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Kornberg A. Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome. ISRN HEPATOLOGY 2014; 2014:706945. [PMID: 27335840 PMCID: PMC4890913 DOI: 10.1155/2014/706945] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 01/03/2014] [Indexed: 12/12/2022]
Abstract
The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.
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Affiliation(s)
- A. Kornberg
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, D-81675 Munich, Germany
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Abstract
The author draws attention on the importance surgical risk analysis from patient's safety point of view. Recently the development in quality assurance affected surgical practice as well, hence determination and evaluation of surgical risk are more exactly defined. This resulted in a significant decrease in mortality during surgical interventions on the liver despite a wider indication and increased numbers, recently. Importantly, surgical risk is much higher in patients with liver disease compared to patients with normal liver. The risk of surgical interventions for liver diseases (HCC, tumor) in patients with diffuse liver diseases (cirrhosis, chronic hepatitis, ALD) can be expressed numerically. For many years the Child-Turcotte-Pugh stadium could have been determined by using actual laboratory values. Recently the "50-50 rule" or more frequently the MELD score -- originally used in the practice of liver transplantation -- mean objective expression of surgical risk. Treatment optimalisation can reduce surgical risk, selected on the basis of risk analysis in multidisciplinary settings, which focus on the need of liver surgeons.
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Affiliation(s)
- Ferenc Jakab
- Uzsoki Utcai Kórház, 1145 Budapest, Uzsoki u. 29-41.
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Mortality predicted accuracy for hepatocellular carcinoma patients with hepatic resection using artificial neural network. ScientificWorldJournal 2013; 2013:201976. [PMID: 23737707 PMCID: PMC3659648 DOI: 10.1155/2013/201976] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 04/03/2013] [Indexed: 12/15/2022] Open
Abstract
The aim of this present study is firstly to compare significant predictors of mortality for hepatocellular carcinoma (HCC) patients undergoing resection between artificial neural network (ANN) and logistic regression (LR) models and secondly to evaluate the predictive accuracy of ANN and LR in different survival year estimation models. We constructed a prognostic model for 434 patients with 21 potential input variables by Cox regression model. Model performance was measured by numbers of significant predictors and predictive accuracy. The results indicated that ANN had double to triple numbers of significant predictors at 1-, 3-, and 5-year survival models as compared with LR models. Scores of accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) of 1-, 3-, and 5-year survival estimation models using ANN were superior to those of LR in all the training sets and most of the validation sets. The study demonstrated that ANN not only had a great number of predictors of mortality variables but also provided accurate prediction, as compared with conventional methods. It is suggested that physicians consider using data mining methods as supplemental tools for clinical decision-making and prognostic evaluation.
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Matsushima-Nishiwaki R, Adachi S, Yoshioka T, Yasuda E, Yamagishi Y, Matsuura J, Muko M, Iwamura R, Noda T, Toyoda H, Kaneoka Y, Okano Y, Kumada T, Kozawa O. Suppression by heat shock protein 20 of hepatocellular carcinoma cell proliferation via inhibition of the mitogen-activated protein kinases and AKT pathways. J Cell Biochem 2012; 112:3430-9. [PMID: 21769911 DOI: 10.1002/jcb.23270] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heat shock protein (HSP) 20, one of the low-molecular weight HSPs, is known to have versatile functions, such as vasorelaxation. However, its precise role in cancer proliferation remains to be elucidated. While HSP20 is constitutively expressed in various tissues including the liver, we have previously reported that HSP20 protein levels in human hepatocellular carcinoma (HCC) cells inversely correlate with the progression of HCC. In this study, we investigated the role of HSP20 in HCC proliferation. The activities of extracellular signal-regulated kinase (ERK), c-jun N-terminal kinase (JNK), and AKT were negatively correlated with the HSP20 protein levels in human HCC tissues. Since HSP20 proteins were hardly detected in HCC-derived cell lines, the effects of HSP20 expression were evaluated using human HCC-derived HuH7 cells that were stably transfected with wild-type human HSP20 (HSP20 overexpressing cells). In HSP20 overexpressing cells, cell proliferation was retarded, and the activation of the mitogen-activated protein kinases (MAPKs) signaling pathways, including the ERK and JNK, and AKT pathways, as well as cyclin D1 accumulation induced by either transforming growth factor-α (TGFα) or hepatocyte growth factor, were significantly suppressed compared with the empty vector-transfected cells (control cells). Taken together, our findings strongly suggest that HSP20 suppresses the growth of HCC cells via the MAPKs and AKT signaling pathways, thus suggesting that the HSP20 could be a new therapeutic target for HCC.
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Yoshida H, Shiratori Y, Kudo M, Shiina S, Mizuta T, Kojiro M, Yamamoto K, Koike Y, Saito K, Koyanagi N, Kawabe T, Kawazoe S, Kobashi H, Kasugai H, Osaki Y, Araki Y, Izumi N, Oka H, Tsuji K, Toyota J, Seki T, Osawa T, Masaki N, Ichinose M, Seike M, Ishikawa A, Ueno Y, Tagawa K, Kuromatsu R, Sakisaka S, Ikeda H, Kuroda H, Kokuryu H, Yamashita T, Sakaida I, Katamoto T, Kikuchi K, Nomoto M, Omata M. Effect of vitamin K2 on the recurrence of hepatocellular carcinoma. Hepatology 2011; 54:532-40. [PMID: 21574174 DOI: 10.1002/hep.24430] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 05/03/2011] [Indexed: 02/07/2023]
Abstract
UNLABELLED Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative treatment. Vitamin K2, which has been reported to reduce HCC development, may be effective in preventing HCC recurrence. Patients who underwent curative ablation or resection of HCC were randomly assigned to receive placebo, 45 mg/day, or 90 mg/day vitamin K2 in double-blind fashion. HCC recurrence was surveyed every 12 weeks with dynamic computed tomography/magnetic resonance imaging, with HCC-specific tumor markers monitored every 4 weeks. The primary aim was to confirm the superiority of active drug to placebo concerning disease-free survival (DFS), and the secondary aim was to evaluate dose-response relationship. Disease occurrence and death from any cause were treated as events. Hazard ratios (HRs) for disease occurrence and death were calculated using a Cox proportional hazards model. Enrollment was commenced in March 2004. DFS was assessed in 548 patients, including 181 in the placebo group, 182 in the 45-mg/day group, and 185 in the 90-mg/day group. Disease occurrence or death was diagnosed in 58, 52, and 76 patients in the respective groups. The second interim analysis indicated that vitamin K2 did not prevent disease occurrence or death, with an HR of 1.150 (95% confidence interval: 0.843-1.570, one-sided; P=0.811) between the placebo and combined active-drug groups, and the study was discontinued in March 2007. CONCLUSION Efficacy of vitamin K2 in suppressing HCC recurrence was not confirmed in this double-blind, randomized, placebo-controlled study.
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Affiliation(s)
- Haruhiko Yoshida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, and Department of Gastroenterology and Hepatology, Kanto Central Hospital, Tokyo, Japan.
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Abstract
Surgery is the most important therapeutic approach for patients with hepatocellular carcinoma. We have reviewed patients' survival after resection for hepatocellular carcinoma in 17 series since 2000, each including more than 100 patients. Median survival rates were 80% (range 63-97%) at 1 year, 70% (34-78%) at 3 years and 50% (17-69%) at 5 years. Such wide ranges of survival rates are attributed mainly to differences in the hepatocellular carcinoma stage among studies, but the survival rate is obviously much better for early hepatocellular carcinomas. Today, liver resection is an established treatment for hepatocellular carcinoma owing to minimal surgical mortality and improved survival. Liver transplantation is one of the best treatments for hepatocellular carcinoma in patients who meet the selection criteria. Further studies are needed to establish suitable criteria for transplantation in patients with hepatocellular carcinoma. For patients who are not candidates for liver resection or transplantation, percutaneous ablation is the best treatment option. However, no randomized controlled clinical trial has compared the results of ablation with those of surgical therapy for hepatocellular carcinoma, and none of the ablation techniques have been shown to offer a definitive survival advantage. A treatment algorithm based on published evidence is now available, which helps us to select the most suitable therapeutic option for individual patients, depending on tumor characteristics and liver functional reserve. This review paper summarizes the current status of the surgical management of hepatocellular carcinoma.
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Affiliation(s)
- Tadatoshi Takayama
- Department of Digestive Surgery, Nihon University School of Medicine, Oyaguchikami-machi, Itabashi-ku, Tokyo 173-8610, Japan.
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Outcomes of non-anatomic liver resection for hepatocellular carcinoma in the patients with liver cirrhosis and analysis of prognostic factors. Langenbecks Arch Surg 2010; 396:193-9. [PMID: 20852883 DOI: 10.1007/s00423-010-0700-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 07/14/2010] [Indexed: 02/08/2023]
Abstract
PURPOSE In the east countries, patients with hepatocellular carcinoma (HCC) are usually associated with varied degrees of liver cirrhosis, and anatomic resection is therefore limited to use, especially in those with severe liver cirrhosis. This study aims to evaluate the clinical value of non-anatomic resection in HCC patients with cirrhosis. METHODS Seventy-seven consecutive HCC patients with cirrhosis underwent non-anatomic liver resection in Tongji Hospital from January 2003 to December 2006. The clinical data, severity of liver cirrhosis, and survival rates of these patients were retrospectively evaluated, and the prognostic factors were analyzed. RESULTS One-, 2-, and 3-year overall and disease-free survival rates of this cohort of patients were 78%, 68%, 56%, and 66%, 58%, 55%, respectively. The hospital mortality and morbidity were 0% and 24.7%, respectively. The 1-, 2-, and 3-year overall survival rates were 85.7%, 77.1%, and 74.3% in the patients with mild cirrhosis, 81.5%, 63%, and 48.1% in the patients with moderate cirrhosis, and 60.0%, 53.3%, and 26.7% in the patients with severe cirrhosis, respectively. There was a significant difference among the patients with different grades of cirrhosis (P = 0.001). Multivariate and univariate analyses revealed that severity of cirrhosis, tumor diameter larger than 5 cm, and vascular invasion were independent prognostic factors. CONCLUSIONS Non-anatomic liver resection for HCC could yield comparable outcomes with anatomic resection in the patients with mild cirrhosis or tumors diameter smaller than 5 cm. Severity of cirrhosis is an independent factor worsening long-time survival. Non-anatomic resection is a safe and effective surgical modality in the treatment of HCC patients with cirrhosis.
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Zhu XH, Qiu YD, Wu YF, Zhou JX, Jiang CP, Ding YT. Belghiti's liver hanging maneuver in anatomic semi-hepatectomy. Shijie Huaren Xiaohua Zazhi 2009; 17:1680-1683. [DOI: 10.11569/wcjd.v17.i16.1680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the feasibility of the use of Belghiti's liver hanging maneuver in anatomic semi-hepatectomy.
METHODS: Clinical data of 28 patients undergoing semi-hepatectomy by Belghiti's liver hanging maneuver between March 2005 and December 2008 in our department were compared with those without liver hanging maneuver. The amount of intraoperative bleeding and blood transfusion, liver function recovering and postoperative complications were compared between the two groups.
RESULTS: No operative death was found in this study, and the amounts of intraoperative bleeding and transfusion were decreased significantly in the liver hanging maneuver group (426.36 ± 312.79 mL vs 526.58 ± 251.32 mL; 508.13 ± 128.26 mLvs 735.13 ± 216.79 mL, both P < 0.05). There was no significant difference in the liver function test, postoperative complications and length pf hospital-stay between the two groups.
CONCLUSION: Liver hanging maneuver is feasible in terms of anatomy and technique. With liver hanging maneuver, semi-hepatectomy may be safer and the intraoperative blood loss is reduced. It also makes the anterior approach for semi-hepatectomy safer and easier.
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Abstract
Hepatocellular carcinoma (HCC) is one of the most common cancer worldwide. In China, 90% of HCC patients are complicated with chronic liver disease (CLD), and most of them have entered into the stage of cirrhosis. Today, resection with curative intent is still an important treatment. Development of surgical techniques has improved the tolerance of patients and safety of hepatectomy. However, intrahepatic recurrences are very common due to the persistence of the underlying hepatopathy. Recurrences should be screened earlier and, when possible, treated by re-resection, percutaneous destruction, or salvage liver transplantation.
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Li WH, Cheung MT. Recurrence and survival for hepatocellular carcinoma after curative resection: Tertiary centre experience. SURGICAL PRACTICE 2008. [DOI: 10.1111/j.1744-1633.2008.00400.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Yoshida H, Yoshida H, Shiina S, Omata M. Early liver cancer: concepts, diagnosis, and management. Int J Clin Oncol 2005; 10:384-90. [PMID: 16369741 DOI: 10.1007/s10147-005-0537-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma is a major health problem worldwide. The prognosis of patients depends on the stage when the disease is diagnosed. For the early detection of these tumors, both the selection of patients at high risk and effective surveillance programs are important. When the tumor is diagnosed early, patients can choose potentially curative treatment, including surgical resection, transplantation, and ablation therapy. Here, we give an overview of the present management of hepatocellular carcinoma. Further studies in diagnosis, treatment, and prevention are required to achieve the best clinical management of this disease.
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Affiliation(s)
- Hideo Yoshida
- Department of Gastroenterology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Varotti G, Ramacciato G, Ercolani G, Grazi GL, Vetrone G, Cescon M, Del Gaudio M, Ravaioli M, Ziparo V, Lauro A, Pinna A. Comparison between the fifth and sixth editions of the AJCC/UICC TNM staging systems for hepatocellular carcinoma: multicentric study on 393 cirrhotic resected patients. Eur J Surg Oncol 2005; 31:760-7. [PMID: 15975760 DOI: 10.1016/j.ejso.2005.04.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Revised: 04/01/2005] [Accepted: 04/22/2005] [Indexed: 01/22/2023] Open
Abstract
AIMS To compare the prognostic efficacy of the 5th and 6th edition of the TNM staging system for HCC. METHODS We retrospectively applied the old and the new systems to 393 resected patients, comparing the efficacy of both in prognostic evaluation. RESULTS The 1-, 3- and 5-year overall survival rates were 89.7, 71.1 and 56.3%, respectively. The 1-, 3- and 5-year disease-free survival rates were 79.4, 54.6 and 39.4%, respectively. Among the factors evaluated, Child's grade B and C (p=0.001) and presence of multiple nodules (p=0.01) were found to be related either to a worse long-term survival or to a worse disease-free survival. Stratifying patient survivals according to the old TNM system, we found significant differences only between stages II and IIIA (p=0.001); otherwise stages I and II (p=0.9) as well as stages IIIA and IVA (p=0.9) showed similar survival rates. Analysing the new TNM system, we found a more homogeneous staging stratification, with significant differences both between stage I and II (p=0.02) and between stage II and IIIA (p=0.05). CONCLUSIONS In the present multicentric study, long term overall and disease-free survival after liver resection for HCC was strongly affected by the number of tumours and the underlying liver disease. Our results suggest that the new classification appears to achieve an accurate stratification of patients, simpler than the previous edition, as well as a more reliable comparative analysis of outcome after hepatic resection for HCC.
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Affiliation(s)
- G Varotti
- Liver and Multiorgan Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy.
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Huang YH, Wu JC, Chen CH, Chang TT, Lee PC, Chau GY, Lui WY, Chang FY, Lee SD. Comparison of recurrence after hepatic resection in patients with hepatitis B vs. hepatitis C-related small hepatocellular carcinoma in hepatitis B virus endemic area. Liver Int 2005; 25:236-41. [PMID: 15780044 DOI: 10.1111/j.1478-3231.2005.01081.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are two important factors in the development of hepatocellular carcinoma (HCC). The carcinogenic mechanism of HBV and HCV is considered to be different. It is interesting to compare the recurrence after hepatic resection in patients with small HCC who were infected with HBV or HCV. METHODS From 1991 to 1995, 145 patients who were positive for hepatitis B surface antigen (HBsAg) or antibody to HCV (anti-HCV) and diagnosed as small HCC (< or =3 cm) in three medical centers in Taiwan were evaluated in this study. All patients underwent hepatic resection. Among them, 83 (57.2%) were infected by HBV, 51 (35.2%) were infected by HCV, and 11 (7.6%) had dual HBV and HCV infection. RESULTS Anti-HCV+ HCCs were associated with older age, lower serum albumin, higher alanine transaminase (ALT) level and multi-nodular tumors during diagnosis. During the follow-up, 92 (63.4%) patients developed tumor recurrence. Anti-HCV + HCC had a higher cumulated recurrence rate than HBsAg+ HCC (72.4% vs 53.6 % at 5 year, P = 0.032). In multivariate analysis, the presence of vascular invasion and lower serum albumin levels (<3.9 g/dl) were the determinants for tumor recurrence. CONCLUSIONS HCV infection, as compared with HBV infection, had a higher cumulated recurrence after hepatic resection in patients with small HCC. Low serum albumin level was significantly associated with recurrence among these patients.
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Affiliation(s)
- Yi-Hsiang Huang
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Fiorentino M, Altimari A, Ravaioli M, Gruppioni E, Gabusi E, Corti B, Vivarelli M, Bringuier PP, Scoazec JY, Grigioni WF, D'Errico-Grigioni A. Predictive value of biological markers for hepatocellular carcinoma patients treated with orthotopic liver transplantation. Clin Cancer Res 2004; 10:1789-95. [PMID: 15014033 DOI: 10.1158/1078-0432.ccr-1149-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To help stratify candidates with hepatocellular carcinoma (HCC) for orthotopic liver transplantation (OLT), biomarkers are needed that are capable of predicting recurrence of disease (ROD). We investigated the prognostic role in this setting of immunohistochemical markers reported previously to predict poor prognosis in HCC patients treated with resection. EXPERIMENTAL DESIGN Eighty-three patients with HCC who underwent OLT between 1987 and 2001 with a minimum clinical follow up of 12 months were included in this retrospective study. We analyzed immunohistochemical expression of the adhesion molecules E-cadherin and beta-catenin (membrane/nuclear localization), MIB-1 proliferative index and the cyclin-dependent kinase inhibitor p27, alongside the main clinical-pathological variables. RESULTS At univariate analysis, vascular thrombosis, high MIB-1 index, lower membrane expression of E-cadherin and beta-catenin, and nuclear beta-catenin localization were associated with ROD. At multivariate analysis, only MIB-1 index, low equal E-cadherin (with respect to non-neoplastic surrounding tissue), and nuclear beta-catenin appeared as independent predictors of ROD. The logistic regression analysis model indicated that detection of any one parameter was associated with at least 88% estimated risk of ROD (up to 99% for all three). CONCLUSIONS We propose these three molecular parameters as an additional tool for rational selection of OLT candidates among HCC patients (stratification according to the risk of ROD might help provide a similar life expectancy for cirrhotic candidates with and without HCC).
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Affiliation(s)
- Michelangelo Fiorentino
- Pathology Unit of the "F. Addarii" Institute of Oncology, Department of Oncology and Hematology, Hopital Edouard Herriot, Lyon, France
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