The outcome of liver transplantation in patients with hepatocellular carcinoma in the United States between 1988 and 2001: 5-year survival has improved significantly with time

The Future Frontier of Liver Transplantation Exploring Young Donor Allocation Strategies for HCC Recipients

Background

The role of donor age in liver transplantation (LT) outcomes for hepatocellular carcinoma (HCC) is controversial. Given the significant risk of HCC recurrence post-LT, optimizing donor/recipient matching is crucial. This study reassesses the impact of young donors on LT outcomes in patients with HCC.

Methods

A retrospective review of 11 704 LT cases from the United Network for Organ Sharing database (2012-2021) was conducted. The study focused on the effect of donor age on recurrence-free survival, using hazard associated with LT for HCC (HALT-HCC) and Metroticket 2.0 scores to evaluate post-LT survival in patients with HCC.

Results

Of 4706 cases with young donors, 11.0% had HCC recurrence or death within 2 y, and 18.3% within 5 y. These outcomes were comparable with those of non-young donors. A significant correlation between donor age and post-LT recurrence or mortality (P = 0.04) was observed, which became statistically insignificant after tumor-related adjustments (P = 0.32). The Kaplan-Meier curve showed that recipients with lower HALT-HCC scores (<9) and Metroticket 2.0 scores (<2.2) significantly benefited from young donors, unlike those exceeding these score thresholds. Cox regression analysis showed that donor age significantly influenced outcomes in recipients below certain score thresholds but was less impactful for higher scores.

Conclusions

Young donors are particularly beneficial for LT recipients with less aggressive HCC, as indicated by their HALT-HCC and Metroticket 2.0 scores. These findings suggest strategically allocating young donors to recipients with less aggressive tumor profiles, which could foster more efficient use of the scarce donor supply and potentially enhance post-LT outcomes.

Development of a nomogram for predicting liver transplantation prognosis in hepatocellular carcinoma

BACKGROUND

At present, liver transplantation (LT) is one of the best treatments for hepatocellular carcinoma (HCC). Accurately predicting the survival status after LT can significantly improve the survival rate after LT, and ensure the best way to make rational use of liver organs.

AIM

To develop a model for predicting prognosis after LT in patients with HCC.

METHODS

Clinical data and follow-up information of 160 patients with HCC who underwent LT were collected and evaluated. The expression levels of alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin, Golgi protein 73, cytokeratin-18 epitopes M30 and M65 were measured using a fully automated chemiluminescence analyzer. The best cutoff value of biomarkers was determined using the Youden index. Cox regression analysis was used to identify the independent risk factors. A forest model was constructed using the random forest method. We evaluated the accuracy of the nomogram using the area under the curve, using the calibration curve to assess consistency. A decision curve analysis (DCA) was used to evaluate the clinical utility of the nomograms.

RESULTS

The total tumor diameter (TTD), vascular invasion (VI), AFP, and cytokeratin-18 epitopes M30 (CK18-M30) were identified as important risk factors for outcome after LT. The nomogram had a higher predictive accuracy than the Milan, University of California, San Francisco, and Hangzhou criteria. The calibration curve analyses indicated a good fit. The survival and recurrence-free survival (RFS) of high-risk groups were significantly lower than those of low- and middle-risk groups (P < 0.001). The DCA shows that the model has better clinical practicability.

CONCLUSION

The study developed a predictive nomogram based on TTD, VI, AFP, and CK18-M30 that could accurately predict overall survival and RFS after LT. It can screen for patients with better postoperative prognosis, and improve long-term survival for LT patients.

Management of Hepatocellular Carcinoma in 2024: The Multidisciplinary Paradigm in an Evolving Treatment Landscape

Liver cancer is the third most common cause of cancer-related deaths worldwide, and hepatocellular carcinoma (HCC) makes up the majority of liver cancer cases. Despite the stabilization of incidence rates in recent years due to effective viral hepatitis treatments, as well as improved outcomes from early detection and treatment advances, the burden of HCC is anticipated to rise again due to increasing rates of metabolic dysfunction-associated steatotic liver disease and alcohol-related liver disease. The treatment landscape is evolving and requires a multidisciplinary approach, often involving multi-modal treatments that include surgical resection, transplantation, local regional therapies, and systemic treatments. The optimal approach to the care of the HCC patient requires a multidisciplinary team involving hepatology, medical oncology, diagnostic and interventional radiology, radiation oncology, and surgery. In order to determine which approach is best, an individualized treatment plan should consider the patient's liver function, functional status, comorbidities, cancer stage, and preferences. In this review, we provide an overview of the current treatment options and key trials that have revolutionized the management of HCC. We also discuss evolving treatment paradigms for the future.

Development and validation of a machine learning-based early prediction model for massive intraoperative bleeding in patients with primary hepatic malignancies

BACKGROUND

Surgical resection remains the primary treatment for hepatic malignancies, and intraoperative bleeding is associated with a significantly increased risk of death. Therefore, accurate prediction of intraoperative bleeding risk in patients with hepatic malignancies is essential to preventing bleeding in advance and providing safer and more effective treatment.

AIM

To develop a predictive model for intraoperative bleeding in primary hepatic malignancy patients for improving surgical planning and outcomes.

METHODS

The retrospective analysis enrolled patients diagnosed with primary hepatic malignancies who underwent surgery at the Hepatobiliary Surgery Department of the Fourth Hospital of Hebei Medical University between 2010 and 2020. Logistic regression analysis was performed to identify potential risk factors for intraoperative bleeding. A prediction model was developed using Python programming language, and its accuracy was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 406 primary liver cancer patients, 16.0% (65/406) suffered massive intraoperative bleeding. Logistic regression analysis identified four variables as associated with intraoperative bleeding in these patients: ascites [odds ratio (OR): 22.839; P < 0.05], history of alcohol consumption (OR: 2.950; P < 0.015), TNM staging (OR: 2.441; P < 0.001), and albumin-bilirubin score (OR: 2.361; P < 0.001). These variables were used to construct the prediction model. The 406 patients were randomly assigned to a training set (70%) and a prediction set (30%). The area under the ROC curve values for the model's ability to predict intraoperative bleeding were 0.844 in the training set and 0.80 in the prediction set.

CONCLUSION

The developed and validated model predicts significant intraoperative blood loss in primary hepatic malignancies using four preoperative clinical factors by considering four preoperative clinical factors: ascites, history of alcohol consumption, TNM staging, and albumin-bilirubin score. Consequently, this model holds promise for enhancing individualised surgical planning.

Sonographic features of thoracoabdominal wall metastases of liver cancer after liver transplantation

Objective

Sonographic features are not well-defined in thoracoabdominal wall metastases (TAWM) of liver cancer after liver transplantation (LT), which is one of the most important reasons affecting the long-term survival of transplant recipients. The purpose of this study was to analyze the sonographic features of TAWM from liver cancer after LT and to identify the role of ultrasound (US) in the differential diagnosis between TAWM and benign lesions of the thoracoabdominal wall after LT.

Methods

This retrospective study included 1,999 LT recipients between January 2008 and July 2021. Clinical characteristics and sonographic features of 32 patients with thoracoabdominal wall lesions were analyzed. The types of thoracoabdominal wall lesions were studied, and the US findings of benign and malignant lesions were compared. Whether TAWM from liver cancer after LT exhibited any distinctive sonographic appearance was evaluated.

Results

All seven malignant cases were metastases from liver cancer. The benign group included 13 cases of thoracoabdominal wallencapsulated effusion/hematoma, nine of abdominal incisional hernia, and three of thoracoabdominal wall inflammatory mass. Sonographic features were significantly different between two groups. Compared with the benign group, metastases lesions were frequently located in the parietal peritoneum/pleura (4/7 vs 1/25, p = 0.009), fewer lesions were located at abdominal incisions (3/7 vs 23/25, p = 0.012), all metastatic lesions were hypoechoic (7/7 vs 5/25, p = 0.001), and most lesions had blood flow signals (4/7 vs 3/25, p = 0.026). Additionally, most metastatic cases had intrahepatic lesions (4/7 vs 1/25, p = 0.004) and multiple extrahepatic solid lesions in the abdomen (6/7 vs 0/25, p = 0.000).

Conclusions

Compared with benign lesions, TAWM of liver cancer after LT exhibited unique sonographic features.

Decoding Immune Signature to Detect the Risk for Early-Stage HCC Recurrence

Hepatocellular carcinoma (HCC) is often recognized as an inflammation-linked cancer, which possesses an immunosuppressive tumor microenvironment. Curative treatments such as surgical resection, liver transplantation, and percutaneous ablation are mainly applicable in the early stage and demonstrate significant improvement of survival rate in most patients. However, 70-80% of patients report HCC recurrence within 5 years of curative treatment, representing an important clinical issue. However, there is no effective recurrence marker after surgical and locoregional therapies, thus, tumor size, number, and histological features such as cancer cell differentiation are often considered as risk factors for HCC recurrence. Host immunity plays a critical role in regulating carcinogenesis, and the immune microenvironment characterized by its composition, functional status, and density undergoes significant alterations in each stage of cancer progression. Recent studies reported that analysis of immune contexture could yield valuable information regarding the treatment response, prognosis and recurrence. This review emphasizes the prognostic value of tumors associated with immune factors in HCC recurrence after curative treatment. In particular, we review the immune landscape and immunological factors contributing to early-stage HCC recurrence, and discuss the immunotherapeutic interventions to prevent tumor recurrence following curative treatments.

Immune checkpoint inhibitor therapy for malignant tumors in liver transplantation recipients: A systematic review of the literature

BACKGROUND

Treatment for de novo or recurrent tumors of liver transplantation (LT) recipients is challenging and immune checkpoint inhibitor (ICI) is recently well developed and could be a potentially effective option for this population. There remains limited evidence on the safety and efficacy of ICI therapy in LT recipients.

METHODS

A systematic literature search was conducted on PubMed database through April 1, 2022, to identify publications reporting ICI treatment for malignant tumors in LT recipients. We summarized the allograft rejection, mortality, and tumor response of ICI treatment.

RESULTS

24 articles with 41 LT recipients were identified. The age of LT recipients ranged from 14 to 78, 76.2% were male, 56.1% had recurrent HCC, and 87.8% received anti-PD-1 therapy. Allograft rejection occurred in 31.7% of patients, death was reported in 46.3% and 6 cases died secondary to allograft rejection. Progressive disease rate of this population was 48.8% and 10 patients responded to immunotherapy. Half of recipients with positive PD-L1 staining (4/8) experienced allograft rejection.

CONCLUSIONS

ICI therapy has potential therapeutic value on malignant tumors for LT recipients, accompanied by a high rate of allograft rejection and mortality. PD-L1 expression, type of ICI, and immunosuppression agent should be taken into consideration before initiation of immunotherapy. Further studies are needed to optimize this anticancer treatment approach in these patients.

A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality

BACKGROUND

Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

METHODS

Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

RESULTS

Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

CONCLUSION

A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

Tumour site is a risk factor for hepatocellular carcinoma after hepatectomy: a 1:2 propensity score matching analysis

Background

The effect of the anatomic location of HCC on the prognosis of patients after hepatectomy is currently unclear.

Methods

Patients who underwent hepatectomy were retrospectively enrolled and divided into the right tumour resection group (R group) and the left tumour resection group (L group) according to the tumour anatomic location. To avoid bias, 1:2 propensity score matching (PSM) analysis was used. Based on the survival data, disease-free survival (DFS) and overall survival (OS) were evaluated by the Kaplan–Meier method, and long-term survival analysis was performed. Cox proportional hazards regression was used to analyse the risk factors associated with postoperative prognosis.

Results

A total of 700 patients were enrolled in our study. After 1:2 PSM, 354 and 177 patients were enrolled in the R group and the L group, respectively, with comparable baseline characteristics. Survival analysis showed that patients in the L group had a significantly higher recurrence rate than patients in the R group (P = 0.036), but there was no significant difference in the survival rate (P = 0.99). Long-term survival analysis showed that the survival rate of the L group was lower than that of the R group (P < 0.01). Multivariate analysis showed that tumour location in the left liver was an independent risk factor for tumour recurrence (hazard ratio, 1.263; 95% CI, 1.005–1.587) and long-term survival (hazard ratio, 3.232; 95% CI, 1.284–8.134).

Conclusion

For HCC patients, the recurrence rate and long-term survival rate of left liver tumours were significantly higher than those of right liver tumours, indicating that the anatomical location of the tumour has a significant effect on the survival of HCC patients.

Trial registration Chinese Clinical Trial Registry, ChiCTR2100052407. Registered 25 October 2021, http://www.chictr.org.cn/showproj.aspx?proj=135500.

Verifying the Benefits of Radical Treatment in Posttransplant Hepatocellular Carcinoma Oligo-recurrence: A Propensity Score Analysis

This study verified whether radical treatment for hepatocellular carcinoma (HCC) oligo-recurrence after liver transplantation conveys survival benefits. A retrospective study of 144 patients with posttransplant HCC recurrence was performed. Propensity score matching was performed to adjust for baseline covariates between patients who received radical and palliative treatments. The primary endpoint was postrecurrence survival. A total of 50 patients (35%) received radical treatment for recurrence, and 76 (53%) and 18 (13%) patients received palliative and supportive treatments, respectively. Compared with the radical group, patients who received palliative treatment had more early recurrences (time from transplant 17 versus 11 months; P = 0.01) and more extensive disease in terms of tumor numbers (1 versus 4; P < 0.001), size of largest tumor (1.8 versus 2.5 cm; P = 0.046), numbers of involved organs (interquartile range [IQR], 1-1 versus 1-2; P = 0.02), and alpha-fetoprotein (AFP) level (7 versus 40 ng/mL; P = 0.01). Multivariate Cox regression analysis revealed that early recurrence (time from transplant hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P = 0.001), larger recurrent tumor (HR, 1.12; 95% CI, 1.03-1.23; P = 0.01), liver recurrence (HR, 1.84; 95% CI, 1.17-2.90; P = 0.01), and log₁₀ AFP level at recurrence (HR, 1.27; 95% CI, 1.07-1.52; P = 0.01) predicted poor survival. Mammalian target of rapamycin inhibitor (HR, 0.331; 95% CI, 0.213-0.548; P < 0.001) and radical treatment (HR, 0.342; 95% CI, 0.213-0.548; P < 0.001) were associated with improved survival. After 2-to-1 propensity score matching for covariates, the 50 patients who received curative treatment survived significantly longer than the 25 matched patients who received palliative treatment (median survival time, 30.9 ± 2.4 versus 19.5 ± 3.0 months; P = 0.01). Radical treatment conveys survival benefits to HCC oligo-recurrence after liver transplantation.

Biological therapies in patients with liver disease: are they really lifesavers?

INTRODUCTION

The liver plays a key role in the setting of immune tolerance. Targeting antigens for presentation by antigen-presenting cells in the liver can induce immune tolerance to either autoantigens from the liver itself or organs outside of the liver. Despite its non-conventional capacity for tolerance induction, the liver remains a target organ for autoimmune diseases. Whereas chronic inflammation and intra-hepatic immuno-suppressive microenvironment occurring during liver fibrosis lead to hepatocellular carcinoma. Monoclonal antibodies have revolutionized the therapeutic strategies of many autoimmune diseases and some cancers.

AREAS COVERED

We review data from literature regarding the safety and efficacy of biologics in treating hepatobiliary autoimmune diseases and primary liver cancers. Furthermore, we describe their potential use in the setting of liver transplants and their main immune-related liver adverse events.

EXPERT OPINION

Biological therapies have changed the natural history of main autoimmune diseases and solid cancers. Compared to other organs and disease settings, the liver lags behind in biologics and their applications. The development of novel diagnostic and therapeutic strategies based on the immunological and antigenic characteristics of the hepatobiliary system could reduce mortality and transplant rates linked to chronic liver diseases.

Performance of Dual-tracer PET-CT for Staging Post-Liver Transplant Hepatocellular Carcinoma Recurrence

Precise staging is essential in the management of patients with recurrent hepatocellular carcinoma (HCC) after liver transplantation. There is no current consensus on the optimal staging strategy. We conducted this study to evaluate the performance of dual-tracer positron emission tomography-computed tomography (PET-CT) for this purpose and to investigate whether the results of dual-tracer PET-CT affected patient management.

Methods

A retrospective study was conducted. Patients who underwent dual-tracer PET-CT for suspected or confirmed HCC recurrence after liver transplant were included. The lesion-based sensitivity and positive predictive value of dual-tracer PET-CT were determined.

Results

Fifty-six patients and 189 recurrent tumors were included. The lesion-based sensitivity and positive predictive value of dual-tracer PET-CT were 94.7% and 90.4%, respectively. The sensitivity of dual-tracer PET-CT was better than the standard imaging in the surveillance protocol (82.5% versus 94.7%, P < 0.001), especially for detecting liver recurrence (71.0% versus 96.8%, P < 0.001). Half of the dual-tracer PET-CT detected additional recurrence (n = 26, 46.4%) and one-third led to a change in management (n = 19, 33.9%). Ten patients (17.9%) with inconclusive standard imaging had metabolic recurrence confirmed on PET-CT and treatment was commenced early. Four patients (7.1%) had revised locoregional treatment, and 5 (8.9%) had to withdraw from locoregional treatment after the detection of additional metastatic disease.

Conclusions

Dual-tracer PET-CT is effective for staging posttransplant HCC recurrence. It often provides valuable information to guide clinical management.

Surgical Outcome of Pulmonary Metastasectomy for Hepatocellular Carcinoma Recurrence in Liver Transplant Patients

Background

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) results in poor survival outcome. This study assessed the clinical outcomes of pulmonary metastasectomy in LT recipients with pulmonary metastasis of HCC in a high-volume transplant center and analyzed factors prognostic of survival following metastasectomy.

Material/Methods

This study analyzed outcomes in 52 patients who underwent pulmonary resection due to pulmonary metastasis as the first recurrence of HCC after LT from January 2004 to December 2017 in a single center.

Results

The 52 enrolled patients included 46 men and 6 women, aged 56.0±6.6 years. Their 1-, 3-, and 5-year survival rates after pulmonary resection were 75.0%, 43.5%, and 33.9%, respectively. The 1-, 3-, and 5-year survival rates were 85.3%, 47.1%, and 34.2%, respectively, in patients with further metastases and 55.6%, 38.1%, and 38.1%, respectively, in patients without further metastases (P=0.45). The size and number of pulmonary metastatic nodules were unrelated to survival rates (all P>0.10). A shorter recurrence-free period after LT (hazard ratio [HR]=0.553, P=0.006), elevated alpha-fetoprotein concentration at metastasectomy (HR=2.142, P=0.03), and adjuvant chemotherapy after metastasectomy (HR=3.79, P=0.003) were independent risk factors for survival after metastasectomy.

Conclusions

Pulmonary metastasectomy for HCC recurrence in LT recipients showed favorable survival outcomes. Independent risk factors for survival after metastasectomy included recurrence-free survival after LT, alpha-fetoprotein level at metastasectomy, and adjuvant chemotherapy after metastasectomy.

Surgical treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world, and cirrhosis is a risk factor for HCC. Resection is indicated for those unilobar tumors without vascular invasion and metastases in the liver and preserved liver function. Small HCC (< 2 cm) without microvascular invasion is associated with a 5-year recurrence rate as high as 50% to 60%, whereas liver transplantation is indicated for those within the Milan criteria (solitary tumor ≤ 5 cm or two or three nodules ≤ 3 cm) who have decompensated cirrhosis. The 1-, 3-, and 5-year survival rates of living donor liver transplantation for HCC are 85%, 75%, and 70%, respectively. This review summarizes the scientific evidence supporting the clinical practice recommendations for patients with HCC, and it discusses surgical treatment of HCC.

Liver Transplantation Following Yttrium-90 Radioembolization: 15-Year Experience in 207-Patient Cohort

BACKGROUND AND AIMS

Radioembolization (yttrium-90 [Y90]) is used in hepatocellular carcinoma (HCC) as a bridging as well as downstaging liver-directed therapy to curative liver transplantation (LT). In this study, we report long-term outcomes of LT for patients with HCC who were bridged/downstaged by Y90.

APPROACH AND RESULTS

Patients undergoing LT following Y90 between 2004 and 2018 were included, with staging by United Network for Organ Sharing (UNOS) tumor-node-metastasis criteria at baseline pre-Y90 and pre-LT. Post-Y90 toxicities were recorded. Histopathological data of HCC at explant were recorded. Long-term outcomes, including overall survival (OS), recurrence-free survival (RFS), disease-specific mortality (DSM), and time-to-recurrence, were reported. Time-to-endpoint analyses were estimated using Kaplan-Meier. Univariate and multivariate analyses were performed using a log-rank test and Cox proportional-hazards model, respectively. During the 15-year period, 207 patients underwent LT after Y90. OS from LT was 12.5 years, with a median time to LT of 7.5 months [interquartile range, 4.4-10.3]. A total of 169 patients were bridged, whereas 38 were downstaged to LT. Respectively, 94 (45%), 60 (29%), and 53 (26%) patients showed complete, extensive, and partial tumor necrosis on histopathology. Three-year, 5-year, and 10-year OS rates were 84%, 77%, and 60%, respectively. Twenty-four patients developed recurrence, with a median RFS of 120 (95% confidence interval, 69-150) months. DSM at 3, 5, and 10 years was 6%, 11%, and 16%, respectively. There were no differences in OS/RFS for patients who were bridged or downstaged. RFS was higher in patients with complete/extensive versus partial tumor necrosis (P < 0.0001). For patients with UNOS T2 treated during the study period, 5.2% dropped out because of disease progression.

CONCLUSIONS

Y90 is an effective treatment for HCC in the setting of bridging/downstaging to LT. Patients who achieved extensive or complete necrosis had better RFS, supporting the practice of neoadjuvant treatment before LT.

Anti-Programmed Cell Death Protein 1 (PD-1) Immunotherapy for Metastatic Hepatocellular Carcinoma After Liver Transplantation: A Report of Three Cases

The treatment of recurrent hepatocellular carcinoma (HCC) after liver transplantation is difficult due to the lack of effective treatment options. The available evidence on the emerging immunotherapy in liver transplantation is based on anecdotal experiences and requires additional investigations. To determine the efficacy and safety of immunotherapy in liver transplant recipients, we report three cases of recurrent metastatic HCC after liver transplantation who were treated with nivolumab as off-label salvage therapy.

AFP ratio predicts HCC recurrence after liver transplantation

Background/aims

Hepatocellular carcinoma (HCC) is a leading indication for liver transplantation (LT) worldwide. Early identification of patients at risk for HCC recurrence is of paramount importance since early treatment of recurrent HCC after LT may be associated with increased survival. We evaluated incidence of and predictors for HCC recurrence, with a focus on the course of AFP levels.

Methods

We performed a retrospective, single-center study of 99 HCC patients who underwent LT between January 28^th, 1997 and May 11^th, 2016. A multi-stage proportional hazards model with three stages was used to evaluate potential predictive markers, both by univariate and multivariable analysis, for influences on 1) recurrence after transplantation, 2) mortality without HCC recurrence, and 3) mortality after recurrence.

Results

19/99 HCC patients showed recurrence after LT. Waiting time was not associated with overall HCC recurrence (HR = 1, p = 0.979). Similarly, waiting time did not affect mortality in LT recipients both with (HR = 0.97, p = 0.282) or without (HR = 0.99, p = 0.685) HCC recurrence. Log₁₀-transformed AFP values at the time of LT (HR 1.75, p = 0.023) as well as after LT (HR 2.07, p = 0.037) were significantly associated with recurrence. Median survival in patients with a ratio (AFP at recurrence divided by AFP 3 months before recurrence) of 0.5 was greater than 70 months, as compared to a median of only 8 months in patients with a ratio of 5.

Conclusion

A rise in AFP levels rather than an absolute threshold could help to identify patients at short-term risk for HCC recurrence post LT, which may allow intensification of the surveillance strategy on an individualized basis.

Outcomes Following Resection of Hepatocellular Carcinoma in the Absence of Cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) occasionally occurs in non-cirrhotic patients; however, outcomes for these patients are not extensively documented.

METHODS

We performed an institutional review of patients without cirrhosis who underwent resection for HCC. Clinical data were evaluated to identify factors impacting recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Forty-two patients underwent hepatectomy for HCC in the absence of cirrhosis over a 10-year period. Median follow-up was 22 months. For the entire cohort, 1-, 3-, and 5-year RFS was 62%, 42%, and 38% and 1-, 3-, and 5-year OS was 78%, 60%, and 49%, respectively. On univariate analysis, RFS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.027), vascular invasion (p = 0.030), elevated alkaline phosphatase (p = 0.004), and tumor size > 10 cm (p = 0.016). OS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.044), obesity (p = 0.036), and elevated alkaline phosphatase (p = 0.007) with a trend towards decreased OS for tumor size > 10 cm (p = 0.07).

CONCLUSIONS

Patients undergoing resection for HCC in the absence of cirrhosis have fairly high recurrence and modest survival rates. Pre-operative alkaline phosphatase, tumor size, tumor encapsulation, and vascular invasion are important prognostic factors.

Liver transplantation for colorectal liver metastasis

PURPOSE OF REVIEW

The aim of this review is to discuss existing data on liver transplantation for colorectal liver metastasis, emerging controversies, and future directions.

RECENT FINDINGS

Contemporary experience with transplanting patients with liver metastasis from colon cancer is mainly derived from European centers, with a large proportion being from a single institution (SECA study), made possible in part by a relatively high donor pool. The initial results prove to be encouraging by demonstrating an overall survival advantage over unresectable patients with liver-limited disease managed with chemotherapy only. Recurrence patterns, however, suggest a need for better patient selection and treatment sequencing optimization. In North America, the main barriers in establishing similar protocols result from national liver graft shortage, which represents an issue of competing resources when indications have yet to be well defined. Evolving strategies in transplantation, such as the utilization of marginal liver grafts and living donor liver transplantation might constitute potential solutions.

SUMMARY

Evidence suggests a potential survival benefit of liver transplantation for a subset of patients with unresectable liver-limited CRLM. Further prospective trials are needed to clarify the role and feasibility of this treatment strategy in oncotransplantation.

Efficacy and Safety of Sorafenib After Liver Transplantation: Experience in Our Center

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is increasing, with a consequent impact on survival. Here we report our experience with sorafenib to treat HCC recurrence after LT. PATIENTS AND METHODS: We undertook a retrospective cohort study of LT patients with recurrent HCC. RESULTS: The study included 12 patients with recurrent HCC after LT between January 2008 and March 2019; 9 were men and 3 women, with a median age of 58 years. Adverse effects were manageable in most patients with symptomatic treatment or with sorafenib dose adjustment. Stable disease was the best response and was achieved. Eight patients (66.7%) died during the study period, 5 (62.5%) due to tumor progression and 3 (37.5%) because of sepsis. The median survival time was 7.5 months.

Liver transplantation for hepatocellular carcinoma: Management after the transplant

Hepatocellular carcinoma (HCC) is an increasingly common indication for liver transplantation (LT) in the United States and in many parts of the world. In the last decade, significant work has been done to better understand how to risk stratify LT candidates for recurrence of HCC following transplant using a combination of biomarker and imaging findings. However, despite the high frequency of HCC in the LT population, guidance regarding posttransplant management is lacking. In particular, there is no current evidence to support specific post-LT surveillance strategies, leading to significant heterogeneity in practices. In addition, there are no current recommendations regarding recurrence prevention, including immunosuppression regimen or secondary prevention with adjuvant chemotherapy. Finally, guidance on treatment of disease recurrence is also lacking and there is significant controversy about the use of immunotherapy in transplant recipients due to the risk of rejection. Thus, outcomes for patients with recurrence are poor. This paper therefore provides a comprehensive review of the current literature on post-LT management of patients with HCC and identifies gaps in our current knowledge that are in urgent need of further investigation.

Clinical and laboratory parameters as predictors of long-term outcome according to the etiology of underlying chronic liver disease in patients who underwent liver transplantation for hepatocellular carcinoma treatment

OBJECTIVES

This study aimed to analyze clinical and laboratory parameters and their association with long-term outcomes in patients who underwent liver transplantation for hepatocellular carcinoma treatment, according to the etiology of the underlying chronic liver disease, in order to identify predictors of response to this therapeutic modality.

METHODS

Demographic, clinical, and laboratory data from a cohort of 134 patients who underwent orthotopic liver transplantation for hepatocellular carcinoma treatment at a referral center in Brazil were retrospectively selected and compared according to the etiologic group of the underlying chronic liver disease. Events, defined as tumor recurrence or death from any cause, and event-free survival were also analyzed, and multivariate analysis was performed.

RESULTS

The etiologies comprised hepatitis C and B virus infection, alcohol abuse, and cryptogenic disorder. Although liver transplantation was performed outside the Milan criteria in 33.3% of the subjects, according to pathologic examination of the explanted liver, the Model for End-Stage Liver Disease score was low (<22) in most patients (70.6%) and recurrence was identified in only 10 (7.9%) patients. Events occurred in 37 patients (28.5%), and the median event-free survival was 75 months (range, 24-116 months). No difference among etiologic groups was found in the parameters analyzed, which were not independently associated with outcome.

CONCLUSION

Clinical and laboratory characteristics according to etiologic groups were not different, which might have led to comparable long-term outcomes among these patient groups and failure to identify predictors that could aid in better selection of subjects for liver transplantation in the management of this cancer.

Statin Use is Associated with Decreased Hepatocellular Carcinoma Recurrence in Liver Transplant Patients

Statins have been reported to prevent the development of hepatocellular carcinoma (HCC). We examined whether statin therapy is associated with decreased HCC recurrence in patients who underwent liver transplantation for HCC. Three hundred forty-seven patients ≥ 20 years old who underwent liver transplantation for HCC from 2006 to 2016 were enrolled in this study. Statin therapy was defined as the administration of statins for more than 30 days after liver transplantation. One hundred twelve (32.3%) patients treated with statins over 30 days were defined as the statin group, and the remaining 235 (67.7%) were defined as the non-statin group. Several risk factors reported to be associated with HCC recurrence, such as proportion of underlying liver disease, above Milan criteria, differentiation of HCC, vascular invasion, and preoperative alpha-fetoprotein level were not different between the two groups. Time-dependent Cox regression analysis showed that statin treatment was associated with significantly lower recurrence risk of HCC after adjusting for other risk factors (hazard ratio = 0.32, 95% CI = 0.11–0.89).

Novel Combination of Mesenchymal Stem Cell-Conditioned Medium with Sorafenib Have Synergistic Antitumor Effect of Hepatocellular Carcinoma Cells

Objective:

Hepatocellular carcinoma (HCC) is the most common liver malignancy. Sorafenib is the first-line systemic treatment for advanced HCCs. However, due to safety concerns, researchers are now looking for ways to boost the efficacy of the medication. One approach for reducing toxicity is combining sorafenib with other agents so that a lower dose of sorafenib is required. Mesenchymal stromal cells (MSCs) can have an inhibitory effect on HCC tumor growth. Mesenchymal Stem Cell-Conditioned Medium (MSC-CM) is the substance extracted from MSC culture and contains most of the potential cytokines secreted by MSCs. We, therefore, anticipated a synergistic Antitumor Effect of sorafenib in Combination with MSC-CM. In this study, we used HepG2 as our target cell lines.

Methods:

HepG2 cells were treated with sorafenib alone and with sorafenib + MSC-CM. CCK-8 assay was used to evaluate and compare the inhibition of cell growth between the two groups with different treatments.

Results:

The combination treatment of cell lines with sorafenib and MSC-CM had significantly reduced the values of IC50 compared to the use of sorafenib alone (3.4 vs. 2.7 respectively).

Conclusion:

This study suggests that a combination of sorafenib with MSC-CM can synergistically suppress the growth of HCC cells.

Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm

A large number of liver transplants have been performed for hepatocellular carcinoma (HCC), and recurrence is increasingly encountered. The recurrence of HCC after liver transplantation is notoriously difficult to manage. We hereby propose multi-disciplinary management with a systematic approach. The patient is jointly managed by the transplant surgeon, physician, oncologist and radiologist. Immunosuppressants should be tapered to the lowest effective dose to protect against rejection. The combination of a mammalian target of rapamycin inhibitor with a reduced calcineurin inhibitor could be considered with close monitoring of graft function and toxicity. Comprehensive staging can be performed by dual-tracer positron emission tomography-computed tomography or the combination of contrast computed tomography and a bone scan. In patients with disseminated recurrence, sorafenib confers survival benefits but is associated with significant drug toxicity. Oligo-recurrence encompasses recurrent disease that is limited in number and location so that loco-regional treatments convey disease control and survival benefits. Intra-hepatic recurrence can be managed with graft resection, but significant operative morbidity is expected. Radiofrequency ablation and stereotactic body radiation therapy (SBRT) are effective alternative strategies. In patients with more advanced hepatic disease, regional treatment with trans-arterial chemoembolization or intra-arterial Yttrium-90 can be considered. For patients with extra-hepatic oligo-recurrence, loco-regional treatment can be considered if practical. Patients with more than one site of recurrence are not always contraindicated for curative treatments. Surgical resection is effective for patients with pulmonary oligo-recurrence, but adequate lung function is a pre-requisite. SBRT is a non-invasive and effective modality that conveys local control to pulmonary and skeletal oligo-recurrences.

Spotlight on Bortezomib: potential in the treatment of hepatocellular carcinoma

INTRODUCTION

This study reviews the evidence for the use of Bortezomib (BZB), a first-in-class proteasome inhibitor in advanced Hepatocellular carcinoma (HCC). This review aims to delineate the role of BZB within the management of non-surgical and metastatic HCC, either as an alternative or as an adjunct to the current treatment paradigm.

AREAS COVERED

In addition to BZB pharmacology and mechanism of action, safety and tolerance profiles of the drug obtained from clinical trials are explored. The utility of BZB as a therapeutic agent either alone or in combination with other therapies against HCC, including its application in both preclinical and clinical settings has been reviewed. In particular, we highlight the importance of preclinical evaluation of BZB as a combinatorial agent in synergism with other therapies for the use in the management of HCC.

EXPERT OPINION

There has been much interest surrounding the use of BZB, a first-in-class proteasome inhibitor for HCC therapy. The discernment of outcomes of BZB clinical trials for HCC need to take into consideration the disease-specific factors that can affect survival outcomes including patient selection and aetiological differences. Further preclinical testing of BZB in combination with other therapeutic modalities can be important for eliciting enhanced anti-HCC effects.

Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Background

To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) from live donors (LD) or extended criteria donors (ECD).

Methods

Data from consecutive LT procedures for HCC involving either LD or ECD were reviewed. Patient survival was our primary outcome. Re-transplantation (Re-LT), ischemic type bile lesions (ITBL), and tumor recurrence represented secondary outcomes. The primary outcome was statistically analyzed using Kaplan-Meier estimates and Cox proportional hazards regression; logistic regression analyses were used for statistical analysis of the secondary outcomes. Propensity score was calculated based on patient age, sex, hepatitis C viral infection (HCV), laboratory model for end-stage liver disease (labMELD) score, bridging treatment, Milan criteria, α-fetoprotein levels, and tumor grade.

Results

The study evaluated 109 recipients undergoing LT from either LD (n=57) or ECD (n=52). LT procedure (hazard ratio [HR] 2.349, 95% confidence interval [CI] 1.151-4.794, P=0.0190), age (HR 1.075, 95%CI 1.020-1.133, P=0.0074) and labMELD score (HR 1.082, 95%CI 1.021-1.147, P=0.0075) reached significance by Cox proportional hazards regression. After adjustment with the propensity score (stratification with 5 strata), the LT procedure was still significant (HR 2.401, 95%CI 1.114-5.175, P=0.0253). Tumor grade (odds ratio [OR] 9.628, 95%CI 1.120-82.752, P=0.0391), labMELD score (OR 1.224, 95%CI 1.019-1.471, P=0.0306), and Milan criteria (OR 6.375, 95%CI 1.239-32.796, P=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL, and tumor recurrence, respectively.

Conclusions

LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, ITBL, and tumor recurrence showed no significant differences between the two groups. However, the diverging criteria for the definition of ECD grafts represent a considerable limitation for the wide application of this policy.

Hepatobiliary MRI as novel selection criteria in liver transplantation for hepatocellular carcinoma

BACKGROUND & AIMS

Hepatobiliary magnetic resonance imaging (MRI) provides additional information beyond the size and number of tumours, and may have prognostic implications. We examined whether pretransplant radiological features on MRI could be used to stratify the risk of tumour recurrence after liver transplantation (LT) for hepatocellular carcinoma (HCC).

METHODS

A total of 100 patients who had received a liver transplant and who had undergone preoperative gadoxetic acid-enhanced MRI, including the hepatobiliary phase (HBP), were reviewed for tumour size, number, and morphological type (e.g. nodular, nodular with perinodular extension, or confluent multinodular), satellite nodules, non-smooth tumour margins, peritumoural enhancement in arterial phase, peritumoural hypointensity on HBP, and apparent diffusion coefficients. The primary endpoint was time to recurrence.

RESULTS

In a multivariable adjusted model, the presence of satellite nodules [hazard ratio (HR) 3.07; 95% confidence interval (CI) 1.14-8.24] and peritumoural hypointensity on HBP (HR 4.53; 95% CI 1.52-13.4) were identified as independent factors associated with tumour recurrence. Having either of these radiological findings was associated with a higher tumour recurrence rate (72.5% vs. 15.4% at three years, p <0.001). When patients were stratified according to the Milan criteria, the presence of these two high-risk radiological findings was associated with a higher tumour recurrence rate in both patients transplanted within the Milan criteria (66.7% vs. 11.6% at three years, p <0.001, n = 68) and those who were transplanted outside the Milan criteria (75.5% vs. 28.6% at three years, p <0.001, n = 32).

CONCLUSIONS

Radiological features on preoperative hepatobiliary MRI can stratify the risk of tumour recurrence in patients who were transplanted either within or outside the Milan criteria. Therefore, hepatobiliary MRI can be a useful way to select potential candidates for LT.

LAY SUMMARY

High-risk radiological findings on preoperative hepatobiliary magnetic resonance imaging (either one of the following features: satellite nodule and peritumoural hypointensity on hepatobiliary phase) were associated with a higher tumour recurrence rate in patients transplanted either within or outside the Milan criteria.

Liver targeted therapies for hepatocellular carcinoma prior to transplant: contemporary management strategies

Hepatocellular carcinoma (HCC) is an aggressive neoplastic disease that has been rapidly increasing in incidence. It usually occurs in the background of liver disease, and cirrhosis. Definitive therapy requires surgical resection. However, in majority of cases surgical resection is not tolerated, especially in the presence of portal hypertension and cirrhosis. Orthotopic liver transplant (OLT) in well selected candidates has been accepted as a viable option. Due to a relative scarcity of donors compared to the number of listed recipients, long waiting times are anticipated. To prevent patients with HCC from dropping out from the transplant list due to progression of their disease, most centers utilize loco-regional therapies. These loco-regional therapies(LRT) include minimally invasive treatments like percutaneous thermal ablation, trans-arterial chemoembolization, trans-arterial radio-embolization or a combination thereof. The type of therapy or combination used is determined by the size and location of the HCC and Barcelona Clinic Liver Cancer (BCLC) classification. The data regarding the efficacy of LRT in reducing post-transplant recurrence or disease-free survival is limited. This article reviews the available therapies, their strengths, limitations, and current use in the management of patients with hepatocellular carcinoma awaiting transplant.

Prognostic value of CpG island methylator phenotype among hepatocellular carcinoma patients: A systematic review and meta-analysis

OBJECTIVE

CpG island methylator phenotype (CIMP), characterized by multiple genes are concurrently methylated, has been reported to be associated with the prognosis of colorectal cancer. However, current studies have not explored the relationship between CIMP status with hepatocellular carcinoma (HCC) clinicopathological features.

METHODS

To assess these associations, we performed a comprehensive search of PubMed, EMBASE, and the Web of Science to identify all eligible studies. Publication bias was tested using Begg's and Egger's test.

RESULTS

Seven studies that involved 568 HCC patients (379 CIMP+ and 189 CIMP-) were eligible for inclusion in our study. CIMP+ in HCC was significantly associated with distant metastasis (OR = 4.28, 95% CI = 2.57-7.10, P < 0.00001, heterogeneity = 0.888), TNM tumor stage IIII + IV (OR = 5.73, 95% CI = 3.70-8.88, P < 0.0001, heterogeneity = 0.449), cirrhosis (OR = 2.54, 95% CI = 1.33,4.83, P = 0.005, heterogeneity = 0.121) and a higher level of AFP (>300 ng/ml) than those with CIMP- (OR = 2.63, 95% CI = 1.79,3.89, P < 0.00001, heterogeneity = 0.432). Moreover, CIMP+ was associated with an unfavorable overall survival (OS) (HR = 3.02, 95% CI = 1.60-5.70, P < 0.001, heterogeneity = 0.251) and a disease-free survival (DFS) (HR = 2.80, 95% CI = 1.79-4.37, P < 0.001, heterogeneity = 0.603).

CONCLUSION

CIMP is independently associated with significantly worse prognosis in HCC patients. Examination of CIMP status may be useful for identifying patients who are at higher risk for disease progression.

miR‑145‑5p reduces proliferation and migration of hepatocellular carcinoma by targeting KLF5

MicroRNAs (miRs) are important in hepatocellular carcinoma (HCC) progression. miR‑145‑5p acts as a tumor suppressor in certain malignancies, however, its role in HCC remains unclear. The present study aimed to perform a functional analysis of miR‑145‑5p in HCC in order to elucidate its role in the pathogenesis of HCC. Reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR) was performed to analyze tissue and cellular expression of miR‑145‑5p in HCC. Following miRNA mimics transfection, cell viability, apoptosis and cells migration were determined by Cell Counting kit‑8, Annexin V‑FITC/propidium iodide staining and Transwell analyses. The target of miR‑145‑5p was analyzed by luciferase reporter assay and western blot analysis. It was observed that miR‑145‑5p was significantly decreased in HCC tissues and cell lines. Overexpression of miR‑145‑5p significantly increased apoptosis, reduced cell proliferation and suppressed HCC cell migration. Kruppel‑like factor 5 (KLF5) is regarded as a target of miR‑145‑5p in HCC cells. In addition, KLF5 overexpression partially attenuated the tumor suppressive effects of miR‑145‑5p. KLF5 expression was negatively associated with levels of miR‑145‑5p in HCC tissues. The present study demonstrated that miRNA‑145‑5p may, by targeting KLF5, partially suppress HCC cell growth and motility. The results of the present study suggested that miRNA‑145‑5p alteration in HCC may serve a role in the progression of HCC.

Peroxiredoxin 1, restraining cell migration and invasion, is involved in hepatocellular carcinoma recurrence

OBJECTIVE

Hepatocellular carcinoma (HCC) is a high-burden disease. Peroxiredoxin 1 (PRDX1) is a member of the peroxiredoxin family of antioxidant enzymes. The aim of this study was to assess the value of PRDX1 for predicting HCC recurrence after curative resection and to explore the role of PRDX1 in HCC cell migration and invasion.

METHODS

Data of patients with HCC who had undergone complete resection between 2002 and 2006 were collected. Immunohistochemical detection of PRDX1 in HCC tissue and adjacent non-cancerous tissue was conducted. Kaplan-Meier survival estimate and log-rank test were used to assess the relationship between PRDX1 expression and prognostic significance. HCC cell migration and invasion together with the interaction between PRDX1 and ubiquitin C-terminal hydrolase 37 (UCH37) were studied in vitro.

RESULTS

PRDX1 was expressed at lower levels in HCC tissues than in adjacent non-cancerous tissues, and PRDX1 was found to be an independent risk factor for disease-free survival and overall survival. PRDX1 restrained cell migration and invasion in vitro. PRDX1 was found to interact with UCH37 to affect HCC cell migration and invasion.

CONCLUSION

PRDX1 restrains cell migration and invasion in HCC cell lines and that may be involved in a UCH37-relevant pathway, suggesting that PRDX1 may be a new marker for HCC recurrence after surgery.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

Liver-directed therapy for hepatocellular carcinoma

Liver-directed therapy is a critical component of treatment strategies for hepatocellular carcinoma. These therapies included percutaneous image-guided ablation, transarterial chemoembolization, and transarterial radioembolization, and are administered by interventional radiologists. Depending on the stage of disease, a particular treatment modality, or a combination thereof, is expected to be most efficacious in achieving the goals of treatment for a particular patient. This article seeks to review the various liver-directed treatment modalities for treatment of hepatocellular carcinoma, with attention to their efficacy and patient selection criteria.

Arsenite-loaded nanoparticles inhibit the invasion and metastasis of a hepatocellular carcinoma: in vitro and in vivo study

Postoperative recurrence and metastasis are the major problems for the current treatment of hepatocellular carcinomas (HCC) in the clinic, including hepatectomy and liver transplantation. Here, we report that arsentic-loaded nanoparticles (ALNPs) are able to reduce the invasion of HCC cells in vitro, and, more importantly, can strongly suppress the invasion and metastasis of HCC in vivo without adverse side effects. Compared to free drug arsenic trioxide , ALNPs can deliver the drug into cancer cells more efficiently, destroy the structure of microtubules and reduce the aggregation of microfilaments in cell membranes more significantly. Furthermore, our results also reveal that tumor cells in murine blood were reduced remarkably after intravenous injection of ALNPs, indicating that this nano-drug may efficiently kill circulating tumor cells in vivo. In conclusion, our nano-drug ALNPs have great potential for the suppression of metastasis of HCC, which may open up a new avenue for the effective treatment of HCC without metastasis and recurrence.

Outcomes of Simultaneous Liver Kidney Transplantation in Patients With Hepatocellular Carcinoma

BACKGROUND

The frequency of simultaneous liver kidney (SLK) transplantation has increased following the implementation of the model for end-stage liver disease system for liver transplantation (LT). There is a paucity of data evaluating SLK outcomes in patients undergoing LT for hepatocellular carcinoma (HCC). Our aim was to compare outcomes between patients with HCC who underwent SLK and those who received SLK for other indications.

METHODS

We performed a retrospective analysis of adult recipients receiving SLK between 2002 and 2013 from the United Network for Organ Sharing registry. The primary outcome was posttransplant mortality. Patient survival was determined using Kaplan-Meier analysis and predictors of mortality were identified using proportional Cox hazard regression models. Propensity score matching was performed between SLK-HCC and SLK in the absence of HCC (SLK-A) groups to reduce confounding.

RESULTS

Between 2002 and 2013, 186 HCC patients underwent SLK-HCC and 3599 patients underwent SLK-A. The 1-year and 3-year survival rates were 89.0% and 76.7% in the SLK-HCC group and 84.5% and 76.3% in the SLK-A group (P = 0.20). In multivariable Cox regression, HCC was not associated with post-LT survival among all patients (hazard ratio, 1.15; 95% confidence interval, 0.84-1.58) or the propensity score-matched cohort (hazard ratio, 0.97; 95% confidence interval, 0.64-1.47). SLK-HCC patients had similar rates of acute rejection (13.3% vs 10.5%, P = 0.36) and liver graft failure requiring re-transplantation (3.2% vs 2.3%, P = 0.44) compared with SLK-A patients.

CONCLUSIONS

Liver transplant candidates with advanced renal dysfunction and HCC may be considered for SLK.

Predictive Value of 18F-FDG PET/CT for Vascular Invasion in Patients With Hepatocellular Carcinoma Before Liver Transplantation

BACKGROUND

Positron emission tomography-computed tomography using F-fluorodeoxyglucose (F-FDG PET/CT) has been widely used in oncology. Vascular invasion of hepatocellular carcinoma (HCC) is associated with a high risk of tumor recurrence and low survival rates after liver transplantation (LT). This retrospective study determined the predictive value of F-FDG PET/CT for vascular invasion in patients with HCC before LT.

METHODS

Sixty-five patients with HCC who underwent F-FDG PET/CT before LT were retrospectively included between January 2010 and July 2012. Volumes of interest (VOIs) were drawn for the tumors and normal liver tissues, and the standardized uptake value (SUV) in each VOI was measured. The maximal SUV (SUVmax) of the tumor, the ratio of tumor SUVmax to normal liver SUVmax (TSUVmax/LSUVmax), and the ratio of tumor SUVmax to normal liver SUVmean (TSUVmax/LSUVmean) were measured. The predictive value of metabolic parameters and conventional prognostic factors were analyzed.

RESULTS

Vascular invasion was pathologically confirmed in 15 (23.08%) of 65 patients. Compared with patients without vascular invasion, patients with vascular invasion exhibited significantly higher serum alpha-fetoprotein (AFP) (P < 0.001), larger tumor size (P = 0.001), higher tumor number (P = 0.017), and higher SUVmax, TSUVmax/LSUVmax ratio, and higher TSUVmax/LSUVmean ratio (P = 0.008, P = 0.002, and P = 0.006, respectively). Univariate analysis revealed that SUVmax, TSUVmax/LSUVmax ratio, and TSUVmax/LSUVmean ratio of FDG PET/CT were significantly associated with vascular invasion in patients with HCC before LT (P = 0.019, P = 0.018, and P = 0.015, respectively). Multivariate analysis revealed that the TSUVmax/LSUVmean ratio of F-FDG PET/CT was a significant predictor of vascular invasion (P = 0.04) and that the TSUVmax/LSUVmax ratio of F-FDG PET/CT was an independent predictor of vascular invasion, although this finding demonstrated borderline statistical significance (P = 0.06) in patients with HCC before LT.

CONCLUSIONS

According to the study results, the TSUVmax/LSUVmean ratio is an independent and significant predictor of vascular invasion, and the TSUVmax/LSUVmax ratio of F-FDG PET/CT is an independent predictor of vascular invasion, which is the main negative outcome after LT. Therefore, FDG PET/CT can provide vital information for determining prognosis and selecting an optimal candidate of LT for HCC.

From Clinical Standards to Translating Next-Generation Sequencing Research into Patient Care Improvement for Hepatobiliary and Pancreatic Cancers

Hepatobiliary and pancreatic (HBP) cancers are associated with high cancer-related death rates. Surgery aiming for complete tumor resection (R0) remains the cornerstone of the treatment for HBP cancers. The current progress in the adjuvant treatment is quite slow, with gemcitabine chemotherapy available only for pancreatic ductal adenocarcinoma (PDA). In the advanced and metastatic setting, only two targeted drugs have been approved by the Food & Drug Administration (FDA), which are sorafenib for hepatocellular carcinoma and erlotinib for PDA. It is a pity that multiple Phase III randomized control trials testing the efficacy of targeted agents have negative results. Failure in the development of effective drugs probably reflects the poor understanding of genome-wide alterations and molecular mechanisms orchestrating therapeutic resistance and recurrence. In the post-ENCODE (Encyclopedia of DNA Elements) era, cancer is referred to as a highly heterogeneous and systemic disease of the genome. The unprecedented potential of next-generation sequencing (NGS) technologies to accurately identify genetic and genomic variations has attracted major research and clinical interest. The applications of NGS include targeted NGS with potential clinical implications, while whole-exome and whole-genome sequencing focus on the discovery of both novel cancer driver genes and therapeutic targets. These advances dictate new designs for clinical trials to validate biomarkers and drugs. This review discusses the findings of available NGS studies on HBP cancers and the limitations of genome sequencing analysis to translate genome-based biomarkers and drugs into patient care in the clinic.

Contribution of alpha-fetoprotein in liver transplantation for hepatocellular carcinoma

Alpha-fetoprotein (AFP) is the main tumor biomarker available for the management of hepatocellular carcinoma (HCC). Although it is neither a good screening test nor an accurate diagnostic tool for HCC, it seems to be a possible prognostic marker. However, its contribution in liver transplantation for HCC has not been fully determined, although its use to predict recurrence after liver transplantation has been underlined by international societies. In an era of organ shortages, it could also have a key role in the selection of patients eligible for liver transplantation. Yet unanswered questions remain. First, the cut-off value of serum AFP above which liver transplantation should not be performed is still a subject of debate. We show that a concentration of 1000 ng/mL could be an exclusion criterion, whereas values of < 15 ng/mL indicate patients with an excellent prognosis whatever the size and number of tumors. Monitoring the dynamics of AFP could also prove useful. However, evidence is lacking regarding the values that should be used. Today, the real input of AFP seems to be its integration into new criteria to select patients eligible for a liver transplantation. These recent tools have associated AFP values with morphological criteria, thus refining pre-existing criteria, such as Milan, University of California, San Francisco, or “up-to-seven”. We provide a review of the different criteria submitted within the past years. Finally, AFP can be used to monitor recurrence after transplantation, although there is little evidence to support this claim. Future challenges will be to draft new international guidelines to implement the use of AFP as a selection tool, and to determine a clear cut-off value above which liver transplantation should not be performed.

Current Treatment Approaches to HCC with a Special Consideration to Transplantation

Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. The mainstay of treatment of HCC has been both resectional and transplantation surgery. It is well known that, in selected, optimized patients, hepatectomy for HCC may be an option, even in patients with underlying cirrhosis. Resectable patients with early HCC and underlying liver disease are however increasingly being considered for transplantation because of potential for better disease-free survival and resolution of underlying liver disease, although this approach is limited by the availability of donor livers, especially in resectable patients. Outcomes following liver transplantation improved dramatically for patients with HCC following the implementation of the Milan criteria in the late 1990s. Ever since, the rather restrictive nature of the Milan criteria has been challenged with good outcomes. There has also been an increase in the donor pool with marginal donors including organs retrieved following cardiac death being used. Even so, patients still continue to die while waiting for a liver transplant. In order to reduce this attrition, bridging techniques and methods for downstaging disease have evolved. Additionally new techniques for organ preservation have increased the prospect of this potentially curative procedure being available for a greater number of patients.

Rhamnetin induces sensitization of hepatocellular carcinoma cells to a small molecular kinase inhibitor or chemotherapeutic agents

BACKGROUND

The rapid development of multi-drug resistance (MDR) process has hindered the effectiveness of advanced hepatocellular carcinoma (HCC) treatments. Notch-1 pathway, which mediates the stress-response, promotes cell survival, EMT (epithelial-mesenchymal transition) process and induces anti-apoptosis in cancer cells, would be a potential target for overcoming MDR process. This study investigated the potential application of rhamnetin, a specific inhibitor of Notch-1 pathway, in anti-tumor drug sensitization of HCC treatment.

METHODS

The expression of miR-34a, proteins belonging to Notch-1 signaling pathway or MDR-related proteins was detected by quantitative polymerase chain reaction (qPCR) and western blot assay. To identify whether rhamnetin induces the chemotherapeutic sensitization in HCC cells, the MTT-assays, flow cytometry, soft agar, trans-well and nude mice assays were performed.

RESULTS

The endogenous expression of miR-34a was significantly increased and the expression of Notch-1 and Survivin was downregulated after rhamnetin treatment. Treatment of rhamnetin also reduced the expression of MDR related proteins P-GP (P-glycoprotein) and BCRP (breast cancer resistance protein). Rhamnetin increased the susceptibility of HCC cells and especially HepG2/ADR, a MDR HCC cell line, to a small molecular kinase inhibitor sorafenib or chemotherapeutic drugs etoposide and paclitaxel. The IC(50) value of those drugs correspondingly decreased.

CONCLUSIONS

Together, our findings suggest that rhamnetin treatment may attenuate the MDR process in HCC cells. These findings may contribute to more effective strategies for HCC therapy.

GENERAL SIGNIFICANCE

Rhamnetin acts as a promising sensitizer to chemotherapy and may be a novel approach to overcome the MDR process of HCC.

Role of endoscopic ultrasound in diagnosis and management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an aggressive tumor and a leading cause of cancer-related deaths globally. The mortality rate remains high despite many advances in treatment. HCC is frequently diagnosed late in its course due to lack of classical symptoms at earlier stages. Endoscopic ultrasound (EUS) has emerged as an important diagnostic tool for the diagnostic evaluation, staging, and treatment of gastrointestinal tract disorders. EUS-guided fine needle aspiration has been a valuable addition to EUS by being able to obtain tissue under direct visualization. Here, we review the potential role of EUS in the diagnosis and management of HCC. EUS seems to be a safe and reliable alternative method for obtaining tissue for diagnosis of liver cancer, especially for lesions that are inaccessible by traditional methods. EUS could play an important role in the diagnosis and management of HCC.

Krüppel-like Factor 4 Blocks Hepatocellular Carcinoma Dedifferentiation and Progression through Activation of Hepatocyte Nuclear Factor-6

PURPOSE

Tumor differentiation is a behavioral index for hepatocellular carcinoma (HCC) and a prognostic factor for patients with HCC who undergo orthotopic liver transplantation (OLT). However, the molecular basis for HCC differentiation and prognostic value of the underlying molecules that regulate HCC differentiation are unclear. In this study, we defined a potential driver pathway for HCC differentiation and prognostication.

EXPERIMENTAL DESIGN

The regulation and function of Krüppel-like factor 4 (KLF4) and hepatocyte nuclear factor-6 (HNF-6) in HCC differentiation was evaluated using human tissues, molecular and cell biology, and animal models, and its prognostic significance was determined according to its impact on patient survival.

RESULTS

There was a direct relationship between the expression levels of KLF4 and HNF6 in HCC. Reduced KLF4 or HNF6 expression correlated with high HCC grade. Poorly differentiated HCC cells had lower expression of KLF4 or HNF6 and differentiation-associated markers than did well-differentiated cells. Elevated KLF4 of HNF6 expression induced differentiation of poorly differentiated hepatoma cells. Mechanistically, KLF4 trans-activated HNF-6 expression. Restored HNF-6 expression upregulated expression of differentiation-associated markers and inhibited HCC cell migration and invasion, whereas HNF-6 knockdown did the opposite. Loss of KLF4 expression in primary HCC correlated with reduced overall survival and shortened relapse-free survival durations after OLT. Combination of KLF4 expression and the Milan criteria improved prognostication for HCC after OLT.

CONCLUSIONS

The dysregulated KLF4/HNF-6 pathway drives dedifferentition and progression of HCC, and KLF4 is a biomarker for accurate prognostication of patients with HCC treated by OLT when integrated with the Milan Criteria.

The phospholipase A2 activity of peroxiredoxin 6 promotes cancer cell death induced by tumor necrosis factor alpha in hepatocellular carcinoma

In this study, we used proteomic profiling to compare hepatocellular carcinoma (HCC) and peri-tumoral tissues to identify potential tumor markers of HCC. We identified eight differentially expressed proteins (>3-fold), including Peroxiredoxin 6 (PRDX6). PRDX6 is a bifunctional enzyme with both peroxidase and calcium-independent phospholipase A2 (iPLA2) activity. We found that peri-tumoral tissues expressed higher levels of PRDX6 mRNA (n = 59, P = 0.018) and protein (n = 265, P < 0.001) than HCC tissues, and that decreased expression of PRDX6 in HCC tissues was an independent risk factor indicating a poor prognosis (n = 145, P = 0.007). Combining the examination of serum PRDX6 with α-fetoprotein improved the diagnostic sensitivity of tests for HCC compared to α-fetoprotein alone (85.0% vs 50.0%, n = 40). We found that PRDX6 induced S phase arrest in HCC cells and inhibited HCC tumorigenicity in mice injected with cancer cells. When treated with H2 O2 , PRDX6 inhibited apoptosis. When treated with tumor necrosis factor alpha (TNF-α), PRDX6 promoted apoptosis. Inhibition of iPLA2 activity of PRDX6 decreased the apoptosis induced by TNF-α. In conclusion, PRDX6 inhibited the carcinogenesis of HCC, and the iPLA2 activity of PRDX6 promoted cancer cell death induced by TNF-α. © 2015 Wiley Periodicals, Inc.

Hepatocellular Carcinoma Growth Is Inhibited by Euphorbia helioscopia L. Extract in Nude Mice Xenografts

Euphorbia helioscopia L. is a traditional Chinese medicine; recently research found that its ethyl acetate extract (EAE) plays an important role on tumor cell proliferation, apoptosis, invasion, and metastasis in vitro. But the effect of EAE for tumor cells in vivo has not been reported. To explore the inhibitory effect of EAE and molecular mechanism on hepatocellular carcinoma (HCC) SMMC-7721 cells in vivo, we utilized the nude mouse xenograft model of HCC. Treated with EAE (50, 100, and 200 μg/mL), the volume of xenograft was measured during the entire process of EAE treatment. In EAE treatment group, the volume of xenograft was significantly reduced compared with the control group (P < 0.05) and the protein expressions of CyclinD1, bcl-2, and MMP-9 were reduced, while those of bax, caspase-3, and nm23-H1 were increased. A significant change trend with increasing EAE concentrations has presented, compared with controls. Moreover, the ultrastructural morphology of xenografts showed significant changes, including nuclear pyknosis and chromatin condensation, We found that EAE could effectively inhibit tumor growth, induce apoptosis, and inhibit tumor invasion and metastasis in vivo; it is suggested that EAE is a potential candidate for as a new anticancer agent.

Classification and staging of hepatocellular carcinoma: an aid to clinical decision-making

Classification and staging of hepatocellular carcinoma in a way that allows optimal treatment selection is challenging. This article summarizes some of the classification and staging schemes and discusses the conceptual framework that guides optimal treatment selection for each patient. The article does not exhaustively discuss each staging system proposed in the last three decades, but rather reviews the most commonly used staging systems, evaluates the rationale behind some of the newer staging systems, and compares them focusing on their use in clinical decision-making, notably choice of therapy.