The best strategy for HCC patients at each BCLC stage: a network meta-analysis of observational studies

The application of 18F-FDG PET/CT imaging for human hepatocellular carcinoma: a narrative review

Background and Objective

Primary hepatocellular carcinoma (HCC) poses a significant threat to human health. The mean overall survival (OS) of HCC is approximately 15.8 months whereas the 6-month and 1-year OS rates are only 71.6% and 49.7%, respectively. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) has been widely used for the management of several solid cancers; however, HCC frequently displays low 18F-FDG uptake; approximately 50% of HCC cases do not take up 18F-FDG. Therefore, 18F-FDG PET is not considered very useful for the visualization of HCC and is not currently a recommended standard imaging modality for HCC. Conversely, 18F-FDG PET/CT has been reported to be clinically important in the management, staging, and prognosis of HCC patients. Currently, reports relating to 18F-FDG uptake in HCC are unclear and controversial. There is an urgent need to clarify the efficacy of 18F-FDG PET for the management of HCC.

Methods

The PubMed database was searched for all articles on the application of 18F-FDG PET/CT imaging for human HCC up to December 2021. The following search terms were used: 'Hepatocellular carcinoma', '[18F]FDG PET/CT', 'Hypoxia', '[11C]Choline'.

Key Content and Findings

In this review, we re-evaluate the potential hypoxia-dependent uptake mechanism of 18F-FDG in HCC and review the usefulness of 18F-FDG PET/CT for identifying, managing, and investigating the biological properties of HCC.

Conclusions

18F-FDG PET/CT is very useful for HCC visualization, management, and the evaluation of biological properties. A negative test for 18F-FDG uptake is not meaningless and may reflect a relatively better outcome. 18F-FDG-positive lesions indicate a significantly less favorable prognosis.

Clinically ill patients' experiences of early mobilisation after liver transplantation: a qualitative study using Pender's health promotion model

The aim of this study is to explore the factors influencing early mobilisation behaviours and patients' needs in critically ill patients after liver transplantation (LT). This interview study used phenomenological research, and Pender's health promotion model (HPM) was used to construct the interview guide. With the use of purposeful sampling, a total of 19 critically ill patients who experienced early mobilisation after LT were recruited at three tertiary hospitals in Beijing from August to November 2022. Data were collected through semi-structured interviews and analysed using Colaizzi's seven-step method. Nine themes were categorised into the three domains of Pender's HPM. The first domain was individual characteristics and experiences: (1) symptoms of end-stage liver disease limiting premobility behaviours and (2) previous treatment experience affecting understanding of early mobilisation after LT. The second domain was behaviour-specific cognition and affect: (3) coexistence of benefits and concerns in early mobilisation after LT, (4) barriers to early mobilisation after LT, (5) high self-efficacy in early mobilisation after LT, (6) individual differences in early mobilisation and (7) support and encouragement from family, wardmates and medical staff. The final domain was behavioural outcomes: (8) the need for sufficient staff, a quiet environment, safety, goals, guidance and family participation and (9) a strong willingness to comply with early mobilisation plans. The three areas and nine themes extracted in this study are helpful for the long-term development of early mobilisation in patients after LT.

Long Non-Coding RNA MAFG-AS1 as a Potential Biomarker for Hepatocellular Carcinoma: Linkage with Tumor Features, Markers, Liver Functions, and Survival Profile

Purpose

Long non-coding RNAs musculoaponeurotic fibrosarcoma oncogene family, protein G antisense 1 (lnc-MAFG-AS1) regulates hepatocellular carcinoma (HCC) progression and treatment resistance in multiple ways, while its engagement in HCC clinical management remains obscure. The current study aims to explore the relationship of lnc-MAFG-AS1 with tumor features, liver function indexes, tumor markers, and prognosis in HCC patients.

Methods

One hundred and fifty-two surgical HCC patients who underwent tumor resection were retrospectively analyzed. Their tumor and adjacent tissues were acquired and then proposed to reverse transcription-quantitative polymerase chain reaction to detect lnc-MAFG-AS1 expression.

Results

Lnc-MAFG-AS1 expression was increased in HCC tumor tissue than in adjacent tissue [median (interquartile range): 2.730 (1.685–4.198) vs. 0.990 (0.703–1.468), p < 0.001], with a high area under the curve [0.889, 95% confidence interval (CI): 0.854–0.924] to distinguish them via receiver operating characteristic curve analysis. Tumor lnc-MAFG-AS1 was linked with multifocal nodules (p < 0.001), increased Barcelona Clinic Liver Cancer (BCLC) stage (p = 0.018), and elevated China Liver Cancer (CNLC) stage (p = 0.008), which also correlated with an abnormal alpha-fetoprotein (AFP) level (p = 0.004), However, lnc-MAFG-AS1 was not linked with other disease conditions, tumor properties, liver function indexes, or tumor markers (all ps > 0.05). In addition, patients with a high expression of lnc-MAFG-AS1 exhibited worse overall survival than those with a low expression of lnc-MAFG-AS1 [median (95% CI): 34.0 (24.5–43.5) vs. 48.0 (41.5–54.5) months] (p = 0.011), which was further validated by univariate Cox’s analysis [hazard ratio (HR) = 1.827, p = 0.013] and multivariate Cox’s analysis (HR = 1.697, p = 0.040).

Conclusion

Lnc-MAFG-AS1 relates to multifocal nodules, increased BCLC stage, elevated CNLC stage, and abnormal AFP level and predicts pejorative prognosis in HCC patients.

Immunotherapy and Transarterial therapy of HCC: What the interventional radiologist needs to know about the changing landscape of HCC treatment?

Hepatocellular carcinoma (HCC) is the fourth most common cancer worldwide and its incidence is increasing in Australia. Transarterial therapy, predominantly transarterial chemoembolization (TACE) but increasingly transarterial radioembolization (TARE), plays an important role in patients with intermediate‐stage disease and preserved liver function. However, despite advances in TACE, TARE and adjunctive procedures, overall survival has only modestly increased over the last 20 years. Immunotherapy has emerged as a newer cancer treatment and uses antibodies directed at checkpoint inhibitors to upregulate T‐cell mediated tumour‐specific death. These drugs have been shown to increase survival in patients with HCC and have changed the landscape for advanced disease. Trials are now ongoing combining transarterial therapy and immunotherapy. This manuscript introduces these trials and interventional radiologists should be aware of the changing landscape so that they can partner with immunotherapy and remain relevant in the HCC multidisciplinary group as immunotherapy use increases.

Patient stratification in hepatocellular carcinoma: impact on choice of therapy

INTRODUCTION

HCC comprises around 60 to 80% of all primary liver cancers and exhibits wide geographical variability. Appropriate treatment allocation needs to include both patient and tumor characteristics.

AREAS COVERED

Current HCC classification systems to guide therapy are either liver function-centric and evaluate physiologic liver function to guide therapy or prognostic stratification classification systems broadly based on tumor morphologic parameters, patient performance status, and liver reserve assessment. This review focuses on different classification systems for HCC, their strengths, and weaknesses as well as the use of artificial intelligence in improving prognostication in HCC.

EXPERT OPINION

Future HCC classification systems will need to incorporate clinic-pathologic data from a multitude of sources and emerging therapies to develop patient-specific treatment plans targeting a patient's unique tumor profile.

Cerium Oxide Nanoparticles: A New Therapeutic Tool in Liver Diseases

Oxidative stress induced by the overproduction of free radicals or reactive oxygen species (ROS) has been considered as a key pathogenic mechanism contributing to the initiation and progression of injury in liver diseases. Consequently, during the last few years antioxidant substances, such as superoxide dismutase (SOD), resveratrol, colchicine, eugenol, and vitamins E and C have received increasing interest as potential therapeutic agents in chronic liver diseases. These substances have demonstrated their efficacy in equilibrating hepatic ROS metabolism and thereby improving liver functionality. However, many of these agents have not successfully passed the scrutiny of clinical trials for the prevention and treatment of various diseases, mainly due to their unspecificity and consequent uncontrolled side effects, since a minimal level of ROS is needed for normal functioning. Recently, cerium oxide nanoparticles (CeO₂NPs) have emerged as a new powerful antioxidant agent with therapeutic properties in experimental liver disease. CeO₂NPs have been reported to act as a ROS and reactive nitrogen species (RNS) scavenger and to have multi-enzyme mimetic activity, including SOD activity (deprotionation of superoxide anion into oxygen and hydrogen peroxide), catalase activity (conversion of hydrogen peroxide into oxygen and water), and peroxidase activity (reducing hydrogen peroxide into hydroxyl radicals). Consequently, the beneficial effects of CeO₂NPs treatment have been reported in many different medical fields other than hepatology, including neurology, ophthalmology, cardiology, and oncology. Unlike other antioxidants, CeO₂NPs are only active at pathogenic levels of ROS, being inert and innocuous in healthy cells. In the current article, we review the potential of CeO₂NPs in several experimental models of liver disease and their safety as a therapeutic agent in humans as well.

Two elder cases of hepatocellular carcinoma adjacent to intrahepatic vessels successfully treated by carbon ion radiotherapy

The treatment for hepatocellular carcinoma (HCC) adjacent to the portal vein and/or bile duct requires considerable caution to avoid the complications, such as hepatic infarction and obstructive jaundice. Carbon ion radiotherapy (CIRT) has been attempted for HCC and has become accepted as a promising modality for minimizing hepatic damage with good local tumor control. We experienced two elder cases of HCC adjacent to intrahepatic vessels successfully treated by CIRT. Case 1, a 75-year-old man, was treated by CIRT for a 2-cm HCC near the porta hepatis adjacent to the right first portal branch. The treatment was sufficiently effective, and no vascular damage was demonstrated after CIRT. The liver function transiently deteriorated after CIRT, but recovered quickly. Alpha-fetoprotein transiently increased after the treatment and decreased thereafter. Tumor stain persisted for 3 months after CIRT, so a liver tumor biopsy was performed. However, no viable carcinoma cells were detected. There was no local recurrence or complications for 17 months. Case 2, 76-year-old male HCC patient, showed dilation of the peripheral bile duct in the left lobe, suggesting tumor invasion to the duct. The tumor was hypovascular and was found to be well-differentiated HCC by a tumor biopsy. He was treated with CIRT, because he had a history of cerebral infarction and was being administered an antiplatelet agent daily. He achieved complete remission, and no adverse events were observed after the treatment for 3 years.

Evaluation of Targeted Agents for Advanced and Unresectable Hepatocellular Carcinoma: A Network Meta-Analysis

Objective: To evaluate different targeted anticancer agents for patients with advanced or unresectable hepatocellular carcinoma (HCC) based on network meta-analysis.

Methods: Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, PMC, EMBASE and Cochrane Central to find relevant randomized controlled trials (RCTs). Relative parametric data, including overall survival (OS), progression-free survival (PFS) and adverse event (AE), were quantitatively pooled and estimated based on the Bayesian theorem. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated and ranked. Node-splitting analysis was performed to test the inconsistency of the main results, and publication bias was assessed by examining funnel-plot symmetry.

Results: After a detailed review, 31 RCTs containing 20 different agents or combinations were finally included for network meta-analysis. For patients without previously systematic treatments, lenvatinib had the best clinical effects on OS (SUCRA, 0.22), and apatinib was superior regarding PFS (SUCRA, 0.41) and AE (SUCRA, 0.15). For patients who received previously targeted agents therapies, regorafenib exhibited the superior clinical effects on OS (SUCRA, 0.42) and PFS (SUCRA, 0.30), while codrituzumab showed the greatest safety benefit on AE (SUCRA, 0.75). Moreover, node-splitting analysis and funnel-plot symmetries illustrated no inconsistency or obvious publication bias in the current study.

Conclusions: According to current evidence, lenvatinib and apatinib had superior clinical effects for patients without previously systematic treatments, and regorafenib seemed to be more suitable for patients with previously targeted agent therapies. However, our conclusions still need more statistical validations, and more high-quality trials are expected.

The 100 most influential manuscripts on hepatocellular carcinoma: a bibliometric analysis

Objective

Citation analysis represents one of the best available methods to identify the most influential articles. This study aimed to identify and characterize the top 100 highly cited articles (T100) that focus on hepatocellular carcinoma and to reveal the trends in accomplishments within this field.

Methods

A search of the Thomson Reuters Web of Science citation indexing database was conducted using terms related to hepatocellular carcinoma. The T100 were selected and analyzed further based on the number of citations, authorship, year of publication, journal, country of origin, institution, and article type.

Results

Hepatology published the highest number of papers (n = 15), and the United States produced the highest number of contributions (n = 31). Barcelona University was the institution with the highest number of articles in the T100 (n = 9). The T100 articles included 35 observational studies, 13 randomized control studies, 25 basic research articles, 18 reviews, seven clinical guidelines, and two meta-analyses.

Conclusions

This is the first bibliometric study to identify the most influential papers in hepatocellular carcinoma research. This report presents major advances and changes in research regarding hepatocellular carcinoma and can serve as a guide for writing a citable article.

18F-fludeoxyglucose positron emission tomography for diagnosis of HCC: implications for therapeutic strategy in curative and non-curative approaches

Hepatocellular carcinoma (HCC) is a global health issue with increasing incidence and high mortality rate. Depending on the tumor load and extent of underlying liver cirrhosis, aggressive surgical treatment by hepatectomy or liver transplantation (LT) may lead to cure, whereas different modalities of liver-directed locoregional or systemic tumor treatments are currently available for a noncurative approach. Apart from tumor burden and grade of liver dysfunction, assessment of prognostic relevant biological tumor aggressiveness is vitally important for establishing a promising multimodal therapeutic strategy and improving the individual treatment-related risk/benefit ratio. In recent years, an increasing body of clinical evidence has been presented that ¹⁸F-fludeoxyglucose (¹⁸F-FDG) positron emission tomography (PET), which is a standard nuclear imaging device in oncology, may serve as a powerful surrogate for tumor invasiveness and prognosis in HCC patients and, thereby, impact individual decision making on most appropriate therapy concept. This review describes the currently available data on the prognostic value of ¹⁸F-FDG PET in patients with early and advanced HCC stages and the resulting implications for treatment strategy.

What have we learned from network meta-analyses applied to critical care?

It is widely accepted in modern medicine that medical decisions must be supported by scientific evidence. Identifying the best intervention when several options are available constitute a great challenge for every clinician. Traditional meta-analysis (TMA) allows summarizing evidence from studies that compare the same two interventions for one event (head to head studies or direct comparisons). Network meta-analysis (NMA) is a relatively new procedure that allows to compare multiple interventions for one event, even when non-head to head studies have been conducted (indirect evidence). Other advantages of NMA include increasing the accuracy of the results and ranking all the interventions according to their effectiveness. These features are of paramount importance as: 1) they summarize information from events (e.g. diseases or outcomes) that has more than two possible interventions (e.g. treatments or procedures); 2) they strengthen the level of guideline recommendations; and 3) they identify new hypotheses based on indirect comparison. As this is a narrative review, all manuscripts have been selected from PubMed according to our best knowledge with the aim to illustrate different features, options or applications of NMA in critical care. First, we provide a description of the usefulness, interpretation, assumptions and main plots related to NMAs. Second, we analyzed some examples of NMAs related to critical care medicine. Third, we include a pragmatic approach about how results from NMAs can improve the clinical practice as well an R script with a database to conduct an NMAs and reproduce figures and tables that have been shown here. As a conclusion, NMA is an established, robust, objective and reproducible statistic technique that has been applied to several critical care areas. Clinical practice guidelines have started to include NMA evidence to support their recommendations. In future years, it seems highly probable that this technique will increase it applicability in almost all areas of critical care medicine.

A Systematic Review and Meta-Analysis Comparing the Short- and Long-Term Outcomes for Laparoscopic and Open Liver Resections for Hepatocellular Carcinoma: Updated Results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017

BACKGROUND

The laparoscopic approach to liver resection has experienced exponential growth in recent years; however, its application is still under debate and objective, evidence-based guidelines for its safe future progression are needed.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for hepatocellular carcinoma (HCC).

METHODS

To identify all the comparative manuscripts reporting on laparoscopic and open liver resection for HCC, all published English-language studies with more than 10 cases were screened. In addition to the primary meta-analysis, four specific subgroup analyses were performed on patients with Child-Pugh A cirrhosis, resections for solitary tumors, and those undergoing minor and major resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and the Newcastle-Ottawa Scale.

RESULTS

From the initial 361 manuscripts, 28 were included in the meta-analysis. Five of these 28 manuscripts were specific to patients with Child-Pugh A cirrhosis (321 cases), 11 focused on solitary tumors (1003 cases), 16 focused on minor resections (1286 cases), and 3 focused on major resections (164 cases). Three manuscripts compared 1079 cases but could not be assigned to any of the above subanalyses. In general terms, short-term outcomes were favorable when using a laparoscopic approach, especially in minor resections. The only advantage seen with an open approach was reduced operative time during major liver resections. No differences in long-term outcomes were observed between the approaches.

CONCLUSIONS

Laparoscopic liver resection for HCC is feasible and offers improved short-term outcomes, with comparable long-term outcomes as the open approach.

NEAT1_2-SFPQ axis mediates cisplatin resistance in liver cancer cells in vitro

Background

Liver cancer is a type of malignant tumor with high morbidity and mortality in People’s Republic of China. Its occurrence and development involve the variation and expression changes of multiple genes, and the pathogenesis and related regulatory networks are complex.

Purpose

In the present research, we investigate the involvement of NEAT1_2 and SFPQ in cisplatin resistance in liver cancer. The effects of LncRNA NEAT1 and SFPQ expression on the chemotherapeutic resistance of liver cancer cells were analyzed.

Methods

The expression level of NEAT1_2 and SFPQ mRNA in tissue specimens or cell lines were examined by RT-qPCR and western blotting. CCK-8 assay was performed to evaluate cell viability. Cell proliferation was performed using the EdU cell proliferation assay.

Results

Our data showed that increase NEAT1_2 and SFPQ expressions in liver cancer specimens were associated with the development of cisplatin resistance; high SFPQ expression level impaired patients’ survival from liver cancer. Gain-and loss-of function assay using NEAT1_2 knock-in and knock-out cells constructed using CRISPER/Cas9 system revealed that NEAT1_2 is essential for liver cancer cell survival and mediates cisplatin resistance in liver cancer cells at least partially through SFPQ. Artificial change in NEAT1_2 expression level didn’t significantly influence SFPQ transcription or translation level.

Conclusion

Our data revealed NEAT1_2—SFPQ axis as a novel cisplatin resistance mechanism in liver cancer cells in vitro.

Intra-Arterial TheraSphere Yttrium-90 Glass Microspheres in the Treatment of Patients With Unresectable Hepatocellular Carcinoma: Protocol for the STOP-HCC Phase 3 Randomized Controlled Trial

BACKGROUND

Globally, hepatocellular carcinoma is the second most common cause of cancer deaths. It remains challenging to intensify cancer treatment without impairing liver function.

OBJECTIVE

The objective of the TheraSphere in the Treatment of Patients with Unresectable Hepatocellular Carcinoma (STOP-HCC) study is to examine the hypothesis that transarterial radioembolization (TheraSphere yttrium-90 glass microspheres) combined with standard first-line treatment with sorafenib will improve outcomes over treatment with sorafenib alone in unresectable hepatocellular carcinoma. The STOP-HCC study is the largest international, multicenter, prospective study of intra-arterial treatment in combination with sorafenib in unresectable hepatocellular carcinoma. Here we report the study design.

METHODS

STOP-HCC is a prospective, phase 3, open-label, randomized controlled study conducted across up to 105 sites in North America, Europe, and Asia. Eligible adults have unresectable hepatocellular carcinoma and a life expectancy of at least 12 weeks, 1 or more unidimensional measurable lesions, Child-Pugh score 7 points or less, and Eastern Cooperative Oncology Group Performance Status score 1 or lower, and are candidates for treatment with sorafenib. Presence of branch portal vein tumor thrombosis is permitted. Patients were randomly assigned in a 1:1 ratio to receive either sorafenib alone or transarterial radioembolization followed by sorafenib within 2 to 6 weeks. The primary outcome is overall survival. Secondary outcomes are time to progression, time to untreatable progression, time to symptomatic progression, tumor response, quality of life, and adverse event occurrence. The study is an adaptive trial, comprising a group-sequential design with 2 interim analyses with 520 patients, and an option to increase the sample size to 700 patients at the second interim analysis. The sample size of 520 patients allows for 417 deaths to give 80% power to detect an increase in median overall survival from 10.7 months for the sorafenib group (based on the Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol [SHARP] trial) to 14.2 months for the transarterial radioembolization+sorafenib group (hazard ratio 0.754) with 2-sided alpha of .05. The increased sample size of 700 patients allows for 564 deaths to give 80% power to detect a smaller difference in median overall survival from 10.7 months for the sorafenib group to 13.7 months for the transarterial radioembolization+sorafenib group (hazard ratio 0.781).

RESULTS

Enrollment for the study completed in September 2017. Results of the first and second interim analyses were reviewed by the Independent Data Monitoring Committee. The recommendation of the committee, at both interim analyses, was to continue the study without any changes.

CONCLUSIONS

The STOP-HCC study will contribute toward the establishment of the role of combination therapy with transarterial radioembolization and sorafenib in the treatment of unresectable hepatocellular carcinoma with and without branch portal vein tumor thrombosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01556490; https://clinicaltrials.gov/ct2/show/NCT01556490 (Archived by WebCite at http://www.webcitation.org/7188iygKs).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/11234.

Efficacy of bi-monthly hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma

Background

Even though the Barcelona Clinic Liver Cancer (BCLC) staging system is widely accepted, controversies on the management of hepatocellular carcinoma (HCC) still exist. We evaluated the efficacy of an approach with repeated hepatic arterial infusion chemotherapy (HAIC) given at eight-week intervals for the treatment of advanced HCC.

Methods

Of the 66 compensated cirrhotic patients with advanced HCC refractory to transcatheter arterial chemo-embolization (TACE) enrolled in our study, 21 were treated by bi-monthly hepatic arterial infusion chemotherapy (B-HAIC) and the rest by sorafenib. The overall survival periods, curative responses, and adverse events in each group were retrospectively analyzed.

Results

The efficacy rate was significantly higher in the B-HAIC group (38%, 11%, P<0.05). The median survival time and the survival rate at 12 months in the B-HAIC group were 567 days and 70.8%, and those in the sorafenib group were 366 days and 47.6%, respectively. Thus, our data suggests that the B-HAIC treatment is not inferior to sorafenib for the treatment of advanced HCC in compensated cirrhotic patients. Furthermore, the occurrence of serious adverse events leading to discontinuation of treatment was less frequent in the B-HAIC group.

Conclusions

Given the hepatic function reserve preservation afforded by the B-HAIC treatment in our experience, we suggest that B-HAIC should be considered an alternative strategy for advanced HCC patients who do not respond to TACE.

Identifying the Best Anticancer Agent Combination in TACE for HCC Patients: A Network Meta-analysis

Objective: We conducted a network meta-analysis to comprehensively compare various anticancer agents used in transarterial chemoembolization (TACE) based on the Bayesian theorem. Methods: Globally recognized electronic databases, including PubMed, EMBASE, and Cochrane Central, were searched to retrieve relevant randomized controlled trials (RCTs) comparing anticancer agents in TACE for hepatocellular carcinoma (HCC) patients. The therapeutic response, adverse events and overall survival rate were selected as parametric data to evaluate the clinical efficacy. Quantitative network meta-analysis and pair-wise analysis were conducted to compare the relative parameters. Results: Of the 4242 retrieved articles, 17 RCTs containing 2330 patients fulfilled the inclusion criteria. The network meta-analysis exhibited that the application of anthracycline and mitomycin plus pyrimidine presented the best clinical values regarding all parametric data (probability P=0.45, 0.32 and 0.35 regarding comparison of response rate, adverse event and overall survival, respectively). Accordingly, further investigation on specific anticancer agents indicated that the combination of doxorubicin and mitomycin plus gemcitabine was the best agent combination in TACE (probability P=0.49, 0.37 and 0.77 regarding comparison of response rate, adverse event and overall survival, respectively). Moreover, an additional study indicated that the single use of an anticancer agent prior to embolism brought no benefit compared with bland embolism without any agent (Test Z=0.15, 0.84, 1.22 and P=0.88, 0.40, 0.22 regarding comparison of response rate, adverse event and overall survival, respectively). However, the combined use of anticancer agents in TACE showed significantly better clinical efficacy than single use (Test Z=4.40, 3.94, 0.24 and P<0.001, <0.001, =0.81 regarding comparison of response rate, adverse event and overall survival, respectively); thus, combination utilization was recommended. Conclusions: The combined use of anticancer agents in TACE was recommended. Application of anthracycline and mitomycin plus pyrimidine seemed to be the best choice for clinical consideration. Additionally, the combination of doxorubicin and mitomycin plus gemcitabine may be the best specific anticancer agent combination in TACE currently, although additional RCTs are expected to support our conclusion.

Adjuvant celecoxib and lanreotide following transarterial chemoembolisation for unresectable hepatocellular carcinoma: a randomized pilot study

Recurrence of hepatocellular carcinoma (HCC) after transarterial chemoembolisation (TACE) is common due to neoangiogenesis. Cyclooxygenase-2 inhibitors and somatostatin analogues were reported to inhibit tumour angiogenesis. The pilot randomized controlled trial was aimed to prospectively evaluate the protocol of TACE combined with celecoxib and lanreotide (TACE+C+L) in patients with unresectable and advanced HCC. A total of 71 patients with HCC were enrolled and randomly assigned to either TACE (n=35) or TACE+C+L (n=36) group. Overall survival, disease control rate (DCR), and adverse events were assessed during a 3-year follow-up period. The median overall survival of the TACE+C+L group (15.0 months) was doubled compared to that of TACE group (7.5 months), p = 0.012. DCR of the TACE+C+L group was significantly higher than that of the TACE group either at 6 months (72.2% vs 42.9%, p = 0.012) or at 12 months (61.1% vs 28.6%, p = 0.006). The median overall survivals (13 months vs 4.5 months, p = 0.013) and DCR at 12 months (50% vs 13.6%, p = 0.008) of patients with advanced HCC in TACE+C+L groups were significantly higher than those in TACE group. No significant difference of adverse events was observed between the two groups. The occurrence of post-embolisation syndrome in TACE+C+L group was significantly lower than that in TACE group (16.7% vs 60.0%, p = 0.001). In conclusion, the regimen of TACE+C+L prolonged overall survival, enhanced tumour response, reduced post-embolisation syndrome and was well-tolerable in the patients with unresectable HCC. It may be more beneficial for advanced HCC.

Systematic review of preservation solutions for allografts for liver transplantation based on a network meta-analysis

AIMS

The aim of this work was to determine the best preservation solutions for allografts for liver transplantation by quantitative network meta-analysis.

METHODS

Global electronic databases including PubMed, EMBASE, and Cochrane Library were searched for relevant randomized controlled trials. Seven pieces of parametric data were extracted from included studies for pooled estimation. A consistency model was used for direct and indirect comparisons. The cumulative probability P value was utilized to rank the solutions. A node-splitting model was utilized for testing the consistency of final data. Quality of evidence was assessed using the GRADE (Grades of Recommendations Assessment, Development and Evaluation) system.

RESULTS

Eleven 2-arm trials including 1319 patients and 5 different solutions were finally included. HTK (Histidine-tryptophan-ketoglutarate) solution exhibited the best efficacy for decreasing the primary dysfunction rate, biliary complications and ICU-stay time (probability P = 0.43, 0.45 and 0.58, respectively). Celsior solution significantly decreased the rate of rejection and early retransplantation (probability P = 0.73 and 0.38, respectively), and enhanced patient and graft survival (probability P = 0.90 and 0.98, respectively) more than did other solutions. Overall, the quality of evidence was rated high or moderate.

CONCLUSIONS

We suggested that HTK solution may offer the best safety during the perioperative period. However, Celsior solution led to better graft tolerance and exhibited greater benefit for long-term outcomes. And our conclusions still need to be further validated.

TransArterial ChemoEmbolization (TACE) with platinum versus anthracyclines for hepatocellular carcinoma: A meta-analysis

OBJECTIVE

To determine the clinical efficacy of TACE with platinum versus anthracyclines for hepatocellular carcinoma (HCC) patients using a meta-analysis.

METHODS

We conducted a systematic review of the literature in PubMed, Embase, and the Cochrane Library database to discover relevant randomized controlled trials (RCTs) and observational studies. Data on therapeutic response, adverse event and overall survival rate from studies that compared TACE with platinum versus anthracyclines for HCC patients was extracted for pooled estimation. Subgroup analysis was used if further investigation was needed. The Q statistic and the I² index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test.

RESULTS

Four RCTs and seven observational studies containing 1405 patients were included in this meta-analysis. After comparing RCTs and observational studies separately, the pooled estimation results indicated that no significant difference existed between platinum and anthracyclines regarding therapeutic response, adverse event and overall survival rate. Furthermore, Egger's test revealed bias in pooled estimation of survival rate among RCTs.

CONCLUSIONS

Based on current results, we concluded that TACE with platinum revealed similar clinical efficacy compared with anthracyclines. And more relative studies in this field were expected in the future.

New nomogram predicts the recurrence of hepatocellular carcinoma in patients with negative preoperative serum AFP subjected to curative resection

BACKGROUND

There is currently no established model for predicting the recurrence of hepatocellular carcinoma (HCC) in patients with negative alpha-fetoprotein (AFP) after curative resection. Therefore, the objective of this study was to establish a nomogram to identify the risk of recurrence in AFP-negative (<or = 20 ng/mL) patients with HCC.

METHODS

A retrospective study was conducted to establish the recurrence-free survival (RFS) nomogram in a training cohort of 326 AFP-negative HCC patients. The results were validated on a well-matched validation cohort in the literature.

RESULTS

Macrovascular tumour invasion (P = 0.018, HR = 1.642), macronodular cirrhosis (P < 0.001, HR = 2.128), tumor size (P = 0.004, HR = 1.691), and γ-glutamyl transferase (P = 0.039, HR = 1.496) were found to be independent risk factors for RFS in the training cohort, and all these factors were included in the nomogram. The C-index for RFS in the nomogram was 0.661, which was higher than that of the BCLC system (0.551), the CLIP score (0.537), and the prediction model of Ju (0.618). The high consistency between the nomogram prediction and actual observation was further demonstrated by the calibration curve. In the subsequent study, the better net benefit and higher threshold probability of the nomogram were determined by decision curve analysis, and these advantages were confirmed in the validation cohort.

CONCLUSIONS

The present RFS nomogram for AFP-negative HCC patients after curative resection provides an accurate and reliable prognostic model to facilitate recurrence surveillance. Once AFP-negative patients are predicted to have a high recurrence score, additional high-end imaging examinations, such as MRI or CT exams, should be considered, and the interval time of regular folow-up should be reduced.

Value of HCC-MELD Score in Patients With Hepatocellular Carcinoma Undergoing Liver Transplantation

CONTEXT

Liver transplantation (LT) is considered the ideal therapy for patients with hepatocellular carcinoma (HCC) having cirrhosis but the shortage of liver donors and the risk of dropout from the wait list due to tumor progression severely limit transplantation. A new prognostic score, the HCC-model for end-stage liver disease (HCC-MELD), was developed by combining α-fetoprotein (AFP), MELD, and tumor size, to improve risk stratification of dropout in patients with HCC.

OBJECTIVES

In this study, we investigated the ability of the HCC-MELD score in predicting the posttransplant for patients fulfilling Milan criteria (MC).

DESIGN

Two hundred patients with stage II tumor were retrospectively reviewed from a total of 1290 transplants performed at our institution from October 1997 through April 2015. Cox regression analysis was performed to identify the prognostic factors impacting the posttransplant survival.

RESULTS

Overall survival at 1, 5, and 10 years was 89.3%, 71.1%, and 67.2%, whereas disease-free survival was 86.4%, 66.5%, and 52.4%, respectively. Multivariate analysis showed HCC-MELD score (hazard ratio [HR] 39.6, P < .001) and microvascular invasion (HR 2.41, P = .002) to be independent risk factors for recurrence, whereas HCC diameter (HR 1.15, P = .041), HCC-MELD (HR 15.611, P = .006), and grading (HR 2.17, P = .03) proved to be predictive factors of poor overall survival.

CONCLUSION

Our study showed the validity of the HCC-MELD equation in the evaluation of patients undergoing LT for HCC. This score offers a reliable method to assess the risk of waiting list dropout and predict posttransplantation outcomes.

Reduced miR-125a levels associated with poor survival of patients with hepatocellular cancer

MicroRNAs (miRNAs) serve an important role in tumorigenesis and development. Although a low expression of miR-125a in hepatocellular carcinoma (HCC) has been reported, the clinical significance remains unknown. In the current study, the data of Gene Expression Omnibus datasets was analyzed and significantly low expression of miR-125a in HCC was verified. Furthermore, the expression and clinical significance of miR-125a was investigated in 27 normal liver and 98 HCC tissue samples using reverse transcription-quantitative polymerase chain reaction analysis. The results demonstrated that the level of miR-125a expression was lower in HCC biopsies compared with that in normal liver tissues. Survival analysis established that miR-125a expression was negatively associated with the prognosis of HCC. Multivariate survival analysis demonstrated that patients with HCC with lowmiR-125a and Ki67-positive expression have shorter overall, and disease-free survival times. Altogether, the results of the current study provide the first evidence that reducedmiR-125a expression is associated with HCC progression and poor prognosis in patients, suggesting that miR-125a may have potential prognostic value as a tumor biomarker for patients with HCC.

Impact of intraoperative vascular occlusion during liver surgery on long-term outcomes: A systematic review and meta-analysis

OBJECTIVE

To determine the impact of intraoperative vascular occlusion during liver surgery on postoperative long-term outcomes for hepatocellular carcinoma (HCC) patients using a meta-analysis.

METHODS

A systematic literature search of PubMed, EMBASE, and Cochrane Central was conducted to discover relevant randomized controlled trials (RCTs) and observational studies. Studies that reported postoperative long-term outcomes; 1-, 3-, and 5-year overall survival (OS); and/or 1-, 3-, and 5-year recurrence-free survival (RFS) for both an observation group (vascular occlusion) and a control group (vascular non-occlusion) were included. Forest plots were performed to calculate the difference between the 2 groups. The Q statistic and the I² index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test.

RESULTS

Four observational studies containing 2917 patients were included in this meta-analysis. The pooled estimation results indicated that intraoperative vascular occlusion would not shorten the postoperative OS (RR = 1.01; 95%CI: 0.98-1.03; P = 0.763) and would not increase the risk of HCC recurrence (RR = 0.99; 95%CI: 0.97-1.02; P = 0.320) with low heterogeneity (I² = 0.0% and 12.7%, respectively). Furthermore, Egger's test did not reveal any publication bias (P = 0.405 and P = 0.269, respectively) in this research.

CONCLUSIONS

Intraoperative vascular occlusion during liver surgery is safe for HCC patients. It does not affect the postoperative overall survival or increase the risk of HCC recurrence.