strategy for this disease.

Methods

Quantitative RT-PCR, Western blot, immunofluorescence and immunohistochemistry were used to measure gene and protein expression. Colony formation and cell cycle analysis were performed to evaluate the proliferation. The gene set enrichment analysis were performed to identify the function which THOC1 was involved in. The effects of THOC1 on the malignant phenotypes of hepatocellular cells were examined in vitro and in vivo.

Results

The gene set enrichment analysis reveals that THOC1 can promote the proliferation and G2/M cell cycle transition of HCC. Similarly, experimental results demonstrate that THOC1 promotes HCC cell proliferation and cell cycle progression. The knockdown of THOC1 leads to R-loop formation and DNA damage and confers sensitivity to cisplatin. In addition, in vivo data demonstrate that THOC1 can enhance tumorigenesis by increasing tumor cell proliferation. Furthermore, virtual screening predicts that THOC1 as a direct target of luteolin. Luteolin can induce DNA damage and suppress the proliferation of HCC by targeting THOC1. Furthermore, the inhibition of THOC1 activity by luteolin enhances the chemosensitivity of HCC tumor cells to cisplatin.

Conclusions

THOC1 was identified as a predictive biomarker vital for HCC-targeted treatments and improvement of clinical prognosis. Luteolin combined with cisplatin can effectively suppress HCC tumor growth, indicating a potential and effective therapeutic strategy that uses luteolin in combination with conventional cytotoxic agents for HCC treatment.

Role of microRNA-210-3p in hepatitis B virus-related hepatocellular carcinoma

Hepatitis B virus (HBV)-related hepatocarcinogenesis is not necessarily associated with the liver fibrotic stage and is occasionally seen at early fibrotic stages. MicroRNAs (miRNAs) are essentially 18- to 22-nucleotide-long endogenous noncoding RNAs. Aberrant miRNA expression is a common feature of various human cancers. The aberrant expression of specific miRNAs has been shown in hepatocellular carcinoma (HCC) tissue compared with nontumor tissue. Thus, we examined targetable miRNAs as a potential new biomarker related to the high risk of HBV-related hepatocarcinogenesis, toward the prevention of cancer-related deaths. HCC tissue samples from 29 patients who underwent hepatectomy at our hospital in 2002-2013 were obtained. We extracted the total RNA and analyzed it by microRNA array, real-time RT-PCR, and three comparisons: 1) HBV-related HCC and adjacent nontumor tissue, 2) HCV-related HCC and adjacent nontumor tissue, and 3) non-HBV-, non-HCV-related HCC and adjacent nontumor tissue. We also performed a functional analysis of miRNAs specific for HBV-related HCC by using HBV-positive HCC cell lines. MiR-210-3p expression was significantly increased only in the HBV-related HCC tissue samples. MiR-210-3p expression was upregulated, and the levels of its target genes were reduced in the HBV-positive HCC cells. The inhibition of miR-210-3p enhanced its target gene expression in the HBV-positive HCC cells. In addition, miR-210-3p regulated the HBx expression in HBV-infected Huh7/NTCP cells. The enhanced expression of miR-210-3p was detected specifically in HBV-related HCC and regulated various target genes, including HBx in the HBV-positive HCC cells. MiR-210-3p might, thus, be a new biomarker for the risk of HBV-related HCC.NEW & NOTEWORTHY Our present study demonstrated that miR-210-3p is the only microRNA with enhanced expression in HBV-related HCC, and the enhanced expression of miR-210-3p upregulates HBx expression. Therefore, miR-210-3p might be a pivotal biomarker of HBV-related hepatocarcinogenesis, and the inhibition of miR-210-3p could prevent inducing hepatocarcinogenesis related to HBV infection.

Repeat liver resection versus salvage liver transplant for recurrent hepatocellular carcinoma: A propensity score-adjusted and -matched comparison analysis

Backgrounds/Aims

Repeat liver resection (RLR) and salvage liver transplantation (SLT) are viable treatment options for recurrent hepatocellular carcinoma (HCC). With possibly superior survival outcomes than RLR, SLT is however, limited by liver graft availability and poses increased perioperative morbidity. In this study, we seek to compare the outcomes of RLR and SLT for patients with recurrent HCC.

Methods

Between 1999 and 2018, 94 and 16 consecutive patients who underwent RLR and SLT respectively were identified. Further retrospective subgroup analysis was conducted, comparing 16 RLR with 16 SLT patients via propensity-score matching.

Results

After propensity-score adjusted analyses, SLT demonstrated inferior short-term perioperative outcomes than RLR, with increased major morbidity (57.8% vs 5.4 %, p=0.0001), reoperations (39.1% vs 0, p<0.0001), renal insufficiency (30.1% vs 3%, p=0.0071), bleeding (19.8% vs 2.2%, p=0.0289), prolonged intensive care unit stay (median=4 vs 0 days, p<0.0001) and hospital stay (median=19.8 vs 7.1days, p<0.001). However, SLT showed significantly lower recurrence rate (15.4% versus 70.3%, p=0.0005) and 5-year cumulative incidence of recurrences (19.4% versus 68.4%, p=0.005). Propensity-matched subgroup analysis showed concordant findings.

Conclusions

While SLT offers potentially reduced risks of recurrence and trended towards improved long-term survival outcomes relative to RLR, it has poorer short-term perioperative outcomes. Patient selection is prudent amidst organ shortages to maximise allocated resources and optimise patient outcomes.

Outcomes of salvage liver transplant for recurrent hepatocellular carcinoma: A comparison with primary liver transplant

Backgrounds/Aims

Salvage liver transplantation (SLT) is a therapeutic strategy for recurrent hepatocellular carcinoma (HCC). However, it remains controversial with compromised survival outcomes and increased perioperative morbidity compared to primary liver transplant (PLT). In the present work, we describe our institution's experience on SLT by comparing outcomes of SLT to PLT for HCCs.

Methods

Retrospective analysis was conducted for 49 transplant patients from 2006-2017. A comparative analysis was carried out between 14 SLT patients and 35 PLT patients.

Results

SLT patients demonstrated significantly shorter time to recurrence than PLT patients (median=5.5 versus 23 months, p<0.001) with a trend towards increased perioperative major morbidity (42.9% versus 37%, p=0.711), inferior 5-year overall survival (61% versus 75%, p=0.345) and inferior 5-year recurrence-free survival (57% versus 72%, p=0.263). However, overall survival from the point of primary resection over a 10-year period showed no statistical difference between the 2 groups (SLT=60% versus PLT=61%, p=0.685).

Conclusions

SLT is a viable treatment strategy for HCCs. However, it exhibited poorer short-term perioperative and oncologic outcomes than PLT. SLT requires better patient selection with liver donor grafts for optimization of resource allocation in this era of organ shortage. Considering the worldwide shortages in liver grafts, it is hypothesized that optimization of a salvage transplant strategy may improve resource allocation and reap optimal patient outcomes.

Impact of Preoperative Hepatitis B Virus Levels on Prognosis After Primary and Repeat Hepatectomies for Hepatocellular Carcinoma Patients-a Retrospective Study

BACKGROUND

Chronic HBV plays an important role in hepatocellular carcinoma pathogenesis. Previously, most studies have been focusing on HBV DNA levels before the primary curative hepatectomy. However, the association of virus level before repeat hepatectomy with the degrees of inflammation and fibrosis on histopathology and prognosis has not been surveyed.

METHODS

From January 2002 to December 2009, all patients who were seropositive for hepatitis B surface antigen (HBsAg) were enrolled and assigned into four groups based on their HBV DNA levels before the primary and repeat hepatectomies. The cancer prognoses of these four groups of patients after the first and second operations were assessed and compared. The disease-free survival and overall survival were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify risk factors for the primary and repeat hepatectomies.

RESULTS

For the 385 patients in this study, a low level of serum HBV DNA before repeat hepatectomy, but not primary hepatectomy, was significantly associated with improvement in prognosis, in terms of tumor recurrence, liver fibrosis, and liver-related mortality.

CONCLUSION

The levels of HBV DNA before hepatectomies were crucial prognostic risk factors of HBV-related hepatocellular carcinoma patients. Surveillance of serum HBV DNA levels at multiple time points, rather than at a single time point, and antiviral therapy to suppress the virus to a low level had beneficial effects for these patients.

Ultrasound-guided radiofrequency ablation enhances natural killer-mediated antitumor immunity against liver cancer

For patients with liver cancer who are not sufficiently fit for surgical resection, radiofrequency ablation (RFA) is an effective and low risk treatment modality; however, the mechanism underlying this procedure is not fully understood. In the present study, a series of experiments were conducted, which demonstrated that RFA therapy stimulates innate antitumor immunity via directly enhancing natural killer (NK) cell cytotoxicity, thus achieving a favorable outcome for patients with liver tumors. It was determined that the percentage of NK cells within the peripheral blood of the rabbits in the RFA treatment groups were significantly higher, compared with the control groups. The levels of interferon-γ and tumor necrosis factor-α in NK cells were also significantly upregulated following thermal coagulation induced via RFA. In addition, RFA enhanced the NK cell receptor, NK group 2D (NKG2D), expression and NK cell antitumor cytotoxicity in hepatic cancer cells. The results indicated that the RFA treatment could effectively eliminate liver tumors via enhancing NK-mediated antitumor activity and NKG2D expression.

Progress of liver resection for hepatocellular carcinoma in Taiwan

Taiwan is a well-known endemic area of hepatitis B. Hepatocellular carcinoma (HCC) has consistently been the first or second highest cause of cancer death over the past 20 years. This review article describes the progress of liver resection for HCC in Taiwan in the past half century. The mortality rate for HCC resection was 15-30% in Taiwan in the 1970s. The rate decreased to 8-12% in the early 1990s, and it declined to <1-3% recently. The development of new operative instruments, and surgical techniques, increased knowledge of liver anatomy and pathophysiology after hepatectomy, and more precise patient selection have contributed to this improvement. The use of intermittent hepatic inflow blood occlusion, a restrictive blood transfusion policy and intraoperative ultrasonography, have also led to substantial improvements in resectability and safety for HCC resection in Taiwan. Advances in non-operative modalities for HCC treatment have also helped to improve long-term outcomes of HCC resection. Technical innovations have allowed the application of complex procedures such as mesohepatectomy, unroofing hepatectomy, major portal vein thrombectomy, hepatic vein reconstruction in resection of the cranial part with preservation of the caudal part of the liver, and inferior vena cava and right atrium tumor thrombectomy under cardiopulmonary bypass. In selected patients, including patients with end-stage renal failure, renal graft recipients, patients with portal hypertension, hypersplenic thrombocytopenia and/or associated gastroesophageal varices, octogenarian, ruptured HCC, recurrent HCC and metastatic HCC can also be resected with satisfactory survival benefits. We conclude that the results of liver resection for HCC in Taiwan are improving. The indications for HCC resection continue extending with lower the surgical risks and increasing the long-term survival rate.

Changes of alpha-fetoprotein levels could predict recurrent hepatocellular carcinoma survival after trans-arterial chemoembolization

Background

There is paucity of information concerning whether AFP change is a predictor of prognosis for recurrent hepatocellular carcinoma (RHCC) patients after trans-arterial chemoembolization (TACE).

Methods

A total of 177 RHCC patients who received TACE as first-line therapy were retrospectively analyzed. The patients were classified into three groups according to their pre-TACE and post-TACE AFP levels (group A: AFP decreased, group B: AFP consistent normal, and group C: AFP increased). The recurrence to death survival (RTDS) and overall survival (OS) were estimated by the Kaplan-Meier method, and compared by the log-rank test. Multivariate analyses were performed to identify prognostic factors for OS and RTDS.

Results

There was no significant difference among the three groups concerning the baseline characteristics. The median overall survival (OS) was 74.5 months in group A (95% confidence interval (CI): 63.5, 85.6), 64.0 months in group B (95% CI: 52.3, 75.7) and 29.0 months in group C (95% CI: 24.1, 33.9; P<0.001). The median recurrence to death survival (RTDS) was 66.5 months (95% CI: 53.4, 79.6) in group A, 50.4 months (95% CI: 39.5, 61.4) in group B and 17.7 months (95% CI: 13.4, 22.1; P<0.001) in group C. Multivariate analysis revealed that tumor size at resection stage, tumor number at recurrent stage, cycles of TACE, mRECIST response and AFP change after TACE were significant independent risk factors for RTDS and OS.

Conclusions

AFP change could predict the prognoses of patients with RHCC who received trans-arterial chemoembolization, which may help clinicians make subsequent treatment decision.

Meta-analysis of determinants of survival following treatment of recurrent hepatocellular carcinoma

Background

Intrahepatic recurrence of hepatocellular carcinoma (HCC) following resection is common. However, no current consensus guidelines exist to inform management decisions in these patients. Systematic review and meta-analysis of survival following different treatment modalities may allow improved treatment selection. This review aimed to identify the optimum treatment strategies for HCC recurrence.

Methods

A systematic review, up to September 2016, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of different treatment modalities was carried out using a random-effects model, with further assessment of additional prognostic factors for survival.

Results

Nineteen cohort studies (2764 patients) were included in final data analysis. The median 5-year survival rates after repeat hepatectomy (525 patients), ablation (658) and transarterial chemoembolization (TACE) (855) were 35·2, 48·3 and 15·5 per cent respectively. Pooled analysis of ten studies demonstrated no significant difference between overall survival after ablation versus repeat hepatectomy (hazard ratio 1·03, 95 per cent c.i. 0·68 to 1·55; P = 0·897). Pooled analysis of seven studies comparing TACE with repeat hepatectomy showed no statistically significant difference in survival (hazard ratio 1·61, 0·99 to 2·63; P = 0·056).

Conclusion

Based on these limited data, there does not appear to be a significant difference in survival between patients undergoing repeat hepatectomy or ablation for recurrent HCC. The results also identify important negative prognostic factors (short disease-free interval, multiple hepatic metastases and large hepatic metastases), which may influence choice of treatment.

Nomogram predicting long-term survival after the diagnosis of intrahepatic recurrence of hepatocellular carcinoma following an initial liver resection

BACKGROUND

The aim of this study was to construct and validate a nomogram for predicting survival after the intrahepatic recurrence of hepatocellular carcinoma (HCC) following an initial hepatectomy.

METHODS

A primary cohort of 268 patients who underwent curative hepatectomy for HCC at Shinshu University Hospital between 1990 and 2010 was retrospectively studied. A nomogram was constructed based on independent prognostic factors for overall survival after recurrence. The predictive performance was evaluated using the concordance index (c-index) and a calibration curve. The nomogram was then externally validated in a cohort of patients from Tokyo University Hospital (n = 296).

RESULTS

In multivariate analysis, the following 5 variables were identified as independent predictors of overall survival and incorporated into the nomogram-Japan Integrated Stage score at initial liver resection, platelet count at initial liver resection, time until intrahepatic recurrence, vascular invasion at recurrence, and type of treatment used for intrahepatic recurrence. The nomogram had a c-index of 0.75 (95% confidence interval 0.60-0.85) for the Shinshu cohort and 0.71 (0.57-0.81) for the Tokyo cohort. The predicted 3- and 5-year survival probabilities corresponded well with the actual outcomes.

CONCLUSIONS

The established nomogram might be useful for estimating survival after the intrahepatic recurrence of HCC.

MicroRNA profiles in various hepatocellular carcinoma cell lines

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-associated mortality worldwide. Although surgery is considered the most effective treatment for patients with HCC, its indication is restricted by limited criteria and a high relapse rate following surgery; therefore, systemic chemotherapy is required for patients with advanced-stage HCC to prolong their survival. MicroRNAs (miRNAs) are endogenous non-coding RNAs of 18-22 nucleotides in length. It has been reported that aberrant expression of miRNAs is a feature shared by various types of human cancer. Previous studies have indicated that the modulation of non-coding RNAs, particularly miRNAs, may be a valuable therapeutic target for HCC. The aim of the present study was to elucidate the miRNA profiles associated with differentiation and hepatitis B virus (HBV) infection observed in HCC cell lines. The human Alex, Hep3B, HepG2, HuH1, HuH7, JHH1, JHH2, JHH5, JHH6, HLE, HLF and Li-7 HCC cell lines were used for an miRNA array. Replicate data were analyzed following their classification into: i) Poorly- and well-differentiated human HCC cells and ii) HBV-positive and -negative human HCC cells. Out of the 1,719 miRNAs, 4 were found to be significantly upregulated and 52 significantly downregulated in the poorly-differentiated cells, as compared with the well-differentiated cells. Conversely, in the HBV-positive cells 125 miRNAs were found to be upregulated and 2 downregulated, as compared with the HBV-negative cells. Unsupervised hierarchical clustering analysis with Pearson's correlation revealed that the miRNA expression levels were clustered both together and separately in each group. In conclusion, miRNA profile characterization based on various parameters may be a novel approach to determine the etiology of HCC.

Efficacy of radiofrequency ablation compared with transarterial chemoembolization for the treatment of recurrent hepatocellular carcinoma: a comparative survival analysis

BACKGROUND

This study aims to assess if radiofrequency ablation (RFA) has any oncological superiority over transarterial chemoembolization (TACE) on post-hepatectomy recurrence.

METHODOLOGY

From 2002 to 2011, 60.15% of 823 patients developed recurrence after hepatectomy for Hepatocellular carcinoma (HCC). 102 patients with recurrence underwent RFA (n = 42) or TACE (n = 60) for tumor size ≤5 cm and number of lesion ≤3 when tumors were not resectable or transplantable. Those with renal impairment, portal vein thrombosis and poor liver reserve were excluded. Primary outcome was overall survival, which was determined using log-rank test and Kaplan Meier plots performed. Categorical data were analyzed using Chi-square test and continuous variable were analyzed using Mann-U Whitney test.

RESULTS

Demographics and primary tumor characteristics were similar in both groups (p > 0.05). Overall survival after initial hepatectomy and salvage treatment for recurrence was similar (p > 0.05) in both groups with 5-year OS after salvage treatment for RFA and TACE at 24.1% and 25.7%, respectively. For patients with second recurrence after salvage treatment, an interchangeable treatment strategy of RFA and TACE conferred a better survival outcome than a stand-alone treatment with RFA or TACE (p < 0.05).

CONCLUSIONS

RFA and TACE may be equally effective for intrahepatic recurrence after hepatectomy when tumor size is ≤5 cm and ≤3 lesion when re-resection or salvage transplantation is not considered feasible.

Microarray profiling shows distinct differences between primary tumors and commonly used preclinical models in hepatocellular carcinoma

BACKGROUND

Despite advances in therapeutics, outcomes for hepatocellular carcinoma (HCC) remain poor and there is an urgent need for efficacious systemic therapy. Unfortunately, drugs that are successful in preclinical studies often fail in the clinical setting, and we hypothesize that this is due to functional differences between primary tumors and commonly used preclinical models. In this study, we attempt to answer this question by comparing tumor morphology and gene expression profiles between primary tumors, xenografts and HCC cell lines.

METHODS

Hep G2 cell lines and tumor cells from patient tumor explants were subcutaneously (ectopically) injected into the flank and orthotopically into liver parenchyma of Mus Musculus SCID mice. The mice were euthanized after two weeks. RNA was extracted from the tumors, and gene expression profiling was performed using the Gene Chip Human Genome U133 Plus 2.0. Principal component analyses (PCA) and construction of dendrograms were conducted using Partek genomics suite.

RESULTS

PCA showed that the commonly used HepG2 cell line model and its xenograft counterparts were vastly different from all fresh primary tumors. Expression profiles of primary tumors were also significantly divergent from their counterpart patient-derived xenograft (PDX) models, regardless of the site of implantation. Xenografts from the same primary tumors were more likely to cluster together regardless of site of implantation, although heat maps showed distinct differences in gene expression profiles between orthotopic and ectopic models.

CONCLUSIONS

The data presented here challenges the utility of routinely used preclinical models. Models using HepG2 were vastly different from primary tumors and PDXs, suggesting that this is not clinically representative. Surprisingly, site of implantation (orthotopic versus ectopic) resulted in limited impact on gene expression profiles, and in both scenarios xenografts differed significantly from the original primary tumors, challenging the long-held notion that orthotopic PDX model is the gold standard preclinical model for HCC.

Efficacy of radiofrequency ablation compared with transarterial chemoembolization for the treatment of recurrent hepatocellular carcinoma: a comparative survival analysis

BACKGROUND

This study aims to assess if radiofrequency ablation (RFA) has any oncological superiority over transarterial chemoembolization(TACE) on post-hepatectomy recurrence.

METHODS

From 2002 to 2011, 60.15% of 823 patients developed recurrence after hepatectomy for HCC. One hundred and two patients with recurrence underwent RFA (n = 42) or TACE (n = 60) for tumour size ≤5 cm and number of lesions ≤ 3 when tumours were not resectable or transplantable. Those with renal impairment, portal vein thrombosis and poor liver reserve were excluded. The primary outcome was overall survival, which was determined using log-rank test and Kaplan-Meier plots performed. Categorical data were analysed using the chi-square test and continuous variable were analysed using the Mann-Whitney U-test.

RESULTS

Demographics and primary tumour characteristics were similar in both groups (P > 0.05). Overall survival (OS) after an initial hepatectomy and salvage treatment for recurrence was similar (P > 0.05) in both groups with a 5-year OS after salvage treatment for RFA and TACE at 24.1% and 25.7%, respectively. For patients with the second recurrence after salvage treatment, an interchangeable treatment strategy of RFA and TACE conferred a better survival outcome than a stand-alone treatment with RFA or TACE (P < 0.05).

CONCLUSIONS

RFA and TACE may be equally effective for intrahepatic recurrence after hepatectomy when the tumour size is ≤ 5 cm and ≤ 3 lesions when re-resection or salvage transplantation is not considered feasible.

Prognostic Significance of Sarcomatous Change in Patients with Hepatocellular Carcinoma After Surgical Resection

BACKGROUND

Hepatocellular carcinoma (HCC) with sarcomatous change (SC) is a rare malignancy associated with high aggressiveness and poor prognosis; however, its prognostic significance remains unclear.

METHODS

From January 1994 to April 2012, surgically resected HCCs with SC (n = 52) at West China Hospital were retrospectively reviewed. HCC with SC was defined as the concomitant presence of the sarcomatous component occupying at least 10 % (but not predominantly) of the HCC-bearing tissue. To validate its prognostic significance, we compared the clinicopathological features and survival rates of these patients with a cohort of 214 randomly selected ordinary HCC patients during the same period.

RESULTS

The clinicopathological characteristics of HCC with SC were similar to those of ordinary HCC, with the exception of capsule formation, adjacent organ invasion, lymph node metastasis, and TNM staging. A total of 45 (86.5 %) HCC patients with SC experienced a recurrence, with a median time to recurrence of 6.0 months. Overall survival (OS) rates in the sarcomatous HCC group at 1, 2, and 3 years were 55.8, 25, and 17.3 %, respectively, which were significantly lower than those in the ordinary HCC group (p < 0.001). On multivariable analysis, macrovascular invasion, satellite nodules, and R1/R2 resection were identified as independent risk factors for shorter disease-free survival and OS.

CONCLUSIONS

The presence of SC in HCC was uncommon, and was associated with much poorer prognosis than ordinary HCC. Radical resection with negative margin is essential for improving the prognosis. Future prospective studies are warranted to determine if recurrent patients can benefit from postoperative adjuvant therapies.

Surgical results for recurrent hepatocellular carcinoma after curative hepatectomy: Repeat hepatectomy versus salvage living donor liver transplantation

The aims of this study were to evaluate the efficacy of repeat hepatectomy (Hx) and salvage living donor liver transplantation (LDLT) for recurrent hepatocellular carcinoma (HCC). A retrospective cohort study was performed to analyze the surgical results of repeat Hx and salvage LDLT for patients with recurrent HCC within the Milan criteria from 1989 to 2012. A total of 159 patients were divided into 2 groups: a repeat Hx group (n = 146) and a salvage LDLT group (n = 13). Operative results and patient prognoses were compared between the 2 groups. The operative invasiveness, including the operation time (229.1 ± 97.7 versus 862.9 ± 194.4 minutes; P < 0.0001) and blood loss (596.3 ± 764.9 versus 24,690 ± 59,014.4 g; P < 0.0001), were significantly higher in the salvage LDLT group. The early surgical results, such as morbidity (31% versus 62%; P = 0.0111) and the duration of hospital stay (20 ± 22 versus 35 ± 21 days; P = 0.0180), were significantly worse in the salvage LDLT group. There was no significant difference in the overall survival (OS) rate, but the disease-free survival rate of the salvage LDLT group was significantly better (P = 0.0002). The OS rate of patients with grade B liver damage in the repeat Hx group was significantly worse (P < 0.0001), and the 5-year OS rate was quite low, that is, 20% (liver damage A, 77% for the repeat Hx group and 75% for the salvage LDLT group). The prognosis of patients with grade B liver damage after repeat Hx for recurrent HCC is poor, and salvage LDLT would be a potent option for such patients.

MicroRNA profiles in cisplatin-induced apoptosis of hepatocellular carcinoma cells

Cisplatin [cis-diamminedichloroplatinum (II)], is a platinum coordination compound that is commonly used to treat hepatocellular carcinoma (HCC). It is also one of the most compelling anticancer drugs. Recent studies suggest that cisplatin may reduce cancer risk and improve prognosis. However, the antitumor mechanism of cisplatin in several types of cancers, including HCC, has not been elucidated. The goal of the present study was to evaluate the effects of cisplatin on the proliferation of HCC cells in vitro and to determine which microRNAs (miRNAs) are associated with the anticancer effects of cisplatin in vitro. We used various human HCC-derived cell lines to study the effects of cisplatin on human HCC cells. Cisplatin led to a strong dose- and time- dependent inhibition of cell proliferation in HLE, HLF, HuH7, Li-7, Hep3B and HepG2 cells in vitro. Cisplatin also blocked the progression of the cell cycle in the G0/G1 phase, which inhibited cyclin D1 and induced apoptosis. In addition, miRNA expression was markedly altered by treatment with cisplatin in vitro. Therefore, various miRNAs induced by cisplatin may also contribute to the suppression of cellular proliferation and apoptosis. Our results demonstrate that cisplatin inhibits the growth of HCC, possibly through the induction of G1 cell cycle arrest and apoptosis through the alteration of microRNA expression.

Nonsurgical multidisciplinary approach for recurrent hepatocellular carcinoma after surgical resection

Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative resection and local ablation, and this represents a major challenge for HCC treatment. Although several treatment guidelines have been reported, they detail initial treatment choices and there are no established guidelines for recurrent HCC. The current treatment options for recurrent HCC do not differ from the primary treatments, but the unique characteristics of HCC recurrence should be considered when choosing treatments and each treatment should be individualized to different clinical situations. Furthermore, combinations of various treatments have been recently attempted. This review summarizes the current evidence for nonsurgical treatments of recurrent HCC after resection and suggests a multidisciplinary approach to improving the prognosis of recurrent HCC.

Lesson from 610 liver resections of hepatocellular carcinoma in a single center over 10 years

Background

Recent advances in surgical techniques and perioperative management have led to improved surgical outcomes, especially perioperative outcomes. The aim of this study was to review our experience with hepatic resection for hepatocellular carcinoma (HCC) over a ten-year period to determine how to improve long-term surgical outcomes.

Methods

From January 1996 to December 2007, 610 patients underwent curative resection for HCC at Yonsei University Health System, Seoul, Korea. Prognostic factors for disease-free and overall survival were identified, and surgical outcomes were compared between two time periods: before 2003 and after 2003.

Results

The 1-, 3-, and 5-year overall survival rates were 90.1%, 74.9% and 64.4%, respectively. The patients after 2003 tended to have improved overall survival. The survival rate after recurrence in patients with tumors > 3 cm was significantly greater after 2003. (P = 0.044).

Conclusions

The improved survival rates after 2003 may be explained by better selection of surgical candidates, a reduced perioperative transfusion rate due to improved surgical techniques, and active multimodal treatment for recurrent HCC.

Novel aspects of the liver microenvironment in hepatocellular carcinoma pathogenesis and development

Hepatocellular carcinoma (HCC) is a prevalent primary liver cancer that is derived from hepatocytes and is characterised by high mortality rate and poor prognosis. While HCC is driven by cumulative changes in the hepatocyte genome, it is increasingly recognised that the liver microenvironment plays a pivotal role in HCC propensity, progression and treatment response. The microenvironmental stimuli that have been recognised as being involved in HCC pathogenesis are diverse and include intrahepatic cell subpopulations, such as immune and stellate cells, pathogens, such as hepatitis viruses, and non-cellular factors, such as abnormal extracellular matrix (ECM) and tissue hypoxia. Recently, a number of novel environmental influences have been shown to have an equally dramatic, but previously unrecognized, role in HCC progression. Novel aspects, including diet, gastrointestinal tract (GIT) microflora and circulating microvesicles, are now being recognized as increasingly important in HCC pathogenesis. This review will outline aspects of the HCC microenvironment, including the potential role of GIT microflora and microvesicles, in providing new insights into tumourigenesis and identifying potential novel targets in the treatment of HCC.

All-trans retinoic acid potentiates the chemotherapeutic effect of cisplatin by inducing differentiation of tumor initiating cells in liver cancer

BACKGROUND & AIMS

Systemic chemotherapy serves as an adjuvant treatment for post-operation patients with hepatocellular carcinoma (HCC), and provides curative option for the patients with unresectable HCC. However, its efficiency is largely limited because of the high incidence of chemo-resistance. Increasing evidence has shown that tumor initiating cells (TICs) not only have the ability to self-renew and drive the initiation and progression of cancer, but also exhibit greater resistance to conventional chemo- and radio-therapies than non-TICs. It was the aim of this study to investigate the effects of ATRA with and without cisplatin on TIC differentiation and apoptosis in human HCC.

METHODS

In the present study, we evaluated the TICs of HCC cell differentiation induced by all-trans retinoic acid (ATRA), and developed a novel chemotherapeutic approach to HCC, by characterizing the function of combinatorial treatment with cis-diammineplatinum(II) (cisplatin) and ATRA in vitro and in vivo.

RESULTS

ATRA effectively induced differentiation of TICs, which potentiated the cytotoxic effects of cisplatin. The combinatorial treatment of ATRA acid and cisplatin reduced protein kinase B (AKT) (Thr308) phosphorylation, and promoted apoptosis of HCC cells more significantly than treatment with cisplatin alone. In addition, the combined treatment with the two drugs exerted stronger inhibition on either HCC cell migration in vitro or metastasis in vivo, when compared to the treatment with either drug alone.

CONCLUSIONS

These results indicated that ATRA could significantly improve the effect of cisplatin, which is at least partially attributed to ATRA-induced differentiation of HCC TICs, and the subsequent decrease in this chemo-resistant subpopulation.

Assessment of treatment outcomes based on tumor marker trends in patients with recurrent hepatocellular carcinoma undergoing trans-catheter arterial chemo-embolization

PURPOSE

The aim of the present study was to evaluate whether serum alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) trends might be correlated with overall survival rates in patients with recurrent hepatocellular carcinoma (HCC) undergoing trans-catheter arterial chemo-embolization (TACE).

METHODS

We performed a retrospective cohort study of 142 patients with recurrent HCC who were treated by TACE at our hospital from April 1990 to December 2011. Patients were divided into three groups, as follows, according to the trends of the two tumor markers AFP and DCP: the low group, comprising patients with tumor marker levels below the cutoff values (AFP 100 ng/mL and DCP 100 mAU/mL) both pre- and post-TACE; the decreased group, comprising patients with elevated tumor marker levels pre-TACE in whom the levels decreased post-TACE; and the elevated group, comprising patients with elevated tumor marker levels post-TACE.

RESULT

Analysis using a Cox proportional hazards model identified the DCP trend (elevated group vs. low group, hazard ratio 8.47, 95 % confidence interval 4.53-15.84, p < 0.0001), but not the AFP trend, as an independent prognostic factor for survival. While the AFP trend was correlated only with the overall response rate assessed using the modified Response Evaluation Criteria in Solid Tumors (mRECIST; p = 0.041), the DCP trend was strongly associated with both the overall response rate (p = 0.009) and the disease control rate (p = 0.004).

CONCLUSION

The DCP trend might be useful for assessing treatment outcomes after TACE in patients with recurrent HCC.

Third or more repeat hepatectomy for recurrent hepatocellular carcinoma

BACKGROUND

We sought to evaluate the surgical results of third or more repeat hepatectomy for recurrent hepatocellular carcinoma (HCC). The role of repeat hepatectomy for recurrent HCC, especially in cases with third or more repeat hepatectomy, is controversial.

METHODS

We performed A retrospective, cohort study to analyze the surgical results of repeat hepatectomy performed at a single medical center from 1989 to 2011. A total of 1,000 hepatectomies for HCC were divided into 3 groups: A first hepatectomy group (n = 791), second hepatectomy group (n = 163), and third or more hepatectomy group (n = 46). Operative results and patient prognoses were compared among the 3 groups.

RESULTS

There were no differences in early surgical results such as mortality and morbidity among the 3 groups. The 5-year survival rates after the first, second, and third or more hepatectomy were 67%, 60%, and 43%, respectively (P = .1913). There was a significant difference in disease-free survival among the 3 groups, and the 5-year disease-free survival rates after first, second, and third or more hepatectomy were 37%, 29%, and 18%, respectively (P = .0169).

CONCLUSION

Third or more repeat hepatectomy for recurrent HCC was performed safely and associated with relatively long-term survival. Third or more repeat hepatectomy for recurrent HCC seems justified, but high rate of HCC recurrence remains a problem.

Long-term results of a randomized, observation-controlled, phase III trial of adjuvant interferon Alfa-2b in hepatocellular carcinoma after curative resection

OBJECTIVE

To investigate the clinical efficacy of adjuvant interferon alfa-2b (IFNα-2b) therapy on recurrence-free survival (RFS) of patients with postoperative viral hepatitis-related hepatocellular carcinoma (HCC).

BACKGROUND

Despite most individual trials have failed to meet their primary endpoint, recent pooled-data meta-analyses suggest that adjuvant IFN therapy may significantly reduce the incidence of recurrence in curatively ablated HCC.

METHODS

Patients with curative resection of viral hepatitis-related HCC were eligible, and were stratified by underlying viral etiology and randomly allocated to receive either 53 weeks of adjuvant IFNα-2b treatment or observation alone. The primary endpoint of this study was RFS.

RESULTS

A total of 268 patients were enrolled with 133 in the IFNα-2b arm and 135 in the control arm. Eighty percent of them were hepatitis B surface antigen seropositive. At a median follow-up of 63.8 months, 154 (57.5%) patients had tumor recurrence and 84 (31.3%) were deceased. The cumulative 5-year recurrence-free and overall survival rates of intent-to-treat cohort were 44.2% and 73.9%, respectively. The median RFS in the IFNα-2b and control arms were 42.2 (95% confidence interval [CI], 28.1-87.1) and 48.6 (95% CI, 25.5 to infinity) months, respectively (P = 0.828, log-rank test). Adjuvant IFNα-2b treatment was associated with a significantly higher incidence of leucopenia and thrombocytopenia. Thirty-four (24.8%) of treated patients required dose reduction, and 5 (3.8%) of these patients subsequently withdrew from therapy because of excessive toxicity. Adjuvant IFNα-2b only temporarily suppressed viral replication during treatment period.

CONCLUSIONS

In this study, adjuvant IFNα-2b did not reduce the postoperative recurrence of viral hepatitis-related HCC. More potent antiviral therapy deserves to be explored for this patient population. This study is registered at ClinicalTrials.gov and carries the identifier NCT00149565.

Survival in patients with recurrent hepatocellular carcinoma after primary hepatectomy: comparative effectiveness of treatment modalities

BACKGROUND

Insufficient data are available on the survival of recurrent hepatocellular carcinoma after primary hepatectomy in patients receiving different treatments. We evaluated retrospectively the effects of treatment modalities on long-term survival.

METHODS

Between 2001 and 2007, 435 posthepatectomy hepatocellular carcinoma patients who developed recurrence were grouped by treatment modality into re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups. Treatment strategies for both primary hepatocellular carcinoma and its recurrence were selected using the same criteria. Postrecurrence survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazard model with adjusted independent prognostic factors. Survival rates after primary resection without recurrence were also compared.

RESULTS

In re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups, the 2-year postrecurrence survival rates were 90%, 96%, 75%, and 20%, respectively, and the 5-year survival rates were 72%, 83%, 56%, and 0%, respectively. The adjusted hazard of death was less for the re-resection and radiofrequency ablation groups than for the transarterial chemoembolization group, and the adjusted hazard ratios for the re-resection and radiofrequency ablation groups were 0.45 (95% confidence interval, 0.20-0.98) and 0.25 (0.08-0.81), respectively. The adjusted hazard ratio (95% confidence interval) of death for the radiofrequency ablation group compared to the re-resection group was 0.64 (0.19-2.19). Survival in the single resection group did not differ from that in the re-resection and radiofrequency ablation groups.

CONCLUSION

Postrecurrence survival in the re-resection and radiofrequency ablation groups was significantly better than that in the transarterial chemoembolization group and similar to that of patients in the primary resection without recurrence group.

Prognostic factors for pulmonary metastasectomy in the treatment of hepatocellular carcinoma

BACKGROUND

This study aimed to present our experience with pulmonary metastasectomy in the treatment of hepatocellular carcinoma and to evaluate the prognostic factors.

METHODS

The clinicopathologic data of 17 patients including presence of viral hepatitis, the serum alpha-fetoprotein (AFP) level, the number of metastases, and laterality were analyzed. The overall survival rates and the prognostic factors were estimated using the Kaplan-Meier method and Cox proportional hazards model for multivariate analysis.

RESULTS

The median follow-up periods after pulmonary resection and initial hepatic resection were 28.9 and 46.2 months, respectively. The actuarial overall 1-, 3-, and 5-year survival rates after pulmonary metastasectomy were 64.7 +/- 11.6%, 29.4 +/- 11.1%, and 11.8 +/- 7.8%, respectively. Using multivariate analysis, disease-free interval (DFI) of more than 24 months (hazard ratio = 2.36, 95% confidence interval = 1.33-25.33, p = 0.020) and AFP levels after pulmonary resection (hazard ratio = 51.3 95% confidence interval = 3.68-716.66, p = 0.003) were found to be independent prognostic factors.

CONCLUSIONS

Although only a small number of patients were enrolled in this study, a disease-free interval more than 24 months and the serum AFP level after pulmonary metastasectomy might be important prognostic factors.

Repeat hepatectomy for recurrent hepatocellular carcinoma: a local experience and a systematic review

Background

This study aimed to assess the efficacy and safety of repeat hepatectomy for recurrent hepatocellular carcinoma (HCC).

Methods

Thirty-seven patients who underwent a curative repeat hepatectomy in our hospital were retrospectively studied. An extensive database literature search was performed to obtain for all relevant studies.

Results

In our series, there were no perioperative deaths during repeat hepatectomy for recurrent HCC. Patients survival after repeat hepatectomy were similar to 429 patients undergoing initial hepatectomy. A computerized search of the Medline and PubMed databases found 29 retrospective studies providing relevant data in 1149 patients were included for appraisal and data extraction. After the repeat hepatectomy, postoperative morbidity ranged from 6.2% to 68.2% with a median per cohort of 23.5 per cent. There were 7 perioperative deaths (0.7 per cent of 993 for whom mortality data were provided). The overall median survival ranged from 21 to 61.5 months, with 1 -, 3 -, and 5-year survival of 69.0% to 100%, 21.0% to 87.0%, and 25.0% to 87.0%, respectively.

Conclusions

Repeat hepatectomy can be performed safely and is associated with long-term survival in a subset of patients with recurrent HCC. However, the findings have to be carefully interpreted due to the lower level of evidence. A randomized controlled study is needed to compare repeat hepatectomy and other modalities for recurrent HCC.

Complete necrosis after transarterial chemoembolization could predict prolonged survival in patients with recurrent intrahepatic hepatocellular carcinoma after curative resection

BACKGROUND

We explored the predictors of response to transarterial chemoembolization (TACE) in patients with recurrent intrahepatic hepatocellular carcinoma (HCC) after hepatectomy and investigated the survival of these patients according to the response to TACE.

METHODS

We analyzed data from 199 consecutive HCC patients who underwent curative liver resection and who later received repeat TACE for intrahepatic HCC recurrence.

RESULTS

Of 199 patients, 139 (69.8%) achieved complete necrosis (CN) of HCC after repeated TACE (mean TACE session number, 1.3) and the other 60 (30.2%) (non-CN group) did not achieve CN. At hepatectomy, the CN group showed significantly smaller proportions of tumor capsular invasion, microvascular invasion, and pathologic tumor-node-metastasis stage III or IV HCCs. At first TACE, the CN group showed a significantly greater proportion of patients with time to recurrence > or = 1 year, Child-Pugh class A, serum alpha-fetoprotein (AFP) levels < 200 ng/mL, tumor size < 3 cm, solitary tumors, and nodular tumor types; portal vein invasion were less common than seen in the non-CN group. After multivariate analysis, tumor size < 3 cm and a single tumor at first TACE were independently related to attainment of CN after TACE. Median survival after first TACE was significantly longer in the CN group (48.9 versus 17.0 months). In a Cox regression model, CN after TACE was an independent predictor of favorable survival outcome after first TACE.

CONCLUSIONS

CN after repeat TACE for postresection intrahepatic recurrence was attained more commonly in patients with smaller tumor size and lower tumor number at first TACE and favored longer survival in recurrent patients.

Efficacy of surgical resection in management of isolated extrahepatic metastases of hepatocellular carcinoma

AIM: To clarify the benefit of surgical excision for patients with extrahepatic metastases of hepatocellular carcinoma (HCC).

METHODS: We retrospectively reviewed the medical records of 140 patients with pathologically proven extrahepatic metastases of HCC and evaluated the outcomes of those who had undergone surgical resection (SR) for extrahepatic metastatic lesions. Prognoses made on the basis of extrahepatic metastatic sites were also examined.

RESULTS: The survival rates of patients who underwent SR of extrahepatic metastases were significantly better than those of patients who did not receive SR. For the SR group, 1- and 3-year survival rates were 24% and 7%, respectively, while for the non-resection group, the survival rates were 8% and 0%, respectively (P < 0.0001). Survival rates related to metastatic sites were also significantly superior after SR of extrahepatic metastases: median survivals were 32 mo with lung metastasis, 10 mo with bone metastasis, 6.1 mo with brain metastasis.

CONCLUSION: SR can provide survival benefits for patients with 1 or 2 isolated extrahepatic metastases and who concurrently exhibit good hepatic functional reserve and general performance status as well as successful treatment of intrahepatic HCC.

Second and third hepatectomies for recurrent hepatocellular carcinoma are justified

BACKGROUND

Liver resection is the main curative treatment for hepatocellular carcinoma (HCC), but recurrence rates are high. The remnant liver is the most common site of recurrence, but the role of repeat hepatectomy in the treatment of recurrent HCC is controversial.

METHODS

Patients who underwent curative hepatectomy for HCC and subsequent repeat hepatectomy for recurrent HCC between 1990 and 2007 were reviewed retrospectively. Clinicopathological characteristics, and early- and long-term outcomes of patients who had a first, second, third and fourth hepatectomy were compared.

RESULTS

Some 1177 patients underwent a first hepatectomy for HCC, and 149, 35 and eight patients respectively had a second, third and fourth hepatectomies for recurrence. There were no significant differences in early postoperative outcomes after first and repeat hepatectomies. Five-year disease-free and overall survival rates after first, second and third hepatectomies were 43.6, 31.8 and 33.8 per cent (P = 0.772), and 52.4, 56.4 and 59.4 per cent (P = 0.879), respectively. Patients undergoing second and third hepatectomies for recurrence had better survival rates than those who did not have a repeat hepatectomy, but not those after fourth hepatectomy.

CONCLUSION

Second and third hepatectomies seem justified for hepatic recurrence of HCC. The role of fourth hepatectomy needs further investigation.

Long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma undergoing hepatectomy

OBJECTIVE

The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy.

MATERIAL AND METHODS

From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, > or =70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively.

RESULTS

The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked alpha-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor-node-metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC.

CONCLUSION

HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.

Prognostic impact of treatment modalities on patients with single nodular recurrence of hepatocellular carcinoma

PURPOSE

To evaluate the prognostic impact of various therapeutic modalities, such as repeat hepatectomy, ablation therapy, and transcatheter arterial chemoembolization (TACE) therapy, used to treat single nodular recurrent hepatocellular carcinoma (HCC).

METHODS

Thirty-two patients with single nodular intrahepatic recurrence after curative primary resection of HCC were enrolled in this study. The prognostic factors after recurrence were established using 13 clinicopathologic variables, including the therapeutic modalities; namely, repeat hepatectomy, ablation therapy, or TACE therapy.

RESULTS

Of the 32 patients, 9 underwent repeat hepatectomy, 10 underwent ablation therapy, and 13 underwent TACE therapy. The therapeutic modality was the only prognostic factor. In comparison with TACE therapy, the relative risks associated with ablation therapy and repeat hepatectomy were 0.19 and 0.29, respectively. The 5-year survival rates after single nodular recurrence were 57% in the ablation therapy group, 29% in the repeat hepatectomy group, and 0% in the TACE therapy group.

CONCLUSIONS

Repeat hepatectomy and ablation therapy are more effective than TACE therapy for improving the prognosis of patients with single nodular intrahepatic recurrent HCC.

The preoperative positivity for serum hepatitis B e antigen did not affect overall survival after curative resection of hepatitis B virus-related hepatocellular carcinoma

BACKGROUND AND AIM

Previous studies have reported different risk factors for early and late intrahepatic recurrence after resection of hepatocellular carcinoma (HCC). However, the prognostic significance of the risk factors for early and late recurrence has not been clarified.

METHODS

A total of 190 Hepatitis B surface antigen-positive patients who received curative resection for HCC were reviewed. We investigated prognostic factors for disease-free and overall survival after resection, and further analyzed the relationship between significant prognostic factors and risk factors for early (<or=14 months) and late (>14 months) intrahepatic recurrence.

RESULTS

The 5-year disease-free and overall survival rates were 43.9% and 71.5%, respectively. In multivariate analysis, adverse prognostic factors for disease-free survival were presence of serum HBeAg, perioperative transfusion, and the presence of portal vein invasion (PVI) and/or intrahepatic metastasis (IM). Multivariate analysis revealed that overall survival was associated with ICG R15, serum albumin, Edmondson-Steiner grade, and the presence of PVI and/or IM. Independent risk factors for early intrahepatic recurrence were perioperative transfusion and PVI and/or IM, whereas positivity for HBeAg was the only risk factor for late recurrence. In addition, post-recurrence survival in patients with late intrahepatic recurrence was completely comparable to that of patients who never experienced recurrence.

CONCLUSIONS

The presence of serum HBeAg, the risk factor for late intrahepatic recurrence did not affect overall survival after resection because late recurrence was relatively well controlled by current available treatments. To further improve long-term surgical outcomes, effective treatment and preventive methods for early intrahepatic recurrence should be investigated.

Re-evaluation of lipiodolized transarterial chemoembolization therapy for intrahepatic recurrence of hepatocellular carcinoma after curative liver resection

BACKGROUND/PURPOSE

While lipiodolized transarterial chemoembolization (lip-TACE) is effective for treating unresectable hepatocellular carcinoma (HCC), its effect for treating recurrent HCC after curative liver resection needs to be clarified.

METHODS

Of 163 patients who had undergone curative liver resection between 1992 and December 2003, 65 patients (39.8%) had recurrent HCC in the liver without extrahepatic recurrence and were indicated for lip-TACE. The overall survival rate after lip-TACE was calculated, and its correlation with factors such as the histology of the primary HCC and background noncancerous tissue were analyzed.

RESULTS

The overall survival rates after lip-TACE after the detection of the first recurrent HCC were 82.6%, 44.5%, and 24.8% at 1, 3, and 5 years, respectively. The factors affecting patient survival after lip-TACE were microscopic portal venous involvement of HCC at liver resection, grade of inflammation in the noncancerous liver parenchyma, and recurrence within 1 year after the initial liver resection. Multivariate analysis showed that the period between the resection and first recurrence had the highest hazard ratio.

CONCLUSIONS

Lip-TACE is a reasonable procedure for treating recurrent HCC in selected patients who are not eligible for hepatic re-resection. When HCC recurred within 1 year from the primary liver resection, the effect of lip-TACE on patient survival was limited.

Analysis of prognostic factors affecting survival after initial recurrence and treatment efficacy for recurrence in patients undergoing potentially curative hepatectomy for hepatocellular carcinoma

BACKGROUND

Survival analysis in patients with initial recurrence after curative hepatectomy for hepatocellular carcinoma (HCC) has not been well evaluated. In addition, selections of the most effective treatments for patients with recurrent HCC still remain controversial.

METHODS

Three hundred and nineteen patients who underwent potentially curative hepatectomies were followed for initial recurrence, and factors predictive of recurrence were determined. The factors affecting survival including pattern of recurrence and treatment modalities from the time of initial recurrence in 211 patients were retrospectively analyzed.

RESULTS

The overall 5-year disease-free survival rate of 319 patients was 31.1%. The 5-year survival rate of 211 patients from the time of initial recurrence was 31.9%. In a multivariate analysis, a low indocyanine green retention rate, lack of liver cirrhosis, a long interval before recurrence, the absence of portal vein invasion, and intrahepatic recurrence (<or=3 nodules) were shown to be significantly favorable prognostic factors after the initial recurrence. The 5-year survival rate of patients with intrahepatic recurrence (<or=3 nodules) was 42.3%, and no survival differences were observed among different treatment modalities.

CONCLUSION

When the initial recurrence occurred after a longer interval, and/or with three or fewer intrahepatic recurrent nodules, a favorable prognosis could be expected in those patients with better liver function and no portal vein invasion at the time of the primary hepatectomy. It is important to conduct a randomized controlled trial to clarify a method for selecting optimal treatment in patients with a smaller number of initial intrahepatic recurrences.

Improved long-term survival after liver resection for hepatocellular carcinoma in the modern era: retrospective study from HCV-endemic areas

INTRODUCTION

It remains unclear whether recent progress in perioperative management and treatment for recurrent hepatocellular carcinoma (HCC) has improved patient outcomes in hepatitis C virus-endemic areas.

METHODS

The clinicopathologic and follow-up data of 218 consecutive HCC patients who underwent curative resection between 1982 and 2003 were analyzed. Patients were assigned to one of two groups: before 1992 (early group; n=82) and 1992 and later (late group; n=136). Factors influencing survival rates were investigated by multivariate analysis. The effects of the period during which the hepatic resection was done on the patients' outcome were examined with respect to tumor size.

RESULTS

The 5-year cancer-related and disease-free survival rates were 51.4% and 20.4%, respectively. The late group showed better 5-year cancer-related survival than the early group (64.1% vs. 33.8%), but disease-free survival did not differ significantly between the groups. On multivariate analysis, the period of the hepatic resection was identified as an independent prognostic factor for cancer-related survival (relative risk 0.70, P<0.01) but not disease-free survival. There were no differences in the cancer-related and disease-free survival rates between the two groups for patients with tumors<or=25 mm. In patients with HCCs>50 mm, both cancer-related and disease-free survival rates were better in patients in the late group.

CONCLUSIONS

During the past two decades, improvements in the treatment of recurrent HCC tumors have contributed to controlling large HCCs but not to controlling the multicentric development of HCCs. It may be important to control multicentric recurrence of HCC to improve patient survival in areas where the hepatitis C virus is endemic.

Long-term outcome of resection of large hepatocellular carcinoma

BACKGROUND

The role of hepatectomy in the treatment of large hepatocellular carcinoma (HCC) is still controversial. This retrospective study evaluated whether the long-term outcome of hepatectomy for large HCC improved over 14 years in one centre.

METHODS

Data from 2102 patients who underwent hepatectomy for large HCC were collected prospectively and divided into two time intervals for analysis: before end of December 1996 (group 1) and after December 1996 (group 2). Clinicopathological data for the two groups were compared, and factors associated with long-term prognosis were further analysed.

RESULTS

Cumulative 1-, 3- and 5-year overall survival rates were 71.2, 58.8 and 38.7 per cent respectively in group 2, and were significantly better than respective rates of 67.8, 50.7 and 27.9 per cent in group 1. Cumulative 1-, 3- and 5-year disease-free survival rates were 61.5, 38.6 and 23.8 per cent respectively in group 2, and 56.5, 34.7 and 18.9 per cent in group 1. There was a significant difference in median survival time after recurrence between groups 2 and 1 (17 and 10 months respectively; P = 0.043).

CONCLUSION

Hepatic resection in patients with large HCC has improved overall and disease-free survival during the past decade at this institute. Long-term survival can be improved significantly by aggressive treatment of recurrent tumours.

Effects of Location and Extension of Portal Vein Tumor Thrombus on Long-Term Outcomes of Surgical Treatment for Hepatocellular Carcinoma

BACKGROUND

The role of surgical resection and thrombectomy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is controversial. This study aimed to evaluate the effects of the location and extent of PVTT on the long-term outcomes of surgical treatment for HCC.

METHODS

A total of 438 patients with HCC and PVTT underwent liver resection with or without thrombectomy. These 438 patients were divided into 2 groups: in group A, PVTT was located in the hepatic resection area or protruded into the first branch of the main portal vein beyond the resection line for < 1 cm (286 patients), and in group B, PVTT extended into the main portal vein (152 patients). Concomitant thrombectomy was performed in 147 patients (51.4%) of group A and in all patients of group B.

RESULTS

PVTT recurrence within 6 months after surgery in group B was significantly higher than that in group A: 76.9% vs. 11.3%. Remnant liver recurrence within 1 year after surgery was 45.0% in group A and 78.8% in group B. The cumulative 1-, 2-, 3-, and 5-year overall survival rates were 58.7%, 39.9%, 22.7%, and 18.1% for group A and 39.5%, 20.4%, 5.7%, and 0% for group B, respectively. The overall survivals were significantly better in group A than group B (P < .02).

CONCLUSIONS

Liver resection with thrombectomy yielded better outcomes in the HCC patients with PVTT confined to the first or second branch of the main portal vein compared with PVTT extending into the main portal vein.

Repeated proton beam therapy for hepatocellular carcinoma

PURPOSE

To retrospectively evaluate the safety and effectiveness of repeated proton beam therapy for newly developed or recurrent hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

From June 1989 through July 2000, 225 patients with HCC underwent their first course of proton beam therapy at the University of Tsukuba. Of them, 27 with 68 lesions who had undergone two or more courses were retrospectively reviewed in this study. Median interval between the first and second course was 24.5 months (range 3.3-79.8 months). Median total dose of 72 Gy in 16 fractions and 66 Gy in 16 fractions were given for the first course and the rest of the courses, respectively.

RESULTS

The 5-year survival rate and median survival period from the beginning of the first course for the 27 patients were 55.6% and 62.2 months, respectively. Five-year local control rate for the 68 lesions was 87.8%. Of the patients, 1 with Child-Pugh class B and another with class C before the last course suffered from acute hepatic failure.

CONCLUSIONS

Repeated proton beam therapy for HCC is safe when the patient has a target in the peripheral region of the liver and liver function is Child-Pugh class A.

A long-term follow-up and management study of hepatocellular carcinoma patients surviving for 10 years or longer after curative hepatectomy

BACKGROUND

The aims of the current study were to elucidate the clinicopathologic characteristics and disease recurrence patterns of patients with hepatocellular carcinoma (HCC) who survived for 10 years or longer after undergoing an initial hepatectomy.

METHODS

Between January 1987 and December 1993, 578 patients underwent potentially curative hepatectomy at the study institution. Disease recurrence and follow-up data were available for 481 of these patients, who then were followed for more than 10 years after the initial hepatectomy. Fourteen clinicopathologic features were compared between the 10-year survivors and those patients who died within 10 years after the surgery. The risk factors for disease recurrence, the recurrence status, time to recurrence, and treatment modalities for recurrence were examined among the 10-year survivors.

RESULTS

There were 105 10-year survivors (21.8%), including 42 disease-free survivors (8.7%). Favorable independent factors found to be correlated with 10-year survival were age < 55 years, a plasma retention rate of indocyanine green at 15 minutes of < 15%, the presence of a solitary tumor, the absence of intrahepatic metastases, the absence of portal vein invasion, and the absence of underlying cirrhosis. A negative test for the the hepatitis C antibody and the absence of intrahepatic metastases were found to be independent predictive factors for 10-year disease-free survival among the 10-year survivors.

CONCLUSIONS

The results suggest that younger patients without underlying cirrhosis who have a solitary HCC that does not demonstrate vascular invasion might survive for longer than 10 years after the initial hepatectomy. In addition to close surveillance in such patients after hepatectomy, repeat hepatectomy, local ablation therapy, and transhepatic arterial chemoembolization may contribute to long-term survival, even if disease recurrence occurs.