Clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma: a study of a prospective cohort

Novel postoperative nomograms for predicting individual prognoses of hepatitis B-related hepatocellular carcinoma with cirrhosis

Background

Liver cirrhosis is a well-known risk factor for carcinogenesis of hepatocellular carcinoma (HCC). The aim of the present study was to construct individual prognostic models for HCC with cirrhosis.

Methods

The clinical differences between HCC patients with and without cirrhosis were compared using a large cohort of 1003 cases. The patients with cirrhosis were randomly divided into a training cohort and a validation cohort in a ratio of 2:1. Univariate and multivariate analyses were performed to reveal the independent risk factors for recurrence-free survival (RFS) and overall survival (OS) in HCC patients with cirrhosis. These factors were subsequently used to construct nomograms.

Results

Multivariate analyses revealed that five clinical variables (hepatitis B e antigen (HBeAg) positivity, alpha-fetoprotein (AFP) level, tumour diameter, microvascular invasion (MVI), and satellite lesions) and seven variables (HBeAg positivity, AFP level, tumour diameter, MVI, satellite lesions, gamma-glutamyl transpeptidase level, and histological differentiation) were significantly associated with RFS and OS, respectively. The C-indices of the nomograms for RFS and OS were 0.739 (P < 0.001) and 0.789 (P < 0.001), respectively, in the training cohort, and 0.752 (P < 0.001) and 0.813 (P < 0.001), respectively, in the validation cohort. The C-indices of the nomograms were significantly higher than those of conventional staging systems (P < 0.001). The calibration plots showed optimal consistence between the nomogram-predicted and observed prognoses.

Conclusions

The nomograms developed in the present study showed good performance in predicting the prognoses of HCC patients with hepatitis B virus-associated cirrhosis.

How important is the role of iterative liver direct surgery in patients with hepatocellular carcinoma for a transplant center located in an area with a low rate of deceased donation?

Introduction

Hepatocellular carcinoma (HCC) accounts for nearly 90% of primary liver cancers, with estimates of over 1 million people affected by 2025. We aimed to explore the impacting role of an iterative surgical treatment approach in a cohort of HCC patients within the Milan criteria, associated with clinical risk factors for tumor recurrence (RHCC) after liver transplant (LT) and loco-regional therapies (LRT), as well as liver resection (LR) and/or microwave thermal ablation (MWTA).

Methods

We retrospectively analyzed our experience performed during an 8-year period between January 2013 and December 2021 in patients treated for HCC, focusing on describing the impact on preoperative end-stage liver disease severity, oncologic staging, tumor characteristics, and surgical treatments. The Cox model was used to evaluate variables that could predict relapse risks. Relapse risk curves were calculated according to the Kaplan–Meier method, and the log-rank test was used to compare them.

Results

There were 557 HCC patients treated with a first-line approach of LR and/or LRTs (n = 335) or LT (n = 222). The median age at initial transplantation was 59 versus 68 for those whose first surgical approach was LR and/or LRT. In univariate analysis with the Cox model, nodule size was the single predictor of recurrence of HCC in the posttreatment setting (HR: 1.61, 95% CI: 1.05–2.47, p = 0.030). For the LRT group, we have enlightened the following clinical characteristics as significantly associated with RHCC: hepatitis B virus infection (which has a protective role with HR: 0.34, 95% CI: 0.13–0.94, p = 0.038), number of HCC nodules (HR: 1.54, 95% CI: 1.22–1.94, p &lt; 0.001), size of the largest nodule (HR: 1.06, 95% CI: 1.01–1.12, p = 0.023), serum bilirubin (HR: 1.57, 95% CI: 1.03–2.40, p = 0.038), and international normalized ratio (HR: 16.40, 95% CI: 2.30–118.0, p = 0.006). Among the overall 111 patients with RHCC in the LRT group, 33 were iteratively treated with further curative treatment (12 were treated with LR, two with MWTA, three with a combined LR-MWTA treatment, and 16 underwent LT). Only one of 18 recurrent patients previously treated with LT underwent LR. For these RHCC patients, multivariable analysis showed the protective roles of LT for primary RHCC after IDLS (HR: 0.06, 95% CI: 0.01–0.36, p = 0.002), of the time relapsed between the first and second IDLS treatments (HR: 0.97, 95% CI: 0.94–0.99, p = 0.044), and the impact of previous minimally invasive treatment (HR: 0.28, 95% CI: 0.08–1.00, p = 0.051).

Conclusion

The coexistence of RHCC with underlying cirrhosis increases the complexity of assessing the net health benefit of ILDS before LT. Minimally invasive surgical therapies and time to HCC relapse should be considered an outcome in randomized clinical trials because they have a relevant impact on tumor-free survival.

A nomogram for predicting the risk of postoperative recurrence of hepatitis B virus-related hepatocellular carcinoma in patients with high preoperative serum glutamyl transpeptidase

BACKGROUND

Recurrence is a major risk factor affecting the postoperative survival of patients with hepatocellular carcinoma (HCC), especially those with high preoperative serum γ-glutamyl transpeptidase (GGT) levels. This study had the aim of developing a personalized predictive tool to accurately determine the risk of postoperative recurrence of hepatitis B-virus (HBV)-related HCC in patients with high preoperative serum GGT levels.

METHODS

Patients who underwent curative liver resection of HBV-related HCC and had high preoperative GGT levels were consecutively enrolled between 2008 and 2011. Prognostic indicators for recurrence were determined using Cox regression analysis. A nomogram was then developed and assessed by integrating the independent risk factors into the model.

RESULTS

A total of 603 eligible patients were included. The final nomogram for predicting HCC recurrence in patients with high preoperative GGT levels consisted of five independent prognostic factors: α-fetoprotein (AFP), HBV-DNA, satellite nodules, microvascular invasion, and tumor grade. The C-index of the nomogram for predicting recurrence was 0.759, and validation showed high accuracy and discriminatory.

CONCLUSIONS

The predictive nomogram developed and validated in this study performs well in predicting postoperative recurrence of HBV-related HCC in patients with high preoperative GGT levels. It can provide personalized assessments to inform the development of surveillance strategies and allows patients with a high risk of recurrence to be selected for further adjuvant treatment.

Critical appraisal of TNM versus HKU staging system for postoperative prognostic evaluation of hepatocellular carcinoma

Background

The 8^th edition of the American Joint Committee on Cancer tumor-node-metastasis staging system (AJCC 8^th) has been launched with modifications in T staging. The University of Hong Kong liver cancer staging system (HKUSS) has been proven to better categorize hepatocellular carcinoma (HCC) into different T stages. This study aimed to compare the two systems’ predictive ability for HCC recurrence after primary surgical resection.

Methods

Patients who had primary, curative resection for HCC between 1989 and 2017 were reviewed. The Kaplan-Meier plot was used to estimate disease-free survival (DFS), and the log-rank test was used for survival comparison between subgroups. The two systems’ prediction of recurrence was evaluated by the Cox regression model.

Results

Totally 1,815 patients were included. With AJCC 8^th, the 5-year DFS was 58.9% for T1a, 52.3% for T1b, 30% for T2, 16.9% for T3, and 14.4% for T4. No survival difference was demonstrated between T1a and T1b (P=0.668) or between T3 and T4 (P=0.562). With HKUSS, the 5-year DFS was 57.7% for T1, 43.4% for T2, 28.9% for T3, and 15.7% for T4. The T staging in HKUSS showed significant survival differences (T1 vs. T2, T2 vs. T3, and T3 vs. T4; P<0.001). Using receiver operating characteristic curves to show the recurrence status in the two systems, HKUSS had the largest area under curve (AUC) (HKUSS: AUC =0.655, SE 0.014, P<0.001, 95% CI, 0.628–0.681; AJCC 8^th: AUC =0.652, SE 0.013, P<0.001, 95% CI, 0.625–0.677).

Conclusions

HKUSS showed better categorization of HCC. In the context of primary surgical resection, HKUSS may be more appropriate for stratification of patients with HCC with various T stages, and thus the choice of staging system when primary surgical resection is considered for patients of HCC.

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.

Survival comparison between radiofrequency ablation and surgical resection for patients with small hepatocellular carcinoma: A systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate and compare the long-term therapeutic efficacy of radiofrequency ablation (RFA) versus that of surgical resection in small hepatocellular carcinoma (HCC).

METHODS

Relevant articles in English from PubMed, EMBASE, and the Cochrane Library were retrieved. Pooled hazard ratios (HRs) were calculated to assess the prognostic value of RFA compared with that of surgical resection.

RESULTS

A total of 19 studies involving 15,071 patients were included. The combined HRs (95% confidence interval [CI]) of RFA for recurrence/relapse-free survival (RFS) and overall survival (OS) were 1.55 (95% CI = 1.29-1.86, I2 = 72.5%) and 1.61 (95% CI = 1.29-2.01, I2 = 60.4%), respectively, compared with surgical resection. In subgroup analyses according to study design, both RFS and OS of the prospective subgroups showed statistical significance, and no statistical heterogeneity existed between studies.

CONCLUSION

Our clinical data suggest that surgical resection offers better long-term oncologic outcomes than RFA.

Impact of patient age on outcome after resection for hepatocellular carcinoma

There is little information on the impact of aging on liver resection of hepatocellular carcinoma (HCC). The aim of study was to evaluate the prognostic impact of the patient's age on the long-term survival after resection of HCC. The postoperative outcomes of the 291 elderly (≥ 70 years) and 340 younger (< 70 years) patients underwent curative liver resection for HCC were analyzed using multivariate and propensity-score matching. Risk score were calculated from the results of Cox regression analysis. The overall survival rate was significantly lower in the elderly group than that in the younger group (p = 0.01). Factors related to overall survival were vascular invasion (absent vs. present, HR 2.25; 95% CI 1.52-3.33, p = 0.0001), albumin level (< 3.0 vs. ≥ 3.0 g/dl, HR 2.23; 95% CI 1.31-3.79, p = 0.003), and number of tumors (solitary vs. multiple, HR 1.68; 95% CI 1.24-2.27, p = 0.001). The results of risk-score analysis with a Cox proportional-hazards model indicated that the proportion of poor-risk patients was significantly higher in the elderly than in the younger group. Propensity-score matching analysis yielded 234 pairs of patients. There were no significant differences in baseline profiles or risk scores between the two groups (p = 0.43). There were also no significant differences in the overall survival between the two groups (p = 0.23). Advanced age does not have a significant impact on the outcomes of patients after resection of HCC.

The prognostic value of aspartate aminotransferase-to-lymphocyte ratio index in early-stage hepatocellular carcinoma after hepatectomy: A propensity-score matched analysis

BACKGROUND

An elevated preoperative aspartate aminotransferase-to-lymphocyte ratio index (ALRI) may predict poor survival in various cancers. However, the prognostic value of aminotransferase-to-lymphocyte ratio index (ALRI) in patients with hepatocellular carcinoma (HCC) remains to be determined.

MATERIALS AND METHODS

A retrospective cohort study was conducted among 983 patients with HCC in our hospital from February 2007 to March 2016. A propensity-score matching (PSM) was performed to correct the selection bias and confounding factors. The risk of death and recurrence was plotted over aminotransferase-to-lymphocyte ratio index (ALRI) using the locally weighted scatterplot smoothing (LOWESS)-smoothed fit curve. Time-dependent receiver operating characteristic (ROC) and Kaplan-Meier method analysis was utilized to the role of aminotransferase-to-lymphocyte ratio index (ALRI) in HCC. Multivariate analysis was conducted to identify independent prognostic factors associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

With the increase of aminotransferase-to-lymphocyte ratio index (ALRI), the risk of recurrence and death in HCC patients increases. In time-dependent ROC analysis, the AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year OS were 0.668 (95% CI: 0.596-0.740), 0.605 (95% CI: 0.560-0.649) and 0.613 (95% CI: 0.570-0.656), respective. The AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year RFS were 0.598 (95% CI: 0.555-0.641), 0.590 (95% CI: 0.552-0.628) and 0.604 (95% CI: 0.562-0.646), respectively. HCC patients with high aminotransferase-to-lymphocyte ratio index (ALRI) had a poor overall survival. Moreover, cox regression analysis revealed that aminotransferase-to-lymphocyte ratio index (ALRI) was an independent factor affecting the prognosis of HCC patients.

CONCLUSIONS

Elevated preoperative aminotransferase-to-lymphocyte ratio index (ALRI) is a noninvasive, simple, and effective predictor in the prognosis of patients with HCC.

Characteristics of atypical large well-differentiated hepatocellular carcinoma: a specific subtype of hepatocellular carcinoma?

BACKGROUND

Hepatocellular carcinoma (HCC) de-differentiation is thought to correlate with size, therefore well-differentiated HCC ≥3 cm are considered rare and not fully understood.

METHODS

Patients who underwent hepatectomy for HCC between 1998-2016 were retrospectively analyzed. Patient's characteristics and recurrence-free (RFS) and overall (OS) survival were compared between those with atypical- (well-differentiated-HCC ≥3 cm) and typical-HCC (moderate-to-poorly-differentiated HCC ≥3 cm).

RESULTS

Of 176 patients included in this study, 37 (21%) had atypical-HCC. Patients with atypical-HCC were less likely to be Asian ethnicity (3% vs. 17%, p = 0.062), have lower rate of viral infection (14% vs. 43%, p = 0.003), cirrhosis (8% vs. 27%, p = 0.015). The tumors were less likely to demonstrate vascular invasion (30% vs. 59%, p = 0.002), and were associated with a lower alpha-fetoprotein level (3.5 ng/ml vs. 33.2 ng/ml, p < 0.001). Patients with atypical-HCC had a longer RFS (5-y RFS: 58.3% vs. 35.7%, p = 0.016) and OS (5-y OS: 79.1% vs 53.3%, p = 0.029) as compared to those with typical-HCC following univariate analysis, however this did not appear following multivariate analysis.

CONCLUSION

Patients with atypical-HCC have different characteristic in terms of epidemiology, etiology, cirrhosis and vascular invasion as compared to typical-HCC. The etiology of atypical-HCC may be non-alcoholic fatty liver disease-related and/or malignant transformation of hepatocellular adenoma.

Long-term prognostic factors of patients with hepatocellular carcinoma who survive over 10 years after hepatectomy

BACKGROUND AND OBJECTIVES

The aim was to evaluate long-term prognostic factors in hepatocellular carcinoma (HCC) patients who survived over 10 years after hepatectomy and compare prognostic factors between patients with recurrence who died and survived 10 years after initial hepatectomy.

METHODS

We analyzed the HCC patients without recurrence over 10 years after hepatectomy (n = 35), those with recurrence who survived over 10 years (n = 48), and those who died within 10 years (n = 132).

RESULTS

The rate of recurrence was 16.3%, 10-year overall survival rate was 38.6%, and the 10-year recurrence-free survival (RFS) rate was 16.7%. Nonviral, solitary tumor, well differentiation, and without severe fibrosis were independent favorable factors for long-term RFS. High cholinesterase levels, small tumors and without portal vein invasion were independent favorable factors for long-term survival among patients with recurrence. Long-term survivors with recurrence showed significantly low early recurrence, extrahepatic recurrence, multiple intrahepatic recurrences.

CONCLUSION

Important factors for long-term prognoses in HCC patients were a solitary tumor, small tumors, and no advanced fibrosis. A treatment for nonviral hepatitis is needed to achieve long-term RFS. Even patients who relapse might survive long term if they have a late or solitary intrahepatic recurrence, nonsevere cirrhosis, and curative treatment at recurrence.

Usefulness of plasma full-length glypican-3 as a predictive marker of hepatocellular carcinoma recurrence after radial surgery

Predicting the risk of hepatocellular carcinoma (HCC) recurrence before treatment is necessary for developing subsequent treatment policies. Several tumor markers found in blood, such as alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II), are presently used to determine the occurrence and recurrence of HCC and to predict patient prognosis. However, these markers are insufficient for these purposes as certain patients have HCC recurrence despite exhibiting negative AFP and PIVKA-II. The present study identified glypican-3 (GPC3), an embryonal carcinoma antigen that is expressed specifically in HCC and is secreted into blood. Although the N-terminal domain of GPC3 in sera may be a potential prognostic factor for HCC, its biological role remains unclear. By contrast, full-length GPC3 (FL-GPC3) is reported to serve important roles in cell differentiation, proliferation and signaling events that cause HCC. Given the biological roles of FL-GPC3 in HCC progression, the present study evaluated its potential as a predictive marker of HCC recurrence. In the present study, a novel measurement system was constructed to specifically measure plasma FL-GPC3. Subsequently, its ability to predict recurrence after radical surgery in 39 HCC patients was evaluated. The results revealed that preoperative FL-GPC3 levels in patients with recurrence were significantly higher than those in patients without recurrence, suggesting that FL-GPC3 could be a better predictive maker of risk of recurrence than AFP or PIVKA-II. Furthermore, it was determined that the combination of FL-GPC3, AFP and PIVKA-II could predict recurrence within one year of radical surgery with high sensitivity and specificity. Based on these results, the validation of FL-GPC3 as a predictive marker of HCC recurrence in a larger population is warranted.

Postoperative albumin-bilirubin grade and albumin-bilirubin change predict the outcomes of hepatocellular carcinoma after hepatectomy

Background

The albumin-bilirubin (ALBI) grade is an index that could objectively evaluate liver function. The purpose of this study was to evaluate the prognostic value of postoperative ALBI (post-ALBI) grade and ALBI changes (△ALBI) after hepatectomy in patients with hepatocellular carcinoma (HCC).

Methods

The clinical and pathological data of 300 patients with HCC who underwent hepatectomy in the Third Affiliated Hospital of Sun Yat-Sen University from January 19, 2009 to December 25, 2014, were analyzed retrospectively. According to the test data, the patients were divided into post-ALBI grade I, post-ALBI grade II, and post-ALBI grade III groups. According to the receiver operating characteristic curves (ROC), the patients were divided into △ALBI (△ALBI >0.71) high and low groups (△ALBI ≤0.71). Baseline clinical data, recurrence-free survival (RFS) and overall survival (OS) rates were compared between the groups.

Results

The 1-, 3-, and 5-year RFS rates and OS rates of patients with post-ALBI grade III were significantly reduced in comparison to those with post-ALBI grade II (P<0.001 both). Between the △ALBI groups, patients with low △ALBI level had significantly reduced 1-, 3-, and 5-year RFS rates and OS rates compared to those with a high △ALBI level (P<0.001 both). Multivariate analyses indicated that higher post-ABLI grade and △ALBI level were significantly independent predictors of an inferior OS and RFS (P<0.05).

Conclusions

This study confirmed for the first time that post-ALBI grade and △ALBI could predict the prognosis of patients with HCC after hepatectomy.

Utility and Limitation of Preoperative Neutrophil Lymphocyte Ratio as a Prognostic Factor in Hepatocellular Carcinoma

Background

The neutrophil lymphocyte ratio (NLR) has been proposed to be a surrogate marker of inflammation and immunological status and to have prognostic value in various malignancies. This study was conducted to clarify the prognostic significance of preoperative NLR in hepatocellular carcinoma (HCC).

Methods

We enrolled 135 patients with histologically-proven HCC who underwent initial curative hepatectomy. Based on the median NLR values, patients were divided into: NLR ≥ 2.0 (NLR-high, n = 69) and NLR < 2.0 (NLR-low, n = 66).

Results

In univariate analysis, the 5-year overall survival (OS) rates were 59.8 % ± 6.7% and 75.6% ± 6.5% (P = 0.028) in the NLR-high and NLR-low groups, respectively. Furthermore, the 5-year disease specific survival rates were 68.6% ± 6.7%, and 81.2 ± 6.4% (P = 0.048) in the NLR-high and NLR-low groups, respectively.

Conclusion

Our results showed that high NLR was an independent predictor for OS in hepatectomy-treated HCC, suggesting that NLR may be a novel prognostic biomarker for HCC. On the other hand, NLR also has a limitation to predict postoperative prognosis of HCC patients by itself.

Long-Term Prognostic Factors after Hepatic Resection for Hepatitis C Virus-Related Hepatocellular Carcinoma, with a Special Reference to Viral Status

BACKGROUND

Although studies have reported on long-term (10-year) survival after hepatic resection for hepatocellular carcinoma (HCC), they did not focus on patients with hepatitis C virus (HCV)-related HCC, and the contribution of antiviral therapy to long-term survival (especially ≥15 years) has not been adequately examined. We investigated the long-term outcome after hepatic resection for HCV-related HCC, including the effects of interferon (IFN) therapy, and the changes in prognostic factors according to postoperative duration.

METHODS

The data of 207 patients who underwent hepatic resection for HCV-related HCC between January 1992 and December 2001 were retrospectively reviewed. We investigated the disease-free and overall survival rates after surgery and analyzed the prognostic factors at 5, 10, and 15 years postoperatively.

RESULTS

The proportion of patients who survived at 5, 10, and 15 years after hepatic resection was 52% (n = 107), 18% (n = 38), and 9% (n = 19). The overall survival rate was significantly higher in patients who achieved sustained virological response (SVR) with IFN therapy than in those without SVR. Tumor-related factors such as multiple tumor, microscopic vascular invasion, and a high indocyanine green retention rate at 15 min (ICGR15) were unfavorable prognostic factors for 5-year survival. Conversely, a low ICGR15 and SVR were favorable prognostic factors at 10 years, and SVR alone was a favorable prognostic factor at 15 years postoperatively; no tumor-related factors were prognostic factors at 10 and 15 years postoperatively.

CONCLUSION

The prognostic factors varied according to the duration after hepatic resection for HCV-related HCC. Tumor-related factors were unfavorable prognostic factors in the early postoperative period, whereas SVR and good liver function were favorable prognostic factors at 10 and 15 years postoperatively. Achievement of SVR with IFN therapy is essential for long-term (≥15 years) survival after hepatic resection for HCV-related HCC.

Usefulness of aspartate aminotransferase to platelet ratio index as a prognostic factor following hepatic resection for hepatocellular carcinoma

Liver function is a major prognostic factor following hepatic resection for hepatocellular carcinoma (HCC), which is well correlated with the degree of fibrosis. On the other hand, the presence of liver cirrhosis itself leads to a higher incidence of HCC than chronic hepatitis. Therefore, preoperative noninvasive markers of fibrosis are important for the assessment of prognosis for treatment of HCC. The present study aimed to analyze whether aspartate aminotransferase to platelet ratio index (APRI) could predict prognosis following hepatic resection for HCC. The subjects were 162 patients who underwent hepatic resection for HCC between January 2000 and December 2011. The relationship between APRI and disease-free and overall survival were retrospectively investigated. In multivariate analysis, indocyanine green at 15 min (ICG-R15) ≥15% (P=0.0306), APRI ≥0.45 (P=0.0184), perioperative blood transfusion of red cell concentrates (RCC; P=0.0034) and TNM stage II, III or IV (P=0.0184) were significant predictors in disease-free survival. For overall survival, ICG-R15 ≥15% (P=0.0454), APRI ≥0.45 (P=0.0417), perioperative blood transfusion of RCC (P=0.0036) and TNM stage II, III or IV (P=0.0033) were significant predictors. In addition, higher APRI values were positively correlated with hepatitis C virus infection and preoperative liver function. In conclusion, APRI is an independent risk factor for disease-free and overall survival following hepatic resection for HCC.

A meta-analysis of long-term survival outcomes between surgical resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤ 2 cm (BCLC very early stage)

INTRODUCTION

The optimal management choice in consideration of long-term overall survival (OS) and disease-free survival (DFS) for patients with BLCL very early stage is a matter of debate.

AIM

A systematic review and meta-analysis was conducted to evaluate the efficacy of liver resection (RES) and radiofrequency ablation (RFA) for single HCC 2 cm or less.

MATERIAL AND METHOD

The primary sources of the reviewed studies through December 2017, without restriction on the languages or regions, were Pubmed and Embase. The hazard ratio (HR) was used as a summary statistic for long-term outcomes.

RESULTS

A total of 5 studies qualified for inclusion in this quantified meta-analysis with a total of 729 HCC patients of BCLC very early stage. Only postoperative 1-year OS was comparable in both RES and RFA groups. As for long-term outcomes of 3-year and 5-year OSs, RES was significantly better than RFA, the HRs were 0.64 (95%CI: 0.41, 1.00; P = 0.05) and 0.63 (95%CI: 0.42, 0.95; P = 0.03) respectively. In terms of postoperative DFS, reduced tumor recurrence was observed in RES, and all the short- and long-terms outcomes were favored RES.

DISCUSSION

RES offers better long-term oncologic outcomes compared with RFA in current clinical evidences.

Model predicting the microvascular invasion and satellite lesions of hepatocellular carcinoma after hepatectomy

BACKGROUND

Microvascluar invasion and satellite lesion (MS), important unfavourable pathological factors, significantly contribute to tumour recurrence and impair the prognosis in hepatocellular carcinoma. We aimed to construct a model for the prediction of MS in order to plan treatment better.

METHODS

A total of 1135 consecutive patients with hepatocellular carcinoma who received radical hepatectomy at West China Hospital were randomly assigned to a training set and a validation set. Multivariate analysis was preformed to identify independent risk factors of MS in the training set, and a nomogram was then constructed based on the risk factors. The concordance index (C-index) and a calibration curve were used to assess the predictive performance of the model.

RESULTS

The occurrence rate of MS was about 36.5%. Based on the multivariate analysis, the following six variables were incorporated into the nomogram: age (hazard ratio (HR): 0.531), alpha fetoprotein (HR: 1.327), neutrophil-to-lymphocyte ratio (>2.8, HR: 1.732), international normalized ratio (>1.07, HR: 1.702), tumour size (HR: 1.116) and tumour number (HR: 1.842). The model showed satisfactory discrimination abilities, with a C-index of 0.721 for the training set and 0.704 for the validation set. The receiver operating characteristic curve confirmed the predictive power. Meanwhile, the calibration curve presented a goodness of fit between prediction of the model and actual observations.

CONCLUSIONS

The user-friendly model may be useful for prediction of the occurrence of MS and to plan treatment more rationally preoperatively.

Proton Beam Therapy without Fiducial Markers Using Four-Dimensional CT Planning for Large Hepatocellular Carcinomas

We evaluated the effectiveness and toxicity of proton beam therapy (PBT) for hepatocellular carcinomas (HCC) >5 cm without fiducial markers using four-dimensional CT (4D-CT) planning. The subjects were 29 patients treated at our hospital between March 2011 and March 2015. The median total dose was 76 Cobalt Gray Equivalents (CGE) in 20 fractions (range; 66-80.5 CGE in 10-32 fractions). Therapy was delivered with end-expiratory phase gating. An internal target volume (ITV) margin was added through the analysis of respiratory movement with 4D-CT. Patient age ranged from 38 to 87 years (median, 71 years). Twenty-four patients were Child-Pugh class A and five patients were class B. Tumor size ranged from 5.0 to 13.9 cm (median, 6.9 cm). The follow-up period ranged from 2 to 72 months (median; 27 months). All patients completed PBT according to the treatment protocol without grade 4 (CTCAE v4.03 (draft v5.0)) or higher adverse effects. The two-year local tumor control (LTC), progression-free survival (PFS), and overall survival (OS) rates were 95%, 22%, and 61%, respectively. The LTC was not inferior to that of previous reports using fiducial markers. Respiratory-gated PBT with 4D-CT planning without fiducial markers is a less invasive and equally effective treatment for large HCCs as PBT with fiducial markers.

Surgical outcome of laparoscopic hepatic resection for hepatocellular carcinoma: A matched case-control study with propensity score matching

Background:

Although the number of reports on laparoscopic hepatic resection (LHR) has increased, studies of long-term outcomes regarding tumor recurrence and patient survival compared to the conventional open approach are limited. We evaluated the long-term survival and feasibility of LHR in patients with hepatocellular carcinoma (HCC).

Patients and Methods:

A retrospective analysis was performed on the clinical data of patients who underwent hepatic resection for primary HCC between August 2000 and December 2013. The patients were divided into the LHR or open hepatic resection (OHR) groups. To control for selection bias in the two groups, propensity score matching was used at a 1:1 ratio based on the following covariates: Child–Pugh grade, tumour size, tumour number and tumour location. Following propensity score matching, thirty patients were included in the LHR group and thirty were included in the OHR group.

Results:

The respective disease-free survival rates at 1 year, 3 years and 5 years were 78.4%, 61.1% and 38.9%, respectively, for the LHR group, and 89.3%, 57.5% and 47.9%, respectively, for the OHR group (P = 0.89). Also, the overall survival rates at 1 year, 3 years and 5 years were 96.4%, 68.2% and 62.5%, respectively, for the LHR group and 100.0%, 95.8% and 72.3%, respectively, for the OHR group (P = 0.44).

Conclusions:

According to our study, using propensity score matching, LHR for HCC is safe, feasible and comparative, with good oncologic results.

Impact of hepatocellular carcinoma heterogeneity on computed tomography as a prognostic indicator

We assessed the relationship between the heterogeneity of HCC on preoperative non-contrast-enhanced CT and patient prognosis. The heterogeneity of CT images from 122 patients was assessed and texture feature parameters such as mean, standard deviation (SD), entropy, mean of the positive pixels (MPP), skewness, and kurtosis were obtained using filtration. The relationship between CT texture features and 5-year overall survival (OS) or disease-free survival (DFS) was assessed. Multivariate regression analysis was performed to evaluate the independence of texture feature from clinical or pathological parameters. The Kaplan-Meier curves for OS or DFS was significantly different between patient groups dichotomized by cut-off values for all CT texture parameters with filtration at at least one filter level. Multivariate regression analysis showed the independence of most CT texture parameters on clinical and pathological parameters for OS with filtration at at least one filter level and without filtration except kurtosis. SD, entropy, and MPP with coarse filter, and skewness without filtration showed a significant correlation for DFS. CT texture features of non-contrast-enhanced CT images showed a relationship with HCC prognosis. Multivariate regression analysis showed the possibility of CT texture feature increase the prognostic prediction of HCC by clinical and pathological information.

Survival prediction model for postoperative hepatocellular carcinoma patients

This study is to establish a predictive index (PI) model of 5-year survival rate for patients with hepatocellular carcinoma (HCC) after radical resection and to evaluate its prediction sensitivity, specificity, and accuracy.Patients underwent HCC surgical resection were enrolled and randomly divided into prediction model group (101 patients) and model evaluation group (100 patients). Cox regression model was used for univariate and multivariate survival analysis. A PI model was established based on multivariate analysis and receiver operating characteristic (ROC) curve was drawn accordingly. The area under ROC (AUROC) and PI cutoff value was identified.Multiple Cox regression analysis of prediction model group showed that neutrophil to lymphocyte ratio, histological grade, microvascular invasion, positive resection margin, number of tumor, and postoperative transcatheter arterial chemoembolization treatment were the independent predictors for the 5-year survival rate for HCC patients. The model was PI = 0.377 × NLR + 0.554 × HG + 0.927 × PRM + 0.778 × MVI + 0.740 × NT - 0.831 × transcatheter arterial chemoembolization (TACE). In the prediction model group, AUROC was 0.832 and the PI cutoff value was 3.38. The sensitivity, specificity, and accuracy were 78.0%, 80%, and 79.2%, respectively. In model evaluation group, AUROC was 0.822, and the PI cutoff value was well corresponded to the prediction model group with sensitivity, specificity, and accuracy of 85.0%, 83.3%, and 84.0%, respectively.The PI model can quantify the mortality risk of hepatitis B related HCC with high sensitivity, specificity, and accuracy.

The preoperative globulin-to-albumin ratio, a novel inflammation-based prognostic system, predicts survival after potentially curative liver resection for patients with hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Although the globulin-to-albumin ratio (GAR) is useful for prognostication of patients with various cancers, its relationship with hepatocellular carcinoma (HCC) remains unclear. The study aims to investigate the relationship between GAR and postoperative survival among patients with HCC undergoing potentially curative liver resection (LR).

METHODS

We retrospectively reviewed 368 patients with newly diagnosed HCC who underwent initial and potentially curative LR. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS). Kaplan-Meier analysis and log-rank test were used to compare OS and disease-free survival (DFS).

RESULTS

The result of multivariate analysis using 25 clinical characteristics selected by univariate analysis revealed that the GAR (≥0.918/<0.918) was significantly associated with OS (hazard ratio [HR], 2.398; 95% confidence interval [CI], 1.012-5.683; P = 0.047), as well as platelet count (<14/≥14, ×10⁴ /mm³ ) and portal vein invasion (presence/absence). Kaplan-Meier analysis and log-rank test demonstrated that the OS and DFS of patients with a high GAR (>0.918) were significantly worse than that of patients with a low GAR (≤0.918).

CONCLUSIONS

The GAR is a useful predictor of postoperative survival among patients with HCC undergoing potentially curative LR.

Glasgow prognostic score predicts therapeutic outcome after hepatic resection for hepatocellular carcinoma

Systemic inflammation, as evidenced by the Glasgow prognostic score (GPS), predicts cancer-specific survival in various cancer types. The aim of this study was to evaluate the significance of the GPS in the therapeutic outcome of the patient following surgical resection for hepatocellular carcinoma. In total, 144 patients underwent surgical resection for hepatocellular carcinoma. For the assessment of systemic inflammatory response using the GPS, patients were classified into three groups: Patients with normal serum albumin (<3.5 g/dl) and normal serum C-reactive protein (CRP) (≤1.0 mg/dl) were classified as GPS 0 (n=76), those with low serum albumin (<3.5 g/dl) or elevated serum CRP (>1.0 mg/dl) were classified as GPS 1 (n=58), and those with low serum albumin (<3.5 g/dl) and elevated serum CRP (>1.0 mg/dl) were classified as GPS 2 (n=10). Retrospectively, the relationship between patient characteristics including GPS, disease-free as well as overall survival were investigated. In disease-free survival, GPS 2 (P=0.019), with a tumor number ≥3 (P=0.004), and positive portal or venous invasion (P=0.034) were independent predictors of cancer recurrence in multivariate analysis. In overall survival, GPS 1 (P=0.042), GPS 2 (P<0.001) and positive portal or venous invasion (P<0.001) were independent predictors of poor patient outcome according to multivariate analysis. To conclude, the GPS in patients with hepatocellular carcinoma is an independent prognostic predictor after hepatic resection.

Actual 10-Year Survivors After Resection of Hepatocellular Carcinoma

BACKGROUND

Resection of hepatocellular carcinoma (HCC) offers a chance of cure, but recurrence is common and survival is often limited. The clinical and pathological characteristics of long-term survivors have not been well studied.

METHODS

We retrospectively reviewed 212 patients who underwent partial hepatectomy for HCC with curative intent from 1992 to 2006. Fifty patients who survived beyond 10 years were compared with 109 patients who died of recurrence within 10 years.

RESULTS

Multivariate analysis showed that tumors <5 cm (odds ratio [OR] 2.3, p = 0.04), solitary tumors (OR 3.2, p = 0.01), and absence of vascular invasion (OR 2.3, p = 0.04) were independently associated with actual 10-year survival. However, more than 20% of long-term survivors also possessed established poor prognostic factors, including α-fetoprotein >1000 ng/mL, unfavorable serum inflammatory indices, tumor size >10 cm, microvascular invasion, poor tumor differentiation, cirrhosis, and metabolic syndrome. None of the 10-year survivors had an R1 resection. While 77% of the short-term survivors developed recurrence within 2 years, 42% of the 10-year survivors developed recurrence during their decade of follow-up, although most of the recurrences among 10-year survivors were intrahepatic and amenable to further treatment. Among patients who survived beyond 10 years, 42% remained alive without recurrence.

CONCLUSIONS

In this largest Western series of actual 10-year survivors after HCC resection, almost one in four patients survived over a decade, even though nearly half of this subset had developed recurrence. While many well-known variables were associated with a poor outcome, only a positive microscopic margin precluded long-term survival.

IS RESECTION OF HEPATOCELLULAR CARCINOMA IN THE ERA OF LIVER TRANSPLANTATION WORTHWILE? A single center experience

ABSTRACT Background - Liver resection for hepatocellular carcinoma is a potentially curative therapeutic procedure that can be performed readily after its indication, without the need of a long waiting time and lower costs when compared to liver transplantation, being a good alternative in patients with preserved/good liver function. Objective - Evaluate long-term results of liver resection from a high volume single center for selected patients with hepatocellular carcinoma in a context of a long waiting list for liver transplant. Methods - One hundred and one patients with hepatocellular carcinoma, with a mean age of 63.1 years, and preserved liver function were submitted to liver resection. Clinical and pathological data were evaluated as prognostic factors. Mean follow-up was 39.3 months. Results - All patients had a single nodule and 57 (58.2%) patients were within the Milan criteria. The size of the nodule ranged from 1 to 24 cm in diameter. In 74 patients, liver resection was performed with the open approach and in 27 (26.7%) was done laparoscopically. Postoperative morbidity was 55.3% being 75.5% of the complications classified as Dindo-Clavien I and II and operative mortality was 6.9%. Five-year overall and disease free survival rates were 49.9% and 40.7%, respectively.After a log-rank univariate analysis, the levels of preoperative alpha-fetoprotein (P=0.043), CA19-9 (P=0.028), capsule invasion (P=0.03), positive margin (R1-R2) (P=0.004) and Dindo-Claviens' morbidity classification IV (P=0.001) were the only parameters that had a significant negative impact on overall survival. On the odds-ratio evaluation, the only significant factors for survival were high levels of alpha-fetoprotein (P=0.037), and absence of free margins (P=0.008). Conclusion - Resection, for selected cases, is a potentially curative treatment with acceptable morbidity and mortality and, in a context of a long waiting list for transplant, plays an important role for the treatment of hepatocellular carcinoma.

Co-occurrence of liver metastasis of gastrointestinal stromal tumor and hepatocellular carcinoma: a case report

Gastrointestinal stromal tumors (GISTs) are potentially malignant mesenchymal tumors that can give rise to distant metastases, mainly in the liver. The co-occurrence of synchronous primary liver tumors (e.g., hepatocellular carcinoma (HCC)) in patients with GIST is extremely rare. This report describes a 77-year-old male patient with liver metastasis of GIST originating in the small intestine and synchronous HCC. The patient had undergone resection of the small intestine for the primary GIST 3 years earlier and partial hepatectomy and radiofrequency ablation for liver metastases of GIST 1 year earlier. Despite the continuation of adjuvant therapy with imatinib, two new lesions in the liver were detected by follow-up computed tomography scanning, which showed the gradual enlargement of one tumor. A second hepatectomy was performed. Pathological examination revealed that one tumor was a liver metastasis of GIST and the other was a primary HCC. To our knowledge, this is the first report of the synchronous co-occurrence of a liver metastasis of GIST and a primary HCC.

Clinical Impact of Anatomical Liver Resection for Hepatocellular Carcinoma with Pathologically Proven Portal Vein Invasion

BACKGROUND

Portal vein invasion (PVI) is known to be a poor prognostic factor for hepatocellular carcinoma (HCC) patients. Anatomical liver resection (ALR) is a preferable procedure for treating HCC. However, the effect of ALR for HCC with PVI has not been fully evaluated. The aim of this study is to investigate the survival benefit of ALR for HCC patients with or without pathologically proven portal vein invasion (pPVI).

METHODS

Curative hepatic resection was performed for a single HCC in 313 patients. The patients were divided into two groups according to the absence or presence of pPVI (absence: n = 216, presence: n = 97). These groups were then subclassified by the surgical procedures employed (ALR or non-ALR), and the clinical characteristics and stratified prognoses were compared according to the surgical procedure between the subgroups. Uni- and multivariate analyses were performed to explore the significant prognostic factors.

RESULTS

Among the patients without pPVI, there was no significant difference in postoperative survival between the groups. However, among the patients with pPVI, both the 5-year overall and recurrence-free survival rates in the ALR group were significantly higher than those in the non-ALR group (46.1 % vs. 16.3 %; p = 0.0019 and 33.8 % vs. 0 %; p = 0.0010). Multivariate analyses revealed that tumor differentiation and intraoperative blood loss (IOB) were associated with postoperative survival in patients without pPVI. On the other hand, in patients with pPVI, ALR, serum AFP level, and IOB were associated with postoperative survival.

CONCLUSION

ALR confers a survival benefit for HCC patients with pPVI.

Surgical Resection Versus Radiofrequency Ablation for Single Hepatocellular Carcinoma ≤ 2 cm in a Propensity Score Model

OBJECTIVES

To evaluate the efficacy of surgical resection (SR) and radiofrequency ablation (RFA) for single hepatocellular carcinoma (HCC) 2  cm or less.

BACKGROUND

The optimal management for Barcelona Clínic Liver Cancer (BCLC) very early-stage HCC is undetermined.

METHODS

Between 2002 and 2013, a total of 237 (SR, 109; RFA, 128) patients with BCLC very early-stage HCC were enrolled. Their overall survival (OS) and recurrence-free survival (RFS) were compared. Propensity score matching analysis identified 79 matched pairs of patients to compare outcomes.

RESULTS

At baseline, patients with SR were younger and had larger tumors (both P < 0.05). The 5-year OS rates were 81% versus 76% (P = 0.136), whereas 5-year RFS rates were 49% versus 24% (P < 0.001) for SR and RFA groups, respectively. In the propensity model, the baseline variables were well balanced between 2 groups. Surgical resection was significantly associated with better OS and RFS compared with RFA; the 5-year OS rates were 80% versus 66% (P = 0.034), and 5-year RFS rates were 48% versus 18% (P < 0.001) for SR and RFA groups, respectively. The Cox proportional hazards model identified RFA as an independent predictor for mortality and tumor recurrence in the propensity model (hazard ratio, 2.120 and 2.421, respectively; both P < 0.05). Patients with recurrent HCC had inferior prognosis compared with patients without recurrence (P = 0.001). However, the survival after recurrence was similar between patients initially treated with SR or RFA (P = 0.415).

CONCLUSIONS

Surgical resection provides better long-term OS and RFS compared with RFA in patients with BCLC very early-stage HCC. Surgical resection should be considered as the first-line treatment for these patients.

Knockdown of CD44 inhibits the invasion and metastasis of hepatocellular carcinoma both in vitro and in vivo by reversing epithelial-mesenchymal transition

Mounting evidence has shown that induction of epithelial-mesenchymal transition (EMT) contributes to the the expression of CSC (cancer stem cell) markers. However, whether and how CSC markers could be involved in regulating EMT has rarely been reported. CD44, being one of the most commonly used CSC markers in hepatocellular carcinoma (HCC), has been demonstrated to act as a multidomain, transmembrane platform that serves to integrate a wide variety of extracellular signals. Therefore, we determined to seek whether CD44 is necessary for the EMT process in HCC. First, we noticed that CD44 expression was associated with the mesenchymal phenotype in HCC cell lines, and knocking down CD44 with lentivirus-mediated shRNA in HCC cell lines resulted in the mesenchymal-epithelial-transition (MET) and the subsequent impaired migration and invasion in vitro. Moreover, in a metastatic mice model established by tail vein injection of luciferase labelled MHCC97-H cells, we confirmed that CD44 knockdown resulted in the decreased metastasis of HCC cells. Furthermore, we found that the induction of MET by CD44 inhibition might be achieved, at least in part, by repressing the ERK/Snail pathway.

SPAG9 is involved in hepatocarcinoma cell migration and invasion via modulation of ELK1 expression

Background

Sperm-associated antigen 9 (SPAG9) is upregulated in several malignancies and its overexpression is positively correlated with cancer cell malignancies. However, the specific biological roles of SPAG9 in hepatocellular carcinoma (HCC) are less understood.

Methods

We analyzed SPAG9 and ETS-like gene 1, tyrosine kinase (ELK1) expression in 50 paired HCC specimens and adjacent noncancerous liver specimens using immunohistochemistry. SPAG9 small interfering RNA (siRNA) was used to knockdown SPAG9 expression in HCCLM3 and HuH7 cell lines. We used plasmids to upregulate ELK1 expression and siRNA to downregulate ELK1 expression in HuH7 cells. Quantitative real-time polymerase chain reaction and Western blot were used to evaluate the expression of SPAG9 and ELK1 at the mRNA and protein level, respectively. Wound healing, matrigel migration, and invasion analyses were performed to determine the effect of SPAG9 and ELK1 on HCC metastasis.

Results

SPAG9 and ELK1 were overexpressed in HCC tissue specimens and their expressions were higher in HCCLM3 and HuH7 cells compared to the low-metastatic HepG2 cells. Overexpression of SPAG9 was positively associated with tumor-node-metastasis staging (P=0.032), metastasis parameters (P=0.018) of HCC patients, and ELK1 expression (r=0.422, P<0.001) in HCC tissue specimens. In addition, knockdown of SPAG9 in HCCLM3 and HuH7 cells using siRNA significantly suppressed cell migration and invasion. Furthermore, we observed inhibition of ELK1 expression and p38 signaling. However, ELK1 overexpression reversed the inhibitory effects of SPAG9 siRNA on HCC cell metastasis and ELK1 depletion inhibited HuH7 cell migration and invasion.

Conclusion

SPAG9 overexpression was positively correlated with HCC metastasis and SPAG9-induced migration and invasion were partially dependent on ELK1 expression in HCC cell lines. These results suggest that SPAG9 may be a potential anti-metastasis target effective in HCC therapy.

Downregulated Expression of PTPN9 Contributes to Human Hepatocellular Carcinoma Growth and Progression

Human hepatocellular carcinoma (HCC) is one of the most common malignant cancers, whose molecular mechanisms is remains largely. PTPN9 has recently been reported to play a critical role in breast cancer development. However, the role of PTPN9 in human HCC remains elusive. The present study aimed at investigating the potential role of PTPN9 in HCC. Western blot and immunohistochemistry were used to examine the expression of PTPN9 protein in HCC and adjacent non-tumorous tissues in 45 patients. Furthermore, Cell Counting Kit-8, flow cytometry and RNA interference experiments were performed to analyze the role of PTPN9 in the regulation of HCC cell proliferation. We showed that the expression level of PTPN9 was significantly reduced in HCC, compared with adjacent non-tumorous tissues. PTPN9 expression was inversely associated with Tumor size (P = 0.014), serum AFP level (P = 0.004) and Ki-67 expression. Low expression of PTPN9 predicted poor survival in HCC patients. Moreover, PTPN9 interference assay that PTPN9 inhibited cell proliferation in HepG2 cells. Cell apoptosis assay revealed that, silencing of PTPN9 expression significantly reduced cell apoptosis, compared with control ShRNA treatment group. Our results suggested that PTPN9 expression was down-regulated in HCC tumor tissues, and reduced PTPN9 expression was associated with worsened overall survival in HCC patients. Depletion of PTPN9 inhibits the apoptosis and promotes the proliferation of HCC cells.

When to Perform Surgical Resection or Radiofrequency Ablation for Early Hepatocellular Carcinoma?: A Nomogram-guided Treatment Strategy

Radiofrequency ablation (RFA) is indicated for early-stage hepatocellular carcinoma (HCC), but the comparative efficacy between RFA and surgical resection (SR) is inconclusive. We aim to develop a prognostic nomogram for predicting recurrence-free survival (RFS) after RFA. We also evaluate the possibility of using nomogram in improving treatment algorithm.We retrospectively enrolled 836 patients with Barcelona Clínic Liver Cancer very-early/early-stage HCC receiving SR or RFA. A visually-orientated nomogram was constructed with Cox proportional hazards model, and number and size of tumor, platelet count, albumin level, and model for end-stage liver disease score were included. The concordance index of the nomogram was 0.69.Radiofrequency ablation patients were stratified into low and high-risk groups by the median of nomogram scores. The RFS and overall survival (OS) of 2 risk groups were compared with SR patients with propensity score matching analysis. SR provided better RFS and OS compared with high-risk (nomogram score ≥9.8) RFA patients in the propensity model. The 5-year RFS rates were 36% versus 11%, whereas the 5-year OS rates were 74% versus 60% for SR and high-risk RFA groups, respectively (both P < 0.05). However, SR was associated with better RFS (5-year RFS rates 41% vs 29%), but similar OS (5-year OS rates 80% vs 81%), compared with low-risk (nomogram score <9.8) RFA patients in the propensity model (P < 0.05 and P > 0.05, respectively).In conclusion, this user-friendly nomogram offers individualized recurrence risk estimation and stratification for early HCC patients receiving curative RFA. The nomogram can be integrated into current treatment algorithm. SR should be considered the first-line treatment for high-risk patients to achieve better long-term survival.

The Feasibility of Third or More Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma

OBJECTIVES

To investigate the feasibility and prognostic benefits of third or more hepatectomy (third or more Hx) for recurrent hepatocellular carcinoma.

BACKGROUND

Second hepatectomy (second Hx) has been accepted as an effective treatment of recurrent hepatocellular carcinoma after first hepatectomy (first Hx). However, the feasibility and efficacy of third or more Hx have not been adequately assessed.

METHODS

Data were reviewed from 1340 patients with hepatocellular carcinoma who underwent curative hepatectomy. Among them, 941, 289, and 110 underwent first Hx, second Hx, and third or more Hx, respectively. Surgical outcomes and long-term survival were compared among the groups.

RESULTS

Surgical duration was significantly longer in third or more Hx (median, 6.4 hours) than in second Hx (median, 5.9 hours). Postoperative bile leakage and wound infection were more frequently observed in third or more Hx versus second Hx (12.5% vs 6.2%, [P = 0.04] and 2.9% vs 0.4% [P = 0.03], respectively). Three and 5-year disease-free survival rates were 36.8% and 27.1% in first Hx, 24.4% and 17.9 % in second Hx, and 26.1% and 12.8% in third or more Hx, respectively (P < 0.01 [first Hx vs third Hx], P = 0.95 [second Hx vs third or more Hx]). The 5-year overall survival rates from each resection were similar among the groups (65.3%, 60.5%, 68.2%, respectively). The 5- and 10-year overall survival rates from initial hepatectomy in patients who received third or more Hx were 91.4% and 75.5%, respectively.

CONCLUSIONS

Third or more Hx is technically demanding in terms of surgical duration and morbidity compared with second Hx. However, aggressive repeat resection offers a survival similar to second Hx, leading to cumulative long-term survival from initial resection.

Downregulation of FOXP2 promoter human hepatocellular carcinoma cell invasion

Hepatocellular carcinoma (HCC) is a major health concern with a high morbidity and mortality rate worldwide. However, the mechanism underlying hepatocarcinogenesis remains unclear. Forkhead box P2 (FOXP2) has been implicated in various human cancer types. However, the role of FOXP2 in HCC remains unknown. Western blot and immunohistochemistry were used to measure the expression of FOXP2 protein in HCC and adjacent normal tissues in 50 patients. Wound healing and transwell assays were used to determine the cell invasion ability. We showed that the level of FOXP2 was significantly reduced in HCC compared with the adjacent non-tumorous tissue. There was statistical significance between the expression of FOXP2 and vein invasion (P = 0.017), number of tumor nodes (P = 0.028), and AFP (P = 0.033). Low expression of FOXP2 correlated with poor survival. Moreover, wound healing and transwell assays showed that FOXP2 could decrease cell invasion and affect the expression of vimentin and E-cadherin. Our results suggested that FOXP2 expression was downregulated in HCC tumor tissues, and reduced FOXP2 expression was associated with poor overall survival. In addition, downregulation of FOXP2 significantly enhanced cell invasiveness. These findings uncover that FOXP2 might be a new prognostic factor and be closely correlated with HCC cell invasion.

Survival outcomes after stereotactic body radiotherapy for 79 Japanese patients with hepatocellular carcinoma

Stereotactic body radiotherapy (SBRT) is a relatively new treatment for liver tumor. Outcomes of SBRT for liver tumors unsuitable for ablation or surgical resection were evaluated. A total of 79 patients treated with SBRT for primary hepatocellular carcinoma (HCC) between 2004 and 2012 in six Japanese institutions were studied retrospectively. Patients treated with SBRT preceded by trans-arterial chemoembolization were eligible. Their median age was 73 years, 76% were males, and their Child-Pugh scores were Grades A (85%) and B (11%) before SBRT. The median biologically effective dose (α/β = 10 Gy) was 96.3 Gy. The median follow-up time was 21.0 months for surviving patients. The 2-year overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival were 53%, 40% and 76%, respectively. Sex and serum PIVKA-II values were significant predictive factors for OS. Hypovascular or hypervascular types of HCC, sex and clinical stage were significant predictive factors for PFS. The 2-year PFS was 66% in Stage I vs 18% in Stages II-III. Multivariate analysis indicated that clinical stage was the only significant predictive factor for PFS. No Grade 3 laboratory toxicities in the acute, sub-acute, and chronic phases were observed. PFS after SBRT for liver tumor was satisfactory, especially for Stage I HCC, even though these patients were unsuitable for resection and ablation. SBRT is safe and might be an alternative to resection and ablation.

The role played by gender in viral hepatitis

Although not a classical target for estrogens, the liver is a target for their action and is sensitive to their deprivation. The occurrence of menopause is accompanied by a chain of events depending on the progressive estrogen deprivation that eventually leads to a shift from a low inflammatory to a high inflammatory state. This has a series of well-known consequences in many different organs and tissues (bone, heart, brain, body fat etc.) among which the liver is particularly interesting. The consequences are extremely evident in HCV-positive women in whom HCV infection and menopause cooperate to induce higher necro-inflammatory features, increased hepatic steatosis and eventually faster progression of fibrosis. In addition, menopause is the strongest negative factor for sustained viral response (SVR) in HCV-positive females, especially HCV genotype 1 (in whom menopause was the only independent factor for failure of antiviral therapy). This suggests that HCV-positive women should be treated early during fertile age to obtain maximal response to antiviral therapy.

Clinical analysis of anatomical resection for the treatment of hepatocellular carcinoma based on the stratification of liver function

BACKGROUND

This study aimed to clarify the efficacy of anatomical resection (AR) for the treatment of hepatocellular carcinoma (HCC) compared with that of nonanatomical resection (NAR) based on the stratification of liver function (LF).

METHODS

The clinical records of 174 patients with a single HCC, 2-5 cm in diameter and without macroscopic vascular invasion, were analyzed. AR was performed in 132 patients and NAR was performed in 42 patients. The indocyanine green retention rate at 15 min (ICGR15) of the 78 patients classified as the good-LF group was 10-20 % and the ICGR15 of the 54 patients classified as the poor-LF group was 20-40 %.

RESULTS

The 5-year overall survival (OS) and disease-free survival rates of the 174 patients were 67.6 and 33.4 %, respectively. Cox proportional hazard analysis identified ICGR15 ≥ 20 %, liver cirrhosis, α-fetoprotein ≥ 100 mg/dL, and infiltrating growth as independent prognostic factors. Liver cirrhosis was significantly less frequent in patients who underwent AR than in patients who underwent NAR (52 vs. 79 %, p = 0.002). In the subgroup analysis of the good-LF group, there were no significant differences in 5-year OS after AR and NAR (73.3 vs. 65.2 %, p = 0.857). By contrast, in the subgroup analysis of the poor-LF group, the 5-year OS after AR was significantly worse than after NAR (45.3 vs. 77.4 %, p = 0.044).

CONCLUSION

In patients with an ICGR15 ≥ 20 %, we recommend NAR rather than AR for the treatment of a solitary 2-5-cm-diameter HCC and without macroscopic vascular invasion.

Hepatocellular carcinoma: surveillance CT schedule after hepatectomy based on risk stratification

PURPOSE

To evaluate alternative schedules for surveillance computed tomography (CT) for patients who underwent hepatectomy for hepatocellular carcinoma ( HCC hepatocellular carcinoma ) and to demonstrate an appropriate schedule on the basis of stratification for risk of recurrence.

MATERIALS AND METHODS

CT and pathologic reports for consecutive patients with HCC hepatocellular carcinoma who underwent hepatectomy at one institution were evaluated with institutional review board approval. Univariate and multivariate analyses were performed to identify risk factors for recurrence. Patients were categorized into risk groups on the basis of classification and regression tree analysis. Average recurrence detection rates ( RDR recurrence detection rate s) between consecutive CT scans were calculated for existing and alternative surveillance schedules for each risk group, and the difference in RDR recurrence detection rate was determined by using the Student t test. A P value of less than .05 was considered to indicate a significant difference. Expected delay in diagnosis was also computed for the alternative surveillance schedules for each risk group.

RESULTS

Two hundred sixty patients (216 men; mean age, 56.0 years ± 22.5) underwent 2705 CT studies. Independent risk factors for recurrence were microvascular invasion (P = .001), cirrhosis (P = .007), and tumor multiplicity (P = .001). Three risk groups (low, intermediate, and high) were identified. For low- and intermediate-risk groups, average RDR recurrence detection rate was not significantly different in the first 2 years after hepatectomy when the interval was extended from 3 months (3.3% and 4.6%, respectively) to 4 months (4.3% [expected delay, 16 days] and 6.1% [expected delay, 18 days], respectively) or for the subsequent 3 years when the interval was extended from 6 months (1.3% and 3.5%, respectively) to 12 months (2.5% [expected delay, 72 days] and 7.0% [expected delay, 103 days], respectively). This alternative schedule included five (35.7%) fewer CT scans than the 14 in the original schedule, and a reduction in radiation dose and cost during the 5-year follow-up period.

CONCLUSION

Posthepatectomy surveillance CT schedules may be tailored and optimized according to stratification by risk of recurrence to reduce the frequency of CT scans without compromising surveillance benefits.

(18)F-Fluorodeoxyglucose positron-emission tomography could have a prognostic role in patients with advanced hepatocellular carcinoma

INTRODUCTION

We set out to evaluate the prognostic value of (18)F-fluorodeoxyglucose positron-emission tomography (pet) in patients with advanced (non-transplant-eligible) hepatocellular carcinoma (hcc) and to evaluate the correlation between standardized uptake values (suvs) and survival outcomes.

METHODS

We identified patients with hcc who, from 2005 to 2013, underwent pet imaging before any treatment. This retrospective study from our hcc database obtained complete follow-up data for the 63 identified patients.

RESULTS

Of the 63 patients, 10 underwent surgical resection, and 59 underwent locoregional therapy. In this cohort, 28 patients were pet-positive (defined as any lesion with a suv ≥ 4.0) before any therapy was given, and 35 patients were pet negative (all lesions with a suv < 4.0). On survival analysis, median survival was greater for the pet-negative than for the pet-positive patients: 29 months (range: 16.3-41.1 months) versus 12 months (range: 4.0-22.1 months) respectively, p = 0.0241. The pet-positive patients more often had large tumours (≥5 cm), poor differentiation, and extrahepatic disease, reflecting more aggressive tumours. On multivariate analysis, only pet positivity was associated with poor survival (p = 0.049).

CONCLUSIONS

Compared with pet-positive patients, pet-negative patients with hcc experienced longer survival. Imaging by pet can be of value in early prognostication for patients with hcc, especially patients receiving locoregional therapy for whom pathologic tumour differentiation is rarely available. This potential role for pet requires further validation in a prospective study.

Impact of sex on the survival of patients with hepatocellular carcinoma: a Surveillance, Epidemiology, and End Results analysis

BACKGROUND

Men are 4 to 8 times more likely to develop hepatocellular carcinoma (HCC) than women. Preclinical models have suggested a role for sex hormones in the development of HCC. In the current study, the authors investigated the impact of age, sex, race, and ethnicity on the survival of patients with HCC using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patients diagnosed with HCC from 1988 through 2010 were identified from the SEER registry. Hazard ratios (HR) for overall survival (OS) were derived using the Cox regression model adjusted for race, year of diagnosis, marital status, treatment, birthplace, tumor differentiation, and tumor size.

RESULTS

A total of 39,345 patients were identified; 76% were men and 34% were women (50% white, 12% African American, 21% Asian, 16% Hispanic, and 1% Native American). The median age at the time of diagnosis was 61 years for men and 67 years for women. Approximately 84% of patients had liver-limited disease and 16% had metastatic disease. Treatment information was available for patients diagnosed after 1998 (34,674 patients): 11% received liver-directed therapy, 11% underwent surgical resection, and 7% underwent liver transplantation. The HR for the OS of women versus men was 0.83 (95% confidence interval [95% CI], 0.77-0.88) for patients aged <55 years. The protective effect of sex on OS was found to be greatest in patients aged 18 to 44 years (HR, 0.75; 95% CI, 0.65-0.86 [P<.001]), especially those with surgically resected tumors (HR, 0.68; 95% CI, 0.54-0.86 [P = .001]) and those who were African American (HR, 0.85; 95% CI, 0.78-0.92 [P<.001]). There was no survival difference between sexes noted among Hispanics or patients aged >65 years.

CONCLUSIONS

Sex appears to be associated with survival in patients with HCC. The role of androgens and estrogens in the development and progression of HCC warrants further investigation.

Comparison of inflammation-based prognostic scores as predictors of tumor recurrence in patients with hepatocellular carcinoma after curative resection

BACKGROUND

Various inflammation-based prognostic scores, including the Glasgow prognostic score (GPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic index (PI), and prognostic nutritional index (PNI), have been associated with survival in patients with several types of cancer. This study compared the ability of these scores to predict recurrence-free survival (RFS) in patients with hepatocellular carcinoma (HCC) after curative hepatectomy.

METHODS

Data were collected prospectively from 113 patients who underwent curative resection for HCC from January 2003 to December 2012. Clinicopathological variables including preoperative inflammation-based prognostic scores were analyzed. Univariate and multivariate analyses were performed to identify factors predictive of RFS.

RESULTS

Univariate analysis showed that NLR (P < 0.0001) and PI (P = 0.0194) were significantly associated with RFS. Multivariate analysis showed that NLR (hazard ratio [HR]; 2.58, P = 0.0020), tumor differentiation (HR; 9.55, P < 0.0001), serosal invasion (HR; 2.24, P = 0.0112), and vascular invasion (HR; 2.18, P = 0.0106) were independently correlated with RFS.

CONCLUSIONS

Preoperative NLR is an independent predictor of RFS in patients with HCC after curative hepatectomy, and is superior to the other inflammation-based prognostic scores.

Decreased TIP30 promotes Snail-mediated epithelial-mesenchymal transition and tumor-initiating properties in hepatocellular carcinoma

The poor prognosis of hepatocellular carcinoma (HCC) is mainly due to tumor recurrence and metastases. Recently, epithelial-mesenchymal transition (EMT) has been implicated in tumor invasion and metastasis. However, the underlying molecular mechanisms are yet to be elucidated. Here, we show that 30-kDa Tat-interacting protein (TIP30), also called CC3, is significantly downregulated during transforming growth factor-β-induced EMT. In our in vitro and in vivo studies, we show that decreased TIP30 expression leads to EMT, as well as enhanced motility and invasion of HCC cells. Also, increased self-renewal ability and chemotherapeutic resistance are observed with TIP30 depletion. Moreover, Snail is one of the key transcription factors promoting EMT, and overexpression of TIP30 greatly decreased nucleic accumulation in Snail through the regulation of intracellular localization. Small interfering RNAs targeting Snail attenuated EMT and tumor-initiating properties induced by TIP30 deficiency. We further confirmed that TIP30 competitively interrupted the interaction of Snail with importin-β2 to block the nuclear import of Snail. Consistently, TIP30 expression significantly correlates with E-cadherin expression in HCC patients. TIP30 or combination of E-cadherin is a powerful marker in predicting the prognosis of HCC. Taken together, our results suggest a novel and critical role of TIP30 involved in HCC progression and aggressiveness.

High CD44s expression is associated with the EMT expression profile and intrahepatic dissemination of hepatocellular carcinoma after local ablation therapy

BACKGROUND/PURPOSE

Local ablation therapy (LAT) is a widely used treatment for hepatocellular carcinoma (HCC) because it is less invasive than hepatic resection. The precise molecular mechanism underlying local HCC recurrence after LAT is largely unknown. The CD44 standard isoform (CD44s) is involved in epithelial-mesenchymal transition (EMT) in HCC. We investigate the significance of CD44s expression and EMT expression profile in local HCC recurrence after LAT.

METHODS

We studied the expression levels of CD44s, EMT expression profile (E-cadherin(low)/vimentin(high) expression) and their association with clinicopathological factors in 30 HCC samples from patients with locally recurrent HCCs after LAT following hepatic resection. The alterations of CD44s expression was compared with those in initial HCCs from 150 patients without prior any anticancer treatment including LAT.

RESULTS

A high CD44s expression was significantly associated with the EMT expression profile (P = 0.002), and it was also detected with a higher frequency in the locally recurrent HCCs after LAT compared to initial HCCs (P < 0.001). In addition, high CD44s expression was associated with the intrahepatic dissemination of HCC after LAT (P = 0.006).

CONCLUSIONS

These results suggest that high CD44s expression is associated with the aggressive recurrence pattern via EMT after LAT for HCC.

Transarterial embolization with use of lipiodol and gelatin sponge for active nasal bleeding from hepatocellular carcinoma metastasis in the pituitary gland

A 58-year-old man presented with a very rare case of pituitary metastasis from hepatocellular carcinoma with active nasal bleeding which was treated by transarterial embolization using ethiodized oil (Lipiodol) and gelatin sponge. After treatment, nasal bleeding ceased and tumor size decreased. The prognosis for patients with pituitary metastases is very poor, so aggressive treatment is recommended to alleviate symptoms. This minimally invasive approach may be a reasonable therapeutic option for pituitary metastases.

Evaluation of the seventh edition of the American Joint Committee on Cancer tumour-node-metastasis (TNM) staging system for patients undergoing curative resection of hepatocellular carcinoma: implications for the development of a refined staging system

OBJECTIVES

This study aimed to evaluate the seventh edition of the American Joint Committee on Cancer (AJCC) tumour-node-metastasis (TNM) staging system and to compare its efficacy with those of the fifth and sixth editions of the AJCC staging system and the TNM staging system defined by the Liver Cancer Study Group of Japan.

METHODS

Data for 754 patients submitted to hepatectomy for hepatocellular carcinoma (HCC) between 1989 and 2005 were reviewed. Tumour-free survival was estimated using the Kaplan-Meier method and compared between subgroups using the log-rank test. Prognostic factors for tumour-free survival were identified by multivariable analysis. The accuracy of these staging systems was evaluated using the Cox regression model and a refined staging system was developed based on the drawbacks of the respective systems.

RESULTS

According to the criteria defined by the seventh AJCC TNM staging system, 5-year survival was 50.6% in patients with T1 tumours, 21.0% in patients with T2 tumours, 14.6% in patients with T3a tumours, 12.1% in patients with T3b tumours, and 12.9% in patients with T4 tumours. There was no survival difference between patients with T3a and T3b tumours (P = 0.073), nor between those with T3b and T4 tumours (P = 0.227). Significant prognostic tumour factors were microvascular invasion, tumour multiplicity, bilobar disease and a tumour size of ≥5.0 cm. The fifth and sixth editions of the AJCC TNM staging system were found to be more accurate in prognosis than the seventh.

CONCLUSIONS

The seventh edition of the AJCC TNM staging system is able to adequately stratify patients with early HCC only. A refined staging system is therefore proposed.

Effects of genomic changes in hepatitis B virus on postoperative recurrence and survival in patients with hepatocellular carcinoma

PURPOSE

To determine whether the genomic changes in hepatitis B virus (HBV) affect the clinical outcomes of hepatocellular carcinoma (HCC) in patients with HBV-associated HCC treated with curative surgical resection.

METHODS

A total of 247 patients with HBV-associated HCC were treated with curative surgical resection. They were followed regularly for a median of 30 months. The whole X, S, basal core promoter (BCP), and precore regions of HBV were sequenced.

RESULTS

The genomic changes such as the G1896A at precore, the A1762T/G1764A at BCP, the C1653T and the T1753V at X gene, and pre-S2 deletion were not significantly associated with postoperative recurrence of HCC or survival of patients after curative resection. However, in univariate analysis, younger age, elevated serum α-fetoprotein level, elevated serum alanine aminotransferase level, larger tumor size, microvascular invasion, and advanced Cancer of the Liver Italian Program stage were closely associated with shorter survival after surgical resection. In multivariate analysis, only microvascular invasion revealed to be an independent risk factor of postoperative recurrence (relative risk [RR] 5.406; P < 0.001); the independent risk factors of shorter survival appeared to be infiltrative type (RR 5.110; P = 0.032), larger tumor size (RR 1.976; P = 0.047), and microvascular invasion (RR 6.118; P < 0.001).

CONCLUSIONS

The postoperative recurrence or survival period may not be affected by the genomic changes at the precore, BCP, X, and pre-S2 regions in HBV of genotype C2 in patients with HBV-associated HCC treated with curative surgical resection. Rather, it may be closely associated with tumor characteristics, such as the size and type of HCC or presence of microvascular invasion.