Hepatocellular carcinoma: clinicopathological aspects

Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report

BACKGROUND

Metastatic lung tumor with a tumor thrombus in the peripheral pulmonary vein is very rare. We present a case of a metastatic lung tumor from hepatocellular carcinoma (HCC) with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy.

CASE PRESENTATION

A 77-year-old man underwent laparoscopic lateral segment hepatectomy for HCC eight years ago. Protein induced by vitamin K absence or antagonist-II remained elevated from two years ago. Contrast-enhanced chest computed-tomography (CT) showed a 27 mm nodule in the right apical segment (S1). He was pathologically diagnosed with a metastatic lung tumor from HCC via transbronchoscopic biopsy. We planned to perform right S1 segmentectomy. Before surgery, contrast-enhanced CT in the pulmonary vessels phase for three-dimensional reconstruction showed that the tumor extended into the adjusting peripheral pulmonary vein, and we diagnosed tumor thrombus invasion in V1a. The surgery was conducted under 3-port video-assisted thoracic surgery. First, V1 was ligated and cut. A1 and B1 were cut. The intersegmental plane was cut with mechanical staplers. Pathological examination revealed moderately-differentiated metastatic HCC with tumor thrombus invasions in many pulmonary veins, including V1a. No additional postoperative treatments were performed.

CONCLUSIONS

As malignant tumors tend to develop a tumor thrombus in the primary tumor, it might be necessary to perform contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus before the operation for metastatic lung tumors.

Hepatectomy versus sorafenib for advanced hepatocellular carcinoma with macroscopic portal vein tumor thrombus: A bi-institutional propensity-matched cohort study

AIM

Sorafenib was previously considered a first-line treatment for hepatocellular carcinoma (HCC) patients with macroscopic portal vein tumor thrombus (PVTT). This case-matched analysis was performed to evaluate the best first-line treatment for HCC in patients with macroscopic PVTT.

METHODS

The HCC patients with Vp2 (PVTT invaded into a second-order portal branch), Vp3 (first-order portal branch), and Vp4 (main trunk or contralateral portal vein) PVTT who underwent hepatectomy and those treated with sorafenib were included. Treatment results were compared between the two modalities for each PVTT category, and a propensity analysis was performed for patients with Vp3 and Vp4 (Vp3/4).

RESULTS

The median survival times (MSTs) of patients with Vp2, Vp3, and Vp4 PVTT who underwent hepatectomy were 21.4, 13.6, and 14.9 months, respectively; the MSTs for those with Vp2, Vp3, and Vp4 PVTT who received sorafenib treatment were 6.9, 5.5, and 3.6 months, respectively, with a significant difference. In a propensity-matched cohort of patients with Vp3/4 PVTT (36 patients in each), the MST of patients who underwent hepatectomy (15.1 months) was significantly better than the patients treated with sorafenib (4.5 months).

CONCLUSION

Hepatectomy can be associated with prolonged survival in HCC patients with macroscopic PVTT.

Combined Hepatocellular-Cholangiocarcinoma: What the Multidisciplinary Team Should Know

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare type of primary liver malignancy. Among the risk factors, hepatitis B and hepatitis C virus infections, cirrhosis, and male gender are widely reported. The clinical appearance of cHCC-CCA is similar to that of HCC and iCCA and it is usually silent until advanced states, causing a delay of diagnosis. Diagnosis is mainly based on histology from biopsies or surgical specimens. Correct pre-surgical diagnosis during imaging studies is very problematic and is due to the heterogeneous characteristics of the lesion in imaging, with overlapping features of HCC and CCA. The predominant histological subtype within the lesion establishes the predominant imaging findings. Therefore, in this scenario, the radiological findings characteristic of HCC show an overlap with those of CCA. Since cHCC-CCAs are prevalent in patients at high risk of HCC and there is a risk that these may mimic HCC, it is currently difficult to see a non-invasive diagnosis of HCC. Surgery is the only curative treatment of HCC-CCA. The role of liver transplantation (LT) in the treatment of cHCC-CCA remains controversial, as is the role of ablative or systemic therapies in the treatment of this tumour. These lesions still remain challenging, both in diagnosis and in the treatment phase. Therefore, a pre-treatment imaging diagnosis is essential, as well as the identification of prognostic factors that could stratify the risk of recurrence and the most adequate therapy according to patient characteristics.

Typical and Atypical Imaging Findings of Hepatocellular Carcinoma on Multiphasic MDCT Scan in Histologically Proved Cases

Objective The purpose of this study was to find out the incidence of typical and atypical radiological imaging findings of hepatocellular carcinoma (HCC) on multiphase multidetector computed tomography (MDCT) scans in histologically proven cases.

Materials and Methods A multiphase computed tomography study of 73 patients with histologically proven HCC was evaluated by a radiologist. Our multiphasic protocol was composed of precontrast, arterial, portal, and delayed venous phases. The reviewers analyzed the CT images for tumor size, enhancement patterns of HCC in different phases, relative timing of washout, internal cystic changes, and presence of dysmorphic intratumoral vessel aneurysms or arteriovenous shunt.

Results Most of the cases (95.9%) showed typical enhancement patterns in MDCT, i.e., enhancements in the arterial phase with the portal or delayed venous phase contrast washout. Three cases (4.9%) out of 73 HCC showed enhancements in the portal phase and washout in the delayed venous phase. Seven cases out of total 73 HCC (9.5%) patients showed heterogeneous enhancements in both arterial and portal phases and contrast washout in the delayed venous phase. Venous thrombosis was noted in about 44 cases (60%) out of total 73 patients, in which portal vein thrombosis was more common than hepatic veins/inferior vena cava.

Conclusion Most of the HCC show typical enhancement patterns, i.e., heterogeneous enhancements in the arterial phase and washout in the portal venous phase when we use MDCT. These findings are higher than those described previously. However, in our study, the main difference with MDCT was lower frequency of intratumoral pseudoaneurysm and bile duct invasion, and intratumoral fat and calcification (atypical character of HCC) were not found which were rare findings in previous study.

Tumor attenuation and quantitative analysis of perfusion parameters derived from tri-phasic CT scans in hepatocellular carcinoma: Relationship with histological grade

The aim of the current study was to explore the value of tumor attenuation and quantitative analysis of perfusion parameters obtained from traditional tri-phasic CT scans in grading hepatocellular carcinoma (HCC).Totally 39 patients (42 lesion samples) with pathologically confirmed HCC who underwent tri-phasic CT scans were enrolled. HCC lesions were divided into non-poorly differentiated HCC (NP-HCC; n = 31) and poorly differentiated HCC (pHCC; n = 11). All lesions were divided into 5 groups according to the attenuation on different CT enhancement phase. The values of tumor attenuation on different scanning phases were measured. The following parameters were calculated: arterial enhancement fraction (AEF), portal venous supply coefficient (PVC), and hepatic arterial supply coefficient (HAC). The relationship of perfusion parameters with the histological grade of HCC was analyzed. Receiver operating characteristic curves were generated.No significant correlation was observed between the perfusion parameters and tumor grading. Only HAC showed a non-significant trend in different grades of HCC (pHCC < NP-HCC; P = .07). The pHCC cases had significantly decreased values of tumor attenuation on the unenhanced phase (TAu), tumor attenuation on the portal phase portal phase (TAp), and equilibrium phase (TAe) (P < .01). The difference of tumor attenuation between the portal phase and the unenhanced phase (TAp-TAu) of the pHCC cases was decreased than that of the NP-HCC cases (P < .01), whereas the difference of attenuation between the equilibrium phase and portal phase (TAe-TAp) was significantly higher in the pHCC cases than that in the NP-HCC cases (P < .01). TAe-TAp had the highest area under the curve. The number of tumor enhancement pattern in Group 5 of HCCs with a diameter of 3 cm or more was significantly more than that of HCCs with a diameter of less than 3 cm or with other different enhancement patterns (P < .01).Histological HCC grading cannot be predicted by the perfusion parameters derived from traditional tri-phasic CT scans, whereas the tumor attenuation on different phases and the tumor attenuation differences among different phases, especially the mean value of TAe-TAp, might be useful for non-invasive prediction on the degree of HCC differentiation.

Diagnosis, treatment and prognosis of hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus

Although tumor thrombus (TT) infringement of the inferior vena cava (IVC) and right atrium (RA) is rarely observed in hepatocellular carcinoma (HCC), the prognosis for this condition is extremely poor, with a median survival time of several months, given that the condition is often diagnosed at an advanced tumor stage or combined with multiple systemic metastases. Furthermore, there is no established effective treatment for the condition. However, some investigators insist that active treatment, including surgery, chemotherapy (systemic or intra-arterial), radiation therapy, best supportive care or a combination of these, may help prolong overall survival time in these patients. The management of patients with advanced HCC and a TT extending into the RA and IVC is extremely difficult and risky. To this end, the present review assessed the literature on the clinical features and treatments of this condition in recent years, with the aim of providing assistance for clinical work.

Expression And Biological Interaction Network Of RHOC For Hepatic Carcinoma With Metastasis In PBMC Samples

Objectives

Hepatic carcinoma with metastasis remains incurable, and clinical diagnostic methods lacked adequate sensitivity and specificity. Therefore, seeking effectively diagnostic biomarkers is still essential for it. RHOC was reported to be linked to metastasis of hepatic carcinoma. However, almost all of the studies used tissues as detection samples, which was not ideal for clinical course minoring. Therefore, here, it was aimed to use PBMC samples that were not only easily accessible but also minimally invasive to determine the expression and biological interaction network of RHOC for hepatic carcinoma with metastasis.

Methods

PBMC samples were isolated. Then, RNA-seq was performed to identify the DEGs between hepatic carcinoma with metastasis and hepatic carcinoma with solitary tumor. Subsequently, q-RT-PCR was used to verify the expression level of RHOC. Finally, bioinformatic analysis was used to present the biological interaction network of RHOC for hepatic carcinoma with metastasis in PBMC samples.

Results

The results of both RNA-seq and q-RT-PCR showed that the expression level of RHOC was significantly higher in the PBMC samples of hepatic carcinoma with metastasis than in those of hepatic carcinoma with solitary tumor. By using variety of bioinformatic analysis platforms, in PBMCs, 18 co-expression genes with RHOC were identified and their interaction network showed that MYL9 and RHOC had the highest edge evidence, and were involved in some cell migration-related pathways.

Conclusion

Our results indicated that RHOC in PBMCs could be potentially minimally invasive indicators for the diagnosis and clinical course supervision of hepatic carcinoma with metastasis, and its biological interaction network determined based on bioinformatic methods would lay a foundation for further study of the role of RHOC in tumor invasion and metastasis.

Hypofractionated radiotherapy as a salvage treatment for recurrent hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: a multi-center analysis

Background

Recurrent hepatocellular carcinoma (HCC) with a tumor thrombus (TT) extending into the inferior vena cava (IVC)/right atrium (RA) is generally regarded as a terminal-stage condition and there is no worldwide consensus on the proper management of this situation. In the present study, we report the efficacy of hypofractionated radiotherapy (HFRT) as a salvage treatment for recurrent HCC with IVC/RA TT.

Methods

We retrospectively reviewed 75 HCC patients with an IVC/RA TT who were referred for HFRT at three institutions between 2008 and 2016. 57 cases had a TT located in the IVC (IVC group), and 18 cases had a TT located in the IVC and RA (IVC + RA group). HFRT was designed to focus on the TT with or without the primary intrahepatic tumors.

Results

In all cases, the TT completely disappeared (CR) in 17 patients (22.7%), 55 patients (73.3%) had a partial response (PR), and 3 patients (4.0%) had a stable disease (SD). There were no cases of progressive disease (PD). The 1-, 2-, and 3-year overall survival rates of the 75 patients were 38.7% (29/75), 13.3% (10/75) and 5.3% (4/75), respectively. The overall median survival time was 10 months. The mean survival times for the IVC group and IVC+ RA group were 13.8 ± 1.1 and 11.6 ± 2.5 months, respectively. There was no significant difference in survival between the two groups (p = 0.205). Log-rank test revealed that factors predicting poor survival were Child-Pugh B liver function classification, AFP ≥ 400 μg/L, intrahepatic multiple tumors, distant metastases, only the TT as the target, a biological effective dose (BED) < 55 Gy and no chance of further radiotherapy.

Conclusions

HFRT appears to be an effective and reasonable treatment option for recurrent HCC patients with IVC/RA TT. The location of the tumor thrombus, either in IVC or in IVC and RA, is not the factor that influences the efficacy of radiotherapy or survival.

Intracardiac Thrombosis and Heart Failure in a Patient with Hepatocellular Carcinoma and Cardiac Amyloidosis and an Implanted Cardiac Resynchronization Therapy Device

BACKGROUND Intracardiac thrombosis has been known to be associated with not only hepatocellular carcinoma but also with amyloidosis and use of a cardiac implantable electronic device. We report a case of a continuous tumor thrombus with hepatocellular carcinoma from the portal vein and hepatic vein to the right atrium via the inferior vena cava in a patient with a cardiac amyloidosis and an implanted cardiac resynchronization therapy (CRT) device. CASE REPORT A 68-year-old female first admitted to our hospital because of heart failure with an AL type primary cardiac amyloidosis. After 3 years, she underwent an implantation of a CRT device for biventricular pacing following repeated episodes of heart failure and low left ventricular ejection fraction of 34% with NYHA class III. Again, she presented with symptoms of heart failure and cardiomegaly on chest x-ray at 7 years after the CRT device implantation. The echocardiography showed a huge echogenic mass occupying the right atrium, and 64 multi-detector computed tomography showed a lobulated heterogeneously enhancing mass of hepatocellular carcinoma in the right upper lobe of her liver and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava. CONCLUSIONS Intracardiac thrombosis and heart failure occurred in a patient with hepatocellular carcinoma and cardiac amyloidosis, who had an implanted CRT device, which resulted not only in hypercoagulability by the hepatocellular carcinoma itself and the accumulation of various risk factors, but also the progression of myocardial damage with the development of amyloidosis.

Comprehensive treatments for hepatocellular carcinoma with portal vein tumor thrombosis

Portal vein tumor thrombosis (PVTT) is one of the most common complications in hepatocellular carcinoma (HCC). HCC with PVTT usually indicates poor prognosis, which has a number of characteristics including a rapidly progressive disease course, worse liver function, complications connected with portal hypertension, and poorer tolerance to treatment. The exact mechanisms of PVTT remain unknown, even though some concerned signal transduction or molecular pathways have been identified. In western countries, sorafenib is the only recommended therapeutic strategy regardless of PVTT types. However, multiple treatment options including transhepatic arterial chemoembolization, hepatectomy, radiotherapy, and sorafenib available in the clinic. In this review, we enumerate and discuss therapeutics against patients with HCC having PVTT available in the clinic and put forward directions for future research.

Hepatocellular Carcinoma: Retrospective Evaluation of the Correlation Between Gadobenate Dimeglumine-Enhanced Magnetic Resonance Imaging and Pathologic Grade

OBJECTIVE

The aim of this study was to evaluate the usefulness of gadobenate dimeglumine-enhanced magnetic resonance imaging in characterizing the grade of hepatocellular carcinoma (HCC) using the signal intensity (SI) of the erector spinae as internal reference.

MATERIALS AND METHODS

Clinical data of 40 patients (a total of 44 lesions) confirmed by pathology for HCC were retrospectively reviewed. Gadobenate dimeglumine-enhanced magnetic resonance imaging was performed in all patients, and SI of lesions (SIles), liver parenchyma around the lesions (SIhep), erector spinae (SImus) and standard deviation of SI of the surrounding noise (SDnoi) on nonenhanced T2WI, nonenhanced T1WI, and contrast-enhanced T1WI (in both arterial and hepatobiliary phase [AP and HBP]) were measured, respectively. Contrast-to-noise ratio (CNR) were separately defined as CNR1 ([SIles - SIhep]/SDnoi) and CNR2 ([SIles - SImus]/SDnoi). Statistical analyses were performed using one-way analysis of variance, least significant difference test, logistic regression analysis, Spearman rank correlation, and receiver operating characteristic curves analysis.

RESULTS

Forty-four HCCs, including 3 well-differentiated HCCs, 26 moderately differentiated HCCs, and 15 poorly differentiated (PD) HCCs, were confirmed. On logistic regression analysis, only CNR2 in the HBP was predictor of PD HCCs (P = 0.015, odds ratio = 1.040). The size of lesions, CNR1 in the AP, CNR2 in the AP, and CNR2 in the HBP, showed significant correlations with the degree of differentiation (correlation coefficients = -0.371, 0.435, 0.503, and 0.512, respectively; P = 0.013, 0.003, 0.001, and 0.000, respectively). Contrast-to-noise ratio 2 in the HBP with the cutoff of less than 4.56 could distinguish moderately differentiated HCCs from PD HCC with the sensitivity and specificity of 84.6% and 60.0%, respectively.

CONCLUSIONS

Relatively low arterial enhancement and low CNR2 value in the HBP are predictive for poor histological grade of HCCs.

Outcomes of surgery for hepatocellular carcinoma with tumor thrombus in the inferior vena cava or right atrium

The prognosis of hepatocellular carcinoma (HCC) patients with tumor thrombus (TT) in the inferior vena cava (IVC) or right atrium (RA) is extremely poor. We reviewed the recent surgical treatments and outcomes of this form of advanced HCC. TT is classified into three types according to its anatomic location relative to the heart: the inferior hepatic type (type I), where the TT is in the IVC below the diaphragm; the superior hepatic type (type II), where the TT is in the IVC above the diaphragm, but still outside the RA; and the intracardiac type (type III), where the TT is above the diaphragm and has entered the RA. Type I can be treated relatively easily by standard radical hepatectomy. For type II, the intrathoracic IVC is approached via the abdominal cavity and an incision in the diaphragm with total hepatic vascular exclusion (THVE). For type III, hepatectomy plus thrombectomy is generally performed under cardiopulmonary bypass. If the TT is only just inside the RA, THVE can be performed by mobilizing the liver caudally. The median overall survival of HCC patients with TT in the IVC or RA, who undergo curative resection, is 19.0-30.8 months. As postoperative recurrence is likely to develop, even after curative surgery, effective postoperative adjuvant chemotherapy is required.

A Patient with Hepatocellular Carcinoma with Isolated Right Atrial Metastases

Hepatocellular carcinoma (HCC) with isolated right atrial metastasis is extremely rare; most cases are considered inoperable. We herein report the case of a 74-year-old man with HCC with isolated right atrial metastases without hepatic vein invasion; the right atrial lesion was resected because of the risk of heart failure and sudden death. Postoperatively, he underwent transcatheter arterial chemoembolization and radiofrequency ablation for intrahepatic HCC. He recovered completely, with a long-term survival of 36 months. This is the first report of an HCC patient with isolated right atrial metastases without hepatic vein invasion. Tumorectomy for solitary atrial metastasis is effective for HCC patients.

Deep sequencing and comprehensive expression analysis identifies several molecules potentially related to human poorly differentiated hepatocellular carcinoma

Hepatocellular carcinoma (HCC) that is graded histologically as poorly differentiated has a high recurrence, metastasis and poor prognosis. We sought to determine the regulatory mechanisms of HCC tumorigenesis and to identify molecules closely related to poorly differentiated HCC. High‐throughput sequencing was used to construct microRNA (miRNA) and mRNA expression profiles for poorly differentiated HCC tissues and adjacent tissues. Network analysis was carried out to study miRNA–target interactions. Integrating the miRNA and mRNA data of HCC with four tumor grades from The Cancer Genome Atlas (TCGA) portal enabled the identification of potential closely related molecules for early diagnosis of poorly differentiated HCC. Electronic validation of RNA‐seq data and survival analysis was also performed. In total, 1051 differentially expressed genes and 165 differentially expressed miRNAs were identified between HCC tumor and paired non‐tumorous tissue. Based on 3718 miRNA–target interactions, we established an miRNA–target interaction network; the target genes were mainly involved in bile acid biosynthesis and bile secretion. Integrating expression data of HCC from TCGA indicated that two proteins, TM4SF1 and ANXA2, are convincing indicators for initial diagnosis of poorly differentiated HCC. According to the survival analysis, three proteins, ANXA2, C8orf33 and IGF2BP3, were identified as being associated with the survival time of HCC patients. Moreover, we suggest that hsa‐miR‐1180 may be an effective biomarker for poorly differentiated HCC. Three molecules, TM4SF1, ANXA2 and C8orf33, are potential biomarkers for distinguishing poorly differentiated from well‐differentiated HCC.

Joint Covariate Detection on Expression Profiles for Identifying MicroRNAs Related to Venous Metastasis in Hepatocellular Carcinoma

Expression profiles of cancer are generally composed of three dimensions including gene probes, patients (e.g., metastasis or non-metastasis) and tissues (i.e., cancer or normal cells of a patient). In order to combine these three dimensions, we proposed a joint covariate detection that not only considered projections on gene probes and tissues simultaneously, but also concentrated on distinguishing patients into different groups. Due to highly lethal malignancy of hepatocellular carcinoma, we chose data GSE6857 to testify the effectiveness of our method. A bootstrap and accumulation strategy was introduced in, which could select candidate microRNAs to distinguish metastasis from non-metastasis patient group. Two pairs of microRNAs were further selected. Each component of either significant microRNA pair was derived from different cliques. Targets were sought and pathway analysis were made, which might reveal the mechanism of venous metastasis in primary hepatocellular carcinoma.

HCC with tumor thrombus entering the right atrium and inferior vena cava treated by percutaneous ablation

Background

In the advanced stages of hepatocellular carcinoma (HCC), a tumor thrombus (TT) can form in the portal or hepatic vein. The management of patients with advanced HCC and a TT extending into the right atrium (RA) and inferior vena cava (IVC) is extremely difficult and risky.

Case presentation

We report the case of a patient with HCC and a large TT (85 × 45 mm) extending into the RA through the hepatic vein and IVC, which is very rare. We performed percutaneous microwave ablation of the TT and the two intrahepatic tumors (maximum diameter, 57 mm). The treatment shrank the tumors, and the patient is in good condition and has survived for 16 months thus far. A literature review was also performed. This is the first such case to be treated with percutaneous microwave ablation.

Conclusion

The outcomes in this case suggest that percutaneous ablation is useful for the treatment of TT extending into the RA and IVC in patients with HCC.

Fatty change in moderately and poorly differentiated hepatocellular carcinoma on MRI: a possible mechanism related to decreased arterial flow

AIM

To clarify the frequency of fatty change in moderately and poorly differentiated hepatocellular carcinomas (mHCCs and pHCCs) and its relationship to arterial blood flow.

MATERIALS AND METHODS

One hundred and thirty-six surgically resected HCC lesions were studied. All patients had undergone dynamic magnetic resonance imaging (MRI) with chemical-shift-encoded water-fat imaging (CSI). The presence of fat was identified by a signal drop-off on CSI and confirmed at pathology. Lesions were classified into four groups in the arterial phase; G1, hypointense; G2, isointense; G3, slightly and heterogeneously hyperintense; G4, markedly and homogeneously hyperintense. The number of cumulative arteries (CAs) in the tumours in the pathology examination were counted.

RESULTS

A fat component was observed significantly more frequently in the pHCCs (13/21; 61.9%) compared to the mHCCs (32/101; 31.7%; p=0.013). The numbers of lesions in each group were as follows: (G1, G2, G3, G4) = (18, 9, 23, 4) in the HCCs with fat; (1, 6, 24, 51) in the HCCs without fat (p<0.001); (5, 5, 18, 4) in the mHCCs with fat; (0, 3, 19, 47) in the mHCCs without fat (p<0.001); (11, 0, 2, 0) in the pHCCs with fat; (0, 2, 3, 3) in the pHCCs without fat (p=0.001). The number of CAs in the fat-containing HCCs (5.5±2.9) was significantly lower than that in the HCCs without fat (10.8±5.3; p<0.001).

CONCLUSION

A fat component was more commonly observed in the pHCCs than in the mHCCs. The present results showed a possible mechanism of fatty change in mHCCs and pHCCs in relation to decreased arterial blood supply.

Evaluation of fluorescence imaging with indocyanine green in hepatocellular carcinoma

Background

We hypothesized that indocyanine green (ICG) fluorescence patterns using Clairvivo OPT in resected liver specimens could confirm hepatocellular carcinoma (HCC) better than earlier commercial imaging systems. This preclinical trial evaluated the effectiveness of fluorescence imaging as an intraoperative cancer navigation tool.

Methods

ICG fluorescence images of resected specimens from 190 patients with HCC were classified into two groups according to whether high fluorescence was seen in the HCC (high cancerous [HC] group) or in the surrounding liver tissue (high surrounding [HS] group). The HC and HS groups were sub-classified into whole and partial types and whole and ring types, respectively.

Results

The HC group had significantly higher prevalence of esophageal or gastric varices, and worse liver function than patients in the HS group. The HC group also had a higher percentage of limited resection cases than did the HS group. Cirrhotic liver histology was significantly more common in the HC group than in the HS group. Multivariate analysis revealed that the HC group was a predictive factor for cirrhosis in HCC patients. Among the HC patients, a higher percentage of well-differentiated HCC cases were seen in the partial-type subgroup than in the whole-type subgroup (23/48 (48 %) vs. 7/68 (10 %)). In the HS group, the ring-type subgroup had a higher percentage of poorly differentiated HCC cases than did the whole-type subgroup (6/37 (16 %) vs. 0/37 (0 %)).

Conclusion

Tumor differentiation and fibrosis in the non-cancerous liver parenchyma could affect ICG fluorescence imaging in HCC. ICG fluorescence imaging may be a good indication for fibrosis stage. In future, we will try to evaluate fluorescence imaging with ICG for intraoperative cancer navigation in HCC, using a portable near-infrared fluorescence imaging system.

Advances in computed tomography and magnetic resonance imaging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Imaging is important for establishing a diagnosis of HCC and early diagnosis is imperative as several potentially curative treatments are available when HCC is small. Hepatocarcinogenesis occurs in a stepwise manner on a background of chronic liver disease or cirrhosis wherein multiple genes are altered resulting in a range of cirrhosis-associated nodules. This progression is related to increased cellularity, neovascularity and size of the nodule. An understanding of the stepwise progression may aid in early diagnosis. Dynamic and multiphase contrast-enhanced computed tomography and magnetic resonance imaging still form the cornerstone in the diagnosis of HCC. An overview of the current diagnostic standards of HCC in accordance to the more common practicing guidelines and their differences will be reviewed. Ancillary features contribute to diagnostic confidence and has been incorporated into the more recent Liver Imaging Reporting and Data System. The use of hepatocyte-specific contrast agents is increasing and gradually changing the standard of diagnosis of HCC; the most significant benefit being the lack of uptake in the hepatocyte phase in the earlier stages of HCC progression. An outline of supplementary techniques in the imaging of HCC will also be reviewed.

Thai red rice extract provides liver protection in paracetamol-treated mice by restoring the glutathione system

CONTEXT

The incidence of drug-induced liver disease associated with oxidant-antioxidant imbalance is increasing. Colored rice can potentially improve these hepatic disorders through antioxidative and glutathione-restoring effects.

OBJECTIVES

The objective of this study is to determine the in vitro antioxidant properties of extracts from red (Hom-Dang and Hom-Kularb-Dang) and black (Hom-Dum-Sukhothai and Kum-Doi-Saket) Thai rice cultivars [Oryza sativa L. (Poaceae)] and to examine the in vivo hepatoprotective potential of Hom-Dang extract in paracetamol-treated mice.

MATERIALS AND METHODS

The in vitro antioxidant properties of the extracts were determined by ABTS, [Formula: see text], [Formula: see text], metal chelating capacity, and lipid peroxidation assays. To investigate hepatoprotective effects in vivo, mice administered 60 mg/kg/d paracetamol were given Hom-Dang extract (128, 256, and 512 mg/kg/d) and/or control antioxidant N-acetyl-cysteine (NAC, 150 mg/kg/d) for 7 and 30 d. Liver health was ascertained by measuring levels of hepatic transaminases (GPT/GOT), determining the glutathione profile (GSH/GSSG ratio), and histomorphological examination of liver tissue.

RESULTS

Hom-Dang extract showed the highest in vitro antioxidant potency (an IC50 value of 36.50 ± 0.46, 12.98 ± 0.23, 21.83 ± 2.58, 15.87 ± 0.30, and 86.21 ± 2.45 mg/mL for ABTS, OH(•), [Formula: see text], metal chelating, and lipid peroxidation, respectively). Mice administered paracetamol exhibited increases in GPT/GOT with decreases in GSH and GSH/GSSG ratio followed by histomorphological signs of liver injury. In the presence of the Hom-Dang extract, the GPT/GOT values were normalized, GSH production was induced, and the GSH/GSSG ratio was increased.

CONCLUSION

Thai colored rice cultivars, especially the Hom-Dang variety, are promising candidates for health supplements due to their antioxidative and hepatoprotective properties.

Hepatocellular Carcinoma With Tumor Thrombus Occupying the Right Atrium and Portal Vein: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) patients with tumor thrombus extended through the major hepatic veins and inferior vena cava into the right atrium (RA) are rare, and most cases are considered as the advanced stage with a poor prognosis.We report a case of HCC with a tumor thrombus extending into the RA and a tumor thrombus in the portal vein. A literature search for case reports was performed on PubMed.Compared with the published literature, our case is one of the youngest patients, but with the most advanced HCC that invades both the hepatic inflow and outflow vasculature. For this patient, we resected the tumor thrombus in the RA with the use of cardiopulmonary bypass, and then removed the tumor thrombus in the portal vein and ligated the left branch of portal vein. Because of insufficient remnant liver volume, microwave ablation and transcatheter arterial chemoembolization were performed to control the growth of HCC. The patient survived 6 months after surgery.This case suggests that for patients with extension of HCC into the RA and portal vein, surgery is a useful therapeutic modality, even in case that liver tumor cannot be resected.

Expression of NEDD9 in hepatocellular carcinoma and its clinical significance

Neural precursor cell expressed, developmentally downregulated 9 (NEDD9) plays an integral role in natural and pathological cell biology. Overexpression of NEDD9 protein has been correlated with poor prognosis in various types of cancer. However, few available data address the precise function of the NEDD9 gene in hepatocellular carcinoma (HCC). In the present study, we investigated NEDD9 expression in 40 primary human HCC tissues compared with matched adjacent non-tumor hepatic tissues using RT-qPCR and western blot analysis. Immunohistochemistry was performed to analyze the correlations between NEDD9 expression and clinicopathological factors. Statistical analyses were applied to derive prognostic values of NEDD9 in HCC. The results showed that the NEDD9 mRNA and protein expression levels in HCC tissues were significantly higher than those in matched adjacent non-tumor hepatic tissues. High NEDD9 expression was correlated with larger tumor size, advanced tumor grade, metastasis, intrahepatic venous invasion and high UICC TNM stages in HCC patients. Patients with high NEDD9 expression levels exhibited poorer recurrence-free and overall survival than those with a low NEDD9 expression. Additionally, NEDD9 expression status was an independent prognostic factor for survival. This correlation remained significant in patients with early-stage HCC or with normal serum AFP levels. The results of this study suggest that NEDD9 may be a valuable prognostic biomarker for HCC, including early-stage and AFP-normal patients.

CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part I. Development, growth, and spread: key pathologic and imaging aspects

Computed tomography (CT) and magnetic resonance (MR) imaging play critical roles in the diagnosis and staging of hepatocellular carcinoma (HCC). The first article of this two-part review discusses key concepts of HCC development, growth, and spread, emphasizing those features with imaging correlates and hence most relevant to radiologists; state-of-the-art CT and MR imaging technique with extracellular and hepatobiliary contrast agents; and the imaging appearance of precursor nodules that eventually may transform into overt HCC.

Hepatocellular carcinoma: clinical significance of signal heterogeneity in the hepatobiliary phase of gadoxetic acid-enhanced MR imaging

OBJECTIVES

To clarify the relationship between the biological behaviour of hepatocellular carcinomas (HCCs) and their signal intensity in the hepatobiliary phase of gadoxetic acid-enhanced MR imaging with a special focus on the signal heterogeneity.

METHODS

A total of 68 patients with 70 pathologically proven HCCs were enrolled. On the basis of the signal intensity in the hepatobiliary phase, the lesions were classified into three groups: group 1, homogeneous hypointensity (n = 44); group 2, heterogeneous hyperintensity (n = 20); and group 3, homogeneous hyperintensity (n = 6). The clinicopathological findings were compared among the three groups.

RESULTS

The tumour size and the serum level of protein induced by vitamin K absence or antagonist-II (PIVKA-II) were significantly higher in group 2 compared to group 1 (p = 0.0155, p = 0.0215, respectively) and compared to group 3 (p = 0.0330, p = 0.0220, respectively). The organic anion transporting polypeptide 8 (OATP8) expression in group 2 and group 3 was significantly higher than in group 1 (p < 0.0001, p < 0.0001, respectively). Group 2 showed a significantly lower disease-free survival rate compared to group 1 (p = 0.0125), and group 2 was an independent prognostic factor for disease-free survival (p = 0.0308).

CONCLUSIONS

HCCs in the hepatobiliary phase that are heterogeneously hyperintense on gadoxetic acid-enhanced MR imaging have more malignant potential than other types of HCCs.

KEY POINTS

• Heterogeneous uptake of gadoxetic acid suggests more malignant potential in HCC • Uptake of gadoxetic acid does not suggest less malignancy in HCC • Evaluation of signal heterogeneity on gadoxetic acid-enhanced MR imaging is useful.

Role of tumor-associated macrophages in the angiogenesis of well-differentiated hepatocellular carcinoma: pathological-radiological correlation

The role of tumor-associated macrophages (TAMs) in hepatocellular carcinoma (HCC) has not been fully investigated. The aim of the present study was to clarify whether TAMs are associated with the angiogenesis of HCC during its multistep development, especially at an early stage. Forty‑three well-differentiated HCCs and 30 well- to moderately differentiated HCCs (nodule-in-nodule lesion) were used. We immunohistochemically assessed microvessel density (by CD34) and macrophage count (by CD68 or CD163). Computed tomography hepatic angiography (CTHA) was performed for 26 well-differentiated HCCs and all 30 well- to moderately differentiated HCCs. The pathological analysis of the 43 well-differentiated HCCs revealed a positive correlation between microvessel density and macrophage count (p=0.0026, r=0.4486). Based on the CTHA findings, 26 well-differentiated HCCs classified into a hyperattenuation group (n=14) and a hypo- or isoattenuation group (n=12). The microvessel density and macrophage count of the hyperattenuation group were significantly higher than those of the hypo- or isoattenuation group (p=0.0372 and p=0.0476). In the 30 well- to moderately differentiated HCCs, microvessel density of the moderately differentiated components was significantly higher than that of the well-differentiated components (p<0.0001). However, the macrophage count of the moderately differentiated component was significantly lower than that of the well-differentiated component (p<0.0001). All the moderately differentiated components showed marked hyperattenuation on CTHA. Tumor vascularity was correlated with macrophage count in the tumor when limited to well-differentiated HCCs. TAMs may have a role in promoting angiogenesis of HCC at an early stage during its multistep development.

Suppression of KIF3B expression inhibits human hepatocellular carcinoma proliferation

BACKGROUND

Human hepatocellular carcinoma (HCC) is one of the most common fatal cancers and an important health problem worldwide, but its mechanism is still unclear. Microtubule (MT) kinesin motor proteins orchestrate a variety of cellular processes (e.g. mitosis, motility and organelle transportation) and have been involved in human carcinogenesis. KIF3B, the kinesin superfamily of proteins (KIFs), plays an important role in the regulation of mitotic progression.

AIM

The expression of KIF3B and its involvement in HCC was investigated.

METHODS

Western blot and immunohistochemistry were used to measure the expression of KIF3B protein in HCC and adjacent non-tumorous tissues in 57 patients and Cell Counting Kit-8 to analyze the effects of growth and interference of KIF3B in the cell cycle process.

RESULTS

KIF3B protein level was increased in HCC tissues compared with the adjacent non-tumorous tissues. It was significantly associated with histological differentiation, tumor size, the level of alpha fetal protein (AFP) and proliferation marker Ki-67. Over-expression of KIF3B was correlated with poor survival. Following release of HepG2 cells from serum starvation, the expression of KIF3B was up-regulated. Furthermore, suppression of KIF3B not only decreased cancer cell growth but also induced apoptosis of cells.

CONCLUSIONS

Our results suggested that KIF3B expression was upregulated in HCC tumor tissues and proliferating HCC cells, and an increased KIF3B expression was associated with poor overall survival. KIF3B over-expression is involved in the pathogenesis of hepatocellular carcinoma and may serve as a potential therapeutic target for human HCC.

Surgical management of hepatocellular carcinoma with tumor thrombi in the inferior vena cava or right atrium

Background

The prognosis for advanced hepatocellular carcinoma (HCC) with tumor thrombi in the inferior vena cava (IVC) or right atrium (RA) is poor, and there is no established effective treatment for this condition. Thus study aimed to evaluate the efficacy of surgical resection and prognosis after surgery for such cases.

Methods

Between January 1990 and December 2012, 891 patients underwent hepatectomy for HCC at our institution. Of these, 13 patients (1.5%) diagnosed with advanced HCC with tumor thrombi in the IVC or RA underwent hepatectomy and thrombectomy. Data detailing the surgical outcome were evaluated and recurrence-free and overall survival rates were calculated using the Kaplan-Meier method.

Results

Seven patients had an IVC thrombus and six had an RA thrombus. Extra-hepatic metastasis was diagnosed in 8 of 13 patients. Surgical procedures included three extended right lobectomies, three extended left lobectomies, five right lobectomies, and two sectionectomies. Right adrenal gland metastases were excised simultaneously in two patients. All IVC thrombi were removed under hepatic vascular exclusion and all RA thrombi were removed under cardiopulmonary bypass (CPB). Four patients (30.8%) experienced controllable postoperative complications, and there was no surgical mortality. The mean postoperative hospital stay for patients with IVC and RA thrombi was 23.6 ± 12.5 days and 21.2 ± 4.6 days, respectively. Curative resection was performed in 5 of 13 cases. The 1- and 3-year overall survival rates were 50.4%, and 21.0%, respectively, and the median survival duration was 15.3 months. The 1- and 3-year overall survival rates for patients who underwent curative surgical resection were 80.0% and 30.0%, respectively, with a median survival duration of 30.8 months. All patients who underwent curative resection developed postoperative recurrences, with a median recurrence-free survival duration of 3.8 months. The 1-year survival rate for patients who underwent noncurative surgery and had residual tumors was 29.2%, with a median survival duration of 10.5 months.

Conclusions

Aggressive surgical resection for HCC with tumor thrombi in the IVC or RA can be performed safely and may improve the prognoses of these patients. However, early recurrence and treatment for recurrent or metastatic tumors remain unresolved issues.

Management of bleeding in the terminally ill patient

Clinically significant bleeding occurs in approximately 6%-10% of patients in the palliative-care setting. Bleeding can range from persistent and small in quantity (but enough to interfere with a patient's quality of life), to catastrophic bleeding that ultimately leads to the rapid demise of the patient. Uncontrolled bleeding can be very distressing for staff, patients and families. Advanced planning is necessary in all bleeding circumstances. This session will review the types of cancer associated with bleeding, as well as management options for these situations. Emphasis will be placed on aspects of communication with families.

MicroRNA-140-5p suppresses tumor growth and metastasis by targeting transforming growth factor β receptor 1 and fibroblast growth factor 9 in hepatocellular carcinoma

By comparing the expression profiles of microRNAs (miRNAs) in different hepatocellular carcinoma (HCC) subtypes, we identified miR-140-5p as an HCC-related miRNA. We found that miR-140-5p was significantly decreased in HCC tissues and all of six liver cancer cell lines examined and its expression levels were correlated with multiple nodules, vein invasion, capsular formation, and differentiation, as well as overall and disease-free survival of HCC. We also found that miR-140-5p suppressed HCC cell proliferation and HCC metastasis. Multipathway reporter arrays suggested that miR-140-5p inhibited transforming growth factor β (TGF-β) and mitogen-activated protein kinase / extracellular signal-regulated kinase (MAPK/ERK) signaling. TGFB receptor 1 (TGFBR1) and fibroblast growth factor 9 (FGF9) were then characterized as the direct targets for miR-140-5p after it was found that ectopic miR-140-5p expression suppressed TGFBR1 and FGF9 expression. Silencing TGFBR1 and FGF9 by small interfering RNA (siRNA) resembled the phenotype resulting from ectopic miR-140-5p expression, while overexpression of TGFBR1 and FGF9 attenuated the effect of miR-140-5p on HCC growth and metastasis.

CONCLUSION

These data elucidated a tumor suppressor role for miR-140-5p in HCC development and progression with therapeutic potential. Our correlation studies in clinical HCC samples further suggest that miR-140-5p could be a valuable biomarker for HCC prognosis.

Reduction of fatty acid oxidation and responses to hypoxia correlate with the progression of de-differentiation in HCC

The prognosis of patients with hepatocellular carcinoma (HCC) may be improved by novel treatments focusing on the characteristic metabolic changes of this disease. Therefore, we analyzed the biological interactions of metabolic features with the degree of tumor differentiation and the level of malignant potential in 41 patients with completely resectable HCC. The expression levels in resected samples of mRNAs encoded by genes related to tumor metabolism and metastasis were investigated, and the correlation between these expression levels and degrees of differentiation was analyzed. Of the 41 patients, 2 patients had grade I, 27 had grade II, and 12 had grade III tumors. Reductions in the levels of 3-hydroxyacyl-CoA dehydrogenase (HADHA) and acyl-CoA oxidase (ACOX)-2 mRNAs, and increases in pyruvate kinase isoenzyme type M2 (PKM2) mRNA were significantly correlated with the progression of de-differentiation. Analysis of partial correlation coefficients showed that the level of PKM2 mRNA expression was significantly correlated with those of pro-angiogenic genes, vascular endothelial growth factor (VEGF) and ETS-1. Moreover, the levels of VEGF-A and ETS-1 mRNA expression were independently correlated with that of the epithelial-mesenchymal transition (EMT)‑related gene SNAIL. These findings suggest that reductions in fatty acid oxidation and responses to hypoxia may affect the progression of malignant phenotypes in HCC.

CT prediction of histological grade of hypervascular hepatocellular carcinoma: utility of the portal phase

PURPOSE

To elucidate whether the attenuation of hypervascular hepatocellular carcinoma (HCC) on the portal phase of dynamic CT is correlated with histological grade.

MATERIALS AND METHODS

This study group consisted of 66 patients with 74 surgically resected, hypervascular HCCs. On a preoperative dynamic study with a 64-multidetector row CT, the portal phase was scanned 60 s after injecting the contrast agent following the pre-contrast image and hepatic arterial phase. The tumor attenuation of each HCC on the portal phase was categorized into high, iso-, or low, and was compared with the predominant histological grade using Mann-Whitney's U test.

RESULTS

Twenty-nine, 29, and 16 HCCs showed high, iso-, and low attenuation on the portal phase, respectively. Tumors were classified into three well- (w-), 58 moderately (m-), or 13 poorly (p-) differentiated HCCs. The tumor attenuation of p-HCC on the portal phase was significantly lower than those of w-HCC and m-HCC (p < 0.05 and p < 0.00001).

CONCLUSION

The tumor attenuation on the portal phase may help when diagnosing the histological grade of hypervascular HCC. p-HCC are considered to show a faster contrast washout than w-HCC and m-HCC.

Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study

BACKGROUND

The significance of surgery in the treatment of hepatocellular carcinoma (HCC) extending into the inferior vena cava (IVC)/right atrium (RA) is currently unclear. We sought to clarify whether surgical treatment can improve survival in such patients.

METHODS

A retrospective review was undertaken of patients with HCC and IVC/RA tumor thrombus who were potential candidates for surgery but who were finally treated surgically and nonsurgically between September 2000 and October 2010. The patients were subdivided according to therapeutic modalities, and the results for each group were compared.

RESULTS

A total of 56 patients were included in this study. They were divided into three groups. Twenty-five patients underwent hepatectomy plus thrombectomy (surgical group), with minor morbidity and no mortality; the patients in this group had 1-, 3-, and 5-year survival rates of 68.0, 22.5, and 13.5%, respectively, with a median survival of 19 months. Twenty patients were treated with transcatheter arterial chemoembolization, with 1- and 3-year survival rates of 15.0 and 5.0%, respectively (median survival 4.5 months). Eleven patients received symptomatic treatment only, and no one in this group survived longer than 1 year (median survival 5 months). The patients in surgical group survived significantly longer than the patients in the other two groups (p < 0.001).

CONCLUSIONS

Although technically challenging, surgery for HCC with IVC/RA tumor thrombus can be safely performed and should be considered in patients with resectable primary tumor and sufficient hepatic reservoir because compared with transcatheter arterial chemoembolization or symptomatic treatment, it significantly improved patient survival.

Ginsenoside Rh1 suppresses matrix metalloproteinase-1 expression through inhibition of activator protein-1 and mitogen-activated protein kinase signaling pathway in human hepatocellular carcinoma cells

Invasion and metastasis are the major causes of treatment failure in patients with cancer. Here, we investigated the effects of ginsenoside Rh1 on tumor invasion and metastasis in human hepatocellular carcinoma HepG2 cells and its possible mechanism of action. Rh1 showed concentration- and time-dependent inhibition of HepG2 cell migration and invasion. Matrix metalloproteinase-1 (MMP-1) gene expression and its promoter activity were also concentration-dependently inhibited by Rh1 treatment. The inhibitory effect of Rh1 on MMP-1 expression was due to inactivation of the mitogen-activated protein kinases (MAPKs) ERK, JNK, and p38 MAPK. By transient transfection analysis with the MMP-1 promoter (-2846 to -29 nt) and AP-1 promoter, MMP-1 and AP-1 promoter activities were induced by phorbol myristate acetate (PMA) but were significantly inhibited by PD98059 (ERK1/2 inhibitor) or SP600125 (JNK inhibitor). The induction of MMP-1 and AP-1 promoters by PMA was attenuated by Rh1, and both promoter activities were synergistically inhibited by co-treatment with PD98059. To evaluate the effects of Rh1 on AP-1 dimers, expression analysis and electrophoretic mobility shift (EMSA) assay using radiolabeled AP-1-specific oligomers at proximal site (-73 nt) and distal site (-1600 nt) of the MMP-1 promoter were performed. The results showed that Rh1 inhibited the expression of c-Jun and c-Fos but did not affect the DNA binding ability of AP-1-specific oligomers. However, Rh1 attenuated the stability of c-Jun. Therefore, Rh1 has potential for development of novel chemotherapeutic agents for treatment of malignant cancers, including early hepatocellular carcinoma related to MMP-1 expression.

Identification of LZAP as a new candidate tumor suppressor in hepatocellular carcinoma

Background

LZAP was isolated as a binding protein of the Cdk5 activator p35. LZAP has been highly conserved during evolution and has been shown to function as a tumor suppressor in various cancers. This study aimed to investigate LZAP expression and its prognostic value in hepatocellular carcinoma (HCC). Meanwhile, the function of LZAP in hepatocarcinogenesis was further investigated in cell culture models and mouse models.

Methods

Real-time quantitative PCR, western blot and immunohistochemistry were used to explore LZAP expression in HCC cell lines and primary HCC clinical specimens. The functions of LZAP in the proliferation, colony formation, cell cycle, migration, invasion and apoptosis of HCC cell lines were also analyzed by infecting cells with an adenovirus containing full-length LZAP. The effect of LZAP on tumorigenicity in nude mice was also investigated.

Results

LZAP expression was significantly decreased in the tumor tissues and HCC cell lines. Clinicopathological analysis showed that LZAP expression was significantly correlated with tumor size, histopathological classification and serum α-fetoprotein (AFP). The Kaplan–Meier survival curves revealed that decreasing LZAP expression was associated with poor prognosis in HCC patients. LZAP expression was an independent prognostic marker of overall HCC patient survival in a multivariate analysis. The re-introduction of LZAP expression in the HepG2 and sk-Hep1 HCC cell lines significantly inhibited proliferation and colony formation in the HCC cells and induced G1 phase arrest and apoptosis of the HCC cells in vitro. Restoring LZAP expression in the HCC cell lines also inhibited migration and invasion. In addition, experiments with a mouse model revealed that LZAP overexpression could suppress HCC tumorigenicity in vivo.

Conclusions

Our data suggest that LZAP may play an important role in HCC progression and could be a potential molecular therapy target for HCC.

Downregulation of MAGI1 associates with poor prognosis of hepatocellular carcinoma

OBJECTIVE

MAGI1 (membrane-associated guanylate kinase, WW and PDZ domain containing 1) plays an important role in stabilization of adherens junctions and suppression of invasiveness and metastasis. However, its expression and clinical revelance in hepatocellular carcinoma (HCC) are still unknown. So, this study was performed to detect the expression and clinical significance of MAGI1 in human HCC.

METHODS

The mRNA and protein expression levels were examined by using reverse transcription-PCR (RT-PCR) and Western blotting in 31 paired HCC and paracarcinomatous liver tissues (PCLT). Furthermore, samples of 104 HCC patients were determined immunohistochemically for MAGI1 expression and the correlation of MAGI1 levels with prognosis was analyzed.

RESULTS

The expression levels of MAGI1 were significantly downregulated in HCCs than those in PCLTs (p < .01). Importantly, the decreased expression of MAGI1 correlated with multiple tumor nodules (p < .05), absence of capsular formation (p < .05), worse Edmondson-Steiner grade (p < .05), vein invasion (p < .01), shortened median overall survival time (25 versus 42 months; p = .013), and disease-free survival time (20 versus 40 months; p = .018) of HCC. Multivariable Cox regression analysis revealed that MAGI1 expression level was an independent factor for prognosis (p = .038).

CONCLUSIONS

MAGI1 expression is decreased in HCC, which correlates with poor prognosis, suggesting MAGI1 as a novel prognostic marker for HCC.

Heat shock factor 1 promotes invasion and metastasis of hepatocellular carcinoma in vitro and in vivo

BACKGROUND

Heat shock factor 1 (HSF1) is a powerful, multifaceted modifier of carcinogenesis. However, the clinical significance and biologic function of HSF1 in hepatocellular carcinoma (HCC) remain unknown.

METHODS

Quantitative reverse transcriptase-polymerase chain reaction analysis, Western blot analysis, and immunohistochemical staining were used to detect expression levels of HSF1, and its correlation with clinicopathologic parameters and the prognosis for patients with HCC were analyzed. In addition, the biologic function and molecular mechanisms of HSF1 in HCC were investigated in vitro and in vivo.

RESULTS

HSF1 levels were elevated predominantly in HCC, especially in venous emboli from HCC (P < .05), and high expression levels of HSF1 were correlated significantly with multiple nodules, venous invasion, absence of capsular formation, and high Edmondson-Steiner grade as well as poor overall survival and disease-free survival in patients with HCC (P < .05). Multivariate Cox regression analysis revealed that high HSF1 expression was an independent prognostic factor for overall survival in patients with HCC (relative risk, 4.874; P < .001). Finally, HSF1 was capable of promoting HCC cell migration and invasion in vitro and in vivo by facilitating the expression and phosphorylation of heat shock protein 27.

CONCLUSIONS

Collectively, the current findings suggested that HSF1 may serve as a novel prognostic marker and therapeutic target for HCC.

Enhancement pattern analysis of hypervascular hepatocellular carcinoma on dynamic MR imaging with histopathological correlation: validity of portal phase imaging for predicting tumor grade

PURPOSE

To elucidate the correlation between hypervascular hepatocellular carcinoma (HCC) enhancement patterns on dynamic MR imaging and histological findings.

MATERIALS AND METHODS

Surgically proven 46 hypervascular HCCs of forty-one patients were enrolled. For each HCC, the signal intensity in the portal phase (SIPP) was evaluated. In this study, high, iso-, or low intensity in the portal phase was hypothesized as late, moderate, or early washout pattern, respectively. The SIPP of each HCC was correlated to histological grade and architectural subtypes that represent degrees of trabecular structure. For the trabecular HCCs, the thickness of tumor plate was also correlated for indirect estimation of tumor sinusoid.

RESULTS

There was a significant correlation between the SIPP vs. histological grade and also vs. architectural subtypes, namely the degree of trabecular structure. Washout of hypervascular HCC occurred earlier as the histological grade advanced and the histological architecture got closer to pure trabecular HCC. For the trabecular HCCs, the thickness of tumor plate correlated significantly with SIPP or histological grade. Hypervascular HCCs with thicker tumor plates showed worse histological grade and earlier washout pattern.

CONCLUSIONS

Histological grade of hypervascular HCC may be predicted using SIPP. The thickness of tumor plate, resultantly the size of sinusoid between tumor plates, can account for the relationship between washout pattern and histological grade in the trabecular HCCs.

Paradoxical high signal intensity of hepatocellular carcinoma in the hepatobiliary phase of Gd-EOB-DTPA enhanced MRI: initial experience

PURPOSE

To describe the paradoxical high signal intensity of hepatocellular carcinoma (HCC) in the hepatobiliary phase on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI).

MATERIALS AND METHODS

A database search was performed to identify cases of HCC that showed unusual prolonged enhancement in the hepatobiliary phase of Gd-EOB-DTPA MRI. All patients received 3.0-T liver MRI including precontrast T1-weighted images, T2-weighted images and a post Gd-EOB-DTPA-enhanced dynamic study. The signal intensity of HCC was measured at pre-enhanced, arterial, portal, delayed and hepatobiliary phase using regions of interest. Radiologic and pathologic correlation was performed for the paradoxically prolonged enhancing portion of HCC in the hepatobiliary phase.

RESULTS

Four patients (all male, age range 44-70; mean 57.5 years) were included in this study. All patients showed HCC lesions that were low signal intensity (SI) on T1-WI, high SI on T2-WI, enhanced in arterial phase, and washed-out in delayed phase. All cases showed paradoxically high SI in hepatobiliary phase, which was unusual for HCC. Pathologically, they were all diagnosed as well-differentiated HCC with prominent cytoplasm and a bile secreting appearance.

CONCLUSION

HCC may demonstrate the prolonged high signal intensity at the hepatobiliary phase on Gd-EOB-DTPA enhanced MRI. These HCCs tended to be highly differentiated and to have prominent bile secretion.

Anti-invasive effect of a rare mushroom, Ganoderma colossum , on human hepatoma cells

Ganoderma colossum is a rare species of the Ganodermataceae family with biological activity but has not been widely used to date. Because of its rareness and hard availability, the literature regarding the bioactivity of G. colossum is very limited and the bioactive components in G. colossum have never been explored. In the present study, an ethanol extract was prepared from the fruiting body of a G. colossum strain (EEGC) and then fractionated by reverese-phase high-performance liquid chromatography (HPLC). The inhibitory effects and molecular mechanisms of the EEGC on the phorbol-12-myristate-13-acetate (PMA)-induced invasion of HepG2 cells were investigated. The fractions of the EEGC cannot be totally identified, but the lucidenic acids were considered as the major component. When HepG2 cells were treated with the EEGC, the PMA-induced invasion was reduced in a dose-dependent manner and the PMA-induced matrix metalloproteinase (MMP)-9 was also suppressed at the transcriptional level. The EEGC also showed an inhibitory effect on the PMA-induced phosphorylation of extracellular signal-regulated kinase (ERK1/2) and protein kinase B (Akt) in cytosol, as well as the activator protein-1 (AP-1) and nuclear factor-kappaB (NF-kappaB) levels in the nucleus of HepG2 cells. This study provides the first evidence demonstrating that the EEGC is an effective inhibitior on the PMA-induced invasion of hepatoma cell. The EEGC could be further tested by an in vivo model to verify whether it is effective for the prevention of hepatoma invasion or metastasis.

Down-regulation of artery in moderately differentiated hepatocellular carcinoma related to tumor development

Hepatocellular carcinoma develops in a multistep process. Previous studies have revealed changes in blood supply in hepatocellular carcinoma during its carcinogenesis. However, little is known about the relationship between tumor vasculature and the biological behavior of moderately differentiated hepatocellular carcinoma which demonstrates varied degrees of biological behavior. We immunohistochemically assessed intratumoral arterial vessel density (by high-molecular-weight caldesmon and calponin) and microvessel density (by CD34) in 123 cases of moderately differentiated hepatocellular carcinomas, and compared these densities with clinicopathological findings. Arterial vessel density and microvessel density of 19 well-differentiated and 37 poorly differentiated hepatocellular carcinomas were also evaluated. The arterial vessel density of moderately differentiated hepatocellular carcinomas with capsule formation, infiltration to the capsule, portal venous invasion, and high Ki-67 labeling index was lower than that of moderately differentiated hepatocellular carcinomas without these pathological findings (high-molecular-weight caldesmon: P < .0001, P = .0074, P = .0009, P = .0244, calponin: P < .0001, P = .0695, P = .0033, and P = .0155, respectively). The low arterial vessel density group (<10) of moderately differentiated hepatocellular carcinomas tended to show poorer overall survival than the high arterial vessel density group (>or=10) (high-molecular-weight caldesmon: P = .0347, calponin: P = .0404). The arterial vessel density and microvessel density of moderately differentiated hepatocellular carcinomas were significantly higher than those of well-differentiated hepatocellular carcinomas (high-molecular-weight caldesmon: P = .022, calponin: P = .027, CD34: P = .036) and poorly differentiated hepatocellular carcinomas (high-molecular-weight caldesmon, calponin and CD34: P < .0001). The moderately differentiated hepatocellular carcinomas with lower arterial vessel density had more malignant potential than those with higher arterial vessel density. The changes of arterial vessel density in moderately differentiated hepatocellular carcinomas were suggested.

Inhibitory effects of ganoderma lucidum on tumorigenesis and metastasis of human hepatoma cells in cells and animal models

Metastasis is considered to be the major cause of death in patients with cancers, and hepatocellular carcinoma (HCC) is a highly metastatic cancer. Ganoderma lucidum , a well-known mushroom with various biological effects, is a functional food known to contain lucidenic acid. The objectives of this study were to investigate the anti-invasion effect of a lucidenic acid-rich G. lucidum extract (GLE) on human hepatoma HepG2 cells as well as the antiproliferative and antimetastatic effects of GLE in human hepatoma cells implanted into ICR-nu/nu mice. Phorbol-12-myristate-13-acetate (PMA)-induced invasion and matrix metalloproteinase (MMP)-9 expression levels of HepG2 cells were reduced by GLE treatment in a dose-dependent manner. The inhibitory effects of GLE on MMP-9 expression proceeded by inhibiting the phosphorylation of extracellular signal-regulated kinase (ERK1/2) and protein kinase B in the cytosol as well as reducing activator protein-1 and nuclear factor-kappa B levels in the nucleus of HepG2 cells. In a human tumor xenograft model, a dose-response inhibition was observed in the average size, volume, and weight of tumors upon oral administration of GLE. The number of metastatic tumor-bearing mice, the number of affected organs, and the number of tumor foci as well as the MMP-2 and -9 activities in serum of mice were also significantly suppressed by oral administration of GLE. These results suggest that the lucidenic acid-rich GLE could serve as a chemopreventive agent for the tumorigenesis and metastasis of highly invasive hepatoma cells.

Decreased expression of inhibitor of growth 4 correlated with poor prognosis of hepatocellular carcinoma

OBJECTIVE

Inhibitor of growth 4 (ING4) is a candidate tumor suppressor that plays an important role in tumor growth and angiogenesis. Here, we examined the expression of ING4 in hepatocellular carcinoma (HCC) tissues and analyzed its correlation with the progression of HCC.

METHODS

Specimens from 136 HCC patients were determined immunohistochemically for ING4 expression. The correlation of ING4 levels with clinicopathologic variables, prognosis, and metastatic potential was analyzed. Among the 136 cases, 36 paired HCC and paracarcinomatous liver tissue specimens were analyzed for ING4 expression levels by real-time quantitative reverse transcription-PCR and Western blotting. MVD was determined by CD34 immunostaining to test whether it correlated with ING4 protein expression level.

RESULTS

The ING4 mRNA and protein levels were significantly lower in HCC than paracarcinomatous liver tissue from both real-time quantitative reverse transcription-PCR and Western blotting (P = 0.039 and 0.012, respectively). Importantly, the ING4 protein level correlated with the Edmondson-Steiner grade (P = 0.035), vein invasion (P = 0.015), and microvessel density (P = 0.005). Survival and metastasis analysis indicated that HCC patients with lower ING4 expression had poorer overall survival and disease-free survival than those with high expression (P = 0.0001 and 0.0065; respectively). Multivariable Cox regression analysis revealed that the ING4 expression level was an independent factor for prognosis (hazard risk, 9.63; P = 0.001).

CONCLUSIONS

ING4 expression is down-regulated in HCC tissues. ING4 expression level correlates with prognosis and metastatic potential, which suggests that ING4 is a candidate prognostic marker of HCC.

RhoC is essential for angiogenesis induced by hepatocellular carcinoma cells via regulation of endothelial cell organization

The angiogenesis induced by tumor cells is essential for metastasis of hepatocellular carcinoma. Available information suggests that RhoC participates in angiogenesis through regulation of vascular endothelial growth factor expression in tumor cells. For its broad functions in cell migration and cytoskeletal organization, we hypothesized that RhoC regulating angiogenesis does not exclusively depend on regulation of vascular endothelial growth factor expression. To address this question, in the present study, we used a retroviral small interfering RNA approach to selectively knockdown the expression of RhoC in a neovascularization model in vivo and in vitro. Our present results indicate that RhoC is the downstream regulator of vascular endothelial growth factor in endothelial cells and is essential for angiogenesis induced by vascular endothelial growth factor, notwithstanding that RhoC regulates the expression of vascular endothelial growth factor in tumor cells. Furthermore, we show that knockdown of RhoC is associated with the inhibition of invasion and migration but not apoptosis of endothelial cells. Knockdown of RhoC results in inhibition of endothelial cell organization through restraining the reorganization of F-actin filaments, which represses endothelial cell network and sprout formation. In conclusion, our results demonstrate that knockdown of RhoC inhibits angiogenesis induced by tumor cells not only through effecting the release of vascular endothelial growth factor, but also through inhibiting endothelial cell migration and organization, which implies that it blocks tumor metastasis by specifically inhibiting RhoC in endothelial cells.

Quantitative promoter methylation analysis of hepatocellular carcinoma, cirrhotic and normal liver

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Little is known about its molecular pathogenesis and the relevance of DNA methylation for disease initiation and progression. Nevertheless, promoter methylation of some genes has been implicated as potential marker for HCC. Thirty-four HCC, 34 matching non-malignant, cirrhotic livers and 16 normal livers were analyzed for the methylation status of the genes p16(INK4a), GSTP1, MGMT, DAP-K and APC by quantitative methylation-specific PCR. DNA promoter methylation frequencies in HCC and matching non-malignant cirrhotic liver, respectively, were as follows: p16(INK4a) (76% vs. 24%), GSTP1 (53% vs. 32%), MGMT (6 vs. 12%), DAP-K (68 vs. 100%) and APC (100 vs. 100%). GSTP1 and/or p16(INK4a) promoter methylation was observed in 88% of the HCC samples. In normal liver tissue, the p16(INK4a), GSTP1 and MGMT promoter were not methylated. DAP-K was methylated in 31% and APC even in 100% of normal liver samples. Quantitative levels of methylated promoter DNA of all genes were significantly different in the various tissue types except for MGMT. Our results suggest that promoter methylation of tumor-associated genes is a common event in hepatocarcinogenesis. Significantly, higher levels and frequencies of promoter methylation in HCC were found for p16(INK4a) and GSTP1 compared to non-malignant cirrhotic liver. This indicates that these epigenetic events may serve as a good marker for HCC. These data also demonstrate the importance of the quantification of methylated promoter DNA within a given sample and the use of normal tissue as controls. Quantitative analyses of methylated GSTP1 and p16(INK4a) promoter may serve as a powerful molecular marker in detecting HCC in biopsies.

Moringa oleifera Lam prevents acetaminophen induced liver injury through restoration of glutathione level

Initiation of acetaminophen (APAP) toxicities is believed to be promoted by oxidative stress during the event of overdosage. The aim of the present study was to evaluate the hepatoprotective action of Moringa oleifera Lam (MO), an Asian plant of high medicinal value, against a single high dose of APAP. Groups of five male Sprague-Dawley rats were pre-administered with MO (200 and 800 mg/kg) prior to a single dose of APAP (3g/kg body weight; p.o). Silymarin was used as an established hepatoprotective drug against APAP induced liver injury. The hepatoprotective activity of MO extract was observed following significant histopathological analysis and reduction of the level of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) in groups pretreated with MO compared to those treated with APAP alone. Meanwhile, the level of glutathione (GSH) was found to be restored in MO-treated animals compared to the groups treated with APAP alone. These observations were comparable to the group pretreated with silymarin prior to APAP administration. Group that was treated with APAP alone exhibited high level of transaminases and ALP activities besides reduction in the GSH level. The histological hepatocellular deterioration was also evidenced. The results from the present study suggested that the leaves of MO can prevent hepatic injuries from APAP induced through preventing the decline of glutathione level.