A comparison of clinical manifestations and prognoses between patients with hepatocellular carcinoma and Child-Pugh scores of 5 or 6

Unraveling the Complexities of Immune Checkpoint Inhibitors in Hepatocellular Carcinoma

Immune checkpoint inhibitors (ICIs) have emerged as effective therapeutics for multiple cancers. Nevertheless, as immunotherapeutic approaches are being extensively utilized, substantial hurdles have arisen for clinicians. These include countering ICIs resistance and ensuring precise efficacy assessments of these drugs, especially in the context of hepatocellular carcinoma (HCC). This review attempts to offer a holistic overview of the latest insights into the ICIs resistance mechanisms in HCC, the molecular underpinnings, and immune response. The intent is to inspire the development of efficacious combination strategies. This review also examines the unconventional response patterns, namely pseudoprogression (PsP) and hyperprogression (HPD). The prompt and rigorous evaluation of these treatment efficacies has emerged as a crucial imperative. Multiple clinical, radiological, and biomarker tests have been advanced to meticulously assess tumor response. Despite progress, precise mechanisms of action and predictive biomarkers remain elusive. This necessitates further investigation through prospective cohort studies in the impending future.

Feasibility of liver stiffness measured using two-dimensional shear wave elastography in assessing preoperative liver function for patients with hepatocellular carcinoma

OBJECTIVES

To evaluate the feasibility of liver stiffness (LS) measured using two-dimensional shear wave elastography (2D SWE) in assessing preoperative liver function for patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 143 patients who underwent surgical resection for HCC between August 2018 and December 2019 were enrolled prospectively. LS measurement, liver function tests including serum biochemical indicators, and indocyanine green (ICG) clearance test were performed preoperatively. Child-Pugh (CP) score, Albumin-bilirubin (ALBI) score and Model for End-Stage Liver Disease score were calculated. ICG retention rate at 15 min (ICG R15) and ICG elimination rate constant (ICG K) were determined automatically. Fibrosis stage was determined based on pathological findings. The association between LS and serum biochemical indicators, liver function scores, and the ICG results were analyzed.

RESULTS

Weak to moderate correlations were identified between LS and biochemical indicators of liver function (all p < 0.01). Weak correlation was identified between LS and CP score, and between LS and ALBI score (all p < 0.001). Moderate correlation was identified between LS and ICG R15 (Pearson r = 0.62, p < 0.001), and between LS and ICG K value (Pearson r =  - 0.49, p < 0.001). The best cutoff of LS to discriminate a normal ICG R15 was 10.6 kPa, with area under the curve (AUC), sensitivity, specificity of 0.874, 0.900 and 0.724, respectively.

CONCLUSIONS

LS determined using 2D SWE could be a potential tool for the preoperative evaluation of liver function in patients with HCC.

Predictive Outcomes Using Child-Turcotte-Pugh and Albumin-Bilirubin Scores in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

INTRODUCTION

We assessed the ability of the Child-Turcotte-Pugh score and the albumin-bilirubin grade to predict the outcomes of hepatocellular carcinoma (HCC) in patients treated with transarterial chemoembolization.

METHODS

We retrospectively assessed 158 patients with HCC who underwent transarterial chemoembolization. The ability of the Child-Turcotte-Pugh score and the albumin-bilirubin grade to predict patient survival was assessed using the Kaplan-Meier method. The Cox proportional hazards model was used to evaluate survival-predictive variables and the relationship between the obtained score and overall survival.

RESULTS

Child-Turcotte-Pugh A (n = 102 (64.6%)) patients showed better overall survival than Child-Turcotte-Pugh B (n = 56 (35.4%)) patients (log-rank P = 0.017), while no significant difference in the overall survival between albumin-bilirubin ≤ 1 (n = 37 (23.4%)) and albumin-bilirubin > 1 (n = 121 (76.6%)) was detected (log-rank P = 0.140). Multivariate analysis identified alcoholic liver disease (P = 0.029), tumor size > 5 cm (P = 0.004), and serum alpha-fetoprotein > 200 ng/mL (P < 0.001) as independent predictive factors of mortality risk. A higher Child-Turcotte-Pugh score was positively associated with decreased overall survival (P = 0.031); however, a higher albumin-bilirubin grade showed marginally significant association (P = 0.088).

CONCLUSIONS

The Child-Turcotte-Pugh score precisely categorized the outcomes of HCC in patients undergoing transarterial chemoembolization, and cirrhotic patients with Child-Turcotte-Pugh A will have a better overall survival than those with Child-Turcotte-Pugh B, regardless of HCC status. These results suggest that the Child-Turcotte-Pugh classification system is a more powerful tool to predict patient outcomes than the albumin-bilirubin grading system.

Overview of lenvatinib as a targeted therapy for advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide. Patients commonly present with advanced/unresectable HCC where several treatment options are not effective. In this review, the authors discuss the indications and usage of lenvatinib, a multikinase inhibitor, as first-line therapy for advanced/unresectable HCC, its mode of action, efficacy, drug reactions, response to treatment and adverse effects. Since its approval in 2007, sorafenib has been used as first-line therapy for unresectable HCC. In 2018, a phase III multinational REFLECT trial on subjects with unresectable HCC (Child-Pugh class A) demonstrated that lenvatinib was non-inferior compared to sorafenib for overall survival, with a controllable toxicity profile, leading to its approval. In addition, our review discusses studies that compare the safety and efficacy profile of lenvatinib especially in patients who have a decline in their liver function to Child-Pugh class B. A current real world analysis of lenvatinib approval for unresectable HCC worldwide is reported.

Review article: time to revisit Child-Pugh score as the basis for predicting drug clearance in hepatic impairment

BACKGROUND

Prescription information for many drugs entering the market lacks dosage guidance for hepatic impairment. Dedicated studies for assessing the fate of drugs in hepatic impairment commonly stratify patients using Child-Pugh score. Child-Pugh is a prognostic clinical score with limitations in reflecting the liver's metabolic capacity.

AIMS

To demonstrate the need for better drug dosing approaches in hepatic impairment, summarise the current status, identify knowledge gaps related to drug kinetic parameters in hepatic impairment, propose solutions for predicting the liver disease impact on drug exposure and discuss barriers to dosing guidance in those patients.

METHODS

Relevant reports on dosage adjustment in hepatic impairment were analysed concerning the prediction of the impairment impact on drug kinetics using physiologically-based pharmacokinetic (PBPK) modelling.

RESULTS

PBPK models are suggested as a potential framework to understand drug clearance changes in hepatic impairment. Quantifying changes in abundance and activity of drug-metabolising enzymes and transporters, understanding the impact of shunting, and accounting for interindividual variations in drug absorption could help in extending the success of these models in hepatically-impaired populations. These variables might not correlate with Child-Pugh score as a whole. Therefore, new metabolic activity markers, imaging techniques and other scoring systems are proposed to either support or substitute Child-Pugh score.

CONCLUSIONS

Many physiological changes in hepatic impairment determining the fate of drugs do not necessarily correlate with Child-Pugh score. Quantifying these changes in individual patients is essential in future hepatic impairment studies. Further studies assessing Child-Pugh alternatives are recommended to allow better prediction of drug exposure.

Predicting hyperprogressive disease in patients with advanced hepatocellular carcinoma treated with anti-programmed cell death 1 therapy

BACKGROUND

Hyperprogressive disease (HPD) is a new progressive pattern in patients with advanced hepatocellular carcinoma (HCC) treated with programmed cell death 1 (PD-1) inhibitors. We aimed to investigate risk factors associated with HPD in advanced HCC patients undergoing anti-PD-1 therapy.

METHODS

A total of 69 patients treated with anti-PD-1 therapy between March 2017 and January 2020 were included. HPD was determined according to the time to treatment failure, tumour growth rate, and tumour growth rate ratio. Univariate and multivariate analyses were performed to identify clinical variables significantly associated with HPD. A risk model was constructed based on clinical variables with prognostic significance for HPD.

FINDINGS

Overall, 10 (14·49%) had HPD. Haemoglobin level, portal vein tumour thrombus, and Child-Pugh score were significantly associated with HPD. The risk model had an area under the curve of 0·931 (95% confidence interval, 0·844-1·000). Patients with HPD had a significantly shorter overall survival (OS) than that of the patients with non-HPD (p < 0·001). However, there was no significant difference in OS between PD (progressive disease) patients with and without HPD (p = 0·05).

INTERPRETATION

We identified three clinical variables as risk factors for HPD, providing an opportunity to aid the pre-treatment evaluation of the risk of HPD in patients treated with immunotherapy.

FUNDING

This study was funded by the National Natural Science Foundation of China (81571664, 81871323, and 81801665); National Natural Science Foundation of Guangdong Province (2018B030311024); Scientific Research General Project of Guangzhou Science Technology and Innovation Commission (201707010,328); and China Postdoctoral Science Foundation (2016M600145).

Considerations of heterogeneity in clinical trials for hepatocellular carcinoma

Introduction: Clinical trials in hepatocellular carcinoma (HCC) exhibit a high degree of heterogeneity. These heterogeneities may lead to unexpected results among clinical trials. Area covered: In this review, we address the heterogeneity noted in early phase HCC trials, trials involving transarterial chemoembolization, and advanced HCC trials. Furthermore, we discuss possible methods to attenuate the detrimental effects of heterogeneity when conducting clinical trials. Expert opinion: Clinical trials in HCC exhibit an inherently high degree of heterogeneity because of various reasons: tumor heterogeneity, different cirrhotic backgrounds, various etiologies of cirrhosis, and geographical differences in practice and expertise. Such heterogeneity may cause imbalance among the enrolled patient population, premature withdrawal from the clinical trial, and variable response to the treatment. In addition, methodological heterogeneity also exists in designing trial protocol and response evaluation. All these factors may eventually lead to conflicting results among clinical trials. Accounting for these heterogeneities is important to foster the success of future trials. In recent years, significant progress with molecular targeted agents and immune checkpoint inhibitors was made in advanced HCC. These new agents are also being tested in clinical trials involving earlier stage HCC and will also face the challenge of these issues.

To determine the prognostic value of the albumin-bilirubin grade (ALBI) in patients underwent transarterial chemoembolization for unresectable hepatocellular carcinoma

AIM

We aimed at determining the prognostic value of the albumin-bilirubin grade (ALBI) in patients undergoing transarterial Chemoembolization for unresectable Hepatocellular carcinoma.

BACKGROUND

Various noninvasive liver reserve markers are used to predict the severity of liver injury. The role and probability of these markers in predicting the prognosis of patients with hepatocellular carcinoma (HCC) is still unknown.

METHODS

Patients who underwent TACE from 2013 to 2017 were included. Patient's age, gender, cause of cirrhosis, ALBI Grade along with the site, size and number of tumors were recorded. Radiological response to TACE was assessed by CT scan at 1 and 3 months after the procedure, respectively. Survival assessment was performed and all patients were assessed for survival until the last follow-up.

RESULTS

A total of 71 patients were included. Majority of them were male (80.3 %). The mean tumor size of 6 ± 3.9 cm. Majority of patients (54.9 %) had a single lesion and it was mostly localized to the right lobe (60.5 %). The most common cause of chronic liver disease was HCV (65.3%). Median Child class score (CTP) and MELD score were 7 and 10, respectively. Ascites was treated prior to TACE in 12 patients (16.9 %).Mean ALBI score in the study population was -1.59 ± 0.69, with the majority (49. 2 %) falling in grade 2. The mean duration of survival at the last follow up was of 12.1 ± 12.14 months (1- 49).Univariate analysis showed serum albumin (p = 0.003), serum bilirubin (p = 0.018), CTP score (p = 0.019), ALBI grade (p = 0.001) and presence of varices (p = 0.04) to be the main predictors of 6 months survival after TACE. On Cox analysis, only ALBI score (p = 0.038) showed statistical significant association.

CONCLUSION

ALBI grade may serve as a surrogate marker in predicting the prognosis of HCC patients undergoing Transarterial Chemoembolization.

Application of contrast-enhanced ultrasound and enhanced CT in diagnosis of liver cancer and evaluation of radiofrequency ablation

This study investigated the application effect of contrast-enhanced ultrasound (CEUS) and enhanced CT in diagnosis of liver cancer and response evaluation of radiofrequency ablation (RFA). A total of 60 patients with liver cancer were selected in Dongying People's Hospital from April 2016 to May 2017. All patients were subjected to CEUS and enhanced CT. With pathological examination as the gold standard, diagnostic consistency of the two methods was compared. After RFA, patients were subjected to CEUS and enhanced CT to assess the efficacy, and the consistency was compared. There was no significant difference in diagnostic accuracy between CEUS and CT (p>0.05). Area under the ROC curve of CEUS was 0.896, with a sensitivity of 91.2% and a specificity of 88.7%. The area under the ROC curve for enhanced CT diagnosis was 0.907, with a sensitivity of 91.8% and a specificity of 89.7%. No significant difference in the maximal cross sectional area of lesions was found between CEUS and enhanced CT, and there was no significant difference in evaluation of therapeutic efficiency between the methods (p>0.05) before and 1 and 3 months after treatment. Bland-Altman test showed that there was a strong consistency between CEUS and enhanced CT in the measured maximum cross-sectional area of lesions at 1 and 3 months after treatment. Linear regression analysis showed that maximum section cross-sectional area measured by CEUS was significantly correlated with that detected by enhanced CT (r²=0.617). The results suggested that diagnostic efficiency of CEUS was similar to that of enhanced CT, and both showed high sensitivity and specificity. Two methods showed high consistency in evaluating the curative effect of RFA. CEUS can achieve real-time observation of focal blood flow perfusion, and was more economically affordable and convenient.

XRCC1 and XPD polymorphisms and their relation to the clinical course in hepatocarcinoma patients

In this study genotyping of hepatocellular carcinoma (HCC) patients was conducted to detect polymorphisms on the X-ray repair cross-complementing 1 (XRCC1) and xeroderma pigmentosum complementary group D (XPD) genes and analyze the relationship of their presence with the clinical features of the cancer. A total of 172 patients with HCC were selected in Qilu Hospital, Shandong University, from January 2010 to September 2011. All patients underwent resection of HCC and no tumor metastases were found. Peripheral venous blood samples (3–5 ml) were collected from the patients to extract genomic DNA. Genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and gene sequencing. During the five-year follow-up, the survival of patients with various genotypes of XRCC1 and XPD genes were observed and compared. Logistic regression analysis was used to analyze the association between single nucleotide polymorphisms of XRCC1 and XPD genes and the prognosis of patients with HCC. χ² tests showed that XRCC1-194, XRCC1-280 and XPD-312 gene polymorphisms were significantly correlated with the number, location and diameter of the tumors (p<0.05). No significant difference was found in the survival curve of patients presenting different genotypes of the XRCC1-194 locus (p>0.05). Nevertheless, a significant difference was found in the survival curve of patients with AA and GG genotypes of the XRCC1-280 locus and in the patients with AA, GA and GG genotypes of the XPD-312 locus (p<0.05). Logistic regression analysis showed that the XRCC1-194 genotype was not an independent risk factor for HCC mortality risk (p>0.05), but XRCC1-280 (OR=1.815, p<0.01) and XPD-312 (OR=1.815, p<0.01) genotypes were independent risk factors for a poor prognosis. Taken together our results point to polymorphisms in XRCC1 and XPD genes as being related to the clinical characteristics of HCC, making them suitable prognostic markers of HCC.

Prognostic value of the albumin-bilirubin grade in patients with hepatocellular carcinoma: Validation in a Chinese cohort

AIM

The prognostic value of the newly raised objective liver function assessment tool, the albumin-bilirubin (ALBI) grade, in patients with hepatocellular carcinoma has not been fully validated. We aimed to compare the performance of ALBI grade with the specific Child-Pugh (C-P) score in predicting prognosis in this study.

METHODS

The clinical data of 491 C-P class A patients who underwent liver resection as initial therapy from January 2000 to December 2007 in Cancer Hospital, Chinese Academy of Medical Sciences (Beijing, China) were retrospectively analyzed. The prognostic performances of ALBI and C-P score in predicting the short- and long-term clinical outcomes were compared.

RESULTS

The ALBI score gained a significantly larger area under the receiver operating characteristic curve for predicting the occurrence of severe postoperative complications than that of C-P score. With a median follow-up of 57 months, the 1-year, 3-year, and 5-year overall survival rates of the patients were 92.1%, 65.8%, and 45.2%, respectively. Tumor number, tumor size, and ALBI grade were proved to be the independent prognostic factors for overall survival in the multivariate analysis. Prognostic performance was shown to be better for ALBI grade when it was compared to C-P score in terms of both the Akaike information criterion value and χ² value of likelihood ratio test.

CONCLUSIONS

The ALBI grade, which was featured by simplicity and objectivity, gained a superior prognostic value than that of C-P grade in patients with hepatocellular carcinoma who underwent liver resection. Future well-designed studies with larger sample sizes are warranted.

Comparison Between Child-Turcotte-Pugh and Albumin-Bilirubin Scores in Assessing the Prognosis of Hepatocellular Carcinoma After Stereotactic Ablative Radiation Therapy

PURPOSE

To evaluate the prognostic performance of the Child-Turcotte-Pugh (CTP) score and the albumin-bilirubin (ALBI) score in hepatocellular carcinoma (HCC) patients treated using stereotactic ablative radiation therapy (SABR).

METHODS AND MATERIALS

This retrospective study evaluated the data of patients with HCC who underwent SABR between December 2007 and June 2015. We collected pretreatment CTP and ALBI scores and analyzed their correlation with survival and liver toxicity.

RESULTS

This study included 152 HCC patients: 78.3% of CTP class A and 21.7% of CTP class B. The median ALBI score was -2.49 (range, -3.67 to -0.84) with 39.5% of grade 1, 56.6% of grade 2, and 3.9% of grade 3. The CTP classification and ALBI grade were significantly associated with overall survival (P<.001). Albumin-bilirubin grade (1 vs 2) had a trend to stratify CTP class A patients into 2 risk groups of mortality (P=.061). Combined CTP class and ALBI score could predict development of radiation-induced liver disease (2.4% in CTP A-ALBI < -2.76, 15.1% in CTP A-ALBI ≥ -2.76, and 25.8% in CTP B).

CONCLUSION

Albumin-bilirubin score is a potential predictor for both survival and liver toxicity. Complementary use of CTP and ALBI score could predict the risk of post-SABR liver toxicity. Further prospective studies are necessary before use of the ALBI score can become part of daily practice.

Conditional disease-free survival after liver transplantation for hepatocellular carcinoma: A two-center experience

Traditionally, survival estimates following liver transplantation (LT) of hepatocellular carcinoma (HCC) patients were calculated as survival from the surgery date, but future survival probabilities can change over time and conditional disease-free survival (CDFS) may provide patients and clinicians with more accurate prognostic information. This study aimed to assess CDFS in HCC patients after LT.Three hundred eighty-four HCC patients who underwent LT were included. Disease-free survival (DFS) was calculated using the Kaplan-Meier analysis. The 3-year CDFS, which represents the probability of remaining disease free for an additional 3 years, was calculated.1-, 3-, and 5-year DFS rates after LT were 69.9%, 45.8%, and 39.0 %, respectively. Based on the concept of CDFS, the probability of surviving an additional 3 years given that the patient was disease free at 1 year, 3 years, and 5 years were 58.4%, 76.9%, and 83.1%, respectively. Multivariate analysis indicated that larger tumor size (hazard ratio [HR], 1.509; 95% CI, 1.146-1.985; P = 0.003) was associated with poorer DFS. Patients with worse prognostic features at baseline demonstrated the greater increase in CDFS over time.Survival estimates following liver transplantation of HCC patients change according to survival time accrued since surgery. CDFS estimates improved dramatically over time especially among patients with worse prognostic features at the time of surgery. CDFS may be a useful tool in counseling patients with HCC, as it is a more accurate assessment of future survival for those patients who have already survived a certain amount of time.

Prognosis of Early-Stage Hepatocellular Carcinoma: The Clinical Implications of Substages of Barcelona Clinic Liver Cancer System Based on a Cohort of 1265 Patients

The prognostic implication of Barcelona Clinic Liver Cancer (BCLC) substages in Asian patients with hepatocellular carcinoma (HCC) is still obscure.The aim to this study is to compare the prognoses among HCC patients in different substages of the BCLC stage 0 and A.We enrolled 1265 treatment-naive HCC patients with BCLC stage 0 or A from 2007 to 2014. Factors in terms of prognoses were analyzed by multivariate analysis.There were 184, 446, 271, 92, and 272 patients in substage 0, A1, A2, A3, and A4, respectively. After a median follow-up period of 21.0 months, patients in stages 0 and A1 had comparable prognoses (P = 0.136). Both of them had significantly higher overall survival rates than those in stages A2-A4 (all P < 0.001). Multivariate analysis revealed that the factors associated with mortality were serum albumin ≤3.5 g/dL (hazard ratio [HR] 1.459), alpha-fetoprotein >20 ng/mL (HR 1.863), tumor size >3 cm (HR 1.542), BCLC stage A2-A4 (HR 1.488), and treatment modality. Surgical resection had the highest overall survival rate followed by radiofrequency ablation (RFA) (HR 1.598), transarterial chemoembolization (HR 2.224), and other treatments (HR 3.707). Verus patients receiving RFA, those who underwent resection had a higher overall survival rate and lower recurrence rate especially in BCLC stages A2-A4.The BCLC-staging system provided good prognostic stratification for early-stage HCC. Patients with a single tumor >2 cm but without portal hypertension or jaundice had similar prognosis to those in BCLC stage 0. Curative therapies-especially hepatic resection-are suggested in early-stage HCC.