Novel Imaging Diagnosis for Hepatocellular Carcinoma: Consensus from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014)

Hepatocellular Carcinoma in Asia: Physician and Patient Perspectives on Surveillance, Diagnosis, and Treatment

PURPOSE

In several Asian countries, hepatocellular carcinoma (HCC) is a leading cause of cancer deaths. HCC risk factors in Asia differ from those elsewhere and are changing with the treatment landscape as systemic treatment options increase. This study was conducted to gain insight from physicians and patients into HCC screening, diagnosis, and treatment strategies in Indonesia, Korea, Malaysia, Singapore, Taiwan, Thailand, and Vietnam.

METHODS

Two cross-sectional, anonymized, online surveys were completed between July and December 2022 by physicians diagnosing and treating HCC (55 questions on risk factors, surveillance, diagnosis, and treatment) and patients ≥ 18 years old diagnosed with HCC (36 questions on disease knowledge, quality of life, and experiences of diagnosis and treatment).

RESULTS

Responses were received from 276 physicians in all 7 countries and 130 patients in Thailand, Taiwan, and Vietnam. From the physician's perspective, surveillance programs are widespread but identify insufficient HCC cases; only 18% are early-stage HCC at diagnosis. From the patient's perspective, knowledge of risk factors increases after diagnosis, but few seek support from patient associations; patients would benefit from better communication from their doctors. Treatment affordability and side effects are key issues for patients.

CONCLUSIONS

Awareness of the risk factors for HCC should be raised in primary care and the general population, and surveillance should identify early-stage HCC. Because patients rely on their doctors for support, doctors should better understand their patients' needs, and patients could be supported by trained nurses or case managers. Programs are needed to increase patients' access to proven HCC treatments.

Superselective Transarterial Chemoembolization for Unresectable or "Ablation Unsuitable" Hepatocellular Carcinoma in the Caudate Lobe: A Real World, Single-Center Retrospective Study

OBJECTIVES

To analyze the clinical outcomes of Transarterial chemoembolization (TACE) for unresectable or "ablation unsuitable" hepatocellular carcinoma (HCC) in the caudate lobe (CL) found at initial presentation in clinical practice.

METHODS

Fifty-eight patients with HCC-CL undergoing conventional TACE from January 2015 to January 2020 were enrolled in our medical center. Overall survival (OS), progression-free survival (PFS), tumor response rate and major complication rates were analyzed. Multivariate analyses for potential clinical and radiologic factors were performed by using the Cox proportional hazard model.

RESULTS

The median OS was 23 months (95%CI: 18.1-27.9), and the median PFS was 11 months (95%CI: 7.4-14.6). The 1-, 3-, and 5-years OS rates were 66.5%, 31.9% and 15.7%, respectively. The 0.5, 1-, and 3-years PFS rates were 60.3%, 44.5% and 6.3%, respectively. Objective response rate was 53.4% and disease control rate was 79.3%. The most serious complication was bile duct injury, with an incidence of 3.4%. Multivariable analysis revealed that total bilirubin, Barcelona Clinic Liver Cancer stage, nonselective chemoembolization and TACE session were four significant factors associated with OS.

CONCLUSIONS

Superselective TACE treatment might be associated with better survival benefits in unresectable or "ablation unsuitable" HCC in the CL without macroscopic vascular invasion (MVI) and adequate liver function, compared with the non-selective TACE group, and should be considered as an important reliable therapy for surgeons and interventional radiologists.

Consensus of Minimally Invasive and Multidisciplinary Comprehensive Treatment for Hepatocellular Carcinoma - 2020 Guangzhou Recommendations

In China, the majority of patients with hepatocellular carcinoma (HCC) result from long-term infection of hepatitis B. Pathologically, HCC is characterized by rich blood supply, multicentric origins, early vascular invasion and intrahepatic metastasis. Therefore, HCC is not a local disease but a systemic disease at the beginning of its occurrence. For this reason, a comprehensive treatment strategy should be adopted in the management of HCC, including local treatments (such as surgical resection, radiofrequency ablation, microwave ablation, chemical ablation and cryoablation, etc.), organ-level treatments [such as transcatheter arterial infusion of chemotherapy and transcatheter arterial chemoembolization (TACE)], and systemic treatments (such as immunotherapy, antiviral therapy and molecular targeted therapy, etc.). This consensus sets forth the minimally-invasive and multidisciplinary comprehensive guideline of HCC, focusing on the following eight aspects (1) using hepaticarteriography, CT hepatic arteriography (CTHA), CT arterial portography (CTAP), lipiodol CT (Lp-CT), TACE-CT to find the intrahepatic lesion and make precise staging (2) TACE combined with ablation or ablation as the first choice of treatment for early stage or small HCC, while other therapies are considered only when ablation is not applicable (3) infiltrating HCC should be regarded as an independent subtype of HCC (4) minimally-invasive comprehensive treatment could be adopted in treating metastatic lymph nodes (5) multi-level subdivision of M-staging should be used for individualized treatment and predicting prognosis (6) HCC with severe hepatic decompensation is the only candidate criterion for liver transplantation (7) bio-immunotherapy, traditional Chinese medicine therapy, antiviral therapy, and psychosocial and psychopharmacological interventions should be advocated through the whole course of HCC treatment (8) implementation of multicenter randomized controlled trials of minimally-invasive therapy versus surgery for early and intermediate stage HCC is recommended.

Additional Diagnostic Value of Fusion Imaging of CEUS and First CEUS of Invisible Hepatic Lesions ≤2 cm

OBJECTIVE

To explore the clinical value of image fusion of contrast-enhanced ultrasonography (CEUS) and contrast-enhanced computed tomography (CECT) in the diagnosis of invisible lesions with a size ≤2 cm on conventional ultrasound imaging, and compare it with the clinical value of "first CEUS" .

METHODS

A total of 132 patients with 147 lesions with abnormal blood supply with a size ≤2 cm on CECT were included in this study. "first CEUS" was performed for these lesions. Then "fusion CEUS," that is, CEUS administered after fusion of US and CECT images, was carried out. The detection rates of the "first CEUS" and "fusion CEUS" were compared. How "fusion CEUS" corrects the misdiagnosis of liver lesions on CECT was analyzed.

RESULTS

One hundred nine lesions considered as HCC and 38 lesions considered as benign lesions on CECT were included. The detection rates for the lesions of "first CEUS" and "fusion CEUS" were 71.4% and 96.6%, respectively (P < 0.001). Among the 147 lesions, 68 were with a diameter ≤ 1 cm. The detection rate of "first CEUS" and "fusion CEUS" were 55.9% and 95.6%, respectively (P < 0.001) for the lesions with a size ≤1 cm. "Fusion CEUS" and "first CEUS" corrected the misdiagnosis in 2 lesions on CECT.

CONCLUSION

The "first CEUS" and "fusion CEUS" can improve the lesion conspicuity. Compared with "first CEUS," "fusion CEUS" has a higher diagnostic ability and hence can detect most of the invisible lesions on the former.

Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China (2017 Edition)

BACKGROUND

Hepatocellular carcinoma (HCC) (about 85-90% of primary liver cancer) is particularly prevalent in China because of the high prevalence of chronic hepatitis B infection. HCC is the fourth most common malignancy and the third leading cause of tumor-related deaths in China. It poses a significant threat to the life and health of Chinese people.

SUMMARY

This guideline presents official recommendations of the National Health and Family Planning Commission of the People's Republic of China on the surveillance, diagnosis, staging, and treatment of HCC occurring in China. The guideline was written by more than 50 experts in the field of HCC in China (including liver surgeons, medical oncologists, hepatologists, interventional radiologists, and diagnostic radiologists) on the basis of recent evidence and expert opinions, balance of benefits and harms, cost-benefit strategies, and other clinical considerations.

KEY MESSAGES

The guideline presents the Chinese staging system, and recommendations regarding patients with HCC in China to ensure optimum patient outcomes.

Vasculogenic mimicry in hepatocellular carcinoma contributes to portal vein invasion

Portal vein invasion (PVI) is common in hepatocellular carcinoma (HCC) and largely contributes to tumor recurrence after radical tumor resection or liver transplantation. Vasculogenic mimicry (VM) was an independent vascular system lined with tumor cells and associated with poor prognosis of HCC. The present study was conducted to evaluate the relationship between VM and portal vein invasion. A total of 44 HCC cases receiving anatomic liver resection were included in the study and were divided into groups with and without PVI. The prevalence of VM in each group was examined by CD34-PAS dual staining. The regulatory molecules of VM formation such as Notch1, Vimentin and matrix metalloproteinases (MMPs) were investigated by immunohistochemical staining. Analysis was performed to explore the association of PVI, VM and the VM regulatory molecules. PVI was found in 40.91% (18/44) cases and VM was found in 38.64% (17/44) cases in total samples. The incidence of VM was 72.22% (13/18) in PVI group while it was 15.38% (4/26) in non-PVI group (P<0.001), VM formation was positively correlated with PVI (r=0.574, P<0.001). The VM forming regulatory molecules such as Notch1, Vimentin, MMP-2 and MMP-9 were found to be correlated with PVI in HCC patients. Taken together, our results suggested that VM formation, alone with its regulatory molecules, is the promoting factor of PVI in hepatocellular carcinoma.

MR visible localization device for radiographic-pathologic correlation of surgical specimens

PURPOSE

The detection of small parenchymal hepatic lesions identified by preoperative imaging remains a challenge for traditional pathologic methods in large specimens. We developed a magnetic resonance imaging (MRI) compatible localization device for imaging of surgical specimens aimed to improve identification and localization of hepatic lesions ex vivo.

MATERIALS AND METHODS

The device consists of two stationary and one removable MR-visible grids lined with silicone gel, creating an orthogonal 3D matrix for lesion localization. To test the device, five specimens of swine liver with a random number of lesions created by microwave ablation were imaged on a 3T MR scanner. Two readers independently evaluated lesion coordinates and size, which were then correlated with sectioning guided by MR imaging.

RESULTS

All lesions (n=38) were detected at/very close to the expected localization. Inter-reader agreement of lesion localization was almost perfect (0.92). The lesion size estimated by MRI matched macroscopic lesion size in cut specimen (±2mm) in 34 and 35, respectively, out of 38 lesions.

CONCLUSION

Use of this MR compatible device for ex vivo imaging proved feasible for detection and three-dimensional localization of liver lesions, and has potential to play an important role in the ex vivo examination of surgical specimens in which pathologic correlation is clinically important.

Recent Trends in the Management of Hepatocellular Carcinoma with Special Emphasis on Treatment with Regorafenib and Immune Checkpoint Inhibitors

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.