Microvascular invasion (MVI) is a poorer prognostic predictor for small hepatocellular carcinoma

Radiomics-Based Prediction of Microvascular Invasion Grade in Nodular Hepatocellular Carcinoma Using Contrast-Enhanced Magnetic Resonance Imaging

Objective

The aim of this study is to develop and verify a magnetic resonance imaging (MRI)-based radiomics model for predicting the microvascular invasion grade (MVI) before surgery in individuals diagnosed with nodular hepatocellular carcinoma (HCC).

Methods

A total of 198 patients were included in the study and were randomly stratified into two groups: a training group consisting of 139 patients and a test group comprising 59 patients. The tumor lesion was manually segmented on the largest cross-sectional slice using ITK SNAP, with agreement reached between two radiologists. The selection of radiomics features was carried out using the LASSO (Least Absolute Shrinkage and Selection Operator) algorithm. Radiomics models were then developed through maximum correlation, minimum redundancy, and logistic regression analyses. The performance of the models in predicting MVI grade was assessed using the area under the receiver operating characteristic curve (AUC) and metrics derived from the confusion matrix.

Results

There were no notable statistical differences in sex, age, BMI (body mass index), tumor size, and location between the training and test groups. The AP and PP radiomic model constructed for predicting MVI grade demonstrated an AUC of 0.83 (0.75-0.88) and 0.73 (0.64-0.80) in the training group and an AUC of 0.74 (0.61-0.85) and 0.62 (0.48-0.74) in test group, respectively. The combined model consists of imaging data and clinical data (age and AFP), achieved an AUC of 0.85 (0.78-0.91) and 0.77 (0.64-0.87) in the training and test groups, respectively.

Conclusion

A radiomics model utilizing-contrast-enhanced MRI demonstrates strong predictive capability for differentiating MVI grades in individuals with nodular HCC. This model could potentially function as a dependable and resilient tool to support hepatologists and radiologists in their preoperative decision-making processes.

Survival in Patients With Recurrent Intermediate-Stage Hepatocellular Carcinoma: Sorafenib Plus TACE vs TACE Alone Randomized Clinical Trial

Importance

Transarterial chemoembolization (TACE) is commonly used to treat patients with recurrent intermediate-stage hepatocellular carcinoma (HCC) and positive microvascular invasion (MVI); however, TACE alone has demonstrated unsatisfactory survival benefits. A previous retrospective study suggested that TACE plus sorafenib (SOR-TACE) may be a better therapeutic option compared with TACE alone.

Objective

To investigate the clinical outcomes of SOR-TACE vs TACE alone for patients with recurrent intermediate-stage HCC after R0 hepatectomy with positive MVI.

Design, Setting, and Participants

In this phase 3, open-label, multicenter randomized clinical trial, patients with recurrent intermediate-stage HCC and positive MVI were randomly assigned in a 1:1 ratio via a computerized minimization technique to either SOR-TACE treatment or TACE alone. This trial was conducted at 5 hospitals in China, and enrolled patients from October 2019 to December 2021, with a follow-up period of 24 months. Data were analyzed from June 2023 to September 2023.

Interventions

Randomization to on-demand TACE (conventional TACE: doxorubicin, 50 mg, mixed with lipiodol and gelatin sponge particles [diameter: 150-350 μm]; drug-eluting bead TACE: doxorubicin, 75 mg, mixed with drug-eluting particles [diameter: 100-300 μm or 300-500 μm]) (TACE group) or sorafenib, 400 mg, twice daily plus on-demand TACE (SOR-TACE group) (conventional TACE: doxorubicin, 50 mg, mixed with lipiodol and gelatin sponge particles [diameter, 150-350 μm]; drug-eluting bead TACE: doxorubicin, 75 mg, mixed with drug-eluting particles [diameter: 100-300 μm or 300-500 μm]).

Main Outcomes and Measures

The primary end point was overall survival by intention-to-treat analysis. Safety was assessed in patients who received at least 1 dose of study treatment.

Results

A total of 162 patients (median [range] age, 55 [28-75] years; 151 males [93.2%]), were randomly assigned to be treated with either SOR-TACE (n = 81) or TACE alone (n = 81). The median overall survival was significantly longer in the SOR-TACE group than in the TACE group (22.2 months vs 15.1 months; hazard ratio [HR], 0.55; P < .001). SOR-TACE also prolonged progression-free survival (16.2 months vs 11.8 months; HR, 0.54; P < .001), and improved the objective response rate when compared with TACE alone based on the modified Response Evaluation Criteria in Solid Tumors criteria (80.2% vs 58.0%; P = .002). Any grade adverse events were more common in the SOR-TACE group, but all adverse events responded well to treatment. No unexpected adverse events or treatment-related deaths occurred in this study.

Conclusions and Relevance

The results of this randomized clinical trial demonstrated that SOR-TACE achieved better clinical outcomes than TACE alone. These findings suggest that combined treatment should be used for patients with recurrent intermediate-stage HCC after R0 hepatectomy with positive MVI.

Trial Registration

ClinicalTrials.gov Identifier: NCT04103398.

Drug-eluting bead transarterial chemoembolization as neoadjuvant therapy pre-liver transplantation for advanced-stage hepatocellular carcinoma

BACKGROUND

The objectives of this study were to assess the safety and efficacy of drug-eluting bead transarterial chemoembolization (DEB-TACE) as neoadjuvant therapy before liver transplantation (LT) for advanced-stage hepatocellular carcinoma (HCC) and to analyze the prognostic factors.

AIM

To determine whether DEB-TACE before LT is superior to LT for advanced-stage HCC.

METHODS

A total of 99 individuals diagnosed with advanced HCC were studied retrospectively. The participants were categorized into the following two groups based on whether they had received DEB-TACE before LT: DEB-TACE group (n = 45) and control group (n = 54). The participants were further divided into two subgroups based on the presence or absence of segmental portal vein tumor thrombus (PVTT). The DEB-TACE group consisted of two subgroups: Group A (n = 31) without PVTT and group B (n = 14) with PVTT. The control group also had two subgroups: Group C (n = 37) without PVTT and group D (n = 17) with PVTT. Data on patient demographics, disease characteristics, therapy response, and adverse events (AEs) were collected. The overall survival (OS) and recurrence-free survival (RFS) rates were assessed using Kaplan-Meier curves. Univariate and multivariate Cox regression analyses were conducted to determine the parameters that were independently related to OS and RFS.

RESULTS

The DEB-TACE group exhibited an overall response rate of 86.6%. Following therapy, there was a significant decrease in the median alpha-fetoprotein (AFP) level (275.1 ng/mL vs 41.7 ng/mL, P < 0.001). The main AE was post-embolization syndrome. The 2-year rates of RFS and OS were significantly higher in the DEB-TACE group than in the control group (68.9% vs 38.9%, P = 0.003; 86.7% vs 63.0%, P = 0.008). Within the subgroups, group A had higher 2-year rates of RFS and OS compared to group C (71.0% vs 45.9%, P = 0.038; 83.8% vs 62.2%, P = 0.047). The 2-year RFS rate of group B was markedly superior to that of group D (64.3% vs 23.5%, P = 0.002). Results from multivariate analyses showed that pre-LT DEB-TACE [hazard ratio (HR) = 2.73, 95% confidence interval (CI): 1.44-5.14, P = 0.04], overall target tumor diameter ≤ 7 cm (HR = 1.98, 95%CI: 1.05-3.75, P = 0.035), and AFP level ≤ 400 ng/mL (HR = 2.34; 95%CI: 1.30-4.19, P = 0.009) were significant risk factors for RFS. Additionally, pre-LT DEB-TACE (HR = 3.15, 95%CI: 1.43-6.96, P = 0.004) was identified as a significant risk factor for OS.

CONCLUSION

DEB-TACE is a safe and efficient therapy for advanced-stage HCC and also enhances patient survival after LT.

Drug-eluting bead transarterial chemoembolization as neoadjuvant therapy pre-liver transplantation for advanced-stage hepatocellular carcinoma

BACKGROUND

The objectives of this study were to assess the safety and efficacy of drug-eluting bead transarterial chemoembolization (DEB-TACE) as neoadjuvant therapy before liver transplantation (LT) for advanced-stage hepatocellular carcinoma (HCC) and to analyze the prognostic factors.

AIM

To determine whether DEB-TACE before LT is superior to LT for advanced-stage HCC.

METHODS

A total of 99 individuals diagnosed with advanced HCC were studied retrospectively. The participants were categorized into the following two groups based on whether they had received DEB-TACE before LT: DEB-TACE group (n = 45) and control group (n = 54). The participants were further divided into two subgroups based on the presence or absence of segmental portal vein tumor thrombus (PVTT). The DEB-TACE group consisted of two subgroups: Group A (n = 31) without PVTT and group B (n = 14) with PVTT. The control group also had two subgroups: Group C (n = 37) without PVTT and group D (n = 17) with PVTT. Data on patient demographics, disease characteristics, therapy response, and adverse events (AEs) were collected. The overall survival (OS) and recurrence-free survival (RFS) rates were assessed using Kaplan-Meier curves. Univariate and multivariate Cox regression analyses were conducted to determine the parameters that were independently related to OS and RFS.

RESULTS

The DEB-TACE group exhibited an overall response rate of 86.6%. Following therapy, there was a significant decrease in the median alpha-fetoprotein (AFP) level (275.1 ng/mL vs 41.7 ng/mL, P < 0.001). The main AE was post-embolization syndrome. The 2-year rates of RFS and OS were significantly higher in the DEB-TACE group than in the control group (68.9% vs 38.9%, P = 0.003; 86.7% vs 63.0%, P = 0.008). Within the subgroups, group A had higher 2-year rates of RFS and OS compared to group C (71.0% vs 45.9%, P = 0.038; 83.8% vs 62.2%, P = 0.047). The 2-year RFS rate of group B was markedly superior to that of group D (64.3% vs 23.5%, P = 0.002). Results from multivariate analyses showed that pre-LT DEB-TACE [hazard ratio (HR) = 2.73, 95% confidence interval (CI): 1.44-5.14, P = 0.04], overall target tumor diameter ≤ 7 cm (HR = 1.98, 95%CI: 1.05-3.75, P = 0.035), and AFP level ≤ 400 ng/mL (HR = 2.34; 95%CI: 1.30-4.19, P = 0.009) were significant risk factors for RFS. Additionally, pre-LT DEB-TACE (HR = 3.15, 95%CI: 1.43-6.96, P = 0.004) was identified as a significant risk factor for OS.

CONCLUSION

DEB-TACE is a safe and efficient therapy for advanced-stage HCC and also enhances patient survival after LT.

Preoperative and postoperative MRI-based models versus clinical staging systems for predicting early recurrence in hepatocellular carcinoma

BACKGROUND

To predict the early recurrence of HCC patients who received radical resection using preoperative variables based on Gd-EOB-DTPA enhanced MRI, followed by the comparison with the postoperative model and clinical staging systems.

METHODS

One hundred and twenty-nine HCC patients who received radical resection were categorized into the early recurrence group (n = 48) and the early recurrence-free group (n = 81). Through COX regression analysis, statistically significant variables of laboratory, pathologic, and Gd-EOB-DTPA enhanced MRI results were identified. The preoperative and postoperative models were established to predict early recurrence, and the prognostic performances and differences were compared between the two models and clinical staging systems.

RESULTS

Six variables were incorporated into the preoperative model, including alpha-fetoprotein (AFP) level, aspartate aminotransferase/platelet ratio index (APRI), rim arterial phase hyperenhancement (rim APHE), peritumoral hypointensity on hepatobiliary phase (HBP), CERHBP (tumor-to-liver SI ratio on hepatobiliary phase imaging), and ADC value. Moreover, the postoperative model was developed by adding microvascular invasion (MVI) and histological grade. The C-index of the preoperative model and postoperative model were 0.889 and 0.901 (p = 0.211) respectively. Using receiver operating characteristic curve analysis (ROC) and decision curve analysis (DCA), it was determined that the innovative models we developed had superior predictive capabilities for early recurrence in comparison to current clinical staging systems. HCC patients who received radical resection were stratified into low-, medium-, and high-risk groups on the basis of the preoperative and postoperative models.

CONCLUSION

The preoperative and postoperative MRI-based models built in this study were more competent compared with clinical staging systems to predict the early recurrence in hepatocellular carcinoma.

A multi-parametric prognostic model based on clinicopathologic features: vessels encapsulating tumor clusters and hepatic plates predict overall survival in hepatocellular carcinoma patients

BACKGROUND

Vessels encapsulating tumor clusters (VETC) is a newly described vascular pattern that is distinct from microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC). Despite its importance, the current pathological diagnosis report does not include information on VETC and hepatic plates (HP). We aimed to evaluate the prognostic value of integrating VETC and HP (VETC-HP model) in the assessment of HCC.

METHODS

A total of 1255 HCC patients who underwent radical surgery were classified into training (879 patients) and validation (376 patients) cohorts. Additionally, 37 patients treated with lenvatinib were studied, included 31 patients in high-risk group and 6 patients in low-risk group. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to establish a prognostic model for the training set. Harrell's concordance index (C-index), time-dependent receiver operating characteristics curve (tdROC), and decision curve analysis were utilized to evaluate our model's performance by comparing it to traditional tumor node metastasis (TNM) staging for individualized prognosis.

RESULTS

A prognostic model, VETC-HP model, based on risk scores for overall survival (OS) was established. The VETC-HP model demonstrated robust performance, with area under the curve (AUC) values of 0.832 and 0.780 for predicting 3- and 5-year OS in the training cohort, and 0.805 and 0.750 in the validation cohort, respectively. The model showed superior prediction accuracy and discrimination power compared to TNM staging, with C-index values of 0.753 and 0.672 for OS and disease-free survival (DFS) in the training cohort, and 0.728 and 0.615 in the validation cohort, respectively, compared to 0.626 and 0.573 for TNM staging in the training cohort, and 0.629 and 0.511 in the validation cohort. Thus, VETC-HP model had higher C-index than TNM stage system(p < 0.01).Furthermore, in the high-risk group, lenvatinib alone appeared to offer less clinical benefit but better disease-free survival time.

CONCLUSIONS

The VETC-HP model enhances DFS and OS prediction in HCC compared to traditional TNM staging systems. This model enables personalized temporal survival estimation, potentially improving clinical decision-making in surveillance management and treatment strategies.

Multiparametric MRI manifestations of the spontaneous intratumoral coagulative necrosis in HCC

PURPOSE

To investigate the MRI manifestations of the spontaneous intratumoral coagulative necrosis (iCN) in patients with hepatocellular carcinoma (HCC) and its value in predicting the postoperative early recurrence (≤ 2 years).

METHODS

Patients with HCC who underwent preoperative multiparametric MRI between January 2015 and February 2019 were enrolled in this retrospective study. The MRI manifestations of iCNs on TIWI, T2WI, and ADC were recorded. The sensitivity and specificity of MRI for the detection of iCNs were also evaluated. A multivariable Cox proportional hazards model and the Kaplan-Meier method were used to verify the value of histologically-confirmed and MRI-identified iCNs, respectively, in predicting early recurrence.

RESULTS

A total of 163 patients (median age, 56 years; interquartile range, 49-64 years; 139 men) with HCCs were evaluated, of whom 27(16.6%) had histologically-confirmed iCNs. MRI identified 92.6% (25 of 27; 95% confidence interval [CI] 74.2%, 98.7%) of iCNs (sensitivity), with a specificity of 79.4% (78 of 136; 95% CI 71.4%, 85.7%), based on non-enhancement on post-contrast MRI. And the MRI-identified iCNs were characterized by a similar appearance to surrounding tumour tissue shown on pre-contrast MRI but not enhanced on post-contrast MRI. The multivariable Cox proportional hazards model revealed that only the presence of histologically-confirmed iCN was independently associated with early HCC recurrence (hazard ratio = 2.73; 95% CI 1.20, 6.21; P = 0.017). The Kaplan-Meier curve showed that the presence of MRI-identified iCN was also associated with early recurrence (P < 0.001).

CONCLUSION

Multiparametric MRI identified iCNs with high sensitivity and modest specificity. The presence of iCNs is associated with early HCC recurrence.

Nomogram prediction of vessels encapsulating tumor clusters in small hepatocellular carcinoma ≤ 3 cm based on enhanced magnetic resonance imaging

BACKGROUND

Vessels encapsulating tumor clusters (VETC) represent a recently discovered vascular pattern associated with novel metastasis mechanisms in hepatocellular carcinoma (HCC). However, it seems that no one have focused on predicting VETC status in small HCC (sHCC). This study aimed to develop a new nomogram for predicting VETC positivity using preoperative clinical data and image features in sHCC (≤ 3 cm) patients.

AIM

To construct a nomogram that combines preoperative clinical parameters and image features to predict patterns of VETC and evaluate the prognosis of sHCC patients.

METHODS

A total of 309 patients with sHCC, who underwent segmental resection and had their VETC status confirmed, were included in the study. These patients were recruited from three different hospitals: Hospital 1 contributed 177 patients for the training set, Hospital 2 provided 78 patients for the test set, and Hospital 3 provided 54 patients for the validation set. Independent predictors of VETC were identified through univariate and multivariate logistic analyses. These independent predictors were then used to construct a VETC prediction model for sHCC. The model's performance was evaluated using the area under the curve (AUC), calibration curve, and clinical decision curve. Additionally, Kaplan-Meier survival analysis was performed to confirm whether the predicted VETC status by the model is associated with early recurrence, just as it is with the actual VETC status and early recurrence.

RESULTS

Alpha-fetoprotein_lg10, carbohydrate antigen 199, irregular shape, non-smooth margin, and arterial peritumoral enhancement were identified as independent predictors of VETC. The model incorporating these predictors demonstrated strong predictive performance. The AUC was 0.811 for the training set, 0.800 for the test set, and 0.791 for the validation set. The calibration curve indicated that the predicted probability was consistent with the actual VETC status in all three sets. Furthermore, the decision curve analysis demonstrated the clinical benefits of our model for patients with sHCC. Finally, early recurrence was more likely to occur in the VETC-positive group compared to the VETC-negative group, regardless of whether considering the actual or predicted VETC status.

CONCLUSION

Our novel prediction model demonstrates strong performance in predicting VETC positivity in sHCC (≤ 3 cm) patients, and it holds potential for predicting early recurrence. This model equips clinicians with valuable information to make informed clinical treatment decisions.

Development and validation of nomograms for predicting prognosis in patients with solitary HCC: A TRIPOD-Compliant study

Objective

To develop and validate nomograms for predicting the OS and CSS of patients with Solitary Hepatocellular Carcinoma (HCC).

Methods

Using the TRIPOD guidelines, this study identified 5206 patients in the Surveillance, Epidemiology, and End Results (SEER) 17 registry database. All patients were randomly divided in a ratio of 7:3 into a training cohort (n = 3646) and a validation cohort (n = 1560), and the Chinese independent cohort (n = 307) constituted the external validation group. The prognosis-related risk factors were selected using univariate Cox regression analysis, and the independent prognostic factors of OS and CSS were identified using the Lasso-Cox regression model. The nomograms for predicting the OS and CSS of the patients were constructed based on the identified prognostic factors. Their prediction ability was evaluated using the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve in both the training and validation cohorts.

Results

We identified factors that predict OS and CSS and constructed two nomograms based on the data. The ROC analysis, C-index analysis, and calibration analysis indicated that the two nomograms performed well over the 1, 3, and 5-year OS and CSS periods in both the training and validation cohorts. Additionally, these results were confirmed in the external validation group. Decision curve analysis (DCA) demonstrated that the two nomograms were clinically valuable and superior to the TNM stage system.

Conclusion

We established and validated nomograms to predict 1,3, and 5-year OS and CSS in solitary HCC patients, and our results may also be helpful for clinical decision-making.

Identification of molecular characteristics of hepatocellular carcinoma with microvascular invasion based on deep targeted sequencing

BACKGROUND

As an indicator of tumor invasiveness, microvascular invasion (MVI) is a crucial risk factor for postoperative relapse, metastasis, and unfavorable prognosis in hepatocellular carcinoma (HCC). Nevertheless, the genetic mechanisms underlying MVI, particularly for Chinese patients, remain mostly uncharted.

METHODS

We applied deep targeted sequencing on 66 Chinese HCC samples. Focusing on the telomerase reverse transcriptase (TERT) promoter (TERTp) and TP53 co-mutation (TERTp+/TP53+) group, gene set enrichment analysis (GSEA) was used to explore the potential molecular mechanisms of the TERTp+/TP53+ group on tumor progression and metastasis. Additionally, we evaluated the tumor immune microenvironment of the TERTp+/TP53+ group in HCC using multiplex immunofluorescence (mIF) staining.

RESULTS

Among the 66 HCC samples, the mutated genes that mostly appeared were TERT, TP53, and CTNNB1. Of note, we found 10 cases with TERTp+/TP53+, of which nine were MVI-positive and one was MVI-negative, and there was a co-occurrence of TERTp and TP53 (p < 0.05). Survival analysis demonstrated that patients with the TERTp+/TP53+ group had lower the disease-free survival (DFS) (p = 0.028). GSEA results indicated that telomere organization, telomere maintenance, DNA replication, positive regulation of cell cycle, and negative regulation of immune response were significantly enriched in the TERTp+/TP53+ group (all adjusted p-values (p.adj) < 0.05). mIF revealed that the TERTp+/TP53+ group decreased CD8+ T cells infiltration (p = 0.25) and enhanced PDL1 expression (p = 0.55).

CONCLUSIONS

TERTp+/TP53+ was significantly enriched in MVI-positive patients, leading to poor prognosis for HCC patients by promoting proliferation of HCC cell and inhibiting infiltration of immune cell surrounding HCC. TERTp+/TP53+ can be utilized as a potential indicator for predicting MVI-positive patients and poor prognosis, laying a preliminary foundation for further exploration of co-mutation in HCC with MVI and clinical treatment.

Nomogram based on CMTM6 expression and clinical characteristics to predict postoperative overall survival in patients with hepatocellular carcinoma

BACKGROUND

The purpose of this study was to investigate the expression of CMTM6 in HCC tissues and its prognostic value, and to try to develop a nomogram prognostic model based on CMTM6.

METHODS

In this retrospective study, immunohistochemical (IHC) staining was performed in 178 patients who underwent radical hepatectomy in the same surgical team. R software was used to construct the nomogram model. The Bootstrap sampling method was used for internal validation.

RESULTS

CMTM6 is significantly expressed in HCC tissues and is closely associated with decreased overall survival (OS). PVTT (HR = 6.2, 95% CI: 3.06 12.6, P<0.001), CMTM6 (HR=2.30, 95% CI: 1.27 4.0, P=0.006) and MVI (HR=10.8, 95% CI: 4.19-27.6, P<0.001) were independent predictors of OS. The nomogram combined with CMTM6, PVTT and MVI was more predictive than the traditional TNM scoring system, and the prediction effects of 1-year and 3-year OS were accurate.

CONCLUSIONS

The prognosis of a patient may be predicted using high levels of CMTM6 expression in HCC tissues, and the nomogram model including CMTM6 expression has the best predictive ability.

Multiple Machine-Learning Fusion Model Based on Gd-EOB-DTPA-Enhanced MRI and Aminotransferase-to-Platelet Ratio and Gamma-Glutamyl Transferase-to-Platelet Ratio to Predict Microvascular Invasion in Solitary Hepatocellular Carcinoma: A Multicenter Study

Background

Currently, it is still confused whether preoperative aminotransferase-to-platelet ratio (APRI) and gamma-glutamyl transferase-to-platelet ratio (GPR) can predict microvascular invasion (MVI) in solitary hepatocellular carcinoma (HCC). We aimed to develop and validate a machine-learning integration model for predicting MVI using APRI, GPR and gadoxetic acid disodium (Gd-EOB-DTPA) enhanced MRI.

Methods

A total of 314 patients from XinQiao Hospital of Army Medical University were divided chronologically into training set (n = 220) and internal validation set (n = 94), and recurrence-free survival was determined to follow up after surgery. Seventy-three patients from Chongqing University Three Gorges Hospital and Luzhou People's Hospital served as external validation set. Overall, 387 patients with solitary HCC were analyzed as whole dataset set. Least absolute shrinkage and selection operator, tenfold cross-validation and multivariate logistic regression were used to gradually filter features. Six machine-learning models and an ensemble of the all models (ENS) were built. The area under the receiver operating characteristic curve (AUC) and decision curve analysis were used to evaluate model's performance.

Results

APRI, GPR, HBPratio3 ([liver SI‒tumor SI]/liver SI), PLT, peritumoral enhancement, non-smooth margin and peritumoral hypointensity were independent risk factors for MVI. Six machine-learning models showed good performance for predicting MVI in training set (AUCs range, 0.793-0.875), internal validation set (0.715-0.832), external validation set (0.636-0.746) and whole dataset set (0.756-0.850). The ENS achieved the highest AUCs (0.879 vs 0.858 vs 0.839 vs 0.851) in four cohorts with excellent calibration and more net benefit. Subgroup analysis indicated that ENS obtained excellent AUCs (0.900 vs 0.809 vs 0.865 vs 0.908) in HCC >5cm, ≤5cm, ≤3cm and ≤2cm cohorts. Kaplan‒Meier survival curves indicated that ENS achieved excellent stratification for MVI status.

Conclusion

The APRI and GPR may be new potential biomarkers for predicting MVI of HCC. The ENS achieved optimal performance for predicting MVI in different sizes HCC and may aid in the individualized selection of surgical procedures.

Recurrence-free Survival After Liver Transplantation Versus Surgical Resection for Hepatocellular Carcinoma: Role of High-risk MRI Features

BACKGROUND

This study aimed to evaluate recurrence-free survival (RFS) and overall survival (OS) after liver transplantation (LT) or liver resection (LR) for hepatocellular carcinoma (HCC) and perform subgroup analysis for HCC with high-risk imaging findings for recurrence on preoperative liver magnetic resonance imaging (MRI; high-risk MRI features).

METHODS

We included patients with HCC eligible for both LT and LR and received either of the treatments between June 2008 and February 2021 from 2 tertiary referral medical centers after propensity score-matching. RFS and OS were compared between LT and LR using Kaplan-Meier curves with the log-rank test.

RESULTS

Propensity score-matching yielded 79 patients in the LT group and 142 patients in the LR group. High-risk MRI features were noted in 39 patients (49.4%) in the LT group and 98 (69.0%) in the LR group. The Kaplan-Meier curves for RFS and OS were not significantly different between the 2 treatments among the high-risk group (RFS, P  = 0.079; OS, P  = 0.755). Multivariable analysis showed that treatment type was not a prognostic factor for RFS and OS ( P  = 0.074 and 0.937, respectively).

CONCLUSIONS

The advantage of LT over LR for RFS may be less evident among patients with high-risk MRI features.

Circulating tumor cells participate in the formation of microvascular invasion and impact on clinical outcomes in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignant tumor worldwide. Although the treatment strategies have been improved in recent years, the long-term prognosis of HCC is far from satisfactory mainly due to high postoperative recurrence and metastasis rate. Vascular tumor thrombus, including microvascular invasion (MVI) and portal vein tumor thrombus (PVTT), affects the outcome of hepatectomy and liver transplantation. If vascular invasion could be found preoperatively, especially the risk of MVI, more reasonable surgical selection will be chosen to reduce the risk of postoperative recurrence and metastasis. However, there is a lack of reliable prediction methods, and the formation mechanism of MVI/PVTT is still unclear. At present, there is no study to explore the possibility of tumor thrombus formation from a single circulating tumor cell (CTC) of HCC, nor any related study to describe the possible leading role and molecular mechanism of HCC CTCs as an important component of MVI/PVTT. In this study, we review the current understanding of MVI and possible mechanisms, discuss the function of CTCs in the formation of MVI and interaction with immune cells in the circulation. In conclusion, we discuss implications for potential therapeutic targets and the prospect of clinical treatment of HCC.

Dynamic contrast-enhanced ultrasonography with sonazoid predicts microvascular invasion in early-stage hepatocellular carcinoma

OBJECTIVE

Microvascular invasion (MVI) is an independent risk factor for the early recurrence and poor survival of hepatocellular carcinoma (HCC). This study aims to investigate the potential clinical value of dynamic contrast-enhanced ultrasound (DCE-ultrasound)-Sonazoid in pre-operatively assessing MVI in HCC.

METHODS AND MATERIALS

This single centre prospective study included 140 patients with histopathologically confirmed single HCC lesions. Patients were classified according to the post-operative pathological information presence of MVI: MVI+ group (n = 32) and MVI- group (n = 108). All patients underwent DCE-ultrasound within 1 week before surgery. The quantitative perfusion parameters of HCC lesions, margins of HCC lesions, and distal liver parenchyma were obtained and analyzed.

RESULTS

Clinicopathological (serum alpha-fetoprotein, Des-gamma-carboxyprothrombin, and pathological grade) and grayscale imaging features (tumor size) were significantly different between the MVI+ and MVI- groups (p < 0.05). Further quantitative analysis showed that when comparing the MVI+ and MVI- groups, half-decrease time and wash-out rate of HCC lesions and peak enhancement in the arterial phase of difference between the margin area of HCC and distal liver parenchyma were significantly different (p = 0.045, p = 0.035, and p = 0.023, respectively). Combining the above three quantitative parameters, the accuracy, sensitivity, specificity, positive-predictive value, and negative-predictive value were 69.3% (97/140), 37.8% (17/45), 84.3% (80/95), 53.1% (17/32), 74.1% (80/108), respectively.

CONCLUSION

DCE-ultrasound with quantitative perfusion analysis has the potential to predict MVI in HCC lesions.

ADVANCES IN KNOWLEDGE

DCE-ultrasound with quantitative perfusion analysis has the potential to predict MVI in HCC lesions.

Radiomics models for preoperative prediction of the histopathological grade of hepatocellular carcinoma: A systematic review and radiomics quality score assessment

OBJECTIVE

To systematically review the efficacy of radiomics models derived from computed tomography (CT) or magnetic resonance imaging (MRI) in preoperative prediction of the histopathological grade of hepatocellular carcinoma (HCC).

METHODS

Systematic literature search was performed at databases of PubMed, Web of Science, Embase, and Cochrane Library up to 30 December 2022. Studies that developed a radiomics model using preoperative CT/MRI for predicting the histopathological grade of HCC were regarded as eligible. A pre-defined table was used to extract the data related to study and patient characteristics, characteristics of radiomics modelling workflow, and the model performance metrics. Radiomics quality score and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) were applied for research quality evaluation.

RESULTS

Eleven eligible studies were included in this review, consisting of 2245 patients (range 53-494, median 165). No studies were prospectively designed and only two studies had an external test cohort. Half of the studies (five) used CT images and the other half MRI. The median number of extracted radiomics features was 328 (range: 40-1688), which was reduced to 11 (range: 1-50) after feature selection. The commonly used classifiers were logistic regression and support vector machine (both 4/11). When evaluated on the two external test cohorts, the area under the curve of the radiomics models was 0.70 and 0.77. The median radiomics quality score was 10 (range 2-13), corresponding to 28% (range 6-36%) of the full scale. Most studies showed an unclear risk of bias as evaluated by QUADAS-2.

CONCLUSION

Radiomics models based on preoperative CT or MRI have the potential to be used as an imaging biomarker for prediction of HCC histopathological grade. However, improved research and reporting quality is required to ensure sufficient reliability and reproducibility prior to implementation into clinical practice.

Liver Segment Disposition of Hepatocellular Carcinoma Predicts Microvascular Invasion

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer morbidity and mortality. Findings of microvascular invasion (MVI) in patients with HCC have emerged as an important prognostic factor for poor survival after tumor resection.

Aim

This study evaluated the relation between MVI and HCC within various anatomical Couinaud's segments of the liver.

Method

A multicenter retrospective review of HCC records was conducted from 2012 to 2017. HCC cases were identified using ICD-9 and 10 codes 155, C22.0, and C22.8. HCC patients who underwent liver transplants were included in this study. Liver segment of the location of HCC was obtained from radiographic records, and MVI information was obtained from pathology reports. Segmental distributions of HCC in MVI versus non-MVI groups were compared using Wilcoxon rank sum tests. p value was set at <0.05.

Results

We analyzed 120 HCC patients who underwent liver transplantation. The mean age of our cohort was 57 years, and the most common etiology of liver disease was hepatitis C at 58.3%. The median HCC size was 3.1 cm, and MVI was present in 23.3% of the explanted specimens. MVI was 2 to 3 times significantly higher in patients with HCC affecting segments 2 and 3 and segments 4b and 5 (p = 0.01). Moreover, median survival was significantly lower in patients with MVI versus those without MVI (50 vs. 137 months, p < 0.05).

Conclusion

MVI was significantly higher in HCC tumors located in liver segments 2 and 3 and 4b and 5, and survival was lower in patients with MVI compared with those without.

A nomogram for preoperative prediction of microvascular invasion in ruptured hepatocellular carcinoma

BACKGROUND AND AIM

Microvascular invasion (MVI) is defined as the presence of micrometastatic cancer cell emboli in hepatic vessels, including small vessels, and at present, researchers believe that is an important factor for early postoperative recurrence and survival. Here, we developed and validated a preoperative predictive model for the presence of MVI in patients with ruptured hepatocellular carcinoma (rHCC).

METHODS

We retrospectively collected data for 210 rHCC patients who underwent staged hepatectomy at Wuhan Tongji Hospital, and 91 patients who underwent staged hepatectomy at Zhongshan People's Hospital between January 2010 and March 2021. Then, the former was used as the training cohort and the latter was used as the validation cohort. Logistic regression was used to screen for variables associated with MVI, and these variables were used to construct nomograms. We used R software to assess the discrimination, calibration ability, as well as clinical efficacy of nomograms.

RESULTS

Multivariate logistic regression analysis identified four risk factors independently associated with MVI: max tumor length [odds ratio (OR) = 1.385; 95% confidence interval (CI), 1.072-1.790], number of tumors (OR = 2.182; 95% CI, 1.129-5.546), direct bilirubin (OR = 1.515; 95% CI, 1.189-1.930), and alpha-fetoprotein (cutoff = 400 ng/mL) (OR = 2.689; 95% CI, 3.395-13.547). Nomograms were built from the four variables and they were tested for discrimination and calibration, and the results were good.

CONCLUSION

We developed and validated a preoperative predictive model for the presence of MVI in patients with ruptured HCC. This model can help clinicians identify patients at risk of MVI and make better treatment options.

Prediction of microvascular invasion in hepatocellular carcinoma based on preoperative Gd-EOB-DTPA-enhanced MRI: Comparison of predictive performance among 2D, 2D-expansion and 3D deep learning models

Purpose

To evaluate and compare the predictive performance of different deep learning models using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI in predicting microvascular invasion (MVI) in hepatocellular carcinoma.

Methods

The data of 233 patients with pathologically confirmed hepatocellular carcinoma (HCC) treated at our hospital from June 2016 to June 2021 were retrospectively analyzed. Three deep learning models were constructed based on three different delineate methods of the region of interest (ROI) using the Darwin Scientific Research Platform (Beijing Yizhun Intelligent Technology Co., Ltd., China). Manual segmentation of ROI was performed on the T1-weighted axial Hepatobiliary phase images. According to the ratio of 7:3, the samples were divided into a training set (N=163) and a validation set (N=70). The receiver operating characteristic (ROC) curve was used to evaluate the predictive performance of three models, and their sensitivity, specificity and accuracy were assessed.

Results

Among 233 HCC patients, 109 were pathologically MVI positive, including 91 men and 18 women, with an average age of 58.20 ± 10.17 years; 124 patients were MVI negative, including 93 men and 31 women, with an average age of 58.26 ± 10.20 years. Among three deep learning models, 2D-expansion-DL model and 3D-DL model showed relatively good performance, the AUC value were 0.70 (P=0.003) (95% CI 0.57-0.82) and 0.72 (P<0.001) (95% CI 0.60-0.84), respectively. In the 2D-expansion-DL model, the accuracy, sensitivity and specificity were 0.7143, 0.739 and 0.688. In the 3D-DL model, the accuracy, sensitivity and specificity were 0.6714, 0.800 and 0.575, respectively. Compared with the 3D-DL model (based on 3D-ResNet), the 2D-DL model is smaller in scale and runs faster. The frames per second (FPS) for the 2D-DL model is 244.7566, which is much larger than that of the 3D-DL model (73.3374).

Conclusion

The deep learning model based on Gd-EOB-DTPA-enhanced MRI could preoperatively evaluate MVI in HCC. Considering that the predictive performance of 2D-expansion-DL model was almost the same as the 3D-DL model and the former was relatively easy to implement, we prefer the 2D-expansion-DL model in practical research.

The diagnostic performance of radiomics-based MRI in predicting microvascular invasion in hepatocellular carcinoma: A meta-analysis

Objective

The aim of this study was to assess the diagnostic performance of radiomics-based MRI in predicting microvascular invasion (MVI) in hepatocellular carcinoma (HCC).

Method

The databases of PubMed, Cochrane library, Embase, Web of Science, Ovid MEDLINE, Springer, and Science Direct were searched for original studies from their inception to 20 August 2022. The quality of each study included was assessed according to the Quality Assessment of Diagnostic Accuracy Studies 2 and the radiomics quality score. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated. The summary receiver operating characteristic (SROC) curve was plotted and the area under the curve (AUC) was calculated to evaluate the diagnostic accuracy. Sensitivity analysis and subgroup analysis were performed to explore the source of the heterogeneity. Deeks' test was used to assess publication bias.

Results

A total of 15 studies involving 981 patients were included. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.79 (95%CI: 0.72-0.85), 0.81 (95%CI: 0.73-0.87), 4.1 (95%CI:2.9-5.9), 0.26 (95%CI: 0.19-0.35), 16 (95%CI: 9-28), and 0.87 (95%CI: 0.84-0.89), respectively. The results showed great heterogeneity among the included studies. Sensitivity analysis indicated that the results of this study were statistically reliable. The results of subgroup analysis showed that hepatocyte-specific contrast media (HSCM) had equivalent sensitivity and equivalent specificity compared to the other set. The least absolute shrinkage and selection operator method had high sensitivity and specificity than other methods, respectively. The investigated area of the region of interest had high specificity compared to the volume of interest. The imaging-to-surgery interval of 15 days had higher sensitivity and slightly low specificity than the others. Deeks' test indicates that there was no publication bias (P=0.71).

Conclusion

Radiomics-based MRI has high accuracy in predicting MVI in HCC, and it can be considered as a non-invasive method for assessing MVI in HCC.

Current status and future perspectives of radiomics in hepatocellular carcinoma

Given the frequent co-existence of an aggressive tumor and underlying chronic liver disease, the management of hepatocellular carcinoma (HCC) patients requires experienced multidisciplinary team discussion. Moreover, imaging plays a key role in the diagnosis, staging, restaging, and surveillance of HCC. Currently, imaging assessment of HCC entails the assessment of qualitative characteristics which are prone to inter-reader variability. Radiomics is an emerging field that extracts high-dimensional mineable quantitative features that cannot be assessed visually with the naked eye from medical imaging. The main potential applications of radiomic models in HCC are to predict histology, response to treatment, genetic signature, recurrence, and survival. Despite the encouraging results to date, there are challenges and limitations that need to be overcome before radiomics implementation in clinical practice. The purpose of this article is to review the main concepts and challenges pertaining to radiomics, and to review recent studies and potential applications of radiomics in HCC.

Prognostic Analysis of Single Large Hepatocellular Carcinoma Following Radical Resection: A Single-Center Study

Objective

To investigate the survival and independent prognostic factors for single large hepatocellular carcinoma (SLHCC) after surgical resection.

Methods

Patients with SLHCC who underwent radical resection from January 2013 to December 2017 were retrospectively analyzed. The Kaplan-Meier method was used to analyze the overall survival (OS) rate and recurrence-free survival (RFS) rates. Cox forward stepwise regression was performed to analyze the independent prognostic factors.

Results

A total of 485 cases were included. The average age was 51.2±11.2 years, 88.9% had a history of hepatitis B virus infection, and most patients had normal liver function. The average tumor diameter was 8.8±3.0 cm. The 1-, 3-, and 5-year OS and RFS rates were 76.8%, 56.7%, and 45.7%, and 61.0%, 46.2%, and 34.7%, respectively. Multivariate analysis showed that liver cirrhosis (HR=1.456, P=0.004), total bilirubin (TB) ≥17.1 μmol/L (HR=1.437, P=0.011), glutamyl transferase (GGT) >60 U/L (HR=1.438, P=0.020), lactate dehydrogenase (LDH) >225 U/L (HR=1.442, P=0.007), blood loss ≥400 mL (HR=1.339, P=0.027), microvascular invasion (MVI) (HR=1.492, P=0.004), satellite lesions (HR=1.859, P<0.0001) and Edmondson-Steiner grade III+IV (HR=1.740, P=0.018) were independent risk factors for reduced OS in SLHCC patients. Sex (HR=1.763, P=0.003), liver cirrhosis (HR=1.382, P=0.007), GGT >60 U/L (HR=1.512, P=0.003), LDH >225 U/L (HR=1.480, P=0.002), MVI (HR=1.545, P=0.001), and satellite lesions (HR=1.564, P=0.001) were independent risk factors for reduced RFS. OS and RFS nomograms were constructed using risk factors with C-index values of 0.692 (95% CI: 0.659-0.724) and 0.659 (95% CI: 0.623-0.693), respectively. The Hosmer-Leme test demonstrated the good fit of both nomograms.

Conclusion

Surgical resection is the standard and effective treatment for SLHCC patients. Sex, liver cirrhosis, TB≥17.1 μmol/L, GGT>60 U/L, LDH>225 U/L, blood loss≥400 mL, MVI, Edmondson-Steiner grade III+IV, and satellite lesions were found to be independent prognostic factors in SLHCC patients following radical resection. The OS and RFS nomograms accurately predicted the prognosis of SLHCC patients.

A new prognostic model predicting hepatocellular carcinoma early recurrence in patients with microvascular invasion who received postoperative adjuvant transcatheter arterial chemoembolization

BACKGROUD

In this study, we aimed to develop a prognostic model to predict HCC early recurrence (within 1-year) in patients with microvascular invasion who received postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE).

METHODS

A total of 148 HCC patients with MVI who received PA-TACE were included in this study. The modes were verified in an internal validation cohort (n = 112) and an external cohort (n = 36). Univariate and multivariate Cox regression analyses were performed to identify the independent prognostic factors relevant to early recurrence. A clinical nomogram prognostic model was established, and nomogram performance was assessed via internal validation and calibration curve statistics.

RESULTS

After data dimensionality reduction and element selection, multivariate Cox regression analysis indicated that alpha fetoprotein level, systemic inflammation response index, alanine aminotransferase, tumour diameter and portal vein tumour thrombus were independent prognostic factors of HCC early recurrence in patients with MVI who underwent PA-TACE. Nomogram with independent factors was established and achieved a better concordance index of 0.765 (95% CI: 0.691-0.839) and 0.740 (95% CI: 0.583-0.898) for predicting early recurrence in training cohort and validation cohort, respectively. Time-dependent AUC indicated comparative stability and adequate discriminative ability of the model. The DCA revealed that the nomogram could augment net benefits and exhibited a wider range of threshold probabilities than AJCC T stage.

CONCLUSIONS

The nomogram prognostic model showed adequate discriminative ability and high predictive accuracy.

Preoperative Evaluation of Gd-EOB-DTPA-Enhanced MRI Radiomics-Based Nomogram in Small Solitary Hepatocellular Carcinoma (≤3 cm) With Microvascular Invasion: A Two-Center Study

BACKGROUND

Preoperative evaluation of microvascular invasion (MVI) in small solitary hepatocellular carcinoma (HCC; maximum lesion diameter ≤ 3 cm) is important for treatment decisions.

PURPOSE

To apply gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI to develop and validate a nomogram for preoperative evaluation of MVI in small solitary HCC and to compare the effectiveness of radiomics evaluation models based on different volumes of interest (VOIs).

STUDY TYPE

Retrospective.

POPULATION

A total of 196 patients include 62 MVI-positive and 134 MVI-negative patients were enrolled (training cohort, n = 105; testing cohort, n = 45; external validation cohort, n = 46).

FIELD STRENGTH/SEQUENCE

3.0 T, fat suppressed fast-spin-echo T2-weighted and Gd-EOB-DTPA-enhanced T1-weighted magnetization-prepared rapid gradient-echo sequences.

ASSESSMENT

Radiomics features were extracted on T2-weighted, arterial phase (AP), and hepatobiliary phase (HBP) images from different VOIs (VOI_intratumor and VOI_{intratumor+peritumor} ) and filtered by the least absolute shrinkage selection operator (LASSO) regression. From VOI_intratumor and VOI_{intratumor+peritumor} , eight radiomics models were constructed based on three MRI sequences (T2-weighted, AP, and HBP) and fused sequences (combined of three sequences). Nomograms were constructed of a clinical-radiological (CR) model and a clinical-radiological-radiomics (CRR) model.

STATISTICAL TESTS

One-way analysis of variance, independent t-test, Chi-square test or Fisher's exact test, Wilcoxon rank-sum test, LASSO, logistic regression analysis, area under the curve (AUC), nomograms, decision curve, net reclassification improvement (NRI), integrated discrimination improvement (IDI) analyses, and DeLong test.

RESULTS

Among eight radiomics models, the fused sequences-based VOI_{intratumor+peritumor} radiomics model showed the best performance. The CRR model containing the best performance radiomics model and CR model with the AUC values were 0.934, 0.889, and 0.875, respectively. NRI and IDI analyses showed that the CRR model improved evaluation efficacy over the CR model for all three cohorts (all P-value <0.05).

DATA CONCLUSION

The CRR model nomogram could preoperatively evaluate MVI in small solitary HCC. The radiomics model based on VOI_{intratumor+peritumor} might achieve better evaluation results.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY STAGE: 2.

Radiomics and nomogram of magnetic resonance imaging for preoperative prediction of microvascular invasion in small hepatocellular carcinoma

BACKGROUND

Microvascular invasion (MVI) of small hepatocellular carcinoma (sHCC) (≤ 3.0 cm) is an independent prognostic factor for poor progression-free and overall survival. Radiomics can help extract imaging information associated with tumor pathophysiology.

AIM

To develop and validate radiomics scores and a nomogram of gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) for preoperative prediction of MVI in sHCC.

METHODS

In total, 415 patients were diagnosed with sHCC by postoperative pathology. A total of 221 patients were retrospectively included from our hospital. In addition, we recruited 94 and 100 participants as independent external validation sets from two other hospitals. Radiomics models of Gd-EOB-DTPA-enhanced MRI and diffusion-weighted imaging (DWI) were constructed and validated using machine learning. As presented in the radiomics nomogram, a prediction model was developed using multivariable logistic regression analysis, which included radiomics scores, radiologic features, and clinical features, such as the alpha-fetoprotein (AFP) level. The calibration, decision-making curve, and clinical usefulness of the radiomics nomogram were analyzed. The radiomic nomogram was validated using independent external cohort data. The areas under the receiver operating curve (AUC) were used to assess the predictive capability.

RESULTS

Pathological examination confirmed MVI in 64 (28.9%), 22 (23.4%), and 16 (16.0%) of the 221, 94, and 100 patients, respectively. AFP, tumor size, non-smooth tumor margin, incomplete capsule, and peritumoral hypointensity in hepatobiliary phase (HBP) images had poor diagnostic value for MVI of sHCC. Quantitative radiomic features (1409) of MRI scans) were extracted. The classifier of logistic regression (LR) was the best machine learning method, and the radiomics scores of HBP and DWI had great diagnostic efficiency for the prediction of MVI in both the testing set (hospital A) and validation set (hospital B, C). The AUC of HBP was 0.979, 0.970, and 0.803, respectively, and the AUC of DWI was 0.971, 0.816, and 0.801 (P < 0.05), respectively. Good calibration and discrimination of the radiomics and clinical combined nomogram model were exhibited in the testing and two external validation cohorts (C-index of HBP and DWI were 0.971, 0.912, 0.808, and 0.970, 0.843, 0.869, respectively). The clinical usefulness of the nomogram was further confirmed using decision curve analysis.

CONCLUSION

AFP and conventional Gd-EOB-DTPA-enhanced MRI features have poor diagnostic accuracies for MVI in patients with sHCC. Machine learning with an LR classifier yielded the best radiomics score for HBP and DWI. The radiomics nomogram developed as a noninvasive preoperative prediction method showed favorable predictive accuracy for evaluating MVI in sHCC.

Antiviral Therapy Improves Survival in Hepatocellular Carcinoma with Microvascular Invasion: A Propensity Score Analysis

BACKGROUND AND AIMS

To investigate the effect of postoperative adjuvant antiviral therapy (AVT) on hepatitis B virus (HBV) related hepatocellular carcinoma (HCC) with microvascular invasion (MVI) after R0 liver resection.

METHODS

A total of 1008 patients with HBV-related HCC with MVI were recruited, which comprises 378 non-AVT groups and 630 AVT groups. Propensity score matching (PSM) was developed to reduce any bias in patient selection. Independent risk factors were identified by Cox regression analysis.

RESULTS

After PSM, the 1-, 3-, and 5-year overall survival rates in the AVT group and non-AVT group were 89.2%, 62.4%, 42.1%, and 73.3%, 46.3%, 22.1%, (p < 0.01), respectively. The 1-, 3-, and 5-year recurrence-free survival rates in the AVT group and non-AVT group were 52.5%, 30.4%, 22.1%, and 46.3%, 26.8%, 13.2% (p = 0.02), respectively. Multivariate Cox analysis revealed that postoperative adjuvant AVT was the independent protective factor associated with mortality (HR = 0.55, 95%CI = 0.46-0.67, p < 0.01) and tumor recurrence (HR = 0.81, 95%CI = 0.69-0.96, p = 0.01).

CONCLUSIONS

Among patients who underwent curative hepatectomy for HBV-related HCC with MVI, postoperative adjuvant AVT was the independent protective factor associated with mortality and tumor recurrence. Given the high rate of postoperative recurrence and poor prognosis of HBV-related HCC with MVI, our findings may have useful clinical significance in the prevention of tumor recurrence in these patients.

Patterns, treatments, and prognosis of tumor recurrence after resection for hepatocellular carcinoma with microvascular invasion: a multicenter study from China

BACKGROUND

Microvascular invasion (MVI) is a risk factor of post-hepatectomy tumor recurrence for hepatocellular carcinoma (HCC). The patterns, treatments, and prognosis have not been documented in HCC patients with MVI.

METHODS

A multicenter database of patients with HCC and MVI following resection was analyzed. The clinicopathological and initial operative data, timing and first sites of recurrence, recurrence management, and long-term survival outcomes were analyzed.

RESULTS

Of 1517 patients included, the median follow-up was 39.7 months. Tumor recurrence occurred in 928 patients, with 49% within 6 months of hepatectomy and 60% only in the liver. The incidence of intrahepatic only recurrence gradually increased with time after 6 months. Patients who developed recurrence within 6 months of hepatectomy had worse survival outcomes than those who developed recurrence later. Patients who developed intrahepatic only recurrence had better prognosis than those with either extrahepatic only recurrence or those with intra- and extrahepatic recurrence. Repeat resection of recurrence with curative intent resulted in better outcomes than other treatment modalities.

CONCLUSION

Post-hepatectomy tumor recurrence in patients with HCC and MVI had unique characteristics and recurrence patterns. Early detection of tumor recurrence and repeat liver resection with curative intent resulted in improved long-term survival outcomes.

Radiomics models for preoperative prediction of microvascular invasion in hepatocellular carcinoma: a systematic review and meta-analysis

PURPOSE

To assess the methodological quality and to evaluate the predictive performance of radiomics studies for preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC).

METHODS

Publications between 2017 and 2021 on radiomic MVI prediction in HCC based on CT, MR, ultrasound, and PET/CT were included. The risk of bias was assessed using the prediction model risk of bias assessment tool (PROBAST). Methodological quality was assessed through the radiomics quality score (RQS). Fourteen studies classified as TRIPOD Type 2a or above were used for meta-analysis using random-effects model. Further analyses were performed to investigate the technical factors influencing the predictive performance of radiomics models.

RESULTS

Twenty-three studies including 4947 patients were included. The risk of bias was mainly related to analysis domain. The RQS reached an average of (37.7 ± 11.4)% with main methodological insufficiencies of scientific study design, external validation, and open science. The pooled areas under the receiver operating curve (AUC) were 0.85 (95% CI 0.82-0.89), 0.87 (95% CI 0.83-0.92), and 0.74 (95% CI 0.67-0.80), respectively, for CT, MR, and ultrasound radiomics models. The pooled AUC of ultrasound radiomics model was significantly lower than that of CT (p = 0.002) and MR (p < 0.001). Portal venous phase for CT and hepatobiliary phase for MR were superior to other imaging sequences for radiomic MVI prediction. Segmentation of both tumor and peritumor regions showed better performance than tumor region.

CONCLUSION

Radiomics models show promising prediction performance for predicting MVI in HCC. However, improvements in standardization of methodology are required for feasibility confirmation and clinical translation.

Enhancing the efficacy of albendazole for liver cancer treatment using mesoporous silica nanoparticles: an in vitro study

The present study aimed to synthesize albendazole (ABZ)-loaded Mobil Composition of Matter No. 41 (MCM-41 NPs) to increase the efficacy of the drug against liver cancer. ABZ was loaded into MCM-41 NPs, and after in vitro characterization, such as size, size distribution, zeta potential, morphology, chemical composition, thermal profile, drug release, surface and pore volume, and pore size, their biological effects were evaluated using 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) cell migration assays. The results demonstrated that monodispersed and spherical NPs with a size of 220 ± 11.5 and 293 ± 8.7 nm, for MCM-41 NPs and ABZ-loaded MCM-41 NPs, respectively, and drug loading efficiency of 30 % were synthesized. ABZ was loaded physically into MCM-41 NPs, leading to a decrease in surface volume, pore size, and pore volume. Also, MCM-41 NPs could increase the cytotoxicity effects of ABZ by 2.9-fold (IC₅₀ = 23 and 7.9 µM for ABZ and ABZ-loaded MCM-41 NPs, respectively). In addition, both ABZ and ABZ-loaded MCM-41 NPs could restrain the cell migration by 12 %. Overall, the results of the present study suggest evaluating the potency of MCM-41 NPs, as a potent nanoplatform, for ABZ delivery in vivo environment.

See also the Graphical Abstract(Fig. 1).

Cancer Genomic Alterations Can Be Potential Biomarkers Predicting Microvascular Invasion and Early Recurrence of Hepatocellular Carcinoma

Background

High recurrence incidence and poor survival after hepatectomy are enormous threats to hepatocellular carcinoma (HCC) patients, which can be caused by microvascular invasion (MVI). However, it is difficult to predict preoperative MVI status. In this study, we focus on cancer genomic alterations to comprehensively explore potential MVI and early recurrence biomarkers and provide clues to the mechanisms of HCC invasion and metastasis.

Methods

Forty-one patients with initially suspected HCC who were undergoing hepatectomy were finally enrolled. High-throughput targeted sequencing was performed on genomic alterations in their preoperative plasma and surgical fresh tumor tissues utilizing the 1,021-gene panel.

Results

HCC patients without MVI had longer RFS than MVI ones (p < 0.0001). The mutant incidence of genes like KEAP1, TP53, HIST1H3D, NFKBIA, PIK3CB, and WRN was higher in both MVI and early-recurrence patients than their counterparts. Besides, the alteration rates of Rap1 and Ras signaling pathways were significantly higher in MVI patients than NMVI ones (p < 0.05), and a similar trend of differences was also found in early-recurrence/non-recurrence comparison. The maximal variant allele frequency (VAF) of circulating tumor DNA (ctDNA) was statistically higher in MVI patients than NMVI ones (0.038 vs. 0.012, p = 0.0048). With the cutoff value of 0.018, ctDNA maximal VAF could potentially predict the presence of MVI with an AUC of 0.85 (95% CI 0.693–0.998, p = 0.0062).

Conclusion

The integration of a panel containing specific mutated genes and ctDNA maximal VAF for predicting MVI and early recurrence of HCC may achieve better performance.

Comparison of the Efficacy of Anatomic and Non-anatomic Hepatectomy for Hepatic Alveolar Echinococcosis: Clinical Experience of 240 Cases in a Single Center

Background

Hepatic alveolar echinococcosis (AE) is a zoonotic parasitic disease. There are more than 16,000 new cases each year, approximately 60 million people are threatened, and the annual direct economic loss is RMB 3 billion. The prevalence of AE in some areas of the Qinghai–Tibet Plateau is as high as 6.0%. Radical resection, including anatomic and non-anatomic hepatectomy, for advanced AE can significantly prolong the survival time of patients. However, there is no literature compared the efficacy of anatomic and non-anatomic hepatectomy. Therefore, by comparing various clinical evaluation indices between anatomic and non-anatomic hepatectomy, this study explored the short-term and long-term efficacy of these two surgical methods for AE.

Methods

The clinical data of patients with AE who underwent radical hepatectomy at Qinghai Provincial People's Hospital from January 2015 to January 2021 were retrospectively analyzed. The patients were divided into two groups by surgical method, that were, non-anatomic hepatectomy group and anatomic hepatectomy group. We compared these two groups focusing on basic preoperative data, such as age, sex, lesion size, and liver function parameters; main intraoperative evaluation indices, such as operation time, intraoperative porta hepatis occlusion time, intraoperative blood loss, and blood transfusion; and postoperative recovery evaluation indicators, such as postoperative liver function, incidence of surgical complications, and AE recurrence.

Results

A total of 240 patients were enrolled in this study, including 123 in anatomic hepatectomy group and 117 in non-anatomic hepatectomy group. There were no significant differences (P > 0.05) between baseline characteristics. Anatomic hepatectomy group was advantageous than non-anatomic hepatectomy group regarding intraoperative blood loss (P < 0.001), blood transfusion (P < 0.001), and porta hepatis occlusion time (P < 0.001). There were statistically significant differences in postoperative liver function (aspartate aminotransferase: P < 0.001; alanine aminotransferase: P < 0.001), surgical complications (P < 0.001), and AE recurrence rate (P = 0.003). The median survival of patients in the anatomic hepatectomy group was 66 months, compared to 65 months in the non-anatomic hepatectomy group (χ² = 4.662, P = 0.031).

Conclusions

Anatomic hepatectomy was not only safe for AE but also showed better short-term and long-term superiority than non-anatomic hepatectomy.

Liver-specific LINC01146, a promising prognostic indicator, inhibits the malignant phenotype of hepatocellular carcinoma cells both in vitro and in vivo

Background

Long non-coding RNAs (lncRNAs) are involved in the development of hepatocellular carcinoma (HCC). We aimed to investigate the function of LINC01146 in HCC.

Methods

The expression of LINC01146 in HCC tissues was explored via The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases and was verified using quantitative real-time polymerase chain reaction (qRT–PCR) in our HCC cohort. Kaplan–Meier analysis was used to assess the relationship between LINC01146 and the prognosis of HCC patients. Cell Counting Kit 8, colony formation assays, Transwell assays, flow cytometric assays, and tumour formation models in nude mice were conducted to reveal the effects of LINC01146 on HCC cells both in vitro and in vivo. Bioinformatic methods were used to explore the possible potential pathways of LINC01146 in HCC.

Results

LINC01146 was significantly decreased in HCC tissues compared with adjacent normal tissues and was found to be related to the clinical presentations of malignancy and the poor prognosis of HCC patients. Overexpression of LINC01146 inhibited the proliferation, migration, and invasion of HCC cells in vitro, while promoting their apoptosis. In contrast, downregulation of LINC01146 exerted the opposite effects on HCC cells in vitro. In addition, overexpression of LINC01146 significantly inhibited tumour growth, while downregulation of LINC01146 promoted tumour growth in vivo. Furthermore, the coexpressed genes of LINC01146 were mainly involved in the “metabolic pathway” and “complement and coagulation cascade pathway”.

Conclusion

LINC01146 expression was found to be decreased in HCC tissues and associated with the prognosis of HCC patients. It may serve as a cancer suppressor and prognostic biomarker in HCC.

Radiomic Features of Multi-ROI and Multi-Phase MRI for the Prediction of Microvascular Invasion in Solitary Hepatocellular Carcinoma

Objectives

To develop and validate an MR radiomics-based nomogram to predict the presence of MVI in patients with solitary HCC and further evaluate the performance of predictors for MVI in subgroups (HCC ≤ 3 cm and > 3 cm).

Materials and Methods

Between May 2015 and October 2020, 201 patients with solitary HCC were analysed. Radiomic features were extracted from precontrast T₁WI, arterial phase, portal venous phase, delayed phase and hepatobiliary phase images in regions of the intratumoral, peritumoral and their combining areas. The mRMR and LASSO algorithms were used to select radiomic features related to MVI. Clinicoradiological factors were selected by using backward stepwise regression with AIC. A nomogram was developed by incorporating the clinicoradiological factors and radiomics signature. In addition, the radiomic features and clinicoradiological factors related to MVI were separately evaluated in the subgroups (HCC ≤ 3 cm and > 3 cm).

Results

Histopathological examinations confirmed MVI in 111 of the 201 patients (55.22%). The radiomics signature showed a favourable discriminatory ability for MVI in the training set (AUC, 0.896) and validation set (AUC, 0.788). The nomogram incorporating peritumoral enhancement, tumour growth type and radiomics signature showed good discrimination in the training (AUC, 0.932) and validation sets (AUC, 0.917) and achieved well-fitted calibration curves. Subgroup analysis showed that tumour growth type was a predictor for MVI in the HCC ≤ 3 cm cohort and peritumoral enhancement in the HCC > 3 cm cohort; radiomic features related to MVI varied between the HCC ≤ 3 cm and HCC > 3 cm cohort. The performance of the radiomics signature improved noticeably in both the HCC ≤ 3 cm (AUC, 0.953) and HCC > 3 cm cohorts (AUC, 0.993) compared to the original training set.

Conclusions

The preoperative nomogram integrating clinicoradiological risk factors and the MR radiomics signature showed favourable predictive efficiency for predicting MVI in patients with solitary HCC. The clinicoradiological factors and radiomic features related to MVI varied between subgroups (HCC ≤ 3 cm and > 3 cm). The performance of radiomics signature for MVI prediction was improved in both the subgroups.

Association Between Adjuvant Sorafenib and the Prognosis of Patients With Hepatocellular Carcinoma at a High Risk of Recurrence After Radical Resection

Background

The use of sorafenib in the adjuvant management of hepatocellular carcinoma (HCC) is controversial.

Aim

To analyze the effects of adjuvant sorafenib therapy in patients with HCC at high recurrence risk after radical resection.

Methods

This was a retrospective study of patients who underwent radical resection (R0 resection) for HCC at the Cancer Hospital of Tianjin Medical University between August 2009 and August 2017. All patients had microvascular invasion and were evaluated for portal vein tumor thrombus. The outcomes were overall survival (OS), recurrence-free survival (RFS), and survival after recurrence. Propensity score matching (PSM) was used.

Results

Before matching, there were 56 and 167 patients in the sorafenib and non-sorafenib groups. After PSM, there were 42 patients/group, and there were no significant differences in patient characteristics (all P>0.05). After PSM, compared with the non-sorafenib group, the sorafenib group showed longer median OS (34 vs. 26 months, P=0.032) and survival after recurrence (16 vs. 9 months, P=0.002), but no difference in RFS (14 vs. 11 months, P=0.564). Adjuvant sorafenib was the only factor independently associated with OS (HR=0.619, 95% CI: 0377–0.994, P=0.047). No factors were independently associated with RFS (all P>0.05).

Conclusion

Although adjuvant sorafenib therapy for patients with HCC and high recurrence risk does not reduce the recurrence risk of HCC, it might be associated with longer survival and a lower risk of death.

Pharmacokinetic analysis of different contrast agents on multiphase enhanced MRI for microvascular invasion: preoperative prediction in hepatocellular carcinoma

BACKGROUND

The preoperative diagnosis of microvascular invasion (MVI) for the solitary small hepatocellular carcinoma (sHCC) is crucial for the decision of surgical strategies.

PURPOSE

To compare the kinetic parameters and diagnostic effects of two contrast agents for preoperatively predicting MVI of sHCC on multiphase enhanced magnetic resonance imaging (MRI).

MATERIAL AND METHODS

Two groups of patients with known solitary sHCC underwent an enhanced MRI examination before hepatic resection: Data A (n = 61) patients underwent Gd-EOB-DTPA-enhanced MRI, and Data B (n = 41) patients had a normal contrast agent. The two sets of data were processed in the same way. Arterial peritumoral enhancement measured from multiphase enhanced MRI was analyzed using quantitative kinetic parameters, including initial signal enhancement (SE₁), peak signal enhancement (SE_peak), and calculation of the signal enhancement ratio (SE_R).

RESULTS

The statistical analysis showed that the average SE₁ and SE_R (Data A) for the MVI-positive group were significantly higher (P < 0.05) than those in the MVI-negative group. The SE_R (Data B) and SE_peak showed no significant difference for either group. In Data A, the receiver operating characteristic analysis between the two groups had an area under the curve of 0.74 and 0.71 for SE₁ and SE_R, respectively, which was higher than that of Data B. The different contrast agents had the same enhancement curve trend.

CONCLUSION

Gd-EOB-DTPA-enhanced MRI had a better quantitative kinetic parameter analysis effect for arterial peritumoral enhancement on predicting MVI of sHCC in clinical practice.

Effect of surgical margin on postoperative prognosis in patients with solitary hepatocellular carcinoma: A propensity score matching analysis

Objective: The effect of surgical margin (SM) on the postoperative prognosis of patients with solitary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the effect of SM on the postoperative prognosis of patients with solitary HCC by using propensity score matching (PSM).

Methods: Patients with solitary HCC who underwent liver resection were divided into a wide margin group (1.0 cm or more, group W) and a narrow margin group (< 1.0 cm, group N). Progression-free survival (PFS) and overall survival (OS) associated with the SM status and the factors influencing postoperative prognosis were evaluated.

Results: Before PSM, the indicators were not balanced between the two groups. PFS and OS were significantly lower in group N than group W. The factors affecting postoperative prognosis were international normalized ratio (INR), AST, capsule integrity, microvascular invasion, tumour embolus and tumour size. After PSM, data of both groups were balanced and comparable, and no significant differences in OS or PFS between the two groups. The INR in the above affecting factors was excluded.

Conclusion: For solitary HCC patients with negative SMs, SM size does not affect prognosis. INR, AST, capsule integrity, microvascular invasion, tumour embolus and tumour size are independent factors influencing the postoperative prognosis of solitary HCC patients.

An excellent nomogram predicts microvascular invasion that cannot independently stratify outcomes of small hepatocellular carcinoma

Background

Whether microvascular invasion is a prognosis factor for small hepatocellular carcinoma (sHCC) is controversial, and a preoperatively predictive model based on gadoxetate disodium (Gd-EOB-DTPA) MRI is clinically needed for MVI in sHCC.

Methods

Between March 2012 and September 2020, 455 consecutive patients with pathologically confirmed HCC ≤3 cm who underwent hepatectomy and preoperative Gd-EOB-DTPA MRI were retrospectively enrolled. Univariate and multivariate logistic regression combined with cox regression were conducted to find the confounding factors in the cohorts. Propensity score matching (PSM) was employed to balance the biases between MVI and non-MVI groups. Nomogram with C-index visualized the predictive model of MVI.

Results

Multivariate logistic regression identified that 5 characteristics (AFP, tumor size, tumor margin, peritumoral enhancement, radiologic capsule) were markedly associated with MVI of sHCC and incorporated into the nomogram with excellent predictive performance in the training (AUC/C-index: 0.884/0.874, n=288), validation (AUC/C-index: 0.845/0.828, n=123) and test cohorts (AUC/C-index: 0.903/0.954, n=44). Before PSM, histologic MVI independently affected tumor recurrence (hazard ratio: 1.555, 95% CI: 1.055–2.293, P=0.026). However, due to the confounder of tumor size, there was a significant bias between MVI-positive and MVI-negative groups (propensity score: 0.249±0.105 vs. 0.179±0.106, P<0.001). Meanwhile, the frequency of MVI significantly increased as tumor size growing (P<0.001). After PSM, 70 of 79 MVI cases matched with 171 non-MVI (total 332), and no biases were observed between the two groups (propensity score: 0.238±0.104 vs. 0.217±0.109, P=0.186). Although the median recurrence time in non-MVI sHCC was still longer than that in MVI group (74.3 vs. 43.0 months, P=0.063), MVI was not an independent risk factor for RFS in sHCC. Additionally, MVI was not independently vulnerable to mortality in our population.

Conclusions

A preoperative model, mainly based on the peritumoral hallmarks of Gd-EOB-DTPA MRI, showed an excellent performance to predict the occurrence of MVI. Nevertheless, MVI was a potential but not an independent risk factor for recurrence and mortality in sHCC ≤3 cm.

Actual long-term survival in hepatocellular carcinoma patients with microvascular invasion: a multicenter study from China

BACKGROUND

Microvascular invasion (MVI) is a risk factor for postoperative survival outcomes for hepatocellular carcinoma (HCC) after liver resection (LR). This study aims to investigate the actual long-term survival and its associated prognostic factors after LR for HCC patients with MVI.

METHODS

This study was conducted on HCC patients with MVI who underwent LR from January 2009 to December 2012 at five major hospitals in China. The patients were divided into the 'long-term survivor group' and the 'short-term survivor group'. The clinicopathologic characteristics, perioperative data and survival outcomes were compared between these two groups. Univariate and multivariate regression analyses were performed to identify predictive factors associated with long-term survival outcomes.

RESULTS

The study included 1517 patients with an actual 5-year survival rate of 33.3%. Multivariate regression analysis revealed that HBV DNA > 10⁴ IU/mL, alanine aminotransferase > 44 U/L, alpha-fetoprotein > 400 ng/ml, anatomical hepatectomy, varices, intraoperative blood loss > 400 ml, tumor diameter > 5 cm, tumor number, satellite nodules, tumor encapsulation, wide resection margin and adjuvant transarterial chemoembolization (TACE) were independent prognostic factors associated with actual long-term survival.

CONCLUSIONS

One-third of HCC patients with MVI reached the long-term survival milestone of 5 years after resection. Anatomical hepatectomy, controlling intraoperative blood loss, a wide resection margin, and postoperative adjuvant TACE should be considered for patients to achieve better long-term survival outcomes.

Prediction of Patient Survival Following Hepatic Resection in Early-Stage Hepatocellular Carcinoma with Indexed Ratios of Aspartate Aminotransferase to Platelets: A Retrospective Cohort Study

Purpose

To predict patient survival in early-stage hepatocellular carcinoma (HCC) following hepatic resection. We evaluated the prognostic potential of the aspartate aminotransferase to platelet ratio index (APRI) in order to use it to model a nomogram.

Patients and Methods

We randomized 901 early-stage HCC patients treated with hepatic resection at our center into training and validation cohorts that were followed from January 2009 to December 2012. X-tile software was used to establish the APRI cut-off threshold in the training cohort. The validation cohort was subsequently assessed to determine threshold value accuracy. Data generated from the multivariate analysis in the training cohort were used to design a prognostic nomogram. Decision curve analyses (DCA), concordance index values (C-index) and calibration curves were used to determine the performance of the nomogram.

Results

X-tile software revealed that the optimal APRI cut-off threshold in the training cohort that distinguished between patients with different prognoses was 0.9. We, therefore, validated its prognostic value. Multivariate analyses showed that poor overall survival was associated with APRI above 0.9, blood loss of more than 400 mL, liver cirrhosis, multiple tumors, tumor size greater than 5 cm, microvascular invasion and satellite lesions. When the independent risk factors were integrated into the prognostic nomogram, it performed well with accurate predictions. Indeed, the performance was better than comparative prognosticators (P<0.05 for all) with 0.752 as the C-index (95% CI: 0.706–0.798). These results were verified by the validation cohort.

Conclusion

APRI was a noninvasive and accurate predictive indicator for patients with early-stage HCC. Following hepatic resection to treat early-stage HCC, individualized patient survival predictions can be aided by the nomogram based on APRI.

Narrow-Margin Hepatectomy Resulted in Higher Recurrence and Lower Overall Survival for R0 Resection Hepatocellular Carcinoma

Purpose

To evaluate the impact of resection margin on recurrence pattern and survival for hepatocellular carcinoma (HCC) with narrow margin resection, with the aim to guide postoperative treatment.

Materials and Methods

Two hundred forty HCC patients after curative hepatectomy between 2014 and 2016 were reviewed retrospectively. The cases were divided into narrow-margin (width of resection margin <1cm, n=106) and wide-margin (width of resection margin ≥1cm, n=134) groups based on the width of resection margin. Recurrence pattern, recurrence-free survival (RFS), and overall survival (OS) were compared between the above two groups. An additional cohort of nine cases with positive margin plus post-operative stereotactic body radiotherapy (SBRT) was also analyzed for the recurrence pattern.

Results

Postoperative recurrence was found in 128 (53.3%) patients. The recurrence rate was significantly higher in narrow-margin group than that in wide-margin group (P=0.001), especially for the pattern of marginal recurrence (20.8 vs. 4.5%, P=0.003). The 1-, 2-, 3-year RFS rates for the narrow-margin and wide-margin groups were 55.8, 43.9, 36.9, and 78.7, 67.9, 60.2%, respectively, with significant difference between the two groups (P<0.001). Patients with narrow margin showed a tendency of decreased OS than those with wide margin (P<0.001). As comparison, the nine cases with positive margin treated with postoperative SBRT showed low recurrence rate and no marginal recurrence was found.

Conclusion

Patients with narrow resection margin were associated with higher recurrence rate and worse survival than those with wide resection margin. These patients may benefit from adjuvant local treatment, such as radiotherapy.

Integration of pre-surgical blood test results predict microvascular invasion risk in hepatocellular carcinoma

Microvascular invasion (MVI) is one of the most important factors leading to poor prognosis for hepatocellular carcinoma (HCC) patients, and detection of MVI prior to surgical operation could great benefit patient's prognosis and survival. Since it is still lacking effective non-invasive strategy for MVI detection before surgery, novel MVI determination approaches were in urgent need. In this study, complete blood count, blood test and AFP test results are utilized to perform preoperative prediction of MVI based on a novel interpretable deep learning method to quantify the risk of MVI. The proposed method termed as "Interpretation based Risk Prediction" can estimate the MVI risk precisely and achieve better performance compared with the state-of-art MVI risk estimation methods with concordance indexes of 0.9341 and 0.9052 on the training cohort and the independent validation cohort, respectively. Moreover, further analyses of the model outputs demonstrate that the quantified risk of MVI from our model could serve as an independent preoperative risk factor for both recurrence-free survival and overall survival of HCC patients. Thus, our model showed great potential in quantification of MVI risk and prediction of prognosis for HCC patients.

A standardized pathological proposal for evaluating microvascular invasion of hepatocellular carcinoma: a multicenter study by LCPGC

BACKGROUND AND AIMS

Microvascular invasion (MVI) is a key pathological factor that severely affects the postoperative prognosis of patients with hepatocellular carcinoma (HCC). However, no MVI classification schemes based on standardized gross sampling protocols of HCC are available at present.

METHODS

119 HCC specimens were sampled at multiple sites (3-, 7-, and 13 points) for the optimum MVI detection rate. 16,144 resected HCCs were graded as M0, M1 or M2 by adopting three-tiered MVI grading (MVI-TTG) scheme based on the seven-point sampling protocol (SPSP). Survival analyses were performed on 2573 patients to explore the advantages of MVI-TTG.

RESULTS

The MVI detection rate determined by SPSP was significantly higher than that determined by the 3-point sampling method (34.5% vs. 47.1%, p = 0.048), but was similar to that determined by the 13-point sampling method (47.1% vs. 51.3%, p = 0.517). Among 16,144 resected HCCs, the proportions of M0, M1 and M2 specimens according to SPSP were 53.4%, 26.2% and 20.4%, respectively. Postoperative survival analysis in 2573 HCC patients showed that the 3-year recurrence rates in M0, M1 and M2 MVI groups were 62.5%, 71.6% and 86.1%, respectively (p < 0.001), and the corresponding 3-year overall survival (OS) rates were 94.1%, 87.5% and 67.0%, respectively (p < 0.001). M1 grade was associated with early recurrence, while M2 grade was associated with both early and late recurrence. MVI-TTG had a larger area under the curve and net benefit rate than the two-tiered MVI grading scheme for predicting time to recurrence and OS.

CONCLUSIONS

SPSP is a practical method to balance the efficacy of sampling numbers and MVI detection rates. MVI-TTG based on SPSP is a better prognostic predictor than the two-tiered MVI scheme. The combined use of SPSP and MVI-TTG is recommended for the routine pathological diagnosis of HCC.

Radiomic Feature-Based Predictive Model for Microvascular Invasion in Patients With Hepatocellular Carcinoma

Objective

This study aimed to build and evaluate a radiomics feature-based model for the preoperative prediction of microvascular invasion (MVI) in patients with hepatocellular carcinoma.

Methods

A total of 145 patients were retrospectively included in the study pool, and the patients were divided randomly into two independent cohorts with a ratio of 7:3 (training cohort: n = 101, validation cohort: n = 44). For a pilot study of this predictive model another 18 patients were recruited into this study. A total of 1,231 computed tomography (CT) image features of the liver parenchyma without tumors were extracted from portal-phase CT images. A least absolute shrinkage and selection operator (LASSO) logistic regression was applied to build a radiomics score (Rad-score) model. Afterwards, a nomogram, including Rad-score as well as other clinicopathological risk factors, was established with a multivariate logistic regression model. The discrimination efficacy, calibration efficacy, and clinical utility value of the nomogram were evaluated.

Results

The Rad-score scoring model could predict MVI with the area under the curve (AUC) of 0.637 (95% CI, 0.516–0.758) in the training cohort as well as of 0.583 (95% CI, 0.395–0.770) in the validation cohort; however, the aforementioned discriminative approach could not completely outperform those existing predictors (alpha fetoprotein, neutrophilic granulocyte, and preoperative hemoglobin). The individual predictive nomogram which included the Rad-score, alpha fetoprotein, neutrophilic granulocyte, and preoperative hemoglobin showed a better discrimination efficacy with AUC of 0.865 (95% CI, 0.786–0.944), which was higher than the conventional methods’ AUCs (nomogram vs Rad-score, alpha fetoprotein, neutrophilic granulocyte, and preoperative hemoglobin at P < 0.001, P = 0.025, P < 0.001, and P = 0.001, respectively). When applied to the validation cohort, the nomogram discrimination efficacy was still outbalanced those above mentioned three remaining methods (AUC: 0.705; 95% CI, 0.537–0.874). The calibration curves of this proposed method showed a satisfying consistency in both cohorts. A prospective pilot analysis showed that the nomogram could predict MVI with an AUC of 0.844 (95% CI, 0.628–1.000).

Conclusions

The radiomics feature-based predictive model improved the preoperative prediction of MVI in HCC patients significantly. It could be a potentially valuable clinical utility.

Preoperative circulating tumor cells to predict microvascular invasion and dynamical detection indicate the prognosis of hepatocellular carcinoma

Background

This study explored the diagnostic power of preoperative circulating tumor cells (CTCs) for the presence of microvascular invasion (MVI) and the relationship between dynamic changes in postoperative CTCs and prognosis.

Methods

A total of 137 patients were recruited for the study. Preoperative blood samples were collected from all patients to detect CTCs. The time points for blood collection were before the operation, during the operation, and at 1 week, 1 month, 2 months, 3 months, 6 months, and 1 year after surgery. The predictive power of CTC count for the presence of MVI was analyzed by receiver operating characteristic (ROC) curve analysis. According to recurrence status, 137 patients were divided into three groups: no recurrence, early recurrence, and non-early recurrence groups.

Results

A threshold CTC count of 5 showed the most significant power for predicting the existence of MVI. In multivariate analysis, the parameters of preoperative CTC count, alpha-fetoprotein (AFP) and tumor diameter were independent predictors of MVI (P <  0.05). A CTC count greater than or equal to 5 had better predictive value than AFP > 400 μg/L and tumor diameter > 5 cm. The number of intraoperative CTCs in the three groups did not increase compared to that before surgery (P > 0.05). The number of CTCs in the nonrecurrence group and the non-early recurrence group decreased significantly 1 week after surgery compared with the intraoperative values (P <  0.001), although there was no significant difference in the early recurrence group (P = 0.95). Patients with mean CTC count ≥5 had significantly worse long-term outcomes than those with mean CTC count < 5 (P <  0.001).

Conclusion

The preoperative CTC counts in the peripheral blood of patients with HCC are closely correlated with MVI. The intraoperative manipulation of the lesion by the surgeon does not increase the number of CTCs in peripheral blood. Surgical removal of the tumor decreases the number of CTCs. The persistence of CTCs at a high level (≥ 5) after surgery suggests a risk of early recurrence.

Clinical trial registration

Registration number is ChiCTR-OOC-16010183, date of registration is 2016-12-18.

Computational quantitative measures of Gd-EOB-DTPA enhanced MRI hepatobiliary phase images can predict microvascular invasion of small HCC

PURPOSE

This study was designed to preoperatively predict microvascular invasion (MVI) of solitary small hepatocellular carcinoma (sHCC) by quantitative analysis of Gd-EOB-DTPA enhanced hepatobiliary phase (HBP) magnetic resonance imaging (MRI).

METHOD

Sixty-one patients, 19 with and 42 without histologically confirmed MVI following hepatic resection for solitary sHCC (≤ 3 cm), were preoperatively examined with Gd-EOB-DTPA-enhanced MRI. The regions of interest (ROIs) of the hepatic lesions were manually delineated on the maximum cross-sectional area in the HBP images and used to calculate the lesion boundary index (LBI) and marginal gray changes (MGC). Histogram analysis was performed to measure standard deviations (STD) and coefficients of variation (CV). Correlations between quantitative parameters and MVI were evaluated and differences between MVI positive and negative groups were assessed.

RESULTS

The average LBI (0.85 ± 0.07) and MGC (0.48 ± 0.27) values of the negative group were significantly higher (p < 0.05) than the corresponding LBI (0.72 ± 0.07) and MGC (0.28 ± 0.18) values of the positive group. STDs and CVs in the negative group were significantly smaller (p < 0.05) than those of the positive group. Receiver operating characteristic (ROC) analysis revealed that LBI had the best predictive value with an AUC, sensitivity, and specificity of 0.91, 87 %, and 80 %, respectively.

CONCLUSIONS

Quantitative analysis of HBP images is useful for predicting MVI and beneficial to clinicians in making decisions before treatment.

Preoperative Prediction for Early Recurrence Can Be as Accurate as Postoperative Assessment in Single Hepatocellular Carcinoma Patients

Objective

To evaluate the performance of predicting early recurrence using preoperative factors only in comparison with using both pre-/postoperative factors.

Materials and Methods

We retrospectively reviewed 549 patients who had undergone curative resection for single hepatcellular carcinoma (HCC) within Milan criteria. Multivariable analysis was performed to identify pre-/postoperative high-risk factors of early recurrence after hepatic resection for HCC. Two prediction models for early HCC recurrence determined by stepwise variable selection methods based on Akaike information criterion were built, either based on preoperative factors alone or both pre-/postoperative factors. Area under the curve (AUC) for each receiver operating characteristic curve of the two models was calculated, and the two curves were compared for non-inferiority testing. The predictive models of early HCC recurrence were internally validated by bootstrap resampling method.

Results

Multivariable analysis on preoperative factors alone identified aspartate aminotransferase/platelet ratio index (OR, 1.632; 95% CI, 1.056–2.522; p = 0.027), tumor size (OR, 1.025; 95% CI, 0.002–1.049; p = 0.031), arterial rim enhancement of the tumor (OR, 2.350; 95% CI, 1.297–4.260; p = 0.005), and presence of nonhypervascular hepatobiliary hypointense nodules (OR, 1.983; 95% CI, 1.049–3.750; p = 0.035) on gadoxetic acid-enhanced magnetic resonance imaging as significant factors. After adding postoperative histopathologic factors, presence of microvascular invasion (OR, 1.868; 95% CI, 1.155–3.022; p = 0.011) became an additional significant factor, while tumor size became insignificant (p = 0.119). Comparison of the AUCs of the two models showed that the prediction model built on preoperative factors alone was not inferior to that including both pre-/postoperative factors {AUC for preoperative factors only, 0.673 (95% confidence interval [CI], 0.623–0.723) vs. AUC after adding postoperative factors, 0.691 (95% CI, 0.639–0.744); p = 0.0013}. Bootstrap resampling method showed that both the models were valid.

Conclusion

Risk stratification solely based on preoperative imaging and laboratory factors was not inferior to that based on postoperative histopathologic risk factors in predicting early recurrence after curative resection in within Milan criteria single HCC patients.

Sorafenib in the treatment of patients with hepatocellular carcinoma (HCC) and microvascular infiltration: a systematic review and meta-analysis

OBJECTIVE

Microvascular invasion is shown to be an independent risk factor for liver cancer recurrence. Timely treatment may reduce the recurrence rate and prolong total survival time. The aim of this study was to investigate the effectiveness of sorafenib in treating patients with hepatocellular carcinoma (HCC) and microvascular invasion.

METHODS

A comprehensive literature search was conducted in PubMed, EMBASE, MEDLINE, web of science and Cochrane Library databases for articles published up to December 2019. Two researchers independently reviewed and cross-checked independent reports with sufficient information. A meta-analysis was conducted to assess the impact of sorafenib on mortality in patients with HCC and microvascular involvement.

RESULTS

Four studies were included in the qualitative and quantitative analyses, comprising 955 cancer events and 505 cancer deaths. Meta-analyses showed that sorafenib treatment was associated with an improved survival rate versus no sorafenib treatment in patients with HCC and microvascular invasion (relative risk 1.369, 95% confidence interval 1.193, 1.570).

CONCLUSIONS

Sorafenib treatment may improve survival in patients with HCC and microvascular invasion. However, due to the potential for residual confounding, the results should be interpreted with caution.