Comparison of staging systems of hepatocellular carcinoma

Uncovering gene expression signatures and diagnostic - Biomarkers in hepatocellular carcinoma through multinomial logistic regression analysis

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide, and classifying the developmental stages of HCC can help with early prognosis and treatment. This study aimed to investigate diagnostic and prognostic molecular signatures underlying the progression of HCC, including tumor initiation and growth, and to classify its developmental stages based on gene expression levels. We integrated data from two cancer systems, including 78 patients with Edmondson-Steiner (ES) grade and 417 patients with TNM stage cancer. Functional profiling was performed using identified signatures. Using a multinomial logistic regression model (MLR), we classified controls, early-stage HCC, and advanced-stage HCC. The model was validated in three independent cohorts comprising 45 patients (neoplastic stage), 394 patients (ES grade), and 466 patients (TNM stage). Multivariate Cox regression was employed for HCC prognosis prediction. We identified 35 genes with gradual upregulation or downregulation in both ES grade and TNM stage patients during HCC progression. These genes are involved in cell division, chromosome segregation, and mitotic cytokinesis, promoting tumor cell proliferation through the mitotic cell cycle. The MLR model accurately differentiated controls, early-stage HCC, and advanced-stage HCC across multiple cancer systems, which was further validated in various independent cohorts. Survival analysis revealed a subset of five genes from TNM stage (HR: 3.27, p < 0.0001) and three genes from ES grade (HR: 7.56, p < 0.0001) that showed significant association with HCC prognosis. The identified molecular signature not only initiates tumorigenesis but also promotes HCC development. It has the potential to improve clinical diagnosis, prognosis, and therapeutic interventions for HCC. This study enhances our understanding of HCC progression and provides valuable insights for precision medicine approaches.

Prediction of prognosis of patients with hepatocellular carcinoma based on immune-related score

BACKGROUND

Immune-related scores are currently used for prognostic evaluation and as an immunotherapy reference in various cancers. However, the relationship between immune-related score and hepatocellular carcinoma (HCC) prognosis has not yet been investigated. This study aimed to explore the clinical application value of immune-related score for predicting HCC prognosis-related indicators including disease-free survival (DFS) and overall survival (OS), and to construct a clinical nomogram prediction model related to verification.

METHODS

This study included 284 HCC patients who were selected from the Cancer Genome Atlas (TCGA) database and linked to the immune-related score downloaded from the public platform. A Cox proportional hazards regression model was used to estimate the adjusted risk ratio, and a nomogram was constructed based on multivariate analysis results and clinical significance. The model was internally verified by bootstrap. The performance of the prediction model was evaluated using the C-index and calibration curves.

RESULTS

Patients were divided into three subgroups according to the immune-related score level. Compared with patients in the low immune-related score group, the DFS of patients in the medium and high immune-related score groups was significantly prolonged (HR: 0.53, 95% CI: 0.32-0.87; HR: 0.37, 95% CI: 0.21-0.63, respectively). The OS of patients in the medium and high immune-related score groups was also significantly prolonged (HR: 0.43, 95% CI: 0.20-0.95, p = 0.038; HR: 0.29, 95% CI: 0.14-0.58, p < 0.001, respectively). The C-indexes for predicting DFS and OS were 0.687 (95% CI: 0.665-0.700) and 0.743 (95% CI: 0.709-0.776), respectively. The calibration curves of 3-year and 5-year DFS and OS showed that the results predicted by the nomogram were in good agreement with the actual observations.

CONCLUSIONS

Moderate/high-grade immune-related score was significantly associated with better DFS and OS in HCC patients. In addition, a nomogram for prognosis estimation can help clinicians predict the survival status of patients.

SEER-based risk stratification system for patients with primary non-cirrhotic liver cancer

BACKGROUND

Little research has been done on the factors affecting the survival of patients with non-cirrhotic hepatocellular carcinoma (HCC-NCL). Our aim was to develop and validate a nomogram and a new risk stratification system that can evaluate overall survival (OS) in HCC-NCL patients.

METHODS

We retrospectively analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019 to study HCC-NCL patients. The patients were randomly split into training and validation groups at a 7:3 ratio and subjected to single-factor and multi-factor COX regression analysis. We then developed a nomogram and evaluated its accuracy and clinical validity using time-dependent ROC, DCA, and calibration curves. We compared the nomogram with the AJCC staging system by calculating C-index, NRI, and IDI. Finally, we used Kaplan-Meier curves to compare the nomogram and AJCC staging. These analyses were performed without altering the original intended meaning.

RESULTS

AFP levels, surgical intervention, T-stage, tumor size, and M-stage were independent prognostic indicators for overall survival among the HCC-NCL population studied. We developed a nomogram based on these factors, and time-dependent ROC, calibration curves, DCA analyses, and C-index proved its accuracy. Compared to the AJCC staging system, the nomogram showed better prognostic accuracy through time-dependent ROC, DCA analyses, C-index, NRI, IDI, and Kaplan-Meier curves.

CONCLUSION

We have developed and validated a survival nomogram applicable to HCC-NCL patients, with risk stratification. Our nomogram offers personalized treatment and management options superior to those provided by the AJCC staging system.

Serum Albumin Levels Relation to Tumor Aggressiveness in Patients with Hepatocellular Carcinoma from a Tertiary Care Hospital in Pakistan

Background: Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in patients with chronic liver diseases (CLDs). Studies have shown a correlation between low serum albumin levels and the aggressiveness of liver cancer. We aimed to determine the prevalence of hypoalbuminemia and its relationship with HCC aggressiveness in our patients. Methods: This study was conducted retrospectively, and data were gathered from the gastroenterology unit of the Department of Medicine at the Aga Khan University Hospital in Karachi, Pakistan. The study included all patients who had been diagnosed with HCC between February 2015 and February 2019. Results: In total, 380 patients with HCC were included in this study. The mean serum albumin level was 2.79 g/dL (SD±0.655) and 318 (83.7%) had serum albumin levels of≤3.5 g/dL. No statistically significant association was identified between albumin levels and parameters of tumor aggressiveness (tumor size, number of tumor nodules, portal vein thrombosis [PVT], and alpha-fetoprotein [AFP] levels) in our patients. Conclusion: We found no association between low albumin levels and parameters of HCC progression in our patients. This highlights the need for additional markers to determine the severity of HCC in underdeveloped populations.

A necroptosis -related signature for predicting prognosis and immunotherapy in hepatocellular carcinoma

Background: Hepatocellular Carcinoma (HCC) is an aggressive tumor with an inferior prognosis. Necroptosis is a new form of programmed death that plays a dual effect on the tumor. However, the role of necroptosis-related genes(NRGs) in HCC remains unknown.

Methods: All datasets were downloaded from publicly available databases. The consensus clustering analysis was used to classify patients into different subtypes based on NRGs. The Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression were used to develop a prognostic signature. Tumor Immune Dysfunction and Exclusion (TIDE) was used to predict immunotherapy response.

Results: The genetic and transcriptional changes of NRGs were observed in HCC. Patients were classified into three clusters based on differentially expressed NRGs, of which Cluster-3 had the worst prognosis and the highest immune infiltration. The prognostic signature was developed based on 8-NRGs, which have shown excellent prognostic performance. The high-risk group in the signature presented significantly higher immune infiltration, such as aDCs, iDCs, macrophages, and Treg, compared to the low-risk group. TMB and immune checkpoints were also higher in the high-risk group. Moreover, a lower TIDE score was observed in the high-risk group, indicating the patients with high risk-score may be suitable for immunotherapy. Via the dataset of IMvigor210, we found a higher risk score in the immunotherapy response group.

Conclusion: We developed a new necroptosis-related signature for predicting prognosis with the potential to predict immunotherapy for HCC patients.

The combination of transcatheter arterial chemoembolisation (TACE) and thermal ablation versus TACE alone for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the sixth most common cancer worldwide. Hepatic resection is regarded as the curative therapy for hepatocellular carcinoma. However, only about 20% of people with hepatocellular carcinoma are candidates for resection, which highlights the importance of effective nonsurgical therapies. Until now, transcatheter arterial chemoembolisation (TACE) is the most common palliative therapy for hepatocellular carcinoma, but its clinical benefits remain unsatisfactory. During recent years, some studies have reported that the combination of TACE plus thermal ablation can confer a more favourable prognosis than TACE alone. However, clear and compelling evidence to prove the beneficial or harmful effects of the combination of TACE and thermal ablation therapy is lacking.

OBJECTIVES

To assess the beneficial and harmful effects of the combination of thermal ablation with TACE versus TACE alone in people with hepatocellular carcinoma.

SEARCH METHODS

We performed searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science. We endeavoured to identify relevant randomised clinical trials also in the China National Knowledge Infrastructure (CNKI) and Wanfang databases. We searched trial registration websites for ongoing studies. We also handsearched grey literature sources. The date of last search was 22 December 2020.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing the combination of TACE plus thermal ablation versus TACE alone for hepatocellular carcinoma, no matter the language, year of publication, publication status, and reported outcomes.

DATA COLLECTION AND ANALYSIS

We planned to use standard methodological procedures expected by Cochrane. We planned to calculate risk ratios (RRs) with the corresponding 95% confidence intervals (CIs). For time-to-event variables, we planned to use the methods of survival analysis and express the intervention effect as a hazard ratio (HR) with 95% Cl. If the log HR and the variance were not directly reported in reports, we planned to calculate them indirectly, following methods for incorporating summary time-to-event data into meta-analysis. We planned to assess the risk of bias of the included studies using the RoB 2 tool. We planned to assess the certainty of evidence with GRADE and present the evidence in a summary of findings table.

MAIN RESULTS

Out of 2224 records retrieved with the searches, we considered 135 records eligible for full-text screening. We excluded 21 of these records because the interventions used were outside the scope of our review or the studies were not randomised clinical trials. We listed the remaining 114 records, reporting on 114 studies, under studies awaiting classification because we could not be sure that these were randomised clinical trials from the information in the study paper. We could not obtain information on the registration of the study protocol for any of the 114 studies. We could not obtain information on study approval by regional research ethics committees, either from the study authors or through our own searches of trial registries. Corresponding authors did not respond to our enquiries about the design and conduct of the studies, except for one from whom we did not receive a satisfactory response. We also raised awareness of our concerns to editors of the journals that published the 114 studies, and we did not hear back with useful information. Moreover, there seemed to be inappropriate inclusion of trial participants, based on cancer stage and severity of liver disease, who should have obtained other interventions according to guidelines from learned societies. Accordingly, we found no confirmed randomised clinical trials evaluating the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma for inclusion in our review. We identified five ongoing trials, by handsearching in clinical trial websites.

AUTHORS' CONCLUSIONS

We could not find for inclusion any confirmed randomised clinical trials assessing the beneficial or harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma. Therefore, our results did not show or reject the efficiency of the combination of TACE plus thermal ablation versus TACE alone for people with hepatocellular carcinoma. We need trials that compare the beneficial and harmful effects of the combination of TACE plus thermal ablation versus TACE alone in people with hepatocellular carcinoma, not eligible for treatments with curative intent (liver transplantation, ablation surgical resection) and who have sufficient liver reserve, as assessed by the Child Pugh score, and who do not have extrahepatic metastases. Therefore, future trial participants must be classified at Barcelona Clinic Liver Cancer Stage B (intermediate stage) (BCLC-B) or an equivalent, with other staging systems.

Survival inequity in vulnerable populations with early-stage hepatocellular carcinoma: a United States safety-net collaborative analysis

BACKGROUND

Access to health insurance and curative interventions [surgery/liver-directed-therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access-to-care barriers for vulnerable populations.

METHODS

Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic/clinical parameters.

RESULTS

Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p < 0.001)], and decreased median OS (PI-SNH:32.1 vs. GI-SNH:22.8 vs. NI-SNH:9.4 months, p = 0.002). On multivariable regression controlling for sociodemographic/clinical parameters, NI-SNH (HR:2.5, 95% CI:1.3-4.9, p = 0.007) was the only insurance type/hospital system combination with significantly worse OS.

CONCLUSION

NI-SNH patients received less curative treatment than other insurance/hospitals types suggesting that treatment barriers, beyond access-to-care, need to be identified and addressed to achieve survival equity in early-stage HCC for vulnerable populations (NI-SNH).

Overview of Prognostic Systems for Hepatocellular Carcinoma and ITA.LI.CA External Validation of MESH and CNLC Classifications

Prognostic assessment in patients with HCC remains an extremely difficult clinical task due to the complexity of this cancer where tumour characteristics interact with degree of liver dysfunction, patient general health status, and a large span of available treatment options. Several prognostic systems have been proposed in the last three decades, both from the Asian and European/North American countries. Prognostic scores, such as the CLIP score and the recent MESH score, have been generated on a solid statistical basis from real life population data, while staging systems, such as the BCLC scheme and the recent CNLC classification, have been created by experts according to recent HCC prognostic evidences from the literature. A third category includes combined prognostic systems that can be used both as prognostic scores and staging systems. A recent example is the ITA.LI.CA prognostic system including either a prognostic score and a simplified staging system. This review focuses first on an overview of the main prognostic systems for HCC classified according to the above three categories, and, second, on a comprehensive description of the methodology required for a correct comparison between different systems in terms of prognostic performance. In this second section the main studies in the literature comparing different prognostic systems are described in detail. Lastly, a formal comparison between the last prognostic systems proposed for each of the above three categories is performed using a large Italian database including 6882 HCC patients in order to concretely apply the comparison rules previously described.

Management and survival for patients with stage-I hepatocellular carcinoma: An observational study based on SEER database

It is controversial regarding the treatment allocation for patients with stage I hepatocellular carcinoma (SI-HCC). The aim of the present study was to compare the long-term survival in SI-HCC patients undergoing liver transplantation (LT), liver resection (LR), local tumor destruction (LTD), or none. SI-HCC patients diagnosed between 2004 and 2015 were extracted from the SEER 18 registry database. Multivariable Cox models and propensity score matching (PSM) method were used to explore the association between surgical methods and long-term prognosis. A total of 5165 patients with stage I (AJCC, 6th or 7th) HCC were included in the study. Only 36.9% of patients diagnosed with HCC in stage I received surgical therapy. The incidence of LT was decreased over time (P < .001). In the multivariable-adjusted cohort (n = 5165), after adjusting potential confounding factors, a clear prognostic advantage of LT was observed in OS (P < .0001) compared with patients after LR. Patients undergoing LTD had a worse OS in comparison with patients who underwent LR (P < .0001). Patients who received no surgical treatment had the worst OS (P < .0001) among 4 treatment groups. In stratified analyses, the salutary effects of LT vs LR on OS were consistent across all subgroups except for a similar result in the noncirrhotic subgroup (P = .4414). The inferior survival effects of LTD vs LR on OS were consistent across all subgroups, and even in the subgroup with tumor size < 3 cm (P = .0342). In the PSM cohort, patients in LT group showed a better OS (P < .001) than patients in LR group (P < .0001) and patients undergoing LTD had a worse OS compared with patients who underwent LR (P = .00059). In conclusion, LT offered a survival advantage compared with LR among patients with Stage I HCC. LT is the best surgical treatment for stage I HCC in patients with advanced fibrosis, whereas LR provides comparable long-term outcomes to LT in patients without advanced fibrosis and should be considered as the first-line surgical option. LTD can be used as an alternative method when LR and LT are unavailable.

Prognostic value of glucose transporter 3 expression in hepatocellular carcinoma

Determining an effective biomarker for predicting the prognosis of patients with hepatocellular carcinoma (HCC) may improve patient survival rates. The present study aimed to investigate the expression of glucose transporter 3 (GLUT-3) in HCC and to determine its predictive value for the survival of patients with HCC. Immunohistochemistry was used to detect GLUT-3 expression in HCC tissues of 275 and 140 patients with HCC from training and validation cohorts, respectively. The association between GLUT-3 expression and the clinicopathological characteristics of patients with HCC, and between GLUT-3 expression and patient survival rates were analyzed. The predictive value of GLUT-3 expression was confirmed using the validation cohort. The results demonstrated that the high GLUT-3 expression in HCC tissues was significantly associated with elevated α-fetoprotein level, large tumor size, poor histological differentiation and Tumor-Node-Metastasis stages III and IV (P<0.05). In addition, GLUT-3 high expression was also significantly associated with reduced overall survival of patients with HCC in the training and validation cohorts. In conclusion, the results from the present study suggested that GLUT-3 may be considered as a potential independent prognostic factor for predicting the survival of patients with HCC.

Using natural language processing to extract clinically useful information from Chinese electronic medical records

AIMS

To develop a natural language processing (NLP)-based algorithm for extracting clinically useful information for patients with hepatocellular carcinoma (HCC) from Chinese electronic medical records (EMRs) and use these data for the assessment of HCC staging.

MATERIALS AND METHODS

Clinical documents, including operation notes, radiology and pathology reports, of 92 HCC patients were collected from Chinese EMRs. We randomly grouped these patients into training (n = 60) and testing (n = 32) datasets. Rule-based and hybrid methods for extracting information were developed using the training set of manually-annotated operation notes. The method with better performance was used to process other documents. The performance of the algorithm was assessed via calculating the precision, recall and F-score for exact-boundary and partial-boundary matching strategies. The utility of clinically useful information for the HCC staging was assessed in comparison with that manually reviewed.

RESULTS

For operation notes, the rule-based and hybrid methods had a precision, recall and F-score ≥80% when the exact-boundary and partial-boundary matching strategies were applied to the testing dataset. By using the rule-based method (which has better performance than the hybrid method), three other types of documents also obtained good performance. When the extracted clinically useful information was applied for the HCC staging, the concordance rate with the manual review was 75%.

CONCLUSION

A NLP system was developed for clinical information extraction and HCC staging based on EMRs, and the results indicate that Chinese NLP has potential utility in clinical research.

Staging systems of hepatocellular carcinoma: A review

Staging of hepatocellular carcinoma (HCC) is necessary for guiding prognostication, management, and research purposes that further aid in the improvement of existing clinical and epidemiological health services. Though there are some new staging systems for HCC developed in different parts of the world, there is no globally accepted staging system that allows for comparison of current management protocols among heterogeneous populations. In this review, we discuss the evolution and applicability in clinical practice of different clinical staging systems of HCC-Okuda, CLIP (Cancer of the Liver Italian Program) score, MESIAH (Model to Estimate Survival In Ambulatory HCC patients) score, ITA.LI.CA (Italian Liver Cancer) score, BCLC (Barcelona Clinic Liver Cancer) staging, HKLC (Hong Kong Liver Cancer) staging, and the Alberta algorithm. This review aims to highlight the main criteria for assessing the prognosis of HCC that these different staging systems take into account, their strengths and limitations for use in modern clinical practice. Despite the limitations of the BCLC staging system, it remains the most validated and reliable system for prognostication. However, there is a need to update the BCLC staging system to include recent data on locoregional and systemic therapies for HCC, expanded criteria for transplantation, and systemic therapy for hepatitis C infection.

Is there an optimal staging system or liver reserve model that can predict outcome in hepatocellular carcinoma?

Background

Many staging systems and liver reserve models have been proposed to predict hepatocellular carcinoma (HCC) prognosis. However, there is no consensus as to which model provides the best prognostic value. We aimed to investigate the prognostic role of 8 noninvasive models including the albumin-bilirubin index (ALBI), AST to platelet ratio index (APRI), Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP) system, Child-Pugh (CP) class, Fibrosis-4 (FIB-4) score, model for end-stage liver disease (MELD) score, and platelet-albumin-bilirubin index (PALBI) in patients with HCC.

Methods

This is a retrospective study of 900 HCC patients. Patients who underwent transplantation were excluded. The Kaplan-Meier method was used to estimate the survival probabilities. Multivariate cox proportional hazard models were used to calculate the survival trend. P<0.05 was considered significant. The area under receiver operating characteristic curve (AUC) was calculated to test the discriminatory power over 1- and 3-year mortality and recurrence.

Results

For predicting 1- and 3-year mortality, the CLIP score provided the highest AUC value, followed by the BCLC stage and the PALBI grade. For predicting 3-year recurrence, the CLIP score demonstrated the highest discriminative power followed by the PALBI grade, ALBI grade and BCLC system. However, all included models were found to be poor predictors for recurrence.

Conclusions

The CLIP score is more accurate prognostic model to predict mortality and recurrence than the BCLC stage. Regarding the liver reserve models, the PALBI is the most accurate prognostic models among 6 models to predict mortality and recurrence.

Characteristics of Hepatocellular Carcinoma Aggressiveness Factors in Turkish Patients

A large cohort of hepatocellular carcinoma (HCC) patients from several collaborating Turkish institutions were examined for the tumor parameters of maximum diameter (MTD), portal vein thrombosis (PVT), and α-fetoprotein (AFP) levels. A relationship was found between MTD and blood platelet levels. Patients with large ≥5 cm tumors who had normal platelet levels had significantly larger tumors, higher percent of PVT, and significantly lower blood total bilirubin and liver cirrhosis than similar ≥5 cm tumor patients having thrombocytopenia. A comparison of patients with and without PVT showed significantly larger tumors, greater multifocality, blood AFP, and C-reactive protein levels, and, interestingly, lower HDL levels in the patients with PVT. Fifty-eight percent of the total cohort had AFP levels ≤100 IU/mL (and 42.1% had values ≤20 IU/mL). These patients had significantly smaller tumors, less tumor multifocality and percent PVT, lower total bilirubin, and less cirrhosis. There was considerable geographic heterogeneity within Turkey in the patterns of HCC presentation, with areas of higher and lower hepatitis B virus, hepatitis D virus, cirrhosis, and tumor aggressiveness parameters. Turkish patients thus have distinct patterns of presentation, but the biological relationships between MTD and both platelets and bilirubin levels are similar to the relationships that have been reported in other ethnic patient groups.

Evaluation of eight different clinical staging systems associated with overall survival of chinese patients with hepatocellular carcinoma

Background:

Hepatocellular carcinoma (HCC) is a common cancer in China, an area of high hepatitis B virus (HBV) infection. Although several staging systems are available, there is no consensus on the best classification to use because multiple factors, such as etiology, clinical treatment and populations could affect the survival of HCC patients.

Methods:

This study analyzed 743 HBV-related Chinese HCC patients who received surgery first and evaluated the predictive values of eight different commonly used staging systems in the clinic.

Results:

The overall 1-, 3-, 5-year survival rates and a median survival were 91.5%, 70.3%, 55.3% and 72 months respectively. Barcelona Clinic Liver Cancer (BCLC) staging systems had the best stratification ability and showed the lowest Akaike information criterion (AIC) values (2896.577), followed by tumor-node-metastasis 7^th (TNM 7^th) (AIC = 2899.980), TNM 6^th (AIC = 2902.17), Japan integrated staging score (AIC = 2918.085), Tokyo (AIC = 2938.822), Cancer of the Liver Italian Program score (AIC = 2941.950), Chinese University Prognostic Index grade (AIC = 2962.027), and Okuda (AIC = 2979.389).

Conclusions:

BCLC staging system is a better staging model for HBV infection patients with HCC in Chinese population among the eight currently used staging systems. These identifications afford a large group of Chinese HCC patients with HBV infection and could be helpful to design a new staging system for a certain population.

Single Hepatocellular Carcinoma: Preoperative MR Imaging to Predict Early Recurrence after Curative Resection

PURPOSE

To identify magnetic resonance (MR) imaging features that enable prediction of early recurrence (<2 years) after curative resection of hepatocellular carcinoma (HCC) and to derive a preoperative prediction model.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. The requirement to obtain written informed consent was waived. A total of 268 patients who underwent hepatic resection for a single HCC from January 2008 to August 2011 were divided into two cohorts: a training cohort, which was used to derive a prediction model (n = 187), and a validation cohort (n = 81). All MR images from the training cohort were reviewed by two radiologists. A prediction model was constructed by using MR imaging features that were independently associated with early recurrence with use of multiple logistic regression analysis. The performance of the prediction model in the validation cohort was evaluated with respect to discrimination (ie, whether the relative ranking of individual predictions of subsequent early recurrence is in the correct order).

RESULTS

In the training cohort, four MR imaging features were independently associated with early recurrence: rim enhancement (odds ratio [OR] = 3.83; 95% confidence interval [CI]: 1.39, 10.52), peritumoral parenchymal enhancement in the arterial phase (OR = 2.64; 95% CI: 1.27, 5.46), satellite nodule (OR = 4.07; 95% CI: 1.09, 15.21), and tumor size (OR = 1.66; 95% CI: 1.31, 2.09). A prediction model derived from these variables showed an area under the receiver operating characteristic curve (AUC) of 0.788 in the prediction of the risk of early recurrence in the training cohort. When applied to the validation cohort, this model showed good discrimination (AUC, 0.783).

CONCLUSION

The prediction model derived from rim enhancement, peritumoral parenchymal enhancement, satellite nodule, and tumor size can be used preoperatively to estimate the risk of early recurrence after resection of a single HCC.

A discussion of serum albumin level in advanced-stage hepatocellular carcinoma: a medical oncologist's perspective

Hepatocellular carcinoma is the most common primary malignant tumor of the liver, and it is particularly prevalent in East and Southeast Asia. With surgical and/or local interventional treatment methods, survival rates for early-stage hepatocellular cancers have increased. However, it is not yet clear which staging systems are more applicable in hepatocellular carcinoma. Serum albumin level is already being used as a criterion in most staging systems. Albumin is an important serum protein in human bodily functions, but only 5 % of the daily amount needed is synthesized by the liver. The serum albumin level is affected by multifactorial situations, including capillary permeability, drugs, liver insufficiency, inflammation and/or infections, dehydration or overhydration, protein loosing disorders, and decreased nutrition intake in anorexia-malnutrition syndrome and cancer cachexia. Because of this complex situation, serum albumin level may affect many staging systems for hepatocellular carcinoma by leading to false-negative results. In this paper, the statuses of current staging systems are reviewed, and possible negative events regarding the serum albumin levels found in these staging systems are discussed.

Prognosis evaluation in patients with hepatocellular carcinoma after hepatectomy: comparison of BCLC, TNM and Hangzhou criteria staging systems

Purpose

This study is to evaluate the Hangzhou criteria (HC) for patients with HCC undergoing surgical resection and to identify whether this staging system is superior to other staging systems in predicting the survival of resectable HCC.

Method

774 HCC patients underwent surgical resection between 2007 and 2009 in West China Hospital were enrolled retrospectively. Predictors of survival were identified using the Kaplan–Meier method and the Cox model. The disease state was staged by the HC, as well as by the TNM and BCLC staging systems. Prognostic powers were quantified using a linear trend χ2 test, c-index, and the likelihood ratio (LHR) χ2 test and correlated using Cox's regression model adjusted using the Akaike information criterion (AIC).

Results

Serum AFP level (P = 0.02), tumor size (P<0.001), tumor number (P<0.001), portal vein invasion (P<0.001), hepatic vein invasion (P<0.001), tumor differentiation (P<0.001), and distant organ (P = 0.016) and lymph node metastasis (P<0.001) were identified as independent risk factors of survival after resection by multivariate analysis. The comparison of the different staging system results showed that BCLC had the best homogeneity (likelihood ratio χ² test 151.119, P<0.001), the TNM system had the best monotonicity of gradients (linear trend χ² test 137.523, P<0.001), and discriminatory ability was the highest for the BCLC (the AUCs for 1-year mortality were 0.759) and TNM staging systems (the AUCs for 3-, and 5-year mortality were 0.738 and 0.731, respectively). However, based on the c-index and AIC, the HC was the most informative staging system in predicting survival (c-index 0.6866, AIC 5924.4729).

Conclusions

The HC can provide important prognostic information after surgery. The HC were shown to be a promising survival predictor in a Chinese cohort of patients with resectable HCC.

Staging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is different from other malignancies because the prognosis in HCC is not only dependent upon the tumor stage but also on the liver function impairment due to accompanying cirrhosis liver. Various other staging systems used in HCC include the European systems [French staging system, Barcelona Clinic Liver Cancer (BCLC) staging system and the cancer of the liver Italian program (CLIP)] and Asian systems [Okuda staging system, Japan integrated Staging (JIS), Tokyo score and Chinese University Prognostic Index (CUPI)]. Out of all the staging systems used in HCC, Barcelona Clinic Liver Cancer (BCLC) staging system is probably the best because it takes in to account the tumor status (defined by tumor size and number, presence of vascular invasion and extrahepatic spread), liver function (defined either by the Child-Pugh's class) and general health status of the patient (defined by the ECOG classification and the presence of symptoms). Since most of the extrahepatic spread in HCC occurs to lymph nodes, lungs and bones, the assessment can be done with either PET/CT or a combination of CT (Chest and abdomen) and a bone scan. This article describes the various staging systems used in HCC, guides choosing a staging system particularly in the Indian context and the assessment of extra-hepatic spread in HCC.

Thrombocytosis as a prognostic marker in gastrointestinal cancers

Thrombocytosis is an adverse prognostic factor in many types of cancer. These include breast cancer, ovarian and other gynecologic cancers, renal cell carcinoma and lung cancers. In gastrointestinal cancers of various locations and histologic types, thrombocytosis has been reported in general to be associated with adverse clinical outcomes. Platelet count measurement is well standardized and available in every clinical laboratory, making its use as a prognostic marker practical. This paper will discuss the data on the prognostic value of thrombocytosis in gastrointestinal cancers as well as pathogenic aspects of the association that strengthen the case for its use in clinical prognostication.

MicroRNA-21 promotes hepatocellular carcinoma HepG2 cell proliferation through repression of mitogen-activated protein kinase-kinase 3

BACKGROUND

microRNA 21 (miR-21) has been demonstrated to be significantly elevated in many types of cancers, including the hepatocellular carcinoma (HCC). In the present study, we investigated the role of miR-21 in HCC by identifying its novel targets, as well as its underlying molecular mechanism.

METHODS

The expression of mitogen-activated protein kinase-kinase 3 (MAP2K3) in human HCC tumor tissues and adjacent non-tumor tissues was determined by immunohistochemistry staining (IHC) analysis. The 3'-untranslated region (3'-UTR) of MAP2K3 combined with miR-21 was experimentally verified by a miRNA luciferase reporter approach. Moreover, the role of miR-21 in regulating HCC cell proliferation was analyzed by an MTT assay infected with miR-21mimics/sponge inhibitor Adenoviral viral vectors.

RESULTS

By immunohistochemistry staining analysis, we found that mitogen-activated protein kinase-kinase 3 (MAP2K3) was strikingly repressed in the human HCC tumor tissues, in comparison with the adjacent non-tumor tissues in clinical settings. More importantly, the repression of MAP2K3 was inversely correlated with the expression of miR-21 in HCC. Further study demonstrated that the MAP2K3 was a novel direct target of miR-21, which was experimentally validated by a miRNA luciferase reporter approach. In HepG2 cells, inhibition of miR-21 expression with an adenoviral miR-21 sponge vector profoundly suppressed cell proliferation by up-regulating MAP2K3 expression at both mRNA and protein levels.

CONCLUSIONS

These results provide a clinical evidence that MAP2K3 may be a tumor repressor gene, and it is a direct target of miR-21 in HCC, indicating an underlying mechanism by which miR-21 is able to directly target MAP2K3 and inhibit its expression during the carcinogenesis of HCC, at both transcriptional and post-translational levels. This study also suggests that targeting miR-21-MAP2K3 pathway may be a promising strategy in the prevention and treatment of HCC.

Treatment of hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with an increasing incidence. With advances in surgical techniques and instrumentation and the development of molecular-target drugs, a number of potentially curative treatments have become available. Management of HCC patients depends on the stage of their tumor. Liver resection remains the first choice for very early-stage HCC, but it is being challenged by local ablative therapy. For early-stage HCC that meet the Milan criteria, liver transplantation still offers a better outcome; however, local ablative therapy can be a substitute when transplantation is not feasible. Local ablation is also used as a bridging therapy toward liver transplantation. HCC recurrence is the main obstacle to successful treatment, and there is currently no effective means of preventing or treating HCC recurrence. Transarterial therapy is considered suitable for intermediate-stage HCC, while sorafenib is recommended for advanced-stage HCC. This stage-based approach to therapy not only provides acceptable outcomes but also improves the quality of life of HCC patients. Because of the complexity of HCC, therapeutic approaches must be adapted according to the characteristics of each individual patient. This review discusses the current standards and trends in the treatment of HCC.