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Honda M, Isono K, Hirukawa K, Tomita M, Hirao H, Hirohara K, Sakurai Y, Irie T, Mori T, Shimata K, Shimojima N, Sugawara Y, Hibi T. Reappraisal of anatomical liver resection for hepatoblastoma in children. Surg Open Sci 2023; 16:215-220. [PMID: 38035224 PMCID: PMC10687054 DOI: 10.1016/j.sopen.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 12/02/2023] Open
Abstract
Background The principle of hepatoblastoma (HB) treatment is complete resection. The removal of tumor-bearing section(s) or hemiliver is widely accepted. However, neither the standardized anterior approach for right hepatectomy nor parenchymal sparing anatomical liver resection has been described for HB. Methods We retrospectively reviewed the clinical course of two pediatric HB patients who underwent extended right hepatectomy using the anterior approach with the liver hanging maneuver and one who underwent parenchymal sparing anatomical liver resection of S4 apical+S8 ventral/dorsal+S7. The critical aspects of surgical techniques are described in detail. Results In all three patients, R0 resection was achieved without complications and are currently alive without recurrence after an average follow-up of 23 months. Intraoperative cardiac hemodynamics were stable, even in a trisomy 18 patient with cardiac disease. Conclusions Our findings suggest that these innovative techniques established in adults are safe and feasible for HB in children. These techniques also allow optimal anatomical liver resection to accomplish curative surgery while maintaining the functional reserve of the remnant liver.
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Affiliation(s)
- Masaki Honda
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kaori Isono
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kazuya Hirukawa
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Masahiro Tomita
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hiroki Hirao
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kazuki Hirohara
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuto Sakurai
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Tomoaki Irie
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Teizaburo Mori
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Keita Shimata
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoki Shimojima
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yasuhiko Sugawara
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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Yu JI, Park HC, Shin H, Park H, Shin SW, Cho SK, Hyun D, Shin J, Goh MJ, Choi MS, Park B, Yoon SM, Jung J. External validation of subclassification system and progression pattern analysis in hepatocelluar carcinoma with macroscopic vascular invasion. Radiother Oncol 2023; 187:109841. [PMID: 37543052 DOI: 10.1016/j.radonc.2023.109841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND PURPOSE The present study aimed to validate the performance of a previously proposed subclassification model to predict prognosis after combined transarterial chemoembolization (TACE) and external beam radiotherapy (RT) for hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) in an independent cohort that received the same first-line treatment for the patients with the similar disease extent characteristics, and analyzed the progression patterns as well as progression-free survival (PFS). MATERIALS AND METHODS This study was conducted using prospectively collected data from the XXXXX HCC registry for newly diagnosed, previously untreated HCC between 2005 and 2018. Finally, 417 patients who satisfied the eligibility criteria were included and analyzed. RESULTS The median PFS and overall survival (OS) were 5.2 and 13.9 months, respectively. Similar to a previous study, subclassification of patients into very low-, low-, intermediate-, and high-risk groups showed a median OS of 98.4, 18.3, 9.7, and 5.8 months, respectively (P < 0.001). Additionally, subclassification of patients into the very low-, low-, intermediate-, and high-risk groups showed median PFS of 18.7, 6.7, 3.3, and 2.3 months, respectively (p < 0.001). Overall, intrahepatic progression was the most common pattern of progression; however, extrahepatic progression was more common in the intermediate- and high-risk groups. CONCLUSION The previously proposed subclassification model was successfully validated in an independent cohort. Treatment modification should be considered in the intermediate- and high-risk patient groups because of their frequent extrahepatic as well as intrahepatic progressions after combined TACE and RT.
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Affiliation(s)
- Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hyunju Shin
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyunki Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jaeseung Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung Ji Goh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Moon Seok Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung medical Center, Seoul, Republic of Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Vitale A, Cabibbo G, Iavarone M, Viganò L, Pinato DJ, Ponziani FR, Lai Q, Casadei-Gardini A, Celsa C, Galati G, Gambato M, Crocetti L, Renzulli M, Giannini EG, Farinati F, Trevisani F, Cillo U. Personalised management of patients with hepatocellular carcinoma: a multiparametric therapeutic hierarchy concept. Lancet Oncol 2023; 24:e312-e322. [PMID: 37414020 DOI: 10.1016/s1470-2045(23)00186-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/07/2023] [Accepted: 04/20/2023] [Indexed: 07/08/2023]
Abstract
Advances in the surgical and systemic therapeutic landscape of hepatocellular carcinoma have increased the complexity of patient management. A dynamic adaptation of the available staging-based algorithms is required to allow flexible therapeutic allocation. In particular, real-world hepatocellular carcinoma management increasingly relies on factors independent of oncological staging, including patients' frailty, comorbid burden, critical tumour location, multiple liver functional parameters, and specific technical contraindications impacting the delivery of treatment and resource availability. In this Policy Review we critically appraise how treatment allocation strictly based on pretreatment staging features has shifted towards a more personalised treatment approach, in which expert tumour boards assume a central role. We propose an evidence-based framework for hepatocellular carcinoma treatment based on the novel concept of multiparametric therapeutic hierarchy, in which different therapeutic options are ordered according to their survival benefit (ie, from surgery to systemic therapy). Moreover, we introduce the concept of converse therapeutic hierarchy, in which therapies are ordered according to their conversion abilities or adjuvant abilities (ie, from systemic therapy to surgery).
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Affiliation(s)
- Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
| | - Giuseppe Cabibbo
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy.
| | - Massimo Iavarone
- Division of Gastroenterology and Hepatology, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Viganò
- Hepatobiliary Unit, Department of Minimally Invasive General & Oncologic Surgery, Humanitas Gavazzeni University Hospital, Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Francesca Romana Ponziani
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, Istituto di Ricovero Cura a Carattere Scientifico San Raffaele Scientific Institute Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy; Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giovanni Galati
- Unit of Clinical Medicine and Hepatology, University Campus Bio-Medico, Rome, Italy
| | - Martina Gambato
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Laura Crocetti
- Department of Radiology and Interventional Radiology, University of Pisa, Pisa, Italy
| | - Matteo Renzulli
- Department of Radiology, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Farinati
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Franco Trevisani
- Unit of Semeiotics, Liver and Alcohol-related diseases, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Cheung TT, Yu SCH, Chan SL, Poon RTP, Kwok P, Lee AS, Tai A, Tam D, Cheung CC, Lai TW, Chia NH, Law A, Shum T, Lam YK, Lau V, Lee V, Chong C, Tang CN, Yau T. The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021. Hepatobiliary Surg Nutr 2023; 12:366-385. [PMID: 37351136 PMCID: PMC10282685 DOI: 10.21037/hbsn-21-405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/10/2022] [Indexed: 08/30/2023]
Abstract
Background and Objective Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used. Methods In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018. Key Content and Findings The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence. Conclusions Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.
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Affiliation(s)
- Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Simon Chun-Ho Yu
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Stephen L. Chan
- State Key Laboratory of Translational Oncology and Department of Clinical Oncology, Sir YK Pao Centre for Cancer, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronnie T. P. Poon
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Philip Kwok
- Department of Radiology and Imaging, Queen Elizabeth Hospital, Hong Kong, China
| | - Ann-Shing Lee
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, China
| | - Anna Tai
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong, China
| | - Derek Tam
- Department of Surgery, United Christian Hospital, Hong Kong, China
| | | | - Tak-Wing Lai
- Department of Surgery, Princess Margaret Hospital, Hong Kong, China
| | - Nam-Hung Chia
- Department of Surgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Ada Law
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Tracy Shum
- Department of Clinical Oncology, Princess Margaret Hospital, Hong Kong, China
| | - Yim-Kwan Lam
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong, China
| | - Vince Lau
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | - Victor Lee
- Department of Clinical Oncology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Charing Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Chung-Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Thomas Yau
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Pandrowala S, Patkar S, Goel M, Mirza D, Mathur SK. Surgical resection for large hepatocellular carcinoma and those beyond BCLC: systematic review with proposed management algorithm. Langenbecks Arch Surg 2023; 408:144. [PMID: 37041364 DOI: 10.1007/s00423-023-02881-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 04/02/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) accounts for the sixth most common cancer and ranks third in mortality worldwide with inhomogeneity in terms of resection for advanced-stage disease. METHODS A systematic review of published literature using the PubMed, Medline, and Google Scholar databases from 1995 to 2020 was conducted to identify studies that reported outcomes of resection for solitary HCC > 10 cm, BCLC B/C, and multinodular HCC. Our aim was to assess overall survival for resection, identify poor prognostic factors, and to compare it to trans-arterial chemotherapy (TACE) where data was available. RESULTS Eighty-nine articles were included after a complete database search in the systematic review as per our predefined criteria. Analysis revealed a 5-year overall survival of 33.5% for resection of HCC > 10 cm, 41.7% for BCLC B, 23.3% for BCLC C, and 36.6% for multinodular HCC. Peri-operative mortality ranged from 0 to 6.9%. Studies comparing resection versus TACE for BCLC B/C had a survival of 40% versus 17%, respectively. CONCLUSION Our systematic review justifies hepatic resection wherever feasible for hepatocellular carcinomas > 10 cm, BCLC B, BCLC C, and multinodular tumors. In addition, we identified and proposed an algorithm with five poor prognostic criteria in this group of patients who may benefit from adjuvant TACE.
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Affiliation(s)
- Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
| | - Mahesh Goel
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India.
| | - Darius Mirza
- Hepato-Pancreato-Biliary and Transplant Surgery, University Hospital Birmingham and Birmingham Children's Hospital, Birmingham, UK
| | - S K Mathur
- Zen Digestive Disease Center, Zen Hospital, Mumbai, India
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Inmutto N, Nimitrungtawee N, Srisuwan T, Kattipathanapong T, Jantarangkoon A, Puttisri O. Investigating Up-to-Seven Criteria and APRI (AST Platelet Ratio) as Prognostic Factors in Intermediate-Stage Hepatocellular Carcinoma Patients Who Received Transarterial Chemoembolization. Asian Pac J Cancer Prev 2022; 23:3939-3946. [PMID: 36444608 PMCID: PMC9930952 DOI: 10.31557/apjcp.2022.23.11.3939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Transarterial chemoembolization (TACE) is one of the locoregional treatments for intermediate-stage hepatocellular carcinoma (HCC). Multidetector computed tomography (MDCT) is a widely used diagnostic tool for HCC. It can also evaluate tumor size, tumor number, and tumor invasion. This study aimed to determine the median survival time in intermediate-stage HCC patients who underwent TACE and to find out prognostic factors influencing patients' survival time after TACE. METHODS A computerized search of medical record database in Maharaj Nakorn ChiangMai Hospital from January 2016 to December 2019 revealed 187 intermediate-stage HCC patients who received TACE as the first-line treatment. RESULTS The median survival time of patients in this study was 9.9 months (95% CI: 8.3-11.6). The patients with aspartate aminotransferase-to-platelet ratio (APRI) less than 0.5 had a significantly better median survival time as compared with patients with APRI ratio more than 0.5; (13.2 months versus 9.9 months, p-value < 0.05). Univariate and multivariate Cox regression analysis demonstrated that tumor number > 7 and tumor size > 5 centimeters (cm) could be considered as independent parameters predicting poor overall survival time in the sufferers (HR 2.64 95%CI 1.68-4.15 and HR 2.38 95%CI 1.32-4.31, respectively). CONCLUSION Based on our findings, patients with intermediate-stage HCC who received TACE had a lower median survival time compared to previous studies. However, we identified APRI less than 0.5, tumor size less than 5 cm, and tumor number less than 7 as prognostic factors improving survival time in intermediate-stage HCC patients.
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Liu DM, Leung TW, Chow PK, Ng DC, Lee RC, Kim YH, Mao Y, Cheng YF, Teng GJ, Lau WY. Clinical consensus statement: Selective internal radiation therapy with yttrium 90 resin microspheres for hepatocellular carcinoma in Asia. Int J Surg 2022; 102:106094. [PMID: 35662438 DOI: 10.1016/j.ijsu.2021.106094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is subject to different management approaches and guidelines according to Eastern and Western therapeutic algorithms. Use of selective internal radiation therapy (SIRT) with resin yttrium 90 microspheres for HCC has increased in Asia in recent years, without clearly defined indications for its optimal application. The objective of this systematic review and expert consensus statement is to provide guidance and perspectives on the use of SIRT among patients with HCC in Asia. MATERIALS AND METHODS A systematic literature review identified current publications on HCC management and SIRT recommendations. A group of 10 experts, representing stakeholder specialties and countries, convened between August 2020 and March 2021 and implemented a modified Delphi consensus approach to develop guidelines and indications for use of SIRT for HCC in Asia. Final recommendations were organized and adjudicated based on the level of evidence and strength of recommendation, per approaches outlined by the American College of Cardiology/American Heart Association and Oxford Centre for Evidence-Based Medicine. RESULTS The experts acknowledged a general lack of evidence relating to use of SIRT in Asia and identified as an unmet need the lack of phase 3 randomized trials comparing clinical outcomes and survival following SIRT versus other therapies for HCC. Through an iterative process, the expert group explored areas of clinical relevance and generated 31 guidance statements and a patient management algorithm that achieved consensus. CONCLUSION These recommendations aim to support clinicians in their decision-making and to help them identify and treat patients with HCC using SIRT in Asia. The recommendations also highlight areas in which further clinical trials are needed to define the role of SIRT in management of HCC among Asian populations.
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Affiliation(s)
- David M Liu
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Wt Leung
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, Hong Kong
| | - Pierce Kh Chow
- National Cancer Centre Singapore, Singapore General Hospital, Duke-NUS Medical School, Singapore
| | - David Ce Ng
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore, Duke-NUS Medical School, Singapore
| | - Rheun-Chuan Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yun Hwan Kim
- Department of Radiology, Presbyterian Medical Center, Jeonju, South Korea
| | - Yilei Mao
- Department of Liver Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yu-Fan Cheng
- Department of Diagnostic Radiology, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Gao-Jun Teng
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Wan Yee Lau
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong.
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Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third-leading cause of cancer-related mortality in the world. AREAS COVERED This review will discuss risk factors, demographic differences, global trends, and the economic burden of HCC. Viral hepatitis, particularly hepatitis B virus (HBV) infection, is the most common underlying liver disease leading to HCC in those with cirrhosis. Other important risk factors include alcoholic liver disease, nonalcoholic fatty liver disease, metabolic syndrome, etc. With the introduction of direct-acting antiviral agents for hepatitis C virus infection, routine vaccination against HBV, and increasing support for robust public screening programs, the incidence rates for HCC due to viral hepatitis is falling in many countries. Meanwhile, the prevalence of obesity and metabolic syndrome are on the rise, as is NAFLD-related HCC incidence. Asia and Africa have the highest incidence rates of HCC. In multiethnic countries, racial and ethnic minorities experience disparities in HCC incidence as well as mortality, representing an essential area for improvement in terms of healthcare inequity. EXPERT OPINION Interventions to minimize the global burden of HCC aim to reduce rates of the most common risk factors and implement effective treatment of underlying etiology and comprehensive screening programs for HCC.
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Affiliation(s)
- Peter Konyn
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Yoon SM. External Beam Radiotherapy for Hepatocellular Carcinoma: a Review of the Current Guidelines in the East and the West. JOURNAL OF LIVER CANCER 2021; 21:25-33. [PMID: 37384266 PMCID: PMC10035720 DOI: 10.17998/jlc.21.1.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 06/30/2023]
Abstract
The incidence of hepatocellular carcinoma (HCC) is geographically heterogeneous depending on the underlying liver disease. Moreover, the decisions and recommendations about standard treatments differ between countries, especially between the East and the West. Because of the complexity of treatment decisions for the management of HCC, a multidisciplinary approach is recommended to maximize the therapeutic efficacy. External beam radiotherapy (RT) has been increasingly used to manage HCC when recommended treatments cannot be applied in real-world clinical practice. However, Western guidelines for the management of HCC do not recommend RT as a treatment option due to the lack of clinical evidence. RT has often been used more in Eastern countries than in Western countries; hence, it is necessary to review both Eastern and Western guidelines for HCC treatment regarding the recommendations about RT. In this study, the comments and potential roles of external beam RT are summarized from several treatment guidelines for the management of HCC.
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Affiliation(s)
- Sang Min Yoon
- Department of Radiation Oncology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ito K, Takemura N, Inagaki F, Mihara F, Kokudo N. Difference in treatment algorithms for hepatocellular carcinoma between world's principal guidelines. Glob Health Med 2020; 2:282-291. [PMID: 33330822 DOI: 10.35772/ghm.2020.01066] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related death globally. Clinical guidelines for HCC have been established and revised by many countries and regions. We summarized and compared the treatment algorithms in the updated HCC guidelines established by Japan, China, Hong Kong, the Asian-Pacific Association for the Study of the Liver, the American Association for the Study of Liver Diseases, and the European Association for the Study of the Liver and European Organization for Research and Treatment of Cancer. Variations in treatment algorithms between the guidelines is inevitable, considering the differences in the prevalence and etiology of HCC, local clinical practice, and medical and insurance systems between countries or regions, and this might be confusing for practitioners worldwide. A comprehensive understanding of the guidelines that are globally available might be useful for future improvement of each guideline.
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Affiliation(s)
- Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Cai M, Li B, Lin L, Huang J, An Y, Huang W, Zhou Z, Wang Y, Shuai X, Zhu K. A reduction and pH dual-sensitive nanodrug for targeted theranostics in hepatocellular carcinoma. Biomater Sci 2020; 8:3485-3499. [PMID: 32432234 DOI: 10.1039/d0bm00295j] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sorafenib (SF) is the first drug demonstrated to improve the survival of patients diagnosed with advanced-stage hepatocellular carcinoma (HCC). However, its clinical application is limited by the poor oral bioavailability and severe side effects. In this study, a multifunctional micellar nanodrug was developed for simultaneous HCC-targeted delivery of SF and tumor detection with magnetic resonance imaging (MRI). The micellar nanodrug incorporating SF and superparamagnetic iron oxide nanoparticles (SPIONs) was prepared from a diblock copolymer of monomethoxyl poly(ethylene glycol) and poly(N-(2-aminoethanethiol-co-2-aminoethyldiisopropylamine) aspartamide) and then decorated with anti-glypican-3 antibody (AbGPC3). Owing to the small size, weak positive charge and AbGPC3-mediated active targeting to HCC cells, the nanodrug exhibited an easy cellular uptake and enhanced tumor accumulation. The prominent reduction and pH dual-sensitivity allowed the nanodrug to rapidly release SF inside cancer cells via responding to the cytoplasmic glutathione and lysosomal acidity. The nanodrug not only significantly improved the anticancer effects of SF in hepatoma treatment but also facilitated a noninvasive tumor detection and monitoring of in vivo drug delivery by MRI, which revealed its great potential as a promising theranostic system.
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Affiliation(s)
- Mingyue Cai
- Laboratory of Interventional Radiology, Department of Minimally Invasive Interventional Radiology, and Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, China.
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12
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Wang Y, Nichol MB, Yan BP, Wu J, Tomlinson B, Lee VW. Descriptive analysis of real-world medication use pattern of statins and antiplatelet agents among patients with acute coronary syndrome in Hong Kong and the USA. BMJ Open 2019; 9:e024937. [PMID: 31315855 PMCID: PMC6661883 DOI: 10.1136/bmjopen-2018-024937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The objective was to explore the differences in medication use pattern of lipid-lowering drug (LLD) and antiplatelet agents among post-percutaneous coronary intervention patients with acute coronary syndrome aged <65 in Hong Kong (HK) and the USA. DESIGN Retrospective study. SETTING This study used deidentified claims data from Clinformatics Data Mart database (OptumInsight, Eden Prairie, Minnesota, USA) and electronic health records from HK Hospital Authority Clinical Data Analysis and Reporting System database. PARTICIPANTS We used 1 year prescription records of LLDs and antiplatelet agents among 1013 USA patients and 270 HK Chinese patients in 2011-2013. PRIMARY AND SECONDARY OUTCOME MEASURES Continuity was investigated on the assumption that one defined daily dose represented 1 day treatment. Medication possession ratio method was used to evaluate the adherence. Multivariate-adjusted logistic regressions were constructed to compare the good continuity and adherence levels in the merged database with the cutoffs set at 80%, and Cox proportional hazard models were built using the time to discontinuation as the dependent variable, to assess the persistence level. RESULTS HK Chinese patients were less adherent (67.41% vs 84.60%, adjusted odds ratio (AOR) for Americans over Chinese=2.23 (95% CI=1.60 to 3.12), p<0.001) to antiplatelet agents compared with American patients but better adherent to statins (90.00% vs 78.18%, AOR=0.37 (0.23 to 0.58), p<0.001). The discontinuation with statins was more common in American patients (13.33% vs 34.25%, adjusted hazard ratio (AHR)=2.95 (2.05 to 4.24), p<0.001). Low-to-moderate potency statins and clopidogrel were favoured by our HK local physicians, while American patients received higher doses of statins and prasugrel. CONCLUSIONS We seemed to find HK physicians tended to prescribe cheaper and lower doses of statins and antiplatelet agents when compared with the privately insured patients in the USA, though the adherence and persistence levels of HK patients with statins were relatively good.
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Affiliation(s)
- Yun Wang
- Peninsula Clinical School, Monash University, Clayton, Victoria, Australia
| | - Michael B Nichol
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Bryan Py Yan
- Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Joanne Wu
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Brian Tomlinson
- Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Prince of Wales Hospital, Hospital Authority, Hong Kong, China
| | - Vivian Wy Lee
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
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13
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Liu TH, Shao YY, Lu LC, Shen YC, Hsu C, Lin ZZ, Hsu CH, Cheng AL. Considerations of heterogeneity in clinical trials for hepatocellular carcinoma. Expert Rev Gastroenterol Hepatol 2019; 13:615-621. [PMID: 31132887 DOI: 10.1080/17474124.2019.1621165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Clinical trials in hepatocellular carcinoma (HCC) exhibit a high degree of heterogeneity. These heterogeneities may lead to unexpected results among clinical trials. Area covered: In this review, we address the heterogeneity noted in early phase HCC trials, trials involving transarterial chemoembolization, and advanced HCC trials. Furthermore, we discuss possible methods to attenuate the detrimental effects of heterogeneity when conducting clinical trials. Expert opinion: Clinical trials in HCC exhibit an inherently high degree of heterogeneity because of various reasons: tumor heterogeneity, different cirrhotic backgrounds, various etiologies of cirrhosis, and geographical differences in practice and expertise. Such heterogeneity may cause imbalance among the enrolled patient population, premature withdrawal from the clinical trial, and variable response to the treatment. In addition, methodological heterogeneity also exists in designing trial protocol and response evaluation. All these factors may eventually lead to conflicting results among clinical trials. Accounting for these heterogeneities is important to foster the success of future trials. In recent years, significant progress with molecular targeted agents and immune checkpoint inhibitors was made in advanced HCC. These new agents are also being tested in clinical trials involving earlier stage HCC and will also face the challenge of these issues.
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Affiliation(s)
- Tsung-Hao Liu
- a Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsinchu , Taiwan.,b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan
| | - Yu-Yun Shao
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan.,e Department of Medical Oncology , National Taiwan University Cancer Center , Taipei , Taiwan
| | - Li-Chun Lu
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan.,e Department of Medical Oncology , National Taiwan University Cancer Center , Taipei , Taiwan
| | - Ying-Chun Shen
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan
| | - Chiun Hsu
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan
| | - Zhong-Zhe Lin
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan.,e Department of Medical Oncology , National Taiwan University Cancer Center , Taipei , Taiwan
| | - Chih-Hung Hsu
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan.,e Department of Medical Oncology , National Taiwan University Cancer Center , Taipei , Taiwan
| | - Ann-Lii Cheng
- b Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,c Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan.,d Graduate Institute of Oncology , National Taiwan University College of Medicine , Taipei , Taiwan.,e Department of Medical Oncology , National Taiwan University Cancer Center , Taipei , Taiwan
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14
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Liang H, Xiong Z, Li R, Hu K, Cao M, Yang J, Zhong Z, Jia C, Yao Z, Deng M. BDH2 is downregulated in hepatocellular carcinoma and acts as a tumor suppressor regulating cell apoptosis and autophagy. J Cancer 2019; 10:3735-3745. [PMID: 31333791 PMCID: PMC6636298 DOI: 10.7150/jca.32022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/05/2019] [Indexed: 02/06/2023] Open
Abstract
BDH2 is a short-chain dehydrogenase/reductase family member involved in several biological and pathological processes, including the utilization of cytosolic ketone bodies, immunocyte regulation and tumor progression. In this study, we first revealed that BDH2 was downregulated in HCC tissues by qRT-PCR and immunohistochemistry analysis and that low BHD2 expression was significantly associated with poor overall survival, poor tumor differentiation, increased tumor size, venous invasion and an advanced BCLC stage. Moreover, the results of a univariate analysis and multivariate analysis revealed that BDH2 may be regarded as an independent prognostic marker. As a member of a gene family involved in ketone metabolism, BDH2 upregulated the level of β-HB in liver cells as well as the level of H3 histone acetylation. Functional analysis showed that BDH2 expression inhibited tumor cell growth, proliferation and migration. The results of the mechanistic analysis revealed that BDH2 induced mitochondrial apoptosis and inhibited autophagy through the unfolded protein response. Therefore, BDH2 may be a new HCC prognostic marker and a useful treatment target.
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Affiliation(s)
- Hao Liang
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China.,Department of General Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhiyong Xiong
- Department of General Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Ruixi Li
- Department of Hepatobiliary Surgery, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518000, China
| | - Kunpeng Hu
- Department of General Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Mingbo Cao
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Jiarui Yang
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhaozhong Zhong
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Changchang Jia
- Department of Cell-gene Therapy Translational Medicine Research Center, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhicheng Yao
- Department of General Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Meihai Deng
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510000, China
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15
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Krishan S, Dhiman RK, Kalra N, Sharma R, Baijal SS, Arora A, Gulati A, Eapan A, Verma A, Keshava S, Mukund A, Deva S, Chaudhary R, Ganesan K, Taneja S, Gorsi U, Gamanagatti S, Madhusudan KS, Puri P, Shalimar, Govil S, Wadhavan M, Saigal S, Kumar A, Thapar S, Duseja A, Saraf N, Khandelwal A, Mukhopadyay S, Gulati A, Shetty N, Verma N. Joint Consensus Statement of the Indian National Association for Study of the Liver and Indian Radiological and Imaging Association for the Diagnosis and Imaging of Hepatocellular Carcinoma Incorporating Liver Imaging Reporting and Data System. J Clin Exp Hepatol 2019; 9:625-651. [PMID: 31695253 PMCID: PMC6823668 DOI: 10.1016/j.jceh.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind.
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Affiliation(s)
- Sonal Krishan
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Radha Krishan Dhiman, MD, DM, FACG, FRCP, FAASLD, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Navin Kalra
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay S. Baijal
- Department of Diagnostic and Intervention Radiology, Medanta Hospital, Gurgaon, India
| | - Anil Arora
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Ajay Gulati
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anu Eapan
- Department of Radiology, Christian Medical College, Vellore, India
| | - Ashish Verma
- Department of Radiology, Banaras Hindu University, Varanasi, India
| | - Shyam Keshava
- Department of Radiology, Christian Medical College, Vellore, India
| | - Amar Mukund
- Department of Intervention Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - S. Deva
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Chaudhary
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | | | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | | | - Kumble S. Madhusudan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Puri
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shalimar
- Department of GastroEnterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manav Wadhavan
- Institute of Digestive and Liver Diseases, BLK Hospital, Delhi, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | - Ashish Kumar
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shallini Thapar
- Department of Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | | | | | - Ajay Gulati
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Nitin Shetty
- Department of Radiology, Tata Memorial Hospital, Kolkata, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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16
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Khanna R, Verma SK. Pediatric hepatocellular carcinoma. World J Gastroenterol 2018; 24:3980-3999. [PMID: 30254403 PMCID: PMC6148423 DOI: 10.3748/wjg.v24.i35.3980] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/11/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Pediatric hepatocellular carcinoma (HCC) is the second common malignant liver tumor in children after hepatoblastoma. It differs from the adult HCC in the etiological predisposition, biological behavior and lower frequency of cirrhosis. Perinatally acquired hepatitis-B virus, hepatorenal tyrosinemia, progressive familial intrahepatic cholestasis, glycogen storage disease, Alagille’s syndrome and congenital portosystemic shunts are important predisposing factors. Majority of children (87%) are older than 5 years of age. Following mass immunization against hepatitis-B, there has been a drastic fall in the incidence of new cases of pediatric HCC in the Asia-Pacific region. Management is targeted on complete surgical removal either by resection or liver transplantation. There is a trend towards improving survival of children transplanted for HCC beyond Milan criteria. Chemotherapeutic regimens do not offer good results but may be helpful for down-staging of advanced HCC. Surveillance of children with chronic liver diseases with ultrasound and alpha-fetoprotein may be helpful in timely detection, intervention and overall improvement in outcome of HCC.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Sanjeev Kumar Verma
- Department of Pediatrics, King George Medical University, Uttar Pradesh 226003, India
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17
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Zhang Y, Huang J, Chen J, Yang K, Chen J, Xu L, Zhou Z, Chen M. The mutation of hepatitis B virus and the prognosis of hepatocellular carcinoma after surgery: a pilot study. Cancer Manag Res 2018; 10:599-611. [PMID: 29628773 PMCID: PMC5877868 DOI: 10.2147/cmar.s160047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Although hepatitis B virus (HBV) is still one of the most common etiological factors for hepatocellular carcinoma (HCC), the association between the HBV mutations and the clinical characteristics and prognosis of HBV-related HCC patients (HBV-HCC) after surgical resection remains largely unknown. Materials and methods A cohort of 131 consecutive patients who received hepatectomy for HBV-HCC were retrospectively enrolled. The HBV genotype and 14 genomic mutations, which have been reported to relate to HCC in liver samples, were sequenced. The associations between the genomic mutations and clinical characteristics and outcomes were analyzed. Results Both A1762T/G1764A mutation and Pre S deletion related to worse overall survival (OS, p=0.040 and p<0.001, respectively) and disease-free survival (DFS, p=0.040 and p<0.001, respectively), G1899A mutation related to worse OS (p=0.030), A1762T/G1764A mutation correlated with tumor size (r=0.204, p=0.019), G1899A mutation correlated with vascular invasion (r=0.332, p<0.001), and Pre S deletion correlated with alpha-fetoprotein (AFP; r=0.254, p=0.003) positively. Multivariate analysis with Cox proportional hazards model revealed that both A1762T/G1764A mutation and Pre S deletion were independent prognostic factors for OS (hazard ratio [HR]=3.701, 95% CI=1.390–9.855, p=0.009, and HR=4.816, 95% CI=2.311–10.032, p<0.001, respectively) and DFS (HR=3.245, 95% CI=1.400–7.521, p=0.006, and HR=2.437, 95% CI=1.311–4.530, p<0.001, respectively), and patients with dual mutations were found to have the worst OS and DFS (p<0.001 and p<0.001, respectively). Patients with A1762T/G1764A mutation or Pre S deletion were more likely to have early recurrence (p=0.042 and p=0.019, respectively). Conclusion HBV DNA genomic mutations in A1762T/G1764A and Pre S deletion were associated with worse prognoses and early recurrence for HBV-HCC patients after surgery.
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Affiliation(s)
- Yaojun Zhang
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Junting Huang
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jinbin Chen
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Keli Yang
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jiancong Chen
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li Xu
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Zhongguo Zhou
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Minshan Chen
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
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18
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Cheung TTT, Kwok PCH, Chan S, Cheung CC, Lee AS, Lee V, Cheng HC, Chia NH, Chong CC, Lai TW, Law AL, Luk MY, Tong CC, Yau TC. Hong Kong Consensus Statements for the Management of Unresectable Hepatocellular Carcinoma. Liver Cancer 2018; 7:40-54. [PMID: 29662832 PMCID: PMC5892367 DOI: 10.1159/000485984] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is highly prevalent in Hong Kong due to the high prevalence of chronic hepatitis B infection. Liver cancer is the fourth most common cancer and the third most common cause of cancer death. Due to the high case load, there is a high level of local expertise in treating HCC, and the full spectrum of treatment modalities is available. This document summarizes how these modalities should be used based on the latest evidence. SUMMARY In 2 meetings held in early 2017, a multidisciplinary group of Hong Kong clinicians, including liver surgeons, interventional radiologists, clinical oncologists, and medical oncologists, met to update local consensus statements for management of HCC. These statements are based on the latest evidence and give detailed guidance on how to deploy these modalities, in particular for cases of HCC which are not suited to surgical resection. KEY MESSAGES These statements give detailed information on how to decide if a patient is a candidate for resection, methods to improve candidacy for resection, and guidance for use of various nonsurgical interventions to manage patients ineligible for resection.
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Affiliation(s)
- Tom Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | | | - Stephen Chan
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Ann-Shing Lee
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, China
| | - Victor Lee
- Department of Clinical Oncology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Hoi-Ching Cheng
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong, China
| | - Nam-Hung Chia
- Department of Surgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Charing C.N. Chong
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Tak-Wing Lai
- Department of Surgery, Princess Margaret Hospital, Hong Kong, China
| | - Ada L.Y. Law
- Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Mai-Yee Luk
- Department of Clinical Oncology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Chi Chung Tong
- Department of Clinical Oncology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Thomas C.C. Yau
- Department of Medicine and Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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19
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Bruix J, Cheng AL, Meinhardt G, Nakajima K, De Sanctis Y, Llovet J. Prognostic factors and predictors of sorafenib benefit in patients with hepatocellular carcinoma: Analysis of two phase III studies. J Hepatol 2017; 67:999-1008. [PMID: 28687477 DOI: 10.1016/j.jhep.2017.06.026] [Citation(s) in RCA: 422] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/05/2017] [Accepted: 06/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Sorafenib, an oral multikinase inhibitor, significantly prolonged overall survival (OS) vs. placebo in patients with unresectable hepatocellular carcinoma (HCC) in two phase III studies, SHARP (Sorafenib HCC Assessment Randomized Protocol) and Asia Pacific (AP). To assess prognostic factors for HCC and predictive factors of sorafenib benefit, we conducted a pooled exploratory analysis from these placebo-controlled phase III studies. METHODS To identify potential prognostic factors for OS, univariate and multivariate (MV) analyses were performed for baseline variables by Cox proportional hazards model. Hazard ratios (HRs) and median OS were evaluated across pooled subgroups. To assess factors predictive of sorafenib benefit, the interaction term between treatment for each subgroup was evaluated by Cox proportional hazard model. RESULTS In 827 patients (448 sorafenib; 379 placebo) analyzed, strong prognostic factors for poorer OS identified from MV analysis in both treatment arms were presence of macroscopic vascular invasion (MVI), high alpha-fetoprotein (AFP), and high neutrophil-to-lymphocyte ratio (NLR; ⩽ vs. >median [3.1]). Sorafenib OS benefit was consistently observed across all subgroups. Significantly greater OS sorafenib benefit vs. placebo was observed in patients without extrahepatic spread (EHS; HR, 0.55 vs. 0.84), with hepatitis C virus (HCV) (HR, 0.47 vs. 0.81), and a low NLR (HR, 0.59 vs. 0.84). CONCLUSIONS In this exploratory analysis, presence of MVI, high AFP, and high NLR were prognostic factors of poorer OS. Sorafenib benefit was consistently observed irrespective of prognostic factors. Lack of EHS, HCV, and lower NLR were predictive of a greater OS benefit with sorafenib. LAY SUMMARY This exploratory pooled analysis showed that treatment with sorafenib provides a survival benefit in all subgroups of patients with HCC; however, the magnitude of benefit is greater in patients with disease confined to the liver (without extrahepatic spread), or in those with hepatitis C virus, or a lower neutrophil-to-lymphocyte ratio, an indicator of inflammation status. These results help inform the prognosis of patients receiving sorafenib therapy and provide further refinements for the design of trials testing new agents vs. sorafenib. Clinical Trial Numbers: NCT00105443 and NCT00492752.
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Affiliation(s)
- Jordi Bruix
- Hepatic Oncology, BCLC Hospital Clínic Barcelona, IDIBAPS, University of Barcelona CIBERehd, Barcelona, Spain.
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.
| | | | | | | | - Josep Llovet
- Hepatic Oncology, BCLC Hospital Clínic Barcelona, IDIBAPS, University of Barcelona CIBERehd, Barcelona, Spain; Mount Sinai Liver Cancer Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain.
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20
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Gavriilidis P, Roberts KJ, Askari A, Sutcliffe RP, Huo TL, Liu PH, Hidalgo E, Compagnon P, Lim C, Azoulay D. Evaluation of the current guidelines for resection of hepatocellular carcinoma using the Appraisal of Guidelines for Research and Evaluation II instrument. J Hepatol 2017; 67:991-998. [PMID: 28690176 DOI: 10.1016/j.jhep.2017.06.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Numerous guidelines for the management of hepatocellular carcinoma (HCC) have been developed. The Appraisal of Guidelines for Research & Evaluation (AGREE II) is the only validated instrument to assess the methodological quality of guidelines. We aim to appraise the methodological quality of existing guidelines for the resection of HCC using the AGREE II instrument. METHODS Cochrane, Medline, Google Scholar and Embase were searched using both PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and free text. The assessment of the included clinical practice guidelines and consensuses were performed using the AGREE II instrument, version 2013. Guidelines with a score ⩾80% for the overall appraisal item were considered as applicable without modifications. RESULTS Literature searches identified 22 clinical practice guidelines. Five out of 22 guidelines passed the 70% mark on overall assessment, 11 out of 22 had shortcomings on indications, contraindications, side effects, key recommendations, technical aspects, transparency and health economics. Ten of 22 scored below the 50% mark showing that the guideline had low methodological and overall quality. Only 3/22 clinical practice guidelines were considered applicable without modifications. CONCLUSIONS The methodological quality of guidelines for the surgical management of HCC is generally poor. Future guideline development should be informed by the use of the AGREE II instrument. Guidelines based upon high quality evidence could improve stratification of patients and individualized treatment strategies. Lay summary: The methodology of clinical practice guidelines for resection for hepatocellular carcinoma (HCC) evaluated with the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument is generally poor. However, there are some clinical practice guidelines that are based upon higher quality evidence and can form the framework within which patients with HCC can be selected for surgical resection. Future guideline development should be informed by the use of the AGREE II instrument.
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Affiliation(s)
- Pascal Gavriilidis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; Department of Hepato-Pancreato-Biliary and Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - Alan Askari
- Department of Surgery, Ipswich Hospital NHS Trust, Heath Rd, Ipswich, Suffolk IP4 5PD, UK
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - Teh-la Huo
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital & National Yang-Ming University, No: 201, Sec 2, Shipai Rd, Taipei 11217, Taiwan
| | - Po-Hong Liu
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital & National Yang-Ming University, No: 201, Sec 2, Shipai Rd, Taipei 11217, Taiwan
| | - Ernest Hidalgo
- Department of HPB and Transplant Surgery, St James's University Hospital, Beckett Str Leeds LS9 7TF, UK
| | - Philippe Compagnon
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; INSERM U 955, Créteil, France
| | - Chetana Lim
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; INSERM U 955, Créteil, France.
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21
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Abstract
There is great geographical variation in the distribution of hepatocellular carcinoma (HCC), with the majority of all cases worldwide found in the Asia–Pacific region, where HCC is one of the leading public health problems. Since the “Toward Revision of the Asian Pacific Association for the Study of the Liver (APASL) HCC Guidelines” meeting held at the 25th annual conference of the APASL in Tokyo, the newest guidelines for the treatment of HCC published by the APASL has been discussed. This latest guidelines recommend evidence-based management of HCC and are considered suitable for universal use in the Asia–Pacific region, which has a diversity of medical environments.
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22
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Manzini G, Henne-Bruns D, Porzsolt F, Kremer M. Is there a standard for surgical therapy of hepatocellular carcinoma in healthy and cirrhotic liver? A comparison of eight guidelines. BMJ Open Gastroenterol 2017; 4:e000129. [PMID: 28405349 PMCID: PMC5372044 DOI: 10.1136/bmjgast-2016-000129] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 12/12/2022] Open
Abstract
Background and aims Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis. Methods We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines. Results All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria. Conclusions Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.
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Affiliation(s)
- Giulia Manzini
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
| | - Doris Henne-Bruns
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
| | - Franz Porzsolt
- Health Care Research Group at the Hospital of General and Visceral Surgery, University Hospital of Ulm , Ulm , Germany
| | - Michael Kremer
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
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23
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Kudo M. Immune Checkpoint Inhibition in Hepatocellular Carcinoma: Basics and Ongoing Clinical Trials. Oncology 2017; 92 Suppl 1:50-62. [PMID: 28147363 DOI: 10.1159/000451016] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinical trials of antibodies targeting the immune checkpoint inhibitors programmed cell death 1 (PD-1), programmed cell death ligand 1 (PD-L1), or cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) for the treatment of advanced hepatocellular carcinoma (HCC) are ongoing. Expansion cohorts of a phase I/II trial of the anti-PD-1 antibody nivolumab in advanced HCC showed favorable results. Two phase III studies are currently ongoing: a comparison of nivolumab and sorafenib in the first-line setting for advanced HCC, and a comparison of the anti-PD-1 antibody pembrolizumab and a placebo in the second-line setting for patients with advanced HCC who progressed on sorafenib therapy. The combination of anti-PD-1/PD-L1 and anti-CTLA-4 antibodies is being evaluated in other phase I/II trials, and the results suggest that an anti-PD-1 antibody combined with locoregional therapy or other molecular targeted agents is an effective treatment strategy for HCC. Immune checkpoint inhibitors may therefore open new doors to the treatment of HCC.
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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24
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Huang C, Zhu XD, Ji Y, Ding GY, Shi GM, Shen YH, Zhou J, Fan J, Sun HC. Microvascular invasion has limited clinical values in hepatocellular carcinoma patients at Barcelona Clinic Liver Cancer (BCLC) stages 0 or B. BMC Cancer 2017; 17:58. [PMID: 28095820 PMCID: PMC5240309 DOI: 10.1186/s12885-017-3050-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background Microvascular invasion (MVI) is recognized as a prognostic factor associated with poor outcome in hepatocellular carcinoma (HCC) patients after curative resection. It remains unclear, however, whether MVI can provide prognostic information for patients at a specific tumor stage. Methods Consecutive HCC patients who underwent curative resection in years of 2007 and 2008 (discovery cohort) were enrolled in this retrospective study. Patients were stratified by the Barcelona Clinic Liver Cancer (BCLC) staging system. The prognostic significance of MVI for overall survival (OS) and recurrence-free survival (RFS) was studied in each subgroup. The clinical significance of MVI was validated in another cohort of patients underwent curative surgery in the year of 2006 (validation cohort). Results Of the 1540 patients in the discovery cohort, 389 (25.3%) patients had detectable MVI. Occurrence rates of MVI in the BCLC stage 0, A, and B subgroups were 12.4, 26.2, and 34.4%, respectively. In univariate analysis, MVI was associated with poor OS and RFS (P < 0.001 for both) in HCC patients at stage A, with poor OS in patients at stage 0 (P = 0.028), and with poor RFS at stage B (P = 0.039). In multivariate analysis, MVI was an independent risk factor for OS (HR = 1.431, 95% CI, 1.163–1.761, P < 0.001) and RFS (HR = 1.400, 95% CI, 1.150–1.705, P = 0.001) in patients at stage A; and an independent risk factor for RFS (P = 0.043) in patients at stage B. A similar clinical significance of MVI was found in the validation cohort. Conclusions MVI has limited prognostic value for HCC patients at BCLC stages 0 and B. For those at stage A, MVI was associated with patient survival and may help to select patients with high risk of disease recurrence. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3050-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cheng Huang
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Xiao-Dong Zhu
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital, Fudan University, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Guang-Yu Ding
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Guo-Ming Shi
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Ying-Hao Shen
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Jian Zhou
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Jia Fan
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China
| | - Hui-Chuan Sun
- Liver Cancer Institute and Zhongshan Hospital, Fudan University, Key Laboratory for Carcinogenesis and Cancer Invasion, the Chinese Ministry of Education, 136 Yi Xue Yuan Rd, Shanghai, 200032, China.
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25
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Abstract
Global incidence and mortality of hepatocellular carcinoma (HCC) has increased over the past two decades. Although transplantation and surgical resection offer a chance for cure and long-term survival, most patients present with more advanced tumor stage when these therapies are not possible. Although rarely curative, locoregional therapy with transarterial chemoembolization or radioembolization offers a survival benefit for those with liver-isolated HCC who are not amenable to curative therapies. Patients with metastatic disease or macrovascular invasion are treated with systemic therapy; however, median survival remains below 1 year. Patients with severe liver dysfunction or poor performance status should be treated with best supportive care given poor prognosis and no survival benefit for treatment. Lack of predictive and prognostic biomarkers in intermediate and advanced HCC tumors has hampered integration of clinical and molecular data to aid tailoring treatment decisions. However, with increasingly complex treatment decisions, optimal outcomes are achieved through multidisciplinary care.
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26
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Chishina H, Hagiwara S, Nishida N, Ueshima K, Sakurai T, Ida H, Minami Y, Takita M, Kono M, Minami T, Iwanishi M, Umehara Y, Watanabe T, Komeda Y, Arizumi T, Kudo M. Clinical Factors Predicting the Effect of Tolvaptan for Refractory Ascites in Patients with Decompensated Liver Cirrhosis. Dig Dis 2016; 34:659-664. [PMID: 27750234 DOI: 10.1159/000448828] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Refractory ascites reduces the quality of life of liver cirrhosis patients. Albumin preparation and diuretics, such as furosemide, have been used to treat refractory ascites, but the effect was poor in many patients. In this study, we analyzed patients treated with tolvaptan (TLV) at our hospital and investigated predictors of the effect. METHODS The subjects were 70 patients for whom TLV was introduced to treat refractory ascites who could be analyzed between November 2013 and March 2015 at our hospital. Patient background before initiation of oral TLV treatment, the dose of diuretics, and each item of biochemical tests of blood and urine were investigated, and factors correlated with the treatment effect were analyzed. An increase of ≥1,000 ml in the daily urine volume from the day before oral treatment or a decrease of ≥1 kg in the body weight within 7 days as an early effect was observed in 33 patients and not observed in 37 patients. TLV treatment was continued for 60 days or longer in 12 of the 37 patients in whom no early effect was observed, and the presence or absence of a delayed effect and predictors of the effect were investigated. A decrease in ascites on abdominal CT with improvement of subjective symptoms at 60 days was defined as a delayed effect. RESULTS When early predictors of the effect were investigated by univariate analysis, serum blood urea nitrogen (BUN) and serum creatinine (Cr) were significantly higher in the non-responder group (BUN: p = 0.03, Cr: p = 0.04), but no factor independently associated with the treatment effect was extracted on multivariate analysis. The delayed effect was noted in 4 (33.3%) of the 12 patients, but no predictor of the effect before treatment was identified. However, reactions, such as an increase in serum Na and reduction of urinary osmotic pressure, were observed early after TLV administration in some patients in whom the delayed effect was observed. CONCLUSIONS The diuretic effect of TLV may decrease in renal hypofunction patients. Since the delayed effect was noted in a specific ratio of patients, continuation of TLV administration is an option even though the early treatment effect is poor unless ascites aggravates or adverse effects develop.
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27
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Kudo M. Recent Trends in the Management of Hepatocellular Carcinoma with Special Emphasis on Treatment with Regorafenib and Immune Checkpoint Inhibitors. Dig Dis 2016; 34:714-730. [PMID: 27750243 DOI: 10.1159/000448864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third leading cause of cancer deaths worldwide. Sonazoid-enhanced ultrasound and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRI are the most important imaging modalities in diagnosing HCC. There are 2 non-contradictory HCC treatment algorithms in Japan. Hepatic arterial infusion chemotherapy plays an important role in the treatment of advanced HCC with main or branch portal vein invasion. Regorafenib, as a second-line systemic treatment, prolongs survival in patients with intermediate and advanced HCC who progressed on sorafenib. In recent clinical trials, immune check point inhibitors show promising results for the treatment of HCC. This review describes recent trends in the management of HCC.
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28
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Wu T, Wang P, Zhang T, Zheng J, Li S, Zeng J, Kudo M, Zheng R. Comparison of Two-Dimensional Shear Wave Elastography and Real-Time Tissue Elastography for Assessing Liver Fibrosis in Chronic Hepatitis B. Dig Dis 2016; 34:640-649. [PMID: 27750231 DOI: 10.1159/000448825] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Noninvasive assessment of liver fibrosis has important clinical significance. Different techniques including two-dimensional shear-wave elastography (2D SWE) and real-time tissue elastography (RTE) are reported to be useful for the noninvasive diagnosis of hepatic fibrosis. All these techniques are affected by many factors. How to choose a reasonable method needs further studies. PURPOSE This study was conducted to comparatively assess the diagnostic performance of 2D SWE and RTE in patients with Chronic Hepatitis B (CHB) and influence of inflammation on the stiffness values obtained by both techniques, so as to objectively assess the reasonable choice between these 2 elastography techniques for noninvasive assessment of hepatic fibrosis in clinical practice. MATERIALS AND METHODS Four-hundred and thirty-seven patients with CHB meeting the inclusion criteria were enrolled in the study. All patients underwent liver stiffness measurements by using 2D SWE and RTE on the same day. Histologic fibrosis was staged and inflammation activity was graded based on the METAVIR scoring system on liver biopsy specimens. RESULTS The liver stiffness values by using 2D SWE and RTE both increased in parallel with the degree of liver fibrosis and the grade of inflammation. However, the diagnostic efficacy of significant fibrosis and cirrhosis using 2D SWE was significantly higher than that of RTE. The 2D SWE measurement values were statistically different in different alanine aminotransferase (ALT) levels and METAVIR activity grades; however, no statistically significant differences were observed by using RTE. The diagnostic efficacy of 2D SWE significantly varied with elevated ALT levels compared with RTE. CONCLUSION 2D SWE was more accurate than RTE in the assessment of significant fibrosis and cirrhosis in patients with CHB. Compared with RTE, the measurement values and diagnostic performance obtained by 2D SWE were prone to be more easily affected by the inflammation fluctuations.
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Choo SP, Tan WL, Goh BKP, Tai WM, Zhu AX. Comparison of hepatocellular carcinoma in Eastern versus Western populations. Cancer 2016; 122:3430-3446. [PMID: 27622302 DOI: 10.1002/cncr.30237] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 01/27/2023]
Abstract
Hepatocellular carcinoma (HCC) is a heterogeneous disease that remains highly prevalent in many Asian countries and is the second most common cause of cancer-related mortality worldwide. Significant differences exist between Eastern and Western populations on many key aspects of HCC, contributing to the potential different treatment outcomes and challenges of clinical trial design and data interpretation. In this review, the authors compare HCC in Asia versus the West and highlight 1) differences in terms of epidemiology and trends and their correlation with etiology, 2) differences in genetics and how they relate to underlying etiology, 3) differences in treatment approaches based on existing guidelines and consensus statements, and 4) differences in clinical outcomes for Asian versus non-Asian patients with HCC in clinical trials and the implications for future clinical trial design. Cancer 2016;122:3430-3446. © 2016 American Cancer Society.
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Affiliation(s)
- Su Pin Choo
- Department of Medical Oncology, National Cancer Center, Singapore
| | - Wan Ling Tan
- Department of Medical Oncology, National Cancer Center, Singapore
| | - Brian K P Goh
- Department of Hepato-Pancreaticobiliary Surgery, Singapore General Hospital, Singapore
| | - Wai Meng Tai
- Department of Medical Oncology, National Cancer Center, Singapore
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
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30
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Baheti AD, Dunham GM, Ingraham CR, Moshiri M, Lall C, Park JO, Li D, Katz DS, Madoff DC, Bhargava P. Clinical implications for imaging of vascular invasion in hepatocellular carcinoma. Abdom Radiol (NY) 2016; 41:1800-10. [PMID: 27142384 DOI: 10.1007/s00261-016-0763-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is the second largest cause of cancer mortality in the world, with vascular invasion being one of the most important prognostic factors. HCC with tumor thrombus was traditionally considered to have very limited treatment options. However, multiple promising treatment strategies have emerged in recent years, with diagnostic and interventional radiologists playing a major role in patient management. We provide a comprehensive update on the diagnosis and management of HCC with vascular invasion and the role of the radiologist in this condition.
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Bauschke A, Altendorf-Hofmann A, Freesmeyer M, Winkens T, Malessa C, Schierz JH, Teichgraeber U, Settmacher U. [Selective internal radioembolization in nonresectable hepatocellular carcinoma]. Chirurg 2016; 87:956-963. [PMID: 27460230 DOI: 10.1007/s00104-016-0259-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The role of selective internal radioembolization (SIRT) in the treatment of hepatocellular carcinoma (HCC) is currently unclear. MATERIALS AND METHODS We investigated 52 patients with nonresectable HCC in cirrhosis who underwent SIRT at the Department of General, Visceral and Vascular Surgery in co-operation with the Department of Nuclear Medicine and the Institute of Diagnostic and Interventional Radiology between April 2011 and October 2015. RESULTS In five patients, SIRT was employed for bridging to liver transplantation. In patients who had undergone pre-treatment with SIRT, histological examination of the explanted livers showed extensive tumor necrosis in the targeted areas with only minor remnant vital tissue at the margins. Four of the patients who underwent SIRT as local bridging treatment are tumor-free after transplantation. In the 47 palliatively treated patients, a total of 76 radioembolizations were performed. The observed 1‑ and 2‑year survival rates in these patients were 58 and 29 %, respectively, after the first SIRT. In the multivariate analysis of the observed survival, AFP before the first SIRT >30ng/ml, time interval of <12 months between the initial diagnosis and the first SIRT, largest tumor diameter >5 cm and portal vein thrombosis were independent negative prognostic factors. In the multi-variate analysis, the time to progression was independently influenced only by the AFP level before the first SIRT. In addition to standard treatment with transarterial chemoembolization (TACE), SIRT is feasible in nonresectable HCC, in particular with portal vein thrombosis, with identical results, less interventions and few side effects.
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Affiliation(s)
- A Bauschke
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland.
| | - A Altendorf-Hofmann
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - M Freesmeyer
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - T Winkens
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - C Malessa
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - J-H Schierz
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - U Teichgraeber
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - U Settmacher
- Klinik für Allgemein-,Visceral-und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
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32
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Chow PKH, Choo SP, Ng DCE, Lo RHG, Wang MLC, Toh HC, Tai DWM, Goh BKP, Wong JS, Tay KH, Goh ASW, Yan SX, Loke KSH, Thang SP, Gogna A, Too CW, Irani FG, Leong S, Lim KH, Thng CH. National Cancer Centre Singapore Consensus Guidelines for Hepatocellular Carcinoma. Liver Cancer 2016; 5:97-106. [PMID: 27386428 PMCID: PMC4906434 DOI: 10.1159/000367759] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world, but the second most common cause of cancer death. There is no universally accepted consensus practice guidelines for HCC owing to rapid developments in new treatment modalities, the heterogeneous epidemiology and clinical presentation of HCC worldwide. However, a number of regional and national guidelines currently exist which reflect practice relevant to the epidemiology and collective experience of the consensus group. In 2014, clinicians at the multidisciplinary Comprehensive Liver Cancer Clinic (CLCC) at the National Cancer Centre Singapore (NCCS) reviewed the latest published scientific data and existing international and regional practice guidelines, such as those of the National Comprehensive Cancer Network, American Association for the Study of Liver Diseases and the Asian Pacific Association for the Study of the Liver, and modified them to reflect local practice. These would serve as a template by which treatment outcomes can be collated and benchmarked against international data. The NCCS Consensus Guidelines for HCC have been successfully implemented in the CLCC since their publication online on 26(th) September 2014, and the guidelines allow outcomes of treatment to be compared to international data. These guidelines will be reviewed periodically to incorporate new data.
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Affiliation(s)
- Pierce K. H. Chow
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore,Department of Hepatopancreatobiliary/Transplantation Surgery, Singapore General Hospital, Singapore,Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, Singapore,*Pierce K. H. Chow, MBBS, PhD, Division of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore (Singapore), Tel. +65 6326 6091, E-Mail
| | - Su Pin Choo
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - David C. E. Ng
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Richard H. G. Lo
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Han Chong Toh
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - David W. M. Tai
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary/Transplantation Surgery, Singapore General Hospital, Singapore
| | - Jen San Wong
- Department of Hepatopancreatobiliary/Transplantation Surgery, Singapore General Hospital, Singapore
| | - Kiang Hiong Tay
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Anthony S. W. Goh
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Sean X. Yan
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Kelvin S. H. Loke
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Sue Ping Thang
- Department of Nuclear Medicine & PET, Singapore General Hospital, Singapore
| | - Apoorva Gogna
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Chow Wei Too
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Sum Leong
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Kiat Hon Lim
- Department of Pathology, Singapore General Hospital, Singapore
| | - Choon Hua Thng
- Division of Oncologic Radiology, National Cancer Centre Singapore, Singapore
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33
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Arizumi T, Ueshima K, Iwanishi M, Minami T, Chishina H, Kono M, Takita M, Kitai S, Inoue T, Yada N, Hagiwara S, Ida H, Minami Y, Sakurai T, Nishida N, Kitano M, Kudo M. Evaluation of ART Scores for Repeated Transarterial Chemoembolization in Japanese Patients with Hepatocellular Carcinoma. Oncology 2015; 89 Suppl 2:4-10. [PMID: 26584030 DOI: 10.1159/000440625] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Transarterial chemoembolization (TACE) is recommended as a first-line therapy for hepatocellular carcinoma (HCC) patients ineligible for curative therapy and without portal invasion. The Assessment for Retreatment with TACE (ART) scoring system was recently proposed for identifying patients who would not show sufficient survival benefit from repeated TACE. We reevaluated the performance of ART in HCC patients treated in Japan, where selective TACE is commonly used. METHODS Between 2000 and 2013, 988 patients with HCC underwent TACE at Kinki University Hospital, and 627 received ≥2 sessions of TACE. Seventy-six patients who underwent ≥2 TACE sessions within 90 days were investigated for their performance of the ART score in the context of overall survival (OS). RESULTS Only 12% (76/627) of patients underwent ≥2 TACE sessions within 90 days. Of those, 52 patients showed a low ART score (0-1.5), and 24 had a high ART score (≥2.5); the median OS was 20.2 and 37.6 months, respectively (p = 0.8207). CONCLUSION The ART scoring system did not demonstrate a sufficiently predictive impact on OS among the patients who underwent ≥2 TACE sessions within 90 days. Application of the ART score should be carefully considered because differences in TACE procedures and post-TACE treatment can affect the results while evaluating OS.
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Affiliation(s)
- Tadaaki Arizumi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kinki University, Osaka-Sayama, Japan
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34
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Kudo M, Kitano M, Sakurai T, Nishida N. Challenges of Clinical Research on Hepatocellular Carcinoma. Dig Dis 2015; 33:780-90. [PMID: 26488399 DOI: 10.1159/000439103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Challenges of clinical practice and research on hepatocellular carcinoma (HCC) were reviewed. There are several differences in clinical practice between Japan and the Western countries such as tumor markers, understanding of pathological early HCC, imaging diagnosis, treatment strategy, staging system and subclassification of HCC. Further studies are warranted for the clinical practices of Japan to be adopted in the rest of the world.
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-Sayama, Osaka, Japan
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