Risk factors of early recurrence after curative hepatectomy in hepatocellular carcinoma

Lower Geriatric Nutritional Risk Index and Prognostic Nutritional Index Predict Postoperative Prognosis in Patients with Hepatocellular Carcinoma

Increasing evidence suggests that nutritional indices, including the geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI), are predictors of poor prognosis in patients with hepatocellular carcinoma (HCC). Hence, this study aimed to explore the value of the GNRI and PNI in evaluating postoperative prognosis in patients with HCC, particularly regarding its recurrence patterns. We performed a retrospective analysis of 203 patients with HCC who underwent initial hepatic resection. Patients were divided into two groups according to the GNRI (cutoff: 98) and PNI (cutoff: 45). The GNRI and PNI were significantly associated with body composition (body mass index and skeletal muscle mass index), hepatic function (Child-Pugh Score), tumor factors (tumor size and microvascular invasion), and perioperative factors (blood loss and postoperative hospitalization). Patients with a low PNI or low GNRI had significantly worse overall survival (OS) and recurrence-free survival. Patients with early recurrence had lower PNI and GNRI scores than those without early recurrence. Patients with extrahepatic recurrence had lower PNI and GNRI scores than those without extrahepatic recurrence. The PNI and GNRI might be useful in predicting the prognosis and recurrence patterns of patients with HCC after hepatic resection.

Extracellular vesicles as potential biomarkers for diagnosis and recurrence detection of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor and a leading cause of cancer-related deaths worldwide. However, current diagnostic tools are often invasive and technically limited. In the last decade, non-invasive liquid biopsies have transformed the field of clinical oncology, showcasing the potential of various liquid-biopsy derived analytes, including extracellular vesicles (EVs), to diagnose and monitor HCC progression and metastatic spreading, serving as promising novel biomarkers. A prospective single-center cohort study including 37 HCC patients and 20 patients with non-malignant liver disease (NMLD), as a control group, was conducted. Serum EVs of both groups were analyzed before and after liver surgery. The study utilized microbead-based magnetic particle sorting and flow cytometry to detect 37 characteristic surface proteins of EVs. Furthermore, HCC patients who experienced tumor recurrence (R-HCC) within 12 months after surgery were compared to HCC patients without recurrence (NR-HCC). EVs of R-HCC patients (n = 12/20) showed significantly lower levels of CD31 compared to EVs of NR-HCC patients (p = 0.0033). EVs of NMLD-group showed significantly higher expressions of CD41b than EVs of HCC group (p = 0.0286). The study determined significant short-term changes in CD19 dynamics in EVs of the NMLD-group, with preoperative values being significantly higher than postoperative values (p = 0.0065). This finding of our pilot study suggests EVs could play a role as potential targets for the development of diagnostic and therapeutic approaches for the early and non-invasive detection of HCC recurrence. Further, more in-depth analysis of the specific EV markers are needed to corroborate their potential role as diagnostic and therapeutic targets for HCC.

Effect of ABO blood group on postoperative overall survival and recurrence-free survival rate in patients with hepatocellular carcinoma after hepatectomy: a multi-center retrospective cohort study

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. The survival rate after hepatectomy as the first line of treatment for HCC depends on various factors. This study evaluated the association of the ABO blood group and Rh with overall survival (OS) and Recurrence-free survival (RFS) rate after hepatectomy.

METHODS

This multicenter retrospective cohort study reviewed the medical files of 639 HCC patients who underwent hepatectomy from 2010 to 2022 in three medical centers affiliated with the Iran University of Medical Sciences. Patient data, including demographic, clinical, tumor characteristics, and post-surgery outcomes, were collected by referring to the patient's medical profiles. The Cox proportional hazard investigated the relationship between ABO blood group type and OS and RFS rate after hepatectomy.

RESULTS

The five-year OS and RFS rates were 25.4% and 18.7%, respectively. The five-year OS (Lok rank:40.89, P:0.001) and RFS rate in patients with blood type A were significantly lower than in non-A patients. (Lok rank:10.8, P:0.001) The multivariate Cox analysis showed that blood type A, age < 45 years, tumor size > 5 cm, Poor tumor differentiation, presence of metastasis, The number of involved lymph nodes ≤ 2, and serum Alpha-Fetoprotein)AFP( level ≥ 400 were significantly related to the decreased survival rate of HCC patients after hepatectomy (P < 0.05) There was no significant association between Rh with OS and RFS (P > 0.05).

CONCLUSION

Blood group type A, compared to non-A, can be associated with decreased OS and RFS rates in patients with HCC after hepatectomy.

Development of nomograms to predict recurrence after conversion hepatectomy for hepatocellular carcinoma previously treated with transarterial interventional therapy

BACKGROUND

Lack of opportunity for radical surgery and postoperative tumor recurrence are challenges for surgeons and hepatocellular carcinoma (HCC) patients. This study aimed to develop nomograms to predict recurrence risk and recurrence-free survival (RFS) probability after conversion hepatectomy for patients previously receiving transarterial interventional therapy.

METHODS

In total, 261 HCC patients who underwent conversion liver resection and previously received transarterial interventional therapy were retrospectively enrolled. Nomograms to predict recurrence risk and RFS were developed, with discriminative ability and calibration evaluated by C-statistics, calibration plots, and the Area under the Receiver Operator Characteristic (AUROC) curves.

RESULTS

Univariate/multivariable logistic regression and Cox regression analyses were used to identify predictive factors for recurrence risk and RFS, respectively. The following factors were selected as predictive of recurrence: age, tumor number, microvascular invasion (MVI) grade, preoperative alpha-fetoprotein (AFP), preoperative carbohydrate antigen 19-9 (CA19-9), and Eastern Cooperative Oncology Group performance score (ECOG PS). Similarly, age, tumor number, postoperative AFP, postoperative protein induced by vitamin K absence or antagonist-II (PIVKA-II), and ECOG PS were incorporated for the prediction of RFS. The discriminative ability and calibration of the nomograms revealed good predictive ability. Calibration plots showed good agreement between the nomogram predictions of recurrence and RFS and the actual observations.

CONCLUSIONS

A pair of reliable nomograms was developed to predict recurrence and RFS in HCC patients after conversion resection who previously received transarterial interventional therapy. These predictive models can be used as guidance for clinicians to help with treatment strategies.

Viral Status and Treatment Efficacy in Recurrent Hepatocellular Carcinoma After Primary Resection

BACKGROUND

The impact of viral background on long-term effectiveness of different treatment modalities for recurrent hepatocellular carcinoma (HCC) was not fully analyzed.

METHOD

Consecutive 726 patients who developed intrahepatic recurrence after primary hepatectomy for HCC between 2008 and 2015 were retrospectively studied. Post-recurrence survival (PRS) and rerecurrence-free survival (R-RFS) and risk factors were analyzed.

RESULTS

After a median follow-up period of 56 months, the 5-year PRS rates of the patients who underwent rehepatectomy, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE) were 79.4%, 83.0%, and 54.6%, respectively. The treatment benefit for PRS was consistently observed in patients with hepatitis B virus (HBV) and non-B, non-C subgroups, but not hepatitis C virus (HCV). For patients with late recurrence of HCC, R-RFS was superior in HBV subgroup and HCV subgroup which received antiviral treatment (compared to naïve HCV subgroup). Survival difference triaged by viral status was lost in the counterpart with early recurrence. Overall, RFA improved PRS and R-RFS in patients receiving antiviral treatment.

CONCLUSION

To achieve long-term survival after HCC recurrence, rehepatectomy and RFA were comparably effective, particularly among those with HBV. Antiviral treatment complemented survivals of patients with HCV after RFA, particularly in late first recurrence.

Macrotrabecular-massive subtype-based nomogram to predict early recurrence of hepatocellular carcinoma after surgery

OBJECTIVES

To analyze the predictive factors on early postoperative recurrence of hepatocellular carcinoma (HCC) and to establish a new nomogram to predict early postoperative recurrence of HCC.

METHODS

A retrospective analysis of 383 patients who had undergone curative resection between February 2012 and September 2020 in our center was performed. The Kaplan-Meier method was used for survival curve analysis. Univariate and multivariate Cox regression were performed to identify independent risk factors associated with early recurrence, and a nomogram for predicting early recurrence of HCC was established.

RESULTS

A total of 152/383 patients developed recurrence after surgery, of which 83 had recurrence within 1 year. Multivariate Cox regression analysis showed that preoperative alpha-fetoprotein level ≥400 ng/ml (P = 0.001), tumor diameter ≥5 cm (P = 0.009) and MVI (P = 0.007 and macrotrabecular-massive HCC (P = 0.003) were independent risk factors for early postoperative recurrence of HCC. The macrotrabecular-massive-based nomogram obtained a good C-index (0.74) for predicting early recurrence of HCC, and the area under the curve for predicting early recurrence was 0.767, which was better than the single American Joint Committee on Cancer T stage and Barcelona Clinic Liver Cancer stage.

CONCLUSIONS

The nomogram based on macrotrabecular-massive HCC can effectively predict early postoperative recurrence of HCC.

Predictors of early and late hepatocellular carcinoma recurrence

Hepatocellular carcinoma (HCC) is the most frequent liver neoplasm, and its incidence rates are constantly increasing. Despite the availability of potentially curative treatments (liver transplantation, surgical resection, thermal ablation), long-term outcomes are affected by a high recurrence rate (up to 70% of cases 5 years after treatment). HCC recurrence within 2 years of treatment is defined as “early” and is generally caused by the occult intrahepatic spread of the primary neoplasm and related to the tumor burden. A recurrence that occurs after 2 years of treatment is defined as “late” and is related to de novo HCC, independent of the primary neoplasm. Early HCC recurrence has a significantly poorer prognosis and outcome than late recurrence. Different pathogenesis corresponds to different predictors of the risk of early or late recurrence. An adequate knowledge of predictive factors and recurrence risk stratification guides the therapeutic strategy and post-treatment surveillance. Patients at high risk of HCC recurrence should be referred to treatments with the lowest recurrence rate and when standardized to combined or adjuvant therapy regimens. This review aimed to expose the recurrence predictors and examine the differences between predictors of early and late recurrence.

Interval dynamics of transplantability for hepatocellular carcinoma after primary curative resection: risk factors for nontransplantable recurrence

BACKGROUND

To investigate the changes in transplantability between primary and recurrent Hepatocellular carcinoma (HCC) after hepatic resection (HR) and the risk factors for nontransplantable recurrence (NTR).

METHODS

Consecutive 3122 patients who received HR for primary HCC between 2001 and 2019 were analyzed for changes in transplantability. Predictors of survival and NTR were evaluated using a competing risk analysis.

RESULTS

After a median follow-up of 78.3 months, the 5-year overall survival rate was 82.6%. Also, 58.2% of them developed recurrence after a median of 45.6 months. Recurrence occurred in 1205 and 611 patients with primary transplantable and nontransplantable HCC, respectively, of whom 26.1% and 63.2%, respectively, had NTR. Tumor diameter >3 cm [subdistribution hazard ratios (95% CI), 2.00 (1.62-2.48)], major resection [1.20 (1.00-1.43)], pathological grade >2 [1.28 (1.07-1.52)], microvascular invasion [1.74 (1.45-2.08)], and early recurrence (<1 year) [9.22 (7.83-10.87)] were associated with NTR. The overall transplantable pool increased from 72.3% to 77.5%.

CONCLUSION

Microvascular invasion and early recurrence were risk factors for NTR. Nonetheless, the transplantable pool increased after HR, 41.8% of the patients had no recurrence and may not require liver transplantation. If the patient's liver function is acceptable, HR should be considered the treatment of choice for HCC.

Preoperative prediction of early recurrence of HBV-related hepatocellular carcinoma (≤5 cm) by visceral adipose tissue index

Background

This study aimed to investigate whether visceral adipose tissue index (VATI) is a significant risk factor for the early recurrence (ER) of HBV-related hepatocellular carcinoma (HCC) (≤5 cm) after hepatectomy.

Methods

The recruited cohort patients who were positive for hepatitis B virus, presented with surgically confirmed HCC (≤5 cm) from Army Medical University (internal training cohort: n = 192) and Chongqing Medical University (external validation group: n = 46). We measured VATI, subcutaneous adipose tissue index (SATI) via computed tomography (CT). ER was defined as recurrence within 2 years after hepatectomy. The impact of parameters on outcome after hepatectomy for HCC was analyzed.

Results

Univariate analysis showed that alpha-fetoprotein levels (p = 0.044), body mass index (BMI) (p < 0.001), SATI (p < 0.001), and VATI (p < 0.001) were significantly different between ER and non-ER groups in internal training cohort. Multivariate analysis identified VATI as an independent risk factor for ER (odds ratio = 1.07, 95% confidence interval: 1.047-1.094, p < 0.001), with a AUC of 0.802, based on the cut-off value of VATI, which was divided into high risk (≥37.45 cm²/m²) and low risk (<37.45 cm²/m²) groups. The prognosis of low risk group was significantly higher than that of high risk group (p < 0.001). The AUC value of VATI in external validation group was 0.854.

Conclusion

VATI was an independent risk factor for the ER, and higher VATI was closely related to poor outcomes after hepatectomy for HBV-related HCC (≤5 cm).

Clinical value of serum AFP and PIVKA-II for diagnosis, treatment and prognosis of hepatocellular carcinoma

BACKGROUND

The accuracy of alpha-fetoprotein (AFP) as a diagnostic marker for hepatocellular carcinoma (HCC) is insufficient, and the application of abnormal prothrombin (PIVKA-II) in HCC is still controversial.

METHODS

Serum AFP and PIVKA-II levels were analyzed in 145 cases of HCC, 57 of benign liver disease, 55 of cholangiocarcinoma and gallbladder carcinoma, 112 of other gastrointestinal tumors with liver metastasis, and 101 healthy controls. Receiver operating characteristic curve and area under the curve were used to evaluate the diagnostic value of AFP and PIVKA-II for HCC. The changes in serum AFP and PIVKA-II levels before and after treatment in 47 HCC patients who underwent surgery and 77 who received interventional treatment were used to evaluate treatment efficacy and prognosis in HCC.

RESULTS

The concentrations of AFP and PIVKA-II in the HCC group were significantly higher than those in other groups (p < 0.01). The diagnostic value of PIVKA-II in HCC was better than that of AFP, and combined detection improved the diagnostic sensitivity and specificity. The levels of AFP and PIVKA-II after liver cancer surgery were significantly lower than those before surgery. Elevated levels of PIVKA-II before surgery predicted disease progression, and patients who remained positive for PIVKA-II after surgery had worse prognosis than those who became negative after surgery.

CONCLUSIONS

Combined detection of AFP and PIVKA-II is superior to both tests alone. We found that higher serum level of PIVKA-II indicates more severe HCC, with worse prognosis, while the level of AFP had no correlation with the prognosis.

The ratio of serum des-gamma-carboxy prothrombin to tumor volume as a new biomarker for early recurrence of resected hepatocellular carcinoma

BACKGROUND

Early recurrence (ER) of hepatocellular carcinoma (HCC) (within 1 year after resection) is known to be a poor prognostic factor. The aim was to identify the risk factors associated with ER after HCC resection.

METHODS

Data were analyzed retrospectively from patients who underwent primary resection for HCC from two hospitals. For cross-validation, HCC resection cases were divided into the training and testing cohort. The clinicopathological factors between the ER and non-ER groups and factors for predicting ER and prognosis after HCC resection were compared.

RESULTS

Out of 173 patients in the training dataset, 33 patients had ER and the ER group showed larger tumor size, more intrahepatic metastasis (IM), and a higher ratio of serum des-gamma-carboxy prothrombin (DCP) to tumor volume (TV) (DCP/TV) than the non-ER group. Out of 203 patients in the testing dataset, 30 patients had ER and the ER group demonstrated larger tumor size, more IM, and higher serum alpha-fetoprotein, AFP/TV, DCP/TV, AFP/tumor maximum diameter (TMD), and DCP/TMD than the non-ER group. The patients were divided into high and low DCP/TV groups and high serum DCP/TV was associated with unfavorable overall survival in the training and testing dataset. Multivariate analysis confirmed that high serum DCP/TV and IM were independently associated with ER.

CONCLUSION

Preoperative high serum DCP/TV may be useful for stratifying patients at risk of early HCC recurrence after curative resection.

Liver Transplantation for Hepatocellular Carcinoma: How Should We Improve the Thresholds?

Simple Summary

The ideal treatment for hepatocellular carcinoma (HCC) is liver transplantation (LT), which both eliminates the HCC and cures the diseased liver. Once considered an experimental treatment with dismal survival rates, LT for HCC entered a new era with the establishment of the Milan criteria over 20 years ago. However, over the last two decades, the Milan criteria, which are based on tumor morphology, have come under intense scrutiny and are now largely regarded as too restrictive, and limit the access of transplantation for many patients who would otherwise achieve good clinical outcomes. The liver transplant community has been making every effort to reach a goal of establishing more reliable selection criteria. This article addresses how the criteria have been extended, as well as the concept of pre-transplant down-staging to maximize the eligibility.

Abstract

Hepatocellular carcinoma (HCC) is the third highest cause of cancer-related mortality, and liver transplantation is the ideal treatment for this disease. The Milan criteria provided the opportunity for HCC patients to undergo LT with favorable outcomes and have been the international gold standard and benchmark. With the accumulation of data, however, the Milan criteria are not regarded as too restrictive. After the implementation of the Milan criteria, many extended criteria have been proposed, which increases the limitations regarding the morphological tumor burden, and incorporates the tumor’s biological behavior using surrogate markers. The paradigm for the patient selection for LT appears to be shifting from morphologic criteria to a combination of biologic, histologic, and morphologic criteria, and to the establishment of a model for predicting post-transplant recurrence and outcomes. This review article aims to characterize the various patient selection criteria for LT, with reference to several surrogate markers for the biological behavior of HCC (e.g., AFP, PIVKA-II, NLR, 18F-FDG PET/CT, liquid biopsy), and the response to locoregional therapy. Furthermore, the allocation rules in each country and the present evidence on the role of down-staging large tumors are addressed.

LPCAT1 functions as a novel prognostic molecular marker in hepatocellular carcinoma

This study aimed to investigate the relationships between LPCAT1 expression and clinicopathologic parameters of hepatocellular carcinoma (HCC), further, to explore the effect of LPCAT1 on overall survival (OS) in patients with HCC, and its possible mechanism. Bioinformatics analysis using high throughput RNA-sequencing data from TCGA was utilized to explore the differential expression of LPCAT1 between normal and tumor tissues, and the associations between LPCAT1 expression and clinicopathological parameters. Survival analyses and subgroup survival analyses were utilized to elucidate the effect of LPCAT1 on OS in patients with HCC. Univariate analysis and multivariate analysis were used to investigate the prognostic factors. Potential LPCAT1 related tumor genes were identified by the methodology of differentially expressed genes (DEGs) screening. GO term enrichment analysis, KEGG pathway analysis and the PPI network were used to explore the potential mechanism. LPCAT1 was significantly overexpressed in HCC tumor tissues compared with normal tissues. The LPCAT1 expression was related to tumor grade, ECOG score, AFP and TNM stage, with P values of 0.000, 0.000, 0.007 and 0.000, respectively. Multivariate analysis demonstrated that LPCAT1 expression was independently associated with OS, with an HR of 1.04 (CI: 1.01-1.06, P = 0.003). The KEGG pathway enrichment analyses showed that overlapped DEGs mainly participate in the cell cycle. Finally, we identified a hub gene, CDK1, which has been reported to act on the cell cycle, consistent with the result of KEGG enrichment analysis. Collectively, these data confirmed LPCAT1 was upregulated in HCC, and was an independent predictor of the prognosis.

Impact of prognostic nutritional index on the recurrence of hepatocellular carcinoma after a curative resection

Backgrounds/Aims

The purpose of this retrospective study was to determine the association between prognostic nutritional index (PNI) and recurrence of hepatocellular carcinoma after a curative resection.

Methods

Between 2007 to 2019, 130 patients who underwent curative hepatectomy for hepatocellular carcinoma were enrolled. PNI was calculated. Its cutoff value was identified through receiver operating characteristic curve analysis. According to PNI, patients were divided into two groups. Univariate and multivariate analyses were performed to identify independent risk factors for recurrence.

Results

The cutoff value of PNI was 52. In univariate analysis, alcoholic liver cirrhosis (p = 0.041), protein induced by vitamin K antagonist- II &ge; 200 (p = 0.012), indocyanine green retention test (ICG R15) >10% (p = 0.001), estimated blood loss &ge; 800 mL (p = 0.037), tumor size (p = 0.001), microvascular invasion (p = 0.023), T-stage (p = 0.001), and PNI < 52 (p = 0.001) were significant factors affecting the recurrence. In multivariate analysis, alcoholic liver cirrhosis (p = 0.046), ICG R15 >10% (p = 0.025), T-stage (p = 0.003), and PNI < 52 (p = 0.046) were independent prognostic factors for disease-free survival.

Conclusions

PNI, a nutritional and immunologic factor, is an independent prognostic factor that can predict the recurrence of hepatocellular carcinoma in patients undergoing a curative resection.

Factors Associated with Recurrence of Hepatocellular Carcinoma in 197 Patients Following Transarterial Chemoembolization: A Retrospective Study from a Single Center

Background

Hepatocellular carcinoma (HCC) is the second leading cause of cancer deaths. Transarterial chemoembolization (TACE) has been widely applied for treating patients with unresectable HCC. This study explored the factors influencing early recurrence (ER) after TACE in HCC patients.

Material/Methods

A total of 197 patients were divided into the ER group and the non-ER group. Univariate and multivariate Cox regression analyses were carried out to explore the influencing factors. Univariate Kaplan-Meier survival curves and restricted cubic splines were plotted for visualizing the relations between the influencing factors and ER.

Results

According to the multivariate analysis, for every 1-cm increase in the maximum tumor diameter, the risk of ER increased by 0.235 times (95% CI: 1.144–1.333, P<0.001). Patients with adjacent lobe invasion had a 1.227-fold higher risk of ER than those without (95% CI: 1.461–3.394, P<0.001). For every unit increase in neutrophil-to-lymphocyte ratio (NLR), the risk increased by 0.107-fold (95% CI: 1.012–1.211, P=0.027). Compared to patients at the very early/early Barcelona clinic liver cancer (BCLC) stage, those at the advanced/end stage had a 2.045-fold increased risk of ER (95% CI: 1.259–7.366, P=0.014).

Conclusions

The maximum tumor diameter, adjacent lobe invasion, NLR, and advanced/end stage BCLC stage were all risk factors for ER after TACE in HCC patients.

The Benefit of Apparent Diffusion Coefficient in Evaluating the Invasiveness of Hepatocellular Carcinoma

Background

This study aimed to evaluate hepatocellular carcinoma (HCC) invasiveness using the apparent diffusion coefficient (ADC).

Methods

Eighty-one patients with HCC confirmed by pathology and examined by preoperative magnetic resonance imaging diffusion-weighted imaging from January 2015 to September 2020 were retrospectively analyzed. Clinical and pathological data were recorded. The minimum ADC (ADCmin), average ADC (ADCmean), and the ratio of ADCmean to normal-appearing hepatic parenchyma ADC (ADCnahp) were assessed. The associations between clinical information, ADC value, and HCC invasiveness (microvascular invasion [MVI], tumor differentiation, and Ki-67 expression) were evaluated statistically. Independent risk factors related to HCC invasiveness were screened using binary logistic regression, and the diagnostic efficiency was evaluated by the receiver operating characteristic curve and its area under the curve (AUC) value.

Results

Tumor size was related to HCC MVI and tumor differentiation (P < 0.05). HCC MVI was associated with ADCmin, ADCmean, and the ADCmean-to-ADCnahp ratio (all P < 0.05) with AUC values of 0.860, 0.860, and 0.909, respectively. If these were combined with tumor size, the AUC value increased to 0.912. The degree of tumor differentiation was associated with ADCmin, ADCmean, and the ADCmean-to-ADCnahp ratio (all P < 0.05) with AUC values of 0.719, 0.708, and 0.797, respectively. If these were combined with tumor size, the AUC value increased to 0.868. Ki-67 expression was associated with ADCmin, ADCmean, and the ADCmean-to-ADCnahp ratio (all P < 0.05) with AUC values of 0.731, 0.747, and 0.746, respectively. Combined them, the AUC value increased to 0.763.

Conclusions

The findings indicated that the ADC value has significant potential for the non-invasive preoperative evaluation of HCC invasiveness.

Liver Transplantation in Patients with Hepatocellular Carcinoma beyond the Milan Criteria: A Comprehensive Review

The Milan criteria (MC) were developed more than 20 years ago and are still considered the benchmark for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). However, the strict application of MC might exclude some patients who may receive a clinical benefit of LT. Several expanded criteria have been proposed. Some of these consider pretransplant morphological and biological variables of the tumor, others consider post-LT variables such as the histology of the tumor, and others combine pre- and post-LT variables. More recently, the HCC response to locoregional treatments before transplantation emerged as a surrogate marker of the biological aggressiveness of the tumor to be used as a better selection criterion for LT in patients beyond the MC at presentation. This essential review aims to present the current data on the pretransplant selection criteria for LT in patients with HCC exceeding the MC at presentation based on morphological and histological characteristics of the tumor and to critically discuss those that have been validated in clinical practice. Moreover, the role of HCC biological markers and the tumor response to downstaging procedures as new tools for selecting patients with a tumor burden outside of the MC for LT is evaluated.

Tumor Stiffness Measurements on MR Elastography for Single Nodular Hepatocellular Carcinomas Can Predict Tumor Recurrence After Hepatic Resection

BACKGROUND

Tumor stiffness (TS), measured by magnetic resonance elastography (MRE), could be associated with tumor mechanical properties and tumor grade.

PURPOSE

To determine whether TS obtained using MRE is associated with survival in patients with single nodular hepatocellular carcinoma (HCC) after hepatic resection (HR).

STUDY TYPE

Retrospective.

POPULATION

In all, 95 patients with pathologically confirmed HCCs.

FIELD STRENGTH/SEQUENCE

1.5T/3D spin-echo echo-planar imaging MRE.

ASSESSMENT

TS values of the whole tumor (TS-WT) and of a solid portion of the tumor (TS-SP) after excluding the necrotic area were measured on stiffness maps. Known imaging prognostic factors of HCC were also analyzed. After surgery, pathologic findings were evaluated from resected pathology specimens.

STATISTICAL TESTS

Fisher's exact test and the Mann-Whitney U-test were performed to determine the significance of differences according to the tumor grade. Overall survival (OS) / recurrence-free survival (RFS) analyses were performed using Kaplan-Meier analyses and Cox multivariable models.

RESULTS

The average TS-WT was 2.14 ± 0.74 kPa, and the average TS-SP was 2.51 ± 1.07 kPa. The cumulative incidence of RFS was 73.1%, 63.1%, and 57.3% at 1, 3, and 5 years, respectively. The TS-WT, TS-SP, and tumor size (≥5 cm) were significant prognostic factors for RFS (P < 0.001; P < 0.001; P = 0.017, respectively). The estimated overall 1-, 3-, and 5-year survival rates were 95.7%, 86.9%, and 80.8%, respectively. The alpha-fetoprotein changes, platelets, tumor size (≥5 cm), and vascular invasion in pathology were significant predictive factors for overall survival (all P < 0.05). Tumor necrosis, TS-WT, TS-SP, and vascular invasion in pathology were significantly correlated with poorly differentiated HCC (all P < 0.05).

DATA CONCLUSION

The TS-WT, TW-SP, and tumor size (≥5 cm) were significant predictive factors of RFS after HR in patients with HCC. Level of Evidence Technical Efficacy Stage 5 J. MAGN. RESON. IMAGING 2021;53:587-596.

Development and Validation of a Clinicopathological-Based Nomogram to Predict the Survival Outcome of Patients with Recurrent Hepatocellular Carcinoma After Hepatectomy Who Underwent Microwave Ablation

Aim

To develop and validate a nomogram for predicting the overall survival (OS) in patients with recurrent hepatocellular carcinoma (HCC) after hepatectomy who underwent microwave ablation (MWA).

Methods

The training cohort included 299 patients with recurrent HCCs after hepatectomy who met the Milan criteria and received MWA from April 2007 to December 2017. Baseline characteristics were collected to identify risk factors for the determination of death after MWA. A multivariate Cox proportional hazards model based on significant risk factors was used to develop the nomogram, which was then assessed for its predictive accuracy using Harrell’s C-index and the area under the curve (AUC). The nomogram was validated by internal (n = 240) and external cohorts (n = 205) from another hospital.

Results

After a median follow-up of 32.3 months, 38.8% (116/299) of patients had died. Multivariate Cox proportional hazards analyses showed that comorbid disease, early recurrence, and albumin-bilirubin (ALBI) grades 2–3 were independent prognostic factors for poor OS. This nomogram accurately stratified patients into subgroups with low or high risk. The 1-, 3- and 5-year OS rates in the low-risk subgroup were 99.4%, 97.2%, and 86.1%, respectively, and they were 92.8%, 70.3%, and 45.8% in the high-risk subgroup (P < 0.001). The nomogram predicted OS in the training cohort with a C-index score of 0.801 (95% CI 0.761–0.841). The nomogram was validated by internal and external cohorts, with C-index scores of 0.792 (95% CI 0.738–0.846) and 0.744 (95% CI 0.703–0.785), respectively.

Conclusion

The nomogram provides individualized risk estimates for long-term OS for patients with recurrent HCC after hepatectomy who underwent MWA.

Gross type of hepatocellular carcinoma reflects the tumor hypoxia, fibrosis, and stemness-related marker expression

BACKGROUND

Hepatocellular carcinoma (HCC) is subclassified into five gross types, namely, vaguely nodular (VN), single nodular (SN), single nodular with extranodular growth (SNEG), confluent multinodular (CM), and infiltrative (INF) type. However, the pathological background underlying differences in biological behavior of different gross types of HCC remains unclear.

METHODS

The histopathological features, clinical outcomes of HCC gross types, and their relationships with stemness-related marker status and fibrotic/hypoxic tumor microenvironment (TME) were evaluated in 266 resected HCCs. The stemness-related markers (CD24, CD44, CD133, SALL4, YAP1, K19 and EpCAM), fibrous tumor stroma (αSMA), and hypoxia (CAIX) were evaluated with immunohistochemistry.

RESULTS

Poorer differentiation, reduced capsule formation, higher microvascular invasion, larger tumor size and larger area of necrosis were observed in order of VN-SN-SNEG-CM-INF type (p = 0.005 for all, linear-by-linear association). The expression of summed stemness-related markers and hypoxic/fibrotic TME showed an increasing trend in order of VN-SN-SNEG-CM-INF type (p < 0.005), and their expression well correlated with each other. INF type was found only in HCCs with hypoxic/fibrotic TME or high expression of stemness-related markers. CAIX expression and tumor necrosis ≥ 30% were independent prognostic markers for disease-specific survival. Early recurrence-free survival showed a significant difference based on gross types, revealing best outcome with VN type and worst outcome with INF type.

CONCLUSION

The marker expression of stemness-related and hypoxic/fibrotic TME of HCC showed an increasing trend in order of VN-SN-SNEG-CM-INF gross types, and their cross-talk may be involved in the determination of various gross-morphological features and their distinct biological behavior.

Characteristics of Early Recurrence After Curative Liver Resection for Solitary Hepatocellular Carcinoma

BACKGROUND

Early recurrence after liver resection of hepatocellular carcinoma (HCC) has a great effect on the survival of patients. The aims of this study were to identify risk factors for early recurrence and to clarify whether early recurrence is related to patient survival rate.

METHODS

We identified a total of 1010 patients with HCC recurrence after hepatic resection between 2009 and 2014 in Samsung Medical Center and Seoul National University Hospital. Inclusion criteria were preoperative solitary tumor Child-Pugh class A and curative hepatectomy. Early recurrence was defined as HCC recurrence < 1 year after surgery.

RESULTS

A total of 628 patients were included in this study: 302 with early recurrence and 326 with late recurrence. Multivariate analysis showed that HCC grade 3 or 4, tumor size > 3 cm, and microvascular invasion were closely associated with early recurrence after liver resection for solitary HCC. When HCC recurred, the early recurrence group had large tumor size, increased tumor numbers and AFP levels, and high incidence of diffuse intrahepatic recurrence compared with the late recurrence group. The overall survival curve for the early recurrence group was lower than that for the late recurrence group (P < 0.001). Multivariate analysis demonstrated early recurrence was closely associated with patient survival.

CONCLUSIONS

Patients with early recurrence had different characteristics compared to patients with late recurrence after hepatic resection in solitary HCC. Early detection of recurrence is necessary through active postoperative surveillance in hepatectomy patients with poor prognostic factors.

Serum biomarkers and risk of hepatocellular carcinoma recurrence after liver transplantation

Liver transplantation (LT) is the only potentially curative treatment for selected patients with cirrhosis and hepatocellular carcinoma (HCC) who are not candidates for resection. When the Milan criteria are strictly applied, 75% to 85%of 3- to 4-year actuarial survival rates are achieved, but up to 20% of the patients experience HCC recurrence after transplantation. The Milan criteria are based on the preoperative tumor macromorphology, tumor size and number on computed tomography or magnetic resonance imaging that neither correlate well with posttransplant histological study of the liver explant nor accurately predict HCC recurrence after LT, since they do not include objective measures of tumor biology. Preoperative biological markers, including alpha-fetoprotein, des-gamma-carboxiprothrombin or neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, can predict the risk for HCC recurrence after transplantation. These biomarkers have been proposed as surrogate markers of tumor differentiation and vascular invasion, with varied risk magnitudes depending on the defined cutoffs. Different studies have shown that the combination of one or several biomarkers integrated into prognostic models predict the risk of HCC recurrence after LT more accurately than Milan criteria alone. In this review, we focus on the potential utility of these serum biological markers to improve the performance of Milan criteria to identify patients at high risk of tumoral recurrence after LT.