Hepatocellular carcinoma surveillance: Eastern and Western perspectives

Adjusting to living with chronic liver disease among patients who continue regular healthcare visits for hepatocellular carcinoma surveillance: A grounded theory study

AIM

To explore patients' process of living with chronic liver disease while continuing regular healthcare visits for hepatocellular carcinoma surveillance.

METHODS

Semistructured interviews and participant observations were conducted in this qualitative constructivist grounded theory study. The participants included 11 patients undergoing regular hepatocellular carcinoma surveillance every 1-6 months for 2-30 years. Data were analyzed using coding, memo-writing, theoretical sampling, and constant comparison.

RESULTS

The participants incorporated regular healthcare visits into their living cycle. The cycle's core comprised two categories ("inferring my liver condition" and "desiring status quo"). The cycle underwent a transition described by three phases ("seeking ways to live with my chronic liver disease," "being overwhelmed by living with my chronic liver disease," and "reconstructing my life to live with my chronic liver disease"). This transition involved adjusting to living with chronic liver disease while continuing regular healthcare visits. The relative importance of the cycle's core progressively shifted from "inferring my liver condition" to "desiring status quo."

CONCLUSIONS

This study revealed the transition phases of patients' living cycles in adjusting to living with chronic liver disease while continuing regular healthcare visits. Understanding the different phases in which patients are and the psychological impact of healthcare visits can help them look forward to recuperative actions. Furthermore, patients who have a sense of ownership experience loneliness because of regular healthcare visits. A support system including nurses as part of regular hepatocellular carcinoma surveillance should be established to help ease patients' sense of loneliness by utilizing their sense of ownership.

Hepatocellular carcinoma surveillance in Australia: current and future perspectives

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide, and is increasing in incidence in Australia. For most people with cirrhosis and chronic hepatitis B, HCC screening and surveillance is recommended with 6-monthly ultrasound. However, most patients with HCC are still diagnosed outside of surveillance with incurable disease. While HCC surveillance almost certainly reduces cancer-related mortality, the potential harms of surveillance are incompletely understood. Surveillance uptake remains suboptimal in many contexts, and stems from a combination of patient, clinician and system level barriers. Improved case-finding strategies may be required to identify high risk individuals in need of surveillance, as cirrhosis and viral hepatitis are often asymptomatic. HCC prediction models and novel surveillance tools such as biomarker panels, computed tomography and magnetic resonance imaging may have a future role in personalised HCC surveillance. Analyses suggest surveillance may be cost-effective, but Australian data remain limited. A centralised HCC surveillance program may ultimately have a role in delivering improved and more equitable care.

The Era of Immunotherapy in Hepatocellular Carcinoma: The New Mission and Challenges of Magnetic Resonance Imaging

In recent years, significant advancements in immunotherapy for hepatocellular carcinoma (HCC) have shown the potential to further improve the prognosis of patients with advanced HCC. However, in clinical practice, there is still a lack of effective biomarkers for identifying the patient who would benefit from immunotherapy and predicting the tumor response to immunotherapy. The immune microenvironment of HCC plays a crucial role in tumor development and drug responses. However, due to the complexity of immune microenvironment, currently, no single pathological or molecular biomarker can effectively predict tumor responses to immunotherapy. Magnetic resonance imaging (MRI) images provide rich biological information; existing studies suggest the feasibility of using MRI to assess the immune microenvironment of HCC and predict tumor responses to immunotherapy. Nevertheless, there are limitations, such as the suboptimal performance of conventional MRI sequences, incomplete feature extraction in previous deep learning methods, and limited interpretability. Further study needs to combine qualitative features, quantitative parameters, multi-omics characteristics related to the HCC immune microenvironment, and various deep learning techniques in multi-center research cohorts. Subsequently, efforts should also be undertaken to construct and validate a visual predictive tool of tumor response, and assess its predictive value for patient survival benefits. Additionally, future research endeavors must aim to provide an accurate, efficient, non-invasive, and highly interpretable method for predicting the effectiveness of immune therapy.

Gadoxetate-Enhanced MRI as a Diagnostic Tool in the Management of Hepatocellular Carcinoma: Report from a 2020 Asia-Pacific Multidisciplinary Expert Meeting

Gadoxetate magnetic resonance imaging (MRI) is widely used in clinical practice for liver imaging. For optimal use, we must understand both its advantages and limitations. This article is the outcome of an online advisory board meeting and subsequent discussions by a multidisciplinary group of experts on liver diseases across the Asia-Pacific region, first held on September 28, 2020. Here, we review the technical considerations for the use of gadoxetate, its current role in the management of patients with hepatocellular carcinoma (HCC), and its relevance in consensus guidelines for HCC imaging diagnosis. In the latter part of this review, we examine recent evidence evaluating the impact of gadoxetate on clinical outcomes on a continuum from diagnosis to treatment decision-making and follow-up. In conclusion, we outline the potential future roles of gadoxetate MRI based on an evolving understanding of the clinical utility of this contrast agent in the management of patients at risk of, or with, HCC.

Multimarker Panels for Detection of Early Stage Hepatocellular Carcinoma: A Prospective, Multicenter, Case-Control Study

Hepatocellular carcinoma (HCC), the sixth most common cancer worldwide, has an incidence rate equal to mortality. Over 80% of HCC cases occur within a high‐risk population, mainly patients with both cirrhosis and chronic hepatitis B or C. With a 5‐year survival rate ranging from <16% for advanced HCC to >90% for early stage HCC, there is a high medical need for the early detection of HCC. In this study, we systematically evaluated biomarkers mentioned in international guidelines and peer‐reviewed literature for HCC surveillance and diagnosis with the aim of identifying combinations that display high sensitivity and specificity for early stage HCC. Fifty biomarkers were measured in the first sample panel, panel A (n = 110), and subjected to univariate analysis. Of these, 35 biomarkers (38 assays) from panel A and an additional 13 biomarkers from the literature were prioritized for subsequent multivariate evaluation with lasso regression and exhaustive search of two‐ to four‐biomarker combinations (panel B). Panel B included 1,081 samples from patients with HCC (n = 308) or with chronic liver diseases (n = 740). Among all patients, 61.0% had hepatitis B, 32.9% had hepatitis C, and 60.5% had cirrhosis; 40.6% of patients with HCC had early stage cancer. Protein induced by vitamin K absence‐II (PIVKA‐II; also known as des‐gamma‐carboxy prothrombin [DCP]) and alpha‐fetoprotein (AFP) demonstrated the best clinical performance, both individually and in combination, and the addition of a third biomarker (Lens culinaris agglutinin‐reactive fraction of AFP [AFP‐L3], cartilage oligomeric matrix protein [COMP], insulin‐like growth factor‐binding protein 3 [IGFBP3], or matrix metalloproteinase 3 [MMP3]) further increased sensitivity for the detection of both early stage and all‐stage HCC. The addition of age and sex to the three‐biomarker panel resulted in an improved diagnostic performance. Conclusion: The combination of AFP and PIVKA‐II, with either IGFBP3, COMP or MMP3, plus age and sex, demonstrated the best performance for the detection of early‐ and all‐stage HCC. These novel panels performed similar to that of the GALAD score (sex [gender], age, plus serum levels of AFP, AFP‐L3 and DCP [PIVKA‐II]), a promising screening tool developed for HCC detection.

Label-free electrochemical aptasensor based on reduced graphene oxide–hemin–chitosan nanocomposite for the determination of glypican-3

A GPC3 electrochemical aptasensor was constructed using an RGO–H–CS-modified SPE as a biosensing platform and GPC3 aptamer as the recognition element.

Current status of image-based surveillance in hepatocellular carcinoma

Although the overall prognosis of patients with hepatocellular carcinoma (HCC) remains poor, curative treatment may improve the survival of patients diagnosed at an early stage through surveillance. Accordingly, ultrasonography (US)-based HCC surveillance programs proposed in international society guidelines are now being implemented and regularly updated based on the latest evidence to improve their efficacy. Recently, other imaging modalities such as magnetic resonance imaging have shown potential as alternative surveillance tools based on individualized risk stratification. In this review article, we describe the current status of US-based surveillance for HCC and summarize the supporting evidence. We also discuss alternative surveillance imaging modalities that are currently being studied to validate their diagnostic performance and cost-effectiveness.

Electrochemical aptasensor for analyzing alpha-fetoprotein using RGO-CS-Fc nanocomposites integrated with gold-platinum nanoparticles

Herein, a label-free electrochemical aptasensor for alpha-fetoprotein (AFP) analysis was established. The AFP aptamer (AFP-Apt), as the recognition molecule, was immobilized on the surface of a screen-printed carbon electrode, which was modified by gold-platinum metallic nanoparticles and reduced graphene oxide-chitosan-ferrocene nanohybrids (Au-Pt NPs/RGO-CS-Fc), to build the AFP electrochemical aptasensor. The construction process of the aptasensor was characterized by scanning electron microscopy, X-ray photoelectron spectroscopy, Raman spectroscopy, and electrochemical impedance spectroscopy. With the addition of AFP, the formation of the AFP-aptamer conjugation blocked the electron transfer reaction, reducing the differential pulse voltammetric responses of the current of Fc in the RGO-CS-Fc nanohybrids. By optimizing the experimental parameters, AFP could be detected with the dynamic concentration range of 0.001 to 10.0 μg mL^-1 and with a detection limit of 0.3013 ng mL^-1. In addition, the approach was manifested to have good selectivity, reproducibility, and stability. The fabricated aptasensor had a good recovery rate of 102.36% to 118.09% in real human serum samples. This work demonstrates that the electrochemical aptasensor is a useful tool for analyzing AFP inexpensively, rapidly, and accurately.

Adherence to Hepatocellular Carcinoma Surveillance and Perceived Barriers Among High-Risk Chronic Liver Disease Patients in Yunnan, China

Background

Data concerning adherence to hepatocellular carcinoma (HCC) surveillance among chronic liver disease (CLD) patients at high risk of developing HCC in China are limited. We aimed to examine the relationship between HCC-related knowledge dimensions and adherence to HCC surveillance procedures among chronic liver disease patients at high risk of developing HCC and to identify potential barriers.

Methods

A total of 380 patients with chronic liver disease at high risk of developing HCC were recruited between May and August 2018 to complete a survey during the first week of their first hospitalization at the Third People's Hospital of Kunming in China. We followed up each patient up to 7 months by telephone to confirm whether the patient returned to complete investigations for HCC surveillance. Patient's socio-demographic characteristics, HCC-related knowledge, and perceived barriers to HCC surveillance were measured using a structured questionnaire during their hospitalization. Factor analysis was performed on the knowledge questions to reduce the dimensions. Univariate and multivariate analyses were performed to examine the association between dimensions of HCC-related knowledge and patients' adherence to HCC surveillance.

Results

A total of 327 eligible patients had been successfully contacted in the follow-up phase. Only a quarter of patients completed HCC surveillance within 7 months after their first admission to hospital. High costs and perceived poor test efficacy were the two major barriers for HCC surveillance. Three common factors were derived from the factor analysis of HCC-related knowledge, namely, "Surveillance", "Lifestyle", and 'Prognosis'. Knowledge of HCC surveillance and lifestyle but not prognosis had an influence on adherence to HCC surveillance. Patients with better surveillance and lifestyle knowledge domain had better adherence to HCC surveillance.

Conclusion

Adherence to HCC surveillance procedures is low in the study area. Closing the gap in HCC-related knowledge, particularly regarding surveillance and lifestyle, may help to increase adherence rates.

US LI-RADS visualization score: diagnostic outcome of ultrasound-guided focal hepatic lesion biopsy in patients at risk for hepatocellular carcinoma

PURPOSE

This study investigated the diagnostic outcome of ultrasound (US)-guided focal hepatic lesion biopsy in patients at risk for hepatocellular carcinoma (HCC) and evaluated the US visualization score as a risk factor for non-diagnostic results.

METHODS

We retrospectively evaluated 208 focal hepatic lesions in 208 patients who underwent US-guided biopsy in 2016. Using the US Liver Imaging Reporting and Data System version 2017, each exam was assigned a US visualization score (A, B, or C). Final diagnoses were made using pathology reports, and biopsy results were categorized as diagnostic or non-diagnostic. Univariable and multivariable analyses were performed to determine risk factors for non-diagnostic results, including US visualization score and other clinical covariates.

RESULTS

Of the 208 lesions, 85.1% were diagnostic and 14.9% were non-diagnostic. The rates of non-diagnostic results were 8.9%, 25.5%, and 57.1% for scores of A, B, and C, respectively. In the univariable analysis, scores of B or C were associated with a significantly higher rate of nondiagnostic results than scores of A (58.1% vs. 24.9%, P<0.001). In the multivariable analysis, US visualization score of B or C (adjusted odds ratio [aOR], 2.7; P=0.027), high-risk needle pathway usage (aOR, 5.7; P=0.001), and lesion size ≤2.0 cm (aOR, 2.7; P=0.024) were independent risk factors for non-diagnostic results.

CONCLUSION

US-guided biopsy had a high diagnostic yield for focal hepatic lesions in patients at risk for HCC. US visualization score of B or C, lesion size ≤2.0 cm, and high-risk needle pathway usage were independent risk factors for non-diagnostic results.

m6A demethylase FTO promotes hepatocellular carcinoma tumorigenesis via mediating PKM2 demethylation

N6-methyladenosine (m6A) acts as the most common mRNA modification in mammal cells. Fat Mass and Obesity-associated protein (FTO) is the firstly identified demethylase in the m6A modification. This research tries to discover the potential roles of FTO in the m6A modification in the hepatocellular carcinoma (HCC). FTO level was found to be up-regulated in the HCC tissue and cells. The over-expression of FTO was correlated to the poor prognosis of HCC individuals. Knockdown of FTO suppressed the proliferation and in vivo tumor growth, and induced the G0/G1 phase arrest. Mechanically, FTO triggered the demethylation of PKM2 mRNA and accelerated the translated production. Overall, this finding suggests the critical function of FTO in the HCC oncogenesis and its m6A modification.