Surgical therapy of hepatocellular carcinoma

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

Contrast enhanced ultrasound in mixed hepatocellular cholangiocarcinoma: Case series and review of the literature

BACKGROUND

Mixed hepatocellular cholangiocarcinoma is a rare form of primary liver cancer.

AIMS

The aim of this study is to report the results of the use of contrast enhanced ultrasound in a series of patients with confirmed mixed hepatocellular cholangiocarcinoma and to provide an updated literature review.

METHODS

Between January 2012 and October 2016, 25 Asian patients with confirmed mixed hepatocellular cholangiocarcinoma were included in this bicentric retrospective analysis. Clinical data as well recorded images of a standardized conventional B-mode ultrasound and contrast-enhanced ultrasound examination were interpreted by two blinded, independent, experienced radiologists in consensus.

RESULTS

All mixed hepatocellular cholangiocarcinoma lesions were heteroechoic on B-mode ultrasound, with ill-defined margins and irregular shapes. Arterial phase hyperenhancement was present in all 25 patients. Late-phase washout and hypoenhancement was present in 24/25 (96%) patients. However, rim-enhancement and early wash-out (which are common in cholangiocellular carcinoma) were found in over 60% of the cases.

CONCLUSION

Contrast-enhanced ultrasound demonstrated findings not typical for HCC in a large proportion of patients with confirmed mixed hepatocellular cholangiocarcinoma. Therefore, histological confirmation is crucial, especially in lesions with atypical findings.

Nomogram for preoperative estimation of long-term survival of patients who underwent curative resection with hepatocellular carcinoma beyond Barcelona clinic liver cancer stage A1

Background and Aims

This retrospective cohort study developed a prognostic nomogram to predict the survival of hepatocellular carcinoma (HCC) patients diagnosed as beyond Barcelona clinic liver cancer stage A1 after resection and evaluated the possibility of using the nomogram as a treatment algorithm reference.

Results

The predictors included in the nomogram were total tumour volume, Child-Turcotte-Pugh class, plasma fibrinogen and portal vein tumour thrombus. Patients diagnosed as beyond A1 were stratified into low-, medium- and high-risk groups using nomogram scores of 0 and 51 with the total points of 225. Patients within A1 exhibited similar recurrence-free survival (RFS) and overall survival (OS) rates compared with the low-risk group. Patients in the medium-risk group exhibited a similar OS but a worse RFS rates compared with patients within A1. The high-risk group was associated with worse RFS and OS rates compared with the patients within A1 (3-year RFS rates, 27.0% vs. 60.3%, P < 0.001; 3-year OS rates, 49.2% vs. 83.1%, P < 0.001).

Methods

A total of 352 HCC patients undergoing curative resection from September 2003 to December 2012 were included to develop a nomogram to predict overall survival after resection. Univariate and multivariate survival analysis were used to identify prognostic factors. A visually orientated nomogram was constructed using a Cox proportional hazards model.

Conclusions

This user-friendly nomogram offers an individualized preoperative recurrence risk estimation and stratification for HCC patients beyond A1 undergoing resection. Resection should be considered the first-line treatment for low-risk patients.

Surgical resection versus liver transplantation for hepatocellular carcinoma within the Hangzhou criteria: a preoperative nomogram-guided treatment strategy

BACKGROUND

With the expansion of surgical criteria, the comparative efficacy between surgical resection (SR) and liver transplantation (LT) for hepatocellular carcinoma is inconclusive. This study aimed to develop a prognostic nomogram for predicting recurrence-free survival of hepatocellular carcinoma patients after resection and explored the possibility of using nomogram as treatment algorithm reference.

METHODS

From 2003 to 2012, 310 hepatocellular carcinoma patients within Hangzhou criteria undergoing resection or liver transplantation were included. Total tumor volume, albumin level, HBV DNA copies and portal hypertension were included for constructing the nomogram. The resection patients were stratified into low- and high-risk groups by the median nomogram score of 116. Independent risk factors were identified and a visually orientated nomogram was constructed using a Cox proportional hazards model to predict the recurrence risk for SR patients.

RESULTS

The low-risk SR group had better outcomes compared with the high-risk SR group (3-year recurrence-free survival rate, 71.1% vs 35.9%; 3-year overall survival rate, 89.8% vs 78.9%, both P<0.001). The high-risk SR group was associated with a worse recurrence-free survival rate but similar overall survival rate compared with the transplantation group (3-year recurrence-free survival rate, 35.9% vs 74.1%, P<0.001; 3-year overall survival rate, 78.9% vs 79.6%, P>0.05).

CONCLUSIONS

This nomogram offers individualized recurrence risk evaluation for hepatocellular carcinoma patients within Hangzhou criteria receiving resection. Transplantation should be considered the first-line treatment for high-risk patients.

Prognostic prediction of male recipients selected for liver transplantation: With special attention to neutrophil to lymphocyte ratio

AIM

Neutrophil to lymphocyte ratio (NLR) is an inflammatory biomarker that has a close relationship with tumor progression and metastasis. In this study, we aimed to investigate the role of NLR in the prognosis of male candidates with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT).

METHODS

We analyzed the clinical data of 248 male HCC candidates who underwent LT in our Liver Transplantation Center between 2002 and 2012. All risk factors were analyzed by univariate and multivariate Cox analysis and survival rates were calculated by Kaplan-Meier log-rank test.

RESULTS

NLR was proved to be an independent risk factor affecting overall survival (OS) (P < 0.001) and tumor-free survival (TFS) (P = 0.003) of male candidates with HCC following LT. Additionally, our study showed that elevated NLR (>4) was associated with early tumor recurrence by Kaplan-Meier analysis. Furthermore, we established Model_OS and Model_TFS to predict prognosis based on multivariate Cox analysis. Our study showed that male candidates with HCC who exceeded the Milan criteria but within Model_OS could achieve similar OS as those within the Milan criteria (P = 0.220). Similarly, male patients who exceeded the Milan criteria but within Model_TFS could achieve similar TFS as those within the Milan criteria (P = 0.197).

CONCLUSION

Proper inflammatory response may effectively reduce tumor recurrence after LT. Elevated NLR (>4) within a certain range is associated with early tumor recurrence. NLR-based models are efficient and safe for prognostic prediction among male candidates with HCC for LT.

Interferon-α2b gene-modified human bone marrow mesenchymal stem cells inhibit hepatocellular carcinoma by reducing the Notch1 levels

AIMS

Hepatocellular carcinoma (HCC) is the most common liver cancer worldwide. IFN-α has been used in clinics as a potential therapeutic strategy to treat HCC. In spite of the therapeutic effects, IFN-α caused many side effects due to its short half-life and high dose. Here, we aim to detect the anti-tumor effect of a novel gene delivery system - IFN-α2b gene-modified human bone marrow mesenchymal stem cells (BMSCs) in HCC.

MAIN METHODS

Two HCC cell lines, HepG2 and Huh7 were used in the current study. The secretion of IFN-α2b in the BMSC cultured conditioned media (CM) was measured by ELISA. The cell cycle was determined by flow cytometry. The Xenografted NOD/SCID mouse tumor model was generated by subcutaneous inoculation with HepG2 cells.

KEY FINDINGS

We found that the IFN-α2b-modified BMSC (BMSC/IFN-α2b) could express IFN-α2b stably. The CM from BMSC/IFN-α2b inhibited the proliferation of HCC cells with a much lower growth rate compared with BMSC/vector-CM or DMEM culture group. We further demonstrated that the population of G2/M phase was higher in BMSC/IFN-α2b-CM treated cells than the other two groups. In addition, BMSC/IFN-α2b could significantly inhibit tumor growth in NOD/SCID mice. Moreover, we found that BMSC/IFN-α2b-CM could significantly decrease the mRNA and protein levels of Notch signaling molecules of HCC in vitro and in vivo.

SIGNIFICANCE

Our data demonstrated that BMSC/IFN-α2b could significantly inhibit HCC cell growth through negatively regulating the Notch signaling, which suggested that IFN-α2b-modified BMSC may be used as an effective therapeutic strategy for hepatomas.

Tumor PHD2 expression is correlated with clinical features and prognosis of patients with HCC receiving liver resection

The role of prolyl hydroxylase domain protein 2 (PHD2) in carcinogenesis has been studied in a variety of cancer types. However, the association between PHD2 and human hepatocellular carcinoma (HCC) has not been documented. A total of 220 patients with primary HCC who underwent a curative liver resection were enrolled in this study. The tumor samples were obtained during the surgical procedure from each patient for PHD2 immunohistological staining. All the patients were followed up and the disease-free survival (DFS) and overall survival (OS) were evaluated. We found that that high PHD2 expression was significantly associated with higher stage (stages III + IV) (odds ratio [OR] = 5.576, P < 0.001), larger tumor size (> 5 cm) (OR = 6.176, P < 0.001), poorer tumor differentiation (OR = 1.424, P = 0.003), and higher serum alpha fetoprotein (AFP) level (OR = 6.861, P < 0.001). Compared to those with high PHD2 expressions, patients with low PHD2 expression had significantly longer DFS and OS periods (both P < 0.001). Cox regression analyses revealed that higher levels of PHD2, tumor size, tumor stage, as well as serum AFP level were predictors for a worse prognosis in patients with HCC. PHD2 expression in the tumors is associated with the clinical features and prognosis of patients with HCC; it may be used as a histological marker for HCC.

Major hepatectomy is a safe modality for the treatment of intrahepatic cholangiocarcinoma in selected patients complicated with cirrhosis

OBJECTIVE

The objective of this paper is to evaluate the perioperative outcomes of major hepatectomy for intrahepatic cholangiocarcinoma (ICC) in patients with cirrhosis.

METHODS

We retrospectively evaluated the preoperative, intraoperative, and postoperative findings in 42 consecutive patients with cirrhosis and in 102 patients with normal livers who underwent major hepatectomy for ICC.

RESULTS

Preoperative liver function was worse in patients with cirrhosis compared to patients without cirrhosis. Cirrhotic patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than non-cirrhotic patients. However, the two groups had similar overall morbidity and hospital mortality rates and similar rates of liver failure or other complications. Their R0 resection rates, resection margin widths and disease-free survival rates were also similar.

CONCLUSIONS

Major hepatectomy for ICC can be performed in selected cirrhotic patients with acceptable morbidity and mortality rates, as compared to patients without cirrhosis.

Surgical resection versus liver transplant for patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is a major worldwide health problem, involving more than half a million new patients yearly, with a different incidence in different parts of the world. Hepatocellular carcinoma develops in about 80% of cirrhotic patients, and cirrhosis is considered the strongest predisposing factor for it. Surgical resection and liver transplantation are conventional treatment modalities that can offer long-term survival for patients with hepatocellular carcinoma.

OBJECTIVES

To assess the benefits and harms of surgical resection compared with those of liver transplantation in patients with hepatocellular carcinoma.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (SCI-EXPANDED) at ISI Web of Science (last search February 2013). We also searched the abstracts from annual meetings of the American Society of Clinical Oncology, the American Association for the Study of Liver Diseases (AASLD), and the European Association for the Study of the Liver (EASL), provided through The Cochrane Hepato-Biliary Group until February 2013.

SELECTION CRITERIA

Randomised clinical trials comparing surgical resection and hepatic transplantation.

DATA COLLECTION AND ANALYSIS

The search strategies were run and two authors individually evaluated whether the retrieved studies fulfilled the inclusion criteria.

MAIN RESULTS

No randomised clinical trials comparing surgical resection and liver transplantation as the major methods of treating hepatocellular carcinoma were found.

AUTHORS' CONCLUSIONS

There are no randomised clinical trials comparing surgical resection and liver transplantation for hepatocellular carcinoma treatment.

Multimodal treatment strategies in patients undergoing surgery for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the major health problems worldwide, and continues to grow because of its association with hepatitis B and C viruses. In patients with HCC, liver transplantation (LT) and liver resection are the only two curative treatment options. LT remains the best option since it not only removes the tumor, but also the underlying disease. The prerequisite for long-term success of LT for HCC depends on the tumor load and strict selection criteria with regard to the size and number of existing HCC lesions. The need to obtain the optimal benefit from a limited number of grafts has prompted the implementation of well-defined selection criteria that identify patients with early HCC who may benefit from better long-term outcome after LT. Unfortunately, LT can only be proposed in approximately 30% of patients with HCC due to limitations in donor graft availability. In this particular setting, open and laparoscopic surgical resection represent reasonable treatment modalities in noncirrhotic HCC patients. The decision-making process for liver resection should integrate the tumor stage, quality and function of the underlying liver parenchyma, volume of the future liver remnant, and general condition of the patient. In patients with favorable features (solitary tumor, compensated Child-Pugh A cirrhosis, no portal hypertension), the reported 5-year survival rates range between 50 and 70%. In specific cases, liver resection and LT may be combined in the same patient.

Integrative genomic identification of genes on 8p associated with hepatocellular carcinoma progression and patient survival

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) is an aggressive malignancy; its mechanisms of development and progression are poorly understood. We used an integrative approach to identify HCC driver genes, defined as genes whose copy numbers associate with gene expression and cancer progression.

METHODS

We combined data from high-resolution, array-based comparative genomic hybridization and transcriptome analysis of HCC samples from 76 patients with hepatitis B virus infection with data on patient survival times. Candidate genes were functionally validated using in vitro and in vivo models.

RESULTS

Unsupervised analyses of array comparative genomic hybridization data associated loss of chromosome 8p with poor outcome (reduced survival time); somatic copy number alterations correlated with expression of 27.3% of genes analyzed. We associated expression levels of 10 of these genes with patient survival times in 2 independent cohorts (comprising 319 cases of HCC with mixed etiology) and 3 breast cancer cohorts (637 cases). Among the 10-gene signature, a cluster of 6 genes on 8p, (DLC1, CCDC25, ELP3, PROSC, SH2D4A, and SORBS3) were deleted in HCCs from patients with poor outcomes. In vitro and in vivo analyses indicated that the products of PROSC, SH2D4A, and SORBS3 have tumor-suppressive activities, along with the known tumor suppressor gene DLC1.

CONCLUSIONS

We used an unbiased approach to identify 10 genes associated with HCC progression. These might be used in assisting diagnosis and to stage tumors based on gene expression patterns.

A scoring model based on neutrophil to lymphocyte ratio predicts recurrence of HBV-associated hepatocellular carcinoma after liver transplantation

BACKGROUND

Neutrophil to lymphocyte ratio (NLR) has been proposed to predict prognosis of hepatocellular carcinoma (HCC). However, the cut-off values are empirical. We determined the optimal cut-off value to predict HCC recurrence after liver transplantation (LT) and further established a scoring model based on NLR.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed the outcome of 101 HBV-associated HCC patients undergoing LT. Preoperative risk factors for tumor recurrence were evaluated by univariate analysis. By using ROC analysis, NLR≥3 was considered elevated. The disease-free survival (DFS) and overall survival (OS) for patients with high NLR was significantly worse than that for patients with normal NLR (the 5-year DFS and OS of 28.5% and 19.5% vs. 64.9% and 61.8%, respectively; P<0.001). Univariate analysis revealed that tumor size >5 cm, tumor number >3, macrovascular invasion, AFP≥400 µg/L, NLR≥3, and HBV-DNA level >5 log10 copies/mL were preoperative predictors of DFS. Cox regression analysis showed macrovascular invasion, tumor number, and high NLR were independent prognostic factors. We then established a preoperative prognostic score based on multivariate analysis. Each factor was given a score of 1. Area under the ROC curve of the score was 0.781. All nine patients with score 3 developed recurrence within 6 months after LT. Of 71 patients without vascular invasion, three patients with both tumor number >3 and NLR≥3 developed recurrence within 14 months after LT while the 5-year DFS and OS for patients with a score of 0 or 1 were 68.1% and 62.8%, respectively.

CONCLUSIONS/SIGNIFICANCE

Preoperative elevated NLR significantly increases the risk of recurrence in patients underwent LT for HCC. Patients with both NLR≥3 and tumor number >3 are not a good indication for LT. Our score model may aid in the selection of patients that would most benefit from transplantation for HCC.

Patient selection for surgical management of primary and metastatic liver cancers: current perspectives

The surgical management of liver malignancies remains a mainstay in the treatment of such patients, and has benefited from dramatic advancements over the last two decades. Improvements in surgical technique, better understanding of hepatic anatomy, and improvement in anesthesiological supportive care has resulted in a decline in perioperative morbidity and operative mortality. Proper patient selection for surgical and nonsurgical treatment currently employs a multidisciplinary approach in our institution. This review will focus on the surgical treatment options for both primary and secondary liver cancers.

Treating hepatocellular carcinoma with sorafenib in liver transplant patients: an initial experience

Sorafenib has been approved for the treatment of advanced hepatocellular carcinoma (HCC). However, there are no data reported on its use in HCC patients with localized disease who have undergone orthotopic liver transplantation (OLT). Herein, we have reviewed our initial experience with 7 HCC patients who were candidates for OLT and were treated with sorafenib. Treating liver transplant patients with sorafenib appeared to be safe based upon our limited experience. There is a strong need for clinical trials to comprehensively study the safety of sorafenib before OLT.

Repeated radiofrequency ablation for management of patients with cirrhosis with small hepatocellular carcinomas: a long-term cohort study

In most patients with cirrhosis, successful percutaneous ablation or surgical resection of hepatocellular carcinoma (HCC) is followed by recurrence. Radiofrequency ablation (RFA) has proven effective for treating HCC nodules, but its repeatability in managing recurrences and the impact of this approach on survival has not been evaluated. To this end, we retrospectively analyzed a prospective series of 706 patients with cirrhosis (Child-Pugh class ≤ B7) who underwent RFA for 859 HCC ≤ 35 mm in diameter (1-2 per patient). The results of RFA were classified as complete responses (CRs) or treatment failures. CRs were obtained in 849 nodules (98.8%) and 696 patients (98.5%). During follow-up (median, 29 months), 465 (66.8%) of the 696 patients with CRs experienced a first recurrence at an incidence rate of 41 per 100 person-years (local recurrence 6.2; nonlocal 35). Cumulative incidences of first recurrence at 3 and 5 years were 70.8% and 81.7%, respectively. RFA was repeated in 323 (69.4%) of the 465 patients with first recurrence, restoring disease-free status in 318 (98.4%) cases. Subsequently, RFA was repeated in 147 (65.9%) of the 223 patients who developed a second recurrence after CR of the first, restoring disease-free status in 145 (98.6%) cases. Overall, there were 877 episodes of recurrence (1-8 per patient); 577 (65.8%) of these underwent RFA that achieved CRs in 557 (96.5%) cases. No procedure-related deaths occurred in 1,921 RFA sessions. Estimated 3- and 5-year overall and disease-free (after repeated RFAs) survival rates were 67.0% and 40.1% and 68.0 and 38.0%, respectively.

CONCLUSION

RFA is safe and effective for managing HCC in patients with cirrhosis, and its high repeatability makes it particularly valuable for controlling intrahepatic recurrences.

Model for end-stage liver disease exceptions committee activity in Argentina: does it provide justice and equity among adult patients waiting for a liver transplant?

BACKGROUND

In 2005, the model of end-stage liver disease (MELD)-based allocation system was adopted to assess potential liver transplant (LT) recipients in Argentina. The aim of the present study was to revise the activity of the MELD Exception Experts Committee.

METHODS

Between 2005 and 2009, 1623 patients were listed for LT. Regulation provides extra-MELD points for amyloidosis, hepatopulmonary syndrome (HPS) and T(2) hepatocellular carcinoma (T(2) HCC). Centres could also request priority for other situations. Using a prospective database, we identified patients in whom priority points were requested. Pathology reports of explanted livers were analysed for patients with T(2) HCC.

RESULTS

From 234 out of 1623 (14.4%) requests, the overall approval rate was 60.2% including: 2 amyloidosis, 6 HPS, 111 T(2) HCC and 22 non-regulated situations. Of the 111 patients with T(2) HCC, 6 died (5.4%), 8 had tumour progression (7.2%), 94 were transplanted (84.2%) and 3 are still waiting. An explants correlation showed that presumed diagnosis of T(2) HCC was incorrect in 20/94 (22%) and was correct in only 41/94 (43%) cases being T(1) HCC in 9 and T(3) HCC in 23.

CONCLUSIONS

MELD exceptions are frequently requested in Argentina. Unfortunately, most receiving priority points for T(2) HCC benefited by medical error or imaging limitations. An intense review process is urgently needed to maintain equity and justice in the allocation system.

Transcatheter arterial chemoembolization plus radiofrequency ablation therapy for early stage hepatocellular carcinoma: comparison with surgical resection

BACKGROUND

Radiofrequency ablation (RFA) is becoming a well-known local therapy for hepatocellular carcinoma (HCC). Transcatheter arterial chemoembolization (TACE) is expected to enhance the effects of subsequent RFA by reducing arterial blood flow. However, the long-term efficacy of this combined therapy has not been elucidated. In this study, the survival rates of patients who received TACE combined with RFA (TACE + RFA) were compared with those of patients treated surgically.

METHODS

The study included consecutive patients who received TACE+RFA or surgical resection as the initial curative treatment for HCC between 2000 and 2005 at Tokai University Hospital. Inclusion criteria were a single HCC<or=50 mm or up to 3 HCCs<or=30 mm, presence of cirrhosis classified as Child-Pugh class A, no vascular invasion, and no extrahepatic metastasis.

RESULTS

Sixty-two patients (23 women, 39 men; aged 67.5+/-8.4 years [mean+/-standard deviation]) received TACE+RFA, and 55 patients (15 women, 40 men; aged 66.1+/-8.4 years) underwent surgical resection. Median follow-up periods were similar (50 months in the TACE+RFA group vs 49 months in the resection group). The probabilities of overall survival at 1, 3, and 5 years in the TACE+RFA group (100%, 94.8%, and 64.6%, respectively) were similar (P=.788) to those in the resection group (92.5%, 82.7%, and 76.9%, respectively). Two major RFA-related complications were observed (1.5%).

CONCLUSIONS

RFA combined with TACE is an efficient and safe treatment that provides overall survival rates similar to those achieved with surgical resection.

Outcome of combined hepatocellular and cholangiocarcinoma of the liver

Background. The objective of this study was to examine the epidemiology, natural history, and prognostic factors of combined hepatocellular and cholangiocarcinoma (cHCC-CC) using population-based registry. Methods. The Surveillance, Epidemiology, and End Results Program database (1973–2004) was used to identify cases of cHCC-CC. Multivariable logistic regression was used to evaluate factors associated with cancer-directed surgery (CDS). The influence of CDS on cancer specific survival was evaluated using Kaplan-Meier curves and Cox proportional hazards modeling. Results. A total of 380 cases of cHCC-CC were identified, which account for approximately 0.87% of primary liver tumors. Of all patients, 69.8% of patients had regional or distant stage; 65.6% of patients had poorly or undifferentiated histology. Only 44.9% of patients with localized disease, received CDS. By logistic regression analysis, being widowed, advanced stage, and earlier diagnosis year were associated with lower rate of utilization of CDS. In multivariate analysis, tumor stage, receipt of CDS, and recent year of diagnosis were found to be significant predictors for cancer-specific survival. Conclusions. Patients with localized cHCC-CC who are selected for CDS were strongly associated with improved survival. However, many patients with localized tumors did not receive potentially curative cancer-directed surgery. Further study is warranted to address the barriers to the delivery of appropriate care to these patients.

Approach to radiation therapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the 5th most common cancer and the third most common cause of cancer-related death in the world with an estimated incidence of approximately 1 million new cases annually, has becoming a major global health problem in the world. A variety of treatment modalities, including resection, liver transplantation, transarterial chemoembolization (TACE), local ablative therapy and radiation therapy (RT) have been reported. Although partial hepatectomy and liver transplantation may offer the best chance of cure, only 15% of the patients have the chance to be treated by surgery when diagnosed. The effectiveness of systemic chemotherapy for HCC has been minimal, and local ablative therapy may offer comparable survival in patients with small HCC and preserve liver function. Recently, with developments in radiotherapy techniques, radiotherapy has been shown to play potential roles in a wide spectrum of HCC and to become more important so that it is necessary to evaluate the effect of radiotherapy in treatment of HCC. This paper is aiming mainly at the current radiation therapy strategies and their current advances, the optimal radiation therapy strategies will complement the current treatments and improve the treatment efficiency.

Minor versus major hepatic resection for small hepatocellular carcinoma (HCC) in cirrhotic patients: a 20-year experience

BACKGROUND

The choice between minor versus major resection or anatomic versus nonantatomic resection for small (<5 cm) solitary hepatocellular carcinoma (HCC) in patients with cirrhosis is controversial. The aim of our study was to evaluate the long-term disease-free survival (DFS) and overall survival (OS) after minor or major hepatic resection for small solitary HCC in cirrhotic patients.

METHODS

Between January 1983 and December 2002, patients with solitary HCC of < or = 5 cm in size who had histologically proven liver cirrhosis and microscopically tumor-free margin were included. These selected patients underwent either minor (< or = 2 segments) or major (> or = 3 segments) hepatectomy.

RESULTS

In 373 patients, 259 underwent minor and 114 underwent major hepatectomy. Patients in the minor resection group had more severe underlying liver disease (P = .005). Therefore, only 29.3% received anatomic resection in the minor resection group in comparison with 72.8% in the major hepatectomy group (P = .0001). No difference was found in postoperative morbidity (P = .105), mortality (P =.222), intrahepatic recurrence (P = .742), and 5-year DFS and OS (31.6% vs 31.8%, P = .932 and 50.7% vs 44.0%, P = .114) in both groups. The type of operative resection was not found to be a significant factor affecting survival in univariate analysis, but the preoperative liver function (alanine aminotransferase [AST] or alanine aminotransferase [ALT], serum albumin, or Child-Pugh status), tumor characteristics (alpha-feto protein, size, and presence of daughter nodules), and blood transfusion were found to be independent factors that affect the DFS and OS in a multivariate analysis.

CONCLUSION

The severity of cirrhosis and tumor characteristics depicts long-term survival rather than the type of resection in HCC.

Single HCC smaller than 2 cm: surgery or ablation: interventional oncologist's perspective

In the EASL and AASLD guidelines, hepatic resection (HR) is considered the first option for patients in stage 0 (very early HCC). This statement was not based on randomized controlled trials (RCTs) versus other therapies, but on the oncological assumption that HR is the better procedure for obtaining complete tumor ablation including a safety margin. Subsequently, three RCTs compared percutaneous radiofrequency ablation (RFA) versus HR in patients with early HCC. All failed to demonstrate better survival in favor of HR, even though the larger size of the early stage needs a larger area of necrosis. A recent study focused on stage 0 demonstrated a sustained local complete response after RFA comparable with that of HR. All these trials established that RFA is less invasive and associated with lower complication rates and lower costs. These data suggest that RFA can be considered the first option for operable patients with very early HCC. Other options (HR, PEI, selective TAE/TACE) can be used as salvage therapy for the few cases in which RFA is unsuccessful or unfeasible.

Systematic review and meta-analysis of interferon after curative treatment of hepatocellular carcinoma in patients with viral hepatitis

BACKGROUND

A combined antiviral and tumoricidal effect of interferon (IFN) is assumed to occur after resection or ablation of hepatocellular carcinoma (HCC).

METHODS

An electronic search of the Medline, Embase and Central databases from January 1998 to October 2007 was conducted to identify randomized controlled trials evaluating adjuvant effects of IFN after curative treatment of HCC. A meta-analysis was performed to estimate the effects of IFN on 2-year outcome.

RESULTS

Seven trials enrolling a total of 620 patients were included in the meta-analysis. Adjuvant treatment with IFN significantly reduced the 2-year mortality rate after curative treatment of HCC, with a pooled risk ratio of 0.65 (95 per cent confidence interval 0.52 to 0.80); P < 0.001) in absence of any significant heterogeneity (I(2) = 0 per cent, P = 0.823 for chi(2)). The effect on reduction of tumour recurrence was less pronounced but still significant (pooled risk ratio 0.86 (95 per cent c.i. 0.76 to 0.97); P = 0.013). IFN had to be discontinued in 8-20 per cent of patients.

CONCLUSION

IFN has a significant beneficial effect after curative treatment of HCC in terms of both survival and tumour recurrence.

A case of recurrent metastatic hepatocellular cancer controlled with immunotherapy and antiviral therapy following resection

Hepatocellular carcinoma (HCC) is the most frequent malignant tumour of the liver. The risk of HCC in chronically hepatitis B virus (HBV) infected individuals is approximately 100-fold higher than in the uninfected population. Despite all therapeutic advances, the benefit of systemic chemotherapy in patients with HCC has limited. But, the phase III clinical trial conducted in patients with advanced HCC treated with sorafenib has showed significant improvements in both overall and progression-free survival Metastasis from liver to extrahepatic tissues is reported to be quite uncommon and has a poor prognosis. Here we present a case of HCC which metastasized to the vertebrae, lung and kidney in order of appearance and controlled with immunotherapy and antiviral therapy following resection.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinicopathologic features between multicentric occurence and intrahepatic metastasis of multiple hepatocellular carcinomas related to HBV

AIMS

To clarify the incidence of multicentric occurrence (MO) and intrahepatic metastasis (IM) for hepatocellular carcinoma (HCC) related to hepatitis B virus (HBV) in China and to identify the differences between them.

PATIENTS AND METHODS

Histopathologic features of multiple tumors in 82 cases with HCC were analyzed. The two groups, the origin was determinable as of multicentric occurrence or as of intrahepatic metastasis, were analyzed for their survival rate, disease-free survival and clinicopathologic differences.

RESULTS

According to histological findings, 19.5% and 69.5% patients were considered to be MO and IM, respectively. In total 73 cases from the histopathological method were selected and divided into group MO (16 cases) and the group IM (57 cases). Analysis of stepwise regression identified that: Child's stage, cholinesterase (host factors), tumor size, histological grade and positive portal vein invasion (tumor factors) were the most important discriminating factors between MO and IM (p<0.05). As for their prognosis, Kaplan-Meier and Log rank test showed the survival rate in group MO was significantly better than that in the group IM (p=0.003). No statistical significance was found between the disease-free survival in group MO and that in group IM (p=0.141). The analysis of Cox's proportional hazards model showed that tumor type (MO or IM) and Child's stage were the important prognostic factors (p=0.002 and 0.014, respectively).

CONCLUSIONS

The incidence of MO in patients with multiple HCCs related to HBV is only about 20%, which is lower than that of Japan. Child's stage, cholinesterase (host factors), tumor size, histological grade and positive portal vein invasion (tumor factors) are the most important discriminating factors between MO and IM. The prognosis of patients with MO compared to IM is significantly better and tumor type (MO or IM) and Child's stage are important prognostic factors.

Liver surgery in the presence of cirrhosis or steatosis: Is morbidity increased?

Background data

The prevalence of steatosis and hepatitis-related liver cirrhosis is dramatically increasing together worldwide. Cirrhosis and, more recently, steatosis are recognized as a clinically important feature that influences patient morbidity and mortality after hepatic resection when compared with patients with healthy liver.

Objective

To review present knowledge regarding how the presence of cirrhosis or steatosis can influence postoperative outcome after liver resection.

Methods

A critical review of the English literature was performed to provide data concerning postoperative outcome of patients presenting injured livers who required hepatectomy.

Results

In clinical studies, the presence of steatosis impaired postoperative outcome regardless the severity and quality of the hepatic fat. A great improvement in postoperative outcome has been achieved using modern and multidisciplinary preoperative workup in cirrhotic patients. Due to the lack of a proper classification for morbidity and a clear definition of hepatic failure in the literature, the comparison between different studies is very limited. Although, many surgical strategies have been developed to protect injured liver surgery, no one have gained worldwide acceptance.

Conclusion

Surgeons should take the presence of underlying injured livers into account when planning the extent and type of hepatic surgery. Preoperative and perioperative interventions should be considered to minimize the additional damage. Further randomized trials should focus on the evaluation of novel preoperative strategies to minimize risk in these patients. Each referral liver center should have the commitment to report all deaths related to postoperative hepatic failure and to use a common classification system for postoperative complications.

Future of molecular profiling of human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a fatal disease occurring worldwide and developing mainly in chronic liver diseased patients. Despite routine screening of individuals at high risk, most of the patients are diagnosed at late stages of HCC. In addition, the recurrence rate after surgical resection of small tumors is high. Molecular profiling, including expression analysis, comparative genomics and proteomics, provides powerful tools to gain insight into the molecular mechanisms underlying carcinogenesis. Advances in bioinformatics have also allowed for the evaluation of large data sets. Therefore, molecular profiling of HCC using a Biological Expression Network Discovery (BLEND) strategy that integrates global molecular profiling data, including mRNA, miRNA, DNA methylation and DNA copy numbers from both the tumor and the surrounding microenvironment, along with mechanistic studies, may improve the diagnosis, treatment and prognosis of HCC patients. Such an approach will provide mechanistic insight into the pathogenesis of HCC, potentially leading to personalized medicine and the identification of new therapeutic targets.

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice?

If liver transplantation is not feasible, partial resection is considered the treatment of choice for hepatocellular carcinoma (HCC) in patients with cirrhosis. However, in some centers the first-line treatment for small, single, operable HCC is now radiofrequency ablation (RFA). In the current study, 218 patients with single HCC <or= 2.0 cm (very early or T1 stage) underwent RFA. We assessed 2 primary end points that could be easily compared with those reported for resective surgery: (1) the rate of sustained, local, complete response and (2) the rate of treatment-related complications. The secondary end point was 5-year survival in the 100 patients whose tumors had been considered potentially operable. After a median follow-up of 31 months, sustained complete response was observed in 216 patients (97.2%). In the remaining 6, percutaneous ethanol injection, selective intraarterial chemoembolization, or resection were used as salvage therapy. Perioperative mortality, major complication, and 5-year survival rates were 0%, 1.8%, and 68.5%, respectively.

CONCLUSION

Compared with resection, RFA is less invasive and associated with lower complication rate and lower costs. RFA is also just as effective for ensuring local control of stage T1 HCC, and it is associated with similar survival rates (as recently demonstrated by 2 randomized trials). These data indicate that RFA can be considered the treatment of choice for patients with single HCC <or= 2.0 cm, even when surgical resection is possible. Other approaches can be used as salvage therapy for the few cases in which RFA is unsuccessful or unfeasible.

Combined hepatectomy and radiofrequency ablation for multifocal hepatocellular carcinomas: long-term follow-up results and prognostic factors

BACKGROUND

For multifocal hepatocellular carcinomas (HCCs) that are untreatable with resection only, locoregional therapies added to hepatectomy have been introduced. However, some preliminary reports have documented average survival results and relatively high complication rates. We evaluated the long-term survival results and safety of combined hepatectomy and radiofrequency ablation (RFA) in patients with HCCs and assessed the prognostic factors affecting their survival.

METHODS

A total of 53 patients who had 148 HCCs in their livers underwent hepatectomy combined with ultrasound-guided intraoperative RFA. The mean diameter of the 82 resected tumors was 4.8 cm (range 1.3-21.0 cm) and that of 66 ablated tumors was 1.5 cm (range 0.8-3.5 cm). We evaluated the primary effectiveness rates, survival rates, and complications. In addition, we assessed the prognostic factors associated with the survival rates using Cox proportional hazard models.

RESULTS

The primary effectiveness rate of RFA was 98% (65 of 66). Local tumor progression was observed in two (3%) ablation zones of 65 tumors with complete primary effectiveness. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 87, 83, 80, 68, and 55%, respectively. Patients with smaller resected tumors (< or = 5 cm) demonstrated better survival results (P = 0.004). No procedure-related deaths occurred. We observed hepatectomy-related complications in 4 patients (8%, 4 of 53) and an RFA-related complication in 1 patient (2%, 1 of 53).

CONCLUSIONS

Combined hepatectomy and RFA is an effective and safe treatment modality for multifocal HCCs. Resected tumor size was a significant prognostic predictor of long-term survival.

Difference in tumor invasiveness in cirrhotic patients with hepatocellular carcinoma fulfilling the Milan criteria treated by resection and transplantation: impact on long-term survival

SUMMARY BACKGROUND DATA

Some previous studies demonstrated better survival after transplantation for small hepatocellular carcinoma (HCC) compared with resection, but the influence of differences in tumor invasiveness between transplanted and resected patients has not been studied. This study compared the tumor characteristics of patients with HCC within the Milan criteria treated by resection or transplantation, and elucidated their impact on long-term survival.

PATIENTS AND METHODS

Tumor characteristics and long-term survival of 204 cirrhotic patients with resection and 43 cirrhotic patients with transplantation for HCC within the Milan criteria were compared. A multivariate analysis was performed to determine the prognostic factors of survival in all patients with resection or transplantation.

RESULTS

Tumors in the transplanted group were associated with lower incidence of high-grade tumors, microscopic venous invasion, and microsatellite nodules. The overall 5-year survival was better in the transplantation group than the resection group (81% vs. 68%, P = 0.017). However, there were no significant differences in survival between the two groups when stratified according to presence or absence of venous invasion. Multivariate analysis showed that hepatitis C virus serology, tumor size, tumor number, and microscopic venous invasion, but not resection or transplantation, were of prognostic significance.

CONCLUSIONS

There were significant differences in tumor invasiveness in HCC treated by transplantation and resection as a result of selection bias, even in patients with the tumors fulfilling the Milan criteria. When the different tumor invasiveness was taken into account, there was no significant difference in the long-term survival after resection or transplantation.

Difference in tumor invasiveness in cirrhotic patients with hepatocellular carcinoma fulfilling the Milan criteria treated by resection and transplantation: impact on long-term survival

SUMMARY BACKGROUND DATA

Some previous studies demonstrated better survival after transplantation for small hepatocellular carcinoma (HCC) compared with resection, but the influence of differences in tumor invasiveness between transplanted and resected patients has not been studied. This study compared the tumor characteristics of patients with HCC within the Milan criteria treated by resection or transplantation, and elucidated their impact on long-term survival.

PATIENTS AND METHODS

Tumor characteristics and long-term survival of 204 cirrhotic patients with resection and 43 cirrhotic patients with transplantation for HCC within the Milan criteria were compared. A multivariate analysis was performed to determine the prognostic factors of survival in all patients with resection or transplantation.

RESULTS

Tumors in the transplanted group were associated with lower incidence of high-grade tumors, microscopic venous invasion, and microsatellite nodules. The overall 5-year survival was better in the transplantation group than the resection group (81% vs. 68%, P = 0.017). However, there were no significant differences in survival between the two groups when stratified according to presence or absence of venous invasion. Multivariate analysis showed that hepatitis C virus serology, tumor size, tumor number, and microscopic venous invasion, but not resection or transplantation, were of prognostic significance.

CONCLUSIONS

There were significant differences in tumor invasiveness in HCC treated by transplantation and resection as a result of selection bias, even in patients with the tumors fulfilling the Milan criteria. When the different tumor invasiveness was taken into account, there was no significant difference in the long-term survival after resection or transplantation.

Stepwise carcinogenesis of hepatocellular carcinoma in the cirrhotic liver: demonstration on serial MR imaging

PURPOSE

To demonstrate imaging findings of stepwise carcinogenesis of hepatocellular carcinoma (HCC) in cirrhosis at serial state-of-the-art MR imaging exams.

MATERIALS AND METHODS

In a retrospective search of the hospital archives, three patients were identified in which developing HCC was observed in serial MR examinations, with histopathology or alpha-fetoprotein (AFP) correlation. Image findings were assessed for signal intensity of the lesions at multiple sequences, including dynamic gadolinium-enhanced imaging.

RESULTS

Initial findings in patient A showed a small nodule with fatty infiltration that developed in HCC in follow-up MRI, comprised of low-grade dysplastic nodule (DN; DN I), high-grade DN (DN II), and eventually classic HCC. In patient B, increased signal intensity on T2-weighted images in a single DN among numerous regenerative nodules was the only initial sign. Follow up MRI showed further increase in signal intensity and increased neovascularity, which suggested focal HCC in a DN II. Patient C demonstrated gradually increasing neovascularity as only initial sign, with development of classic HCC over time.

CONCLUSION

MR imaging provides insight in various pathways of stepwise carcinogenesis of developing HCC in cirrhosis. This may further explain the genetic heterogeneity, and may facilitate early detection and better selection of patients for follow-up.

Radiation therapy for hepatocellular carcinoma: from palliation to cure

Technologic advances have provided the means to deliver tumoricidal doses of radiation therapy (RT) to patients with unresectable hepatocellular carcinoma (HCC) while avoiding critical normal tissues, providing the opportunity to use RT for curative intent treatment of HCC. For the current report, the expanded role of external beam RT in the setting of HCC from palliation to cure was reviewed. A systematic literature search was undertaken using the MEDLINE data base and secondary references to identify peer-reviewed, English-language articles that reported clinical outcomes after external beam RT alone or in combination with other treatments for HCC. Abstracts from the 2005 American Society of Clinical Oncology, American Society for Therapeutic Radiology and Oncology, American Gastrointestinal Association, and Society of Surgical Oncology Gastrointestinal Cancer Symposium also were included in the search. More than 60 articles reporting on clinical outcomes among patients who received RT for HCC have been published since 1990, including 20 articles that described unique sets of at least 15 patients. RT was used for palliation, to improve local control, and with curative intent in a wide spectrum of patients who most often were unsuitable for surgery and other treatments. Pain reduction following RT was noted in approximately 75% of patients with bone metastases from HCC who received RT. For patients with liver-confined disease treated with conformal RT, proton beam RT, and/or image guided RT with or without transarterial chemoembolization (TACE), local control response rates ranged from 40% to 90%, and the median survival ranges from 10 months to 25 months. For patients with HCC who had portal vein thrombus, the median survival after RT to treat the thrombus and/or the hepatic tumor with or without TACE ranged from 5.3 months to 9.7 months. Although outcomes after high-dose conformal RT for liver-confined HCC were excellent, the potential survival benefit of RT should be tested in randomized controlled trials that require international collaboration.

Hepatocellular carcinoma: overcoming challenges in disease management

Hepatocellular carcinoma is the third most frequent cause of death from cancer and the eighth most commonly occurring cancer in the world. In the United States, hepatocellular carcinoma appears to be increasing along with evolution of chronic hepatitis infection, especially in the immigrant population, a major risk group. A disease of multifactorial etiology, hepatocellular carcinoma confers many management challenges. Hepatocarcinogenesis is a multistep process involving different genetic alterations that ultimately lead to malignant transformation of the hepatocyte. Early hepatocellular carcinoma is characteristically silent and slow growing with few symptoms until late in disease. Early and accurate diagnosis of hepatic tumors relies on clinical suspicion, screening protocols, serologic testing, radiologic imaging, and tissue confirmation. Lack of clinically validated biomarkers and clinical identification of hepatocellular carcinoma at advanced disease make diagnosis and treatment difficult. Advances in computed tomography and magnetic resonance imaging have markedly increased the sensitivity and specificity of testing, yet they are still flawed with a relatively high false-positive rate. Several surgical and nonsurgical therapies have been developed and used with varying degrees of success. Options include surgical resection, liver transplantation, local ablation therapies, and pharmaceutical interventions. At 5 years after resection, in those patients who are surgical candidates, the recurrence rate ranges between 30% and 60%. In patients with nonresectable disease, the prognosis is dismal, with a median survival of less than 12 months even with chemotherapy. The medical community faces numerous challenges in hepatocellular carcinoma and must work toward better management and multidisciplinary care of this complex disease.